Every finding on record at Kettering Heights Post Acute

Based on observation, interview, review of facility environmental and pest control documents and policy review, the facility failed to ensure an effective pest control program. This had the potential to affect all residents residing in the facility. The facility census was 99.Findings Included:Review of a facility document titled Environmental Safety/Maintenance, dated 03/16/2026 revealed a concern related to pests possible back in attic. During an interview on 05/26/26 at 11:10 AM, the Central Supply Clerk/Housekeeper (CSC) stated they had a racoon issue and had a company come out to trap them. The CSC stated two raccoons were caught about a week and a half prior. The CSC stated in January 2026, he noticed squirrels and had someone come out and trap them. He stated they heard them in the ceiling of the MedBridge B Unit. At that time, the Maintenance Director went into the attic and found droppings. The CSC stated that in February 2026, he found a hole in the corner of the courtyard and reported it to the Maintenance Director. He said the Maintenance Director did not take care of the hole. During an observation on 05/26/26 at 11:15 AM, with the CSC, a large gaping hole where the soffit and fascia connected above the gutter was observed. Gnaw marks were observed on the fascia too. The CSC estimated the hole was about the size of a basketball. The CSC stated that previously a raccoon was trapped on the ground in that corner. A 2-foot-long by 1.5-inch-wide piece of vent from the soffit was observed on the ground behind the bush and [NAME]. An additional hole was observed in the opposite corner behind the bush that filled the whole corner from the ground to the roof. The hole was 3 to 4 inches wide and about a foot long. The CSC stated it was big enough for a squirrel to get into. During an observation on 05/26/26 at 11:33 AM, the CSC pointed out another small hole in the back of the building in the corner of the soffit outside room [ROOM NUMBER]. The CSC stated it was about the size a squirrel could get into. He stated that if that were a hole the squirrels came through, they would be able to travel down the 300 Hall (MedBridge Unit B). Review of a Termite & Pest Service Report dated 01/23/2026 revealed Pest Control Vendor #25 provided a wildlife inspection/estimate to the facility. The Report revealed proposed services with no documented estimated cost. During a telephone interview on 05/26/26 at 6:42 PM, Pest Control Representative (Rep) #16 for Pest Control Vendor #25 stated he provided general pest control for the facility. He verified that in January of 2026, the Maintenance Director reported residents were hearing noises in the attic, so an estimate was completed at that time. He stated based on the documents, entry points for squirrels were identified. During an interview on 05/26/26 at 9:41 AM, the Administrator stated staff had reported hearing something run around in the ceiling, so they called a pest control company. The Administrator stated there was a hole in the roof where squirrels got in, saying the pest control company came and within three weeks removed squirrels and racoons. He believed the point of entry was in the courtyard area around the corner of the therapy gym where there was a gap in the flashing. The Administrator verified a wildlife estimate was requested in January of 2026, but the decision was made to go with a different company. Review of a Special Service Agreement dated 02/10/26 from Pest Control Vendor #26 revealed agreement instructions for a 5-day wildlife trapping for squirrels in the attic, with four follow-ups included. The document revealed an electronic signature by the facility Administrator signed and dated on 05/06/2026. Review of a Service Inspection Report dated 05/11/26 from Pest Control Vendor #26 revealed multiple entry points were identified that were large enough to grant access to squirrels, raccoons, and birds. The Service Inspection Report indicated squirrel traps were set and that the vender would return with larger traps to also target racoons, and that traps would be checked once a day for the next four days. Review of a Service Inspection Report dated 05/13/26 from Pest Control Vender #26 revealed two adult raccoons were trapped. An additional Service Inspection Report, dated 05/14/26, revealed one adult gray squirrel and one cat were trapped. The Pest Control Vendor #26 Service Inspection Report dated 05/15/26 revealed two raccoons were trapped. Telephone interview on 05/26/2026 at 12:27 PM and 05/27/26 at 8:36 AM were attempted with the Maintenance Director with no return calls. During a telephone interview on 05/27/26 at 8:42 AM, Pest Control Rep #18 stated he provided the facility with a wildlife estimate. He stated he met with the Administrator and the Maintenance Director at that time and identified entry points that were large enough for racoons to fit through. He said he reached out and stopped by following up between February and May and was told the facility was waiting for corporate approval. Pest Control Rep #18 stated he informed the facility that the pest control company would put something in place to block the holes such as wire netting, but that it would be a temporary fix and would not last for years. He stated that the holes needed a lot of work, so he recommended the facility hire a contractor to close the holes. During a follow-up telephone interview on 05/27/26 at 9:11 AM, Pest Control Rep #18 stated the technician indicated the holes at the facility were bigger than originally observed once service was started in May 2026, therefore recommended the facility get a contractor to seal the holes because the technician would not be able to seal them properly. During an interview on 05/27/26 at 11:11 AM, the Administrator stated he was told attempts had been made to reach Pest Control Vendor #26 and were unsuccessful from February to May 2026, so he reached out to Pest Control Vender #26 himself and hired the company. The Administrator said he was not told they needed a contractor to seal the holes. Review of a facility policy titled, Pest Control, revised in May 2008 revealed Our facility shall maintain an effective pest control program. The policy also indicated, 1. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Additionally, the policy indicated, 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.This deficiency represents non-compliance investigated under Complaint Number 3016001.

Based on observation, interview, and facility policy review, the facility failed to ensure food items were stored in a sanitary manner when items in a nourishment refrigerator were not labeled with a date or a resident name. This had the potential to affect 14 (Residents #117, #37, #41, #45, #48, #52, #55, #71, #125, #84, #123, #97, #120, and #8) out of 15 residents who resided on the hall. The facility census was 99.Findings Included:An observation of the facility's resident nourishment refrigerator was conducted with the Dietary Manager (DM) on 05/25/26 at 10:19 AM. The observation of the resident nourishment refrigerator revealed: (1) opened package of frozen hot dogs - no use-by date or resident name. (1) opened box of popsicles - no use-by date or resident name. (2) pints of ice cream - no use-by date or resident name. (1) frozen breakfast bowl meal - no use-by date or resident name. (2) opened 1/2 gallons of ice cream containers - no use-by date or resident name. (1) opened package of ice cream sandwiches - no use-by date or resident name. (1) opened package of ice cream bites - no use-by date or resident name. (1) bag of left-over fast-food meal - no use-by date or resident name. During an interview on 05/25/26 at 10:22 AM, the DM stated nursing or housekeeping staff were responsible for maintaining the resident nourishment refrigerator. A follow-up observation of the facility's resident nourishment refrigerator was conducted on 05/26/26 at 3:38 PM. The observation of the resident nourishment refrigerator revealed the same two items below from the first observation: opened frozen breakfast bowl meal - no use-by date or resident name. opened pint of ice cream - no use-by date or resident name. During an interview on 05/25/26 at 3:38 PM, the DM stated that nursing staff were responsible for maintaining the resident nourishment refrigerator. During an interview on 05/26/26 at 3:49 PM, the MedBridge Unit Manager (MBUM) stated that it was the nursing staff's responsibility for ensuring all foods brought in from families were labeled and dated. The MBUM stated that nursing staff were responsible for maintaining the facility's resident nourishment refrigerator. During an interview on 05/27/26 at 9:52 AM, the Assistant Director of Nursing (ADON) stated that all foods brought in from families should be labeled with the resident's name and the date the food item was placed into the refrigerator. The ADON confirmed the nursing staff were responsible for maintaining the facility's resident nourishment refrigerator. During an interview on 05/27/26 at 9:55 AM, the Director of Nursing (DON) stated that all stored food items should be labeled with the resident's name and opened date and should be thrown away after three days. The DON stated that nursing staff were responsible for maintaining the facility's resident nourishment refrigerator. During an interview on 05/27/26 at 11:54 AM, the Administrator (ADM) stated their expectation was that all food brought in from families should be labeled with resident name and open date and should be discarded within three to four days. The ADM stated it was the nursing staff's responsibility to ensure all food items were labeled and discarded after three days.Review of a facility policy titled Foods Brought by Family/Visitors, dated 05/28/2025 revealed, 8. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Non-perishable foods are stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. Perishable foods are stored in re-sealable containers with tightly-fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the 'use by' date. 9. The nursing staff will discard perishable foods on or before the 'use by' date. 10. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).

Based on observation, interview, record review, facility document review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines review, and CDC isolation precautions signage review, the facility failed to ensure staff implemented appropriate infection control practices when staff failed to put on required personal protection equipment (PPE) when entering a room of a resident on contact precautions. This affected one (Resident #37) out of one resident reviewed for transmission based precautions. In addition, the facility failed to ensure staff performed proper hand hygiene while delivering meal trays on one (100 Hall) out of four resident halls observed. The 100 hall had 20 residents who resided on the hall. Additionally, the facility failed to ensure a catheter collection bag was kept under clean and sanitary conditions. This affected one (Resident #34) out of two residents reviewed who had a catheter. The facility census was 99. Findings Included: 1.Review of an admission Record revealed the facility admitted Resident #37 on 04/08/26. According to the admission Record the resident had a medical history that included diagnoses of cognitive communication deficit, an open wound of the right lower leg, a local infection of the skin and subcutaneous tissue, and a sepsis organism. Review of a modification to an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/26 revealed Resident #37 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated that the resident had a wound infection. The MDS indicated that the resident required set-up and clean-up assistance for eating. Review of Resident #37's Order Summary Report with active orders as of 05/24/26 contained an order dated 04/08/26 revealed the resident was to be on contact precautions due to methicillin-resistant staphylococcus aureus (MRSA) in a wound. The Order Summary Report contained an order dated 04/15/26 for contact isolation for MRSA in a wound. Review of Resident #37's Care Plan Report included a focus area initiated 04/09/26 revealed the resident was in a single room for contact isolation precautions due to a MRSA infection. Interventions initiated 04/09/26 directed staff to follow universal precautions when working with residents in isolation; maintain isolation using contact single room precautions; safely handle potentially contaminated equipment or surfaces in the resident's environment, and respiratory hygiene/cough etiquette; and use of PPE as recommended for the type of infection. The Care Plan Report included a focus area revised 04/22/26 revealed the resident required assistance with activities of daily living. Interventions included the resident required set-up and clean-up assistance for eating (revised 04/22/26). Review of a CDC Contact Precautions sign was observed on 05/24/26 at 10:03 AM on the wall next to the doorframe of Resident #37's room. The Contact Precautions sign indicated Everyone Must: Clean their hands, including before entering and when leaving the room. The sign also revealed, Providers and Staff Must Also, which included Put on gloves before room entry. Discard gloves before room exit and Put on gown before room entry. Discard gown before room exit. An observation on 05/24/26 at 12:14 PM revealed the Contact Precautions sign was outside Resident 37's door. Certified Nursing Assistant (CNA) #2 delivered a lunch meal tray to Resident #37 in the resident's room. STNA #2 did not put on PPE prior to entry of Resident #37's room. STNA #2 touched Resident #37's beverage cup located on the resident's bedside table and adjusted the bedside table for the resident after setting the meal tray on the bedside table. During an interview on 05/24/26 at 12:17 PM, CNA #2 stated she should put on the PPE that was indicated on a Contact Precaution sign. She stated she would put on a gown and gloves if she was going to have contact with the resident. She stated that if she were to move a resident's items, she should wear gloves. She stated that she did not think she needed to wear any other PPE other than gloves when delivering a meal tray and touching a resident's items for a resident on contact isolation. During an interview on 05/26/26 at 3:14 PM, the Assistant Director of Nursing (ADON), who was the Infection Preventionist, stated that when a resident was on contact precautions, staff needed to have the required PPE on before they went into the room. He stated that for contact precautions, the required PPE was a gown and gloves. He stated they had to wear a gown and gloves whether or not they were getting ready to provide care for the resident. During an interview on 05/27/26 at 1:48 PM with the Director of Nursing (DON) and the Administrator, the DON stated her expectation was that staff put on PPE in a contact precaution room as required. She stated staff were to follow the signage as to what to wear. During the interview, the Administrator stated his expectation was the same as the DON's. Review of a facility policy titled Isolation - Categories of Transmission–Based Precautions, dated revised 2022 revealed Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The policy also indicated in the Contact Precautions section, 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident–care items in the resident's environment; 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room; and 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 2. An observation of meal service on the 100 Hall on 05/24/26 at 12:29 PM revealed CNA #8 entered room [ROOM NUMBER] to deliver the resident's lunch tray. CNA #8 prepared the tray and exited the room without performing any hand hygiene. CNA #8 then returned to the food cart, grabbed the next meal tray and entered room [ROOM NUMBER] and delivered the meal to the resident in Bed 1. She placed the tray on the resident's overbed table, removed the tray lid, and exited the room without performing any hand hygiene. CNA #8 then returned to the food cart, grabbed the next meal tray, and room [ROOM NUMBER] and delivered the meal to the resident in Bed 2. She placed the tray on the resident's overbed table, and removed the tray lid, then raised the resident's head of the bed (HOB) with the bed controls at the end of the bed. She then exited the room without performing any hand hygiene. CNA #8 then returned to the food cart, grabbed the next meal tray, and entered room [ROOM NUMBER] and delivered the meal to the resident in Bed 1. She placed the tray on the resident's overbed table, removed the tray lid, cut the resident's food using the resident's utensils, touched the overbed table, raised the HOB with the bed controls at the end of the bed, and then exited the room without performing any hand hygiene. CNA #8 then returned to the food cart, grabbed the next meal tray, and entered room [ROOM NUMBER] and delivered the meal to the resident in Bed 2. She placed the tray on the resident's overbed table, removed the tray lid, and exited the room without performing any kind of hand hygiene. CNA #8 then returned to the food cart, grabbed the next meal tray, and entered room [ROOM NUMBER] and delivered the meal to the resident in Bed 1. She placed the tray on the resident's overbed table, removed the tray lid, touched the overbed table, raised the HOB with bed controls at the end of the bed, and then spilled some liquids from the meal tray onto the bed linens. CNA #8 removed the linens from the resident's bed and placed them in a chair. CNA #8 went back to set up the tray, touched the end of the bed again, placed her hand on the door frame to speak to a nurse, and then exited the room without performing any kind of hand hygiene. CNA #8 then returned to the food cart, grabbed the next meal tray, and entered room [ROOM NUMBER] and delivered the meal to the resident in Bed 2. She placed the tray on the overbed table, removed the tray lid, and exited the room without performing any kind of hand hygiene. CNA #8 then returned to the food cart, grabbed the next meal tray, and entered room [ROOM NUMBER] and delivered the meal to the resident in Bed 1. She placed the tray on the overbed table, removed the tray lid, and exited the room without performing any kind of hand hygiene. CNA #8 then returned to the food cart, grabbed the next meal tray, and entered room [ROOM NUMBER] and delivered the meal to the resident in Bed 2. She placed the tray on the overbed table, removed the tray lid, turned the room light on, touched the overbed table, touched the bed control to raise the HOB, touched the bed linens, and exited the room without performing any kind of hand hygiene. During an observation and interview on 05/24/26 at 12:49 PM, in regard to if she had sanitized her hands at any point during the meal delivery, CNA #8 stated, I have not, I apologize. I should be. CNA #8 then delivered a meal tray to room [ROOM NUMBER] without performing hand hygiene, then sanitized her hands when leaving the room. During an interview on the 100 Hall on 05/24/26 at 12:51 PM, Licensed Practical Nurse (LPN) #10 stated that CNAs should be sanitizing their hands during meal delivery, to decrease the risk of infections. During an interview on 05/25/26 at 2:32 PM, the Assistant Director of Nursing (ADON), who was the Infection Preventionist, stated the process for infection control with meal delivery was to deliver the tray and sanitize hands when walking out of the resident's door. He stated that if staff were raising the HOB or touching anything in between, like bed linens, then staff should wash their hands. During an interview on 05/27/26 at 2:03 PM, the Director of Nursing (DON) stated her expectations with meal delivery were for staff to sanitize their hands between resident rooms, wash their hands every third room, and wash their hands if they touched any items while in the resident's room. During an interview on 05/27/26 at 4:00 PM, the Administrator stated his expectations with meal delivery were for staff to disinfect their hands with hand sanitizer as they delivered meal trays and to wash their hands as needed. Review of a facility policy titled Handwashing/Hand Hygiene, revised 08/2019 revealed This facility considers hand hygiene the primary means to prevent the spread of infections. The policy revealed 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. The policy revealed, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy revealed, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations, which included l. After contact with objects (e.g. [exempli gratia, for example], medical equipment) in the immediate vicinity of the resident, and p. Before and after assisting a resident with meals. 3. Review of an admission Record revealed the facility admitted Resident #34 on 04/30/26. According to the admission Record, the resident had a medical history that included a diagnosis of neuromuscular dysfunction of the bladder (a dysfunction of the bladder due to brain, spinal cord, or nerve problems). Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/26 revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident had an active diagnosis of neurogenic bladder. Review of Resident #34's Nursing - Bowel and Bladder Observation/assessment dated [DATE] revealed Resident #34 had an indwelling urinary catheter due to neurogenic bladder. Review of Resident #34's Care Plan Report included a focus area initiated 05/25/26 revealed the resident had an indwelling urinary catheter. Interventions initiated 05/25/26 directed staff to provide catheter care and use a privacy cover for the catheter bag to promote dignity. During an observation in Resident #34's room on 05/24/26 at 9:30 AM, Resident #34's indwelling urinary catheter drainage bag was observed attached to the right side of the bed's second rail, with approximately 1700 milliliters (mL) of fluid in the collection bag in direct contact with the floor. During a concurrent observation and interview on 05/25/26 at 1:30 PM, CNA #2 stated catheter care included maintaining the drainage bag below bladder level, without kinks in tubing, and securing appropriately. CNA #2 stated that the drainage bag should not be on the floor because it was unsanitary. Upon entering the resident's room at that time, CNA #2 observed Resident #34's catheter drainage bag resting in direct contact with the floor and stated that was not the expected practice. An observation in Resident #34's room on 05/26/26 at 2:28 PM revealed Resident #34 was resting in bed, and the urinary drainage bag was observed in direct contact with the floor, inside a blue privacy bag. An observation in Resident #34's room on 05/27/26 at 9:12 AM revealed Resident #34 was sitting upright in bed with the catheter collection bag contained within a blue privacy bag; the blue privacy bag was hanging on the right lower bed rail, closest to the window, and was in direct contact with the floor. During an interview on 05/26/26 at 4:45 PM, Licensed Practical Nurse (LPN) #1 stated catheter drainage bags should remain below the bladder level and be secured to the bed. LPN #1 stated that if a drainage bag was observed out of position, staff were expected to correct it. During an interview on 05/27/26 at 1:49 PM, the Assistant Director of Nursing (ADON), who was the Infection Preventionist stated catheter drainage bags should be secured appropriately and remain off the floor and stated that was the expectation for proper catheter care. During an interview on 05/28/26 at 10:33 AM, Physician Assistant (PA) #9 stated catheter drainage bags should be maintained off the floor and secured to prevent contamination and ensure proper drainage and indicated improper positioning could interfere with drainage and allow urine to back up in the tubing. During an interview on 05/27/26 at 6:40 PM, the Medical Director stated that repeated contact of a catheter drainage bag with the floor could increase the risk of infection. During an interview on 05/27/26 at 3:00 PM, the Director of Nursing (DON) stated catheter drainage bags should not be in contact with the floor and should be monitored to ensure proper placement and condition. Review of a facility policy titled Catheter Care, Urinary, revised 09/2014 revealed The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy revealed the section titled, Infection Control included 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag, and included b. Be sure the catheter tubing and drainage bag are kept off the floor. Review of a CDC guideline titled Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, last updated 06/06/2019 indicated III. Proper Techniques for Urinary Catheter Maintenance included B. Maintain unobstructed urine flow, which included 2. Keep the collecting bag below the level of the bladder at all times and do not rest the bag on the floor. Review of a facility policy titled Policies and Practices – Infection Control, revised October 2018 revealed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The policy revealed, 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents' right of a dignified existence, specifically, staff failed to ensure urinary catheter bags were covered. This affected two (Resident #28 and Resident #34) out of two residents reviewed for dignity. The facility census was 99. Findings Included: 1. Review of the admission record revealed the facility admitted Resident #28 on 09/30/25. According to the admission Record, Resident #28 had a medical history that included diagnoses of obstructive and reflux uropathy (condition where the flow of urine is blocked), unspecified hydronephrosis (swelling of one or both kidneys due to urine being unable to drain), neuromuscular dysfunction of the bladder, unspecified (a dysfunction of the bladder due to brain, spinal cord, or nerve problems), presence of urogenital implants (medical devices used to treat conditions of the urinary and productive systems), and retention of urine. Review of an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/26 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #28 had an indwelling catheter. Review of Resident #28's Care Plan Report included a focus area revised 05/13/26 that revealed the resident was at risk for infection and/or trauma related to the use of a suprapubic catheter (a flexible tube inserted directly into the bladder through a small incision in the lower abdomen). Interventions directed the staff to provide catheter care every shift (initiated 10/03/23). Review of Resident #28's Order Summary Report with active orders as of 05/25/26 contained an order dated 03/09/2026 for a suprapubic catheter, for neuromuscular dysfunction of the bladder. During observations on 05/24/26 at 10:48 AM, 12:52 PM, and 2:33 PM, Resident #28's catheter bag was visible from the hallway, hanging on the left side of the resident's bed, without a privacy cover. The catheter bag had approximately 200 milliliters of pale-yellow urine. During an observation and interview on 05/24/26 at 2:34 PM, Licensed Practical Nurse (LPN) #7 walked past Resident #28's doorway. In regard to if Resident #28's catheter bag should be visible from the doorway, LPN #7 stated there should have been a cover on the bag for the resident's dignity. During a telephone interview on 05/28/26 at 9:03 AM, Resident #28's family member (FM), FM #23 stated the resident's catheter bag had always been uncovered and had been that way as long as she could remember. During an interview on 05/25/26 at 2:28 PM, the Assistant Director of Nursing (ADON) stated the facility's process for caring for a resident with a urinary catheter was to provide full catheter care every shift, monitor its function, ensure the bag was not on the floor, and the catheter was draining appropriately. He stated that a privacy bag should be on the catheter bag. During an interview on 05/27/26 at 6:25 PM, the Medical Director (MD) stated the catheter bags should be out of sight for dignity issues. During an interview on 05/27/26 at 2:03 PM, the Director of Nursing (DON) stated her expectations for indwelling catheters were for staff to assess for proper function, secure the catheter below the bladder, and provide a dignity bag. During an interview on 05/27/26 at 2:50 PM, the Administrator stated his expectations were to have dignity bags for indwelling catheters. 2. Review of an admission Record revealed the facility admitted Resident #34 on 04/30/26. According to the admission Record, the resident had a medical history that included a diagnosis of neuromuscular dysfunction of the bladder (a dysfunction of the bladder due to brain, spinal cord, or nerve problems). Review of an admission MDS with an ARD of 05/07/26 revealed Resident #34 had a BIMS score of 15 which indicated the resident had intact cognition. The MDS indicated that the resident had an active diagnosis of neurogenic bladder. Review of Resident #34's Nursing - Bowel and Bladder Observation/assessment dated [DATE] revealed Resident #34 had an indwelling urinary catheter due to neurogenic bladder. Review of Resident #34's Care Plan Report included a focus area initiated 05/25/26 revealed the resident had an indwelling urinary catheter. Interventions initiated 05/25/26 directed staff to provide catheter care and use a privacy cover for the catheter bag to promote dignity. During a concurrent observation and interview in Resident #34's room on 05/24/26 at 9:30 AM, Resident #34's urinary catheter drainage bag was observed attached to the right side of the bed with approximately 1700 milliliters (mL) of fluid and was visible from the room entrance. During the interview at that time, Resident #34 reported feeling self-conscious when others entered the room and observed the urine. During a concurrent observation and interview on 05/25/26 at 1:30 PM, Certified Nursing Assistant (CNA) #2 stated catheter drainage bags should remain below bladder level, secured appropriately, and not on the floor because it was unsanitary. CNA #2 stated Resident #34's catheter bag was visible from the hallway. Upon entering the room, the resident's catheter drainage bag was observed in direct contact with the floor. CNA #2 that was not expected practice. CNA #2 stated that catheter drainage bags should be positioned out of view and stated that visibility from the hallway could be embarrassing for residents. During a concurrent observation and interview on 05/25/26 at 1:55 PM in Resident #34's room, the resident's urinary catheter drainage bag was observed positioned off the floor and contained within a protective bag, with the urine less visible due to the cover. During an interview at that time, Resident #34 stated that they were unaware that a privacy cover for the catheter bag existed and stated that they felt self-conscious about others observing the urine in the catheter bag. Resident #34 stated that they had felt ashamed and stated that the use of the protective bag reduced those concerns. The resident stated that knowing about the availability of a privacy cover and earlier knowledge would have helped. Resident #34 stated visibility of the urine in the catheter bag could affect others' appetites. During an observation on 05/28/26 at 9:14 AM, Resident #34's catheter drainage bag was uncovered and visible from the hallway. The Assistant Director of Nursing (ADON), CNA #4, and CNA #5 verified they could see urine in the drainage bag from the hallway. The ADON entered the room and repositioned a cover over the drainage bag. During an interview on 05/26/26 at 4:45 PM, LPN #1 stated that Resident #34's catheter drainage bag had been visible from the hallway and stated that an uncovered bag did not maintain resident dignity or privacy. LPN #1 stated that staff were expected to ensure catheter bags were covered and positioned appropriately. During an interview on 05/27/26 at 1:49 PM, the ADON stated that catheter drainage bags should be covered and not visible in the hallway, to maintain resident dignity. During an interview on 05/27/26 at 3:00 PM, the DON stated that catheter drainage bags should be covered and positioned appropriately and stated that use of a privacy bag was expected to promote resident dignity. During an interview on 05/27/26 at 6:40 PM, the Medical Director stated that privacy measures for catheter bags supported resident preference and dignity. During an interview on 05/27/26 at 2:50 PM, the Administrator stated his expectations were to have dignity bags for indwelling catheters. Review of a facility policy titled, Resident Rights, revised 08/2009, revealed Employees shall treat all residents with kindness, respect, and dignity. The policy revealed, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to, which included d. Privacy and confidentiality.

Based on record review, observation, interview, and policy review, the facility failed to ensure a resident who had a medication at their bedside and self-administered the medication was assessed by the interdisciplinary team (IDT) for safe self-administration and had an order for the medication. This affected one (Resident #12) out of one resident reviewed for self-administration of medications. The facility census was 99.Findings Include:Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/26 revealed the facility admitted Resident #12 on 03/13/26. The MDS indicated the resident had active diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure. The MDS revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. During a concurrent observation and interview in Resident #12's room on 05/24/26 at 10:00 AM, a budesonide-glycopyrrolate-formoterol fumarate inhaler was on the resident's bedside table. Resident #12 stated the inhaler was brought into the facility by a family member and was self-administered three times daily for personal use. During an observation of medication administration on 05/25/26 at 08:00 AM with Licensed Practical Nurse (LPN) #17, a budesonide-glycopyrrolate-formoterol fumarate inhaler was observed on Resident #12's bedside table. When the nurse questioned Resident #12 during the observation, Resident #12 told LPN #17 the inhaler was self-administered three times daily and stated that a family member brought the inhaler into the facility. During an interview on 05/25/26 at 08:08 AM, LPN #17 stated that Resident #12's inhaler present at their bedside was not included in the resident's physician orders and indicated further investigation would occur. During an interview on 05/28/26 at 10:00 AM, Resident #12 stated they did not recall being asked if they wanted to self-administer. During an interview on 05/28/26 at 08:48 AM, LPN #21, stated she had seen Resident #12 with an inhaler. LPN #21 stated Resident #12 self-administered the inhaler with proper direction and stated the inhaler was stored on the resident's bedside table or in a drawer. Review of Resident #12's Care Plan Report included a focus area initiated 03/14/26 revealed the resident was at risk for complications with their respiratory system related to COPD. Interventions directed staff to administer medications as ordered and monitor effectiveness and adverse reactions (initiated 03/14/2026). The Care Plan Report revealed no documentation regarding self-administration of medications. Review of Resident #12's Order Summary Report with active orders as of 05/28/26 contained an order dated 05/27/26 (after the observation on 05/24/26), for budesonide-glycopyrrolate-formoterol fumarate inhalation aerosol (an anticholinergic agent) 160 9 4.8 micrograms (mcg) per actuation, two inhalations orally two times daily for COPD. During an interview on 05/26/26 at 03:43 PM, Certified Nursing Assistant (CNA) #2 stated that if medication was found in a resident room, staff reported it to the nurse, and the nurse removed the medication due to safety concerns. During an interview on 05/28/26 at 10:33 AM, Physician Assistant (PA) #9 stated that Resident #12 would be an appropriate candidate for self-administration. PA #9 stated that the inhaler was compatible with the resident's current medication regimen and would not pose a concern. The PA stated that there was no prior self-administration assessment completed. During an interview on 05/28/26 at 09:39 AM, Assistant Director of Nursing (ADON) stated that medications eligible for self-administration required a physician's order and completion of a self-administration assessment and stated that care plan interventions were be updated to reflect self-administration if approved. The ADON also stated that Resident #12 was not assessed to self-administer, and that the medication should not have been left at bedside. During a concurrent interview on 05/27/26 at 03:00 PM, the Director of Nursing (DON) and the Assistant Regional Director of Clinical Services (ARDCS) both stated that medications should not be kept at the bedside. The ARDCS stated that the facility was not aware the resident intended to self-administer; therefore, no self-administration assessment had been completed. Review of a facility policy titled, Self-Administration of Medications, revised 02/2021 indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy revealed, 2. The IDT [interdisciplinary team] considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident, which included f. The resident is able to safely and securely store the medication. The policy revealed, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.Review of a facility policy titled, Resident Rights, revised 08/2009, indicated Employees shall treat all residents with kindness, respect, and dignity. The policy revealed, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include, which included m. Self-administer medication, if the interdisciplinary care planning team determines it is safe.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff provided nail care. This affected one (Resident #37) out of two residents reviewed for activities of daily living (ADL). The facility census was 99. Findings Include:Review of an admission Record revealed the facility admitted Resident #37 on 04/08/26. According to the admission Record, the resident had a medical history that included diagnoses of cognitive communication deficit and a need for assistance with personal care. Review of a modification to an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/26 revealed Resident #37 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #37 required substantial to maximum assistance from staff with showering and bathing and required supervision or touching assistance for personal hygiene. Review of Resident #37's Care Plan Report included a focus area revised on 04/10/26 indicated the resident required assistance with ADLs. Interventions revised on 04/22/26 indicated the resident was dependent on staff for hygiene. During a concurrent observation and interview on 05/24/26 at 2:36 PM, Resident #37 was lying in bed. Resident #37's fingernails on the right hand were observed to extend approximately one-half inch past the end of the fingertips. Resident #37's fingernails on the left hand, except for the index finger and thumb, were observed to be approximately one-half inch past the end of the fingertips. Resident #37 stated staff did not file or trim their nails. Resident #37 stated that they needed their nails to be trimmed but did not know who to ask. Resident #37 stated that they did not like their nails being long. Review of a 30 day look back period for Resident #37's Shower Days specifically Nail Care, revealed staff documented showers occurred on 04/26/26, 04/30/26, 05/03/26, 05/10/26, 05/14/26, 05/17/26, 05/20/26 and 05/24/26. The record revealed that staff documented that nail care was provided on 04/26/26. Per the record, staff documented that nail care was Not Applicable on 04/30/26, 05/10/26, 05/14/26, and 05/24/26; none provided on 05/17/26; and documented the resident refused on 05/03/26 and 05/20/26. Review of Resident #37's Comprehensive Skin Evaluation/Assessment records, dated 05/13/26, 05/20/26, and 05/22/26, revealed no documented evidence of the resident's nails being long. Review of Resident #37's Progress Notes for the timeframe from 05/03/26 through 05/27/26, revealed no documented evidence to indicate that Resident #37 had refused nail care. During an interview on 05/25/26 at 3:30 PM, Registered Nurse (RN) #13 stated that nail care was expected to be completed during the resident's shower. During a concurrent observation and interview on 05/25/26 at 3:59 PM, RN #13 observed Resident #37's nails on both hands while the resident lay in bed. RN #13 stated Resident #37's nails were clean and long and needed to be cut. At that time, Resident #37 stated to RN #13 that their nails were too long and wanted them cut. During an interview on 05/27/26 at 1:25 PM, RN #15 stated that when completing a skin assessment, nurses did a full-body assessment of the resident. RN #15 stated if the nails of a resident were long and the resident was not diabetic; the RNs could cut the resident's nails. During an interview on 05/26/26 at 11:51 AM, Licensed Practical Nurse (LPN) #1 stated she was not informed by the Certified Nursing Assistants (CNAs) that there were any issues with Resident #37's nail care or that the resident refused nail care. LPN #1 stated nail care, which included trimming, was part of a resident's shower or bed bath. LPN #1 stated that CNAs should of checked to see if the resident's nails were extra-long, and if they were, the CNA should ask the resident if they would like their nails trimmed. During a telephone interview on 05/27/26 at 9:10 AM, CNA #11 stated she provided Resident #37 a shower on 05/14/26. CNA #11 stated that for the nail care task, if nail care was not completed, not applicable would be documented. She verified she had not cleaned or trimmed the resident's nails. During an interview on 05/27/26 at 9:32 AM, the Assistant Director of Nursing (ADON) stated CNAs were to offer nail care when providing residents a shower. CNAs should trim the nails of a resident who was not diabetic. The ADON stated if a resident refused nail care the CNA should alert the nurse. The nurse should educate the resident and try to encourage the resident to allow nail care. He stated that if the resident refused, the nurse should document that in the progress notes. The ADON indicated CNAs should not document applicable for nail care. During an interview on 05/27/26 at 1:35 PM, the ADON stated that when nurses completed a skin assessment, they should look at a resident's nails. During an interview on 05/27/26 at 11:37 AM, the Director of Nursing (DON) stated that the expectation was that staff made sure residents' nails were cleaned, filed, and cut. The DON stated if a resident refused nail care, staff should document it and alert the nurse. The DON stated that staff should be checking a resident's nails and providing nail care. During an interview on 05/27/26 at 11:03 AM, the Administrator stated the expectations are that CNAs communicate to the nurse if residents refused a shower, nail care, or ADL care. The Administrator stated that the expectation was that staff followed policy regarding nail care. Review of a facility policy titled Care of Fingernails/Toenails, revised October 2010 revealed The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy also revealed, 1. Nail care includes daily cleaning and regular trimming.Review of a facility policy titled Activities of Daily Living (ADLs), Supporting, revised March 2018 revealed Residents will [sic] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a enteral nutrition tube feeding bag was labeled and dated. This affected one (Resident #6) out of two residents reviewed for tube feedings. The facility census was 99.Findings Include:Review of an admission Record revealed the facility admitted Resident #6 on 01/09/26. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, heart failure, and chronic kidney disease. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/26 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had a feeding tube and received 26 to 50 percent of their total calories via (by way of) a feeding tube. Review of Resident #6's Care Plan Report included a focus area initiated 01/11/26 revealed the resident had a gastrostomy tube and was at risk for enteral nutrition complications. Interventions directed staff to monitor intake and output per protocol and provide enteral tube care as needed. Review of Resident #6's Order Summary Report contained an active order dated 04/23/25 for enteral feeding formula at a rate of 35 milliliters (ml) per hour to start at 6:00 PM and run until 700 ml was infused. An observation on 05/24/26 at 10:33 AM revealed Resident #6 in bed with tubing attached to an unlabeled bag of brown-colored substance running via a pump at 35 ml per hour. The tube feeding bag was not labeled with the resident's name, room number, date the feeding was hung, time the bag was hung, the type/brand of the tube feeding formula, or the nurse's initials. An observation on 05/25/26 at 9:20 AM revealed Resident #6 in bed with tubing attached to an unlabeled bag of brown-colored substance running via a pump at 35 ml per hour. The tube feeding bag was not labeled with the resident's name, room number, date the feeding was hung, time the bag was hung, the type/brand of the tube feeding formula, or the nurse's initials. During an interview on 05/25/26 at 9:32 AM, Licensed Practical Nurse (LPN) #22 confirmed Resident #6's tube feeding was not labeled, dated, or initialed by a nurse and should have been. During an interview on 05/27/26 at 10:08 AM, the Director of Nursing (DON) stated when hanging tube feeding that nursing staff should verify the order to make sure they have the correct formula and should label the tube feeding with the resident's name, the date, nurse initials, and time the tube feeding was started. She stated the reason for doing these things was to know if there were any concerns such as if the rate was slower than 24 hours and the next nurse needed to change it. She stated that it did not meet her expectations to have the tube feeding bag hung with no labeling, nurse initials, or time the feeding was initiated. During an interview on 05/26/26 at 3:49 PM, the Administrator (ADM) stated that he expected nursing staff to follow facility policy and procedure regarding tube feeding. Review of a facility policy titled, Enteral Feedings - Safety Precautions, revised in April 2026 indicated Preventing errors in administration, included, 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.

Based on interview, record review, and facility policy review, the facility failed to ensure residents were free of significant medication errors, when midodrine (a miscellaneous cardiovascular agent, used to treat a sudden drop in blood pressure) was administered 17 times between 03/01/26 and 04/30/26 when it should have been held per the physician-ordered parameters. This affected one (Resident #5) out of five residents reviewed for unnecessary medications. The facility census was 99.Findings Included:Review of an admission Record revealed the facility admitted Resident #5 on 05/19/22. According to the admission Record the resident had a medical history that included diagnoses of coronary artery bypass graft, chronic systolic (congestive) heart failure (CHF), and orthostatic hypotension (low blood pressure). Review of an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/26 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of Resident #5's Care Plan Report included a focus area initiated 02/26/24 revealed the resident was at risk for decreased cardiac output related to CHF, hyperlipidemia, hypertension, and peripheral vascular disease. Interventions initiated 02/26/24 directed staff to administer medications per physician orders and monitor for signs and symptoms of elevated blood pressure. Review of Resident #5's Order Summary Report with active orders as of 03/31/26 included an order dated 11/25/25 for midodrine hydrocholoride (HCl) tablet 2.5 milligrams (mg), one tablet by mouth before meals for orthostatic hypotension. The order specified to hold the medication from administration if systolic blood pressure (SBP), (the top number in a blood pressure reading) was greater than 120 millimeters of mercury (mmHg). Review of Resident #5's March 2026 PACS [Picture Archiving and Communication System] Medication Administration Record (MAR) revealed staff documented the resident received midodrine HCl on the following dates and times when the resident's SBP was greater than 120 mmHg: - 03/06/2026 at 8:00 AM. - 03/10/2026 at 8:00 AM and 11:00 AM. - 03/15/2026 at 8:00 AM and 11:00 AM. - 03/19/2026 at 8:00 AM and 11:00 AM. - 03/23/2026 at 4:00 PM. - 03/29/2026 at 8:00 AM, 11:00 AM, and 4:00 PM. Review of Resident #5's April 2026 PACS MAR revealed staff documented the resident received midodrine HCl on the following dates and times when the resident's SBP was greater than 120 mmHg: - 04/01/2026 at 4:00 PM. - 04/03/2026 at 4:00 PM. - 04/06/2026 at 4:00 PM. - 04/07/2026 at 11:00 AM and 4:00 PM. - 04/12/2026 at 8:00 AM. During an interview on 05/27/26 at 8:23 AM, Licensed Practical Nurse (LPN) #1, verified her initials for administration of the midodrine given outside of the parameters on 03/19/26. She stated, I should have held the medication. It brings Resident #5's blood pressure up. During an interview on 05/27/26 at 8:48 AM, LPN #19 verified her initials for administration of midodrine outside of the parameters on 03/06/26. She stated, I shouldn't have given the medication. During an interview on 05/28/26 at 8:57 AM, Registered Nurse (RN) #13 stated the process for documenting medication administration was to verify the correct medication, verify the medication was there, verify the identification of the resident, and mark yes, and the electronic system placed a check mark to verify the administration of the medication. During a telephone interview on 05/27/26 at 11:28 AM, Pharmacist #24 stated the process for reviewing unnecessary medications was to review all the resident medication orders and review the MAR. Pharmacist #24 stated, I do make sure the medications are given within their parameters. Pharmacist #24 reviewed Resident #5's midodrine administration record for 03/2026 and 04/2026 and acknowledged the medication had been given outside the physician parameters for 17 administrations. Pharmacist #24 stated that the nurse initials with a check mark meant the medication was administered, and if the medication had been held from being administered, it would be noted as a hold, on the MAR. Pharmacist #24 stated she performed sporadic checks and could not comment with any certainty she had performed a review of Resident #5's midodrine administration. Pharmacist #24 stated that if there was an irregularity, it would prompt her to make a recommendation. During an interview on 05/27/26 at 6:25 PM, the Medical Director reviewed Resident #5's 03/2026 and 04/206 MAR for the administration of midodrine and stated, I would expect them to follow those orders. In regard to what could happen to Resident #5 with the midodrine given when the blood pressure was greater than 120 mmHg, he stated, Blood pressure would increase. The MD stated the medication was given in error multiple times but that he did not see any ill effects for Resident #5 after reviewing the medical record. During an interview on 05/27/26 at 2:03 PM with the Assistant Regional Director of Clinical Services (ARDCS) and the Director of Nursing (DON), the DON stated the facility had LPN #7 check and monitor the MARs daily for errors. She stated that if there were any significant errors, the process would be to make sure the resident was safe, check their vital signs, and to let the Medical Director and family know of the error. The DON stated midodrine was given to Resident #5 outside the parameters for 17 administrations. The DON and the ARDCS both stated that the administration of the midodrine outside of the parameters of the physician's order was a significant medication error. During an interview on 05/28/26 at 8:50 AM, LPN #7 stated that she reviewed the MAR daily for omissions, but she did not review for medications given outside of parameters. LPN #7 stated that she was not aware of Resident #5's midodrine being administered outside of the ordered parameters. During an interview on 05/27/26 at 2:50 PM, the Administrator stated his expectations were for nursing to follow the physician orders when giving medications. Review of a facility policy titled Adverse Consequences and Medication Errors, revised 02/2023 revealed 1. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. The policy revealed the Procedures included 1. Review the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis.Review of a facility policy titled Administering Medications, revised 04/2019 revealed Medications are administered in a safe and timely manner, and as prescribed. The policy further indicated, 4. Medications are administered in accordance with prescriber orders, including any required timeframe. The policy further indicated, 6 Medication errors are documented, reported, and reviewed by the QAPI [Quality Assurance and Performance Improvement] committee to inform process changes and or the need for additional staff training. The policy revealed, 11. The following information is checked/verified for each resident prior to administering medications, which included a. Allergies to medications; and b. Vital signs, if necessary.

Based on review of the facility staffing documents, interview and policy review, the facility failed to ensure the daily staff posting information was accurate for staff directly responsible for resident care for 24 (05/01/26 through 05/24/26) of 24 days reviewed. This had the potential to affect all 99 residents who resided in the facility. Findings Included:Review of the facility's daily staffing posting documents for the timeframe from 05/01/26 through 05/24/26 revealed the documents only contained scheduled nursing hours and not actual hours worked. During an interview on 05/25/26 at 4:02 PM, Licensed Practical Nurse (LPN) #7 stated that the daily staff posting information only contained scheduled hours and not actual hours worked. During an interview on 05/27/26 at 10:08 AM, the Director of Nursing (DON) stated she expected the daily staff posting information to reflect the census, the nurse and nursing assistant hours. She stated that it would not reflect the actual hours initially, but if someone called off work then she expected the scheduler to update the daily staff posting with actual hours worked. During an interview on 05/27/26 at 10:34 AM, the Administrator stated he did not expect the daily staff posting information to include the actual hours worked, but just the initial scheduled hours worked. Review of a facility policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2006 indicated 1. Within two (2) hours of the beginning of each day, the number of Licensed Nurses (RNs [Registered Nurses], LPNs [Licensed Practical Nurses], and LVNs [Licensed Vocational Nurses]) and the number of unlicensed nursing personnel (CNAs) [Certified Nurse Aide] directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The policy also indicated, 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: a. The name of the facility. b. The day for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift.

Based on interview, record review, and policy review, the facility failed to ensure the care plan represented the resident's current status of having a pressure ulcer. This affected one (Resident #49) of three residents reviewed for care planning. The census was 99. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included gastrostomy, gastrojejunal ulcer, cognitive communication deficit, unspecified atrial flutter, and malignant neoplasm of the prostate.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact. Review of the Comprehensive Skin Evaluation dated 03/13/26 for Resident #49 revealed the resident had a stage II pressure ulcer to the coccyx present upon admission. Review of the baseline care plan dated 03/13/26 for Resident #49 revealed the stage II pressure ulcer was not listed and there were no interventions in place related to the pressure ulcer.Interview on 03/20/26 at 11:55 A.M. with the Director of Nursing (DON) and MDS Coordinator #10 confirmed the care plan did not address Resident #49's pressure ulcer and there were no interventions in place. Review of the policy titled, Baseline Care Plan, dated 03/2022 revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.This deficiency represents non-compliance investigated under Complaint Number 2795881.

Based on interview, record review, and policy review, the facility failed to develop a comprehensive person-centered care plan for pressure ulcers for two residents (#106 and #107). This affected two residents (#106 and #107) of three residents reviewed for care planning. The facility census was 99.Findings include:1.Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] and discharged on 02/25/26. Diagnoses included essential hypertension, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #106 cognitively intact and had an unstageable pressure ulcer upon admission.Review of the progress notes for Resident #106 dated 02/18/26 revealed the resident had a stage II pressure ulcer. Review of the care plan for Resident #106 revealed no plan or interventions for stage two pressure ulcer.2. Review of the medical record revealed Resident #107 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, chronic obstructive pulmonary disease, and cognitive communication deficit.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #107 was cognitively intact.Review of the skin evaluation dated 02/05/26 for Resident #107 revealed the resident had a pressure injury to sacrum present upon admission.Review of the care plan for Resident #107 revealed no plan or interventions for a pressure ulcer. Interview on 03/20/26 at 2:04 P.M. with MDS coordinator #10 and the Director of Nursing (DON) confirmed the care plans did not address the residents' pressure ulcers or contain interventions for Residents #106 and #107. Review of the policy titled, Care Planning, dated 09/2013 revealed a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment. This deficiency represents non-compliance investigated under Complaint Number 2795881.

Based on record review, staff interview, resident interview, and policy review the facility failed to treat residents with dignity and respect when Certified Nurse Aide (CNA) #268 was observed urinating in Resident #50 and #68's closet. This affected two Residents (#50 and #68) out of three residents reviewed for dignity and respect. The facility census was 97.Findings include:1.Medical record review for Resident #50 revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, essential primary hypertension, hyperlipidemia, anorexia, gastro-esophageal reflux disease (GERD), mixed hyperlipidemia, and major depressive disorder.Review of the Minimum Data Set (MDS) assessment, dated 12/01/25, for Resident #50 revealed she was cognitively intact. Review of the progress notes dated 12/12/25 at 11:50 A.M. for Resident #50 revealed on 12/09/25 Licensed Social Worker (LSW) #113 visited Resident #50 after an alleged incident with CNA #268. Resident #50 revealed she felt ok after the initial shock wore off.Interview on 01/05/25 at 11:48 A.M. with Resident #50 revealed CNA #268 had attempted to change her depends and appeared to be very confused. Resident #50 stated CNA #268 used a glove that did not fit his hand, and his pinky finger and thumb did not fit into the glove. Resident #50 stated he acted confused. Resident #50 stated she observed CNA #268 open the closet door and could hear him urinate as the urine stream hit a box lying in the closet. Resident #50 stated she and her roommate, Resident #68, began to scream. 2. Medical record review for Resident #68 revealed she was admitted to the facility on [DATE]. Her diagnoses included COPD, chronic respiratory failure with hypoxia, diabetes mellitus (DM), major depressive disorder, adult failure to thrive tachycardia, GERD, and essential hypertension.Review of the Minimum Data Set (MDS) assessment dated [DATE] dated for Resident #68 revealed she was cognitively intact. Review of the progress notes on 12/12/25 at 11:57 A.M. revealed Licensed Social Worker (LSW) #113 visited with Resident #68 on 12/09/25 after an alleged incident with CNA #268. Resident #68 reported an increase in her anxiety immediately following the incident and she reported still being somewhat in shock during the conversation.Review of the Psychiatric Nurse note dated 12/09/25 at 1:43 P.M. for Resident #68 revealed she reported feeling shaken up due to the incident with the CNA #268 earlier in the day. Resident #68 stated she felt scared and unsafe due to this incident.Interview with Resident #68 on 01/05/26 at 12:00 P.M. confirmed on 12/09/25, Resident #68 observed CNA #268 walk into her room open the closet door proceed to urinate on a box in the closet. Resident #68 stated he left the door open and she could see his side profile as he urinated in the closet. Resident #68 stated she began to scream loudly, and CNA #268 started to walk toward her and she did not know why. Resident #68 stated he had urine on his pants. Resident #68 stated she was very upset and confused regarding why CNA #268 would do this.Interview on 01/05/26 at 11:08 A.M. with the Human Resource Manager (HRM) #123 confirmed CNA #268 urinated in the closet of Resident #50 and #68 on 12/09/25. HRM #123 confirmed the facility terminated CNA #268 on 12/15/25 related to not treating Resident #50 and #68 with dignity and respect when he urinated in their closet on 12/09/25. Review of the employee chart for Certified Nurse Aide (CNA) #268 revealed his hire date was listed as 11/08/25. CNA #268 was terminated on 12/15/25 for an incident that occurred on 12/09/25. Review of the form titled, Employee Counseling Form, dated 12/15/25, revealed the type of violation was marked as conduct and abuse. The violation date was listed as 12/09/25 at 9:53 A.M. The nature of infarction was listed as the employee, CNA #268, urinated in a resident's room (Resident #50 and #68) in a cardboard box on 12/09/25 at 10:00 A.M. This violated the PACS Code of Conduct.Review of the facility policy titled, PACS Code of Conduct and Business Ethics, undated, revealed the facility is dedicated to providing quality care and other services to each resident, patient, or other individual served. Each person served is an individual entitled to dignity and respect.Review of the facility policy titled, Dignity, dated 2001 confirmed each resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents will be treated with dignity and respect at all times. This deficiency represents non-compliance investigated under Complaint Number 2693364.

Based on review of the medical record, staff interviews, and policy review, the facility failed to timely notify the physician of signs and symptoms of dry gangrene toes and ankle which in turn resulted in delayed treatment. This resulted in actual harm when Resident #98's toes on the left foot began to show signs and symptoms of dry gangrene and the facility staff had not notified the physician in a timely manner. Resident #98 required a left above knee amputation (AKA) the same night he was sent to the hospital for acute limb ischemia and dry gangrene. This affected one (Resident #98) of three residents reviewed for wound care. Additionally, the facility also failed to ensure the accuracy of skin assessments. This affected two (#98 and #99) of three reviewed for skin assessments. The facility census was 95.1.Review of the medical record revealed Resident #98 was admitted to the facility on [DATE] and discharged [DATE] with the following diagnoses: non-stemi elevation myocardial infarction (a type of heart attack where a coronary artery is partially or completely blocked, reducing blood flow to the heart and causing damage to the heart muscle), sepsis due to Escherichia coli and Type II diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had intact cognition. This resident was assessed to be moderate assistance with toileting and dressing with maximal assistance with bathing. Review of the skin assessment dated [DATE] revealed there was a small area on left lower shin and left toes. Review of the care plan initiated 12/05/24 for Resident #98 revealed skin checks to be completed weekly due to anticoagulants. Review of the skin assessment dated [DATE] revealed there were no skin issues. There were no other skin assessments completed in the medical record. Review of the Physician’s note dated 12/30/24 revealed Resident #98 had ongoing chronic pain syndrome especially with neuropathy pain, and because of issues with lethargy and sleepiness, he will be a poor candidate for Neurontin or Lyrica, and with underlying diabetes, cannot be on NSAIDs. Physician noted: Skin-Warm and dry, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of shower sheets dated 01/10/25 noted no skin issues and 01/14/25 noted left foot and back of left ankle to be turning black and painful. Review of the Nurse Practitioner’s (NP) #600 note dated 01/14/25 at 3:34 P.M. revealed the NP addressed abnormal laboratory results. Resident #98 complained of increased urinary frequency and requested a sleep aid. NP #600 ordered a urinalysis test to be completed. NP noted: Skin-Warm and dry, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of the nurse’s notes dated 01/14/25 at 11:13 P.M. revealed Resident #98 had toes on left foot that looked gangrenous and were painful. Nurse placed a note in the doctor’s book and stated she would pass it on to morning shift to notify the physician. Review of the Physician’s notes dated 01/16/25 revealed Resident #98 was having issues with worsening left toe wounds with necrosis and concerns for limb ischemia and concerns for gangrene of the toes with issues of pain control. Resident #98 was sent to the hospital for further workup and possible revascularization. Review of the hospital records dated 01/16/25 to 01/22/25 revealed Resident #98 received a left leg above the knee amputation due to dry gangrene of the left lower extremity on 01/16/25 through 01/17/25. Resident #98 was found to have an occlusion of left superficial femoral artery with blood flow to the left profunda. Contracture to the left lower extremity. The aspect of the foot was dusky purple red. The foot and ankle demonstrated two ulcerated lesions, 1.7 centimeters (cm) and 4.6 cm each in greatest dimension. Toes number one through four demonstrated red-purple dusky areas of skin discoloration that demonstrate sloughing of the skin. Within these dusky areas, there are areas of mummification. Sections through these areas revealed hemorrhagic and necrotic soft tissue. Resident #98 was discharged on 01/22/25 to a different rehabilitation facility. Interview with Administrator on 08/11/25 at 11:10 A.M. revealed gangrenous area was found on 01/14/25 and the physician was notified and saw Resident #98 on 01/16/25. The Administrator educated Registered Nurse (RN) #201 on 01/20/25 regarding notifying physician with high level change of condition. Interview with Nurse Practitioner (NP) #360 on 08/11/25 at 3:51 P.M. revealed NP #360 does not complete a head-to-toe assessment every time a resident is seen. NP #360 stated he does not always look in the doctor’s book because the nurse manager tells him who he needs to see and why. NP #360 recalls Resident #98 and visiting him on 01/14/25 to review the resident’s laboratory results. Resident #98 only complained of frequent urination and a urinalysis was ordered. NP #360 verbalized not being notified the night of 01/14/25 or on 01/15/25 of Resident #98’s condition. NP #360 stated on 01/15/25, he was in the building because Wednesdays are his day to be in the facility. NP #360 was not sure but thought maybe the wound doctor was seeing Resident #98. Interview with Certified Nursing Assistant (CNA) #293 on 08/11/25 at 4:17 P.M. revealed CNA #293 does not remember Resident #98. CNA #293 was the employee who signed the shower sheets for 01/10/25 and 01/14/25. Interview with NP #360 on 08/12/25 at 8:24 A.M revealed dry gangrene usually takes weeks to turn into gangrene and shows signs and symptoms of becoming dry, shrinking, and turning black, related to poor vascular. NP #360 verbalized he was never notified of Resident #98’s change of condition. NP #360 reviewed the chart, and the last skin assessment was completed 12/12/24 stating no skin issues. NP #360 stated he felt skin assessments should have been completed weekly on Resident #98 due to his condition and possibly facility policy. NP #360 verified the facility staff should have noticed Resident #98’s gangrene toes. Interview with Wound Physician #601 on 08/12/25 at 8:39 A.M. revealed Resident #98 was never seen by Wound Physician #601 and facility never sent a consultation. Wound Physician #601 stated a gangrene foot is more of a vascular doctor consult than for wound. Review of facility policy, “Prevention of Pressure Injuries,” dated April 2020, revealed a skin assessment should be conducted on admission, with each risk assessment, as indicated to the resident’s risk factors and prior to discharge. The policy did not address if skin assessment should be completed weekly. Review of facility policy, “Change in Resident’s Condition or Status,” dated February 2021, revealed the nurse will notify the resident’s attending physician or physician on call when there has been a significant change in resident’s physical/emotional/mental condition. 2. Review of the medical record for Resident #99 revealed an admission date of 01/01/25 and discharge date of 01/14/25. Diagnoses included chronic non-pressure ulcer of the left foot with muscle involvement, Lobar pneumonia, atherosclerosis of arteries of extremities with intermittent claudication of the left leg, chronic obstructive pulmonary disease, diabetes, peripheral vascular disease, malnutrition, surgical aftercare following surgery of the skin and tissue, pressure ulcer of the sacral region stage four, rhabdomyolysis, heart failure, and recent COVID-19. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Resident #99 was dependent on staff for toileting and transfers and required partial and moderate assistance for walking 10 feet. The MDS stated Resident #99 admitted with a stage four pressure wound, a vascular wound, and a surgical incision. Review of hospital discharge information dated 01/01/25 revealed wound treatment recommendations for sacrum wound included cleanse with wound cleanser, pat dry and apply silverdene then silver alginate, cover with bordered foam dressing and change daily and as needed. A treatment order for a right elbow wound included cleanse with wound cleanser, pat dry and apply small piece of Xeroform, cover with bordered foam dressing and change daily and as needed. Review of the admission assessment dated [DATE] revealed the resident was admitted for post acute care with a left vascular foot wound and staples to left pelvic area. Assessment of the skin found the resident had a left heel documented as soft, a left foot dorsal open area measuring five inches by three inches by one centimeter was documented as a suspected deep tissue injury, a groin wound documented as upper left with 36 staples, and a sacrum pressure wound measuring six by five by one to two centimeters and labeled a stage four. It was also mentioned the resident was incontinent of bladder. The assessment included no mention of a right elbow wound. Review of the physician note dated 01/02/25 revealed the resident was seen in the hospital for left foot non-healing wound with excisional debridement and was placed on antibiotics. The physician note did not include any mention of a stage four pressure wound, surgical incision wound, or elbow wound. Review of the comprehensive skin evaluation dated 01/02/25 revealed Resident #99 had a vascular right dorsal foot wound measuring eight by nine by 0.1 and a sacrum pressure wound measuring six by five by two and was documented as a stage four pressure wound. The wound had small serosanguinous drainage with 70% slough and 30% eschar. The assessment was completed by the Director of Nursing (DON). The assessment did not include any information of a surgical wound of the groin with staples, a soft heel, or an elbow wound. Review of the wound Nurse Practitioner (NP) note dated 01/02/25 revealed a vascular right foot wound was assessed and dressing change completed. No other skin impairments were reviewed or assessed by the NP The assessment included inaccurate location as wound was on the left foot. Review of the comprehensive skin evaluation dated 01/08/25 revealed the resident had a vascular right dorsal foot wound measuring nine by seven by 0.1 and a sacrum pressure wound measuring nine by five by 0.1 and was listed as a stage four. The assessment was completed by the DON. Review of the wound NP note dated 01/08/25 revealed a pelvis coccyx wound was assessed with measurements of nine by five by 0.1. The assessment stated the wound was unstageable with 100% slough. A treatment for santyl for enzymatic debriding with bordered gauze daily and as needed was recommended. Interview on 08/07/25 at 1:10 P.M. with Wound Nurse #345 revealed she began employment around 01/20/25. She revealed upon admission, a resident should have a full skin assessment completed by two staff with findings documented in the medical record. She revealed the wound NP would come to facility once weekly and could be reached for questions on days she was not onsite at the facility. Wound Nurse #345 verified all skin impairments shall be documented so they can be followed until healed including scratches, bruising, skin tear, pressure wounds, and surgical incisions. Interview on 08/07/25 at 2:15 P.M. with the DON and the Administrator confirmed the admission assessment for Resident #99 had four skin items marked, left foot dorsal wound, heel soft, surgical incision with 36 staples, and a pressure stage four to coccyx/sacrum. The DON confirmed she completed the second assessment the same day (01/02/25) that included two skin notations including the dorsal foot open wound and the stage four pressure sore to the sacrum. The DON reported the heel being soft would not need to go on a skin assessment as it had no treatment. The DON also reported she typically would not put surgical incisions as well as incisions with staples on a comprehensive skin assessment stating, “we don’t always have dressings for surgical incisions.” The DON verified staff would monitor incision sites each shift for signs of infection and also verified the facility had no evidence of orders or documentation to monitor areas and incision sites and confirmed no record of staff documentation of monitoring. Interview on 08/11/25 at 11:00 A.M. with the Administrator revealed the facility had identified non-compliance for skin and wounds and were back in compliance. The Administrator verified compliance meant wound assessments were completed according to nursing standards and per interview with the DON and Administrator on 08/07/25, the expectations for staff did not meet standards of practice. The Administrator confirmed staff should document any and all skin impairments including scratches, bruising, soft heels, and surgical wounds. Interview on 08/11/25 at 3:48 P.M. with Licensed Practical Nurse (LPN) #312 verified all skin impairments should be documented on the admission and weekly assessment no matter the size. He revealed he did not remember caring for Resident #99, but if a wound treatment was mentioned on hospital discharge paperwork, the facility should make a note if they did not see the skin impairment on facility admission skin exam and get clarification from medical provider. LPN #312 also stated the importance of documenting a soft heel due to higher risk of developing a pressure sore and stated it would need increased monitoring or interventions. Review of facility policy titled, Prevention of Pressure Injuries, dated 04/2020, revealed facility shall identify risk factors as well as interventions. Facility shall conduct a comprehensive skin assessment upon admission and as indicated. This deficiency represents non-compliance investigated under Complaint Number 1306087 and 1306090.

Based on record review, staff interviews, review of hospital records, and policy review, the facility failed to ensure timely treatments and interventions were completed for a resident's pressure ulcer. This resulted in Actual Harm on 01/14/25 when Resident #99 was hospitalized with a pressure ulcer to the sacrum which deteriorated in condition and developed purulent drainage and necrotic tissue from a delay in treatment. This affected one (Resident #99) of three residents reviewed for wounds. The facility identified six residents (#8, #11, #51, #76, #83 and #92) with pressure ulcers. The facility census was 95. Findings include:Review of the medical record for Resident #99 revealed an admission date of 01/01/25 and a discharge date of 01/14/25. Diagnoses included chronic non-pressure ulcer of the left foot with muscle involvement, lobar pneumonia, atherosclerosis of the arteries of the extremities with intermittent claudication of the left leg, chronic obstructive pulmonary disease, diabetes, peripheral vascular disease, malnutrition, surgical aftercare following surgery of the skin and tissue, pressure ulcer of the sacral region stage four (full thickness skin and tissue loss, exposing or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone), rhabdomyolysis, heart failure and recent coronavirus (COVID-19). Review of the hospital referral information dated 12/09/24 to 12/30/24 revealed Resident #99 had a left chronic foot wound with vascular surgery consulted. On 12/19/24 a pre-procedure note stated a plan for debridement of the left foot and possible trans-metatarsal amputation. Hospital orders included Augmentin 875-125 milligrams (mg) tablet twice daily for cellulitis and a coccyx wound treatment order dated 12/18/24 for silver sulfadiazine (Silvadene) topical cream with instructions to cleanse with wound cleanser, pat dry and apply Silvadene then silver alginate, cover with bordered foam dressing and change daily and as needed.Review of the hospital discharge information dated 01/01/25 revealed wound treatment recommendations for the sacrum wound included orders to cleanse with wound cleanser, pat dry and apply Silvadene then silver alginate, cover with bordered foam dressing and change daily and as needed. Review of the baseline care plan dated 01/02/25 revealed Resident #99 had a history of an ulcer and rhabdomyolysis. An arterial ulcer was documented under the skin integrity section, while pressure ulcers and an option for other were left unmarked. The interventions and goals included a select all that applied question asking reasons for nursing services, other was marked off with a comment stating, physical deconditioning. Wound care and skin breakdown prevention were left blank. No skin related interventions were documented on the baseline care plan.Review of the admission assessment dated [DATE] revealed Resident #99 was admitted to the facility for post-acute care with a left vascular foot wound and staples to the left pelvic area. An assessment of the skin found the resident had a left heel documented as soft, a dorsal left foot open area measured 5 inches by 3 inches by 1 centimeter (cm) was documented as a suspected deep tissue injury, an upper left groin wound with 36 staples, and a sacrum pressure wound measuring 6 by 5 by 1 to 2 centimeters (cm) and labeled as a stage four. It was also mentioned that the resident was incontinent of bladder.Review of the physician note dated 01/02/25 revealed the note did not include any mention of a stage four pressure wound or surgical incision wound.Review of the Braden scale (pressure ulcer risk) assessment dated [DATE] revealed Resident #99 was at risk for the development of pressure sores. Review of the comprehensive skin evaluation dated 01/02/25 revealed Resident #99 had a vascular right dorsal foot wound (though the admission assessment on 01/02/25 stated it was a left foot wound) measuring 8 by 9 by 0.1 deep with no measurement descriptors. The evaluation also noted a sacrum pressure wound measuring 6 by 5 by 2 deep, with no measurement descriptors, and was documented as a stage four pressure wound. It revealed a wound had small serosanguinous drainage with 70% slough and 30% eschar, but it was not specific to which of the two wounds the documentation was referring to. The assessment was completed by the Director of Nursing (DON).Review of the wound Nurse Practitioner (NP) #362 note dated 01/02/25 revealed a vascular right foot wound was assessed and the dressing change was completed. No other skin impairments were reviewed or assessed by the NP.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Resident #99 was dependent on staff for toileting and transfers and required partial and moderate assistance for walking 10 feet. Further activity was not assessed due to safety concerns. The MDS indicated Resident #99 admitted with a stage four pressure wound, a vascular wound, and a surgical incision.Review of the comprehensive skin evaluation dated 01/08/25 revealed Resident #99 had a vascular right dorsal foot wound measuring 9 by 7 by 0.1, with no measurement descriptors, and a sacrum pressure wound measuring 9 by 5 by 0.1, with no measurement descriptors, and it was listed as a stage four. The assessment was completed by the DON. Review of the wound NP #362 note dated 01/08/25 revealed a pelvis coccyx wound was assessed with measurements of 9 cm by 5 cm by 0.1 cm. The assessment noted the wound was unstageable with 100% slough. A treatment for Santyl for enzymatic debriding with bordered gauze daily and as needed was recommended.Review of the Treatment Administration Record (TAR) from January 2025 revealed barrier cream was ordered from 01/01/25 to 01/14/25 with instructions to administer after each incontinence episode as needed. The barrier cream treatment was not documented as completed. The TAR included a coccyx wound order dated from 01/08/25 to 01/14/25 with instructions to cleanse the area with wound cleanser, apply Santyl and cover with foam dressing once daily. The Santyl treatment was documented as completed daily.Review of the physician note dated 01/14/25 revealed Resident #99 was seen for coughing with shortness of breath. Resident #99 also reported pain on his buttocks where he had a wound. After the initial assessment, Resident #99 began to deteriorate with a pulse in the 30's (normal pulse rate is between 60 beats per minute (bpm) and 100 bpm) and oxygen saturations in the 50's [percent (%)] (normal ranges from between 90 % to 100 %). Resident #99 was placed on five liters of oxygen and the oxygen saturations only increased to the 60's [%]. After a few minutes on oxygen his saturations did not improve over the 80's [%] and the resident was transferred to the hospital for an evaluation.Review of the history and physical dated 01/14/25 revealed Resident #99 reported he was bedbound the past month and developed a bedsore on his backside. Resident #99 stated his backside was very tender with a general surgery consultation for suspected necrosis. Upon physical examination, a large sacral ulcer was noted with a surrounding deep tissue injury with an exposed dermis and a large area of necrotic tissue at the center of the wound. Review of the pelvic computed tomography (CT) scan dated 01/14/25 revealed no definite osseous erosion of the sacrum could be confirmed. There was suggestion of some osseous erosion of the distal two coccygeal segments suspicious for osteomyelitis. It noted to suspect coccygeal osteomyelitis.Review of hospital record acute care surgery consult dated 01/14/25 revealed Resident #99 presented from the nursing facility due to shortness of breath and was found to have a malodorous sacral decubitus ulcer stage three to four. A CT of the pelvis on 01/14/25 showed a decubitus ulcer with suspected coccygeal osteomyelitis. It noted that Resident #99 would benefit from a sharp debridement of the sacral wound this admission. Interview on 08/07/25 at 1:10 P.M. with Wound Nurse #345 revealed she began employment around 01/20/25. She revealed upon admission; a resident should have a full skin assessment completed by two staff with findings documented in the medical record. She revealed the wound NP #362 would come to the facility once weekly and could be reached for questions on days she was not onsite at the facility.Interview on 08/07/25 at 2:15 P.M. with the Director of Nursing (DON) and the Administrator confirmed the admission assessment for Resident #99 had four skin items marked including a left foot dorsal wound, a soft left heel, a surgical incision with 36 staples and a stage four pressure wound to the coccyx/sacrum. The DON confirmed she completed a second assessment the same day (01/02/25) that included two skin notations including the dorsal foot open wound and the stage four pressure sore to the sacrum. The DON confirmed the baseline care plan was not thoroughly completed including no mentions of wound care or skin protection and treatments. The DON confirmed she signed off on the baseline care plan and revealed it was a new form the facility was not familiar with and confirmed there was no documented evidence of wound or pressure relieving interventions on the care plan. The DON confirmed the wound NP #362 saw Resident #99 for the foot wound on 01/02/25 and did not see Resident #99 for the pressure wound until 01/08/25. The DON had no explanation for the delay in the NP seeing the wound as she had assessed his foot wound the week prior, and no explanation for the delay in treatment/interventions until he was seen by the wound NP on 01/08/25. Interview on 08/07/25 at 3:51 P.M. with Wound Nurse Practitioner (WNP) #362 revealed she was onsite once weekly at the facility. She confirmed she rounded with the wound nurse and worked from the list of residents from the prior week while adding residents based on the nursing report of new admissions or new wounds that needed evaluation. She reported the facility would place a consult for a resident with wounds and she could follow the resident for any and all wounds as needed. WNP #362 revealed Resident #99 was admitted while the facility was between wound nurses. WNP #362 revealed she would round with the DON or bedside nurses during that time. She confirmed she was not informed of the stage four pressure wound for Resident #99 and stated she would definitely want to see a resident with a stage four pressure wound during her rounds. The WNP confirmed she only saw the foot wound on the first visit with Resident #99 on 01/02/25 and confirmed the pressure wound had no treatment orders in place until her first assessment of it on 01/08/25.Interview on 08/11/25 at 11:00 A.M. with the Administrator revealed she thought the wound had improved but acknowledged the measurements increased and that Resident #99's wound, going from stage four to unstable, was a decline. Interview on 08/11/25 at 12:50 P.M. with the Administrator, the DON, Regional Nurse #365, and Wound Nurse #345 confirmed the facility identified errors and non-compliance regarding Resident #99's care but stated they had made changes such as terminating the previous wound nurse on 12/30/24 and hiring Wound Nurse #345. They revealed the facility was going through a change in ownership and the facility had put new practices in place. They acknowledged Resident #99 was admitted during the time the wound nurse had been terminated. Review of the facility policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, dated 04/2018, revealed nursing staff and practitioners (NP) shall assess and document risk factors for pressure ulcers. The nurse shall also document a full assessment of pressure sores. The NP shall examine skin for evidence of pressure ulcers. The Physician shall order pertinent wound treatments including wound dressings and treatments. Review of the facility policy titled, Care Plan - Baseline, dated 03/2022, revealed the facility shall include instructions needed to provide effective person-centered care. The baseline care plan was used until staff could complete the comprehensive care plan. The baseline care plan shall include any services and treatments to be administered by facility and personnel acting on behalf of the facility.This deficiency represents non-compliance investigated under Complaint Number OH001306087.

Based on record review, staff interview, and policy interview, the facility failed to ensure resident records were provided timely upon request. This affected two residents (#97 and #101) of three reviewed for record requests. Facility census was 95. 1. Review of the medical record for Resident #97 revealed an admission date of 05/31/23 and discharge date of 10/15/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13, indicating intact cognition. Review of the authorization to disclose health information dated 06/23/25 revealed a record request was made for the entire electronic nursing home chart from dates 05/28/23 to 10/15/24 by an attorney handling the estate of Resident #97. Review of the letter dated 06/24/25 revealed a records request for Resident #97 requesting the electronic nursing chart. A handwritten note on the letter stated, emailed 07/01/25. Review of email communication dated 07/30/25 from the Administrator to Medical Records (MR) #301 revealed an attorney for Resident #97 stated he requested records three times and was going to subpoena records. The Administrator requested MR #301 to contact him. Review of email communication dated 07/30/25 from MR #301 to the Administrator revealed a record request was received for a resident that was admitted when facility was Legacy (they recently were sold). The email stated they had received more requests. MR #301 reported she had not been instructed on what to do with records from the previous ownership and reported she had paper copies. She stated, I did not think we were supposed to send information that was before the facility was sold. The email also noted the attorney was now threatening subpoena for the records. Review of multiple email communications between facility staff and regional legal department staff dated 07/03/25, revealed staff asked if any direction was given from the previous company and stated if an official request or subpoena had been provided, the facility staff can produce the records. An email then stated to wait until they received the subpoena. A separate email stated, if they get exasperated and say they would just serve you with a subpoena, that's fine, it might actually light a fire under someone. Review of multiple email communications between facility staff and regional legal department staff dated 08/01/25 to 08/04/25 stated the facility heard from the previous ownership company stating they no longer manage these buildings. Staff was instructed to send the request to the regional legal department and proceed with gathering records to the law firm. Additional emails instructed staff to send records to legal department for them to prepare. Interviews on 08/11/25 from 2:48 P.M. to 3:10 P.M. with MR #301 confirmed she had not provided any medical records since 01/2025 when the new company took over ownership. MR #301 stated records had not been sent to Resident #97's estate attorney. She confirmed she received an email from the Administrator that the attorney was threatening to subpoena for records. MR #301 acknowledged Resident #97's attorney had waited over a month to receive records without results. 2. Review of the medical record for Resident #101 revealed an admission date of 01/10/24 and discharge date of 01/26/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of seven, indicating impaired cognition. Review of authorization to disclose health information dated 01/13/25 revealed a record request was made for all records by Resident #101. Review of the letter dated 07/29/25 revealed a records request for Resident #101 requesting the medical record. MR #301 revealed this was a subpoena for documents. Review of email communication dated 08/04/25 from regional legal staff to additional regional legal staff as well as MR #301 revealed the record request was valid and requested for documents to be prepared and files shared with legal to authorize release. Interviews on 08/11/25 from 2:48 P.M. to 3:10 P.M. with MR #301 confirmed she had not provided any medical records since 01/2025 when the new company took over ownership. MR #301 stated records had not been sent to Resident #101 or his attorney. She confirmed she was unaware and never saw the medical release request from 01/2025. MR #301 did not have knowledge or understanding of the requirement to provide records in a timely manner even when residents were admitted under a previous ownership name. MR #301 acknowledged the policy stated record requests should be provided within two business days upon written or oral request and confirmed the facility did not follow that policy/procedure. Review of policy titled, Access to Personal and Medical Records, dated 05/2017 revealed each resident had the right to access and or obtain copies of his or her personal and medical records upon request. It stated a request shall be submitted orally or in writing. Access shall be provided within 24 hours (excluding weekends and holidays and two business days for copies of the records. This deficiency represents non-compliance investigated under Complaint Number 2581293.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to address a resident's representative concerns regarding care concerns. This affected one (#105) out of the three residents reviewed for timely response to resident and/or resident representative concerns. The facility census was 93. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE] with medical diagnoses of diabetes mellitus, metabolic encephalopathy, hypertensive heart disease, congestive heart failure, and dysphagia oropharyngeal. The medical record indicated Resident #105 discharged from the facility on 12/29/24. Review of the medical record for Resident #105 revealed an admission Minimum Data Set (MDS) assessment, dated 11/19/24, which indicated Resident #105 had moderate cognitive impairment and required staff supervision with eating, bed mobility, and transfers, and required partial/moderate staff assistance for toilet hygiene and bathing. Review of the medical record for Resident #105 revealed a nurse's note dated 12/29/24 at 12:25 P.M. which stated Resident #105's daughter stated she felt her concerns were being dismissed. Interview on 01/06/25 at 8:45 A.M. with Director of Nursing (DON) stated she spoke with Resident #105's daughter on 12/22/24 about care/service concerns, staff not answering phone calls, and staff not returning her phone calls. DON stated she agreed with everything Resident #105's daughter said because she did not want to argue with the daughter. DON confirmed on 12/29/24 Resident #105's daughter left her a voicemail message which stated she had concerns about Resident #105's care and wanted a return call. DON stated she did not return Resident #105's daughter's call because Resident #105 daughter used foul language in the message and Resident #105 discharged to the hospital on 12/29/24 and the facility was notified Resident #105 would not be returning to the facility. Review of the facility policy titled, Resident Rights, revised December 2016, the resident has the right to voice grievances to the facility and the right to have the facility respond to the grievances. This deficiency represents non-compliance investigated under Complaint Number OH00161119 and Complaint Number OH00159866.

Based on medical record reviews, staff interview, and policy review, the facility failed to conduct quarterly care conferences. This affected two (#08 and #38) out of the three residents reviewed for care conferences. The facility census was 93. Findings include: 1. Review of the medical record for Resident #08 revealed an admitted [DATE] with medical diagnoses of dementia, chronic obstruction pulmonary disease (COPD), hypertensive heart and chronic kidney disease, anxiety, congestive heart failure (CHF), and atrial fibrillation. Review of the medical record for Resident #08 revealed a quarterly Minimum Data Set (MDS) assessment, dated 11/07/24, which indicated Resident #08 was cognitively intact and was dependent upon staff for toilet hygiene and transfers, required partial/moderate staff assistance for bathing, and substantial/maximum staff assistance for bed mobility. Review of the medical record for Resident #08 revealed a quarterly care conference note on 09/11/24. Review of the medical record for Resident #08 revealed no documentation to support the facility had conducted or offered to conduct a care conference since 09/11/24. 2. Review of the medical record for Resident #38 revealed an admitted [DATE] with medical diagnoses of COPD, CHF, chronic respiratory failure, morbid obesity, and hypertensive heart disease. Review of the medical record for Resident #38 revealed a quarterly MDS assessment, dated 11/14/24, which indicated Resident #38 was cognitively intact and was independent with all her activities of daily living. Review of the medical record for Resident #38 revealed a care conference note dated 05/14/24. Review of the medical record for Resident #38 revealed no documentation to support the facility had conducted or offered to conduct a care conference since 05/14/24. Interview on 01/07/25 at 4:08 P.M. with Regional Nurse #310 confirmed the medical records for Residents #08 and #38 did not contain documentation to support the care conferences were conducted with quarterly MDS assessments. Review of the facility policy titled, Care Planning-Interdisciplinary Team, revised September 2013, stated the resident, resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. This deficiency represents non-compliance investigated under Complaint Number OH00161119.

Based on medical record review, staff interviews, and policy review, the facility failed to timely provide a therapeutic diet as per speech therapy recommendations. This affected one (#105) out of the three residents reviewed for diets. The facility census was 93. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE] with medical diagnoses of diabetes mellitus, metabolic encephalopathy, hypertensive heart disease, congestive heart failure, and dysphagia oropharyngeal. The medical record indicated Resident #105 discharged from the facility on 12/29/24. Review of the medical record for Resident #105 revealed an admission Minimum Data Set (MDS) assessment, dated 11/19/24, which indicated Resident #105 had moderate cognitive impairment and required staff supervision with eating, bed mobility, and transfers, and required partial/moderate staff assistance for toilet hygiene and bathing. Review of the MDS revealed Resident #105 received a mechanically altered diet, had no swallowing or chewing problems, and no weight loss. Review of the medical record for Resident #105 revealed a physician order dated 11/27/24 for regular diet, dysphagia pureed texture and thin liquids. Review of the medical record revealed an order dated 12/12/24 for regular diet, dysphagia texture and thin liquids. Review of the medical record for Resident #105 revealed a speech therapy note dated 12/06/24 which stated Resident #105 had a request for diet upgrade. The note stated Resident #105 received a trial tray of dysphagia advanced diet and tolerated the meal well. The note stated a diet order was given to upgrade Resident #105's diet to dysphagia advanced. Further review of the medical record for Resident #105 revealed a speech therapy note dated 12/11/24 which stated Resident #105's diet had not been changed from pureed to dysphagia advanced and that nursing and the director of rehab were notified. Interview on 01/07/25 at 3:35 P.M. with Speech Therapist (ST) #320 stated the facility offered a dysphagia pureed diet which had all foods pureed and a dysphagia advanced diet which had all meat ground but all other food on the tray were regular texture. ST #320 confirmed Resident #105 requested a diet upgrade because she did not like the consistency of the food. ST #320 stated she explained to Resident #105 that her diet had to be updated by levels and the resident would have to complete trial trays to determine if diet was safe for resident to consume. ST #320 confirmed on 12/06/24, Resident #105 had a trial tray of dysphagia advanced diet and tolerated the tray well. ST #320 stated she wrote a dietary order change for Resident #105 and gave to the facility rehabilitation director. ST #320 stated the nursing staff are responsible for getting an order from the physician to upgrade the diet. ST #320 confirmed on 12/11/24 she notified nursing and the director of rehabilitation that Resident #105's diet had not been updated to advanced dysphagia on 12/06/24. Interview on 01/07/25 at 2:06 P.M. with Regional Nurse #310 confirmed the medical record did not have documentation to support Resident #105's physician was notified of the speech therapy recommendation on 12/06/24 to upgrade Resident #105's diet from dysphagia pureed to advanced dysphagia. Review of the facility policy titled, Therapeutic Diets, revised October 2017 stated therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. The policy stated a therapeutic diet is considered a diet ordered by the physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of the diet. This deficiency represents non-compliance investigated under Complaint Number OH00161119.

Based on medical record reviews, staff interviews, and policy review, the facility failed to ensure medications were administered as ordered resulting in significant medication errors. This affected three (#08, #95, and #100) out of the five residents reviewed for medication administration. The facility census was 93. Findings include: 1. Review of the medical record for Resident #08 revealed an admitted [DATE] with medical diagnoses of dementia, chronic obstruction pulmonary disease (COPD), hypertensive heart and chronic kidney disease, anxiety, congestive heart failure (CHF), and atrial fibrillation. Review of the medical record for Resident #08 revealed a quarterly Minimum Data Set (MDS) assessment, dated 11/07/24, which indicated Resident #08 was cognitively intact and was dependent upon staff for toilet hygiene and transfers, required partial/moderate staff assistance for bathing, and substantial/maximum staff assistance for bed mobility. Review of the medical record for Resident #08 revealed a physician order dated 08/05/24 for oxycodone 5 milligram (mg) one tablet by mouth every six hours as needed. Review of the medical record for Resident #08 revealed a nurse's note dated 10/02/24 at 8:48 A.M. which indicated Resident #08 received oxycodone 5 mg one tablet by mouth, a note dated 10/02/24 at 1:41 P.M. which indicated Resident #08 received oxycodone 5 mg one tablet by mouth and a note dated 10/02/24 at 3:54 P.M. which stated Resident #08 was given an extra dose of oxycodone by mistake and daughter and on call doctor were notified. Review of the medical record for Resident #08 revealed the October 2024 Medication Administration Record (MAR) which indicated Resident #08 received one oxycodone at 8:48 A.M. Review of the MAR revealed no documentation to support Resident #08 received another dose of oxycodone on 10/02/24. Review of the facility investigation report, dated 10/02/24, stated Licensed Practical Nurse (LPN) #240 received a verbal warning for not following physician orders and on the Five Rights of Medication Pass which was signed by LPN #240 on 10/07/24. The investigation report stated LPN #240 administered Resident #08 an oxycodone tablet instead of a Lyrica. The investigation indicated an assessment was completed on Resident #08 and no injuries were reported post incident. 2. Review of the medical record for Resident #95 revealed an admitted [DATE] with medical diagnoses of right tibia fracture, chronic osteomyelitis of right tibia and fibula, diabetes mellitus with polyneuropathy, and epilepsy. Review of the medical record for Resident #08 revealed Resident #08 discharged home on 11/19/24. Review of the medical record for Resident #95 revealed a quarterly MDS assessment, dated 10/29/24 which indicated Resident #95 was cognitively intact and required partial/moderate staff assistance with toileting hygiene, substantial/maximum staff assistance with bathing, and was dependent upon staff for transfers. Review of the medical record for Resident #95 revealed a physician order dated 10/30/24 for doxycycline 100 mg one tablet by mouth two times per day for wound infection and had not stop date. Review of the medical record for Resident #95 revealed the October and November 2024 MAR's which contained no documentation to support Resident #95 received doxycycline as ordered on 10/30/24 to 11/04/24. Review of the medical record for Resident #95 revealed a Nurse Practitioner (NP) note, dated 11/05/24 which stated there was an issue with the pharmacy discontinuing the previous order for doxycycline and the new order was cued but not active and was restarted today for her chronic prophylactic doxycycline 100 mg two times per day. The NP note stated Resident #95 missed six days of doxycycline. Review of the facility medication error investigation report, dated 11/07/24, indicated the DON educated all nursing regarding pending medication orders. The report indicated the facility staff audited the medical records for residents who were ordered antibiotics to ensure the medication was administered as ordered. 3. Review of the medical record for Resident #100 revealed an admitted [DATE] with medical diagnoses of COPD, myasthenia gravis, attention to gastrostomy, hypertensive chronic kidney disease, and restless leg syndrome. The medical record indicated a discharge date of [DATE]. Review of the medical record for Resident #100 revealed an admission MDS assessment, dated 11/06/24, which indicated Resident #100 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene, bathing, supervision with bed mobility, and set-up assistance with eating. Review of the medical record for Resident #100 revealed physician orders dated 10/31/24 for fluticasone propionate nasal suspension 50 micrograms (mcg) per activation (act) one spray in both nostrils daily, for mirtazapine 15 mg one tablet via gastrostomy tube (g-tube) daily at bedtime (QHS), for ropinirole 1 mg tablet via g-tube) QHS, for azelastine nasal solution 137 mcg per spray one spray in both nostrils daily, for budesonide-formoterol fumarate inhalation aerosol 160-4.5 mcg per activation two puffs orally two times per day, for calcium carbonate 1250 mg one tablet via g-tube two times per day, for glycopyrrolate 2 mg one tablet via g-tube three times per day, for pyridostigmine bromide 60 mg one tablet via g-tube three times per day, lisinopril 40 mg one tablet via g-tube daily to hold if systolic blood pressure (SBP) was less than 120 per millimeter of mercury (mm/Hg) and for scopolamine transdermal patch 72 hour 1 mg per 3 days to apply one patch transdermal every 72 hours. Further review of the medical record revealed physician orders dated 11/04/24 for melatonin 5 mg one tablet via g-tube QHS, for montelukast sodium 5 mg two tablets via g-tube daily, and for gabapentin 250 mg per five milliliter (ml) give 8 ml via g-tube three times per day. The medical record for Resident #100 revealed physician order dated 11/08/24 for sodium chloride 1 gram one tablet via g-tube two times per day, an order dated 11/12/24 for acetaminophen 160 mg per 5 ml to give 32.5 ml via g-tube three times per day, orders dated 11/19/24 for Flomax 0.4 mg one tablet via g-tube daily and methocarbamol 500 mg one tablet via g-tube four times per day, an order dated 11/21/24 for prevacid 30 mg one tablet via g-tube every 12 hours and an order dated 11/23/24 for sertraline 50 mg one tablet via g-tube daily. Review of the medical record for Resident #100 revealed the November 2024 MAR which had no documentation to support Resident #100 received the following medications as ordered on 11/24/24: Flomax, fluticasone propionate nasal suspension, melatonin, mirtazapine, montelukast sodium, ropinirole, sertraline, azelastine, nasal solution, budesonide-formoterol fumarate inhalation aerosol, calcium carbonate, prevacid, sodium chloride, acetaminophen, gabapentin, glycopyrrolate, pyridostigmine, methocarbamol, and scopolamine transdermal patch. Review of the November 2024 MAR revealed no documentation to support Resident #100 received gabapentin as ordered on 11/07/24 through 11/11/24. Further review of the November 2024 MAR revealed documentation Resident #100 received lisinopril 40 mg one tablet via g-tube on 11/09/24 with a SBP of 108, on 11/13/24 with a SBP of 110, on 11/21/24 with a SBP of 119, on 11/22/24 with a SBP of 118 and on 11/27/24 with a SBP of 118. Interview on 01/02/25 at 11:40 A.M. with Regional Nurse #310 confirmed the medical record for Resident #100 did not contain documentation to support the facility administered her medications as ordered on 11/24/24 or the gabapentin as ordered from 11/07/24 to 11/11/24. Regional Nurse #310 also confirmed the medical record revealed documentation to support the facility staff administered Lisinopril 40 mg to Resident #100 on 11/09/24, 11/23/24, 11/21/24, 11/22/24, and 11/27/24 even though her blood pressure was outside of the order parameter for administration. Interview on 01/02/25 at 1:30 P.M. with Regional Nurse #310 confirmed the medical record for Resident #95 did not have documentation to support Resident #95 received doxycycline as ordered from 10/30/24 through 11/04/24. Interview on 01/02/25 at 3:00 P.M. with Regional Nurse #310 stated LPN #240 accidentally pulled the oxycodone from Resident #08's roommate, Resident #76's medications, and signed for the oxycodone on Resident #76's controlled substance record. Regional Nurse #310 stated Resident #08 was scheduled to receive her Lyrica on 10/02/24 at 10:00 A.M. but LPN #240 administered an oxycodone instead. Review of the facility policy titled, Medication Administration, revised April 2019, stated medications are administered in a safe and timely manner, and as prescribed. The policy stated medications are to be administered within one hour of their prescribed time, unless otherwise specified. The policy stated the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The policy stated the individual administering the medication initials the resident's MAR on the appropriate line after giving the medication and before administering the next ones. This deficiency represents non-compliance investigated under Complaint Number OH00159866.

Based on medical record reviews, staff interview and policy review, the facility failed to ensure surgical wound care was completed as ordered. This affected one (#95) out of the three residents reviewed for wound care. The facility also failed to ensure peripherally inserted central catheter (PICC) line dresses were changed as ordered. This affected two (#95 and #96) out of the three residents reviewed for intravenous (IV) or PICC line placement. The facility census was 87. Findings include: 1. Review of the medical record for Resident #95 revealed an admitted [DATE] with medical diagnoses of chronic multifocal osteomyelitis, methicillin resistance staphylococcus aureus (MRSA), disorder of kidney and ureter, and conduct disorder. The medical record review revealed a discharge date of [DATE]. Review of the medical record for Resident #95 revealed an admission Minimum Data Set (MDS) assessment, dated 10/02/24, which indicated Resident #95 was cognitively intact and was independent with toileting, bed mobility, and transfers. Review of the MDS revealed Resident #95 received IV medications. Review of the MDS indicated Resident #95 had a surgical wound. Review of the medical record for Resident #95 revealed hospital discharge orders dated 09/26/24 which contained an order to change dressing to PICC line weekly unless it becomes loose, damp, or soiled. Further review of the hospital discharge orders revealed an order for wound care- dressing to be removed three days after surgery and replace dry dressing daily. Review of the medical record for Resident #95 revealed an order dated 10/09/24 for wound care to right shoulder with 33 staples to apply xeroform and island dressing every other day and as needed. Review of the physician orders for Resident #95 revealed no documentation to support there was an order for surgical wound care prior to 10/09/24 or any orders for PICC line dressing change. Review of the medical record for Resident #95 revealed the September 2024 Treatment Administration Record (TAR) did not contain documentation to support the facility completed surgical wound care or PICC line dressing change as per hospital orders. Review of the October 2024 TAR revealed documentation to support wound care was completed on 10/11/24 as ordered. The October TAR did not have documentation to support the facility completed the dressing change to the PICC line as per hospital orders. Interview on 10/28/24 at 1:56 P.M. with Administrator confirmed Resident #95's medical record did not contain documentation to support Resident #95's surgical wound care or PICC line dressing was changed as per hospital discharge orders. 2. Review of the medical record for Resident #97 revealed an admitted [DATE] with medical diagnoses of diabetes mellitus, arthritis due to bacteria right knee, atrial fibrillation, osteomyelitis, and congestive heart failure. Review of the medical record for Resident #97 revealed an admission MDS assessment, dated 08/23/24, which indicated Resident #97 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, bathing, and bed mobility, and substantial/maximum assistance with transfers. The MDS indicated Resident #97 received IV medications. Review of the medical record for Resident #97 revealed a physician order dated 08/21/24 for PICC line dressing and cap change every seven days and as needed and to measure length of exposed tubing with each dressing change. Review of the medical record for Resident #97 revealed the August 2024 TAR contained no documentation to support Resident #97's PICC line dressing was changed as ordered on 08/28/24. Further review of the September 2024 TAR revealed no documentation to support Resident #97's PICC line dressing was changed as ordered on 09/11/24. Interview on 10/29/24 at 10:20 A.M. with Regional Clinical Support #225 confirmed the medical record for Resident #97 did not contain documentation to support the facility changed PICC line dressing as ordered on 08/28/24 and 09/11/24. Review of the facility policy titled, Dressing Change (Clean), revised 06/08/22 stated the purpose was to protect wound, prevent irritation, infection and spread of infection, and promote healing. The policy stated staff are to wash hands, apply gloves, and remove soiled dressing and discard in plastic bad and dispose of gloves, and wash hands. Apply new gloves and cleanse wound. Dispose of gloves, wash hands, and apply new gloves. Apply new glove and apply dressing as ordered. Review of the facility policy titled, Catheter insertion and care, revised November 2022, stated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-sire dressing. The policy stated to change the dressing if it became damp, loosened or visible soiled and at least every 7 days for transparent semi-permeable membrane (TSM) and at least every 2 days for sterile gauze dressing. This deficiency represents non-compliance investigated under Complaint Number OH00158773.

Based on medical record review, staff interview, resident interview, review of the facility fall investigation, and review of facility monitoring, the facility failed to ensure two staff were providing assistance during care for one resident (#1). Actual harm occurred when only one staff was providing assistance for the care of Resident #1 while he was in bed. The staff walked away from the resident and the resident fell from the bed, receiving a fractured right clavicle and a laceration to the right side of the head which required sutures. This affected one (#1) of three residents reviewed for falls in a census of 89. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 01/18/19, identified the resident to be cognitively intact. The resident required two staff for bed mobility and transfers. Review of the plan of care revealed the resident was at risk for falls due to unsteady gait and weakness. Planned interventions included two person assistance for changes and bed mobility. Review of the nurse aide Kardex identified Resident #1 required two person assistance for changes and bed mobility, with the bed to be in the lowest position. Review of the record revealed on 03/06/19 a low air loss mattress was placed on the bed for comfort. Review of the nursing progress notes dated 09/12/19 at 8:06 [NAME]M. revealed Resident #1 was receiving care, was rolled to the left side, and was secure at that time. State tested Nurse Aide (STNA) #15 did not have the correct size brief and stepped out of the room. Licensed Practical Nurse (LPN) #18 was attending to the room mate when Resident #1 moved in the bed, displaced himself, and rolled out of bed. The nurse attempted to catch him to stop his momentum but was unable to reach him before he fell . The resident received a quarter size gash to the right side of his head. Pressure was applied to the laceration. The physician and wife were notified of the incident. The squad was called and the resident was sent to the emergency room for evaluation and treatment. The resident did not lose consciousness, was awake, and denied pain anywhere besides his head. At 1:00 P.M., the resident returned to the facility with a noted fracture to the right clavicle and sutures to the right side of the head. Review of the hospital documentation dated 09/12/19 revealed Resident #1 had a two centimeter laceration to the right side of his head which required three sutures. Additionally, Resident #1 had a mildly displaced [MEDICAL CONDITION] clavicle which required a sling. Review of the facility fall investigation dated 09/12/19, revealed STNA #15 indicated she was providing care to Resident #1 alone when she walked away from the resident. The resident had been in the middle of the bed when she walked away. STNA #15 indicated she had not asked anyone to help her with the resident's care. Observation on 10/07/19 at 8:30 [NAME]M. noted Resident #1 was observed in bed with the low air loss mattress in place. The bed was in the lowest position without side rails in use. There was an overbed trapeze for the resident to use to assist in repositioning. Interview on 10/07/19 at 10:15 [NAME]M., Resident #1 stated when staff assist him with care, there is supposed to be two staff members to help. Resident #1 stated there was only one staff providing care when he rolled out of bed and fell on to his right side on 09/12/19. Interview with the Director of Nursing (DON) on 10/07/19 at 10:00 [NAME]M. verified there was only one staff providing assistance to Resident #1 at the time he fell out of bed on 09/12/19. The DON verified Resident #1 had been assessed to require two staff for incontinence care and bed mobility and at the time of the fall. This deficiency substantiated Complaint Number OH 313. This deficiency is continued non-compliance from the survey dated 09/04/19.

Based on record review, observation, staff interviews, review of radiology reports, review of hospital report, review of the facility incident investigation report, review of employee personnel file and review of policy the facility failed to transfer a resident appropriately. This resulted in actual harm to Resident #65 who sustained a fractured left humeral (upper arm) while being transferred from the bed to the chair and had an increase in pain medication. This affected one Resident (#65) of three reviewed for accidents. The facility identified 83 residents who required assistance of one or two staff for transferring. The facility census was 88. Findings include: Review of Resident #65's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 11/30/17, revealed Resident #85 had severe cognitive impairment and required extensive assist with bed mobility, transfers, dressing, toileting, and hygiene, was totally dependent for locomotion, and required limited assist with eating. Review of care plans revealed the resident required assistance with activity of daily living (ADL) related to physical limitations and weakness. Resident was also care planned for falls due to impaired balance, poor coordination and unsteady gait. Interventions included to provide assist with transfers. Review of the Radiology Report dated 11/08/17 revealed a [MEDICAL CONDITION] neck. The osseous structures are diffusely demineralized. There was soft tissue swelling. Review of Hospital encounter report dated 11/08/17 revealed three views of the left humerus were obtained. Oblique slightly displaced [MEDICAL CONDITION] neck with no discrete dislocation noted. Minimal spurring of the acromioclavicular joint (where the shoulder and clavicle meet). Osseous structures are diminished. There was no significant soft tissue swelling. The care plan for ADL's was updated on 11/09/17 to include transfers with mechanical lift with two persons. Review of the Facility's Incident Investigation Report completed by the Director of Nursing (DON) and dated 11/09/17. LPN #110 completed a written statement and revealed she/he was called to Resident #65's room because the resident was yelling about left arm pain, after being transferred to the chair from the bed. Upon exam of the resident's arm, there was no swelling, discoloration, or other signs of injury; however, the resident was unable to perform range of motion (ROM) due to the complaint of pain. The physician and family were notified and the physician ordered an x-ray of the left arm. Further review of the Facility Incident Investigation report revealed written statements submitted by State tested Nursing Assistants (STNA) #102 and #105. STNA #102 indicated STNA #105 reported she/he thought they hurt Resident #65 during a transfer. STNA #105 indicated she/he transferred Resident #65 without the use of a gait belt and Resident #65 complained of arm pain after the transfer. Further review of the Incident Investigation Report revealed the DON had STNA #105 demonstrate how she transferred Resident #65 from the bed to chair. STNA #105 revealed she did not use a gait belt and was aware she should have. STNA #105 received counseling regarding the use of gait belt with all manual transfers. Review of the Medication Administration Record [REDACTED]. Further review of the MAR for 11/2017 revealed the resident did not utilize the pain medication until after the fracture of her left humeral. From 11/09/17 to 11/31/17 the resident was medicated with the [MEDICATION NAME] sulfate 10 times. Review of the 12/2017 MAR indicated [REDACTED]. On 12/26/17 at 11:15 A.M. an observation was made of Resident #65, she was in her room and was noted to have a blue splint on her left arm. The resident was not interviewable. On 12/27/17 at 10:02 A.M., during an interview STNA #102 revealed she/he was working on 11/08/17 on the same unit Resident #65 resided on. STNA #102 reported STNA #105 came out of Resident #65's room and indicated she/he thought they hurt Resident #65 during a transfer. STNA #102 immediately reported the discussion with STNA #105 to Licensed Practical Nurse (LPN) #110. On 12/28/17 at 8:45 A.M., an interview was conducted with STNA # 105 and revealed she/he was the STNA whom transferred Resident #65 on 11/08/17. The resident complained of left arm pain after being transferred from the bed to the chair. STNA #105 stated Resident #65 had no complaints of left arm pain prior to the transfer. STNA #105 stated she gave Resident #65 a hug with both arms around the resident's waist and transferred Resident #65 to the chair, the resident immediately complained of left arm pain when STNA #105 sat the resident in her chair. During the interview STNA #105 revealed she/he did not use a gait belt during the transfer, and acknowledged she had been trained by the facility to use gait belts when transferring resident's that required assistance with transfers. Review of STNA #105's employee personnel file revealed a Nursing Assistant /Preceptor Orientation Checklist signed by STNA #105 on 08/01/17. STNA #105 met expectations of using the gait belt during ambulation and transferring of residents. Further review of the employee personnel file revealed a Counseling Contact form completed by Registered Nurse (RN) #15, also referred to as the Director of Care Delivery, Unit Manager dated 11/09/17, documented the reason for discussion as a gait belt must be used with all manual transfers. Gait belt was a part of the uniform and must be with the STNA at all times. If this occurs again further disciplinary action will follow. STNA #105's certification was in good standing and there were no other disciplinary actions noted. Review of the facility's policy and procedure entitled Transfer: Bed-Chair/Wheelchair and dated 01/2001, revealed under One Person-Stand Pivot, instructions as follows: 4.) Assist to sitting on side of bed. 5.) Apply gait belt. 6.) stand in front of the patient with flexed hips and knees aligning knees in front of patient's knees. Stand with feet apart and bent. 7.) Instruct/assist patient to lean forward to get body weight over hips. 8.) Rock patient to standing position on count of three while straightening hip and legs and keeping knees slightly flexed. Patient may use hands to push is able. 9.) Once standing pivot feet to reach chair/wheelchair. 10.) Instruct/assist patient to place hands onto armrests of chair/wheelchair, lean slightly forward and slowly lower self to chair/wheelchair. 11.) assist patient to move buttocks against back of chair and if applicable swing footrest of wheelchair into position. 12.) align patient in chair/wheelchair using pillows to support proper positioning, if necessary. 13.) Remove gait belt.