Every finding on record at Laurels of Steubenville the

Based on record review, interview, and facility policy review, the facility failed to protect the confidentiality of medication records for two residents, (Resident #61 and Resident #65) of four residents reviewed for confidentiality. The facility census was 69.Findings include:Review of photographs sent via email by Resident #80's spouse revealed four medication cards containing medications which had not been prescribed for Resident #80. The medications were Anastrozole (a medication to treat breast cancer in postmenopausal women), isosorbide (a medication used to prevent and manage chest pain caused by coronary artery disease), and oxybutynin (a medication to treat overactive bladder symptoms such as sudden urges to urinate, frequent urination and urine leakage) ordered for Resident #65. The fourth medication card was for levothyroxine (a medication to treat an underactive thyroid gland) ordered for Resident #61. This was confirmed by the Director of Nursing (DON) after viewing the photographs on 08/17/26 at 1:13 P.M.Review of the medical record for Resident #80 revealed an admission date of 07/22/26. Diagnoses included chronic diastolic (congestive) heart failure, muscle weakness, cognitive communication deficit, need for assistance with personal care, hypertensive heart disease with heart failure, depression, atherosclerotic heart disease of native coronary artery without angina pectoris, sleep apnea, insomnia, hyperlipidemia, chronic atrial fibrillation,The resident was discharged on 07/31/26.Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief interview for Mental Status (BIMS) score of 11 out of a possible 15 indicating the resident had moderate problems with thinking and memory.Review of orders for Resident #80 reveal no physician orders for anastrozole, isosorbide, levothyroxine or oxybutynin.Review of a Discharge summary dated [DATE] for Resident #80 revealed a discharge medication list was included for Resident #80 indicating the medications which needed to be continued at home. The medication list did not include anastrozole, isosorbide, levothyroxine or oxybutynin. Review of facility grievance log revealed the facility received a concern from Resident #80s representative on 08/03/26. The report indicated on 07/31/26, the resident had been sent home with medications belonging to another resident. The grievance was marked unresolved due to the family of Resident #80 not returning the medication to the facility. On 08/17/26 at 11:18 A.M., an interview with the spouse of Resident #80 revealed the resident was discharged on 07/31/26. When the resident got home, he had medications for two other residents, Resident #61 and Resident #65. The spouse would have given the medications according to the orders on the packaging, however her daughter arrived and noticed the medications were for another resident and not Resident #80 so the medications were not given. On 08/17/26 at 8:28 A.M., an interview with Registered Nurse #300 revealed on discharge, the nurse should review each medication for the resident. Medication cards being sent home with the resident should be compared to the discharge medication orders given by the physician, including the dose, the medication, and the resident name. A resident should never be given medication from another resident. On 08/17/26 at 8:37 A.M., an interview with Licensed Practical Nurse (LPN) #104 revealed medications should always be checked to be sure the medication was for the correct resident prior to sending them home at discharge. The nurse should compare the name on the card, the medication, and the dose for each medication card being sent. The nurse should then explain each medication, when it should be taken, and how it should be taken to the resident or the family. It would not be good to send another resident's medication home with a resident.On 08/17/26 at 1:13 P.M., an interview with the Director of Nursing (DON) confirmed four medications were sent home with Resident #80 which were not prescribed for him. The medications were Anastrozole, isosorbide, oxybutynin (prescribed for Resident #65) and levothyroxine (prescribed for Resident #61). These medications had been sent home with Resident in error. She believed the medications had gotten mixed in with his medications when they were delivered by the pharmacy and when they could not be located for the other residents (#61 and #65) on 07/29/26, the facility had re-ordered those medications at the facility's expense. She reported LPN #104 had advised her she checked the first couple medications in Resident #80's medications which were sent home with him, but did not check them all. The DON confirmed the facility did not maintain Resident #61's and Resident #65's privacy when their medications with their name, strength and doseage were sent home with Resident #80 at the time of discharge. On 08/17/26 at 1:18 P.M., a telephone interview with Physician #500 revealed if a resident was sent home with the incorrect medications, they would need to be notified immediately and told to discontinue the medication. If Resident #80 had been sent home with anastrozole, isosorbide, oxybutynin and levothyroxine, it would be dangerous for him to take them and staff should be educated to use more caution when discharging a resident to be sure all medications they were discharged with were prescribed for them and not another resident.Review of a facility policy titled Discharge Planning Policy revised 02/03/26, revealed transfers and discharges would meet regulatory requirements. The facility would take steps to ensure the transfer or discharge was documented in the resident's medical record and necessary information was communicated to the receiving health care institution or provider. When a resident's discharge was anticipated, the facility would develop and implement a discharge plan which focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. When a discharge was anticipated, the facility would develop a discharge summary/instructions which included, but was not limited to the following: A summary of the resident's stay which included diagnoses, source of illness, treatment or therapy, and pertinent lab, radiology, and consultation results; a final summary of the resident's status to include the resident's needs, strengths, goals, life history and preferences at the time of the discharge which were available for release to authorized persons and agencies, with the consent of the resident or resident's representative; reconciliation of all pre-discharge medications with the resident's post-discharge medications both prescribed and over-the counter; and a post-discharge plan of care developed with the participation of the resident and, with the resident's consent, the resident representative, which would assist the resident to adjust to his or her new living environment. This deficiency represents non-compliance investigated under Complaint Number 3132899

Based on record review, interview and review of facility policy, the facility failed to ensure a safe discharge for Resident #80. This affected one resident (Resident #80) of three residents reviewed for safe discharge. The facility census was 69.Findings include:Review of photographs sent via email by Resident #80's spouse revealed four medication cards containing medications which had not been prescribed for Resident #80. The medications were Anastrozole (a medication to treat breast cancer in postmenopausal women), isosorbide (a medication used to prevent and manage chest pain caused by coronary artery disease), and oxybutynin (a medication to treat overactive bladder symptoms such as sudden urges to urinate, frequent urination and urine leakage) ordered for Resident #65. The fourth medication card was for levothyroxine (a medication to treat an underactive thyroid gland) ordered for Resident #61. This was confirmed by the Director of Nursing (DON) after viewing the photographs on 08/17/26 at 1:13 P.M.Review of the medical record for Resident #80 revealed an admission date of 07/22/26. Diagnoses included chronic diastolic (congestive) heart failure, muscle weakness, cognitive communication deficit, need for assistance with personal care, hypertensive heart disease with heart failure, depression, atherosclerotic heart disease of native coronary artery without angina pectoris, sleep apnea, insomnia, hyperlipidemia, and chronic atrial fibrillation, The resident was discharged on 07/31/26.Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief interview for Mental Status (BIMS) score of 11 out of a total 15 indicating moderate problems with thinking and memory.Review of physicain orders for Resident #80 reveal no orders for anastrozole, isosorbide, levothyroxine or oxybutynin. This was confirmed by the Director of Nursing on 08/17/26 at 1:13 P.M.Review of a discharge summary for Resident #80 revealed a discharge medication list was included which indicated the medications the resident should continue at home. The medication list did not include anastrozole, isosorbide, levothyroxine or oxybutynin. This was confirmed by the Director of Nursing on 08/17/26 at 1:13 P.M.On 08/17/26 at 11:18 A.M., an interview with the spouse of Resident #80 revealed the resident was discharged on 07/31/26. When the resident got home, he had medications for two other residents, Resident #61 and Resident #65. The spouse would have given the medications according to the orders on the packaging, however her daughter arrived and noticed the medications were for another resident and not Resident #80. The medication was stored in her safe at her home. On 08/17/26 at 1:13 P.M., an interview with the Director of Nursing (DON) confirmed four medications were sent home with Resident #80 which were not prescribed for him, Anastrozole, isosorbide, oxybutynin, and levothyroxine. The DON verified these medications had been sent home with Resident #80 and had the resident taken the medications, it could have been dangerous for him. On 08/17/26 at 1:18 P.M., a telephone interview with Physician #500 revealed if a resident was sent home with the incorrect medications, they would need to be notified immediately and told to discontinue the medication. If Resident #80 had been sent home with anastrozole, isosorbide, oxybutynin and levothyroxine, it would be dangerous for him to take them and staff should be educated to use more caution when discharging a resident to be sure all medications they were discharged with were prescribed for them and not another resident.Review of a facility policy titled discharged Resident Medication Policy updated 11/21/25 revealed when a resident was discharged from the facility, the medication would either be sent back to pharmacy for credit, destroyed, or sent home with the resident. The nurse discharging the resident would remove all medication from the cart. The remaining supply of all medications would be sent home with the resident or resident representative. In the event the resident or family declined the medications the remaining supply of the medication would be returned to the pharmacy. This policy was provided by the DON via email on 08/17/26.Review of a facility policy titled Discharge Planning Policy revised 02/03/26, revealed transfers and discharges would meet regulatory requirements. The facility would take steps to ensure the transfer or discharge was documented in the resident's medical record and necessary information was communicated to the receiving health care institution or provider. When a resident's discharge was anticipated, the facility would develop and implement a discharge plan which focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. When a discharge was anticipated, the facility would develop a discharge summary/instructions which included, but was not limited to the following: A summary of the resident's stay which included diagnoses, source of illness, treatment or therapy, and pertinent lab, radiology, and consultation results; a final summary of the resident's status to include the resident's needs, strengths, goals, life history and preferences at the time of the discharge which were available for release to authorized persons and agencies, with the consent of the resident or resident's representative; reconciliation of all pre-discharge medications with the resident's post-discharge medications both prescribed and over-the counter; and a post-discharge plan of care developed with the participation of the resident and, with the resident's consent, the resident representative, which would assist the resident to adjust to his or her new living environment. This deficiency represents non-compliance investigated under Complaint Number 3132899.

Based on review of medical records and interview with facility staff, the facility failed to administer medications as ordered for Resident #531. This affected one (Resident #531) of three records reviewed during the complaint survey. The facility census was 81.Findings include:Review of the medical record for Resident #531 revealed admission to facility on 03/18/22 with diagnoses including seizures, bilateral shoulder pain, anxiety, anemia (low blood count), diabetes, and high blood pressure.Review of the most recent Minimum Data Set (MDS) 3.0 quarterly assessment completed on 04/28/26 revealed Resident #531 was independent with using her wheelchair, independent with bathing and dressing and required supervision for transfers.Review of the medication administration record (MAR) for June of 2026 revealed an order on 03/01/2025 at 2:00 P.M. for Clonidine HCL oral tablet (high blood pressure medication) 0.1 milligrams (mg) give one tablet by mouth three times a day when systolic (top number) blood pressure is greater than 165 or diastolic (bottom number) is greater than 92.Further review of the MAR revealed on 06/03/26 at 6:00 A.M. Resident #531's blood pressure was 147/68 and the dose of clonidine was administered at that time. On 06/03/26 at 10:00 P.M. Resident #531's blood pressure was 132/74 and the clonidine was administered. On 06/05/26 at 2:00 P.M. Resident #531's blood pressure was 118/63 and the clonidine was administered. On 06/07/26 at 10:00 P.M. Resident #531 blood pressure was 134/78 and the clonidine was administered. There were a total of 10 incidents for the month of June 2026 in which Resident #531 received her clonidine when her blood pressure was under 165/92.Review of the nursing progress notes for Resident #531 revealed no adverse reactions or effects from the incorrect administration of the clonidine. Interview on 07/15/26 at 1:25 P.M. with the interim director of nursing (DON) revealed verification that the MAR for June Resident #531 had received several doses of the clonidine despite her blood pressure not falling in the parameters to receive it. The DON was going to immediately education the nursing staff. The DON also confirmed that Resident #531 had no ill effects to her knowledge related to the incorrect administration.

Based on closed medical record review, review of hospice records, review of a facility soft file, interview, and policy review the facility failed to implement an effective pain management program, including the administration of scheduled and as needed opioid medication to effectively manage Resident #86's pain.Actual Harm occurred beginning on [DATE], when Resident #86, who was identified with chronic pain and a new onset of end of life care for pain management, did not receive scheduled or as needed Oxycodone (narcotic pain medication), resulting in uncontrolled pain affecting the resident's end of life care requiring increasing and changing the residents pain medication to re-gain control of the resident's pain. This affected one resident (#86) of three residents reviewed for pain.Findings include: Review of Resident #86's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome, Parkinsonism, pain and stiffness in right and left shoulder, osteoarthritis, carpal tunnel syndrome, hereditary and idiopathic neuropathy, thrombocytopenia, metabolic encephalopathy, aphasia, and cerebral infarction. The resident was discharged to a hospice facility on [DATE].Review of Resident #86's plan of care dated [DATE] revealed the resident was at risk for pain and/or had chronic pain related to neuropathy, cerebral infarction, shoulder replacement, osteoarthritis, depression, left hip pain, bilateral lower extremities pain, and history of chronic pain. Interventions included to offer non-pharmacological interventions, administer medication as ordered and observe for ineffectiveness and side effects, report abnormal findings, anticipate the residents need for pain relief as needed and respond immediately to any complaint of pain, identify residents' existing conditions which may increase pain and or discomfort (arthritis, neuropathy, osteoporosis) and provide appropriate pain management treatments, notify physician if interventions are unsuccessful or if current complaints was significant change from residents past experience of pain, observe and report any signs and symptoms of non-verbal pain, vocalizations, mood/behaviors (more irritable, restless, aggressive, squirmy, constant motion), eyes (tearing), body (tense, ridged, rocking, curled up, thrashing) and report abnormal findings to the physician.Review of Resident #86's risk for discomfort or adverse side effects from pain medication plan of care dated [DATE] revealed the resident was on pain medication therapy (Oxycodone, Tylenol, Ibuprofen, and Gabapentin) for chronic shoulder pain. Interventions included administering medication as ordered and observe for altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritis, respiratory distress, sedation, urinary retention, and notify physician if indicated.Review of Resident #86's risk for decline in condition, pain, depression, weight loss and other symptom related to terminal prognosis dated [DATE] revealed the resident was receiving hospice services. Intervention included assess resident's coping strategies and respect the residents wishes, consult hospice, encourage resident/family to express feelings, observe for adverse reactions and symptoms of end of life such as nausea/vomiting, difficulty breathing, agitation, observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there was breakthrough pain, refer to hospice plan of care, work cooperatively with hospice team, and work with nursing staff to provide maximum comfort for the resident.Review of Resident #86's nursing progress notes revealed on [DATE] the resident had increased drowsiness, trouble with fine motor skills, and decreased appetite. Cymbalta had been increased to 60 milligrams (mg) twice daily on [DATE]. New orders to hold Cymbalta for 24 hours and restart 20 mg for two days, then start 30 mg daily was provided at this time. Review of Resident #86's nursing progress note dated [DATE] revealed the resident's daughter was aware of the resident's acute functional decline and wished to have hospice consulted. Hospice in facility and consulted with daughter and daughter has decided to move forward and sign paperwork.Review of Resident #86's hospice agreement and note dated [DATE] revealed the resident's prior pain medication regime included Lidocaine patch four percent apply for 12 hours and remove for 12 hours daily for pain, Gabapentin 300 mg twice daily for neuropathy, Ibuprofen 400 mg twice daily for pain, Oxycodone 5 mg twice daily for pain, and Tylenol Extra Strength 500 mg two tablets three times daily. The resident's daughter had reported the resident had knee replacement and surgery on both shoulders and had been in constant pain and was taking Oxycodone, Tylenol, and ibuprofen scheduled. Resident grimaced any time she moves, above medications were not effective. Hospice recommended to increase Oxycodone to every eight hours and as needed. Message left with provider for approval. Review of Resident #86's hospice psychosocial admission assessment dated [DATE] revealed the resident was asleep when the social worker arrived. The resident arose easily, her speech was mumbled and she was confused and unable to answer questions appropriately. The facility nurse reported the resident had been sleeping most of the day.Review of Resident #86 hospice note date [DATE] revealed hospice had met with Resident #86's daughter. The resident was alert sitting up in bed and attempted to communicate but speech was garbled, but did shake head yes and no. The daughter was grateful for support and wanted comfort for the resident. The physician approved the Oxycodone recommendation; the daughter agreed with the medication changes and the facility nurse was updated and voiced no concerns. The resident's prescription was sent to the pharmacy.Review of Resident #86's hospice physician order dated [DATE] revealed new orders for Oxycodone 5 mg every eight-hour scheduled, and every four hours as needed for pain and Zofran 4 mg every six hours as needed for nausea and vomiting. An order was also provided to discontinue the Oxycodone 5 mg twice daily. Review of the Oxycodone control sheet dated [DATE] and received on [DATE] revealed Oxycodone 5 mg every eight hours scheduled, and every four hours as needed.Review of Resident #86's medical record revealed no evidence the new orders to change the Oxycodone 5 mg to every eight hours scheduled and every four as needed and Zofran 4 mg every six hours as needed was implemented on [DATE]. The orders were not implemented until [DATE] at 7:43 P.M. (three days after medication was ordered).Review of Resident #86's hospice note dated [DATE] revealed the resident was alert and pleasant but speech was garbled. The resident had a fall yesterday which resulted in no injuries. The resident could not respond to pain questions; however, breathing was normal, no facial expressions of pain, and body was relaxed. Review of Resident #86's medication administration records (MAR) dated 05/2025 revealed the resident did not receive the scheduled Oxycodone 5 mg at 10:00 P.M. on [DATE] or the 6:00 A.M. dose on [DATE] because she was sleeping. The narcotic control sheet dated [DATE] revealed the Oxycodone 5 mg was signed out on [DATE] at 10:00 P.M. with no evidence the medication was wasted. In addition, there was no evidence the resident had received the Oxycodone as needed from [DATE] to [DATE].Review of Resident #86 significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was absent of spoken words and sometimes understood. The resident had severe cognition impairment and no behavioral symptoms. The assessment revealed Resident #86 was on a scheduled pain medication regimen and could not answer the pain assessment interview questions. The staff assessment pain section was conducted and indicated the resident had non-verbal sounds and facial expression for indicators for pain. The resident had indicators of pain or possible pain observed one to two days. The resident was receiving hospice care. Review of Resident #86's hospice note dated [DATE] revealed the resident had been anxious since this morning. Daughter pushes the resident in her wheelchair. The resident shook head yes she was having pain. The resident was tearful during visit and fidgeting. New orders received for Ativan 0.5 mg four times daily as needed and Oxycodone increased to 10 mg every six hours and discontinue 5 mg every eight hours scheduled, and every four hours as needed.Review of Resident #86 narcotic control sheet and MAR dated 05/2025 revealed the Resident received the scheduled Oxycodone 5 mg on [DATE] at 2:00 P.M. per the MAR, however there was no evidence the Oxycodone 5 mg was signed off the narcotic control sheet. The MAR indicated the Oxycodone 5 mg scheduled and the as needed orders were discontinued on [DATE] at 7:43 P.M. There was no evidence that the resident had received Oxycodone 5 mg or 10 mg on [DATE] (as evidenced by the Oxycodone not being signed off on the narcotic control sheet). Review of Resident #86's orders and MAR dated [DATE] revealed the resident did not receive the Oxycodone 10 mg at midnight on [DATE] because she was sleeping.Review of Resident #86's progress notes dated [DATE] at 11:08 A.M. revealed the resident's daughter had spoken to this nurse regarding the resident's new hospice orders. Upon chart review it was discovered that the resident was historically on Oxycodone 5 mg twice daily, while reviewing the chart this nurse noted the scheduled 2:00 A.M., dose was not administered on more than one occasion with charting code sleeping. Residents' pain was well controlled with this regimen when all doses were administered. The resident's daughter was made aware of missed doses and changes in pain management routine that resulted in the resident's increased pain that hospice had noted upon assessment. At this time the resident's daughter wished to resume original order of 5 mg Oxycodone at 2:00 A.M. and 4:00 P.M. Hospice nurse made aware of the above. Physician aware of the above and agreeable to resume historical order. Review of a clarification note dated [DATE] at 11:28 A.M., revealed Oxycodone was historically scheduled at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and every four hours as needed. Review of Resident #86's progress note dated [DATE] revealed the resident's daughter was very teary eyed. The daughter stated she spoke with her mom after yesterday's fall, and the resident and family wanted to start hospice end of life drugs. She (the resident) doesn't want to be in pain and suffer any longer.Review of Resident #86's hospice physician orders dated [DATE] revealed new orders for Morphine concentrated solution 20 mg/milliliter (ml) give 0.25 ml every four hours as needed for pain/dyspnea. There was no documented evidence to discontinue the Oxycodone 5 mg scheduled or as needed.Review of progress note dated [DATE] revealed the nurse documented the physician reviewed medication and discontinued some medications. Keep Oxycodone until morphine starts and then discontinue. The note didn't indicate which Oxycodone order to discontinue the scheduled or as needed.Review of Resident #86's Morphine (narcotic) control sheet revealed the Morphine was received on [DATE] and the first as needed dose was administered on [DATE] at 4:30 P.M.Review of Resident #86's orders revealed on [DATE] at 9:34 P.M., the three times a day scheduled and the as needed Oxycodone orders were both discontinued.Review of the hospice note dated [DATE] revealed the resident was sitting up in wheelchair, pleasant, and no signs or symptoms of distress. The daughter was tearful as it was a rough weekend. The unit manager had called the physician to ask if the new pain medication order was not being started as a medication dose was missing at 2:00 A.M. The resident was agitated Saturday ([DATE]) and had a fall Saturday afternoon and was transported to the hospital with a hematoma to the top of the head. The CT was negative. The resident's daughter stated the resident was in pain on Sunday and frustrated as the resident was suffering. New orders were obtained from hospice for Morphine 5 mg as needed every four hours. Education was provided on use of as needed Ativan for increased anxiety to nurse (Registered Nurse (RN) #113). After medical record review with RN #113 the previous Oxycodone 5 mg order (from [DATE]) was not placed in the resident orders and the resident had not received it. The previous Oxycodone 5 mg order every 8 hours scheduled was added. The resident's daughter was at the beside aware and grateful.Review of a progress note dated [DATE] revealed the hospice nurse was present and had ordered this nurse to restart the Oxycodone 5 mg every eight hours as scheduled. Review of a progress note dated [DATE] revealed the resident's daughter had concerns the resident was having uncontrolled pain. Hospice updated and requested we give the Morphine every four hours and keep the as needed and monitor.Review of a hospice note dated [DATE] revealed the facility had changed the resident's pharmacy. There was a new order for Oxycodone 10 mg three times daily. Resident #86's daughter reported that the resident was doing wonderful, does not want to change pain regimen at this time. Further review of Oxycodone narcotic control sheets and MAR dated 06/2025 revealed the MAR indicated Oxycodone 10 mg was administered at 8:00 A.M., on [DATE], [DATE] at midnight, 8:00 A.M., and 6:00 P.M., and [DATE] at 8:00 A.M., however the medication was not signed off on the narcotic control sheets. The control sheet indicated 20 pills were received on [DATE] of Oxycodone 10 mg. On tablet was removed on [DATE] at 4:39 P.M., one tablet on [DATE] at midnight and 11:30 P.M., no tablets were removed on [DATE], one on [DATE] at midnight and 4:00 P.M. and [DATE] at midnight. The remaining 14 tablets were destroyed on [DATE].Review of a progress note dated [DATE] revealed the resident was displaying increased signs of anxiety during medication administration, including physically grasping at this nurse's arm. Hospice contacted about increased agitation. Hospice stated they would be in today to assess resident.Review of hospice note dated [DATE] revealed the resident pain was assessed by non-verbal. The resident was tense, distressed, rubbing legs, fidgeting and refusing medication. The resident was yelling, smacking and kicking. New orders for Fentanyl patch and discontinue the scheduled Morphine order. Review of a hospice note dated [DATE] revealed the Director of Nursing (DON) called asking for Morphine to be scheduled as some facility nurses do not administer. The resident was exhibiting signs of pain. The nurse had reported prior to hospice arriving the resident was crying, moaning; morphine was administered prior to hospice arriving. Nurse reported the resident receives Morphine every four hours, she experiences good effects. Physician updated and Morphine scheduled every four hours. Review of the facility's soft file for Resident #86 revealed a guest satisfaction concern form dated [DATE] indicating Resident #86 daughter called the DON down to 200 hall Unit Mangers office to voice concerns the resident's pain medication was not being administered when the resident was sleeping. She stated she wanted the resident to be woken up and given pain medication regardless. The daughter voiced a concern that RN #113 wasn't giving medication when her mom was sleeping. The investigation indicated the MAR was reviewed and medications were given as ordered. Hospice notified of daughter's concerns. The Administrator had an unsigned typed letter dated [DATE] at the top that indicated Resident #86's daughter didn't feel her mom was medicated properly. The daughter had a time of events, however never told the DON because the Unit Manager told her that they wouldn't get addressed. The daughter felt staff could benefit from Hospice training and the Administrator agreed and set up empathy training for staff with Hospice. Included in the soft file was an email from the [NAME] President of Operations dated [DATE] that himself and Division Director of Clinical Service reviewed the medical record (of Resident #86). It was his understanding the that the Ohio Department of Health had been into the facility to investigate the same concerns. Information contained in the soft file revealed the [NAME] President of Operations indicated that appropriate actions had been taken with the facility staff to address (family) concerns and provide education as necessary.The soft file included staff education on hospice services on [DATE] and all staff meeting in June (2025) that included notifying hospice of change of condition and when to administer as needed medication. Review of the facility policy titled Pain Management dated [DATE] and revised [DATE] revealed the facility would evaluate and identify residents' pain, determine the type, location, severity, and develop a care plan for pain management. If a resident who has dementia and cannot verbalize that they are feeling pain, symptoms of pain can be manifested by particular behavior such as calling out of help, facial expression, refusing to eat, striking out when moved or touched, and increased confusion.Interview on [DATE] from 12:39 P.M. to 3:30 P.M. and [DATE] at 10:13 A.M., with anonymous staff members #103, #107, and #111 confirmed Resident #86's daughter was upset due to a facility nurse not administering Resident #86 medication per hospice orders. The nurse didn't believe in hospice.Interview on [DATE] at 3:19 P.M., with the Administrator revealed Resident #86's daughter had voiced concerns to the corporate office, and they completed an investigation and had no negative findings related to the daughters' concerns. The daughter had voiced concerns to the Unit Manager; however, the Unit Manager did not forward the concerns to the DON or herself. The Unit Manager was no longer employed by the facility. The Administrator reported the DON was not aware of the family's concerns until the end of July (2025) after the resident had expired. Resident #86 had gone to the hospice house around [DATE] and expired a few days later. The Administrator reported she would have to see if the DON completed a concern form. Interview on [DATE] at 10:00 A.M., with Resident #86's daughter revealed in [DATE] she had consulted Hospice for pain management for her mother. There was one nurse who would refuse to medicate her mother per hospice orders and plan of care. She (the daughter) visited her mother daily. Her mom was not able to speak but showed non-verbal cues of pain. When she (the daughter) would request pain medication the nurse would say She doesn't need it or She has been fine and been sleeping. The nurse told hospice once she didn't agree with their orders. On [DATE]th (2025) the daughter had spoken to the DON and was assured staff would be educated on pain management and as needed orders including the nurse that refused to medicate her mother. (See above hospice note dated [DATE] that the DON called hospice requesting scheduling Morphine due some facility nurses don't administer medication). Resident #86's daughter reported she could not continue to arrive for routine visit daily to find her mother in severe pain and distress. She moved her mom to the hospice house where she had expired a few days later. Interview on [DATE] at 3:27 P.M., with the DON and Administrator confirmed the hospice order on [DATE] to increase the Oxycodone 5 mg to every eight hours schedule and every four hours as needed, and Zofran was not implemented until [DATE] because the facility was not aware of the new orders on [DATE]. The Administrator reported the facility had changed pharmacies on [DATE] and she would have to call the previous pharmacy for records. The Administrator received a printout; the records were not legible, however the narcotic control sheet indicated the new order was received by the facility on [DATE]. The DON confirmed Resident #86 did not receive scheduled Oxycodone on [DATE] at 10:00 P.M. and [DATE] at 6:00 A.M., per the MAR because the resident was sleeping. The DON reported nurses use their assessment skills to determine if it was safe to administer medications. The DON confirmed there was some confusion regarding the Oxycodone and Morphine order that was received on [DATE], however the hospice nurse clarified on [DATE] the scheduled Oxycodone should have been given resulting in the resident missing two doses of Oxycodone the morning of [DATE]. The DON confirmed there were no narcotic control sheets to prove the resident had received Oxycodone 10 mg on 8:00 A.M., on [DATE], [DATE] at midnight, 8:00 A.M., and 6:00 P.M., and [DATE] at 8:00 A.M. per the MAR. The medication was not removed from the emergency contingency machine either per the DON. Another resident had concerns on [DATE] that pain medication was not provided upon request timely. This residents' concerns were not identified as part of the facility's investigation. This deficiency represents non-compliance investigated under Complaint Number 2614918.

Based on medical record review and interview the facility failed to ensure narcotic medication was not misappropriated. This affected one resident (#86) of three residents reviewed for pain management. Findings include:Closed record review revealed Resident #86 was admitted to the facility on [DATE] with a diagnoses including chronic pain syndrome, Parkinsonism, pain and stiffness in right and left shoulder, osteoarthritis, carpal tunnel syndrome, hereditary and idiopathic neuropathy, thrombocytopenia, metabolic encephalopathy, aphasia, and cerebral infarction. The resident was discharged to the hospice facility on 07/28/25. Review of Resident #86's significant change in status minimum data set (MDS) dated [DATE] revealed the resident was absent of spoken words and sometimes understood. The resident had severe cognition impairment and no behavioral symptoms. Resident #86 was on a scheduled pain medication regimen and could not answer the pain assessment interview questions. The staff assessment pain section was conducted and indicated the resident had non-verbal sounds and facial expression for indicators for pain. The resident had indicators of pain or possible pain observed one to two days. The resident was receiving hospice care. Review of Resident #86's plan of care dated 06/19/23 revealed the resident was at risk for pain and/or has chronic pain related to neuropathy, cerebral infarction, shoulder replacement, osteoarthritis, depression, left hip pain, bilateral lower extremities pain, and history of chronic pain. Intervention included to offer non-pharmacological interventions, administer medication as ordered and observe for ineffectiveness and side effects, report abnormal findings, anticipate the resident's need for pain relief as needed and respond immediately to any complaint of pain, identify residents' existing conditions which may increase pain and or discomfort (arthritis, neuropathy, osteoporosis) and provide appropriate pain management treatments, notify physician if interventions are unsuccessful or if current complaints was significant change from residents past experience of pain, observe and report any signs and symptoms of non-verbal pain, vocalizations, mood/behaviors (more irritable, restless, aggressive, squirmy, constant motion), eyes (tearing), body (tense, ridged, rocking, curled up, thrashing) and report abnormal findings to the physician. Review of Resident #86's risk for discomfort or adverse side effects from pain medication plan of care dated 01/25/25 revealed the resident was on pain medication therapy (Oxycodone, Tylenol, Ibuprofen, and Gabapentin) for chronic shoulder pain. Intervention included administering medication as orders and observe for altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress, sedation, urinary retention, and notify physician if indicated. Review of Resident #86's risk for decline in condition, pain, depression, weight loss and other symptom related to terminal prognosis dated 05/22/25 revealed the resident was receiving hospice. Intervention included assess resident's coping strategies and respect the residents wishes, consult hospice, encourage resident/family to express feelings, observe for adverse reactions and symptoms of end of life such as nausea/vomiting, difficulty breathing, agitation, observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there was breakthrough pain, refer to hospice plan of care, work cooperatively with hospice team, and work with nursing staff to provide maximum comfort for the resident.a. Review of Resident #86's narcotic control sheet dated 05/22/25 revealed the facility had received 60 Oxycodone 5 milligram (mg) tablets on 05/23/25. The sheet indicated there were 27 remaining on 06/09/25 and only one was disposed of on 06/23/25. Review of the MAR dated 06/2025 revealed the resident had received Oxycodone 5 mg one tablet on 06/09/25 at 8:00 A.M. and 4:00 P.M., 06/10/25 at midnight, 8:00 A.M., and 6:00 P.M., 06/11/25 at midnight, 8:00 A.M., and 6:00 P.M., 06/12/25 at midnight at midnight, 8:00 A.M., noon, and 6:00 P.M., and two tablets on 06/13/25 at midnight and 8:00 A.M., however there was no evidence of the narcotic control sheet for the 16 doses administered from 06/09/25 to 06/13/25. A new card of Oxycodone 10 mg was received on 06/13/25 and started on 06/13/25 at 4:39 P.M. Reconciliation of the narcotic control sheet and MAR revealed there should have been 11 Oxycodone 5 mg remaining if the doses were administered per the MAR. Interview on 12/30/25 at 3:27 P.M., with the Administrator and Director of Nursing confirmed there was no narcotic control sheet to account for the 27 Oxycodone 5 mg that remained on 06/09/25. The Administrator reported the narcotic control sheet may have been double sided and the facility did not scan the other side of the control sheet. b. Review of Resident #86's orders dated 05/30/25 to 06/17/25 revealed Resident #86 was ordered Ativan 0.5 mg every six hours as needed for anxiety/restlessness. Reconciliation of the June 2025 MAR and narcotic control sheet for Ativan 0.5 mg revealed on 06/01/25 a narcotic was signed off the narcotic control sheet at 1800 (6:00 P.M.), however was not documented on the MAR. On 06/07/25 the narcotic control sheet indicated Ativan 0.5 mg was administered at 9:00 A.M. and 4:00 P.M., however was never documented on the MAR. On 06/08/25 the narcotic control sheet indicated Ativan 0.5 mg was administered at 2:00 P.M., however was never documented on the MAR. On 06/14/25 the narcotic control sheet indicated Ativan 0.5 mg was administered at 12:20 P.M., however was never documented on the MAR. Further review revealed the resident had refused Ativan 0.5 mg on 06/17/25 at 2:00 P.M., 06/17/25 at 10:00 P.M., and 06/18/25 at 6:00 P.M., the narcotics were signed off the narcotic control sheet, however no evidence the medication was wasted. c. Review of Resident #86's orders dated 07/26/25 revealed Ativan was changed to 1 mg every four hours scheduled and every hour as needed. Review of the narcotic control sheet revealed two tablets were removed at 2:45 P.M. on 07/26/25, however it was not documented on the MAR. Interview on 12/30/25 at 4:22 P.M., with the Administrator and DON reconciled Ativan with the surveyor and confirmed the above findings during the reconciliation. d. Review of Resident #86's orders dated 06/01/25 revealed Morphine Sulfate 0.25 milliliters (ml) every four hours as needed for pain. On 06/18/25 the order was changed to 0.5 ml every two hours as needed. Reconciliation of the June (2025) MAR and narcotic control sheet dated 06/2025 revealed Morphine 0.25 ml was signed off the narcotic control sheet on 05/15/25 at 10:30 A.M. and 2:30 P.M., 06/16/25 at 6:00 P.M., 06/22/25 at noon and 4:00 P.M., however not signed off on the MAR. Further review of the narcotic control sheet revealed on 07/24/25, 0.5 ml was removed at 8:00 A.M., 12:00 P.M., and 4:00 P.M., however not signed off by the nurse administering. Review of the facility policy tilted Medication Administration dated 03/01/13 and revised 10/17/23 revealed to record the dose, route, and time of medication on the Medication/Treatment Administration Record. Interview on 12/29/25 from 12:39 P.M. to 3:30 P.M. and 12/30/25 at 10:13 A.M., with anonymous staff members #103, #107, and #111 confirmed Resident #86 daughter was upset due to one nurse would not administer Resident #86's pain medication per hospice orders. Interview on 12/30/25 at 4:22 P.M., with the director of nursing (DON) and Administrator confirmed findings during reconciliation with the surveyor. The DON confirmed the nurse did not sign off the Morphine on the control sheets on 07/24/25. Interview on 12/30/25 at 10:00 A.M., with Resident #86's daughter confirmed her mother did not receive pain medication as ordered by hospice. This deficiency represents non-compliance investigated under Complaint Number 2614918.

Based on observation and interview, the facility failed to maintain a sanitary, clean and comfortable environment for all residents. This affected residents residing in 10 of 13 rooms observed, involved one of two resident shower/bathing rooms and had the potential to affect all 81 residents residing in the facility. Findings include:On 08/06/2025 between 11:20 A.M. and 12:17 P.M. observations of random rooms throughout the facility with Housekeeping Supervisor #190 revealed the following concerns which were verified by the supervisor at the time of the observation: Handrails in the hallway outside the dining room and office areas were observed being used by multiple unidentified residents as they propelled themselves to the main dining room. The inside ledge of the handrails were dusty with some debris observed. This was verified by the Administrator at the beginning of the tour. room [ROOM NUMBER] had dirt observed around the baseboard while entering the room. In the bathroom, a bag with a brief was observed under the sink counter. One brief was observed on the floor in the same area. Tissues were observed on floor. There was a large black discoloration on the floor at the right side of the base of the toilet. Interview with Housekeeping Supervisor #190 at the time of the observation verified this and stated the facility had tried to clean the discoloration unsuccessfully. There was splatter on the wall to the right of the toilet. Housekeeping Supervisor #190 indicated she could not state what caused the splatter or what it was. In Resident #46's room, Housekeeping Supervisor #190 verified the bathroom floor was stained and verified Resident #46's over bed table was dirty. room [ROOM NUMBER] was observed to have stains on the bathroom floor and there was staining noted on the wall under the bathroom sink. room [ROOM NUMBER] was observed to have discoloration on the floor on both sides of the toilet. In Resident #77's room the bathroom floor was stained and there was a urine collection container behind the toilet on the floor. The trash can by Resident #77's bed was filled over the top. Housekeeping Supervisor #190 indicated it was the responsibility of both housekeeping and nursing to empty trash cans when full. In Resident #82's room there was a yellow discoloration to the bathroom floor and Resident #82's over bed table was dirty. Housekeeping Supervisor #190 stated dirt in the window sill came from a plant Resident #82 used to have but was unable to state when the plant was removed from the window sill. The 300 hall spa had a thick dark yellow discoloration noted on the tiles of the floor and wall off the shower to the right of the room. A black discoloration was noted on the corner where the two walls met at the base of the shower. Housekeeping Supervisor #190 verified the discoloration and stated it appeared to be soap build-up. Resident #74 had an unused wheelchair in his room with a large dirt streak on the backrest which would come into contact with the resident's back and the cushion area was dirty. The top of the resident's dresser was dirty and the bathroom floor was discolored. On 08/06/25 at 11:47 A.M., the Administrator approached stating she understood there were concerns about the stained bathroom floors. The Administrator indicated there had been talks with corporate about addressing the stained areas. However, there were no definitive plans at that time on doing the repairs, purchasing the required materials, or a plan on time frames as residents had to be removed from their rooms for the day while the repairs were made. Continuation of the environmental tour with Housekeeping Supervisor #190 revealed the following: In room [ROOM NUMBER] there was a hole in the bathroom floor linoleum and rust spots on the floor by the toilet.In Resident #30's room there was discoloration of the bathroom floor as well as a trash can in the bathroom that was overflowing with wet paper towels on the floor by the trash can and trash under Resident #30's bed. In room [ROOM NUMBER] the bathroom floors were stained. During the course of the room inspections, Housekeeping Supervisor #290 reported two housekeepers were scheduled each day and they tried to get to every room on a daily basis. However, dependent on how many rooms needed deep cleaned, this was not always able to be done. The supervisor revealed the goal was to ensure each room was cleaned at least every other day.This deficiency represents non-compliance investigated under Master Complaint Number 1270229 (OH00167232).

Based on observations, policy review, and interview, the facility failed to implement appropriate infection control practices during medication administration and incontinence care. This affected one (Resident #9) of seven residents observed for medication administration and one (Resident #84) of one resident observed for incontinence care. Findings include: On 08/06/25 between 9:00 A.M. and 9:16 A.M., Licensed Practical Nurse (LPN) #140 was observed preparing and administering medication to Resident #84. While preparing medication a famotidine 20 milligram (mg) tablet (used to reduce stomach acid production) was dropped on the floor. LPN #140 picked the medication up off the floor and disposed of it. Hand hygiene was not performed. LPN #140 continued to prepare and administer the other four medications (duloxetine 20 mg which is an anti-depressant, florastor 250 mg which is a probiotic, olmesartan 20 mg used to treat high blood pressure and oxycodone IR 5 mg which is a pain medication) to Resident #84. During the medication administration, LPN #140 was observed touching items in Resident #84's environment including the bed control and touching Resident #84 in an attempt to assist her to a more seated position. No hand hygiene was completed. After exiting Resident #84's room, LPN #140 proceeded to walk to the other side of the facility to the medication storage room in order to obtain a famotidine tablet. After obtaining the medication, LPN #140 returned to the medication cart where she proceeded to prepare it for administration. LPN #140 then entered the room and administered the famotidine to Resident #84. While administering the medication to Resident #84, her roommate (Resident #68) was calling out for help stating there was something in her eyes. After administering the famotidine, LPN #140 went to the linen cart and retrieved linens to clean Resident #84's eyes without performing hand hygiene.On 08/06/25 at 9:18 A.M. before LPN #140 could use the linens for Resident #68 she was stopped and verified she had not performed hand hygiene after picking the famotidine tablet up off the floor.Review of the facility's Medication Administration policy (last revised 10/17/23) revealed instructions to follow infection control practices. This included performing hand hygiene after direct resident contact. 2. On 08/07/25 at 10:30 A.M., Certified Nursing Assistant (CNA) #160 was observed providing perineal care to Resident #84. While cleaning Resident #84, CNA #160 was observed cleansing the pelvic area and shaft of the penis by using the same area of the washcloth to make multiple wipes in the same area. After cleaning the pelvic area, Resident #84 was turned to clean his buttocks. CNA #160 used the same area of the washcloth to cleanse the buttocks starting in the coccygeal area and cleaning downward with multiple swipes. After completing the incontinence care, Resident #84's bed control was used to adjust the bed prior to gloves being removed and hand hygiene being completed. On 08/07/25 at 10:45 A.M., CNA #160 verified she had made multiple wipes with the same area of the washcloth and cleansed from the coccygeal area downward when providing care. This deficiency represents non-compliance investigated under Complaint Number 1270228 (OH00166463).

Based on observations, medical record review, and interview, the facility failed to ensure orders were implemented for fall interventions for one (Resident #1) of three residents reviewed for falls. Findings include:Review of Resident #1's open medical record revealed diagnoses including generalized muscle weakness, difficulty walking, hypertensive heart disease, major depressive disorder, solitary pulmonary nodule, aneurysm of the ascending aorta, fatty liver, diverticulosis, and affective mood disorder.Review of Resident #1's admission nursing assessment dated [DATE] revealed Resident #1 was alert and oriented to person, place and time. Resident #1 required one person assist with toileting and ambulation with a device. Fall risks identified included fear of falling/muscle weakness/decreased lower extremity joint function/balance deficit or gait deficit and medication use. Interventions included encouraging Resident #1 to wear appropriate footwear as needed, keeping the environment as safe as possible, Physical Therapy/Occupational therapy (PT/OT) evaluate and treat as ordered and as necessary, providing Resident #1 with activities that minimized the potential for falls while providing diversion and distraction, and placing the call light in reach and encouraging its use. Review of Resident #1's physician orders revealed an order dated 07/14/25 for non-skid strips to the left side of the bed for fall intervention and an order dated 07/17/25 to ensure placement of brightly colored tape to the call bell.During observations with Registered Nurse (RN) #180 on 08/07/25 a 8:57 A.M., RN #180 verified Resident #1 did not have non-skid strips placed on the floor to the left side of his bed and did not have brightly colored tape on his call bell.This deficiency represents non-compliance investigated under Master Complaint Number 1270229 (OH00167232) and Complaint Number 1270228 (OH00166463).

Based on record review, observation, interview and facility policy review, the facility failed to ensure over the counter medication had clearly labeled expiration dates. This was identified in two of four medication carts and had the potential to affect 18 residents (Residents #1, #9, #12, #25, #32, #37, #39, #47, #52, #54, #55, #59, #71, #73, #184, #285, #293, #296) of 24 residents with orders for aspirin 81 milligrams (mg). In addition, the facility failed to ensure medications were secured for Residents #289 and #292. This affected two residents (#289 and #292) of three residents reviewed for medication storage. The facility census was 86. Findings include: 1. On 03/17/25 at 9:27 A.M., RN #1006 was observed preparing and administering medication to Resident #59. One tablet of 81 mg aspirin was prepared and administered. The aspirin bottle had no expiration date. RN #1006 verified she was unable to find an expiration date during the preparation but administered the medication anyway. On 03/19/25 at 8:10 A.M., RN #1005 was observed preparing medication for administration to Resident #293. A bottle of enteric coated aspirin 81 mg was handed to the surveyor for review after it was withdrawn from the drawer. The expiration date on the bottle of aspirin was illegible. RN #1005 retrieved a new bottle of enteric coated aspirin after she inquired what the surveyor was looking for, and verified she was unable to read the expiration date either. The facility identified the following additional residents with orders for enteric coated aspirin (or orders for aspirin which did not designate if it was enteric coated or chewable) from the two involved carts: Residents #1, #9, #12, #25, #32, #37, #39, #47, #52, #54, #55, #71, #73, #184, #285, #296. Review of the pharmacy Storage and Expiration Dating of Medications and Biologicals policy, revised 08/01/24, revealed the facility should destroy and reorder medications and biologicals with illegible, worn labels. 45441 2. Review of the medical record for Resident #289 revealed an admitted [DATE]. Diagnoses included sepsis, muscle weakness, congestive heart failure, atrial fibrillation, sleep apnea, arthritis, kidney failure and pulmonary fibrosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #289 was cognitively intact. He required setup help for eating, supervision for oral and personal care, partial to moderate assistance with toileting and substantial and maximum assistance with showering. He had an indwelling catheter. Observation and interview on 03/17/25 at 10:53 A.M. with Resident #289 revealed Bengay (a topical analgesic cream used for temporary relief of minor muscle and joint pain) lying on the bedside table. Resident #289 revealed the facility was aware he had the Bengay in his possession. Licensed Practical Nurse (LPN) #1009 confirmed Resident #289 did not have an order to self-administer medication, and the Bengay should not have been left at his bedside. Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated 08/01/24, revealed the facility would ensure all medications, including treatment items, were securely locked in a cabinet, cart or medication room that was not accessible to residents or visitors. 3. Review of the medical record for Resident #292 revealed an admitted [DATE]. Diagnoses included kidney failure, heart disease, diabetes, shortness of breath, anxiety and vitamin D deficiency. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #292 was cognitively intact. He required setup help for eating, supervision for oral care, partial to moderate assistance for personal hygiene and was dependent on staff for toileting and showering. Observation and interview on 03/17/25 at 10:14 A.M. with Resident #292 revealed Resident #292 was self-administering allergy eye drops. A bottle of saline nasal spray was also observed at the bedside. Interview with Registered Nurse (RN) #1003 confirmed medication should not be left at the bedside. All medications were to be administered by facility staff and secured in a medication cart or medication storage room. An interview with Resident #292's wife confirmed she had brought the medication in for the resident last week. Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated 08/01/24, revealed the facility would ensure all medications, including treatment items, were securely locked in a cabinet, cart or medication room that was not accessible to residents or visitors.

Based on observation, record review, interview and facility policy review, the facility failed to ensure Resident #289's catheter bag was covered to ensure privacy. This affected one resident (#289) of three residents reviewed for dignity. The facility identified five residents (#2, #11, #70, #289 and #297) as using catheters in the facility. The facility census was 86. Findings include: Review of the medical record for Resident #289 revealed an admitted [DATE]. Diagnoses included sepsis, muscle weakness, congestive heart failure, atrial fibrillation, sleep apnea, arthritis, kidney failure, and pulmonary fibrosis. Review of the physicians' orders for March 2025 revealed an order for Foley catheter care every shift. Review of the care plan dated 03/13/25 revealed Resident #289 was at risk for urinary tract infection and catheter related trauma. Interventions included changing the catheter and tubing, ensuring the urinary drainage bag was secured properly with the dignity cover in place and ensuring the tubing was secured. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #289 was cognitively intact. He required setup help for eating, supervision for oral and personal care, partial to moderate assistance with toileting and substantial and maximum assistance with showering. He had an indwelling catheter. Observation on 3/17/25 at 11:53 A.M. revealed Resident #289 in bed with the catheter urinary drainage bag attached to the side of the bed. There was no privacy cover on the bag. Resident #289 confirmed he had never seen a cover on the catheter bag. Interview at the time of the observation with Registered Nurse (RN) #1009 confirmed all catheter bags should have a privacy cover, and there was not one on Resident #289's catheter bag. Review of the facility policy titled Indwelling Urinary Catheter (Foley) Care and Management, dated 02/28/25, revealed urinary drainage bags would be concealed with a dignity bag.

Based on record review and interview, the facility failed to ensure that advanced directives were consistent within the medical record. This affected two of two residents (#138 and #139) sampled for advanced directives. The facility census was 86. Findings include: 1. Review of Resident #138's medical record revealed an admitted [DATE] and diagnoses including dementia, repeated falls, atrial fibrillation, and moderate protein-calorie malnutrition. Further review revealed Resident #138's admission Minimum Data Set (MDS) assessment was in the process of being completed and an evaluation was completed for the Brief Interview for Mental Status (BIMS) revealing a score of three indicating Resident #138 had severely impaired cognition. Review of Resident #138's medical record revealed an order dated [DATE] and a notation in the information banner, that appears on each screen of the resident's electronic medical record, indicating Resident #138 was a Full Code meaning that if the resident's heart or breathing stopped cardiopulmonary resuscitation (CPR) was to be performed. Further review of Resident #138's medical record revealed a Do Not Resuscitate form dated [DATE] indicating Resident #138 was to have a Do Not Resuscitate Comfort Care (DNRCC) status indicating that if Resident #138's heart or breathing stopped the resident was to be allowed to expire naturally without CPR being performed. In an interview on [DATE] at 1:17 P.M. Regional Nurse #1098 verified the order and banner were not changed when the DNRCC form was signed. In an interview on [DATE] at 8:10 A.M. Licensed Practical Nurse (LPN) #1017 revealed if she was looking to see if a resident was a Full Code or DNRCC she would find the information in the computer banner or in the orders. 2. Review of Resident #139's medical record revealed diagnoses including acute and chronic respiratory failure, morbid obesity, type two diabetes mellitus, protein-calorie malnutrition, chronic obstructive pulmonary disease, atrial fibrillation (irregular heartbeat), hypertensive heart disease with heart failure and chronic pulmonary embolism. Resident #139's face sheet and the area at the top of the computer with code status information indicated Resident #139 was a Full Code. However, Resident #139 had a signed DNRCC order signed dated [DATE]. On [DATE] at 1:01 P.M., Regional Nurse #1098, provided a form dated [DATE] which indicated Resident #139 had determined to change her status to Full Code. Regional Nurse #1098 indicated the form had been in the medical records office waiting to be scanned in. On [DATE] at 8:10 A.M., LPN #197 indicated if she was looking for a resident's code status, she would search the area toward the top of the electronic health record with the code status or look in the code book at the nursing station. On [DATE] at 11:15 A.M., Registered Nurse (RN) #1100 stated if she needed to locate a resident's code status, she would look at the banner area with the code status. On [DATE] at 12:35 P.M., the Director of Nursing (DON) stated nurses were required to determine code status by looking at the orders. Regional Nurse #1098 indicated the facility also had a code status book nurses could refer to. At 12:36 P.M., the DON verified the information in the code book at the nursing station indicated Resident #139 was a DNRCC. Regional Nurse #1098 indicated they must not have updated the code status book when they clarified Resident #139 was a Full Code. 50538

Based on observation, record review and interview, the facility failed to ensure a clean, sanitary environment for a resident with a wound. This affected one resident (#64) of 24 residents' environments which were observed. The facility census was 86. Findings include: Review of Resident #64's medical record revealed diagnoses including depression, emphysema, anemia, and thrombocytopenia. Review of toilet use information between 03/10/25 and 03/16/25 revealed assistance required varied from independent to extensive assistance. On 03/11/25, an order was written to cleanse an abscess to the left gluteal fold with normal saline, apply Aquacel AG with border gauze daily. A skin and wound evaluation dated 03/18/25 revealed Resident #64 had an abscess of the left gluteus measuring 0.9 centimeters (cm) by 0.4 cm. The depth was listed as not applicable. The assessment indicated there was no sign of infection. On 03/17/25 at 4:40 P.M., bowel movement was observed on both sides of the toilet seat. Resident #64 was on contact isolation with the personal protective equipment (PPE) disposed of in the bathroom. The sink for handwashing was also inside Resident #64's bathroom, requiring staff to go into the bathroom to dispose of PPE and perform hand hygiene. On 03/18/25 at 9:45 A.M., Registered Nurse (RN) #1009 verified Resident #64's toilet seat was soiled with bowel movement.

Based on observation, medical record review, facility policy review and interview, the facility failed to timely address reports of intense itching for one (Resident #60) of three residents reviewed for non-pressure-related skin impairment and failed to make timely notification of indicators of congestive heart failure for one (Resident #60) of 24 residents observed for edema. The facility census was 86. Findings include: Review of Resident #60's medical record revealed diagnoses including congestive heart failure (CHF), type two diabetes mellitus, hypertensive heart disease, peripheral vascular disease, atrial fibrillation, stage four chronic kidney disease, cardiomegaly, non-rheumatic aortic valve disorder, chronic cor pulmonale (right ventricular (RV) enlargement secondary to a lung disorder that causes pulmonary artery hypertension), history of pulmonary embolism, presence of a cardiac pacemaker, atherosclerotic heart disease, localized edema and chronic embolism and thrombosis of deep veins of bilateral distal lower extremities. a. On 02/01/25 an order was written to apply point relief pain relieving gel 12% menthol and 4% methyl salicylate to the right shoulder three times a day. The order indicated the gel could be left at bedside according to the nurse practitioner. On 03/18/25 at 7:30 A.M., Resident #60 stated she had something on her right shoulder, and it itched. Resident #60 stated staff told her it was probably arthritis, and they had been applying pain gel. Resident #60 lifted her shirt sleeve enough to allow observation of her upper right shoulder. A patch of dry skin was observed. Resident #60 stated her right shoulder to her neck was itching. On 03/18/25 between 3:00 P.M. and 3:15 P.M., Registered Nurse (RN) #1006 verified the right shoulder and shoulder blade had dry skin with some of the skin toward the mid/lower shoulder blade flaking. There appeared to be patches of skin which appeared to have scratches. RN #1006 stated Resident #60 had a history of her skin drying out and she believed it was from menthol for the pain gel. RN #1006 stated she would consult with the nurse practitioner regarding the itching and flaking skin. On 03/19/25 at 9:10 A.M., Certified Nursing Assistant (CNA) #1060 stated Resident #60 required substantial assistance to bathe and dress. Resident #60 insisted on getting up early and would not lie back down until after she left at 6:00 P.M. Review of a care plan initiated 08/20/24 revealed Resident #60 had a functional ability deficit and required assistance with self-care/mobility related to weakness, impaired mobility, shortness of breath and right shoulder pain. An intervention initiated 12/09/24 indicated Resident #60 was independent with upper body dressing but partial/moderate assistance with bathing. b. Review of a care plan initiated 08/20/24 indicated Resident #60 was at risk for cardiac complications related to multiple cardiovascular diseases: hyperlipidemia, hypertension, CHF, and use of a pacemaker. Interventions included observing, documenting and reporting the physician signs or symptoms of cardiac distress as needed, including shortness of breath and dependent edema, observing and reporting to the physician signs of CHF such as dependent edema of legs and feet, shortness of breath upon exertion, weight gain unrelated to intake, and abnormal breath sounds. Another intervention included observing and reporting to the physician edema and changes in weight. Review of a dietary note dated 08/25/24 at 12:40 P.M. revealed a 5.2% weight gain had been noted since a weight on 08/20/24. Meal intakes were primarily 76-100%. No edema was noted. Upon reviewing Resident #60's weight history, weight variances were normal. No shortness of breath was noted. Resident #60 had an order for daily weights. No new recommendations were provided. The dietitian indicated weights would continue to be monitored. Review of a dietary note dated 08/31/24 at 3:54 P.M. indicated Resident #60 had an 8.9% weight gain since 08/20/24. Meal intakes were primarily 76-100% and weight continued to trend up. No edema or shortness of breath was noted. Weight continued to be monitored daily for management of CHF. No new recommendations were made. A weight of 233.2 pounds was recorded. A nursing Situation, Background, Assessment, and Recommendation (SBAR) summary dated 09/18/24 at 9:15 A.M. indicated staff reported edema (new or worsening) and Resident #60's weight of 233.4 pounds but did not indicate it was a significant weight gain. The summary indicated Resident #60 was noted to have increased edema in bilateral lower legs. Resident #60's skin was tight and shiny. No redness or warmth to touch was noted. Resident #60 denied pain or discomfort related to edema but did state her legs feel like concrete, just heavy. Orders were given to start Lasix 40 milligrams (mg) (diuretic) every day, start potassium 10 milliequivalents (supplement) every day and obtain lab work (basic metabolic panel) on 09/23/24. A dietary note dated 10/08/24 at 3:09 P.M. indicated a weight gain of 11.2% was identified since the weight obtained on 08/20/24 and 5% since the weight obtained on 09/24/24. The note indicated staff reported Resident #60 was requesting double portions frequently. Weight continued to be monitored daily. No edema or shortness of breath was noted. A dietary note dated 11/14/24 indicated Resident #60 continued to trigger for a 9.2% weight gain since 08/20/24. Meal intakes were primarily 76-100%. No new recommendations were provided. No edema or shortness of breath were noted. A Nurse Practitioner (NP) note dated 11/19/24 indicated Resident #60 did not appear to be in acute distress. The NP documented Resident #60's weight and indicated there was no shortness of breath or cough. The NP made no acknowledgement of the significant weight gain but did indicate Resident #60's heart failure appeared to be compensated, and Lasix and potassium would continue. A nursing assessment dated [DATE] indicated Resident #60's breath sounds were clear. Edema was noted to both lower extremities. On 11/30/24, an order was written to apply knee high TED (anti-embolism) hose to both lower extremities: apply in the morning and remove in the evening. A nursing note dated 12/05/24 at 12:15 P.M. indicated the NP was notified of a 25.2-pound weight gain since August 2024. No new orders were provided. Continue to monitor. A dietary note dated 12/11/24 at 2:48 P.M. indicated Resident #60 had a 13% weight gain since 08/20/24, up an additional eight pounds since a weight obtained on 11/14/24. Weight continued to be monitored daily for CHF management. No edema or shortness of breath was noted. No new recommendations were given. A dietary note dated 01/09/25 at 1:46 P.M. indicated Resident #60 had an 8.3% weight gain since 10/13/24 and a 15.6% weight gain since 08/20/24. Meal intakes were good, and Resident #60 requested double portions with meals. A nutrition recommendation form dated 01/09/25 indicated weight was being monitored daily for CHF management and was stable. A request was made to determine if weights could be decreased to weekly, and the NP agreed on 01/20/25. A NP note dated 01/28/25 indicated Resident #60 had no edema and no increased dyspnea (shortness of breath). Continue to monitor. Lungs were clear to auscultation. A dietary note dated 02/11/25 revealed a weight gain of 7.6% since 11/12/24 and a 17% weight gain since 08/20/24. Weight was monitored weekly for CHF management. No edema was noted. No new recommendations were provided. A nursing assessment dated [DATE] indicated Resident #60 had edema of both lower extremities. Breath sounds were clear. A dietary note dated 03/14/25 at 11:25 A.M. revealed Resident #60 continued to trigger for a 10.4% weight gain since 09/13/24. Weekly weights continued to be monitored. On 03/17/25 at 11:45 A.M., Resident #60 was observed sitting in a wheelchair with her legs in a dependent position. Anti-embolism hose were observed on bilateral legs with edema noted. Resident #60 indicated she was aware it would be beneficial to elevate her legs for the edema, but she did not desire to lie in bed all day. On 03/18/25 at 1:06 P.M., Resident #60 was in the wheelchair with her feet in a dependent position with her right leg more edematous than the left leg. Resident #60 stated this was baseline for her. When asked if she had shortness of breath, Resident #60 stated she was always short of breath. Regional Nurse #1098, who was present, was interviewed after the observation and addressed the significant weight gain which continued to trigger with only one note indicating the weight gain was addressed with the NP in December 2024, the edema (dependent versus baseline) and the reported shortness of breath. Regional Nurse #1098 indicated she would have Resident #60 assessed. On 03/19/25 at 12:49 P.M., Registered Dietitian (RD) #2000 stated the facility had risk meetings and discussed residents who had significant weight changes. In the past she was told nursing would notify physicians/nurse practitioners of significant weight changes. RD #2000 stated she also provided a monthly report with significant weight changes. Although Resident #60 started with a rapid weight gain it had been slow and steady for a while. RD #2000 stated it was not until October or November of 2024 she found the responsibility of reporting significant weight changes had changed to be her responsibility. The prior Director of Nursing (DON) had informed her it was something she preferred to do. RD #2000 stated she had no risk notes regarding Resident #60 but insisted she had addressed the significant weight gain with the remainder of the team. RD #2000 acknowledged significant weight gain in a resident with a history of heart problems could represent a precursor to significant concerns such as CHF so timely notifications of significant weight gain were important as a resident's medical condition could deteriorate significantly in a short period of time. RD #2000 stated during her assessments nurses indicated there was no edema or signs of distress. Review of the facility's Weight Management policy, revised 09/22/23, indicated the dietary manager, unit manager and/or registered dietitian were responsible for communicating weight changes to the interdisciplinary team, attending physician and the resident's responsible party. The notification was to be documented in the medical record. The dietary manager or dietitian was responsible for providing a monthly summary of weight changes to the DON.

Based on observation, record review, review of manufacturer information and interview, the facility failed to implement interventions to address identified risk factors for pressure ulcers and failed to implement physician orders for treatment of pressure ulcers. This affected two (Residents #49 and #139) of three residents reviewed for pressure ulcers. The facility census was 86. Findings include: 1. Review of Resident #49's medical record revealed diagnoses including type two diabetes mellitus, quadriplegia, anemia, and peripheral vascular disease. A physician's order dated 01/21/25 gave instructions to cleanse a wound to the right lateral malleolus (the bony prominence on each side of the ankle) with normal saline, pat it dry, and apply CMC fiber dressing (carboxymethylcellulose absorptive dressing for wounds with moderate to heavy exudate) to the wound bed and apply a foam patch every day and as necessary. Review of the weekly wound assessment dated [DATE] revealed Resident #49 had a stage two pressure injury (partial-thickness skin loss with exposed dermis) to the right lateral malleolus that was first identified 12/06/24. The wound measured 1.0 cm by 0.8 cm with 100% epithelial tissue and no drainage. On 03/18/25 at 1:13 P.M., Registered Nurse (RN) #1212 was observed changing the treatment on Resident #49's outer right ankle. The ankle was cleaned with normal saline and patted dry. When RN #1212 started to place the foam dressing on, RN #1002 attempted to intervene stating she believed RN #1212 was missing a step. RN #1212 insisted the order indicated the ulcer was to be cleaned and a dry dressing applied which she proceeded to do. On 03/19/25 at 4:20 P.M., RN #1212 verified she had not applied the CNC fiber dressing to Resident #49's ankle when the dressing was done on 03/18/25. 2. Review of Resident #139's medical record revealed diagnoses including acute and chronic respiratory failure with hypoxia, morbid obesity, type two diabetes mellitus, protein-calorie malnutrition, chronic obstructive pulmonary disease, atrial fibrillation, hypertensive heart disease with heart failure, peripheral vascular disease, lymphedema, and congestive heart failure. A nursing assessment dated [DATE] upon readmission indicated Resident #139 had a stage four sacral ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) with 1.0 cm tunneling (passageways underneath the surface of the skin), a deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) to the outer right ankle, and a black second toe of the left foot. The baseline care plan included with the admission assessment indicated Resident #139 had actual skin breakdown with interventions to observe the location, size and treatment of the skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, and maceration to the physician. A baseline care plan revealed Resident #139 was at risk for impaired skin integrity related to history of impaired skin integrity, pemphigus (autoimmune disorder that causes blisters), impaired bed mobility, incontinence of bowel and bladder, diabetes, obesity, cellulitis of both lower extremities, chronic lymphedema (condition characterized by tissue swelling caused by an accumulation of protein-rich fluid), itching, chronic moisture associated skin damage under the breasts, coronary artery disease, peripheral vascular disease, hammer toes, declining to be assisted with turning and repositioning, and choosing to remain in bed most of the time. Interventions included cueing to reposition as needed. Review of the skin and wound assessments dated 03/13/25 indicated interventions for the treatment and healing of the pressure ulcers included turning/repositioning programs and use of heel boots. A Braden scale dated 03/14/25 indicated risk factors for skin breakdown/development of pressure ulcers included bedfast status, very limited mobility, and a potential problem with friction and shear. On 03/14/25 an order was written for a bariatric bed. On 03/17/25 at 3:45 P.M., Resident #139 was observed sitting in bed with the head of the bed elevated, sitting in a position which would add pressure to the sacrum. On 03/18/25 at 9:00 A.M., Resident #139 was observed lying in bed with the head of the bed elevated up to 30 degrees with Resident #139 lying on her back. At 1:00 P.M., was observed lying on her back. RN #1212 stated Resident #139's sacral ulcer looked better than it did upon admission, and it did not have as much of a smell. RN #1212 stated the mattress utilized by Resident #139 was a regular bariatric mattress. RN #1212 stated Resident #139 usually laid on her back. RN #1212 was unable to state particular interventions which were implemented to reduce the risk factor of bed immobility and pressure, instead stating she was going to request an order for a low air loss mattress. At 2:43 P.M., Resident #139 was observed lying in bed on her back. On 03/19/25 at 8:48 A.M., Resident #139 was observed lying on her back with the head of bed elevated to 45 degrees. On 03/19/25 at 9:10 A.M., Certified Nursing Assistant (CNA) #1060 stated Resident #139 often refused to turn onto her sides. Resident #139 would lie on her back with a sheet over her face. On 03/19/25 at 1:09 P.M., Resident #139 was lying in bed on her back. CNA #1060 reported Resident #139 was receiving a new mattress. Review of the manufacturer information for the Panacea original and support mattress (mattress observed on when admitted ) revealed the top layer provided comfortable pressure redistribution, creating individual load bearing cells that cradled users and improved air flow. Peak and valley middle layers provided suspension-like support while improving immersion on the mattress. The information indicated that the mattress might be appropriate for stage I (non-blanchable redness of intact skin) or stage II (partial thickness loss of skin). Mattresses were one part of an overall care plan to prevent and treat decubitus ulcers. A complete clinical assessment of each individual should be performed before selecting any therapeutic support surface. On 03/19/25 at 3:18 P.M., the Director of Nursing (DON) stated Resident #139 had returned from a long hospital stay. After discussing Resident #139's impaired bed mobility and refusals to reposition, the DON was asked how the facility was addressing those continued risk factors. The DON stated Resident #139 had returned to the facility on the evening of 03/13/25 and was placed on the same bariatric mattress she had used prior to hospitalization . The DON stated it took time to order and receive air mattresses. When residents were being readmitted , it was the responsibility of the marketing director to review referral information to determine if there was any change in equipment or supply needs. On 03/20/25 at 8:05 A.M., the Administrator provided the hospital referral information which indicated Resident #139 had an unstageable pressure ulcer with necrotic (dead) tissue on the sacrum. The Administrator also provided the purchase order for the air mattress dated 03/18/25. The Administrator stated the facility's interdisciplinary team would have been meeting to discuss Resident #139 the week of 03/17/25 after her readmission.

Based on observation, record review, staff interview and facility policy review, the facility failed to ensure Resident #21, who was incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections (UTI) and failed to ensure Resident #21, who was incontinent of bowel, received appropriate treatment and services to restore as much normal bowel function as possible. This affected one resident (#21) of one resident reviewed for bowel and bladder incontinence and UTI. The facility census was 86. Findings include: Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), chronic respiratory failure, type two diabetes mellitus, malnutrition, neuropathy, asthma, chronic obstructive pulmonary disorder (COPD), muscle weakness, antibiotic resistance, depression, and pacemaker. Review of the Minimum Data Set (MDS) assessment completed on 12/01/24 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #21 was cognitively intact. Resident #21 required set up or clean up assistance for meals and oral hygiene, substantial/maximal assistance for toileting hygiene, adjusting clothing before and after voiding or bowel movement (BM), substantial/maximal assistance showering or bathing, partial/moderate assistance for upper and lower body dressing and putting on and taking off footwear. Resident #21 was frequently incontinent of urine (now has a Foley catheter as of January 2025) always incontinent of bowel and had constipation present. Resident #21 was on antidepressants and diuretics. A. Record review revealed an order for a urinalysis (UA) and urine culture & sensitivity (C&S) on 01/17/25 for Resident #21 completed on 01/17/25 with results dated 01/21/25 of UA collected on 01/17/25 for 4+ leukocytes, >50 white blood cells, and trace bacteria. Culture results revealed on 01/23/25 record review revealed urine culture contained klebsiella. Record review revealed an order placed on 01/23/25 to flush Resident #21 Foley catheter as needed for patency. There was no documentation of Resident #21's Foley catheter placement date. Record review revealed an order placed 02/11/25 for a urine C&S for Resident #21 completed on 02/11/25. Record review revealed results from 02/11/25 UA/C&S revealed >50 white blood cells (WBC), trace bacteria with urine culture resulting in klebsiella and enterococcus faecalis. Record review revealed Resident #21 had a urinalysis ordered on 03/03/25 with results of a small number of leukocytes, six to ten white blood cells, and a trace number of bacteria. The C&S came back on 03/06/25 for heavy Escherichia coli (ESCCOL) and heavy Klebsiella (KLEB-ESBL). Record Review revealed no documented evidence of Foley catheter care being completed for Resident #21 for any day in 2025. Observation on 03/17/25 at 11:16 A.M. reveled Resident #21 in enhanced barrier precautions (EBP) in bed in his room with an indwelling Foley catheter present. The indwelling Foley catheter drainage bag and tubing were lying on the floor to the right side of Resident #21's bed. Interview on 03/17/25 at11:45 A.M. with Certified Nurse's Aide (CNA) #1036 revealed the Foley catheter drainage bag should be hooked onto the bed and not lying on the floor. CNA #1036 confirmed the drainage bag was on the floor at this time, applied gloves and placed the tubing and drainage bag off the floor by hooking the drainage bag to the side of the bed below the bladder. Interview on 03/17/25 at 2:06 P.M. with Regional Nurse #1098 revealed the facility was to follow the Lippincott procedures for Foley catheter care and management. Interview on 03/19/25 at 8:15 A.M. with CNA #1030 revealed he was not sure how long Resident #21 has had his Foley catheter. CNA #1030 stated he was unable to locate where to chart Resident #21's Foley catheter care on Point Click Care (PCC) (electronic medical record) and it was usually in the tasks section. CNA ##1030 directed the surveyor to Registered Nurse (RN) #1002 for clarification on documentation of Foley catheter care for Resident #21. Interview on 03/19/25 at 08:19 A.M. with CNA #1048 revealed Resident #21 has had his foley for a few months. CNA #1048 stated aides are to complete Foley care with checks and changes, if the resident does not need changed at checks, then at least once a shift Foley care needs completed. Interview on 03/19/25 at 8:20 A.M. with CNA #1039 revealed Resident #21 had the Foley catheter in for at least a month or more but was not sure an exact date or exactly how long he has had it in. Interview on 03/19/25 8:24 A.M. with CNA #1060 revealed Resident #21 has had the Foley catheter in for a little while. Resident #21 had the Foley catheter when he was on the opposite side of the building in a different room when he was in isolation but does not remember when he was on the other side. Interview on 03/19/25 at 8:27 A.M. with Registered Nurse (RN) #1002 revealed Resident #21 had the foley catheter placed in January of 2025 after his UTI when urology gave the order to place the catheter, urology has since said to keep the catheter due to retention. RN #1002 stated Foley catheter care was to be completed along with checks and changes and at least once per shift. RN #1002 stated after Foley catheter care was completed, it was to be documented under the specific task in PCC. RN #1002 stated she was unable to locate the documentation or task in Resident #21's medical record. RN #1002 stated the task of Foley catheter care had not been activated in Resident #21's record which should be activated as soon as a resident received placement of an indwelling catheter. RN #1002 verified there was no documented evidence of Resident #21 receiving Foley catheter care since having the Foley catheter placed. Review of the undated Lippincott procedure for urinary Foley catheter care and maintenance revealed catheter drainage bag should be kept off the floor to reduce the risk of contamination and subsequent Catheter Associated Urinary Tract Infection (CAUTI). Review of the policy for Catheter Associated Urinary Tract Infection (CAUTI) prevention, dated 12/01/12 effective 01/28/25, revealed the catheter should be secured properly to prevent movement, the urinary collection bag and tubing should be kept off the floor. B. Record review of Resident #21's task for toilet use and continence revealed no documented evidence of a bowel movement (BM) from 02/18/25 through 02/22/25 totaling five days with no BM. Record review of Resident #21's task for toilet use and continence revealed no documentation of a BM from 02/24/25 through 03/04/25 totaling nine days with no BM. Record review of Resident #21's task for toilet use and continence revealed no documentation of a BM from 0 3/15/25 through 03/19/25 totaling five days with no BM. Record review of Resident #21's current medications revealed an order placed on 02/24/25 for tramadol HCl Oral Tablet 50 milligram (mg) (opioid pain medication) give 50 mg by mouth every 12 hours as needed for pain. Record review of Resident #21's care plan completed 10/23/23 revealed Resident #21 was at risk for constipation related to decreased mobility and medication side effects. Goals included Resident #21 will have a BM at least every three days. Interventions include administering medications as ordered and observing for ineffectiveness and side effects, reporting abnormal findings to the physician. Educate resident to notify staff of each BM if toileting self, encourage resident to sit on toilet to evacuate bowels if possible, observe for signs and symptoms of constipation: such as change in color or consistency of bowel movement, difficulty in expulsion, confusion, agitation, bradycardia, abdominal distention/tenderness/guarding/rigidity, vomiting, decreased/absent bowel sounds, diaphoresis, report abnormal findings to the physician, provide one assist to the bathroom with toileting as needed, and record BM pattern after each occurrence describing amount and consistency. Review of Resident #21's medication administration record (MAR) and treatment administration record (TAR) revealed no documentation of interventions being implemented or ordered relating to constipation on 02/18/25 through 02/22/22/25, 02/24/25 through 03/04/25, and 03/15/25 through 03/19/25. Record review of Resident #21's progress notes revealed no documentation of notification to the physician relating to absence of BMs for Resident #21 for the dates of 02/18/25 through 02/22/25, 02/24/25 through 03/04/25, and 03/15/25 through 03/19/25. Record review of Resident #21's care plan completed 01/24/25 revealed Resident #21 was at risk for UTI and catheter related trauma due to having an indwelling urinary catheter. Goals include Resident #21 will show no signs or symptoms (s/sx) of UTI through the next review date and catheter will remain patent and without complications. Interventions include ensuring catheter tubing is secured and ensuring the drainage bag is secured properly. Interventions include providing catheter care per policy. Interview on 03/19/25 at 1:17 P.M. RN #1005 revealed that there were no standing orders to follow if a resident hasn't had a BM. RN #1005 stated the policy was after three days with no BM, you are to implement interventions or reach out to the physician and get orders on what to do next to assist the resident. Interview on 03/19/25 at 1:20 P.M. with Licensed Practical Nurse (LPN) #1003 revealed PCC will alert staff if the resident hasn't had a BM after three days. The unit manager then makes up a list of those who have had no BM that was available at the nurse's station for all to review. This list was updated daily first thing in the morning. It was the expectation that the nurses or aides follow up with the residents to see if they have had a BM that the staff may not be aware of. If the residents had had no BM in the last three days, nurses were to reach out to the physician and receive orders on what the plan is. LPN #1003 stated this was the expectation and procedure across the facility. LPN #1003 if the resident refused any treatment, it should be documented in the medial record. Interview on 03/19/25 at 1:32 P.M. with RN #1001 revealed that the Director of Nursing (DON) prints a bowel list every morning of all residents who have not had a BM in three days. Each nurse received a list of those residents. Throughout the day, staff will ask residents on the list when their last BM was. If it has been more than three days since their last BM, they will check if the resident has any standing orders, and if they do not, nurses were to reach out to the physician to receive orders. If a resident refused treatment, it should be documents. Interview on 03/20/25 at 10:32 A.M. CNA #1029 revealed Resident#21 does not go to the toilet in the room, he stayed in bed and does not like to get out of it. Resident #21 was always incontinent of bowel and was completely dependent on being cleaned and changed. Resident #21 at times can tell staff when he had a BM, but majority of the time, he needed checked, and then you find he needs changed. CNA #1029 stated Resident #21 gets checked every two hours. After a resident has a BM, they were to document it in the resident record.

Based on observation, record review, interview and facility policy review, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #289 and failed to ensure oxygen tubing was dated when changed for Residents #289 and #292. This affected two residents (#289 and #292) of three residents reviewed for oxygen administration. The facility identified 18 residents (#1, #3, #15, #16, #21, #34, #44, #62, #70, #71, #139, #235, #284, #285, #289, #292, #295 and #297) who utilized oxygen. The facility census was 86. Findings include: 1. Review of the medical record for Resident #289 revealed an admitted [DATE]. Diagnoses included sepsis, muscle weakness, congestive heart failure, atrial fibrillation, sleep apnea, arthritis, kidney failure and pulmonary fibrosis. Review of the care plan dated 03/13/25 revealed Resident #289 had difficulty breathing and was at risk for respiratory complications. Interventions included observing for difficulty breathing. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #289 was cognitively intact. He required setup help for eating, supervision for oral and personal care, partial to moderate assistance with toileting and substantial and maximum assistance with showering. He had an indwelling catheter. Review of the physicians' orders for March 2025 revealed an order oxygen at two liters per minute continuously. Observation on 3/17/25 at 10:53 A.M. revealed Resident #289 was wearing his oxygen. The oxygen tank was set at three liters per minute, and there was no date on the oxygen tubing. Resident #289 was unsure how many liters of oxygen he should be receiving and could not confirm if or when the tubing on his oxygen had been changed. Interview at the time of the observation with Registered Nurse (RN) #1009 confirmed Resident #289's oxygen was set at three liters and there was no date on his oxygen tubing. She was unsure what the correct setting for Resident #289's oxygen should be. 2. Review of the medical record for Resident #292 revealed an admitted [DATE]. Diagnoses included kidney failure, heart disease, diabetes, shortness of breath, anxiety and vitamin D deficiency. Review of the care plan dated 03/11/25 revealed Resident #292 had difficulty breathing and was at risk for respiratory complications. Interventions included avoiding extreme temperatures, offering frequent periods of rest, observing for signs of difficulty breathing and obtaining labs as ordered. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #292 was cognitively intact. He required setup help for eating, supervision for oral care, partial to moderate assistance for personal hygiene and was dependent on staff for toileting and showering. He was on oxygen. Review of the physician's orders for March 2025 revealed an order oxygen at two liters per minute continuously. Observation on 03/17/25 at 10:04 A.M. revealed Resident #292 was wearing his oxygen. There was no date evident on the oxygen tubing, and Resident #292 could not verify when the tubing had last been changed. Interview at the time of the observation with Licensed Practical Nurse (LPN) #1003 confirmed all tubing should be changed on Tuesday night and all should currently be dated 03/12/25. She confirmed there was no date on the oxygen tubing for Resident #292. Review of the facility policy titled Use of Oxygen, dated 02/28/25, revealed oxygen masks and tubing should be changed weekly, when soiled or dirty and dated.

Based on record review, interview and facility policy review, the facility failed to ensure pre and post dialysis assessments were consistently completed for Resident #66. This affected one resident (#66) of one resident reviewed for hemodialysis services. The facility census was 86. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included urinary tract infection, kidney disease, muscle weakness and diabetes. Review of the care plan dated 02/04/25 revealed Resident #66 had a need for dialysis due to end stage kidney disease. Interventions included dialysis Tuesday, Thursday and Saturday, administering medications as ordered, observing for side effects and ineffectiveness of medications, checking and reinforcing the dressing at the access site as needed, and utilizing the dialysis communication form to communicate with the dialysis center. Upon return from the dialysis center the communication book would be reviewed and any updates provided to the physician as needed. Review of the comprehensive Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #66 was moderately cognitively impaired. He required setup help for eating, partial to moderate assistance for oral and personal hygiene in substantial or maximum assistance for toileting and showering. He was on dialysis. Review of the physician's orders for March 2025 revealed an order for dialysis every Tuesday, Thursday and Saturday. Review of the pre and post dialysis assessment forms dated 02/06/25 through 03/15/25 revealed pre and post dialysis weights, assessments of the condition of the shunt or access site, mental status and recommended medication changes were not completed consistently. Interview on 03/20/25 at 12:26 P.M. with Licensed Practical Nurse (LPN) #1003 confirmed the nurse on duty was expected to complete the pre dialysis form prior to the resident's departure and ensure dialysis had completed their portion of the form upon the resident's return. She was aware the pre and post dialysis assessments had not been completed thoroughly and had no other documented evidence to verify pre and post dialysis assessments had been completed for Resident #66. Review of the facility policy titled Hemodialysis, dated 03/05/25, revealed residents should be evaluated daily for dialysis access sites and possible complications including but not limited to signs and symptoms of infection or bleeding. The facility would complete the appropriate section of the hemodialysis communication form prior to the resident receiving dialysis and again when the resident returned.

Based on record review, interview and facility policy review, the facility failed to ensure parameters were in place for the administration of pain medication and failed to ensure nonpharmacological interventions were attempted prior to administering narcotic pain medication to Resident #3. In addition, the facility failed to ensure insulin was given according to the physician's orders for Resident #21. This affected two residents (#3 and #21) of five resident reviewed for unnecessary medications. The facility census was 86. Findings include: 1. Review of the medical record for Resident #3 revealed and admitted [DATE]. Diagnoses included depression, bronchitis, history of stroke and failure to thrive. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was severely cognitively impaired. She required setup help for eating, partial to moderate assistance for oral hygiene, substantial to maximum assistance for showering and dressing and was completely dependent on staff for toileting needs. Review of Resident #3's physician's orders for March 2025 revealed an order dated 02/27/25 for Tylenol 325 milligrams (mg) give two tablets by mouth every six hours as needed for fever and an order dated 02/27/25 for Tramadol (narcotic pain medication) 50 mg every eight hours as needed (prn) for moderate and severe pain. Review of the medication administration record (MAR) for March 2025 revealed Resident #3 received Tramadol one time on 03/01/25 a pain level of three, one time on 03/02/25 for a pain level of four, one time on 03/06/25 for a pain level of five, one time on 03/10/25 for a pain level of six and one time on 03/15/25 for a pain level of five, all marked effective. Interview with the Director of Nursing (DON) on 03/20/25 at 10:23 A.M. revealed nurses were expected to call the physician if nonpharmacological interventions for pain did not work, and the patient was still reporting pain or only had controlled pain medicine ordered. She confirmed if a resident was unable to assess their pain using a traditional zero to ten pain scale with ten being the worst, nurses were expected to judge based on nonverbal expressions; she confirmed there was no clear scale to identify when to administer medications. She confirmed there was no documented evidence that the physician had ever been contacted for alternative means of pain medication management for Resident #3 and no documented evidence that nonpharmacological pain management was attempted prior to the administration of narcotic pain medication. Review of the facility policy titled Pain Management, dated 04/11/23, revealed the facility would complete a comprehensive pain assessment, determine the intensity of pain and notify the physician as needed. 51519 2. Record review revealed Resident #21 admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), chronic respiratory failure, type two diabetes mellitus, malnutrition, neuropathy, asthma, chronic obstructive pulmonary disorder (COPD), muscle weakness, antibiotic resistance, depression, pacemaker. Record review revealed an order placed on 11/11/24 for insulin apart flex pen subcutaneous solution pen injector 100 units per milliliter (mL). Inject 8 units subcutaneously in the evening for diabetes mellitus. Review of Resident #21 medical record revealed MDS assessment completed on 12/01/24 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #21 was cognitively intact. Resident #21 required setup or clean up assistance for meals and oral hygiene, substantial/maximal assistance for toileting hygiene, adjusting clothing before and after voiding or bowel movement (BM), showering or bathing, and partial/moderate assistance for upper and lower body and putting on and taking off shoes. Review of Resident #21 care plan initiated 09/06/22, revised 02/26/25 revealed Resident #21 was at risk for fluctuation in blood sugar levels related to diabetes mellitus, medication side effects, and requiring daily insulin. Goals included Resident #21 would be free of signs and symptoms of hypoglycemia or hyperglycemia. Interventions included administering medications as ordered, observing and reporting abnormal findings to the physician. Record review revealed an order placed on 03/03/25 for insulin glargine solution 100 units per mL. Inject 25 units subcutaneously one time a day for diabetes. Hold if blood sugar is less than 150 and notify the medical doctor (MD) if blood sugar is greater than 500. Inject 50 units subcutaneously at bedtime for diabetes. Hold if blood sugar is less than 150, and notify the MD if BS is above 500. Review of the medical record revealed on 03/07/25 documentation on Resident #21's MAR revealed Resident #21's blood sugar was 75 at 10:17 A.M., and 25 units of insulin glargine was administered by Licensed Practical Nurse (LPN) #1022 at 9:00 A.M. Review of the medical record revealed on 03/07/25 documentation on Resident #21's MAR revealed Resident #21's blood sugar was 133 at 5:28 P.M., and 50 units of insulin glargine was administered by LPN #1022 at 5:00 P.M. Review of the medical record revealed on 03/11/25 documentation on Resident #21's MAR revealed Resident #21's blood sugar was 78 at 8:17 A.M., and 25 units of insulin glargine was administered by LPN #1025 9:00 A.M. Review of the medical record revealed on 03/14/25 documentation on Resident #21's MAR revealed Resident #21's blood sugar was 75 at 6:57 A.M., and 25 units of insulin glargine was administered by LPN #1022 at 09:00 A.M. Review of the medical record revealed on 03/15/25 documentation on Resident #21's MAR revealed Resident #21's blood sugar was 100 at 8:30 A.M., and 25 units of insulin glargine was administered by LPN #1013 at 9:00 A.M. Review of the medical record revealed on 03/15/25 documentation on Resident #21's MAR revealed Resident #21's blood sugar was 101 at 4:46 P.M., and 50 units of insulin glargine was administered by LPN #1022 at 5:00 P.M. Review of documentation of Resident #21's MAR revealed Resident #21's blood sugar was 61 on 03/16/25 at 9:05 A.M. Resident #21's blood sugar was re-checked at 4:52 P.M. and was 74. There was no documented evidence that interventions were implemented for the blood sugar of 61 per the facility policy. Interview on 03/19/25 at 2:46 P.M. with the DON confirmed Resident #21's blood sugar was below 150 on above dates and insulin was administered. Insulin was not given as ordered and was given outside of parameter. The DON stated the MD should have been notified and the insulin should have been held. Review of the facility policy titled Diabetic Management, originating 03/01/13 effective 09/22/23, revealed anti-diabetic agents (insulin or oral anti diabetic agents) are administered per the physician order. If blood glucose is below 70 interventions are implemented, and blood glucose is to be re-checked 15-30 minutes after interventions. Review of the facility policy titled Medication Administration, originating 03/01/13 effective 10/17/23, revealed resident medications are administered in an accurate, safe, and timely manner in accordance with written orders of the attending physician. If a dose is inconsistent with the residents age, condition, or diagnosis contact the physician for clarification prior to administration of the medication.

Based on review of the medial record and interview with staff, the facility failed to ensure a physician's order was written for laboratory tests obtained and laboratory tests were obtained immediately (STAT) as ordered by the physician for Resident #2. This affected one resident (#2) of five residents reviewed for antibiotic stewardship. The facility census was 86. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, cerebral infarction, diabetes, moderate protein-calorie malnutrition, epilepsy, abdominal aortic aneurysm, kidney failure, hemiplegia left side, myocardial infarction, obstructive and reflux uropathy, hypertensive heart disease, chronic pain syndrome, presences of cerebrospinal fluid device, and nontraumatic subarachnoid hemorrhage. Review of the Nurse's Note dated 02/05/25 at 11:31 A.M. revealed the Nurse Practitioner (NP) was called because Resident #2 was acting lethargic, with very little verbal interaction. Resident #2's vital signs were taken, documented and told to the NP. The NP ordered a STAT urine, completed blood count (CBC), and a complete metabolic panel (CMP). The NP was also advised that the resident had refused her pill that morning and her blood sugar was 114 in the morning and 88 for lunch. Review of the Nurse's Notes dated 02/06/25 at 11:34 A.M. revealed a follow-up of Resident #2's condition yesterday. She was sitting up in the common area in a chair. The resident had no complaints. She was alert, oriented and responded to questions. Her urine was obtained and sent to the laboratory last night and they were waiting for the results of urine. The physician and daughter were notified. Review of the laboratory order form dated 02/06/25 revealed the laboratory specimens, CMP, CBC, urinalysis were collected from the facility on 02/06/25 at 4:23 A.M. Review of the laboratory results dated [DATE] revealed Resident#2 had 60,000 to 70,000 colony forming units of enterococcus faecalis bacteria indication the resident had a urinary tract infection. Review of the February 2025 physician's orders revealed Resident #2 had an order for Augmentin 875-125 milligrams (mg) (antibiotic) twice a day for seven days dated 02/09/25. Further review of the physician orders revealed no order was placed in the medical record for the NP's orders for STAT urinalysis, urine culture and sensitivity, CBC, or CMP. On 03/19/25 at 3:14 P.M. an interview with the Director of Nursing (DON) revealed the laboratory had taken up to four hours to pick up a STAT lab. On 03/19/25 at 4:30 P.M. an interview with the DON confirmed the laboratory took too long to pick up the STAT urine culture for Resident#2. She verified there was no order written for laboratory work to be done on 2/05/25. She does not know why it was not written. She had the form where they picked up the urine culture in the early morning of 02/06/25, but she does not know the exact time they were in the facility. The facility did not have a laboratory services policy.

Based on review of the medical record, interview with staff, review of information from the PneumoRecs Vax Advisor application and facility policy review, the facility failed to ensure the pneumonia vaccine was up to date for Resident #19. This affected one resident (#19) of five residents reviewed for vaccination status. The facility census was 86. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure, epilepsy, chronic kidney disease, and shortness of breath. Review of the immunizations revealed Resident #19 had the pneumococcal polysaccharide vaccine 23 (PPSV23) pneumonia vaccine on 11/19/23. Review of the PneumoRecs Vax Advisor application revealed if a resident over [AGE] years of age had the PPSV23 and no other pneumonia vaccine they should be administered the Pneumonia conjugate vaccine 15 (PCV) or PCV20 after one year of administration of the PPSV23. On 03/20/25 at 8:42 A.M. an interview with the Director of Nursing (DON) confirmed Resident #19 was not up to date with her pneumonia vaccines. Review of the facility policy titled, Pneumococcal Vaccination (PPV) of Residents, dated 03/27/23, revealed the Advisory Committee of Immunization Practices (ACIP) recommends vaccination persona at high risk for serious complications from pneumococcal pneumonia, including those [AGE] years and older and all residents of nursing homes. Each resident's pneumococcal immunization status would be determined upon admission or soon afterward and would be documented in the resident medical record. If a resident over [AGE] years of age had the PPSV23 and no other pneumonia vaccine they should be administered the Pneumonia conjugate vaccine 15 (PCV) or PCV20 after one year of administration of the PPSV23.

Based on observations, medical record review, policy review, and interview, the facility failed to adequately address residents' complaints of pain for two (Residents #29 and #326) of five residents reviewed for pain. Actual Harm occurred to Resident #326 on 11/13/22 after staff assessed her with pain which was almost constant with a severity of nine on a scale of zero to ten with acknowledgment Resident #326 had no pain interventions in place, but did not pursue attempts to provide pain relief. Actual Harm occurred to Resident #29 on 11/14/22 after she was noted crying with interview revealing she was having pain from a fractured shoulder and requested ordered pain medication which the nurse refused to administer stating Resident #29 had been medicated earlier. Findings include: 1. Review of Resident #326's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #326 was able to make herself understood and was cognitively intact. The MDS indicated Resident #326 had not received any scheduled pain medication or pain medication ordered on an as necessary basis. Nor did she receive any non-medication interventions for pain. A pain interview revealed Resident #326 reported she had almost constant pain over the previous five days which interfered with sleep at night and limited her day-to-day activities. The severity of the worst pain over the prior five days was rated at nine on a scale of zero to ten. There was no documentation indicating the pain was addressed with the physician or any attempts were made to address pain relief. Interview on 11/14/22 at 9:09 A.M., Resident #326 stated she had pain in the right shoulder that she had been having since prior to admission. Resident #326 indicated she had discussed the pain with staff, and her pain was not effectively managed. Interview on 11/14/22 at 9:14 A.M. with Licensed Practical Nurse (LPN) #238 indicated Resident #326 was admitted [DATE] but this was the first time she was assigned to care for her. After review of the medication orders, LPN #238 stated Resident #326 received [MEDICATION(S)] for pain. ([MEDICATION(S)] is a medication used to treat pain from nerve damage.) LPN #238 indicated she had not received any information in her shift report indicating Resident #326 had concerns with pain. At 9:37 A.M., LPN #238 was observed going to Resident #326's room and asking about pain. LPN #238 offered Resident #326 Tylenol (analgesic) and informed the resident she planned to call the physician and ask about a potential x-ray. LPN #238 was observed returning to the medication cart and preparing medication (labels not observed) before returning to Resident #326's room. A nursing note dated 11/14/22 at 9:31 A.M. indicated Resident #326 was complaining of pain in the right shoulder. Resident #326 stated it was an aching pain in her right shoulder and rated it a severity of six on a scale of zero to ten. Resident #326 reported the pain had been going on for some time prior to admission. Resident #326 denied trauma to the right shoulder. No bruising, swelling or redness was noted upon skin assessment. Resident #326 requested an x-ray be obtained. The primary care provider ordered an x-ray of the right shoulder. Results of the right shoulder x-ray obtained 11/14/22 indicated there was no acute fracture or dislocation. The osseous structures appeared intact. Joint spaces were narrowed. Soft tissues were unremarkable. No acute findings were identified. [CONDITION(S)] changes were recorded. On 11/15/22 at 9:48 A.M., Resident #326 was observed propelling herself in the hall and stopped outside the therapy room to talk. Resident #326 stated the facility got an x-ray of her right shoulder on 11/15/22 but there had been no changes in pain management. Resident #326 stated she hoped it got figured out soon because she was tired of waking up at night from the pain. Resident #326 was holding onto her right shoulder as she spoke. At 1:40 P.M., Resident #326 reported she still had not received results of the shoulder x ray. The availability of the results in the electronic health record were discussed with a nurse (name unknown) before she discussed them with Resident #326. At 2:05 P.M., Resident #326 stated she had been receiving Tylenol approximately every six hours, but it was ineffective. Resident #326 stated she believed the pain was also limiting her participation in therapy. Resident #326 stated the nurse told her she was going to inquire if the physician would give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/15/22, an order was written for Tylenol 650 milligrams (mg) every six hours as needed for pain. Interview on 11/15/22 at 2:25 P.M. with State tested Nursing Assistant (STNA) #248 indicated Resident #326 did complain of pain at times and would usually ask for Tylenol. STNA #248 stated she made the complaints and requests known to the nurses when they were voiced to her. Interview on 11/15/22 at 2:58 P.M. with Registered Nurse (RN) #234 indicated the facility had no standing orders for Tylenol. Nurses had to request an order. On 11/15/22 at 4:22 P.M., Resident #326's concerns about pain were discussed with the Director of Nursing (DON) along with her statements she had discussed the pain with staff with a Tylenol order not written until 11/15/22. On 11/16/22, Unit Manager (UM) #202 documented a late entry nursing note dated 11/15/22 at 10:45 A.M. which indicated the Nurse Practitioner was made aware of the results of the shoulder x-ray and that Resident #326 was complaining of chronic discomfort. The pain was rated at a five on a scale of zero to ten. An order was received for Tylenol on a as necessary basis and administered by the staff nurse. UM #202 also documented a late entry for 11/15/22 at 11:45 A.M. indicating Resident #326 verbalized relief of right should discomfort with a pain severity of two. On 11/16/22 at 9:00 A.M., UM #202 verified she documented the administration of the Tylenol by another nurse on 11/15/22 because she noticed the nurse failed to document the administration. A request was made for UM #202 to accompany the surveyor to Resident #326's room to discuss the pain and the effectiveness of Tylenol and the discrepancies between the effectiveness of Tylenol in documentation and interviews. Resident #326 was sitting in her room and reported she had another rough night related to right shoulder pain. UM #202 asked if Resident #326 had received Tylenol that morning, and Resident #326 indicated she had not. When asked if she would like some, Resident #326 indicated she would try it but stated the Tylenol never helped relieve the pain. Resident #326 stated the [MEDICATION(S)] was effective in managing her [CONDITION(S)] but did not help the shoulder pain. On 11/17/22 at 10:14 A.M., Registered Nurse (RN) #300 stated she was cognizant of the assessment reference date (ARD) when she completed the MDS and stated she ensured she has her interviews completed within two days of the ARD. RN #300 verified Resident #326 told her she was having almost constant pain that interfered with sleep and day-to-day activities with a severity level of 9 on a scale of zero to ten over the five days prior to the ARD and that Resident #326 was not receiving any medication or non-pharmacological interventions for pain. RN #300 stated she was new to the MDS role and did not know for sure what to do with concerns that arose from the interviews. RN #300 stated she did not know nurses were not aware of Resident #326 having pain and she was not sure if therapy was addressing the pain. RN #300 verified she should have communicated the resident's concerns about pain timelier. Review of the facility's pain management policy, last revised 07/09/21, indicated residents were to be observed for indicators or pain including moaning, crying, or other vocalizations, wincing or frowning and other facial expression, body posture such as guarding or protecting an area of the body or lying very still, and decrease in usual activities. The Nursing Assistant would communicate to the licensed nurse when a resident was experiencing pain. The licensed nurse would communicate any new onset of resident pain or change in pain to the physician and to the interdisciplinary team (IDT) through the 24-hour report/dashboard process. Staff would implement the care plan for pain, monitor the resident, and administer therapeutic interventions for pain. 2. Review of Resident #29's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 11/03/22 at 7:42 A.M. indicated Resident #29 returned from the hospital with a right humerus fracture after a fall. Orders were received for Tylenol and Ibuprofen (analgesic) on an as necessary basis for pain. A nursing note dated 11/03/22 at 7:00 P.M. indicated Resident #29 complained of pain with a severity of ten on a scale of zero to ten for the right affected arm. Resident #29 reported Tylenol was ineffective. Facial grimacing and crying out in pain were noted. Resident #29 had pain with any provided care. The physician was notified, and staff were awaiting response. A nursing note dated 11/03/22 at 9:00 P.M. indicated a new order was received for [MEDICATION(S)] IR (opioid pain medication) 5 milligrams (mg) every four hours as necessary for pain. A care plan initiated 11/03/22 indicated an alteration in musculoskeletal status related to Resident #29 had a fracture of the right humerus. The goal was for Resident #29 to remain free from pain or at a level of discomfort acceptable to the resident. Interventions included administering analgesics as ordered by the physician. On 11/14/22 at 10:18 A.M., Resident #29 was observed sitting in the wheelchair in her room crying with tears running down her face. Resident #29 stated she was crying because of pain in her right arm. Resident #29 indicated she was unaware when she last had pain medication. With Resident #29's permission, her pain and inquiry as to whether she could have a pain pill was discussed with RN #235. RN #235 stated Resident #29 already had [MEDICATION(S)] and Tylenol, stating Resident #29 had periods where she cried and screamed for no apparent valid reason such as that morning when she started crying and screaming about jelly. The behavior was not congruent with what was occurring at the time. RN #235 stated she had elevated Resident #29's arm on a pillow that morning. Review of the November 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for pain at a severity level of eight. There was no documentation of Tylenol being administered the morning of 11/14/22. On 11/15/22 at 11:30 A.M., Resident #29 stated she had not slept well the previous night because of pain. Resident #29 indicated having a pillow under her right arm did little to help with pain from the fracture. On 11/15/22 at 2:25 P.M., State tested Nurse Aide (STNA) #248 indicated Resident #29 had complained of pain since the fracture occurred. The only behavior she was aware of was Resident #29 crying out in pain. On 11/15/22 at 2:58 P.M., RN #234 stated if residents requested pain medication and it was ordered they should have it administered when requested. RN #234 stated the only behaviors she had noticed were when Resident #29 was in pain. Once the pain was controlled the behavior subsided. On 11/15/22 at 4:22 P.M., the request regarding pain medication and the nurse response were discussed with the Director of Nursing (DON) with no explanation provided.

Based on closed medical record review, facility policy and procedure review and interview the facility failed to ensure Resident #87 was free from a significant medication error when the resident's cardiac medication, [MEDICATION(S)] was not administered as ordered. Actual Harm occurred on 04/09/22 when Resident #87 was transferred to the hospital with shortness of breath and altered mental status after not receiving the ordered [MEDICATION(S)] for three days (04/06/22, 04/07/22 and 04/08/22). Hospital records, dated 04/09/22 revealed the resident's [MEDICATION(S)] level was not super therapeutic 0.49 (normal 0.8-2.0). An electrocardiogram (EKG) showed [CONDITION(S)] (irregular heart rhythm) at 146 beats per minute, [CONDITION(S)] and ST-T wave changes. New orders in the hospital were initiated for intravenous [MEDICATION(S)] and [MEDICATION(S)]. Findings include: Review of the closed medical record for Resident #87 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #87 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/28/22 revealed the resident had intact cognition. Review of physician's orders revealed the resident had an order (dated 04/05/22) for [MEDICATION(S)] 125 micrograms (mcg) once daily at bedtime for CHF. Review of the medication administration records revealed the medication was not administered as ordered on 04/06/22, 04/07/22 or 04/08/22. Review of the nursing progress notes, dated 04/06/22, 04/07/22 and 04/08/22 revealed the [MEDICATION(S)] was unavailable and awaiting pharmacy delivery. There was no evidence the physician was notified of the medication not being available. Review of laboratory results dated [DATE] revealed the resident's [MEDICATION(S)] level was low 0.05 (normal 0.9-2.0). The resident was discharged to the hospital on 04/09/22 with shortness of breath and altered mental status Review of hospital records, dated 04/09/22 revealed the resident's [MEDICATION(S)] level was not super therapeutic 0.49 (normal 0.8-2.0). An electrocardiogram (EKG) showed [CONDITION(S)] (irregular heart rhythm) at 146 beats per minute, [CONDITION(S)] and ST-T wave changes. New orders were initiated for intravenous [MEDICATION(S)] and [MEDICATION(S)]. On 04/21/22 at 1:08 P.M. interview with the Director of Nursing (DON) verified the resident did not receive her [MEDICATION(S)] as ordered on 04/06/22, 04/07/22 or 04/08/22. The medication had just been newly ordered on 04/05/22 when the resident returned from the hospital. Interview with the DON revealed the medication was available at the facility in the medication contingency box and could have been administered to the resident on those dates. The DON also verified there was no evidence the physician was notified the medication was not administered to the resident on 04/06/22, 04/07/22 or 04/08/22. Review of the facility policy titled Medication Administration, dated 12/16/21 revealed medication would be administered in an accurate, safe, timely and sanitary manner. New medication orders would begin timely. Medications were administered in accordance with written orders of the attending physician. This deficiency substantiates Complaint Number OH 909.

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure fall interventions were appropriate and implemented to prevent accidents. This affected two of three residents reviewed for accidents (Residents #80 and #93). The census was 77. Harm occurred when Resident #93 who was an extensive assist of two for bed mobility rolled out of bed onto the floor and lacerated her forehead when she was turned with assist of one staff. Finding include: 1. Review of Resident #93's medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted [DATE] due to status [REDACTED]. Review of the 05/09/15 quarterly Minimum Data Set (MDS) assessment revealed Resident #93 was severely impaired for daily decision making, required extensive assist of two for bed mobility and transfers and had upper and lower functional limitations on both sides. Review of the 06/19/15 significant change MDS assessment revealed Resident #93 was severely impaired for daily decision making, extensive assist of two for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident had upper and lower functional limitations identified on both sides. Physician orders [REDACTED]. The order dated 06/15/15 directed to implement bilateral secondary bolsters to the bed to provide additional positioning and support. Use of mechanical lift for transfers, air mattress with bilateral bolsters to bed to help define boundaries. Record review revealed Resident #93 was readmitted [DATE] and assessed as a high fall risk. A comprehensive plan of care for at risk for falls was initiated 03/04/15 related to impaired communication, resident non-ambulatory, impaired mobility contractures to hand and bilateral knees, history of falls, mechanical lift for transfers, dementia, generalized weakness, failure to thrive, debility, bedfast, opiod medication and psychotropic use. A 03/04/15 potential for impaired skin integrity plan of care indicated to provide extensive assist to reposition frequently and as needed. The Nursing Care Card indicated Resident #93 was an assist of two for bed mobility and assist of two with a mechanical lift for transfers. Review of the nurse note dated 06/08/15 at 9:01 A.M., revealed the nurse was called to Resident #93's room. The resident was observed on the floor at the bedside with the right side of her face on the pad (placed by staff) with minimal blood. Resident #93 was turned to back onto Hoyer pad by four staff and lifted into bed via mechanical lift. A laceration with swelling was noted to the left forehead area, was washed by staff and an ice bag wrapped in towel was applied to the site. Daughter and transport company called. At 9:12 A.M., transport company arrived and at 9:15 A.M. the resident was transported to the hospital. A nurse note at 9:50 A.M. that same day indicated the physician was contacted at 9:50 A.M. after several previous attempts. The resident was admitted to the hospital with [REDACTED].M., identified Resident #93 was admitted to the hospital for a fall/closed head injury. Review of a 06/08/15 computer axial tomography (CAT scan) of the head without contrast revealed a large area of soft tissue swelling seen in the left high frontal parietal scalp consistent with a scalp hematoma. A small amount of air was identified in the subcutaneous tissues in the area. No acute intracranial findings. Review of the emergency room history and physical revealed Resident #93 was septic on arrival with a low grade temperature of 100 degrees Fahrenheit (F), a heart rate of 129 beats per minute (bpm) and positive urinary cultures with Enterococcus species. The left forehead laceration was sutured and Resident #93 was admitted for further evaluation. Resident #93 was readmitted to the facility 06/12/15 with a left forehead laceration with four sutures which measured 2.4 centimeters (cm) in length by 0.4 cm in width. Review of the witness statements revealed State-tested Nurse Aide (STNA) #14 was going to weigh Resident #93 with assistance of STNA #89. She indicated STNA #89 said she had get a Hoyer pad and STNA #14 told her (STNA #89) she would meet her there because she had to get her locker key to get her gait belt and name tag. When STNA #14 was walking down the hall to help STNA #89, a housekeeper told her Resident #93 was on the floor. Review of the investigation revealed on 06/08/15 around 9:00 A.M., STNA #89 went into Resident #93's room to weigh her for weekly weights. STNA #89 wrote that she put her tube feed on hold and lowered the head of her bed. The bed was at her waist level; a working position. The STNA used the bedpad to move the resident over towards her in the bed before rolling the resident over to position the Hoyer pad under her to weigh her. Resident #93 had padded bolsters on both sides of her in the bed. I then, before turning her, stretched out the Hoyer pad beside her on the bed. I began to roll her using the bed pad towards the window. The bolster on the right side of the bed slid off the side (while still attached) because of her body weight. I had ahold of her during this situation and she continued to roll off the side of the bed. She was then layed on her stomach, face down on the floor on top of the gray floor mat on the floor. She had blood coming from her forehead. The tube feed stand was close to her head but I did not see her hit her head on it when she fell . I then yelled for help and a housekeeper got the nurse, Licensed Practical Nurse (LPN) #54 and LPN #20. We then rolled her onto a Hoyer pad and lifted her back into the bed. Review of LPN #20's statement revealed she was called to the room and observed Resident #93 on the bedside mat. Resident's head was on a blue and white bed pad. There was a small amount of blood on blue and white pad. Resident #93's face was right cheek towards the floor. LPN #20 was unable to locate the site that was bleeding so STNA's #89 and #74 assisted her with a log roll to her back onto a Hoyer pad. Resident #93's eyes were opened. Pupils were equal and reactive to light. Resident #93 was contracted, arms rigid, hands contracted with fingers laying flat towards palm of hands, legs contracted with knees toward abdomen. Resident #93 had a small laceration with minimal swelling to the forehead. Resident #93 had a small amount of blood on her face. Resident #93's bed had bolsters on it, they were not in place. The right bolster was in the center of the bed and the left bolster was on the side of the bed to the left. Resident #93 was lifted into bed after bolsters were placed properly by LPN #20, STNA #89, #74 and LPN #54. LPN #54 applied ice to the forehead. Oxygen was applied at two liters per minute (LPM) via nasal cannula due to the oxygen saturation being 77% on room air. The oxygen was increased to four LPM due to oxygen saturation of 83% on two LPM. The oxygen saturation went to 96% after the increase to four LPM. Axillary temperature was 101.2 degrees F and Tylenol (analgesic) was administered via the gastrostomy tube. Squad transported resident to the emergency room . Review of a 06/08/15 Employee Disciplinary record revealed STNA #89 did not follow the guest care card. The card directed the resident was a two person for bed mobility and was rolled by one staff without assistance. Employee was educated on proper two person assist procedures. The Director of Nursing (DON) indicated that on 08/06/15 at 3:26 P.M. the facility did not have a policy on what to do when someone falls. The DON indicated that she would not have moved the resident from the floor and just had transport lift her from the floor. On 08/06/15 at 4:11 P.M., the DON verified harm occurred to Resident #93 when she was turned in bed with assist of one when she was to be assisted of two, resulting in a fall from the bed causing a head injury with sutures. 2. On 08/04/15 at 12:35 P.M., Resident #80 was observed seated in her wheel chair. The resident's call light was located on the resident's bed which was behind the resident. Interview with Licensed Practical Nurse (LPN) #4 confirmed the resident's call light was not within her reach and the resident was functionally able to use her call light. Review of Resident #80's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment and required extensive assistance of two staff members for activities of daily living. The resident was frequently incontinent of urine. Review of the fall risk assessment dated [DATE] revealed the resident was a high risk for falls. Review of the Physician Communication and Progress Note dated 02/10/15 revealed the resident sustained [REDACTED]. Review of the Incident Report dated 02/10/15 at 12:15 A.M. revealed the resident was found on the floor in her room. No injuries were noted and the resident was confused which was usual for the resident. The intervention indicated was to educate the resident on the use of her call light and bladder tracking. Review of the Post Fall Report dated 02/10/15 revealed the resident occasionally used her call light and had periods of confusion and forgetfulness at times. The resident's call light was within reach but was not on and the lighting was adequate in the resident's room. No liquids were noted on the floor. The resident stated she was trying to get underwear to go to the bathroom. Review of the Post Incident Analysis dated 02/12/15 revealed the action plan was educate resident and initiate a bladder tracker. Further review of the medical record did not indicate a bladder tracking worksheet was completed after the fall on 02/10/15. Review of the Nurses' Progress Notes dated 06/16/15 at 3:27 A.M. revealed the resident was found in her bathroom with her body straight out and her head against the bathroom wall. The alarm was sounding and the resident stated she hit her head and also complained of left hip and wrist pain. A puddle of urine was observed underneath the resident and the resident stated she had to pee. Further review of the Nurses' Progress Notes dated 06/16/15 at 6:58 A.M. revealed the emergency room called the facility and shared the resident was being transferred to another hospital with an orthopedic surgeon. Review of the incident report dated 06/1615 at 2:45 A.M. revealed the resident was located in her bathroom, on the floor. The resident tried to get up on her own at times and ambulated. The resident was alert and oriented to two spheres and received frequent reminders to use her call light. The resident informed staff she needed to urinate. Review of the Post Incident Quality Assurance interview dated 06/16/16 and completed by LPN #3 revealed the resident's injury was caused by the resident when the resident tried to take herself to the bathroom and the resident slipped in a puddle of urine. Review of the Hospital Documents Review Report dated 06/19/15 revealed the resident was admitted to the hospital after a fall and sustained fractures at cervical vertebrae #2, #3 and #7 (located in the neck); a closed displaced intertrochanteric fracture of the left femur (fractured left hip) and a closed fracture of the left radius and ulna (wrist). Review of the admission orders [REDACTED]. Review of the Falls Awareness Program revised 10/10 revealed residents at risk for falls will be monitored by staff. Residents who are determined to be at risk for falls will have a green identifier tag placed on his or her assistive device (walker or wheel chair) as appropriate. On 08/05/15 at 9:10 A.M. interview with the DON confirmed the bladder tracking record was not completed after the fall on 02/10/15. Further interview revealed the tracking record was an intervention since the resident fell due to a toileting need. Further interview revealed the fall on 06/16/15 also occurred due to a toileting need. The DON felt education related to call light use was appropriate for the resident after the 02/10/15 fall despite documentation of noncompliance and the resident's moderate cognitive impairment. The DON also shared the resident was placed on a toileting program after re-admission to the facility. On 08/06/15 at 3:25 P.M. interview with LPN #150 verified Resident #80 was a fall risk due to her history of falls. On 08/06/15 at 3:30 P.M. an observation revealed Resident #80 did not have a green identifier tag on her wheel chair to indicate she was a fall risk. Interview with STNA #14 verified the wheel chair did not have a green tag to identify she was a fall risk.

Based on observation, interview, medical record review and review of facility policy and procedure, the facility failed to ensure appropriate interventions were initiated to prevent the development of a pressure ulcer and failed to implement care planned interventions for two residents (Resident #40 and Resident #19). This affected two of three residents reviewed for pressure ulcers Actual harm occurred when Resident #40 developed a deep tissue injury to the right heel. Findings include: 1. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] and a readmission on 03/02/15 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #40 was cognitively impaired, required extensive assistance of two persons for bed mobility and had no pressure ulcers. Review of a pressure ulcer risk assessment dated [DATE] revealed Resident #40 was at risk for the development of pressure ulcers related to poor nutrition, complete immobility and being chair fast. Review of the plan of care initiated on 07/16/14 revealed interventions included frequent repositioning with extensive assistance and weekly skin checks. Review of a wound grid dated 05/24/15 revealed Resident #40 had a DTI of the right inner heel measuring 2.5 cm by 2.5 cm covered with brown eschar (dead or devitalized tissue that is usually black or brown in color). Physician orders and treatment records revealed Resident #40 had an order to float heels on a pillow dated 05/24/15, when the DTI of the right heel was discovered. Review of the wound grid dated 06/03/15 revealed the wound measured 2.0 cm by 3.0 cm and was covered with brown eschar. Observation of the treatment to Resident #40's right heel was made on 06/03/15 at 9:50 A.M. with Licensed Practical Nurse (LPN) #10. The right heel was open to air and had an area measuring 2.0 cm in length by 3.0 cm in width and covered 100 % with eschar that was black in color. LPN #10 indicated the area was discovered when Resident #40 was found lying with his left heel resting on top of his right heel, causing pressure. LPN #10 applied skin prep (a drying agent) to both heels including the area covered by eschar and left the heels open to air. On 06/04/15 at 8:05 A.M., observation of Resident #40 with the DON revealed the resident lying in bed and positioned slightly toward his right side. Two pillows were positioned sideways, under the resident's lower legs and the left heel was resting directly on top of the right heel. The DON verified Resident #40 was not positioned properly to off-load the heel at the time of the observation. Review of the facility policy and procedure entitled Wound and Skin Management, revised 06/11, revealed the basic wound prevention program included assessment to identify residents at risk and implementation of resident specific interventions to prevent the development of a pressure ulcer. 2. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #19 had no cognitive deficits, was dependent on one staff member for bed mobility and had no skin impairment. Resident #19 was hospitalized on two occasions in April 2015: 04/06/15 to 04/11/15 and 04/19/15 to 04/21/15. Review of the readmission nursing assessment dated [DATE] revealed Resident #19 had skin impairments noted. However, there was no skin impairments noted to the bilateral heels. Review of a pressure ulcer risk assessment dated [DATE] revealed Resident #19 was at risk for pressure ulcers due to limited mobility, inadequate nutrition and being chair fast. Review of nurse's notes dated 04/30/15 revealed Resident #19 had a dark purple area on the right heel, a suspected deep tissue injury (DTI), which measured 4.0 centimeters (cm) by 3.0 cm. On 04/30/15 a new intervention was added to elevate heels off the bed as tolerated. On 05/20/15 Resident #19's right heel was described with DTI measuring 5.0 cm by 4.0 cm and covered with brown eschar. On 06/03/15 at 1:20 P.M., the director of nursing (DON) verified Resident #19 was assessed to be at risk for a pressure ulcer and required extensive assistance of one person for bed mobility. The DON verified Resident #19 had a standard pressure reduction mattress and was care planned for frequent repositioning. The DON verified until a deep tissue injury of the right heel was found on 04/30/15, there was no care planned intervention to off-load the resident's heels. On 06/04/15 at 8:00 A.M., observation with the DON revealed Resident #19 was lying in bed on her back with two pillows, positioned lengthwise under both lower legs with both heels resting on the pillows. The DON verified Resident #19 was not positioned properly to off load the heel at the time of the observation. This citation substantiates Complaint Number OH 298

Based on medical record review, review of hospital records, observation and staff interview, the facility failed to position a resident as planned resulting in a fall with fracture. Actual Harm occurred when Resident #52 fractured his Cervical #7 (C7) vertebrae when he fell out of the bed onto his head after being repositioned and the head of the bed was left in an upright position. The resident had decreased upper body stability. This affected one (Resident #52) of three residents reviewed for falls. Findings include: Review of the medical record revealed Resident #52 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the 07/09/14 fall assessment revealed Resident #52 was a high risk for falls related to needing assist for elimination, predisposing diagnoses, medications, balance problems while in sitting position, trunk control or sitting up and required assistive devices. Review of the 10/01/14 Minimum Data Set (MDS) 3.0 Assessment revealed Resident #52 was moderately impaired for decisions of daily living, was an extensive assist of two for bed mobility, totally dependent of two for transfers and occasionally had pain. Review of the nurse's note dated 12/20/14 at 7:15 P.M. revealed "Guest found on the floor. He had fallen out of the bed and was found with his head on the floor and legs still in the air." A nurse's note dated 12/20/14 at 7:30 P.M. indicated the physician was notified of the fall and orders were received to send the resident to the emergency room for evaluation and x-rays. A nurse's note dated 12/20/14 at 8:00 P.M. indicated the spouse was notified of the fall and transfer. "Two attendants from ASI immobilized Guest with Back board and C-collar. Transferred by ASI with two attendants via a gurney." Review of hospital records revealed a CAT scan of the cervical spine dated 12/20/14 revealed an acute, minimally displaced fracture of the C7 spinous process. Review of readmission physician's orders [REDACTED].#52 was readmitted with orders for bilateral bolsters to bed for safety, side of bed against wall, opposite side mat to floor, bed in low position, cervical collar brace intact may remove for activity of daily living care and Percocet 5/325 milligrams one every four hours as needed for fracture. Notify physician if more than three tablets are needed in 24 hours. A soft cervical collar was discontinued on 01/05/15. Review of the fall investigation report revealed State-tested Nurse Aide (STNA) #10's 12/20/14 statement indicated she had set up Resident #52 in his bed for dinner. "I took his tray around five till six. His head was slightly elevated and he was facing the right. I came back from lunch around 7:20 P.M. and the aides were coming down the hall and said he was on the floor. He fell out of the left side of the bed and he doesn't turn himself. He is an every hour turn." Review of Licensed Practical Nurse (LPN) #11's 12/20/14 statement revealed STNA #6 came running up the hall in a hurry and stated Resident #52 was on the floor. She ran to his room and noted Resident #52, "on the floor on his left side with lower body up and feet held along side of the bed. With the help of staff we moved the bed and gently placed guest's legs on the floor and head resting on a pillow." Vital signs were reported to the resident's nurse, LPN #7. The bed was noted to be in high position with the head of bed (HOB) elevated. LPN #11 asked the resident what happened and he said, "I don't know." Review of STNA #6's first statement dated 12/20/14 indicated she was in with another resident and heard someone yelling for help and found out it was Resident #52's roommate. STNA #6 found Resident #52 on the floor laying on his neck and his feet up in the air. She ran to LPN #11 for help. Review of the statement from RN#1 regarding her conversation with STNA #6 on 12/20/14 at 8:30 P.M. revealed she spoke with STNA #6 concerning the fall of Resident #52. STNA #6 told RN #1, "I went into (Resident #52's) room. He still had his tray because he was still drinking his juice. The head of his bed was in the up position." RN #1 asked STNA #6 to clarify "up" position, and did she mean upright as in seated upright? STNA #6 stated, "Yes, I repositioned him and put a pillow behind his right side." Review of STNA #6's second statement dated 12/20/14 indicated she had repositioned Resident #52 on his right side. She had worked the dining room for supper, and was in the dining room from 4:30 P.M. to 6:15 P.M.. After transporting the resident from the dining room she went to lunch. She returned at 6:45 P.M. and was answering call lights. She was in with another resident when she heard the roommate of Resident #52 yelling for help. She stopped what she was doing and ran to his room to where she found Resident #52 laying on his neck with his feet up in the air with his butt propped up against his concentrator. She immediately ran to the closest nurse to ask for help. Resident #52's head was in the upright position from dinner, with a pillow on the right side of the bed and the foot of his bed elevated slightly. STNA #6 had asked who set up Resident #52 for dinner and found out that STNA #10 had removed his tray after supper and left his head in an upright position because he was finishing his juice. Review of LPN #7's statement written 12/21/14 related to the 12/20/14 incident indicated "I was the guest's nurse for 2p-10p on this day. I was in the room at 4:30 P.M.. The guest's bed was at it's normal height and the head of the bed was at 30-40 degrees. Guest was in center of bed. I administered his scheduled medication. I finished the medication pass and went into the dining room. When I returned to the floor I started with the medication passes for other guests. At 7:10 P.M. I left the floor. Upon returning to the unit, one of the STNA's informed me of the guest being on the floor. I quickly grabbed blood pressure cuff and thermometer from the cart and ran to the room. When I entered the room the guest bed was moved out of the way. The guest was laying on his left side and head was supported by a pillow and the other nurse." LPN #11 was with Resident #52. LPN #7, "lightly touched the back of the Guest's head and neck asking if it hurt. The guest responded that it did. I felt the guest needed to be sent out for an x-ray, so I ran to the desk, called the other side for the" RN and the resident's doctor. "I was connected to the doctor and informed him of the fall. He gave orders to send him to the ER. I called ASI for transportation. I then tried contacting his wife. I got busy signals from her number x 3, so I attempted to reach his son. I got in contact with the guest's daughter-in-law, who stated the son was at his mom's. I tried contacting the wife again and got through to inform her of the fall. ASI arrived and placed the Guest in a c-collar and on a backboard and transferred him to the hospital." A statement written 12/21/14 by the Director of Nursing (DON) indicated she had STNA #6 go into Resident #52's room to demonstrate how the resident was positioned in bed. STNA #6 stated he was on his right side around 3:00 P.M. When the incident occurred around 7:10 P.M. - 7:15 P.M., STNA #6 stated the roommate was yelling for help and she responded and found Resident #52 on the left side of the floor/bed with head and neck up against concentrator, on the floor with face up and legs still elevated in bed. There were 1/2 siderails on both sides of the bed and they were there prior to the fall. The DON's statement indicated on 12/21/14, the DON spoke to Resident #52's roommate and he stated he was watching television and saw his roommate roll out of bed on the left side of the bed towards the bathroom. He stated he yelled for help and an STNA came in the room. The facility completed inservice training on 12/21/14 indicating residents who were fed in bed needed to be lowered after meals. Head of bed should be no higher than 30 degrees. Check on the resident frequently. Call lights need to be within reach. On 01/21/15 at 11:55 A.M. during an interview and observation of Resident #52, his right side of the bed was against the wall, bilateral half siderails were up with bilateral blue wedges. He had a firm blue winged air mattress with built in defined perimeters on the upper and lower sides of the mattress. There was a mat on the left side of the bed and his call bell was in reach. He had oxygen on per cannula at 2 1/2 liters per minute. He indicated all he knew from the fall was that when he woke up he was on the floor. He was in pain and yelled for help and they came in. He said the pain had partly gone away. He said that he turned with help because his legs were paralyzed and he didn't know what happened. Interview on 01/21/15 at 2:15 P.M. revealed STNAs #8 and #9 said the bed was usually in the low position and Resident #52 rang the bell when he needed assistance. Both indicated he was a two assist for turns. STNA #9 indicated she was at break when he fell and STNA #6 said she turned him last and the other STNA had not helped her. On 01/21/15 at 6:35 P.M. interview of LPN #7 revealed he gave Resident #52 medication at 4:30 P.M. and the next time he saw him, the resident was on the floor. He indicated the resident was unable to move much at all. LPN #7 indicate by placing the pillow on the right side, the resident would have been turned facing the door, the side he fell out on. LPN #7 indicated he did not assist with any turn for the resident. On 01/21/15 at 3:21 P.M. RN #1 indicated she was the on call manager that night and she interviewed that staff on duty by phone at the time of the fall. RN #1 indicated she interviewed STNA #6 who said she had turned the resident to his left side and placed a pillow behind the right side of his back. She educated the STNA that the resident was an assist of two and needed two people to position him. She verified Resident #52 was turned with an assist of one when he was paralyzed from his waist down and was an assist of two for turns. RN #1 verified the head of the bed was found in the upright position and a pillow was found on the bed on the right side and Resident #52 came out of bed landing head down. RN #1 verfied the facility conducted positioning inservices after the fall and fracture. This deficiency substantiates Complaint Number OH 492.

Based on observation, medical record review, policy and procedure review and interviews, the facility failed to ensure nutritional interventions were initiated to prevent sustained, significant weight loss for Resident #7 and the subsequent development of an unstageable coccyx pressure ulcer and a Stage Two pressure ulcer to her right buttocks. This resulted in Immediate Jeopardy for one (Resident #7) of 17 residents reviewed for nutrition. Harm occurred to Resident #150 who developed recurrent and new skin impairment without nutritional interventions to address low protein levels. The facility also failed to identify significant weight loss, monitor effectiveness of nutritional interventions, and implement appropriate nutritional interventions for four additional residents (Residents #76, #80, #127, and #128). The census was 91. The Administrator was notified on 02/07/13 at 3:10 P.M., that Immediate Jeopardy began on 10/08/12, when Resident #7 sustained an unplanned, significant weight loss of 17.2 pounds within thirty days that was not addressed by the facility. Resident #7 continued with rapid weight loss and on 02/01/13, Resident #7 weighed 122.2 pounds, which represented a total weight loss of 44.4 pounds since admission or a significant weight loss of 36.3% of her body weight without nutritional intervention. On 02/05/13, Resident #7 developed an unstageable (defined on the facility's Pressure Ulcer Record as full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed) pressure ulcer to her coccyx and a Stage Two (partial thickness tissue loss of dermis presenting as a shallow, open ulcer) pressure ulcer to her right buttock. On 02/06/13 Resident #7's pre-[MEDICATION NAME] (an indicator of protein status) was low. The physician had not been notified of any weight loss sustained by this resident and no nutritional interventions were implemented to prevent further weight loss or the development of pressure ulcers for this nutritionally compromised resident. The Immediate Jeopardy was removed on 02/08/13, when the facility implemented the following corrective measures: ? On 02/06/13 a pre-[MEDICATION NAME] level was drawn for Resident #7. The result was low at 12 milligrams per deciliter (mg/dL) with the normal range of 18 to 45 mg/dL. Prostat 30 milliliters (ml) (a liquid protein formula), and Medication Pass supplement, 120 mls, were ordered to be administered three times a day. Resident #7 was placed on weekly weights and an air mattress was placed on her bed. ? On 02/07/13, Dietary Manager #11 reviewed the resident's food preferences. Registered Dietetic Technician (DTR) #2 assessed Resident #7 and made recommendations for appetite stimulants and a speech therapy evaluation. An appetite stimulant, [MEDICATION NAME] 65 mg, was ordered daily. A Speech Therapy evaluation to evaluate swallowing was scheduled for 02/08/13. Resident #7's anti-depressant medication was changed from [MEDICATION NAME] to [MEDICATION NAME] as one of the side effects of [MEDICATION NAME] is appetite stimulation. ? On 02/07/13, Resident #7 was interviewed in her room and expressed the desire to continue to eat meals there. Staff will continue to offer social dining and encourage the resident to eat as appropriate. Resident #7 was offered a tube feeding on 02/07/13, which she refused. A care plan conference was scheduled for 02/08/13 for Resident #7 and/or her responsible party. ? On 02/06/13, the facility reviewed weight records to identify residents with significant weight loss, or at risk for significant weight loss. Interventions were noted via physician orders [REDACTED]. ? On 02/07/13, a facility vendor calibrated the weight scale for accuracy. Weights were obtained for all residents potentially at risk for altered nutrition. ? On 02/07/13, the facility selected and trained specific State tested nursing assistants (STNA) to obtain weights on a consistent basis. ? On 02/07/13, all weights were reviewed for variances of five pounds from the previous weights and additional weights were obtained as appropriate. ? On 02/07/13, two dietary staff were in-serviced related to accommodation of residents' food preferences, the super nutrition program and offering meal alternatives. On 02/08/13 three additional dietary staff (out of five) were in-serviced. No dietary staff will be permitted to work until they have had the training. ? On 02/07/13, six licensed nursing staff were in-serviced related to Physician and Responsible Party Notification regarding significant weight loss and Monitoring Intake Observation. On 02/08/13 thirteen of 27 additional licensed nursing staff were inserviced. The remaining licensed nursing staff will not be permitted to work until they have had the training. ? On 02/07/13, the two Registered Nurse (RN) Unit Managers were in-serviced regarding their responsibility of monitoring weights and weight losses. ? On 02/07/13, eleven STNAs were in-serviced regarding existing Meal Intake and Weight Protocols and offering substitutions. On 02/08/13, nineteen of 51 additional STNAs were in-serviced. No STNAs will be permitted to work until they have the training. Per diem staff and staff on leave of absences would be in-serviced before their next scheduled shift. New hires would be in-serviced during orientation. ? On 02/08/13, eight of eight Interdisciplinary Care Plan Team members received education on reviewing documentation, nutritional interventions and the Nutrition At Risk Program. ? On 02/08/13, five of five Quality Assurance Committee members received education regarding analysis and trending of nutritional outcomes for residents. ? On 02/08/13, per the corporate Vice President of Operations, the decision was made on 02/05/13 to terminate DTR #2's employment with the facility based on the concerns related to nutrition identified during the annual survey. ? On 02/08/13, four contracted Registered Dietitians arrived at the facility to complete comprehensive nutritional assessments for all residents in the facility and were to remain in the facility until all such assessments were completed. The Registered Dietitians would continue to provide ongoing nutritional services to ensure residents' nutritional needs were met. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level three, actual harm, that was not Immediate Jeopardy. Although the dietitians had arrived with plans to review all residents' nutritional status, the assessments had not been completed at the time of survey exit. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] indicated Resident #7 was severely impaired for cognition based on a Brief Interview of Mental Status (BIMS). The February 2013 physician's orders [REDACTED]. The nutritional plan of care was initiated on 08/29/12, was reviewed on 11/27/12 and was not revised. The plan of care included interventions to provide assistance with eating and/or drinking, as needed, and to provide supplements according to orders. The admission "Nutritional Assessment", dated 08/29/12, and signed by Registered Dietician (RD) #125, indicated Resident #7 weighed 166.6 pounds and this weight was "acceptable." A nutritional "Progress Note" dated 10/03/12, identified a September 2012 weight of 164.4 pounds which represented a two pound weight loss since admission. RD #125 made no new recommendations. A quarterly progress note dated 12/03/12 identified Resident #7's November weight as 144.4 pounds which represented a weight loss of 21.3 pounds since admission and a severe weight loss of 14.7%. DTR #2 documented she was "not worried" about the weight loss, indicating the resident was back to her admission weight. No nutritional recommendations were made. "Vital Signs and Weight Record" revealed the following weights: 9/8/12 - 166.6 pounds 9/17/12 - 167 pounds 9/24/12 - 164.4 pounds 10/3/12 - 165.7 pounds 10/8/12 - 149.4 pounds (rechecked two times) 10/15/12 - 147 pounds 10/29/12 - 145.4 pounds 11/02/12 - 144.4 pounds 11/05/12 - 146.2 pounds 11/12/12 - 142.4 pounds 11/19/12 - 144.4 pounds 11/26/12 - 141.2 pounds 12/01/12 - 140.4 pounds 12/10/12 - 137.8 pounds 01/14/13 - 138 pounds 01/21/13 - 123 pounds 02/01/13 - 122.2 pounds Resident #7's weight on 02/01/12, of 122.2 pounds represented a weight loss of 44.4 pounds since the 09/08/12 weight, or a severe weight loss of 36.3% percent since September 2012. Review of Meal Intake Reports for December 2012 through February 2013, revealed Resident #7 began a sharp decline in oral intake beginning on 12/18/12. Her decline included refusing all food on most days for breakfast and lunch. From 12/18/12 through 12/31/12, Resident #7 had no documented intake for breakfast or lunch on 19 days; consumed 10% on three days, 25% on two days and 100% of her lunch on one day. Resident #7 had varied acceptance for supper from 12/18/12 through 12/31/12, ranging from zero on two days; 25% on five days; 50% on one day; 75% on seven days and 100% on two days. Resident #7's very poor appetite for breakfast and lunch continued throughout January 2013, with no documentation of intake 49 times, 5% eaten two times; 10% eaten three times; 25% two times and 50% twice. Resident #7 demonstrated less acceptance of supper during January 2013 with no documented consumption 14 times; 10% once; 25% eight times, and both 50% and 75% four times. February 2013 meal intake records revealed Resident #7 had no documented intakes for breakfast from 02/01/13 through 02/05/13. Lunch intake records indicated she accepted 10% on 02/04/13, and 5% on 02/05/13, with no documented intake on the remaining days. Supper intake records indicated Resident #7 ate 15% of her supper on 02/01/13 and refused supper on the remaining four days. On 02/05/13 at 12:05 P.M., STNA #1 delivered a lunch tray to Resident #7. STNA #1 set up the tray. However, the resident refused to eat. STNA #1 offered the resident applesauce and a grilled cheese sandwich, which the resident also refused. STNA #1 removed the resident's tray from her room and placed it into the cart. During an interview at 12:09 P.M., STNA #1 reported Resident #7 ate lunch independently in her room. STNA #1 indicated she worked part time but when she had taken care of Resident #7 "the other day" she also refused her lunch. STNA #1 reported she left the resident's grape juice on her over-bed tray table for her to drink. STNA #1 indicated she recorded residents' meal intakes on the computerized intake records but did not report refusals to the nurse. At 12:27 P.M., Resident #7 had consumed four ounces of grape juice. On 02/05/13 at 5:09 P.M., STNA #1 delivered and set up Resident #7's dinner tray. STNA #1 exited the resident's room. Resident #7 made no attempt to independently eat her meal situated on the over-bed tray table in front of her. At 5:20 P.M., STNA #1 returned to the room and asked Resident #7 if she wanted her dinner, which Resident #7 refused. STNA #1 was heard to offer Resident #7 a grilled cheese sandwich, which she also refused. STNA #1 left the coffee and juice on the over-bed tray table for Resident #7. During an interview on 02/06/13 at 09:50 A.M., DTR #2 identified she worked in the facility two days a week and was responsible for managing the nutritional care for all 91 residents in the facility. DTR #2 indicated she took over the care for the residents in December 2012. DTR #2 revealed RD #125 visited the facility once every three months to evaluate her work and complete chart audits on residents DTR #2 identified as high risk. DTR #2 revealed she was responsible for monitoring the residents' weights and explained she tracked and calculated the weights. DTR #2 verified according to her Nutritional Progress Note dated 12/03/12 she identified a 21.3 pound/14.7% severe weight loss for Resident #7, however, wrote that she was not worried about the loss due to the resident's admission weight. DTR #2 explained the resident's admission weight was initially documented as 147 pounds but the weight was changed on the admission assessment to 166.6 pounds by RD #125. DTR #2 speculated RD #125 questioned the accuracy of the 147 pound weight based on the weights taken at the facility. DTR #2 acknowledged four concurrent weekly weights from 09/08/12 through 10/03/12, weighed the resident in the 166 pound range. DTR #2 verified no nutritional interventions were put into place to address the severe weight loss. DTR #2 confirmed there were no Nutritional Progress notes subsequent to 12/03/12 for Resident #7. DTR #2 reviewed Resident #7's "Vital Signs and Weight Record" and revealed she was not aware Resident #7 had sustained an additional 22 pound weight loss or 44.4 pounds since admission. Resident #7's intake records were reviewed with DTR #2. DTR #2 indicated she reviewed intake records for the residents in order to complete the MDS assessments. Additionally, DTR #2 indicated if she was notified of a concern, she reviewed the intake records on an as needed basis. However, she did not routinely monitor intake records. DTR #2 indicated she had not been notified of Resident #7's decreased oral intake. DTR #2 was uncertain if there was a policy and procedure for the facility to notify her of decreased appetite or intake. DTR #2 acknowledged no nutritional interventions were implemented to address Resident #7's 44.4 pound weight loss since admission and she was not in a restorative dining program. DTR #2 indicated she was responsible for updating the Nutritional care plans. DTR #2 acknowledged Resident #7's nutritional plan of care had not been updated since admission. DTR #2 indicated RD #125 was working at his full time job at a hospital and was unavailable to speak to the surveyor. During an interview on 02/06/13 at 10:17 A.M., Unit Manager/Registered Nurse (RN) #3 indicated when a five pound or greater weight loss/gain occurred, the resident should be weighed again. RN #3 indicated, however, there was no written policy related to obtaining a second weight. RN #3 verified on 01/21/13 Resident #7 sustained a 15 pound weight loss from the previous weight and an additional weight was not obtained. RN #3 reviewed the nurses' notes and verified there was no documentation the physician had been notified of the continued weight loss for Resident #7. RN #3 acknowledged Resident #7 had sustained a 44.4 pound weight loss since 09/08/12. RN #3 indicated she occasionally reviewed the intake records, but not on a consistent basis. RN #3 indicated the Assistant Director of Nursing (ADON)/RN #4 also reviewed the intake records. RN #3 verified Resident #7 developed two newly opened pressure areas on her buttocks on 02/05/13. RN #3 acknowledged the open areas could be related to [MEDICAL CONDITION] and the lack of nutritional interventions. During an interview on 02/06/13 at 3:19 P.M., ADON/RN #4 was asked who was responsible for monitoring the resident's oral intakes. ADON/RN #4 revealed the responsibility had never been delegated to any one person, stating that it was a "shared responsibility." She explained it was a relatively new system. ADON/RN #4 indicated, ultimately, the Unit Managers should be looking at the intakes. She indicated DTR #2 should also be monitoring the intakes. Similarly, with regard to the weight loss, ADON/RN #4 indicated no one was specifically responsible, but the Unit Managers and DTR #2 should be reviewing the weights. ADON/RN #4 acknowledged Resident #7 sustained significant weight loss with very poor intakes and no nutritional interventions were implemented. ADON/RN #4 acknowledged Resident #7 had a newly opened unstageable pressure ulcer to her coccyx and a stage two pressure ulcer to her right buttock. During an interview on 02/06/13 at 3:10 P.M., STNA #1 indicated she only assisted with the weights and was uncertain of the process. During an interview at 3:15 P.M., STNA #6 indicated a weight book was utilized for monitoring the weights. She indicated if a weight change of five or more pounds was found, the resident's weight would be obtained a second time. STNA #6 indicated the floor nurse would be informed of the weight change. During an interview at 3:25 P.M., STNA #7 indicated the floor nurses identified which residents needed weighed. She verified a weight change of five pounds or more would necessitate another weight be obtained. STNA #7 indicated if the second weight was still five pounds or greater, another weight would be immediately obtained and the floor nurse would be informed of the weight change. During an interview on 02/06/13 at 4:25 P.M., the Medical Director of the facility who was also Resident #7's primary care physician, revealed he was not aware of Resident #7's 44 pound weight loss since September 2012. He reported if he had been notified of the significant weight loss, he would have ordered calorie counts, appetite stimulants, and nutritional supplements for the resident. During an interview on 02/07/13 at 11:50 A.M., the Director of Nursing (DON) indicated it was the expectation of the STNAs to report to the nurses when residents had decreased oral intakes. The DON indicated when a resident ' s weight was up or down by five pounds or greater, the STNAs were supposed to obtain another weight immediately. She indicated if the second weight was still five pounds or greater (loss or gain) the STNAs were expected to report the findings to the nurse. The DON indicated Resident #7's weight loss had not been brought to her attention. Admission and quarterly MDS assessments dated 09/01/12 and 11/30/12 identified Resident #7 at risk for the development of pressure ulcers. The MDS assessments indicated Resident #7 had no pressure ulcers at the time of the assessments. The MDS assessments indicated Resident #7 required extensive assistance of one person for bed mobility, toileting and personal hygiene. A potential for skin breakdown plan of care was initiated on admission and included interventions for Resident #7 to be weighed at least monthly and observed for trends; to provide diet as ordered and encourage meal completion and fluid intake; to observe for food acceptance and offer substitutes, as needed. Nurse's "Progress Notes" dated 02/05/13 at 7:30 P.M., revealed a new order for wound care treatment for [REDACTED].#7's buttocks. The report indicated that "1/4 inch blisters have opened on the right and left buttocks." On 02/06/13 at 2:55 P.M., Wound Nurse/Licensed practical nurse (LPN) #8 was observed providing wound treatment for [REDACTED]. A 0.3 cm by 0.2 cm unstageable pressure ulcer to the coccyx with a greyish colored wound bed was observed. The Wound Nurse acknowledged the wound was unstageable. No pressure area was present to Resident #7's left buttock area. LPN #8 indicated the coccyx wound was erroneously documented the previous evening as a left buttock wound. The "Pressure Ulcer Record" dated 02/06/13 identified the unstageable coccyx wound measured 0.3 cm by 0.2 cm with a wound bed that was grey in color. Risk factors for the pressure areas were identified as [MEDICAL CONDITION] and decreased mobility. The "Pressure Ulcer Record" dated 02/06/13 identified a Stage Two pressure area to the right buttock that measured 0.3 cm by 0.3 cm by less than 0.1 cm with a pink wound bed. Risk factors identified were [MEDICAL CONDITION] and decreased mobility. The facility's "Nutrition at Risk Program (NAR) Overview" policy and procedure, dated 04/10, indicated the interdisciplinary team approach (NAR committee) shall be utilized to identify guests who are at high nutrition risk and to intervene as necessary to meet their nutritional needs. Criteria used to identify guests at high nutrition risk included: Guests with pressure ulcers; weight changes, including insidious weight loss, loss of 5% or more of weight in one month; loss of 7.5% or more of weight in three months; loss of 10% or more of weight in six months; and guests who leave more than 50% of their food uneaten at most meals. The facility's "Weighing Guests" policy and procedure (revised 11/11) indicated any unplanned, significant weight loss or gain should be reported to the physician and the date and time of notification and the physician's response should be documented in the progress notes. 2. Review of Resident #150's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed to be at risk for the development of pressure ulcers with a Braden risk assessment completed upon admission. The admission orders [REDACTED]. A Nutrition at Risk Monitoring Record dated 10/16/12 revealed the resident was identified as having a low pre-[MEDICATION NAME] level of 12.5 (normal ranges 16- 35 milligrams per deciliter) and a low [MEDICATION NAME] (protein in the blood important for tissue growth and healing) level of 2.1 (normal levels 3.5-5.0 grams per deciliter). A nutrition initial assessment note dated 10/16/12 revealed recommendations were made to add a Magic Cup twice daily to add an additional 580 calories and 18 grams of protein per day. The resident developed a stage 2 pressure ulcer to her right gluteal fold on 10/25/12. The area healed on 11/08/12 and re-opened on 11/12/12 healing again on 11/16/12 and re-opening 11/27/12. The Stage 2 pressure ulcer to the right gluteal fold remained open with little to no improvement until the last measurement on 02/06/13. The resident also developed an unstageable pressure ulcer to the right heel on 11/20/12. The unstageable pressure ulcer to the right heel was downgraded to a Stage 1 pressure ulcer on 02/06/13. The resident also developed a Stage 2 pressure ulcer to the left heel on 12/03/12 receiving treatment until 01/16/13 when it was healed. A nutrition note dated 11/11/12 for a 30 day review noted the resident had still not been placed on a nutritional supplement to address her low protein levels needed to promote wound healing as previously recommended. The note indicated the physician would be contacted for clarification on the need for a nutritional supplement. The last nutrition note dated 02/04/13 for a quarterly review and did not indicate the resident was on a nutritional supplement nor did it address the previous recommendations for a supplement not being followed through when needed for wound healing. Interview with RN #3 on 02/06/13 at 9:40 A.M. confirmed the resident had a history of [REDACTED]. She acknowledged pressure ulcers that had previously been healed re-opened on more than one occasion. She confirmed the resident had not been placed on a nutrition supplement to promote wound healing even though she had a low [MEDICATION NAME] and pre-[MEDICATION NAME] level. She stated the need to initiate nutrition interventions was handled by the dietician. She stated the nursing staff were responsible for faxing the physician for the orders and if the physician did not respond, they would refax him to get the supplements ordered. Interview with the DON on 02/06/13 at 9:50 A.M. revealed the facility did discuss wounds in the clinical operations meetings. She stated she received updates from the treatment nurse weekly on all the pressure ulcers. She acknowledged Resident #150 had been recommended to be placed on nutritional supplements to aid in wound healing but the order was never obtained. On 02/06/13 at 9:55 A.M., Resident #150 ' s pressure ulcer dressing change was observed. Resident #150 had a stage II pressure ulcer to the right inner gluteal fold which measured 1 cm x 1.5 cm x 0.1 cm. The wound bed was red with the wound edges white (sign of maceration - softened skin that may be related to moisture against the skin which causes breakdown). The white area extended downward at approximately the four o'clock area of the wound and was triangular in shape. Interview with DTR #2 on 02/06/13 at 2:00 P.M., confirmed the nutritional supplement for Resident #150 was not ordered by the physician when it had been recommended and she made a nutrition note in November 2012, that reflected that information. She acknowledged she did not make any additional nutrition notes until 02/04/13, and the resident was still not on any of the recommended supplements. DTR #2 stated a resident with pressure ulcers should be reviewed monthly. She admitted she had missed the resident and did not make a note as often as she should have. She found that 'Mighty Shakes' was on the resident's meal ticket from a previous admission and these had inadvertently been added to the current admissions meal ticket. She reported the acceptance of the supplement was not being recorded as it was never ordered by the physician or placed on a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated with the resident having a low [MEDICATION NAME] level she should have started the resident on Prostat (a high protein supplement) to promote wound healing especially since she had repeated skin breakdown. DTR #2 also stated additional vitamins such as Vitamin C with Zinc may have been beneficial as well. 3. Review of Resident #76's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An order was received on 09/17/12 for the use of a nutritional supplement, Med Pass 60 milliliters (ml), three times daily. A nutrition assessment completed on 09/17/12, revealed the resident was known to have a poor appetite. She was identified as being on 60 ml of Med Pass supplement three times daily (TID) to be administered with medication administration. A Stage Two pressure ulcer developed to the resident's right buttock on 09/20/12. A protein supplement was added on 09/20/12 to increase her protein intake and promote wound healing. A nutrition note dated 10/19/12 revealed the resident had some weight loss but weight was determined to be stable between 129 and 134 pounds. Her body mass index (BMI) was indicated to be acceptable for the resident's weight. Her meal intakes varied between 25-75% and her supplement acceptance was usually greater than 50%. The resident was noted to have had a previous pressure ulcer to her right buttock that had healed but a Stage Two pressure ulcer to the left buttock had developed. RD #125 indicated the resident required increased protein needs in an effort to promote wound healing. On 10/24/12, her diet was liberalized (from cardiac diet to regular diet) due to poor nutritional intake with hopes of increasing her intake with a regular diet with mechanical soft meats and nectar thick liquids. Speech therapy was ordered on [DATE] for treatment of [REDACTED]. The MBS was completed on 12/05/12, and revealed Resident #76 was recommended to receive a regular diet with thin liquids and the food should be prepared in small bite sized pieces. A nurse's note dated 12/05/12, confirmed the facility was contacted and notified of the results and the recommendations from the MBS. There was no evidence the resident's diet was upgraded based on these results. The medical record did not include any additional nutrition notes until the last note documented on 12/30/12. The annual update nutrition note dated 12/30/12, continued to show the resident was on a mechanical soft diet with nectar liquids. She was also still receiving Med Pass supplement three times daily. Her nutrition intake was still poor with her only consuming 25-50% of her meals. Resident #76's weights were reviewed and indicated the December 2012 weight was 124.2 pounds. The weight was down 10.2 pounds (8.2%) in three months and 12.8 pounds (10.3%) in six months with a significant weight loss being noted at both three and six months. She was determined to take a few drinks of her Med Pass supplement when DTR #2 spoke with the nurse and did not eat her Magic Cup (a frozen nutritional supplement) at lunch when given. A recommendation was made for the Magic Cup to be increased to lunch and dinner. She also acknowledged in the nutrition note that a MBS had been done in November 2012, to see about increasing her liquids to thin liquids but she indicated speech therapy questioned the safety of thin liquids for the resident. A telephone order was received on 01/17/13, to give the Magic Cup at lunch and dinner. Review of the vital signs and weight record revealed the resident's weight continued to decrease after the last nutrition note was made. Resident #76's weight was 117 pounds on 01/01/13; 115 pounds on 01/14/13; 113 pounds on 01/21/13; 110 pounds on 01/28/13 and 109 pounds on 02/01/13. There was no further nutrition intervention. Review of the medication administration records for January and February 2013 revealed the resident was only taking about half of the Med Pass supplement that had been offered to her. She was also documented as having only taken about half of her Magic Cup when offered. An observation of the lunch meal served to the resident on 02/05/13 at 11:48 A.M., revealed she was served a regular diet with mechanically ground meats in her room with set up help being provided. She was served thin liquids and a Magic Cup. Resident #76 complained the food did not have enough salt used when cooking. The resident continued to feed herself slowly without difficulty and ate less than half of the Magic Cup served. The resident reported the Magic Cup was too frozen for her to scoop it out and she gave up on trying to get it out of the container. At 12:38 P.M., STNA #51 was observed to pick up the resident's tray to return it to the kitchen. Interview with STNA #51 on 02/05/13 at 12:38 P.M., revealed she did not offer the resident something else to eat because she was familiar with the resident and knew she liked chicken. She stated the resident usually would tell her when she wanted something else. She was not aware the resident had lost any weight. She was also not aware the resident was having any difficulty eating her Magic Cup due to it being too frozen to scoop out. She reported the facility's practice was to offer substitutes when a resident ate 50% or less. When asked how much the resident ate, STNA #51 stated it was about 25%. She confirmed she did not offer the resident something else to eat. Interview with RN #3 on 02/05/13 at 3:25 P.M., ,evealed it had always been difficult to get the resident to eat. She confirmed a MBS was completed and showed the resident had improved swallowing in which thin liquids could be given. She confirmed the resident was getting thin liquids despite there not being any evidence the order had been given to do so. She acknowledged the resident had been refusing the supplements at times. Interview with DTR #2 on 02/05/13 at 3:32 P.M., revealed she had only worked at the facility since October 2012, and was still learning the policies and the job duties as of December 2012. She reported a dietician came quarterly and she (DTR #3) visited the facili

Based on observation, record review and interview, the facility failed to ensure interventions were initiated as ordered to treat existing pressure ulcers, notification of the physician and responsible party of change and ensure accurate and comprehensive skin assessments were completed. This affected two of three residents reviewed for pressure ulcers (Residents #87 and #150). The facility identified six residents with pressure ulcers. The facility census was 92. Findings include: 1. Review of Resident #150's medical record revealed she was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A nursing admission assessment revealed the resident was admitted with a Stage 1 pressure ulcer (an area of intact skin with non-blanchable redness of a localized area, usually over a bony prominence), to her coccyx and an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by slough- yellow, tan, gray, green or brown, or covered by eschar- tan, brown, or black in the wound bed), to her right heel. Review also revealed a history of a left heel Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed) that progressed to a full thickness wound (Stage 3 or 4). Resident #150 had a current Stage 3 (full thickness tissue loss) pressure ulcer to the right ischial tuberosity described as 0.8 centimeters (cm) length x 0.4 cm width x 0.3 cm depth red in color with serosanguinois drainage. The last "Weekly Skin Assessment" dated 04/29/13 indicated Resident #150 had an existing pressure ulcer and bilateral mushy heels. She was assessed to be at risk for the development of pressure ulcers with a Braden risk assessment completed upon admission and most recently on 02/21/13. Review of the current physician orders [REDACTED]., 03/10/13 to turn every hour and a half from side to side and to only be on back for meals or up in the chair for meals only, 03/11/13 air mattress, 03/16/13 gel cushion to wheelchair, a protein supplement 03/23/13 30 milliliters once a day for wound healing and 03/30/13 apply skin prep every shift. There was no evidence of a care plan for non compliance for any of the ordered device. On 05/01/13 2:30 P.M. observation of Resident #150's room revealed Procare heel boots were in the room on a chair. Resident #150 was positioned on her left side in bed with a pillow behind her back. Resident #150's feet were on the bed with no evidence of a pillow at the foot of the bed to support them. She did not have on EZ boots as ordered. On 05/01/13 4:10 P.M. observation of Resident #150 revealed she remained positioned on her left side with a pillow behind her back. Resident #150's feet were on the bed with no evidence of a pillow at the foot of the bed to support them. She did not have on EZ boots as ordered. Interview with the Director of Nursing on 05/02/13 at 4:11 P.M., confirmed the resident had a history of [REDACTED]. The Director of Nursing acknowledged Resident #150 had areas that had previously been healed had re-opened. The Director of Nursing verified Resident #150 was on her left side, did not have EZ boots on as ordered and did not have a pillow at the foot of her bed to elevate her feet. The Director of Nursing asked a State tested Nurse Aide (STNA) to position her. The Aide states she was unable to find the STNA assigned to Resident #150 and Unit manager #4 assisted with the repositioning and application of the EZ boots at 4:13 P.M. Interview with State tested Nurse Aide #3 on 05/02/13 at 9:00 A.M., revealed she had placed Resident #150 back to bed after lunch at 1:15 P.M. on 05/01/13 and was not aware of the use of EZ boots as a pressure ulcer prevention intervention on day shift. She stated she thought they were for use just on nights. She verified that she did not use them on her shift, even when the resident was in bed. She verified that she did not elevate Resident #150's heels with pillows on 05/01/13 when she placed her to bed but usually did. She confirmed the resident required extensive assistance of two for transfers and repositioning. 2. Review of Resident #87's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's "Pressure Ulcer Record" revealed on 04/04/13 an initial wound description of a deep tissue injury (purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the left heel measuring 1.2 centimeters (cm) x 1.7 cm x unknown. The deep tissue injury was further described as deep purple, non blanchable without drainage. The periwound was pink but blanchable. There was no complaint of pain. The Physician ordered skin prep every shift and Protein supplement 30 milliliters by mouth twice a day. The next measurement was dated 04/04/13, however on 05/03/13 at 12:20 P.M. the Director of Nursing indicated the date should have read 04/10/13, described the pressure ulcer as a purple deep tissue injury 1.0 cm x 0.5 cm there was no depth noted. On 04/17/13 the left heel pressure ulcer was described as 2.0 cm x 1.6 cm x unknown. The color was red instead of the previous purple and described as a blood filled blister. There was no evidence the facility contacted the physician or family of the change in the appearance of the pressure ulcer. Review of a 05/01/13 the Dietician note revealed Resident #87 had a current body weight of 152.5 pounds, a significant weight loss of 10.3 % in the last three months and a 10.9% weight loss in the last six months. The note made note that the deep tissue injury was not showing much improvement and recommended to increase the Prostat to 30 milliliters three times a day to provide more calories of protein. Resident #87's Physician orders [REDACTED].M. to increase Prostat to 30 milliliters three times a day. On 05/03/13 at 11:00 A.M. review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no evidence 18 hours later that the 05/03/13, 5:00 P.M. order to increase the Prostat to three times a day had been transcribed. The facility's 06/11 "Laurel Health Care Company Wound and Skin Management Program" included "any signs of deterioration should be addressed immediately". The Administrator on 05/04/13 at 3:00 P.M. informed the surveyor that the facility does not have a basic notification policy and goes by the regulation. The regulation included the facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is ; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. On 05/03/13 at 12:25 P.M., the Director of Nursing verified there was no evidence the Physician or responsible party was notified of the 04/17/13 change in the appearance of the pressure ulcer. The pressure ulcer doubled in width, over tripled in depth and changed in color and appearance to a red blood filled blister to the heel. The Director of Nursing indicated there was no need for notification since the appearance of the left heel was the normal progression of a deep tissue injury to go to a blister. The Director of Nursing further indicated the second pressure ulcer entry dated 04/04/13, without a documented depth of wound, should have been dated 04/10/13 and was dated 04/04/13 in error. The Director of Nursing verified that the Protein supplement order was not carried out until the surveyor was reviewing the medical record 18 hours after the order was received.

Based on observation, record review, review of incident reports, policy review, and interview, the facility failed to ensure fall interventions were in place for Resident #6 who sustained a fracture, and failed to ensure comprehensive assessments and care plans were updated and accurate for Resident #9 relative to smoking. This affected two (Residents #6 and #9) of four residents reviewed for accident hazards. The facility census was 91. Harm occurred to Resident #6 who sustained a hip fracture when fall interventions were not implemented. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE] indicated Resident #6 was alert with confusion, needed assistance with activities of daily living (ADL's) and was deemed at risk for falls and a plan of care was initiated. On 08/29/12, the physician ordered non-skid footwear at all times. Review of the physician's orders [REDACTED]. Review of the communication care plan dated 09/07/12 revealed Resident #6 did not always understand verbal messages when spoken to. Review of the nursing notes revealed on 09/07/12 Resident #6 required one person extensive assist with ADL's and transfers. On 09/24/12, nursing notes indicated the resident was alert and oriented with periods of confusion. The resident required one to two assistants with ADL's, transfers, ambulation and some bed mobility. On 09/25/12, nursing notes indicated the resident was forgetful at times. On 09/26/12, nursing notes revealed the resident had poor judgement and safety awareness and attempted unassisted ambulation at times. The notes indicated staff instructed resident to utilize the call bell for nursing assistance but staff doubted the resident's retention. The nurses' notes did not address any falls. Review of "incident reports" revealed Resident #6 had two falls on 09/26/12, a fall on 09/29/12, 10/30/12, 11/25/12, 12/08/12, and 01/12/13. Review of the "incident report" dated 09/26/12 at 5:30 P.M. revealed Resident #6 was found on the floor in front of the wheelchair, the incontinence brief was wet, and the wheelchair surface had a urine odor. The resident was alert and confused and could not verbalize to staff what had occurred. There was no evidence the alarm was in place. Review of the fall risk assessment dated [DATE] indicated a score of 31. The score of 10 or higher indicated a high risk for falls. On 09/26/12, orders were written for bed and chair alarms, toilet every two hours and apply a wedge cushion to the wheelchair. Review of the "incident report" dated 09/29/12 at 12:45 A.M. revealed Resident #6 was found on the floor beside the bed. The resident fell out of the wheelchair. The resident did not have on the non-skid footwear as care planned. The staff implemented an intervention for a floor mat beside the bed, despite the resident falling out of the wheelchair. Review of the fall risk assessment dated [DATE] revealed a score of 30. On 09/29/12, an order was written for a floor mat to the floor beside the bed nearest the door. On 10/28/12, an order was written for the bed to be placed against the wall to help define the bed perimeter. Review of the "incident report" dated 10/30/12 at 3:55 P.M. revealed Resident #6's fall was witnessed by a visitor. The resident leaned forward and slid out of the wheelchair. The investigation did not attempt to determine where the resident was located or circumstances surrounding the incident. The visitor left before the facility could obtain a witness statement. Review of the fall risk assessment dated [DATE] revealed a score of 29. On 10/30/12, an order was written for dycem to the wheelchair. Review of the "incident report" dated 11/25/12 at 5:00 P.M., revealed Resident #6 was found on the floor in the room. The investigation did not indicate the location of the resident's fall. The investigation indicated the facility was aware the resident "occasionally turns off alarms". The investigation indicated the resident was using the wheelchair as a walker and her legs gave out and she landed on her bottom. The alarm was not functioning at the time of the fall. There was no investigation to determine if the resident was in the bed or wheelchair prior to the fall. On 11/25/12, a physician order [REDACTED]. Review of the "incident report" dated 12/08/12 at 1:40 P.M. revealed Resident #6 fell during a transfer by state tested nursing assistant (STNA) #110 . The resident did not have on the care planned non-skid footwear. The resident slid out of her slippers. Review of STNA #110's statement verified she was assisting Resident #6 to the toilet when her slippers slid off and the resident fell to the floor. STNA #110 verified she was not able to find a nurse so she and another STNA lifted the resident off of the floor. Review of the "incident report" dated 01/12/13 at 12:00 A.M., revealed Resident #6 was found on the floor in her room. The resident complained of pain in the right knee, swelling to the right hip and pain to the buttocks. The resident was sent to the hospital. The investigation indicated the bedside table was involved in the fall. The investigation verified the alarm was turned off. The investigation did not indicate if the bed was in low position or if the floor mat was in place as care planned. The investigation did not indicate where the resident was found in the room or the position of the resident. The investigation, under circumstances of fall, indicated "somebody turned off the alarm". The resident stated she had to go to the restroom and her knees gave out. The conclusion was "Resident was responding to urinary urgency and was using her bedside table as a "walker" and bed alarm was not sounding due to being turned off". Review of STNA #111's witness statement revealed she was going down the hall and found Resident #6 on the floor by the bathroom door. When asked what happened, the resident replied she was going to the bathroom and she fell . She was holding on to the table as she was walking to the bathroom. She got as far as the door of the bathroom and her legs gave out and she fell to the floor. The resident indicated she was in a lot of pain as staff lifted her up from the floor. Review of the witness statement from STNA #112 revealed she observed Resident #6 laying on the floor by the restroom. The resident's bedside table was by the restroom door. The resident was trying to go to the bathroom using the table to walk. The resident was laying in urine. The alarm on the bed was not turned on. Resident #6 sustained a hip fracture. Care plan updates on 01/14/13 indicated to keep the alarm box out of reach, bed against the wall, provide assistive devices as needed, wheelchair and walker, provide extensive assist with transfers, pommel cushion in wheelchair as ordered and dycem to the wheelchair as ordered. On 02/05/13 at 9:20 A.M., Resident #6 was observed in a low bed against the wall with a mat on the floor with the over bed table long ways across the mat. On 02/05/13 at 10:22 A.M., Resident #6 was observed in a low bed against the wall with a mat on the floor with the over bed table long ways across the mat. On 02/05/13 at 10:22 A.M., interview with Resident #6 indicated she fell because of balance issues. Resident #6 stated "I get up when I have to go to the bathroom and I can't always wait on someone to help me". On 02/05/13 at 2:55 P.M., Resident #6 was observed in her room in the wheelchair, the chair alarm was hanging in plain sight on the right handle bar on the wheelchair, not out of reach of the resident. On 02/05/13 at 2:56 P.M., interview with Resident #6 verified she could reach the alarm on the handle bar. On 02/05/13 at 3:00 P.M., interview with STNA #13 verified the alarm was always placed on the handle bar because if it was hooked to the back of the chair it was uncomfortable for the resident by poking her in the back. On 02/05/13 at 12:05 P.M., interview with the director of nursing (DON) and administrator verified no documentation in the medical record to address the above falls. On 02/05/13 at 4:15 P.M., interview with the DON and corporate quality assurance registered nurse (RN #114) verified the "incident reports" for the above falls did not accurately reflect where the resident was at the time of the fall. They verified there was no documented evidence all fall interventions were in place for the above falls. The DON verified the over the bed table was always placed on top of the fall mat long ways so the resident could reach her liquids despite the bed being in the low position and the mat on the floor for the resident to fall safely. 2. On 02/04/13 at 12:00 P.M., Resident #9 was observed outside smoking and dropping ashes and cigarette butts on the ground. The ground around the wheelchair was covered with ashes, ashes were observed on the blanket that was on the resident's lap, and the resident was observed lighting cigarettes. Resident #9 was in an electric wheelchair with a chair alarm. The resident dropped the cigarette butts on the ground without extinguishing them. The butts were still smoldering while on the ground. The resident did not attempt to utilize the ash tray on the table. This was verified by STNA #115. On 02/04/13 at 3:40 P.M., Resident #9 was observed outside smoking by himself dropping ashes and cigarette butts on the ground. Ashes were observed on the blanket that covered the resident's legs. The resident did not attempt to utilize the ash tray on the table. On 02/04/13 at 3:45 P.M., interview with Resident #9 revealed he always smoked independently since he had been at the facility. The resident indicated he wanted to remain as independent as possible. Resident #9 stated he kept his lighter in his coat pocket. Resident #9 stated he got a hand full of cigarettes at a time from the nurses and his son provided more, as he needed them. On 02/05/13 at 9:25 A.M., Resident #9 was observed smoking outside independently. Ashes were observed on the ground and on the blanket covering the resident's legs. The resident discarded the cigarette butts on the ground and they were observed smoldering. The resident did not attempt to utilize the ash tray on the table. On 02/05/13 at 10:30 A.M., Resident #9 was observed smoking outside and lighting his own cigarettes. The resident removed the lighter from his right coat pocket. The resident was observed flicking the ashes on the ground and ashes were observed on the blanket that covered his legs. The resident did not attempt to utilize the ash tray on the table. Review of the "smoking data collection and assessment" policy and procedure dated March 2005 indicated a smoking assessment would be completed by a LPN for a resident who wished for unsupervised smoking in the designated smoking areas. The assessment would be completed upon admission, quarterly, and with a change in condition if indicated. The procedure indicated to initiate the "smoking data collection and assessment" and proceed to the observation section. The policy called for staff to make three observations of the resident while smoking. During the three observations, staff were to interview the resident and monitor the resident while smoking, record pertinent observations which could include information and skills such as those listed in a check list. After the three observations were complete, staff were to answer the questions in the data collection section by entering a check mark in yes/no columns and record any significant comments related to the questions. Staff were then to select an appropriate conclusion statement to indicate assessment findings. Review of the assessment dated [DATE] indicated Resident #9 was physically able to smoke independently, demonstrated safe use of the lighter and appropriate use of the ashtray, extinguished the cigarette independently, and did not have sensory deficits that would interfere with the ability to smoke independently. Review of the smoking plan of care dated 06/19/12 revealed the problem indicated Resident #9 wished to smoke while in the facility. The approaches included keeping the lighter and cigarettes at the nursing station, instructing the resident on the smoking schedule and designated smoking areas, documenting any noncompliance, and completing a smoke assessment as needed. Review of nursing notes dated 12/18/12 indicated Resident #9 was out to smoke several times. The resident was alert and oriented but did have periods of confusion. Review of the nursing notes dated 12/20/12 revealed Resident #9 was alert at times but disoriented to time. Review of the nursing notes dated 01/07/13 revealed Resident #9 was alert and oriented but did have periods of confusion. Review of the nursing notes dated 01/15/13 revealed Resident #9 propelled himself to the outside smoking patio. On 02/05/13 at 2:50 P.M., interview with Resident #9's floor nurse, LPN #116, verified the resident's cigarettes were in the medication cart but no lighter was in the cart. LPN #116 verified she let the resident borrow her lighter but was not sure the last time he asked to borrow her lighter. The surveyor informed LPN #116 the resident was observed the last two days with the lighter in his coat pocket. The surveyor and LPN #116 proceeded to the resident's room and obtained the lighter from the resident's coat pocket. Resident #9 verified he kept the lighter in the coat pocket. LPN #116 indicated the resident's son visited one to two times a week and provided cigarettes and lighters for the resident. LPN #116 did not check the resident's room to ensure no other lighters were in the room. On 02/05/13 at 2:55 P.M., interview with RN #117 verified she completed the smoking assessment on 12/29/12. RN #117 verified she was aware the resident had ashes on his blanket when he smoked despite the assessment indicating the resident was safe. RN #117 verified she was aware the resident placed his ashes and cigarette butts on the ground and not in the ashtray on the table despite the assessment indicating the resident extinguished the cigarette appropriately. On 02/05/13 at 3:00 P.M., interview with the DON verified the above. The DON verified the family frequently brought in cigarettes and lighters for the resident and it had been an ongoing problem. The DON verified there was no documented evidence the facility discussed the problem with the resident and/or family.

Based on observation, record review and interview, the facility failed to ensure interventions were implemented to prevent the development of pressure ulcers and to treat existing pressure ulcers and ensure accurate skin assessments were completed . This affected three of five residents reviewed for pressure ulcers (Residents #7, #60 and #150). The facility census was 91. This resulted in harm for Resident #7 when nutritional interventions were not implemented for a resident with continued weight loss and the resident developed an unstageable wound to the coccyx and a stage two pressure ulcer to the right buttock. Harm also occurred to Resident #150 who developed recurring stage two pressure ulcers to the right gluteal fold and recurrent skin breakdown to the right heel. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] indicated Resident #7 was severely impaired for cognition based on a Brief Interview of Mental Status (BIMS) score of 03 out of a possible 15 points. February 2013 physician's orders [REDACTED]. No nutritional supplements, vitamin supplements or appetite stimulants were in place. Admission and quarterly MDS assessments dated 09/01/12 and 11/30/12 identified Resident #7 at risk for the development of pressure ulcers. The MDS assessments indicated Resident #7 had no pressure ulcers at the time of the assessments. The MDS assessments indicated Resident #7 required extensive assistance of one person for bed mobility, toileting and personal hygiene. A potential for skin breakdown plan of care was initiated on admission and included interventions for Resident #7 to be weighed at least monthly and observed for trends, to provide her diet as ordered and encourage meal completion and fluid intake, and to observe for food acceptance and offer substitutes as needed. A quarterly nutritional progress note dated 12/03/12 identified Resident #7's November weight as 144.4 pounds, representing a weight loss of 21.3 pounds or a significant weight loss of 14.7%. No nutritional recommendations were made. There were no nutritional progress notes subsequent to 12/03/12 to address the continued, significant weight losses of an additional 22.2 pounds. "Vital Signs and Weight Record" revealed the following weights: 9/8/12 - 166.6 pounds, 9/17/12 - 167 pounds; 9/24/12 - 164.4 pounds; 10/3/12 - 165.7 pounds; 10/8/12 - 149.4 pounds (rechecked two times); 10/15/12 - 147 pounds; 10/29/12 - 145.4 pounds; 11/02/12 - 144.4 pounds; 11/05/12 - 146.2 pounds; 11/12/12 - 142.4 pounds; 11/19/12 - 144.4 pounds; 11/26/12 - 141.2 pounds; 12/01/12 - 140.4 pounds; 12/10/12 - 137.8 pounds; 01/14/13 - 138 pounds; 01/21/13 - 123 pounds and 02/01/13 - 122.2 pounds. Resident #7's weight on 02/01/13 of 122.2 pounds represented a weight loss of 44.4 pounds since the 09/08/12 weight, or a significant weight loss of 36.3% percent since September 2012. Review of Meal Intake Reports revealed Resident #7 began a sharp decline in oral intake beginning on 12/18/12. Her decline included refusing all food on most days for breakfast and lunch. From 12/18/12 through 12/31/12, Resident #7 had no documented intake for breakfast or lunch for 19 meals; consumed 10% on three days, 25% on two days and 100% of her lunch on one day. Resident #7 had varied acceptance for supper from 12/18/12 through 12/31/12, ranging from zero on two days., 25% on five days; 50% on one day; 75% on seven days and 100% on two days. Resident #7's very poor appetite for breakfast and lunch continued throughout January with no documentation of intake 49 times, as 5% eaten two times;, 10% eaten three times; 25% two times and 50% twice. Resident #7 demonstrated much less acceptance of supper during January with no documented consumption 14 times; ten percent once; 25% eight times, and both 50% and 75% four times. February 2013 meal intake records revealed Resident #7 had no documented intakes for breakfast from 02/01/13 through 02/05/13. Lunch intake records indicated she accepted 10% on 02/04/13 and 5% on 02/05/13, with no documented intake on the remaining days. Supper intake records indicated Resident #7 ate 15% of her supper on 02/01/13 and refused supper on the remaining days. On 02/05/13 at 12:05 P.M., State tested Nurses Aide (STNA) #1 delivered a lunch tray to Resident #7. STNA #1 set up the tray and Resident #7 refused to eat. STNA #1 offered the resident applesauce and a grilled cheese sandwich, which the Resident also refused. STNA #1 removed the resident's tray from her room and placed it into the cart. During an interview at 12:09 P.M., STNA #1 reported Resident #7 ate lunch independently in her room. STNA #1 indicated she worked part time, but when she had taken care of Resident #7 " the other day " she also refused her lunch. STNA #1 reported she left the resident's grape juice on her over-bed tray table for her to drink. STNA #1 indicated she records the amount consumed on the computerized intake records. STNA #1 indicated she did not report refusals to the nurse. At 12:27 P.M., Resident #7 had consumed four ounces of grape juice. On 02/05/13 at 5:09 P.M., STNA #1 delivered and set up Resident #7 ' s dinner tray. STNA #1 exited the resident's room. Resident #7 made no attempt to independently eat her meal situated on the over-bed tray table in front of her. A 5:20 P.M., STNA #1 returned to the room and asked Resident #7 if she wanted her dinner, which Resident #7 refused. STNA #1 was heard to offer Resident #7 a grilled cheese sandwich, which she also refused. STNA #1 left the coffee and juice on the over-bed tray table for Resident #7 and removed the tray. During an interview on 02/06/13 at 09:50 A.M., registered dietary tech (DTR) #2 verified according to her Nutritional Progress Note dated 12/03/12 she identified a 21.3 pound/14.7% significant weight loss for Resident #7. The DTR verified no nutritional interventions were put into place to address the significant weight loss. DTR #2 confirmed there were no Nutritional Progress notes subsequent to 12/03/12 for Resident #7. The DTR reviewed Resident #7 's " Vital Signs and Weight Record " and revealed she was not aware Resident #7 had sustained an additional 22 pound weight loss, or 44.4 pounds, since admission. Resident #7's poor oral intakes (per intake records) were reviewed with DTR #2. DTR #2 indicated she had not been notified of Resident #7's decreased oral intake. The DTR acknowledged no nutritional interventions were implemented to address Resident #7's 44.4 pound weight loss since admission or to prevent the development of pressure ulcers. The DTR indicated no laboratory work had been ordered to assess the resident's nutritional parameters. During an interview on 02/06/13 at 10:17 A.M., Unit Manager/Registered Nurse (RN) #3 acknowledged Resident #7 had sustained a 44.4 pound weight loss since 09/08/12. RN #3 verified Resident #7 developed two newly opened pressure areas on her buttocks on 02/05/13. RN #3 acknowledged the open areas could be related to malnutrition and the lack of nutritional interventions. A Nurse's "Progress Notes" dated 02/05/13 at 7:30 P.M. revealed a new order for wound care treatment for [REDACTED]. The "Wound and Skin Condition Record" dated 02/05/13 identified two new, open areas on Resident #7 's buttocks. The report indicated " 1/4 inch blisters have opened on the right and left buttocks." On 02/06/13 at 2:55 P.M., Wound Nurse/ Licensed Practical Nurse (LPN) #8 provided wound treatment for [REDACTED]. Resident #7 was observed with a 0.3 centimeter (cm) by 0.3 cm by less than 0.1 cm Stage Two pressure ulcer to her right upper buttock. A 0.3 cm by 0.2 cm unstageable pressure ulcer to the coccyx with a grayish colored wound bed was observed. The Wound Nurse acknowledged the wound was unstageable, since the wound bed was not visible. The "Pressure Ulcer Record" dated 02/06/13 identified the unstageable coccyx wound that measured 0.3 cm by 0.2 cm with a wound bed that was gray in color. Risk factors for the pressure areas were identified as malnutrition and decreased mobility. A "Pressure Ulcer Record" dated 02/06/13 identified a Stage Two pressure area to the right buttock that measured 0.3 cm by 0.3 cm by less than 0.1 cm with a pink wound bed. Risk factors identified were malnutrition and decreased mobility. Adequate nutrition and hydration are essential for overall functioning. Nutrition provides vital energy and building blocks for all of the body's structures and processes. Skin condition reflects overall body function. Significant unintended weight loss may indicate under-nutrition or worsening health status. A Stage Two pressure ulcer is characterized with a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. An unstageable pressure ulcers has the presence of slough and/or eschar and is not stageable due to the coverage of the wound bed. 2. Review of Resident #150's medical record revealed she was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A nursing admission assessment revealed the resident was admitted with a Stage 1 pressure ulcer (an area of intact skin with non-blanchable redness of a localized area, usually over a bony prominence), to her coccyx and an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by slough- yellow, tan, grey, green or brown, or covered by eschar- tan, brown, or black in the wound bed), to her right heel. No other pressure ulcers were present upon admission. She was assessed to be at risk for the development of pressure ulcers with a Braden risk assessment completed upon admission. The admission orders [REDACTED]. A Nutrition at Risk Monitoring Record dated 10/16/12, revealed the resident was identified as having a low pre-[MEDICATION NAME] level (laboratory test used to help diagnose protein calorie malnutrition) of 12.5 (normal ranges 16- 35 milligrams per deciliter), and a low [MEDICATION NAME] (protein in the blood important for tissue growth and healing) level of 2.1 (normal levels 3.5-5.0 grams per deciliter). A nutrition initial assessment note dated 10/16/12, revealed recommendations were made to add a magic cup (a frozen nutritional supplement) twice daily to add an additional 580 calories and 18 grams of protein per day. Review of the physician telephone orders revealed an order on 10/18/12 for the use of EZ boots (specialty boot to alleviate pressure from the heels) to both heels while in bed. A nurse's note dated 10/18/12, indicated the resident required an extensive assist of two for transfers and bed mobility. A nurse's note dated 10/22/12, revealed the resident spent the majority of the day in her wheelchair and was noted to be incontinent of both her bowel and bladder. A telephone order dated 10/24/12, revealed the use of a pressure reduction cushion to the wheelchair was ordered at that time. A Pressure Ulcer Record sheet revealed a Stage 2 pressure ulcer (partial thickness skin loss of dermis presenting as a shallow, open ulcer with a red pink wound bed, without slough) was noted to the resident's right upper posterior thigh just below the gluteal fold on 10/25/12. The area measured 1.5 centimeters (cm) x 3 cm x <0.1 cm. A treatment was started and the area resolved on 11/08/12. A nutrition note dated 11/11/12 for a 30 day review noted the resident had still not been placed on a nutritional supplement to address her low protein levels needed to promote wound healing. The dietician had indicated she was going to contact the physician for clarification on the need for a nutritional supplement. She noted the Stage 1 pressure ulcer to the coccyx and the deep tissue injury to the right heel remained with treatments being provided. She acknowledged the development of a new Stage 2 pressure ulcer on the right gluteal fold area that resolved on 11/08/12. The pressure ulcer record for the Stage 1 pressure ulcer to the coccyx area revealed the area showed an increase in size on 11/01/12 when it increased from 0.8 cm x 0.4 cm on 10/29/12, to 4 cm x 1 cm on 11/01/12. The coccyx area was marked as healed on 11/08/12. The unstageable pressure ulcer to the right heel was assessed as a suspected deep tissue injury (purple or maroon localized area of discolored, intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) despite the description of the area being described as the area being black and hard which was consistent with the definition of an unstageable pressure ulcer under the description of stages on the Pressure Ulcer Record form. Subsequent assessments continued to identify it as a suspected deep tissue injury. The Pressure Ulcer Record revealed the area did not show any signs of healing with an increase in size from 2.5 cm x 2 cm when first assessed to 3.5 cm x 4 cm on 11/01/12. The pressure ulcer to the right heel was marked as being healed on 11/16/12. The right heel was noted to have another suspected deep tissue injury on 11/20/12 where it remained until 02/06/13, when the treatment nurse assessed it as then being a Stage 1 pressure ulcer. The Stage 2 pressure ulcer to the right gluteal fold that healed on 11/08/12 re-opened on 11/12/12, when it measured 1.6 cm x 3 cm with no depth recorded. The following week the Stage 2 pressure ulcer on the right gluteal fold was a Stage 1 pressure ulcer until it was documented as being healed on 11/16/12. The right gluteal fold opened up again on 11/27/12 when a Stage 2 pressure ulcer was noted measuring 1.7 cm x 1.7 cm x 0.1 cm. Weekly measurements obtained revealed little to no wound healing with last measurement on 02/06/13 as 1 cm x 1.5 cm x 0.1 cm. A Pressure Ulcer Record reviewed revealed the resident also developed a Stage 2 pressure ulcer to the left heel on 12/03/12. The pressure ulcer was resolved on 01/16/13. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Findings verified by RN #3. Interview with RN #3 on 02/06/13 at 9:40 A.M., confirmed the resident had a history of [REDACTED]. She acknowledged some of the areas that had previously been healed had re-opened on more than one occasion. She stated the area to the right gluteal fold possibly could have been from shearing but she did not really look into the possible causes even though the pressure ulcer had developed in the same area more than on one occasion. She did not consider the appropriateness of the interventions used in regards to the use of the pressure reduction cushion to the wheelchair. She denied that she considered the cushion to be a contributing factor to the development of the pressure ulcer to the right gluteal fold nor did she consider that a different type of cushion could have been beneficial for wound healing. She stated the resident was known to be compliant with treatment and repositioning. She acknowledged the resident was assessed as a risk for pressure ulcers, known to be up in a wheelchair, required staff assistance with repositioning and was not ordered to have a pressure reduction cushion to the wheelchair until 10/24/12, the day before the resident developed a stage 2 pressure ulcer to her right gluteal fold. She also acknowledged the resident was admitted with an unstageable pressure ulcer to the right heel and an order was not received to use the EZ boots until 10/18/12 which was 7 days after she was admitted to the facility. She confirmed the resident had not been placed on a nutrition supplement to promote wound healing despite being known to have a low [MEDICATION NAME] and pre-[MEDICATION NAME] level. She stated the need to initiate nutrition interventions was the responsibility of the dietician. She stated they were responsible for faxing the physician for any orders needed for their recommendations and were also responsible for following up with them if the fax was not responded to. Interview with the DON on 02/06/13 at 9:50 A.M. revealed the facility did discuss wounds in the clinical operations meetings. She stated she received updates from the treatment nurse weekly on all the pressure ulcers. She stated the facility had a wound doctor but denied the resident was being seen by him. She knew the resident was using a pressure reduction cushion in her wheelchair but was not sure what kind was being used. She denied they considered the pressure reduction cushion as being a possible cause of the repeated development of the Stage 2 pressure ulcers to the right gluteal folds. She also stated they did not consider the use of any other type of cushion for the resident's wheelchair that may have helped with the healing and prevention of the pressure ulcer. Interview with Licensed Practical Nurse (LPN) #10 on 02/06/13 at 1:55 P.M., revealed she was not aware of the use of EZ boots as a pressure ulcer prevention intervention. She denied she had seen them in use on her shift, even when the resident was in bed. She stated they did elevate her heels when in bed but that was done with pillows. She also denied the resident was on any nutritional supplements. Interview with DTR #2 on 02/06/13 at 2:00 P.M., confirmed the nutritional supplement was not ordered by the physician when it had been recommended. She confirmed she made a nutrition note in November 2012 that indicated the resident was not receiving her house supplement as ordered. She acknowledged she did not make any additional nutrition notes until 02/04/13, and the resident was still not on any of the recommended supplements. She stated a resident with pressure ulcers should have been reviewed monthly. She verified she had missed the resident and did not make a note as often as she should have. She found mighty shakes was on her meal ticket for the resident as it had been carried over from a previous admission. She reported the acceptance of the supplement was not being recorded as it was never ordered by the physician or placed on a Medication Administration Record [REDACTED]. She stated with the resident having a low [MEDICATION NAME] level she should have started the resident on Prostat (a high protein supplement) to promote wound healing, especially since she had repeated skin breakdown. She also stated additional vitamins such as Vitamin C with Zinc may have been beneficial as well. Interview with STNA #50 on 02/06/13 at 2:05 P.M. revealed she was not aware the resident had a pressure ulcer to her right heel heel. She stated when she begins her shift the resident was usually in bed. She denied the resident was wearing any EZ boots on her feet. She stated she did not think they needed to be put on until bedtime. She confirmed the resident required extensive assistance of two for transfers and repositioning. She denied the resident moved much when up in her wheelchair. She was not aware the resident was to use a cushion when she was up in her wheelchair. She denied the resident was on any supplements. 3. Review of Resident #60's medical record revealed an admission date of [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Braden scale assessments for pressure ulcer risk identified the resident as being at a high risk for developing pressure ulcers. The facility initiated a plan of care for risk of skin breakdown with appropriate interventions in place. Further review of the medical record revealed, upon re-admission on 09/05/12, the resident was identified as having a stage two pressure ulcer (partial thickness skin loss of dermis presenting as a shallow, open ulcer with a red pink wound bed, without slough). Review of the resident's "Pressure Ulcer Record" revealed measurements completed on 09/05/12, 09/11/12 and 09/18/12 identified only the length and width of the pressure ulcer. The facility failed to identify the depth of the resident's stage two pressure ulcer. Weekly skin assessment forms completed by the facility on 09/12/12, 09/19/12, 09/26/12, 10/3/12, 10/10/12 and 10/17/12 identified the resident with intact skin. Staff members did not indicate the resident as having an existing pressure ulcer. On 02/06/13 at 1:20 P.M., interview with the Director of Nursing verified measurements on the Pressure Ulcer Record were not completed correctly with the depth of the wound and staff failed to identify an existing pressure ulcer on the weekly skin assessment forms.

Based on record review, policy review, and interview, the facility failed to ensure comprehensive assessment and interventions were in place to maintain or restore normal bladder function for Resident #6. This affected one of two residents reviewed for urinary incontinence. The facility census was 91. Harm occurred when the facility failed to comprehensively assess Resident #6's bladder function and address declines in bladder function. Resident #6 was admitted to the facility continent of urine and declined to being frequently incontinent of urine without evidence of sufficient interventions. Findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "establishing a pattern bowel and voiding chart" policy and procedure (not dated) revealed on admission incontinent or partially incontinent residents' bladder habits would be monitored for a period of up to seven days. During the seven day monitoring period, the resident would be checked hourly for voiding, continence or incontinence and documented on the "bowel and voiding chart". If no obvious pattern could be established after the seven day period, no bladder retraining program was indicated. Staff were to complete the appropriate assessment. If bladder pattern was evident, staff were to complete the appropriate assessment form, obtain a physician order [REDACTED]. Review of the nursing admission assessment dated [DATE] indicated Resident #6 was alert with confusion and needed assistance with activities of daily living (ADL). Resident #6 was continent of bladder and the usual bladder pattern was every two to three hours using a toilet or bedpan. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] indicated Resident #6's brief interview for mental status (BIMS) was a score of nine, indicating her cognitive function was moderately impaired. Resident #6 needed extensive assistance with two or more persons for transfers and extensive assistance of one person for toileting. No trial of a toileting program was attempted. Resident #6 was occasionally incontinent of bladder. Review of the quarterly MDS 3.0 dated 11/30/12 indicated a BIMS score of 10. Resident #6 needed extensive assistance with two or more persons for transfers and extensive assistance of one person for toileting. No trial of a toileting program was attempted. Resident #6 was frequently incontinent of bladder. Review of the significant change MDS 3.0 dated 12/14/12 indicated a BIMS score of 14 indicating the resident was cognitively intact. Resident #6 needed extensive assistance with two or more persons for transfers and extensive assistance of one person for toileting. No trial of a toileting program was attempted. Resident #6 was frequently incontinent of bladder. Review of the ADL's care plan dated 09/07/12 included interventions to toilet every two hours for altered urinary elimination/incontinence and provide skin care for each episode of incontinence. Review of the medical record revealed no indication any type of bladder assessment, voiding tracker or bladder evaluations were completed for Resident #6. Review of the ADL data report completed by the state tested nursing assistants (STNA) for Resident #6 revealed December 2012 and January 2013 showed the resident was both continent and incontinent of bladder. On 02/05/13 at 10:22 A.M., interview with Resident #6 revealed she had falls because she continued to attempt to toilet herself. Resident #6 verified she was able to tell when she had to urinate but needed staff assistance for toileting. On 02/05/13 at 2:40 P.M., interview with Licensed Practical Nurse (LPN) #101 verified Resident #6 had a decline in bladder function from the admission MDS to the quarterly MDS. LPN #101 verified this documentation to determine this was obtained from the ADL data report which was completed by the STNA's when the resident was checked for continence. LPN #101 verified there was no tracker or assessment completed for Resident #6's bladder function. LPN #101 verified Resident #6 was not on any type of toileting program. On 02/05/13 at 3:00 P.M., interview with the DON verified no assessments, trackers or evaluations had been completed for Resident #6 at any point during her admission. The DON verified it was the unit manager's responsibility to determine if toileting times were appropriate. The DON verified the policy and procedure did not have any type of toileting plans the facility offered. The DON verified "we toilet them before meals or after meals whenever they need it." On 02/05/13 at 3:05 P.M., interview with STNA #103 stated she took Resident #6 to the toilet every two hours. STNA #103 verified Resident #6 could tell you when she had to go to the bathroom but needed assistance. On 02/06/13 at 1:30 P.M., interview with RN #102 verified it was the admitting nurse who was responsible for trackers, assessments and monitoring residents for bladder function. RN #102 indicated the unit manager was just responsible to make sure it was completed. RN #102 verified no assessments, trackers of evaluations were completed for Resident #6 at any point during her admission. RN #102 verified the decline in bladder function, verified the resident returned form the hospital on [DATE] with an indwelling catheter that was removed on 01/21/13. RN #102 verified the type of toileting programs offered included toilet in advance of need or the management program which was toilet every two hours or every 1 hour if necessary. The surveyor questioned if that was feasible for the STNAs and RN #102 stated "it's difficult".