Every finding on record at Hall of Fame Rehabilitation and Nursing Center

Based on record review and interview, the facility failed to ensure the Director of Nursing (DON) duties were completed by the registered nurse (RN). This had the potential to affect all 48 residents residing in the facility.Findings include:Review of the key personnel list indicated the Director of Nursing (DON) as Registered Nurse (RN) #419. The list indicated Licensed Practical Nurse (LPN) #423 as the Assistant Director of Nursing (ADON). Review of the personnel file for ADON LPN #423 revealed an employee action form dated 10/21/22 indicating a salary increase effective 10/09/22. Under the comments sections was a handwritten note effective 10/09/22 currently acting DON and all clinical lead, approved by the Administrator. Interview on 03/25/26 at 5:03 P.M. with the Administrator verified he had written the note and stated that it was effective as of 10/09/22 ADON LPN #423 was the acting DON with all clinical leads. The Administrator stated the DON RN #419 was only by title, and ADON LPN #423 did all the DON duties.

Based on review of the Resident Council minutes, observation, staff interview, resident interview and review of the mealtime policy, the facility failed to ensure meals were served in a timely manner. This affected five residents (#13, #31, #47, #48, and #56) of five residents reviewed for frequency of meals and had the potential to affect all 47 residents who received meals from the kitchen. The facility identified one resident (Resident #4) as receiving nothing by mouth (NPO). The facility census was 48.Findings include:Review of the Resident Council minutes dated 01/08/26 revealed meals were often late.Review of the Resident Council minutes dated 02/05/26 revealed meals were often late.Review of the undated facility mealtimes posted at the second-floor nurses' station revealed the second floor was the second cart and should be delivered to the floor at 11:50 A.M.Observation and interview on 03/23/26 at 12:45 P.M. revealed that lunch trays came to the second floor. Licensed Practical Nurse (LPN) #433 verified that the lunch trays for the residents on second floor were 55 minutes late and confirmed the posted mealtime delivery of 11:50 A.M.Interview on 03/24/26 at 8:17 A.M. with Dietary Manager (DM) #449 stated that the times that were posted were when they started tray line for the food cart. When questioned, DM #449 verified the posted mealtimes stated the trays were to be delivered to the second floor at 11:50 A.M.Interviews on 03/24/26 at 1:46 P.M. with Residents #13, #31, #47, #48, and #56 during a resident council meeting for the recertification survey revealed that late meals were a concern. Review of the mealtime policy dated 2023 titled, Frequency of meals, revealed that the facility scheduled three regular mealtimes comparable to normal mealtimes in the community. This deficiency represents non-compliance investigated under Complaint Number 2693841.

Based on observation, staff interview and facility policy review, the facility failed to maintain the kitchen in a clean and sanitary manner and failed to ensure foods were stored in a manner to prevent contamination and spoilage. This had the potential to affect 47 of 48 residents that received food from the facility. The facility identified one resident (Resident #4) as receiving nothing by mouth (NPO). The facility census was 48.Findings include:Tour of the kitchen on 03/23/26 from 8:10A.M. through 8:40 A.M. revealed [NAME] #451 and Dietary Aide (DA) #452 were serving breakfast. [NAME] #451 and DA #452 had full beards with no beard covering on. The mixer on a floor stand had food splatter on the back splash, white mix on the top of the mixer, and there was dried food splatter on the stand. In the dry storeroom, there was a bag of vanilla wafers that were not labeled and dated. The walk-in refrigerator's gasket was ripped and had mold on it. In the cooking area, the shelf on the stove had grease, dust, and food residue on it. The wall near the microwave had food splatter on it. There were grease drippings on the stove. In the dish area, there were missing tiles on the floor.Interview on 03/23/26 at 8:40 A.M. with [NAME] #451 verified the above findings.Review of the kitchen sanitation policy dated 05/14 and revised on 06/25 titled, Environment revealed that all food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary condition.This deficiency represents non-compliance investigated under Complaint Number 2693841.

Based on record review, interview and facility policy review, the facility failed to ensure all required committee members attended the quality assurance and performance improvement (QAPI) and quality assessment and assurance (QAA) meetings at least quarterly. This had the potential to affect all residents. The facility census was 48.Findings include:Review of the sign-in sheets for the QAPI/QAA meetings dated 03/20/25 through 02/19/26 revealed the committee met monthly, and there was no documented evidence that the Director of Nursing (DON) attended any of the meetings. Interview of 03/26/26 at 3:37 P.M. with Assistant Director of Nursing (ADON) #423 stated the DON had attended some but not all of the QAA/QAPI meetings. ADON #423 verified the DON's signatures were not on any of the sign-in sheets and stated she could not say which meetings the DON had attended. Review of the undated policy Quality Assurance and Performance Improvement, revealed the QAA committee shall be interdisciplinary and shall consist of the minimum of the DON the medical director or his/her designee, and at three other members of the facility staff at least of which be the administrator, owner, a board member or other individual in a leadership role; and the infection preventionist.

Based on record review, observations, interviews and facility policy review, the facility failed to maintain infection control by not wearing appropriate personal protection equipment (PPE) when care was being provided to Residents #1, #47, #63 and failed to ensure Resident #65 had contact precautions when admitted to the facility. The facility identified eight residents (#1, #4, #15, #19, #21, #56, #63 and #65) on either enhanced barrier precautions (EBP) or contact precautions. The facility census was 48.Findings include:1. Review of Resident #47's medical record revealed an admission date of 02/16/23 with diagnoses including osteomyelitis of the vertebra. Review of Resident #47's Minimum Data Set (MDS) assessment, dated 02/11/26, revealed Resident #47 had no intravenous (IV) medications listed however IV medications had an order date of 03/04/26. Review of Resident #47's physician's orders revealed an order for EBP due to a peripherally inserted central line (PICC) each shift. Review of Resident #47's comprehensive care plan, dated 02/16/23, revealed there were no revisions that added EBP as an intervention for IV medication administration. Observation on 03/25/2026 at 8:57 A.M. of Resident #47's medication administration with Registered Nurse (RN) #400 revealed EBP were not used during medication administration via PICC line. RN #400 confirmed EBP were not used immediately following the observation. Interview on 03/26/26 at 11:11 A.M. Infection Preventionist Licensed Practical Nurse (LPN) #422 revealed EBP were to be used with wounds, Foley catheters, IVs, and other invasive medical devices. Review of the facility policy for EBP, dated 2025, revealed initiation of EBP for wounds and indwelling medical devices for the prevention of transmission of multi-drug resistant organisms (MDRO). 2. Review of Resident #63's medical record revealed a facility admission date of 03/18/26 with a diagnosis of pyelonephritis. Resident #63's admission MDS assessment was in progress. Review of Resident #63's physician's orders revealed an order for EBP due to a Foley catheter each shift. Review of Resident #63's comprehensive care plan, dated 03/18/26, revealed there were not EBP listed as an intervention for the Foley catheter. Observation on 03/25/2026 at 12:41 P.M. of Resident #63's catheter care with Certified Nurse Assistant (CNA) #442 revealed EBP were not used during catheter care. CNA #442 confirmed EBP were not used immediately following the observation. Interview on 03/26/26 at 11:11 A.M. Infection Preventionist LPN #422 revealed EBP were to be used with wounds, Foley catheters, IVs, and other invasive medical devices. Review of the facility policy for EBP, dated 2025, revealed initiation of EBP for wounds and indwelling medical devices for the prevention of transmission of MDRO. 3. Review of the medical record for Resident #65 revealed an admission date of 03/20/26 with diagnoses including fracture of shaft of the left femur, conjunctivitis, and diabetes mellitus. Resident #65's admission MDS assessment was in progress. Review of Resident #65's physician orders for March 2026 revealed that Resident #65 was on contact precautions and had a Foley catheter. Observation and interview on 03/23/26 at 11:40 A.M. revealed that Resident #65 was lying in bed and had a Foley catheter. Resident #65 stated that her eye was sewed shut because she had an eye infection. Interview on 03/23/26 at 11:42 A.M. with LPN #433 stated that Resident #65 should at least be on EBP, and she was not. LPN #433 stated probably because she was admitted on Friday, 03/20/26. 4. Review of the medical record for Resident #1 revealed an admission date of 01/05/26 with diagnoses including chronic obstructive pulmonary disease (COPD), generalized anxiety disorder, and emphysema. Resident #1 was diagnosed with sepsis due to other specified staphylococcus on 03/23/26. Review of Resident #1's MDS admission assessment dated [DATE] revealed Resident #1 was cognitively intact and required moderate assistance for activities of daily living. Review of Resident #1's physician orders dated 03/23/26 revealed that Resident #1 was on contact precautions. Observation on 03/23/26 at 4:34 P.M. revealed that Resident #1's door had a contact precaution signage on the door that stated gowns and gloves must be worn. Rehabilitation Director #500 was sitting next to Resident #1 with no PPE on. RD #500 stated that she was not providing actual care and was there for therapy. Interview on 03/23/26 at 4:45 P.M. with Assistant Director of Nursing (ADON) #423 verified that staff should wear PPE when a resident was on contact precautions. Review of the facility policy dated 2025 titled, Transmission-Based (Isolation) Precautions, revealed that contact precautions is intended to prevent transmission of pathogens that are spread by direct contact with the resident or resident's environment. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve direct contact with the resident or potentially contaminated areas in the resident's environment.

Based on record review, interview and facility policy review, the facility failed to ensure Resident #63's code status was accurately reflected in both the hard medical record and the electronic medical record. This affected one of 29 residents reviewed for Advanced Directives. The facility census was 48.Findings include:A review of the medical record for Resident #63 revealed an admission date of 03/8/26 with diagnoses of pyelonephritis, diabetes mellitus, and major depressive disorder.Review of the physician's orders for March 2026 revealed Resident #63's revealed code status of Do Not Resuscitate-Comfort Care Arrest (DNR-CCA). A DNR-CCA means a person would receive all emergency and medical care up until the time he or she experiences a cardiac or respiratory arrest, then all lifesaving measures would be stopped. A document on green paper with the words Full Code, was in the hard medical chart on the first page. A full code status means all emergency life saving measures will be provided in the event of respiratory arrest or cardiac arrest. Interview on 03/24/26 at 9:59 A.M. with Assistant Director of Nursing (ADON) #423 brought a copy of Resident #63's signed DNR-CCA and verified that it should have been in the hard chart.Review of the facility policy dated 2026 titled, Residents' Rights Regarding Treatment and Advance Directives, revealed that it is policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical treatment and to formulate advance directives.

Based on medical record review, policy review and interview, the facility failed to ensure Resident #7 and Resident #63's antipsychotic medications had appropriate diagnoses/rationale for use. This affected two residents (#7 and #63) of five residents reviewed for unnecessary medications. The facility census was 48.Findings include:1. Review of the medical record for Resident #7 revealed an admission date of 09/19/25 with diagnoses of dementia, protein-calorie malnutrition, and diverticulosis.Review of the pharmacy recommendations to the attending physician dated 09/20/25 revealed the pharmacist made a recommendation to evaluate Quetiapine Fumarate (commonly known as Seroquel) for an appropriate diagnosis. The physician addressed the pharmacist recommendations that the benefits outweigh the risks and would cause distress.Review of the pharmacy recommendations to the attending physician dated 12/14/25 revealed the pharmacist made a recommendation to evaluate Seroquel for an appropriate diagnosis and a gradual dose reduction (GDR). The physician addressed the pharmacist recommendations that the benefits outweigh the risks and would increase behaviors.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/06/26, revealed Resident #7 had severely impaired cognition and needed partial assistance for activities of daily living (ADL). Further review of the MDS revealed that Resident #7 received antipsychotic medication routinely.Review of the physician's orders for March 2026 revealed Resident #7 was prescribed Quetiapine Fumarate (antipsychotic) 25 milligrams (mg) and give 0.5 tablet by mouth at bedtime for insomnia (ordered 09/19/25).Interview on 03/26/26 at 10:30 A.M. with Assistant Director of Nursing (ADON) #423 verified that insomnia was not an appropriate diagnosis for Resident #7's Quetiapine Fumarate.Interview on 03/26/26 at 10:53 A.M. with Certified Psych Nurse Practitioner #502 stated that she saw Resident #7 twice and did not catch the diagnosis for Seroquel, and she did not attempt a GDR because the resident was new to her. Interview on 03/26/2026 at 12:14 P.M. with ADON #422 verified the pharmacy recommendations dated 09/20/25 and 12/14/25 regarding the physician did not accurately address the recommendation. 2. A review of the medical record for Resident #63 revealed an admission date of 03/08/26 with diagnoses of pyelonephritis, diabetes mellitus, and major depressive disorder. Review of the admission MDS revealed that it was still in progress.Review of the physician's orders for March 2026 revealed Resident #63 was prescribed Vraylar oral capsule (antipsychotic) 1.5 mg by mouth at bedtime for major depressive disorder.Review of the nurses note dated 03/18/26 at 6:24 P.M. revealed that Resident #63 was admitted to the facility from the hospital. Resident #63 was assessed with no concerns and resting. Physician (MD) was called to review medications and orders. MD stated not to order Vraylar due to the resident stated that it is a new medication that was prescribed in the community, and she only had one dose before ending up in the hospital and had not taken it since. Per the MD, have psych see Resident #63 and then let them determine if the resident needs placed on Vraylar since she truly had not started medication at this time. Resident #63 was in agreement at this time. Psych services have been notified, and Resident #63 was added to the list to be seen.Review of the psych consult consent signed 03/18/26 revealed that Resident #63 agreed to psych services.Review of the nurses' notes dated 03/20/26 at 7:29 P.M. revealed new orders for Vraylar oral capsule 1.5 mg by mouth at bedtime for major depressive disorder as well as a sliding scale for insulin.Further review of progress notes from 03/18/26 through 03/22/26 revealed no behaviors noted.Interview on 03/24/26 at 2:02 P.M. with ADON #423 revealed that she was the nurse who wrote the progress note that MD wanted psych to see Resident #63 first, and she signed the psych consultation.Interview on 03/26/26 at 10:30 A.M. with ADON #423 stated that she talked to the Registered Nurse (RN) about the Resident #63's Vraylar and asked why she had the MD put her on Vraylar when it was supposed to be on hold until psych saw the resident. ADON #423 stated that the RN stated that Resident #63 wanted the medication, and she called the physician. ADON #423 verified that the progress note had no documented evidence the resident was asking for a certain medication. Interview on 03/26/26 at 10:53 with psych Nurse Practitioner #502 revealed she was to see Resident #63 on Friday, 03/27/26.Review of the facility policy dated 2025 titled, Use of Psychotropic Medications, revealed that it is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated.

Based on record review and interview, the facility failed to ensure discharge Minimum Data Set (MDS) assessments were created in a timely manner for Residents #5 and #6. This affected two residents (#5 and #6) of three residents reviewed for discharge. The facility census was 48.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 10/31/25. Diagnoses included end stage renal disease, acute pulmonary edema, bipolar disorder, morbid obesity, and immunodeficiency. Review of the progress notes dated 03/15/26 at 9:50 A.M. revealed a nurse's note that the nurse contacted the hospital, and Resident #5 had been admitted to the intensive care unit (ICU) with sepsis. Further review of Resident #5's chart revealed there was no MDS assessment for discharge with return anticipated. Interview on 03/23/26 at 3:52 P.M. with MDS Coordinator (MDSC) #429 verified Resident #5 went to the hospital last week, and she did not create a discharge return anticipated MDS assessment. 2. Review of the medical record for Resident #6 revealed an admission date of 10/31/25 and a discharge date of 01/16/26. Diagnoses included multiple fractures of left side ribs, fall, and type two diabetes mellitus. Review of the nurse's notes dated 01/16/26 at 12:15 P.M. revealed Resident #6 discharged home. Vital signs obtained at time of discharge. All paperwork was reviewed with the resident. The resident voiced understanding and was in good spirits and happy to go home.Further review of Resident #6's medical record revealed there was no discharge no return anticipated MDS assessment.Interview on 03/25/26 at 10:53 A.M. with MDSC #429 verified she recalled Resident #6 and that he had discharged on 01/16/26. MDSC #429 verified there was no discharge no return anticipated MDS assessment.

Based on record review, interview and facility policy review, the facility failed to ensure contact isolation was included in the care plans for Resident #01 and #15. This affected two residents (#01 and #15) of 23 resident records reviewed for care plans. The facility census was 48.Findings include:1. Review of the medical record for Resident #01 revealed an admission date of 01/05/26 with the diagnosis of sepsis.Review of Resident #01's care plan, dated 01/05/26, revealed no care plan for contact isolation.Review of Resident #01's March 2026 physician orders revealed an order for contact isolation due to a Foley catheter each shift.Review of Resident #01's Minimum Data Set (MDS), dated [DATE], revealed a re-entry assessment was in progress.Interview on 03/26/26 at 4:10 P.M. with Licensed Practical Nurse (LPN) #422 confirmed contact isolation was not included in Resident #01's care plan.Review of the facility's policy for comprehensive care plans, dated 2025, revealed the policy of the facility was to develop and implement a comprehensive person-center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical and nursing needs. 2. Review of the medical record for Resident #15 revealed an admission date of 03/03/26 with the diagnosis of osteomyelitis to left ankle/foot with methicillin-resistant staphylococcus aureus (MRSA).Review of Resident #15's March 2026 physician orders revealed an order for contact isolation each shift.Review of Resident #15's care plan, date 03/04/26, revealed no care plan for contact isolation.Review of Resident #15's MDS, dated [DATE], revealed a multi-drug-resistant organism (MRDO) infection, intravenous medication, and isolation.Interview on 03/26/26 at 4:10 P.M. with LPN #422 confirmed contact isolation was not included in Resident #15's care plan.Review of the facility's policy for comprehensive care plans, dated 2025, revealed the policy of the facility was to develop and implement a comprehensive person-center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical and nursing needs.

Based on record review, observation, facility policy review and interview, the facility failed to ensure safe smoking practices affecting Resident #26 and timely smoke breaks affecting Residents #26, #51, #53, #56, and #69. This affected one resident (#26) of one resident reviewed for safe smoking and five residents (#26, #51, #53, #56, and #69) of five residents observed for smoking schedules. The facility census was 48.Findings include:1. Review of the medical record for Resident #26 revealed an initial admission date of 06/23/24. Diagnoses included hypertension, type two diabetes mellitus, muscles weakness, morbid obesity, and chronic systolic congestive heart failure. Review of the smoking safety screen dated 11/05/25 revealed Resident #26 was safe to smoke with supervision and needed the facility to store lighter and cigarettes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition.Review of the current plan of care revealed Resident #26 was a smoker. Interventions included instructing the resident about the facility policy on smoking, locations, times, and safety concerns. Interview on 03/23/26 at 10:37 A.M. with Resident #26 stated she was a smoker and that smoke breaks were not timely, especially at 7:00 hours because of shift change. Observation at this time revealed a cigarette lighter on the resident's tray table. Resident #26 stated she was able to keep her smoking materials. Observation on 03/25/26 at 12:58 P.M. of Resident #26 in her power wheelchair in the hall on her cellphone with a cigarette lighter in her hand. At 1:02 P.M., she was observed going outside into the courtyard with the other smokers. Resident #26 was then observed pulling out her own cigarettes from her jacket and observed lighting it. Interview on 03/25/26 at 1:05 P.M. with Housekeeper (HSK) #420 revealed smoking materials were kept in a clear tote that was kept behind nurse's station. HSK #420 verified Resident #26 kept her own smoking materials and stated she was an independent smoker. HSK #420 stated independent smokers were allowed to hold onto their smoking materials, and some of the staff will let them know who the independent smokers were. Interview on 03/25/26 at 3:25 P.M. with Assistant Director of Nursing (ADON) #423 verified Resident #26's smoking assessment stated she required supervision, and smoking materials were to be stored by the facility. ADON #423 stated all smoking materials were to be kept in a tote behind the nurse's station. 2. Observation on 03/26/26 at 7:30 A.M. of Residents #26, #51, #53, #56, and #69 waiting by the door to the courtyard complaining staff were late for smoke break. Interview on 03/26/26 at 7:34 A.M. with Licensed Practical Nurse (LPN) #422 verified the late time and stated the aides usually take residents to smoke, but they were giving report. LPN #422 stated she was extra today. Review of the policy Resident Smoking, updated 03/19/20, revealed residents are not permitted to maintain smoking materials on their person or in their rooms. Designated smoking times- smoking is permitted only during posted smoke times (7:00 A.M, 10:00 A.M., 1:00 P.M., 4:00pm, 7:00 P.M., and 9:00 P.M.) and only under staff supervision. Smoking time shall last for fifteen (15) minutes, and the number of cigarettes may be limited to ensure that residents smoke within that time frame.

Based on record review, observation and interview, the facility failed to ensure resident food allergies were honored. This affected one resident (#63) of one resident reviewed for food preferences. This had the potential to affect 47 residents out of 48 who received meals from the facility kitchen. The facility identified one resident (#4) as receiving nothing by mouth (NPO). The facility census was 48.Findings include:A review of the medical record for Resident #63 revealed an admission date of 03/8/26 with diagnoses of pyelonephritis, diabetes mellitus, and major depressive disorder.Review of the physician's orders for March 2026 revealed Resident #63 received a regular diet.Review of Resident #63's diet ticket revealed that she was on a regular diet had onion, peanut butter and strawberry allergies.Interview on 03/23/26 at 9:45 A.M. with Resident #63 revealed that the kitchen does not honor her preferences.Observation and interview of lunch tray line service on 03/25/26 at 12:31 P.M. revealed that [NAME] #451 portioned beef tips over noodles for Resident #63. The lid was placed on top of the plate and put into the food cart. The tray was asked to be looked at. Resident #63 was noted to have an onion allergen. [NAME] #451 stated that there were onions in the beef tips. Corporate District Manager (CDM) # 447 asked Dietary Manager (DM) #449 if Resident #63's onion allergen was an actual allergy or just a dislike. DM #449 stated that he just talked to her, and Resident #63 stated that onions make her break out.

Based on record review, observation and interview, the facility failed to ensure Residents #35 and #68 received therapeutic diets as ordered by the physician. This affected two residents (#35 and #63) of three residents (#35, #63, and #68) reviewed therapeutic diets. The facility census was 48.Findings include:1. Review of the medical record for Resident #35 revealed an admission date on 07/13/21 with diagnoses to schizophrenia, bipolar, and diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/26, revealed Resident #35 had severely impaired cognition and was dependent on staff for activities of daily living (ADL) except for eating, Resident #35 required set up assistance only.Review of the physician's orders for March 2026 revealed Resident #35 received a regular diet, dysphagia mechanical soft (Dys Mech) texture and regular fluid consistency diet.Observation of lunch tray line service on 03/25/26 at 12:00 P.M. revealed [NAME] #451 portioned regular textured beef tips over noodles for Resident #35. The lid was placed on top of the plate and put into the food cart. The tray was asked to be looked at. Resident #35 was noted to be on a regular diet, dysphagia mechanical soft texture and regular fluid consistency diet. [NAME] #451 served Resident #35 regular meat instead of ground neat. Dietary Aide (DA) #452 stated that he missed it. Corporate District Manager (CDM) # 447 told DA #452 that he should read the tickets louder to communicate better to the cook, and then she stated that [NAME] #451 should read the tickets before putting the plate on the tray.Review of the spreadsheets for the lunch meal on 03/25/26 revealed that Dys Mech diets were to get ground meat.2. Review of the medical record for Resident #68 revealed an admission date on 03/23/26 with diagnoses to hypertension and diabetes mellitusReview of the admission MDS assessment revealed it was in progress.Review of the physician's orders for March 2026 revealed Resident #68 received a consistent carbohydrate diet (CCD) with regular texture and regular fluid consistency. Observation of lunch tray line service on 03/25/26 at 12:09 P.M. revealed that [NAME] #451 portioned Resident #68's meal. The lid was placed on top of the plate and put into the food cart. The tray was asked to be looked at. Resident #68 was noted to be on a CCD with regular texture and regular fluid consistency. [NAME] #451 did not portion Resident #68's baked apples for dessert. [NAME] #451 stated that he missed the CCD dessert because he does not usually put desserts on resident's trays. CDM #447 verified that a CCD should have gotten baked apples according to the spreadsheet.Review of the spreadsheets for the lunch meal on 03/25/26 revealed that CCD were to have baked apples.

Based on observations, staff interview and review of the facility policy and procedure, the facility failed to ensure a homelike environment. This affected three residents (#9, #10, and #15) of six residents reviewed for physical environment. The facility census was 48.Findings include:1. Observation on 03/23/36 at 10:42 A.M. of Resident #9's room revealed a hole in the bathroom door. Interview at this time with Housekeeper (HSK) #429 verified the observation. 2. Observation on 03/23/26 at 11:19 A.M. of Resident #15's room revealed a urinal and a pair of scissors were observed on the floor. Interview at this time with Licensed Practical Nurse (LPN) #422 verified the observation. 3. Observation on 03/23/26 at 2:08 P.M. of Resident #10's room revealed long deep gash in the lower part of the bathroom door, and there was a large missing chunk on the rim on trash bin. Interview on 03/23/26 at 3:39 P.M. of Resident #10's room with Director of Maintenance (DOM) #428 verified the observation. Review of the undated policy titled Safe and Homelike Environment revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

Based on observation and interview, the facility failed to ensure the daily nursing staff information was posted. This had the potential to affect all 48 residents residing in the facility.Findings include:Observations on 03/24/26 revealed the daily nursing staff information was not posted. Interview on 03/24/26 at 10:01 A.M. with Assistant Director of Nursing (ADON) #423 stated the posted daily nursing information was usually kept at the receptionist desk and verified she had not put it up.

Based on observation, interview, and review of facility policy, the facility failed to serve foods in a manner to prevent contamination, failed to have a sufficient supply of foods in case of emergency, and failed to ensure expired foods were discarded timely. This had the potential to affect all 45 residents in the facility.Findings include:1.On 12/03/25 from 11:25 A.M. to 12:11 P.M., an observation of the lunch meal tray line service revealed [NAME] #146 was wearing gloves while plating foods for the lunch meal. [NAME] #146 used his gloved hands to handle all serving utensils, to hold the baked potatoes on each plate as he cut them open, he used his gloved fingers to open each baked potato after he cut it, and he used his gloved fingers to move and position the meat and creamed spinach after he put those items on the plates. [NAME] #146 did not change or dispose of his soiled gloves at any point during the observed meal service. At 11:36 A.M., Regional Dietary Director #126 told [NAME] #146 to use tongs when handling the baked potatoes. At 11:39 A.M., [NAME] #146 obtained a styrofoam container for one meal requiring paper products only and his gloved hand touched an adjacent container which left spinach on the other container. Regional Dietary Director #126 verified this at the time of observation and disposed of the soiled container. At 11:44 A.M., [NAME] #146 plated a large amount of roast beef using tongs, then used his gloved hand to take part of the meat off the plate and put it back into the serving pan on the steam table. At 11:45 A.M., Regional Dietary Director #126 told [NAME] #146 not to use his hands to handle the food and provided him with a portioned serving spoodle for the roast beef. At 12:02 P.M., [NAME] #146 acquired a new pan of roast beef and poured its contents into the existing serving pan on the steam table that had already been served out of prior to this time. On 12/03/25 at 12:09 P.M., an interview with [NAME] #146 verified he always wore gloves while serving food and confirmed he used his gloved hands to arrange the food items on the plate.On 12/03/25 at 12:30 P.M., an interview with Regional Dietary Director #126 and Dietary Manager #106 confirmed the observations during the meal service. Regional Dietary Director #126 also verified she told [NAME] #146 to stop touching the food and to use utensils.2.On 12/03/25 at 1:15 P.M., an observation of the facility's emergency food supply revealed the following unexpired items: 35 servings of canned chicken and dumplings, 144 servings of canned peaches, 144 servings of canned pineapple, 96 servings of canned tuna, 24 servings of canned beets, 72 servings of canned sloppy joe, 594 servings of dry milk (requiring rehydration for consumption), and six gallons of water. In addition, there were nine boxes of graham crackers that expired in February 2025 and six cans of corned beef that expired in November 2025. An interview at the time of observation with Dietary Manager #106 verified the contents of the facility's emergency food supply and stated the items had been delivered on 10/03/24 based on the shipping labels on the boxes. Dietary Manager #106 further stated he identified this as a concern on 11/21/25 of the facility not having a sufficient emergency food supply and created a list of items to restock the emergency food supply which needed to be approved by management before it could be ordered.On 12/04/25 at 4:05 P.M., an interview with the Administrator stated the order for the emergency food supplies was submitted to the vendor on 12/04/25.Review of the diet order listing report revealed all 45 residents received food from the kitchen.Review of the facility's policy titled Emergency Food Supply, dated 2025, revealed the Dietary Manager would maintain a three to seven day supply of non-perishable foods and supplies of disposable dishes/utensils. This emergency food supply would be replenished every six months.Review of the facility's policy titled Emergency Water Supply, dated 2025, revealed the Dietary Manager would maintain a three day supply of bottled water for drinking and cooking. Review of the facility's policy titled Food Safety Requirements, dated 2025, revealed all equipment used in the handling of food shall be cleaned, sanitized, and handled in a manner to prevent contamination. Gloves would be worn when handling ready to eat foods and staff would take precautions to prevent cross-contamination of foods. This deficiency represents non-compliance identified under Complaint Numbers 2678099 and 2683098.

Based on observation and interview the facility failed to ensure a clean and sanitary environment. This affected one resident (#21) and had the potential to affect twenty five residents (#5, #6, #8, #9, #13, #14, #15, #16, #20, #21, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #37, #38, #44, #45 and #47) who resided on the second floor. The facility census was 45. Findings include:Observation on 12/03/25 at 10:01 A.M. revealed Resident #21's bathroom had a large area of what appeared to be mold or mildew underneath his bathroom sink. Resident #21 was not present in his room during observation.Observation of shower room located on the second floor on 12/03/25 at 10:34 A.M. with Housekeeper #137 revealed a large hole behind the toilet with exposed pipes and a large hole in the ceiling also with exposed pipes. Further observation revealed toilet in shower room had a large amount of dried stool inside the bowl and stool on the outside of bowl and lid. Interview with Housekeeper #137 at time of observation confirmed the observation and Housekeeper #137 stated the water may have been turned off and was unable to flush the toilet.Observation of shower room located on the second floor with Maintenance Director (MD) #120 confirmed previous observation and MD #120 stated he was unaware of the water being turned off to the toilet and was unsure how long it had been off.Observation on 12/03/25 at 11:37 A.M. with Licensed Practical Nurse (LPN) #136 confirmed the large amount of mold or mildew in Resident #21's room and stated he would inform maintenance. Resident #21 was not present in room at time of observation.Observation on 12/03/25 at 3:07 P.M, with LPN #136 confirmed the mold or mildew area in Resident #21's room had been removed. Interview on 12/03/25 at 3:57 P.M. with MD #120 confirmed the area in Resident #21's room had been cleaned and stated the area should have been cleaned prior to observation. Review of facility policy titled Routine Cleaning and Disinfection undated revealed cleaning of walls will be conducted when visibly soiled and routine cleaning and disinfecting of visibly soiled surfaces will be performed in common areas and resident rooms.This deficiency represents non-compliance investigated under complaints 2683098, 2681538 and 2678099.

Based on review of the activities calendar, resident interview, and staff interview, the facility failed to provide activities to meet the needs and interests of all residents in the facility. This affected three residents (#2, #16, and #40) of six interviewed regarding activities. The facility census was 45.Findings include:Review of the facility's activities calendar for December 2025 revealed the planned activities were repetitive, no activities were provided later than 3:00 P.M., and staff led activities on the weekends and on holidays were lacking. The following were the activities listed on the calendar for December 2025:-On Mondays 12/01/25, 12/08/25, 12/15/25, 12/22/25, and 12/29/25, the scheduled activities were True or False at 10:45 A.M. and Crafts at 2:00 P.M. No other activities were planned for Mondays in December.-On Tuesdays 12/02/25, 12/09/25, 12/16/25, 12/23/25, and 12/30/25, the scheduled activities were Book Club at 1:00 P.M. and Bingo at 2:00 P.M. No other activities were planned for Tuesdays in December.-On Wednesdays 12/03/25, 12/24/25, and 12/31/25, the scheduled activities were Yarn Club at 1:30 P.M., Bible Study at 3:00 P.M., and Room Visit with no specified time. On Wednesday 12/10/25, the scheduled activities were Yarn Club at 1:30 P.M., Gospel Singers at 2:00 P.M., and Room Visit with no specified time. On Wednesday 12/17/25, the scheduled activities were Christmas Singer at 1:00 P.M., Bible Study at 3:00 P.M., and Room Visit with no specified time. No other activities were planned for Wednesdays in December.-On Thursdays 12/04/25 and 12/18/25, the scheduled activities were Cards at 10:30 A.M., Nails at 1:00 P.M., and Trivia at 2:00 P.M. On Thursday 12/11/25, the scheduled activities were Cards at 10:30 A.M., Nails at 1:00 P.M., and [NAME] Game at 2:00 P.M. On Thursday 12/25/25 (Christmas Day), the listed activities were Activity Packet and Lifetime Channel with no timed or staff led activities listed. No other activities were planned for Thursdays in December.-On Fridays 12/05/25, 12/12/25, 12/19/25, and 12/26/25, the scheduled activities were Let's Talk at 12:00 P.M., Movie & Popcorn at 1:30 P.M., and Room Visits with no specified time. No other activities were planned for Fridays in December.-On Saturdays 12/06/25, 12/13/25, 12/20/25, and 12/27/25, the listed activities were Activity Packet and Lifetime Channel with no timed or staff led activities listed. No other activities were planned for Saturdays in December.-On Sundays 12/07/25, 12/14/25, and 12/21/25, the listed activities were Activity Packet and Lifetime Channel with no timed or staff led activities listed. On Sunday 12/28/25, the listed activities were Church at 2:00 P.M., and Activity Packet and Lifetime Channel with no specified time. No other activities were planned for Sundays in December.On 12/03/25 at 11:09 A.M., an interview with Activities Director #105 confirmed the activities listed on the facility's activities calendar for December 2025. Activities Director #105 stated the earliest activity was not until after 10:00 A.M. because the first smoke break was at 10:00 A.M. and no residents were up prior to that time. Activities Director #105 further stated no activities were scheduled after 3:00 P.M. because she supervised the 4:00 P.M. smoke break and then she left the facility by 4:30 P.M. every day. She stated she only works Monday through Friday and the weekend activities included the Lifetime channel and activities packets, which she stated consisted of coloring pages, word searches, and puzzles. She also stated she occasionally worked on a Saturday to go shopping for residents and they had church one Sunday per month. Activities Director #105 stated the facility had no additional activities staff and she was the only staff member leading activities.On 12/03/25 at 3:40 P.M., an interview with Social Services Designee (SSD) #104 revealed she was the former activities director for the facility and was still overseeing the activities department because Activities Director #105 had not received her activities professional certification yet. SSD #104 further stated she only helped with scheduling and did not lead any activities because her other duties at the facility did not allow time for that. SSD #104 also said Activities Director #105 did do some weekend activities occasionally, but she was unable to provide any additional information and stated those were not documented anywhere. SSD #104 stated she did not work on the weekends and confirmed there were no activities staff other than SSD #104 and Activities Director #105.On 12/04/25 at 12:40 P.M., an interview with Resident #2 stated he was bored in the evenings and on the weekends.On 12/04/25 at 12:51 P.M., an interview with Resident #16 stated all there was to do at the facility was watch television and he would like to see more activities geared toward veterans.On 12/04/25 at 12:59 P.M., an interview with Resident #40 stated he was bored at the facility.Review of the personnel file for Activities Director #105 revealed a hire date of 11/11/2022 as a Certified Nursing Assistant (CNA), then she became an Activities Assistant on 10/10/24, and became the Activities Director in late 2025 (there was no clear indication as to when this promotion occurred, just a change in rate/salary document indicating a rate increase for the role of Activities Director which was dated and signed 12/01/25 with an effective date of 11/30/25). There was no evidence of any training or certification to be the Activities Director, and there was no evidence Activities Director #105 received a copy of the job description for her current position.

Based on observation, interview and record review the facility failed to ensure adequate foot care had been provided. This affected one resident (#45) of two reviewed for foot care. The facility census was 45.Findings include:Review of Resident #45's medical records revealed an admission date of 07/01/16. Diagnoses included traumatic brain injury, aphasia (difficulty speaking) and cognitive deficits.Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had no cognition score due to being rarely understood. Resident #45 was independent with toileting and required set up assistance with bathing.Review of care plan dated 11/10/25 revealed Resident #45 had self care deficits related to impaired cognition and had been combative when trying to trim facial hair. Interventions included encourage resident to participate to fullest extent possible and reapproach when resistive to care. Resident #45 had behaviors that included yelling out and physical behaviors when she did not want to participate in task. Resident #45 was resistive to working with podiatry and staff trying to clip toe nails. Interventions included document behaviors and response to interventions and review concerns as needed. Resident #45 was resistive to care and refused to cooperate with ancillary services. Resident #45 was taken to an outside podiatrist and had become agitated and refused care. Resident #45's nails continued to be extremely long. Interventions included educate family of the possible outcomes of non compliance, if resident resisted care reassure resident, leave and return 5-10 later and reattempt. Review of podiatry visits dated 02/19/25, 05/12/25, 07/31/24 and 09/30/25 revealed Resident #45 had refused treatment, with no documentation of family being notified. Review of Progress notes dated 07/08/25 and 10/07/25 authored by Activities Director/Social Services #104 revealed a care conference was held with Resident #45 and family. Progress note did not include discussion of Resident #45's refusals of care of podiatry visits.Observation on 12/03/25 at 11:09 A.M. revealed Resident #45 was in a reclining chair in her room with her feet elevated and was wearing a pair of open toes slippers. Resident #45's toe nails were exposed and were extremely long, thick and were curled. Resident #45 was not interviewable and had only said Ok when questions were asked.Interview on 12/03/25 at 11:18 A.M. with Certified Nursing Assistant (CNA) #121 revealed she had been employed at the facility for approximately a week and stated she had asked staff about Resident #45's long toenails. CNA #121 stated she had been told Resident #45 had refused nail care and was unsure of what was to be done with them.Interview on 12/03/25 at 11:37 A.M. with Licensed Practical Nurse (LPN) #136 revealed he had been aware Resident #45 had refused her toe nails to be cut and had been combative in the past regarding nail care.Observation on 12/03/25 at 1:05 P.M. revealed Podiatrist #149 was present at the facility and had been performing nail care. Interview with Podiatrist #149 at time of observation revealed she had observed Resident #45's toe nails and had attempted to provide her with care, however Resident #45 had been combative and refused. Podiatrist #149 stated she had only seen Resident #45 one other time previously and Resident #45 had refused at that time as well. Podiatrist #149 stated she would be making a recommendation to the facility to inquire about adding a sedative medication to allow toe nails to be cut. Podiatrist #149 stated Resident #45's toenails appeared to have been in that condition for possibly 2-3 yearsAttempted telephone interview on 12/04/25 at 9:56 A.M. and 4:06 P.M., with Resident #45's sister with no answer or return call.Interview on 12/04/25 at 12:34 P.M. with Activities Director/Social Services #104 confirmed she had performed care conferences with Resident #45 and her family (sister). Activities Director/Social Services #104 stated she could not recall when she had last discussed Resident #45's refusal of nail care with Resident #45's sister and confirmed care conferences had not included documentation of refusals. Activities Director/Social Services #104 stated Podiatrist #149 had mentioned the possibly of getting sedation medication ordered for Resident #45 in order to perform nail care.Review of facility policy titled Podiatry Services undated revealed facility to ensure residents received proper treatment and care within professional standards of practice to maintain mobility and good foot health.This deficiency represents non-compliance investigated under complaints 2681538 and 267099

Based on interview and record review the facility failed to ensure social services staff was adequately trained and performed duties as required. This affected one resident (#45) of three reviewed for social services duties. The facility census was 45. Findings include:Review of Resident #45's medical records revealed an admission date of 07/01/16. Diagnoses included traumatic brain injury, aphasia (difficulty speaking) and cognitive deficits.Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had no cognition score due to being rarely understood. Resident #45 was independent with toileting and required set up assistance with bathing.Review of care plan dated 11/10/25 revealed Resident #45 had self care deficits related to impaired cognition and had been combative when trying to trim facial hair. Interventions included encourage resident to participate to fullest extent possible and reapproach when resistive to care. Resident #45 had behaviors that included yelling out and physical behaviors when she did not want to participate in task. Resident #45 was resistive to working with podiatry and staff trying to clip toe nails. Interventions included document behaviors and response to interventions and review concerns as needed. Resident #45 was resistive to care and refused to cooperate with ancillary services. Resident #45 was taken to an outside podiatrist and had become agitated and refused care. Resident #45's nails continued to be extremely long. Interventions included educate family of the possible outcomes of non compliance, if resident resisted care reassure resident, leave and return 5-10 later and reattempt. Review of podiatry visits dated 02/19/25, 05/12/25, 07/31/24 and 09/30/25 revealed Resident #45 had refused treatment, with no documentation of family being notified. Review of Progress notes dated 07/08/25 and 10/07/25 authored by Activities Director/Social Services #104 revealed a care conference was held with Resident #45 and family. Progress note did not include discussion of Resident #45's refusals of care of podiatry visits.Observation on 12/03/25 at 11:09 A.M. revealed Resident #45 was in a reclining chair in her room with her feet elevated and was wearing a pair of open toes slippers. Resident #45's toe nails were exposed and were extremely long, thick and were curled. Resident #45 was not interviewable and had only said Ok when questions were asked.Observation on 12/03/25 at 1:05 P.M. revealed Podiatrist #149 was present at the facility and had been performing nail care. Interview with Podiatrist #149 at time of observation revealed she had observed Resident #45's toe nails and had attempted to provide her with care, however Resident #45 had been combative and refused. Podiatrist #149 stated she had only seen Resident #45 one other time previously and Resident #45 had refused at that time as well. Podiatrist #149 stated she would be making a recommendation to the facility to inquire about adding a sedative medication to allow toe nails to be cut. Podiatrist #149 stated Resident #45's toenails appeared to have been in that condition for possibly 2-3 yearsAttempted telephone interview on 12/04/25 at 9:56 A.M. and 4:06 P.M., with Resident #45's sister with no answer or return call.Interview on 12/03/25 at 3:22 P.M. with Human Resources (HR) #150 confirmed Activities Director/Social Services personnel file had not included a signed copy of her job description and stated she would obtain a signed copy. At time of interview HR #150 had provided a copy of the social services job description that included to provide guidance as requested to residents and families in regards to all physical concerns or limitations.Interview on 12/04/25 at 12:34 P.M. with Activities Director/Social Services #104 confirmed she had performed care conferences with Resident #45 and her family (sister). Activities Director/Social Services #104 stated she could not recall when she had last discussed Resident #45's refusal of nail care with Resident #45's sister and confirmed care conferences had not included documentation of refusals. Activities Director/Social Services #104 stated Podiatrist #149 had mentioned the possibly of getting sedation medication ordered for Resident #45 in order to perform nail care. Activities Director/Social Services #104 stated she had not received any official training in the Social Services role, however she had spoken with a social services designee at another facility when needed and she was learning day by day. Activities Director/Social Services #104 stated she had not received a copy of the social services job description when she had taken over the role sometime in April or May of 2025 and stated no one had really explained what she was supposed to be doing. Activities Director/Social Services #104 stated she had been aware the previous social services desginee had not performed care conferences in December of 2024 and she began performing them sometime in July of 2025 and stated care conferences were to be held at least every three months.Review of Activities Director/Social Services #104's personnel file revealed no signed job description.Review of facility policy titled Podiatry Services undated revealed facility to ensure residents received proper treatment and care within professional standards of practice to maintain mobility and good foot health.This deficiency represents non-compliance investigated under complaints 267099.

Based on observation, medical record review, policy review and staff interview the facility failed to ensure supplemental oxygen delivery devices were changed weekly and stored properly. This affected three residents (Residents #12, #24 and #28) of three residents reviewed for supplemental oxygen use. The facility identified 10 residents currently utilizing supplemental oxygen (Residents #4, #11, #12, #14, #22, #24, #28, #30, #34 and #37). Findings include: 1. Review of Resident #12's medical record revealed an admitted [DATE] with diagnoses that included pneumonia, congestive heart failure and hypertension. Physician's orders on [DATE] indicated the use of supplemental oxygen at two liters per minute (lpm) per nasal canula by oxygen concentrator. Additional orders indicated to change nasal canula every night shift on Sunday. An additional order on [DATE] identified the use of DuoNeb (aerosolized medication for shortness of breath) 0XXX,d+[DATE].5 milligrams (mg) per milliliter (ml) via nebulizer every six hours as needed for shortness of breath from [DATE] for five days until [DATE]. Review of the Treatment Administration Record (TAR) revealed the oxygen tubing and nasal canula documented as changed on [DATE] and [DATE]. Observation on [DATE] at 10:05 A.M. revealed Resident #12 sitting in a wheelchair in her room. An oxygen concentrator was observed with the oxygen tubing and nasal canula draped on the oxygen concentrator without being stored in a protective plastic storage bag. Additional observation revealed a medication nebulizer lying on the night stand without being in a protective plastic storage bag. The nasal canula, oxygen tubing, and nebulizer and tubing was dated [DATE]. 2. Review of Resident #24's medical record revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus and vascular dementia. Physician's orders on [DATE] indicated the use of supplement oxygen at two lpm per nasal canula as needed for shortness of breath. An additional order on [DATE] indicated the use of DuoNeb 0XXX,d+[DATE].5 mg/ml via nebulizer every six hours as needed. Observation on [DATE] at 10:10 A.M. revealed Resident #24 was out of her room. An oxygen concentrator with oxygen tubing and nasal canula was observed. The nasal canula was draped on top of the concentrator without being in a protective plastic storage bag. A medication nebulizer was observed sitting on the night stand without being in a protective plastic storage bag. 3. Review of Resident #28's medical record revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure and dependence on supplemental oxygen. Physician's orders on [DATE] indicated the use of DuoNeb 0XXX,d+[DATE].5 mg/ml via nebulizer every two hours as needed for shortness of breath. Observation on [DATE] at 10:00 A.M. revealed Resident #28 sitting in bed and utilizing supplement oxygen via a nasal canula. A medication nebulizer was observed sitting on the night stand without being in a protective plastic storage bag. On [DATE] at 10:35 A.M. interview with the Director of Nursing and Assistant Director of Nursing revealed nursing staff change oxygen tubing and nebulizer equipment weekly on Sunday nights and oxygen delivery equipment is to be stored in plastic protective bags when not in use. They verified Resident's #12, #24 and #28's nasal canula and nebulizer were not stored correctly. They further verified Resident #28's nasal canula was not changed since [DATE] and nebulizer orders expired on [DATE]. Review of the undated facility policy titled Oxygen Administration indicated to change oxygen tubing and mask/canula weekly and as needed if it becomes soiled or contaminated and to keep delivery devices covered in a plastic bag when not in use. This deficiency represents non-compliance investigated under Complaint Number OH00161386.

Based on observation, record review and interview, the facility failed to ensure care planned interventions were in place to prevent Resident #30 from developing a pressure ulcer, and failed to ensure the pressure ulcer was comprehensively assessed, properly treated, and interventions were initiated to promote healing. Actual harm occurred on 09/15/22 when Resident #30 who was cognitively impaired, at risk for pressure ulcer development, and required extensive assistance of staff for bed mobility, was found to have a pressure ulcer to the left heel that was first assessed to be a Stage III (full thickness skin break into subcutaneous tissue but does not go into the muscle and bone) ulcer which deteriorated to an unstageable (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) without proper assessment, treatment, and interventions implemented. This affected one resident (Resident #30) of two residents reviewed for pressure ulcers. Findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes, chronic obstructive pulmonary disease, diabetes neuropathy, peripheral vascular disease, chronic kidney disease, hyperlipidemia, anemia, anxiety disorder, epilepsy, bipolar disorder, major depressive disorder, schizoaffective disorder, insomnia, dementia, cataracts, hypertensive retinopathy, and intellectual disabilities. Review of the plan of care initiated on 07/30/20 revealed Resident #30 was at risk for impaired skin integrity/pressure injury related to having a communication deficit, impaired mobility, muscle weakness, amputated right great toe, peripheral vascular disease, poor safety awareness, and required staff interventions with bed mobility and transfers. Interventions included to conduct weekly head to toe assessments, document and report abnormal findings, encourage to float heels while in bed, follow facility policies for the prevention and treatment of impaired skin, observe finger and toenails to see of they need trimmed, observe for sliding down in chair and reposition, observe skin with care and showers, pressure reduction cushion to wheelchair, pressure reduction mattress to the bed, and provide incontinence care with each incontinent episode. The plan of care had a revision date of 11/01/22, but new interventions were not added on this date. Review of the Braden Scale dated 07/02/22 revealed Resident #30 was at risk for developing pressure ulcers. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident#30 required extensive assistance of two staff for bed mobility. The assessment did not reflect the presence of any type of pressure ulcers. Review of Resident #30's medical record from 07/30/20 through 09/15/22 revealed no documented evidence the resident's heels were floated (as noted as a care plan intervention). Review of Resident #30's therapy note dated 09/15/22 at 1:14 P.M. revealed during dressing the therapist was putting on Resident #30's left sock and noticed a change in the skin condition to his left heel. Review of the nurse's note dated 09/15/22 at 4:40 P.M. revealed per therapy Resident #30 had a half dollar size pressure area to the left heel. The nurse practitioner was notified and gave orders to consult Pinnacle Wound Care and a foam dressing to the site. Review of the physician's orders for Resident #30 revealed an order, dated 09/15/22 to consult Pinnacle Wound Care for a pressure area to the left heel and apply foam dressing to the area until seen. The medical record lacked evidence the left heel was comprehensively assessed to include measurements, description, and staging of the wound at that time. Review of the Weekly Wound Evaluation dated 09/21/22 revealed Resident #30 had an in house Stage III pressure ulcer to his left heel. The wound measured 2.8 centimeters (cm) in length by 3.3 cm in width by 0.1 cm by 0.1 cm in depth. The wound was 25 percent dark purple and 75 percent granulation (healthy tissue). Review of the Wound Care note dated 09/21/22 revealed Resident #30 had a Stage III pressure ulcer to his left heel. The wound measured 2.8 centimeters (cm) in length by 3.3 cm in width by 0.1 cm by 0.1 cm in depth. The wound was 25 percent dark purple and 75 percent granulation. No current treatment was in place. New orders to cleanse the left heel ulcer with normal saline, apply adaptic, cover with a abdominal dressing and wrap with Kerlix daily. Review of the September 2022 Treatment Administration Record (TAR) revealed no documentation of a treatment being completed to the left heel of Resident #30 until 09/22/22. Review of the physician's orders for Resident #30 revealed an order dated 09/22/22 to cleanse the left heel ulcer with normal saline, apply adaptic, cover with a abdominal dressing and wrap with Kerlix daily. Review of Resident #30's medical record from 09/15/22 through 09/28/22 revealed no evidence additional pressure ulcer interventions to assist the pressure ulcer in healing and from deteriorating were implemented, including floating the resident's heels. Review of the Weekly Wound Evacuation dated 09/28/22 revealed Resident #30 had an in house unstageable pressure ulcer (the base of the wound cannot be visualized as to what type of anatomical tissue was involved) to his left heel. The wound measured 3.2 cm in length by 3.2 cm in width by 0.1 cm deep with a moderate amount of serosanguinous drainage. The wound was 50 percent slough (dead tissue) and 50 percent granulation. The wound was worsening. New treatment order implemented for silver alginate, abdominal dressing and wrap with Kerlix. In addition, new orders were obtained for a low air loss mattress, protein supplements twice daily and Prafo (pressure relieving) boot when up in the wheelchair. Review of the Wound Care note dated 09/28/22 revealed Resident #30 had a pressure ulcer to his left heel that was a Stage III but now was unstageable. The wound measured 3.2 cm in length by 3.2 cm in width by 0.1 cm deep with a moderate amount of serosanguinous drainage. The wound was 50 percent slough and 50 percent granulation. The wound was worsening. Review of the physician's orders for Resident #30 revealed an order, dated 09/29/22 for a low air loss mattress and Prafo boots while up in the wheelchair. Review of the plan of care initiated on 11/24/22 revealed Resident #30 had a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer to the left heel. Interventions included to administer medication as ordered, administer treatments as ordered, assess/record/monitor wound healing. measure the length, width, and depth where possible, assess and document status of the wound perimeter, wound bed and healing, report and improvements and declines to the physician's, and avoid positioning the resident left heel on the bed and float heels as needed. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #30 had moderately impaired cognition. He required extensive assistance of two staff members for bed mobility and had an in house Stage III pressure wound. Review of the physician's orders for Resident #30 revealed an order, dated 04/12/23 to encourage resident to use a foot boot to left lower extremity while up as tolerated to protect the left heel. Observation on 04/25/23 at 10:10 A.M. of Licensed Practical Nurse (LPN) #841 providing wound care to Resident #30 revealed the resident's left heel wound was nickel-size with a dark pink non-blanchable wound bed with dried peeling skin surrounding the wound. There was no drainage or odor noted to the wound. Observation on 04/25/23 at 3:10 P.M. revealed Resident #30 was up in the wheelchair in the hallway by nurse's station. The resident did not have his foot boot on his left foot as ordered. On 04/25/23 at 3:12 P.M. interview with LPN #841 revealed she did not see an order for Resident #30's foot boot. The LPN then checked the orders and verified there was an order for the resident to have his foot boot while up in the chair. Observation on 04/26/23 at 1:25 P.M. revealed Resident #30 was sitting in the hallway. The resident did not have his foot boot on his left foot. An interview at this time with Registered Nurse (RN) #836 verified the resident did not have his foot boot on his left foot. On 04/26/23 at 10:56 A.M. interview with RN #836 revealed she had just starting doing wound care in January 2023 and prior to that wound care was done by Pinnacle Wound Care, however this provider no longer came to the facility. She stated when a wound was found, the floor nurses were able to assess and grid the wound. She stated she would then look at the wound as soon as she was able, usually the next day she worked. RN #835 verified there was no pressure ulcer injury assessment, measurement, staging or treatment in place for Resident #30 from 09/15/22 to 09/21/22 and no pressure ulcer injury interventions in place from 09/15/22 to 09/28/22. She verified the wound had been assessed to deteriorate following the initial development. On 04/26/23 at 2:55 P.M. interview with RN #836 verified there was no documentation of staff floating Resident #30's heels prior to the left heel pressure ulcer developing or after the injury was identified from 09/15/22 to 09/28/22. On 04/26/23 at 3:00 P.M. interview with LPN #840 revealed Pinnacle Wound did not want the facility to stage any wounds and she verified it had taken staff from Pinnacle Wound Care seven days to come into the facility to assess Resident #30's left heel wound, as they only came to the facility on Wednesdays. She verified Resident #30's left heel was not thoroughly assessed until 09/21/22 and confirmed pressure ulcer interventions were not put in place until 09/28/22. LPN #840 stated they implement pressure ulcer interventions when they stage the wound and they did not know the stage of the wound until Pinnacle Wound care assessed the wound. She verified Resident #30's wound had deteriorated after it developed.

Based on medical record review, review of hospital records, interviews with staff and Physician #5, observations, review of the facility policy titled Anticoagulation Protocol, and review of the Medscape Guidelines 2020, the facility failed to ensure adequate monitoring was completed for one resident (Resident #11) who received the oral anticoagulant (blood thinning) medication, [MEDICATION NAME]. The failure to monitor the anticoagulant therapy resulted in Immediate Jeopardy and potential serious-life threatening harm for Resident #11 who did not receive ordered [MEDICATION NAME] time (PT) and International Normalized Ratio (INR) testing after having a critical level of 13.28 on [DATE] and receiving an antidote of Vitamin K the previous day. This affected one (Resident #11) of four residents who received anticoagulant medication. The facility census was 51 residents. On [DATE] at 4:32 P.M., Corporate Nurse #3, the Director of Nursing (DON), and the Administrator were notified Immediate Jeopardy began on [DATE] when the facility failed to obtain a physician ordered PT/INR test to monitor Resident #11's [MEDICATION NAME] level. A level was not obtained until [DATE] when the resident was transferred to the hospital after becoming unresponsive at [MEDICAL TREATMENT] and found to have a supratherapeutic INR level of 5.5. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Resident #11 was transferred to the hospital and no longer resides in the facility. · On [DATE], the DON and Corporate Nurse #3 audited the medical records of four residents (Resident #12, #13, #17, and #19) who had received [MEDICATION NAME] therapy since [DATE] to ensure their PT/INR's were completed as scheduled with no issues found, including no missed labs. · On [DATE] at 6:00 P.M., the DON/designee developed and began education for five registered nurses, which included PT/INR protocol, medication administration, anti-coagulant medication protocol. A post-test questionnaire was included to assess their understanding. This was completed on [DATE] by 11:59 P.M. · On [DATE] at 6:00 P.M., the DON/designee developed and began education for all 19 state tested nursing assistants (STNAs) which included reporting acute changes in the resident's skin condition, mental status, and abnormal behaviors. A post-test questionnaire was included to assess their understanding. This was completed on [DATE] by 11:59 P.M. · On [DATE] at 6:00 P.M., the DON/designee developed and began education for the licensed therapy staff, including the Director of Rehabilitation, two Physical Therapists, two Physical Therapy Assistants, three Certified Occupational Therapy Assistants, and two Speech Therapists. This included reporting acute changes in the resident's skin condition, mental status, and abnormal behaviors, as well as a post-test questionnaire to assess their understanding. This was completed on [DATE] by 11:59 P.M. · On [DATE] at 6:43 P.M., Infection Control Nurse #40 notified Physician #5 who was the facility medical director and resident's attending physician of the Immediate Jeopardy. · On [DATE], Physician #5 reviewed all residents on anticoagulant medication. Any recommended modifications were confirmed by the DON in the physician orders. · On [DATE], Physician #5 began the process of weaning Residents #12 and #17, who were the two residents currently on [MEDICATION NAME] therapy, to make a medication change. This was completed on [DATE]. · On [DATE], RN #30 began the facility process/clinical review of residents receiving anticoagulant therapy to verify labs have been drawn and completed as ordered. This will continue daily for 30 days by the DON or nurse manager. Any concerns will be reported to the physician and addressed per physician orders. The DON/Nurse Manager will ensure the audit is completed and will complete audits on weekends and holidays. The Administrator will ensure compliance. · On [DATE] a Quality Assurance and Performance Improvement (QAPI) team meeting was held to review the audits and facility process/clinical review. This information will be reported to and reviewed by the QAPI team weekly for four weeks at meetings scheduled for [DATE]/21, [DATE], [DATE], and [DATE]. · On [DATE] between 12:20 P.M. and 12:30 P.M., the surveyor observed the two current residents (Residents #12 and #17) receiving [MEDICATION NAME] therapy. The observations revealed the residents did not exhibit any signs or symptoms related to anticoagulant medication administration such as bruising or bleeding. · On [DATE] at 2:30 P.M. Registered Nurse #30 completed full body assessment on the two residents (Residents #12 and #17) currently receiving anticoagulant therapy to ensure no signs or symptoms of possible complications. No issues were observed on skin assessments. Visual checks will be completed for the next three days by RN #30 to check for any signs or symptoms of adverse effects of anticoagulant therapy. Visual checks will then be completed twice weekly for four weeks; then monthly for two months; and randomly thereafter. · On [DATE] at 5:00 P.M. the DON began auditing the STNAs reporting of changes in resident condition, which will be done weekly for four weeks, then monthly for two months, and randomly thereafter. · On [DATE] at 5:00 P.M. the DON began auditing licensed nurses reporting of changes in resident condition, which will be completed weekly for four weeks, then monthly for two months, and randomly thereafter. · On [DATE] between 5:05 P.M. and 5:20 P.M., the surveyor interviewed LPN #20, LPN #22, and LPN #23 who confirmed they received education and were knowledgeable regarding the new system for [MEDICATION NAME] therapy including the use of the flow sheet, lab results and diagnostic test results, anticoagulation, and bleeding precautions. · On [DATE] between 5:10 P.M. and 5:30 P.M., the surveyor interviewed STNA #50, STNA #51, and STNA #52 who confirmed they received education and was knowledgeable regarding bleeding precautions. · On [DATE] by 11:59 P.M., all education was completed for the licensed nurses, STNA's and licensed therapy staff. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the anticoagulant plan of care, dated [DATE], revealed Resident #11 required the use of anticoagulant medication and remained at risk for alteration in hematological status related to anticoagulant side effects from [MEDICATION NAME] therapy. Interventions included monitoring for abnormal bleeding, obtaining labs per order, and reporting abnormal findings to the physician. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 received an anticoagulant medication for three out of seven days during the assessment period. Further review revealed Resident #11 was cognitively impaired with a brief interview for mental status of 11 out of 15. Resident #11 required extensive assistance of two plus staff for bed mobility and one plus assistance for transfers. Review of the [DATE] physician orders for Resident #11 revealed an order dated [DATE] for [MEDICATION NAME] 3.0 milligrams (mg) by mouth in the evening every Tuesday, Thursday, Saturday, and Sunday; and [MEDICATION NAME] 2.5 mg to be given by mouth in the evening every Monday, Wednesday, and Friday for treating and preventing blood clots. It was noted that as of [DATE] these medications were on hold. On [DATE] a physician's order was present to check Resident #11's PT/INR levels on [DATE] for supratherapeutic INR. Review of lab reports for Resident #11 for [DATE] revealed an elevated INR value of 8.9 and a PT result of 86.6. The physician was notified and ordered the resident to have an antidote of Vitamin K 10 mg intramuscularly and to repeat the lab in the morning. Review of Resident #11's PT/INR report on [DATE] revealed a level that was greater than 8 and a PT that was greater than 86.6. The physician was notified, and an order was received to send the resident to the emergency department for evaluation. Review of the nurse progress note for Resident #11 revealed the resident was sent to the hospital on [DATE] for evaluation. Review of the hospital Emergency Department (ED) summary for [DATE] revealed that Resident #11 was brought in for evaluation due to an elevated INR of greater than 8. At the ED the resident's INR was rechecked, and it was revealed to be 13.28 (critically high). The resident received another antidote of Vitamin K, 5 mg. The hospital diagnosed the resident with a supratherapeutic INR level and gave instructions to continue to monitor the residents INR at the facility, indicating the resident would receive normal [MEDICAL TREATMENT] that day, and to hold [MEDICATION NAME]. The resident was then discharged from the ED back to the facility. Review of Resident #11 physician orders dated [DATE] revealed a PT/IRN was ordered to be done on [DATE]. Review of Resident #11's [MEDICAL TREATMENT] information revealed that she did not receive her scheduled [MEDICAL TREATMENT] on [DATE] due to the emergency room visit, or on [DATE] due to the holiday. Review of Physician #5's progress note dated [DATE] revealed that Resident #11 had a critical INR level on [DATE] and was sent to the ED for evaluation. It was further revealed that she missed [MEDICAL TREATMENT] on [DATE], her [MEDICATION NAME] was on hold, and she had an order for [REDACTED].>Review of the lab reports for Resident #11 revealed PT/INR values were not drawn for the resident on [DATE] or [DATE]. Review of the [DATE] [MEDICAL TREATMENT] progress note revealed Registered Nurse #14 documented that Resident #11 arrived for treatment was awake and vital signs were stable. Fluid set to be removed was at one litter. No treatment was given on Wednesday ([DATE]) due to an emergency room visit that day. During treatment the resident had complaints of nausea. Resident #11 received [MEDICATION NAME] 4.0 mg (antinausea medication) around 9:00 A.M. The resident's level of consciousness changed, and she became hard to arouse, diaphoretic, had clenched jaws and fist. She was noted to have slight swelling around her neck and shoulders. Her treatment was ended and RN #14 called 911 and the floor nurse, and the resident was sent to the emergency department. Review of the [DATE] emergency department report revealed on [DATE] Resident #11 was brought in for evaluation due to an unresponsive episode while receiving [MEDICAL TREATMENT] treatment. The clinical impression revealed the resident had suffered a subarachnoid hemorrhage, concern for a ruptured subarachnoid aneurysm, [MEDICAL CONDITION], supratherapeutic INR, and end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], and was placed on a ventilator. Further review revealed the emergency department obtained lab work which showed an elevated INR of 5.5. The resident expired later that same day. Interview on [DATE] at 1:50 P.M. with the DON confirmed Resident #11 was sent to the hospital on [DATE] for elevated PT/INR and had a critical INR level of 13.28. The DON further confirmed Resident #11 did not receive her ordered INR lab draw for [DATE] which was ordered by Physician #5 on [DATE]. She confirmed the facility did not obtain an INR lab draw on [DATE] or [DATE] as well, and the lab testing was not done until the resident was at the emergency department on [DATE]. It was also confirmed that on [DATE] when the resident became unresponsive and was sent to the emergency department that one her [DIAGNOSES REDACTED]. Interview on [DATE] at 5:09 P.M. with the Medical Director (Physician #5) confirmed Resident #11 should have had her INR monitored daily until stable. He said that he had ordered an INR level to be done on [DATE] after her return from the hospital on [DATE]. Review of the facility's policy titled Anticoagulation Protocol, dated [DATE], revealed the facility staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. In individuals receiving anticoagulation who have markedly elevated PT/INR, it may suffice to stop the anticoagulant and recheck PT/INR if the induvial is stable, there is no more than minor bleeding, and the INR is not more than 9. Once Vitamin K is given to try to reverse the effects of [MEDICATION NAME], it can hamper subsequent resumption of anticoagulant for a week or more. Review of the medication information titled Medscape Guidelines 2020 revealed [MEDICATION NAME] was an anticoagulant and was indicated for indefinite duration of treatment for [REDACTED]. Normal values include the following, the reference range for [MEDICATION NAME] time (PT) is 11XXX,[DATE].5 seconds. The reference range for the international normalized ratio (INR) is 0XXX,[DATE].1 with possible critical values of an INR: >5.5. Under the black box warning it indicated [MEDICATION NAME] could cause major or fatal bleeding and risk factors for bleeding included high intensity of anticoagulation (INR greater than 4), and a patient age of sixty-five years or older. Regular INR monitoring of INR should be performed on all treated patients; those at high risk for bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR and a shorter duration of therapy is recommended if possible. This deficiency substantiates Complaint Number OH 357.

Based on medical record review, hospital emergency department records, and interviews, the facility failed to ensure Resident #14 received his antibiotic as ordered for [MEDICAL CONDITION]. Actual harm occurred when Resident #14 did not receive an ordered antibiotic for four days, and was admitted to the hospital on [DATE] for bilateral lower extremity [MEDICAL CONDITION]. This affected one (Resident #14) of three residents reviewed for antibiotic use. The facility's census was 51 residents. Findings include: Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition, received an antibiotic for zero out of seven days, and did not have any noted infections. Review of Resident #14's 02/19/21 physician's orders [REDACTED]. Review of the Febuary, 2021 Medication Administration Record [REDACTED]. Review of Resident #14's nursing notes from 02/19/21 through 02/23/21 revealed that on 02/20/21 Licensed Practical Nurse (LPN) #20 documented an order for [REDACTED]. Review of Resident #14's nursing note on 02/23/21 at 12:05 A.M. revealed LPN #21 noted Resident #14 was sent to the emergency department for pain. Another note from 02/23/21 revealed that the resident was admitted with a [DIAGNOSES REDACTED]. Review of Resident #14's emergency room documentation revealed that the resident was brought into the emergency department on 02/23/21, and was admitted with [DIAGNOSES REDACTED]. Interview on 02/25/21 at 1:50 P.M. with Registered Nurse (RN) #30 revealed that she passed medication to Resident #14 on 02/21/21 and did not administer his antibiotic. RN #30 further stated that she forgot to ask someone to pull it for her out of the facility's contingency medication. It was also revealed that she did not call the pharmacy to see why the medication was not in the medication cart, and she did not notify the physician that Resident #14 had not yet received his antibiotic. Interview on 02/25/21 at 1:55 A.M. with LPN #22 revealed she passed medication to Resident #14 on 02/21/21 and 02/22/21. LPN #22 reported that if she did not give the medication it was because it did not come in from pharmacy. She further revealed she does not remember calling pharmacy to check on the status of the medication, pulling it from the facility's contingency stock, or notifying the doctor that it was not given. Interview on 02/25/21 at 1:40 P.M. with LPN #20 revealed that she passed medication to the resident on 02/20/21 and 02/21/21. She reported that she did not give the medication because pharmacy had not delivered the medication. Interview on 02/25/21 at 1:13 P.M. with Infection Control Nurse #40 confirmed that Resident #14 did not receive his scheduled antibiotic from 02/19/21 through 02/22/21. She further reported that the order was written on 02/19/21, but it was not put into the system until 02/20/21. She further reported that the facility has the antibiotic in their facility contingency supply, and it should have been started right away, or the nurses should have called the pharmacy to have it drop shipped. Lastly she confirmed that the physician was not notified that the antibiotic was not given. This deficiency is an example of continued non-compliance from the 02/08/21 survey. This deficiency substantiates Complaint Number OH 357.

Based on observation, review of a medical record, the facility policy and procedure for skin management, interviews with nursing staff, Wound Physician #425, [MEDICAL TREATMENT] Registered Nurse #291, the facility medical director (Physician #424), and resident interview the facility failed to implement a comprehensive and effective pressure ulcer prevention program to prevent the development of avoidable pressure ulcers for one resident (Resident #13). This resulted in Immediate Jeopardy that was actual harm on 09/05/19 when Resident #13, who was assessed as high risk for the development of pressure ulcers, had a history of [REDACTED]. The unstageable pressure ulcer was identified to be a deterioration of a previously identified area of moisture associated skin [MEDICAL CONDITION]. The Immediate Jeopardy continued on 12/17/19 when Resident #13 was identified by the surveyor with unstageable pressure ulcers to both heels. The facility had not identified these areas. Actual harm occurred when the facility failed to prevent, identify and treat skin impairment resulting in unstageable pressure ulcers for Resident #13 who was known to have previous skin impairment, had a [DIAGNOSES REDACTED]. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified related to the facility ' s failure to appropriately assess/monitor and identify a Stage II pressure ulcer to Resident #68 ' s sacrum. This affected two of three residents reviewed for pressure ulcers. On 12/24/19 the facility identified eight residents (Residents #13, #68, #24, #18, #229, #48, #54 and #179) who had current pressure ulcers. On 12/20/19 at 12:30 P.M. the Administrator, Director of Nursing (DON) and Regional Clinical Coordinator (RCC) #299 were notified Immediate Jeopardy began on 09/05/19 when staff documented Resident #13 had an unstageable pressure ulcer, described as being necrotic, to the sacrum measuring 5.8 centimeters in length by six centimeters width which resulted from the lack of effective monitoring, treatment and preventative skin interventions prior to the development. The Immediate Jeopardy continued on 12/12/19 when the resident was identified to have unstageable dark/black scabbed appearing pressure ulcers to the bilateral heels with the left heel measuring three centimeters in length by 1.6 centimeters width and the right heel measuring one centimeter in length by 0.7 centimeters width. Prior to the development of the pressure ulcers, the facility was unable to provide evidence of regular skin assessments and monitoring, individualized and effective skin interventions being in place, and evidence of implementation of comprehensive pressure ulcer care to prevent the development and promote the timely healing of the pressure ulcers. The Immediate Jeopardy was removed on 12/23/19 when the facility implemented the following corrective actions: · On 12/17/19 at 9:03 [NAME]M., observation with State tested Nurse Aide (STNA) #335 identified currently ordered skin prevention interventions for Resident #13 were not in place to promote healing for the resident. The DON was notified and placed a Roho (a special pressure relieving cushion used to prevent and heal pressure ulcers) in the resident ' s geriatric (geri) chair. · On 12/17/19 pressure ulcer treatments were implemented for Resident #13 ' s right and left heel pressure ulcers and sacral pressure ulcer. · On 12/19/19 the DON, RCC #299 and Physician #424, (Medical Director), reviewed Resident #13 ' s skin management interventions and identified the following interventions were necessary for the resident: Roho cushion, air mattress, Posey (heel protector) boots and turning and repositioning by staff every two hours. · On 12/20/19 RCC #299 provided re-education to the DON on the skin management policy. · On 12/23/19 a Braden/Skin Risk assessment was completed for Resident #13. The resident was assessed to be at moderate risk for skin breakdown; this reflected the resident having an indwelling urinary catheter and ostomy which decreased the risk from high to moderate. · On 12/23/19 Resident #13 was assessed by Physician #424. Laboratory testing was ordered to be completed for the resident on 12/24/19 to evaluate nutritional parameters for healing. · On 12/23/19 Resident #13 ' s Kardex (for direct care staff) and plan of care were reviewed and updated to reflect the resident ' s current treatment orders and skin interventions. · Beginning 12/23/19 a plan for the DON to conduct audits to ensure treatments were administered as ordered for Resident #13 daily for four weeks was implemented. A plan for the administrator to review completion of the audits of the treatment administration five times per week for four weeks was also implemented. · On 12/20/19 the DON, Administrator, Medical Director and RCC #299 reviewed the facility current Skin Management policy. No changes were made to the policy at that time. Between 12/20/19 and 12/23/19 the Administrative staff identified auditing and follow up of existing skin management protocols were not in place resulting in the concerns identified for Resident #13. As a result of this identification the facility identified the need for audits to reduce the risk of further system breakdown (see audit information below). · From 12/20/19 through 12/23/19 Registered Nurse (RN) #300, RN #267, RN #268, RN #266, Licensed Practical Nurse (LPN) #314 and LPN #265 completed Total Body Skin Assessments for 68 of 72 current facility residents. Four residents refused to have the skin assessment completed. Four new residents (#68, #24, #18 and #229) were identified to have new skin impairments. The DON re-assessed all four residents and new wound care orders were implemented. One resident (Resident #48) was assessed to have a decline in a current pressure ulcer status with new orders obtained and a newly identified deep tissue injury to the right heel. Two residents (Residents #54 and #179) who had previously been assessed to have skin breakdown were determined to have effective treatments in place. · From 12/20/19 through 12/23/19 the DON and RCC #299 completed Braden/Skin Risk Assessments for all current facility residents. Residents assessed to be at risk for skin breakdown were reviewed to ensure appropriate interventions were in place and care plans were updated. · On 12/23/19 the DON, RCC #299 and Unit Managers (UM) #301 and #302 reviewed the care plans and Kardex information for those residents identified to be at risk for skin breakdown and updated the plans as necessary. The care plans and resident Kardex information was to be reviewed and updated during the morning clinical meeting by the DON, UMs #301 and #302 or designee. · Beginning on 12/23/19 a plan for UMs #301 and #302 to update the Kardex information to reflect changes made to resident care plan and copy and place the Kardex in the resident closet with a master kept at the nursing station was implemented. · Beginning on 12/23/19 a plan for LPN #314, the facility wound nurse, to review all residents with pressure ulcers on a weekly basis was implemented. A plan for the DON to audit the wound care nurse documentation each week for accuracy for four weeks. · Beginning on 12/23/19 a plan for all residents with pressure ulcers to be reviewed during the resident at risk meeting weekly by the interdisciplinary team (including UMs #301, UM #302, the Administrator, the DON and Social Service Director #416) was implemented. This included input from the dietitian (RD) for nutritional interventions. The RD was also to be notified of all changes in skin condition via the Point Click Care (PCC) dashboard communication center by the DON. · From 12/20/19 through 12/23/19 RN #300, RN #267, RN #268, RN #266, LPN #314 and LPN #265 completed staff education. Education was provided to all 23 licensed nurses and 39 state tested nursing assistants (STNAs). Staff were educated on the Skin Management Policy. In addition, STNA education included an emphasis on interventions being in place, monitoring the skin and feet during showers and daily ADL care, and if new areas were present to alert the nurse via the clinical alert in PCC, and verbal notification to the nurse. The STNAs were also educated to ensure they were reviewing the resident Kardex daily for any changes in the skin interventions. Licensed nurse education emphasized ensuring weekly skin assessments were completed, including removal of footwear, and ensuring the care plan and Kardex were updated to reflect current interventions. · Beginning on 12/20/19 a plan for the following audits was implemented: a. Floor nurses would complete weekly head to toe evaluations as per the facility Skin Management policy for residents who have been triggered through PCC. The DON, UMs #301 and #302 would then audit the weekly head to toe evaluations for accuracy and ensure no skin issues had been identified daily for four weeks and then monthly for three months. b. For residents with pressure ulcers, a plan for the wound nurse/LPN #314 accompanied by the DON will complete weekly skin rounds for four weeks and then monthly for three months. c. Braden scale/skin risk assessments will be audited weekly for four weeks and then monthly by the DON, UMs #301 and #302 to ensure completion. The IDT team (members including UM #301, UM #302, the Administrator, the DON and SSD #416) will conduct audits to ensure skin prevention interventions were in place three times per week for one month and then weekly for three months during completion of Ambassador rounds to ensure interventions were in place. d. LPN #314/the wound nurse will audit residents with air mattresses weekly for four weeks and then monthly for three months to ensure air mattress inflations were appropriate. e. A plan was implemented for any areas of non-compliance identified to be addressed immediately and then reported to the QA committee for further recommendations. · On 12/24/19 from 7:30 [NAME]M. until 10:20 [NAME]M., Residents #13, #68, #24 and #48 were observed with pressure ulcer prevention interventions in place as ordered and care planned. Review of the head to toe assessment, Braden skin risk assessment, care plan and Kardex information for each resident revealed no concerns. · On 12/24/19 from 9:00 [NAME]M. until 10:20 [NAME]M., interview with UM #302, LPNs #332, #312, STNAs #335, #328 and #349 revealed all staff interviewed verified they had received education related to the skin management policy and were knowledgeable of skin prevention interventions and how to identify and/or treat pressure ulcers. Although the Immediate Jeopardy was removed on 12/23/19 the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the treatment administration record (TAR) revealed an intervention (dated 12/13/17) to off load heels at all times. Review of Resident #13 ' s current plan of care (with a revision date of 08/16/18) revealed Resident #13 was at risk for developing pressure ulcers. Interventions included weekly skin checks, a Braden assessment (an assessment tool used to identify the level of risk of developing skin impairment), reposition frequently, a pressure reliving cushion to the chair and a pressure relieving mattress to the bed. The care plan did not include the intervention to off load heels at all times. Review of the 05/23/19 wound/skin assessment revealed Resident #13 did not have any pressure ulcers. Review of the wound/skin assessment dated [DATE] revealed Resident #13 was assessed to have moisture associated skin damage (MASD) to the coccyx/sacral area that had a scant amount of serous drainage. However, there were no measurements or additional description of the area at that time. In addition, there was no evidence the facility identified the source of the moisture associated skin [MEDICAL CONDITION] as the resident had a [MEDICAL CONDITION] and indwelling urinary catheter or evidence new skin prevention interventions or treatments were implemented at that time. Review of the wound/skin assessment dated [DATE] revealed Resident #13 had MASD described with a scant amount of serosanguineous drainage and a slight odor measuring 1.2 cm in length by 0.7 cm width. In addition, there were three wound/skin assessments completed by different nurses all on 08/01/19 all with different measurements and descriptions of the same area, all of which documented the area was MASD. Review of the (MONTH) 2019 physician's order [REDACTED]. with a foam dressing daily. Review of the TAR revealed there was no evidence the dressing was changed as ordered on [DATE], 08/05/19, 08/11/19, 08/14/19 or 08/24/19. Review of Consultant Surgical Wound Care Services (SWCS) Certified Nurse Practitioner (CNP) #260 ' s progress note, dated 08/15/19 revealed Resident #13 had an area to the sacrum that was MASD. The wound was described as being excoriated with having a scant amount of serosanguinous drainage. The progress note did not reflect the order for calcium alginate daily but indicated to apply barrier cream twice daily and as needed to the area. There was no evidence this order was implemented. The progress note reflected standing orders for treatment included to reposition every two hours, low air loss mattress, Roho cushion to the chair and check for incontinence every two hours. However, there was no evidence a Roho cushion or low air loss mattress was implemented. In addition, these interventions were not included on the STNA Kardex or on the TAR for staff to implement or ensure they were in place. The progress note reflected barriers to healing the wound included immobility, malnutrition, atrophy, fecal incontinence and urinary incontinence (however, the resident was noted to have a [MEDICAL CONDITION] and indwelling urinary catheter which would decrease the risk of skin breakdown due to incontinence). Review of CNP #260 ' s progress note dated 08/22/19 revealed no change in the description of the wound but the CNP documented to change the treatment to apply calcium alginate to the wound bed and cover with an adhesive foam dressing daily. However, review of the physician's order [REDACTED]. Record review revealed between 07/25/19 and 09/05/19 there was no evidence the resident was provided turning and repositioning by staff, or the presence of a ROHO cushion to the chair or a low air loss mattress to promote the healing of pressure ulcers. In addition, on 08/08/19 the facility incorrectly documented the MASD area to the sacrum had healed. Review of the 09/05/19 wound/skin assessment, completed by the wound nurse/LPN #314 using a facility phone that took measurements, revealed Resident #13 ' s sacral wound was unstageable and measured 4.5 cm in length by 3.7 cm width with 90 percent slough tissue with a moderate amount of serosanguineous drainage. An order was obtained for Santyl ointment 250 unit/gm (removes dead tissue from wounds); apply to sacral area every day shift and cover with an abdominal pad (ABD). Review of SWCS CNP #242 ' s progress note dated the same as LPN #314 ' s assessment, 09/05/19, revealed the resident ' s sacral wound was deteriorating. The wound was described as being necrotic (dead tissue due to injury or failure of blood supply) with a scant amount of serosanguinous drainage. The wound was assessed to be unstageable and measured 5.8 centimeters (cm) in length by 6.0 cm width. A high protein nutritional supplement was added. There was no evidence LPN #314 and CNP #242 observed the wound together to ensure accurate measurements and descriptions of the wound were documented despite completing the assessments on the same day. Resident #13 ' s plan of care was updated on 09/06/19 to include the use of an air mattress. However, an actual physician order [REDACTED]. Review of the (MONTH) 2019 physician's order [REDACTED]. Review of the TAR revealed no evidence the Santyl treatment was provided as ordered on [DATE], 09/15/19 or 09/25/19. The Santyl was subsequently discontinued on 10/01/19. On 09/26/19 a new order was obtained for a [DEVICE] (vac) treatment continuous with black foam on 09/26/19 for treatment of [REDACTED]. The order indicated the foam was to be changed every Tuesday, Thursday and Saturday. Review of the TAR revealed there was no evidence it was changed on Saturday 09/28/19. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/25/19 revealed Resident #13 was cognitively intact. The resident was assessed to be totally dependent on staff for all activities of daily living (ADL) care. The MDS assessment revealed turning and repositioning was not provided. Review of facility CNP #210 ' s progress note dated 10/09/19 revealed the resident had an elevated white blood cell count, was currently on a wound vac for a pressure ulcer treatment and ordered blood and wound cultures. Orders for the blood and wound cultures were obtained on 10/10/19. However, there was no evidence the wound culture was ever obtained as ordered. Review of the (MONTH) 2019 TAR revealed the wound vac was not documented as being changed as ordered on any Tuesday, Thursday or Saturday in October, 2019. Review of CNP #242 ' s 10/31/19 progress note revealed Resident #13 was malnourished and the sacral wound was deteriorating. The wound was assessed to be a Stage IV with undermining (caused by erosion of the wound edges) 10-1 deepest 4 cm at 10 o ' clock with a medium amount of serosanguinous drainage and slough. Treatment remained as the continuous wound vac with black foam to the area which was to be changed three times a week. The note failed to address why the area was deteriorating or evaluate whether the black foam was actually being changed three times per week as the (MONTH) 2019 TAR revealed no evidence of the foam being changed. On 10/31/19 Resident #13 ' s care plan was updated to include follow the protocol for treatment of [REDACTED]. There was no evidence these interventions were implemented. From 05/23/19 to 09/05/19 weekly head to toe skin assessments were only documented as being completed on 05/23/19, 07/25/19, 08/01/19, 08/08/19, 08/15/19 and 09/05/19. In addition, there was no documented evidence the facility had identified and/or eliminated any causative factors related to the development and/or continued deterioration of Resident #13 ' s sacral pressure ulcer. Review of the 11/07/19 wound/skin assessment completed by LPN #314 revealed the sacral wound measured 3.6 cm in length by 3.2 cm width with 2.5 cm depth with one cm undermining. The wound had a moderate amount of serosanguineous drainage but was healable. The assessment note revealed to continue the wound vac. However, there was no reference to any other skin prevention interventions being in place at this time. A corresponding note, dated 11/07/19 by CNP #242 revealed the sacral wound was improving, no measurements documented, however the CNP noted the wound had a moderate amount of serosanguinous drainage with undermining 10-1 deepest 4 cm at 1 o ' clock. The note indicated to continue with the same treatment and interventions as planned. There was no evidence the facility wound nurse/LPN #314 and CNP #242 assessed Resident #13 together to ensure the assessments as noted above were consistent and/or accurate as they noted two different descriptions. Review of CNP #242 ' s progress notes dated 11/21/19 reveled the sacral wound was a Stage IV pressure ulcer with a medium amount of serosanguinous drainage with excoriation and undermining 10-1 deepest 4 cm at 1 o ' clock. No changes were made to the care at that time. Review of the (MONTH) TAR revealed there was no evidence the wound vac with black foam was changed as ordered from 11/01/19 through 11/30/19. Review of the (MONTH) TAR revealed there was no evidence the wound vac with black foam was changed as ordered from 12/01/19 through 12/12/19 when the wound vac was placed on hold. Review of CNP #260 ' s progress notes dated 12/05/19 reveled the sacral wound was a Stage IV with a medium amount of serosanguinous drainage with excoriation. No changes were made at that time. Review of CNP #260 ' s progress note dated 12/12/19 revealed the sacral wound was necrotic with a medium amount of serosanguinous drainage and excoriation. There were no measurements of the wound. The wound vac was placed on hold and a new treatment order was obtained. The new order indicated to gently clean the wound bed, pat dry, apply Dakin ' s solution to sterile gauze and lightly pack wound bed three times a week. Dakin ' s solution is an antiseptic solution containing sodium hypochlorite used to treated infected wounds. Review of the physician's order [REDACTED]. On 12/16/19 at 10:32 [NAME]M. and 11:50 [NAME]M., Resident #13 was observed sitting in a chair without any type of preventative pressure relieving cushion/ROHO cushion in the chair. The resident ' s heels were observed directly on the foot rests of the chair with no evidence of the heels being off loaded. On 12/16/19 at 11:51 [NAME]M. RN #302 verified Resident #13 ' s heels were directly on the leg rests of the wheelchair. On 12/16/19 at 12:55 P.M. and at 5:00 P.M., Resident #13 was observed sitting in a chair without any type of cushion and with her heels directly on the foot rests of the chair with no evidence her heels were being off loaded. On 12/17/19 at 8:59 [NAME]M. the resident was observed on her back in bed with her heels directly on the bed, with non-skid socks on her feet. There was no evidence of her heels being off loaded. On 12/17/19 at 9:00 [NAME]M. interview with Resident #13 verified she did not have any type of cushion to use while sitting in her chair. The resident also verified her heels were directly on the mattress of the bed. During the interview, the resident reported she had [MEDICAL CONDITION] and could not move her arms or legs on her own. The resident revealed she had a pressure ulcer on her bottom that was healing but did not know of any other pressure ulcers and revealed she was not being treated for [REDACTED]. The resident indicated she received bed baths and stated the STNAs did not always remove her socks and wash her feet during baths. During the interview, Resident #13 also revealed staff did not assist her with turning and repositioning in bed and she stated she was on her back at all times while in bed. The resident again indicated she could not turn or reposition herself while in bed or when up in a chair. The resident stated she was up early, around 3:00 to 4:00 [NAME]M. three times per week to go to [MEDICAL TREATMENT]. Resident #13 stated she remained in her chair without a cushion and her heels not elevated or repositioned for extended periods of time most days. On 12/17/19 at 9:03 [NAME]M. interview with STNA #335, who was present when Resident #13 stated she only received bed baths and usually the STNAs did not remove her socks and wash her feet, verified the resident ' s heels were currently directly on the bed (with no off loading) with the resident wearing only non-skid socks. The STNA revealed staff did not turn or reposition the resident in bed or when in the chair. On 12/17/19 at 9:05 [NAME]M. observation of Resident #13 ' s right heel, with STNA #335, revealed it was mushy with a dark thick scab the size of a dime in the center of the heel. The resident ' s left heel was mushy with a black scab the size of a silver dollar. The edges of the scab were pulling away from the skin. There were no treatments in place for either heel. The condition of the resident ' s bilateral heels was verified by STNA #335 at the time of the observation. On 12/17/19 at 9:10 [NAME]M. interview with RN #302 verified Resident #13 was laying on her back and her heels were directly on the bed without any preventative skin interventions being in place, despite the resident being at risk for skin breakdown and having a Stage IV pressure ulcer to her sacral area. On 12/17/19 at 3:22 P.M., Resident #13 was observed reclined in a geriatric chair without any type of pressure reducing/relieving cushion to the seat. Review of a wound/skin assessment, completed by wound nurse/LPN #314, dated 12/17/19 revealed a new pressure ulcer/deep tissue injury (DTI) to the left heel measuring 3.0 in length by 1.6 cm width. A treatment order was obtained at that time to apply skin preparation (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) and for Posey boots (heel cushion protector pillow to relieve pressure from ulcers). A new pressure ulcer/DTI to the right heel was also assessed measuring 1.0 cm in length by 0.7 cm width. A treatment order was obtained to apply skin preparation and Posey boots. The resident ' s sacral wound was assessed to measure 5.0 cm in length by 4.3 cm width with 0.8 cm depth with a moderate amount of serosanguinous drainage. On 12/18/19 at 5:10 [NAME]M. interview with STNA #351 revealed she had gotten Resident #13 up and out of bed using a mechanical lift at about 3:00 [NAME]M. because she had to take her to [MEDICAL TREATMENT] at 4:15 [NAME]M. On 12/18/19 at 8:30 [NAME]M. Resident #13 returned to the unit from [MEDICAL TREATMENT]. The resident was taken to her room by STNA #351 where she remained in the geriatric chair until 9:30 [NAME]M. The resident was transferred back to bed at 9:30 [NAME]M. On 12/18/19 at 11:00 [NAME]M. Resident #13 was observed in bed on her back (the same position she was in when staff left her at 9:30 [NAME]M.). On 12/18/19 at 12:20 P.M. interview with RN #300 and RN #302 revealed they were not aware Resident #13 had unstageable pressure ulcers on her bilateral heels. RN #300 verified the care plan did not address the use of heel protection for the resident. RN #300 also verified the care plan had not been updated to include off loading of the heels as ordered (in (YEAR)). The care plan also had not been updated to include wearing of the Posey boots. On 12/18/19 at 4:00 P.M., interview with RN #300 revealed the facility had identified a system failure on 12/12/19 related to not identifying, assessing, treating and ensuring interventions were appropriate and in place related to skin impairments (including pressure ulcers) but had not yet implemented a plan to correct the problem. During the interview, RN #300 verified the assessment on 08/08/19 noted the area of MASD had healed when in fact it had not. On 12/19/19 at 7:02 [NAME]M., Resident #13 was observed in bed on her back. On 12/19/19 at 1:30 P.M., interview with the facility wound nurse/LPN #314 revealed she was a floor nurse and kept finding residents who had unidentified pressure ulcers so she was transitioned into the wound nurse position. LPN #314 verified the Braden assessments, the wound/skin weekly assessments and skin checks were not being done as planned for all residents, including Resident #13. LPN #314 indicated she did wound rounds with wound CNP #260 or CNP #242 when they came to the facility but otherwise completed weekly measurements by herself with a facility camera that had an application that took the measurements of the wounds with a picture. During the interview, LPN #314 revealed she had never observed Resident #13 with skin prevention interventions (including the use of Posey boots) in place. On 12/20/19 at 7:55 [NAME]M., interview with [MEDICAL TREATMENT] RN #291 revealed Resident #13 came to [MEDICAL TREATMENT] without any type of cushion/pressure relief device in her seat, without Posey boots or without anything to elevate her heels off the leg rests of the geriatric chair. RN #291 revealed she had to know and would document if any such items were in place because the weight of those items would have to be accounted for. RN #291 revealed the resident remained in the chair from the nursing home and was taken right to the scale before entering [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] staff did not transfer or reposition Resident #13 during the course of her [MEDICAL TREATMENT] treatments. On 12/20/19 at 10:10 [NAME]M., observation of Resident #13 ' s sacral area revealed the wound was clean with a small amount of serosanguineous drainage and a small amount of eschar noted in the wound bed. On 12/20/19 at 10:44 [NAME]M., telephone interview with SWCS Wound Physician #425 revealed neither of the wound center CNPs (CNP #242 or CNP #260) were available this week for interview and he had never seen Resident #13 but had progress notes to review. When asked about the order for the calcium alginate, he stated it could be ordered for MASD if the resident had a lot of moisture, it could be applied over barrier cream. The physician verified the resident had a [MEDICAL CONDITION] and an indwelling urinary catheter. The physician stated calcium alginate would also be ordered for tissue ulcers if it was thought to be a deep tissue injury. Physician #425 verified the resident had multiple co-morbidities and was about as high risk as you could get for pressure ulcers. Including not being able to off load herself, being a quadriplegic, having a history of a Stage IV pressure ulcer to the same area, having [DIAGNOSES REDACTED]. Wound Physician #425 stated Resident #13 would need to have aggressive interventions in place at all times including a Roho cushion for the chair, frequent repositioning and off loading her heels. At the time of the interview, Physician #425 was not aware the resident had unstageable pressure ulcers to both her heels. He was not aware interventions ordered by the SWCS CNPs were not implemented. Physician #425 verified surgical debridement of the sacral area wound had been done at Resident #13 ' s bedside. He was aware of the order for wound cultures but did not see any evidence they were completed. He stated all of the resident ' s wounds were definitely infected as the resident had an elevated white blood cell count which could lead [MEDICAL CONDITION]. When asked about the ability to heal a Stage III or Stage IV pressure ulcer, he indicated they could be healed but the skin would remain so fragile (TRUNCATED)

Based on observation, interview, record review and review of facility policy the facility failed to ensure eight residents (Residents #25, #26, #27, #31, #39, #43, #49 and #57 )received restorative/maintenance programs to maintain function for activities of daily living (ADLs) and/or prevent decline in ADLs after being discharged from skilled therapy. This affected eight of eight sampled residents. Actual Harm occurred when skilled therapy recommendations were not followed/implemented by the restorative nursing program resulting in avoidable decline in ambulation for Residents #25, #27, #31, #43, #49 and #57. The facility census was 72. Findings include: 1. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physical therapy (PT) discharge summary dated 03/12/19 revealed Resident #27 was able to ambulate 60 feet with a walker and stand by assistance. Resident #27 was referred to the restorative nursing program (RNP) for ambulation. Further review of the monthly restorative documentation for March, April, (MONTH) and (MONTH) 2019 reveled there was no evidence the program was implemented as planned to maintain the resident's current level of function. Review of the PT evaluation dated 06/03/19 revealed Resident #27 was picked back up due to a decline in ambulation. Resident #27 needed assistance of staff with ambulation using the walker and was able to ambulate 100 feet. Review of the discharge summary dated 08/09/19 revealed the resident was able to ambulate 200 feet using the walker without assistance. The resident was referred to the RNP for ambulation. Further review of the monthly restorative documentation for August, September, October, (MONTH) and (MONTH) 2019 revealed there was no evidence the program was implemented as planned to maintain the resident's current level of function. Review of the annual minimum data set (MDS) 3.0 dated 10/06/19 revealed Resident #27 was moderately impaired for cognition. The resident needed limited assistance of one person for ambulation. On 12/18/19 at 3:30 P.M., interview with State tested Nurse Aide (STNA) #280 revealed he was pulled to work the floors an average of one to two days a week. When he was able to work in the restorative program it was for about four hours a day but he was not able to complete the ambulation programs. STNA #280 was aware of Resident #27's decline in ambulation because of not receiving the RNP as planned. On 12/18/19 at 4:00 P.M., interview with Registered Nurse (RN) #300 verified the facility had identified the RNP was not being implemented as planned and there was no nurse at this time to ensure the programs were assessed and implemented as planned. There was one STNA (STNA #280) who worked part time in the restorative program but he was not able to service the needs of all the residents in the program. There were no evaluations, individualized goals, plans or evidence of re-evaluation of the effectiveness of the programs. On 12/19/19 at 11:45 [NAME]M., interview with Physical Therapy Assistant (PTA) #363 revealed Resident #27 had a decline in ambulation after being referred to the RNP. PTA #363 verified she was not aware the RNP was not being implemented as planned. 2. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 01/30/19 quarterly MDS 3.0 revealed Resident #49 was not interviewable and was able to walk with staff assistance. Review of the PT evaluation dated 03/27/19 revealed Resident #49 was referred due to a decline in functional mobility. The resident was able to ambulate 100 feet with staff assistance and the walker. Further review of the 04/19/19 quarterly MDS 3.0 revealed the resident did not walk and was mobile only in a wheelchair. Review of the PT discharge summary dated 04/19/19 revealed the resident was able to ambulate 60 feet with only stand by assistance with the walker. Resident #49 was referred to the RNP program for ambulation. Further review of the monthly participation documentation for April, May, June, July, August, September, October, (MONTH) and (MONTH) 2019 revealed the program was never implemented. The resident was picked back up by PT on 11/07/19 due to functional decline in wheelchair mobility. The resident was non ambulatory and the resident was totally dependent on transfers and did not attempt to initiate. Review of the 12/06/19 quarterly MDS 3.0 revealed the resident was not interviewable and the resident did not walk. On 12/18/19 at 3:30 P.M., interview with STNA #280 revealed he was pulled to work the floors an average of one to two days a week. When he was able to work in the restorative program it was for about four hours a day but he was not able to complete the ambulation programs. STNA #280 was aware of Resident #49's decline in ambulation because of not receiving the RNP as planned. On 12/18/19 at 4:00 P.M., interview with RN #300 verified the facility had identified the RNP was not being implemented as planned and there was no nurse at this time to ensure the programs were assessed and implemented as planned. There was one STNA (STNA #280) who worked part time in the restorative program but he was not able to service the needs of all the residents in the program. There were no evaluations, individualized goals, plans or evidence of re-evaluation of the effectiveness of the programs. On 12/19/19 at 11:45 [NAME]M., interview with PTA #363 revealed Resident #49 had a decline in ambulation after being referred to the RNP. PTA #363 verified she was not aware the RNP was not being implemented as planned. 3. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 04/27/19 revealed the resident was not interviewable. The resident needed limited assistance of one person for walking. Review of the PT evaluation dated 05/23/19 revealed the resident was referred to therapy due to a decline in ambulation after the resident had been referred to the RNP by therapy. On evaluation the resident was able to ambulate 50 feet with walker and contact guard (one or two hands actually touching the body but providing no other assistance). Review of the PT discharge summary dated 06/12/19 revealed the resident was able to ambulate 200 feet with the walker and stand by assistance. The resident was referred to the RNP for ambulation. Further review of the RNP participation documentation revealed the resident was not ambulated as planned for June, July, August, (MONTH) or (MONTH) 2019. Review of the annual MDS 3.0 dated 10/04/19 revealed the resident was not interviewable and the resident did not ambulate. Further review of the RNP participation documentation revealed the resident was not ambulated as planned for October, (MONTH) or (MONTH) 2019. Review of the PT evaluation dated 12/09/19 revealed the resident had a decline in ambulation and was picked back up on therapy. The resident was able to ambulate 60 feet with walker and contact guard (prior was stand by assist). On 12/18/19 at 3:30 P.M., interview with STNA #280 revealed he was pulled to work the floors an average of one to two days a week. When he was able to work in the restorative program it was for about four hours a day but he was not able to complete the ambulation programs. STNA #280 was aware of Resident #25's decline in ambulation because of not receiving the RNP as planned. On 12/18/19 at 4:00 P.M., interview with RN #300 verified the facility had identified the RNP was not being implemented as planned and there was no nurse at this time to ensure the programs were assessed and implemented as planned. There was one STNA (STNA #280) who worked part time in the restorative program but he was not able to service the needs of all the residents in the program. There were no evaluations, individualized goals, plans or evidence of re-evaluation of the effectiveness of the programs. On 12/19/19 at 11:45 [NAME]M., interview with PTA #363 revealed Resident #25 had a decline in ambulation after being referred to the RNP. PTA #363 verified she was not aware the RNP was not being implemented as planned. 4. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 04/10/19 revealed the resident was severely cognitively impaired. The resident was able to ambulate with staff assistance and had limitations in ROM of one leg. Review of the RNP participation documentation from (MONTH) and (MONTH) 2019 revealed the ambulation program was not delivered as planned. Review of the PT evaluation dated 05/16/19 revealed the resident was in the RNP for ambulation and had a decline. Review of the PT discharge date d 06/12/19 revealed the resident was able to ambulate 120 feet with a walker and supervision. The resident was referred to the RNP for ambulation. Further review of the RNP ambulation participation documentation from June, July, (MONTH) and (MONTH) 2019 revealed there was no evidence the program was implemented as planned. Review of the PT evaluation dated 09/04/19 revealed the resident was referred due to a decline in ambulation and was only able to ambulate 20 feet with walker and contact guard. Review of the PT discharge summary dated 11/01/19 revealed the resident was able to ambulate 150 feet with walker and stand by assistance. Further review of the RNP participation documentation for September, (MONTH) and (MONTH) 2019 revealed there was no evidence the program was implemented as planned. Review of the 11/11/19 quarterly MDS 3.0 revealed the resident was severely cognitively impaired and the resident did not walk. The resident had limitations in ROM of both legs. On 12/18/19 at 3:30 P.M., interview with STNA #280 revealed he was pulled to work the floors an average of one to two days a week. When he was able to work in the restorative program it was for about four hours a day but he was not able to complete the ambulation programs. STNA #280 was aware of Resident #57's decline in ambulation because of not receiving the RNP as planned. On 12/18/19 at 4:00 P.M., interview with RN #300 verified the facility had identified the RNP was not being implemented as planned and there was no nurse at this time to ensure the programs were assessed and implemented as planned. There was one STNA (STNA #280) who worked part time in the restorative program but he was not able to service the needs of all the residents in the program. There were no evaluations, individualized goals, plans or evidence of re-evaluation of the effectiveness of the programs. On 12/19/19 at 11:45 [NAME]M., interview with PTA #363 revealed Resident #57 had a decline in ambulation after being referred to the RNP. PTA #363 verified she was not aware the RNP was not being implemented as planned. 5. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also had difficulty walking. Review of the PT discharge summary dated 12/21/18 revealed the resident was referred to the RNP for ambulation. The resident was able to ambulate 300 feet with a walker and stand by assistance. Further review of the RNP participation documentation for (MONTH) (YEAR) and (MONTH) 2019 revealed the ambulation program was not delivered as planned. Review of the quarterly MDS 3.0 dated 01/22/19 revealed the resident was cognitively intact. Ambulation occurred one to two days out of the seven day reference period. The resident was unsteady but able to stabilize without staff and had limitations of ROM of one leg. Review of the PT evaluation dated 01/23/19 revealed the resident was to be on a RNP for ambulation and had recently sustained a fall. The resident was only able to ambulate two steps with a walker and maximum assistance. Review of the quarterly MDS 3.0 dated 04/24/19 revealed the resident did not walk and had limitations of ROM one leg. Review of the discharge summary dated 05/07/19 revealed the resident was able to ambulate 50 feet with a walker and minimum assistance. The resident was referred to the RNP for ambulation. Review of the RNP participation documentation for May, (MONTH) and (MONTH) 2019 revealed the program was not delivered as planned. Review of the PT evaluation dated 07/31/19 revealed the resident was to be on a RNP for ambulation and had a decline. The resident was able to ambulate 10 feet with the walker with a shuffled gait and frequent freezing episodes. Further review of the discharge summary dated 11/05/19 revealed the resident was able to ambulate 25 feet with the walker and contact guard. The resident was referred to the RNP for ambulation. Review of the RNP participation documentation for (MONTH) and (MONTH) 2019 revealed the program was not delivered as planned. On 12/23/19 at 3:32 P.M., interview with Resident #43 revealed if he was lucky he would get walked once a week but there was usually no one available to walk him. On 12/18/19 at 3:30 P.M., interview with STNA #280 revealed he was pulled to work the floors an average of one to two days a week. When he was able to work in the restorative program it was for about four hours a day but he was not able to complete the ambulation programs. STNA #280 was aware of Resident #43's decline in ambulation because of not receiving the RNP as planned. On 12/18/19 at 4:00 P.M., interview with RN #300 verified the facility had identified the RNP was not being implemented as planned and there was no nurse at this time to ensure the programs were assessed and implemented as planned. There was one STNA (STNA #280) who worked part time in the restorative program but he was not able to service the needs of all the residents in the program. There were no evaluations, individualized goals, plans or evidence of re-evaluation of the effectiveness of the programs. On 12/19/19 at 11:45 [NAME]M., interview with PTA #363 revealed Resident #43 had a decline in ambulation after being referred to the RNP. PTA #363 verified she was not aware the RNP was not being implemented as planned. 6. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 04/14/19 revealed the resident was moderately impaired for cognition. The resident needed limited assistance of one person for walking. Review of the RNP participation documents for (MONTH) and (MONTH) 2019 revealed the resident's ambulation program was not delivered as planned. Review of the PT evaluation dated 05/28/19 revealed the resident was referred due to decreased ambulation. The resident was able to ambulate 75 feet with minimum assistance. Review of the discharge summary dated 06/24/19 revealed the resident was able to ambulate 180 feet with contact guard. The resident was referred to the RNP for ambulation. Further review of the RNP participation documentation for May, June, July, (MONTH) and (MONTH) 2019 revealed the program was not delivered as planned. Review of the PT evaluation dated 09/19/19 revealed the resident had a decline in ambulation. The resident was able to ambulate 40 feet with hand in hand assistance. Further review of the discharge summary dated 10/30/19 revealed the resident was able to ambulate 90 feet with stand by assistance for safety due to unsteadiness. The resident had a shuffling gait with decreased step length. The resident was referred to the RNP for ambulation. Review of the RNP participation documentation for September, October, (MONTH) and (MONTH) 2019 revealed the program was not delivered as planned. On 12/18/19 at 3:30 P.M., interview with STNA #280 revealed he was pulled to work the floors an average of one to two days a week. When he was able to work in the restorative program it was for about four hours a day but he was not able to complete the ambulation programs. STNA #280 was aware of Resident #31's decline in ambulation because of not receiving the RNP as planned. On 12/18/19 at 4:00 P.M., interview with RN #300 verified the facility had identified the RNP was not being implemented as planned and there was no nurse at this time to ensure the programs were assessed and implemented as planned. There was one STNA (STNA #280) who worked part time in the restorative program but he was not able to service the needs of all the residents in the program. There were no evaluations, individualized goals, plans or evidence of re-evaluation of the effectiveness of the programs. On 12/19/19 at 11:45 [NAME]M., interview with PTA #363 revealed Resident #31 had a decline in ambulation after being referred to the RNP. PTA #363 verified she was not aware the RNP was not being implemented as planned. On 12/23/19 at 3:30 P.M., interview with Resident #31 verified no one walked him and it had been a long time since he had been walked and did not know if he could walk anymore safely. 7. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 dated 05/10/19 revealed the resident was not interviewable. The resident walked with supervision of one person with a walker. Review of the PT evaluation dated 06/27/19 revealed the resident sustained [REDACTED]. On 08/19/19 the resident was picked back up for ambulation and was able to ambulate 20 feet with minimum assistance. Review of the discharge summary dated 10/04/19 revealed the resident was able to ambulate 100 feet with supervision. The resident was referred to the RNP for ambulation. Further review of the RNP participation documentation for October, (MONTH) and (MONTH) 2019 revealed the program was never implemented. Review of the quarterly MDS 3.0 dated 10/04/19 revealed the resident was not interviewable, did not walk and had impairment of one leg. On 12/18/19 at 3:30 P.M., interview with STNA #280 revealed he was pulled to work the floors an average of one to two days a week. When he was able to work in the restorative program it was for about four hours a day but he was not able to complete the ambulation programs. STNA #280 verified Resident #26's ambulation program was never initiated. On 12/18/19 at 4:00 P.M., interview with RN #300 verified the facility had identified the RNP was not being implemented as planned and there was no nurse at this time to ensure the programs were assessed and implemented as planned. There was one STNA (STNA #280) who worked part time in the restorative program but he was not able to service the needs of all the residents in the program. There were no evaluations, individualized goals, plans or evidence of re-evaluation of the effectiveness of the programs. 8. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 10/16/19 revealed the resident was cognitively intact. The resident did not walk. Review of the PT discharge summary dated 10/31/19 revealed the resident was referred to the RNP for ambulation. Further review of the RNP participation documentation for (MONTH) and (MONTH) 2019 revealed the program was never implemented. On 12/18/19 at 3:30 P.M., interview with STNA #280 revealed he was pulled to work the floors an average of one to two days a week. When he was able to work in the restorative program it was for about four hours a day but he was not able to complete the ambulation programs. STNA #280 verified Resident #39's ambulation program was never initiated. On 12/18/19 at 4:00 P.M., interview with RN #300 verified the facility had identified the RNP was not being implemented as planned and there was no nurse at this time to ensure the programs were assessed and implemented as planned. There was one STNA (STNA #280) who worked part time in the restorative program but he was not able to service the needs of all the residents in the program. There were no evaluations, individualized goals, plans or evidence of re-evaluation of the effectiveness of the programs. Review of the restorative nursing policy, revised (MONTH) (YEAR), revealed the program was in place to assure each resident could attain and maintain the highest practicable level of physical well-being. Measurable restorative goals would be implemented and achieved with nursing support. A licensed nurse would help manage the RNP. The programs would be provided six to seven days a week. Completion of a restorative initial evaluation would be completed, development of measurable goals and individualized interventions, evaluation of progress towards goals and effectiveness of interventions would be completed for each resident on a RNP. Document any refusals and re-evaluate at least quarterly.

Based on observation, staff interviews, resident interviews, family interviews, review of the smoking policy and resident smoking assessments the facility failed to ensure one resident (Resident #1), who required supervision with smoking and used oxygen as needed, was prevented from smoking unsupervised in his room. This resulted in Immediate Jeopardy when Resident #1 placed a lit cigarette in a napkin and put it inside his coat pocket to avoid being caught smoking in his room. This was likely to cause serious harm when the lit cigarette resulted in a smoldering fire, was extinguished by staff and prompted the fire department to respond. In addition, Resident #2 was observed to extinguish a cigarette in a homemade foil wallet and place the wallet in her purse while outside smoking. The facility identified eight residents that were smokers (Residents #1, #2, #3, #4, #5 #6, #7 and #8). This had the potential to affect all residents in the facility. The census was 61. On 11/22/16 at 4:40 P.M., the administrator, director of nursing (DON), corporate Registered Nurse (RN) #20 and Director of Operations #21 were notified Immediate Jeopardy began on 11/20/16 when Resident #1 was smoking in his room on his bed and extinguished the cigarette in a napkin inside his coat resulting in the coat smoldering. Resident #1 had an oxygen concentrator in his room for as needed use and it was undetermined when it had last been used. The Immediate Jeopardy was removed on 11/23/16 when the facility implemented the following corrective actions: · On 11/22/16 all the rooms of residents identified as smokers and their person were searched to ensure all smoking materials were secured at the nursing station. · On 11/22/16 the smoking policy and procedure was updated to include a statement that partially smoked cigarettes may not be saved to smoke later . · On 11/22/16 the administrator began training with all staff, residents who smoke, and their families regarding the smoking policy to ensure compliance. The training was completed on 11/23/16. · On 11/23/16 all residents identified as smokers received additional training on the updated smoking policy and signed acknowledgement they had the policy reviewed with them. All smoking residents agreed to follow the new smoking policy. All residents were assessed or reassessed if necessary to determine if supervision was required. Resident #1 was assessed to need supervision prior to the event and continued to need supervision after being reassessed. Although the Immediate Jeopardy was removed the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility continued to monitor residents who smoke for compliance with the new smoking policy. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the five day admission Minimum Data Set (MDS) 3.0 dated 10/24/16 revealed the resident had intact memory. Resident #1 required extensive assistance of one person for activities of daily living (ADL). Review of the smoking assessment dated [DATE] revealed Resident #1 may only smoke with supervision due to the use of oxygen. Review of the plan of care initiated 11/07/16 indicated to document any noncompliance and keep lighter and cigarettes at the nursing station. On 11/07/16 Resident #1 was placed on hospice services for COPD and [DIAGNOSES REDACTED]. Review of a nursing note dated 11/20/16 revealed Resident #1 was found smoking in his room. Staff members took the cigarette and lighter out of the room and Resident #1 was educated on the dangers of smoking in his room. Review of the facility ' s investigation revealed on 11/20/16 Resident #1 stated he kept an eye on the clock to watch for smoke breaks but at some point lit his cigarette. He realized he had made a mistake, panicked and tried to extinguish the cigarette by grabbing a napkin and using it to crumble the cigarette into his hand. When he overheard staff stating they smelled smoke he put the cigarette and napkin into the pocket of his coat that was on his wheelchair. Staff came in and removed the carton of cigarettes and lighter that were sitting out but did not ask about the lit cigarette. Review of Fire Prevention Investigator #100 ' s investigation dated 11/20/16 revealed an interview with Resident #1 where he stated this morning he finished his breakfast, while still lying in his bed he retrieved a cigarette and lighter from his end table drawer and lit a cigarette. He stated he typically goes outside to smoke, but this morning he decided to smoke in his room. He stated he typically had cigarettes and lighters on his person in his room and in his end table drawer. The resident stated after lighting the cigarette, he realized that he should not have been smoking inside and he put it out and placed the cigarette butt in a napkin that was located on his end table. He then hid the napkin in his coat pocket which was located on his wheelchair near his bed. Staff came in the first time and confiscated the cigarettes and lighter he had on the end table. He did not advise them of the cigarette butt, lighter or additional pack of cigarettes in his coat pocket. He noticed smoke at approximately 8:45 A.M. and then the staff came in at the same time. Review of Fire Investigator #100 ' s report revealed the first floor common hallway area directly outside of Resident #1 ' s room presented with evidence of a wheelchair and coat located in this area and residual dry chemical powder from a fire extinguisher. Nursing home staff indicated the wheelchair and coat were located in Resident #1 ' s room near the bed with the coat draped on the wheelchair. The coat was examined and a pack of cigarettes was discovered in the right front pocket. The left front pocket was examined and a lighter, cigarette butt, and charred debris were discovered in this pocket. The items discovered in the pockets were taken as evidence. The left front pocket presented with evidence of heat damage from an event that occurred inside the pocket. The remainder of the coat did not present with any other damage. Both the wheelchair and the coat were heavily covered with dry powder chemical from the fire extinguisher. The items found near the resident ' s bed included an oxygen concentrator, bed, end table and a wheeled stand. Underneath and around the bed area was evidence of a charred material similar to that of a paper napkin. The end table was re-examined and a lighter was discovered in the top drawer. On 11/22/16 at 9:20 A.M., Resident #1 was observed in his room in the wheelchair. Interview with Resident #1 at 9:48 A.M. revealed staff knew he kept his cigarettes and lighters on his person. Resident #1 verified it was a mistake on 11/20/16 when he lit his cigarette in bed and heard staff say they smelled smoke. The resident stated he put the lit cigarette in a napkin to smother it out and then he hid it in his coat pocket that was on the wheelchair beside his bed. Resident #1 stated the cigarette then caught the coat on fire. On 11/22/16 at 11:15 A.M., Resident #1 was observed outside smoking. RN #17 was also observed outside smoking. She verified it was difficult to monitor residents to assure that smoking materials were returned because visitors and other residents would give them cigarettes and lighters. On 11/22/16 at 12:05 P.M., a phone interview was conducted with Resident #1 ' s daughter, who verified the resident was started on Valium, a medication for anxiety, on 11/18/16. The daughter felt the medication was making him crazy and confused . She stated he had fallen twice since starting it and he would have not smoked in his room prior to this. The daughter verified she left cigarettes with the resident but not the lighters. There was no documentation to indicate any increase behaviors that started with the addition of Valium. On 11/22/16 at 12:50 P.M., phone interview with RN #25 verified it was the responsibility of the staff who took the residents outside to smoke to ensure the smoking materials were returned to the box kept at the nursing station. RN #25 stated she was not involved with the smoke breaks. RN #25 verified she was called to Resident #1 ' s room because of the smell of cigarette smoke. RN #25 stated she educated Resident #1 on not smoking in his room. She stated staff already took his pack of cigarettes and lighter out of the room and she did not see anything more. RN #25 stated she assisted in adjusting Resident #1 in bed and left the room. A little while later RN #25 stated they called her back to the room and she observed smoke coming from the resident ' s coat. RN #25 stated she threw the coat in the hallway and got Resident #1 and his roommate out of their room. The smoldering coat was extinguished with the fire extinguisher. On 11/22/16 between 1:25 P.M. and 1:35 P.M. phone interview with STNA #26 and STNA #27 verified they had prior knowledge of residents keeping their cigarettes and lighters on their person. On 11/22/16 at 3:15 P.M., a phone interview with Staff #28 verified in the past staff smoking monitors and residents would return the smoke materials back to the box at the nurse ' s station. Staff #28 verified at times the nurses were too busy to give residents their smoking materials for break times so the residents just started keeping the items in their rooms. Staff #28 verified no one monitors to ensure the materials are returned to the smoking box. Monitoring was completed by the administrator to ensure compliance with the new policy. Staff are now being held accountable to assure smoking materials are returned and held in the smoking box at the nurse ' s station. This was also being monitored by the administrator. On 11/23/16 at 9:30 A.M., interview with STNA #22 verified she was constantly taking cigarettes and lighters away from Residents #1, #2, #4, #7, #8 and #9, at least two or three times a week. STNA #22 stated she told the charge nurse each time she found cigarettes and lighters on residents. STNA #22 indicated while passing breakfast trays on 11/20/16, STNA #23 stated she smelled cigarette smoke. She stated they went into Resident #1 ' s room together and he denied smoking. STNA #22 removed the pack of cigarettes and lighter from the night stand. STNA #22 did not search the area for a lit cigarette and she was not sure if STNA #23 did or not. STNA #22 stated she told Licensed Practical Nurse (LPN) #24. STNA #22 stated that 15 minutes later she smelled smoke from a fire. She told LPN #24 who told her to tell RN #25. STNA #22 stated the wheelchair was on fire. STNA #22 and RN #25 brought the wheelchair out into the hall and used the fire extinguisher to extinguish it. After the incident STNA #22 stated she removed cigarettes and lighters from Resident #2, #4, #7, #8 and #9. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of the current plan of care for smoking revealed document any non-compliance and keep lighter and cigarettes at nursing station. Review of the smoking assessment dated [DATE] revealed Resident #2 was to be supervised while smoking. Review of the quarterly MDS 3.0 dated 11/14/16 revealed Resident #2 had severe cognitive impairment. On 11/22/16 at 9:30 A.M., Resident #2 was observed in her room with oxygen on via nasal cannula. Interview with the resident revealed she had a purse a friend made for her that she kept her cigarettes and lighter in. She stated she always kept it in her room until a couple days ago when someone was smoking in their room and they came and took all the smoking materials, even the purse. Resident #2 stated staff were aware she kept the smoking materials with her. On 11/22/16 at 1:12 P.M., Resident #2 was observed outside smoking with Activities Assistant #19. Resident #2 had her cloth blue purse around her arm and a smoking apron on. After she was finished smoking Resident #2 reached into her purse and removed an aluminum foil wallet, placed her lighter and cigarette inside and closed the wallet together. The resident then started pressing it together with her fingers and placed the wallet into her cloth purse. Resident #2 stated she did not want to litter so that was how so discarded her cigarette butts. When the wallet got full Resident #2 stated she emptied it into the outside trash can. Resident #2 indicated she disposed of her cigarette butts in the plastic lined container full of paper combustibles. Activities Assistant #19 then asked Resident #2 to give her the wallet. The resident got very upset stating I made this, it is mine. I always keep it in my purse with my cigarettes and lighter . The resident eventually and reluctantly gave Activities Assistant #19 the wallet and she removed the cigarette butt and placed it in the appropriate receptacle. Review of the undated smoking policy and procedure revealed a smoking assessment would be completed by a licensed nurse. It indicated if resident was assessed to be able to smoke independently, smoking would be in the designated area. Residents who were their own responsible party and were assessed to be safe to smoke independently, may sign themselves out of the building to smoke during non-smoking times. These residents were assuming responsibility for their own safety and may obtain smoking materials from the first floor nurses station prior to leaving the facility. The residents were responsible to turn the smoking materials back to the first floor nurses station upon returning into the building. Residents who were assessed to need supervision had set supervised times to smoke. All cigarettes and lighters were kept at the first floor nurses station. Nursing staff would be available at the designed times to give residents and/or staff cigarettes and lighters. At no time was it acceptable for a resident to have cigarettes and lighters in their possession outside of the designated smoking times. Failure to follow the smoking policy could lead to restrictions of smoking privileges and possible discharge from the facility. The policy was updated on 11/22/16 to include partially smoked cigarettes may not be saved to smoke later.

Based on observation, interview and record review the facility failed to ensure adequate pain relieving interventions were implemented during a pressure ulcer dressing change to maintain the highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed for pressure ulcers (Resident #38). The facility census was 75. Harm occurred when Resident #38 experienced intense break through pain during a dressing change when the old dressing was pulled off of the sacrum. Resident #38 moaned and expressed pain during this observations. Findings Include: Review of the record revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #38 sustained a fall at his home and laid on the floor for two days, and was admitted to the facility with multiple pressure areas. Review of the medical record revealed Resident #38 had an unstageable (full thickness tissue loss with the base of the ulcer is covered by slough or eschar) wound to his left sacrum that measured 5.0 centimeters (cm) by 2.4 cm by 0.1 cm. and also had a Stage II (partial thickness skin loss presenting as a shallow open wound) to his left knee measuring 3.0 cm by 5.0 cm by 0.1 cm. An observation of a dressing change with Registered Nurse (RN) #22 was completed on 06/08/16 at 3:30 P.M. RN #22 stated that Resident #38 had been medicated for pain with [MEDICATION NAME], a narcotic pain medication, at 3:00 P.M. She entered the room and explained to Resident #38 that she would be changing the dressing to his wounds. As RN #22 and State tested Nurse Aide (STNA) #23, who was assisting her, rolled the resident to his side, RN #22 exposed the dressing on the coccyx and began to remove the old dressing, which was sticky around the outside. As RN # 22 pulled the sticky dressing from the skin of the resident, he moaned loudly in pain. RN #22 stated several times during the process, You are doing fine; we will be done soon. Resident #38 moaned out loud during the removal of the dressing and also as RN #22 cleaned and measured the wound. After completing the dressing change to the resident's sacrum, she then changed the dressing to the resident's left lateral knee. The dressing in place for that area was the same adhesive dressing as was present on the sacrum and the resident also moaned as that dressing was pulled off, although did not seem to be quite as uncomfortable for that wound. After the dressing change was completed, an interview with RN #22 at 3:50 P.M. revealed she had not changed the dressing for the resident prior to the observed dressing change. She stated RN # 27, who was assigned to the resident that day, had medicated him for pain at 3:00 P.M. in preparation for the dressing change. She stated that RN #27 had told her he still had pain at times during dressing changes, despite receiving the medication. She verified the resident had moaned and expressed that he was having pain, however, she continued the procedure. An interview with RN #27 on 06/08/16 at 4:45 P.M. revealed Resident #38 had unspecified pain often and was premeditated for pain prior to dressing changes. He stated he had medicated the resident with [MEDICATION NAME], a narcotic pain medication, at 3:00 P.M. on 06/09/16, in preparation for the dressing change, but that he had changed the dressing at times and noted the resident had pain even after the medication administration. An interview with Resident #38 on 06/08/16 at 4:50 P.M. revealed that he had pain during the dressing change, especially to his left sacrum area. He was aware of the pain medication administration but stated it did not always keep him pain free. Review of the record revealed the [MEDICATION NAME] was originally ordered to be given every 6 hours as needed for pain, but had been increased to every 4 hours as needed on 05/24/16. Review of the facility policy for Pain Management (dated March, 2005) revealed residents should be assessed for pain when observed to exhibit non verbal symptoms of pain or verbalized pain as well as residents who use pain medication regularly or have pressure areas should also be evaluated for pain, to promote comfort and the ability to reach their highest functional level. An interview with the Administrator and corporate nurse (RN # 25) on 06/09/16 at 9:00 A.M. revealed to them the details of the dressing change, including the observation of the resident moaning as the dressing change continued. They verified that the nurse should have stopped the dressing change to assess whether another pain relieving interventions could have been utilized to keep the resident comfortable.