Every finding on record at Franciscan Care CTR Sylvania

Based on observation, staff interview, medical record review, and review of facility policies, the facility failed to maintain the kitchen in a clean and sanitary manner, failed to ensure temperatures for food storage were properly monitored to prevent spoilage, failed to ensure the dishwasher temperature was adequately monitored to prevent food-borne illness, and failed to ensure residents were provided with sanitary eating utensils. This had the potential to affect all 65 residents who received food from the facility kitchen. The facility identified one resident (#11) as receiving nothing by mouth. The facility census was 66.Findings include: 1. Observation on 05/17/26 at 7:37 A.M. of the main kitchen revealed a thick layer of grease and buildup underneath of the commercial gas-range stove and fryer. Interview on 05/17/26 at 7:38 A.M. with Dietary [NAME] #201 verified the grease/buildup underneath the stove and fryer. Dietary [NAME] #201 reported staff were aware the area needed cleaned but did not know how to clean it since the stove was connected to a gas line. Observation on 05/18/26 at approximately 2:15 PM revealed a dried brown substance splattered on the ceiling in the main kitchen. Interview on 05/18/26 at approximately 2:17 P.M. with Dietary Manager #200 verified there was a substance (likely food splatter) on the ceiling in the kitchen. 2. Review of the refrigerator temperature logs for 05/01/26 through 05/17/26 for the refrigerator and the freezer located in the main kitchen revealed staff were to record the temperatures three times (breakfast, lunch, and dinner) daily. There were no refrigerator or freezer temperatures recorded for breakfast or lunch on 05/02/26, 05/03/26, 05/15/26, and 05/16/26. There were also no temperatures recorded for dinner on 05/15/26 05/15/26, or for any meal on 05/17/26. Interview on 05/17/26 at 7:45 A.M. with Dietary [NAME] #201 verified staff were supposed to document the temperatures for both the refrigerator and freezer three times per day and also verified the missing temperatures. Review of the refrigerator temperature logs for 05/01/26 through 05/18/26 for the unit refrigerator located on the E-Unit revealed staff were to record the temperatures three times (breakfast, lunch, and dinner) daily. There were no refrigerator temperatures recorded for breakfast or lunch from 05/02/26 through 05/07/26, for breakfast, lunch, or dinner from 05/08/26 through 05/11/26, for breakfast or lunch on 05/12/26 and 05/13/26, and for breakfast, lunch and dinner on 05/14/26 and 05/15/26. Interview on 05/19/26 at 9:58 A.M. with Social Services Director #222 verified staff were supposed to document the temperatures for both the refrigerator and freezer three times per day and also verified the missing temperatures. Review of the undated facility policy titled, Refrigerated Storage, revealed temperatures of refrigerators should be documented twice daily at minimum. Review of the undated facility policy titled, Frozen Storage, revealed temperatures of freezers should be documented twice daily at minimum. 3. Review of the dishwashing machine temperature logs for 05/01/26 through 05/17/26, revealed staff were to record an initial temperature strip reading each day, as well as temperatures for the lunch and evening dishwashing cycles. There were no temperatures recorded on 05/01/26, or for the initial or lunch cycles for 05/02/26 through 05/11/26. There were also no temperatures recorded for the initial or lunch cycles for 05/14/26 through 05/17/26. Interview on 05/18/26 at 12:04 P.M. with Dietary Manager #200 verified staff were supposed to document the temperatures for the dish machine three times per day and also verified the missing temperatures. 4. Observation during breakfast meal service on 05/18/26 at 7:56 A.M. revealed Certified Nurse Aide (CNA) #183 answered Resident #9's call light. Continued observation revealed Resident #9 was lying in bed on her right side facing the door with her overbed table parallel with the bed and a meal tray was on the overbed table. Resident #9 stated she dropped her spoon. CNA #183 picked up the spoon from the carpeted floor next to Resident #9's bed and handed it to Resident #9. Resident #9 stated she wanted the spoon to eat her oatmeal. Resident #9 also requested coffee and CNA #183 left the room to obtain coffee from the cart in the hall. Interview with CNA #183 confirmed she did not provide a clean spoon to Resident #9. An interview with Dietary Manager #200 on 05/26/26 at 2:08 P.M. verified if a resident dropped a spoon, staff should absolutely pick it up and get a fresh one. Staff should not give the spoon to a resident if it had fallen on the floor.

Based on observation, review of the facility's Legionella policy and maintenance records, staff interview, and policy review, the facility failed to ensure measures to prevent Legionella growth were implemented per the facility plan, and failed to ensure infection control measures were properly implemented for obtaining resident blood glucose levels and administering injectable medications. This had the potential to affect all 66 residents residing in the facility. The census was 66.Findings include: 1. Review of the facility's Legionella policy, under the section Control Scheme and Auditing, revealed hot and cold water services should be operated and maintained carefully. Further review revealed to flush all showers not used within the last week and flush all irregularly used outlets not used within the last week. Additionally, the facility would monthly monitor hot water tanks and large hot water heaters and gas fired hot water heaters were storing water above 140 degrees Fahrenheit (F), and where hot water services were circulated to check the flow and return temperatures were above 140 degrees F and 120 degrees F, respectively. Interview on 05/26/26 at 11:20 A.M. with Director of Facilities #213 revealed the facility did not document the flushing of unused showers or outlets and did not maintain documentation of hot water tanks and circulated water flow and return temperatures. 2. Observation on 05/18/26 at 4:15 P.M. of Licensed Practical Nurse (LPN) #180 performing fingerstick glucose checks revealed she obtained glucose readings for Resident #5 and Resident #30, utilizing the same glucometer, and did not disinfect the glucometer between residents. Interview on 05/18/26 at 4:35 P.M. with LPN #180 confirmed she did not disinfect the glucometer prior to, between residents, nor after use and should have. Review of facility policy titled, Glucometer Disinfection, dated 05/12/26, revealed glucometers would be disinfected after each use. 3. Observation on 05/18/26 at 4:25 P.M. of LPN #180 administering insulin for Resident #30 revealed she did not disinfect the insulin pen tip prior to applying the needle. Interview on 05/18/26 at 4:35 P.M. with LPN #180 confirmed she did not disinfect the insulin pen tip prior to applying the needle and should have. Review of facility policy titled, Insulin Pen Administration Instructions, dated 08/31/16, revealed the facility would swab the top of insulin pens for 15 seconds prior to applying the needle.

Based on observation, medical record review, resident interview, staff interview, and review of facility policies, the facility failed to provide residents with a clean, comfortable, and homelike environment. This directly affected three (#11, #12, and #22) of three residents reviewed for environment with the potential to affect all 12 (#2, #3, #4, #11, #25, #31, #37, #39, #42, #47, #56, and #63) residents who resided on the C-Unit. The facility census was 66.Findings include: 1. Observation on [DATE] at 7:47 A.M., revealed multiple flooring planks near the nursing station located on the C-Unit were coming up. An interview with Housekeeper #215 at the time of observation verified the flooring was coming up. Housekeeper #215 reported the flooring had been that way for months. Observation on [DATE] at 8:26 A.M. revealed there was dried brown splatter along the wall near the end of the C-Unit. Interview with Resident #31 at the time of the observation stated it had been that way for quite some time. Observation and interview on [DATE] at 10:52 A.M. with Housekeeper #215 verified the splatter on the wall. Observation during an environmental tour of the C-Unit on [DATE] at 2:08 P.M. revealed the soiled utility room door had tape across the width of the door, slightly below the door handle. The tape was partially worn, revealing a black and grey underlayer with buildup. There were also scrapes and marks along the width near the bottom of the door, and chipped paint around the metal trim surrounding the door. There was dried brown splatter on the door. Near the door, a rectangular board labeled CPR Board was leaning against the wall in the hallway. The board was visibly dirty and had chipped wood and missing paint. The transition-strips between the hallway and the rooms occupied by Resident #2, Resident #39, Resident #42, and Resident #56 were missing, which resulted in a gap in the floor where the subflooring, dirt, and buildup could be seen. There was a piece of drywall attached to the wall behind Resident #47's bed, which had plaster that was cracking and crumbling. Resident #47's bed also had a wheel used to prevent wall damage, which was cracked and broken. There was an outlet box partially detached from the wall and with a visibly broken cover next to Resident #2's bed. There was also a dried brown substance along the lower corner of the wall near the outlet box. The shared bathroom of Resident #2 and #39 had scrapes along the lower wall and inside of the bathroom door. A mechanical lift with chipped paint was also located in the bathroom, and the transition strip between the resident room and bathroom was loose and broken. An environmental tour on [DATE] at 11:01 with Maintenance Director (MD) #213 verified all of the aforementioned concerns. Review of the facility policy titled, Safe and Homelike Environment, revised [DATE], revealed the facility would provide a safe, clean, comfortable and homelike environment. 2. During an observation on [DATE] at 12:00 P.M., Resident #11's room was noticeably cold. There was no thermostat in the room. Observation during an interview on [DATE] at 12:02 P.M., Resident #11 was asked how the temperature was and the resident began stating, No, no, no, and showing the surveyor three fleece blankets which were covering her in bed. Observation and interview on [DATE] at 2:26 P.M. with Licensed Practical Nurse (LPN) #173 verified Resident #11's room was noticeably cold. LPN #173 stated the room was freezing and the resident was probably cold. Observation on [DATE] at 2:35 P.M. revealed MD #213 utilized an infrared thermometer to obtain the temperature in Resident #11's room. The air coming out of the three ceiling vents located in Resident #11's room were registering at 59 degrees Fahrenheit (F). An interview on [DATE] at 2:37 P.M. with MD #213 verified Resident #11's room was too cold. Review of the facility policy titled, Safe and Homelike Environment, revised [DATE], revealed the facility would maintain comfortable and safe temperature levels. 3. During an observation on [DATE] at 8:59 A.M., a loud buzzing noise was heard coming from the toilet located in Resident #12's bathroom. The noise made it difficult to hear what was being said during a conversation with the resident. During an interview on [DATE] at 9:01 A.M., Resident #12 reported he was unsure of how long the noise had been present. Observation on [DATE] at 9:50 A.M. revealed the buzzing noise could be heard in the hallway located outside of Resident #12's room. Observation and interview on [DATE] at 10:14 A.M. with Housekeeper #217 verified the buzzing noise coming from Resident #12's toilet. Housekeeper #217 flushed the toilet, which began buzzing in a different tone and at a lower volume. Observation on [DATE] at 10:52 A.M. revealed the buzzing noise could be heard in the hallway located outside of Resident #12's room. Observation on [DATE] at 9:18 A.M. revealed Resident #12's door was cracked and the buzzing noise could be heard from the hallway. Further observation revealed the resident's bathroom door was fully closed. Observation and interview on [DATE] at 9:24 A.M. with Maintenance Technician (MT) #214 verified the loud buzzing noise coming from Resident #12's toilet. MT #214 flushed the toilet, which began making a loud, repetitive clicking noise. Review of the facility policy titled, Safe and Homelike Environment, revised [DATE], revealed the facility would maintain comfortable sound levels. 4. Review of the medical record for Resident #22 revealed she was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set assessment dated [DATE] for Resident #22 revealed she was cognitively impaired and did not exhibit behaviors nor refusals of care at the time of the assessment. She was dependent for most activities of daily living and required maximal assistance with mobility. Observation on [DATE] at 9:00 A.M. of Resident #22's room revealed her oxygen concentrator had clear drip marks in a spill pattern from the top down the front that were sticky to the touch. The floor at her bedside closest to the window was also sticky. Interview on [DATE] at 10:50 A.M. with LPN #170 confirmed there was a clear sticky substance on Resident #22's oxygen concentrator and floor. LPN #170 indicated something must have spilled and she would alert housekeeping to come clean the substance. Observation on [DATE] at 2:05 P.M. of Resident #22's room revealed her oxygen concentrator had clear drip marks in a spill pattern from the top down the front that were sticky to the touch. Concurrent interview with Certified Nurse Aide (NCA) #145 confirmed the observation. Review of facility policy titled, Safe and Homelike Environment, dated [DATE], revealed the facility would provide housekeeping and maintenance services to provide a sanitary, orderly, and comfortable environment.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure dependent residents received adequate grooming and mobility assistance. This affected four (#3, #20, #23, and #37) of four residents reviewed for activities of daily living. The facility census was 66.Findings include: 1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included asthma, type II diabetes mellitus, contracture of the left knee, hypotension, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. The resident was dependent on assistance from staff for all activities of daily living, including personal hygiene. Review of the medical record revealed no evidence Resident #3 was offered or received assistance with trimming her toenails since August 2025. Observation on 05/19/26 at 10:35 A.M. revealed Resident #3 was lying in bed with her feet uncovered. Resident #3's toenails were long, extending past the tips of her toes at least three-fourths of an inch, and several toenails were curled. Interview on 05/19/26 at 10:36 A.M. with Resident #3 revealed staff were supposed to trim her toenails but they did not. Interview on 05/19/26 at 11:02 A.M. with Certified Nurse Aide (CNA) #148 verified Resident #3's toenails were long and needed trimmed. CNA #148 reported they believed the nurses were responsible for trimming resident toenails. Interview on 05/19/26 at 4:42 P.M. with Licensed Practical Nurse (LPN) #168 revealed all residents had their toenails trimmed by a podiatrist who came into the facility. Interview on 05/20/26 at 8:59 A.M. with Licensed Social Worker (LSW) #221 revealed there was no evidence Resident #3 had been seen by the podiatrist since August 2025. 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included muscle weakness, anxiety disorder, and need for assistance with personal care. Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 was cognitively intact. The resident required setup or cleanup assistance with personal hygiene. Review of the plan of care dated 04/09/26 revealed Resident #23 had potential/actual impairment to skin integrity related to fragile skin and decreased mobility. Interventions included avoiding scratching, keeping hands and body parts from excessive moisture, and keeping fingernails short. Review of the plan of care dated 04/09/26 revealed Resident #23 had an activities of daily living self-care performance deficit related to activity intolerance, hemiplegia, and muscle weakness. Interventions included providing supervision with personal hygiene. Review of the medical record revealed no evidence staff had ever assisted or attempted to assist Resident #23 with trimming their fingernails or toenails. Observation on 05/17/26 at 10:55 A.M. revealed Resident #23 was sitting up in a wheelchair located in his room. The fingernails on the resident's right hand were long, past the fingertips, and had a dark brown substance underneath of them. Interview at the time of observation revealed Resident #23 was unable to trim the fingernails on his right hand because he was paralyzed on his left side. Resident #23 reported he would like his fingernails to be trimmed but he needed help to complete the task. Resident #23 reported no staff members had ever offered to trim his fingernails. Interview on 05/19/26 at 9:32 A.M. with CNA #143 revealed the staff member worked with Resident #23 on a regular, full-time basis and was unsure of who was responsible for trimming resident fingernails. Observation on 05/19/26 at 9:35 A.M. with CNA #143 verified Resident #23's fingernails were long, past his fingertips, and had buildup underneath. Interview on 05/19/26 at 9:44 A.M. with LPN #168 revealed CNAs were responsible for trimming resident fingernails. Observation on 05/19/26 at 3:54 P.M. revealed Resident #23 was lying in bed with his feet uncovered. Resident #23's toenails were long, extending past the tips of his toes, and several toenails appeared sharp. Interview on 05/19/26 at 3:56 P.M. with Resident #23 revealed the resident stated they would like their toenails trimmed but they were unable to reach them. Resident #23 reported staff had not offered to assist with trimming their toenails and they had not been seen by a podiatrist. Observation on 05/19/26 at 4:42 P.M. with LPN #168 verified Resident #23's toenails were long and needed trimmed. LPN #168 reported all residents had their toenails trimmed by a podiatrist who came into the facility. Interview on 05/20/26 at 8:59 A.M. with LSW #221 revealed Resident #23 had never been seen by the podiatrist since he was admitted to the facility. Review of the facility policy titled, Podiatry Services, dated 02/19/26, revealed the facility would ensure residents received proper treatment and care to maintain mobility and good foot health. 3. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included need for assistance with personal care, heart failure, dysphagia, hypertension, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #37 was severely cognitively impaired. The resident was dependent on assistance from staff for the activities of daily living, including transfers. Review of the plan of care dated 05/29/25, and last revised on 02/24/26, revealed Resident #37 had an activities of daily living self-care performance deficit related to limited mobility and Alzheimer's disease. Interventions included assisting with all transfers, dependent with the assistance of two staff via Hoyer (mechanical) lift. Random intermittent observations throughout the day on 05/17/26 from 7:30 A.M. to 3:13 P.M., on 05/18/26 from 7:09 A.M. to 4:47 P.M., and on 05/19/26 from 7:02 A.M. to 11:01 A.M. revealed Resident #37 was lying in bed all throughout the day. Interview on 05/18/26 at 11:02 A.M. with CNA #148 revealed the staff member worked on 05/18/26 and on 05/19/26 and had not offered to get the resident up and out of bed. CNA #148 reported Resident #37 did like to get up sometimes and would go and offer to assist the resident in getting up and out of bed. Review of the facility policy titled, Activities of Daily Living (ADLs), dated 10/06/25, revealed care and services provided for the activities of daily living was to include resident transfers and ambulation. 4. Review of the medical record for Resident #20 revealed an admission date of 02/02/19 with diagnoses of asthma, morbid obesity, and anxiety. Review of the quarterly MDS assessment, dated 02/12/26, revealed Resident #20 had intact cognition, required substantial/maximal assistance for personal hygiene, and was dependent on staff for showers/bathing. Review of the current care plan initiated 02/04/19, and revised 01/13/23, revealed Resident #20 had an activities of daily living self care performance deficit related to impaired balance and a fracture of the left femur. Interventions included the resident required assistance with personal hygiene care and was dependent on staff to provide a bath as necessary. Observation and interview on 05/17/26 at 10:36 A.M. revealed Resident #20 lying in bed with her head against a pillow. Resident #20 stated her hair was full of knots and she could not remember the last time staff attempted to brush her hair. During the interview, Resident #20 began attempting to comb her hair out using her fingers. Resident #20's hair appeared to extend below her shoulders. Further observation of the back of Resident #20's hair revealed the hair appeared to matted. Interview on 05/19/26 at 10:08 A.M. with CNA #125 revealed staff should be brushing residents hair daily. CNA #125 was not familiar with Resident #20. Interview on 05/19/26 at 10:54 A.M. with CNA #139 revealed she was about to provide a bed bath for Resident #20. Observation of Resident #20's hair and concurrent interview with CNA #139 confirmed Resident #20's hair was matted. CNA #139 stated Resident #20's hair was difficult to brush out in the back because Resident #20 was lying in bed all the time. Concurrent interview with Resident #20 confirmed she chose to remain in bed throughout the day. Interview on 05/19/26 at 11:45 A.M. with Resident #20 stated her hair remained tangled and stated the staff gave up. Follow-up interview on 05/19/26 at 1:13 P.M. with CNA #139 stated Resident #20 would not let CNA #139 finish brushing her hair. CNA #139 further stated Resident #20 appeared to be grimacing while CNA #139 was trying to brush out the knots. Additionally, CNA #139 stated she noticed Resident #20's hair was tangled the last time she worked with her, but it was worse on 05/19/26. CNA #139 stated she believed she previously worked with Resident #20 two weeks prior. Interview on 05/19/26 at 1:51 P.M. with the Director of Nursing (DON) and Registered Nurse #152 revealed they were unaware Resident #20's hair was matted. Review of the policy titled, Activities of Daily Living (ADLs), effective 10/06/25, revealed the facility will provide care and services for bathing, dressing, grooming and oral care.

Based on medical record review, review of pharmacy documents, staff interview, and review of a facility policy, the facility failed to ensure pharmaceutical recommendations were reviewed and addressed in a timely manner. This affected four (#4, #6, #10, and #30) of five residents reviewed for pharmacist recommendations. The facility census was 66.Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included muscle weakness, need for assistance with personal care, difficulty in walking, hypertension, heart failure, seizures, dysphagia, and glaucoma. Review of Resident #4's prescribed medications list for May 2025 through September 2025 identified an order dated 01/30/25 for the narcotic pain medication oxycodone five (5) milligrams (mg) by mouth every four hours as needed for pain and an order dated 01/30/25 for the pain medication acetaminophen 1000 mg via gastrostomy tube every eight hours as needed for pain. Review of the pharmaceutical recommendations made to the attending physician for Resident #4 on 05/31/25, 07/29/25, and 09/30/25, revealed Resident #4 was receiving acetaminophen and oxycodone as needed for pain, and no current pain scale was in the directions by which to choose between the medications. The pharmacist recommended considering adding these parameters in order to ensure the resident was receiving adequate and consistent pain control. The recommendations were not reviewed or signed by the physician. Interview on 05/20/26 at 11:40 A.M. with the Director of Nursing (DON) verified there was no evidence the pharmaceutical recommendations for 05/31/25, 07/29/25, and 09/30/25 were reviewed or signed by the physician. 2. Review of the medical record for Resident #6 revealed she was admitted on [DATE] with diagnoses including end stage renal disease, hemiplegia and hemiparesis of right dominant side, type two diabetes mellitus, peripheral vascular disease, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 revealed she was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a wheelchair and required maximal assistance to dependence with activities of daily living. Review of the monthly pharmacy medication regimen review documents from May 2025 through April 2026 revealed pharmacy recommendations were initiated for Resident #6 in June and September of 2025. Review of these pharmacy recommendations revealed a request for the physician to initiate or decline a gradual dose reduction of trazodone and paroxetine; no action was taken by the facility to have these recommendations reviewed by the physician. Interview on 05/20/26 at 9:45 A.M. with the Administrator revealed the pharmacy recommendations for Resident #6 in June and September of 2025 were not addressed with the physician. 3. Review of the medical record for Resident #10 revealed he was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, cellulitis of the right lower limb, depression, anxiety, heart failure, non-pressure chronic ulcer of the right lower limb, and cervical disc degeneration. Review of the quarterly MDS assessment dated [DATE] for Resident #10 revealed he was cognitively intact, did not exhibit any behaviors, and did not refuse care. He was diabetic and received insulin injections. Resident #10 utilized a walker and wheelchair and required supervision to moderate assistance with activities of daily living. The assessment indicated he received scheduled pain medications. Review of the monthly pharmacy medication regimen review documents from May 2025 through April 2026 revealed pharmacy recommendations were initiated for Resident #10 in September of 2025. Review of the pharmacy recommendations revealed a request for the physician to initiate or decline a gradual dose reduction of Ambien, Buspar, and sertraline; no action was taken by the facility to have these recommendations reviewed by the physician. Interview on 05/20/26 at 9:45 A.M. with the Administrator revealed the pharmacy recommendations for Resident #10 in September of 2025 were not addressed with the physician. 4. Review of the medical record for Resident #30 revealed an admission date of 05/18/21 with diagnoses of depression, insomnia, anxiety, and psychosis. Review of the quarterly MDS assessment, dated 02/12/26, revealed Resident #30 had intact cognition and received an anti-anxiety medication. Review of the current physician order, initiated 07/12/25 revealed Resident #30 was prescribed hydroxyzine hydrochloride (HCl) 25 milligrams (mg) with instructions to give one tablet by mouth every 12 hours as needed for anxiety. Review of the March 2026 medication administration record (MAR) revealed Resident #30 received hydroxyzine HCl on 03/02/26 and 03/07/26. Review of the April 2026 MAR revealed Resident #30 did not receive hydroxyzine HCl. Review of the May 2026 MAR revealed Resident #30 received hydroxyzine HCl on 05/11/26. Review of the documents provided by the facility's pharmacy titled, Note to Attending Physician/Prescriber, dated 07/29/25, 09/30/25, and 11/30/25 revealed the resident was currently receiving hydroxyzine HCI 25 mg, one (1) tablet by mouth every 12 hours as needed for anxiety. The document further revealed to evaluate the continued need for the medication, and if it was to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration. Further review revealed a handwritten response of, Will review, with a signature dated 12/03/25. Review of the document provided by the facility's pharmacy titled, Review of Medication Regimen, dated 02/28/26, revealed the resident was currently receiving hydroxyzine HCl 25 mg, 1 tablet by mouth every 12 hours as needed for anxiety. The document further revealed to please evaluate the continued need for this medication, and if it was to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration. Further review revealed a handwritten response of, Continue, with a signature dated 03/04/26. Interview on 05/26/26 at 8:14 A.M. with the DON confirmed hydroxyzine HCl was used to treat anxiety on an as-needed basis for Resident #30 from 07/12/25 through 05/20/26. Follow-up interview on 05/26/26 at 10:05 A.M. with the DON confirmed Resident #30's medical record did not include any rationale regarding the continued use of hydroxyzine HCl for anxiety treatment. Review of the facility policy titled, Medication Regimen Review and Recommendations, dated 10/08/25, revealed non-emergent pharmacy recommendations would be presented to the physician and addressed by the end of the following month.

Based on observation, staff interview, and review of facility policies, the facility failed to ensure medications were stored in a safe and secured manner. This affected two (#6 and #57) of two residents observed for medication storage with the potential to affect 22 (#3, #4, #5, #8, #10, #11, #14, #17, #20, #24, #30, #34, #36, #40, #45, #47, #54, #56, #58, #60, #62, and #63) additional residents whose medications required refrigeration. The facility census was 66.Findings include:1. Observation on 05/18/26 at 2:15 P.M. of the medication refrigerator in the storage room for the rehabilitation unit revealed the refrigerator temperature log for May 2026 was incomplete for 05/02/26, 05/03/26, 05/06/26, and 05/08/26.Observation on 05/19/26 at 10:00 A.M. of the medication refrigerator at the A-hall nurse station revealed the refrigerator temperature log on the front of the refrigerator was for February 2026 was incomplete for all days except 02/05/26, 02/08/26, 02/14/26, 02/22/26, 02/23/26, and 02/24/26.Interview on 05/18/26 at 2:15 P.M. with Licensed Practical Nurse (LPN) #172 revealed the medication refrigerator temperatures were supposed to be obtained each night on third shift by the nurse on duty.Interview on 05/19/26 at 10:00 A.M. with LPN #177 revealed the medication refrigerator temperatures were supposed to be obtained each night on third shift by the nurse on duty.Interview on 05/19/26 at 10:35 A.M. with the Director of Nursing (DON) revealed none of the medication refrigerator temperatures were monitored daily to ensure consistent and optimal temperatures.Review of facility policy titled, Medication Storage, dated 04/20/26, revealed the facility would store medications under proper temperature controls and medication refrigerators would be monitored daily to ensure the temperatures were between 36 and 46 degrees Fahrenheit (F).2. Observation on 05/19/26 at 10:15 A.M. with LPN #177 of Resident #57's bedside table revealed the resident had brimonidine, Xalatan, and Cosopt eyedrops prescriptions in an unsecured basket on her bedside table. Concurrent interview with LPN #177 confirmed the eyedrops were typically housed in Resident #57's room as they were ordered to be self-administered by the resident.Interview on 05/26/26 at 8:00 A.M. with the DON confirmed Resident #57's eyedrops should not be unsecured at her bedside.Review of facility policy titled, Self-Administration and Bedside Storage of Medications, dated 10/08/25, revealed the facility would store medications at a resident's bedside if there was a physician order in the medical record and the manner of storage prevented access by other residents.3. Observation on 05/26/26 at 11:20 A.M. of Resident #6's dialysis binder, located in her room in the pocket on the back of her wheelchair, revealed three white round pills in the sleeve protector containing her face sheet. Concurrent interview with LPN #170 confirmed the observation and identified the pills as midodrine 10 milligram (mg) tablets.Continued interview with LPN #170 revealed Resident #6's dialysis binder was typically housed in an unsecured bookshelf at the nurse station, and it was not uncommon for pills to be in the dialysis binder.Review of facility policy titled, Medication Storage, dated 04/20/26, revealed the facility would store medications in a locked compartment.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received education and were offered pneumococcal vaccines timely to maintain vaccination status. This affected five (#14, #18, #22, #27, and #57) of seven residents reviewed for vaccinations. The facility census was 66.Findings include:1. Review of the medical record for Resident #14 revealed an admission date of 03/12/25 with diagnoses including cardiomyopathy, hypertension, and left ventricular failure.Review of the annual Minimum Data Set (MDS) assessment, dated 03/12/26, revealed Resident #14 had intact cognition.Review of pneumococcal immunization record for Resident #14 revealed his pneumococcal immunizations were not up to date.2. Review of the medical record for Resident #18 revealed she was admitted on [DATE] with diagnoses including acute kidney injury, adjustment disorder, need for assistance with personal care, anxiety, irritable bowel syndrome, cerebral infarction, and type two diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] for Resident #18 revealed she was cognitively intact, did not display any behaviors, and did not refuse care. Review of the medical record indicated Resident #18 refused the Prevnar pneumococcal vaccine on 12/13/24. There was no evidence education had been provided to the resident.3. Review of the medical record for Resident #22 revealed she was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease.Review of the quarterly MDS assessment dated [DATE] for Resident #22 revealed she was cognitively impaired and did not exhibit behaviors nor refusals of care at the time of the assessment. She was dependent for a majority of the activities of daily living. Resident #22 had chronic lung disease with respiratory failure.Review of pneumococcal immunization record for Resident #22 revealed her pneumococcal immunizations were not up to date.4. Review of the medical record for Resident #27 revealed an admission date of 10/25/24 with diagnoses of chronic obstructive pulmonary disease, adult failure to thrive, repeated falls, and scoliosis.Review of the annual MDS assessment, dated 03/24/26, revealed Resident #27 had intact cognition, required substantial/maximal assistance for personal hygiene, and was dependent on staff for toileting, moving from a sitting to standing position, transfers, and bed mobility.Review of pneumococcal immunization record for Resident #27 revealed her pneumococcal immunizations were not up to date.5. Review of the medical record for Resident #57 revealed an admission date of 07/10/23 with diagnoses of congestive heart failure, chronic lymphocytic leukemia of B-cell type, and malignant neoplasm of the left breast.Review of the quarterly MDS assessment, dated 02/17/26, revealed Resident #57 had intact cognition.Review of pneumococcal immunization record for Resident #57 revealed her pneumococcal immunizations were not up to date.Interview on 05/20/26 at 3:36 P.M. with the Director of Nursing (DON) confirmed the facility could provide no evidence pneumococcal vaccines were offered to Resident #14, #22, #27, and #57. The DON further verified there was no evidence Resident #18 received education regarding the pneumococcal vaccine.Review of the facility policy titled, Pneumococcal Vaccine (Series), dated 05/12/26, revealed each resident would be offered a pneumococcal immunization unless it was contraindicated or the resident had already been immunized. Prior to offering the immunization, each resident or the resident's representative would receive education regarding the benefits and potential side effects of the immunization.

Based on medical record review, review of a fall investigation, staff interview, and policy review, the facility failed to make proper notifications after a fall. This affected one (#27) of three residents reviewed for falls. The facility census was 66.Findings include:Review of the medical record for Resident #27 revealed an admission date of 10/25/24 with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive, repeated falls, and scoliosis.Review of the annual Minimum Data Set assessment, dated 03/24/26, revealed Resident #27 had intact cognition, required substantial/maximal assistance for personal hygiene, and was dependent on staff for toileting, moving from a sitting to standing position, transfers, and bed mobility. Further review revealed Resident #27 did not have a fall since the previous assessment.Review of a nursing progress note dated 04/08/26 revealed Resident #27's daughter came to the facility inquiring about the specifics of a fall Resident #27 sustained that neither she nor hospice were notified of. Review of the undated fall investigation revealed no indication Resident #27's representative was notified.Telephone interview on 05/19/26 at 11:01 A.M. with Registered Nurse (RN) #167 confirmed she was the nurse on duty during Resident #27's fall on 04/07/26. RN #167 stated it was a four-hour shift, and very busy, and further stated she did not notify the provider or Resident #27's representative of the fall. Additionally, RN #167 stated she did not tell the oncoming nurse about Resident #27's fall because there were so many things going on that night.Interview on 05/19/26 at 1:27 P.M. with the Director of Nursing (DON) confirmed notifications should have been made regarding Resident #27's fall on 04/07/26, and further confirmed timely notifications were not completed by the nurse on duty at the time of the fall.Review of the policy titled, Fall Prevention Program, approved 05/22/25, revealed physician and family will be notified after any resident experiences a fall. This deficiency represents non-compliance investigated under Complaint Number 2982457.

Based on medical record review, resident interviews, and staff interviews, the facility failed to ensure Minimum Data Set assessments were completed accurately. This affected three (#22, #23, and #27) of 19 residents reviewed for MDS assessment accuracy. The facility census was 66.Findings include: 1. Review of the medical record for Resident #22 revealed she was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 revealed she was cognitively impaired and did not exhibit behaviors nor refusals of care at the time of the assessment. The assessment indicated she had chronic lung disease with respiratory failure and did not utilize oxygen. Review of physician orders for Resident #22 revealed an order dated 05/29/20 for oxygen to be delivered at two liters per minute. Observation on 05/17/26 at 9:00 A.M. of Resident #22 resting in her bed revealed she was wearing a nasal cannula connected to an oxygen concentrator delivering oxygen at three liters per minute. Interview on 05/20/26 at 11:00 A.M. with the Director of Nursing (DON) confirmed Resident #22 utilized oxygen and the MDS assessment dated [DATE] was incorrect. 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included hemiplegia, unspecified affecting left nondominant side, muscle weakness, anxiety disorder, and need for assistance with personal care. Review of the admission MDS assessment dated [DATE], the Medicare five-day MDS assessment dated [DATE], and the quarterly MDS assessment dated [DATE], revealed Resident #3 had no impairment resulting in a functional limitation in range of motion to their upper extremity (shoulder, elbow, wrist, hand). Interview and observation on 05/17/26 at 10:55 A.M. with Resident #23 revealed the resident was unable to move or utilize his left upper and lower extremities. Interview on 05/19/26 at 2:51 P.M. with the DON verified the three MDS assessments listed Resident #23 as having no impairment to his upper extremities, although the resident was unable to utilize his left side. 3. Review of the medical record for Resident #27 revealed an admission date of 10/25/24 with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive, repeated falls, and scoliosis. Review of the comprehensive annual MDS assessment, dated 03/24/26, revealed Resident #27 had intact cognition, required substantial/maximal assistance for personal hygiene, and was dependent on staff for toileting, moving from a sitting to standing position, transfers, and bed mobility. Further review revealed Resident #27 was not on a scheduled pain regimen. A pain assessment was not completed. Staff assessment for pain revealed no signs of pain were observed or documented. Review of Resident #27's current physician orders revealed she received the narcotic pain medication Percocet oral tablet 10-325 milligrams (mg) (oxycodone with acetaminophen) with instructions to give one tablet by mouth every four hours for pain. Review of Resident #27's medication administration record (MAR), dated March 2026, revealed she received Percocet every four hours daily. Interview on 05/19/26 at 12:12 P.M. with the DON confirmed Resident #27's MDS assessment was completed incorrectly regarding the scheduled pain regimen. Interview on 05/20/26 at 2:50 P.M. with the DON revealed the facility followed the most recent edition of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, provided by Centers for Medicare and Medicaid Services, for guidelines regarding the accurate completion of MDS assessments.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure care plans were implemented to include person-centered needs and interventions of residents. This affected three (#23, #30, and #33) of 19 residents reviewed for care plans. The facility census was 66.Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included hemiplegia, unspecified affecting the left nondominant side, muscle weakness, anxiety disorder, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. The resident required setup or cleanup assistance with personal hygiene. Interview and observation on 05/17/26 at 10:55 A.M. with Resident #23 revealed the resident was unable to move or utilize his left upper and lower extremities. Review of Resident #23's current plan of care revealed there was no care plan or corresponding interventions in place to address limitations affecting the resident's left side. Interview on 05/19/26 at 2:51 P.M. with the Director of Nursing (DON) verified Resident #23 did not have a care plan in place to address his limited function on their left side. 2. Review of the medical record for Resident #30 revealed an admission date of 11/26/25 with diagnoses of atrial fibrillation, chronic obstructive pulmonary disease, morbid obesity, depression, and muscle weakness. Review of the quarterly MDS assessment, dated 02/12/26, revealed Resident #30 had intact cognition, had moderate difficulty hearing, and did not use a hearing aid. Review of Resident #30's current care plan, initiated 05/19/21, revealed no care areas regarding hearing. Observation and interview on 05/17/26 at 10:23 A.M. with Resident #30 revealed her lying in bed. Resident #30 stated her hearing was terrible and stated she asked so many times to see someone about her ears. Review of audiology assessments, dated 07/06/22, 09/26/23, and 09/23/24, revealed Resident #30's hearing could not be assessed due to wax in both ears. Interview on 05/19/26 at 1:47 P.M. with the DON revealed the audiologist came to the facility 05/19/25 and saw one resident, not Resident #30. Interview on 05/20/26 at approximately 3:30 P.M. with the DON revealed the facility could provide no evidence Resident #30 received assistance with ear wax removal since 07/06/22. Interview on 05/26/26 at 2:25 P.M. with the DON confirmed Resident #30's care plan should include a care area for hearing, and did not. 3. Review of the medical record for Resident #33 revealed she was admitted on [DATE] with diagnoses including atherosclerotic heart disease, atrial fibrillation, chronic respiratory failure with hypoxia and hypercapnia, and emphysema. Review of the admission MDS assessment dated [DATE] for Resident #33 revealed she was cognitively intact and did not exhibit behaviors nor refusals of care. She utilized a wheelchair and required maximal assistance with activities of daily living. Resident #33 had chronic lung disease with respiratory failure and required oxygen therapy. Review of the current care plan for Resident #33 revealed the absence of a focus area related to respiratory care. Observation on 05/17/26 at 10:40 A.M. of Resident #33 resting in her bed revealed she was wearing a nasal cannula connected to an oxygen concentrator delivering oxygen at seven liters per minute. Interview on 05/20/26 at 11:00 A.M. with the DON confirmed Resident #33 did not have a care plan related to respiratory care. Review of the facility policy titled, Comprehensive Care Plans, dated 05/12/26, revealed the facility would implement person-centered care plans that would meet residents' medical needs.

Based on medical record review, resident interview, resident representative interview, staff interview, and review of a facility policy, the facility failed to ensure care conferences were completed quarterly and residents were included in their care planning process. This affected one (#18) of one residents reviewed for care planning conferences. The facility census was 66.Findings include:Review of the medical record for Resident #18 revealed she was admitted on [DATE] with diagnoses including acute kidney injury, adjustment disorder, need for assistance with personal care, anxiety, irritable bowel syndrome, cerebral infarction, and type two diabetes mellitus.Review of the quarterly Minimum Data Set assessment dated [DATE] for Resident #18 revealed she was cognitively intact, did not display any behaviors, and did not refuse care. The assessment indicated Resident #18 participated in her care planning.Interview on 05/17/26 at 9:20 A.M. with Resident #18 revealed she was not included in decisions made regarding her care needs.Review of a social services progress note dated 05/20/26 at 10:21 A.M. revealed Resident #18's daughter was contacted to schedule a care conference. Continued review of progress notes from 12/13/24 through 05/20/26 revealed the absence of notations indicating care conferences had been conducted.Interview on 05/20/26 at 2:40 P.M. with Resident #18's representative, her daughter, revealed only one care conference had been scheduled when Resident #18 was admitted to the facility, and it was ultimately cancelled because several team members were unable to attend. Further interview revealed no other care conferences were scheduled until she was contacted today (05/20/26) by the facility social worker.Interview on 05/20/26 at 3:00 P.M. with the Director of Nursing (DON) confirmed there was no evidence indicating Resident #18 had been involved with planning for her care needs.Review of facility policy titled, Comprehensive Care Plans, dated 05/12/26, revealed the facility would include the resident and/or resident's representative in the care planning process.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure weekly skin assessments were completed as ordered to assess for new wounds. This affected one (#53) of two residents reviewed for skin assessments. The facility census was 66. Findings include:Review of the medical record for Resident #53 revealed an admission date of 06/11/25 with a readmission date of 10/31/25. Diagnoses included congestive heart failure, aphasia, need for assistance with personal care, and atrial fibrillation.Review of the quarterly Minimum Data Set assessment, dated 04/30/26, revealed Resident #53 had impaired cognition and required partial/moderate staff assistance for bed mobility, moving from sitting to a lying position, substantial/maximal assistance for moving from sitting to standing, and transfers from bed to chair and was dependent on staff for transfers to the toilet. Further review revealed Resident #53 had no skin breakdown.Review of Resident #53's care plan, created 02/18/25 and updated 03/10/25, revealed Resident #53 was at risk for skin breakdown due to immobility, incontinence, and fragile skin. Interventions included to inform the resident, family, and caregivers of any new area of skin breakdown; monitor, document, and report to the medical director as needed changes in skin status including appearance, color, wound healing, signs/symptoms of infection, wound size, and stage; and weekly skin checks.Review of Resident #53's physician order, dated 04/08/26, revealed weekly skin assessments should be completed every Wednesday on first shift.Review on 05/18/26 of Resident #53's electronic medical record revealed the most recent weekly skin assessment was completed 03/19/26.Observation on 05/17/26 at 9:54 A.M. revealed Resident #53 sitting up in bed with both arms above the covers. Further observation revealed a circular bruise, approximately three to four inches in diameter near her left elbow. Near the center of the bruise revealed an open area of skin which appeared to be approximately one-fourth inch in length. The red/purplish bruising appeared to be around the perimeter of the bruise and the skin was not discolored near the center, except at the spot that appeared to be open which was also red.Interview on 05/19/26 at 1:38 P.M. with the Director of Nursing (DON) revealed she believed she was told about Resident #53's injury, and was told Resident #53 bumped her arm. However, the DON stated she could not recall when or by whom she heard of the injury. Further, the DON confirmed no assessment of the wound was documented at the time of the interview, and weekly skin checks were not performed since 03/19/26. Review of the policy titled, Skin Assessment, effective 05/12/26, revealed a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter.

Based on resident and staff interview, medical record review, and policy review, the facility failed to ensure residents received adequate ear care to facilitate hearing. This affected one (#30) of one residents reviewed for hearing services. The facility census was 66. Findings include:Review of the medical record for Resident #30 revealed an admission date of 11/26/25 with diagnoses of atrial fibrillation, chronic obstructive pulmonary disease, morbid obesity, depression, and muscle weakness.Review of the quarterly Minimum Data Set assessment, dated 02/12/26, revealed Resident #30 had intact cognition and had moderate difficulty hearing, and did not use a hearing aid. Observation and interview on 05/17/26 at 10:23 A.M. with Resident #30 revealed her lying in bed. Resident #30 stated her hearing was terrible and stated she asked so many times to see someone about her ears.Review of the audiology assessment, dated 07/06/22, revealed Resident #30 was referred due to a new change in behavior. Further review revealed wax needed removed in both ears. A medical doctor consultation for wax removal was recommended and noted to contact the audiology group to coordinate services and they would re-evaluate Resident #30 after wax removal.Review of the audiology assessment, dated 09/26/23, revealed Resident #30 was referred due to a new complaint of ear pain. Further review revealed an assessment was not completed. Review of the recommendations revealed a medical doctor consultation for wax removal to both ears and would re-evaluate the resident after wax removal. Review of the audiology assessment, dated 09/23/24, revealed Resident #30 was referred due to family/staff noticed recent decreased responsiveness by the resident with complaints of newly decreased hearing. Further review revealed an assessment was not completed. Additional comments revealed, bilateral wax removal needed - both. Review of the recommendations revealed wax removal needed bilaterally and they would re-evaluate the resident after wax removal.Interview on 05/19/26 at 1:47 P.M. with the Director of Nursing (DON) revealed she was not aware of a request by Resident #30 to see the audiologist. The DON stated the audiologist came to the facility on [DATE] and saw one resident, not Resident #30. Interview on 05/20/26 at approximately 3:30 P.M. with the DON revealed the facility could provide no evidence Resident #30 received assistance with ear wax removal since 07/06/22.Review of the policy titled, Hearing and Vision Services, revised 02/19/26, revealed it was the policy of the facility to ensure all residents had access to hearing and vision services.

Based on medical record review, staff interview, and resident interview, the facility failed to ensure pressure ulcer treatments were completed per physician order. This affected one (#31) of one residents reviewed for treatment of pressure ulcers. The facility census was 66.Findings include:Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included pressure ulcer of other cite (stage four), need for assistance with personal care, muscle weakness, hypertension, and other acute osteomyelitis, left ankle and foot.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact. The resident was dependent on assistance from staff for the activities of daily living. Review of the current plan of care, last revised 10/29/25, revealed Resident #31 was admitted with four unstageable pressure ulcers (obscured full-thickness skin and tissue loss) on his bilateral heels and ankles. Interventions included providing treatments as ordered.Review of Resident #31's physician orders for May 2026 identified an order dated 04/21/26 to cleanse the left heel with soap and water, pat dry, apply moistened gauze and let sit for three to five minutes, then pat dry, apply medical honey to the wound bed and gently pack with one-fourth iodoform, leaving a tail for retrieval, cover with abdominal pad and Kerlix (a type of absorbent, loosely woven, crinkled cotton gauze used primarily to dress, pack, and bandage wounds), apply a double layer of tubi-grip (elasticated tubular bandage), and cover with all cotton elastic wrap one time a day. There was also an order dated 05/12/26 to cleanse the left heel with soap and water, pat dry, apply moistened gauze and let sit for three to five minutes, then pat dry, apply alginate to wound bed, cover with abdominal pad and Kerlix, apply double layer of tubi-grip, and cover with all cotton elastic wrap.Review of Resident #31's treatment administration record for 05/01/26 through 05/21/26 revealed the treatment to the left heal was not completed on 05/01/26, 05/06/26, and 05/20/26.An interview on 05/18/26 at 3:21 P.M. with Resident #31 revealed his wound treatments were often not completed when they were supposed to be.An interview on 05/26/26 at 11:59 A.M. with the Director of Nursing (DON) verified Resident #31's treatments were not completed in accordance with physician orders on 05/01/26, 05/06/26, and 05/20/26.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were assessed for fall risk and were properly assessed following a fall. This affected one (#27) of three residents reviewed for falls. The facility census was 66.Findings include: Review of the medical record for Resident #27 revealed an admission date of 10/25/24 with diagnoses of chronic obstructive pulmonary disease, adult failure to thrive, repeated falls, and scoliosis. Review of the annual MDS assessment, dated 03/24/26, revealed Resident #27 had intact cognition, required substantial/maximal assistance for personal hygiene, and was dependent on staff for toileting, moving from a sitting to standing position, transfers, and bed mobility. Further review revealed Resident #27 did not have a fall since the previous assessment. Review of the fall risk evaluation, dated 06/02/25, revealed Resident #27 was at risk for falls. Review of a nursing progress note dated 04/08/26 revealed Resident #27's daughter came to the facility inquiring about the specifics of a fall Resident #27 sustained that neither she nor hospice were notified of and indicated she had footage of her mother falling out of bed and being returned to bed without being assessed. Review of Resident #27's electronic medical record revealed no evidence neurological checks were completed and no evidence a fall assessment was completed after the fall on 04/07/26. Telephone interview on 05/19/26 at 11:01 A.M. with Registered Nurse (RN) #167 revealed she worked on 04/07/26 when Resident #27 had an unwitnessed fall. RN #167 stated after the fall, she checked Resident #27's vital signs and orientation. RN #167 stated she did not perform range of motion prior to moving Resident #27, with assistance from additional staff, from the floor to the bed. Additionally, RN #167 stated she did not initiate neurological checks after the unwitnessed fall because Resident #27 was able to answer all orientation questions appropriately (such as name, date, time, and location). Interview on 05/19/26 at 1:27 P.M. with the Director of Nursing (DON) verified Resident #27 was not assessed appropriately after the unwitnessed fall on 04/07/26, and neurological assessments were not completed. Interview on 05/20/26 at 8:48 A.M. with the DON and concurrent review of Resident #27's fall investigation revealed the cause of the fall was recent medication changes causing acute confusion. The DON further confirmed the medication changes resulted from Resident #27's narcotic pain medication Percocet order not being refilled timely prior to 04/07/26, and Resident #27 not receiving five doses of Percocet; Resident #27 therefore received four doses of as needed narcotic pain medication Dilaudid resulting in the medication changes and acute confusion leading to the fall on 04/07/26. Interview on 05/26/25 at 10:20 A.M. with the DON confirmed fall risk evaluations were not completed every 90 days for Resident #27. Review of the policy titled, Fall Prevention Program, effective 05/22/25, revealed each resident will be assessed for fall risk every 90 days and as indicated when the resident's condition changes. Further, the policy stated when a resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, and document all assessments and actions. This deficiency represents non-compliance investigated under Complaint Number 2982457.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure oxygen tubing and humidification was changed timely. This affected three (#22, #33, and #51) of three residents reviewed for respiratory care. The facility census was 66.Findings include:1. Review of the medical record for Resident #22 revealed she was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease.Review of the quarterly Minimum Data Set assessment dated [DATE] for Resident #22 revealed she was cognitively impaired and did not exhibit behaviors nor refusals of care at the time of the assessment. She was dependent for most activities of daily living. Resident #22 had chronic lung disease with respiratory failure.Review of physician orders for Resident #22 revealed an order dated 04/28/25 to change oxygen tubing and humidification, label both the tubing and the humidification, every night shift weekly on Sundays.Observation on 05/17/26 at 9:00 A.M. of Resident #22 revealed she was resting in bed wearing a nasal cannula connected to an oxygen concentrator running at three liters per minute. The oxygen tubing did not have a date indicating when it had been initiated.Interview on 05/17/26 at 10:50 A.M. with Licensed Practical Nurse (LPN) #170 confirmed Resident #22's oxygen tubing was not labeled with the date it was initiated and confirmed it should be changed weekly and as needed.2. Review of the medical record for Resident #33 revealed she was admitted on [DATE] with diagnoses including atherosclerotic heart disease, atrial fibrillation, chronic respiratory failure with hypoxia and hypercapnia, and emphysema.Review of the admission MDS assessment dated [DATE] for Resident #33 revealed she was cognitively intact and did not exhibit behaviors nor refusals of care. She utilized a wheelchair and required maximal assistance with activities of daily living. Resident #33 had chronic lung disease and respiratory failure and required oxygen therapy.Observation on 05/17/26 at 10:40 A.M. of Resident #33 revealed she was resting in bed wearing a nasal cannula connected to an oxygen concentrator running at seven liters per minute. The oxygen tubing was dated 05/03/26 indicating it was two weeks old.Interview on 05/17/26 at 10:55 A.M. with LPN #182 confirmed Resident #33's oxygen tubing was two weeks old and should be changed weekly and as needed.3. Review of the medical record for Resident #51 revealed she was admitted on [DATE] with diagnoses including neurogenic bladder, stage four pressure ulcer, pulmonary hypertension, chronic respiratory failure, and malignant neoplasm of the lung,Review of the quarterly MDS assessment dated [DATE] for Resident #51 revealed she experienced mild cognitive impairment, did not exhibit behaviors, and did not refuse care. She utilized a wheelchair for mobility and required maximal assistance to dependence with activities of daily living. Resident #51 had pulmonary diagnoses including chronic lung disease and respiratory failure requiring oxygen therapy.Review of physician orders for Resident #51 revealed an order dated 04/28/25 to change oxygen tubing and humidification, label both the tubing and the humidification, every night shift weekly on Sundays.Observation on 05/17/26 at 10:35 A.M. of Resident #51 revealed she was resting in bed wearing a nasal cannula connected to an oxygen concentrator running at five liters per minute. The oxygen tubing did not have a date indicating when it had been initiated. Additionally, the humidification bottle on the concentrator was empty.Interview on 05/17/26 at 10:50 A.M. with LPN #170 confirmed Resident #51's humidification bottle was empty, and the oxygen tubing was not labeled with the date it was initiated. LPN #170 further confirmed oxygen tubing should be changed weekly and as needed.Review of facility policy titled, Respiratory Services Policy Manual, section PRC107 dated 12/29/25, revealed oxygen tubing would be changed weekly or as needed. Continued review revealed oxygen humidification bottles would be changed weekly or as needed when empty.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents had accurate orders for and received pertinent medications to provide effective pain management. This affected two (#18 and #27) of three residents reviewed for pain. The facility census was 66.Findings include: 1. Review of the medical record for Resident #18 revealed she was admitted on [DATE] with diagnoses including acute kidney injury, adjustment disorder, need for assistance with personal care, anxiety, irritable bowel syndrome, cerebral infarction, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed she was cognitively intact, did not display any behaviors, and did not refuse care. She required supervision to maximal assistance with activities of daily living. She indicated her worst pain was eight on a scale of one to 10 and her pain occasionally interfered with her daily activities and sleep. Review of physician orders for Resident #18 revealed an active order dated 10/22/25 for 50 milligrams (mg) of tramadol to be administered every eight hours as needed for pain for three days. Review of medication administration records (MARs) for Resident #18 from October 2025 through February 2026 revealed duplicate orders for tramadol were concurrently active. In addition to the order noted above dated 10/22/25, there was an order dated 04/25/25 through 02/25/26 for 50 mg of tramadol to be administered as needed up to three times daily for pain. Review of the MAR for Resident #18 for December 2025 revealed 50 mg of tramadol was administered on 12/15/25 against the order dated 10/22/25 that was written for three days only. Review of the MAR for Resident #18 for January 2026 revealed 50 mg of tramadol was administered twice on 01/05/26 and once on 01/27/26 against the order dated 04/25/25. Additionally, 50 mg of tramadol was administered once on 01/25/26 against the order dated 10/22/25 that was written for three days only. Review of the MAR for Resident #18 for February 2026 revealed 50 mg of tramadol was administered on 02/08/26, 02/29/26, 02/18/26, 02/23/26, 02/25/26, 02/26/26, and 02/27/26 against the order dated 10/22/25 that was written for three days only. Additionally, 50 mg of tramadol was administered once on 02/23/25 against the order dated 04/26/25. Review of the MAR for Resident #18 for March 2026 revealed 50 mg of tramadol was administered eight times against the order dated 10/22/25 that was written for three days only. Review of the MAR for Resident #18 for April 2026 revealed 50 mg of tramadol was administered once against the order dated 10/22/25 that was written for three days only. Review of the MAR for Resident #18 for May 2026 revealed 50 mg of tramadol was administered twice against the order dated 10/22/25 that was written for three days only. Interview on 05/20/26 with the Director of Nursing (DON) confirmed there were two active orders for tramadol as needed from 10/22/25 through 02/25/26. Continued interview confirmed the order dated 10/22/25, written for three days only, was still being used to administer the tramadol. Review of facility policy titled, Medication Administration, dated 12/20/25, revealed the facility would administer medications as ordered by the physician. 2. Review of the medical record for Resident #27 revealed an admission date of 10/25/24 with diagnoses of chronic obstructive pulmonary disease, adult failure to thrive, repeated falls, and scoliosis. Review of the annual MDS assessment, dated 03/24/26, revealed Resident #27 had intact cognition, required substantial/maximal assistance for personal hygiene, and was dependent on staff for toileting, moving from a sitting to standing position, transfers, and bed mobility. Review of the physician order dated 10/27/25 revealed Resident #27 received the narcotic pain medication Percocet oral tablet 10-325 milligrams with instructions to give one tablet by mouth every four hours for pain. Review of the physician order initiated 10/27/25 and discontinued 05/15/26 revealed Resident #27 was prescribed a different narcotic pain medication, Dilaudid oral liquid one (1) mg/milliliter (ml) with instructions to give three (3) ml by mouth every two hours as needed for pain. Review of the MAR, dated April 2026, revealed Resident #27 did not receive five doses of Percocet on 04/07/26 at 12:00 A.M., at 4:00 A.M., at 8:00 A.M., at 12:00 P.M., and at 4:00 P.M. Further review revealed Resident #27 received four doses of Dilaudid on 04/07/26 at 6:00 A.M. (pain level two), at 10:16 A.M. (pain level nine), at 2:46 P.M., (pain level eight), and at 5:02 P.M. (pain level six). Further review of the April 2026 MAR revealed Resident #27's pain levels ranged from zero to nine most days. Interview on 05/17/26 at 2:28 P.M. with Licensed Practical Nurse (LPN) #182 confirmed Resident #27's Percocet was not ordered by facility staff and was not available on 04/07/26. LPN #182 stated she was the usual nurse on the hall, but did not work on the hall 04/06/26 or 04/07/27. Interview on 05/19/26 at 4:38 P.M. with LPN #177 revealed she worked 04/07/26 and received in report from the night nurse the facility should provide Dilaudid while Percocet was out of stock. Additionally, LPN #177 stated hospice staff visited Resident #27 on 04/07/26 and further reiterated to LPN #177 to use Dilaudid until Percocet was delivered. Interview on 05/19/26 at 1:27 P.M. with the DON confirmed the facility staff and hospice staff were expected to coordinate to ensure residents medications remained restocked and available. Interview on 05/19/26 at 1:31 P.M. with RN #152 and concurrent review of Resident #27's April 2026 MAR confirmed five doses of Percocet were not given on 04/07/26. Interview on 05/26/26 at 9:58 A.M. with the DON revealed the Dilaudid was not given every four hours on 04/07/26 because the received order did not specifically indicate the Dialudid should be given every four hours. The DON stated the order was to use as-needed Dilaudid until the Percocet was replaced. This deficiency represents non-compliance investigated under Complaint Number 2982457.

Based on medical record review and staff interview, the facility failed to ensure the accurate medication orders were in the medical record. This affected one (#57) of one residents reviewed for accuracy of medication orders. The facility census was 66. Findings include:Review of the medical record for Resident #57 revealed she was admitted on [DATE] with diagnoses including congestive heart failure, respiratory disorders, hypertension, and glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 revealed she was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a wheelchair and required partial to maximal assistance with activities of daily living. She was dependent for transfers and mobility. Review of active physician orders for Resident #57 revealed an order dated 04/27/26 for brimonidine tartrate ophthalmic solution 0.2 percent (%), an order dated 01/15/26 for dorzolamide hydrochloride ophthalmic solution, an order dated 04/27/26 for rocklatan ophthalmic solution 0.02-0.005%, and an order for Xalatan ophthalmic solution 0.002%.Review of physician notes from Resident #57's most recent eye doctor appointment on 02/16/26 revealed orders to continue the brimonidine and Xalatan eye drops, to discontinue dorzolamide hydrochloride drops, and to start Cosopt ophthalmic solution.Interview on 05/19/26 at 3:00 P.M. with Eye Care Physician Staff #231 confirmed Resident #57's current eye drop regimen should be brimonidine, Xalatan, and Cosopt.Interview and observation on 05/19/26 at approximately 3:30 P.M. with the Director of Nursing (DON) confirmed Resident #57's current eyedrop regimen should be brimonidine, Xalatan, and Cosopt, and the orders in the medical record were incorrect.

Based on observation and staff interview, the facility failed to post daily nurse staffing data as required. This had the potential to affect all 66 residents residing in the facility. The facility census was 66.Findings include:Observation on 05/17/26 and 05/18/26, at random times, revealed the daily nurse staffing data was not posted in the facility.Interview on 05/18/26 at 4:45 P.M. with the Director of Nursing confirmed the daily nurse staffing data had not been posted in the facility on 05/17/26 and 05/18/26.

Based on resident interview, staff interview, review of facility call light logs, review of facility staffing tool, and review of facility policy, the facility failed to ensure sufficient staffing to meet resident needs. This had the potential to affect all facility residents. The facility also failed to timely respond to resident call lights. This affected 42 residents who's call lights alarmed for greater than 30 minutes on 02/15/26 through 02/18/26. The facility census was 71.Findings Include:Review of facility call light logs from 02/15/2026 through 02/18/2026 revealed that 42 residents had call lights that remained activated and unanswered for 30 minutes or longer prior to staff response.Review of the Facility Staffing Tool for 02/12/26 through 02/18/26 revealed facility staffing fell below the Minimum Staffing Requirement on 02/13/25, 02/14/26, and 02/15/26. Interview on 02/18/26 at 11:25 A.M. with Resident #20 revealed call lights are not responded to timely, and she often has to wait for her call light to be answered for greater than 30 minutes. Interview on 02/18/26 at 12:51 P.M. with Resident #36 revealed call lights are not responded to timely, and she often has to wait for her call light to be answered for greater than 30 minutes. Interview on 02/18/26 at 1:11 P.M. with Resident #47 revealed call lights are not responded to timely, and she often has to wait for her call light to be answered for greater than 30 minutes. Interview on 02/18/26 at 1:24 P.M. with Resident #7 revealed call lights are not responded to timely, and she often has to wait for her call light to be answered for greater than 30 minutes. Interview on 02/18/26 at 2:05 P.M. with Resident #8 revealed call lights are not responded to timely, and she often has to wait for her call light to be answered for greater than 30 minutes. Interview on 02/18/26 at 2:46 P.M. with Resident #27 revealed call lights are not responded to timely, and he often has to wait for his call light to be answered for greater than 30 minutes. Interview on 02/19/26 at 6:30 A.M. with Resident #42 revealed call lights are not responded to timely, and she often has to wait for her call light to be answered for greater than 30 minutes. Interview with the Administrator on 02/19/26 at approximately 3:30 P.M. verified the facility staffing fell below the Minimum Staffing Requirement on 02/13/25, 02/14/26, and 02/15/26. Interview with Registered Nurse (RN) #100 on 02/24/26 at 10:36 A.M. verified from 0215/26 through 02/18/26 42 residents had call lights that remained activated and unanswered for 30 minutes or longer prior to staff response. Review of the facility policy titled, Call Lights: Accessibility and Timely Response, dated 12/01/25, revealed call lights will directly relay to a staff member or centralized location to ensure appropriate response. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. This deficiency represents non-compliance investigated under Complaint Number 2743940.

Based on medical record review, staff interview, and policy review, the facility failed to ensure adequate and timely wound assessments were completed, physician notifications were made promptly, and treatments were completed as ordered for newly discovered pressure ulcers. This resulted in actual harm when a resident (#514) was discovered to have an open wound to the skin on [DATE] with no notification to the physician made or adequate assessment of the area completed. The resident continued with no treatment orders or notification of the wound to the physician until [DATE] when the wound was assessed to be larger in size, and on [DATE], was determined to be a stage IV pressure ulcer. Subsequently, following implementation of wound treatment orders, the facility failed to complete Resident #514's wound treatments timely which inhibited the resident's wound healing progression. Additionally, the facility failed to ensure wounds were timely assessed and treatments were provided as ordered for an additional resident (#573) which did not result in actual harm. This affected two (#514 and #573) of three residents reviewed for pressure ulcers. The facility census was 70. Findings include:1. Review of Resident #514's medical record revealed an admission date of [DATE]. Diagnoses included contracture of the right hip and knee, diabetes mellitus type one, and peripheral vascular disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #514 was identified with moderate cognitive impairment and assessed to require total assistance for all mobility including rolling left and right. Review of a care plan initiated on [DATE], and revised [DATE], for Resident #514 revealed, due to a self-care performance deficit, the resident was dependent on staff for bed mobility. Due to peripheral vascular disease and diabetes, the resident was to change positions frequently.Review of Resident #514's Braden scale (standardized assessment tool to determine pressure ulcer development risk) dated [DATE] revealed the resident was at a high risk for skin breakdown.Review of Resident #514's nursing progress note dated [DATE] revealed a small open area was noted on the resident's right buttock which measured approximately 0.5 centimeter (cm) in size. The resident needed to be turned on his left side more frequently to prevent the area from getting larger. Review of Resident #514's medical record revealed there was no further documentation regarding the right buttock wound dated [DATE] until [DATE].Review of Resident #514's wound care note dated [DATE] revealed there was a new skin issue at the rear right trochanter (hip) which was in-house acquired. The wound was painful and measured 3.0 cm long by (x) 5.0 cm wide. Orders were to cleanse the wound with normal saline and apply a hydrocolloid dressing daily. Staff were to encourage the resident to turn and reposition every two hours and the certified nurse practitioner was notified.Review of Resident #514's medical record revealed a physician's order dated [DATE] to cleanse the right hip stage IV pressure wound (full-thickness skin and tissue loss) with house wound cleanser, apply silver alginate to the wound bed cover with border gauze dressing and change the dressing daily and as needed if the dressing becomes saturated, loose, or soiled for skin issues (pressure ulcer).Review of Resident #514's [DATE] treatment administration record (TAR) revealed the ordered dressing was not changed on [DATE] and [DATE]. The resident was hospitalized from [DATE] through [DATE].Review of a wound evaluation and management summary dated [DATE] revealed Resident #514's wound was noted as a stage IV pressure area to the right hip measuring 4.0 cm long x 2.0 cm wide x 0.2 cm deep with 80 percent (%) slough (non-viable tissue). On [DATE] the wound measured 4.0 cm long x 2.0 cm wide x 0.3 cm deep with 80% slough, and on [DATE] the wound measurements remained the same with 40% slough. The wound remained a stage IV pressure ulcer. Review of Resident #514's medical record revealed a physician's order dated [DATE] to cleanse the right hip stage IV pressure wound with house wound cleanser, apply Santyl to the wound bed then silver alginate wound dressing, cover with border gauze dressing, and change the dressing daily and as needed if the dressing becomes saturated, loose, or soiled for skin issues (pressure ulcer).Review of Resident #514's [DATE] TAR revealed the physician ordered dressing change were not completed on [DATE], [DATE], [DATE], and [DATE].Review of the wound evaluation and management summary dated [DATE] revealed Resident #514's right hip wound measured 4.5 cm long x 2.5 cm wide x 0.3 cm deep. There was 40% slough present, and the wound remained a stage IV pressure ulcer. Further review of the document revealed the wound progress was exacerbated due to generalized decline of the patient and the dressing needed to be changed timely.Review of Resident #514's [DATE] TAR revealed ordered wound treatments were not completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the wound evaluation and management summary dated [DATE] revealed Resident #514's right hip wound measured 3.5 cm long x 2.0 cm wide x 0.3 cm deep, on [DATE] the wound measured 4.0 cm long x 2.0 cm wide x 0.3 cm deep, and on [DATE] the wound measured 5.0 cm long x 3.5 cm wide x 0.3 cm deep and remained as a stage IV pressure ulcer. Review of the wound evaluation and management summary dated [DATE] revealed Resident #514's right hip pressure ulcer measured 4.5 cm long x 2.5 cm wide x 0.3 cm deep and debridement was completed. At the time of the investigation on [DATE], Resident #514 was unavailable for observation and interview.Interview with the Director of Nursing (DON) on [DATE] at 12:40 P.M. verified there was no documentation on Resident #514's October and [DATE] TARs to provided evidence of wound treatments being completed to the right hip pressure ulcer on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The DON further confirmed there was no wound care treatment orders nor physician notification of the right hip wound when identified on [DATE] until [DATE] at which time the wound was assessed to be a stage IV pressure ulcer.2. Review of Resident #573's medical record revealed an admission date of [DATE]. Diagnoses included left breast cancer, pneumonia, and congestive heart failure. The resident expired in the facility on [DATE].Review of Resident #573's Minimum Data Set (MDS) assessment note dated [DATE] revealed she required total care for all activities of daily living.Review of Resident #573's care plan [DATE] revealed the resident had potential/actual impairment to skin integrity of the left breast malignant neoplasm and fragile skin. Interventions included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations. Review of Resident #573's clinical admission assessment dated [DATE] revealed the resident had no skin issues documented. Review of Resident #573's medical record revealed a physician's order dated [DATE] to cleanse the left breast stage III pressure ulcer (full-thickness skin loss) with wound cleanser, pat dry, and apply border gauze. The facility staff was to change the dressing every day shift every other day for optimal healing and as needed.Review of Resident #573's [DATE] TAR dated revealed the physician ordered wound care was not completed on [DATE] and [DATE]. Review of Resident #573's Braden scale dated [DATE] revealed she was at high risk for skin breakdown.Review of Resident #573's progress notes dated [DATE] through [DATE] revealed no documentation regarding the resident's stage III pressure ulcer to the left breast including any assessment or description of the wound. Further review of the resident's medical record revealed no documented assessment of the resident's pressure ulcer to the left breast to include measurements, description, or stage. Interview with the DON on [DATE] at 12:40 P.M. verified there was no documentation on Resident #573's [DATE] TAR to provide evidence of wound treatments being completed to the left breast pressure ulcer right hip pressure ulcer on [DATE] and [DATE]. The DON further confirmed there were no assessments of the resident's left breast pressure ulcer nor measurements completed in the medical record.Review of the facility policy titled, Wound Treatment Management, dated [DATE], revealed in the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.This deficiency represents non-compliance investigated under Complaint Number 1305375 (OH00166629).

Based on observation, staff interview, medical record review, hospital record review, and review of facility policy, the facility failed to ensure hazardous chemicals were properly stored in a secured area and outside the reach of residents. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 09/02/25 when Resident #77 applied a mixture of cleaning chemicals to the top of both feet resulting in second degree chemical burns, followed by a repeat incident 30 days later on 10/01/25 when Resident #77 applied an assortment of chemicals to his peri-area and a verbal order was obtained on 10/02/25 to send Resident #77 out to the hospital for evaluation due to altered mental status. On 10/02/25 at 1:18 P.M., Resident #77 was admitted to the Intensive Care Unit (ICU) at 8:03 P.M. with a concern for sepsis (a body's extreme reaction to an infection). Resident #77 had a body temperature of 93.3, and a white creamy discharge from the gastrostomy tube site. Intravenous fluids were administered and medications to support blood pressure were started as the sepsis work up continued. This affected one (#77) of three residents reviewed for accident hazards. The facility census was 70. On 10/08/25 at 4:42 P.M., the Administrator, interim Director of Nursing (DON), Director of Reimbursement (#616), and Corporate Director of Clinical (#617) were notified the Immediate Jeopardy began on 09/02/25 at 4:30 P.M. when Resident #77 was sent out to the hospital, transferred to a burn unit, admitted , and treated for partial thickness (second degree) chemical burns to both feet after Certified Nursing Assistant (CNA) #521 responded to Resident #77's call light, removed Resident #77's wet socks when the resident complained of his feet hurting and found the top of Resident #77's feet bright red, inflamed, and blistered. CNA #521 and Licensed Practical Nurse (LPN) #578 searched Resident #77's room and found a spray bottle labeled Odor Control in Resident #77's bathroom. The warning label on the bottle stated if on skin, wash with plenty of water, if skin irritation or rash occurs get medical attention immediately, and keep out of reach of children. Resident #77 returned to the facility on [DATE]. The Immediate Jeopardy continued on 10/01/25 when CNA #521 found Resident #77 walking out of his bathroom with what smelled like hand sanitizer in the palm of one hand while holding a wet blue liquid-soaked brief to his genitals with the other hand. CNA #521 alerted LPN #506. LPN #506 assessed Resident #77 and found the resident to have bright red skin to his entire peri area. Resident #77 voiced complaints of a sore penis. Upon searching the resident's room, LPN #506 found blue colored mouthwash, hand sanitizer, and liquid hand soap. The Immediate Jeopardy was removed on 10/09/25 at 4:07 P.M., the deficiency remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was continuing to implement corrective action and ensure ongoing compliance. On 10/08/25, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held. On 10/08/25, the facility was searched by Staff Development Coordinator (SDC) #555, Director of Facilities #552, and the Administrator for unsecured hazardous chemicals. Unsecured hazardous chemicals found were collected and secured and included the following: multiple packages of germicidal wipes and skin creams were collected from various common areas, nurse's station counter tops, and resident rooms. Spray bottles of bleach solution and odor control were removed from public bathrooms. Odor control and multi surface peroxide were removed from each of the four nurses' stations, several resident rooms and from the counter tops in the activity room and common sitting areas. Spray bottles of odor control, multi surface peroxide, floor cleaner, and bleach solution located on the top of the three housekeeping carts were relocated into a locking compartment on each of the housekeeping carts. On 10/08/25, SDC #555 conducted a facility wide audit to ensure all hazardous chemicals were properly stored, supply room doors and cabinets were locked, housekeeping carts were locked, and all hazardous chemicals were secured within the housekeeping cart if not in use. On 10/08/25, the DON/designee completed skin assessments on all residents. On 10/08/25, Director of Facilities #552/designee completed door audits to ensure all hazardous material storage rooms had properly functioning doors and that the doors locked securely. On 10/08/25, the DON/designee started education with all staff on policies related to chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured. On 10/09/25, any staff not yet educated will be educated by the DON/designee at the start of their first scheduled shift. On 10/09/25, new hires will be educated by the DON/designee or SDC #555 during new hire orientation on chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured. On 10/09/25, random audits with staff by the DON/designee were conducted to ensure the understanding of where to find pertinent policies to ensure the safe storage of harmful chemicals. Employees unable to speak to the policies and the safe storage of hazardous chemicals will be reeducated. Audits will continue daily for one month, then three times a week until specific interventions identified, and policies and procedures are operationalized to prevent the same actions or practices from occurring in the future. Starting on 10/09/25, any concerns or questions regarding hazardous chemicals will be addressed immediately by the DON/designee. On 10/13/25, the Administrator verified the education on policies related to chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured had been completed by all staff. Audits will be conducted by the DON/designee of the facility to ensure all hazardous chemicals are properly stored, supply room doors and cabinets are locked, housekeeping carts are locked when not in use. Audits will occur daily for one month and then three times a week until deemed compliant. Audits will be conducted by Director of Facilities #552/designee on doors where hazardous materials are kept daily for one month and then three times a week until deemed compliant. Any door found to be unsecured or in need of repair, will be secured or repaired immediately. Any door found unsecured and in the need of repair will have the work order entered in the electronic work order system by Director of Facilities #552/designee. The work orders will be used for tracking and reporting. Audits will be provided to the Administrator daily. Audits will be reviewed monthly in Quality Assurance (QA) and monitored in the QAPI meeting, until deemed compliant. On 10/14/25, at various times throughout the day, interviews with staff including LPN #506, LPN #522, LPN #561, LPN #578, Housekeeping Aide #512, CNA #52, CNA #556, Registered Nurse (RN) #573, Director of Facilities #552, and Housekeeping Aide #575 revealed education on hazardous chemicals, storage, and interventions were conducted and staff were knowledgeable on the subjects. Various observations throughout the facility on 10/14/25, 10/15/25, and 10/16/25 revealed no hazardous materials were found to be unsecured, and all chemical storage rooms and housekeeping carts were locked and functioning properly.Review of the medical record for Resident #77 revealed an admission date of 08/08/22. Diagnoses included unspecified protein-calorie malnutrition, anxiety, sarcopenia, paranoia, and epilepsy. A diagnosis of schizophrenia with disorganized thoughts was added in April 2025. Resident #77 was identified to have a history of acquiring items from the facility including cleaning chemicals. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, but was noted to have poor decision-making skills. Resident #77 required supervision for mobility, set up assistance for eating, and partial to moderate assistance for showering or bathing. Review of Resident #77's care plan updated 07/27/25 revealed the resident was unable to care for himself independently and required 24-hour supervision, used psychoactive medications with the potential for complications, refused care from staff, and a new behavior of potentially causing harm to self or others. On 03/09/25 a nurse's note entered at 3:30 P.M. revealed LPN #506 removed wound cleanser and a pair of scissors from Resident #77's room due to Resident #77 pouring the wound cleanser onto his gastrostomy (feeding) tube site. Resident #77 claimed to be cleaning the wound hole. LPN #506 informed Resident #77 that he should not have wound cleanser in his possession. Review of the progress notes revealed Resident #77 was sent out to the hospital on [DATE] at 4:30 P.M. for evaluation due to what appeared to be chemical burns on both feet. Resident #77's feet were purple/red, swollen with drainage present. CNA #521 found a spray bottle from a housekeeping cart in the resident's room. The liquid in the bottle was purple. Resident #77 denied spraying the contents of bottle on his feet. Review of the emergency department medical record dated 09/02/25, revealed after evaluating Resident #77, the resident was transferred to a burn center. Review of the burn center medical record revealed Resident #77 arrived at the center on 09/03/25 at 12:55 A.M., was diagnosed with partial thickness (second degree) burns to both feet and was admitted to the burn unit. Resident #77 was discharged from the burn unit on 09/04/25, with an order written to cleanse bilateral foot wounds with Hibiclens (wound cleaner used to cleanse and disinfect skin) and apply triple antibiotic ointment four times a day. Review of the progress notes revealed Resident #77 returned to the facility on [DATE] at 2:40 P.M. Review of Resident #77's care plan updated 09/05/25 revealed Resident #77 was compulsive, hoarded food, takes items off of nurse's carts, takes unsafe items (scissors and bottled items) from various areas around the facility and keeps them in his room, makes poor choices and has self-inflicted injuries, covers toilet with garbage bags, and stuffs clothing with items and covers them with blankets on his bed. Intervention was for staff to redirect the resident. On 09/25/25 a physician's note entered by Physician #604 at 6:42 P.M. revealed that according to staff, the resident had been exhibiting paranoid behaviors, such as covering vents in his room and taking various items from around the facility. Staff reported soaps, creams, shaving razors, and other items, including potentially harmful cleaning chemicals, had been removed from Resident #77's room. Review of a progress note written by LPN #506 on 09/30/25 at 7:58 P.M revealed Resident #77 complained of his feet hurting. Upon assessment, LPN #506 found both feet to be red. While in the room, LPN #506 noticed various facility cleaning chemicals and supplies, which were removed from the room. On 10/01/25 a nurse's note entered by RN #555 at 3:21 P.M. revealed Resident #77 had mouthwash, an ear bulb syringe, multiple dressings, and tape in his room which were removed after CNA #521 found Resident #77 walking out of his bathroom with what smelled to be hand sanitizer in the palm of one hand while holding a wet blue liquid soaked brief to his genitals with the other hand. CNA #521 alerted LPN #506. LPN #506 assessed Resident #77 and found the resident to have bright red skin to his entire peri area. Resident #77 voiced complaints of a sore penis. Review of the Statement of Expert Evaluation dated 10/02/25, completed by Psychologist #611 at 9:40 A.M. revealed Resident #77 was noted to be disheveled, disorganized, delusional, with indications of auditory hallucinations, as well as poor insight and judgement, had significantly disorganized speech and thought, and rambled in a scattered manner with inability to stay focused and on topic. Resident #77 was evidenced to have multiple impairments in his mental status consistent with serious mental illness as evidenced by odd mentation, apt to say unusual things, paranoia, and a flattened affect with lack of insight. Resident #77 had no history of mental health problems and conveyed the sentiment that nothing is wrong with him. Upon interview, Resident #77 minimized his application of chemicals to his body and potential hazards the chemicals posed. Resident #77 could not engage in a rational discussion about his medical needs or finances. Review of a progress note dated 10/02/25 at 11:49 A.M. by LPN #560 revealed a verbal order was obtained to send Resident #77 out to the hospital for evaluation due to an altered mental status. Review of emergency department record dated 10/02/25 at 1:18 P.M. revealed Resident #77 was admitted to the Intensive Care Unit (ICU) at 8:03 P.M. with a concern for sepsis (a body's extreme reaction to an infection). Resident #77 had a body temperature of 93.3, and a white creamy discharge from the gastrostomy tube site. Intravenous fluids were administered and medications to support blood pressure were started as the sepsis work up continued. Interview on 10/06/25 at 1:03 P.M. with Hospital Social Worker (HSW) #612 revealed she was informed by the nurses that Resident #77's peri area was bright red and blistered with the top layer of skin missing in almost a perfect outline of where a brief would be. HSW #612 indicated that it looked like the resident was cleaned with bleach or a Lysol brand wipe. Interview on 10/06/25 at 2:16 P.M. with LPN #578 revealed that on 09/02/25 at approximately 1:00 P.M. CNA #521 summoned her to Resident #77's room because CNA #521 had discovered Resident #77's feet were bright red and blistered. After assessing Resident #77 and notifying the provider, Resident #77 was sent out to the hospital for evaluation. LPN #578 stated she and CNA #521 inspected Resident #77's room and found what appeared to be a spray bottle labeled Odor Control. LPN #578 stated however, the spray bottle appeared to have two different chemicals mixed in it as the chemicals appeared to have separated and a blue colored chemical was clumped in the bottom of the spray bottle. LPN #578 also stated that on the prior day, 09/01/25, other cleaning chemicals were found in Resident #77's room and were removed. LPN #578 was unsure exactly what the chemicals were that were removed from Resident #77's room. Interview on 10/07/25 at 2:50 P.M. with Facility Director (FD) #552 revealed the facility still had the spray bottle found in Resident #77's room on 09/02/25. FD #552 showed the spray bottle labeled Odor Control and upon observation the bottle appeared to be two mixed chemicals, one predominantly clear liquid and the other a bright blue liquid that was clumped. The two chemicals were separated within the bottle, and when the bottle was shaken the liquids did not mix well. The bottle had a strong chemical smell. Interview on 10/08/25 at 8:37 A.M. with LPN #506 revealed that on 10/01/25 at approximately 2:00 P.M. she was summoned to Resident #77's room by CNA #521 to assess the resident. Upon arrival a strong smell of mouthwash was noted throughout the room. LPN #506 asked Resident #77 if she could assess his peri area, Resident #77 refused but LPN #506 noticed the resident's skin where a brief would be to be bright red. LPN #506 inspected the resident's room and found a large bottle of [NAME] brand antiseptic mouthwash comparable to brand name Listerine, hand sanitizer, and a large container of antimicrobial hand soap that would be used in a wall mounted hand soap dispenser commonly found in the restrooms throughout the facility. LPN #506 stated when she attempted to remove all the chemicals from Resident #77's room, the resident became angry and told both her and CNA #521 to get out of his room. Interview on 10/08/25 at 8:50 A.M. with CNA #521 revealed she was the aide assigned to Resident #77 on both 09/02/25 and 10/01/25. CNA #521 stated that on 09/02/25 sometime around 2:00 P.M. she responded to Resident #77's call light and upon entering the resident's room, Resident #77 complained that his feet were hurting and when she looked down, she noticed Resident #77's socks were soaking wet. Upon removing the socks, the top of both of Resident #77's feet were bright red, inflamed, and blistered looking. CNA #521 said she called for LPN #578 to assess Resident #77 after which the resident went to the hospital. Continued interview with CNA #521 revealed that on 10/01/25 between noon and 2:00 P.M. Resident #77's call light went off so she went to see what Resident #77 needed. CNA #521 stated when she opened the door to Resident #77's room to enter, a strong smell of mouthwash filled the room. Resident #77 was noted to be walking out of his bathroom with what appeared to be hand sanitizer in the palm of one hand, and with the other hand he was holding a wet blue colored liquid soaked brief up to his genitals. CNA #521 had Resident #77 sit on the bed and requested LPN #506 come to the room. Interview on 10/15/25 at 10:50 A.M. with Medical Director (MD) #604 revealed the physician was new to the facility when Resident #77 returned from the hospital on [DATE]. MD #604 verified he did see Resident #77 on 09/05/25 and stated Resident #77 had disorganized thought processes, delusions, and paranoia. MD #604 said he educated Resident #77 about the adverse effects of putting cleaning chemicals on his body. Without knowing the resident, MD #604 said he was not sure if the facility was the appropriate setting for Resident #77 at the time, but after the incident in October he recommended Resident #77 have a psychiatric evaluation completed. Interview on 10/15/25 at 1:55 P.M. with Psychiatric Nurse Practitioner #602 revealed that he had seen Resident #77 through June 2025 and again just recently on 10/08/25. NP #602 indicated that Resident #77 had schizophrenia with disorganized thoughts and paranoia. NP #602 was unaware of the recent events surrounding Resident #77's hospitalizations but added Resident #77 was noted to be having an increase in behaviors back in March and April of 2025. Observation on 10/6/25 at 2:07 P.M revealed germicidal wipes called Micro-Kill were sitting in the common area near the sitting area unattended. LPN #545 verified the germicidal wipes at the time of the observation and stated normally the wipes are more secure and not sitting out in the open. LPN #545 was not sure why they were there and proceeded to remove them from the common area and secured them in a locked storage closet behind the nurse's station. Observation on 10/06/25 at 3:14 P.M. revealed the clean linen room door across the hall from Suite 6 was wide open. A sign outside the door said please keep door closed at all times. Inside the clean linen room was a three-drawer plastic container with one of the drawers containing one six-ounce mouthwash and three four-ounce skin creams. CNA #556 verified the findings at the time of the observation and then closed the door and verified the door was locked prior to walking away. Observation on 10/07/25 at 7:43 A.M. revealed the soiled linen room across from room [ROOM NUMBER] was unlocked and in the room was a 32-ounce bottle of Micro-Kill germicidal bleach solution approximately 75 percent full. CNA #558 verified the unlocked soiled linen room door and the germicidal bleach solution in the room. CNA #558 stated the door should be locked. Further investigation revealed the lock on the door was not functioning. FD #552 verified the lock on the door was broken. FD #552 denied knowledge of the broken lock. Observation on 10/07/25 at 8:03 A.M. revealed the housekeeping supply and soiled utility room across from room [ROOM NUMBER] was unlocked. On the outside of the door was a sign that stated please keep door locked at all times. Inside the room was a wall mounted filling station for the cleaning chemicals used in the facility. The chemicals were noted to be the following: Odor Control, Neutral Floor Cleaner, Micro-Kill, and Multi-Surface Peroxide. All the cleaning chemicals were noted to have warning labels to keep out of reach of children, avoid contact with skin, and if contact with skin and irritation is noted, seek medical attention. The unlocked door and the chemicals were verified by FD #552 and Housekeeper #575. FD #552 discovered at the time of the observation that the door could not be locked as the lock was not functioning properly. Review of the facility policy titled Environmental Services Safety Procedures, dated 10/07/25 revealed staff will ensure equipment (e.g., cords, ladders, or chemicals) is properly stored and not left unattended in areas that are accessible to residents. When not in use, equipment will be stored in a locked closet, cabinet, or storage area for safety. This violation represents non-compliance investigated under Master Complaint Number 2630848 and Complaint Numbers 2617726, 2617497, 2609625, 2572811, 1305377, 1305376, and 1305372.

Based on medical record review, staff interview, and review of facility policy, the facility failed to follow their policy to for skin assessments, failed to assess the presence of a new pressure ulcer, failed to provide pressure relief interventions as ordered, and failed to ensure the resident was kept dry without a saturated dressing. Actual harm occurred when Resident #1 was discovered with irritant dermatitis to the left buttock with no initial treatment ordered and no additional pressure relieving interventions were implemented. On 10/16/23 the resident was discovered with a stage 3 pressure ulcer to the coccyx identified to be of five days duration. Ordered pressure reduction was not implemented as ordered following the identification of the pressure ulcer and the resident was discovered in bed with a saturated brief and dressing to the pressure ulcer. This affected one (#1) of three sampled residents reviewed for skin breakdown prevention management. The facility identified five current residents with pressure ulcers. Facility was census 76. Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included gastrostomy, sacral pressure ulcer stage 3, anxiety disorder, osteoarthritis, lymphedema, dementia, hypertension, venous insufficiency, dysphagia, acute cystitis, and sepsis. The resident readmitted to the facility from the hospital on 10/03/23. Review of the 10/03/23 nursing admission assessment revealed Resident #1 was assessed with severe cognitive impairment, lethargic, dependent on staff for activities of daily living, including transfer and positioning requiring two persons, had a pressure area to the right heel and scar to sacrum, and was incontinent of bladder. Review of the skin breakdown risk assessment dated [DATE] revealed Resident #1 was assessed at a very high risk for the development of skin breakdown. Review of the significant change Minimum Data Set assessment, dated 10/07/23, revealed Resident #1 had severe cognitive impairment, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, was at risk for pressure ulcer development and admitted with a stage 2 pressure ulcer. Review of the nursing plan of care, revised on 07/13/23, revealed Resident #1 was at risk for skin breakdown. Interventions included encourage and assist with repositioning routinely and as needed, follow facility policies and procedures for prevention and treatment of skin breakdown, pressure relieving mattress to bed, inform resident/family/caregiver of any new area of skin breakdown, monitor document and report to physician changes in skin status such as appearance, color, wound healing, signs and symptoms of infection, wound size and stage. Review of wound specialist documentation noted the resident was evaluated on 10/09/23 and discovered irritant dermatitis to the left buttock as a result of body fluid. No further skin breakdown was assessed and no new intervention to promote skin integrity were implemented. No treatment was ordered at the time of this observation. Review of physician orders revealed on 10/11/23 a physician order was initiated to apply zinc oxide based barrier cream every shift and as needed. The treatment was added to the plan of care. Review of the wound specialist note dated 10/16/23 revealed Resident #1 had a stage 3 pressure wound to the coccyx identified as full thickness with a duration of greater than five days. The pressure ulcer measured 6.0 centimeters (cm) long by 4.0 cm wide by 0.2 cm deep with moderate serous exudate. Recommendations included limit sitting to 60 minutes, off-load wound, reposition per facility protocol, and a low air loss mattress. No documentation was contained in the medical record identifying Resident #1 was assessed with skin breakdown to the coccyx until the 10/16/23 documentation which identified the area as a stage 3 pressure wound. Review of the progress notes dated 10/18/23 by Certified Nurse Practitioner (CNP) #1 documented Resident #1 was found resting in bed, appears uncomfortable, and moaning. Unit Manager present for visit. The resident was not able to speak and was inconsistently following some very simple commands. The low air loss (LAL) mattress was still in delivery packaging and not on the bed as ordered. Resident #1 was found in a brief soaked in urine with the dressing to the coccyx soiled. Review of the transfer form documentation on 10/21/23 at 10:00 P.M. revealed Resident #1 was discharged to the hospital due to fever. Review of the facility policy titled Pressure Injury Prevention Guidelines, revised 01/10/2023, interventions will be implemented in accordance with physician orders, including type of prevention devices to be used and for tasks the frequency performing them. Interventions will be documented in the care plan and communicated to all relevant staff. Preventative skin care includes inspecting skin while providing care, paying close attention to bony prominence's. Avoid positioning the resident on an area of redness whenever possible. Keep skin clean and dry. Manage incontinence with absorptive products. Check every two hours and provide perineal care as needed after incontinent episodes. Diaper usage when in bed is not recommended. Consider use of prophylactic dressings for prevention of sacral and heel pressure injuries. Routine repositioning schedule: every two hours, using both side lying and back positions. Provide alternative support surfaces as needed. Considerations for utilizing specialized support surfaces include medical condition and weight, stage 3, 4, unstageable, or deep tissue injury on trunk. Review of the facility policy titled Skin Assessment, implemented 09/14/22, revealed a full body, or head to toe assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three days, and weekly thereafter. Document skin assessment to include date and time, observations, type of wound, and wound description. Interview on 11/01/23 at 1:45 P.M. with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator confirmed a skin assessment was completed on admission of 10/03/23. However, no additional skin assessments were completed between 10/04/23 and 10/16/23. The DON confirmed nursing staff are to inspect resident skin integrity with each shower/bath twice weekly, during incontinence care, three days following admission and then weekly. No documentation included skin assessment or physical interventions to promote further skin breakdown from 10/09/23, when skin integrity was observed to be compromised with irritant dermatitis, until 10/16/23 when the wound specialist completed an assessment of the stage 3 pressure ulcer to the coccyx and a treatment was implemented. The ADON stated the air mattress recommended on 10/16/23 was not placed to the bed until 10/18/23 at approximately 2:00 P.M. The DON also verified Resident #1 required frequent incontinence checks and changes. No documentation was provided indicating the facility assessed and established specific toileting habits for Resident #1 and on 10/18/23 the resident was discovered by the Certified Nurse Practitioner #1 soaked in urine, including the coccyx dressing. This deficiency represents non-compliance investigated under Complaint Number OH00147704.

Based on medical record review, staff interview, and review of facility Pressure Ulcers/Skin Breakdown clinical protocol , the facility failed to ensure interventions for pressure reduction were consistently implemented and failed to timely obtain a treatment once skin breakdown occurred. This resulted in actual harm when a resident developed avoidable pressure injury/deep tissue injuries to the left heel, left medial foot, coccyx, and left buttock. This affected for one (#1) of three residents reviewed for skin breakdown. The facility census was 80. Findings include: Review of the closed medical record for Resident #1 revealed an admission date of [DATE], with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], the resident was identified as alert, oriented with mild cognitive impairment, requiring one staff assistance with activities of daily living, and incontinent of bowel and bladder. The MDS also recorded the resident at risk for skin breakdown with no current skin breakdown identified and pressure reducing device to bed and chair. The residents weight was noted at 110 pounds with no identified weight loss. According to the assessment the resident was administered an antibiotic medication for three days during the assessment period. Review of a skin risk assessment dated [DATE] recorded the resident was at risk for skin breakdown. Review of the plan of care, dated 11/03/20, revealed the plan was developed to address the resident risk for impaired skin integrity. Interventions included: evaluate skin for areas of blanching or redness, evaluate skin for redness or excoriation, evaluate skin integrity, perform objective pressure ulcer risk tool such as Braden / Norton scale and position resident to reduce causes of friction or shear. A care plan, dated 11/04/20, was implemented due to the residents risk for skin breakdown due to impaired mobility. Interventions included: encourage and assist with repositioning routinely and as needed, pressure relief cushion to chair, low air loss mattress to bed, monitor/document/report skin changes to physician, off-loading boots to bilateral heels while in bed. Review of a skin observation sheet, dated 11/28/20, identified a blister to the coccyx. However, no wound assessment, wound treatment or intervention was documented in the record. Review of the skin observation tool initiated on 12/01/20, revealed an area of skin breakdown to the left heel was identified as pressure and a skin tear to the coccyx. The tool noted a wound consult would be completed. No measurements or wound description were documented in the record. Review of an additional physician order, dated 12/03/20, revealed an order to apply off-loading boots while in bed. Review of December 2020 treatment administration records noted the boots were applied on 12/03/20 in the evening. Review of the skin observation tool, dated 12/05/20, revealed an area identified as pressure was discovered to the left great toe. Again the tool noted a wound consult would be completed. No measurements or wound description were documented in the record. Review of the wound specialist documentation, dated 12/07/20, recorded the wounds as follows: left heel pressure length 4.0 centimeters (cm) by 5.0 cm wide by 0 depth staged as suspected deep tissue injury with scant drainage; coccyx pressure 0.5 cm by 0.5 cm by 0.1 cm stage II with scant drainage; left medial foot pressure 1.0 cm by 1.0 cm by 0 cm staged as suspected deep tissue injury and left buttock pressure 1.4 cm x 1.4 cm x 0.1 cm stage II with scant drainage. Interventions included wound treatments and to be followed by wound nurse practitioner. Review of a physician order, dated 12/07/20, noted for treatments to the wounds to include, left medical foot wound cleanse with normal saline cover with bordered gauze change 3 times weekly and as needed, left heel wound cleanse with normal saline apply foam dressing change 3 times weekly and as needed, and apply house barrier cream to the buttocks every shift and as needed. Review of the medical record lacked documentation indicating the application of the bilateral offloading boots was implemented until recorded on treatment administration records (TAR) dated the evening of 12/03/20. No documentation contained in the medical record noted the resident to have a low air loss mattress applied to the bed during admission to the facility. On 12/08/20, the resident was discharged to a different long term care facility. Review of the facility protocol Pressure Ulcers/Skin Breakdown clinical protocol revised April 2018, revealed nursing staff and the practitioner will assess and document an individuals significant risk factors for developing pressure ulcers; for example immobility, recent weight loss, and history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following; a full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; residents mobility status; current treatments, including support surfaces; all active diagnoses. Interview on 01/11/21 at 1:25 P.M., with the Director of Nursing (DON), during a review of the medical record, verified no documentation indicated the discovery of skin breakdown and implementation of treatments to the wounds until evaluated by the wound specialist. The DON also confirmed no documentation indicated the low air loss mattress or pressure relief boots were in place prior to the wounds being discovered. This deficiency substantiates Complaint Number OH 322.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, staff interview, review of a police report, review of an employee personnel file, review of the facility's Emergency Procedure for Missing Residents policy, review of the witness statements, review of Weather Underground computerized environmental temperatures website, review of employee time cards, and review of an undated form used during an in-service regarding responding to door alarms, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at high risk for elopement from the facility and with a history of attempting to leave the facility, did not elope from the facility. This resulted in Immediate Jeopardy and placed the resident at potential risk for serious life-threatening harm and/or injuries when Resident #24 left the facility without staff knowledge and was found by police officers sitting on a bench outside a pizza shop appearing confused, wearing one shoe, and having crossed a five-lane road in order to arrive at the pizza shop. This affected one (#24) of three residents (#24, #28, #29) reviewed for being at risk for elopement. The facility identified one (#29) current resident who was assessed as being at risk for elopement. The census was 94. On 02/18/20 at 3:57 P.M., the Administrator was notified Immediate Jeopardy began on 12/28/19 at approximately 6:55 P.M., when Resident #24 left the facility through the alarmed front lobby doors without staff supervision and was subsequently discovered approximately 25 minutes later by police officers at a pizza shop appearing confused and wearing one shoe. The facility was unaware Resident #24 was missing until police officers returned him to the facility between 7:30 P.M. and 7:45 P.M. At approximately 6:55 P.M. Resident #24 walked out of the front doors of the facility with a female visitor, which caused the front lobby door alarm to activate, alerting staff a resident may have exited the building. At 6:59 P.M. State tested Nurse Aide (STNA) #665 responded to the door alarm and performed a visual scan of the immediate area, never went outside to look for the source of the alarm being activated, subsequently silenced the door alarm, and returned to work without notifying other staff members of the door alarm activating; therefore, not following the facility procedure for responding to an activated door alarm. The Immediate Jeopardy was removed on 12/29/19 at 4:00 P.M. when the facility placed Resident #24 on direct one-to-one continuous staff observation, performed an audit on all residents with alarming devices to ensure placement and function, and completed staff education about responding to door alarms. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 01/17/20 when the facility implemented the following corrective actions: · On 12/28/19 at 7:45 P.M., Resident #24 was provided direct one-to-one continuous staff observation, which continued through 01/01/20 when Resident #24 was discharged . On 12/28/19 at 8:00 P.M., the Administrator arrived and began an investigation into the incident. · On 12/28/19 at 8:15 P.M., the Administrator completed an audit of other residents identified at risk for elopement to ensure their Wander Guards were in place and functioning. · On 12/28/19, the Administrator and Former Director of Nursing (FDON) #40 began education for all staff regarding responding to door alarms and the procedure for initiating a Code Orange for missing, exit-seeking, and wandering residents. This was completed on 12/29/19 at 4:00 P.M. · On 12/29/19, FDON #40 and the Administrator assessed all facility residents for risk of elopement and proper placement of Wander Guards. Three residents (#24, #28, and #29) were identified to be at high risk for elopement. · On 12/29/19, the medical records for the residents identified to be at high risk for elopement were audited for physician orders [REDACTED]. · On 12/29/19, STNA #665 did not return to the facility for work assignments and was terminated from employment on 01/07/20. · On 12/29/19, the facility held a Quality Assurance Performance Improvement (QAPI) Committee meeting to discuss the facility ' s plan of correction related to Resident #24 ' s elopement. The meeting was attended by the Administrator, FDON #40, Physician #271 (via telephone), and Registered Nurse (RN) Unit Manager #528. · The facility completed audits for Wander Guard placement of current facility residents on 01/08/20 and 01/17/20, with placement and functionality of the Wander Guard verified. · The facility conducted Code Orange drills on 12/31/19, 01/09/20, and on 01/17/20 with all staff members responding appropriately and each drill conducted successfully. · Interviews on 02/18/20 between 4:30 P.M. and 5:00 P.M. with STNA #700, Licensed Practical Nurse (LPN) #640, STNA #745, Director of Nursing (DON) #01, Assistant Director of Nursing (ADON) #01, LPN #679, STNA #756, and LPN #619 all verified they were in-serviced about responding to door alarms and the procedure for initiating a Code Orange for a missing, exit-seeking, or wandering resident. · The closed medical record for Resident #28 and the current medical record for Resident #29, identified as the only other residents at risk for elopement, were reviewed with appropriate assessment and plan of care in place. There were no other identified elopement events. Findings include: Review of Resident #24 ' s medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 10/31/19, revealed Resident #24 had severely impaired cognition and was assessed to require supervision only for bed mobility, transfers, walking in the room and corridor, and locomotion on and off the unit. Review of an admission elopement risk assessment dated [DATE] revealed Resident #24 was disoriented times two spheres, was forgetful with a short attention span, and had unsafe decision making. Resident #24 was determined to be not at risk for elopement. Review of a nursing progress note dated 09/23/19 at 5:39 P.M. revealed Resident #24 went out of the facility doors in the back of the building twice on second shift. The resident made it to the facility parking lot on one occasion, and facility staff were able to redirect him safely back into the facility. The on-call unit manager was made aware, an elopement assessment was completed, and facility staff attempted to place a Wander Guard to Resident #24 but the resident refused. Review of a subsequent elopement risk assessment dated [DATE] revealed Resident #24 remained disoriented times two spheres, was forgetful with a short attention span, made attempts to or opened exit doors, and hovered around exit doors. A comment was made in the assessment indicating Resident #24 went out the doors of the facility twice and was in the facility parking lot but returned to the facility with staff unharmed. Review of a physician order [REDACTED].#24 had a Wander Guard placed to his left ankle with placement and function to be checked every shift. Review of a care plan dated 09/24/19, revealed Resident #24 was at risk for wandering due to his mental status. Care plan interventions included for staff to provide distraction if Resident #24 was exit-seeking, apply a Wander Guard to Resident #24 ' s left ankle, and check placement and function every shift. Review of the Treatment Administration Records from September 2019 through December 2019 revealed Resident #24 ' s Wander Guard was in place and functioning every shift each day. Review of a nursing progress note dated 10/05/19 at 9:45 P.M., revealed a staff member was sitting at the nurses ' station charting when the staff member heard alarms going off. When the staff member looked up, Resident #24 was noted to be walking out of the facility. The staff member was able to redirect Resident #24 back into the facility safely. Review of a nursing progress note dated 11/29/19 at 7:20 P.M., revealed Resident #24 exited the lobby doors and indicated he was going home. Resident #24 was stopped by two staff members before he was able to get to the facility parking lot and was escorted back in the facility to his room. Review of a nursing progress note, dated 12/21/19, revealed Resident #24 continued to wander around the facility and staff redirection was not successful. Resident #24 tried to elope from the facility but was caught by a nurse aide before making it out the door. Review of an elopement risk assessment, dated 12/23/19, revealed Resident #24 was disoriented times three spheres, was forgetful with a short attention span, exhibited unsafe decision-making, was not easily directed, attempts to or opens exit doors, and was ambulatory. Resident #24 was assessed to be at a high risk for elopement. Review of a local township police report, dated 12/28/19 at 7:22 P.M., revealed officers were dispatched in reference to a safety check. When officers responded to the area, they encountered Resident #24 sitting on a bench outside of a pizza shop appearing confused. The officers were able to verify Resident #24 ' s name and noted Resident #24 to be out of his element, evident by missing one shoe, having what appeared to be a tracking bracelet on his left ankle, and Resident #24 did not make much sense in responding to routine questions. The officers noted the location where Resident #24 was found had several nursing facilities in the area, and eventually were able to identify Resident #24 was a resident of the facility. The officers returned Resident #24 to the facility, with staff members identifying Resident #24 as a current resident of the facility. A nurse obtained Resident #24 ' s vital signs and no injuries were observed as a result of Resident #24 ' s wandering. The police report ended on 12/28/19 at 8:30 P.M. Review of a nursing progress note dated 12/28/19, entered into the electronic medical record at 11:42 P.M., revealed a staff member was notified that Resident #24 was outside the facility. Resident #24 was assisted back to his room with vital signs obtained and a head-to-toe assessment completed with no abnormal findings. The resident ' s blood pressure was 122/75 millimeters of mercury (mm/hg), pulse was 88 beats per minute, respirations were 16 breaths per minute, and his blood oxygen levels were 95 percent. Resident #24 was placed on one-to-one direct observation at this time. Review of a nursing progress note dated 01/01/20 revealed Resident #24 was discharged from the facility to another facility in the community with a family member. During an interview on 02/18/20 at 12:07 P.M., the Administrator stated the facility had video footage of Resident #24 ' s elopement from the facility on 12/28/19; however, the facility ' s security system automatically records over the video footage every 12 days, therefore video of the incident was no longer available for viewing. The Administrator stated she viewed the video footage and determined Resident #24 eloped from the facility on 12/28/19 at 6:55 P.M. Resident #24 was observed to have exited the front lobby doors while engaged in conversation with an unidentified female visitor. The Administrator verified Resident #24 activated the front lobby door alarm as he exited the building. STNA #665 responded to the door alarm on 12/28/19 at 6:59 P.M. STNA #665 was observed on the video to perform a visual scan of the area through the interior of the doors, silence the door alarm, and returned to her assigned work area. The Administrator stated STNA #665 did not physically go outside to look for any missing resident when she responded to the door alarm. The Administrator stated STNA #665 told no other staff members about the front lobby doors alarming; therefore, no missing person search was initiated. None of the facility staff knew Resident #24 was no longer in the facility until police officers returned him to the facility on [DATE] at approximately 7:30 P.M. The Administrator stated the police officers told her Resident #24 went to a gas station and purchased a drink and a beef jerky and proceeded to a nearby bench where he ate and drank his snack. The Administrator verified STNA #665 did not follow the facility policy and procedure when responding to door alarms and initiating the facility ' s missing resident procedure. Review of STNA #665 ' s written statement, as part of the facility investigation, revealed she did not see Resident #24 leave the facility on 12/28/19, but did hear the door alarm sounding and turned it off. STNA #665 noted she heard the door alarm and went through the first set of glass doors in the front lobby and did not see anyone in the parking lot. Observation on 02/18/20 at 1:03 P.M. revealed the distance walked by Resident #24 from the facility front lobby doors to the bench at the gas station was approximately 0.20 miles. The gas station was on the corner of an intersection on the same side of the road as the facility. Observation of the pizza shop where police officers located Resident #24 revealed it was located on the other side of the road from the gas station. The section of road at this location was noted to consist of four lanes of traffic with a center turn lane and was observed to be a heavy traffic area. During an interview on 02/18/20 at 1:30 P.M., the Administrator stated Resident #24 was wearing jeans and a sweatshirt when he exited the facility on 12/28/19 at 6:55 P.M. but could not verify if he left wearing both shoes or if he was wearing a coat. The Administrator stated the front lobby doors alarm but do not lock when a resident with a Wander Guard exits through the doors. Observation on 02/18/20 at 1:41 P.M. of the front lobby doors revealed the exit consisted of two sets of automatic sliding glass doors. The interior glass door was equipped with the Wander Guard alarming mechanism and upon passing through the interior doors there was a small foyer area with the exterior glass doors which led to the facility parking lot. The exit doors were tested with a Wander Guard device and observed to open and activate the alarm upon passing the electronic barrier. Review of STNA #665 ' s personnel file with Human Resource Manager #01 revealed STNA #665 ' s hire date was 10/14/19. STNA #665 was educated during orientation about the facility ' s missing person procedure. The STNA was terminated on 01/07/20 for failure to provide information to the facility about Resident #24 ' s elopement from the facility. Review of STNA #665 ' s timecards revealed her last day worked in the facility was on 12/28/19 between 1:54 P.M. and 10:07 P.M. Review of the Weather Underground computerized environmental temperatures on 12/28/19 revealed at 6:52 P.M. the outside temperature was 38 degrees Fahrenheit, cloudy with 75% humidity, and an easterly wind at nine miles per hour. Review of a facility policy titled Emergency Procedures for Missing Resident, revised 09/16/15, revealed staff should notify the charge nurse if a resident cannot be easily located in the facility. Staff should use the pictures from the resident ' s chart to positively identify the resident. The responsible nurse (person) in charge will overhead page Code Orange to signify a resident is potentially missing. The responsible nurse (person) in charge will direct staff members to systematically search the facility, inside and out and ensure all areas of the facility are assigned to a search team. If the resident is not found within 15 minutes call 911. Review of an undated document included as part of the staff in-service about the facility ' s missing person procedure, revealed staff should respond promptly to all door alarms. If it is clear why the alarm is sounding, and everyone is safe, the door alarm may be silenced. If it is unclear why the alarm is sounding staff should check the immediate area inside and outside and do a head count of all residents. If any residents are unaccounted for staff should proceed with the Code Orange policy. During an interview on 02/18/19 at 4:56 P.M., the Administrator verified the information about staff responding to door alarms was not formally part of the written missing resident policy but was taught to all staff members when the missing person policy is covered upon hire and during in-services. This deficiency substantiates Complaint Number OH 947.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place to prevent falls for one resident (#1). This resulted in actual harm when Resident #1 did not have edge identifiers present on her bed which resulted in a fractured toe as a result of a fall. Additionally, there was no evidence fall interventions were in place at the time of a fall which resulted in Resident #1 being transported to the hospital and two staples being placed on the top of her head. This affected one (#1) resident of three residents reviewed for fall prevention management. The facility census was 99. Findings include: Review of the medical record revealed Resident #1admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 10/16/19, the resident was identified with moderately impaired cognition. The resident was dependent on staff for the completion of activities of daily living, including bed mobility. Resident #1 required two staff for transfer and utilized a wheelchair for mobility. Review of the care plan dated 10/14/18 revealed the resident was at risk for injury related to falls due to gait/balance problems. Interventions included: assist with gait, transfers with one assist as needed for safety, provide edge identifiers on the bed to help resident recognize the edge of bed (implemented 01/16/19), education on waiting for assistance, and call light within reach when in room and encourage to use it before attempting to transfer. Review of the nurses note dated 09/07/19 at 6:01 [NAME]M. documented at approximately 4:45 [NAME]M. the resident was found on the floor yelling for help. The resident had a laceration on her forehead and blood was coming from the wound. The resident was confused, scared, and agitated. The nurse summoned 911 and the resident was transported the local hospital. The physician was notified and the nurse left a voice message for the residents daughter. Review of the incident description information and the medical record revealed no documentation indicating if fall prevention interventions were in place at the time of the fall or when the resident was last observed prior to the fall. Review of hospital documentation from 09/07/19 revealed the resident sustained [REDACTED]. The resident was assessed as alert and oriented to person, place, and time. On 09/10/19 at 6:30 P.M. the resident was returned to the facility following hospitalization . Review of the fall care plan revealed on 09/11/19 the intervention was added to keep Resident #1's bed in the low position when in the resident was in bed to prevent her from rolling out and being injured. Review of the nurses notes on 10/19/19 at 1:00 [NAME]M. revealed Resident#1 was found partially laying on the floor with her feet on the bed. The resident was laying on the left side with the left arm under her body. The resident was transported to the hospital for evaluation. On 10/19/19 at 7:32 [NAME]M. the note revealed the nurse was informed of the resident's status and that the resident was returning to the facility. The hospital nurse reported the resident had received two staples placed to the top of the head. At 8:00 [NAME]M. the resident was returned to the facility. No documentation contained in the medical record indicated if fall prevention devices were in place at the time of the fall. Interview on 11/12/19 at 2:02 P.M., Licensed Practical Nurse (LPN) #202 stated on 09/07/19 Resident #1's bed was in the low position. However LPN #202 was unable to indicate if the edge identifiers were in place on the bed. LPN#202 stated checks and interventions listed on the fall plan of care are not documented unless the interventions are physician orders. Interview on 10/19/19 at 2:30 P.M., the interim Director of Nursing (DON) during verified there was no evidence the fall prevention interventions were in place at the time of Resident #1's falls on 09/07/19 and 10/19/19. Review of the facility policy titled Falls Clinical Protocol, revised (MONTH) (YEAR), noted based on assessments the staff and physician will identify pertinent interventions to try to prevent subsequent falls. This deficiency substantiates Complaint Number OH 162.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to implement pressure relief measures to prevent the development of a pressure ulcer and failed to provide ongoing assessments of pressure ulcers for one resident (#85). Actual harm occurred when the facility failed to provide pressure relieving interventions for the lower extremities of Resident #85, who was admitted with a Stage 4 pressure ulcer to the left heel, which subsequently led to the development of a deep tissue injury pressure ulcer (purple or maroon localized area or discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the resident's right heel. This affected one (#85) of three residents reviewed for pressure ulcers. The facility identified three residents currently residing in the facility who had developed in-house acquired pressure ulcers. The facility census was 93. Findings include: Review of the medical record revealed Resident #85 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the hospital community referral, dated 04/11/18, identified Resident #85 to have a Stage 4 pressure area to the left lateral foot and associated diabetic [MEDICAL CONDITION]. Review of the admission orders [REDACTED] Review of the admission assessment, dated 04/11/18, revealed the resident was admitted with a pressure ulcer to the left lateral foot measuring 5 centimeters (cm) by 4 cm. Additionally the resident was assessed with [REDACTED]. No further skin breakdown was identified on the assessment. The record contained no evidence any pressure relief was being provided to the resident's heels. Review of a skilled nurse's note on 04/12/18 documented the pressure wound to left outer foot with a yellow and dark brown wound bed and moderate clear, yellow drainage. No further skin breakdown was documented. Documentation in the nurse's notes on 04/12/18 at 1:26 P.M. revealed the nurse to schedule a follow-up appointment with the wound care specialist as per community referral form. Review of the skin breakdown assessment dated [DATE] identified the resident at low risk for pressure ulcer development. On 04/12/18 the facility implemented a pressure relieving mattress to the bed related to being at risk for skin breakdown due to decreased mobility and diabetes mellitus. There was no identification of pressure relief being provided to the resident's lower extremities. Review of the admission Minimum Data Set (MDS) assessment, completed 04/18/18, revealed the Resident #85 had intact cognitive skills and was able to make needs known. The resident was noted to require extensive assistance of two staff for bed mobility, transfer, and personal hygiene. The assessment identified the resident at risk for developing a pressure ulcer and identified the resident with a current pressure ulcer on admission and an unstageable deep tissue injury not present upon admission. Review of the plan of care dated 04/12/18 addressed Resident #85's risk for skin breakdown due to decreased mobility and diabetes mellitus. Interventions included to encourage resident with repositioning routinely and as needed and a pressure relieving mattress to the bed. Additional intervention included to monitor/document/report to the physician as needed any changes in skin status such as appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. Review of the nurse's notes on 04/16/18 at 2:53 P.M. documented Resident #85's right heel was purple and soft. The physician was notified. There were no documented measurements of the area and no intervention was documented to relieve pressure to the lower extremities. Review of the nurse's notes on 04/17/18 at 9:16 A.M. revealed the facility notified the resident's family an appointment for wound care was scheduled for 3:00 P.M. The nurse documented the resident was in the recliner with heels floated on pillows. Review of the wound care specialist notes dated 04/17/18 revealed the resident was assessed for an open wound to the left foot which was documented to measure 3.2 cm long by 2.4 cm wide by 1.3 cm deep. The left foot had a small amount of serosanguineous (blood tinge) drainage. The wound care specialist note identified a deep tissue injury to the right heel and right anterior ankle. No measurements were documented regarding the skin breakdown of the right lower extremity. New interventions ordered included avoid direct pressure to wounds at all times, reposition at least every two hours, continue the alternating air mattress, and start pressure relief boots to bilateral lower extremities continuously. Review of the (MONTH) (YEAR) treatment administration records recorded the order to float the residents heels with a start date of 04/17/18 at 3:00 P.M. The pressure relief boots were recorded as initiated on 04/18/18 at 7:00 A.M. Review of the medical record revealed the first measurements of the deep tissue injury to Resident #85' right heel were not obtained until 04/25/18. At that time the right heel wound measured 8.0 cm by 8.0 cm. and left lateral foot 3.0 cm x 2.4 cm x 1.3 cm. No further measurements or assessments of the pressure ulcers were recorded in the medical record as obtained by the facility. Review of the wound care specialist notes revealed the pressure ulcers were measured on 05/01/18 with the left lateral foot measuring 3.7 cm by 2.3 cm by 1.5 cm deep. The right heel measured 4.5 cm by 7.5 cm. Review of the wound care specialist notes revealed the pressure ulcers were measured on 05/21/18 with the left lateral foot measuring 4.8 cm by 2.3 cm by 1.2 cm deep. The right heel measured 4.5 cm by 8 cm with depth undetermined. Review of the wound care specialist notes revealed the pressure ulcers were measured on 06/04/18 with the left lateral foot measuring 3.3 cm by 1.8 cm by 0.5 cm deep and the right heel measuring 4.4 cm by 7.6 cm by undetermined depth. The medical record had no further measurements or assessments of the pressure ulcers by the facility between the wound care specialist assessments of 05/01/18, 05/21/18, and 06/04/18. Observation on 06/06/18 at 7:01 A.M. of the left lateral foot and right heel pressure ulcers were made with Licensed Practical Nurse (LPN) #202 during the treatment to both areas. The right heel was observed to be a deep tissue injury which was purple in color with no drainage or odor measuring 8.5 cm by 4.7 cm. The left lateral foot ulcer measured 3.5 cm by 2 cm by 1 cm. Interview during the treatment observation on 06/06/18 at 7:01 A.M., Resident #85 stated he was experiencing pain to the right heel. Review of the undated facility policy titled Pressure Ulcer Prevention and Treatment revealed a deept tissue injury was described as a pressure related injury to subcutaneiuos tissues under intact skin. These [MEDICAL CONDITION] may quickly develop to a Stage 3 or 4 pressure ulcer. The policy also notes to use positioning devices to raise a pressure ulcer off the support surface. wounds will be assessed when they are noted and at least every seven days until resolved. Assess the wound(s) for location, size, undermining, tunneling, exudates, necrotic tissue, and presence or absence of granulation tissue and [MEDICATION NAME], and document this assessment. Interview on 06/07/18 at 9:30 A.M., the Director of Nursing (DON) verified interventions were not consistently implemented or documented to prevent the development of the deep tissue injury to Resident #85's right heel until the discovery of the injury on 04/16/18. The DON also verified wound measurements and assessments were not obtained every seven days as indicated in the pressure ulcer prevention and treatment policy for the left heel and right heel pressure ulcers.