Every finding on record at Lost Creek Rehabilitation and Nursing Center

Based on policy review, observations, and staff interview, the facility failed to ensure medications were stored securely. This had the potential to affect all residents on the 200-hall when the medication cart was left unlocked, with the key in the lock during medication administration. The facility census was 38.Findings include:Observation on 06/29/26 at 7:16 A.M. revealed Licensed Practical Nurse (LPN) #241 was observed preparing medications for Resident #33. After the medications were prepared, LPN #241 took the medication cup into the room leaving the medication cart unattended and unsecured in the hallway. The drawers of the cart were facing the hall and the top drawer was open approximately one inch, with the keys hanging from the lock.A second observation was made on 06/29/26 at 7:39 A.M. revealed LPN #241 preparing medications for Resident #3. After the medications were prepared, LPN #241 took the medication cup into the room leaving the medication cart unattended and unsecured in the hallway. The drawers of the cart were facing the hall and the top drawer was open approximately one inch, with the keys hanging from the lock.Interview on 06/29/26 at 7:57 A.M. with LPN #241 verified the medication cart was left unattended and unsecured twice while completing medication administration, with the top drawer left ajar and the keys were left in the lock while administering medications to the residents.Review of the facility policy titled Storage of Medications revised 04/2007 revealed compartments containing drugs and biologics shall be locked when not in use and shall not be left unattended if open or potentially available to others.

Based on observation, staff interviews, and policy review, the facility failed to ensure a safe smoking environment for the residents. This had the potential to affect four residents (Residents #2, #23, #31, and #33) who the facility identified as smokers. The facility census was 38.Findings include:Observation on 06/28/26 at 3:05 P.M. revealed Resident #33 sitting in her wheelchair with an oxygen tank in place attached to the back of her wheelchair. There were two other residents in the smoking area. Certified Nursing Assistance (CNA) #221 was in the smoking area. He handed one resident a vape and then handed the other resident and Resident #33 a cigarette. CNA #221 proceeded to light the other resident's and Resident #33's cigarette.Interview on 06/28/26 at 3:07 P.M. with CNA #221 confirmed it was the facility staff's responsibility to ensure all residents were safe while smoking. CNA #221 confirmed Resident #33 should not be allowed to smoke while wearing oxygen or when there was an oxygen tank present in the smoking area. CNA #221 stated Resident #33 has smoked on multiple occasions with her oxygen on and that she will even hide her oxygen tank by covering it with her jacket while she smokes.Interview on 06/29/26 at 12:40 P.M. with Social Services Director #257 confirmed he has educated Resident #33 on not using oxygen while smoking when she signed out of the facility and was noted smoking off the property while having her oxygen on.Interview on 06/29/36 at 12:58 P.M. with the Administrator confirmed the facilities expectation has always been no oxygen is allowed in the smoking area. Because of this incident of Resident #33 smoking in the smoking area with an oxygen tank on (06/28/26 incident), staff were currently being educated on their responsibility to remove oxygen from resident prior to entering the smoking area.Review of the facility's Smoking policy, undated, revealed the facility will establish and maintain a safe resident smoking practices. Oxygen use is prohibited in smoking areas. All residents will have supervision while smoking.

Based on record review, review of a Self-Reported Incident and investigation, and staff interviews, the facility failed to submit accurate and pertinent information in the SRI. This affected one (#8) of five residents reviewed for SRIs. The facility census was 38.Findings include:Review of the medical record for Resident #8 revealed an admission date of 02/26/25. Diagnosis included hemiplegia following cerebral infarction affecting the left non-dominant side and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had impaired cognition and was dependent on staff with toileting hygiene, bed mobility and transfers.Review of the SRI number 275931 revealed on 06/18/26, Resident #8 reported to Behavioral Health Specialist (BHS) #271 that Certified Nursing Assistant (CNA) #218 was rough with him when changing the resident's brief and CNA #218 spanked him on his bottom. The SRI stated they completed a head to toe assessment on resident with negative outcomes. Review of the facility's investigation revealed the head-to-toe assessment for Resident #8 documented a circled area on the left upper arm of a body diagram with skin tear written above the circle. Additionally, there was a circle with a line drawn through it with the words no other issues noted written beside it. This was verified on 06/29/26 at 2:12 P.M. with the Administrator.Interview on 06/30/26 at 7:24 A.M. the Administrator verified the SRI did not contain information regarding the skin tear which was found during Resident #8 skin assessment on 06/18/26 and stated she was not clinical and was not aware a skin tear would be considered a negative outcome. The Administrator acknowledged without the information regarding a skin tear, the person reviewing the SRI did not have all the pertinent information regarding the incident.

Based on record review, staff interview, guardian interview, and policy review, the facility failed to ensure the proper authorization was obtained for the facility to manage a resident funds funds account. This affected one (#9) of five residents reviewed for Resident Fund Accounts. The facility census was 38.Findings include:Review of the medical record for Resident #9 revealed an admission date of 03/09/17. Diagnoses included schizophrenia, dementia, and epilepsy.Review of the guardianship papers dated 12/17/22 revealed Resident #9 was deemed incompetent and was assigned guardianship to the county Guardianship Services Board.Review of the Resident Fund Management authorization forms for Resident #9 revealed the following: on 06/22/18, the form was signed by an attorney who was Resident #9's legal guardian; and on 04/12/22 and 01/06/26, the forms were signed by Resident #9.Review of the significant change Minimum Data Set (MDS) assessment, dated 05/25/26 revealed Resident #9 had moderate cognitive impairment.Interview on 06/30/26 at 11:35 A.M. with Business Office Manager (BOM) #202 stated Resident #9 has had a legal guardian since 2018. BOM #202 stated Resident #9's legal guardianship changed in 2022 from an attorney to the county Guardianship Services Board. BOM #202 confirmed Resident #9's Resident Fund Management authorization forms dated 04/12/22 and 01/06/26 were signed by Resident #9 and not the legal guardian.Interview on 06/20/26 at 12:03 P.M. with Case Manager #266 from the county Guardianship Services Board confirmed she had taken over as Resident #9's guardian in 2022 and she had not signed any Resident Fund Management authorization forms.Review of the facility policy titled Deposit of Resident Funds, revised April 2017 revealed resident personal funds are held and managed by the facility would be safeguarded. A copy of the resident's or representative's authorization designating the facility as the agency to manage the resident's funds is filed in the resident's financial record.

Based on record review, staff interviews, and policy review the facility failed to develop a comprehensive person-centered care plan. This affected three (Resident #5, #32, and #37) of 18 residents reviewed for care plans. The facility census was 38.Findings include: 1. Review of Resident #5's medical record revealed an admission date of 03/20/26 with diagnoses including hypertensive heart disease with heart failure, and acute kidney failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, and required set-up assistance with eating and required substantial assistance from staff with all other activities of daily living (ADLs). Review of the care plan for Resident #5, dated 03/23/26 revealed there was no care plan for ADLs. Interview on 06/30/26 at 7:32 A.M. with Licensed Practical Nurse (LPN) #252 confirmed Resident #5 did not have an ADL care plan and there should be an ADL care plan for Resident #5. 2. Review of the medical record for Resident #32 revealed an admission date of 09/09/25. Diagnoses included vascular dementia, dysphagia, and cerebral palsy. Review of the admission evaluation, dated 09/09/25, revealed Resident #32 had her own teeth with some broken/carious teeth. Review of the dental consent form, dated 09/09/25, revealed Resident #32 had poor dental hygiene as the reason for the dental consult. Review of the admission Minimum Data Set (MDS) assessment, dated 09/18/25, revealed Resident #32 had severely impaired cognition and no dental issues/concerns were noted. There was no documentation to support the facility developed a comprehensive person-centered dental care plan for Resident #32. Observation on 06/28/26 at 1:00 P.M. revealed Resident #32 was sitting in her wheelchair in her room and Resident #32's had several missing teeth and several decayed teeth. Interview on 06/29/26 at 2:11 P.M. with Director of Nursing (DON) confirmed Resident #32 admitted with several missing teeth and some teeth broken or in poor condition as stated on the admission evaluation dated 09/09/25. Interview on 06/29/26 at 2:24 P.M. with Licensed Practical Nurse (LPN) #252 confirmed the facility had not developed a dental care plan for Resident #32. 3. Review of the medical record for Resident #37 revealed an admission date of 04/26/24. Diagnoses included cerebral palsy, hypertensive heart disease without heart failure, mood disorder, mild intellectual disabilities, and epilepsy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact and had behavioral symptoms not directed towards others. Review of Resident #37's care plan revealed there was no documentation to support Resident #37 refused to allow staff to assist with activities of daily living (ADL). Resident #37 required assistance with personal hygiene. Interviews on 06/20/26 at 8:14 A.M. with Certified Nursing Assistants (CNA) #203 and #221 stated Resident #37 refused to allow staff to assist her with grooming her facial hair. Both CNA #203 and #221 stated Resident #37 was resistant to staff assisting with any ADL care/services. Interview on 06/20/26 at 8:22 A.M. with Licensed Practical Nurse (LPN) #252 confirmed Resident #37's care plans did not have documentation to support Resident #32 refused staff assistance with personal care needs including grooming of facial hair. LPN #252 stated Resident #37's medical record did not have any documentation to support she refused staff assistance with ADLs so she wouldn't have known to care plan refusal of care/service. Observation with interview on 06/28/26 at 1:35 P.M. revealed Resident #37 sitting on her bed and was noted to have long facial hair on her chin. Resident #37 stated she doesn't allow staff to help with shower or grooming needs. Review of the facility policy titled Resident Participating- Assessment/Care Plan, revised December 2016 stated the resident and his/her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The policy stated the care planning process would include an assessment of the resident's strengths and his/her needs and incorporate the resident's personal and cultural preferences in establishing goals of care.

Based on record review, observations, staff and physician interviews, and policy review. the facility failed to assess, treat, and monitoring of resident's wounds. The affected two (Residents #3 and #8) of two resident reviewed for skin issues. The facility census was 38.Findings include: 1. Review of Resident #3's medical record revealed an admission date of 07/01/24. Diagnoses included spastic diplegic cerebral palsy and morbid (severe) obesity due to excess calories. Review of the care plan dated 07/02/24 revealed Resident #3 was at risk for skin breakdown. Interventions included to provide treatments as ordered, apply lotion/moisture barrier cream as needed, apply barrier cream with each episode of incontinence, observe skin for redness or open areas, and notify the nurse, and skin assessment as needed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. Resident #3 was independent with motorized wheelchair mobility and resident was dependent with staff assistance with toileting and personal hygiene. Review of the physician orders for Resident #3 revealed an order dated 04/28/25 for weekly skin assessments every Monday. There was an order dated 09/01/25 for Caldesene medicated powder to buttocks each shift and an order dated 03/30/26 to apply antifungal ointment to left and right buttock and to leave open to air every evening shift for wound healing. Review of the shower sheets for Resident #3 beginning on 03/30/26 revealed on 04/06/26, it was documented an open area on left buttocks with bleeding. On 04/09/26, there was an open area on bilateral buttocks, and marked as not new. On 04/23/26, an open area on bilateral buttocks and right gluteal fold area with bleeding. On 05/11/26, an open area to bilateral buttocks and red area under bilateral abdominal folds. On 05/28/26, a blister to left abdominal fold, and an open/red area to bilateral gluteal folds. On 06/01/26, open areas to left buttocks and right posterior thigh. On 06/15/26, it was documented no new open areas. In 06/29/26, open areas to the right buttocks. Review of the weekly skin assessments for Resident #3 revealed no documentation of any skin concerns or measurements of any wounds, including open areas to his bilateral buttocks or right gluteal fold from 04/06/26 to 06/29/26. Observation and interview on 06/29/26 at 2:09 P.M. revealed Resident #3's buttocks and gluteal area was observed with Licensed Practical Nurse (LPN) #241, Certified Nursing Assistants (CNA) #203 and #213. Resident #3's bilateral buttocks were red and moist with macerated area surrounding approximately 3.5 centimeters (cm) in length by 1.5 cm in width with an open shallow area approximately 2.5 cm round. There were two open areas noted to Resident #3's right gluteal fold. One area measured approximately 1.3 cm round and the second area measured approximately 4.2 cm in length by 0.6 cm in width with no depth. CNA #213 confirmed the area to Resident #3's right gluteal fold was not new and that it had been there and stated it was from the Hoyer pad. LPN #241 confirmed the area to the right gluteal fold did not have a treatment in place and stated staff had been applying had antifungal cream on bilateral buttocks. LPN #241 stated the areas were not open before. Interview on 06/29/26 at 3:23 P.M. with CNA #213 stated staff utilizes two different Hoyer pads. The smaller Hoyer pad was causing the open wound to his right gluteal fold. Interview on 06/30/26 at 8:24 A.M. with the Director of Nursing (DON) confirmed it was documented multiple times on the shower sheets that Resident #3 had open areas to his buttocks and right gluteal crease since 04/06/26. The DON confirmed the weekly skin assessments did not have any measurements on the areas since the areas were found. At 8:45 A.M., the DON confirmed she did look at Resident #3's wounds last evening (06/29/26) and they did measure the wound but did not document the measurements or initiate a treatment. The DON explained she notified the wound physician and he will assess it on 06/30/26 and document the measurements and order the needed treatment. Observation and interview on 06/30/26 at 6:30 A.M. with Wound Physician #269 confirmed Resident #3 had an area measuring 3.0 cm in length by 1.5 cm in width by 0.1 cm in depth to his left buttocks caused by moisture associated skin damage (MASD) and had an area measuring 6.0 cm in length by 1.2 cm in width by 0.1 cm in depth and it was caused by a skin tear. Wound Physician #269 confirmed he had not treated Resident #3's wounds prior to this date (06/30/26). 2. Review of the medical record for Resident #8 revealed an admission date of 02/26/25. Diagnoses included diabetes mellitus type two and hemiplegia following cerebral infarction affecting the left non- dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had impaired cognition and was dependent upon staff with toileting hygiene, bed mobility and transfers. There was no documentation in Resident #8's medical record that Resident #8 sustained a skin tear on his upper arm and there was no treatment ordered to treat the skin tear. Observation on 06/28/26 at 10:54 A.M. with Resident #8 revealed his left upper lateral arm which revealed four, distinct scabbed areas. A thin layer of betadine was observed covering the area. Interview on 06/28/26 at 2:02 P.M. with the Assistant Director of Nursing (ADON) #201 revealed there was a skin tear present on Resident #8's left arm since 06/18/26. ADON #201 confirmed there was no skin assessment completed on Resident #8's skin tear from 06/18/26 to 06/28/26. ADON #201 confirmed there was no progress note indicating the description, size, appearance or appearance of the skin tears. Interview on 06/28/26 at 2:12 P.M. with the Administrator revealed a skin assessment was completed on paper dated 06/18/26 which revealed skin tear to his arm left upper arm. The Administrator confirmed there was no description or measurements of the skin tear on the paper skin assessment. Interview on 06/28/26 at 2:49 P.M. with Licensed Practical Nurse (LPN) #243 revealed she had cared for Resident #8 on 06/18/26 when she observed him scratching his left upper lateral arm. LPN #243 stated she covered the area with a band-aid and verified she had not documented the skin tears or the treatment in Resident #8's medical record. Interview on 06/29/26 at 12:15 P.M. with the Director of Nursing (DON) stated she completed skin assessment for Resident #8 on 06/18/26 and had observed one small skin tear, which she was unable to provide documentation for. The DON verified no skin assessments had been completed in the medical record or progress notes for the skin tears obtained on 06/18/26. The DON confirmed the presence of four distinct skin tears on Resident #8's left upper arm. Review of the facility's policy titled Skin Tear – Abrasions and Minor Breaks dated 09/2013 revealed when a skin tear is discovered, an incident/accident report will be completed. The wound will be assessed for edema, drainage, and stage. Notify the physician and a treatment will be implemented immediately.

Based on medical record review, staff interview, and policy review, the facility failed to obtain laboratory values as physician ordered. This affected one (#1) of five residents reviewed for unnecessary medications. The facility census was 38.Findings include:Review of the medical record for Resident #1 revealed an admission date of 12/06/23. Diagnoses included anxiety, lymphedema, congestive heart failure, morbid obesity, hypertension, and anemia. The quarterly Minimum Data Set (MDS) assessment, dated 04/07/26, revealed Resident #1 was cognitively intact.Review of Resident #1's physician orders revealed an order dated 08/30/24 for complete blood count (CBC), basic metabolic panel (BMP), hepatic function, thyroid function, and Vitamin D levels every six months and an order dated 10/07/25 for Vitamin D3 1.25 milligram (mg) one time daily as supplement.Review of Resident #1's laboratory results revealed no documentation to support the facility obtained Vitamin D levels since 06/18/25.Interview on 06/20/26 at 10:21 A.M. with Director of Nursing (DON) confirmed the facility had not obtained Vitamin D levels for Resident #1 as physician ordered. The DON confirmed the last Vitamin D level obtained for Resident #1 was on 06/18/25.Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised September 2012, revealed the physician would identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff would process test requisitions and arrange for tests.

Based on staff interviews, record review, and policy review the facility failed to residents were provided timely dental services. This affected two (#8 and #32) of two residents reviewed for dental services. The facility census was 38. Findings include: 1. Review of medical record for Resident #8 revealed an admission date of 2/26/25 . The resident had diagnosis which included Chronic Obstructive Pulmonary Disease, Diabetes Mellitus type two, hemiplegia following cerebral infarction affecting the left non- dominant side, and Congestive Heart Failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 11indicating impaired cognition. Review of the dental visit note dated 05/24/26 revealed Resident #8 had a physician order for a surgical referral. From 05/24/26 to 06/28/26, there was documentation the facility attempted to obtain a surgical referral for Resident #8. Interview on 06/29/26 at 11:02 A.M. with Social Services Designee (SSD) #257 stated he sent a referral four days after the dental visit. SSD #257 verified he had not followed up on the referral he sent. A request for documentation of the referral was made at the time of the interview. Review of the progress notes dated 06/29/26 at 11:11 A.M. by SSD #257 documented he called to check on the dental referral and confirmed an appointment. A second interview on 06/29/26 at approximately 3:20 P.M. with SSD #257 verified there was no documentation of the referral. SSD #257 stated another staff person had followed up with the dental appointment and he confirmed with the dental surgeon's office Resident #8 had an appointment on 07/10/26. Interview on 06/30/26 at 9:55 with Dental Staff #267 revealed Resident #8 had an appointment scheduled and the appointment had been made on 06/29/26. 2. Review of the medical record for Resident #32 revealed an admission date of 09/09/25. Diagnoses included vascular dementia, dysphagia, and cerebral palsy. The quarterly Minimum Data Set (MDS) assessment, dated 03/21/26, revealed Resident #32 had severe cognitive impairment and was dependent upon staff with oral hygiene. Review of the admission evaluation, dated 09/09/25, revealed Resident #32 had her own teeth with some broken/carious teeth. Review of the dental consent form, dated 09/09/25, revealed Resident #32 had poor dental hygiene as the reason for the dental consult. Review of Resident #32's dental screen, dated 06/09/26 stated Resident #32 had own teeth with broken/carious teeth. No swallowing or chewing problems noted. Review of Resident #32's care plans revealed no documentation to support the facility developed a comprehensive person-centered care plan for dental concerns. From 09/09/25 to 06/28/26, there was no documentation to support Resident #32 was seen by a dentist. Review of the facility's list for residents seen by dentist on 05/14/26 revealed no documentation to support Resident #32 had been seen by the dentist. Observation on 06/28/26 at 1:00 P.M. revealed Resident #32 sitting in her wheelchair in her room. Resident #32 had several missing teeth and several decayed teeth. Interview on 06/29/26 at 2:24 P.M. with the Director of Nursing (DON) confirmed Resident #32 had a dental referral on 09/09/25 and Resident #32 had not been seen by a dentist since admission to the facility. The DON confirmed Resident #32 admitted with missing teeth and several teeth in poor condition. The DON stated she did not know why Resident #32 was not added to the dentist list to be seen. Review of the facility policy titled Dental Services, revised December 2016 stated routine and emergency services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Review of the facility policy titled Dental Examination/Assessment, revised December 2013 revealed each resident shall undergo a dental assessment prior to or within ninety days of admission. Residents should be offered dental services as needed and dental examinations would be done by the resident's personal dentist or by the facility's consultant dentist. Lastly, the policy stated upon conducting a dental examination, a resident needing dental services would be promptly referred to a dentist.

Based on record review, staff interviews, and policy review, the facility failed to follow their Antibiotic Stewardship program and policy to ensure antibiotic use was appropriate. This affected three (Resident #1, #34, and #36) of three residents reviewed for antibiotic use. The facility census was 38.Findings include:1. Review of Resident #1's medical record revealed an admission date of 12/06/23. with diagnoses of anxiety disorder, essential hypertension, anemia, and metabolic encephalopathy.Review of Resident #1's physician order dated 06/16/26 revealed an order for Bactrim DS (antibiotic) 800-160 milligrams (mg) tablet was ordered twice daily for wound infection.Review of the facilities June 2026 Infection Log revealed on 06/16/26, Resident #1 had an order for Bactrim for coccyx wound. There was no documentation of a wound culture being completed.Review of the McGeer's form completed on 06/16/26 revealed Resident #1 was noted with a red, warm wound.Interview on 06/30/26 at 3:13 P.M. with the Director of Nursing (DON) confirmed the facility did not complete a wound culture on Resident #1's wound and initiated the Bactrim DS 800-160 mg twice daily. The DON stated she does not question the physicians on antibiotic use.2. Review of Resident #34's medical record revealed an admission date of 06/01/23 with diagnosis of chronic kidney disease stage 3, major depressive disorder, essential hypertension, and metabolic encephalopathy.Review of Resident #34's physician order dated 06/24/26 revealed an order for Cefdinir (antibiotic) 300 milligrams (mg) tablet twice daily for pharyngitis.Review of the facilities June 2026 Infection Log revealed on 06/24/26, Resident #34 was on the list with no antibiotic listed for pharyngitis. There was no documentation of a culture being completed.There was not a McGreer's assessment completed for antibiotic use.Interview on 06/30/26 at 3:11 P.M. with the Director of Nursing (DON) confirmed the facility did not complete a culture on Resident #34 related to pharyngitis. The DON confirmed Resident #34's only complaint was a sore throat and there were no other signs or symptoms noted. The DON stated she does not question the physicians on antibiotic use.3. Review of Resident #36's medical record revealed an admission date of 04/16/25. Diagnoses included chronic diastolic heart failure and osteoarthritis.Review of Resident #36's physician's order dated 05/04/26 revealed an order for Azithromycin (antibiotics) 500 milligrams (mg) tablet for one day and 250 mg tablet for four days for respiratory symptoms.Review of the facilities May 2026 Infection Log revealed on 05/04/26, Resident #36 was on the list with no antibiotic listed for upper respiratory infection. There was no documentation of a culture being completed.Review of McGreer's assessment completed for antibiotic use on 05/04/26 revealed respiratory infection criteria not met with runny nose and sore throat.Interview on 06/30/26 at 3:04 P.M. with the DON confirmed the facility did not complete a chest x-ray on Resident #36 related to upper respiratory infection. The DON confirmed Resident #36's only complaint was a sore throat and there were no other signs or symptoms noted. The DON stated she does not question the physicians on antibiotic use.Review of the Antibiotic Stewardship Orders for Antibiotics policy, dated 12/2016 revealed it is the policy of the facility to meet criteria for clinical definition of active infection or sepsis prior to administering an antibiotic.

Based on medical record review, observation, staff interviews, and review of the resource from the National Pressure Injury Advisory Panel titled Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, the facility failed to monitor a resident's leg where a brace was applied. This resulted in actual harm when the resident developed a Deep Tissue Injury (DTI) later resulting in a stage four pressure ulcer (deep wound that may impact muscle, tendons, ligaments, and bone) that ultimately required two surgical debridements in an attempt to promote wound healing. This affected one (#9) of three residents reviewed for pressure wounds. The facility census was 39. Findings include: Review of medical record for Resident #9 revealed an admission date of of 11/29/24 with diagnoses including but not limited to occlusion and stenosis of right carotid artery, muscle weakness, periodic breathing, fracture of lower end of right femur, cervical disc disorder with myelopathy, peripheral vascular disease, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of current physician orders revealed wound treatment to right upper lateral calf was to cleanse with soap and water, pat dry and apply calcium alginate to the wound bed, cover with abdominal (ABD) pad and wrap with kerlix, weight bearing as tolerated (WBAT) to right lower extremity while in knee brace with walker (03/19/25-04/16/25), liquid protein 30 milliliters (ml) daily for wound healing. Review of the care plan dated 03/26/25 revealed the resident is at risk for skin breakdown related to increased need for assistance with bed mobility and transfers, neuropathy, peripheral vascular disease, and right lateral calf pressure. Interventions included apply lotion/moisture barrier cream as needed, can transition out of brace, WBAT to right lower extremity with walker, encourage to float heels as tolerated, observe skin for redness or open areas notify the nurse, skin assessment as needed, supplements per order, and turn and reposition every two hours as tolerated. Review of a general progress note dated 02/19/25 at 2:02 P.M. revealed the resident returned from an orthopedic appointment with order indicating okay to put right foot down for balance. Continue physical therapy (PT) and occupational therapy (OT). No Range of Motion (ROM) to right knee. Continue brace. Follow up in one month. Review of a general progress note dated 03/19/25 at 1:42 P.M. revealed the resident returned from an orthopedic appointment with new order to begin Weight Bearing as Tolerated (WBAT) to right lower extremity in the knee brace. Okay for ROM to right knee and continue PT/OT. Review of a general progress note dated 04/16/25 at 3:00 P.M. revealed the resident returned from an orthopedic appointment with new order to transition out of knee brace. WBAT to right lower extremity with walker. Continue with PT/OT. Review of a general progress note dated 04/17/25 at 11:58 A.M. revealed Certified Nursing Assistant (CNA) reported the resident had a skin tear on the outer right calf caused by the brace. Resident is to transition out of the brace and therapy is working with the resident towards that goal. Steristrips applied. Review of a general progress note dated 04/20/25 at 8:41 P.M. revealed this order was updated to cleanse and apply border foam to right outer calf. This nurse went to treat the area and found that the skin flap is slothing off and area had opened. Area measured 4.7 centimeters (cm) by 5.4 cm, area warm, seeping and plus two pitting edema compared to left leg at plus one pitting edema. Daughter present in room and explained they will await treatment plan and the resident could be seen by the in-house wound physician. Review of the wound physician note dated 04/21/25 revealed an unstageable wound to right upper lateral calf full thickness. Wound was a pressure wound. Wound measured 7.0 cm length by 5.9 cm width with a non measurable depth. Surface area 41.30 cm squared. Periwound surrounding deep tissue injury (purple/maroon). Moderate serous exudate. Thick adherent black necrotic tissue 60 percent (%), granulation tissue 40% with no pain or signs of infection. Treatment plan santyl apply once daily and as needed if saturated, soiled, or dislodged for 30 days and cover with gauze island with border dressing once daily and as needed. Reason for no sharp debridement chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor for now. Recommended lower extremity arterial Doppler. Review of wound physician note dated 04/28/25 revealed a stage four pressure wound to the right upper lateral calf full thickness. Per note patient had a fractured femur for which the resident was wearing a brace. The pad of the brace created a pressure wound on the calf. Wound measured 7.0 cm length by 6.0 cm width by depth is unmeasurable due to presence of non-viable tissue and necrosis. Surface area 42.00 cm squared. Periwound induration and maceration. Light serous exudate. 100% thick adherent black necrotic tissue. No pain or signs of infection observed. Debridement procedure completed to remove necrotic tissue and establish the margins of viable tissue, remove thick adherent eschar and devitalized tissue, and remove hematoma. Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a stage 4 pressure injury. This is not a wound deterioration. Lower extremity arterial Doppler left and right performed on 04/28/25 with mild to moderate peripheral vascular disease without occlusion in the right lower leg. Review of the wound physician note dated 05/05/25 revealed a stage four pressure wound to the right upper lateral calf full thickness measuring 6.8 cm length by 5.8 cm width by 0.7 cm in depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased necrotic tissue and decreased surface area. No pain or signs of infection. Review of the wound physician note dated 05/12/25 revealed a stage four pressure wound to the right upper lateral calf full thickness measuring 7.0 cm length by 5.6 cm width by 0.4 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Review of the wound physician note dated 05/19/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 6.9 cm length by 5.0 cm width by 0.3 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Review of the wound physician note dated 05/26/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 6.5 cm length by 4.5 cm width by 0.2 cm depth with light serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Review of the wound physician note dated 06/02/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 5.8 cm length by 3.8 cm width by 0.1 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Surgical excisional debridement completed. The wound was cleansed with normal saline and anesthesia was achieved using topical bensocaine. Curette was used to surgically excise devitalized tissue and necrotic tissue subcutaneous level tissues were removed to a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 3% to 0%. Hemostasis was achieved and a clean dressing was applied. Interview on 06/04/25 at 8:39 A.M. with the Director of Nursing (DON) revealed the resident's brace came off every night at bedtime. The DON stated the nurses would look at the residents skin then. The DON stated that two days prior to the wound being discovered, she treated a skin tear. The DON stated she then treated another skin tear by cleaning the wound and applying Steristrips and kerlix. The DON stated that approximately two days later she was notified that the area was open and bleeding. The DON stated that when she cleaned the skin tear she thought the wound looked weird as the skin appeared to be darker. The DON stated the wound doctor saw the resident the next day and he removed what they thought was a big clot. Further review of the medical record revealed no evidence the facility was removing the brace at night and checking the skin around the brace on a daily basis. Interview on 06/04/25 at 3:18 P.M. with the DON and Assistant Director of Nursing (ADON #403) revealed they both verified the wound was caused by the brace. ADON #403 stated if you lined up the brace the wound was located where the dial of the brace was located. The DON verified they could have padded the area that the dial was on had they realized it would or was causing pressure. The DON verified the wound was staged by the wound physician. The DON verified the weekly wound documentation prior to the discovery of the deep tissue injury did not contain any lesions or open areas to the right lower extremity and on 04/20/25 there was documentation of a skin tear to the area. The DON verified there was no supporting documentation regarding the removal of the brace for care or skin assessments under the brace. Review of the resource from the National Pressure Injury Advisory Panel titled Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, dated February 2020, indicates, in part, the following: Inspect the skin under and around the device at least daily (if not medically contraindicated); Cushion and protect the skin with dressings in high risk areas; Be aware of edema under the device(s) and potential for skin breakdown; and Educate staff on correct use of devices and prevention of skin breakdown.

Based on employee file review and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of inservices annually. This affected two (CNA #510 and CNA #519) of three CNA employee files reviewed. This had the potential to affect all residents who reside in the facility. The facility census was 39. Findings include: Review of employee file for CNA #510 revealed a hire date of 01.09/23. Review of education file revealed the CNA #510 did not complete 12 hours of inservices annually. Review of employee file for CNA #519 revealed a hire date of 10/10/23. Review of education file revealed the CNA #519 did not complete 12 hours of inservices annually. Interview on 06/09/25 at 11:05 A.M. with Medical Records #655 verified the facility could not locate any documentation regarding the 12-hour inservices for CNA #510 and CNA #519 for 2024 and 2025.

Based on record review, interview, and policy review, the facility failed to ensure quarterly care conferences were held including the families, residents, and interdisciplinary team and failed to ensure care conferences were held timely. This affected five (#10, #16, #33, #5, and #6) of 21 residents reviewed for care conferences. The facility census was 39. Findings include: 1. Review of medical record for Resident #10 revealed an admission date of 11/11/20 with diagnoses including but not limited to bipolar disorder current episode depressed, mild or moderate severity, schizoaffective disorder bipolar type, type two diabetes, visual hallucinations, altered mental status, auditory hallucinations, cognitive communication deficit, inadequate social skills, adult antisocial behavior, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of care conference documentation revealed a care conference was held on 01/31/24, 05/29/24, 09/12/24, 12/05/24, 02/05/25, and 05/21/25. Care conferences were held with dietary, social worker, and activities. Interview on 06/02/25 at 04:24 P.M. with Resident #10 revealed they do not have care conference meetings with her or her family that she can remember. 2. Review of medical record for Resident #16 revealed an admission date of 02/05/19 with diagnoses including but not limited to chronic obstructive pulmonary disease, type two diabetes, asthma, cervicalgia, congestive heart failure, unspecified mood affective disorder, and hypertension. Review of MDS dated [DATE] revealed the resident was cognitively intact. Review of care conferences revealed conferences were held on 02/14/24, 06/26/24, 09/26/24, and 02/26/25 with only dietary, social services, and activities attending. Interview on 06/02/25 at 10:17 A.M. with Resident #16 revealed they do not hold care conferences any more. Resident #16 stated she has not had one in about a year. 3. Review of medical record for Resident #33 revealed an admission date of 02/26/25 with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting non-dominant left side, chronic obstructive pulmonary disease, type two diabetes, atrial fibrillation, hypertension, bipolar disorder, and congestive heart failure. Review of MDS dated [DATE] revealed a BIMS score of 13 which indicated the resident was cognitively intact. Review of medical record revealed no care conferences have been held. Interview on 06/02/25 at 3:12 P.M. with Resident #33 and spouse revealed they have never had a care conference since admission. Interview on 06/03/25 at 1:25 P.M. with the Administrator revealed Resident #33 has not had any care conferences scheduled. Interview on 06/05/25 at 1:37 P.M. with Managed Care Coordinator (MCC #903) verified the care conferences were not attended by the interdisciplinary team (IDT). MCC #903 verified Resident #10 and Resident #16 care conferences were not held every three months. MCC #903 verified the facility did not send out letters for care conferences with the date and time of the conference. MCC #903 stated they would just tell the resident when the care conferences were going to be held. 4. Record review for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #5 include cerebral palsy, chronic obstructive pulmonary disease, dysphagia, and contractures. Review of Resident #5's Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #5's contact census in the medical record revealed the resident was listed as his own person and can make his own medical decisions. Review of Resident #5's progress notes dated 05/28/25 revealed Social Worker (SS) #651 documented the resident's had a care conference meeting, see specifics in care conference assessment. Review of Resident #5's care conference assessment dated [DATE] revealed the meeting was documented in the form as being held on 05/28/25 at 11:00 A.M. Per the assessment, staff who attended included a Registered Nurse, activity staff, dietary staff, and the social worker. No family or resident was documented as having been invited or attending the meeting. No concerns from resident or family were documented in the assessment. Interview on 06/02/25 at 11:17 A.M. with Resident #5 revealed the resident stated he did not know if he had every attended a care conference meeting with the staff at the facility. Resident #5 denied being invited to a care conference per his knowledge. Interview on 06/03/25 at 3:30 P.M. with Social Services (SS) #651 verified Resident #5 had not been in attendance for his 05/28/25. SS #651 verified there was no documentation his family or the resident had been invited and there was no documented input or concerns in the assessments from Resident #5. 5. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #6 include cerebral infarction, hypertension, dysphagia, pain, and falls. Review of the progress notes dated 05/07/25 at 1:30 A.M. the social worker wrote Resident #6 had a care conference on 05/07/25. Review of the history of the note revealed the progress note was created and signed on 05/22/25 at 1:08 P.M. Review of the progress note dated 05/07/25 at 8:48 A.M. revealed the social worker contacted Resident #6's son, family representative, to invite him to attend the care conference and the son stated he will not be able to attend. Per the note the son voiced concerns and the concerns will be followed up. Interview on 05/02/25 at 3:14 P.M. with Resident #6's son stated he could not recall when the last time he attended a care conference with the staff at the facility. Per the son, he could not recall any invitations to any care conferences in the year 2025. Interview on 06/03/25 at 3:30 P.M. with SS #651 verified there was missing documentation in Resident #6's most recent 05/07/25 care conference assessment. Per SS #651, the social worker held the care conference with dietary staff, the social worker, and activities. SS #651 verified there was no nurses or aides in the care conference. SS #651 verified Resident #6 did not attend the care conference. SS #651 stated she had contacted the resident's family representative the day prior to the care conference and the son reported he could not attend due to not having enough notice of time for the care conference. SS #651 verified when the care conferences are scheduled they are held with available staff and residents and their family representative sometimes are not able to attend and the social worker does not reschedule the meetings. SS #651 verified some care conferences do not include nurses and no aides come to the conferences. Review of policy titled, Resident Participation - Assessment/Care Plans, revised December 2016 revealed the resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to participate in the planning process, identify individuals to be included in the planning process, request meetings, request revisions, participate in establishing his or her goals and expected outcomes of care, participate in the type, amount, frequency, and duration of care, receive the services and/or items included in the care plan, have access to and review the care plan, and be informed of, review and sign the care plan after any significant changes are made. The care planning process will facilitate the inclusion of the resident and/or representative, include an assessment of the resident's strengths and his or her needs, and incorporate the resident's personal and cultural preferences in establishing goals of care. A seven day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. The social services director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include: the date, time, and location of the conference, the name of each person contacted and the date he or she was contacted, the method of contact (mail, telephone, email), input from the resident or representative if they are not able to attend, refusal of participation, if applicable, and the date and signature of the individual making the contact.

Based on observation, record review, and staff interview the facility failed to ensure proper handwashing, cleansing of re-usable equipment, and proper glove use was followed during resident care. This affected two residents (#23 and #9) out of five residents reviewed for infection control protocols. The facility census was 39. Findings include: 1. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 include neoplasm of nervous system, anxiety, urinary tract infection, dysphagia, and weakness. Review of Resident #23's Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition and was receiving enteral nutrition via a feeding tube. Review of Resident #23's care plans dated 12/11/24 revealed a focus for Enhanced Barrier Precautions (EBP) protocols due to indwelling medical device. Intervention include signage placed on doorway and gloves and gown to be worn during direct care with resident. Observation on 06/05/24 at 9:00 A.M. with Licensed Practical Nurse (LPN) #511 revealed the nurse prepared the supplies for the feeding tube care. LPN #511 was observed placing on a gown and gloves prior to entering Resident #23's room. LPN #511 was not observed sanitizing her hands prior to applying the gloves. LPN #511 was observed discontinuing the feeding solution on the pump, removing the old tubing from the resident's feeding tube catheter. LPN #511 did not change her gloves during the care. LPN #511 was observed retrieving a syringe from the resident's bathroom, and filling a plastic cup with water to 150 milliliters. LPN #511 was observed checking the placement of the feeding tube with a stethoscope, checking the residual amount of tube feeding, and flushing the tube with 150 milliliters of water. LPN #511 was not observed washing her hands or changing her gloves during the care observed. LPN #511 was observed taking all supplies back into the bathroom and retrieving a new gauze pad. LPN #511 was observed opening the gauze pad and then stated she should change her gloves before applying the new bandage. LPN #511 was observed removing the current set of gloves and then put on a new set of gloves. LPN #511 did not use hand sanitizer or wash her hands in between the application of gloves. Interview on 06/05/25 at 9:25 A.M. with LPN #511 verified she only used one pair of gloves during most of the care provided until she applied the new bandage to the tube feeding site. LPN #511 stated it was protocol to wash her hands and apply new gloves frequently during the care she provided. LPN #511 verified she did not sanitize or wash her hands during the care of Resident #23's feeding tube. 2. Review of medical record for Resident #9 revealed an admission date of of 11/29/24 with diagnoses including but not limited to occlusion and stenosis of right carotid artery, muscle weakness, periodic breathing, fracture of lower end of right femur, cervical disc disorder with myelopathy, peripheral vascular disease, and major depressive disorder. Review of MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of current physician orders revealed wound treatment to right upper lateral calf was to cleanse with soap and water, pat dry and apply calcium alginate to the wound bed, cover with ABD pad and wrap with kerlix. Observation on 06/04/25 at 11:39 A.M. of Registered Nurse (RN #506) completing wound care for Resident #9 revealed the nurse placed a clean barrier on the over the bed table and placed one new wash basin with soap and water onto the barrier. RN #506 placed a second new wash basin with rinse water beside the other one on the clean barrier. RN #506 placed the dressing supplies (package of kerlix, box of silver alginate, and ACE bandage) on the clean barrier. Nursing student precepting with the nurse was also in the room. RN #506 washed hands, donned gown and gloves and cleansed the wound to right calf with soap and water and rinsed the wound. Wound appeared to be beefy red in the bed of the wound. Wound edges were slightly macerated but intact. RN #506 removed her gloves, washed hands, and donned new gloves. RN #506 then patted the wound dry. RN #506 removed gloves, washed hands, and donned new gloves. RN #506 then touched the box of silver alginate dressings and pulled out one package of the silver alginate. RN #506 opened the package of silver alginate and placed the silver alginate into the wound bed. RN #506 then removed the dressing to cut the dressing to size with scissors that were removed from the student nurse preceptors pocket. The nurse was not observed cleansing the scissors prior to cutting the dressing. RN #506 then placed the dressing back in the wound bed and removed it for a second time to cut more off to fit it to the wound size. RN #506 then placed the dressing into the wound bed and placed an ABD pad over the silver alginate and wrapped the wound with kerlix. RN #506 then wrapped the leg with ACE bandage. RN #506 then cleaned up the area and removed gloves, washed hands and removed the trash from the room. Interview on 06/04/25 at 11:52 A.M. with RN #506 revealed the nurse verified she placed the dressing in the wound bed and removed it to cut it to size so the dressing would not touch good skin twice. RN #506 verified the student pulled her scissors out of her pocket and did not sanitize them prior to cutting the dressing. RN #506 verified she touched the box of silver alginate and pulled out one package without changing gloves or washing hands prior to placing the dressing into the wound bed.

Based on record review, observation, interview, and policy review, the facility failed to ensure call lights were in reach of residents. This affected two (#17 and #27) of 21 residents reviewed for call lights. The facility census was 39. Findings include: 1. Review of medical record for Resident #17 revealed an admission date of 03/20/23 with diagnoses including but not limited to urinary tract infection, anxiety, metabolic encephalopathy, dementia with agitation, major depressive disorder, and paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of five which indicates severe cognitive impairment. Review of the care plan dated 04/21/25 revealed the resident was at risk for falls. Interventions included be sure the call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation and interview on 06/05/25 at 8:41 A.M. revealed the resident lying in bed with the call light hooked to the privacy curtain out of reach. Interview at the time with Activity Director (AD #668) verified the resident uses the call light. AD #668 verified the call light was hooked to the privacy curtain and out of reach for the resident. 2. Review of medical record for Resident #27 revealed an admission date of 03/31/25 with diagnoses including but not limited to Parkinson's disease, muscle weakness, hypertension, difficulty walking, and thrombocytopenia. Review of the MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of care plan dated 04/18/25 revealed the resident was at risk for falls. Interventions included be sure the call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation and interview on 06/05/25 at 8:28 A.M. revealed the resident sitting in his chair in his room stating he needed to use the bathroom. Call light was observed to be lying on the bed out of reach of the resident. Interview at the time of the observation with AD #668 verified the call light was lying on the bed out of reach for the resident. Review of policy titled, Answering the Call Light, revised October 2010 revealed be sure the call light is plugged in at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on record review and interview the facility failed to ensure the hard chart and the electronic medical record contained the correct advance directive information. This affected one (#27) of 21 residents reviewed for advanced directives. The facility census was 39. Findings include: Review of medical record for Resident #27 revealed an admission date of 03/31/25 with diagnoses including but not limited to Parkinson's disease, muscle weakness, hypertension, other specified forms of tremor, and thrombocytopenia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of current physician orders revealed the resident was a full code. Review of hard chart for Resident #27 revealed the resident was a Do Not Resuscitate Comfort Care Arrest (DNR CCA). Review of care plan dated 04/18/25 revealed the residents advanced directive: DNR CCA with interventions including but not limited to acknowledge and maintain resident wishes regarding advanced directives and assess advanced directive upon admission, quarterly, annually, and with significant change to ensure resident wishes are maintained regarding advanced directive. Interview on 06/03/25 at 11:27 A.M. with the Director of Nursing (DON) verified the physician order was for a full code and the hard chart had a DNRCCA form signed by the physician. Review of policy titled Advance Directives updated 03/17/25 revealed upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on record review and staff interview the facility failed to provide a discharge notice and notice of transfer to residents, residents' representatives, and the Ombudsman. This affected two residents (#28 and #42) out of four residents reviewed for notices. The facility census was 39. Findings include: 1. Record review for Resident #28 revealed the resident was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Diagnoses for Resident #28 include diabetes type two, paraplegia, chronic obstructive pulmonary disease, pain, and schizoid personality disorder. Review of Resident #28's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Review of Resident #28's progress note dated 06/01/25 at 2:10 A.M. the nurse documented Resident #28 had a change in condition with declining vital signs and was transferred to the hospital via emergency squad at 2:30 P.M. Per the note dated 06/01/25 at 3:11 P.M. the nurse documented Resident #28 had been admitted to the hospital post fall. Further review of Resident #28's medical records revealed there was no evidence of any transfer summary dated from 06/01/25 to 06/05/25 sent to the hospital, resident, resident's representative, or the Ombudsman. Interview on 06/05/25 at 3:30 P.M. with Managed Care Provider (MCP) #903 verified there was no transfer notification to Resident #28, the resident's family representative, or the Ombudsman. 2. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses for Resident #42 include complications post surgery to repair a femur fracture, depression, and myeloma. Review of Resident #42's MDS dated [DATE] revealed the resident had mildly impaired cognition. Review of Resident #42's progress notes dated 03/14/25 revealed Resident #42's sister notified the facility Resident #42 was transferred and admitted to the hospital from her outside physician appointment due to syncopal episode and possible urinary tract infection. Further review of Resident #42's medical records revealed no evidence of any notification of discharge or transfer to the resident, resident's representative or the Ombudsman. Interview on 06/04/25 at 11:22 A.M. with Administrator verified there was no discharge or transfer summary documented for Resident #42. The Administrator verified Resident #42 was discharged from the facility as of 03/14/25.

Based on record review and interview the facility failed to implement a baseline care plan that included all care concerns from admission. This affected one (#96) of three residents reviewed for baseline care plan. The facility census was 39. Findings include: Review of medical record for Resident #96 revealed an admission date of 06/01/25 with diagnoses including but not limited to chronic obstructive pulmonary disease with exacerbation, chronic ischemic heart disease, bacteremia, heart failure, chronic kidney disease stage four, atrial fibrillation, and obstructive sleep apnea. Review of current physician orders revealed ampicillin sodium injection solution 2 grams (gm) intravenous (IV) every eight hours for implantable cardioverter-defibrillator (ICD) infection until 06/30/25, ceftriaxone 2000 milligrams (mg) IV twice daily for ICD infection, change life vest (wearable cardioverter defibrillator) battery every 24 hours during evening shift, check life vest back-up battery pack is getting charged every shift, check life vest placement every shift, and change peripherally inserted central catheter (PICC) dressing and caps weekly. Review of baseline care plan dated 06/01/25 revealed no care plan for the PICC line, life vest, infection, or receiving any antibiotics which were all present on admission. Interview on 06/04/25 at 01:25 P.M. with Director of Nursing (DON) verified the resident was on IV antibiotics, had an actual infection, and was wearing a life vest on admission and should be reflected in the baseline care plan. DON verified the above was not included on the baseline care plan.

Based on record review and interview the facility failed to ensure a resident had the mental capacity to sign into an arbitration agreement and further failed to explain arbitration agreements in a language that the residents would understand. This affected three (#9, #25, and #31) of five residents reviewed for arbitration agreements. The facility census was 39. Findings include: 1. Review of medical record for Resident #9 revealed an admission date of 11/29/24 with diagnoses including but not limited to occlusion and stenosis of right carotid artery, muscle weakness, periodic breathing, fracture of lower end of right femur, cervical disc disorder with myelopathy, peripheral vascular disease, and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of arbitration agreement revealed the agreement was signed on 02/03/25 by the resident. Interview on 06/05/25 at 10:09 A.M. with Resident #9 revealed the resident did not know what an arbitration agreement was. Resident #9 stated he could not remember if the facility explained it to him. Resident #9 stated he did not know if he would sign one or not. 2. Review of medical record for Resident #25 revealed an admission date of 02/06/24 with diagnoses including but not limited to pneumonia, type two diabetes, unspecified asthma, paraplegia, heart failure, and atrial fibrillation. Review of MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of arbitration agreement revealed the resident signed the agreement on 02/19/25. Interview on 06/04/25 at 02:08 P.M. with Resident #25 revealed an arbitration agreement is that if they have a disagreement with the facility it goes to the judge and they argue the points and the decision of the judge is final. Resident #25 stated it takes place in a court. Resident #25 stated he is unsure if he signed one when he came to the facility. 3. Review of medical record for Resident #31 revealed an admission date of 09/20/23 with diagnoses including but not limited to ischemic heart disease and dementia without behavioral disturbances. Review of MDS dated [DATE] revealed a BIMS score of 03 which indicated the resident had severe cognitive impairment. Review of arbitration agreement dated 02/19/25 revealed the agreement was signed by the resident. Interview on 06/04/25 at 01:43 P.M. with the Administrator revealed they are currently the one responsible for doing the arbitration agreements. Administrator stated she would explain to the resident that if they do not understand the arbitration agreement they do not have to sign it. Administrator stated she does not usually explain the agreement to them she would have them read it. Follow-up interview on 06/04/25 at 01:52 P.M. with the Administrator revealed that she would have the resident read the arbitration agreement and explain to the resident that it is their legal right to voluntarily obtain legal council prior to signing and they do not have to sign the agreement. Interview on 06/05/25 at 10:20 A.M. with Resident #31 revealed the resident did not know exactly what an arbitration agreement was. Resident #31 stated he did not remember signing one. Interview on 06/05/25 at 11:04 A.M. with the previous admission Director (AD #905) revealed that she would explain the arbitration agreement to the resident. AD #905 stated she would let the residents know it was voluntary and if they wanted to obtain legal council prior to signing it would be okay. AD #905 stated she would explain to the resident if they had an issue with the facility or their care they would go to an arbitrator instead of going to court. AD #905 stated she would let them know it would be faster and cheaper for both parties. AD #905 stated if the resident did not understand the agreement she would go to the next of kin or responsible party. Interview on 06/05/25 at 11:27 A.M. with Regional Director of Operations (RDO #902) verified that Resident #31 had a BIMS score of three and the power of attorney should have signed the second agreement as well.

Based on record review, interview, and policy review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed accurately. This affected one (#10) of one resident reviewed for PASARR. The facility census was 39. Findings include: Review of medical record for Resident #10 revealed an admission date of 11/11/20 with diagnoses including but not limited to bipolar disorder current episode depressed mild or moderate severity, schizoaffective disorder bipolar type, visual hallucinations, altered mental status, auditory hallucinations, cognitive communication deficit, inadequate social skills, anxiety, and adult antisocial behavior. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of current physician orders revealed depakote 500 milligrams (mg) at bedtime (bipolar), depakote 250 mg twice a day (bipolar), duloxetine 40 mg twice a day (depression), risperidal 0.5 mg at bedtime (hallucinations), seroquel 100 mg twice a day in the afternoon and bedtime (bipolar and schizoaffective disorder), and seroquel 300 mg half a tablet in the morning. Review of Preadmission Screening and Resident Review (PASARR) dated 01/07/24 revealed the only diagnoses listed were mood disorders and panic or other severe anxiety disorders. No psychotropic medications were listed on the PASARR. Interview on 06/04/25 at 01:50 P.M. with Managed Care Coordinator (MCC #903) revealed they verified the PASARR did not include any psychotropic medications for Resident #10. MCC #903 verified there were no other diagnoses included besides mood disorder and panic or other severe anxiety disorders. Review of policy titled, Resident Assessment - Coordination with PASARR Program, dated October 2024 revealed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on observation and interview the facility failed to ensure there was a visible posting on where to locate the survey results. This had the potential to affect all residents. The facility census was 39. Findings include: Observation on 06/04/25 at 2:27 P.M. of the front lobby revealed three black letter holders hanging on the wall between the business office and the admissions office with a binder with a small label that stated survey results. Black binder was not easily identified as the survey results unless you were right up on it. No signage observed indicating where the binder is located. Interview on 06/05/25 at 8:09 A.M. with the Administrator verified there was no signage in the lobby or common area to indicate where the survey results were located.

Based on observation, medical record review, resident and staff interviews, review of hospital documentation, revealed of fall investigations, review of manufacturer's guidelines, and review of a facility policy, the facility failed to ensure residents dependent for transfers and activities of daily living were kept free from falls. This resulted in actual harm when Resident #10 sustained a fall during a mechanical lift transfer on 06/12/24 which was being completed by one staff member and Resident #2 sustained a fall on 06/07/24 when the resident was left unattended in bed after it was elevated to perform incontinence care. Consequently, Resident #10 suffered a fractured left femur requiring surgery and Resident #2 suffered fractures to both femurs. This affected two (#2 and #10) of three residents reviewed for falls. The census was 41. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included wedge compression of vertebrae, obesity, chronic obstructive pulmonary disease, and embolisms. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had mildly impaired cognition and was an extensive assist with transfers. Review of Resident #10's care plans revealed a focus for falls. Interventions dated 11/03/23 included to anticipate needs, keep the call light within reach, educate the resident on safety, follow fall protocols, therapy evaluation, review information post fall and attempt to determine cause of falls, record root cause of falls, and alter or remove potential causes if possible. A revised intervention dated 06/06/24 included the use of a walker for ambulation and transfers. Further review of Resident #10's care plans revealed there were no revised interventions added to the care plans regarding lifts used for transfers post fall on 06/12/24. Review of Resident #10's physical therapy notes dated 04/15/24 revealed the therapist documented the resident required a maximum heavy assist with two staff for a stand lift bed-chair with the wheelchair for proper technique and safety. There were no other assessments for lifts or equipment noted in the medical record. Review of Resident #10's physician orders dated June 2024 revealed no physician ordered interventions for prevention of falls were noted in the records. Review of Resident #10's progress notes dated 06/13/24 at 10:58 A.M., late entry, revealed the resident had a fall witnessed by a nurse aide. Per the note, the resident fell to her knees onto the floor while being assisted with a sit-to-stand lift. Resident #10 was lowered to the floor and complained of pain to the left knee and left hip. Resident #10 was assessed by the nurse and emergency medical services (EMS) were called with the resident being sent to the hospital on 06/12/24 at 9:00 P.M. Review of Resident #10's fall investigation revealed on 06/12/24 at 8:30 P.M., the nurse aide was transferring Resident #10 back to bed using a sit-to-stand mechanical lift. Per the investigation, the nurse aide was in the room with the resident and her family member. The nurse aide documented the resident slid out of the stand lift and fell to floor. Per the nurse aide's written interview, the nurse aide had taken the resident to the shower room, bathed her, and was transferring the resident back into bed from a wheelchair using the sit-to-stand lift. The nurse aide attempted to stop Resident #10 from falling, but was unable to, and lowered her to the ground. The nurse aide called for help and two nurses responded. Per the nurse aide's written interview, EMS was called, and the resident was transported to the hospital. Review of Resident #10's hospital paperwork dated 06/12/24 revealed the resident was admitted to the emergency room (ER) on 06/12/24 at 9:04 A.M. when the first set of vital signs were recorded in the documentation. Per the documentation, Resident #10 sustained a left distal femur fracture which required surgery to repair the fracture and the resident was returned to the facility on [DATE]. Interview on 06/25/24 at 2:00 P.M. with Resident #10 revealed there was one nurse aide with her in the bathroom on 06/12/24, the day of her fall. Resident #10 stated she was brought back to her room and the nurse aide was using the sit-to-stand lift to get her back into bed from the wheelchair. Resident #10 stated she was weak, her foot slipped on the floor during the transfer, and the nurse aide could not keep her from falling to her knees on the floor. Resident #10 stated she could not recall who the nurse aide was, but stated there was only one nurse aide assisting her with her bathing and transfer. Resident #10 stated she suffered a broken bone in her leg and had surgery to repair it. Interview on 06/25/24 at 7:55 P.M. with Licensed Practical Nurse (LPN) #200 revealed the nurse was present in the building at the time Resident #10 fell on [DATE]. Per LPN #200, she heard the nurse aide calling for help to Resident #10's room and stated she and another nurse responded quickly to the room. LPN #200 stated the resident was lying on the floor and the nurse aide was holding her to prevent her from falling further and hurting herself more. Per LPN #200, the nurses began to assess Resident #10 for injuries and the resident stated her leg hurt. LPN #200 stated a staff member called EMS and the resident was transferred to the hospital within one hour of the fall. LPN #200 verified there was to be two staff members performing the transfers with lifts and at the time of Resident #10's fall there was only one nurse aide in the room providing care and using the lift. Interview on 06/26/24 at 2:30 P.M. with Assistant Director of Nursing (ADON) #275 and Regional Nurse #595 verified the facility fall policy revealed all lifts are to be used by two staff members. Regional Nurse #595 stated the nurse aide who witnessed Resident #10's fall was following the manufacturer's guidelines and not the facility's policy. During a follow-up interview on 06/27/24 at 9:20 A.M. with Regional Nurse #595 and ADON #275 verified there was no full clinical assessment of Resident #10's condition and suitability to use the sit-to-stand lift per manufacturer's guidelines. Review of the facility policy titled, Lifting Machine Using a Mechanical, dated 07/2017, revealed per the policy at least two nursing assistants are needed for all transfers using a lift. Review of the manufacturer's guideline dated 11/2014, for the mechanical sit-to-stand lift used during Resident #10's fall on 06/12/24, revealed per the guidelines, prior to using the lift each resident must have a full clinical assessment and his/her condition and suitability must be completed by a qualified person. 2. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, dysphagia, impulse disorder, intellectual disabilities, and cognitive communication deficit. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #2 had impaired cognition and was dependent for assistance with activities of daily living (ADLs). Review of Resident #2's care plans dated 10/31/19 revealed Resident #2 was at risk for falls. Interventions include to keep the call light within reach, keep personal items within reach, perimeter mattress to the bed, and maintain the bed in a low position. An intervention was added to the revised care plan on 06/08/24 for staff to take the bedside table out of the room with books and hat and return after care had been provided. Review of Resident #2's fall investigation dated 06/07/24 revealed one nurse aide was providing care for Resident #2 and raised the bed to waist level. Per the investigation, the nurse aide turned to leave the room and was in the doorway to retrieve the lift in the hallway, when the resident reached out of his bed for items on his bedside table and fell out of the bed landing on his face down on the floor. Per the investigation, the resident sustained femur fractures to bilateral legs. Observation on 06/25/24 to 06/27/24 at random times throughout the survey revealed Resident #2 was wearing bilateral leg braces. Interview on 06/25/24 at 5:00 P.M. with Resident #2 revealed the resident did not recall specific details regarding the fall. Resident #2 stated he fell out of bed and hurt his legs but could not give details on the incident. Resident #2 stated his legs were uncomfortable and hurt sometimes. Resident #2 denied pain at the time of the interview. Interview on 06/25/24 at 6:50 P.M. with LPN #200 revealed, per the nursing report, there was one nurse aide in Resident #2's room providing care when the resident rolled out of the bed and sustained the fractures to his legs. Interview on 06/26/24 at 4:00 P.M. with Regional Nurse #595 and ADON #275 verified State tested Nurse Aide (STNA) #350 raised Resident #2's bed to provide incontinence care to the resident and did not lower the bed prior to leaving the room. ADON #275 stated STNA #350 was close to the bed when she turned to go out to the hallway to ask for another staff to help her with the lift. ADON #275 stated, per the fall investigation, the lift was in the hallway at the time of the incident and verified the resident did reach out of the bed to his bedside table, which was out of reach, fell out of the waist high raised bed, and sustained the bilateral femur fractures. ADON #275 verified Resident #2's care plans and the interventions were not followed by STNA #350 at the time of the fall. This deficiency represents non-compliance investigated under Master Complaint Number OH00155120, Complaint Number OH00155118, Complaint Number OH00154905, and Complaint Number OH00154469.

Based on observation, staff interview, record review and policy review, the facility failed to assess newly identified skin breakdown, implement interventions/treatments to aid in the healing of the existing skin breakdown, and conduct ongoing monitoring of the skin breakdown. This resulted in Actual Harm when Resident #32 was found to have a Stage III pressure ulcer to coccyx on 11/14/22 and deep tissue injuries (DTI) to right lateral foot and right lateral fifth toe. This affected one (#32) of one resident reviewed for pressure ulcers. There were a total of two residents identified by the facility with pressure ulcers. The facility census was 38. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #32 revealed a Minimum Data Set (MDS) dated [DATE] which revealed Resident #32 had severe cognitive impairment. The MDS revealed Resident #32 required extensive staff assist with bed mobility, transfers, ambulation, dressing, toileting, and bathing. Review of the medical record for Resident #32 revealed the resident enrolled in Hospice services 09/16/22 and changed Hospice providers on 11/14/22 per family request. Review of the medical record for Resident #32 revealed a shower sheet dated 10/24/22 that had documentation that Resident #32 had a sore that was open and red to the resident's right buttock/coccyx area. Review of the medical record revealed no documentation to support the wound was assessed or a treatment initiated. Review of the medical record for Resident #32 revealed a weekly skin assessment completed 10/26/22 which documented Resident #32 had a pressure ulcer to the coccyx but did not have documentation of the wound measurement. Further review of the medical record for Resident #32 did not have documentation to support the staff assessed the wound or contacted the physician regarding the pressure ulcer for treatment orders. Review of the medical record for Resident #32 revealed a Hospice nursing aide note dated 10/27/22 which indicated Resident #32 had a new skin issue on his bottom and the Hospice aide reported the skin issue. Review of the medical record for Resident #32 revealed a Hospice progress note dated 10/28/22 which documented the Hospice nurse was notified by facility staff that Resident #32 had several open areas on his buttocks and an area above the crease of the buttock was open. Review of the medical record revealed the Hospice nurse ordered a treatment to the wounds and stated Hospice would access the wounds with the next nurse visit. Review of the medical record for Resident #32 revealed a nurse's note dated 10/28/22 at 5:36 P.M. which documented the nurse notified Resident #32's daughter of dressing change orders due to two new areas of skin breakdown on Resident #32's bottom. Review of the medical record for Resident #32 did not contain documentation to support an assessment or measurement of the wounds were completed. Review of the medical record for Resident #32 revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed the treatment order was changed on 11/01/22. Review of the Hospice aide visit note dated 10/31/22 revealed the Hospice aide reported Resident #32's wound to his bottom was worse than last report. Review of the Hospice note dated 11/01/22 revealed Resident #32 had a large open area to left buttock, no drainage noted. Further review of the medical record for Resident #32 revealed a Hospice aide visit note dated 11/03/22 which documented Resident #32 had a dressing over the wound to bottom. Review of the medical record for Resident #32 did not have documentation to support assessment/monitoring of wounds. Continued review of the medical record for Resident #32 revealed a Hospice nurse aide visit note dated 11/10/22 revealed Resident #32 had an area to outer right foot and nurse was notified. Review of the medical record for Resident #32 revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record did not contain documentation to support the assessment or measurement of the wound to the right lateral foot. Review of the medical record for Resident #32 revealed a progress note dated 11/10/22 at 4:00 P.M. which documented the DTI to coccyx area had U-shaped area of granulation tissue and measured 8 x 6. The note did not specify the unit of measurement used to measure the wound. Further review of the medical record for Resident #32 did not contain documentation to support the wound to the coccyx or left buttock was assessed or monitored from 10/28/22 to 11/10/22. Review of the medical record for Resident #32 revealed a Hospice assessment completed 11/14/22 which revealed the resident had a Stage III pressure ulcer to coccyx with measurements of 5 centimeters (cm) width x 4 cm length x 0.1 cm depth. The Hospice assessment did not contain documentation to support any wounds to Resident #32's right foot. An observation on 11/15/22 at 2:15 P.M. with Licensed Practical Nurse (LPN) #305 was made while LPN #305 completed a dressing change to Resident #32's wound to the coccyx. The wound was observed to be a round area on the coccyx with dark purple color on the edges of the wound and pink area inside the wound. Continued observation of Resident #32's dressing change revealed blood was noted to the old dressing. LPN #305 confirmed Resident #32's old dressing contained blood. LPN #305 confirmed the wound measurements were 5 cm x 4 cm x 0.1 cm. Interview on 11/15/22 at 9:29 A.M. with the Director of Nursing (DON) revealed the facility had not been monitoring or assessing Resident #32's coccyx wound due to the resident receiving Hospice services. The DON stated she believed the Hospice provider was assessing, monitoring, and measuring Resident #32's wound. Observation on 11/16/22 at 2:02 P.M. of State tested Nursing Assistant (STNA) #337 examining Resident #32's right foot revealed a dressing to resident's right lateral fifth toe. The observation also revealed a dark purplish-black circle, the size of a nickel, to Resident #32's lateral right foot. Observation on 11/16/22 at 2:39 P.M. of the DON examining Resident #32's right foot revealed a dark purplish-black area, the size of a nickel, to resident's right lateral foot. Further observation included observing the DON remove the dressing to Resident #32's fifth toe on his right foot which revealed a one inch oblong dark purplish-black area to right lateral fifth toe. Review of the medical record did not have documentation to support a treatment order for the area to Resident #32's right lateral fifth toe. Interview on 11/16/22 at 2:41 P.M. with the DON confirmed Resident #32 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also confirmed the facility had not completed assessments or monitored the wounds to Resident #32's lateral right fifth toe or right lateral foot. The DON stated Resident #32's wounds to his right foot looked to be DTIs based on her observation. Review of the Prevention of Pressure Ulcer/Injuries policy revealed the facility was to evaluate, report, and document potential changes in skin and to review the interventions and strategies for effectiveness on an ongoing basis.