Every finding on record at Gem City Healthcare and Rehabilitation Center

Based on record review, observation, interview, and facility policy review the facility failed to wear proper Personal Protective Equipment (PPE) while providing personal care. This affected one Resident #02 out of 23 residents requiring PPE for Enhanced Barrier Precautions (EBP). the faciity also failed to ensure clean linens were stored appropriately. This had the potential to affect all residents. The facility census was 33.Findings include: 1. A chart review revealed Resident #02 was admitted on [DATE] with diagnosis including hemiplegia/hemiparesis, dysphagia, diabetes, and depression. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #02 received nutrition through enteral method and was dependent on staff for completion of activities of daily living. Review of physician order dated 05/28/25 revealed Resident #02 was ordered to have Enhanced Barrier Precautions due to gastronomy tube. An observation on 05/20/26 at 10:18 A.M. with Licensed Practical Nurse (LPN) #15 revealed Certified Nursing Assistant (CNA) #47 was providing incontinence care to Resident #02 without wearing PPE. An interview on 05/20/26 at 10:18 A.M. with LPN #15 verified CNA #47 was not wearing the proper PPE while providing care to Resident #02. An interview on 05/20/26 at 10:18 A.M. with CNA #47 revealed she was unaware that she was supposed to wear PPE while providing care to Resident #02. Review of the Enhanced Barrier Precautions not dated revealed PPE for EBP is only necessary when performing high-contact care such as: providing hygiene, dressing, bathing, transferring, changing linens, and changing briefs or assisting with toileting. 2. Observation and interview on 05/19/26 at 8:20 A.M. with the Maintenance Director (MD) #12 and the Administrator of the clean linen room revealed a large 30 gallon trash can full to the top of dirty clothes with a sign on it stating resident dirty clothing only sitting next to the clean exit door filled with dirty clothes and trash. The Administrator stated the trash can should not be in the clean linen room. Observation and interview on 05/19/26 at 8:25 A.M. with the MD #12 of the clean linen room revealed clean linen in six large boxes on the floor. The floor was observed to be covered with a black and brown substance and appears very dirty. The MD #12 confirmed the observation of the clean linen room dirty floor and large trash can with full of dirty clothes. Review of the policy titled, Laundry, dated 12/2024, revealed soiled laundry shall be kept separate from clean laundry at all times. This deficiency represents non-compliance investigated under Complaint Number 2975623.

Based on observations, interviews, and facility policy review the facility failed to ensure food was stored and prepared under sanitary conditions. The facility failed to ensure portion sizes were accurate according to the approved recipe, and the facility failed to ensure a substitution log was maintained. This had the potential to affect 29 residents who consumed meals prepared in the facility kitchen. The facility census was 33.Findings include:1.Observations on 05/18/26 at 9:45 A.M. of the kitchen revealed no hair nets available for staff to use upon entry into the kitchen. Additional observation of the kitchen and dry storage revealed the floors in the kitchen food preparation and storage areas were dirty with crumbs, pieces of food, sugar packets, single serving maple syrup packets, and empty boxes located on the floors throughout the kitchen and dry storage area. Observation of dry food storage revealed three bags of Tostitos chips with a use by date of 03/24/26 on a storage shelf for active use. Observation on 05/18/26 at 10:04 A.M. of walk-in refrigerator revealed a box of eggs with damaged eggshells with what appeared to be egg yolk which had run out of the box of eggs and dripped onto an opened box of individual coffee creamers on the shelf below the eggs. Additional observation revealed containers of Frenches yellow mustard with an open date of 02/16/26, sweet pickle relish with an opened date of 12/21/25, vanilla cream icing with an opened date of 02/25/26, and two containers of mayonnaise with an opened date of 02/23/26. Continued observation of the walk-in refrigerator revealed three gallons of whole milk with expiration dates of 04/26/26 on each gallon. Observations also revealed condensation dripping from the ceiling of the refrigerator onto the floor resulting in a puddle of water on the refrigerator floor. Observation on 05/18/26 at 10:12 A.M. of the walk-in freezer revealed pieces of french fries littered on the freezer floor. In addition, there was a bag of unopened cauliflower on the floor, a box containing a chocolate cream pie and an unopened box containing chicken on the floor of the freezer. Continued observation of the walk-in freezer revealed a buildup of approximately one-inch-thick ice on the floor of the freezer covering an area approximately 16 inches by 24 inches directly under the compressor to the left of the freezer door.An interview on 05/18/26 at 10:15 A.M. with Acting Kitchen Manager (AKM) #91 confirmed the lack of hair nets available for staff at the entrance to the kitchen. AKM #91 confirmed that the floors in the kitchen preparation area and dry good storage area were dirty and should be cleaned. Continued interview with AKM #91 revealed the three bags of Tostitos chips with a use by date of 03/24/26 were on a storage shelf for dry goods in active use to feed residents. AKM #91 confirmed a box of eggs in the walk-in refrigerator contained eggs with cracked shells and that what appeared to be egg yolk had dripped down onto an opened box of individual coffee creamers on the shelf below the eggs. AKM #91 confirmed opened dates written on the containers of Frenches yellow mustard of 02/16/26, sweet pickle relish of 12/21/25, vanilla cream icing of 02/25/26, and two containers of mayonnaise of 02/23/26. AKM #91 revealed he was unsure of the policy on how long after the documented open date the mustard, relish, icing and mayonnaise were allowed to be used. Continued interview with AKM #91 confirmed three gallons of whole milk with expiration dates of 04/26/26 on each gallon, which were still on a shelf for active use, and AKM #91 confirmed the condensation dripped from the ceiling of the refrigerator onto the floor resulting in a puddle of water on the refrigerator floor. Continued interview with AKM #91 confirmed the walk-in freezer had pieces of french fries littered on the freezer floor, confirmed there was a bag of unopened cauliflower on the floor, a box containing a chocolate cream pie and an unopened box containing chicken on the floor of the freezer. AKM #91 confirmed that no food items should be stored on the floor. Continued interview with AKM #91 confirmed the buildup of approximately one-inch-thick ice on the floor of the walk-in freezer covering an area approximately 16 inches by 24 inches directly under the compressor to the left of the freezer door.Interview on 05/19/26 at 1:41 P.M. with Director of Maintenance (DM) #12 confirmed a buildup of approximately one-inch-thick ice on the floor of the walk-in freezer covering an area approximately 16 inches by 24 inches directly under the compressor to the left of the freezer door. Continued interview with DM #12 confirmed condensation had dripped from the ceiling of the refrigeraor onto the floor resulting in a puddle of water on the frefrigerator floor. Continued interview with DM #12 revealed DM #12 would reach out to an HVAC company to look at the walk-in freezer and refrigerator.Review of a document titled Hearthstone Hospitality Management Dining [NAME] Policy and Procedure Manual with an effective date of 01/01/25 revealed, The kitchen and associated equipment will be properly maintained. All non-food contact equipment will be clean and free of debris. All foods will be stored and wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Additional document review revealed, The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.2.Observation on 05/18/26 at 12:00 P.M. of lunch tray line service revealed AKM #91 used a six oz scoop to plate the carrots being served. Continued observations revealed AKM #91 ran out of carrots prior to plating the last five resident meals. AKM #91 substituted a salad on the last five plates for resident meals.Interview on 05/18/26 at 12:00 P.M. with AKM #91 confirmed the use of a six oz scoop to serve the carrots and reported it should have been a three oz scoop, but the kitchen's only three oz scoops were still dirty from last night's dinner service, so AKM #91 estimated a three oz portion in the six oz scoop. AKM #91 confirmed his decision to substitute a salad for the carrots for the last five resident plates.Interview on 05/20/16 at 3:25 P.M. with AKM #91 revealed the kitchen staff did not have method of documenting and tracking menu substitutionsReview of a document titled Hearthstone Hospitality Management Dining [NAME] Policy and Procedure Manual with an effective date of 01/01/25 revealed, A menu substation log will be maintained on file.3. Observation on 05/19/26 at 12:20 P.M. revealed lunch was served as an open-faced turkey sandwich with mashed potatoes and gravy on top with a side of brussel sprouts and pudding for dessert. Interview on 05/19/26 at 1:14 P.M. with [NAME] #92 confirmed that lunch was served as an open-faced turkey sandwich with mashed potatoes and gravy on top with a side of brussel sprouts and pudding for dessert. [NAME] #92 confirmed this meal did not match the menu listed for today and reported they did not have the menu items listed for today in stock so [NAME] #92 made a substation meal. Continued interview with [NAME] #92 revealed he was not aware of any substation log in which to track menu item substitutions.Interview on 05/20/16 at 3:25 P.M. with AKM #91 revealed the kitchen staff did not have method of documenting and tracking menu substitutionsReview of a document titled Hearthstone Hospitality Management Dining [NAME] Policy and Procedure Manual with an effective date of 01/01/25 revealed, A menu substation log will be maintained on file.4.Review of food temperature logs revealed that food temperature logs were missing for 03/02/26 through 03/05/26, 03/07/26 through 04/06/26, and from 04/26/26 through 04/31/26. Interview on 05/21/26 at 1:16 P.M. with AKM #91 confirmed that food temperature logs were missing for 03/02/26 through 03/05/26, 03/07/26 through 04/06/26, and from 04/26/26 through 04/31/26. Continued interview with AKM #91 revealed that food temperatures are expected to be checked and recorded at every meal and he was unable to locate documentation indicating this practice had been followed for the above-mentioned dates.Interview on 05/21/26 at 2:39 P.M. with Administrator #01 revealed the facility never had any issues with foodborne illnesses for residents. Review of a document titled Hearthstone Hospitality Management Dining [NAME] Policy and Procedure Manual with an effective date of 01/01/25 revealed, Temperature of Time/Temperature Control for Safety (TCS) foods will be recorded at time of services, and monitored periodically during meal service periods. Further review of this policy revealed no specific time frame after which opened containers of condiments housed in a refrigerator should be discarded.This deficiency represents non-compliance investigated under Complaint Number 3013025.

Based on observation, interview, and policy review, the facility failed to properly store medications. This had the potential to affect 10 Residents (#11, #26, #42, #43, #44, #45, #46, #47, #51 and #52) admitted in the last 30 days. The facility census was 33.Findings include:Observation on 05/20/26 at 8:09 A.M. with Licensed Practical Nurse (LPN) #15 of the second floor medication room revealed an opened vial of Aplisol 5 milliliter/milligrams (ml/mg) that was not dated. Interview on 05/20/26 during observation with LPN #15 verified the vial of Aplisol 5 ml/mg was open and not dated.Observation on 05/20/26 at 10:25 A.M. with LPN #14 of the second floor medication room revealed an opened vial of Aplisol 5 ml/mg that was not dated and a second vial dated 11/06/25.Interview on 05/20/26 during observation with LPN #14 verified the vial of Aplisol 5 ml/mg was open and not dated and a second vial dated 11/06/25.Review of the Food and Drug Administration STN:BL 103782 revealed Aplisol/Tuberculin, Purified Protein Derivative is utilized to aid in the detection of infection with Mycobacterium tuberculosis. https://www.fda.gov/vaccines-blood-biologics/vaccines/tuberculin-purified-protein-derivative-aplisolReview of the manfacture package insert for Aplisol revealed Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.Review of the Medication Storage Policy dated 02/2023 revealed that this facility to ensure all medication housed on premises will be stored in pharmacy and/or medication room according to the manufacturer's recommendations to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on observation, interview, and facility policy review, the facility failed to ensure that garbage cans in the kitchen were properly covered when not in active use. This had the potential to affect all 29 residents who consumed meals prepared in the facility kitchen. The facility census was 33.Findings include:Observation on 05/18/26 at 9:45 A.M. revealed two garbage cans located in the kitchen food prep area and one garbage can located in the dish room of the kitchen, all without lids on them and all three cans not in active use.Interview on 05/18/26 at 10:23 A.M. with Acting Kitchen Manager #91 confirmed there are two garbage cans in the kitchen food preparation area and one in the dish room area all without lids. AKM #91 revealed he is unable to locate lids for any of these three garbage cans and is unable to cover them when not in active use.Review of a document titled Hearthstone Hospitality Management Dining [NAME] Policy and Procedure Manual with an effective date of 01/01/25 revealed, All trash will be contained in covered, leak-proof containers that prevent cross contamination. This deficiency represents non-compliance investigated under Complaint Number 3013025.

Based on observation, interview, and policy review the facility failed to ensure the steam table in the kitchen was functioning properly. This had the potential to affect all 29 residents who consumed meals prepared in the facility kitchen. The facility census was 33.Findings include:Observation on 05/18/26 at 12:00 P.M. revealed that the steam table used to maintain food at safe serving temperatures in the kitchen would not turn on.An interview on 05/18/26 at 12:00 P.M. with the Acting Kitchen Manager (AKM) #91 revealed the steam table did not turn on today when AKM #91 was preparing to set up for lunch service. Further interview with AKM #91 revealed he had informed maintenance the steam table would not turn on.Observation on 05/20/26 at 3:25 P.M. revealed the steam table in the kitchen was not in working order.Interview on 05/20/26 at 3:25 P.M. with AKM #91 confirmed that the steam table was still not in working order and that maintenance was aware.Review of a document titled Hearthstone Hospitality Management Dining [NAME] Policy and Procedure Manual with an effective date of 01/01/25 revealed, The kitchen and associated equipment will be properly maintained and that all Dining Services staff follow safe operating practices. All kitchen and kitchen equipment issues will be promptly reported to facility staff and recorded according to facility protocol.

Based on interviews, record review, and facility policy review, the facility failed to maintain an accurate medical record regarding administration of diabetes related medication. This affected one resident (Resident #15) out of six residents reviewed for insulin administration. The facility census was 33.Findings include:Review of the medical record of Resident #15 revealed an admission date of 11/21/25. Diagnoses included acute and chronic respiratory failure, dependence on respirator (ventilator) status, tracheostomy status, major depressive disorder, personal history of other venous thrombosis and embolism, Type II Diabetes Mellitus, dependence on supplemental oxygen, chronic kidney disease stage III, and muscle weakness.Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, did not reject care and did not wander. Resident #15 required supervision assistance for eating, oral hygiene, maximal assistance for toileting hygiene, upper body dressing, lower body dressing, personal hygiene, dependent assistance to roll left and right, and chair to bed transfers.Further record review for Resident #15 revealed a physician order for 1.2 mg of Victoza subcutaneous solution pen-injector daily from 11/22/25 through 03/06/26. Further record review revealed another physician order for 1.8 mg of Victoza subcutaneous solution pen-injector daily starting 03/07/26 and with no end date.Review of Resident #15's Medication Administration Records (MAR) revealed there was no documentation indicating administration of the resident's Victoza medication on 03/04/26, 03/10/26, 03/13/26, 03/17/26, 04/11/26, 04/20/26, and 04/28/26.During an interview on 05/28/26 at 2:08 P.M. with Resident #15 the resident reported that she consistently received her diabetes-related medication, Victoza, on time and as prescribed.An interview on 05/21/26 at 9:20 A.M. with the Director of Nursing (DON) #13 confirmed Resident #15's MAR indicates the resident did not receive Victoza medication on the following dates 03/04/26, 03/10/26, 03/13/26, 03/17/26, 04/11/26, 04/20/26, and 04/28/26. In continued interview with DON #13 she reported she knows Resident #15 received her Victoza medications on the above dates and DON #13 believes these blank administration blocks on Resident #15's MAR were related to a documentation error and not a medication administration error.Review of an undated facility policy titled Documentation in Medial Record revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observation, interview and facility policy review, the facility failed to provide a functional and sanitary environment for one, (Resident #32) of four reviewed for the environment. The facility census was 33.Findings include:Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included morbid obesity with alveolar hypoventilation, major depressive disorder, and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 cognitively intact. Observation and interview on 05/20/2026 at 9:56 A.M. with a confidential employee in Resident #32's room revealed the sink filled completely up with brown water and the pipe to floor under the sink is discolored and dripping. The floor under the sink had a puddle of water, stain, and strong foul smell was noted out to the hallway. The confidential employee stated the sink had been clogged on and off for months. Interview on 05/20/26 at 10:01 A.M. with Resident #32 revealed the sink has been clogging up for months. Resident #32 stated it happened first in February, and the facility had snaked the sink multiple times but it keeps clogging and the smell is bad. Interview with Maintenance Director (MD) #12 on 05/20/26 at 10:16 A.M. confirmed he has been aware of the sink being clogged on and off and had snaked it. The MD #12 also confirmed no plumber had been to the facility to look at or repair the sink.Interview on 05/20/26 at 10:18 A.M. with the Administrator confirmed Resident #32's sink had clogged multiple times. Review of the policy titled, Environmental Services Inspection, dated 02/2024, revealed it is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. This deficiency represents non-compliance investigated under Complaint Numbers 3013025, 2987498, and 2975623.

Based on record review, interview, and facility policy review, the facility failed to submit a Discharge Return not Anticipated Minimum Data Set (MDS). This affected one, (Resident #31) of 17 residents reviewed in the initial pool. The facility census was 33.Findings include:Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including cardiac arrest, hypothermia, schizophrenia, epilepsy, and anxiety.Review of the Discharge Return not Anticipated MDS dated [DATE] revealed Resident #31 had no cognitive deficits and was independent with activities of daily living. MDS dated [DATE] revealed it was completed but was never submitted to Centers for Medicaid/Medicare Services (CMS) for acceptance.A telephone interview on 05/21/26 at 12:30 P.M. with MDS Nurse #25 verified if a MDS assessment shows completed then it has not been submitted/transmitted to CMS for acceptance. Review of the MDS Coordinator Job Description not dated revealed to transmit assessments in accordance with current regulations. To facilitate timely receipt of validation reports, will transmit as frequently (daily) as necessary to obtain timely validation of MDS acceptance into the Quality Improvement and Evaluation System, Assessment Submission and Processing System database.

Based on interview, record review and facility policy review, the facility failed to ensure three residents, (#22, #4 and #13) of 19 reviewed, had comprehensive care plans that reflected the resident's care needs. The total facility census was 33.Findings include: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, dependence on respirator, neuralgia and neuritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact, required set up for eating, was dependent for toileting, bathing and personal hygiene. Resident #22 had adequate vision and utilized corrective lenses. Review of the provider orders dated 05/13/25 for Resident #22 revealed resident may receive vision consults as needed per personal plan of care. Review of the care plan dated 08/17/22 revealed Resident #22 did not have vision needs or interventions in the care plan. Interview on 05/18/2026 at 10:34 A.M. with Resident #22 revealed the need for an eye doctor. Resident #22 stated she has requested to see an eye doctor for months and has not seen one yet. Interview on 05/20/26 at 11:16 A.M. with the Director of Nursing (DON) confirmed Resident#22's care plan did not address the resident's vision needs. 2. Review of the medical record for Resident #04 revealed the resident was admitted on [DATE] with diagnoses including insomnia, obesity, anxiety, schizoaffective disorder, chronic pain, and depression. Review of the Quarterly MDS dated [DATE] revealed Resident #04 had no cognitive deficits and required substantial to dependence on staff to complete activities of daily living. Review of physician order dated 10/08/25 revealed Resident #04 had an order to give Oxycodone (opioid) five milligrams (mg) every six hours as needed for pain in the right leg. Review of physician order dated 04/07/26 revealed to apply skin prep to bilateral heels topically one time a day for skin integrity. Review of Resident #04 care plans revealed the absence of a pain care plan and a skin integrity care plan. An interview on 05/21/26 at 11:37 A.M. with the DON verified that Resident #4 did not have a care plan for pain. 3. Review of the medical record for Resident #13 revealed the resident was admitted on [DATE] with diagnosis including depression, adjustment disorder, and diabetes. Review of Resident #13's physician orders revealed an order dated 02/26/26 for Sertraline (antidepressant) 50mg and Lexapro (antidepressant) 5mg. Review of the care plans for Resident #13 revealed the absence of care plans for depression or antidepressant medications. An interview on 05/21/26 at 11:37 A.M. with the DON verified Resident #13 did not have a care plan for depression or anti-depressant medication use. Review of the Comprehensive Care Plans Policy dated 02/01/20 revealed it is the policy to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on resident interview, staff interview, record reviews, and policy review, the facility failed to provide showers to residents as scheduled. This affected one, (Resident #10) of 12 residents reviewed for provision of Activities of Daily Living (ADL) care. The facility census was 33.Findings include:Review of the medical record of Resident #10 revealed an admission date of 03/10/26. Diagnoses included neoplasm of unspecified behavior of brain, Type II Diabetes Mellitus, pulmonary embolism without acute cor pulmonale, torsade's de pointes, and presence of other vascular implants and grafts.Review of the most recent admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment was not completed as the resident was rarely/never understood, did not reject care and did not wander. Resident #10 was dependent on assistance for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers.An interview on 05/18/26 at 2:52 P.M. with Resident #10 revealed the resident was not receiving showers as scheduled. Resident #10 reported she was scheduled to receive a shower from staff every Tuesday and Friday.Review of the facility's shower schedule confirmed Resident #10 was scheduled to receive a shower on Tuesdays and Fridays. Review of a facility document titled STNA Skin Condition Report Sheet revealed Resident #10 did not receive a shower on 03/16/26, 03/23/26, 03/31/26, 04/03/26, 04/06/26, 04/21/26, 04/28/26, 05/01/26, and 05/08/26.An interview on 05/21/26 at 11:41 A.M. with the Director of Nursing (DON) #13 revealed Resident #10 was scheduled to have a shower twice a week on Tuesdays and Fridays. Further interview with DON #13 revealed the facility document titled STNA Skin Condition Report Sheet was required to be completed each time a resident received a shower. DON #13 confirmed staff documentation for Resident #10 indicated the resident did not receive a shower on 03/16/26, 03/23/26, 03/31/26, 04/03/26, 04/06/26, 04/21/26, 04/28/26, 05/01/26, and 05/08/26.Review of an undated facility policy titled Resident Showers revealed Residents will be provided showers as per request or as per facility schedule protocols.This deficiency represents non-compliance investigated under Complaint Number 2669725and 2669635.

Based on interview, record review and facility policy review, the facility failed to ensure residents were provided vision services. This affected one resident ( #22) and had the potential to affect 19 Residents (#16, #9, #10, #15, #44, #5, #18, #17, #12, #32, #8, #13, #30, #28, #7, #14, #19, #2, #29) who the facility identifiedas being signed up to receive vision services. This had the potential to affect all residents. The facility census was 33. Findings include-Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, dependence on respirator, neuralgia and neuritis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact, required set up assistance for eating, was dependent for toileting, bathing, personal hygiene, had adequate vision and utilized corrective lenses.Review of the provider orders dated 05/13/25 revealed Resident #22 may receive vision consults as needed per personal plan of care.Review of quarterly nursing assessment dated [DATE] revealed Resident #22 had a general impairment of vision.Interview on 05/18/2026 at 10:34 A.M. with Resident #22 revealed the need for an eye doctor. Resident #22 stated she had requested to see an eye doctor for months and had not seen one yet. Resident #22 stated she had not been seen by an eye provder while a resident at the facility and she wanted to be checked as it had been a long time since she had been seen. Interview on 05/20/26 at 8:41 A.M. with the Social Service Director (SSD) #74 revealed the facility had an eye care provider until 10/2025 and then they refused to see patients at bedside. The SSD #74 confirmed they have not been able to offer any vision services to residents since 10/2025. Interview on 05/20/26 at 9:08 A.M. with the Administrator confirmed the timeframe is too long in obtaining vision services and said he was working on a contract with another provider. Review of the policy titled, Hearing and Vision Services, dated 2024, revealed it is the policy of this facility to ensure all residents have access to vision services.

Based on record review and staff interview, the facility failed to ensure provision of wound care for a resident's pressure ulcer as ordered. This affected one resident (Resident #42) of two residents with identified pressure ulcers. The facility census was 33.Findings include:Review of the medical record of Resident #42 revealed an admission date of 05/07/26. Diagnoses included acute and chronic respiratory failure, sepsis due to Escherichia coli, acute kidney failure, Type II Diabetes Mellitus, dysphagia, pressure ulcer of sacral region stage IV, nonrheumatic mitral valve insufficiency, and nonrheumatic aortic valve insufficiency.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the MDS assessment was still in process.Further record review for Resident #42 revealed upon admission to the facility the resident had a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar maybe present on some parts of the wound bed. Often includes undermining and tunneling.)to his bilateral buttocks. Review of medical orders for Resident #42 revealed an order to wash sacrococcyx to bilateral buttocks with wound cleanser, pat dry, apply Dakin's solution soak gauze roll pack lightly to wound bed cover with boarder foam every day shift for wound healing with a start date of 05/08/26.Review of Resident #42's Treatment Administration Record (TAR) dated 05/19/26 revealed no documentation that Resident #42 received the ordered wound care on 05/14/26, 05/15/26, and 05/16/26.An interview on 05/20/26 at 10:39 A.M. with the Director of Nursing (DON) #13 confirmed Resident #42's TAR dated 05/19/26 revealed no documentation that Resident #42 received the ordered wound care on 05/14/26, 05/15/26, and 05/16/26. Further interview with DON #13 revealed no progress notes in Resident #42's electronic medical record indicating a reason this wound care was not provided on 05/14/26, 05/15/26, and 05/16/26.Review of a facility policy titled, Wound Treatment Management with an implemented date of 01/01/20 revealed, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of change. Further review of this policy revealed, Treatments will be documented on the Treatment Administration Record.This finding substantiates allegations in Complaints #2680098, #2669914, #2669725, #2669635, and #3018612.

Based on observations, record review, and interviews the facility failed to apply braces for residents with contractors as ordered. This affected one, Resident #02, of one reviewed for contractures. The facility census was 33.Findings include:Review of the medical record of Resident #02 revealed an admission date of 05/13/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, gastrostomy status, dysphagia, aphasia following cerebral infarction, Type II Diabetes Mellitus, contracture of right hip, contracture of left ankle, contracture of right knee, contracture of left knee, major depressive disorder, pneumonia, and encephalopathy. Resident #02 did not reject care and did not wander.Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have a Brief Interview for Mental Status (BIMS) completed due to being rarely/never understood. The resident received nutrition through enteral method, was dependent for oral hygiene, toileting hygiene, bathing, upper and lower body dressing, personal hygiene, roll left and right, chair to bed transfers, and used a wheelchair for mobility assistance.Review of medical orders for Resident #02's revealed an order for a left palm protector at all times except for hygiene and skin checks. Palm protector to decrease contractors and improve skin integrity with a start date of 05/13/25.Observation on 05/18/26 at 10:54 A.M. revealed Resident #02's fingers on his left hand were contracted and no palm protector was present in the resident's left hand at the time of the observation. Observation on 05/19/26 at 11:56 A.M. revealed Resident #02's left hand again did not have a palm protector in place.Observation and interview on 05/19/26 at 12:36 P.M. of Resident #02 with Licensed Practical Nurse (LPN) #15 confirmed the resident did not have a palm protector on his left hand. Continued observation and interview with LPN #15 revealed that after searching in the resident's room, LPN #15 was unable to locate the palm protector for Resident #02 in the resident's room. Continued interview with LPN #15 revealed she has been unable to locate the resident's palm protector for a while and that she had not reached out to the therapy department to obtain a replacement palm protector.Review of Resident #02's Treatment Administration Records for April 2026 and May of 2026 revealed the resident did not have his palm protector applied as ordered on 04/07/26, 04/11/26, 04/20/26, 04/21/26, 04/24/26, 04/26/26, 04/28/26, 04/29/26, 05/14/26, 05/15/26, and 05/16/26.Interview on 05/20/26 at 9:58 A.M. with the Director of Nursing (DON) #13 confirmed Resident #02's Treatment Administration Records for April 2026 and May of 2026 indicate the resident did not have his palm protector applied as ordered on 04/07/26, 04/11/26, 04/20/26, 04/21/26, 04/24/26, 04/26/26, 04/28/26, 04/29/26, 05/14/26, 05/15/26, and 05/16/26. Further interview with DON #13 confirmed the medical record did have have nursing progress notes to indicate why Resident #02's palm protector was not put in place on these dates.Review of an undated policy titled Splint / Orthotic Device Program revealed, Nurse and STNA is responsible to monitor splint / orthotic schedule.

Based on observation, interviews, record review, and facility policy review the facility failed to ensure ongoing care of a gastrostomy (G) tube. This affected one, (Resident #10) of three residents reviewed for enteral tube feeding. The facility census was 33.Findings include: Review of the medical record of Resident #10 revealed an admission date of 03/10/26. Diagnoses included neoplasm of unspecified behavior of brain, Type II Diabetes Mellitus, pulmonary embolism without acute cor pulmonale, torsade's de pointes, and presence of other vascular implants and grafts.Review of the most recent admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment was not completed as the resident was rarely/never understood, did not reject care and did not wander. Resident #10 was dependent on assistance for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers.Observation on 05/18/26 at 2:52 P.M. of Resident #10's G-tube revealed numerous pieces of yellow colored debris as well as numerous black spots within the tube between the access port and a lock which was placed on the tubing of the G-tube. In the tubing between the lock and the external retention disk there was approximately one and a half inches of an orange colored liquid followed by an approximately one-inch length of similarly colored material which did not move within the tubing as Resident #10 placed this tubing in different positions.Interview on 05/18/26 at 2:52 P.M. with Resident #10 revealed the resident was concerned about the state of her G-tube. Resident #10 reported that staff stopped flushing the G-tube when the resident's nothing by mouth (NPO) diet order was discontinued on 04/13/26 and an order for a regular diet was started. Resident #10 reported staff continued to change the dressing around her G-tube since 04/13/26 but have not flushed the G-tube. Resident #10 reported she would like the particulates in her g-tube addressed but does not want the material flushed into her intestines at this time.Observation on 05/20/26 at 2:04 P.M. of Resident #10's G-tube revealed numerous pieces of yellow colored debris as well as numerous black spots within the tube between the access port and a lock which was placed on the tubing of the G-tube. In the tubing between the lock and the external retention disk there was approximately one and a half inches of an orange colored liquid followed by an approximately one-inch length of similarly colored material which did not move within the tubing as Resident #10 placed this tubing in different positions.Interview on 05/20/26 at 2:04 P.M. with the Director of Nursing (DON) #13 confirmed the presence of orange fluid in the G- tube between the resident's abdomen and the lock placed on the tube. DON #13 reported this fluid appeared to be gastric drainage. DON #13 confirmed the numerous, yellow-colored pieces of debris and black particles in the G-tube between the lock and the G-tube access port. DON #13 stated the G-tube needed to be changed and DON #13 reported that G-tubes are changed as needed (PRN).Interview on 05/20/26 at 2:04 P.M. with Resident #10 revealed the resident would like the G-tube either changed or removed and that Resident #10 did not want the particulates and fluid currently located in her G-tube tubing to be flushed into her body.Review of an undated facility policy titled, Changing a Gastrostomy Tube revealed, Balloon-type G-tubes can typically be changes at home by nurses every three months to prevent tubing degradation and balloon malfunction. This policy further stated, When to replace tubes immediately: there are visible cracks, leaks or clogging in the tube.

Based on record review and interviews the facility failed to ensure that anticoagulant medications were administered as ordered. This affected one, (Resident #47) of six residents reviewed with prescribed anticoagulants. The facility census was 33.Findings include: Review of the medical record of Resident #47 revealed an admission date of 05/01/26. Diagnoses included acute kidney failure, disorder of parathyroid gland, hypoglycemia, coagulation defect, depression, major depressive disorder, and generalized anxiety disorder. Resident #47 did not reject care and did not wander.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Resident #47 was setup assistance for eating, oral hygiene, upper body dressing, lower body dressing, supervision assistance for toileting, bathing, personal hygiene, roll left and right, sit to lying, lying to sitting, sit to stand, transfers, moderate assistance to walk 10 feet, walk 50 feet, and used a walker for mobility assistance.Further review of Resident #47's medical record revealed a physician order for heparin sodium (porcine) solution of 5,000 units to be injected subcutaneously three times daily starting on 05/01/26 and ending on 05/08/26. Administration times were identified as 6:00 A.M., 2:00 P.M., and 10:00 P.M.Review of Resident #47's Medication Administration Record (MAR) revealed the resident did not receive ordered heparin injections on 05/01/26 at 10:00 P.M., 05/02/26 at 6:00 A.M., 2:00 P.M., 10:00 P.M., 05/03/26 at 6:00 A.M., 10:00 P.M., and 05/04/26 at 6:00 A.M. Nurse progress notes for these above dates indicated staff were unable to administer the medication because they were waiting for delivery of the heparin from the pharmacy. Nurse progress notes do not indicate that the prescriber was notified of these missed heparin doses. The MAR indicates the last dose of heparin was administered on 05/08/26 at 10:00 P.M.An interview on 05/20/26 at 9:58 A.M. with the Director of Nursing (DON) #13 confirmed Resident #47's MAR indicated the resident did not receive ordered heparin injections on 05/01/26 at 10:00 P.M., 05/02/26 at 6:00 A.M., 2:00 P.M., 10:00 P.M., 05/03/26 at 6:00 A.M.,10:00 P.M., and 05/04/26 at 6:00 A.M. and that nursing progress notes indicated they were waiting on delivery from the pharmacy. Further interview with DON #13 revealed a pharmacy packing slip noting delivery of Resident #47's heparin on 05/03/26 at 11:19 A.M. DON #13 unable to explain why heparin was not administered as ordered on 05/03/26 at 10:00 P.M. and 05/04/26 at 6:00 A.M. as the medication had been delivered prior to these administration times. DON #13 also confirmed the last dose of heparin was administered on 05/08/26 at 10:00 P.M.An interview on 05/21/26 at 12:50 P.M. with the Administrator (Admin) #01 revealed the prescribing physician was informed of Resident #47's missed heparin doses by the Admin #01 on 05/20/26 and that the prescriber had not been made aware of these missed doses prior to 05/20/26. An interview on 05/21/26 at 12:50 P.M. with DON #13 revealed Resident #47's heparin medication was not ordered for a stat drop from the pharmacy when the resident admitted and DON #13 reported the medication should have been ordered for stat drop by the pharmacy.An interview on 05/21/26 at 12:58 P.M. with Physician #90 confirmed Physician #90 was not aware of Resident #47 missing doses of heparin until 05/20/26. Physician #90 reported the medication should have been ordered as a stat drop from the pharmacy. Physician #90 reported no significant concerns with Resident #47 having missed heparin doses based on the resident's overall health status, the resident's age, and the resident's mobility status. Additionally, Physician #90 reported no negative outcomes related to the resident's missed heparin doses.Review of an undated facility policy titled Medication Administration revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice.This finding substantiates allegations in Complaint #2669635.

Based on observation and interview, the facility failed to ensure daily staffing was posted in the facility. This had the potential to affect all residents. The facility census was 33.Findings include:Interview and observation on 05/21/26 at 9:10 A.M. with the Director of Nursing (DON) confirmed the facility does not have staffing posted for resident care on floor one, two and three. Review of the policy titled, Nurse Staffing Posting Information, dated 2024, revealed the nurse staffing sheet will be posted on a daily basis and will contain the following information facility name, the current date, facility's current resident census, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift for registered nurses, licensed practical nurses, and certified nurse aides. The information posted will be in a prominent place readily accessible to residents and visitors.

Based on observation, resident and staff interview, and record review, the facility failed to ensure comfortable and safe temperatures were maintained throughout the facility when temperatures exceeded 95 degrees Fahrenheit (F) in resident rooms. This affected all ten residents (#01, #02, #03, #04, #05, #06, #07, #108, #109 and #158) residing in the facility. The facility census was 10. Findings include: Interview with Resident #04 on 06/29/25 at 9:50 A.M. revealed it was hot in her room. Observation on 06/29/25, beginning at 10:00 A.M., with Director of Plant Operations (DPO) #306 revealed the following ambient room temperatures on the second floor of the facility, where all 10 of the facility's residents resided: the dining room was 89.2 degrees Fahrenheit (F), the 200 hallway was 88.5 degrees F, Resident #01 and Resident #03's room was 93.7 degrees F, Resident #02's room was 94.6 degrees F, Resident #04's room was 82.5 degrees F, Resident #05's room was 94.6 degrees F, Resident #06's room was 94.6 degrees F, Resident #07's room was 91.2 degrees F, Resident #108's room was 89 degrees F, Resident #109's room was 91.7 degrees F, and Resident #158's room was 92.8 degrees F. Portable air conditioning units and fans were observed in all of the resident rooms and hallways. Concurrent interview with DPO #360 verified the above air temperatures. DPO #306 stated the air conditioning in the facility was not working because the cooling tower did not work when it was turned on for the summer, adding the cooling tower did not receive maintenance and was not winterized over the past year. Interview with Licensed Practical Nurse (LPN) #309 on 06/29/25 at 10:09 A.M. verified it was warm in resident rooms. Interview with Resident #01 on 06/29/25 at 10:15 A.M. revealed it was hot in his room. Interview with Resident #03 on 06/29/25 at 10:17 A.M. revealed it was hot in his room. Interview with Resident #07 on 06/29/25 at 10:18 A.M. revealed the resident stated, It's so hot I can't sleep or get comfortable. It's miserable. Interview with Resident #05 on 06/29/25 at 10:18 A.M. revealed it was hot in his room. Interview with Resident #02 on 06/29/25 at 10:22 A.M. revealed her room could get hot. Interview with Resident #108 on 06/29/25 at 10:24 A.M. revealed it was too hot in his room and that his room heated up around 12:00 P.M. Resident #108 stated that he was moved from another room because of the heat but his current room was still too hot. Interview with Resident #158 on 06/29/25 at 10:36 A.M. revealed it was hot in his room. Interview with the Director of Nursing (DON) on 06/29/25 at 11:03 A.M. revealed the facility had no discharges related to the excessively warm temperatures in the facility. Observation on 06/29/25, beginning at 1:06 P.M., with DPO #306 revealed the following ambient room temperatures on the second floor: the dining room was 89.2 degrees F, the 200 hallway was 88.5 degrees F, Resident #01 and Resident #03's room was 93.7 degrees F, Resident #02's room was 94.6 degrees F, Resident #04's room was 82.5 degrees F, Resident #05's room was 94.6 degrees F, Resident #06's room was 94.6 degrees F, Resident #07's room was 91.2 degrees F, Resident #108's room was 90.1 degrees F, Resident #109's room was 91.7 degrees F, and Resident #158's room was 92.8 degrees F. Concurrent interview with DPO #306 verified the above room temperatures. Interview with the Administrator on 06/29/25 at 1:19 P.M. revealed the facility identified the issue with the cooling tower on 06/04/25 when the facility turned on the air conditioning and it did not work. The Administrator stated the facility had previously received estimates on 03/31/25 and 04/14/25 to replace the cooling tower, but the facility was not aware that the cooling tower was not going to work until the cooling tower was turned on 06/04/25. A follow-up interview with the DON on 06/29/25 at 2:34 P.M. revealed the facility did not have any heating, ventilation, and air conditioning (HVAC) maintenance records from 06/29/23 through 06/29/25. A follow-up interview with the Administrator on 06/29/25 at 3:07 P.M. revealed the facility was in the process of looking for a temporary chiller but they were unable to find one that was the appropriate size for the facility. The Administrator stated the facility started to take daily temperatures and auditing residents for safety while the air temperatures were outside of a comfortable range. Observation on 06/29/25, beginning at 5:13 P.M. with DPO #306, revealed the following room temperatures on the second floor: the dining room was 90.6 degrees F, the 200 hallway was 88.1 degrees F, Resident #01 and Resident #03's room was 87.9 degrees F, Resident #02's room was 90.6 degrees F, Resident #04's room was 83.1 degrees F, Resident #05's room was 89.7 degrees F, Resident #06's room was 91.7 degrees F, Resident #07's room was 93.3 degrees F, Resident #108's room was 88.1 degrees F, Resident #109's room was 90.1 degrees F, and Resident #158's room was 90.5 degrees F. Concurrent interview with DPO #306 verified the above room temperatures. Interview with the Administrator and DON on 06/30/25 at 7:40 A.M. verified the facility did not enact the transfer agreement when the air temperatures went above 81 degrees F in the facility. Interview with the DON on 06/30/25 at 8:00 A.M. revealed the facility staff were educated about air temperatures being out of range on 06/03/25. The DON stated that the facility did not have temperatures out of range until 06/04/25 but the facility was able to predict that it was going to occur. Observation on 06/30/25, beginning at 8:09 A.M. with DPO #306, revealed the following room temperatures on the second floor: the dining room was 86.7 degrees F, the 200 hallway was 82.4 degrees F, Resident #01 and Resident #03's room was 79.3 degrees F, Resident #02's room was 82.7 degrees F, Resident #04's room was 77.1 degrees F, Resident #05's room was 82.5 degrees F, Resident #06's room was 85.6 degrees F, Resident #07's room was 87.2 degrees F, Resident #108's room was 80.7 degrees F, Resident #109's room was 86.5 degrees F, and Resident #158's room was 82.2 degrees F. Concurrent interview with DPO #306 verified the above room temperatures. Interview with the DON on 06/30/25 at 10:14 A.M. verified the facility was provided the initial estimate from the heating and cooling company for a new cooling tower unit on 03/31/25 and the facility received an updated estimate for the cooling tower unit on 04/14/25. The DON confirmed the payment for the heating and cooling company to order the new cooling tower was not made until 05/08/25. The DON was not able to provide the reason for the delay in payment for the new cooling tower. Review of the facility's HVAC maintenance records from 06/29/23 to 06/29/25 revealed no evidence the facility had routine HVAC maintenance during this time. Review of a heating and air conditioning estimate, dated 03/31/25, revealed the facility received an estimate for a closed circuit cooling tower unit, with the total amount costing $69,000.00. Review of a heating and air conditioning estimate, dated 04/14/25, revealed the facility received an estimate for a new cooling tower unit, with the total amount costing $112,472.00. The estimate stated a 75 percent (%) deposit was required to order the new tower and to purchase the necessary materials. Review of a facility provided copy of a check revealed the facility did not make payment to replace the cooling tower unit until 05/08/25. Review of the facility's air temperature logs revealed on 06/26/25, resident room temperatures ranged ranged from 81 to 83 degrees F; on 06/27/25, resident room temperatures ranged from 80 to 89 degrees F; and on 06/28/25, resident room temperatures ranged from 78 to 82 degrees F. Review of the facility's cooling plan, dated 06/29/25, revealed the facility added seven additional industrial fans to circulate air from the portable air conditioners, black out covers to the windows to keep out additional heat, and insulation to cover the windows to vent out heat and prevent it from coming back in the windows. The facility also offered cold drinks and checked on the residents for comfort every 15 minutes. The facility also planned to continue to search for a temporary chiller to rent. Review of the facility policy titled, Safe and Homelike Environment, undated, revealed the facility would maintain comfortable and safe temperature levels. The facility would strive to keep temperatures in common resident areas between 71 and 81 degrees F. Review of the facility policy titled, HVAC System, undated, revealed the facility maintained an HVAC system in a manner that protected resident health and safety from fire and extreme temperatures. HVAC installation and maintenance shall be in accordance with the manufacturer's specifications and life safety code.

Based on observation, staff interview and review of the facility policy, the facility failed to ensure food was stored in a manner to prevent food born illness. This had the potential to affect all residents, except one (#5) who received no food from the kitchen. The facility census was 10. Findings include: Observations on 06/29/25 at 11:00 A.M. revealed the refrigerator located on the second-floor dining room contained the following items: a half gallon of chocolate milk with an expiration date of 06/23/25, a bag of opened Parmesan cheese with an expiration date of 05/20/25, and a bag of unopened lettuce that was brown and slimy. The pantry area also had an opened loaf of bread with an expiration date of 06/28/25. Interview with Certified Nursing Assistant (CNA) # 302 on 06/29/25 at 11:30 A.M. revealed no one was in charge of the dietary department at the present time because the facility had resident meals brought in due to kitchen construction. CNA # 302 stated she did not know who was responsible for removing expired foods. CNA #302 verified the expired food items in the refrigerator and pantry. Review of the undated facility policy for food storage revealed the facility would store food in accordance with professional standards for food service safety.

Based on observation, staff interview and review of the menu, the facility failed to ensure alternative food options were available. This affected all residents, except one (#5) resident identified by the facility as received no meals from the facility. The facility census was 10. Findings include: Observations on 06/29/25 and 06/30/25 revealed resident meals were delivered to the facility from an outside vendor, with nine meals delivered for each meal. Further observation revealed each of the meals were exactly the same and no alternate or extra foods were delivered. Interview with CNA #302 on 06/29/25 at 10:00 A.M. revealed resident meals were delivered to the facility by an outside vendor approximately 30 minutes prior to meal times. CNA #302 stated only nine meals were delivered for each meal and no alternatives or extras were provided. CNA #302 stated sometimes residents did not eat if they did not like what was delivered, adding she had nothing else to offered except for a peanut butter sandwich. Interview with Resident #109 on 06/29/25 at 10:14 A.M. revealed they had no choice for their meals and they could not get any extra food, if they wanted it. Interview with Resident #108 on 06/29/25 at 10:18 A.M. revealed they could not make any food choices and had to each what was served. Resident #108 stated he had to buy his own food. Interview with Resident #2 on 06/29/25 at 10:22 A.M. revealed there were no choices offered for meals. Interview with Food Vendor (FV) #350 on 06/29/25 at 12:00 P.M. confirmed the vendor only provided one meal for each resident at each meal. FV #350 verified residents could not request extra food or an alternative meal to what was provided, adding the residents had no choices. Review of the facility menu for June 2025 revealed three meals were offered per day. The menu listed one choice per meal, with no alternatives available.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure the medication error rate did not exceed five percent (%) when 13 medication errors were observed of 36 opportunities, resulting in an error rate of 36.11%. This affected three (Residents #108, #4, and #7) of three residents observed for medication administration. The facility census was 10. Findings include: Review of medical record for Resident #108 revealed an admission date of 06/03/25, with diagnoses including diabetes mellitus Type II, hypertension, atherosclerotic heart disease, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and benign prostatic hyperplasia (BPH). Review of the current physician orders for Resident #108 revealed the resident had the following orders: albuterol-budesonide inhalation aerosol 90-80 micrograms per actuation (mcg/act) two puffs every morning, aspirin 81 milligrams (mg) every morning, bumetanide 0.5 mg every morning, carboxymethylcellulose 1 percent (% ) one drop in both eyes every morning, cholecalciferol 25 mcg every morning, finasteride five mg every morning, Steglatro five mg every morning, metoprolol tartrate 25 mg twice a day, guaifenesin 400 mg twice a day, Lyrica 50 mg every 12 hours, and albuterol sulfate nebulization solution 0.83% 2.5 mg/3 ml four times a day. Observation of medication administration on 06/30/25 at 8:45 A.M. for Resident #108 revealed Licensed Practical Nurse (LPN) #309 administered Lyrica, aspirin, finasteride, guaifenesin, and albuterol sulfate nebulization solution. Further observation revealed metoprolol tartrate, albuterol-budesonide inhalation aerosol, bumetadine, cholecalciferol, and Steglatro were not administered as ordered. Concurrent interview with LPN #309 verified the medications were not administered, adding the medications were unavailable for administration. 2. Review of the medical record for Resident #4 revealed an admission date of 10/05/25, with diagnoses including cerebral infarction (stroke) without residual deficits, diabetes mellitus type II, and COPD. Review of the current physician orders for Resident #4 revealed the resident had the following orders: lasix 20 mg every morning, losartan potassium 25 mg daily, magnesium 400 mg every morning, omeprazole 20 mg every morning, oxybutynin chloride extended release 15 mg daily, probiotic product acidophilus every morning, Thera M Plus every morning, Cystex Urinary Pain Relief 162-162.5 mg twice a day, Eliquis 2.5 mg twice a day, Lantus Subcutaneous Solution 100 unit/ml inject 56 units subcutaneously two times a day, meclizine 25 mg twice a day, metoprolol tartrate 25 mg twice a day, spironolaction 50 mg twice a day, Symbicort Aerosol 160-2.5 mg/act twice a day, Topamax 100 mg twice a day, and Humalog Injection Solution 100 unit/milliliter (u/ml) inject 15 units subcutaneously with meals. Observation of medication administration on 06/30/25 at 9:23 A.M. for Resident #4 revealed LPN #309 administered losartan, oxybutynin, topiramate (Topamax), lasix, Lantus Solostar, meclizine, metoprolol tartrate, omeprazole, acidophilus (probiotic), spironolactone, and Thera-M (vitamin supplement). Further observation revealed Cystex Urinary Pain Relief, Eliquis, magnesium, and Symbicort were not administered as ordered. Concurrent interview with LPN #309 verified the medications were not administered and stated they were not available. 3. Review of the medical record for Resident #7 revealed an admission date of 05/16/25, with diagnoses including congestive heart failure, hypertension, diabetes mellitus type II, and major depressive disorder. Review of the current physician orders revealed Resident #7 was ordered the following: esomeprazole magnesium 20 mg every morning, Lantus Subcutaneous Solution 100 u/ml inject 20 units subcutaneously every morning and at bedtime, Novolog Subcutaneous Solution 100 u/ml inject 10 units subcutaneously with meals, sertraline 25 mg every morning, Cardizem Extended Release 240 mg every morning, Colace 100 mg every morning, ferrous sulfate 325 mg every morning, Flonase Allergy Relief Nasal Suspension 50 mcg/act two spray in both nostrils every morning, lasix 40 mg every morning, and buspirone 30 mg twice a day. Observation of medication administration on 06/30/25 at 9:46 A.M. for Resident #7 revealed LPN #309 administered buspirone, Colace, esomeprazole magnesium, ferrous sulfate, Flonase, Novolog Flex Pen, and sertraline 50 mg. Further observation revealed Cardizem and lasix were not administered as ordered. Concurrent interview with LPN # 309 verified Cardizem and lasix were not administered as ordered, adding the medications were unavailable. A follow-up interview on 06/30/25 at 09:56 A.M. with LPN #309 confirmed the physician order for sertraline was for 25 mg and further verified she administered sertraline 50 mg to Resident #7. Review of the facility policy titled, Medication Errors, undated, revealed the facility would ensure medications were administered according to physician's orders, per manufacturer's specifications regarding the preparation, and administration of the drug or biological, and in accordance with accepted standards and principles which apply to professionals providing services.

Based on medical record review, staff and physician interviews, review of facility policy, and review National Pressure Injury Advisory Panel (NPIAP) information, the facility failed to initiate pressure ulcer treatments, complete pressure ulcer treatments as ordered, assess pressure ulcers weekly, and consult wound care as ordered. This resulted in Actual Harm when Resident #03's facility acquired pressure ulcers to the right and left rear thighs increased in size. This affected one (#03) of three residents reviewed for skin breakdown. The census was two. Findings include: Review of Resident #03's closed medical record revealed an admitted [DATE]. Diagnoses listed included hypertension, acute and chronic respiratory failure, seizures, hydrocephalus, dysphagia, schizophrenia, type II diabetes mellitus, and respiratory ventilator dependence. Resident #03 was discharged to a local hospital on 12/08/22. Review of a care plan dated initiated on 08/08/22 revealed Resident #03 was at risk for skin alterations in skin integrity related to impaired mobility. Interventions listed included encourage frequent position changes, treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. Administer treatments as ordered and monitor for effectiveness. Obtain and monitor laboratory/diagnostic work as ordered. Report results to physician (MD). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #03 was assessed by staff as being severely cognitively impaired. Resident #03 required significant assistance of staff for bed mobility and hygiene. Review of wound documentation dated 12/08/23 revealed Resident #03 currently had six documented wounds. Resident #03 was documented as having an unstageable pressure ulcer to left rear calf, a right heel blister, a right lateral calf laceration, a right rear thigh stage two pressure ulcer, a left rear thigh unstageable pressure ulcer, and a stage three pressure ulcer to the sacrum. Further review of Resident #03's wound documentation revealed the right rear thigh stage two pressure ulcer was documented as acquired in-house on 09/22/22. The wound measured 2.48 centimeters (cm) x 0.94 cm with a surface area of 1.84 square cm. Wound assessments were completed on 09/22/22, 09/30/22, 10/06/22, 10/13/22, 10/20/22, 10/27/22, 11/11/22, 11/18/22, 12/02/22, and 12/08/22. A weekly wound assessment was not completed between 11/18/22 and 12/02/22. Review of a wound assessment dated [DATE] revealed Resident #03's wound to the right rear thigh had increased in size and measured 4.52 cm x 6.22 cm with a surface area of 17.52 square cm. The wound remained as stage two pressure ulcer. Review of physician orders revealed there was not an order for treatment of the right rear thigh stage two pressure ulcer. Review of Resident #03's treatment administration records (TAR's) revealed no documentation of treatment being completed on the right rear thigh stage two pressure ulcer. Further review of wound documentation revealed Resident #03's left rear thigh unstageable pressure ulcer was documented as acquired in-house on 08/25/22. The wound measured 3.5 cm x 4.08 cm with a surface area of 7.9 square cm. Wound assessments were completed on 08/25/22, 09/09/22, 09/15/22, 09/22/22, 09/30/22, 10/06/22, 10/13/22, 10/20/22, 10/27/22, 11/11/22, 11/18/22, 12/02/22, and 12/08/22. A weekly wound assessment was not completed between 11/18/22 and 12/02/22. Review of Resident #03's wound assessment dated [DATE] revealed the left rear thigh wound had increased in size and measured 3.42 cm x 4.55 cm x 0.4 cm depth with a surface area of 15.67 square cm. The wound remained as an unstageable pressure ulcer. Review of Resident #03's physician orders revealed a treatment for the left rear thigh unstageable pressure ulcer was not started until 08/31/22. An order dated 08/31/22 for clean pressure area to back of left thigh with wound cleanser, pat dry apply Calcium Alginate (absorbent wound dressing) to peri-wound and cover with border foam in the afternoon and as needed (PRN) for wound healing. An order dated 09/02/22 for clean pressure area to back of left thigh with wound cleanser, pat dry apply Calcium Alginate (absorbent wound dressing) to peri-wound and cover with border foam every day shift and PRN for wound healing. An order dated 11/09/22 was for remove wound vacuum if on resident. Clean wound with sterile water, pat dry, and apply sterile water-soaked gauze to wound bed, and cover with foam dressing two times a day for 10 days and PRN. Review of Resident #03's TAR's revealed no documentation of a wound treatment to the left rear thigh pressure ulcer until 09/01/22. Wound cleanser, pat dry, apply Calcium Alginate to peri-wound and cover with border foam treatments were not documented as being completed on 09/09/22, 09/10/22, 09/11/22, 09/12/22, 09/26/22, 09/30/22, 10/02/22, 10/09/22, 10/11/22, 10/12/22, 10/16/22, 10/19/22, 10/20/22, 10/21/22, 10/22/22, 10/23/22, 10/24.22, 10/28/22, 10/29/22, and 11/06/22. Remove wound vacuum if on resident. Clean wound with sterile water, pat dry, and apply sterile water-soaked gauze to wound bed, and cover with foam dressing two times a day for 10 days was not documented as being completed on 11/09/22 P.M. (7:00 P.M. to 10:00 P.M.), 11/10/22 A.M. (11:00 A.M. to 1:00 P.M.) and P.M., 11/11/22 A.M. and P.M., 11/12/22 P.M., 11/13/22 P.M., 11/18/22 A.M., and 11/19/22 A.M. Further review of physician orders revealed an order dated 06/13/22 for resident may receive dental, vision, audiology, psychiatry, podiatry, wound, and psychology consults PRN per personal plan of care. Further review of Resident #03's closed medical record revealed no documentation of any wound care consults. During a phone interview on 03/09/23 at 11:10 A.M. the Director of Nursing (DON) confirmed that wounds Resident #03 had acquired while at the facility had increased in size. The DON confirmed Resident #03 had six wounds when he was discharged from the facility. The DON confirmed wound treatments had not been completed for the left rear thigh unstageable pressure ulcer as ordered and wound treatment had not been ordered for the right rear thigh stage two pressure ulcer. The DON also confirmed a wound care physician had not been consulted for Resident #03. The DON stated it was difficult to get a wound care physician to come to the facility and had made calls with no results. The DON as unable to provide any documentation of any wound care consult attempts. During a phone interview on 03/09/23 at 1:48 P.M. Physician #180 stated she was aware of Resident #03's multiple wounds. Physician #180 confirmed she was not a wound care physician and had not assessed every one of Resident #03's wounds herself. Either Licensed Practical Nurse (LPN) #170 or the DON would communicate the status of Resident #03's wounds to her. Physician #180 confirmed she never attempted a wound consult for Resident #03. Physician #180 stated wound consults are difficult to obtain. Review of the facility 's policy titled Nursing Policies and Procedures Wound Management dated 01/01/20 revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatments will be documented on the TAR. Wound assessments are documented upon admission, weekly, and PRN if the resident or wound condition deteriorates. Referrals to podiatrists, vascular or orthopedic surgeons, or wound care physicians will be made when appropriate. The facility will arrange for transportation to and from any appointments. Review of information from the NPIAP website (https://npiap.com/page/PressureInjuryStages?&hhsearchterms=%22stages%22) revealed a stage two pressure injury is defined as partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). An unstageable pressure ulcer was defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. This deficiency represents non-compliance investigated under Complaint Number OH00139552.

Based on medical record review, staff interview, physician interview, and review of facility policy, the facility failed to initiate wound treatments, assess wounds weekly, and consult wound care as ordered. This resulted in actual harm to Resident #3 when a facility acquired wound increased in size. This affected Resident #3 of three reviewed. The census was two. Findings include: Review of Resident #3's closed medical record revealed an admitted [DATE]. Diagnoses listed included hypertension, acute and chronic respiratory failure, seizures, hydrocephalus, dysphagia, schizophrenia, type II diabetes mellitus, and respiratory ventilator dependence. Resident #3 was discharged to a local hospital on 12/08/22. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was assessed by staff as being severely cognitively impaired. Resident #3 required significant assistance of staff for bed mobility and hygiene. Further review of wound documentation revealed the right lateral calf laceration was documented as acquired in-house on 11/11/22. The wound measured 7.38 centimeters (cm) x 2.05 cm with a surface area of 12.34 square cm. Wound assessments were completed on 11/11/22, 11/18/22, 12/02/22, and 12/08/22. A weekly wound assessment was not completed between 11/18/22 and 12/02/22. Review of a wound assessment dated [DATE] revealed the wound had increased in size and measured 16.79 centimeters (cm) x 2.89 cm with a surface area of 19.72 square cm. Review of physician orders revealed there was not an order for treatment of the right lateral calf laceration. Review of treatment administration records (TAR's) revealed no documentation of treatment being completed on the right lateral calf laceration. Further review of physician orders revealed an order dated 06/13/22 for resident may receive dental, vision, audiology, psychiatry, podiatry, wound, and psychology consults PRN per personal plan of care. Further review of Resident #3's closed medical record revealed no documentation of any wound care consults. During a phone interview on 03/09/23 at 11:10 A.M. the Director of Nursing (DON) confirmed that wounds Resident #3 had acquired while at the facility had increased in size. The DON confirmed Resident #3 had six wounds when he was discharged for m the facility. The DON confirmed a wound treatment had not been ordered and completed for the right lateral calf laceration . The DON also confirmed a wound care physician had not been consulted for Resident #3. The DON stated it was difficult to get a wound care physician to come to the facility and had made calls with no results. The DON as unable to provide any documentation of any wound care consult attempts. During a phone interview on 03/09/23 at 1:48 P.M. Physician #180 stated she was aware of Resident #3's multiple wounds. Physician #180 confirmed she was not a wound care physician and had not assessed every one of Resident #3's wounds herself. Either Licensed Practical Nurse (LPN) #170 or the DON wound communicate wounds conditions to her. Physician #180 confirmed she never attempted a wound consult for Resident #3. Physician #180 stated wound consults are difficult to obtain. Review of the facility 's policy titled Nursing Policies and Procedures Wound Management dated 01/01/20 revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatments will be documented on the treatment administration record (TAR). Wound assessments are documented upon admission, weekly, and as needed (PRN) if the resident or wound condition deteriorates. Referrals to podiatrists, vascular or orthopedic surgeons, or wound care physicians will be made when appropriate. The facility will arrange for transportation to and from any appointments. This deficiency represents non-compliance investigated under Complaint Number OH00139552.