Every finding on record at Galion Meadows Skilled Nursing and Rehabilitation

Based on observations and interviews, the facility failed to ensure a sanitary kitchen environment, failed to ensure proper food storage and labeling, failed to ensure adequate hand hygiene during meal service, and failed to maintain clean equipment in the food preparation and service areas. This had the potential to affect all residents in the facility. The facility census was 55.Findings include: Observation and interview during the initial kitchen tour on 05/17/26 between 8:19 A.M. and 8:44 A.M. revealed multiple cleanliness concerns. A black substance was present under the sink. Vents above the stove and food preparation areas had loose dust with additional dust collected on the ceiling light fixture. Dust was hanging around the sprinkler head above the food preparation area. The vent by the refrigerator and freezer was heavily coated in dust. A fan with a large amount of dust on the back was blowing directly onto clean dishes. These findings were confirmed at the time of observation with Dietary Aide #232 and Dietary Manager #284 at 8:45 A.M. Observation and interview on 05/17/26 between 8:19 A.M. and 8:44 A.M. revealed multiple food storage and labeling concerns. In the dry storage, two bags of pasta noodles and one bag of spaghetti were open with no open dates. In the refrigerator at 33 degrees Fahrenheit (F), a pitcher of lemonade had no label, open date, or expiration date. In the large refrigerator at 34 degrees F, an open bag of beef had no open date, open chicken base had no open date, sausage patties in a metal container had no label or open date, and multiple opened blocks and bags of cheese had no open dates or labels. In the freezer at 0 degrees F, opened hash browns, sausage patties, and three bags of Eggos had no open dates or labels. These findings were confirmed at the time of observation with Dietary Aide #232 at 8:45 A.M. Observation and interview on 05/17/26 between 8:19 A.M. and 8:44 A.M. revealed equipment concerns. A pipe behind the fan in the large refrigerator had visible mold with a wet box underneath where water was dripping. The freezer fan had ice buildup with ice chunks on boxes underneath. The juice spout had a visible substance present. These findings were confirmed at the time of observation with Dietary Aide #232 at 8:45 A.M. Observation on 05/18/26 at 11:30 A.M. during lunch meal service revealed multiple hand hygiene violations. Dietary staff #280 grabbed the outside of the bun bag with gloved hands, then used the same gloves to pick up and place bread onto resident trays. The same gloved hands then touched her clothes, refrigerator handles, forehead, and dishwasher handles before continuing to handle ready-to-eat bread. Dietary staff #280 touched the floor to pick up dropped bread with gloved hands, then reached inside the puree mixer and touched the inside of the lid with the same gloves. Staff also used gloved hands to write temperatures with a pen and then push green beans on plates with those gloved hands. Multiple times throughout the meal service, Dietary staff #280 removed their gloves, exited the kitchen, returned without washing hands, and immediately put on new gloves before resuming food service. Staff turned on the gas stovetop with gloved hands and then used those same gloves to handle bread and cheese directly with the same gloves after being cooked.Interview on 05/18/26 at 11:59 A.M. with Dietary staff #280 confirmed all of the above hand hygiene concerns.

Based on observation, medical record review, review of the infection control and surveillance plan, interview, and review of the facility policy, the facility failed to ensure appropriate infection surveillance. This had the potential to affect all residents. Additionally, the facility failed to ensure Personal Protective Equipment (PPE) was worn during care for a resident on Enhanced Barrier Precautions (EBP). This affected one resident (#9) of one resident reviewed for EBP. The facility identified 12 residents on EBP. The facility census was 55.Findings Include: 1. Review of the infection surveillance and control sheets for 01/2026 through 03/2026 revealed the facility did not track each infections bacteria when indicated. Further review of the infection surveillance and control sheets revealed there was no surveillance for the month of 04/2026. Interview on 05/26/26 at 8:32 A.M. with Assistant Director of Nursing (ADON) #263, also the infection control nurse, confirmed the facility was not tracking the bacteria of infections that were being treated with antibiotics. ADON #263 further confirmed that there was no documentation for the 04/2026 for infection surveillance and control. Review of the undated facility policy titled Antibiotic Stewardship revealed when a culture and sensitivity is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. 2. Review of the medical record for Resident #9 revealed an admission date of 05/27/25. Diagnoses included chronic pancreatitis, gastrostomy status, type two diabetes mellitus, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of the physician orders dated 08/05/25 revealed an enteral feed order to provide a 90 milliliter (ml) fluid flush every four hours. Review of the plan of care initiated 08/18/25 and revised on 05/01/26 revealed the resident had a gastrostomy feeding tube with an intervention for enhanced barrier precautions. Review of a physician order dated 12/25/25 revealed the resident required enhanced barrier precautions for a gastrostomy tube. Observation on 05/19/26 beginning at 4:02 P.M. of Resident #9 revealed the resident had an enhanced barrier precaution (EBP) sign posted on the room door. The sign stated for staff to wear a gown and gloves during high contact care including device care including feeding tube care. Further observation revealed Licensed Practical Nurse (LPN) #272 administered oral medications for Resident #9. Further observation on 05/19/26 at 4:05 P.M. revealed LPN #272 administered a 90-milliliter enteral flush for Resident #9. LPN #272 wore gloves but was not wearing a gown. Interview on 05/19/26 at 4:10 P.M., LPN #272 verified the resident was on EBP. LPN #272 verified she had not worn a gown while flushing the resident's gastrostomy tube. Interview on 05/19/26 at 4:17 P.M., the Director of Nursing (DON) verified staff should wear a gown when flushing a resident's feeding tube. Review of the facility policy Enhanced Barrier Precautions, revealed EBP refers to the use of gown and gloves during high contact care activities for residents with known infection or colonization with a resistant organism when contact precautions do not other wise apply, chronic wounds, and indwelling medical devices. High contact care activity would include caring for or using and indwelling medical device.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness and adverse effects. This affected five (#5, #8, #17, #31, and #59) of five residents reviewed for unnecessary medications. The facility identified 43 residents receiving psychotropic medications. The facility census was 55. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 03/30/26. Diagnoses included dementia with behavioral disturbance, psychotic disturbance, atrial fibrillation, altered mental status, and cerebral infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of the plan of care initiated 03/31/26 and last revised 04/16/26 revealed to monitor and report for adverse effects of antidepressant medication, antianxiety medication and antipsychotic medications. Review of the physician orders dated 03/30/26 revealed the resident had orders for mirtazapine 7.5 milligrams (mg) daily for depression, and olanzapine 5 mg twice daily for psychotic disturbance. Review of a physician order dated 05/08/26 revealed an order for buspirone 10 mg every eight hours for anxiety. Further review of the physician orders revealed no orders for monitoring efficacy and adverse effects of the psychotropic medications. Review of the progress notes, medication administration record, and treatment administration records dated 04/01/26 through 05/18/26 revealed no documentation of monitoring for adverse effects and efficacy of the psychotropic medications. Interview on 05/18/26 at 10:28 A.M., the Director of Nursing (DON) verified there was no documentation of monitoring for adverse effects of the psychotropic medications. Interview on 05/18/26 at 10:28 A.M., the Regional Director of Nursing (RDON) #307 revealed the resident's care plan had an intervention to monitor for adverse effects and the nurse would monitor when administering medications. 2. Review of the medical record for Resident #17, revealed an admission date of 11/22/25. Diagnoses included Alzheimer's disease, nontraumatic subdural hemorrhage, anxiety disorder, major depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #17 revealed the resident had severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with toileting, showering, lower body dressing, putting on footwear and personal hygiene. Review of the care plan dated 11/25/25 and revised on 03/28/26 revealed Resident #17 took antianxiety and antidepressant medication related to anxiety, and depression. Interventions included monitoring and reporting to the physician any adverse effects of antianxiety and antidepressant medication use. Review of the physician orders for Resident #17 revealed an order for buspirone oral tablet 5 mg at bedtime for anxiety. Further review of the physician's orders revealed an order for Mirtazapine oral tablet 15mg at bedtime for depression. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed there was no monitoring for side effects of antidepressants, or antianxiety medication. 3. Review of the medical record for Resident #59 revealed an admission on [DATE]. Diagnoses included depression, anxiety, and epilepsy. Review of the admission MDS dated [DATE] revealed Resident #59 had cognitive impairment. Further review of the MDS revealed Resident #59 received antipsychotic, and antidepressant medication. Review of the care plan dated 05/17/26 revealed Resident #59 took psychotropic and antidepressant medications related to depression. Interventions included monitor for and report to physician adverse effects of antipsychotic medication, and antidepressant medication use. Review of the physician's orders for Resident #59 revealed an order for cariprazine oral capsule 3 mg every day for depression. Further review of the physician's orders revealed an order for sertraline 50 mg every day for depression. Additional review of the physician's orders revealed an order for benztropine mesylate oral tablet 0.5mg, one table every day for depression. Review of the MAR and TAR revealed there was no monitoring for side effects of antidepressant, or antipsychotic medication. Interview on 05/19/26 at 11:52 A.M. with the DON revealed the only location to monitor for adverse effects for antipsychotic medications was located in the care plan, however there was no documentation of the monitoring for adverse effects related to antipsychotic medication. 4. Review of the medical record for Resident #05, revealed an admission date of 05/09/25. Diagnoses included: vascular dementia, severe, with other behavioral disturbance, dysphasia, type II diabetes mellitus, major depressive disorder, generalized anxiety disorder, and chronic kidney disease, stage 3B. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #05 had severe cognitive impairment. The resident was assessed to require setup or cleanup assistance for eating and oral hygiene. The resident was dependent for toileting and required partial/moderate assistance for showering/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. The resident required supervision or touching assistance for upper body dressing. A care plan focus revised on 03/28/26 revealed Resident received psychotropic/antianxiety medications due to anxiety, depression, delusional disorders and insomnia. Further review of the care plan revealed an intervention to monitor for and report to physician adverse effects (drowsiness, dizziness, restlessness, weight gain, dry mouth, constipation, nausea and vomiting, blurred vision, low blood pressure, uncontrolled movements, tics, tremors, seizures, and increased risk for falls) of antipsychotic medication use. Review of physician orders for Resident #05 revealed two orders dated 04/16/26 for Ziprasidone hydrochloride (HCl) oral capsule 60 mg, with instructions to give 1 capsule by mouth once daily and Ziprasidone HCl oral capsule 80 mg, with instructions to give 1 capsule by mouth at bedtime for bipolar disorder. Review of the MAR for 05/01/26 thru 05/25/26 for Resident #05 revealed the medication was administered daily as prescribed, however, there was no indication on the MAR that nurses were tracking the resident's response to the medication for effectiveness, adverse effects or side effects. 5. Review of the medical record for Resident #31 revealed an admission date of 01/27/26. Diagnoses included pulmonary embolism, emphysema, chronic obstructive pulmonary disease, and asthma. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed no behaviors were identified. Additional review revealed the resident required extensive to dependent assistance with activities of daily living, utilized a wheelchair, and had shortness of breath with exertion and while lying flat. Review of the care plan initiated 03/19/26 and revised 03/28/26 revealed the resident received psychotropic medications related to antipsychotic, antianxiety, and antidepressant medication use. Further review of the care plan revealed an intervention for staff to monitor for and report adverse effects of antipsychotic medication use including drowsiness, dizziness, restlessness, weight gain, dry mouth, constipation, nausea and vomiting, blurred vision, low blood pressure, uncontrolled movements, tics, tremors, seizures, and increased risk for falls. Review of physician orders revealed an active order dated 04/01/26 for Lurasidone Hydrochloride 20 milligrams by mouth every evening related to bipolar disorder. Review of the MAR from 04/01/26 through 05/19/26 revealed the resident received the antipsychotic medication daily as ordered. Further review revealed no documented monitoring for effectiveness, adverse effects, or side effects related to the antipsychotic medication. Interview on 05/19/26 at 11:52 A.M. with Regional Director of Nursing #307, and Director of Nursing, confirmed the only location for monitoring adverse effects related to antipsychotic medications was located in the care plan. They further confirmed there was no documentation the resident was monitored for adverse effects related to the resident's antipsychotic medication use. Review of the facility policy titled, Documentation: Charting, dated 08/2023, revealed documentation in the clinical record was to include adverse reactions to medications and responses to medications and treatments. Further review revealed charting was to be complete and accurate and include follow-up action to nursing observations. Review of the facility policy Psychotropics, dated 09/2021, revealed the facility would use psychotropic medication appropriately working with the interdisciplinary team to ensure appropriate use, evaluation, and monitoring. Adverse reaction would be monitored according to the resident plan of care.

Based on observation, medical record review, interview, and facility policy review, the facility failed to ensure resident medical records were accurate and complete. This affected six (#3, #9, #18, #26, #43, and #49) of 22 sampled residents reviewed for accuracy of the medical record. The facility census was 55. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 05/27/25. Diagnoses included chronic pancreatitis, gastrostomy status, type two diabetes mellitus, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of the care plan for hospice care last revised 12/25/25 revealed for the facility to collaborate with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Review of the physician orders dated 12/25/25 revealed the resident was admitted to hospice services. Review of the resident's hospice documentation revealed no documentation of hospice care provided since 01/02/26. Interview on 05/18/26 at 2:00 P.M. with the Administrator and Assistant Director of Nursing (ADON) #263 revealed the facility had no recent documentation of hospice care provided for the resident. ADON #263 revealed she was unaware who was designated as the facility hospice coordinator. ADON #263 revealed hospice had not been updating the resident's binder with care documentation. ADON #263 revealed they received hospice documentation quarterly. The Administrator revealed she would review the hospice contract. 2. Review of the medical record for Resident #18 revealed an admission date of 12/04/20. Diagnoses included dementia, Alzheimer's disease, anxiety, peripheral vascular disease, atrial fibrillation, hypertension, and depressive disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for activities of daily living. Review of the care plan revised 04/17/25 for the resident's impaired cognitive function revealed the resident had dementia with behaviors and was physically and verbally aggressive during care. Review of the care plan revised 05/19/26 revealed the resident was at risk for impaired skin integrity due to dementia, impaired musculoskeletal status, cardiac status, renal status, and behaviors. Staff were to notify the nurse of any new areas of skin breakdown noted during bathing or daily care including redness, blisters, bruises, or discoloration. Staff were also to notify the physician of new skin breakdown. Review of the weekly skin assessments and review of the nurse's notes dated 04/13/26 through 05/19/26 revealed no documentation of the resident having bruising to the bilateral forearms. Review of the Certified Nursing Assistant (CNA) task charting for monitoring/skin observations dated 04/27/26 through 05/26/26 revealed a new unidentified skin area was observed on 05/12/26. There was no documentation in the nurse's notes on 05/12/26 regarding the unidentified skin area. Review of a nurse's note dated 05/15/26 at 8:20 A.M. revealed the resident had a skin tear on the back of the left hand. There was no documentation regarding bruising to the bilateral lower arms. Review of an incident report dated 05/15/26 at 5:30 A.M. revealed the resident was combative and agitated. The CNA notified the nurse the resident had a skin tear to the back of the left hand as he was attempting to swing his hands and arms on the CNA, he accidently hit his hands/arms on his bedrail. A scant amount of blood was noted. The skin tear to the left hand was well approximated and a new treatment was ordered. Injuries noted post incident included bruising to the right and left forearm. The physician and family were notified. A new intervention included physician ordered protective sleeves to the bilateral arms. Observation on 05/17/26 at 1:59 P.M. revealed Resident #18 had multiple bruised areas on his bilateral lower arms. The resident had no protective sleeves in place. Observation on 05/18/26 at 12:18 P.M. revealed Resident #18 was in the dining room. The resident had no protective sleeves in place. The resident had visible bruising on the bilateral lower arms. Observation on 05/20/26 at 2:08 P.M. with the Director of Nursing (DON) and Regional Director of Nursing (RDON) #307 verified the resident had bruised areas to his bilateral arms. Interview on 05/26/26 at 10:42 A.M., ADON #263 revealed the nursing assistants should have been aware of the residents bruising and reported the areas to the nurse. ADON #263 revealed the nurse should have assessed the bruising and documented the evaluation and skin assessment. Interview on 05/26/26 at 1:19 P.M., RDON #307 revealed the incident report was not part of the resident's medical record. Review of the undated facility policy Change in a Resident's Condition or Status, revealed the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 3. Review of the medical record for Resident #49 revealed an admission date of 11/03/25. Diagnoses included malignant neoplasm of the brain, cerebrovascular disease, depression, and a stage three pressure ulcer of the right ankle. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was at risk for skin breakdown. Review of the care plan dated 04/15/26 revealed the resident had a pressure area to the right lateral lower leg. Interventions included to provide wound treatments per physician orders. Review of a physician order dated 05/04/26 revealed to cleanse area to the right lateral ankle with wound cleanser. Apply collagen particles and calcium alginate. Cover with bordered dressing daily and as needed for wound management. Review of the treatment administration record (TAR) dated 04/01/26 through 05/26/26 revealed staff documented the wound treatment was completed on 05/23/26, 05/24/26, and 05/25/26. Observation on 05/26/26 at 10:46 A.M. of wound care for Resident #49 with the Assistant Director of Nursing (ADON) #263 revealed the resident had a wound dressing in place on the right lateral ankle dated 05/22/26. Interview on 05/26/26 at 10:46 A.M., ADON #263 verified the wound dressing was dated 05/22/26 and had not been completed per physician orders. ADON #263 revealed the wound dressing to the right lateral ankle should have been changed daily. Interview on 05/26/26 at 1:23 P.M. with the DON and RDON #307 verified the resident's wound treatments were incorrectly documented by agency staff as completed on 05/23/26, 05/24/26, and 05/25/26. The DON revealed the facility was going to notify the agency staffing providers. 4. Review of the medical record for Resident #03 revealed an original admission date of 07/17/2019 with a discharge to a local hospital on [DATE] and readmission of 12/09/25. Pertinent diagnoses included: Paraplegia, Type 2 diabetes mellitus, schizoaffective disorder, bipolar type; cognitive communication deficit, major depressive disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder, unspecified intellectual disabilities, chronic kidney disease and dysphagia oropharyngeal phase and dysphasia pharyngoesophageal phase. A diagnosis of acute respiratory failure with hypoxia was added 12/09/25 after Resident #03's hospitalization. Review of Resident #03's progress notes revealed no progress notes were recorded on 12/03/25 regarding Resident #03 eating his stool. Review of a progress note dated 12/04/25 at 3:00 P.M. revealed Resident #03 was sent to the emergency room (ER) due to a sudden drop in his oxygen saturation to 72% on room air from his norm of 95-96% on room air, tachycardia with a pulse of 154 (beats per minute), sweating, and a low grade fever of 99.9 degrees Fahrenheit by temporal route. Resident #03 was reported to have gotten into his colostomy bag 24 hours previously and was observed eating his stool. He experienced nausea and dry heaves over the last 24 hours and would not eat any food. Fluid intake was minimal and only when encouraged. The progress note indicated the signs and symptoms came on rapidly and the nurse noted he was in the room [ROOM NUMBER] minutes prior working with the resident and his roommate, at which time the resident was not showing the above symptoms. 911 called and report was called to the local hospital prior to the arrival of Emergency Medical Services (EMS). No family or guardian was listed to call, but nursing staff did notify his friend per the resident's request. During an interview on 05/19/26 at 6:54 A.M., Licensed Practical Nurse (LPN) #273 reported Resident #03 was very childlike and she had seen him pick at his colostomy bag. She said she also had seen him eat his own scabs four or five times. She said she didn't think she had documented either because it wasn't a big deal. During an interview on 05/19/26 at 7:09 A.M. Certified Nursing Assistant (CNA) #259 said that she had seen resident #03 put ten packets of salt on his food and she thought that was bad for him but when she was dismissed by nurses who said it was just a craving she stopped trying to report it. She said he grabs salt packages and puts it on his dessert every day. During an interview on 05/19/26 at 11:52 A.M. the Director of Nursing (DON) said she would expect the 12/03/25 observation of resident eating feces and subsequent change in condition (as referenced in the 12/04/25 progress note) to be documented. During an interview on 05/20/26 at 12:43 P.M., Certified Physician Assistant #300 confirmed she managed Resident #03's psychiatric medications. She said she received her information from record review and the nurses and did not speak with any of the aides. She said she was not aware that there were behaviors that were not documented. 5. Review of the medical record for the Resident #42 revealed an admission date of 09/04/24. Diagnoses included chronic obstructive pulmonary disease, type 2 diabetes mellitus with other specified complication, peripheral vascular disease, and type 2 diabetes mellitus with other skin ulcer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Review of the care plan dated 12/20/24 revealed the resident had impaired cardiovascular status related to peripheral vascular disease. Interventions included apply Kerlix to both lower legs from toes to knee, cover with Ace wraps, and change daily. Review of physician orders identified an order dated 05/09/26 to cleanse both lower legs, apply Xeroform to open areas, then Kerlix and Ace wraps to both lower extremities every morning. Review of the Medication Administration Record (MAR) for May 2026 showed the Kerlix and Ace wrap treatment documented as completed daily through 05/16/26, with 05/17/26 marked as chart code 9 (see nurse's note). Review of the nurses notes dated 05/17/26 at 1:57 P.M. revealed staff documented that they were out of Kerlix and obtained an order for an alternative treatment. Observation on 05/17/26 at 1:15 P.M. revealed the resident's legs were not wrapped. The resident stated he had not had Kerlix since the previous Wednesday 05/13/26 and staff had been out of the supply. Interview on 05/17/26 at 1:33 P.M. the resident's roommate confirmed the resident's legs had not been wrapped and Kerlix had been unavailable. Interview on 05/17/26 at 1:49 P.M. Licensed Practical Nurse (LPN) #247 confirmed Kerlix was out of stock. Interview on 05/17/26 at 2:18 P.M. the Director of Nursing (DON) and Certified Nursing Assistant (CNA) #209 stated Kerlix had been out since Wednesday evening and the new supply would not arrive until 05/20/26. Interview on 05/18/26 at 7:56 A.M. Resident stated he refused the alternative ABD pads because they felt too tight and he would wait for Kerlix to return. Review of documentation dated 05/20/26 at 9:28 A.M. revealed the Administrator stated the facility had no policy on central supply processes. 6. Review of the medical record for Resident #26 revealed an admission date of 08/03/23. Diagnoses included Parkinson's disease, infection and inflammatory reaction due to indwelling urethral catheter, obstructive and reflux uropathy, and history of recurrent urinary tract infections. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Review of the care plan dated 12/20/24 revealed the resident required a Foley (indwelling urinary) catheter related to urinary retention and obstructive uropathy. Interventions included provide catheter care every shift and as needed, monitor for signs and symptoms of urinary tract infection, and report changes to the physician. Review of physician orders identified an order for Foley catheter care every shift and as needed dated 03/02/25. Review of the Medication Administration Record (MAR) showed Foley catheter care documented as completed on the morning of 05/18/26 by a licensed nurse. Review of the nurses notes revealed the resident had been hospitalized from [DATE] to 03/21/26 for an extended spectrum beta-lactamase (ESBL) urinary tract infection and was currently receiving Hiprex (an antibacterial medication used primarily to prevent recurrent or chronic urinary tract infections. Hiprex is not used to treat active, acute infections but rather as a long-term preventative medication) for urinary tract infection prophylaxis. Interview on 05/18/26 at 2:10 P.M. Licensed Practical Nurse (LPN) #230 stated he signed off on catheter care without verifying it was completed and confirmed this was not proper protocol. Interview on 05/18/26 at 2:36 P.M. Certified Nursing Assistant (CNA) #600 stated catheter care was not provided that morning due to resident refusal during a bed bath. Interview on 05/18/26 at 2:20 P.M. the Director of Nursing (DON) confirmed nurses should be providing catheter care. Review of facility policy titled Documentation: Charting, dated September 2021, revealed the facility's expectation that the clinical record is a legal document that must be accurate and complete. The policy requires staff to record care given including treatments only after it is given and to document follow-up action to nursing observations.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure advance directives were consistent throughout the medical record. This affected three (#17, #38, #59) of four residents reviewed for advance directives. The facility census was 55. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 02/14/26. Diagnoses included chronic obstructive pulmonary disease, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.eview of a Do Not Resuscitate (DNR) Comfort Care (CC) form dated 02/12/26 revealed the resident had chosen a DNRCC-Arrest (DNRCC-A) code status (all measures of care provided until the point of cardiac or respiratory arrest.) Review of the care plan initiated 02/15/26 and last revised on 02/25/26 revealed the resident code status was a Do Not Resuscitate Comfort Care - Arrest DNRCC-A. Interventions included involving the physician in advanced directive conversations, periodically review advance directive with the resident and family, and record the resident's advanced directives in the clinical record. Review of a physician order dated 02/27/26 revealed an order for a Do Not Resuscitate (DNR) Comfort Care (CC) code status. Interview on 05/18/26 at 10:20 A.M., the Director of Nursing (DON) verified Resident #38 had a physician order for a Do Not Resuscitate Comfort Care (DNRCC) code status while the signed DNR order revealed the resident's code status was documented as DNRCC-A. 2. Review of the medical record for Resident #17 revealed an admission date of 11/22/25. Diagnoses included: Alzheimer's disease, nontraumatic subdural hemorrhage, anxiety disorder and major depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #17 revealed resident had severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with toileting, showering, lower body dressing, putting on footwear and personal hygiene. A care plan focus revised on 12/29/25 revealed Resident #17 had a code status of Do Not Resuscitate Comfort Care-Arrest (DNRCC-A). Interventions included to involve the physician in advanced directives conversations, periodically review advanced directives with resident/family, and recording the resident's advanced directives in the clinical record. Review of the physician order dated 12/05/25 for Resident #17 revealed code status order of DNRCC-Arrest. Review of the documents uploaded to the electronic medical record for Resident #17 revealed a DNRCC order dated 01/13/26. During an interview on 05/18/2026 at 10:26 A.M. the DON verified that the code status type listed on care plan and the physician order was different than the uploaded document on file and that the order list and care plan should have reflected the updated code status of DNRCC. 3. Review of the medical record for Resident #59 revealed an admission date of 05/14/26. Diagnoses included unspecified fracture of upper end of left humerus, acute respiratory failure, chronic obstructive pulmonary disease, atherosclerotic heart disease, dementia, depression and anxiety. Review of the 5 day Medicare MDS 3.0 assessment dated [DATE] for Resident #59 revealed the resident had severe cognitive impairment. The resident was assessed to require setup or cleanup assistance for eating and partial/moderate assistance for oral hygiene, toileting, showering, upper and lower body dressing, putting on/taking off footwear. Initial review of the electronic medical record for Resident #59 revealed no indication of code status. A care plan focus initiated on 05/17/26 indicated Resident #59 was full code. Review of the physician order dated 05/17/26 for Resident #59 revealed code status of DNRCC-A. During an interview on 05/18/2026 at 5:08 P.M., the DON confirmed that Resident #59 was DNRCC-A the previous day and was the result of the order being entered in without a signed paper, they changed code status to full code. She said they tell people at admission that they need to have a completed and signed form, otherwise the resident is switched to a full code until the paperwork can be completed by the physician. During an interview on 05/18/26 at 5:35 P.M., the resident representative for Resident #59 said her brother had a DNR order. She did not remember whether it was DNRCC or a DNRCC-A. She said the facility asked and she had told them he had DNR. Review of uploaded documents for Resident #59 revealed a DNRCC-A order signed on 05/19/26. Review of the undated facility policy titled, Do not Resuscitate Order revealed do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. Review of the facility policy Advance Directives, dated 09/01/21 revealed during the care planning process, the facility would identify, clarify, and review with the resident or legal representative whether they desired to make any changes related to Advance Directives. Further review of the policy revealed nay decision making would be documented in the resident's medical record and communicated to the interdisciplinary team.

Based on medical record review, interview, and review of the facility policy, the facility failed to ensure proper assessment and notification to the physician after moving a resident to the secured memory care unit. This affected one (#59) of three residents reviewed for dementia care. The facility census was 55.Findings include:Review of the medical record for Resident #59 revealed an admission on [DATE]. Diagnoses included depression, anxiety, and epilepsy.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had cognitive impairment. The resident was assessed to require setup or cleanup assistance for eating and partial to moderate assistance for oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear.Review of the care plan dated 05/21/26 revealed Resident #59 resided on the secured memory care unit for a therapeutic environment related to dementia and had exit seeking behavior. Interventions included to encourage the resident to avoid secured doorways to avoid injury when staff and visitors are entering and exiting the unit and to periodically reevaluate the residents' need for the secured unit.Review of Resident #59's progress notes revealed no documentation pertaining to a room change, or notes of exit seeking behavior.Review of the admission Evaluation dated 05/14/26 revealed Resident #59 had a history of wandering but did not have exit seeking behavior. Resident #59 had not attempted to elope from either the secured unit or the facility.Review of the medical record for resident #59 revealed a census change from the skilled unit to the secured memory care unit on 05/15/26. No further documentation or assessments were noted about a move to the secured memory care unit. Review of the Elopement Evaluation dated 05/17/26 revealed Resident #59 did not wander within the facility or have a history of wandering. Further review revealed no exit seeking behavior or attempts of actual elopement were noted.Interview on 05/18/26 at 5:35 P.M. with Resident #59's sister and Power of Attorney (POA) revealed Resident #59 came to the facility for rehabilitation after falling at an assisted living facility. Resident #59's sister was surprised that Resident #59 needed to be moved to the secured memory care unit and she was unaware of a dementia diagnoses. Resident #59's sister stated the resident was moved to the secured memory care unit soon after admission, but she was unsure of the exact date.Interview on 05/26/26 at 1:58 P.M. with Regional Director of Nursing (RDON) #307 revealed Resident #59 was moved to the secured memory care unit on 05/15/26 after showing exit seeking behaviors of going to the front doors. Resident #59 never exited the facility, but staff were concerned of possible attempts to elope. RDON #307 further confirmed that there were no assessments completed, and that the physician was not contacted related to moving Resident #59 into the secured memory care unit.Review of the facility policy titled Memory Care Unit Policy, dated 09/2024 revealed residents exhibiting behavioral changes or acute decline will be promptly assessed and interventions implemented as indicated.

Based in record review, staff interview, and review of facility policy the facility failed to ensure a bed hold notice and a notice of transfer were given to resident or the resident representative upon discharge to the hospital. This affected one (#56) of one resident reviewed for hospitalization. The facility census was 55. Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/10/26 and a discharge date of 04/22/26. Diagnoses included sepsis due to unspecified organism, cystitis without hematuria, morbid obesity due to excess calories, type II diabetes mellitus with ketoacidosis without coma, unspecified protein-calorie malnutrition, and generalized muscle weakness.Review of nursing documentation dated 04/22/26 at 11:30 A.M. revealed the resident experienced a significant change in condition and was found unresponsive with a snoring sound and no verbal response. Further review revealed emergency medical services were called, oxygen therapy was initiated, and the resident was transferred to the hospital. Review of electronic medical record documentation dated 04/23/26 at 12:04 A.M., 04/23/26 at 9:10 P.M., and 04/24/26 at 8:17 A.M. revealed the resident was documented as being at the hospital.Review of the clinical record revealed no documentation a bed hold notice, or a notice of transfer was provided to the resident or the resident representative.Interview on 05/18/26 at 10:12 A.M. with Social Worker #269, revealed the facility provided Ombudsman notification, but there was no documentation that a notice of transfer or bed hold notice was provided to the resident or the resident representative.Review of the facility policy titled, Transfer or Discharge Notice, dated September 2021, revealed the facility was required to provide a resident and/or resident representative with a 30-day written notice of an impending transfer or discharge. The policy further required that written notice includes the reason for transfer or discharge, effective date, location of transfer, appeal rights, bed hold policy information, Ombudsman contact information, and other required state agency contact information. The policy additionally required that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman and documented in the resident's medical record.Review of the facility policy titled, Bed-Holds and Returns, dated September 2021, revealed residents and resident representatives were to be informed prior to transfer of the bed hold policy. The policy further stated that the facility would provide written information explaining bed hold rights, including Medicaid bed hold limitations, private pay bed hold requirements, and conditions for return to the facility following hospitalization or therapeutic leave.

Based on medical record review and staff interview, the facility failed to notify the state mental health authority for Resident #03 when he was readmitted to the facility with new diagnosis of acute respiratory failure with hypoxia and sepsis after a hospitalization following an incident in which he ingested his own feces and for Resident #16 after a significant change in condition which resulted in a new diagnosed mental health condition. This affected two residents (#03 and #16) of two residents reviewed for preadmission screening and resident review (PASRR). The facility census was 55.Findings include:1. Review of the medical record for Resident #03 revealed an original admission date of 07/17/2019 with a discharge to a local hospital on [DATE] and readmission of 12/09/25. Pertinent diagnoses included paraplegia, type II diabetes mellitus, schizoaffective disorder, bipolar type; cognitive communication deficit, major depressive disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder, unspecified intellectual disabilities, chronic kidney disease and dysphagia oropharyngeal phase and dysphasia pharyngoesophageal phase. A diagnosis of acute respiratory failure with hypoxia was added 12/09/25 after Resident #03's hospitalization.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #03 revealed Resident #03 was cognitively intact. Resident #03 was assessed to be dependent for toileting and required substantial/maximal assistance for showering/bathing, lower body dressing, including putting on footwear. Resident #03 required supervision or touching assistance for personal hygiene, set up or clean-up for oral hygiene. Active diagnoses included paraplegia, anxiety disorder, depression, bipolar, schizophrenia, post-traumatic stress disorder (PTSD).Review of the medical record for Resident #03 revealed a hospital exemption document dated 07/15/19 and no Preadmission Screening and Resident Review (PASRR) documentation in the record.During an interview on 05/18/26 at 1:02 P.M., Social Services Director #269 said she also could not find a historical PASRR for Resident #03.Review of the medical record for Resident #03 revealed a PASRR was completed and submitted by Social Services Director #269 on 05/18/26. Review of the Preadmission Screening and Resident Review Result Notice dated 05/18/26 for Resident #03 revealed to be considered for admission or to continue to reside in a Medicaid certified nursing facility a resident must be screened for indications of serious mental illness and developmental disability. A resident review is required for nursing facility residents upon a significant change in condition. The results indicated that Resident #03 was selected for a level II evaluation to determine if the facility had the appropriate access to services to provide sufficient psychosocial care to the resident.2. Review of the medical record for Resident #16 revealed an admission date of 09/13/19. Diagnoses included bipolar disorder current episode depressed moderate, severe vascular dementia with behavioral disturbance, epilepsy not intractable without status epilepticus.Review of the quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 00 indicating severe cognitive impairment, a mood score of 12 and diagnoses that included bipolar disorder, depression, anxiety, and non-Alzheimer's dementia.Review of documentation dated 05/17/26 at 12:05 P.M. revealed the resident had a newly identified diagnosis of bipolar disorder with an onset date of 01/14/26 and no PASRR was completed to reflect the updated mental health diagnosis.Review of documentation dated 05/18/26 at 3:55 P.M. revealed Social Worker #269, stated the facility previously did not have access to PASRR documentation following corporate acquisition and therefore the newly diagnosed bipolar disorder was not captured on an updated PASRR. Further review revealed a PASRR was completed on 05/18/26 after the deficiency was identified.Review of documentation dated 05/20/26 at 9:28 A.M. revealed the Administrator stated the facility had no policy on PASRR processes.

Based on observation, review of the medical record, staff interview, and policy review, the facility failed to timely assess, monitor, and treat a change in skin condition. Additionally, the facility failed to ensure a skin wound treatment was completed per physician orders. This affected two (#18, #42) of two residents reviewed for non-pressure related skin conditions. The facility census was 55.Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 12/04/20. Diagnoses included dementia, Alzheimer's disease, anxiety, peripheral vascular disease, atrial fibrillation, hypertension, and depressive disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for activities of daily living. Review of the care plan revised 04/17/25 for the resident's impaired cognitive function revealed the resident had dementia with behaviors and was physically and verbally aggressive during care. Review of the care plan revised 05/19/26 revealed the resident was at risk for impaired skin integrity due to dementia, impaired musculoskeletal status, cardiac status, renal status, and behaviors. The resident was noted with a skin tear to the left second finger and back of the left hand. Interventions included assisting the resident with repositioning as needed, completing skin inspections every seven to ten days and as needed, and protective sleeves to the bilateral arms. Staff were to notify the nurse of any new areas of skin breakdown noted during bathing or daily care including redness, blisters, bruises, or discoloration. Staff were also to notify the physician of new skin breakdown. Review of the physician orders through 05/19/26 revealed no orders to monitor bruising. There were no physician orders for the protective sleeves to the bilateral arms. Review of the weekly skin assessments revealed the resident had not had a weekly skin assessment completed since 04/13/26 which noted no new observed skin areas. Review of the nurse's notes dated 04/13/26 through 05/19/26 revealed no documentation of any bruising. Review of the Treatment Administration Record (TAR) dated 04/13/26 through 05/19/26 revealed no documentation to monitor bruising. Also, there was no documentation the protective sleeves were being applied. Review of the Certified Nursing Assistant (CNA) task charting for monitoring/skin observations dated 04/27/26 through 05/26/26 revealed a new unidentified skin area was observed on 05/12/26. There was no documentation in the nurse's notes on 05/12/26 regarding the unidentified skin area. Review of a nurse's note dated 05/15/26 at 8:20 A.M. revealed the resident had a skin tear on the back of the left hand. There was no documentation regarding bruising to the bilateral lower arms. Review of an incident report dated 05/15/26 at 5:30 A.M. revealed the resident was combative and agitated. The CNA notified the nurse that the resident had a skin tear to the back of the left hand as he was attempting to swing his hands and arms on the CNA, he accidentally hit his hands/arms on his bedrail. A scant amount of blood was noted. Skin tear to the left hand was well approximated and a new treatment was ordered. Injuries noted post incident included bruising to the right and left forearm. The physician and family were notified. A new intervention included physician ordered protective sleeves to the bilateral arms. Observation on 05/17/26 at 1:59 P.M. revealed Resident #18 had multiple bruised areas on his bilateral lower arms. The resident had no protective sleeves in place. Observation on 05/18/26 at 12:18 P.M. revealed Resident #18 was in the dining room. The resident had no protective sleeves in place. The resident had visible bruising on the bilateral lower arms. Observation on 05/20/26 at 2:08 P.M. with the Director of Nursing (DON) and Regional Director of Nursing (RDON) #307 revealed the resident had bruised areas to his bilateral arms. Subsequent interview with RDON #307 revealed there should be something in place for monitoring the bruising. Further interview with the DON revealed the resident had protective sleeves and was not sure why they were not in place. RDON #307 revealed the nursing assistants should document when the protective sleeves were in place. Interview on 05/26/26 at 10:42 A.M., the Assistant Director of Nursing (ADON) #263 revealed the nursing assistants should have been aware of the residents' bruising and reported the areas to the nurse. ADON #263 revealed the nurse should have assessed the bruising and documented the evaluation and skin assessment. ADON #263 revealed a head-to-toe skin assessment should be completed weekly. Interview on 05/26/26 at 1:19 P.M., the DON and RDON #307 verified the resident had not had a weekly skin assessment completed since 04/13/26. The DON and RDON #307 verified skin assessment should be completed weekly. RDON #307 revealed the facility had no policy regarding weekly skin assessments. RDON #307 verified the incident report was not part of the resident's medical record. Review of the undated facility policy Change in a Resident's Condition or Status, revealed the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the undated facility policy Documentation: Charting, revealed documentation would include care given including treatments and anything abnormal or out of the ordinary. 2. Review of the medical record for Resident #42 revealed an admission date of 09/04/24. Diagnoses included type II diabetes mellitus, transient cerebral ischemic attack, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, difficulty in walking, muscle weakness, need for assistance with personal care, peripheral vascular disease, hyperlipidemia, cellulitis of part of limb, and acute kidney failure. Review of the quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating intact cognition. Further review revealed the resident required assistance with multiple activities of daily living and utilized a wheelchair for mobility. Additional review revealed skin impairments requiring pressure reducing devices and nonsurgical dressings. Review of the care plan initiated 12/20/24 and revised 04/19/26 revealed the resident required bilateral lower extremity wound care including gauze wrap from toes to knee and elastic (ACE) wraps applied daily. Review of physician orders revealed an active order dated 05/17/26 at 7:00 A.M. for cleansing bilateral lower extremities, applying Xeroform (a sterile, non-adhering occlusive gauze dressing impregnated with petrolatum) to open areas, covering with rolled gauze (Kerlix), and wrapping with ACE bandages from toes to knee. Further review revealed an additional order dated 05/17/26 at 7:00 A.M., after surveyor intervention, allowing the use of abdominal (ABD) pads or light gauze over Xeroform with ACE wraps if Kerlix was not available and monitoring circulation and skin integrity every shift. Review revealed a prior wound care order was discontinued on 05/18/26. Review of Medication Administration Record (MAR) and treatment documentation revealed the ordered bilateral lower extremity wound care was documented as administered through 05/16/26. Further review revealed no completed documentation on 05/17/26 and an entry indicating a nursing note without corresponding documentation. Review of nursing documentation dated 05/17/26 at 1:15 P.M. revealed staff reported Kerlix was not available in the facility and the resident's legs were not wrapped. Further review revealed the resident stated supplies had not been available since the prior week and replacement supplies were not expected until 05/20/26. Interview on 05/17/26 at 1:33 P.M. with Administrator confirmed Resident #42's legs were not wrapped per physician orders. Interview on 05/17/26 at 1:49 P.M. with Licensed Practical Nurse (LPN) #247 confirmed Kerlix was out of stock within the facility since 05/13/26. Interview on 05/17/26 at 2:18 P.M. with DON confirmed Kerlix had been unavailable since approximately the prior week and replacement supply was not expected until 05/20/26. Interview on 05/18/26 at 7:56 A.M. with resident #42 confirmed refusal of ABD pad application and reported he would not allow leg wrapping until Kerlix supplies were available due to the ABD pads feeling tight on his legs. Interview on 05/18/26 at 9:21 A.M. with DON indicated the resident's wound care supplies were typically provided after his wound care appointment but there was no documentation or evidence confirming supply delivery following the last dressing change appointment on 05/13/26. Additionally, she confirmation that ABD pads were being used as an alternative due to Kerlix unavailability. Interview on 05/20/26 at 9:28 A.M. with the Administrator revealed the facility had no policy on central supply processes.

Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure pressure ulcer wound treatments were completed per physician orders. This affected one (#49) of one resident reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 55. Findings include:Review of the medical record for Resident #49 revealed an admission date of 11/03/25. Diagnoses included malignant neoplasm of the brain, cerebrovascular disease, depression, and a stage three pressure ulcer of the right ankle.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was at risk for skin breakdown.Review of the care plan dated 04/15/26 revealed the resident had a pressure area to the right lateral lower leg. Interventions included pressure reducing boots to bilateral feet as tolerated, elevate heels, low air loss mattress, and assist with turning and repositioning as needed. Also to provide wound treatments per physician orders. Review of a physician order dated 05/04/26 revealed to cleanse area to the right lateral ankle with wound cleanser. Apply collagen particles and calcium alginate. Cover with bordered dressing daily and as needed for wound management. Review of a wound nurse practitioner progress note dated 05/21/26 revealed the resident had a chronic stage three pressure ulcer to the right lateral ankle measuring one centimeter (cm) in length, one cm in width, with a depth of 0.3 cm with 100 percent granulation tissue. A new treatment recommendation was ordered to cleanse the wound with wound cleanser/normal saline, apply collagen with silver, normal saline moistened to base of the wound, secure with bordered dressing, change daily and as needed.Review of the Treatment Administration Record (TAR) dated 04/01/26 through 05/26/26 revealed there was no documentation the wound treatment to the right lateral ankle had been completed on 04/22/26, 04/24/26, 04/27/26, 04/28/26, and 05/16/26. Further review of the TAR revealed staff falsely documented the wound treatment was completed on 05/23/26, 05/24/26, and 05/25/26. Observation on 05/26/26 at 10:46 A.M. of wound care for Resident #49 with the Assistant Director of Nursing (ADON) #263 revealed the resident had a wound dressing in place on the right lateral ankle dated 05/22/26. Further observation revealed ADON #263 removed the dressing covering the right ankle revealing there was no calcium alginate in place under the wound dressing. The resident had a stage three pressure ulcer approximately one centimeter in length, one cm in width, with minimal depth. There was no wound odor and no signs of infection. There was a small amount of dried yellow exudate on the wound dressing. ADON #263 applied collagen particles to the wound base, applied calcium alginate, and covered with a bordered dressing. Interview on 05/26/26 at 10:46 A.M., ADON #263 verified the wound dressing was dated 05/22/26 and had not been completed per physician orders. ADON #263 revealed the wound dressing to the right lateral ankle should have been changed daily. Follow up interview with ADON #263 verified the facility had not implemented the new order for wound care treatment recommended by the wound care provider on 05/21/26. Interview on 05/26/26 at 1:23 P.M. with the Director of Nursing (DON) and Regional Director of Nursing (RDON) #307 verified there was no documentation wound treatments were completed on 04/22/26, 04/24/26, 04/27/26, 04/28/26, and 05/16/26. Further interview with the DON and RDON #307 verified the resident's wound treatments were incorrectly documented by agency staff as completed on 05/23/26, 05/24/26, and 05/25/26. The DON revealed the facility was going to notify the agency staffing providers. Review of the facility policy Wound Care, dated 09/2021, revealed wound treatments would be administered as ordered by the physician.

Based on record review, resident interview, staff interview, and facility policy review, the facility failed to ensure residents were was free from accident hazards. This affected one (#31) of three residents reviewed for accidents. The facility census was 55. Findings include:Review of the medical record for Resident #31 revealed an admission date of 01/27/26. Diagnoses included pulmonary embolism, emphysema, chronic obstructive pulmonary disease, and asthma.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 revealing the resident had intact cognition. Additionally, the resident was dependent for bed mobility, transfers, and activities of daily living.Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls.Review of the plan of care dated 05/15/26 revealed the resident was at risk for falls due to generalized weakness, history of falls, decreased strength and endurance, and need for assistance with activities of daily living. Interventions included educate the resident and family to call for assistance before transferring, food and fluids within reach, implement preventative fall interventions and devices, maintain call light within reach and educate the resident to use the call light, maintain needed items within reach, monitor for changes in mobility, non-skid footwear, physical therapy and occupational therapy evaluations, and low bed.Review of the fall investigation dated 05/15/26 revealed the resident was found on the floor on her left side with a knot noted to the left side of her head. The resident stated her legs slid out of the bed first which pulled her body out. The contributing factor identified was the bed left up too high by staff after a transfer. At the time of the fall the resident was dependent for bed mobility and transfers. Two staff members had assisted the resident into bed prior to the fall yet the bed was not lowered. The resident was on anticoagulant medication and was sent to the emergency department for evaluation. A previous positioning fall occurred on 01/28/26 from the recliner. The care plan was updated after the fall to include the low bed intervention. The facility investigated the fall and determined changes were required to ensure consistent implementation of existing interventions.Review of a nursing note dated 05/17/26 at 7:39 P.M. revealed the resident was status post fall out of bed. The resident was moving extremities as per baseline with stable vital signs and no acute pain complaints.Interview on 05/19/26 at 2:14 P.M. the Certified Nursing Assistant (CNA) #259 stated the resident could not move her own feet without assistance, her feet were hanging off the side of the bed, she was yelling for help prior to the fall, and the bed was raised up high prior to the fall.Interview on 05/19/26 at 2:30 P.M. Resident #31 stated she was unable to reach the call light due to upper extremity impairment and had to yell for help. She also confirmed that two staff assisted her into bed prior to the fall.Interview on 05/19/26 at 2:37 P.M. CNA #244 stated protocol for dependent residents is to lower the bed when placing them in bed.Interview on 05/19/26 the Director of Nursing (DON) and Regional DON 307 confirmed the contributing factor noted on the fall investigation was the bed being up too high.Review of facility policy titled Falls, dated September 2021, revealed the facility's expectation to identify appropriate interventions based on the resident's specific risks, implement additional or different interventions if falling recurs, monitor subsequent falls, and ensure interventions such as low bed positioning are consistently applied to prevent falls and minimize injury.

Based on observation, review of the medical record, interview, and policy review, the facility failed to ensure interventions were implemented for significant weight loss, failed to monitor fluid restrictions, and failed to provide nutritional supplements per physician orders. This affected three (#1, #38, #27) of three residents reviewed for nutrition. The facility identified three residents with significant weight loss, two residents with fluid restrictions, and five residents receiving nutritional supplements. The facility census was 55. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 04/27/26. Diagnoses included trigeminal neuralgia, atrial fibrillation, heart failure, pneumonitis, and pleural effusion.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was independent with eating meals. Review of hospital documentation dated 04/24/26 revealed Resident #1 weighed 130 pounds prior to discharge to the facility. Review of the physician orders dated 04/27/26 revealed to obtain weight upon admission and every week for three weeks. Further review of the medical record and physician orders through 05/17/26 revealed no orders or interventions for significant weight loss. Review of the resident's weight record revealed the resident weighed 130 pounds on 04/27/26. On 04/28/26 the resident's weight was documented twice at 130 pounds. On 05/01/26 the resident's weight was documented as 180 pounds and the weight was struck out and noted as incorrect documentation. Review of the care plan dated 04/29/26 revealed the resident was at risk for altered nutritional status related to pneumonitis and altered texture diet. Interventions included monitoring changes in meal intake percentages and periodically obtaining resident's weight and reporting significant weight changes to the registered dietician, physician, and family.Review of a dietary assessment progress note dated 04/29/26 revealed the resident was at moderate nutritional risk related to an altered diet texture. The resident's current body weight was 130 pounds. The resident's current weight goal was weight maintenance. The resident had a pureed textured diet with 50 percent to 75 percent meal intakes noted as less than optimal but adequate to meet estimated needs. The dietician noted for the resident to have weekly weights for four weeks. Meal intakes, laboratory results, and skin status would be monitored with follow up quarterly and as needed for significant changes. Review of a care conference progress note dated 05/06/26 at 1:16 P.M. revealed one topic area discussed during the care conference was nutrition. The resident had lost over 20 pounds since being in the hospital and felt weak. The resident was on a regular diet with regular texture with 75 percent to 100 percent intake for meals. The resident's current body weight was 107.4 pounds. The resident reported she used to be on a pureed diet and had not wanted to eat that. The resident was now on a regular diet and eating well and starting to regain strength.Review of the nurse's notes dated 04/27/26 through 05/17/26 revealed no documentation the physician or registered dietitian had been notified of the resident's weight loss. Interview on 05/17/26 at 12:42 P.M. Resident #1 revealed she had concerns with her weight loss. Resident #1 revealed she was on a pureed diet but now was on a regular diet. The resident revealed she had difficulty eating due to her surgery for trigeminal neuralgia. Interview on 05/18/26 at 11:36 A.M., Licensed Practical Nurse (LPN) #522 revealed the last documented weight for Resident #1 was 130 pounds on 04/28/26. LPN #522 revealed the resident should have been weighed weekly. LPN #522 then requested the nursing assistants to weigh the resident.Observation on 05/18/26 at 11:40 A.M. of Resident #1 with Certified Nursing Assistant (CNA) #259 and CNA #218 revealed the resident weighed 109 pounds indicating a 16 percent weight loss since admission. While being weighed, Resident #1 stated she had been weighing herself on the same scale. CNA #259 revealed the nurses provided a list of residents who needed completed weights. Interview on 05/18/26 at 11:44 A.M., the Director of Nursing (DON) revealed there was no documentation of the resident's weight since 04/28/26 while reviewing the resident's weights in the electronic medical record. Review of the resident's weight documentation on 05/18/26 revealed two additional weights had just been added in the electronic medical record. For 05/04/26 a weight of 109 pounds was added and for 05/11/26 a weight of 109 pounds was added noting a 16.2 percent weight loss since admission. Also, on 05/18/26 the facility stuck out the resident's weight of 130 pounds for 04/27/26 and noted incorrect documentation. Interview on 05/19/26 at 2:41 P.M., Registered Dietitian (RD) #304 revealed he had not been notified of the resident's weight loss until 05/18/26. RD #304 revealed he discussed the resident's weight with the DON and they believed the resident's hospital weight and admission weight completed at the facility were incorrect. RD #304 revealed on 05/18/26 he recommended a nutritional supplement for the resident. Interview on 05/19/26 at 3:20 P.M., the DON revealed if a resident has a significant weight loss then a risk meeting would be held, the dietitian, family, and physician would be notified. The DON revealed no notifications were made to the physician and dietician because they had not believed the resident had a true weight loss. The DON revealed the resident's weight had been written on paper and had not been entered into the electronic medical record. Follow up interview with the DON revealed if an incorrect weight was documented then the resident should have been reweighed the same day.Interview on 05/20/26 at 8:02 A.M., Licensed Social Worker (LSW) #269 revealed a care conference for Resident #1 was held on 05/06/26. LSW #269 revealed the resident had not attended the meeting. LSW #269 revealed present at the meeting was herself and two of the resident's family members. LSW #269 revealed the resident's family reported the resident had felt weak because she had not really eaten but was better since returning to normal food. The resident's family reported that the resident weighed 107 pounds. LSW #269 revealed the resident's family wanted her stronger so she could go home. LSW #269 revealed she had not notified anyone about the resident's 107-pound weight reported by the family because she had not known what the resident's starting weight was. LSW #269 revealed she had not provided nursing with any concern forms from the care conference meeting. Review of the facility policy Weight Assessment and Interventions, dated 09/2021 revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for residents. The nursing staff would measure resident weights on admission and at least monthly unless ordered by the physician. A weight loss of greater than five percent in one month would be considered significant unplanned and undesired weight loss and interventions would be based on careful consideration of the resident choice and preferences. 2. Review of the medical record for Resident #38 revealed an admission date of 02/14/26. Diagnoses included chronic obstructive pulmonary disease, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension.Review of the admission MDS assessment dated [DATE] revealed the resident had intact cognition.Review of the care plan dated 02/20/26 and last revised 05/13/26 revealed the resident was at risk for altered nutritional status due to significant weight loss and a mechanically altered diet. One intervention noted providing meals/snacks/fluids based on resident food preferences and physician orders. Also to provide nutritional supplements as ordered by the physician. Review of a physician order dated 03/02/26 revealed the resident had a regular diet with mechanical soft texture, and thin liquid consistency. The resident also had a physician order dated 03/02/26 for a magic cup three times a day for a nutritional supplement.Review of the resident's meal ticket for 05/18/26 revealed the resident had a mechanical soft diet with an added grilled cheese at each meal. There was no documentation on the meal ticket regarding additional nutritional supplements. Observation on 05/18/26 at 12:22 P.M. revealed Resident #38 received his meal tray for lunch. Further observation of the meal tray revealed that the resident had no nutritional supplement on his meal tray. Interview on 05/18/26 at 12:22 P.M., Certified Nursing Assistant (CNA) #218 verified Resident #38 was on a mechanical soft diet. CNA #218 verified Resident #38 had not received a nutritional treat on his meal tray. CNA #218 also verified Resident #38's meal ticket had not listed the magic cup for a nutritional treat. Interview on 05/18/26 at 12:25 P.M., Dietary Manager (DM) #284 verified if the nutritional supplement was not listed on the meal ticket then the resident was not receiving the supplement. DM #284 stated the dietitian must not have notified her about the nutritional supplement. Further interview on 05/20/26 at 1:41 P.M., DM #284 revealed the dietary manager had sent an electronic communication for the resident to receive magic cups. DM #284 revealed she had missed the email. DM #284 revealed the resident would not have received the magic cup unless the nurse went to the dietary department to ask for the magic cup. Review of the facility policy Therapeutic Diets dated 09/01/21 revealed mechanically altered diets, as well as diet modified for medical or nutritional needs would be considered therapeutic diets. Further review of the policy revealed the food service manager would establish and use a tray identification system to ensure each resident received their diet as ordered.3. Review of the medical record for Resident #27 revealed an admission date of 01/10/25. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, end stage renal failure, chronic kidney disease, vascular dementia, hypertension, atrial fibrillation, and dependence on renal dialysis. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of the care plan dated 02/07/25 revealed the resident had end stage renal disease and was receiving dialysis services. Review of the nutrition care plan last revised 02/27/26 revealed the resident was on 1800 milliliter (ml) fluid restriction (dietary provides 240 ml at breakfast and lunch, 360 ml dinner; nursing provided 600 ml 7:00 P.M. to 7:00 A.M. and 360 ml from 7 A.M. to 7:00 P.M.Review of a physician order dated 02/26/26 revealed the resident received dialysis services three times per week. Review of a physician order dated 02/27/26 revealed the resident was ordered a 1500 milliliter (ml) fluid restriction (420 ml from nursing and 1080 ml from dietary with 380 ml of fluids provided at breakfast, 240 ml at lunch, and 120 ml at dinner). Review of the treatment administration record from 04/01/26 through 05/19/26 revealed the nurses had placed a check mark each shift for the residents' 1500 ml fluid restrictions. There was no documentation of the fluid amount the resident had received. Review of the nursing notes dated 04/01/26 through 05/19/26 revealed no documentation the resident had refused to follow the physician ordered fluid restriction. Observation on 05/17/26 at 11:30 A.M. revealed a large water cup on the resident's bedside table. The cup was half full of water. Observation on 05/18/26 at 2:31 P.M. revealed there was a large water cup in the resident's room on the bedside table. The cup was approximately half full. Interview on 05/18/26 at 2:31 P.M., Resident #27 revealed staff filled the water cup when it was empty. Resident #27 was unaware of how much fluid he was allowed each day. Resident #27 revealed he tried not to drink many fluids. Interview on 05/18/26 at 2:33 P.M., LPN #230 revealed Resident #27 was on fluid restrictions. LPN #230 revealed he gave the resident about 120 ml of fluids with his medications. LPN #230 verified the large cup on the resident's bedside table was half full of water. Interview on 05/18/26 at 2:43 P.M., CNA #218 revealed Resident #27 was on fluid restrictions, so she only filled the resident's water cup half full of water and the other half with ice. Observation on 05/18/26 at 3:17 P.M., with the Assistant Director of Nursing (ADON) #263 revealed ADON #263 measured how much water the resident's water cup would hold when full. Further observation revealed the resident's cup held 580 ml of water. Observation on 05/19/26 at 10:50 A.M. of Resident #27 revealed LPN #522 provided the resident with his morning medications. LPN #522 provided the resident with a water cup with 200 ml of water to take the medications. Further observation revealed the resident drank 60 ml of water with the medications. LPN #522 then took the remaining water out of the room. Continued observation revealed LPN #522 had not documented the amount of fluid given to the resident. Concurrent interview with LPN #522 verified the resident was on fluid restrictions and she had provided the resident with 200 ml of water. LPN #522 revealed the nurses were not required to document the amount of water the resident consumed. Interview on 05/19/26 at 11:33 A.M., the DON verified the monitoring of the resident's fluid restriction was not adequate. The DON revealed the nursing staff should be documenting the amount of fluids the resident had received. The DON verified the resident's physician order for a 1500 ml fluid restriction was not consistent with the 1800 ml fluid restriction noted in the resident's care plan. The DON revealed only the nurses should be providing the resident with fluids not the CNAs. The DON revealed the resident should not have a water pitcher in his room. Review of the facility policy Hydration, dated 09/2021, revealed no guidelines no guidelines for fluid restrictions.

Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure placement of a gastrostomy tube prior to administering a gastrostomy tube flush. This affected one (#9) of one resident reviewed for tube feeding. The facility identified one resident with a feeding tube. The facility census was 55. Findings include:Review of the medical record for Resident #9 revealed an admission date of 05/27/25. Diagnoses included chronic pancreatitis, gastrostomy status, type two diabetes mellitus, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition.Review of the care plan initiated 08/18/25 and revised on 05/01/26 revealed the resident had a gastrostomy feeding tube with interventions to provide enteral nutrition per physician orders, flush feeding tube per physician orders, and check for tube placement and residual as indicated. Review of a physician order dated 05/28/25 revealed to check tube placement every shift prior to feeding, flushing, and administering medication. Review of the physician orders dated 08/05/25 revealed an enteral feed order to provide a 90 milliliter (ml) fluid flush every four hours. Observation on 05/19/26 at 4:05 P.M. revealed Licensed Practical Nurse (LPN) #272 administered a 90 milliliter (ml) enteral flush for Resident #9. LPN #272 had not checked for tube placement prior to flushing the feeding tube. Interview on 05/19/26 at 4:05 P.M., LPN #272 verified she had not checked for placement prior to flushing the feeding tube. Interview on 05/19/26 at 4:17 P.M., the Director of Nursing (DON) verified the nurse should have checked for placement prior to flushing the feeding tube. Review of the facility policy Gastrostomy Tube/Jejunostomy Tube Care, dated 09/2021, revealed to follow treatments as ordered by a physician. To confirm placement of tube in stomach, attach syringe to end of tube and place stethoscope over left quadrant of resident's abdomen. Instill 20 ml of air into the tube and listen for swooshing sound in stomach. Aspirate stomach contents by attaching syringe to end of tube and gently pulling back on plunger.

Based on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received the necessary respiratory care and services to meet their needs. This affected one (#29) out of two residents reviewed for respiratory care. The facility census was 55.Findings include:Review of the medical record for the Resident #29 revealed an admission date of 09/24/24. Diagnoses included chronic obstructive pulmonary disease, severe protein-calorie malnutrition, chronic atrial fibrillation, and chronic combined systolic and diastolic heart failure.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Additionally, the resident experienced shortness of breath with exertion, at rest, and while lying flat.Review of the plan of care dated 01/05/25 and revised 04/27/25 revealed the resident had impaired respiratory status related to chronic obstructive pulmonary disease and shortness of breath. Interventions included oxygen as ordered by physician, change oxygen tubing per policy, and elevate the head of bed as needed for comfort and breathing.Review of physician orders for 02/08/26 identified an order for oxygen at 2 liters per nasal cannula continuously every shift and to change oxygen tubing and set up weekly at bedtime every Sunday related to chronic obstructive pulmonary disease.Interview with Resident #29 on 05/17/2026 at 1:21 P.M. revealed he gets nose bleeds from dryness due to not having a humidifier bottle connected to his oxygen. The resident also stated they do not change his oxygen tubing, he thinks it has been over a year since the tubing was changed. Observation at the time of the interview revealed no date on the oxygen tubing. Resident #29 also stated the filter on the concentrator was fuzzy and that he could smell whatever was growing on the filter. Observation of the filter revealed it appeared to be covered in dust.Interview on 05/17/26 at 1:33 P.M. the Resident #29's roommate, Resident #42 confirmed all of the above concerns voiced by Resident #29 being shared with facility staff, including the dusty filter and the lack of a humidifier bottle.Interview on 05/17/26 at 1:43 P.M. Licensed Practical Nurse (LPN) #247 stated humidifier bottles are only used when oxygen is continuous. LPN #247 confirmed the resident's oxygen was ordered as continuous.Interview on 05/19/26 at 11:25 A.M. the Director of Nursing (DON) stated all residents on continuous oxygen should have humidifier bottles.Review of facility policy titled Oxygen Administration, dated September 2021, revealed the facility's expectation to administer oxygen therapy safely and noted that bacterial contamination associated with certain nebulizers and humidifiers may occur.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure ongoing communication with the dialysis services provider. This affected one (#27) of one resident reviewed for dialysis services. The facility identified two residents as receiving dialysis services. The facility census was 55. Findings include:Review of the medical record for Resident #27 revealed an admission date of 01/10/25. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, end stage renal failure, chronic kidney disease, vascular dementia, hypertension, atrial fibrillation, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the care plan dated 02/07/25 revealed the resident had end stage renal disease and was receiving dialysis services. An intervention dated 02/27/26 revealed for staff to coordinate resident's care in collaboration with the dialysis center. Review of a physician order dated 02/26/26 revealed the resident received dialysis services three times per week. Review of the medical record revealed no dialysis communication forms were found in the medical record from 01/01/26 through 05/26/26. Review of a blank dialysis communication report form used by the facility revealed the nurse would record the residents vital signs, weight, glucose level, cognition status, COVID-19 status, pain medications administered, and any changes in condition since the last dialysis day prior to sending the resident to dialysis. The dialysis center would return the form with the resident's post dialysis weight, vital signs, treatment duration, kilograms of fluid removed, medications administered, condition or events during/post dialysis, and any special instructions. Interview on 05/18/26 at 2:33 P.M., Licensed Practical Nurse (LPN) #230 revealed a packet including a dialysis communication form was prepared by the night shift staff. LPN #230 revealed the form was sent with the resident and returned after dialysis and placed in a file. LPN #230 reviewed the electronic medical record and revealed there were no dialysis communication forms scanned into the medical record since 01/01/26. Interview on 05/19/26 at 11:28 A.M., the Director of Nursing (DON) revealed the dialysis communication forms should be in a binder or folder at the nurse's station. The DON revealed she was unable to find the communication forms at the nurses station. Interview on 05/20/26 at 9:30 A.M., the DON revealed a communication form was sent with residents to dialysis for Resident #27 with the transport driver and the forms were returned to the facility by the transport driver. The DON revealed she was unable to find any dialysis communication sheets for Resident #27 or the binder they were kept in. The DON revealed they had received two reports from dialysis dated 05/15/26 and 05/18/26. The DON also provided a copy of blank dialysis communication form. Follow-up interview on 05/26/26 at 4:00 P.M., the DON verified shewas still not able to locate the resident's dialysis binder with the dialysis communication forms for surveyor review. Review of the facility policy Hemodialysis dated 09/2021, revealed staff would coordinate with the dialysis center. There were no guidelines regarding the use of dialysis communication forms.

Based on record review and staff interview, the facility failed to ensure that residents with post-traumatic stress disorder (PTSD) received necessary care and services to meet the resident's psychosocial needs. This affected two (#31 and #03) of two residents reviewed for trauma informed care. The facility census was 55.Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 01/27/26. Diagnoses included pulmonary embolism without acute cor pulmonale, chronic obstructive pulmonary disease, asthma, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition and that the resident had a diagnoses that included post-traumatic stress disorder. Review of the plan of care dated 03/19/26 and revised 05/18/26 revealed the resident had an impaired psychiatric and mood status related to anxiety, bipolar disorder, and post-traumatic stress disorder. Interventions included behavioral health consults as needed, monitor for signs of mood changes or distress, provide a calm safe environment, encourage expressions of feelings, and refer to social worker as needed. There was no documentation of identified PTSD triggers in the care plan. Review of the nurses notes revealed a PTSD assessment was not completed until 05/19/26 but still had no written triggers documented. Interview on 05/18/26 at 4:00 P.M. the Director of Social Services #269 confirmed that no trauma informed care assessment related to the resident's PTSD triggers had been completed. Director of Social Services #269 stated that moving forward she will complete assessments to capture triggers. 2. Review of the medical record for Resident #03 revealed an original admission date of 07/17/2019 with a discharge to a local hospital on [DATE] and a readmission date of 12/09/25. Pertinent diagnoses included paraplegia, type II diabetes mellitus, schizoaffective disorder, bipolar type; cognitive communication deficit, major depressive disorder, PTSD, generalized anxiety disorder, unspecified intellectual disabilities, chronic kidney disease and dysphagia oropharyngeal phase and dysphasia pharyngoesophageal phase. A diagnosis of acute respiratory failure with hypoxia was added 12/09/25 after Resident #03's hospitalization. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #3 revealed Resident #3 was cognitively intact. Resident #03 was assessed to be dependent for toileting and required substantial/maximal assistance for showering/bathing, lower body dressing, putting on footwear, required supervision or touching assistance for personal hygiene, set up or clean-up for oral hygiene and active diagnoses included paraplegia, anxiety disorder, depression, bipolar, schizophrenia, PTSD. A care plan focus revised on 03/11/25 revealed Resident #03 was at risk for alteration in psychosocial wellbeing due to diagnosis of depression, diagnosis of intellectual/developmental disability. Interventions included: administer medications per physician order. Monitor for effectiveness and side effects, encourage resident to ask questions when concerned with their medical condition to reduce anxiety, give non-judgmental support, monitor for psycho-social changes, observe and report any changes in mental status caused by situational stressors. An additional care plan focus revised on 01/24/26 revealed Resident #03 had an impaired psychiatric/mood status due to anxiety, bipolar disorder, depression, mood disorder and PTSD, anxiety, schizoaffective disorder no family support as evidenced by tearful. Interventions included: assist resident to cope by discussing possible solutions to conflict, behavioral health consults as needed (psycho-geriatric team, psychiatrist etc), encourage ongoing family involvement, encourage participation from resident to make own decision, encourage resident to reminisce and review life to identify past coping skills and personal strengths, monitor mood, monitor sleep pattern changes, provide quality listening time and encourage expressions of feelings, refer to social worker as needed if resident communicates need to speak with someone. Further review of the care plan for Resident #03 revealed no mention of specific triggers related to resident's trauma history. During an interview on 05/18/26 at 1:02 P.M., Director of Social Services #269 confirmed there was no mention in the care plan of Resident #03's trauma history or triggers. She also confirmed she did not know the resident's triggers and did not have trauma assessment. During an interview on 05/19/26 at 6:54 A.M., Licensed Practical Nurse (LPN) #273 said Resident #03 was very childlike and she had seen him pick at his colostomy bag. She said she also had seen him eat his own scabs four or five times. She said she didn't think she had documented either because it wasn't a big deal. She said she didn't know what triggered his behaviors. During an interview on 05/20/26 at 10:35 A.M. Certified Nursing Assistant (CNA) #228 said Resident #03 cried frequently. She said he cried whenever he was told what to do. She said she did not know his triggers. During an interview on 05/20/26 at 12:43 P.M., Certified Physician Assistant (CPA) #300 confirmed she managed Resident #03's psychiatric medications. She confirmed she was not a therapist and she confirmed she did not suggest interventions to staff regarding Resident #03 ingesting his feces. She said she only knew of the couple of documented instances of Resident #03 eating his feces. She said she received her information from record review and the nurses and did not speak with any of the aides. She said she was not aware that there were behaviors that were not documented. She said had she known that his behavior of eating his feces and copious amounts of salt was more chronic she would have listed pica (consumption of non-food items) or copraphogia (consumption of feces) as a diagnosis. CPA #300 said the resident would benefit from talk therapy and that if she had known about the ongoing behaviors, she would have explored more with the resident as to what was going on. CPA #300 also stated she did not know his triggers or trauma history. Review of facility policy titled Behavioral Assessment, Intervention and Monitoring, dated September 2021, revealed the facility's expectation that as part of the comprehensive assessment, staff will evaluate the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers. The policy requires the interdisciplinary team to thoroughly evaluate behavioral symptoms, incorporate findings into the care plan, and monitor residents with impaired cognition and behavior.

Based on observation, interviews, record review, review of hospital records and policy review, the facility failed to facilitate guardianship and appropriate behavioral health services to meet the complex psychosocial needs of a resident with schizoaffective disorder, post-traumatic stress disorder (PTSD), depression, anxiety, and an intellectual disability, which resulted in Resident #03 continuing with behaviors that were detrimental to his psychosocial and physical well-being. This affected one resident (#03) of two residents reviewed for behaviors. The facility census was 55. Findings include:Review of the medical record for Resident #03 revealed an original admission date of 07/17/19 with a discharge to a local hospital on [DATE] and readmission of 12/09/25. Pertinent diagnoses included: Paraplegia, Type 2 diabetes mellitus, schizoaffective disorder, bipolar type; cognitive communication deficit, major depressive disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder, unspecified intellectual disabilities, chronic kidney disease and dysphagia oropharyngeal phase and dysphasia pharyngoesophageal phase. A diagnosis of acute respiratory failure with hypoxia was added 12/09/25 after Resident #03's hospitalization. A care plan focus revised on 12/12/24 revealed Resident #03 had an alteration in elimination due to need for ostomy. Interventions included: empty colostomy bag as needed, treatment to stoma site as ordered, monitor stoma site for complications when colostomy appliance is changed. Further review of the care plan revealed no mention of Resident #03 opening colostomy bag himself, there were no interventions regarding attempting to prevent Resident #03 from eating his feces and no interventions regarding what to do if Resident #03 was observed or suspected of eating his feces.A care plan focus revised on 03/11/25 revealed Resident #03 was at risk for alteration in psychosocial wellbeing due to diagnosis of depression, diagnosis of intellectual/developmental disability. Interventions included: administer medications per physician order. Monitor for effectiveness and side effects, encourage resident to ask questions when concerned with their medical condition to reduce anxiety, give non-judgmental support, monitor for psycho-social changes, observe and report any changes in mental status caused by situational stressors.An additional care plan focus revised on 01/24/26 revealed Resident #03 had an impaired psychiatric/mood status due to anxiety, bipolar disorder, depression, mood disorder and post-traumatic stress disorder (PTSD), anxiety, schizoaffective disorder no family support as evidenced by tearful. Interventions included: assist resident to cope by discussing possible solutions to conflict, behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.), encourage on-going family involvement, encourage participation from resident to make own decision, encourage resident to reminisce and review life to identify past coping skills and personal strengths, monitor mood, monitor sleep pattern changes, provide quality listening time and encourage expressions of feelings, refer to social worker as needed if resident communicates need to speak with someone.Review of the progress note dated 10/13/25 at 8:29 A.M. for Resident #03 revealed the nurse noted when she was doing dressing change, she witnessed Resident #03 eating bowel movements (BM) from a leaking colostomy bag. When the nurse attempted to educate resident to not eat his bowel movements, resident started yelling and hitting nurse. Nurse removed herself from the room and notified the physician. Review of a provider progress note dated 10/15/25 at 12:59 A.M. revealed Resident #03 had been reportedly removing his colostomy intermittently and ingesting stool. The note indicated the resident denied the behavior, but the staff had seen it multiple times. The note indicated the resident was tearful when discussing the issue. The note said the resident's behavior of ingesting stool was consistent with pica (an eating disorder characterized by a compulsive, persistent craving and/or consumption of non-food items) and that the plan was to educate the resident on the risks and dangers of ingesting non-food substances. The note indicated the resident would be monitored for any changes in status.Review of physician progress note dated 11/19/26 at 00:59 A.M. revealed Resident #03 was noted to have schizoaffective disorder, bipolar type, and moderate congenital intellectual delay, and was being evaluated for decision-making capacity and guardianship needs prior to surgery. The note indicated Resident #03 was scheduled for an upcoming surgery but was unable to provide informed consent due to impaired decision-making capacity. His psychiatric condition continued to affect his judgment and comprehension. The note also stated that Resident #03 had a moderate congenital intellectual delay that further limited his understanding. He reported attending regular classes in school and did not recall being told he had special needs or receiving any specific diagnosis related to his cognitive delay. He denied any prior discussions about guardianship and was uncertain whether he was ever supposed to have one. The note indicated Resident #03 was alert and cooperative but demonstrated limited understanding and was a poor historian. The physician noted Resident #03's condition affected his decision-making capacity, particularly in the context of consenting to upcoming surgery and recommended social services to expedite the guardianship process to ensure the resident had appropriate support for medical decision-making.Further review of the medical record for Resident #03 revealed no follow-up documentation related to the guardianship recommendation.Review of a progress note dated 12/01/25 at 11:37 A.M. revealed Certified Nursing Assistant (CNA) reported to the nurse that Resident #03 was in dining room putting five to six salt packets in his pudding. The CNA tried to explain to the resident that was a lot of salt and the resident began getting frustrated and crying. The CNA reported that the resident slammed his meal tray on the table and left the dining room. No further behaviors were noted.Review of Resident #03's progress notes revealed no progress notes were recorded on 12/03/25 regarding Resident #03 eating his stool.Review of a progress note dated 12/04/25 at 3:00 P.M. revealed Resident #03 was sent to the emergency room (ER) due to a sudden drop in his oxygen saturation to 72% on room air from his norm of 95-96% on room air, tachycardia with a pulse of 154 (beats per minute), sweating, and a low grade fever of 99.9 degrees Fahrenheit by temporal route. Resident #03 was reported to have gotten into his colostomy bag 24 hours previously and was observed eating his stool. He experienced nausea and dry heaves over the last 24 hours and would not eat any food. Fluid intake was minimal and only when encouraged. The progress note indicated the signs and symptoms came on rapidly and the nurse noted he was in the room [ROOM NUMBER] minutes prior working with the resident and his roommate, at which time the resident was not showing the above symptoms. 911 called and report was called to the local hospital prior to the arrival of Emergency Medical Services (EMS). No family or guardian was listed to call, but nursing staff did notify his friend per the resident's request.Review of psychiatry progress note dated 12/05/25 at 12:59 A.M. for date of service 12/04/25 revealed two weeks previously, Resident #03's Buspirone (an oral antianxiety medication) dose was reduced from 10 milligrams (mg) twice daily to 7.5 mg twice daily. He was also taking Wellbutrin XL (an oral antidepressant medication) 300 mg daily. The note indicated [on 12/04/25] the patient reported ongoing vomiting and nausea. He also denied depression, anxiety, suicidal ideation, and hallucinations. Staff reported that emesis began today. Yesterday [12/03/25], the patient was observed eating feces from his colostomy bag. Four days ago, he became frustrated and tearful after being educated about adding several salt packets to his pudding, then left the dining room area. No other behaviors were noted in the chart review. Further chart review indicated a diagnosis of schizoaffective disorder, bipolar type, since 2017 from an outside hospital. No further psychiatric history was available. Given recent gradual dose reduction (GDR) and behaviors after medication changes, a decision was made to increase Buspirone to prior dosing. Due to recent medical history findings, further medication adjustments may be necessary if symptoms and behaviors continue. Follow up scheduled for next visit to assess medication changes. Review of emergency room note dated 12/04/25 at 2:44 P.M. revealed Resident #03 presented to the emergency department due to nausea and vomiting and was hypoxic (low oxygen levels) and tachypneic (elevated and abnormally rapid, shallow breathing) and labored breathing in moderate respiratory distress. His oxygen saturation remained hypoxic in the 80's on four (4) liters of supplemental oxygen.Review of the hospital History and Physical dated 12/05/26 at 11:15 A.M. revealed Resident #03 had left lung pneumonia, likely aspiration, and acute respiratory failure with hypoxia associated with pneumonia.Review of the chest abdomen and pelvis computed tomography (CT) scan dated 12/05/25 at 8:18 P.M. revealed an impression of extensive multifocal bilateral airspace disease consistent with pneumonia. Given the appearance and distribution, aspiration should be considered etiology.Review of the progress note for Resident #03 dated 12/09/26 at 10:50 P.M. revealed resident returned from the hospital with a diagnosis of pneumonia.Review of a progress note dated 01/30/26 at 8:00 A.M. for Resident #03 revealed floor staff brought to nursing attention that Resident #03 had been eating out of his colostomy again. The resident did have what appeared to be dried stool on his hands and around his mouth. Nothing was noted in the resident's oral cavity. There was no odor noted by the nurse. Nursing reminded the resident it was not safe to put BM in his mouth nor ingest it and stressed how he could get sick. The resident began crying. Nursing tried to reassure the resident, but he continued to cry.Review of progress note dated 01/30/26 at 1:39 P.M. for Resident #03 revealed the certified nurse practitioner (CNP) was updated on resident having possibly consumed feces from his ostomy this morning. No new orders received.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #03 revealed Resident #03 was cognitively intact on the Brief Interview for Mental Status (BIMS) scale. Resident #03 was assessed to be independent for eating, dependent for toileting and required substantial/maximal assistance for showering/bathing, lower body dressing, and putting on footwear. Resident #03 required supervision or touching assistance for personal hygiene, set up or clean-up for oral hygiene. Active diagnoses included paraplegia, anxiety disorder, depression, bipolar, schizophrenia, and PTSD. Observation and interviews on 05/17/2026 at 10:23 A.M. of Resident #03 sitting in wheelchair facing the wall. Resident #03 said he had lived at facility three years. He denied any concerns with his care. Resident #02, roommate to Resident #03, said that Resident #03 had the mentality (cognition) of a five-year-old.During an interview on 05/18/26 at 1:02 P.M., Director of Social Services #269 confirmed there was no mention in the care plan of Resident #03's trauma history or triggers and there was no evidence a Pre-admission Screening and Resident Review had been filed notifying the local Area Agency on Aging regarding Resident #03's intellectual disability, schizoaffective disorder, Post-Traumatic Stress Disorder and new diagnosis of acute respiratory illness with hypoxia. Director of Social Services #269 additionally confirmed she did not know the resident's triggers.During an interview on 05/18/26 at 2:46 P.M., the Administrator confirmed there was no mention in the care plan of Resident #03 eating feces and therefore no suggested interventions for response when this behavior occurred.During an interview on 05/18/26 at 2:48 P.M., Director of Social Services #269 confirmed she had not followed up on the physician's request for guardianship. She said she felt that a guardian would take away the resident's right to make decisions.During an interview on 05/19/26 at 6:54 A.M., Licensed Practical Nurse (LPN) #273 reported Resident #03 was very childlike and she had seen him pick at his colostomy bag. She said she also had seen him eat his own scabs four or five times. She said she didn't think she had documented either because it wasn't a big deal. She said she didn't know what triggered his behaviors.During an interview on 05:19/26 at 7:09 A.M. CNA #259 said she had seen Resident #03 playing with his colostomy bag and also eating his own feces. She said she has had to clean his mouth out after he ate feces and it was so much that it made her have to leave the room to throw up herself. She said he was very childlike and whenever anyone would tell him not to pick at his [colostomy] bag or eat his feces, he would burst into tears. She stated she had also seen him eat ten salt packets. She said she had brought up the salt packets to the nurses, but they didn't seem to be concerned so she stopped telling them. She said Resident #03 had the mind of a child. She said she saw him on 12/04/25 when he went to the hospital and he was grayish in color and was vomiting. CAN #259 reported he really didn't like going to the hospital and he cried anytime he had to go. She said he typically wouldn't tell you if something was wrong or he was in pain even if you could see that he was hurting.During an interview on 05/19/26 at 12:08 P.M. Physician #301 noted that an individual who ate feces could pick up a parasite. He noted stool consists of a ton of bacteria and there was a potential for hepatitis (an inflammation of the liver, certain types can be caused by ingesting fecal matter).During an interview on 05/20/26 at 12:19 P.M. CNA #239 reported she had seen Resident #03 eat his feces multiple times. She said when she was providing care for him, if the bag was leaking, he would touch it and lick it. CNA #239 reported when he's told not to do it, he got embarrassed. CNA #239 reported he had habit of hiding food in his room that could spoil. CNA #239 reported she found a pork chop once. CNA #239 reported she has seen him put seven or eight salt packets on his food. She stated the friend that he had listed on his chart visited maybe once a year. She admitted she didn't always update the nurses on what she observed because the facility used agency nurses whom she felt didn't care.During an interview on 05/20/26 at 9:18 A.M. Registered Nurse (RN) #299 said had not personally witnessed Resident #03 eating stool, however, he had seen the aftereffects of stool under the nails and nausea. He said that he believed the change in condition on 12/04/26 was a direct result of Resident #03 eating the stool because it was such a drastic and quick change. He said the first thing he noticed was how pale Resident #03 looked. RN #299 said he didn't think Resident #03 understood what he was doing and the impact of eating stool, because Resident #03 was terrified whenever he had to go to the hospital. During an interview on 05/20/26 at 10:35 A.M. CNA #228 said Resident #03 cried frequently. She said he cried whenever he was told what to do. She said she did not know his triggers.During an interview on 05/20/26 at 11:52 A.M. Resident #02, the roommate of Resident #03, said that Resident #03 cried frequently but he wasn't sure why and that Resident #03 never would tell him. He confirmed he had seen the resident's colostomy bag leak on occasion.During an interview on 05/20/26 at 12:43 P.M., Certified Physician Assistant #300 confirmed she managed Resident #03's psychiatric medications. She confirmed she was not a therapist, and she confirmed she did not suggest interventions to staff regarding Resident #03 ingesting his feces. She said she only knew of the couple of documented instances of Resident #03 eating his feces. She said she received her information from record review and the nurses and did not speak with any of the aides. She said she was not aware that there were behaviors that were not documented. She said had she known that his behaviors of eating his feces and using copious amounts of salt were more chronic, she would have listed pica or coprophagia (the medical and behavioral term for the consumption of feces) as a diagnosis. She stated he would benefit from talk therapy and that if she had known about the ongoing behaviors, she would have explored more with him what was going on. She said she did not know his triggers or trauma history. Certified Physician Assistant #300 stated he always did well on the Brief Interview for Mental Status (BIMS) exam [measuring cognitive ability] however, on other tests he would score lower. Certified Physician Assistant #300 reported that he would also benefit from guardianship given his risk behaviors contradict his strong aversion to going to the hospital. During an interview on 05/20/26 at 1:47 P.M. the Director of Nursing (DON) confirmed there were no documentation of behaviors in the Kardex in October or December for Resident #03.During an interview on 05/20/2026 at 2:42 PM, CNA #268 said that she hadn't witnessed Resident #03 eating his feces but had heard about it. She said the resident's brother used to live at the facility as well and would make fun of him for his colostomy bag. She had seen Resident #03 dump five to six packets of salt on his food. She said if staff would say something to him about it, he would burst out and act like he was crying. During an interview on 05/26/26 at 6:05 A.M. CNA #274 confirmed she had seen Resident #03 pick at his colostomy bag until it opened and he recently did that two days in a row.During an interview on 05/26/26 at 8:16 A.M. the DON reported she could not find any documented evidence that the physician was notified on 12/03/25 regarding the resident eating his feces. She stated she would expect the physician to be notified and that if she was on the floor, she definitely would notify the physician. She stated she could not remember the last time that the resident's friend (listed as the resident's first contact in his medical record) came in to see him.During an interview on 05/26/26 at 8:23 A.M., Director of Social Services #269 confirmed she did not have a social work license and did not provide counseling to Resident #03. She reported they generally only notify Resident #03's friend if Resident #03 explicitly requests the friend to be notified. Director of Social Services #269 reported the friend had not been to care conference in a while.During an interview on 05/26/26 at 8:58 A.M., LPN #296 confirmed she had witnessed Resident #03 eating his feces. She said when she told him not to do it, he was very aggressive and she had to leave the room. She said when she had told other people about it, they told her that it wasn't uncommon for him. She expressed belief that he understood that he wasn't supposed to do it, but she didn't think he understood that it was harmful to his health. During an interview on 05/26/26 at 12:53 P.M., Physician #295 said he could not find any record that he was notified on 12/03/25 regarding the resident eating feces. Physician #295 reported he wasn't sure whether there was anything that could be done to stop Resident #03 from eating his feces. He said the care plans are done by nursing so he wouldn't be involved. He said he would expect that they [staff] clean the room and the resident. Physician #295 reported he had not been informed that the guardianship process did not go forward. He said that if Resident #03 didn't understand the implications of his decisions, then that would indicate guardianship might be beneficial. Physician #295 reported he planned to do another capacity evaluation and stated a guardian would also be able to advocate for a counselor as well if that was something Resident #03 wanted. Physician #295 stated we have to do what we can for [Resident #03] to have a good quality of life.Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, dated September 2021 revealed as part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of the medical record and general observations: the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the residents and others from harm.

Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders resulting in a medication error rate exceeding five percent. 26 opportunities were observed with three medication errors, resulting in a medication error rate of 11 percent. This affected two (#27 and #52) of six residents observed for medication administration. The facility census was 55. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 11/04/24. Diagnoses included paranoid schizophrenia, vascular dementia with behavioral disturbance, bipolar disorder, dysphagia, anxiety, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 11/04/25 revealed an order for Robitussin Cough plus Chest Congestion DM (dextromethorphan) oral liquid 20 milligrams (mg)/200 mg per 20 milliliters (ml), give 10 ml by mouth every 8 hours as needed for cough. The cough syrup contained 20 milligrams of dextromethorphan (cough suppressant) and 200 milligrams of guaifenesin (expectorant) per 20 ml. Observation on 05/19/26 at 10:19 A.M. of medication administration with Licensed Practical Nurse (LPN) #522 revealed the Robitussin Cough plus Chest Congestion DM medication was not in the medication cart. LPN #522 then checked the medication room and three medication carts for the ordered medication and was not able to find the medication. Further observation revealed LPN #522 then found another cough medication in the medication cart and proceeded to administer 10 milliliters of dextromethorphan Polistirex equivalent to Dextromethorphan Hydrobromide 30 mg/5ml (a cough suppressant). The cough syrup administered contained no guaifenesin, a cough expectorant. Interview on 05/19/26 at 11:07 A.M., LPN #522 verified the incorrect medication and incorrect dose of medication were administered to Resident #52. Interview on 05/20/25 at 10:49 A.M., the Director of Nursing (DON) verified the ordered cough medication was not the same as the cough medication administered by LPN #522. The DON further revealed LPN #522 had not reported the medication error. 2. Review of the medical record for Resident #27 revealed an admission date of 01/10/25. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, end stage renal failure, chronic kidney disease, vascular dementia, hypertension, atrial fibrillation, and dependence on renal dialysis. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 02/19/26 revealed an order for Divalproex Sodium oral tablet delayed release 250 mg, one tablet by mouth two times daily for a mood disorder. The medication was scheduled for 8:00 A.M. and 8:00 P.M. Further review of the physician orders revealed an order dated 03/02/26 for Sevelamer oral tablet 800 mg, give one tablet before meals for end stage renal disease. The medication was scheduled for administration at 7:00 A.M., 12:00 P.M., and 5:00 P.M.Observation on 05/19/26 at 10:24 A.M. of medication administration with LPN #522 revealed the Sevelamer 800 mg was scheduled for administration at 7:00 A.M. and the Divalproex sodium 250 mg was scheduled for administration at 8:00 A.M. LPN #522 never administered the two medications. Interview on 05/19/26 at 10:24 A.M. LPN #522 reveled she was not able to administer the Sevelamer and Divalproex Sodium on time and it was too late to administer the medications now as Resident #27 would be scheduled to receive another dose soon. Review of the medication administration record (MAR) dated 05/19/26 for Resident #27 revealed LPN #522 initially documented the resident had refused the omitted doses of Sevelamer and Divalproex Sodium. Further interview on 05/19/26 at 4:11 P.M., LPN #522 revealed she had not meant to document the resident had refused the medication and revealed she would correct the documentation in the MAR. LPN #522 revealed she had been running rampant today. Review of the MAR dated 05/19/26 for Resident #27 revealed LPN #522 corrected the documentation after surveyor intervention to note the resident had not received the medications and the physician was then contacted. Interview on 05/20/26 at 10:49 A.M., the DON verified LPN #522 had not reported the omitted medications for Resident #27 until after surveyor intervention.Review of the undated facility policy Administering Medications, revealed medications would be administered in a safe and timely manner, and as prescribed. Medications would be administered within one hour of their prescribed time. The individual administering the medication would verify the right resident, right medication, right dosage, right time, and right route before administering the medication. For medications withheld, refused, or given at a time other than the scheduled time, the nurse would use the appropriate code for documentation. Review of the facility policy Medication Errors, dated 09/2021, revealed medication errors include the wrong medication, wrong time, wrong dose, wrong route or form, wrong resident, and omission. Medication errors would be reported to the physician and Director of Nursing. Residents with medication errors would be monitored closely.

Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure a mechanical soft diet was provided per physician orders. This affected one resident (#38) of two residents reviewed for food. The facility census was 55. Findings include: Review of the medical record for Resident #38 revealed an admission date of 02/14/26. Diagnoses included chronic obstructive pulmonary disease, schizoaffective disorder, anorexia nervosa, anxiety, and hypertension.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.Review of the care plan dated 02/20/26 and last revised 05/13/26 revealed the resident was at risk for altered nutritional status due to significant weight loss and a mechanically altered diet. One intervention noted providing meals/snacks/fluids based on resident food preferences and physician orders.Review of a physician order dated 03/02/26 revealed the resident was ordered a regular diet with mechanical soft texture and thin liquid consistency.Review of the facility menu for 05/18/26 revealed cube steak for a mechanical soft diet should be ground and served with gravy. Review of the resident's meal ticket for 05/18/26 revealed the resident had a mechanical soft diet with an added grilled cheese at each meal. Observation on 05/18/26 at 12:22 P.M. revealed Resident #38 received his meal tray for lunch. Further observation of the meal tray revealed the resident had received a whole (not ground) cube steak.Interview on 05/18/26 at 12:22 P.M., Certified Nursing Assistant (CNA) #218 verified Resident #38 was on a mechanical soft diet. CNA #218 verified the resident had received a whole cube steak which was not appropriate for a mechanical soft diet. Interview on 05/18/26 at 12:25 P.M., Dietary Manager (DM) #284 verified the resident's cube steak should have been ground up and not served whole. DM #284 further revealed the dietary staff should have checked the meal ticket before sending the tray on the hall cart. Review of the facility policy Therapeutic Diets dated 09/01/21 revealed mechanically altered diets, as well as diet modified for medical or nutritional needs would be considered therapeutic diets. Further review of the policy revealed the food service manager would establish and use a tray identification system to ensure each resident received their diet as ordered.

Based on medical record review, interview, and review of the facility policy, the facility failed to ensure residents received the coronavirus (Covid-19) vaccination upon consent. This affected one (#22) of five residents reviewed for vaccinations. The facility census was 55.Findings Include: Review of the medical record for Resident #22 revealed an admission on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic bronchitis, and peripheral vascular disease (PVD). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had impaired cognition. Further review of the MDS revealed Resident #22 was not up to date on the Covid-19 vaccination. Review of the care plan dated 06/25/25 revealed Resident #22 had impaired respiratory status related to COPD, and pulmonary disease. Interventions included labs and diagnostics testing as ordered, and treatments as ordered by physician. Review of the Vaccine Informed Consent Form dated 10/31/25 revealed the facility offered the Covid-19 vaccination, and Resident #22 accepted to receive.Review of Resident #22's immunizations revealed there was no Covid-19 immunization administered. Review of the physician's orders for Resident #22 revealed no orders for the Covid-19 vaccination. Interview with Assistant Director of Nursing (ADON) #263 on 05/26/26 at 10:50 A.M. revealed Resident #22 signed to receive the Covid-19 vaccination however the vaccine never arrived from pharmacy. ADON #263 confirmed that it should have been followed up by ADON #263. ADON #263 further stated that a physician's order should have been obtained for the vaccination. Review of the facility policy titled Covid Vaccine-Residents dated 10/2023 revealed the Covid vaccine shall be offered to residents in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination unless is medically contraindicated.

Based on medical record review, resident and staff interviews, review of hospital records, and review of the facility policy, the facility failed to ensure Resident #10 was safely secured while in his electric wheelchair and failed to ensure his wheelchair was properly secured to the floor of the facility's transport van. Actual Harm occurred on 08/25/25 when, during transit, Resident #10's electric wheelchair tipped and moved forward. Resident #10 landed on the right side of his body while still in the wheelchair and hit his head on the transport van's floor. Resident #10 was admitted to the hospital for three days for treatment and monitoring before being discharged back to the facility. This affected one (Resident #10) of three residents reviewed for accidents. The facility census was 54.Findings include:Review of Resident #10's medical record revealed an admission date of 11/5/21. Diagnoses included acute and chronic congestive heart failure, acute and chronic respiratory failure, diabetes mellites, cerebral infarction, and acute pulmonary edema. Resident #10 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident #10's care plan dated 12/03/24 revealed the resident was at risk for falls due to decreased strength and endurance and a history of falls. Listed interventions included encouraging the resident to keep his self-releasing seat belt buckled when in chair and to provide resident education on safety interventions. Resident #10 had an activities of daily living (ADL) self-care performance deficit. Listed interventions included assisting residents with ADLs as needed, providing two-person assistance for bed mobility, transfers and toileting, utilizing a Hoyer (mechanical) lift for transfers and motorized wheelchair use for ambulation, and reporting changes in ADL abilities to the nurse, physician, and therapy. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment, dated 08/22/25, revealed Resident #10 was cognitively intact. He required extensive assistance from two staff members for bed mobility and required the use of a mechanical lift to move to and from bed to chair. Resident #10 utilized an electric wheelchair for mobility. Review of an incident report dated 08/25/25, at 9:30 A.M., revealed Transportation Specialist (TS) #101 called and reported, during transport with Resident #10, a car in front of her slammed on their brakes causing her to slam on her brakes and Resident #10 flipped forward in his wheelchair. She reported that she did secure Resident #10's wheelchair locks to the floor of the van. Review of an Emergency Medical Services (EMS) incident report dated 08/25/26 revealed EMS arrived on the scene at 9:38 A.M. and documented the patient (Resident #10) was secured in a power chair while being transported via a transport van. The van made a sudden stop and caused the secured wheelchair to break free. The patient flipped forward while secured to the wheelchair and landed on his right side with the wheelchair attached. The patient complained of right arm pain. The patient was paraplegic and denied loss of consciousness, head or neck pain at time of the initial assessment. The patient had a small laceration and swelling to his right eye and bleeding that subsided prior to arrival at the hospital. Review of the Emergency Doctor's Provider Notes dated 08/25/25 at 10:17 A.M. revealed Resident #10 had a history of a cardiovascular accident (stroke) presented to a local emergency department (ED) as a level 2 trauma after falling out of his wheelchair and striking his head when in transport as the vehicle came to a sudden stop. He denied loss of consciousness. Resident #10 was on blood thinners. He had an abrasion and slight swelling along his right eye. Resident #10 endorsed low back pain and right arm pain. All imaging tests were negative for acute fractures, however, Resident #10 was having significant lower back pain. He was admitted for pain control and ongoing monitoring. Review of the hospital Trauma Physician's progress notes, dated 08/25/25 at 8:34 P.M. revealed Resident #10 was in a wheelchair strapped to a van when it came to a sudden stop. The strap broke and he fell out of his chair and hit his head. Resident #10 complained of significant back pain and had an abrasion and slight swelling to the right side of his face. Computed tomography (CT) scan and x-ray imaging were negative but Resident #10 was being admitted to observation for pain control and physical and occupational therapy. The note referenced the resident was admitted with risk variables including coagulation defect, chronic fatigue and reduced mobility. Review of the nursing progress notes dated 08/25/25 revealed Resident #10 was out to a doctor's appointment. The notes revealed no indication of an accident or that Resident #10 was admitted to the hospital until 08/26/25 at 12:00 A.M. when the hospital called the floor nurse to verify the resident's information and the equipment he routinely used. Review of a summary of the incident dated 08/25/25, authored by the Administrator, revealed TS #101 had reported and described the incident to her. TS #101 stated the resident was utilizing his own wheelchair seatbelt, so the vehicle's seatbelt was not needed. The summary referenced following the incident, the Administrator provided re-education to all personnel qualified to drive the facility's van regarding proper utilization of Q'Straints (a fixed wheelchair securement system installed in the transport van) and seatbelt use. Review of a witness statement dated 08/28/25, authored by the Administrator, revealed the Administrator interviewed Resident #10 who stated he was buckled into his wheelchair with a seatbelt, but could not recall being strapped to the floor. He tipped forward with the wheelchair when a car cut TS #101 off and she had to slam on the brakes to avoid hitting another car. The statement concluded that the resident felt safe and well-cared for. The statement did not contain Resident #10's signature or initials. Review of Resident #10's progress notes revealed on 09/02/25, the resident complained of lower back and neck pain and was transferred to a local hospital by EMS. Review of Resident #10's Emergency Department Provider Notes, dated 09/02/25 at 3:36 P.M. revealed the resident was seen at a local hospital for a chief complaint of back and neck pain. Resident #10 reported he had a recent injury when his wheelchair was not secured correctly in a van, the driver slammed on the brakes, and his wheelchair went forward and landed on top of him. The note references Resident #10's family requested a repeat CT scan. Review of the imaging completed in the emergency department revealed a clinical impression of post-concussive syndrome, cervical (neck) pain, and chronic lower back pain. Resident #10 was discharged from the local hospital back to the facility on [DATE] at 5:20 P.M. During an interview on 10/07/25, at 2:00 P.M. the Administrator and the Interim Director of Nursing (DON) confirmed Resident #10 was being transported to an outside appointment on 08/25/25 in the facility van with (TS) #101 driving. During the transport, TS #101 had to slam on her brakes to avoid an accident. When she slammed on the brakes, Resident #10's electric wheelchair moved, and he and the chair moved forward, and the resident landed on the floor of the van directly behind the driver's seat. Resident #10 and his chair tipped over, landing him on his right side while still attached to his electric wheelchair when the van came to a complete stop. The police, firemen and emergency medical services (EMS) arrived, and Resident #10 was transported to a local hospital. A follow up interview on 10/07/25, at 2:30 P.M. with the Administrator stated Maintenance Director (MD) #123, TS #101, and Director of Activities #127 were trained to operate the bus. The Administrator stated the facility does not have any formal training policy or documentation confirming Maintenance Director (MD) #123, TS #101, and Director of Activities #127 were educated on the operation of the van and how to operate the van's lift and the four-point wheelchair securement system. The Administrator stated that MD #123 had demonstrated how to operate the van's systems including the chair lift and the four-point wheelchair securement system.During an interview on 10/07/25, at 3:25 P.M., MD #123 stated he had experience transporting residents to and from the facility for outside appointments. Prior to the incident on 8/25/25, he trained the two drivers from the facility but could not provide any documentation from the training such as a check-off list or topics covered during training. MD #123 shared he showed them how to operate the van, its mechanics, and the four-point wheelchair securement system. MD #123 stated he had accompanied them on transports with residents during a two-week period. TS #101 was trained by MD #123. When the incident with Resident #10 occurred on 08/25/25, he accompanied the Administrator to the van that was in a parking lot. He met with TS #101 who confirmed she secured Resident #10's electric wheelchair with the four-point wheelchair securement system. He drove the van back to the facility and noted Resident #10's chair was on the right side of the van during the transport; the seat belt provided with and attached to the electric chair was cut by the EMS personnel. He tested all four of the QRT-360 retractors (that secured Resident #10's electric wheelchair to the van floor) and they were working properly. It was his belief that the shoulder and belt restraint was not being used in the van during transport and could have hit the red release lever during transport; when the van stopped abruptly it released the tension of the left restraint webbing, allowing the wheelchair to move forward. He could not confirm the wheelchair was attached to the floor when the incident occurred. He did not report the incident to a Q'Straint authorized dealer after he believed the red release button faulted, causing the chair to move forward. During an interview on 10/08/25, at 8:23 A.M., Resident #10 stated he was on his way to a doctor's visit on 08/25/25. A female staff member was driving when she slammed on the van brakes. He was in his wheelchair and went forward, close to the driver's seat, where his wheelchair tipped over. Resident #10 stated he landed on the floor on his right side where he hit his face, head and arms. Resident #10 said his wheelchair had not been strapped into the floor of the van before transport. An ambulance, police officer, and fire truck arrived at the scene. He was transported by EMS to a local hospital where he was admitted for a few days. During an interview on 10/08/25, at 8:51 A.M., TS #101 stated she was driving on 08/25/25 to take Resident #10 to an outside appointment. She escorted Resident #10 to the facility van. She dropped the van lift to the driveway to allow Resident #10 to drive himself onto the lift. She belted him onto the lift; his wheelchair was turned off. She turned on the lift's power to lift him to the van floor. Resident #10 turned on the power of his chair and parked his chair to the designated area in the back of the van to allow her to secure Resident #10 and his wheelchair to the floor prior to leaving. Resident #10's wheelchair has a designated area for each QRT-360 Retractor System (Q'Straint ) to hook onto. She secured each Q'Straint to the designated areas of the wheelchair, two in the back and two in the front of the wheelchair. Because Resident #10 had his wheelchair seatbelt fastened, she did not place the Shoulder Belt across Resident #10. While transporting Resident #10 to the appointment she had to slam on the brakes to avoid hitting the car in front of her who had suddenly slammed on their brakes. The van came to a sudden stop, jolting her and the resident. She was wearing a seatbelt and was not injured. However, the resident's wheelchair and the resident slid up in the van directly behind the driver seat, the wheelchair tipped, and Resident #10 and his wheelchair landed on the floor on his right side. TS #101 stated she called 911. The local police, fire department, and EMS arrived. EMS removed Resident #10 from his wheelchair by cutting his seatbelt and placed him onto a stretcher and transported him to a local hospital. TS #101 started the van and parked it in a local grocery store parking lot and called the facility's Administrator. She could not recall if the wheelchair was still locked to the van floor when she came to a stop and saw it in the van tipped over and close to her seat. Review of Resident #10's Quantum Q6 Edge H.D. Power Chair owner's manual dated 02/2020, page 27, revealed the Positioning Belt on the chair is designed for the operator's comfort. It is designed to support the operator so that he/she does not slide down or forward in the seat. The positioning belt is not designed for use as a restraining device. The manual has a warning label indicating: the positioning belt is not designed for use as a seatbelt in a motor vehicle. Review of the Use and Care Manual QRT-360 4-Point Wheelchair Securement System Complaint Shoulder and Pelvic Belt Restraint must go across occupant's shoulder and pelvis (lap) and not be worn twisted or held away from the occupant's body by wheelchair components. We recommend using both a pelvic and shoulder belt together and not individually since it will compromise the performance system. The system must be regularly inspected, cleaned and maintained. All damage and defects must be reported to a Q'Straint authorized dealer. This deficiency represents non-compliance investigated under Complaint Number 2635799.

Based on medical record review, staff interview, review of the facility's Self-Reported Incident, and review of the facility's policy, the facility failed to safely transfer a resident. This resulted in Actual Harm to Resident #55 when State tested Nursing Aide (STNA) #985 improperly transferred Resident #55 utilizing a 'bear hug' technique and the resident subsequently dislocated her right shoulder and had to be sent to the emergency room for evaluation and treatment. This affected one (Resident #55) of four residents reviewed for accidents. The facility census was 59. Findings Include: Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, difficulty in walking, abnormalities of gait and mobility, dementia, and [CONDITION(S)]. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had mild cognitive impairment, had no behaviors, and required extensive assist of two persons for transfers. Review of the quarterly MDS assessment dated [DATE] revealed Resident #55 was cognitively intact with no behaviors and was dependent on two staff for transfers. Review of the progress note dated 05/12/22 at 2:26 P.M. revealed Resident #55 was transferred with two-person assist using the non-mechanical sit-to-stand lift. The progress note dated 05/13/22 at 8:50 P.M. revealed Resident #55 had a 21.5 centimeter (cm) by 13 cm bruise to the right flank area (side of a person's body between the ribs and the hip). The bruise was found by a staff member assisting Resident #55 to get ready for bed. The staff member reported the bruise to the nurse who documented Resident #55 denied the area being painful. Resident #55 did reveal to the nurse that staff had used the mechanical sit-to-stand twice on this day. Resident #55 denied feeling any pinching sensation during the transfers. Resident #55 stated she bruises easily. The note revealed two staff transferred Resident #55 to bed on this night and Resident #55 tolerated the transfer well. Subsequent review of the progress note dated 05/15/22 at 10:33 A.M. revealed Resident #55 complained of right upper arm pain rating a seven out of ten-pain scale (zero was no pain and a ten was the most severe pain). The nurse practitioner was notified, and a STAT (immediately, without delay) x-ray was ordered of the right upper arm area. Review of the right shoulder x-ray results dated 05/15/22 revealed Resident #55 had a dislocated total right shoulder arthroplasty. The humeral component was displaced medially. Subsequent review of the progress note dated 05/15/22 at 12:29 P.M. revealed the resident's x-ray results were called to the physician who gave orders to send to the emergency room for evaluation and treatment. The progress note dated 05/15/22 at 5:28 P.M. revealed Resident #55 returned to the facility and the family wished for Resident #55 to be a Hoyer lift for transfers. Resident #55 was documented to not use her right arm for pulling or to use it to pull to stand herself up. The progress note dated 05/17/22 at 12:29 P.M. revealed the interdisciplinary team (IDT) team had met and reviewed the resident's bruise to the right flank and the right shoulder dislocation. The note documented the IDT team had performed an investigation on the two injuries Resident #55 sustained. The facility determined Resident #55's injury to her right flank was caused by being transferred with the mechanical sit-to-stand lift and not the Sara Stedy Sit-to-Stand lift (a single caregiver transfer lift). The pressure from the belt on the mechanical sit-to-stand lift caused the bruising on the resident's right flank. The facility determined STNA #985 caused the dislocated right shoulder to Resident #55. During an interview with STNA #985, he stated he had improperly transferred Resident #55 on the overnight shift on 05/14/22. STNA #985 admitted to transferring Resident #55 by himself by using a bear hug technique to transfer Resident #55 and not the Sara Stedy lift. The IDT team determined the pressure of the resident's weight pulling her down and the strength of the STNA holding the resident up could cause Resident #55's shoulder to dislocate. The physician who consulted on the resident's case when Resident #55 was in the emergency room felt Resident #55 was not in discomfort and recommended to leave the injury to heal on its own. The physician did not recommend surgery. Review of the facility's Self-Reported Incident control number 4 revealed there was an allegation of injury of unknown source involving Resident #55 on 05/15/22. Resident #55 was found by staff with bruising in the right rib area and shoulder injury. An x-ray revealed a right shoulder dislocation. The facility's investigation concluded the allegation was substantiated as STNA #985 transferred Resident #55 incorrectly utilizing a bear hug technique. STNA #985 was educated he improperly transferred Resident #55 and was no longer permitted to return to work at the facility. Interview with the Director of Nursing on 08/11/22 at 1:00 P.M. confirmed STNA #985 transferred Resident #55 by using a bear hug transfer, worked the night shift, and provided care for Resident #55 on 05/14/22 into 05/15/22. The DON confirmed the facility determined the bear hug transfer was what caused the right shoulder total dislocation. Review of the facility's policy titled Safe Lifting and Movement of Resident, last revised on 05/31/18, revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The guidelines included the resident's safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents and manual lifting of residents shall be eliminated when feasible.

Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure water temperatures were warm enough while giving bed baths. This resulted in actual harm when two residents received repeated bed baths with cold water even after requesting staff to use warm water. This affected two residents (#38 and #30) of 10 residents reviewed for respect and dignity. The facility census was 54 Findings include: 1. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38 Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #38's care plan for self-care deficit dated 08/08/19 revealed the resident would remain clean, groomed and dressed per her preference. Resident #38 required assistance with mobility, mechanical transfers, and hygiene. Interview on 09/26/19 at 2:54 P.M. with Resident #38 revealed the facility was without hot water in resident rooms for the past couple of weeks. Resident #38 revealed she had a bed bath every day because she had a wound vac and it was her preference. The resident revealed the State tested Nursing Assistants (SNTAs) used cold water for her bed baths from 09/13/19 to 09/18/19 (six days). The resident would ask the STNAs to get hot water and she was told they could not get hot water because it would be cross contamination. The resident revealed finally on 09/19/19 she finally started getting hot water for her bed baths because the Assistant Director of Nursing (ADON) told the STNAs they could use hot water from the kitchen. Resident #38 revealed during the week of cold bed baths she felt unclean. She revealed she felt like it affected her quality of life as she was angry, and she seldom got angry. 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's MDS admission assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #30's current care plan for self-care deficit revealed Resident #30 would remain clean, groomed and dressed per her preference. Resident #30 required assistance with mobility, transfer, and hygiene. Interview on 09/26/19 at 11:36 [NAME]M. with the Director of Nursing (DON) revealed the STNAs were instructed to use foam soap that did not need to be rinsed or they could use wipes. They were also instructed to carry hot water to resident rooms in Ziploc bags if it was requested. Interview on 09/26/19 at 12:47 P.M. with STNA #120 revealed hot water was available in the main shower room, however there was no hot water in two shower rooms and in resident bathrooms. STNA #120 revealed bed baths were given if it was the resident's preference. The STNA revealed residents had complained to her about no hot water for the past couple of weeks. The residents were told last week the water heater would be fixed by 09/23/19 and it was not. The STNA #120 revealed Resident #38 had been receiving cold bed baths for a week because the staff told her it would be cross contamination to get hot water from the kitchen. Interview on 09/26/19 at 1:10 P.M. with the Interim Administrator confirmed residents did not have hot water in their bathrooms for almost two weeks. The parts needed to fix the water heater took a long time to come in, however they did just get them, and the repair is scheduled for 09/30/19. Interview on 09/26/19 at 3:33 P.M. with Resident #30 revealed the facility had no hot water for the past couple of weeks in resident rooms. The resident revealed the STNAs filled up her basin with cold water from her bathroom sink and would state, this is going to be cold, as they washed her up. The resident said she would tell them it was too cold, and it was upsetting to her, however they continued to use cold water. Interview on 09/26/19 at 4:36 P.M. with the DON verified the STNAs should not be using cold water for bed baths. The DON revealed the STNAs received training on getting warm water during their daily nursing huddles. Review of facility policy, Water Temperatures, undated, revealed the facility will maintain hot water temperatures within the acceptable range. This deficiency substantiates Master Complaint Number OH 201.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure appropriate interventions were in place to prevent skin breakdown. Actual harm occurred to Resident #48 when the facility failed to assess the resident's skin and implement inventions for pressure relief resulting in the development and worsening of a Stage III coccyx pressure ulcer. After development of the pressure ulcer the resident exhibited pain requiring the use of narcotic [MEDICATION NAME]. This affected one Resident (#48) of one reviewed for pressure ulcers. The facility identified zero residents residing in the facility with pressure ulcers. The facility census was 52. Findings include: Review of Resident #48's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] identified the resident as having moderate cognitive impairment. The resident required extensive two person assist with bed mobility, transfers, dressing, toilet use and person hygiene. The resident required extensive one person assist with locomotion on and off the unit. The resident was frequently incontinent of urine and always incontinent of bowel. The resident was at risk of developing a pressure ulcer and the resident did not have any pressure ulcers. Review of Resident #48's care plan updated on 04/27/17 identified the resident as being at risk for developing skin breakdown. Interventions included to report changes in skin status to the physician, minimize pressure over bony prominence's, and complete weekly skin checks. Review of Resident #48's medical record identified the resident as seeing the wound clinic for venous ulcers to his lower extremities. Further review of the medical record including weekly skin assessments failed to identify any evidence from March 2017 until April 2017 that weekly skin assessments were being completed for Resident #48. Review of the wound clinic note dated 04/27/17 revealed an initial order to wash the coccyx with soap and water, pat dry, apply [MEDICATION NAME] (a topical antibiotic used to treat or prevent infections) and foam border dressing; change every three days and as needed if becomes soiled. Additionally, interventions included to turn the patient at least very two hours to off load buttocks and back. Additional review of Resident #48's medical record including weekly skin assessments failed to identify any evidence the residents pressure ulcer to the coccyx was being assessed and monitored by the facility after the pressure ulcer was identified on 04/27/17. Review of the wound clinic note dated 05/04/17 revealed the residents coccyx wound measured 2.8 centimeter (cm) x 0.5 cm x 0.2 cm and without tunneling. The wound had moderate serosanguinous (drainage containing both blood and serous fluid) drainage, with a large amount of red and pink granulation tissue (new connective tissue and blood vessels that form on the surface of a wound during the healing process). There was no necrotic (dead tissue) tissue present and without foul odor. Review of the wound clinic note dated 05/16/17 revealed the residents coccyx wound measured 2.4 cm x 0.8 cm x 0.3 cm and without tunneling. The wound had a scant amount of serous drainage and a small amount of pink granulation tissue. It indicated the wound had a moderate amount of yellow necrotic tissue and without a foul odor. Review of the 'non-pressure skin condition record' identified Resident #48 had a mid buttock wound that was first observed on 06/03/17 and the first initial evaluation was completed on 07/11/17. The wound measured 4.5 cm x 1.7 cm x 0.1 cm and without tunneling. The wound was located in the crack of the coccyx. The wound was described as dark pink with macerated edges with a moderate amount of bloody serosangeious drainage and without odors. There was a new treatment ordered per the wound clinic with a follow up appointment on 07/25/17. The speciality interventions that were put into place noted to be a pressure reducing mattress, a pressure reduction cushion to wheel chair and turning and repositioning every two hours. Measurements were then completed on 07/18/17 which identified the wound as deteriorated and on 07/27/17 which indicated the wound had not changed. On 08/01/17 the wound was measured and was 4.5 cm x 2 cm x 0.1 cm with 0.3 cm tunneling at 12 o'clock of the wound. The wound bed was pink with edges intact with a moderate amount of serous drainage noted. There was a new area of tunneling noted to the top of the wound and revealed the wound had not improved. The resident was to follow up with the wound clinic on 08/08/17. Review of the weekly skin note dated 08/07/17 revealed the measurements were 4.5 cm x 2 cm x 0.1 cm with 0.3 cm tunneling at 12 o'clock of the wound. The wound bed was pink with some slough with a small amount of serous drainage. The wound had not improved, and the treatment continued as ordered plus a new order for Dakins solution (solution used to kill germs and prevent germ growth in wounds) half strength to the wound bed because of slight odor and to follow up at the wound clinic on 08/08/17. Review of Resident #48's medical record indicated that treatments were changed per the wound clinic, however, there were no changes in interventions to prevent the worsening of the pressure ulcer. A nurses note on 08/07/17 at 7:47 P.M. revealed the residents wound to coccyx had a very strong odor and had dark discharge. The physician assistant was updated and new order for Dakins half strength solution was obtained. Review of the wound clinic notes dated 08/08/17 identified the resident as having a pressure ulcer of sacral region, stage 3. Review of a nurses note dated 08/11/17 at 6:12 P.M. revealed the resident was experiencing large amounts of pain during the dressing changes and there was a new order received for [MEDICATION NAME] 50 milligrams (mg) my mouth every six hours as needed for pain. Review of the physicians order dated 08/11/17 revealed an order to cleanse the wound to the coccyx with normal saline, pack with Dakins soaked gauze wet to dry dressing two times a day for seven days. Additionally, there was an order dated 08/11/17 for [MEDICATION NAME] 50 mg one tablet by mouth every six hours as needed related to coccyx pain. Review of the physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED]. Interview with Assistant Director of Nursing (ADON) #61 on 09/06/17 at 10:30 A.M. revealed she was the nurse who did wounds. She voiced Resident #48 did not have any pressure area's. She voiced the area to the residents coccyx was not from pressure and was moisture associated. Interview with the Director of Nursing (DON) at this same time indicated Resident #48's wound to his coccyx was not from pressure. The DON voiced this area was open and it started from moisture and then his skin broke down. Observation on 09/06/17 at 2:00 P.M. revealed Resident #48 lying in bed, on his back. Observation on 09/06/17 at 3:34 P.M. revealed Resident #48 lying on his back in bed, sleeping. An additional interview with ADON #61 on 09/06/17 at 4:56 P.M. again denied Resident #48 having a pressure ulcer to his coccyx. She voiced the resident had an area to his mid buttock that was due to moisture. ADON #61 confirmed her skin assessments on 08/01/17 and 08/07/17 identified the resident as having 0.3 cm of tunneling at 12 o'clock on the wound. On 09/06/17 at 5:43 P.M. ADON #61 confirmed she was unable to find any evidence the facility was completing weekly skin assessments with measurements until 07/11/17. ADON #61 confirmed Resident #48 developed an odor to his wound and they started doing a wet to dry dressing with Dakins solution and that cleared up the odor. Interview with the DON on 09/06/17 at 7:00 P.M. confirmed Resident #48 did not have an air mattress in place. She confirmed the resident did not have an air mattress in place because he was not assessed as having a pressure ulcer and air mattresses are only used for residents with pressure ulcers. Interview with ADON #61 on 09/07/17 at 10:40 A.M. confirmed the first day observed for the mid buttocks wound was on 06/03/17: however, the first initial evaluation of the wound was not completed until 07/11/17. ADON #61 voiced Resident #48's area started out with shearing and then the area opened up. Observation on 09/07/17 at 11:05 A.M. revealed Resident #48 lying in bed on his back. Observation on 09/07/17 at 11:08 A.M. revealed ADON #61 and LPN #5 completed Resident #48's dressing to change to his coccyx. The wound was measured by ADON #61 and measured 4 cm x 1.5 cm x 1.5 cm with 0.4 cm tunneling at the 12 o'clock area of the wound. The wound bed appeared to be dark pink with minimal amount of slough observed in the wound bed. There was no odor present. The wound was cleansed with normal saline and pat dried and medi-honey was applied to the wound as ordered and [MEDICATION NAME] was applied. Interview with the DON on 09/07/17 at 12:35 P.M. revealed if a resident had a pressure ulcer at a stage 3 or 4 the resident would have an air mattress per their policy. She voiced measurements would be completed weekly, treatments would be assessed weekly and if the wound did not show improvement the treatment would be changed. The DON voiced if a pressure ulcer contained slough and was not completely covering the wound it would be staged at a stage 2. The DON confirmed she was unaware the wound clinic staged the coccyx wound as a stage 3 pressure ulcer. Interview with the Physician Assistant (PA) #82 on 09/07/17 at 12:34 P.M. revealed he felt the residents coccyx wound was caused from moisture and friction. When the PA was asked if he felt this was pressure related he voiced you can't have friction without pressure. Interview with the DON on 09/08/17 at 10:49 P.M. confirmed she was unable to find any evidence of skin assessments being completed during the months of March-April. Review of the facility policy titled 'Pressure Ulcer Treatment' dated 06/01/15 identified a stage three pressure ulcer as a full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and spibole (rolled wound edges) are often present. Slough and or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. if slough or eschar obscures the extent of tissue loss this is an unstageable pressure ulcer. It indicated for a stage three pressure ulcer to: Protect. Fill dead space including tunnels and undermining. Manage drainage. Promote moist wound healing. Manage pain. Low air loss mattress. Turn/reposition/offload. It further indicated the treatment for [REDACTED]. Apply hydrogel, Silver gel, Medi-honey, or Santyl to the wound cavity. Cover with bordered gauze and if there is medium to heavy drainage may add alginate or foam. Review of the Signature Healthcare Standard Support Surface Algorithm reveled if the resident has a stage three and or stage four pressure ulcer and if moisture management is required then a low air loss mattress is required.