Every finding on record at Gillette Nursing Home

Based on record review, interview and review of facility policy, the facility failed to conduct complete and thorough post-fall investigations to mitigate risk of falls . This affected one resident (Resident #94) of four residents reviewed for falls. The facility census was 93.Findings include: Record review for Resident #94 revealed an admission date of 05/23/25 with diagnoses including unspecified dementia, anxiety, difficulty walking, malnutrition and right femur fracture. Pertinent physician orders included non-skid pad to wheelchair, body pillow to open side of bed, non-skid pad to wheelchair cushion, floor mat to open side of bed, non-skid socks on at all times, brake sentry to wheelchair, and physical therapy evaluate and treat.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had moderate cognitive impairment, had a fall with fracture prior to admission and had a fall since admission. Resident #94 was incontinent bladder.Review of Resident #94's plan of care, date initiated 05/28/25, revealed Resident #94 was at risk for falls related to history of falls, impaired cognition, and safety awareness with history of dementia, decreased abilities to transfer and ambulate, decreased balance, lower extremity strength and endurance. The interventions included to anticipate and meet needs, non-skid pad on top of and underneath wheelchair cushion (06/03/25); be sure call light is within reach, body pillow to open side of bed per order (06/03/25); ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair (06/03/25); follow facility fall protocol , resident needs activities that minimize the potential for fall providing diversion and distraction (06/03/25); one person staff assistance with wheeled walker for transfers (06/04/25), and floor mat to open side of bed (06/17/25); and assist to toilet as needed and per schedule for incontinence; assure that break century is present and functioning properly (06/24/25). Further review of the care plan, date initiated 06/04/25, for Resident #94 revealed she was incontinent of bladder related to impaired functional mobility and incontinence. The interventions included check and change every two hours for incontinence and assist, remind and encourage resident to toilet as per scheduled toileting program. Further review of Resident #94's medical record revealed Resident #94 had falls in the facility on 05/26/25, 06/12/25, 06/16/25, 06/20/25, 06/24/25 and 07/04/25 and concerns were identified regarding complete and thorough post-fall investigations with the following incidents:Review of a progress note dated 06/12/25 revealed staff observed Resident #94 sitting in her wheelchair talking to another resident. Resident #94 was leaning over towards the other residents and slid from the seat of the wheelchair onto the floor landing on her right side with her arm under her head. Vital signs were obtained, and a body assessment revealed no injuries. The resident was placed back in the wheelchair with dycem (non-skid mat) placed under the chair cushion. The physician and family were notified. Review of the facility fall investigation dated 06/12/25 revealed the fall occurred at 10:42 A.M. Resident #94 was found lying on the floor on her right side with right arm underneath her head. There were no obvious injuries noted. A non-skid pad was placed to the top of the wheelchair underneath the buttocks of the residence. The incident occurred in the dining room. Review of the six witness statements within the investigation revealed staff indicated they were unaware of the incident unless notified by other staff to assist in response. There was no documentation within the investigation to indicate when the last time the resident was seen by staff, or last checked or changed for incontinence care. The investigation summary indicated the conclusion was that Resident #94 was leaning to talk to someone and slid out of her wheelchair sustaining no injuries.Review of a progress note dated 06/16/25 revealed the nurse was told by the nurse aide that Resident #94 was on the floor. The nurse found Resident #94 naked, lying on her back in front of her dresser. Resident #94 stated she was not sure what happened. The nurse and aide assisted the resident back to bed. Vital signs were obtained and were within normal limits. A skin assessment revealed a one centimeter skin tear to the right elbow which was treated. Resident #94 denied hitting her head and there were no wounds. An interventions of a floor mat to the left side of the bed was initiated. The residents daughter and the physician were notified. Review of the facility fall investigation dated 06/16/25 revealed the fall occurred at 8:15 P.M. and Resident #94 was found lying on her back naked with her legs out in front of her. A skin tear to the right elbow was noted. The resident had removed all of her clothing, her non-skin socks and her brief. Resident #94 was incontinent of urine. Review of the witness statements by staff within the investigation revealed there was no documentation to indicate when the resident was last seen by staff or when the resident was last toileted or checked and changed for incontinence care prior to the fall. The investigation summary indicated Resident #94 was found on the floor naked after attempting to self transfer. There was no mention in the root cause analysis and investigation of when the resident was last seen by staff or when she was last checked and changed for incontinence care. Review of a progress note dated 06/20/25 revealed Resident #94 was observed on the floor mat on the side of her bed. The body pillow was across the room and her brief was removed. The brief was noted to be wet. An assessment of Resident #94's body revealed no injuries. The resident was placed back in bed and a clean brief was applied. The residents daughter and the physician were notified. Review of the facility fall investigation dated 06/20/25 at 6:40 P.M. revealed Resident #94 was found sitting on the floor mat next to their bed. No injuries were noted. The resident was unable to state what happened and had removed the body pillow. She was not wearing anything on her feet. The root cause analysis was completed and revealed the cause of the fall was Resident #94 was attempting to get out of bed unassisted. Review of the witness statements by staff within the investigation revealed there was no documentation to indicate when the resident was last seen by staff or when the resident was last toileted or checked and changed for incontinence care prior to the fall. The investigation summary indicated Resident #94 was attempting to self transfer and fell. There was no mention in the root cause analysis or investigation of when the resident was last seen by staff or when she was last checked and changed for incontinence care. On 07/30/25 at 4:02 P.M. an interview with the family member of Resident #94 revealed Resident #94 had fallen six times in five weeks and the facility was blaming Resident #94 for the falls. The family member stated she had asked the facility if an alarm could be used to try to help prevent falls and the facility told her they did not use alarms. On 07/30/25 at 4:32 P.M. an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #212 verified the missing information on the witness statements in the fall investigations for falls occurring on 06/12/25, 06/16/25 and 06/20/25. The DON stated when witness statements do not contain the time the resident was last seen by staff, last toileted or other pertinent details, the DON then will investigate that area. The DON verified there was no documentation within the investigation for the falls occurring on 06/12/25, 06/16/25 and 06/20/25 of the last time staff checked on Resident #94. On 07/31/25 at 4:03 P.M. an interview was conducted with the DON and ADON #212 to review the facility protocol for fall prevention. The DON stated change of condition is of consideration such as ordering a urine specimen if needed or a medication review for residents who fell. Both nurses verified the fall policy and stated if the individual continues to fall the staff and physician will reevaluate the situation and consider other possible reasons for the resident falling and will reevaluate the continued relevance of current interventions. Both nurses stated that the physician will also document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. Both nurses stated the physician had been notified of the falls for Resident #94 and interventions were put in place to try to prevent falls. The DON verified the facility did not use alarms or seat belts as fall prevention interventions.A review of the policy titled Falls Clinical Protocol, dated 11/13/12, revealed the staff would evaluate and document falls that occur while the individual was in the facility. For example, when and where the falls happen and any observations of the events. The policy also stated for an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. If the cause of the fall was unclear, the fall may have a significant medical cause such as a stroke or an adverse drug reaction or if the individual continues to fall despite attempted interventions a physician will review the situation and help identify contributing causes. If the individual continues to fall, the staff and physician will reevaluate the situation and consider other possible reasons for the residents falling. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful.This deficiency represents non-compliance investigated under Complaint Number OH00167403 (1363493).

Based on observation, interview, record review and review of facility policy, the facility did not ensure all shower rooms used by residents were maintained at comfortable temperatures. This affected four residents (Residents #4, #9, #23 and #26) and had the potential to affect all residents in the facility excluding 37 residents ( #1, #2, #3,#8, #10, #12, #13, #15, #16, #17, #21, #24, #25, #27, #34, #35, #38, #42, #43, #46, #50, #51, #54, #56, #58, #59, #61, #62, #64, #66, #70, #72, #73, #77, #78, #80, and #84) the facility identified as having personal showers in their resident rooms. The facility census was 87. Findings include: 1. A facility tour was conducted on 03/24/25 at 10:30 A.M. with Maintanence Director (MD) #257 and revealed the facility had two shower rooms for resident use. The first shower room observed was between the 400 and 500 unit hallways. MD #257 took the ambient temperature in the shower room and stated it was 64.8 degrees Fahrenheit (F). The second shower room observed was between the 200 and 300 unit hallways. MD #257 took the ambient temperature in the shower room and stated it was 55.9 degrees F. MD #257 verified the temperatures at the time of the observation. A review of the Resident Council meeting minutes, dated 01/16/25 and 02/20/25, revealed a complaint the shower rooms were too cold. On 03/25/25 at 10:38 A.M. an interview with the Assistant Director of Nursing #210 verified the Resident Council meeting minutes and the complaints within stating shower rooms were too cold. 2 A review of medical records for Resident #4 revealed a date of admission of 08/17/23 with diagnoses including chronic obstructive pulmonary disease (COPD)and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was cognitively intact, and required substantial to maximal assistance with bathing. Review of the care plan dated 01/24/25 revealed Resident #4 had an activity of daily living (ADL) self-care performance deficit and required assistance to bathe. On 03/25/25 at 12:30 P.M. an interview with Resident #4 revealed the shower rooms were sometimes cold. 3. A review of medical records for Resident #9 revealed an admitted [DATE] with diagnoses including cerebral infarction, metabolic encephalopathy and the need for assistance with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact and required substantial to maximal assistance for bathing. Review of the care plan dated 03/14/25 revealed Resident #9 had an ADL self-care performance deficit and required assistance to bathe. On 03/25/25 at 12:35 P.M. an interview with Resident #9 revealed the shower rooms were a little bit cold. 4. A review of medical records for Resident #23 revealed a date of admission of 12/29/23 with diagnoses including COPD and the need for assistance with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact and required substantial to maximal assistance for bathing. Review of the care plan dated 03/13/25 revealed Resident #23 had an ADL self-care performance deficit and required assistance to bathe. On 03/25/25 at 12:40 P.M. an interview with Resident #23 revealed the shower rooms were chilly. 5. A review of medical records for Resident #26 revealed a date of admission of 06/16/21 with diagnoses including obesity, muscle wasting, need for assistance with personal care, encounter for surgical aftercare following surgery on the nervous system, polyneuropathy, and chronic lymphocytic leukemia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #26 was cognitively intact and dependent for bathing. Review of the care plan dated 03/13/25 revealed Resident #26 had an ADL self-care performance deficit and required assistance to bathe. On 03/24/25 at 1:05 P.M. an interview with Resident #26 revealed the shower rooms were ice cold. A review of the policy titled Physical Environment, dated 06/14/19, revealed the facility will provide residents comfortable and safe temperature levels. The facility will maintain temperatures between 71 and 81 degrees F. This deficiency represents non-compliance investigated under Complaint Number OH00163927.

Based on record review, staff interview, and facility policy review, the facility failed to timely report an allegation of misappropriation of narcotic medications to the appropriate state agency. This affected two residents (#33 and #65) of three residents reviewed for misappropriation. The facility identified an additional 21 residents (#7, #14, #17, #18, #24, #26, #28, #31, #32, #59,#60, #68, #69, #74, #75, #76, #77, #80, #81, #83 and #85) as having physician orders for narcotic medications. The facility census was 87. Findings include: 1. A review of medical records for Resident #33 revealed a date of initial admission of 01/29/24, and a readmitted [DATE] with diagnoses including cirrhosis of the liver, chronic obstructive pulmonary disease (COPD), chronic viral hepatitis, hepatomegaly (liver enlargement) and cognitive communication deficit. Review of physician orders revealed orders for Norco oral tablet 5-325 milligrams (a synthetic opioid and painkiller), give one tablet by mouth every six hours as needed for pain, and fentanyl transdermal patch ( a potent synthetic opioid medication used for pain) 72-hour 12 micrograms per hour, apply one patch transdermally (on the skin) one time a day every three days for pain. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had moderate cognitive impairment and was to be on scheduled and as needed pain medications. Pain was noted in the last five days that was occasional in frequency. Review of the care plan dated 01/12/25 revealed Resident #33 was at risk for pain related to a history of hepatomegaly with ascites (a retention of fluid in the abdomen related to liver disease) and generalized discomfort. Interventions included administer analgesia (pain medication) per order, evaluate the effectiveness of pain interventions, review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results on functional ability. Monitor and record pain characteristics, frequency, location, duration, type of pain, and precipitating and relieving factors. The care plan also revealed resident #33 was able to call for assistance when in pain, ask for medication, tell how much pain they experience, and express what increases or alleviates pain. A review of a narcotic count sheet dated 01/14 25 for hydrocodone (Norco) 5-325 milligram revealed one tablet signed out as given on 01/21/25 at 2:48 P.M. by Licensed Practical Nurse (LPN) #331. A review of the Medication Administration Record (MAR) for Resident #33 dated 01/01/25 through 01/31/25 revealed there was not a hydrocodone pill administered at 2:48 P.M. on 01/21/25. A review of progress notes revealed no documentation that a hydrocodone pill was administered at 2:48 P.M. on 01/21/25 for complaints of pain to Resident #33. 2. A review of medical records for Resident #65 revealed an admitted [DATE] with diagnoses including cervical root disorder, generalized arthritis, and radiculopathy of the cervical region (a pinched or irritated nerve in the neck causing pain, numbness or weakness radiating into the chest or arm). Physician orders included tramadol (an opioid pain medication used to treat moderate to severe pain) 50 mg, one tablet every six hours as needed for pain, and morphine sulfate (a potent opioid medication used to treat pain) 15 mg take one tablet by mouth every 12 hours as needed for chest pain. Review of the quarterly MDS dated [DATE] revealed Resident #65 had severe cognitive impairment and received as needed pain medication. There was occasional pain noted in the last five days of the look back. The pain intensity was rated at four on a scale of one to ten. Review of the care plan dated 01/07/25 revealed Resident #65 was at risk for unrelieved or untreated pain related to impaired cognition with a history of cervical neuropathy and spinal stenosis. Interventions included administer analgesia as ordered, evaluate the effectiveness of pain interventions after one hour and location, duration, type of pain, precipitating and relieving factors, and monitor and record symptoms of nonverbal pain. The care plan also revealed Resident # 65 was able to call for assistance when in pain, reposition self, and ask for medication. A review of the narcotic count sheet for Morphine 15 mg dated 01/20/25 revealed on 01/27/25 at 9:22 A.M. one tablet was signed out as given by LPN #331. A review of the MAR for Resident #65 dated 01/01/25 through 01/31/25 revealed no Morphine 15 mg signed out as given at 9:22 A.M. on 01/27/25. A review of progress notes revealed no documentation a Morphine pill was administered on 01/27/25 at 9:22 A.M. for complaints of pain to Resident #65. A review of the narcotic diversion investigation completed by the facility dated 02/05/25 revealed LPN #331 was sent for a drug screen on 02/05/25 and the instant drug test was positive. The specimen was then sent out for further testing. LPN #331 was suspended pending investigation. The final result was received 02/26/25. LPN #331 had a positive result for opiates, morphine, hydrocodone, oxycodone, and oxymorphone. LPN #331 was terminated and reported to the Board of Nursing. A review of the Ohio Department of Health (ODH) Certification and Licensure website revealed no self-reported incident (SRI) was reported to ODH by the facility in regard to the alleged drug misappropriation by LPN #331. On 03/24/25 at 10:15 A.M. an interview with the Administrator and the Director of Nursing (DON) revealed the facility had one nurse (LPN #331) suspected of taking resident narcotics as there were residents being medicated that normally do not complain of pain. The Administrator and the DON stated they were unable to prove a misappropriation of narcotics after an investigation, as residents did receive pain medications. Both verified an SRI was not filed regarding possible misappropriation of narcotics. The Administrator and DON verified LPN #331 had tested positive for multiple narcotics, so was reported to the Board of Nursing for further investigation. A review of the policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/17/22, revealed misappropriation was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of residence belongings or money without the resident's consent. The policy also stated allegations involving neglect, exploitation, mistreatment, or misappropriation of resident property and injuries of unknown source are reported to the Ohio Department of Health immediately, but no later than 24 hours from the time the incident or allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00163927.

Based on record review, interview and review of facility policy the facility did not ensure Resident #26 received adequate supervision and assistance by staff when being transferred with a mechanical lift, and did not ensure adequate supervision was provided, fall interventions were in place at all times, and complete and thorough post-fall investigations including root cause analysis were done to prevent falls for Resident #77. This affected two residents (Residents #26 and #77) of three residents reviewed for falls. The facility census was 87. Findings include: 1. Record review was conducted for Resident #26 who was admitted to the facility on [DATE] with diagnoses including non-traumatic extradural hemorrhage, atrial fibrillation, anxiety, depression, neuromuscular dysfunction of bladder, fracture of unspecified part of neck of left femur dated 10/31/24, panic disorder, obesity, muscle wasting, need for assistance with personal care, encounter for surgical aftercare following surgery on the nervous system, polyneuropathy, and chronic lymphocytic leukemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had no cognitive impairment and had no falls in the previous quarter. Review of the care plan dated 03/13/25 revealed Resident #26 was at risk for falls related to diagnosis of non-traumatic extradural hemorrhage, decreased strength, endurance, and balance, and required use of a mechanical lift for transfers. Interventions include apply nonskid pad to wheelchair, ensure call light was within reach, and resident requires transfers via full lift with two staff assist dated 02/10/2025. Resident #26 had a prior intervention for transfers via stand lift assist with two staff members dated 10/02/24. Other interventions included follow facility fall protocol, ensure resident wearing appropriate footwear, perform fall risk assessment on admission, quarterly and with any significant change or after any fall. Review of a physical therapy (PT) note dated 11/12/24 revealed Resident #26 was being seen for a pathological fracture of the left hip which was an incidental finding when Resident #26 was hospitalized for a urinary tract infection and hemorrhagic cystitis. The PT note also revealed per the orthopedic doctor, there may not be a fracture but an MRI (magnetic resonance imaging) test could not be performed to confirm due to the presence of a pacemaker. The orthopedic doctor recommended activity as normal. The PT note revealed the daughter of Resident #26 wanted the resident returned to a sit-to-stand mechanical lift transfer status. The note revealed the PT reached out to the doctor for a sit-to-stand transfer order. Review of physician orders for Resident #26 revealed an order dated 06/07/24 for a sit-to-stand lift (type of mechanical lift) with two staff assistance and an order dated 11/12/24 for a Hoyer lift (mechanical lift) with two staff assistance. Review of a progress note dated 02/08/25 at 8:15 P.M. and authored by Licensed Practical Nurse (LPN) #203 revealed Resident #26 had to be lowered to the floor. Resident #26 was observed in the shower still attached to a sit-to-stand lift and sitting on her knees. There were no injuries noted, and Resident #26 was assisted back to her wheelchair using a Hoyer lift with two assistants. A review of the fall investigation that was undated and authored by the Director of Nursing (DON) revealed Resident #26 was being transferred via a sit-to-stand lift when her feet came off the stand lift and Resident #26 had to be lowered to the floor. The investigation also revealed Resident #26 was a sit-to-stand lift with two assists for transfers. Further review of the fall investigation documentation revealed a witness statement authored by Certified Nurse Assistant (CNA) #233 which stated CNA #233 was with Resident #26 at the time of the fall. The witness statement revealed Resident #26's feet were not all the way on the sit-to-stand lift. The witness statement also revealed she was the only staff member with Resident #26 at the time of the fall. An interview with the Assistant Director of Nursing (ADON) #210 and Registered Nurse (RN) #239 on 04/03/24 at 2:00 P.M. verified Resident #26 had orders for two person assistance with a mechanical lift. ADON #210 also verified CNA #233 was alone with Resident #26 and tried to perform the mechanical lift transfer by herself with no other staff present during the transfer. An interview on 04/03/25 at 2:30 P.M.with CNA #233 verified she was the only staff member with Resident #26 at the time of the fall. 2. Record review was conducted for Resident #77 who was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, repeated falls, dementia classified mild with psychotic disturbance, difficulty walking and other symbolic dysfunctions. Review of physician orders for Resident #77 revealed an order dated 02/03/25 for nonskid socks on at all times, an order dated 02/24/25 and timed 7:00 A.M. for a body pillow to open side of bed every shift and an order dated 02/24/25 and timed at 7:00 A.M. for a floor mat to open side of bed. Review of the change of condition Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating Resident #77 had severe cognitive impairment. Active diagnoses within the MDS included Parkinson's disease and repeated falls. The MDS also revealed , Resident #77 has had falls since admission. Two or more falls occurred since admission with no injury and two or more falls occurred since admission with injury. Review of the care plan initiated on 12/24/24 and updated on 03/28/25 revealed Resident #77 was at risk for falls related to history of falls, Parkinson's with tremors and rigidity, decreased functional status with impaired strength balance and safety impairments. Interventions included body pillow to open side of bed to be used when in bed dated 02/23/25, nonskid socks on at all times originally dated 12/24/24 and updated on 03/28/25, floor mat to open side of bed per order dated 03/28/25, follow facility fall protocol 12/24/24, resident requires two staff assist with transfers medical lift as needed with two assist originally dated 12/31/24 and updated 03/28/25, and perform fall risk assessment on admission, quarterly, with any significant change or after fall. The care plan also revealed Resident #77 had Parkinson's disease dated 12/24/24. Interventions included monitor risk for falls refer to fall protocol. A review of the admission fall assessment dated [DATE] revealed a score of 13 indicating a moderate risk for falls. A review of the incident log dated 01/02/25 through 03/24/25 revealed Resident #77 had falls on 02/03/25 , 02/22/25, 02/23/25 at 4:00 A.M. and 02/23/25 at 2:24 P.M., 03/06/25, and 03/16/25. A review of the fall investigation summary including the facility forms titled Personnel QAPI Statement for Falls dated 02/03/25 and authored by the Director of Nursing (DON) revealed Resident #77 slid off the side of the bed at 12:40 P.M. while trying to get out of bed. The summary also revealed Resident #77 was not wearing proper footwear as dated in the care plan 12/24/24. There was no root cause analysis completed within the investigation to determine how best to prevent further falls. A review of a fall assessment dated [DATE] revealed a score of 15 indicating a high risk for falls. A review of the fall investigation including the facility forms titled Personnel QAPI Statement for Falls dated 02/22/25 and authored by the DON revealed Resident #77 rolled out of bed and hit the right side of her head at 2:26 P.M. There was no root cause analysis completed within the investigation to determine how best to prevent further falls. A body pillow to the open side of the bed was the intervention put in place. Review of the facility fall investigation including the facility forms titled Personnel QAPI Statement for Falls, dated 02/23/25 revealed on 02/23/25 at 4:00 A.M. CNA #214 heard Resident #77 yelling out from her room and was found on the floor next to her bed. The body pillow was in place and the resident had non-skid socks on her feet. The resident sustained a scratch on her nose. A fall mat to the open side of the bed was the intervention put in place. This form indicated a QAPI 5 Whys - Root Cause would be completed yet this section was not filled out. Review of the Summary authored by the DON revealed a floor mat was placed to the side of the bed and the resident was sent to the emergency room (ER) for an evaluation. There was no documentation of a root cause analysis to determine how best to prevent further falls. The conclusion simply stated Resident #77 was attempting to get out of bed unassisted and slipped. She landed on her buttocks on the floor on the side of her bed. She scratched her nose on the bedframe. Review of the facility fall investigation including the facility forms titled Personnel QAPI Statement of Falls, dated 02/23/25 revealed on 02/23/25 at 2:00 P.M. Resident #77 had a witnessed fall by CNA #304 in her room. CNA #304 indicated on the document she had just toileted/changed the resident, the resident was in her bed in low position, non-skid socks were on, and a body pillow was in place. The resident stated she was reaching for something and fell out of bed hitting the back of her head. The resident was in severe pain and was sent to the ER. This form indicated a QAPI 5 Whys - Root Cause would be completed yet this section was not filled out. Review of the Summary authored by the Director of Nursing (DON) revealed the call light was in reach, non-skid socks on both feet, the reacher was next to the resident and the resident had two falls in the past day. There was no indication in the investigation that the fall mat was in place at the time of the fall. There was also no documentation of a root cause analysis to determine how best to prevent further falls. A review of a fall assessment dated [DATE] revealed a score of 21 indicating a high risk for falls. Review of the facility fall investigation including the facility forms titled Personnel QAPI Statement of Falls, dated 03/06/25 and authored by CNA #304 who was assigned to the resident this day, revealed on 03/06/25 at 1:00 P.M. Resident #77 sustained a fall. The description of the fall was she was laying on the floor beside her bed. R stated she was trying to get to the sink. The rest of the form was blank except for the CNA's signature so there was no information pertaining to when the resident was seen by staff, when she was last toileted, any fall interventions in place, details of the physical environment nor any information pertaining to the QAPI 5 Whys - Root Cause to determine circumstances involved with the fall. Review of the Summary authored by the DON revealed the resident was found laying on the floor in her room on her left side parallel to the bed with no obvious injuries. The resident stated she got up to go to the sink. The call light was in reach. She is able to self-propel her wheelchair but leans forward when doing so and does not stay in a common area for staff to monitor. Interventions included notification to doctor and daughter and she will be observed every hour for her whereabouts and doings. There was no information in the summary to identify if she had on proper footwear, and did she fall from her bed or the wheelchair. There was also no mention of the conditions of the physical environment in her room nor a root cause analysis to determine how best to prevent further falls. A review of a fall assessment dated [DATE] revealed a score of 21 indicating a high risk for falls. Review of the facility fall investigation including the facility forms titled Personnel QAPI Statement of Falls dated 03/16/25 and authored by CNA #293, revealed on 03/16/25 at 2:10 P.M. she heard an abnormal sound and found the resident in her room sitting on the floor. The resident was last seen in her wheelchair and had on shoes. There was no mention by CNA #293 if any fall interventions were in place. Another statement of falls dated 03/16/25 and authored by RN #274 revealed she became aware of the fall by an abnormal sound. The resident was in her room, laying on her left side, feet at the middle of the bed and her head on the recliner. The resident had been in a wheelchair since 11:00 A.M., was last repositioned and toileted at 2:00 P.M. and was also seen at 11:45 A.M., 12:00 P.M. and 1:45 P.M. The resident had on shoes. Devices listed included floor mat and non-skid pad to the wheelchair. The problem statement and reasons why the fall occurred included: resident leans to the left side, resident refused to go with activities and refused to leave the room - hit and pinched staff. It was noted a pillow was placed to the left side. Review of the Summary authored by the DON revealed the fall occurred on 03/16/25 at 2:10 P.M. The resident was found on the floor laying on her left side. An area of purpura opened on her left hand measuring 0.5 centimeters (cm) by 0.5 cm by 0.1 cm. The resident was unable to state what happened. She had a tendency to lean forward in her wheelchair. She cannot self-propel her wheelchair recently. She was wearing shoes. The wheelchair was tipped on its left side. A pillow was placed on her left side prior to the fall to try and prevent her from leaning to her left. She refused to leave her room prior to the fall and was hitting and pinching staff. The conclusion was that she tipped over her wheelchair by leaning to the left side reaching for something. The purpura on her left hand rubbed the floor causing it to open. Interventions included notification to doctor and daughter, vital signs and assessment and resident to be up in Broda chair for positioning. There were no further details regarding whether the fall was witness or unwitnessed or if the resident was supervised or unsupervised in her wheelchair in her room. A review of a fall assessment dated [DATE] revealed a score of 20 indicating a high risk for falls. A review of the Treatment Administration Record (TAR) dated 02/01/25 to 02/28/25 revealed the body pillow to the open side of the bed and the fall mat were not documented as in place until 02/24/25. On 04/01/25 at 4:00 P.M. an interview with ADON #210 verified the fall investigations dated 02/03/25 , 02/22/25, 02/23/25 at 4:00 A.M., 02/23/25 at 2:00 P.M., 03/06/25, and 03/16/25 lacked completed Personnel QAPI Statement of Falls and complete root cause analyses to prevent future falls. ADON #210 also verified the floor mat to the side of the bed that was listed as an immediate intervention for the fall on 02/23/25 at 4:00 A.M. was not ordered for Resident #77 until 02/24/24 and the fall occurring for the second time on 02/23/25 at 2:00 P.M. when documented made no mention of the fall mat being in place when the resident fell . On 04/01/25 at 1:00 P.M. an interview with Registered Nurse (RN) #239 revealed she was the nurse called to the room on 02/03/25. RN #239 could not recall if Resident #77 had any altered mental status the day of the fall. RN #239 verified Resident #77 slipped out of bed trying to get up unassisted. RN #239 verified Resident #77 was high risk for falling. On 04/01/25 at 1:30 P.M. an interview with Licensed Practical Nurse (LPN) #242 revealed she was the nurse called to the room on 02/22/25. LPN #242 stated Resident #77 was slightly agitated on that day and she placed Resident #77 on hourly checks. LPN #242 also stated Resident #77 would often swing legs over the side of the bed, and confirmed Resident #77 was high risk for falling. On 04/01/25 at 4:15 P.M. an interview with RN #274 revealed she was the nurse assigned to Resident #77 on 03/16/25. RN #274 stated Resident #77 was very agitated on 03/16/24 and was unattended by staff when she fell from the wheelchair at 2:10 P.M. RN #274 confirmed Resident #77 was a high fall risk. A review of the policy titled Falls Protocol, dated 11/13/25, revealed for an individual who has fallen staff will attempt to find possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in a fall. If the cause of the fall is unclear, if the fall may have a significant medical cause such as stroke or an adverse drug reaction, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes. Many categories of medications, and especially combinations of medications in several of those categories, increased the risk of falling. The staff and physician will continue to collect and evaluate information until either the cause of falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of the fall in fall risk. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risk of serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If the individual continues to fall, the staff and physician will reevaluate the situation and consider other possible reasons for the residents falling and will reevaluate the continued relevance of current interventions. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. This deficiency represents non-compliance investigated under Complaint Numbers OH00163927, OH00163893, and OH00163881.

Based on record review, interview and policy review, the facility failed to ensure medications remained in original packaging. This affected one resident (Resident #77) of three residents reviewed for medication administration. The facility census was 87. Findings include: A review of medical records for Resident #77 revealed a date of admission of 12/19/24 with diagnoses including Parkinson's disease, repeated falls and dementia with mild psychotic disturbance. Review of physician orders dated 12/19/24 revealed an order for nuplazid (a medication used to treat hallucinations and delusions associated with Parkinson's disease psychosis) 34 milligrams one capsule by mouth daily to start on 12/20/24. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had severe cognitive impairment. There were no hallucinations, delusions or behaviors noted. On 03/24/25 at 12:02 P.M. an interview with the daughter of Resident #77 revealed she obtained the nuplazid from a specialty pharmacy for Resident #77. On 03/25/25 at 1:32 P.M. an interview with the Director of Nursing (DON) revealed during a review of Resident #77's nuplazid medication administration by the nurses, the DON discovered Licensed Practical Nurse (LPN) #231 was taking any remaining nuplazid pills from a currently opened bottle and pouring them into the newest bottle of nuplazid brought into the facility by Resident #77's daughter so the bottles of nuplazid were being combined into one bottle. The DON verified this was not proper medication storage, as each bottle should have been maintained separately. On 03/25/25 at 3:55 P.M. an interview with the daughter of Resident #77 revealed she had knowledge of the nuplazid pills being combined into one bottle. On 03/26/25 at 8:22 A.M. an interview with Registered Nurse (RN) #255 revealed she counted the nuplazid pills on 03/04/25 with the daughter of Resident #77 and there were 39 pills in the bottle. RN #255 stated the new bottles of nuplazid come in counts of 30. RN #255 stated she knew a nurse combined the bottles. On 03/27/25 at 7:50 A.M. an interview with LPN #231 revealed she had combined two bottles of nuplazid into one when the daughter handed her two bottles of the medication. A review of the policy titled; Medication Storage dated October 2013 revealed medications will be kept in the original packaging dispensed by the pharmacy. This deficiency represents non-complaince identified during the investigation of Complaint Number OH00163893 and Complaint Number OH00163881.

Based on record review, interview and facility policy review, the facility failed to ensure showers were provided on a consistent basis for Residents #51 and #51. This affected one resident (#51) of three residents reviewed for showers. The facility census was 90. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including heart failure, diabetes, kidney disease, unsteadiness on feet, and need for assistance with personal care. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was cognitively intact. He was independent in eating, required setup help for eating, substantial assistance for toileting, partial assistance for showering and supervision for personal hygiene. Review of the care plan dated 12/13/24 revealed Resident #51 had a self-care performance deficit due to functional mobility, and lower extremity weakness. Interventions included assistance with bathing. Resident #51 preferred to bathe two to three times per week. Review of the shower sheets revealed Resident #51 only received one shower the weeks of 12/01/24 and 12/21/24. Interview on 02/20/25 at 8:50 A.M. with Resident #51 revealed he needed assistance getting in and out of the shower. He preferred to shower at least twice per week, and there had been times when he had not received his shower. Interview on 02/20/25 at 12:21 P.M. with the Director of Nursing (DON) confirmed she had no additional information to verify Resident #51 received showers according to his preference. Review of the facility policy titled Shower/Tub Bath, dated 09/17/13, revealed the name, date and time the shower was provided would be documented in the resident's chart, as well as any refusals. This deficiency represents noncompliance investigated under Master Complaint Number OH00161928.

Based on record review, interview and facility policy review, the facility failed to ensure the physician visited Resident #36 as required. This affected one resident (#36) of three residents reviewed for physician services. The facility census was 90. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including congestive heart failure, diabetes, anxiety, hypertension, and cancer of the head, neck and face. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] reveal Resident #36 was cognitively intact. He was independent and eating, required setup help for oral hygiene, partial to moderate assistance for personal hygiene, and was dependent on staff for toileting and showering. Review of the physicians' notes revealed Resident #36 was last seen by his physician on 11/06/24. Interview on 02/19/24 at 7:54 A.M. with Resident #36 revealed he had not been seen by the physician since he was admitted to the facility. (The medical record revealed the resident was seen by the physician one time since admission on 11/06/24). Interview on 02/20/25 at 12:21 P.M. with the Director of Nursing (DON) confirmed she had no documented evidence that Resident #36 was seen by the physician except for the visit on 11/06/24. Review of the facility policy titled Physician Visits and Frequency of Visits, dated 11/20/19, revealed the physician would take an active role in supervising the care of residents including medical services, medication management, physical, occupational and speech therapy, nursing care, nutritional interventions, social work and activities and visit as required. This deficiency represents noncompliance investigated under Master Complaint Number OH00161928.

Based on observation, record review, interview and facility policy review, the facility failed to ensure appropriate signage at the entrance of Resident #45's room who had a physician's order for enhanced barrier precautions (EBP) and failed to ensure [NAME] #204 washed her hands after leaving Resident #45's room and entering Resident #23's room. This affected two residents (#23 and #45) out of four residents reviewed for infection control and had the potential to affect 23 residents (#6, #7, #9, #10, #14, #18, #19, #22, #23, #30, #32, #36, #37, #38, #41, #45, #56, #66, #71, #72, #74, #76 and #78) identified by the facility that were on EBP. The facility census was 90. Findings include: Observation on 02/19/25 at 1:46 P.M. of the 500-hall revealed [NAME] #204 was in Resident #45's room talking with her. There was no signage on the outside of Resident #45's door to indicate the resident had an order for EBP. [NAME] #204 exited resident #45's room and walked down the hall and into Resident #23's room. There was a sign indicating EBP on the outside of Resident #23's room. An interview with [NAME] #204, upon exiting Resident #23's room, revealed she did see the sign indicating Resident #23 was on EBP; however, she did not wash her hands before or when entering the room. She also confirmed she did not wash her hands before leaving Resident #45's room and did not know if Resident #45 was on any type of infection control precautions. Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, kidney disease, arthritis, depression, colon cancer, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was moderately cognitively impaired. She was independent with eating, required supervision for oral and personal hygiene, partial assistance with toileting and dressing, and substantial assistance for showering. Review of Resident #45's physician's orders for February 2025 revealed an order for EBP for extended-spectrum beta-lactamase (ESBL) in her urine (a type of urinary tract infection). The order began on 10/23/24. Review of the care plan dated 01/07/25 revealed Resident #45 required EBP for a history of multi drug resistant organisms (MDRO). Interventions included staff cleaning hands before entering and upon leaving the resident's room. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses including dementia, stroke, depression, anemia, and kidney failure. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. He was independent with eating, required partial assistance for oral hygiene, substantial assistance for personal hygiene, and was dependent on staff for toileting and showering. Review of the physicians' orders for February 2025 revealed an order for EBP for a wound. The order began 04/02/24. Review of the care plan dated 12/20/24 revealed Resident #23 required EBP due to a wound. Interventions included staff cleaning hands before entering and upon leaving the resident's room. Interview on 02/19/25 at 2:12 P.M. with the Director of Nursing (DON) confirmed Resident #45 was on EBP, and there was no sign at the entrance of the room indicating what type of precautions were required for Resident #45. She confirmed all staff should wash their hands upon entrance and exit of a resident's room, regardless of whether or not they have made contact with the resident, if they are on EBP. Review of the facility policy titled Isolation- Categories of Transmission Based Precautions, dated 03/26/24, revealed signs would be placed at the entrance of the room indicating what precautions were needed to be taken for that particular resident. For residents on EBP, staff would wash hands immediately when entering the room and again upon leaving the room. Signs would be placed at the entrance of the room indicating what precautions needed to be taken for that particular resident. This deficiency represents noncompliance investigated under Complaint Number OH00161506.

Based on observation, staff and resident interviews, and review of the Resident Council meeting minutes and facility policy, the facility failed to ensure residents rooms on the 600 hall were homelike as evidenced by the walls being in disrepair. This affected 20 residents (#1, #2, #3, #14, #16, #26, #29, #30, #32, #39, #41, #45, #47, #70 #76, #77, #88, #52, #91, #197) out of the 43 residents who resided on the 600 hall. The facility census was 94. Findings include: Interview on 08/05/24 at 2:41 P.M. with Resident #26 revealed when asked about the black scrape marks and gouges in the wall behind her recliner, the resident stated she hadn't done that to the wall, and it bothered her since she kept thinking there were bugs on the wall. Observation of all the rooms on the 600 hall in the facility on 08/07/24 from 8:10 A.M. to 9:09 A.M. revealed the following concerns: In Resident #45's room, there were six black lines on the wall and one dollar size punctured area to the drywall on the back wall next to recliner. On the right-hand side of the room behind the recliner, there was one dollar coin size, six pencil eraser size, and one nickel size punctured areas to the wall. Interview on 08/07/24 at 8:20 A.M. with Resident #45 revealed it would be nice if the facility would fix the marks on the wall. In Resident #14's room, there were approximately 15 linear gouge marks on right wall behind a recliner, and there was an extra-large white patched area, approximately two feet by two feet, on the back beige colored wall. Interview on 08/07/24 at 8:32 A.M. with Resident #14 revealed if it was up to him, he would have had the wall fixed. He stated he was a painter by trade and liked to make the rooms look beautiful. In Resident #52's room, there were six black lines, approximately six inches long by one fourth inch wide, six dime size puncture areas with no dry wall showing, and one quarter size hole with drywall exposed on the left side wall behind the recliner. Interview on 08/07/24 at 8:46 A.M. with Resident #52 revealed the walls were in that condition when he was admitted , and it was a mess. In Resident #91's room, there were approximately 29 vertical gouge marks, between four and six inches long, with dry wall exposed on the right-side wall behind the recliner. On the back wall next to the recliner, there was one large black mark midway up the wall, approximately 12 inches long by one fourth inch wide, and one gouge in wall, approximately four inches long by one fourth inch wide. Interview on 08/07/24 at 8:44 A.M. with family of Resident #91 revealed if the marks on the wall were in their house, the wall would be fixed. In Resident #88's room, there was one black line, approximately twelve inches long by one fourth inches wide, and four black puncture marks, and numerous vertical gouges in wall with drywall exposed on the right-side wall behind the quilt stand near the corner of the right-side wall and the back wall. Interview on 08/07/24 at 8:52 A.M. with Resident #88 revealed the areas of concern were there when she was admitted , and if she were at home, they would have been fixed. Resident #88 stated if the areas were repaired, it would make her room nicer. In Resident #16's room, there was one fist sized hole, which was completely through the drywall, three vertical gouge marks varying in length from one inch to four inches long by one fourth inches wide, numerous black vertical lines, and approximately fourteen round, approximately the size of pencil top erasers, gouge areas on right hand wall in the right-hand corner of room behind the recliner. On the back wall near the right-hand corner of the room, there was one vertical gouge in wall, approximately six inches long by one fourth inches wide, with white dry wall exposed, one dime size gouge area with white dry wall exposed, and two long vertical black lines In Resident #3's room, there were numerous puncture areas the size of pencil top erasers with white dry wall exposed on left side wall behind recliner. In Resident #1's room, there were four puncture areas the size of pencil top erasers with dry wall showing, and numerous black circular areas and black linear marks taking up an area approximately two feet by one foot on the right-side wall. In Resident #41's room, there were multiple gouge vertical lines and pencil top eraser sized puncture areas with white dry wall exposed on left wall behind recliner. In Resident #2's room, there were three unpainted white circular patched areas, varying in size from three inches by two inches to six inches by three inches, on the left side beige wall behind the glider. On the back wall beside the glider, there were approximately 16 pencil top eraser sized puncture areas with no drywall exposed. In Resident #32's room , there was an approximately 12 inch long by one half inch wide gouge with drywall paper hanging off and white drywall exposed, one crescent shaped gouge with drywall paper hanging off and white drywall exposed, and one unpainted circular white patched area on the beige wall on the back wall by the recliner. On the right-side wall behind the recliner, there was one extra-large, approximately twelve inches wide by nine inches long, unpainted white patched area on the beige colored wall. In Resident #39's room, there was one extra-large unpainted white patch area, approximately one and a half feet wide by nine inches long, on left side beige colored wall mid-way up the wall near the back left hand corner of the room In Resident #30's room , there was an extra-large area, approximately four feet wide by 12 inches tall, full of black lines and small puncture wounds with drywall exposed on left side wall behind the headboard of the bed. In Resident #47's room, there was one, approximately 12-inch-long by one fourth inch wide gouge in wall with white drywall exposed and approximately sixteen black vertical marks on the left side wall behind the recliner. On the back wall next to the recliner, there was one dime size gouge and two large black linear marks. In Resident #77's room, there was one extra-large, approximately nine inch by six inch, white patched area on the right side beige colored wall behind the recliner. In Resident #197's room, there were six linear gouge marks, approximately four to six inches long by one fourth inch wide, causing the white from the drywall to show on the right side wall behind the recliner, and one large, approximately six inch long by one fourth inch wide, gouge causing the white from the drywall to show on the back wall next to the recliner. In Resident #26's room, there were multiple black linear marks on the left side wall behind the recliner. In Resident #76's room, there was a large, approximately six inch by six inch round, white patched area on the beige colored wall on the back wall to the right of the window in the middle of the wall. On the right side wall behind the refrigerator, there were three long gouge marks, approximately three to four inches long by one fourth inch wide. In Resident #29's room, there were two pencil eraser head sized puncture wounds and five round puncture wounds and large black marks down the right-side wall behind the recliner In Resident #70's room, there were approximately over 100 black marks and one dime size gouge in drywall in the middle of the side wall. Environmental tour of the 600 hall rooms on 08/07/24 from 9:12 A.M. to 9:22 A.M. with Maintenance Supervisor #381 confirmed areas of concern and he stated it was a never-ending job with painting and patching walls. He stated he would start to repair the walls and would then get pulled to do other things. Review of Resident Council Meeting minutes from 02/08/24 to 07/18/24 revealed the residents had voiced during the 02/08/24 and 05/15/24 meetings concern over repairs not being addressed in a timely manner. Review of facility policy Housekeeping & Maintenance, dated 09/30/12, revealed it was the responsibility of the facility to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on observation, interviews, and review of the facility Spring and Summer 2024 menu, the facility failed to ensure nutritionally equivalent food substitutions were made and provided for Resident #46, #66, #81, #83 and #145. This affected five residents (#46, #66, #81, #83, and #145) out of the 91 residents who the facility identified as receiving meals from the kitchen. The facility identified three residents (#9, #41, and #55) as receiving no meals from the kitchen. The facility census was 94. Findings include: Review of the facility Spring/Summer 2024 menu cycle for day 10 revealed for lunch a chili dog, baked beans, country potatoes, and watermelon was to be served. Observation of tray line on 08/06/24 between 11:38 A.M. to 12:22 P.M. revealed at 12:21 P.M. the facility ran out of baked beans. Dietary Manager (DM) #380 told the dietary staff to use cottage cheese in place of the baked beans for the five residents (#46, #66, #81, #83, and #145) who did not receive the baked beans. After the cottage cheese was placed on those five residents' trays, the food cart was taken to the 200-300 hall by DM #380. Interview on 08/06/24 at 12:30 P.M. with DM #380 revealed when asked why she told the staff to give cottage cheese for the five residents who didn't receive baked beans, DM #380 stated it was a protein, and it was fast. Interview on 08/08/24 at 10:29 A.M. with Dietitian #376 confirmed the baked beans were the starchy vegetable for the lunch meal on 08/06/24 and should have been substituted with another vegetable instead of the cottage cheese.

Based on record review, interview, and facility policy, the facility failed to hold an initial care plan meeting in a timely manner for Resident #91. This affected one resident (#91) out of 22 residents reviewed for care plans. The facility census was 94. Findings include: Review of medical record for Resident #91 revealed an admitted [DATE]. The resident was discharged to the hospital on 08/01/24 and returned on 08/04/24. Diagnoses included unspecified sequelae (an after effect) of other nontraumatic intracranial (within the brain) hemorrhage (heavy discharge of blood), essential hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), obstructive sleep apnea, chronic combined systolic and diastolic (congestive) heart failure, oropharyngeal phase dysphagia (difficulty swallowing), hemiplegia (total or partial paralysis) and hemiparesis (muscular weakness or partial paralysis) following nontraumatic subarachnoid (below the thin membrane of the brain and spinal cord) hemorrhage (heavy discharge of blood) affecting right dominant side. Review of discharge return anticipated/end of PPS (Prospective Payment System) Part A stay Minimum Data Set (MDS) assessment, dated 08/01/24, revealed Resident #91 was moderately impaired cognitively; required supervision or touch assistance with oral and personal hygiene, substantial/maximum assistance for toileting hygiene, and was dependent on staff for shower/bathe self, and transfers. Resident #91 was always incontinent of bowel and bladder and received nutrition and hydration via a feeding tube. Review of the care plan created on 07/11/24 revealed Resident #91 had an activity of daily living (ADL) self care performance deficit related to cerebrovascular accident and significant decline in functional status. Discharge uncertain but would like to be able to return home. Goals included Resident #91 will have current and prior expressed wishes honored as much as possible regarding care through the review date. Interventions included encourage resident to direct care, offer input and make decisions Further review of the medical chart revealed no indication a care conference had been held for Resident #91 since admission on 07/05/24. Interview on 08/05/24 at 9:58 A.M. with family of Resident #91 revealed she had never been invited to a care plan meeting or had not attended a care plan meeting since the resident had been admitted to the facility. Interviews on 08/07/24 at 12:55 P.M. and 1:10 P.M. with Social Worker #422 confirmed a care conference had not been held for Resident #91, but a care conference meeting had been scheduled for 08/13/24. Social Worker #422 stated Resident #91 should have already had a care conference, but the facility was out of compliance since she had to take some time off work and was the only one who scheduled the care conferences. Review of facility policy Care Planning-Interdisciplinary Team, dated 01/21/14, revealed the resident, the resident's family and/or the resident's legal representative/guardian or surrogate would be encouraged to participate in the development of and revisions to the resident's care plan.

Based on record review, observation and interview, the facility did not ensure food at the appropriate consistency for a mechanical soft diet was served to Resident #39. This affected one resident (#39) of four residents reviewed for food and nutrition. The facility identified 23 residents ordered a mechanical soft diet (#1, #3, #6, #13, #15, #17, #30, #24, #28, #32, #39, #43, #47, #48, #50, #65, #66, #68, #75, #77, #81, #83, and #197). The facility census was 94. Findings include: Review of medical record for Resident #39 revealed a readmitted [DATE]. Diagnoses included Alzheimer's disease, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic diastolic (congestive) heart failure, type two diabetes, oropharyngeal phase dysphagia (difficulty swallowing), and generalized anxiety. Review of physician orders for Resident #39 revealed a diet order dated 07/27/24 for a No Added Salt (NAS) No Concentrated Sweets (NCS) mechanical soft, thin (liquid)consistency diet. Review of 08/03/24 quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #39 was severely impaired cognitively, was independent for eating, and was on a mechanically altered diet. Review of modified barium swallow (MBS) study (a special x-ray for evaluation of swallowing), dated 06/12/24, for Resident #39 revealed mild oral dysphagia and mild pharyngeal dysphagia. It was recommended the resident be on a mechanical soft with thin liquids. Review of speech therapy note dated 06/18/24 Resident #39 was being discontinued from therapy on 06/18/24 on a mechanical soft diet with thin liquids. Review of care plan created on 12/02/21 revealed Resident #39 had a potential for a swallowing problem related to history of oropharyngeal dysphagia. Interventions included all staff would be informed of resident's special dietary and safety needs, and diet would be followed as prescribed. Observation on 08/07/24 at 12:47 P.M. of the lunch meal service in the dining room revealed Resident #39 did not like the main entree so an alternate of chicken tenders was brought to her by Dietary Manager #380 who placed three intact, breaded chicken tenders in front of Resident #39. Resident #39 held the intact chicken tender on a fork and proceeded to bite into the chicken tender when the surveyor intervened due to the Resident's diet slip dated 08/07/24 indicated a mechanical soft diet was what the resident should have received at the meal. At the time of the observation, Licensed Practical Nurse (LPN) #429 was present while feeding another resident next to Resident #39 and LPN #429 confirmed Resident #39 required mechanical soft texture and had been served intact, breaded chicken tenders. LPN #429 proceeded to remove the chicken tenders from the resident and took the plate to the kitchen. Resident #39 was next served the appropriate mechanical soft chicken tenders with gravy. Review of Resident #39's diet slip dated Wednesday 08/07/24 revealed the resident was to receive a mechanical soft diet. Interview on 08/08/24 at 8:54 A.M. with Speech Language Pathologist (SLP) #503 revealed an intact breaded chicken tender was not considered mechanical soft. Interview on 08/08/24 at 10:29 A.M. with Registered Dietitian #376 confirmed the chicken tender should have been cut up prior to giving it to Resident #39 who was on a mechanical soft diet. Review of facility document Mechanical Soft Diet Allowances, dated 10/17/13, revealed soft tenders were allowed if cut up.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure Resident #80 was fed in a dignified manner. This affected one resident (#80) out of 20 residents reviewed for dignity. The facility census was 94. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE] and diagnoses including Alzheimer's disease, Bell's Palsy (a neurological disorder that causes paralysis or weakness on one side of the face), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other specified depressive episodes, other idiopathic peripheral autonomic neuropathy (condition that affects the nerves in the hands and feet causing pain, numbness, and weakness), unspecified protein calorie malnutrition, and need for assistance with personal care. Review of annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 was severely impaired cognitively and was dependent on staff for eating. Review of the care plan created on 06/09/23 revealed Resident #80 had an activity daily living (ADL) self-care performance deficit related to severe cognitive and communication deficits related to dementia and was dependent on staff to provide care. Interventions included the resident may require staff participation to eat. Observation on 08/05/24 at 4:58 P.M. revealed State tested Nursing Assistant (STNA) #502 was standing while feeding Resident #80 in the main dining room, who was seated in a Geri chair (geriatric recliner) with her head elevated sitting next to a half circle table. There was a chair observed right behind STNA #502 as she was feeding the resident. Interview on 08/05/24 at 5:01 P.M. with STNA #502 confirmed she had been standing while feeding Resident #80 and stated she couldn't reach the resident's mouth while sitting. STNA #502 then repositioned Resident #80's Geri chair at the time of the interview and was then able to feed and give fluids through a straw to the resident as STNA #502 sat in a chair. Interview on 08/08/24 at 8:54 A.M. with the Speech Language Pathologist confirmed staff should be sitting while feeding residents. Review of facility policy Serving of Food, dated 01/08/14, revealed residents who couldn't feed themselves would be fed with attention to safety, comfort, and dignity.

Based on record review and interview the facility failed to ensure direct care staff were able to verbalize knowledge of and understanding of Resident #62, #81 and #83's experiences and preferences pertaining to trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the residents. This affected three residents (#62, #81 and #82) out of three residents the facility identified as having post traumatic stress disorder (PTSD). The facility census was 94. Findings included: 1. Review of the medical record revealed Resident # 83 was admitted to the facility on [DATE]. Medical diagnoses included spondylosis without myelopathy, anemia, malignancy neoplasm of prostate and depression. Hospice care started 01/15/24. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83's cognition was intact. Review of the care plan, start date of 07/11/24, revealed Resident #83 reported a history of trauma. Interventions included staff to identify triggering situations and share information with all staff unless resident requested otherwise. If Resident #83 experienced re-traumatization staff would validate feelings, offer emotional support, reassure and provide calming techniques. Resident #83 preferred small groups of three to four people at a time. Interview on 08/06/24 at 4:23 P.M. revealed State tested Nurse Assistant (STNA) #377 was unaware of any PTSD triggers and care planned interventions for trauma for Resident # 83. Interview on 08/06/24 at 4:24 P.M. revealed Licensed Practical Nurse (LPN) #321 was unaware Resident #83 had any triggers related to PTSD and did not know what the care planned interventions were to not cause retraumatization. 2. Resident #81 was admitted to the facility on [DATE]. Medical diagnoses included personal history of adult neglect, delusional disorder, schizophrenia, severe protein malnutrition and schizoaffective disorder. Review of MDS 3.0 annual assessment dated [DATE] revealed Resident #81's cognition was intact. Resident #81 did not reject care. Resident #81 was independent to transfer from bed to chair and to walk ten to fifty feet. Resident #81 needed assistance to bathe, to dress and undress. Review of the care plan with start date of 06/07/24 revealed Resident #81's family reported past history of trauma related to abuse and was concerned of difficulty with staff bathing Resident #81 or performing personal care. Interventions included staff to assist Resident #81 to identify triggers and how to manage and share information with staff unless resident requests otherwise. Resident #81 would be encouraged to verbalize thoughts and feelings when triggered and offer emotional support and calming techniques. Review of facility document titled Pre-Admission Review dated 06/12/23 written by previous social worker (PSW) #500 , revealed Resident #81 had trauma and might be uncomfortable with bathing. Review of facility document titled Trauma Checklist dated 01/12/24, written by PSW # 500, revealed Resident #81 had trauma assault and felt helpless and terrified. Interview on 08/06/24 at 6:05 P.M. with Registered Nurse (RN) #354 and Certified Nurse Assistant (CNA) # 315 revealed both were unaware of any PTSD triggers and care planned interventions regarding Resident #81's care. 3. Resident #62 was admitted to the facility on [DATE]. Medical diagnoses included Alzheimer's, legal blindness, bipolar, schizoaffective and anxiety. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident # 62 had long and short-term memory problems and cognitive skills were severely impaired. No hallucinations or delusions. No verbal or physical behaviors exhibited. No rejection of care. Resident # 62 was dependent on staff to roll left to right in the bed, lie to sit on the side of the bed, sit on the side of the bed and led back. Resident # 62 did not attempt to sit to stand. Resident # 62 was dependent for bed to chair transfers. Did not walk ten feet. Review of the care plan date initiated 01/12/21 revealed Resident # 62 had a history of trauma related to assaults. Interventions included assist Resident # 62 to identify triggering situations and how to manage and share all information with all staff unless resident requests otherwise. If Resident # 62 experienced re-traumatization staff would validate feelings, offer emotional support, reassurance and calming techniques. Resident # 62 would be encouraged to verbalize thoughts and feelings on his terms and when triggered. Resident # 62 would be offered to receive psych services. Resident # 62 would be provided a calm, quiet and safe environment when triggered or experiencing signs or symptoms of traumatization based on preferences. Review of facility document titled Trauma Checklist dated 01/12/22 written by PSW #500 revealed Resident #62 had trauma assault history. Resident #62 felt helpless and terrified according to Resident's #62 family member. Interview on 08/06/24 at 5:57 P.M. with Social Worker #422 revealed the facility would evaluate each resident regarding trauma and triggers prior to admission in the facility. The facility administration would updated the care plans and all care staff were to follow the care plan. Interview on 08/06/24 at 6:00 P.M. revealed LPN #321 was not aware of PTSD triggers or care planned interventions for Resident #62's trauma because the resident was laid back. Interview on 08/08/24 at 10:07 A.M. revealed the Director of Nursing ( DON) was not aware of any PTSD triggers and care planned interventions for Resident # 83, #81 and #62. The DON stated she reviewed care plans. Review of facility in-service documentation dated 02/09/24 revealed services in the facility would be delivered within a trauma informed environment. Review of the facility policy titled Trauma Informed Care dated 01/05/22 revealed the facility would use evidence-based services for residents to meet their needs. The services would be delivered within a trauma informed environment. Review of facility policy titled Comprehensive Care Plan revised 10/20/22 revealed an individualized comprehensive care plan would include measurable objectives to meet the resident's medical, nursing, mental and psychological needs was developed for each resident.

Based on observation, record review, interview, and review of facility policy, the facility failed to maintain resident records in a manner that would protect their confidentiality. This affected one resident (Resident #7) of the 94 residents observed for privacy. The facility census was 94. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE] and a re-entry date of 03/08/24 with diagnoses including type two diabetes mellitus, schizophrenia, recurrent depressive disorder, osteoporosis, hypertension, diverticulitis, unspecified phobia, and unsteadiness on feet. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/26/24 revealed Resident #7 had intact cognition. Further review of the MDS revealed Resident #7 required supervision or touching assistance for toileting hygiene, bathing, dressing her lower body and transfers to the toilet or from the toilet. Resident #7 used a walker and required supervision or touching assistance for toileting hygiene, bathing, dressing her lower body, and transfers to the toilet or from a chair/bed to chair. The MDS also revealed Resident #7 was frequently incontinent of urine and always incontinent of stool. Review of the care plan dated 07/26/24 through 10/26/24 revealed Resident #7 had urinary incontinence at least three to four times per day and stool incontinence at least three to four times per week with a tendency to wear more than one brief at a time or place pads or plastic bags inside her briefs increasing her risk for skin breakdown. Interventions included checking Resident #7 for incontinence every two hours and providing perineal care, skin checks with incontinence care assistance, and provision of a toileting program before and after meals, activities, and t bedtime. Further review of the care plan revealed Resident #7 was at risk for impaired function to her bilateral upper and lower extremities and required restorative nursing assistance to prevent further decline in function twice daily, six to seven times a week, for at least 15 minutes a day. Due to her diagnoses of depression and schizophrenia and use of psychotropic medications, the care plan also directs staff to monitor Resident #7 for agitation, changes in mood, mania, paranoia, hallucinations, and any unusual behavioral symptoms. Random observation on 08/08/24 from 9:05 A.M. to 9:37 A.M. of the computer monitor in the 500 hall revealed an open medical record for Resident #7. Further observation revealed the open record contained visible information including the resident's name, medical record, and plan of care tasks. At the time of the observation, no staff were noted in the hallway and one resident, Resident #48, was sitting in the hallway in his wheelchair. During observation of the documentation station/computer monitor in the 500 hallway on 08/08/24 9:11 A.M., State tested Nurse Aide (STNA) #344 was observed in the hallway passing new water cups to the residents while the medical record remained open and visible on Resident #7's plan of care tab. Continued observation of the 500 hallway on 08/08/24 revealed STNA #345 walking past the computer monitor at 9:15 A.M. twice. Interview on 08/08/24 at 9:34 A.M. with Licensed Practical Nurse (LPN) #349 confirmed the screen on the monitor in the 500 hall was opened with some of Resident #7's medical information visible to others who might be nearby in the hallway. She further confirmed staff were to always lock the screen when walking away to keep information private. During the interview, LPN #349 also confirmed she had occasionally come across unlocked screens with visible resident information and when this occurred, she would lock the screen or log the previous employee out and re-educate them on HIPAA (the Health Insurance Portability and Accountability Act) related to protected health information and confidentiality. As the interview concluded at 9:37 A.M., LPN #349 was observed logging the STNA out of the electronic medical record and locking the screen. Interview on 08/08/24 at 9:55 A.M. with Registered Nurse (RN) #310 confirmed resident information should be kept confidential and the screen to the documentation stations in the halls should not be left open to resident information and unattended. Interview on 08/08/24 at 12:40 P.M. with STNA #303 confirmed she left the computer open earlier on this date when she responded to a call-light and that she should have locked the computer screen prior to leaving it unattended. Review of the policy titled Confidentiality of Information dated 03/16/13 revealed the facility was to treat all resident information confidentially and take measures to safeguard all resident records to protect their privacy.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure care plan interventions were implemented as directed for one resident (Resident #5) and failed to ensure comprehensive care plans were developed for two residents (Resident #51 and Resident #67). This affected three residents (Residents #5, #51, and #67) out of 22 residents reviewed for care plans. The facility census was 94. Findings include: 1. Review of the medical record reviewed Resident #5 was admitted on [DATE] with diagnoses including Alzheimer's Disease, systolic congestive heart failure (COPD), and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #5 had moderately impaired cognition, had an impairment to his bilateral upper and lower extremities, and dependent for toileting hygiene and bathing. Further review of the MDS revealed Resident #5 had last received occupational therapy (OT) services from 04/01/24 through 04/23/24 and received passive and active range of motion (ROM), training assistance with walking, and splint/brace assistance seven out of seven days of the look-back period. Review of the care plan dated 05/16/24 revealed Resident #5 was to wear a left arm and wrist splint and a left ankle-foot orthotic (AFO) when out of bed with a goal of risk reduction of worsening contractures of the left upper and lower extremities. Interventions included direction the splint and brace was to be worn when Resident #7 was out of bed and staff were to provide passive ROM (PROM) of the left upper extremity before and after splint removal, assess for discomfort while the splint and brace were worn, and assess and report any skin concerns noted with applying and removing the splint and AFO. Review of the OT evaluation and visit notes from 04/01/24 through 04/23/24 revealed Resident #5 had a new short-term goal added on 04/10/24 to wear the left hand splint daily for at least two to four hours without signs of ill fit or discomfort and a long-term goal to wear and tolerate the left hand splint up to eight hours daily. Further review of the OT notes revealed Resident #5 was able to tolerate wearing the left hand splint four to five hours a day with no discomfort at the time of discharge from OT services. Review of the plan of care tasks from the last 30 days revealed Resident #5 was to wear an AFO to the left leg for walking only and it was to be off when in bed or the recliner. Further review revealed Resident#5 was to wear a left hand/wrist splint when out of bed. Review of the plan of care task revealed both interventions were included on one sign-off form and there was no differentiation as to which splint/brace was applied on Resident #5. Observation on 08/05/24 at 11:26 A.M. revealed Resident #5 had a contracture of his left hand and wrist limited ROM of his left hand. At the time of the observation, Resident #5 stated he was given a brace for his left hand, it was in the drawer, but nobody told him if he was still supposed to wear it because they stopped putting it on. Observation on 08/06/24 at 2:30 P.M. revealed Resident #5 was in the main hallway in his wheelchair with the left AFO on and no brace on his left arm/hand. Interview on 08/06/24 at 2:39 P.M. with State tested Nurse Aide (STNA) #395 revealed she had no knowledge of brace orders for Resident #5. During the interview, Resident #5 informed STNA #395 he did have a brace and that it was in his drawer. At this time, STNA #395 verified the hand/wrist splint was in the top drawer. Of his bedside dresser. STNA #395 confirmed she did not know how long Resident #5 had the brace or where it came from and added that sometimes residents get braces from therapy, but staff are typically informed and trained on what to do and when to do it if the residents were supposed to wear any braces or splints and she did not believe he was supposed to wear one. A follow-up interview on 08/06/24 at 4:39 P.M. with Resident #5 revealed a staff member came into his room after the surveyor's visit earlier that afternoon, opened his drawer, and removed the hand splint from his drawer, informing him that he never had orders for it and shouldn't have it in his room. Resident #5's daughter, who was present during this interview, stated yes, he does have a hand splint in his top drawer he used to wear all the time when he was up (confirmed she visited every other day and observed Resident #5 with the left hand/wrist splint) until just a few months ago. She also opened the drawer and confirmed the left hand brace was no longer in his room and neither knew who had the splint at that time. Additional observations were as follows: 08/07/24 at 10:10 AM Resident #5 was asleep in his recliner with no left hand splint but was wearing the left AFO. 08/07/24 at 12:25 P.M. Resident #5 was sitting in the main dining hall eating with no his left AFO on and no hand/wrist splint to his left upper extremity. 08/08/24 at 9:11 A.M. Resident #5 was up in his recliner with his left AFO on and no left hand/wrist splint. Interview on 08/07/24 at 3:35 PM with Director of Rehab #505 confirmed Resident #5 was receiving OT services from 04/01/24 through 04/23/24 and that upon discharge from OT, Resident #5 was able to tolerate wearing his left hand/wrist splint for up to four to five hours with no signs of ill-fit or discomfort. At the time of the interview, Director of Rehab #505 confirmed the discharge recommendations did not include the left hand/wrist splint and in a follow-up interview at 4:15 P.M. was unable to determine the reason for not continuing to recommend left hand splinting after discharge, other than Resident #5 not reaching the long-term goal of tolerating the brace for up to eight hours a day. Interview on 08/08/24 at 8:35 A.M. with Restorative Licensed Practical Nurse (LPN) #345 confirmed restorative programs are developed/written by the Assistant Director of Nursing (ADON) and the restorative LPN, the program interventions are placed in the plan of care (POC) tasks, the floor aides carry out the restorative tasks with the restorative nurse providing assistance when needed. During the interview, LPN #345 confirmed the STNAs would know what to do by looking in the medical record and signing off assigned tasks daily. LPN #345 further confirmed the facility was doing a splinting program for Resident #5's left hand in April 2024 but the resident stated it was too bulky and didn't wear it. LPN #345 further confirmed someone removed Resident #5's hand/wrist splint from his room on 08/06/24 and it was found late afternoon on 08/07/24 in the therapy room. LPN #345 confirmed the splint was not supposed to be removed from Resident #5's room. During the interview, LPN #345 confirmed it was the expectation the STNAs applied Resident #5's left hand/wrist splint daily up to four to six hours as tolerated and she was not sure when Resident #5 wore it last. She also confirmed staff applied the left AFO when getting Resident #5 out of bed and it remained in place until he was put in bed at night. Interview with on 08/08/24 at 9:46 A.M. with Registered Nurse (RN) #310 confirmed Resident #5 had a restorative program for a left hand/wrist splint for as long as he could tolerate use, but the resident often refused. At the time of the interview, RN #310 confirmed there are no documented refusals of the left hand/wrist splint in Resident #5's medical record. Review of the policy titled Goals and Objectives, Restorative Services dated 03/16/13, revealed goals and objectives for rehabilitative services were to be developed and outlined in the resident's plan of care. Review of the policy titled Care Planning - Interdisciplinary Team dated 01/21/14 revealed resident care plans were to be based on comprehensive assessment data and were developed by the care planning or interdisciplinary team. Review of the policy titled Comprehensive Care Plans Policy revealed the comprehensive care plan interventions should aid in preventing or reducing declines in the residents' functional status and should enhance the optimal functioning of the resident's by focusing on rehabilitative services. 2. Review of the medical record for Resident #51 revealed she was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, stage three kidney disease, atrial fibrillation, recurrent severe depressive disorder, oropharyngeal phase dysphagia, anxiety disorder, and assistance with personal care. Review of the annual Minimum Data Set (MDS) 3.0 assessment completed on 07/19/24 revealed Resident #51 had moderately impaired cognition and had exhibited no behaviors or rejection of care. Further review of the MDS revealed Resident #51 was on a therapeutic and mechanically altered diet. The assessment revealed no broken or loose-fitting dentures, no broken teeth, and no chewing difficulties. Review of the care plan dated 07/11/24 revealed Resident #51 was a nutrition risk, was placed on a minced moist diet on 05/28/24 due to complaints with chewing and was updated on 06/26/24 to reflect tooth extractions. Interventions included providing diet and interventions per orders and interdisciplinary team (IDT) and catering to Resident #51's preferences. Further review of the care plan revealed Resident #51 had an activities of daily living (ADL) self-care deficit related to decreased strength, balance and endurance and fluctuations in mood and cognition. Interventions noted Resident #51 was independent with eating after staff assisted with tray set-up and she was able to perform oral care after set-up by staff. Review of the care plan revealed no indication Resident #51 had complete top dentures or what assistance she needed in denture management. Review of the progress noted revealed a Social Services note dated 07/01/24 revealed Resident #51 was exhibiting fixation on her extracted teeth and area from which they were pulled. Further review of this note confirmed Resident #51 did have upper dentures and was accepting of the moist minced diet prior to her tooth extractions and she was to be seen by the dentist for a follow-up exam on 07/09/24. Review of the 360 Care dental progress notes revealed Resident #51 received upper complete dentures and had a dental visit on 08/17/24 for denture insertion, fitting check, and instructions/denture education. Observation and interview on 08/05/24 at 11:37 A.M. revealed Resident #51's dentures falling out as she attempted to speak. Further observation revealed Resident #51 pulled the dentures out of her mouth and wrapped them in a tissue, then proceeded to state her dentures had been falling out a lot because she lost some weight and her face changed after her bottom teeth were pulled, and she could not keep her teeth in to eat or talk and expressed she had been waiting a long time for them to fit correctly, though she was unable to specify how long. During the interview, Resident #51 had teary eyes and covered her mouth with her had as she spoke. At the time of the interview, Resident #51 expressed she was embarrassed and did not want anyone and the surveyor to see what she looked like without her teeth. Interview on 08/08/24 11:20 A.M. with Licensed Practical Nurse (LPN) #349 in 500 confirmed Resident #51 had top dentures but did not know if there were any instructions on her care plan. Observation and Interview on 08/08/24 at 11:25 A.M. with Resident #51 revealed her top dentures were secured as she informed the surveyor the social worker got her some glue for her dentures and she just had to put a few dots of glue on them and now the dentures stay in until she takes them out and cleans them at night. Interview on 08/08/24 at 11:27 A.M. with State tested Nurse Aide (STNA) #345 confirmed she was aware Resident #51 had dentures but did not know what care or assistance she needed for the dentures since she typically did not work that hall and did not usually see care plans regarding dentures. Interview on 08/08/24 at 12:30 P.M. with STNA #303 confirmed Resident #51 had upper dentures that she typically managed on her own, but the STNAs provided assistance of Resident #51 asked. During the interview, STNA #303 confirmed dentures are typically not on the care plan and there were no plan of care (POC) tasks related to dentures to document while on shift. Interview on 08/08/24 at 12:40 P.M. with LPN #337 revealed the IDT works on care plans collaboratively but the facility does not always include a plan of care related residents with dentures. Interview on 08/08/24 at 12:45 PM with the Registered Nurse (RN) #310 confirmed the IDT was involved in care planning and if a hearing or chewing/swallowing concern, the resident specific care plan would be entered by the MDS nurse. Interview on 08/08/24 at 12:55 P.M. with the MDS LPN #322 confirmed residents with dentures do not often have care plans related to the dentures, unless they had chewing or swallowing concerns. Interview on 08/08/24 01:18 PM with Social Worker (SW) #422 confirmed there was no care plan related to Resident #51 wearing dentures in the medical record. Review of the Policy titled ADLs dated 06/18/24 revealed each resident would receive assistance daily to meet their needs. Review of the policy titled Care Planning - Interdisciplinary Team dated 01/21/14 revealed resident care plans were to be based on comprehensive assessment data and were developed by the care planning or interdisciplinary team. Review of the policy titled Comprehensive Care Plans Policy revealed the comprehensive care plan interventions should be person-centered an address the resident's medical, nursing, mental, and psychological needs. 3. Review of the medical record for Resident #67 revealed she was admitted to the facility on [DATE]. Diagnoses included peritoneal abscess, adjustment disorder with anxiety, primary hypertension, chronic obstructive pulmonary disease (COPD), muscle weakness, pneumonia, and need for assistance with personal care. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 06/17/24 revealed Resident #67 had moderately impaired cognition, had adequate hearing with the use of hearing aids, and had adequate vision with the use of corrective lenses. Further review of the MDS revealed Resident #67 had an upper and lower mobility impairment of both sides, was dependent for bathing and transfers, and required substantial assistance with personal care. Review of the active care plan in the electronic medical record revealed Resident #67 had a self-care deficit in the performance of activities of daily living (ADLs) and required staff participation in performance of personal hygiene and care. Further review of the care plan revealed Resident #67 had impaired cognition affecting the ability for her to attend to her own needs and general health. During review of the care plan, there were no care plan interventions related to impaired hearing or vision, or Resident #67 requiring the use of corrective lenses or hearing aids. Review of the plan of care tasks revealed no documentation Resident #67 received assistance with corrective lenses or hearing aids. Observation and interview of Resident #67 on 08/05/24 at 11:05 A.M. revealed she was in bed with the television on. At the time of the interview, Resident #67 pointed to her right ear several times and stated she could not hear. Resident #67 was not wearing glasses and did not have hearing aids in at the time of the observation and interview. Further observation revealed a sign posed on Resident #67's door directing staff that when Resident #67 uses her hearing aids, staff should take them out, turn them off, and place them back in her drawer once they are finished using them to speak with her. Observation of Resident #67 on 08/06/24 at 2:42 P.M., on 08/07/24 at 7:33 A.M., 10:12 A.M., and 12:6 P.M., and on 08/0824 at 9:06 A.M. revealed no signs Resident #67 was wearing any glasses or hearing aids. Interview on 08/08/24 11:20 A.M. with Licensed Practical Nurse (LPN) #349 in 500 confirmed Resident # 67 had hearing aids but she did not know if she wore them or when. She further confirmed she did not find information on the care plan regarding the hearing aids. Interview on 08/08/24 at 12:30 P.M. with State tested Nurse Aide (STNA) #345 confirmed she helped the assigned STNA get Resident #67 out of bed and observed STNA #303 put a hearing aid in Resident #67's right ear. Further interview with STNA #345 confirmed Resident #67 was supposed to have hearing aides in every day but the resident sometimes would not allow it. Observation at 11:32 A.M. of Resident #67 revealed she was in the dining hall wearing a hearing aide in her right ear. At the time of the observation, Resident #67 stated she was able to hear better and stated she did not have a hearing aide in daily but did not say why. Interview on 08/08/24 at 12:30 P.M. with STNA #303 confirmed Resident #67 had a hearing aid, but only for one ear and she was not sure why. STNA further confirmed there was no plan of care task to document when Resident #67 uses hearing aids, though she did state it was her assumption Resident #67 should wear a hearing aid every day. Interview on 08/08/24 at 12:40 P.M. with LPN #337 revealed the IDT works on care plans collaboratively and hearing aids should all be care planned for. Interview on 08/08/24 at 12:45 P.M. with Registered Nurse (RN) #310 confirmed the IDT is involved in care planning and if a resident had hearing or chewing/swallowing concerns, the care plan would be entered by the MDS nurse. Interview on 08/08/24 at 12:55 P.M. with the MDS LPN #322 confirmed residents with hearing aids should have the hearing aids care planned for. During the interview, LPN #322 was unable to confirm hearing aids were included on Resident #67's care plan. Interview on 08/08/24 01:18 P.M. with Social Worker (SW) #422 confirmed the IDT always want to care plan related to hearing aids. Review of the Policy titled ADLs dated 06/18/24 revealed each resident would receive assistance daily to meet their needs. Review of the policy titled Care Planning - Interdisciplinary Team dated 01/21/14 revealed resident care plans were to be based on comprehensive assessment data and were developed by the care planning or interdisciplinary team. Review of the policy titled Comprehensive Care Plans Policy revealed the comprehensive care plan interventions should be person-centered an address the resident's medical, nursing, mental, and psychological needs.

Based on observation, interview and facility policy review, the facility failed to ensure medications stored in medication carts and medication storage areas were not expired. This affected two residents (#44 and #68) on one of two medication carts observed. The facility census was 83. Findings include: Observation on [DATE] at 3:56 P.M. of the medication cart in the 600 hall revealed the following findings: 1. [MEDICATION(S)] 100 milligram (mg) ER capsules for Resident #68 expired on [DATE]. 2. [MEDICATION(S)] 20 mg tablets for Resident #68 expired on [DATE]. Interview on [DATE] at 3:56 P.M. during observation of the medication cart for the 600 hall with Licensed Practical Nurse #832 verified the above medications were expired. Observation on [DATE] at 4:18 P.M. of the medication storage room in the 600 hall revealed the following findings: 1. [MEDICATION(S)] 25 mg suppositories in the medication refrigerator for Resident #44, eight total in the bag, expired on [DATE]. 2. Potassium Chloride 20 milliequivalents (meq) Micro ER tablets for Resident #68 expired on [DATE]. Interview on [DATE] at 4:18 P.M. with LPN #832 during the observation of the medication storage room on the 600 hall verified the above medications were expired. Review of the facility policy titled Storage of Medications Policy undated, revealed the nursing staff would be responsible for maintaining medication storage and preparation areas in a clean, safe, sanitary manner. The facility would not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs would be returned to the dispensing pharmacy or destroyed.

Based on interview, medical record review, and facility policy review, the facility failed to ensure a resident's code status (level of medical interventions a patient wishes to have started if their heart or breathing stops) matched the State of Ohio DNR (Do Not Resuscitate) document for Resident #48. This affected one of four residents reviewed for advance directives. The facility census was 83. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) of 11 indicating moderate cognitive impairment. She required the extensive assistance of two staff members for bed mobility, transfers, toileting, and total dependence on staff for bathing. Review of Resident #48's chart revealed the facility form titled Advanced Directives dated [DATE]. This form stated Resident #48 was a full code meaning that all life sustaining measures would be performed in the event her heart or breathing would stop. Further review of the chart revealed a signed State of Ohio DNR-CC (do not resuscitate-comfort care) form indicating in the event Resident #48's heart or breathing stopped no life sustaining measures would be provided to the resident. This form was located on the back side of the Advanced Directives page that stated Resident #48 was a full code. The DNR form was dated [DATE]. Review of the physician orders for [DATE] identified an order dated [DATE] stating the resident was a full code. A physician order dated [DATE] identified an order stating the resident was a DNR-CC. Interview on [DATE] at 3:04 P.M. with the Director of Nursing (DON) verified there was conflicting information regarding code status in Resident #48's chart. The DON verified the first page in the chart stated the resident was a full code, and the DNR form on the back of the page stated she was a DNR-CC. Review of the facility policy titled Advance directives revised [DATE], revealed the Social Services Director or designee would provide written information to the resident and or representative concerning the right to make decisions and formulate advance directives and accept or refuse medical or surgical treatments. A Do Not Resuscitate (DNR) indicated in case of respiratory or cardiac failure, the resident or legal guardian, or representative had directed cardiopulmonary resuscitation (CPR) , or other life-saving methods are to not be used. A DNR-CC means a person receives any care that eases pain and suffering, but no resuscitative measures to save or sustain life. A DNRCC-A (Arrest) means a person receives standard medical care until the time he or she experiences a cardiac or respiratory arrest. Once arrest is confirmed, all life sustaining measures would be withdrawn. Information about whether or not the Resident had executed an advance directive shall be displayed prominently in the medical record.

Based on record review and interview the facility failed to ensure Resident #1 was free from a significant medication error when they failed to administer Resident #1's antipsychotic medication per physician order. Actual Harm occurred when the failure to administer Resident #1's [MEDICATION NAME] medication resulted in the resident experiencing an increase in [MEDICAL CONDITION] with delusions. Per psychiatrist assessment, the resident sustained [REDACTED]. This affected one resident (Resident #1) of three residents reviewed for medication administration. Findings Include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 09/14/18 revealed Resident #1 used [MEDICAL CONDITION] medications related to his [MEDICAL CONDITION] disorder, paranoid type with periods of delusional thoughts and auditory hallucinations. Interventions included administer medications as ordered and monitor for side effects and effectiveness. Resident #1 received psychological services in the community for symptoms of his disease process and medication management. Review of Medication Administration Record [REDACTED]. He received the [MEDICATION NAME] injection on 01/24/19 at 6:00 P.M. Review of MAR for (MONTH) 2019 revealed Resident #1 received [MEDICATION NAME] Trinza Suspension 819 mg per 6.625 ml intramuscularly on 02/17/19 at 5:49 P.M. Review of MAR for (MONTH) 2019 revealed Resident #1 did not receive his [MEDICATION NAME] Trinza Suspension as ordered. Review of form titled, Transfer Sheet for Outpatient Services dated 05/29/19 revealed Psychiatrist #607 evaluated Resident #1 and noted he was more paranoid and had a low blood pressure. She adjusted his [MEDICAL CONDITION] medications. Review of nursing notes dated 06/10/19 at 5:26 P.M. by Registered Nurse (RN) #606 revealed Resident #1 was talking loudly to himself a few times during this shift. Review of form titled, Transfer Sheet for Outpatient Services dated 06/12/19 revealed Psychologist #608 consulted with Resident #1 for counseling and noted he was exhibiting paranoid delusions and recommended to re-assess his [MEDICAL CONDITION] medication regimen. Review of nursing notes dated 06/12/19 at 7:15 P.M. by Licensed Practical Nurse (LPN) #605 revealed Resident #1 returned to the facility with his sister after his psychologist appointment. She revealed the sister stated, he had a major outburst of delusions and I am quite concerned. LPN #605 also noted the psychologist transfer sheet indicated he was exhibiting paranoid delusions and recommended to re-assess [MEDICAL CONDITION] medication regimen. Review of a Medication Incident Report dated 06/20/19 revealed Resident #1's [MEDICATION NAME] Trinza Suspension IM was omitted (not given) in (MONTH) 2019. The report revealed the [MEDICATION NAME] was given immediately after the error was communicated and the Director of Nursing was to follow up to ensure every three-month injections. No other preventative interventions were revealed. Review of MAR for (MONTH) 2019 revealed Resident #1 received his [MEDICATION NAME] Trinza Suspension IM on 06/20/19 at 11:00 A.M. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/02/19, revealed Resident #1 had intact cognition as his Brief Interview for Mental Status (BIMS) score was a 15. He hallucinated and received antipsychotic and antidepressants seven days a week. Review of form titled, Transfer Sheet for Outpatient Services dated 07/10/19 revealed Psychologist #608 consulted with Resident #1 for counseling and noted an increase in depression symptoms and increase in psychotic symptoms including hearing voices. He noted Resident #1 missed his appointment with his psychiatrist and he was concerned over the effects on his symptomatology. Interview on 07/18/19 at 12:30 P.M. with the Director of Nursing revealed Resident #1 was to receive his [MEDICATION NAME] Trinza injection every three months and she verified he received his [MEDICATION NAME] injection on 01/24/19 and then again on 02/17/19. At the time of the interview she verified this was a medication error, however she had not been previously aware of the error. She also verified he did not receive his [MEDICATION NAME] injection per physician order [REDACTED]. She revealed she started tracking the injections for Resident #1 when they were due next on her calendar. She revealed she did not know how the errors occurred but stated it appeared to be a computer glitch. She revealed she had not inserviced the nurses or implemented any other interventions as she did not know what could be done since it was a computer glitch as to why the errors occurred. Interview on 07/18/19 at 1:39 P.M. with Resident #1's sister revealed the resident was was not getting his [MEDICATION NAME] injection per the psychiatrist's order. She revealed he had an increase in delusions and had an outburst when she took him to his counseling appointment on 6/12/19. She revealed he had stated to Psychiatrist #607 on 05/29/19 that he had not been receiving his [MEDICATION NAME] injections. The psychiatrist stated she would check into his medications as well as she had brought up the concern on return to the facility that he had stated he had not been receiving his injections and her concern with his increase in behaviors. She revealed the nurse stated he had received his [MEDICATION NAME] injection per orders. She revealed then she found out he had not received the injections after Psychiatrist #607 reviewed his records. She revealed he continued to have an increase in delusions and was not at his baseline. She revealed she contacted the psychiatrist and updated her that he was still not at his baseline this week. Interview on 07/18/19 at 1:49 P.M. with Psychiatrist #607 revealed she was Resident #1's psychiatrist and on 05/29/19 she evaluated him and he had stated he had not been receiving his [MEDICATION NAME] (antipsychotic) injection as she had ordered every three months. She received a call from his sister on 06/13/19 who revealed she accompanied him to his counseling session and he had an increase in delusions which included talking to his pacemaker. Psychiatrist #607 revealed she had her nurse on 06/13/19 contact the facility to verify if he was receiving his [MEDICATION NAME] per her orders. The facility had stated he had received his [MEDICATION NAME] in (MONTH) 2019 and again on 4/25/19. She revealed she felt this was inaccurate as he was to receive his injection every three months. She revealed on 06/17/19 she asked the facility to send her Resident #1's medication administration records to review. She revealed the facility did not send her the records timely. She revealed after three attempts to receive clarification she received the medication administration records on 06/20/19 and it was verified he did not receive his [MEDICATION NAME] per her physician order. She stated he had received the [MEDICATION NAME] on 01/24/19 and then again on 02/17/19. She stated he was to receive the [MEDICATION NAME] injection every three months. She revealed he then went from 02/17/19 to 06/20/19 without receiving his [MEDICATION NAME] injection until she brought the error to the facility staff attention. She revealed she believed as a result he had significant adverse effects with an increase in [MEDICAL CONDITION] with delusions because he did not receive his medications as ordered and he would continue to have adverse effects up to three months as it would take a long time to get back the optimal effect of the medication. She revealed she felt the facility did not investigate the situation timely when they contacted the facility questioning if he was getting his [MEDICATION NAME] which caused a further delay in treatment. She revealed she spoke with Resident #1's sister this week and he had still been having an increase in delusions and not at his baseline. Review of facility policy titled, Administering Medications, dated 12/18/18, revealed the facility did not ensure the policy was implemented as medications were to be administered in a safe, and timely manner as prescribed. This deficiency substantiates Complaint Number OH 455.

Based on observation, interview and record review, the facility failed to ensure call lights were within reach for six residents, Residents #4, #5, #50, #77, #85, and #140. This affected six of 42 residents reviewed for call lights. Findings include : 1. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment of 03/15/19 revealed the resident was severely cognitively impaired, required the extensive assistance of two staff for transfers and toileting, and was frequently incontinent of bladder and bowels. The care plan dated 06/07/19 revealed care areas identified for Resident #5 being at risk for falls and activities of daily living (ADL) self-care performance deficit. Interventions included staff to ensure the call light was within reach and encourage Resident #5 to use it when assistance was needed. Observation on 06/10/19 at 2:45 P.M. revealed Resident #5 was laying in bed. The call light was observed laying on the floor against the the wall and out reach. Interview on 06/10/19 at 2:47 P.M. with State tested Nursing Assistant (STNA) # 110 verified the resident's call light was not in reach and said it should always be in reach. 2. Resident #50 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, was totally dependent on two staff for transfers and toileting and required extensive assistance of one staff for eating. She was always incontinent of bladder and bowels. The care plan dated 04/26/19 revealed care areas identifying her to be at risk for falls and ADL self-care performance deficit. Interventions included staff to ensure her call light was within reach and encourage her to use it as needed for assistance. Observation on 06/10/19 at 10:46 A.M. revealed Resident #50 sitting in her wheelchair with both hands clenched and the call light hanging behind the resident on the tube feed pole, out of her reach. Interview on 06/10/19 at 10:48 A.M. with STNA #103 verified the call light was out of her reach and said the resident could unclench her fists and would sometimes write on a white board to communicate. Observation on 06/11/19 at 11:45 A.M. revealed Resident #50 asleep in bed with the call light hanging on the tube feed pole behind her head and out of reach. Interview and observation on 06/11/19 at 11:46 A.M. with STNA #105 verified the call light was out of reach and should be pinned right next to the resident's hand. Interview on 06/13/19 7:46 A.M. with Registered Nurse (RN) #211 revealed Resident #50 used the call light at times. 3. Resident #77 was admitted on [DATE] with a cervical spinal cord injury and generalized anxiety. The MDS dated [DATE] revealed she was alert, oriented and cognitively intact. She was totally dependent on two staff for most ADLs. Review of the care plan dated 05/17/19 revealed care areas for risk of falls and ADL self-performance deficit with interventions including staff to ensure her call light was within reach and encourage use as needed for assistance. Observation on 06/10/19 at 9:57 A.M. revealed Resident #77 was seated in her wheelchair with her call pad laying on her abdomen, not pinned to her clothing, and out of her reach. Resident #77 verified she had very limited arm movement and demonstrated how she could only move her forearm and hand a few inches and had no finger dexterity. She indicated the call pad had to be very close to her hand in order for her to activate it to get staff assistance. Interview 06/10/19 at 9:57 A.M. with STNA #114 verified the call pad should always be within reach and the STNA adjusted the call pad closer to her hand. 4. Resident #85 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, required extensive assist of two staff for transfers and extensive assist of one staff for toileting. The care plan dated 02/27/19 included care areas for risk of falls and ADL self-care performance deficit. Interventions included staff to ensure the call light was within reach and encourage use for assistance as needed. Observation on 06/11/19 at 11:31 A.M. of Resident #85 revealed the resident seated in her recliner with her dentures clutched in her left hand hand and she was calling out for help. The resident's call light was draped over the dresser to the right and behind her recliner. The call button was in the far side of the top drawer, out of Resident #85's reach. Interview on 06/11/19 11:33 A.M. with STNA #102 verified the resident's call light was not in reach. Interview on 06/13/19 at 12:39 P.M. with Licensed Practical Nurse (LPN) #101 revealed the resident used the call light when she needed assistance. 5. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was totally dependent on one or more staff for ADLs and had limited in range of motion (ROM) of one side for arm and leg. Review of the current pain plan of care revealed staff were to ensure the call light was within reach so the resident could call for assistance when in pain and as needed. On 06/11/19 at 11:25 A.M., Resident #4 was observed laying in bed watching television and the call cord/button was between the wall and the bed, lying on the floor and out of her reach. Resident #4 said she was not able to find her call button. On 06/11/19 at 2:55 P.M., Resident #4 was observed laying in bed grabbing towards the call cord but was not able to reach it. The call cord and button were observed between the wall and the bed, lying on the floor and out of her reach. Resident #4 said she was looking for the call button because she had to use the restroom. On 06/11/19 at 3:00 P.M., interview with State tested Nurse Aide (STNA) #118 verified Resident #4 was able to use the call button and did when she had to use the restroom. STNA #118 verified the call cord and button were on the floor between the bed and the wall, on the floor and out of her reach. On 06/11/19 at 3:15 P.M., interview with STNA #201 revealed Resident #4 used the call button when she needed assistance. On 06/12/19 at 12:25 P.M. and 3:20 P.M., the resident was observed in bed with the call button clipped to the cord itself and was hanging against the wall about one and a half feet above the bed and out of the resident's reach. At 3:21 P.M., interview with Resident #4 confirmed she was not able to reach the call button. On 06/13/19 at 12:28 P.M., Resident #4 was observed in bed with her sister at her side. Interview with the sister revealed she came daily and the call button was not always within the resident's reach. 6. Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was alert and oriented with intact cognition and was totally dependent on two or more staff for transfers. On 06/12/19 at 4:50 P.M., the surveyor heard Resident #140 yelling out repeatedly which continued until 4:55 P.M. when the survey entered the room. Resident #140 was observed in his wheelchair and the call button was clipped to the resident's pillow on his bed and was out of his sight and out of his reach. On 06/12/19 at 4:56 P.M., interview Resident #140 revealed he wanted assistance and was not able to find or reach the call button. This was verified by Licensed Practical Nurse (LPN) #202 who was present during the interview with the resident who was very upset and agitated because he could not ring for assistance.

Based on observation, interview and record review, the facility failed to provide new interventions and treatments in a timely manner resulting in actual harm for Resident #81 as evidenced by the decline of a pressure ulcer from stage two to stage four. In addition actual harm resulted to Resident #55 for failure to assess Resident #55's newly discovered stage two pressure ulcer and implement preventive skin measures. This affected two of three residents reviewed for pressure ulcers. The facility census was 93. Findings include: 1. Resident #81 was admitted to the facility on [DATE], with the most recent readmission on 01/25/13, following a hospital stay for treatment of [REDACTED]. A [DIAGNOSES REDACTED]. On 06/12/13 at 3:14 P.M.,during observation of wound care for Resident #81 the facility wound nurse explained the Clinical Nurse Practitioner (CNP), the facility wound consultant, had just seen Resident #81. The facility wound nurse had already removed the old dressing and measured the wound at 1.5 centimeters (cm) in length x 1.0 cm width and 0.8 cm depth. The wound was observed uncovered and was cleansed with normal saline solution and gauze for a small amount of thin pinkish red drainage. The wound appeared as an open area, with full thickness tissue loss. The wound bed was moist and beefy red in color. The edges were regular except for one area where the wound nurse explained they had noted tunneling that had not been there before. The wound was packed with a 2 inch x 2 inch silver alginate dressing and the area was covered with a protective gel foam dressing. On 06/12/13 at 5:00 P.M., review and discussion of wound documentation with the wound nurse revealed a skin risk assessment for predicting pressure sore risk, completed on 01/25/13, revealed a score of 13, which indicated a moderate risk for the development of a pressure ulcer. A care plan for potential for skin breakdown included an intervention to follow the facility protocol for risk reduction and treatment of [REDACTED]. Resident #81 was first identified with a stage two pressure ulcer of the coccyx on 04/03/13. The stage two pressure ulcer of the coccyx was measured on 04/03/13 as 2.0 centimeters (cm) x 0.8 cm x 0.1 cm. Subsequent weekly assessments revealed a steady increase in the size of the wound. On 4/10/13 the wound was measured at 2.0 cm x 1.0 cm x 0.1 cm, 4/17/13 the wound measured 2.0 cm x 1.5 cm x 0.3 cm and on 4/24/13 the wound measured 2.0 cm x 1.5 cm x 1.0 cm. Wound documentation from 04/02/13 through 04/17/13 revealed a gradual and continual decline of the wound but indicated there were no changes in the wound treatment orders. The wound consultant was not notified to see the resident until 04/24/13, however, the wound consultant had already left for the day and was not expected to return to the facility for a week. On 05/01/13, four weeks after the initial discovery of the stage two pressure ulcer, the wound consultant saw the resident and the stage two pressure ulcer of the coccyx was identified as a stage four pressure ulcer and was measured at 2.0 cm x 1.5 cm x 1.3 cm. The wound was described as beefy red in color with a moderate amount of red to pink watery drainage. Yellow slough/necrotic tissue, covered 75% of the wound. Review of physician's orders revealed, initial wound care orders on 04/02/13 were to cleanse the open area to the coccyx with normal saline and apply Calcium Alginate and cover with a protective foam dressing. There were no changes in the treatment orders until 05/02/13, after the wound consultant saw the resident. The new treatment order was to cleanse with normal saline solution and apply Santyl alginate and cover with a foam dressing. When the wound nurse asked why the treatment orders were not changed when the wound was progressively declining each week the wound nurse explained she notified the CNP/wound consultant on 05/24/13, but they had already left for the day and they were not scheduled to return for a week. The wound nurse said she also sent a weekly wound report to the facility contracted Registered Dietician Licensed Dietician (RDLD) #4 but did not actually discuss the wound progression with RDLD #4. The wound nurse verified no change in treatment orders were made, during a five week period of time, for a pressure ulcer that was identified as progressively declining. Review of the facility policy and procedures regarding pressure ulcer risk assessment, prevention and treatment revealed a resident should be assessed for risk of development of a pressure ulcer upon admission and as needed and medical conditions such as terminal illness and end stage [MEDICAL CONDITION] placed residents at risk. Guidelines for prevention or decline of a pressure ulcer included monitoring for a decline in nutrition and a system to ensure the changes in condition are evaluated and addressed in a timely manner. A stage two pressure ulcer was defined as partial thickness loss of the outer layer of skin and presents as a shallow open ulcer with a reddish pink wound base. A stage four pressure ulcer was defined as full thickness tissue loss with exposed bone, tendon or muscle and often includes undermining and tunneling. On 06/14/13 at 11:00 A.M., the administrator verified the facility failed to implement new intervention in a timely manner for Resident #81 in order to prevent the decline of a pressure ulcer from a stage two to a stage four. 2. Resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set(MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance for all his daily needs. Review of nurses notes dated 05/04/13 at 3:00 A.M. revealed documentation Resident #55 had drainage through the sock on his right heel. The nurses note indicated the area was cleansed with normal saline and a dressing was applied. Review of untimed nurses nurses notes dated 05/06/13 the director of nursing (DON) documented the resident's " right heel with drainage as noted on 5/4/13 " . The DON documented a new physician's order was obtained to float the resident's heels while in bed. Interview with the treatment nurse, Licensed Practical Nurse (LPN)#5, on 06/13/13 at 10:15 A.M., revealed she was notified of the resident's right heel wound on 5/9/13. Review of the Weekly Progress Summary for wound care and the Skilled Nurses Notes revealed LPN #5 noted there were two Stage III pressure ulcers to the resident's right heel.(A Stage III pressure ulcer involves damage or necrosis of subcutaneous tissue and would present clinically as a deep crater.) She assessed the proximal heel wound to measure 0.7 centimeters(cm in length by 1.2 cm. wide by 0.1 cm. deep. The distal heel area wound measured 1.7 cm. long by 1.3 cm. wide x 0.1 cm. deep. She noted both wound bases were covered with yellow slough. She obtained a physician's order to cleanse with the wounds with normal saline, apply santyl ointment (wound debrider) and apply calcium alginate, and cover with a gauze dressing and change every day and as needed. During the interview, LPN #5 verified there was no evidence an assessment of the wound, measurements, appearance of wound bed or consistency of drainage was documented from the date of discovery on 05/04/13 until she was notified on 05/09/13.

Based on interview, observation and record review, the facility failed to promptly identify, monitor, track and treat multiple pressure ulcers for one Resident (#26) resulting in failure to provide effective treatment. This affected one of two residents reviewed for pressure ulcers of three residents with pressure ulcers in the facility. The facility census was 99. Findings include: Resident #26 was admitted to the facility on [DATE], and [DIAGNOSES REDACTED]. The comprehensive assessment, Minimum Data Set 3.0 ((MDS) dated [DATE], indicated Resident #26 was dependent on staff with assistance of two or more for bed mobility and dependence with one staff member for personal hygiene, eating and dressing. A care plan dated 12/15/10, indicated Resident #26 was at risk for injury and skin breakdown related to her skin being desensitized to pain, pressure and discomfort. A care plan dated 06/06/09, was developed for her risk for skin breakdown related to incontinence, altered mobility, nutritional risks, weight loss and receiving hospice services. Interventions included staff using positional devices such as pillows and foam wedges to keep bony prominence from direct contact, keep skin clean and dry, and to turn and reposition the resident at least every two hours. A hospice care plan was initiated on 01/28/11, related to Resident #26's [DIAGNOSES REDACTED]. On 04/01/12 at 3:15 P.M., Licensed Practical Nurse (LPN) #40, assigned to the care of Resident #26, was interviewed. LPN #40 indicated Resident #26 did not have any pressure ulcers. On 04/01/12 at 4:06 P.M., Resident #26 was in bed and her daughters were in the room assisting their mother. Resident #26 was uncovered in bed with a gown on and a cast on her left lower leg. A dressing was noted on Resident #26's right heel that was dated 03/25/12. The daughters indicated their mother had open areas on her coccyx and heel and that her left knee was red. They stated that staff did not turn her every two hours and attributed the pressure ulcers to that. They indicated that at least one of Resident #26's daughters visited every day. They showed the surveyor a dressing on the back of Resident #26's left knee and said that the open area, or pressure ulcer, was caused by the splint Resident #26 had on her leg prior to the application of the cast for her fractured leg. They showed the surveyor abrasions on Resident #26's right great toe, 2nd toe, and bunion area. Resident #26's feet both turned in and the cast on her left foot/lower leg was resting up against her right foot, causing the abrasions. On 04/01/12 at 4:40 P.M., the director of nursing (DON) was asked to check Resident #26's right foot dressing. The DON verified the dressing on Resident #26's right foot was dated 03/25/12, which was seven days old. The DON removed the dressing and her right heel had an approximately one inch in diameter blister area with black discoloration in the center and what appeared to be a darker pink area surrounding it. The DON indicated Resident #26 had not been identified as having pressure ulcers. The DON also verified the presence of abraised areas on Resident #26's right foot where the cast on her left leg/foot had contacted it. The DON went to check for any treatment orders and to call the wound nurse, LPN #32. The DON stated there was a current physician order [REDACTED]. No frequency for this dressing change was specified. The DON verified there would be no wound tracking for the right heel pressure ulcer since staff had not notified the wound nurse. The wound nurse, LPN #32, arrived on the unit within a few minutes and indicated Resident #26 did not have any pressure ulcers. She was notified of the observations made by the daughters, the DON and LPN #32. She stated she would assess the areas. She was asked to check Resident #26's coccyx as well since the daughters had reported a pressure ulcer there. LPN #32 and the surveyor returned to Resident #26's room. Resident #26 was non-verbal and did not open her eyes. The abrasions/pressure ulcers on Resident #26's right foot and the pressure ulcer on her right heel were verified. Resident #26 was turned to her left side and a dressing dated 04/01/12 was observed on her coccyx. LPN #32 removed the dressing from Resident #26's coccyx and verified there was bloody drainage on the dressing and she stated she would measure the area and provide documentation. The area was superficial and irregular in shape. LPN #32 also verified two circular reddened areas on the inner aspect of Resident #26's left knee, where her knees and the cast had been in contact with her skin related to the lack of padding between her knees. LPN #32 indicated staff were to fill out forms to notify her of any new pressure ulcers. In addition, she stated staff should document an assessment with measurements and provide appropriate treatment until she was able to assess the pressure ulcer(s) for herself. LPN #32 verified she had known about the pressure ulcer behind Resident #26's left knee caused by the splint but had not completed any wound tracking. Review of the nurse's notes revealed the fracture was identified on 03/17/12 and Resident #26 was sent to the hospital. The resident returned from the hospital with a splint in place at 8:00 P.M. on 03/17/12. On 03/28/12, the nurse's note indicated an open area was found on the back of the left knee where the "splint touches (the) back of (her) knee". The area was documented as 0.5 centimeters (cm) long by 1.5 cm wide and 0.1 cm deep. This pressure ulcer was cleansed with normal saline and an Allevyn gentle border dressing was applied. The nurse indicated she faxed the physician, however no ongoing treatment order was written for this pressure ulcer. On 04/01/12, the wound nurse completed wound tracking for each identified pressure ulcer and provided them to the surveyor. The coccyx pressure ulcer was not staged but the documented measurements were 1.0 cm long by 0.5 cm wide and 0.1 cm deep and was described as having a beefy red wound base with scant serosanguineous drainage and redness around the ulcer. The right heel pressure ulcer was 1.7 cm long by 2.0 cm wide without any depth. It was described as dry but no description of the appearance and color of the tissue were recorded. No stage of the ulcer was documented. The left posterior knee pressure ulcer was 0.5 cm long by 1.0 cm wide and 0.5 deep with 75% of the wound bed covered in slough and a scant amount of serous drainage. No stage of the wound was assigned by the wound nurse, however, the presence of slough covering almost the entire wound bed would indicate the pressure ulcer was unstageable since the extent of the tissue damage could not be visualized. The only previous wound documentation for the area was documented on 03/23/12, and did not indicate there was any slough, and provided no documentation of the appearance of the wound. Review of the nurse's notes provided no documentation of the wound until 03/28/12. There were two areas on the right medial knee that were reddened. The wound nurse described them as "100% crust". No stage to the wounds were given to either knee area. The right medial knee area was 0.5 cm long by 1.0 cm wide, and the right medial anterior knee area was documented as 0.3 cm long by 0.7 cm wide. The pressure ulcer on Resident #26's right great toe was not staged. The measurements were 2.0 cm long by 0.5 cm wide with "100% crust" describing the wound base. The right bunion wound area was not staged but the measurements were 1.0 cm long by 1.0 cm wide with 100% crust for the wound base. The right great toe wound was not staged. It measured 1.2 cm long and 0.5 cm wide with a wound base of 100% crust. The wound nurse did not document the stage of any of these pressure ulcers on the tracking sheets, however, the wound nurse provided a handwritten paper that indicated the right heel as a "DTI" or deep tissue injury, which was unstageable. The coccyx was listed as a stage II, (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough and may also present as an intact or open/ruptured blister), and the posterior knee was listed as a stage III, (a full thickness tissue loss where subcutaneous fat may be visible but bone, tendon or muscle is not exposed and slough may be present but does not obscure the depth of tissue loss and there may be undermining or tunneling). Treatment orders were obtained for all of the identified pressure ulcers at that time and the nurse practitioner for wound care was consulted to evaluate the pressure areas. LPN #32, was interviewed on 04/04/12 at 10:20 A.M. She reviewed and verified that there was a physician order [REDACTED]. notifying the surveyor. The treatment was to cleanse with normal saline and apply Allevyn, a [MEDICATION NAME] foam dressing. LPN #32 verified no one had notified her of the pressure area so she could begin wound tracking. LPN #32 verified there was no wound tracking for the pressure area behind the left knee. On 04/04/12 at 10:20 A.M., LPN #32 verified the pressure ulcers were avoidable and a pillow or other pressure reduction device should have been in place. The facility policy for wound measurement and wound assessment guidelines indicated wound assessments would include wound type, location, stage, measurements, tissue type, drainage, odor presence, peri-wound description, signs of infection, pain, or the presence of undermining or tunneling. The wound tracking was supposed to be completed at least weekly by the wound nurse.

Based on observation, record review and interview, the facility failed to ensure a pressure ulcer was promptly identified for Resident #73, who was found with a Stage III pressure ulcer on her lateral great toe, failed to ensure preventative measures were implemented timely to prevent the development of a new pressure ulcer on her fourth toe, failed to ensure treatments and dressings were completed as ordered and failed to ensure her skin was routinely checked for skin alterations. This affected one of five residents reviewed with pressure ulcers. The facility census was 96. Findings include: Resident #73 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The minimum data set assessment dated [DATE] indicated Resident #73 had severe cognitive impairment and she required extensive assistance of one staff for personal hygiene, bathing and dressing. This assessment indicated she did not have any current pressure ulcers but she was identified as being at risk for development of them. Review of podiatry progress notes from 05/27/09 indicated Resident #73 had multiple severe foot deformities on both of her feet and special shoes were to be obtained for her. Review of a wound assessment tool from 2009 revealed she had a history of [REDACTED].g., tendon, joint capsule) and undermining & sinus tracts may also be present, on her right second toe and she was no longer to wear any shoes. Two similar care plans were initiated one on 06/02/05 and 10/15/09 indicating Resident #73 had a loss of sensation and diabetic [MEDICAL CONDITION] and was at risk for injury and skin breakdown. The October care plan indicated her legs and feet were the area of concern. Interventions included observing her skin for areas of irritation, redness, injuries or other open areas and to handle skin and extremities with special care and to wash and dry carefully. On 12/16/10 Resident #73 was found with a pressure ulcer at Stage III, a full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia and presents clinically as a deep crater with or without undermining of adjacent tissue, on her right lateral great toe. There was also a Stage II, a partial thickness skin loss involving epidermis, dermis, or both and is superficial & presents clinically as an abrasion, blister, or shallow crater, on her right medial second toe. The care plans for these pressure ulcers dated 12/16/10 indicated they were related to Resident #73's hammer toes and her continuous walking. Interventions included protecting skin from further injury, but no specific interventions were listed. They were also padding and protecting the feet, applying a pad over the toes with a wrap. On 12/16/10 the right great lateral toe pressure ulcer measured 1.5 centimeters (cm) long by 1.4 cm wide and 0.4 cm in depth with light serous drainage and 75 % granulation tissue. The wound nurse indicated it was a Stage III. The medial right second toe area was found measuring 2.6 cm long by 0.5 cm wide and 0.05 cm deep with light serous drainage and 100% granulation tissue and the wound nurse indicated it was a Stage II. These areas were observed on 01/18/11 at 1:55 P.M. with the wound nurse. The circular area on the inner side of the great toe was approximately 1 cm in diameter with thick yellowish tissue. The area was concave and at the center of the open area was an area approximately 0.2 cm which was reddish tissue. The area on the second toe was healed and was on the bony prominence of the joint deformity. When the nurse removed the dressing from between the great toe and the second toe, the bony prominence of the second toe fit directly into the concave open area of the great toe. There was also a dressing between the third and fourth toes on the right foot. There had been another pressure ulcer on the medial fourth toe according to the wound nurse but was now healed. The facility had identified Resident #73's foot deformities as a concern but failed to initiate preventative measures to prevent the development of pressure ulcers between the deformed toes. The great toe pressure ulcer was not discovered until it was a Stage III. There was no evidence that staff were thoroughly checking Resident #73's skin, especially between her toes where the deformities were located and causing tissue contact and rubbing. The wound nurse removed the sock off of Resident #73's left foot. Her left foot was observed with some toe deformities and no padding or protection on her foot or between the toes. On 01/07/11, 23 days after the development of the pressure ulcers on the right foot, a physician order [REDACTED]. Podi-sleeves are a soft, tube like product which would go around each toe to prevent further contact and rubbing. These podi-sleeves were not observed to be in place on either foot on the day of the wound treatment, 01/18/11. Resident #73 developed a third pressure ulcer on 01/06/11 on her right medial fourth toe. This pressure ulcer was a Stage II and measured 0.2 cm long by 0.2 cm wide and was 0.1 cm deep. Review of the treatment record revealed the podi-sleeves were not applied to Resident #73's feet until 01/19/11. Review of the treatment sheets revealed the facility staff did not complete dressing changes as ordered to these pressure ulcers on 12/23/10, 12/25/10, 12/28/10, 01/09/11, 01/10/11 and 01/14/11. Staff did not document that the laclotion was applied as ordered, to both of her feet every day, for 20 days in December 2010. These concerns were verified with the wound nurse on 01/19/11 at 11:10 A.M., and with the wound nurse and the director of nursing on 01/20/11 at 11:10 A.M.