Every finding on record at Grande Oaks

Based on record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure that a resident with a new right leg injury received timely and thorough assessment, monitoring, treatment, and physician notification following a fall related injury. This resulted in the worsening of the untreated right leg condition, which progressed to an open necrotic wound requiring hospitalization, surgical debridement, and treatment for sepsis. This affected one (Resident #18) of four residents reviewed for hospitalization. The facility census was 42.Actual harm began on 02/05/26, when Resident #18 returned from the hospital with the right lower extremity that was red, shiny, and exhibiting moderate drainage, yet the facility failed to perform a wound assessment, implement monitoring, provide treatment, or notify the physician of this significant change in condition. The facility continued to omit monitoring and follow up from 02/06/26 through 02/10/26, during which clinical concerns increased but no documentation or treatment was provided regarding the resident's right leg condition. By 02/20/26, the resident developed a weeping open wound, and by 02/21/26, a necrotic wound measuring 5.5 centimeters (cm) by 7.5 cm. On 02/24/26, the wound care team documented that the wound to the right lower extremity resulted from a fall on 02/04/26 fall, and the resident subsequently required hospitalization and surgical debridement.Findings include:Review of the medical record for Resident #18 revealed she initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included chronic respiratory failure, dependence on respirator and heart failure.Review of the care plan dated 04/15/22 revealed Resident #18 required assistance for activities of daily living (ADL), was at risk for falls, had a high body mass index (BMI) related to obesity, and had potential for alteration in skin integrity with interventions including: protective and preventative care, inspect for any reddened areas during daily care, observe, monitor and report changes, observe changes in ADL ability, and adjusting assistance as needed with a goal to be free from injury. Review of the care plan revealed no actual areas of skin impairment related to the right leg were present.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. She was dependent on staff for bed mobility and showers/bathing and had functional limitations to range of motion to bilateral lower extremities. She was always incontinent of bowel and bladder. Review of the weight summary dated for the last 90 days revealed Resident #18 weighed 557.8 pounds. Review of the progress note dated 02/04/26 at 8:04 A.M. revealed on 02/04/26, at approximately 5:15 A.M., Resident #18 fell during incontinent care being provided by one certified nursing assistant (CNA). Progress notes documented no visible injuries initially; however, by 12:04 P.M., the resident reported pain to the right leg. Portable x rays could not be completed due to pain, and she was transferred to the hospital. Hospital evaluation identified significant right leg pain but no fracture.Review of the hospital paperwork dated 02/04/26 at 2:09 P.M. for Resident #18 revealed she arrived to the Emergency Department (ED) via the fire department due to a fall with a pain level of 10 out of 10 to both legs. Resident #18 revealed she had pain just below her knee to the ankle after receiving care for a fall at the facility. Resident #18's physical exam revealed the right lower extremity had tenderness of the anterior leg to the ankle and after x-rays, no fractures were found. Resident #18 was subsequently discharged back to the facility with a contusion of the right lower extremity after sustaining a fall. Review of the progress note dated 02/05/26 at 3:44 A.M. the resident returned to the facility with the right leg red and shiny with moderate drainage. No wound assessment, no measurements, no documentation of size, no evaluation of drainage, no monitoring parameters, no treatment orders, and no physician notification occurred.From 02/06/26 through 02/10/26, Resident #18's progress notes reflect increasing clinical concerns but contain significant omissions. On 02/06/26, the resident reported moderate pain relieved by medication, and labs remained pending. By 02/07/26, the physician had been notified of lab results, though the documentation did not identify which labs were drawn or why they were clinically relevant. On 02/08/26, the resident was described as somewhat confused with oxygen saturations dropping to 86-89 percent on 10 liters per minute (L/min) via ventilator, later improving to 92 percent after being switched to 5 L/min via nasal cannula. On 02/09/26, continued confusion led to new orders for a urinalysis, culture and sensitivity, complete blood count (CBC) with differential, and complete metabolic panel (CMP); later that day, further labs and chest x rays were ordered. In the early hours of 02/10/26, repeat culture and metabolic panel labs were ordered, and later that morning the provider directed staff to hold Lasix (diuretic), insert a midline IV, place a urinary catheter, and monitor intake and output. By 02/10/26, the resident was transferred to the hospital for altered mental status and unspecified abnormal lab results and subsequently admitted to the intensive care unit (ICU) with sepsis. Throughout all documentation from 02/06/26 through 02/10/26, there is no mention of the right leg redness that had been documented on 02/05/26 following the fall that occurred on 02/04/26, despite the clinical relevance of this earlier finding.Review of the hospital after visit summary dated 02/19/25 revealed Resident #18 was hospitalized for an infection in her bloodstream. The summary was absent of any information regarding the right leg.Review of the progress note dated 02/19/26 at 6:49 P.M. revealed Resident #18 returned from the hospital with some discoloration to the right lower extremity. Review of the progress note dated 02/20/26 at 6:55 A.M. revealed Resident #18 was very weak and tired, waking up for brief periods during conversations but falls right back to sleep. She had 4 plus pitting edema to bilateral lower extremities. At 6:21 P.M., staff were unable to do an adequate skin assessment due to Resident #18 being out of breath while on her side. Noted a weeping area to inner right calf, and a black weeping wound under her right calf. She refused to allow the nurse to measure or dress it. She was educated on the risk of refusal and benefits of wound dressings. She continued to refuse. The nurse practitioner (NP) #950 was notified of her refusal. NP #950 stated to attempt to put an abdominal (ABD) dressing to the site. Resident #18 continued to refuse. The facility wound care team was notified of needing a wound consult form signed. At 8:18 P.M., the nurse attempted to wake Resident #18 to take her medication and she refused. At 10:38 P.M. Resident #18 remained very tired and continued to refuse to take her medication. Review of the progress notes on 02/21/26 revealed at 1:08 A.M. Resident #18 was awake and asking for respiratory and agreed to take her medication. She continued to refuse other care. At 5:59 A.M. she was offered hygiene care and refused multiple times. She was reminded of importance of wound care in which she replied, shut up, I don't care, leave me alone. At 5:04 P.M. an area of necrotic tissue was observed to the right lower extremity measuring 5.5 cm by 7.5 cm by 0.1 cm. The area was cleansed with normal saline and a Xeroform (petroleum-based non-adherent dressing) dressing and ABD pad applied. NP #950 was notified. Review of the care plan created 02/21/26 revealed Resident #18 had an actual area of skin impairment related to right lower leg necrotic tissue. Interventions included asking resident about pain level prior to dressing change procedure, medicate if needed, maintain enhanced barrier precautions (EBP), observe for clinical changes, such as infection and/or worsening of wound, Pressure reducing mattress, pressure reducing chair cushion, refer to the dietitian to determine need/no need for dietary intervention, skin observation and document on bath/shower days, charge nurse to notify the wound nurse, physician, and family of any new areas.Review of the progress notes on 02/22/26 revealed at 1:05 A.M., Resident #18 was resting in bed, all care was completed, all medications were administered, and she denied pain. At 5:38 A.M., she was upset that staff was encouraging hygiene. While staff were attempting to provide hygiene care, she asked them to leave the room. She was educated on the importance of hygiene and continued to refuse. At 5:48 P.M. and 11:58 P.M., Resident #18 had rested in bed all shift, and all medications were administered as ordered. Review of the progress notes on 02/23/26 revealed at 4:42 A.M. Resident #18 consistently made it difficult to perform hygiene by throwing her weight and arms back, swinging and resisting turning during care/ She was educated on the importance of body mechanics and told the staff, The hell with you guys. At 3:15 P.M., she declined the need for incontinent care. She was educated on the importance of routine care.Review of the wound care note dated 02/24/26 at 12:15 P.M. revealed Resident #18 had an initial consultation for wound care services due to having a recent fall out of bed (02/04/26) and being hospitalized for sepsis. Review of the wound note revealed Resident #18's wound to the right lower extremity posterior aspect resulted from the fall on 02/04/26. The wound measured 9.1 cm by 10.1 cm and the depth of the wound was unable to be determined. Treatment orders were in place, and the wound care team will follow-up weekly. Review of the progress notes dated 02/25/26 revealed a note at 7:28 A.M. stating Resident #18 was approached several times throughout the shift for hygiene (check and change), each time she refused. She was educated on the importance of being clean and dry for skin integrity. She verbalized understanding yet continued to refuse. At 12:40 A.M., Resident #18 was assessed by NP #950 for a necrotic area to the right lower extremity. Upon communication with the physician, Resident #18 received new orders to be sent to the hospital for surgical debridement. Review of the progress note dated 02/26/26 at 5:28 P.M. revealed Resident #18 was admitted to the hospital with diagnosis of sepsis and surgical debridement of the right lower extremity.During an interview on 04/19/26 at 10:25 A.M., Resident #18 stated she had fallen out of bed during care. One staff member was providing care when she was pushed out of bed, fell on the floor and injured her leg. Resident #18 said the wound was not healing, and she was now at risk of losing her leg.During an interview on 04/20/26 at 2:26 P.M., the Director of Nursing (DON), Licensed Practical Nurse (LPN) #563 and Regional Nurse #626 revealed Resident #18 had a fall while receiving incontinence care and as a result a hematoma formed that later turned into a leg wound. LPN #563 revealed Resident #18's leg wound was necrotic and had some redness and swelling and required debridement in the hospital.During an interview on 04/22/26 at 10:44 A.M. with LPN #623 stated Resident #18 complained of leg pain since her fall, and the fall caused cellulitis and ongoing issues.During an interview on 04/29/26 at 12:03 P.M., LPN #563 stated Resident #18 had no skin assessments regarding her right lower extremity, no documentation regarding follow-up care and/or notification to the physician and no new orders for treatment. The skin issue related to her right lower extremity did not present itself until 02/20/26, and after a change in condition, Resident #18 was sent to the hospital. Resident #18's hospital stay and return to the facility was related to UTI and was treated with antibiotics. Resident #18's skin issues were not the focus due to her having a history of skin concerns. LPN #563 verified after Resident #18 returned from the hospital on [DATE], a progress note indicated she had a red, swollen area with moderate drainage to her right lower extremity and the wound was not properly assessed, monitored, treated, or documented to prevent further harm. The facility's Pressure Injury Prevention and Management Policy requires staff to follow a systematic process for all skin integrity concerns, including prompt identification, assessment, documentation, treatment, monitoring, and provider notification of any skin changes. The policy mandates that licensed nurses complete full body skin assessments on admission, readmission, weekly, and as needed, and that any skin changes be immediately assessed, with measurements, wound characteristics, and findings documented in the medical record. It further requires the implementation of timely, evidence based interventions based on the wound's characteristics and the resident's risk factors, along with ongoing monitoring to evaluate healing and identify complications. The policy also directs staff to notify the physician of any new wounds, lack of healing, or complications, and to modify the care plan when a wound worsens or the resident's condition changes. These requirements apply broadly to all wounds, not only pressure injuries, and establish the facility's responsibility to ensure prompt assessment, treatment, and monitoring of any newly identified skin issue.This deficiency represents non-compliance investigated under Complaint Number 2795717.

Based on record review, staff interviews, and policy review, the facility failed to ensure sufficient fluid intake to maintain proper hydration and health and facility failed to monitor and implement interventions to maintain proper nutritional health. This affected two (Residents #18 and #46) of four residents reviewed for nutrition. The facility census was 42.Actual harm occurred on 10/31/25 when Resident #46 was transferred to the hospital for treatment of severe dehydration related complications due to the facility's failure to adequately monitor and assess his hydration status, failure to ensure tube feeding and flush orders were written correctly and implemented as intended, and failure to respond appropriately to his documented change in condition.Findings include:1. Record review revealed Resident #46 was admitted on [DATE]. Diagnoses included respiratory failure, hypertension, and dysphagia (difficulty swallowing). Resident #46 discharged from the facility on 10/31/25.Review of the care plan dated 11/07/24 revealed Resident #46 was at risk for alteration in nutrition and/or hydration related to total dependence on enteral tube feed to meet nutrition and hydration needs with interventions including monitoring for signs and symptoms of dehydration, reviewing labs as ordered and requesting dietary interventions.Review of the progress note dated 07/04/25 at 10:00 A.M. revealed Resident #46 received nothing by mouth (NPO) with a feeding tube, had a significant weight loss and was currently on Isosource 1.5 mL at 70 mL every 22 hours with 200 mL free water flush every four hours. Review of the progress note revealed Resident #46's current order was discontinued and new orders for weight and nutrition monitoring and Isosource 1.5 mL at 70 mL with 55 mL free water flush were implemented.Review of the progress note dated 07/04/25 at 10:13 A.M. revealed Resident #46 had a new intervention of weekly weights to determine if intervention was necessary. Review of the physician orders dated 07/04/25 revealed an enteral feed order for Isosource 1.5 milliliters (mL) at 70 mL per hour, off two hours for activities of daily living (ADL) care and a free water flush of 55 mL every 22 hours. Review of the order revealed an end date of 11/03/25.Review of the nutrition assessment dated [DATE] revealed Resident #46 was on an NPO diet with tube feed. Review of the tube feed order revealed Resident #46 was to receive Isosource 1.5 mL with 55 mL free water flush every 22 hours.Review of the Medication Administration Record (MAR) and Treatment Administration Records (TAR) dated July, August, September and October 2025 revealed Resident #46 received enteral feed order for Isosource 1.5 mL at 70 mL with 55 mL free water flush every 22 hours as scheduled. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact and was independent in making decisions regarding tasks of daily life. Resident #46 required some assistance from staff with ADL.Review of the progress note dated 10/31/25 at 10:50 A.M. revealed Resident #46 had a moist cough and was somewhat lethargic during medication administration. Resident #46 required increased verbal stimulation to arouse but reported he was tired and wanted to stay in bed. Resident #46 was given Tylenol (analgesic) and was awaiting further instruction.Review of the progress note dated 10/31/25 at 10:50 A.M. revealed Resident #46 had a change in condition and was transferred to the ER. Review of the follow-up progress note dated 10/31/25 at 2:24 P.M. revealed Resident #46 received new orders for blood work, an urgent chest x-ray, oxygen if needed, Tylenol every six hours for comfort, Augmentin (antibiotic) twice daily for seven days, and Duoneb (inhalation solution to treat bronchospasms) breathing treatments as needed for shortness of breath. Resident #46 also received orders to be closely monitored with vital signs each shift, given extra fluids through the intravenous (IV) line, starting with a bolus of 0.9 percent Normal Saline (NS) and then a continuous infusion and a one-time water bolus through the feeding tube.Review of the progress note dated 10/31/25 at 3:15 P.M. revealed Resident #46 had a reported critical sodium level of 123 millimoles per liter (mmol/L) (normal is between 135 and 145 mmol/L) and was being transferred to the hospital via emergency medical services (EMS). Review of the weight summary dated July, August, September 2025 revealed Resident #46 had monthly weights, but no weekly weights as requested by Registered Dietitian (RD) #630. Review of the weight summary revealed no other documented weights for the duration of Resident #46's stay. Review of the progress note documented by Registered Nurse (RN) #631, dated 10/31/25 revealed Resident #46 had an acute visit after being found with a fever of 101.2 degrees Fahrenheit (F) and tachycardia (increased heart rate) of 104 beats per minute (bpm). Resident #46 had no signs or symptoms of a urinary tract infection (UTI) and had dry mucous membranes. Resident #46 was resting in bed, lethargic, tired, and per staff was normally conversational. Resident #46 received initial orders for blood work, an urgent chest x-ray, oxygen if needed, Tylenol every six hours for comfort, Augmentin twice daily for seven days, and Duoneb breathing treatments as needed for shortness of breath. Resident #46 also received orders to be closely monitored with vital signs each shift, given extra fluids both through the IV and a one-time water bolus through the feeding tube. Resident #46 had a sodium level of 173 mmol/L and was to be sent to the ER.Review of the hospital laboratory results dated [DATE] revealed Resident #46 had NA levels of 173, BUN levels of 58 milligrams per deciliter (mg/dL) (normal is 8 to 24 mg/dL in adult males), Creatinine levels of 1.3 mg/dL (normal is 0.7 to 1.3 mg/dL), and Glomerular Filtration Rate (GFR) levels of 56 milliliters per minute (mL/min) (normal is above 90 mL/min).Review of the hospital paperwork dated 11/03/25 revealed Resident #46 was admitted to the hospital with hypernatremia from free water deficit, acute kidney infection from dehydration and toxic metabolic encephalopathy, multifactorial etiology, significantly due to dehydration and hypernatremia. Resident #46 was transferred to the hospital for lethargy and abnormal labs with high sodium levels above 170, which was confirmed upon arrival.During an interview on 04/20/26 at 2:26 P.M., Assistant Director of Nursing (ADON) #563 stated Resident #46 went to the hospital due to being septic and dehydrated.During an interview on 04/27/26 at 9:22 A.M., Hospital Liaison/RN #951 stated Resident #46 arrived at the hospital without any paperwork, very high levels of sodium and was severely dehydrated. After hospital blood work, Resident #46's sodium level was 173. She spoke with Licensed Practical Nurse (LPN) #612 and requested copies of recent labs from the facility, but was informed there were no copies of recent labs to provide.During an interview on 04/27/26 at 9:59 A.M., ADON #563 stated Resident #46 had a noticeable change in condition, RN #631 was contacted, and new orders were received for labs, fluids and antibiotics. ADON #563 revealed Resident #46 he had critical labs and needed to be sent to the ER and was subsequently admitted . ADON #563 reviewed the tube feeding order and stated she was not sure why the flush order was written to be done every 22 hours. She stated there was no documentation that indicated staff were monitoring, inputting formulas correctly, or following up with RD #630 for confirmation regarding Resident #46 tube feed. During an interview on 04/27/26 at 10:36 A.M., LPN #612 stated she was the night nurse, but she could not recall anything related to Resident #46's transfer to the hospital.During an interview on 04/27/26 at 1:35 P.M., Regional Nurse #626 stated she was not sure if Resident #46's hospitalization was the cause of free water deficit or not getting enough water from the tube feed. She confirmed there were no tube feed machines that could run feed and flushes at the same time. ADON #563, who was present for the interview, stated multiple bags can hang simultaneously but could not run at the same time because different time intervals would need to be entered into the machine to indicate when to start the feed and when to start the flush. During an interview on 04/27/26 at 2:23 P.M., RD #630 stated she changed Resident #46's flush from bolus to having it with the tube feed but could not remember why. She did not know what type of feeding tube pump Resident #46 utilized. After reviewing Resident #46's record, RD #630 could not provide any information regarding why the flush orders were not clarified to prevent too little flushing, the risk of tube clogging, dehydration or excess fluid. Review of the facility document titled Hydration, dated 05/20/22, revealed the facility had a policy in place to provide sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Further review of the policy revealed the dietician would gather and use data from the nutritional assessment and ongoing monitoring to determine if fluid intake was adequate to meet hydration needs. Review of the document revealed the facility did not implement the policy.Review of the facility document titled Appropriate Use of Feeding Tubes, revised 06/04/23, revealed the facility had a policy in place to ensure that a resident acceptable parameter of nutritional and hydration status was maintained. Review of the document revealed the facility did not implement the policy.2. Record review revealed Resident #18 was admitted on [DATE]. Diagnoses included chronic respiratory failure, dependence on respirator (ventilator status), and heart failure.Review of the care plan dated 04/15/22 revealed Resident #18 required assistance for ADL, was at risk for falls, and had a high body mass index (BMI) related to obesity, with interventions including observing, monitoring and reporting changes, assisting with ADL, following physician orders and monitoring weights.Review of the nutrition and hydration assessment dated [DATE] revealed Resident #18 weighed 399 pounds, was on a low concentrated sweets diet with regular texture with interventions that included weight monitoring per physician orders. Resident #18's skin was intact with no new recommendations. Review of the nutrition and hydration assessment dated [DATE] revealed Resident #18 weighed 399 pounds, was on a low concentrated sweets diet with regular texture with interventions that included weight monitoring per physician orders. Resident #18 skin was intact with no new recommendations. Review of the assessment revealed it was dated 10/31/25 and identical to the assessment completed approximately four months prior. Review of the assessment revealed it was dated 10/31/25 but was not locked until 01/23/26.Review of the progress note dated 02/20/26 at 11:20 A.M. revealed resident #18 returned to the facility after being hospitalized . Resident #18 weighed 399 pounds prior to her hospitalization and had a current weight of 573 pounds. s. Resident #18 received no new recommendations and to continue with weight monitoring per physician orders and report any significant changes.Review of the nutrition and hydration evaluation dated 04/03/26 revealed Resident #18 weighed 558 pounds, was considered morbidly obese, had a regular diet with regular textures with interventions that included strict weight monitoring, monitoring weights per physician orders and notify physician of any significant weight changes.Review of the weight summary revealed Resident #18 weighed 381 pounds on 07/02/25; 398.9 pounds on 10/23/25; and 557.8 pounds on 04/02/26. Review of the weight summary revealed Resident #18 was not being weighed weekly, bi-weekly, or monthly.Review of the MDS assessment dated [DATE] revealed Resident #18 was cognitively intact and was dependent on staff for ADL. She had no behavior problems and did not reject care.Review of the current physician orders, completed and discontinued, revealed no orders for weight monitoring.Review of the progress notes dated 04/10/26 at 9:05 A.M. revealed Resident #18 had a nutrition review related to significant weight change. Resident #18 had a most recent weight of 558 pounds with a BMI of 90, which was morbidly obese. Resident #18 had gained 159 pounds over five months, which was unplanned and undesired. Resident #18 received new orders for daily weights for a week to confirm weight gain.Review of the medical record for Resident #18 revealed no documentation related to physician notification, weight orders, weight monitoring, or in-depth assessments of Resident #18 nutritional status related to significant weight gain. Review of the medical record revealed Resident #18 refused being weighed twice with no other attempts documented.During an interview on 04/21/26 at 12:19 P.M., Certified Nurse Assistant (CNA) #570 stated staff CNAs were responsible for weighing residents according to their orders. Most residents were weighed monthly, unless informed by the nurse to do it more often. CNA #570 stated Resident #18 was not weighed often, and she could not remember the last time she was weighed. Resident #18 was not on the list of residents to be weighed daily, weekly, or monthly.During an interview on 04/21/26 at 12:21 P.M., LPN #513 stated CNAs were responsible for weighing residents and reporting the weights to the nurses. Residents were weighed according to their orders and personal care needs. Some residents were on daily, weekly, or monthly weights. LPN #513 stated Resident #18 was morbidly obese and was nutritional risk due to her size, eating habits, medical diagnoses, and skin issues. RD #630 followed Resident #18 to ensure she remained at baseline with no decline in health. LPN #513 verified there were no orders for daily, weekly, or monthly weights.During an interview on 04/22/26 at 11:43 A.M., RD #630 stated Resident #18 was morbidly obese and had a significant weight increase and was recently placed on fluid restrictions. RD #630 stated she was not sure why Resident #18 was placed on fluid restrictions, but she assumed it was due to retaining water. RD #630stated she was only provided updates on Friday's during risk meetings. She was monitoring Resident #18's weights weekly and was aware of her weight gain of over 100 pounds. RD #630 verified there were no orders for daily, weekly, or monthly weights and no ongoing documented refusals. RD #630 also revealed Resident #18's January 2026 assessment was the most recent weight obtained but could not identify where the weight came from since the last weight documented was from October 2025. RD #630 stated she did not have a new weight for Resident #18, so she reused a previous documented weight. RD #630 revealed she had not assessed Resident #18 in person, therefore her documented assessments were only from information gathered from risk meetings and the medical record. EMR. RD #630 revealed she used the information from previous assessments and other areas of Resident #18 medical record to complete nutritional documentation. RD #630 acknowledged that the information documented in Resident #18 medical record did not accurately reflect Resident #18's current nutritional health status. This deficiency represents non-compliance investigated under Complaint Numbers 2668853 and 1320283 (OH00166923).

Based on observation, record review, policy review, and staff interviews, the facility failed to ensure that kitchen and nursing unit refrigerators were maintained in a clean and sanitary condition. This failure had the potential to affect all residents except nine identified by the facility as receiving nothing by mouth (Residents #4, #5, #7, #8, #15, #27, #28, #37, and #38). The facility census was 42. Findings include:During a kitchen tour on 04/19/26 from 10:16 A.M. to 10:36 A.M. with Dietary Manager (DM) #556, the dry storage room floor beneath racks on the right side was observed to be dirty with stains and debris. Beneath the rack holding thickened beverage cartons, a large brownish stain was noted. Across from this area, two large storage containers-one containing a box of sugar and the other a bag of flour-were observed to be dirty both inside and outside, with various debris present. In the walk-in freezer, a large light pink frozen substance was noted on the floor near the door. The bottom of the blue ice machine scoop container contained a moderate amount of black residue. DM #556 verified all observations at the time of the tour.Review of the undated policy titled Sanitary Conditions indicated that all equipment must be maintained in a clean and sanitary manner. The policy further states that non-refrigerated food items must be stored above the floor on shelves, racks, or dollies that allow for proper cleaning and airflow, and that ice machine containers and scoops are to be sanitized through the dish machine at the end of each day.2. On 04/21/26 at 9:00 A.M., an observation of a nursing unit refrigerator with Regional Dietary Manager (RDM) #900 revealed sticky clear shelves on the inside door. A strand of hair was observed beneath the second clear shelf, and a dried orange reddish splatter was noted running down the inside of the refrigerator door. RDM #900 verified these findings at the time of the observation. Review of the diet order list report dated 04/19/26 revealed nine residents (#4, #5, #7, #8, #15, #27, #28, #37, and #38) who received nothing by mouth. Review of the Resident and Snack Refrigerators policy, revised 10/01/24, revealed that unit refrigerators are to be cleaned weekly by nursing or housekeeping staff, with out of compliance food items discarded. The policy also states that nursing staff are responsible for cleaning spills as needed or contacting housekeeping.

Based on resident record reviews, staff interviews, facility policy review, the facility failed to ensure that residents' advance directives were accurately completed, signed by a practitioner when required, and consistently documented in the medical record. This failure resulted in inaccurate, missing, or conflicting code status information for four residents (Residents #4, #17, #18, and #28) of four residents reviewed for advance directives, creating the potential for staff to provide care inconsistent with the residents' expressed wishes. The facility census was 42. Findings include:1. Review of Resident #4's medical record revealed an admission date of [DATE] with diagnoses of vascular dementia, obstructive pulmonary disease, aphasia following unspecified cerebrovascular disease, and chronic kidney disease (CKD) Stage III. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating Resident #4 had moderate cognitive impairment. Review of Resident #4's medical record (hard chart) and electronic medical record (EMR) revealed no code status. Interview with Licensed Practical Nurse (LPN) #587 on [DATE] at 3:10 P.M. revealed no code status in Resident #4's medical record or EMR. 2. Review of Resident #17's medical record revealed an admission date [DATE] with diagnoses of bilateral primary osteoarthritis of hip, morbid obesity, and type II diabetes mellitus with hyperglycemia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #17 was cognitively intact. Review of Resident #17's medical record and EMR revealed no code status. Interview with LPN #587 on [DATE] at 3:15 P.M. confirmed Resident #17 had no code status in their medical chart or EMR. 3. Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, dependence on respirator (ventilator status), and heart failure. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #18 had a BIMS score of 15 out of 15, indicating she was alert and oriented to person, place, and time. Resident #18 was dependent on staff for activities of daily living (ADL). Review of the physician order located within the hard medical chart dated [DATE], revealed an advance directive of Do Not Resuscitate-Comfort Care Arrest (DNR-CCA), that indicated Resident #18 wanted full life-saving treatments provided until her heart or breathing stopped. Resident #18 elected to have comfort care to ease pain and suffering with no Cardiopulmonary Resuscitation (CPR) or resuscitation once arrest occurred. Review of the care plan dated [DATE] revealed Resident #18 chose to have an advance directive of DNR-CCA, and no CPR measures would not be attempted during cardiac arrest. Review of the physician orders located in Point Click Care (PCC) within the EMR, dated [DATE] revealed an advance directive of Full Code, that indicated Resident #18 requested all life-saving measures were to be used if she was to stop breathing or her heart stopped. Interview on [DATE] at 4:16 P.M. with Regional Nurse #626 during review of Resident #18 EMR and hard medical chart revealed Resident #18 advance directives did not match and did not clearly indicate medical treatment preferences if she was to become incapacitated. Regional Nurse #626 verified the above findings at the time of the interview. 4. Record review of Resident #28 revealed he was admitted [DATE] with diagnoses including respiratory failure, paraplegia, and hypoxic encephalopathy. He had a DNR order dated [DATE]. Record review of his paper chart revealed it was dated [DATE] and had no signature from any physician or other practitioner. Interview with LPN #587 on [DATE] at 11:29 A.M. confirmed the above finding. Review of the facility document titled Resident's Rights Regarding Treatment and Advance Directives, revised [DATE], revealed the facility had a policy in place that residents had a right to formulate an advance directive and it would be communicated with staff and documented in the medical chart. Review of the document revealed the facility did not implement the policy.

Based on observation, interview, and record review, the facility failed to ensure staff spoke to Resident #41 respectfully using her preferred name. This affected one (Resident #41) of five residents reviewed for dignity. The facility census was 42.Findings include:Record review of Resident #41 revealed she was admitted [DATE] and had diagnoses including dementia, anxiety disorder, and chronic respiratory failure. Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had mild or no cognitive impairment.Observation of a video dated 01/22/26 revealed an unseen staff member call Resident #41 by her last name during care.Record review of emails sent by the daughter of Resident #41 to facility staff and the Ohio Department of Health revealed that the emails were directed to verified email addresses belonging to administrative staff. An email dated 02/09/26 stated that Certified Nurse Aide (CNA) #576 called Resident #41 by her last name only. The daughter indicated this was disrespectful, as she believed elders should not be addressed solely by their last name. A subsequent email dated 02/18/26 reported that an unidentified aide continued to address Resident #41 in the same manner. The emails also alleged that staff yelled at Resident #41 and spoke to her as if she were a child.Interview with Resident #41 on 04/19/26 at 10:08 A.M. revealed workers yelled at her often and some were 'very nasty.'Interview with the Administrator, Director of Nursing, Assistant Director of Nursing #563, and Regional Nurse #626 on 04/20/26 at 2:26 P.M. revealed they denied knowledge of the above-noted concerns with the resident being yelled at or of concerns for the resident not being called by her preferred name.Interview with Licensed Practical Nurse (LPN) #543 on 04/22/26 at 11:14 A.M. revealed she sometimes called Resident #41 by her last name and denied knowledge of this not being her preference.Interview with Certified Nursing Assistant (CNA) #576 on 04/22/26 at 1:56 P.M. revealed she called Resident #41 by her last name and denied knowledge of this not to being her preference. She denied ever mistreating or yelling at the resident.Interview with Regional Nurse #626 on 04/27/26 at 1:09 P.M. confirmed the video showed a staff member addressing Resident #41 by her last name.Interview with Resident #41 on 04/28/26 at 8:49 A.M. revealed she preferred to be called by her first name. She said staff sometimes called her by her last name, which she felt was rude and disrespectful.Record review of the resident concern log for the past year revealed no documented concerns regarding Resident #41.This deficiency represents noncompliance investigated under Master Complaint Number 2961312 and Complaint Numbers 2726820, 2623912, and 2606964.

Based on observation, record review, interviews and policy review, the facility failed to reasonably accommodate Resident #41's longstanding (since June 2024), care-planned preference to maintain an electronic monitoring device in her room. The facility failed to support continuation of the device in accordance with the residents' rights, preference and care plan. This affected one resident (41) of one reviewed for personal property. The facility census was 42.Findings include:Record review revealed Resident #41 was admitted to the facility on [DATE]. Resident #41 resided in a private room with no roommate. Review of a care plan dated 06/12/24 revealed the resident's preference to use electronic monitoring in her room. The care plan specifically instructed staff not to obstruct, tamper with, or destroy any recording devices. Review of a care conference note dated 12/02/25 revealed Admin discussed alternate placement with resident and POA. At this time facility cannot meet resident's needs and POA is non-compliant with camera policy. Facility will assist POA and resident with finding alternative placement. Daughter is excessive with emails (i.e sending at all hours i.e. 11:49 pm multiple times a day) encouraged daughter to go directly to nursing when she is in facility. The care conference notes failed to contain any additional information related to how the resident's daughter was non-compliant with the facility camera policy and/or any measures taken to ensure the resident's right to use an electronic monitoring device in her room was honored. A progress note dated 03/12/26 revealed the Administrator notified the resident's daughter on 03/09/26 the camera had been removed for noncompliance with policy, and the family retrieved the camera on 03/12/26. Information provided from Resident #41's daughter during the investigation revealed this camera was the third camera she had purchased for use in the facility since the resident's admission as the two prior camera devices had been damaged by facility staff. The daughter indicated this most recent camera (that had been removed by the Administrator on 03/09/26) had been in place since 06/26/25. During the onsite survey, the facility provided no documented evidence of any new or immediate safety risk justifying the abrupt removal of the camera, nor any written notice or progressive steps to warrant the removal of the device between 06/2025 and 03/2026). Observation of Resident #41's room on 04/19/26 at 10:06 A.M. revealed the resident had a posting on the door identifying there was electronic recording in the room.Interview with Resident #41 on 04/19/26 at 10:08 A.M. revealed she had a camera on the drawers at the foot of her bed until a few weeks ago, when staff removed it against her wishes. Observation revealed the resident had no obvious camera in the room, including on the drawers at the foot of her bed. Resident #41 was the only resident residing in the room.Interview with the Administrator on 04/19/26 at 4:56 P.M. revealed he removed Resident #41's camera because it violated facility policy, stating it could be remotely moved. The Administrator denied any Wi-Fi issues in Resident #41's room and explained the camera's noncompliance had been discussed with the family and ombudsman numerous times over the last year before the facility ultimately removed it. The Administrator maintained the camera was noncompliant due to its ability to pan and be remotely controlled and further stated the resident's daughter had spoken or yelled at staff through the cameraInterview with Ombudsman #700 on 04/20/26 at 1:16 P.M. revealed the facility reported Resident #41's camera could follow people when it moved around the room, but Resident #41's daughter said it did not do this. The facility communicated a new camera could be put in the room from a list they said they would provide the daughter; however, Ombudsman #700 was not sure if the list had been provided as of this date. Interview with Ombudsman Team Lead #701 on 04/20/26 at 1:44 P.M. revealed the family of Resident #41 wanted the previous camera (that had been removed by the Administrator on 03/09/26) back in the room as the daughter was refusing to pay for a fourth camera. The Ombudsman Team Lead revealed it was her understanding the facility justified the removal of the camera because the camera could move and because Resident #41's daughter spoke to staff through the camera.Interview with the Administrator, Director of Nursing, Assistant Director of Nursing #563, and Regional Nurse #626 on 04/20/26 at 2:26 P.M. verified the camera that had been in Resident #41's room since 06/2025 had been removed by the Administrator in 03/2026. The administrative staff revealed they had determined Resident #41's camera could pan the room, and they did not allow cameras that could do that. The Administrator removed the camera, and staff returned it to the family. The Administrator said the daughter could place a new camera in the room but needed to go through him first to ensure compliance with facility policy. He said the camera should have a fixed position, and the daughter should not be able to speak through it into the room.During an interview with Resident #41's daughter on 04/21/26 at 4:07 P.M. the daughter showed the surveyor the camera that had been removed from Resident #41's room. Observation of the camera revealed no evidence the camera had independent locomotion; however, it could rotate without direct physical manipulation. Resident #41's daughter showed the surveyor an app on her phone demonstrating the camera could be set to a fixed position. She said that Wi-Fi in the resident's room often went out, and when it did the camera reset its' settings, and she had to turn off its mobility again. The daughter reported she had numerous recorded incidents of staff yelling at or mistreating the resident and staff often blocking the camera by placing towels over it or standing directly in front of it that had been lost because the SD card from the camera was missing when the facility returned the device to her. During the interview, Resident #41's daughter revealed at the 08/28/25 care conference, she attempted to demonstrate the device's fixed position capability, but she stated the Administrator refused to review it. She then shared she had sent emails to facility administrative staff explaining the camera's functionality and need to be reset after Wi-Fi outages to keep it in a fixed, which the facility failed to respond to. Resident #41's daughter revealed she stopped sending emails after a 12/02/25 care plan meeting because she stated during this meeting she was threatened with a 30-day discharge notice for sending excessive emails. Record review revealed the facility provided no documented evidence explaining the loss of the memory card or demonstrating attempts to investigate or recover the resident's memory card from the camera. Review of emails sent by Resident #41's daughter from [NAME] 2025 through March 2026 (including on 08/12/25, 10/02/25, 10/13/25, 11/15/25, 03/12/26, 03/17/26, and 03/25/26) to verified email addresses of facility staff revealed communication voicing concerns of persistent Wi Fi failures within the facility causing the camera to reboot and rotate automatically. The emails noted the camera device was always set to a fixed position and never placed on motion tracking. The emails included repeated requests for maintenance intervention of the facility Wi-Fi system to address connectivity issues which had been ongoing (per the daughter) for over a year.Review of the facility's electronic monitoring policy revealed it required cameras to be fixed position but contained no prohibition against two way audio, despite the Administrator citing audio use as a reason for removal. This discrepancy demonstrated the facility relied on unwritten or inconsistently applied expectations when removing the resident's property.Review of the facility's concern log from March 2025 to March 2026 revealed no entries regarding camera compliance issues, despite the Administrator's assertion the matter had been discussed numerous times over the last year. The absence of such documentation beyond care conference minutes (from the meeting held on 12/02/25 which focused on the volume of the daughter's emails rather than any verified camera related noncompliance and contained no evidence of progressive steps or efforts to reconcile the issue) contradicts the facility's claim of ongoing issues and undermines justification for immediate removal of the resident's property.This deficiency represents noncompliance investigated under Complaint Number 2804759 and Complaint Number 2726820.

Based on record review, interviews, and facility policy review, the facility failed to ensure that a resident's medical records request was honored in accordance with policy. This failure affected one (Resident #41) of one resident reviewed for records requests. The facility census was 42Findings include:Record review showed that the daughter of Resident #41 sent emails on 03/15/26 and 04/25/26 to verified facility email addresses for the Assistant Director of Nursing (ADON) #563, Social Worker #574, and carbon copied (cc) the Long-Term Care Ombudsman requesting the resident's medical records. She also asked to be sent any required forms needed to complete the requestDuring interview on 04/27/26 at 1:47 P.M., ADON #563 confirmed these emails were sent but stated she did not recall seeing the records request.During a separate interview at the same time, Social Worker #574 reported that she began employment on 03/16/26, one day after the first email was sent. Although she used the same social worker email address to which the request was sent, she stated she did not review emails that predated her start date. She denied knowledge of any records request and said such requests would go through the AdministratorAn interview with the Administrator on 04/27/26 at 4:35 P.M. revealed he was not aware that Resident #41's family had made a records request, but he confirmed that an email dated 03/15/26 requesting records had been sent to facility management addressesReview of the facility's medical records release policy dated 06/01/24 revealed that all resident record requests must be referred to the Administrator. The policy directs the facility to review each request, verify the requesting party's access rights, request further information if needed, and notify the relevant office to ensure the request is completed.This deficiency represents noncompliance investigated under Complaint Number 2726820.

Based on record review and interview, the facility failed to uphold its responsibility to protect residents' rights to receive care in a manner that maintains their dignity, autonomy, and personal property. This affected one (Resident #41) of one resident reviewed for personal property. The facility census was 42.Findings include:Record review of Resident #41 revealed she was admitted [DATE] with diagnoses including dementia, anxiety disorder, and chronic respiratory failure. Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had mild or no cognitive impairment. Her progress notes revealed no documentation of any missing SD card, socks, or cord, or of any broken phones or cameras.Review of an email sent to the verified email address of the Director of Nursing (DON), Assistant Director of Nursing (ADON) #563 and Ohio Department of Health (ODH) email addresses by the daughter of Resident #41 on 03/19/26 revealed the daughter reported a set of cabin socks given as a Christmas present were stolen from her room on 03/17/26. She also said she previously reported two cameras, and a phone were broken by staff with no reimbursement.Review of an email sent to the verified email address of the ombudsman's office by the daughter of Resident #41 on 03/14/26 revealed she reported a missing camera and SD card.Review of an email from Regional Nurse #626 dated 04/21/26 revealed the facility did not have an inventory list for Resident #41's possessions.Review of the Ohio Department of Health Certification and Licensure website revealed no alleged misappropriation events were reported by the facility within the last six months.Interview with Resident #41 on 04/19/26 at 10:08 A.M. revealed she had cameras that were missing. She also said staff took the cord off her [NAME] music device last week and now it was unusable. She could not say if she notified the staff but said her daughter probably did so.Interview with Ombudsman #700 on 04/20/26 at 1:16 P.M. revealed her office was notified of a missing SD card for Resident #41's camera in March 2026. They went to the facility to follow up on the concern and staff denied knowledge of the missing SD card.Interview with the Administrator, DON, ADON #563, and Regional Nurse #626 on 04/20/26 at 2:26 P.M. revealed the Administrator removed the camera from Resident #41's room and said there was no SD card present at that time. He said staff had not been told of any missing items including a missing cord, socks, or SD card.Interview with Resident #41's daughter on 04/21/26 at 4:07 P.M. revealed she said staff removed a camera from the resident bedside and returned it to her without the SD card she purchased to store data in it. Staff had also broken two cameras since June 2026 and broke the resident's phone by dropping it.Interview with Regional Nurse #626 on 04/29/26 at 3:30 P.M. confirmed the facility did not have any recent 'soft file' documenting response to concerns for the family of Resident #41 which may not be logged in her official medical records.Record review of the resident concern log from March 2025 to March 2026 revealed no concerns related to Resident #41.This deficiency represents noncompliance investigated under Complaint Numbers 2726820, 2639150, 2623912, and 2606964.

Based on record review, review of the Ohio Department of Health (ODH) Certification and Licensure website, facility policy review, and interviews, the facility failed to follow established policies for responding to allegations of abuse, neglect, and misappropriation. This affected one (Resident #41) of two residents reviewed for abuse. The facility census was 42.Findings include: Record review of Resident #41 revealed she was admitted [DATE] with diagnoses including dementia, anxiety disorder, and chronic respiratory failure. Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had mild or no cognitive impairment. Review of her progress notes revealed no evidence of documented abuse or misappropriation allegations in 2026. She was hospitalized [DATE] for sepsis and returned to the facility 03/06/26.Record review of emails sent by the daughter of Resident #41 to verified email addresses facility staff and ODH revealed the following allegations regarding the care of Resident #41:- An email dated 01/24/26 said Licensed Practical Nurse (LPN) #533 gave Tramadol (opioid pain medication) doses too close together and behaved with animosity and hatred, saying 'ridiculous things' about the resident and daughter.- An email dated 02/02/26 said LPN #533 intimidated Resident #41, who was afraid to be alone with her.- An email dated 02/05/26 said LPN #533 did not give medications as ordered and falsely said the resident refused care. Resident #41 also called for incontinence care and had her light turned off with no response for several hours.- An email dated 02/09/26 said Certified Nurse Aide (CNA) #576 disrespected Resident #41's personal belongings daily and spoke to her like a three-year old.- An email dated 02/18/26 said an unclarified aide enacted verbal abuse by continually yelling at Resident #41.- An email dated 03/19/26 said a set of cabin socks were stolen from Resident #41.Review of an email sent to the ombudsman's office by the daughter of Resident #41 on 03/14/26 revealed she reported a missing camera and SD card.Record review of the ODH Certification and Licensure website revealed the only self-reported incident (SRI) involving Resident #41 within the last six months was SRI #271831 dated 03/09/26, which involved an allegation of neglect and mistreatment by LPN #533 and CNA #576.Interview with Resident #41 on 04/19/26 at 10:08 A.M. revealed workers yelled at her quite often and aides were very nasty. She could not remember the specifics of who or what was involved with these events. She also said staff took the cord from her Bluetooth radio last week, rendering it unusable.Interview with Ombudsman #700 on 04/20/26 at 1:16 P.M. revealed her office was notified of a missing SD card for Resident #41's camera in March 2026. They went to the facility to follow up on the concern and staff denied knowledge of the missing SD card.Interview with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #563, and Regional Nurse #626 on 04/20/26 at 2:26 P.M. revealed they denied knowledge of all abuse, neglect, and misappropriation allegations in the above noted emails.Interview with the daughter of Resident #41 on 04/21/26 at 4:07 P.M. revealed she believed staff stole the SD card from the camera the facility removed from Resident #41's room, which contained footage of staff screaming at the resident.Record review of SRI #271831 dated 03/09/26 revealed staff were alleged to have spoken to the resident in a loud, abrasive manner. The report identified concerns of mistreatment with no specifics noted. There was no noted interview or attempted interview with the daughter, and the only noted interview with Resident #41 was the same questionnaire form other residents received wherein pre-written answers were circled indicating she felt safe and had no concerns with neglect or mistreatment. There was also no documented attempt to request footage from a monitoring camera, which was identified in progress notes to be in the resident's room until the facility removed it on 03/12/26.The surveyor confirmed the above findings in the SRI with Regional Nurse #626 on 04/22/26 at 2:34 P.M.Following the above interview, the facility furnished an email from the daughter of Resident #41 dated 03/07/26. In it, the daughter said the two alleged perpetrators were not allowed to go in Resident #41's room given what took place on February 18 and for the management to please be aware there is video documenting everything that went on in her room that day. She said Resident #41 told her she was terrified of the alleged perpetrators. She said she lost track of how many times she reported the alleged perpetrators via emails. She said that LPN #533 publicly called Resident #41 a pain in the [expletive] and was negligent in giving care and medications. She also said her concerns kept being swept under the carpet.Following the above interview, the facility furnished a call log allegedly demonstrating they made efforts to contact the daughter of Resident #41 for interview during the SRI investigation. The log showed one outbound call to the daughter's phone number labeled no answer, two labeled answered, and one documented inbound call from the daughter. There was no record of the results of these calls.Interview with the Administrator on 04/22/26 at 3:16 P.M. revealed he said Resident #41 did not know what he was talking about when he spoke with her for the SRI investigation. He said the resident's daughter never answers her phone and never calls back when he tries to reach out regarding any of her concerns.Record review of the resident concern log for the past year revealed no documented concerns regarding Resident #41.Record review of the facility's undated electronic monitoring policy revealed the facility would not independently access recordings but would request the recordings if needed for an abuse or other investigation.Record review of the facility's abuse policy dated 01/01/24 revealed the facility was to immediately investigate reports of abuse, neglect, or exploitation. This investigation was to include interviewing all involved persons and to be focused on determining if abuse occurred. All alleged violations were to be reported to the state agency within two hours if the allegations involved abuse and 24 hours if they did not.This deficiency represents noncompliance investigated under Master Complaint Number 2961312, Complaint Numbers 2726820, 2623912 and 2606964.

Based on record review, interview, review of the Ohio Department of Health (ODH) Certification and Licensure website, facility policy review, the facility failed to report alleged abuse, neglect, and misappropriation events to State Agency as required. This affected one (Resident #41) of two residents reviewed for abuse. The facility census was 42.Findings include: Record review of Resident #41 revealed she was admitted [DATE] with diagnoses including dementia, anxiety disorder, and chronic respiratory failure. Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had mild or no cognitive impairment. Review of her progress notes revealed no evidence of documented abuse or misappropriation allegations in 2026. She was hospitalized [DATE] for sepsis and returned to the facility 03/06/26.Record review of emails sent by the daughter of Resident #41 to verified email addresses of facility staff and ODH revealed the following allegations regarding the care of Resident #41:- An email dated 01/24/26 said Licensed Practical Nurse (LPN) #533 gave Tramadol (opioid pain medication) doses too close together and behaved with animosity and hatred, saying 'ridiculous things' about the resident and daughter.- An email dated 02/02/26 said LPN #533 intimidated Resident #41, who was afraid to be alone with her.- An email dated 02/05/26 said LPN #533 did not give medications as ordered and falsely said the resident refused care. Resident #41 also called for incontinence care and had her light turned off with no response for several hours.- An email dated 02/09/26 said Certified Nurse Aide (CNA) #576 disrespected Resident #41's personal belongings daily and spoke to her like a three-year old.- An email dated 02/18/26 said an unclarified aide enacted verbal abuse by continually yelling at Resident #41.- An email dated 03/19/26 said a set of cabin socks were stolen from Resident #41.Record review of the ODH Certification and Licensure website revealed the only self-reported incident (SRI) involving Resident #41 within the last six months was SRI #271831 dated 03/09/26, which involved an allegation of neglect and mistreatment by LPN #533 and CNA #576.Interview with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #563, and Regional Nurse #626 on 04/20/26 at 2:26 P.M. revealed they denied knowledge of all abuse, neglect, and misappropriation allegations in the above noted emails. They confirmed these allegations did not have SRI investigations or documented reporting to ODH.Record review of the resident concern log for the past year revealed no documented concerns regarding Resident #41.Record review of the facility's abuse policy dated 01/01/24 revealed all allegations of abuse, neglect, and exploitation were to be reported to the state agency within 2 hours if the allegations involved abuse and 24 hours if they did not.This deficiency represents noncompliance investigated under Master Complaint Number 2961312 and Complaint Numbers 2726820, 2623912 and 2606964.

Based on record review, interview, review of the Ohio Department of Health (ODH) Certification and Licensure website, and facility policy review, the facility failed to thoroughly investigate all allegations of abuse, neglect, and misappropriation. This affected one (Resident #41) of two residents reviewed for abuse. The facility census was 42.Findings include: Record review of Resident #41 revealed she was admitted [DATE] with diagnoses including dementia, anxiety disorder, and chronic respiratory failure. Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had mild or no cognitive impairment. Review of her progress notes revealed no evidence of documented abuse or misappropriation allegations in 2026. She was hospitalized [DATE] for sepsis and returned to the facility 03/06/26.Record review of emails sent by the daughter of Resident #41 verified email addresses of facility staff and the ODH revealed the following allegations regarding the care of Resident #41:- An email dated 01/24/26 said Licensed Practical Nurse (LPN) #533 gave Tramadol (opioid pain medication) doses too close together and behaved with animosity and hatred, saying 'ridiculous things' about the resident and daughter.- An email dated 02/02/26 said LPN #533 intimidated Resident #41, who was afraid to be alone with her.- An email dated 02/05/26 said LPN #533 did not give medications as ordered and falsely said the resident refused care. Resident #41 also called for incontinence care and had her light turned off with no response for several hours.- An email dated 02/09/26 said Certified Nurse Aide (CNA) #576 disrespected Resident #41's personal belongings daily and spoke to her like a three-year old.- An email dated 02/18/26 said an unclarified aide enacted verbal abuse by continually yelling at Resident #41.- An email dated 03/19/26 said a set of cabin socks were stolen from Resident #41.Record review of the ODH Certification and Licensure website revealed the only self-reported incident (SRI) involving Resident #41 within the last six months was SRI #271831 dated 03/09/26, which involved an allegation of neglect and mistreatment by LPN #533 and CNA #576.Interview with Resident #41 on 04/19/26 at 10:08 A.M. revealed workers yelled at her quite often and aides were very nasty. She could not remember the specifics of who or what was involved with these events. She also said staff took the cord from her Bluetooth radio last week, rendering it unusable.Interview with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #563, and Regional Nurse #626 on 04/20/26 at 2:26 P.M. revealed they denied knowledge of all abuse, neglect, and misappropriation allegations in the above noted emails and interview.Interview with the daughter of Resident #41 on 04/21/26 at 4:07 P.M. revealed she believed staff stole the SD card from a camera she had set up in Resident #41's room until the facility removed it, which contained footage of staff screaming at the resident.Record review of SRI #271831 dated 03/09/26 revealed staff were alleged to have spoken to the resident in a loud, abrasive manner. The report identified concerns of mistreatment with no specifics noted. There was no noted interview or attempted interview with the daughter, and the only noted interview with Resident #41 was the same questionnaire form other residents received wherein pre-written answers were circled indicating she felt safe and had no concerns with neglect or mistreatment. There was also no documented attempt to request footage from a monitoring camera, which was identified in progress notes to be in the resident's room until the facility removed it on 03/12/26.The surveyor confirmed the above findings in the SRI with Regional Nurse #626 on 04/22/26 at 2:34 P.M.Following the above interview, the facility furnished an email from the daughter of Resident #41 dated 03/07/26. In it, the daughter said the two alleged perpetrators were not allowed to go in Resident #41's room given what took place on February 18 and for the management to please be aware there is video documenting everything that went on in her room that day. She said Resident #41 told her she was terrified of the alleged perpetrators. She said she lost track of how many times she reported the alleged perpetrators via emails. She said that LPN #533 publicly called Resident #41 a pain in the [expletive] and was negligent in giving care and medications. She also said her concerns kept being swept under the carpet.Following the above interview, the facility furnished a call log allegedly demonstrating they made efforts to contact the daughter of Resident #41 for interview during the SRI investigation. The log showed one outbound call to the daughter's phone number labeled no answer, two labeled answered, and one documented inbound call from the daughter. There was no record of the results of these calls.Interview with the Administrator on 04/22/26 at 3:16 P.M. revealed he said Resident #41 did not know what he was talking about when he spoke with her for the SRI investigation. He said the resident's daughter never answers her phone and never calls back when he tries to reach out regarding any of her concerns.Record review of the resident concern log for the past year revealed no documented concerns regarding Resident #41.Record review of the facility's undated electronic monitoring policy revealed the facility would not independently access recordings but would request the recordings if needed for an abuse or other investigation.Record review of the facility's abuse policy dated 01/01/24 revealed the facility was to immediately investigate reports of abuse, neglect, or exploitation. This investigation was to include interviewing all involved persons and to be focused on determining if abuse occurred. All alleged violations were to be reported to the state agency within 2 hours if the allegations involved abuse and 24 hours if they did not.This deficiency represents noncompliance investigated under Master Complaint Number 2961312 and Complaint Numbers 2726820, 2623912 and 2606964.

Based on resident record review, staff interviews, and facility policy review, the facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected Resident #18's clinical status. This affected one (Resident #18) of 22 residents sampled during the survey. The facility census was 42.Findings include:Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, dependence on respirator (ventilator status), and heart failure.Record review showed Resident #18 experienced substantial weight changes between October 2025 and April 2026, increasing from 398.9 lbs to 557.8 lbs. Despite this significant change, the MDS assessments dated 10/26/25, 01/21/26, and 04/08/26 all coded that the resident had no 5% weight gain in one month and no 10% gain in six months, and the same weight of 399 lbs was repeatedly entered for multiple assessments.During an interview on 04/22/26 at 11:43 A.M., the Registered Dietitian (RD #630) confirmed that she was aware the resident had gained over 100 lbs but stated she had no current weight available at the time of the January 2026 assessment and therefore reused a previous weight, despite the resident's significant documented weight increase. The RD verified that she had not assessed the resident in person and relied only on risk meetings and the electronic medical record (EMR) to complete nutritional documentation. She acknowledged that the information in the medical record did not accurately reflect Resident #18's current nutritional status and confirmed the MDS coding was not accurate based on available clinical information.Review of the facility's MDS 3.0 Completion policy (revised 12/01/25) showed staff are required to attest to the accuracy of the sections they complete. The facility did not implement this policy as evidenced by the repeated use of outdated weight data and inaccurate MDS coding.

Based on record review, observation, and interview, the facility failed to provide appropriate oral and nail care for dependent residents. This affected one (Resident #28) of three residents reviewed for activities of daily living (ADL). The facility census was 42.Findings include:Record review of Resident #28 revealed he was admitted to the facility 07/03/25 with diagnoses including respiratory failure, paraplegia, and anoxic brain damage. His care plans dated 07/21/25 noted he was totally dependent on staff for ADL, and his nails should be checked daily for length and cleanliness. His Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified he was never or rarely understood, was dependent on staff for ADL care, and his mouth could not be assessed for dental problems. He was ordered to receive oral care twice per day and had no orders indicating any treatment of thrush (an oral fungal infection commonly involving white patches on the tongue).Observation of Resident #28 on 04/21/26 at 11:10 A.M. revealed his teeth appeared brown, although the surveyor could not determine if the color was natural or due to debris in the mouth. He was not interviewable or responsive to questions. His mouth hung open, and a white rough layer could be visualized on the tongue consistent with thrush. His fingernails extended roughly one to two centimeters from the top of the fingers and curled downwards at their ends.Interview with Assistant Director of Nursing (ADON) #563 on 04/21/26 at 11:31 A.M. verified these findings.This deficiency represents noncompliance investigated under Master Complaint Number 2961312, and Complaint Numbers 2726820 and 2668853.

Based on record reviews, observations, resident interviews, staff interviews and facility policy review, the facility failed to ensure resident activity preferences were honored. This affected two (Residents #1 and #26) of two residents reviewed for activities. The facility census was 42.Findings include:1. Review of the medical record for Resident #1 revealed he was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, necrotizing fasciitis and type II diabetes mellitus.Review of the care plan dated 12/31/25 revealed Resident #1 required encouragement to participate in activities of interest, was dependent on staff for activities with interventions including in-room activities if unable to attend out-of-room activities, allow to plan own leisure time activities, and respect choices in regard to limited activities. Review of the activities assessment dated [DATE] revealed Resident #1 preferred independent leisure activities, including but not limited to, a tablet and/or phone.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated he was alert and oriented to person, place, and time. Resident #1 was dependent on staff for activities of daily living (ADL).Interview and observation on 04/19/26 at 10:38 A.M. revealed Resident #1 lying in bed. Resident #1 revealed he was upset due to not being able to watch the National Basketball Association (NBA) Playoffs because certain television channels did not work. Resident #1 revealed he preferred to stay in bed and watch television or use his personal cellphone and/or tablet. Resident #1 revealed he reported his television issues to the facility staff including the maintenance department. Observation and return demonstration by Resident #1, revealed channels 14, 15, 18, and 21, did not work.Review of the completed and closed maintenance work orders dated 03/20/26 through 04/20/26 revealed Resident #1 television channels (14, 18, 21) were not working. Review of the work orders revealed no entry for television channel 15.Interview and observation on 04/21/26 at 10:37 A.M. with Maintenance Director (MD) #590 entered Resident #1's room in regard to the television channels. MD #590 revealed he fixed Resident #1's channels, and there were no present no issues. Resident #1 yelled out No, you didn't. Return demonstration by Resident #1 revealed the television channels were not fixed and were inoperable. MD #590 revealed he had previously reset the system and there was nothing he could do about fixing Resident #1 channels. MD #590 revealed he would have to call the outsourced cable provider to have them visit the facility to fix the issue. MD #590 revealed resident's concerns related to maintenance department were entered into electronic monitoring system and once received, he addressed the issue and closed the work order once completed. MD #590 confirmed and verified Resident #1's work order was submitted, not completed, but closed out as rectified.Follow-up interview on 04/21/26 at 11:13 A.M. with MD #590 revealed Resident #1's television was now fixed after surveyor intervention, after closing the work order as completed, and not requiring contact with the outsourced cable provider. MD #590 verified the above findings at the time of the interview.Review of the facility document titled Safe and Homelike Environment, revised 06/01/24, revealed the facility had a policy in place that any furniture in disrepair would be reported to the maintenance department promptly and resolved. Review of the facility document titled Activities, revised 06/01/24, revealed the facility had a policy in place that ongoing support of resident's choice of activities, including in-room activities, according to their personal preferences would be honored. 2. Review of the medical record for Resident #26 revealed he was admitted to the facility on [DATE] with diagnoses including quadriplegia (C1-C4 complete), osteomyelitis, and injury at C4 level of cervical spinal cord.Review of the recreation assessment dated [DATE] revealed going outside to get fresh air was very important to Resident #26.Review of the MDS 3.0 assessment dated [DATE] revealed Resident #26 had a BIMS score of 15 that indicated he was alert and oriented to person, place, and time. Resident #26 had impairment on both sides upper and lower extremities and was dependent on staff for ADL.Review of the care plan dated 04/29/26 revealed Resident #26 required encouragement to participate in activities of interest, was dependent on staff for activities with interventions including in-room activities if unable to attend out-of-room activities, allow to plan own leisure time activities, arrange for activity aide to visit and designate activity, escort to activities of choice that reflect prior interests, and respect choices in regard to limited activities.Interview on 04/19/26 at 2:21 P.M. with Licensed Practical Nurse (LPN) #563 revealed Resident #26 was noncompliant with outside visits due to violating the smoking policy. Resident #26 was witnessed smoking marijuana outside in the facility parking lot and was now not allowed to go outside without supervision, and Resident #26's Guardian was in agreement. She was unable to identify the last time Resident #26 was taken outside.Interview and observation on 04/19/26 at 2:52 P.M. with Resident #26 revealed he was lying in bed. He stated facility staff informed him he could not go outside. Resident #26 stated I can't do much. I can't walk. I can't do anything for myself. I just want to go outside sometimes. The only thing I can really do is be on my phone. He did not recall the last time he went outside.Interview on 04/22/26 at 1:36 P.M. with Resident #26's Guardian revealed Resident #26 was unable to walk and was completely dependent on staff due to paralysis and quadriplegia. Resident #26 loved to go outside and sit due to being very young, residing in the facility and not having much in common with the facility population. Resident #26 was not allowed to go outside with staff supervision due to a previous incident regarding not following the facility's smoking policy. Resident #26 had not been taken outside by staff, and she was informed by the facility that it was a law that he could not go outside. Resident #26 had not been taken outside.Review of Resident #26's social programs participation log in the last 30 days revealed no participation in patio and/or deck socialization.Review of the participation record for the month of April 2026, provided by Activity Director (AD) #545 revealed Resident #26 was taken to the patio one time.Review of the activities calendars for March and April of 2026 revealed one possible outside activity listed, gardening, on 04/22/26. Reviews of the calendars revealed no designated activities for outside or patio leisure activities.Interview on 04/22/26 at 1:54 P.M. with AD #545 revealed Resident #26 liked to go outside as an activity preference. Resident #26 typically stayed to himself, utilized his phone, listened to music, and only participated in one other activity, which consisted of food activities. She only went outside depending on the weather and the number of residents wanting to participate. Resident #26 went outside once the week prior, 04/12/26 - 04/18/26 and could not recall any other times. AD #545 verified the above findings during the interview.Review of the facility document titled Activities, revised 06/01/24, revealed the facility had a policy in place that ongoing support of resident's choice of activities, including in-room activities, according to their personal preferences would be honored.

Based on record review, observation, and interview, the facility failed to ensure that a resident with a documented Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure injury received repositioning according to their plan of care and accepted standards of practice. This affected one (Resident #28) of three residents reviewed for pressure sore care. The total census was 42.Findings include:Record review of Resident #28 revealed he was admitted to the facility 07/03/25 with diagnoses including respiratory failure, paraplegia, and anoxic brain damage. His care plans dated 07/21/25 noted he was totally dependent on staff for activities of daily living (ADL) and that he was at risk for skin breakdown and should be turned every two hours. His Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified he was never or rarely understood, was dependent on staff for bed mobility, and had pressure sores present on admission. Review of his most recent wound assessment dated [DATE] revealed he had a Stage IV pressure sore on his buttocks.Observation and attempted interview of Resident #28 on 04/20/26 at 10:18 A.M. revealed he was not interviewable and demonstrated no evidence of understanding or awareness of the surveyor's questions. He was in bed laying on his back with a wedge cushion on a bedside table at the foot of the bed. His head was elevated roughly 30 degrees and there were no pillows or other devices beneath either side to turn him off his back.Observations of Resident #28 on 04/20/26 at 12:54 P.M., 3:09 P.M., and 5:05 P.M. revealed he continued to be on his back with the wedge pillow on a bedside table during each observation.Interview with Assistant Director of Nursing (ADON) #563 on 04/20/26 at 5:15 P.M. confirmed Resident #28 had not been repositioned for several hours that day.This deficiency represents noncompliance investigated under Complaint Number 2726820.

Based on medical record review, observation, interview and facility policy review, the facility failed to implement therapy ordered contracture care for one (Resident #7) of one resident reviewed for range of motion and mobility. The facility census was 42.Findings include:Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included Moyamoya Disease (a progressive disorder of blocked arteries at the base of the brain), severe protein calorie malnutrition, anemia, acute kidney failure, metabolic encephalopathy (brain dysfunction), dysphagia (difficulty swallowing), cerebral infarct (tissue death), and hypertension (high blood pressure). She was admitted under hospice services on 08/20/25. The Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed a score of 0 (severe impairment), and the (Minimum Data Set) MDS 3.0 Quarterly assessment dated [DATE] and the MDS 3.0 Quarterly assessment dated [DATE], revealed the resident was dependent on staff for all activities of daily living (ADL) and mobility. Review of the resident care plan initiated on 01/29/25 and revised on 08/25/25, revealed a care plan for assistance needed for ADL related to cognitive impairment, immobility, pain, and weakness. No interventions related to hand/wrist contractures present upon admission were evident in the care plan.Review of the revised care plan (readmission date of 08/19/25) initiated on 09/04/25 revealed a care plan for assistance needed for ADL related to cognitive impairment, decreased mobility, and decreased physical functioning. Interventions included checking nails daily for length and cleanliness, trimming, and cleaning as necessary.Review of the Therapy Communication Form dated 04/10/25 by the Director of Therapy (DOT) #627, revealed communication/instruction to perform hand hygiene, gentle passive range of motion (PROM), apply palm guards, remove for hygiene, monitor skin for any signs or symptoms of discomfort and notify therapy, and provide nail care as needed.Review of the Prescribers Telephone Order dated 04/14/25 and authored by Occupational Therapist (OT) #631, revealed an order for Pt. to be encouraged to wear bilateral palm guards for up to 8 hrs. daily with appropriate skin checks. The telephone order revealed blank spaces for the signature of the prescriber, physician's/prescriber's order sheet, nurses' notes, patient care plan, medication/treatment sheet, dietary, and family notified.Review of the OT notes by DOT #627 dated 06/16/25 through 07/23/25 revealed two new palm protectors were provided when the resident returned from a hospital stay with continued therapy of bilateral upper extremity PROM to improve range of motion as tolerated. Further, the OT notes on 07/02/25 and 07/15/25 revealed staff training for hand hygiene and PROM prior to placing the palm guards. On 07/21/25, the therapy notes revealed to continue with staff education to don/doff (put on and take off) palm protectors following discharge from OT services. On 07/23/25, the OT notes indicated to educate nursing staff to remove the palm guard at least daily for hand hygiene.Review of the Therapy D/C Recommendation Sheet (July 2025), revealed Resident #7 was to wear bilateral palm guards for at least eight hours with appropriate skin checks. The exercise program consisted of two sets of 10 repetitions PROM to bilateral upper extremities, and to provide hand hygiene daily to reduce risk of skin breakdown. Five nursing personnel on 07/07/25, 07/15/25, and 07/19/25 were in-serviced and documented on the sheet.Review of the medical record Treatment Administration Record (TAR) April 2025 through April 2026, and the Facility Order Listing Report, 04/01/25 through 04/30/26 for Resident #7, revealed no treatment order for palm guards.Observation on 04/19/26 at 12:02 P.M. and 1:00 P.M. revealed Resident #7 with bilateral hands with no palm guard or barrier between the fingers and the palm of the hand, such as a pad or washcloth.Observation on 04/20/26 at 7:00 A.M. and 2:00 P.M. and on 04/21/26 at 7:30 A.M., revealed no palm guards or palm barriers to contracted bilateral hands and wrists, with long nails pressing against the palm.Interview on 04/21/26 at 10:30 A.M. with Certified Nurse Aide (CNA) #510, revealed Resident #7 does not have anything for her hand contractures and that they wouldn't be able to put anything in her hands because she was so contracted. Interview on 04/21/26 at 4:15 P.M. with the Regional Director of Clinical (RDC) #626 verified that Resident #7 had no palm guards or palm barriers to bilateral hands. RDC #626 verified the resident's nails on both hands were long and pressing against the skin of the palms.Observation on 04/22/26 at 7:20 A.M. revealed Resident #7's nails were trimmed and no longer pressing against the palm of the hands. Resident #7 had no palm guards or palm barriers to bilateral hands.Interview on 04/22/26 at 8:00 A.M. with CNA #622 revealed she was able to access the Kardex report for Resident #7 on the computer. CNA #622 revealed the care plan for Resident #7 included the interventions of air mattress, float heels as tolerated, every two-hour positioning, inspect skin, pressure reducing cushion to chair, pressure reducing mattress, preventative skin care, check nails daily for length and cleanliness.Interview on 04/22/26 at 9:45 A.M. with the Director of Nursing (DON) and RDC #626 verified there was no care plan regarding contractures for Resident #7, care plan intervention, or treatment for the therapy recommendations on 04/14/25 and the therapy discharge recommendation sheet in July 2025. Further, the DON and RDC #626 verified the therapy orders for palm protectors dated 04/14/25, and no orders were in place. The DON revealed the facility does not have a formal restorative nursing program.Interview on 04/22/26 at 2:00 P.M. with the DOT #627, verified the therapy recommendations for palm protectors dated 04/14/25 were not ordered and verified the Therapy D/C Recommendation Sheet (July 2025) recommendations.Observation on 04/27/26 at 10:10 A.M. and on 04/28/26 at 2:40 P.M., revealed Resident #7 had no palm guards or palm barriers in place.Interview on 04/28/26 at 2:49 P.M. with DOT #627, revealed that the Resident Assessment Coordinator sent out a list of residents requiring therapy screens monthly, and hospice residents were not normally picked up by therapy due to the hospice plan of care and hospice approval process. DOT #627 revealed her goal was to work with hospice to evaluate Resident #7 for a final recommendation regarding the hand contractures, to consider the risk versus the benefit of appliance application.Review of the facility policy titled, Prevention of Decline in Range of Motion (revised 10/01/22), revealed the facility will provide treatment and care which included appropriate equipment (braces or splints), and specialized rehabilitation, restorative, or maintenance, and assistance as needed. Further, the care plan interventions would be developed and delivered through the facility's restorative program or through specialized rehabilitative services as ordered by the attending practitioner.Review of the facility policy titled, Resident Care (revised 10/01/22), revealed personal hygiene for a resident includes the cleaning and cutting of fingernails and toenails (diabetic nail care completed by a nurse).

Based on record review, observations, resident and staff interviews, and policy review, the facility failed to provide adequate supervision and failed to ensure the safe use of assistive devices during care and transfers. This failure resulted in one resident (#18) falling from bed during single staff incontinent care despite weighing 557.8 pounds and being dependent for activities of daily living (ADL), and one resident (#32) sliding from a mechanical lift pad during transfer due to improper pad placement. This deficient practice affected two residents (#18 and #32) of three sampled residents reviewed for accidents. The facility census was 42.Findings include: 1. Review of the medical record for Resident #18 revealed she initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included chronic respiratory failure, dependence on respirator and heart failure. Review of the care plan dated 04/15/22 revealed Resident #18 required assistance for activities of daily living (ADL), was at risk for falls, had high body mass index (BMI) related to obesity, and had potential for alteration in skin integrity with interventions including: protective and preventative care, inspect for any reddened areas during daily care, observe, monitor and report changes, observe changes in ADL ability, and adjusting assistance as needed with a goal to be free from injury. Review of the care plan revealed no actual areas of skin impairment related to the right leg were present. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #18 was cognitively intact, dependent on staff for bed mobility and bathing, had limited range of motion to both lower extremities, and was always incontinent of bowel and bladder. Review of the weight records for the prior 90 days showed the resident weighed 557.8 pounds. Review of the progress notes revealed on 02/04/26 at approximately 5:15 A.M., Resident #18 fell from bed during incontinent care being performed by one certified nursing assistant (CNA). The resident rolled and fell to the floor while the CNA attempted to assist her. There was no visible injuries initially; however, by 12:04 P.M., the resident reported pain to the right leg. Portable x rays could not be completed due to pain, and she was transferred to the hospital. Hospital evaluation identified significant right leg pain but no fracture. Review of the fall investigation dated 02/04/26 at 5:23 A.M. revealed LPN #543 was notified by CNA #606 that Resident #18 was turning during ADL care and fell on the floor. LPN #543 noted Resident #18 was lying in a supine position on the floor, alert, conscious, and talking. Resident #18 was assessed immediately and was able to move all limbs at baseline with no evidence of pain or discomfort noted. Review of the investigation revealed the fire squad was called for assistance to get Resident #18 back into bed. Resident #18 refused to go to the hospital for further evaluation due to reports of no pain or discomfort. Resident #18 was sent to the hospital to have an evaluation after her refusal with all hospital x-rays negative. Review of the witness statement, within the fall investigation, dated 02/04/26 written by CNA #606 revealed she was providing care to Resident #18, and she proceeded to roll over onto her side towards the door. Resident #18 then grabbed the rail and was trying to get her leg on top of the other leg and in the process, she kept rolling and fell onto the floor. CNA #606 revealed she ran to the other side where she was to check on her before running out of the room for assistance. Review of the hospital paperwork dated 02/04/26 at 2:09 P.M. for Resident #18 arrival to the Emergency Department (ED) revealed she arrived via the fire department due to a fall with a pain level of 10 out of 10 to both legs. Resident #18 revealed she had pain just below her knee to the ankle after receiving care for a fall at the facility. Resident #18 physical exam revealed right lower extremity had tenderness of the anterior leg to the ankle and after x-rays, no fractures were found. Resident #18 was subsequently discharged back to the facility with a contusion of the right lower extremity after sustaining a fall. During an interview on 04/19/26 at 10:25 A.M., Resident #18 stated she had fallen out of bed during care. One staff member was providing care when she was pushed out of bed, fell on the floor and injured her leg. Resident #18 said the wound was not healing, and she was now at risk of losing her leg. During interviews on 04/20/26, Regional Nurse #626 and LPN #563 acknowledged Resident #18 required a two person assist for transfers using a mechanical lift and weighed 558 pounds. Nevertheless, they failed to recognize that these same factors necessitated two staff assistance for bed mobility and incontinent care and continued to assert that she required only one staff member for ADL, despite the MDS documenting she was dependent on at least two staff for ADL. A reasonable person, considering Resident #18's 557.8 pound weight, complete dependence for bed mobility, bilateral lower extremity limitations, incontinence, and documented requirement of two staff assistance for transfers, would expect that at least two staff members were necessary to safely perform bed mobility and incontinent care. The facility's failure to provide two staff assistance constituted inadequate supervision and resulted in a foreseeable and avoidable fall with subsequent injury. 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including hemiplegia (partial paralysis) and hemiparesis (partial muscle weakness) following a cerebral infarction (stroke), hypertension (high blood pressure), dysphagia (difficulty swallowing), dysarthria (difficulty speaking), acute and chronic respiratory failure, heart failure, and type II diabetes mellitus. Review of the care plan created on 08/09/22 revealed Resident #32 had a potential risk for falls with interventions including therapy to screen/evaluate when indicated, observe for changes in ADL ability and adjust assistance provided accordingly, ensure the call light is within reach, assist with transfers as needed, high-low bed to be in lowest position while occupied, keep bed against wall (added 09/20/22), educating the resident to use the call light for assistance (added 07/30/23), perimeter mattress to bed (added 01/10/24) remind her to ask for help to obtain items off the floor (added 01/08/26). Review of the care plan created on 08/10/22 revealed Resident #32 required assistance with ADL related to status post craniotomy, encephalopathy, respiratory failure, obstructive hydrocephalus, and dysphagia. Interventions including keeping call light within reach, providing incontinence care with routine rounds and as needed, and chair to bed/bed to chair transfers via mechanical lift (added 02/06/24). The MDS dated [DATE] documented the resident was cognitively intact and dependent on staff for ADLs including toilet hygiene, bathing, lower body dressing, footwear, and transfers. The Fall Risk Assessment (02/05/26) classified her as a moderate fall risk. A nursing progress note (04/04/26) documented that on 04/03/26, during a two staff transfer from wheelchair to bed using a mechanical lift, the resident slid from the lift pad to the floor because the pad was improperly positioned. Review of the facility document titled, Fall/Skin Incident Report (04/03/26), CNA #506 revealed while attempting to transfer the resident to the bed, they noticed the mechanical lift pad was not all the way under the resident's buttocks and tried to adjust her the best we could. It wasn't good enough because she slipped out of it. Review of LPN #618's written statement revealed when the resident was being transferred, she slid from the mechanical lift pad onto the floor. The facility's Fall Prevention and Management Policy (revised 10/02/22) requires that all residents be assessed for fall risks on admission, quarterly, after any fall, and as needed. Identified risks must lead to individualized interventions, added to the care plan, monitored for effectiveness, and revised as needed. All falls must be assessed by nursing, investigated, and reviewed by the interdisciplinary team, and appropriate fall prevention measures must be implemented. Per policy, a fall includes any unintentional descent to the floor, including near misses, and the facility must ensure safe supervision and correct use of assistive devices to prevent foreseeable accidents. This deficiency represents non-compliance investigated under Complaint Number 2795717.

Based on record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure Resident #18's care was adequately supervised by a physician. Specifically, the facility failed to obtain, initiate, and implement physician orders for weight monitoring despite significant, documented changes in nutritional status and body weight. The facility also failed to notify the physician of significant weight gain requiring clinical intervention. This deficient practice resulted in Resident #18 experiencing an undocumented and unmonitored weight increase of approximately 159 pounds over a five month period, with no corresponding physician notifications, no new orders, and no comprehensive assessment or monitoring as required. This affected one (Resident (#18) of four reviewed for nutrition. The facility census was 42.Findings include:Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, dependence on respirator (ventilator status), and heart failure.Review of the care plan dated 04/15/22 revealed Resident #18 required assistance for ADL, was at risk for falls, and had a high body mass index (BMI) related to obesity, with interventions including observing, monitoring and reporting changes, assisting with activities of daily living (ADL), following physician orders and monitoring weights.Review of the medical record revealed Resident #18's weight increased from 398.9 pounds (lbs) on 10/23/25 to 557.8 lbs on 04/02/26, an unplanned gain of 159 lbs. Despite the significant change, there was no documentation of physician notification or orders for daily, weekly, or monthly weights as required.Nutrition assessments dated 10/31/25 and 01/23/26 were identical with no updated recommendations, despite the resident's ongoing nutritional risks. Assessments continued to reference outdated information and did not reflect the resident's significant increases in weight.A progress note dated 02/20/26 documented that Resident #18 had a weight of 573 lbs following hospitalization, yet no physician notification or follow up orders were documented.Although a nutrition review dated 04/10/26 indicated the resident's BMI was 90 and her weight gain required confirmation with daily weights, there were no corresponding physician orders, documentation of attempts to obtain orders, or weight monitoring follow through.Interviews with Certified Nursing Assistant (CNA) #570 on 04/21/26 at 12:19 P.M. and Licensed Practical Nurse (LPN) #513 on 04/21/26 at 12:21 P.M. confirmed that Resident #18 was not on a list for weight monitoring and had no orders for daily, weekly, or monthly weights. Staff were unable to identify when the resident was last weighed.Interview on 04/22/26 at 11:43 A.M. with Registered Dietitian (RD) #630 confirmed that although she was aware the resident gained more than 100 lbs, she was not aware of any weight monitoring orders and verified no physician orders were present in the medical record.Review of the facility document titled Weight Monitoring revised 12/01/22, revealed the facility had a policy in place to ensure all residents maintain acceptable parameters of nutritional status, including body weight, identify, implement, monitor and modify interventions, and to inform the physician of significant changes in weight to order and put in place nutritional interventions and documented in the resident's medical record. Review of the document revealed the facility did not implement the policy. Review of the facility document titled Physician Orders dated 10/01/22, revealed physician, nurse practitioner and physician assistant orders may be received by telephone by a licensed nurse or other licensed or registered health care specialist who are authorized to legally to do so. Review of the document revealed the facility did not implement the policy.

Based on record review, interview and facility policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one (Resident #2) of five residents reviewed for unnecessary medications. The facility census was 42.Findings include:Review of the medical records for Resident #2 revealed an admission date of 10/02/24. Diagnoses included pain, type II diabetes mellitus with diabetic neuropathy, anemia, depression, post-traumatic stress disorder (PTSD), and anxiety disorder.Review of the pharmacy recommendation dated 05/05/25 regarding Diazepam (antianxiety) 2.5 milligrams (mg) twice daily (BID) for a gradual dose reduction (GDR) trial and Duloxetine (antidepressant) 30 mg daily, Sertraline (antidepressant) 100 mg daily, and Trazadone (antidepressant) 100 mg at bedtime (QHS) GDR trial.Review of the pharmacy recommendation dated 07/14/25 regarding Diazepam 2.5 mg BID. The pharmacy recommendation also noted it is time to consider a GDR trial. Please check one of the following. Nothing was noted on the recommendation. Review of the nursing note dated 09/16/25 at 1:11 P.M. revealed pharmacy recommendation reviewed by physician with the decline for GDR trail for Diazepam 2.5 mg, Duloxetine 30 mg, Sertraline 100 mg, and Trazodone 100 mg due to multi contraindications. Resident #2 made aware with no concerns at this time.Review of the pharmacy recommendation dated 11/03/25 revealed the resident is receiving Tylenol/Acetaminophen (analgesic) 1,000 mg three times a day (TID). She also has two other as needed (PRN) orders, one for oral use, one for rectal use. I wanted to ask to discontinue (d/c) the PRN orders since she was already at the maximum recommended daily dosage of three grams with the routine order. Handwritten on the pharmacy recommendation was dc'd 1 prn, decreased routine to 500 mg dated 04/09/26.Review of the pharmacy recommendation dated 03/02/26 revealed 1) The resident (Resident #2) is receiving Tylenol/Acetaminophen 1,000 mg TID. She also has two other PRN orders, one for oral use, one for rectal use. I wanted to ask to d/c the PRN orders since she is already at the maximum recommended daily dosage of 3 grams with the routine order. Handwritten in green next to this was addressed 04/09/26. Nursing entered this resident's Duloxetine for the sprinkle caps, which is only available as brand name Drizalma (costing over $7 per dose). This dosage form is reserved medication via tube. May I please ask you to clarify if this order was to be for the generic Cymbalta (Duloxetine particle capsules, Not sprinkle caps)? *Nursing, once clarified, please d/c and re-enter this order for the correct formulation. Suggest typing in Cymbalta and all equivalent formulations will populate as you type. Handwritten in green was addressed 04/03/26.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had intact cognition, had no behaviors, and received antianxiety, antidepressant, antibiotic, diuretic, opioid, antiplatelet, hypoglycemic, and anticonvulsant. Review of the nursing note dated 04/02/26 at 7:19 P.M. revealed new orders received to discontinue PRN Acetaminophen (Tylenol) as the resident is currently receiving a scheduled dose. Order also received to discontinue Duloxetine 30 mg sprinkle capsule and initiate Duloxetine particles 30 mg by mouth (PO) daily. All orders noted and will be implemented as prescribed.Review of the nursing note dated 04/09/26 at 4:31 P.M. revealed notified physician of pharmacy recommendation of max dose of Tylenol, physician gave new order to d/c Tylenol suppository and reduced Tylenol 500 mg 2 tabs to 1-tab TID. Resident #2 made aware of new order.Interviews on 04/22/26 at 2:47 P.M. and 4:17 P.M. with Regional Registered Nurse (RRN) #626 verified the pharmacy recommendations were not addressed timely. RRN #626 verified the policy did not indicate a timeframe for addressing the pharmacy recommendations.Review of the facility policy Medication Regimen Review, revised 09/30/22, revealed the facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The policy did not indicate a timeframe of when the pharmacy recommendation should be addressed.

Based on record review, observation, review of the facility policy and interview, the facility failed to ensure the correct serving size for the mechanically altered meat was served. This affected three (Residents #6, #22, and #33) of three residents that received a mechanically altered diet. The facility census was 42.Findings include:Observation of the tray line on 04/21/26 between 12:31 P.M. and 12:49 P.M. revealed Dietary Aide (DA) #555 serving mechanically altered meals using a green-handled #12 scoop, providing only one scoop of mechanically altered meat per meal. At 12:49 P.M., staff were observed pushing the last meal cart to the final unit.Review of the diet extension sheet showed that the mechanically altered meat (beef stroganoff) was to be served using a #6 scoop.During an interview on 04/21/26 at 12:50 P.M., DA #555 and Regional Dietary Manager (RDM) #900 confirmed that the green-handled scoop used was a #12 scoop. RDM #900 stated that, when using a #12 scoop, DA #555 should have provided two scoops to meet the required portion size. DA #555 verified she had provided only one scoop to each resident receiving mechanically altered beefReview of the diet order listing report dated 04/19/26 confirmed that three residents (Residents #6, #22, and #33) were receiving mechanically altered diets.Review of the facility's undated Scoop Sizes chart showed that a #12 green scoop provides 2.78 ounces, while the #6 white scoop provides 4.66 ouncesReview of the Portion Control/Spreadsheets policy (revised 08/01/24) indicated that to ensure nutritional adequacy, residents must receive the appropriate portions of food as planned on the menu.This deficiency represents non-compliance investigated under Complaint Numbers 2726820,2623912, and 1320283 (OH00166923).

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interviews, review of hospital records, review of witness statements and wound policy, the facility failed to implement an adequate and effective pressure ulcer prevention program to promote healing and to ensure Resident #154, who was cognitively impaired, dependent on staff for activity of daily living care and incontinent of bowel, received left lateral ankle and foot wound treatments timely when dressings had become saturated with fecal material. Actual Harm occurred on 10/14/24 when nursing staff failed to change Resident #154's dressing to his left lateral ankle and left lateral foot Stage IV pressure ulcers (full-thickness tissue loss with exposed bone, tendon, or muscle) when Certified Nursing Assistant (CNA) #232 notified Licensed Practical Nurse (LPN) #291 the dressings to the areas were saturated with fecal material. This lack of timely and proper wound care resulted in the ulcers deteriorating and contributed to the development of sepsis and osteomyelitis (infection in the bone requiring intravenous antibiotics) and hospitalization in the intensive care unit. This affected one resident (#154) of three residents reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the closed medical record for Resident #154 revealed an admitted [DATE] with diagnoses including osteomyelitis (infection in the bone), hypertension, contracture of the right knee and dementia. Review of the care plan dated 04/04/24 for Resident #154 revealed he had an actual area of skin impairment, Stage IV pressure wound, to the left lateral ankle and foot. Staff were to continue treatments as ordered by the physician and observe for signs of infection or worsening of the wound. Review of the physician's orders and Treatment Administration Record for October 2024 revealed Resident #154 had a treatment dated 10/01/24 to cleanse the left lateral foot with normal saline, pat dry, apply oil emulsion to the wound, cover with an abdominal (ABD) pad and wrap with kerlix daily and as needed. He also had had a treatment (initiated 09/24/24) to cleanse the left lateral ankle with normal saline, pat dry, apply oil emulsion and cover with ABD pad and wrap with kerlix every day on day shift. There was an order to change the left lateral ankle as needed as well. The daily dressing orders were documented as completed on 10/13/24 and 10/14/24 but the as needed orders were not utilized on those dates. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #154 had impaired cognition. The assessment revealed the resident was dependent on staff for activities of daily living including toileting, hygiene and repositioning in bed and the resident was always incontinent of bowel. Review of the wound evaluation and management summary dated 10/07/24 by Wound Physician #360 revealed Resident #154 had a Stage IV pressure wound to the left lateral ankle and left lateral foot. The left lateral ankle Stage IV pressure ulcer measured 2.6 centimeters (cm) length by 2.4 cm width with 0.1 cm depth. There was light serosanguineous (thin clear/pink fluid) drainage with 10 percent (%) slough (dead tissue in wound) and 90% granulation tissue (new tissue). The left lateral foot Stage IV pressure area measured 2.4 cm by 2.3 cm by 0.2 cm. It had moderate serous (thin, watery clear) drainage with 100% granulation tissue. The facility was to continue the dressing changes once daily and off-load the wounds. Review of the wound evaluation and management summary dated 10/14/24 by Wound Physician #360 revealed Resident #154 still had Stage IV pressure wounds to the left lateral ankle and left lateral foot and the wounds had deteriorated. The left lateral ankle Stage IV pressure ulcer measured 7 cm by 5 cm by 0.3 cm and had exacerbated due to infection. There was moderate serous drainage with only 60% granulation tissue noted with 30% other viable tissues observed which included bone, fascia, tendon and muscle. Wound Physician #360 stated the wound was highly suspicious for osteomyelitis and she would start intravenous antibiotics pending the wound culture. The left lateral foot Stage IV pressure ulcer measured 3 cm by 3 cm by 0.2 cm. There was 80% granulation tissue and 20% slough. There was moderate serous drainage noted. The wound progress was noted to be exacerbated due to multifactorial (meaning the wound of the left lateral ankle). Wound Physician #360 ordered laboratory values, wound culture, x-ray and two intravenous antibiotics. Review of the nursing progress note dated 10/14/24 at 5:39 P.M. revealed Resident #154 was transferred to a skilled room for antibiotic intravenous therapy related to a wound infection. On 10/14/24 at 6:27 P.M. Resident #154 had a peripherally inserted central catheter line placed to his left arm for intravenous antibiotics. On 10/15/24 at 7:00 P.M. Resident #154 had a dressing change to his left leg and there was noted to be plus two pitting edema to the knee and it was warm to the touch. Vital signs were obtained and were noted to be abnormal with his blood pressure at 103/57 (normal 120/80), pulse of 121 (normal 60-100), respirations of 22 (normal 12-20) and temperature of 99.9 degrees Fahrenheit (normal 98.6). The physician was updated and a new order was given to send him to the emergency department. On 10/16/24 at 1:09 A.M. it was noted that Resident #154 was admitted to the hospital for septic shock. Review of the left ankle x-ray dated 10/14/24 revealed changes associated with prior osteomyelitis involving the distal fibula. Acute osteomyelitis was not excluded. The impression stated if there was exposed bone, then acute osteomyelitis was presumed. Review of the critical care consult note from the hospital records dated 10/16/24 revealed Resident #154 was at the hospital due to left lower leg swelling. During his stay at the hospital it was noted he had sepsis due to osteomyelitis and possible abscess to his left lower extremity. Review of a disciplinary action form dated 10/17/24 for LPN #291 revealed the LPN was given a written and final warning due to not providing the necessary care to a resident to prevent further breakdown in a wound. Review of the facility investigation revealed a statement dated 10/17/24 by CNA #232 stating Resident #154 had a large bowel movement and she had informed the nurse on duty that his dressing was soiled. She provided care for him and changed his bedding and covered his left foot and dressing with a sheet to protect the new sheets until the nurse came to perform the dressing change. Interview on 11/21/24 at 9:16 A.M. with LPN #206 revealed Resident #154 had contractures to the bilateral lower legs and had many skin impairments throughout his stay. She stated the nursing staff were able to resolve many of these areas, but he had chronic wounds. She stated on 10/14/24 at 12:00 P.M. she was performing wound rounds with Wound Physician #360 to Resident #154. She stated his left lateral foot and ankle dressings were saturated. She stated the dressing was removed and Wound Physician #360 was upset the dressings were contaminated with feces and had not been changed. She stated it was suspected he had a wound infection, and the physician ordered antibiotics, an x-ray, wound culture and laboratory tests. LPN #206 stated she immediately started an investigation which revealed Resident #154's dressings had become saturated with feces on 10/14/24 at 3:00 A.M. She stated CNA #232 had updated LPN #291 the dressings were saturated and needed changed. LPN #206 stated LPN #291 admitted she had gotten busy and forgot to change the dressing. The next dressing changes were on dayshift on 10/14/24 and were not changed until the physician had performed wound rounds. LPN #206 stated she had interviewed the nursing staff who had worked on 10/11/24, 10/12/24 and 10/13/24, who all stated the wounds had no signs or symptoms of infection and the dressings were changed as ordered. Interview on 11/21/24 at 12:50 P.M. with Wound Physician #360 revealed Resident #154's wound deteriorated between 10/07/24 and 10/14/24. She stated when she assessed the resident on 10/14/24 at 12:00 P.M. his left lateral ankle and foot dressings were soiled with feces and were contaminated. She stated upon assessment, the Stage IV pressure ulcers had increased in size and she suspected there was an infection. Wound Physician #360 stated she ordered an x-ray to rule out osteomyelitis, obtained a wound culture, ordered laboratory tests and started two intravenous antibiotics. Attempted phone interviews with CNA #232 and LPN #291 on 11/21/24 and 11/25/24 were unsuccessful. Voicemail messages were left with no return contact made. Review of the facility policy titled, Wound Treatment Management, dated 12/01/21, stated wound treatments would be provided in accordance with the physician's orders. The policy stated dressing changes may be provided if feces had seeped underneath the dressing or the dressing was soiled. The deficient practice was corrected on 10/18/24 when the facility implemented the following corrective actions: On 10/16/24 and 10/17/24 DON and LPN #206 provided nursing staff education on the facility policy titled, Wound Treatment Management, dated 12/01/21, including changing the dressing if feces had seeped underneath the dressing or the dressing was soiled as well as adding an order for all residents with wounds to check the integrity of the dressing each shift and replace if needed. On 10/17/24 by LPN #206 completed wound and dressing audits for all residents to ensure dressings were intact and the orders were correct without negative findings. On 10/17/24 the Administrator provided LPN #291 education and disciplinary action. On 10/18/24 audits were initiated of wound dressing observations including if the dressing was clean, dry and intact as well as if the order was in place to check the integrity of the dressing each shift. These audits were to be completed by the DON or her designed three times a week for one week and then weekly thereafter for three weeks. The results would be taken to the quality assurance meetings. This deficiency represents non-compliance investigation under Complaint Number OH00159247.

Based on observation, medical record review, review of the facility's policy and procedure for skin management, interviews with nursing staff, family interview, and Wound Physician #123 interview, the facility failed to implement a comprehensive and effective pressure ulcer treatment program for two residents (Residents #42 and #18). This resulted in Immediate Jeopardy that was actual harm on 08/01/22 when the facility failed to ensure Resident #18's wound care physician orders were transcribed and treatments implemented, skin assessments completed, and pressure relieving interventions were active and functional resulting in the development of pressure ulcers and the declining condition of the existing pressure ulcers to a Stage 4 pressure ulcer and an Unstageable pressure ulcer. In addition, Immediate Jeopardy that was actual harm resulted when the facility failed to identify Resident #42's pressure ulcer and provide treatment resulting in an Unstageable pressure ulcer to Resident #42's right great toe at the discovery stage. The facility identified 12 residents with pressure ulcers and the facility census was 54. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified related to the facility's failure to appropriately complete pressure ulcer dressing changes as ordered by the physician for Resident #10's left heel pressure ulcer. This affected one of six residents reviewed for pressure ulcers (Resident #10). On 08/25/22 at 3:25 P.M., the Administrator was notified Immediate Jeopardy began on 08/01/22 when Resident #18 had an identified Stage 2 pressure ulcer (defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) to her right heel and no physician orders were put into place for the treatment and care of the wound and no treatment was provided until 08/23/22 resulting in the right heel pressure ulcer declining in condition. The Immediate Jeopardy continued 08/25/22 when Resident #18 received surgical debridement from Wound Physician #123 who classified Resident #18's right heel pressure ulcer as Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed). The Immediate Jeopardy situation continued for Resident #42 when on 08/23/22, the surveyor discovered an Unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) to the resident's right great toe and the facility was not aware. The Immediate Jeopardy was removed on 08/25/22 at 9:30 P.M. when the facility implemented the following corrective action: On 8/24/2022 at approximately 4:30 P.M.: DON completed an audit of all wound orders ensuring that they were all transcribed into the electronic chart. On 08/25/22 at 11:00 A.M.: An assessment of current wounds was completed by the Wound Physician and a facility nurse; all of which had the ordered treatments in place. On 8/25/2022 at approximately 1:00 P.M.: Resident #18's air mattress air pump was replaced by maintenance assistant. On 08/25/22 at 1:30 P.M.: The Maintenance Director completed an inspection of current air mattresses; all of which were functioning correctly. On 08/25/22 (no start time identified): the DON and designees conducted a skin assessment on current residents to ensure any areas identified have treatment orders. Assessments completed on 8/25/2022 by 8:00 P.M. Three new areas were identified by DON and designees. Physicians were notified by DON and designees of the new areas on 8/25/2022 by 8:30 P.M. Treatment orders were received for the new areas by DON and designees on 8/25/2022 by 8:45 P.M. Treatments in place by DON and designees on 8/25/2022 by 9:30 P.M. On 08/25/22 at 8:00 P.M.: All facility Licensed Nurses received education by the Assistant Director of Nursing on the policy titled Wound Treatment Management with emphasis on obtaining treatment orders when wounds are identified and completing wound care treatments as ordered. Education also included reporting if an air mattress is not functioning appropriately to the Maintenance Director. On 08/25/22 (time not identified): DON or designee will be responsible for ensuring all wound physician orders are entered into the electronic chart. Administrator or designee will oversee to ensure this process is completed as appropriate, and concerns will be reported to QAPI committee. Beginning on 08/25/22 (time not identified): An observation of five (5) wound care treatments to be completed weekly for four (4) weeks. Observation to include wound treatment in place as ordered and documentation of the treatment. Results of the observations to be forwarded to the facility QAPI committee for further review and recommendations. Beginning on 08/25/22 (time not identified): Skin assessments to be completed on five (5) residents per week to ensure any identified areas have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin assessments to be completed by the DON/designee with the results forwarded to the facility QAPI committee for further review and recommendation. Beginning on 08/25/22 (time not identified): Maintenance Director or designee will complete an inspection of air mattresses in use to ensure they function correctly weekly for four (4) weeks. Results of the inspections to be forwarded to the facility QAPI committee for further review and recommendations. Beginning on 08/25/22 (time not identified): DON or designee will audit to ensure all new orders received from wound physician are entered into electronic charts correctly once weekly for weeks and as needed thereafter. Administrator or designee will ensure audits is completed as appropriate beginning on 08/25/22. Results of the inspections to be forwarded to the facility QAPI committee for further review and recommendations. On 08/29/22 from 12:05 P.M. to 2:15 P.M. interviews with Licensed Practical Nurse (LPN)'s #111 and 121 revealed they had received education regarding wound treatment and management, as well as proper documentation. Although the Immediate Jeopardy was removed on 08/25/22 the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine if further action is required. Findings Include: 1. Review of Resident #18's medical records revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's pressure ulcer risk assessment dated [DATE] revealed the resident was at high risk for the development of pressure ulcers. Review of the care plan dated 03/01/22 revealed Resident #18 required assistance with activities of daily living related to paralysis. Interventions included to inspect skin daily during routine care and report any impairments to the charge nurse and provide incontinence care with routine rounds and as needed. Resident #18 had actual skin impairments and interventions included air mattress, turn and reposition every two hours as tolerated, initiate wound treatments, provide treatments as ordered and observe for changes that included infection or worsening of the wounds. Review of Resident #18's physician orders dated 06/13/22 revealed the resident was to be repositioned every two hours and as needed while in bed. Physician orders dated 06/15/22 revealed Resident #18 was to have an air mattress to promote skin integrity. Review of Resident #18's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident did not have a cognition score documented due to resident was rarely understood. Resident #18 was dependent for transfers, toileting and personal hygiene and was incontinent of bowel and bladder. Resident #18 had two unidentified Stage 2 pressure ulcers. Review of Resident #18's skin grid dated 7/28/22 revealed the resident had a left buttock Unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) that measured 2.0 centimeters (cm) in length, 2.5 cm in width 0.1 cm in depth. Resident #18 also had a right buttock Stage 3 pressure ulcer (defined as full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) that measured 3.0 cm in length, 4.0 cm in width and unable to determine depth. Review of progress note dated 08/01/22 revealed Licensed Practical Nurse (LPN) #124 had identified an area to Resident #18's right heel. The top layer of skin was gone from the right heel and the area was observed to be a Stage 2 pressure ulcer; however, no measurements were documented of the wound. The wound was cleaned, and a foam dressing was applied, and Physician #125 (Resident #18's primary care physician) was notified with orders given to have the resident be seen by the wound team. Review of Resident #18's skin grid pressure dated 08/04/22 (this was a facility assessment) revealed the resident had a left buttock Unstageable pressure ulcer 1.8 cm in length, 2.3 cm in width 0.2 cm in depth,a right buttock Stage 3 pressure ulcer 2.0 cm in length, 0.8 cm in width 0.1 cm in depth, a right first metatarsal pressure suspected deep tissue injury (DTI) (defined as intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) 2.5 cm in length, 2.5 cm in width, 100% necrotic. In addition, Resident #18 had a right heel pressure ulcer and a suspected deep tissue injury (DTI), the right heel wound had been classified as both pressure as well as a DTI, that measured 3.5 cm in length, 4.0 cm in width, unable to determine depth, and 100% necrotic. The facility DON revealed the measurements contained in this document were actually copied from Wound Physician #123's notes and the areas were not independently measured by facility staff. No further skin assessments were documented for Resident #18. Review of progress note dated 08/16/22 revealed LPN #121 had contacted the physician with concerns related to the resident's right heel, and treatment orders were received. However, the progress note did not include specific information related to the orders. In addition, there was no evidence a treatment order was added to the treatment administration record (TAR) and no evidence a treatment was provided to Resident #18's right heel pressure ulcer. Review of Resident #18's physician orders dated 07/17/22 through 08/24/22 revealed to cleanse right gluteal (buttocks) with normal saline, pat dry, apply nickel sized amount of Santyl to calcium alginate and cover with foam dressing daily and as needed, cleanse left gluteal with normal saline, pat dry, apply a nickel sized amount of Santyl to calcium alginate and apply to wound. Cover with foam dressing daily and as needed. Review of Resident #18's physician orders dated 08/16/22 through 08/24/22 revealed cleanse right heel with normal saline, pat dry, apply Santyl, apply silver alginate, cover with absorbent dressing, and wrap with gauze daily and as needed. Cleanse right great toe (please note, the facility is also documenting this area as metatarsal and using the words great toe and metatarsal interchangeably) with normal saline, pat dry, apply skin prep and cover with absorbent dressing, and wrap with gauze daily and as needed. Review of Resident #18's TAR for August 2022 revealed no documentation ordered treatments had been completed from 08/16/22 through 08/22/22 for the residents' right heel, right great toe, and buttock wounds. Observation on 08/24/22 at 10:25 A.M. revealed Resident #18 was in bed with her right heel positioned underneath her buttocks due to right leg being contracted. Further observation revealed the resident had a gauze dressing to her right heel that appeared to be saturated with urine from her heavily saturated incontinence brief. LPN#119 had removed the soiled gauze and the resident's heel was macerated (softened by being soaked in liquid), and a large amount of thick purulent drainage and a foul pungent odor was detected. LPN #119 obtained measurements of the right heel, measuring 5 cm in length, 6.5 cm in width and unable to determine a depth. Further observation revealed Resident #18 had an area to her right metatarsal that appeared to be a DTI, that had no dressing around it. LPN #119 stated he was not aware of the Resident #18's right foot wounds. LPN #119 and State tested Nurse Aide (STNA) #120 continued to provide incontinence care and removed Resident #18's incontinence brief. The surveyor observed Resident #18 had two open areas, one to her buttocks and one to her sacrum (tailbone) that appeared to also be macerated and reddened. There were no dressings on these wounds when LPN #119 removed the incontinence brief. LPN #119 stated the areas should have had a dressing over the wounds. STNA #120 stated she had not provided incontinence care to the resident since she had started her shift at 7:00 A.M. Resident #18 was not able to speak. Observation further revealed the resident had an air mattress pump at the foot of her bed that had been beeping with a red light lit up that indicated a system malfunction. Resident #18's roommate stated, that thing is always beeping and they come in and silence it and 15 minutes later its beeping again. STNA #120 had silenced the alarm at that time, and LPN #119 stated he was not aware of the reason the pump had indicated a system malfunction. Telephone interview on 08/24/22 at 11:55 A.M. with LPN #121 revealed she was not aware Resident #18 had a skin impairment that had been reported on 08/01/22. LPN #121 stated it would be on the facility's incident report. LPN #121 further stated she was not aware Resident #18's right heel had not been treated and it wasn't until 08/16/22 when the floor nurse had come to her with concerns of the resident's wound. LPN #121 stated she had observed the area and had also been concerned due to the area was open and had necrotic tissue visible. LPN #121 stated she had contacted Physician #125 for orders and had placed the orders in the computer and there had not been any previous orders. Interview on 08/24/22 at 1:12 P.M. with the DON confirmed the incident report had identified a skin impairment for Resident #18 on 08/01/22. The DON stated LPN #124 had contacted Physician #125 and had received orders to have the resident be seen by the wound team. At this time in the interview, the DON produced the wound assessments from Wound Physician #123 that the DON stated should have been uploaded in the computer system, however had not been done. Review of Physician #125's progress note dated 08/04/22 revealed Resident #18's right heel was classified as a pressure ulcer as well as a DTI that measured 3.5 cm in length, 4.0 cm in width and unable to determine depth and was 100% necrotic. This progress note stated orders were to apply calcium alginate (wound dressing) absorbent dressing and gauze daily and as needed. Area to right metatarsal was classified as a pressure ulcer and DTI that measured 2.5 cm in length, 2.5 cm in width and unable to determine depth and was 100% necrotic. Orders were to apply calcium alginate, absorbent dressing and gauze daily and as needed. Review of Wound Physician #123 wound progress note dated 08/11/22 revealed area to the right heel had measured 4.0 cm in length, 5.0 cm in width and unable to determine depth. Orders were changed to apply Santyl (wound ointment) calcium alginate, absorbent dressing and gauze daily and as needed. Area to right metatarsal measured 3.0 cm in length, 3.0 cm in width and unable to determine depth. Orders had remained the same as previous. Review of Wound Physician #123 progress note dated 08/18/22 revealed area to right heel measured 5.0 cm in length, 5.0 cm in width. Orders had remained the same as previous. Area to right metatarsal measured 2.5 cm in length, 2.0 cm in width. Orders had remained the same as previous. At this time in the interview, the DON verified the orders had not been transcribed into Resident #18's records and the orders had not been known by the nursing staff to complete wound care. The DON was unable to provide a clear explanation of the facility wound notification process as far as which physician should be contacted with concerns related to wounds and wound care, and he confirmed the policies were in place to reflect the correct process that included to contact the physician. Interview on 08/25/22 at 6:55 A.M. with Wound Physician #123 revealed he had performed weekly rounds at the facility and stated he had seen Resident #18 the previous week. Wound Physician #123 stated he had written his orders on his progress notes and had given them to the facility after he had completed them. Wound Physician #123 stated he was unaware the orders he had given had not been placed in the computer and was not aware treatments had not been performed as ordered. Wound Physician #123 stated if the staff had concerns related to a resident's wounds they should contact him, however, if he had been unavailable the primary care physician should be contacted. Observation on 08/25/22 at 7:30 A.M. with Wound Physician #123 for Resident #18 revealed area to right heel had continued to appear to have purulent drainage with a pungent odor detected. Wound Physician #123 had debrided (removal of damaged tissue with a surgical instrument) and had reclassified the right heel wound as being a Stage 4 (defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) that measured 5 cm by 5 cm and 0.5 cm in depth. Observation made during the procedure revealed Resident #18 appeared to be in pain during the surgical debridement as evidenced by the resident attempting to pull her leg away during the debridement process. Wound Physician #123 had not administered Resident #18 any numbing medication prior to the debridement and no pain medications had been administered prior. Further observation revealed Wound Physician #123 had removed the outer layer of the skin to the resident's metatarsal area and had reclassified the area as a Stage 3 pressure ulcer that measured 3.0 cm in length, 3.0 cm in width and 0.2 cm in depth. Observation at time of wound care revealed Resident #18's air mattress continued to be beeping and indicated a system malfunction. Interview on 08/25/22 at 3:05 P.M. with DON and Administrator revealed they had not been made aware of Resident #18's air mattress not working properly. Interview on 08/25/22 at 3:45 P.M. with Administrator revealed Resident #18's air mattress had been replaced and an audit of all other mattresses had been completed to ensure they had been working properly. 2. Review of Resident #42's medical records revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan dated 01/25/22 revealed Resident #42 had potential for alterations in skin integrity related to decreased mobility and sacral wound. Interventions included turn and reposition every two hours, pressure reducing mattress, and provide assistance with hygiene as needed. Care plan revised on 06/26/22 revealed Resident #42 had a Stage 4 sacral wound, left leg chronic ulcer and left foot DTI, and a right lateral leg Stage 2 pressure ulcer. Interventions included provide wound care as ordered, nursing staff to observe the wound dressing daily to ensure dressing remained intact and observe for signs and symptoms of infection. Review of Resident #42's skin risk assessment completed 06/26/22 revealed the resident was at very high risk for development of pressure ulcers. Review of the quarterly MDS dated [DATE] revealed Resident #42 had impaired cognition and required total dependence for transfers, bed mobility, toileting, and personal hygiene. Resident #42 was incontinent of bowel and bladder and had an unidentified Stage 4 pressure ulcer (sacral). Review of skin grid dated 08/04/22 revealed Resident #42 had a Stage 4 pressure ulcer to the sacrum that measured 7 cm in length, 5 cm in width and 0.5 cm in depth. The resident's right calf pressure ulcer measured 6.0 cm x 4.0 cm and 0.1 cm depth. No further skin assessments were documented in the electronic records. Review of Resident #42's physician orders dated 07/31/22 through 08/23/22 revealed to cleanse the sacral wound with normal saline, pat dry, apply calcium alginate and cover with dry dressing daily and as needed. Right calf pressure ulcer order (started 07/12/22) cleanse, apply [MEDICATION(S)], collagen, ABD and kerlix, every Tuesday, Thursday and Saturday and PRN. Physician orders dated 08/23/22 revealed to cleanse the right great toe with normal saline, pat dry, apply oil emulsion dressing, calcium alginate and dry dressing daily and as needed. Review of TAR for August 2022 revealed no documented evidence the sacral wound treatments had been completed on 08/10/22, 08/12/22, 08/14/22, or 08/15/22. Observation on 08/23/22 at 5:08 A.M. revealed Resident #42 was in bed slightly on her right side, multiple signs were posted outside as well as inside the resident's room that indicated the resident is to be turned every two hours. Observation on 08/23/22 at 7:31 A.M. revealed Resident #42 appeared to be in the same position as previous observation on 08/23/22 at 5:08 A.M. Interview with LPN #117 at time of observation revealed the resident was to be turned and repositioned every two hours. Further observation with LPN #117 revealed Resident #42 had an undated gauze dressing to her right calf area and the resident's right foot was placed in a pressure relieving boot (PRAFO). LPN #117 removed the Velcro strap on the right boot and a large amount of dried crusted drainage was noted on the boot; the boot also had multiple areas of dirt and debris. As LPN #117 undid the strap, further observation revealed an open area to the resident's right great toe that was draining a large amount of thick bloody [MEDICATION(S)]. LPN #117 denied being aware of the area and confirmed the area was open and draining. LPN #117 also verified the crusted area on the boot. Further observation with LPN #117 revealed Resident #42 had a large sacral wound with a foam dressing that had not been covering the wound. The sacral wound was noted to have a large amount of thick green colored drainage and a foul odor was detected. LPN #117 stated she had cared for the wound yesterday and had not detected an odor at that time. At time of observation LPN #118 had entered the resident's room to assist with care and she confirmed she had not been aware of the open area to the resident's right great toe. Interview and observation on 08/23/22 at 2:31 P.M. with DON confirmed Resident #42's pressure relieving boot had a large amount of crusted drainage and debris and also confirmed the open area to the resident's right great toe. The DON stated he did not believe the open area had recently occurred due to the large amount of drainage on the boot. The DON stated he would inform the wound physician the resident would need to be seen for the area. Observation on 08/25/22 at 7:30 A.M. with Wound Physician #123 for Resident #42, revealed the physician stated he had not been aware of the area (right great toe) previously and had classified the wound as being an Unstageable pressure ulcer. Further observation revealed Wound Physician #123 removed the dressing to the resident's right calf and observed a large amount of green colored drainage to the dressing. Wound Physician #123 asked the DON to obtain a culture of the area because he had concerns the area was infected. The DON swabbed the area and obtained the wound culture at that time. At this time, Wound Physician #123 identified the right calf pressure ulcer was a Stage 2 and measured 7.5 cm (l) x 3.5 cm (w) x 0.1 cm (d). Record review on 08/29/22 revealed no results on Resident #42's right calf wound culture taken on 08/25/22. On 08/29/22, interview with the DON at 12:05 P.M. revealed the culture had not been picked up by the lab due to it had been canceled for an unknown reason. The DON stated he had contacted the lab and they stated the specimen would be picked up today. Interview on 08/30/22 at 8:00 A.M. with LPN #118 revealed the specimen for Resident #42's right calf was still in the refrigerator and the DON had just recently come to locate it. LPN #118 was unaware why the specimen had not been sent previously. Interview on 08/30/22 at 8:20 A.M. with DON confirmed the specimen had not been picked up and stated he had obtained a new culture and it was to be taken to the lab today. DON was unable to provide an explanation as to why the culture still had not been picked up after he had already spoken with the lab the previous day. Telephone interview on 08/31/22 at 1:58 P.M. with Resident #42's daughter revealed she had concerns related to the resident's care that included wound care and turning and repositioning. Resident #42's daughter stated she had placed multiple visible signs in the resident's room to remind staff to turn and reposition the resident frequently and had placed audio and video recording devices in the room to monitor her care. Resident #42's daughter had also stated she had spoken with the DON regarding her concerns and had not seen improvements in her care. Resident #42's daughter stated she had not been made aware of the new area observed to the resident's right great toe. Review of the facility policy titled Skin Assessment revised 08/01/22 revealed a skin assessment is to be done on admission/readmission and weekly or after a change in condition or after a newly identified pressure ulcer. Review of the facility policy titled Wound Treatment Management dated 12/01/21 revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and the frequency of dressing changes, and in the absence of treatment orders the licensed nurse will notify the physician to obtain treatment orders. Review of the facility's CMS-672 form identified 12 residents with pressure ulcers. The facility further identified four of the 12 residents had facility acquired pressure ulcers. 3. Record review revealed Resident #10 was admitted to the facility on [DATE]. His admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had moderate cognitive impairment. He was totally dependent on one to two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #10's skin assessment, from this MDS dated [DATE], revealed the resident was at risk for the development of pressure ulcers. At the time of this MDS, the resident did have a pressure ulcer or injury. This MDS identified Resident #10 had two Unstageable pressure injuries. Review of Resident #10's Braden Score Evaluation dated 07/19/22 revealed the resident was at a low risk for the development of pressure ulcers. His score was a 15. Review of Resident #10's plan of care dated 11/15/19 revealed this resident was at risk for impaired skin integrity secondary to decreased aortic valve insufficiency and a non-ST elevated [CONDITION(S)] (STEMI). Interventions for this plan of care included: Assist with all transfers as needed; Encourage to turn and reposition every two hours and as needed; Inspect for any reddened areas during daily care; Pressure reducing mattress on bed; Pressure reducing cushion to wheelchair; Provide peri-care with each incontinence episode and when transferring, turning, and repositioning use proper techniques to avoid friction and shear. This care plan was not updated to include the pressure ulcers present in June 2022 and did not include other interventions in place which was dressing changes to his heel and buttocks or his prafo boots. Since the time these wounds occurred (which were facility acquired), the right heel pressure ulcer wound (healed 08/18/22) and the buttocks pressure ulcer had healed (08/16/22), but the left heel pressure ulcer remained unhealed. Review of the physician orders for the left heel pressure ulcer revealed: Apply protectant wipe to bilateral extremities, pad and secure with kerlix daily (dated 06/16/22 until 07/14/22) Air mattress to bed; Check placement and function every shift (dated 06/17/22 and still in effect) Turn and reposition the resident every two hours when in bed (dated 06/17/22 and still in effect) Elevate bilateral extremities when in bed (dated 06/17/22 and still in effect) Pro Heal 30 cc two times a day for wounds (dated 06/22/22 and still in effect) Heel protector boots to be worn daily and as tolerated. Remove when providing care (dated 06/24/22 and still in effect.) Cleanse left heel with normal saline, pat dry, apply a dressing and wrap with kerlix daily and as needed if loose or soiled (dated 07/14/22 to 08/24/22) Cleanse left heel with normal saline, pat dry, apply Santyl (skin product used to help heal skin ulcers), calcium alginate (water-soluble cream-colored substance for wound healing), cover with a dry sterile gauze and wrap with kerlix (dated 08/24/22 to 08/31/22) Cleanse left heel with normal saline, pat dry and apply [MEDICATION(S)], calcium alginate to wound, cover with dry sterile pad and wrap with kerlix. Change daily and as needed if loose or soiled (dated 08/31/22 to 09/02/22) Cleanse left heel with normal saline, pat dry and apply calcium alginate, cover with a dry sterile pad, and wrap with kerlix daily and if loose or soiled (dated 09/02/22) Left heel dressing use copious normal saline to remove gauze from wound. Cleanse with normal saline, pat dry and apply calcium alginate, wrap with a dry sterile bad and wrap with kerlix daily and if loose or soiled (dated 09/02/22) Wound Culture of left heel (dated 09/02/22) Xray of the left heel (dated 09/02/22) Review of Resident #10's Treatment Administration Record (TAR) from July, August and September of 2022, revealed the left heel pressure ulcer dressing wasn't completed as ordered on 06/25/22, 06/29/22, 07/03/22, 7/06/22, 7/11/22, 7/14/22, 07/15/22, 07/17/22 ,07/18/22, 07/21/22, 07/29/22, 08/03/22, 08/06/22, 08/07/22, 08/08/22, 08/09/22, 08/10/22, 08/11/22, 08/15/22, 08/17/22, 08/19/22, 08/21/22, and 08/22/22. Review of Resident #10's progress notes revealed on 06/16/22 at 1:59 P.M. Resident #10 was observed with bilateral heel pressure ulcers and right leg was swollen. Both Optum and certified nurse practitioner was notified. New order to apply skin protectant wipe, pad and secure with kerlix daily. There are no further progress notes in Resident #10's medical record from July and August 2022 about the left heel pressure ulcer, progress of the pressure ulcer and/or explanations as to why the pressure ulcer dressings were not completed according to the physician orders. Review of the Wound Physician #123's skin grids for Resident #10's left heel pressure ulcer revealed: On 06/23/22 the left heel pressure ulcer was listed a deep tissue i [TRUNCATED]

Based on interview, record review, observation and policy review, the facility failed to provide wound dressing changes and skin observations as ordered. This affected two of 12 residents with wounds, Residents #21 and Resident #105. This resulted in actual harm to Resident #21 when she developed [CONDITION(S)] requiring antibiotic therapy. The facility also failed to ensure neurological (neuro) checks were completed post-fall. This affected one resident (Resident #20) of three residents reviewed for falls. The facility census was 54. Findings include: 1. Resident #21 was admitted to this facility on 01/28/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's plan of care dated 01/13/17 revealed the resident was at risk for impaired skin integrity secondary to decreased mobility and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included review nutritional status quarterly; encourage resident to turn and reposition with routine rounds; inspect for any reddened areas during daily care; pressure reducing cushion to chair; pressure reducing mattress to bed, and when transferring the resident, use proper techniques to avoid friction and shear. Review of Resident #21's physician order dated 08/25/20 revealed skin observation checks weekly on every Tuesday. Review of Resident #21's skin observation sheets revealed for the month of June 2022, skin observations were not completed the entire month. Review of Resident #21's Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was alert and oriented, required supervision with set up only for some activities of daily living including transfers, dressing and personal hygiene, and extensive assistance of one person for toileting. Resident #21 did not have any pressure ulcers or skin breakdown. Review of a Braden Scale dated 07/09/22 revealed Resident #21 was at a moderate risk for skin break down. Review of Resident #21's skin observation sheets for July 2022 revealed one skin observation was completed on 07/19/22. Review of the skin observation dated 07/19/22 revealed Resident #21 had a left front lower leg skin impairment which measured 5.5 centimeters by 3.8 centimeters by 0.1 centimeters. There was no description of the impairment. Review of nursing documentation revealed on 07/19/22 at 5:14 P.M., the nurse assessed Resident #21's lower left extremity after being asked by the resident to look at it and change the dressing. The leg appeared swollen, red, and warm to touch. The nurse notified the unit manager who notified the nurse practitioner. The nurse applied a clean dressing to the left leg per the resident's request. A new order was received from the nurse practitioner to monitor the leg, elevate the leg to help decrease the swelling and a new antibiotic was ordered. Review of an assessment of Resident #21's wound by Wound Physician #123 dated 07/28/22, revealed an ulceration on the left front lower leg. The wound was classified as venous in nature. The wound bed consisted of 25% slough partial thickness with 75% granular tissue. The slough was yellow in color and soft. There was a moderate amount of serosanguinous drainage. The wound measured 3.5 centimeters by 2.5 centimeters by 0.1 centimeter in depth. The dressing was ordered to be changed daily. The order indicated to clean with normal saline, pat dry, apply calcium alginate, dry sterile dressing and wrap with Kerlix. Review of Wound Physician #123's assessment dated [DATE], revealed the ulceration area measured 4.5 centimeters in length, 2.0 centimeters in width and 0.1 centimeter in depth. The ulceration was declining. The wound care was not changed. Review of Wound Physician #123's assessment dated [DATE] revealed the ulceration on the left lower extremity measured 7.0 centimeters in length by 5.0 centimeters in length and 0.1 centimeters in depth. The ulceration consisted of 75% granular tissue and 25% of slough which was yellow in color. No odor was noted. The ulceration continued to have a moderate amount of serosanguinous drainage. Further review of Resident #21's care plan revealed the care plan was updated 08/11/22 to include the actual skin impairment. Interventions included evaluate for pain and provide pain relieving interventions as ordered; initiate wound treatment as ordered; observe and document character of the wound weekly, observe for clinical changes, such as infection and/or worsening of the wound. Review of Wound Physician #123's assessment dated [DATE] revealed the ulceration of left lower leg was venous in origin. The wound bed consisted of 100% granular tissue, partial thickness. There was a moderate amount of serosanguinous drainage. The wound measured 5.0 centimeters by 4.0 centimeters by 0.1 centimeters in depth. The vascular ulcer was listed as improved. The wound treatment remained the same. Review of Resident #21's physician orders dated 08/24/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to clean with normal saline, pat dry, apply calcium alginate, cover with a dry sterile dressing and wrap with Kerlix daily. Review of Resident #21's skin observation sheets for August 2022 revealed one skin observation was completed on 08/25/22. Interview with the Director of Nursing on 08/31/22 at 7:15 A.M. verified the findings. Review of the Wound Physicians #123's assessment dated [DATE] revealed the vascular ulcer was venous in nature. The dressing per the physician notes was not intact. There was noted to be 100% granular tissue to the wound bed. This continued to have a moderate amount of serosanguinous drainage. The ulcer now measured 2.5 cm by 3.0 centimeters by 0.1 centimeter in depth. The dressing change was changed to cleaning with normal saline daily, pat dry, apply [MEDICATION(S)] and calcium alginate and cover with a dry sterile dressing then wrap in Kerlix. The venous ulcer was listed as improving. Observation of a dressing change performed by Licensed Practical Nurse (LPN) #118 on 08/30/22 at 12:40 P.M. revealed after removal of the dressing dated 08/29/22, the area around the wound including the back of the calf was swollen and red in color. The area had little pustules that were fluid filled and was warm to touch. Per LPN #118, the ulcerative area looked like it had [CONDITION(S)]. LPN #118 felt the appearance of the wound had changed since her last observation. The wound was cleaned and dressed according to the physician orders. LPN #118 attempted to apply TED hose stockings to the left leg but could not apply because the size of the resident's leg. After the dressing change, LPN #118 called the nurse practitioner to report the change in wound status. The nurse practitioner ordered antibiotics and for the leg to be wrapped in an ace wrap all day and off at night. Interview with Resident #21 on 08/30/22 at 1:10 P.M. revealed she told the nurse yesterday that her wound felt tight and more swollen, but nothing was done. Interview with LPN #145 on 08/31/22 at 1:40 P.M. via telephone revealed she changed Resident #21's dressing on 08/29/22. LPN #145 denied the presence of pustules or redness around the wound and calf. LPN #145 said the area was not warm to touch, although it was swollen but the resident's leg was always swollen. LPN #145 confirmed Resident #21 said her leg felt tight and tender to touch. Review of Resident #21's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing on 08/31/22 at 8:11 A.M. verified that if the dressing change was not signed off on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified the dressing change was not signed off as completed on the dates listed. 2. Resident #105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #105's MDS dated [DATE] revealed the resident was alert and oriented times three, required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #105's physician orders dated 08/25/22 revealed the resident had an order to cleanse left lower leg with normal saline, pat dry, and apply a border foam dressing daily. On 08/27/22 the order was changed to cleanse left lateral leg with normal saline, pat dry, apply calcium alginate and a border foam dressing every Tuesday, Thursday, and Saturday. Interview and observation of Resident #105 on 08/29/22 at 9:32 A.M. revealed an elderly gentleman laying in a semi fowlers position in bed. He was interactive and friendly. While talking to the resident, the resident asked the surveyor to get someone to take care of the sore on his left lower leg. He then pulled back the covers and showed his leg. It was noted the resident's nonskid sock on his left foot was half saturated with blood, and there was dried blood noted on the bottom and top sheets. Resident #105 said the dressing on the wound had not been changed in four days therefore he removed the dressing. The date on the dressing which the resident had removed was 08/25/22. The dressing was wet with blood. Resident #105 said he told the nurse, but nothing was done about it, and no one came in to apply a new dressing. Interview on 08/29/22 at 9:50 with Licensed Practical Nurse (LPN) #127 revealed she was not aware Resident #105 had a wound and it must be new. LPN #127 assessed the resident's leg and then assured the resident she would come in to fix the wound and put on a new dressing. LPN #127 verified the dressing Resident #105 had removed was dated 08/25/22. Review of Resident #105's Treatment Administration Record (TAR) for the month of August revealed on 08/27/22, when a new order for [MEDICATION(S)] to be applied to the vascular ulcer was ordered, it was signed off as completed. Interview with the Director of Nursing on 08/30/22 at 10:30 A.M. verified the dressing change was signed off as done but could not have been done when the dressing removed by Resident #105 was dated 08/25/22. 3. Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment dated [DATE] revealed Resident #20 had moderate cognitive impairment and had one fall without injury. Resident #20 required the extensive assistance of one staff for bed mobility and transfers. Review of a fall report dated 06/29/22 at 10:09 A.M. revealed Resident #20 was lying on the floor next to his wheelchair. Resident #20 stated he tried to transfer from his wheelchair to his bed and fell down. Resident #20 denied hitting his head and denied pain. Interventions were put into place including Dycem (non slip mat) to Resident #20's wheelchair and a therapy evaluation was completed. Review of a nurses' note dated 06/29/22 at 1:05 P.M. revealed Resident #20 was observed lying on the floor of his room near his wheelchair. When asked, Resident #20 stated he was trying to transfer from his wheelchair to his bed and fell down. Vitals and skin assessment were completed with no concerns noted. The physician and Resident #20's sister were notified of the fall and neurological checks were initiated. Further review of Resident #20's medical record revealed no evidence neurological checks were completed for the fall on 06/29/22. Interview on 08/23/22 at 3:12 P.M. with Director of Nursing (DON) #102 verified no neuro checks were available to review for Resident #20's fall on 06/29/22 and agreed neuro checks should have been completed as required to ensure appropriate resident monitoring and care after a fall. Review of the facility policy, Neuro (Neurological) Checks, dated 01/29/20 revealed neuro-checks would be completed after a witnessed fall with injury to the head, when a resident was observed on the floor after a suspected fall that was not witnessed by a staff member, when a resident said they fell and per physician's order or nursing judgement. Findings were to be documented on the flow sheet. This deficiency substantiates Complaint Number OH 854.

Based on observation, interview, record review, and review of facility policy and procedure, the facility failed to ensure physician orders were consistently implemented related to Resident #44's pressure ulcer, ensure timely incontinence care to prevent contamination of wound with feces, ensure the resident was turned/repositioned as care planned, and ensure the appearance a hard knot was immediately reported to the physician. This resulted in actual harm as evidenced by a deterioration of the wound requiring hospitalization for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one of three residents reviewed for pressure ulcers. The facility census was 53. Findings include: Review of Resident #44's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 was discharged from the facility on 08/09/21. Review of Resident #44's care plan dated, 06/23/21 revealed the resident experienced bowel and/or bladder incontinence. Resident #44's toileting needs would be met by staff with interventions aimed at the prevention of infection and skin impairment. Interventions included to inspect for skin breakdown and intervene as needed, and to provide incontinence care every two hours and as needed. Review of Resident #44's physician orders revealed orders dated 06/23/21 for weekly skin checks every Tuesday, and a Braden Scale Evaluation (pressure ulcer risk assessment) to be done on admission, the next shift, and weekly for three weeks. Review of Resident #44's care plan dated, 06/24/21 revealed the resident had a potential for alteration in skin integrity, and resident would not develop any skin breakdown through the next comprehensive review. Interventions included to encourage Resident #44 to turn and position every two hours and as needed, and to provide assistance with hygiene, including peri-care as needed. Review of Resident #44's Braden Scale Evaluation dated 06/24/21 revealed the resident was a high risk for development of a pressure injury. The evaluation indicated Resident #44 responded to verbal commands, but could not always communicate discomfort or the need to be turned. Resident #44's skin was often, but not always very moist, linen must be changed at least once a shift. Resident #44 was confined to bed, mobility was very limited, the resident made occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. Resident #44 had a problem with friction and shear, required moderate to maximum assistance moving, complete lifting without sliding against sheets was impossible, and resident frequently slid down in the bed requiring frequent repositioning with maximum assistance. Review of Resident #44's Skin Grid Pressure documentation dated 06/24/21 revealed a sacrum pressure ulcer present on admission. Measurement was 3 centimeters (cm) length x 6 cm width, and depth could not be determined. The wound was described as an unstageable sacral pressure ulcer with intact eschar (hard dead tissue), edges intact, peri-wound intact. The wound was cleansed with normal saline and alginate and a dry dressing were applied. There was no drainage or odor. Review of Resident #44's progress notes revealed he was admitted to the local hospital from 06/28/21 through 07/05/21. Review of Resident #44's discharge instructions from the hospital dated 07/05/21 revealed the resident had an unstageable pressure ulcer to his sacrum. The ulcer was black surrounded by yellow edges, there was red around the edge and no tunneling. There were no measurements included. Review of Resident #44's Admission Assessment with Baseline Care Plan dated, 07/05/21 revealed the resident had a coccyx pressure ulcer. No measurements or description of the wound was included. Review of Resident #44's medical record revealed a Braden Scale Evaluation was completed on 07/05/21 and no further Braden Scale Evaluations were completed. Review of Resident #44's Skin Grid Pressure documentation dated, 07/08/21 revealed an unstageable sacral area pressure ulcer with adhered slough (dead tissue), edges intact, peri-wound intact, measurement was 2 cm length x 7 cm width, and depth could not be determined. The wound was cleansed with normal saline and alginate and a dry dressing were applied. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment dated , 07/12/21 revealed the resident had intact cognition, was total dependence and a two person physical assist for bed mobility, and was total dependence and a one person physical assist for toilet use and personal hygiene. Review of Resident #44's Skin Grid Pressure documentation dated 07/22/21 and 07/29/21 revealed an unstageable sacral area pressure ulcer with adhered slough, edges intact, peri-wound intact. Measurements was 3 cm length x 7 cm width, and depth could not be determined. There was no drainage or odor noted on 07/22/2, but a moderate amount of drainage on 07/29/21(appearance of drainage not described). Review of Resident #44's Wound Care Notes dated, 07/29/21 revealed no dressing was present on the pressure ulcer wound and the wound was contaminated with stool. The wound measured 3 cm in length x 10 cm in width, and depth could not be determined. The wound had 100 percent slough. Review of Resident #44's Wound Care Notes dated, 08/05/21 written by Medical Doctor (MD) #134 revealed the resident had an unstageable pressure wound to his sacrum, tissue bed was 50 percent granular and 50 percent slough. There was a moderate amount of serosanguinous drainage. Measurement of the wound was 3 cm length x 10 cm width, and depth could not be determined. Review of Resident #44's medical record from 07/10/21 through 08/09/21 including review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reveal documentation the resident had been turned and repositioned every two hours and as needed. Review of Resident #44's progress notes from 07/05/21 through 07/17/21 did not reveal documentation of skin checks on Tuesday 07/06/21 or Tuesday 07/13/21 per physician orders. Review of Resident #44's MAR and TAR dated 07/06/21 and 07/13/21 did not reveal documentation the weekly skin checks were completed per physician orders. Observation on 08/09/21 at 8:19 A.M. of Resident #44 revealed State tested Nursing Assistant (STNA) #135 lifting Resident #44's blanket revealing brown liquid material on the gown between his legs, and under his left arm. The brown liquid was dried on the gown around the outer edges of the brown color and wet everywhere else. Brown liquid material was observed under Resident #44's left arm on the sheets and it was dried around the outer edge. STNA #135 stated he needed help to clean the resident. STNA #135 walked out of room to find STNA #124. Upon returning to the room STNA #135 and STNA #124 took the blankets off Resident #44 and rolled him on his right side revealing a very large pool of liquid feces covering the sheets and protective pad from Resident #44's upper back to his calves. Resident #44's gown was saturated with feces around his groin area, the sides of the gown and on the sleeves. Resident #44 had dried feces and wet feces on his skin from his shoulder blades to his calves. The incontinence brief Resident #44 was wearing was saturated with liquid feces and the feces was coming out the sides of the brief onto his thighs and the bed. As STNA #124 and #135 were completing incontinence care continued observation revealed upon removal of the incontinence brief a large pressure wound on the resident's sacrum which extended across the right and left buttocks was covered in feces. There was no dressing covering the wound. Interview of Resident #44 on 08/09/21 at 8:19 A.M. revealed he had not been changed or turned/repositioned since 10:00 P.M. on 08/08/21. STNA #124 asked Resident #44 how he felt he stated rough. Observation on 08/09/21 at 8:45 A.M. of Resident #44 after the feces was cleaned off the buttocks revealed a wound on the right buttocks approximately the size of a fifty cent piece. The wound bed was dark red with some white spots, and had black tissue around the wound edges across the bottom and around the sides of the wound. The right buttock wound extended across the buttocks to the left buttocks and the area on the left buttocks was 95 to 100 percent covered in soft, greenish yellow tissue. Interview of STNA #135 on 08/09/21 at 8:19 A.M. and 2:53 P.M. revealed it did not look like Resident #44 had been changed in awhile. STNA #135 stated he saw Resident #44's pressure ulcer last week and the left buttock did not have an open wound, it was just a hard knot. STNA #135 stated he told the nurse about the hard knot, but could not remember which nurse it was. STNA #135 stated about three times a week when he arrived at 7:00 A.M. to start his assignment the residents, including Resident #44, were wearing incontinence briefs saturated with urine and feces requiring the need to change their gowns and bed linens. STNA #135 stated it made him so angry because he thought of the residents as family, and wanted to ask the night shift STNAs how can you leave the residents like this, but they were gone by the time he arrived and he was not able to speak to them. Interview of STNA #124 on 08/09/21 at 8:19 A.M. revealed she observed Resident #44's wound last week and it did not look like it looked today. STNA #124 stated the left buttock had a hard area and was not open. On 08/09/21 at 9:08 A.M., Unit Manager/Licensed Practical Nurse (UM/LPN) #136 entered Resident #44's room and completed a wound assessment. Interview of UM/LPN #136 at this time revealed she was also the facility wound nurse. UM/LPN #136 stated the soft tissue extending across Resident #44's left buttocks and part of the right buttocks was slough and it covered almost the entire area. UM/LPN #136 measured the wound. The would measured 4 cm in length x 10 cm in width, and the depth could not be determined. UM/LPN #136 confirmed the presence of a hardened area extending approximately 4 cm from the wound edge across the top of the pressure ulcer and around part of the side of the wound. UM/LPN #136 immediately notified MD #134 about the appearance of the wound and the hard area surrounding part of the wound. MD #134 ordered Resident #44 to be transported to the local Emergency Department for evaluation of the pressure ulcer. Interview on 08/09/21 at 9:08 A.M. of the Director of Nursing (DON) confirmed the above findings. Observations on 08/09/21 at 10:00 A.M., 11:00 A.M., 12:00 P.M. and 1:18 P.M. revealed Resident #44 laying on his back. Interview of MD #139 on 08/11/21 at 2:40 P.M. revealed Resident #44 was admitted to the hospital intensive care unit on 08/10/21. MD #139 stated Resident #44 had a debridement of the sacral pressure ulcer on 08/10/21, the pressure ulcer was infected and a CT scan showed he had acute [CONDITION(S)] of the coccyx. MD #139 stated she did not have all the measurements of the sacral pressure ulcer but it was one and a half inches deep. Interview of MD #134 on 08/11/21 at 5:08 P.M. revealed UM/LPN #136 called him on 08/09/21 because she saw some pus around the wound and felt an abscess. MD #134 stated he ordered Resident #44 to be sent to the hospital for evaluation of a sacral abscess. MD #134 stated one would think the presence of stool on a wound would increase the risk of infection and the presence of stool may interfere with wound healing. MD #134 stated Resident #44 was a big guy and probably was not getting turned every two hours due to staffing. MD #134 stated the protocol was to turn and reposition residents with pressure ulcers every two hours. Review of the facility policy titled Resident Care, revised 06/2018, revealed facility staff would provide general care as necessary for each resident per their preferences when able, and per physician orders. Residents would be given nursing care and supervision based upon individual needs. Facility policies and procedures, and nursing and other discipline's standards of practice would be utilized to promote physical, mental, spiritual, nutritional and emotional status of residents. Typical personal hygiene for a resident would include but not limited to care of the skin to include routine and as needed bathing and foot care, residents that were incontinent would be changed as needed and skin care provided with incontinent episodes, clean linen would be provided routinely and as needed for soiling, residents confined to bed or wheelchair would be routinely encouraged and assisted to be turned and repositioned and body alignment maintained. Review of the facility policy titled Dressing Change, Dry/Clean, dated, 11/2015 revealed the following information should be included in the resident's medical record; the date and time the dressing was changed, wound appearance, including wound bed, edges, presence of drainage, the name and title of the individual changing the dressing, the type of dressing used and wound care given, how the resident tolerated the procedure, if the resident refused the treatment and the reason why, notify the supervisor if the resident refused the dressing change. This deficiency substantiates Complaint Number OH 428.

Based on record review and interview, the facility failed to prevent Resident #70 from falling out of bed while staff were providing direct care for the resident. Actual harm occurred when Resident #70 fell to the floor while Certified Nursing Assistant (CNA) #1 rolled him over in bed without the required assistance of a second staff person. Resident #70 fell from the bed onto the floor, and was transferred to the hospital for evaluation, and subsequently hospitalized in the intensive care unit for observation and possible surgery. This affected one (Resident #70) of three residents reviewed for falls. The facility census was 60 residents. Findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].#70 was taking a blood thinning medication ([MEDICATION NAME]) to keep his blood from clotting. A review of Resident #70's admission nursing assessment and baseline care plan, dated [DATE], indicated Resident #70 required two staff members for bed mobility and transfers. Resident #70 was nonverbal and unable to make his needs known to staff. A fall risk assessment was not completed until [DATE], after Resident #70 had a witnessed fall out of bed on [DATE] at 12:30 A.M., due to CNA#1 turning him over in the bed without a second person to assist. A review of the nurses notes dated [DATE] to [DATE] indicated Resident #70 was hospitalized after the fall on [DATE] then readmitted to the facility on [DATE]. Further record review revealed a CT scan report of Resident #70's head was completed on [DATE] at the hospital. The CT scan report indicated that Resident #70 was being assessed due to a head trauma with [MEDICAL CONDITION]. An interview was conducted on [DATE] at 12:26 P.M. with the daughter of Resident #70 who revealed that because Resident #70 had part of his skull removed after his stroke and was taking blood thinning medication, it was very dangerous for him to fall out of bed. An interview was conducted on [DATE] at 5:44 P.M. with the director of nursing (DON) who revealed that CNA #1 was newly hired and was responsible for Resident #70's fall out of bed. The DON explained that Resident #70 required two staff to turn him in bed, and CNA #1 tried to do it herself causing Resident #70 to roll out of bed onto the floor. The DON explained that Resident #70 showed no signs of injury, but the daughter wanted him sent to the emergency room for an assessment. An interview was conducted on [DATE] at 11:15 A.M. with CNA#1 who verified that she rolled Resident #70 by herself because she did not want to wait for help, and he rolled right out of the bed onto the floor. CNA#1 said that she had elevated the bed to waist high, and it was not in low position because she was providing care. CNA#1 explained that she had turned him onto his side and put a pillow behind his back then stepped away from the bed to get water to wash him. CNA#1 revealed that Resident #70 began to roll off the bed from his right side and landed onto his left side. She said that there were no signs of injury, and the nurse was notified right away. An interview was conducted on [DATE] at 12:05 P.M. with Resident #70's wife who was also his guardian. The wife explained that Resident #70 had a history of [REDACTED].#70 had another brain bleed from the [DATE] fall. The wife indicated that Resident #70 was transferred from the emergency room to another hospital where he was assessed in the intensive care unit in case he needed surgery for [REDACTED]. An interview was conducted on [DATE] at 1:22 P.M. with Licensed Practical Nurse (LPN) #2 who found the resident on the floor in his room on [DATE]. LPN #2 revealed that she found Resident #70 lying on his left side on the floor and did not see any surface injuries on Resident #70. LPN#2 explained that Resident #70 was totally dependent on staff to turn him in the bed and required two staff to assist him with turns. LPN #2 indicated that he had been taking a blood thinner and the fall could have caused injury on the inside of his body, so he was sent to the hospital by Certified Registered Nurse Practitioner (CRNP) #80 An interview was conducted on [DATE] at 2:25 P.M with CRNP #80, who said she had worked with Resident #70 during his admission and had known that he had a history of [REDACTED]. CRNP #80 verified that Resident #70 was hospitalized in an intensive care unit from [DATE] to [DATE] and later died at the facility on [DATE]. A review of the death certificate (dated [DATE]) after the autopsy indicated that the cause of death was [MEDICAL CONDITIONS]. A record review was conducted of the facility policy titled Fall Prevention and Management Program, dated (MONTH) 2014. The policy indicated the facility would assess each resident for the potential for falls upon admission. This deficiency substantiates Complaint Number OH 847.

Based on observation, record review, policy review and interview the facility failed to implement appropriate and safe interventions to address Resident #30's right knee pain. This affected one of three residents reviewed for pain management (Resident #30). Actual harm occurred when hot towels were used to relieve Resident #30's knee pain without monitoring for safe temperature of the towels and without correct application of the hot towels resulting in a second degree burn (defined as a burn involving the epidermis and dermis and usually forming blisters that may be superficial. If it involves all levels of the dermis, the skin appendages are preserved) to the resident's her right knee. Findings include: Record review revealed Resident #30 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #30's plan of care initiated on 12/08/10 revealed an alteration in comfort related to pain due to arthritis and [MEDICAL CONDITION] joint disease. Interventions on the plan of care included to assess for the location, type, frequency and precipitating factors and relief factors of pain. Evaluate the effectiveness of the pain medication. Offer alternative interventions such as diversion and repositioning. Offer [MEDICATION NAME] as ordered by the physician and teach resident to ask for pain medication before the pain becomes severe. An interview with State tested Nursing Assistant (STNA) #1 on 06/06/17 at 7:35 A.M. revealed Resident #30 had sustained a burn with blisters. STNA #1 stated she was aware of the burn but was unable to give details. An interview with Licensed Practical Nurse (LPN) #2 on 06/06/17 at 7:45 A.M. revealed she was working at the time of the injury. LPN #2 stated STNA #3 had heated a wet towel in the microwave oven and placed it on Resident #30's right knee to attempt to relieve her complaints of pain. LPN #1 stated she was informed at approximately 5:00 A.M. on 06/02/17 by STNA #1 of blisters present on Resident #30's right knee. A review of STNA #3's written statement dated 06/02/17 revealed Resident #30 was yelling and complained of right knee pain. STNA #3 had informed LPN #2 of the resident's complaints of pain and the resident was asking for pain medication. LPN #2 informed STNA #3 that Resident #30 had no pain medication due to administer at the time. STNA #3 indicated she obtained towels and applied warm water and heated the wet towel in the microwave for a few seconds and then placed the towel on Resident #30's right knee. A review of LPN #2's written statement dated 06/02/17 indicated STNA #3 had informed her on 06/02/17 at approximately 1:00 A.M. of Resident #30's complaints of right knee pain. LPN #2 informed STNA #3 she had recently administered routine pain medication to Resident #30 and she would assess her. LPN #2 repositioned Resident #30 and attempted to relieve her pain with nonpharmacological interventions. At approximately 2:00 A.M. STNA #3 informed her she had placed a warm washcloth on Resident #30's knees for pain relief. At approximately 5:45 A.M. STNA #1 informed her of the blisters present on Resident #30's right knee. LPN #2 assessed the blisters and found multiple blisters on her right knee and reddened skin on the left knee. LPN #2 indicated the Director of Nursing and physician were notified. An interview with the Director of Nursing (DON) on 06/06/17 at 10:45 A.M. revealed she was aware of the blisters on Resident #30's right knee. The DON stated on 06/02/17 at approximately 5:00 A.M. LPN #2 had informed her by phone of the development of blisters on Resident #30's right knee. The DON stated LPN #2 notified her of the events leading to the blisters and directed LPN #2 to document her findings on an incident report, document the incident on a disciplinary form and write a written statement of what had happened. The DON directed LPN #2 to have STNA #3 write a written statement of what happened and after completion of the statement to send her home immediately and not return to work until an investigation was completed. The DON stated Resident #30's family was notified and updated daily on the progress of the blisters and treatments provided. The DON stated she had attempted to phone STNA #3 multiple times for an interview and had left a message to call the DON. The DON stated she had not received a response from STNA #3. An interview with the Wound Physician on 06/06/17 at 10:40 A.M. revealed he was informed of the skin breakdown on Resident #30's right knee and had assessed the wound. The Wound Physician described the wound as a second degree burn type wound. An observation of the wound on 06/06/17 at 1:00 P.M. with the Wound Registered Nurse revealed the right knee was wrapped in a gauze dressing covering two abdominal pads to pad and protect the blistered area. The right knee was surrounded on the lateral side and anterior portion of the knee with a large fluid filled blister. The wound documentation dated 06/06/17 revealed the blister measured 11.5 centimeters (cm) long by 17 cm wide by undetermined depth. The facility policy and procedure titled Pain Identification Process (undated) revealed the licensed nurse would be responsible for assessing and implementing pain interventions with treatments. The licensed nurse will determine the level of pain and contact the physician for orders that are individualized for the resident. The deficiency substantiates Master Complaint Number OH 515

Based on interview and record review, the facility failed to timely identify and treat a pressure ulcer for one resident. (Resident #5) This affected Resident #5, one of three residents reviewed for pressure wounds. The facility census was 62. Actual harm occurred when Resident #5, who was identified to be at high risk for developing pressure ulcers, developed a unstageable pressure area on the sacrum and did not implement any preventative measures. Resident #5 was incontinent and had functional impairment of both the upper and lower extremities. Findings include: Resident #5 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severe cognitive impairment, was rarely or never understood, required extensive assistance from two staff for bed mobility, was totally dependent for transfer and locomotion in a wheelchair, had functional impairment of upper and lower extremities, was incontinent of bowel and had an indwelling urinary catheter. Review of a pressure ulcer risk assessment dated [DATE] revealed Resident #5 was at a high risk for developing pressure ulcers due to cognitive impairment, immobility, and bowel incontinence; however, review of the facility provided care plans to treat and/or prevent pressure ulcers were dated when actual wounds developed 11/01/16, 11/29/16 and 12/03/16. Review of the facility provided care plan for the potential for alteration in skin integrity was dated 12/14/16, the date of the complaint survey. Review of a Wound Evaluation Flow Sheet dated 11/01/16 revealed an unstageable wound was found on the resident's sacrum (lower spine area just above the buttocks). An unstageable wound is defined as the presence of slough or eschar (dead tissue in the process of separating from the viable portions of the body) partially or fully covering the wound bed. The sacral wound was 75% eschar with 25% granulation. The wound measured 8.0 centimeters (cm.) x 8.0 cm. with the depth undetermined. An interview was completed on 12/14/16 at 4:32 P.M. with the Wound Nurse, RN #76. RN #76 revealed she was alerted of the wound on the day it was discovered, 11/01/16, and assessed it at that time. RN #76 was unable to explain why the wound was not discovered prior to becoming unstageable. RN #76 verified Resident #5 was incontinent of stool and was dependent on staff for incontinence care. Review of the bowel monitoring sheet revealed Resident #76 was incontinent of bowel 10/26/16, 10/27/16, 10/28/16 and 10/31/16. During the same interview, RN #76 revealed the wound was not able to be observed on 12/14/16 because a dressing change was not needed and turning and positioning the resident to observe the wound would be painful for the resident. This citation substantiates complaint #OH 227.

Based on observation, staff interview and medical record review, the facility failed to re-evaluate fall interventions for two noncompliant residents. This resulted in Actual Harm for Resident #21 who had a fall with right hip fracture and Actual Harm for Resident #73 who had a fall with a right hip fracture. The facility also failed to provide adequate supervision for Resident #21 who remained at risk for falls. This affected two of three residents reviewed for falls. Findings include: 1. Review of the medical record for Resident #21 revealed [DIAGNOSES REDACTED]. Review of the fall risk care plan, initiated 10/19/14, documented to assist with transfers/ambulation and keep in high traffic areas when out of bed. The plan of care also documented problems of poor vision and wandering behavior. The Fall Risk Assessment completed 11/28/14 identified that the resident was at high risk for falls. Review of the nursing progress notes document that the resident had a fall in her room without injury on 11/28/14. The 01/21/15 Minimum Data Set (MDS) 3.0 Assessment revealed the resident had severe cognitive impairment. Nurses notes dated 01/07/15, 01/08/15, 01/11/15, 01/28/15 and 02/01/15 documented that Resident #21 was noncompliant with safety measures to have staff assisted transfers from the wheelchair. The record contained no re-evaluation of the resident's fall interventions. The progress note dated 02/01/15 at 11:19 A.M. documented that the resident was found lying on the floor in front of the nurses station. The progress note at 1:21 P.M. documented the resident complained of right hip pain. an order for [REDACTED]. The resident had a surgical repair and returned to the facility on [DATE]. On 03/25/15 at 6:32 A.M. Resident #21 was observed on the floor in front of her wheelchair after a loud thud was heard by the surveyor. The resident had been seated in a wheelchair and attempted to get out without assistance. State tested Nurse Aide (STNA) #109 was in the hallway with the surveyor and went to the resident's side. The resident was alert and asked staff to help her. STNA #109 then left the resident and went down the hall to get Licensed Practical Nurse (LPN) #108. LPN #108 assessed the resident and they picked her up from the floor. The resident had a large green/purple bruise and egg sized lump over the right eye. There was also a two centimeters long tear at the right brow that was dark red with blood. After care was provided, the resident was moved to her room. An interview with STNA #109 on 03/25/15 at 6:54 A.M. indicated that the resident had been up frequently that night and was attempting to get out of bed. STNA #109 stated it was difficult to keep an eye on the residents who needed it when they did not have the staff on the floor. There were three staff that night, one nurse and two STNAs on the hall. On 03/25/15 at 6:40 A.M. an interview with LPN #108 verified that Resident #21 had a history of [REDACTED]. 2. Review of the medical record for Resident #73 revealed [DIAGNOSES REDACTED]. Review of the fall risk care plan, initiated 01/18/15, documented to assist with transfers/ambulation. The plan of care also documented problems of urinary incontinence and the assistance of one staff with toileting due to cognitive impairments. No other specific interventions related to potential falls and toileting were on the plan of care. The Fall Risk Assessment completed 01/19/15 identified that the resident was at high risk for falls. The 01/29/15 MDS 3.0 Assessment indicated the resident had severe cognitive impairment. Review of the nursing progress notes documented that Resident #73 was non-compliant with asking staff for assistance with transfers on 01/01/15, 01/03/15, 01/04/15, 01/05/15 and 01/19/15. On 01/19/15 the progress note documented that at 12:45 A.M. the resident was found on the floor in his room with no injury. The note documented a resident statement that he was trying to go to the bathroom. On 03/01/15 the progress note documented the resident was noncompliant with unassisted transfers from the wheelchair. The fall interventions were not re-evaluated. On 03/11/15 at 7:08 A.M. the progress note read that Resident #73 was found on the floor in his room. The note documented that the resident said he was trying to go to the bathroom. The resident had a physician ordered x-ray on 03/11/15 with a result of right hip fracture. The resident was transported to a hospital for treatment of [REDACTED]. The resident had a surgical repair and returned to the facility on [DATE]. Review of the progress notes revealed that on 03/22/15, Resident #73 had two falls in his room, one at the bedside and one in the bathroom. The progress note documented that interventions were added of bed in low position, floor mats and perimeter mattress. On 03/25/15 at 6:40 A.M. an interview with LPN #108 verified that Resident #73 had a history of [REDACTED]. This deficiency substantiates Complaint Number OH 267.

Based on observation, record review and interview the facility failed to address the deterioration of a pressure ulcer for Resident #101 in a timely manner and failed to monitor the resident to prevent additional skin breakdown. Actual harm occurred to Resident #101 when an in-house acquired Stage II pressure ulcer on the resident's right buttock declined to a Stage IV pressure ulcer without evidence of appropriate interventions in place. The resident also developed pressure ulcers to the right elbow and left ear, which were unidentified by facility staff. This affected one resident (Resident #101) of one resident reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. Findings include: Review of Resident #101's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission screening assessment dated [DATE] indicated the resident had no skin breakdown. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was in a persistent vegetative state, was dependent upon staff for all activities of daily living, and was at high risk for developing pressure ulcers. The resident was discharged to the hospital on [DATE]. Review of a readmission screening dated 09/30/14 revealed the resident had a scar to the right and left buttocks and a scabbed area to the left ear, with no open areas noted to the skin. Review of the physician's orders [REDACTED]. Review of a weekly wound report, dated 10/06/14 revealed Resident #101 had a superficial Stage II (a lesion caused by unrelieved pressure that results in damage to the underlying tissue) pressure area to the right buttock measuring 4 centimeters (cm) long by 1.8 cm wide with less than 0.1 cm deep. The certified nurse practitioner (CNP) was updated and gave orders for a treatment of [REDACTED]. The family was notified of the pressure area. The wound report revealed the pressure reducing interventions included orders to turn and reposition every two hours while in bed and off load heels while in bed. Review of a weekly wound report, dated 10/13/14 revealed Resident #101's right buttock wound measured 4.5 cm long by 5.5 cm wide with less than 0.1 cm depth, and was described as a deteriorated Stage II wound. There was no documented evidence the physician or family were notified or the treatment was changed. The wound report revealed the pressure reducing interventions included orders to turn and reposition every two hours while in bed and off load heels while in bed. Review of a telephone order dated 10/15/14 revealed a new order to cleanse area to right buttock with sterile water and pat dry, apply calcium alginate with silver and cover with foam dressing three times a week and as needed. Review of a weekly wound report, dated 10/20/14 revealed the right buttock wound measured 5 cm long by 9 cm wide with less than 0.1 cm depth and 80% slough (a layer or mass of dead tissue separated from surrounding living tissue indicating that the wound bed was unable to be observed which would make the wound unstageable) tissue in the wound bed. However, the wound report continued to reflect the pressure ulcer as a Stage II. There was no documented evidence the physician or family were notified of the deterioration of the wound. The wound report revealed the pressure reducing interventions included orders to turn and reposition every two hours while in bed and off load heels while in bed. Review of a weekly wound report, dated 10/27/14 revealed the right buttock wound measured 6 cm long by 7 cm wide with 4.5 cm depth and 90% slough in the wound bed. The report contained evidence the physician and family were notified at that time of the deterioration of the wound. The wound report revealed the pressure reducing interventions included orders to turn and reposition every two hours while in bed and off load heels while in bed. Review of a telephone order dated 10/27/14 revealed an order for [REDACTED]. Review of a weekly wound report, dated 11/03/14 revealed the right buttock wound measured 5.5 cm long by 6.5 cm wide with 3 cm depth and 30% slough tissue in the wound bed. The wound report revealed a pressure reducing interventions added an air mattress. This was the first evidence an air mattress was in place for the resident. Review of the progress note from the wound care physician dated 11/03/14 noted the right buttock wound was a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present) necrotic infected sacral wound measuring 7 cm long by 8.7 cm wide with 4.7 cm deep. The progress note indicated the resident also had a right elbow Stage II pressure ulcer measuring 1.5 cm long by 1.0 cm wide with 0.1 cm depth and an open area to the left ear measuring 1.8 cm long by 0.8 cm wide with 0.1 cm depth. Record review revealed neither the right elbow or left ear pressure ulcers had been identified by the facility. On 12/04/14 at 11:10 A.M. the assistant director of nursing and licensed practical nurse wound nurse were observed completing the resident's dressing change to the right buttock. The resident continued to have a pressure ulcer to the area at that time. A dressing was noted to be intact to the right elbow that was not due to be changed until 12/05/14. The resident's left ear was observed to be open. An interview with the director of nursing (DON) on 12/04/14 at 4:00 P.M.. confirmed there was no documented evidence the physician was notified of the deterioration of the pressure ulcer to the right buttock between 10/06/14 and 10/27/14, that there was no documented evidence that the right elbow and left ear wounds were identified in the facility prior to the visit with the wound care physician on 11/03/14 and that an air mattress to promote healing was not implemented until 11/03/14. The DON verified the pressure ulcer to the right buttocks had deteriorated to an unstageable pressure ulcer on 10/21/14.

Based on record review and interview, the facility failed to ensure Resident #19 did not sustain urethral trauma with bleeding while receiving personal care. This affected one of four residents reviewed during the complaint survey out of a total of six residents with urinary catheters. The census was 73. Findings include: Resident #19 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was totally dependent on staff to provide all aspects of functional living tasks. The resident opened his eyes and was responsive to pain. The resident was unable to communicate and his cognitive status was not attainable. He had a urinary catheter in place and was always incontinent of bowel. Review of Nurse's Notes dated 07/23/11 at 7:00 P.M. revealed the physician was notified "foley pulled on" and "hematuria" was noted in the catheter drainage bag. The resident had a temperature of 102.4 degrees Fahrenheit (F), with a pulse of 150. The physician ordered stat laboratory testing which included a complete blood count, chest x-ray and urine for culture and sensitivity to be sent when the urine cleared of blood. The nurse documented the labs and chest x-ray were done and the resident was given Tylenol. At 10:00 P.M., the nurse noted the resident's temperature was 99.4 degrees F and pulse was 151. The nurse notified the physician of the resident's elevated pulse and the physician ordered transport to the emergency room . The resident was transported on 07/23/11 at 11:45 P.M. Review of the hospital documentation revealed on 07/24/11 the emergency room physician noted the resident presented from the nursing home with fever, [MEDICAL CONDITION] bleeding from the urethra. The physician noted the resident arrived with the balloon from the catheter inflated and the foley "almost completely out". It was reinserted several times in the emergency room and eventually placed to traction. The physician noted that there was a concern regarding the trauma and a urologist would be following him, and also no emergent surgical interventions were needed as of then. The physician also noted that the nursing home nurse reported the resident had been observed pulling on his catheter and that the resident began to bleed from the site around 6:00 P.M. The resident became febrile and [MEDICAL CONDITION] shortly thereafter. There was no further documentation regarding the nursing home report. On 11/03/11 at 10:10 A.M. it was verified with three staff members on the resident's unit, Licensed Practical Nurse (LPN) #4, Registered Nurse (RN) #5, and State tested Nurse Aide (STNA) #2, that the resident was unable to move his arms independently and would not have been physically capable of pulling on the catheter. Review of the additional hospital documentation revealed the resident's initial hemoglobin (Hgb) blood count was 11.8. A bladder irrigation was started in the emergency room . A recheck of the Hgb on 07/25/11 revealed the resident's Hgb had dropped to 6.6. The resident required transport to the intensive care unit due to his low blood pressure. The physician noted the resident was anemic from acute blood loss, which improved appropriately after he received three units of packed red blood cells. The resident's blood pressure also improved after the blood was administered and with additional intravenous fluid replacement. The resident was also found to have a urinary tract infection and was being treated with intravenous antibiotics. Interview with the facility director of nursing (DON) on 11/03/11 revealed he had recently assumed the DON position when the incident had occurred. He stated he found an incident summary investigation, but could not present the actual incident report. The summary was brief, dated the day of the incident, but not dated when completed. The DON noted that per nurse (did not identify RN or LPN), the resident was sent to the hospital after tugging of Foley catheter during care caused the Foley to pull and have frank blood in the Foley bag. The physician was notified and requested the resident to be sent out for evaluation. The summary also noted that STNA #2 had verified that during care earlier the resident was observed with a leg band on. Attached to the summary, was an undated statement submitted by STNA #2. The STNA noted on the date that the resident was sent to the hospital, he had assisted with the resident's care "earlier that day." On 11/03/11 at 10:00 A.M. interview with the STNA #2 revealed he had worked the day of the incident. He stated earlier in the day he had assisted with the resident's care, but had no knowledge of the resident's catheter bleeding. Interview with the DON on 11/03/11 at 11:30 A.M. revealed he had asked STNA #2 to provide his statement on 11/03/11. The DON stated he had spoken to some of the staff, but could not remember who and did not write down their names. He stated that residents were seen in the emergency room "all the time" for pulling on their catheters. He verified Resident #19 was not capable of pulling his catheter. He stated he had no idea what staff member had pulled on the catheter or if they even continued to work in the facility. The resident was returned to the facility 07/29/11 with the foley catheter intact and draining yellow urine. The resident was readmitted to the hospital with [REDACTED]. This deficiency substantiates Complaint Number OH 917.