Every finding on record at Luxe Rehabilitation and Care Center

Based on observation and staff interview, the facility failed to maintain a safe, functional, and sanitary environment. This affected 21 residents residing on the 100 hallway, 14 residents residing on the 300 hallway and 14 residents residing on the 400 hallway. The facility census was 136. Findings Include:Observation on 08/03/26 at 9:52 A.M. of the 400 hallway carpet contained in the [NAME] building revealed the carpet was heavily soiled with black stains throughout the hallway. Further observations revealed multiple ripped areas with missing carpet posing a tripping hazard. Observation on 08/05/26 at 9:55 A.M. of the 100 hallway carpet contained in the [NAME] building revealed the carpet was heavily soiled with black stains throughout the hallway. Observation on 08/05/26 at 11:36 A.M. of the 300 hallway carpet contained in the [NAME] building revealed the carpet was heavily soiled with ripped areas with missing carpet posing a tripping hazard. The hallway was also noted to have a strong odor of urine. On 08/05/26 at 6:58 A.M., an interview with the Administrator verified the carpeting on the 100, 300 and 400 hallways were heavily soiled with ripped areas posing a tripping hazard. This deficiency represents non-compliance investigated under Master Complaint Number 3105502, Complaint Number 3070098 and Complaint Number 3054258.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents receiving intravenous (IV) antibiotics were adequately monitored for toxic levels of the medication and for adverse drug reactions. This affected two (Residents #29 and #139) of three residents reviewed for IV antibiotic administration. The facility census was 136 residents. Findings include: 1.Review of the closed medical record for Resident #139 revealed an admission date of 04/24/26 with diagnoses including osteomyelitis of the left ankle and foot, sepsis, and diabetes. Review of the hospital discharge summary and instructions revealed the resident was hospitalized from [DATE] to 04/24/26 for bilateral foot wounds and was discharged to the facility with orders for following: IV antibiotic Ceftriaxone 2 grams daily for four weeks, obtaining blood tests every week on Monday while on antibiotics including complete blood count (CBC), basic metabolic panel (BMP), erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP), fax lab results to the infectious disease office. Review of a physician's progress note for Resident #139 dated 04/29/26 revealed the resident was being treated with the IV antibiotic Ceftriaxone, a high-risk medication and should be monitored intensively for toxicity (high drug levels accumulated due to kidney or liver problems which could cause severe reactions and could require stopping the medication). Review of the physician's orders for Resident #139 revealed an order dated 04/30/26 to obtain the weekly blood tests (CBC, BMP, ESR, and CRP) and to fax results to infectious disease office. Review of the lab results for Resident #139 revealed the weekly blood tests were first obtained on 05/01/26. Interview on 08/04/26 at 2:40 P.M with Licensed Practical Nurse (LPN) (Unit Manager) #370 confirmed the recommendations from the hospital 04/24/26 for weekly lab testing. LPN #370 stated the order was missed and an order for weekly lab testing was not obtained until 04/30/26. LPN #370 verified the first blood tests were not obtained until 05/01/26 but should have been obtained on Monday 04/27/26. 2. Review of the medical record for Resident #29 revealed an admission date of 07/22/26 with diagnoses including cellulitis of the right lower leg, right diabetic foot ulcer, diabetes, and chronic kidney disease. Review of the physician's orders for Resident #29 revealed an order dated 07/22/26 for IV antibiotic Meropenem 1 gram three times day for wound infection until 08/17/26. There were no orders for blood testing to monitor the use of the intravenous antibiotic. Review of a physician's progress note for Resident #29 dated 07/29/26 revealed the resident was being treated with Meropenem, a high risk medication, which should be monitored intensively for toxicity. Physician's Review of the physician's orders for Resident #29 revealed an order dated 07/29/26 for CBC, BMP, and liver function tests to be completed every week on Thursday. Review of the lab results for Resident #29 revealed the weekly blood tests were first obtained on Tuesday, 08/04/26. Interview on 08/04/26 at 4:10 P.M. with LPN #370 confirmed Resident #29 was admitted on [DATE] and received IV Meropenem as ordered. Weekly blood testing was not ordered until 07/29/26. The first weekly blood test should have been completed on Thursday, 07/30/26 but the facility did not obtain the first test until 08/04/26. Review of the facility policy titled Lab and Diagnostic Test Results dated 2023 and revised 2025 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. A nurse would identify the urgency of communicating with the attending physician based on physician request, the seriousness of the abnormality, and the individual's current condition. This deficiency represents noncompliance investigated under Complaint Number 3012032.

Based on medical record review and staff interview, the facility failed to ensure resident representatives were involved in the resident care planning process on an ongoing basis. This affected one (Resident #102) of 14 residents sampled. The facility census was 136 residents. Findings include: Review of the medical record for Resident #102 revealed an admission date of 05/08/26 with diagnoses including dementia with agitation and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #102 dated 06/07/26 revealed the resident had severe cognitive impairment. Review of the social service progress note for Resident #102 dated 05/11/26 revealed social services spoke to the resident's representative to arrange an initial care conference meeting. Review of the medical record for Resident #102 revealed the initial care conference was held with the resident's representative on 05/21/26. Review of the social service progress notes for Resident #102 revealed social services gave weekly updates regarding the resident's plan of care to the resident's representative on the following dates: 05/22/26, 06/01/26, 06/09/26, 06/19/26. Interview on 08/04/26 at 2:00 P.M with Social Service Director (SSD) #282 confirmed at Resident #102's initial care conference on 05/21/26, Resident #102's representative expressed concerns about communication with the facility and ensuring the representative would be involved in the resident's care planning on an ongoing basis. SSD #282 stated she and the Director of Nursing (DON) decided a weekly update would be provided to the resident representative to alleviate concerns. SSD #282 verified she provided the weekly updates about Resident #102's care until 06/19/26. SSD #282 stated she then stopped the weekly updates because the resident representative had mostly nursing/medical questions that she felt could be answered better by the nursing department. SSD #282 stated she did not coordinate with nursing for someone to continue to provide the weekly updates to the resident representative after 06/19/26. Interview on 08/04/26 at 2:20 P.M with the Director of Nursing (DON) verified she was not aware the social services department was no longer doing the weekly updates or that they were to be done by nursing. This deficiency represents noncompliance investigated under Complaint Number 3105502.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, self-reported incident (SRI) review, hospital record review, death certificate review, and policy review, the facility failed to ensure residents were transferred safely and appropriately to prevent significant injury. This resulted in Immediate Jeopardy on [DATE] at approximately 6:00 P.M. when Resident #17, who was dependent of two staff members and the use of a mechanical sling lift for safety and the inability to bear weight, was transferred from her bed to her wheelchair by Certified Nursing Assistant (CNA) #400 and #402 without the use of a mechanical sling lift. Resident #17's legs became entangled in her wheelchair; however, this was not reported to additional staff or medical providers. Resident #17 had continued complaints of pain, and an X-ray was completed on the right knee on [DATE]. The X-ray showed a right femur fracture. Resident #17 was transferred to the emergency room and diagnosed with two additional fractures, one to the right shin and one to the left tibial plateau (knee). On [DATE], due to a condition decline related to the multiple fractures, Resident #17 was transferred to an in-patient hospice provider and subsequently died on [DATE] due to complications from the fractures. This affected one (Resident #17) of four residents reviewed who required a mechanical lift for transfers. The facility census was 142.On [DATE] at 3:37 P.M. the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations #403 were notified Immediate Jeopardy began on [DATE] when staff failed to properly transfer Resident #17 using appropriate mechanical equipment resulting in pain, swelling and an identified fracture to the right distal femur. The resident was sent to the emergency room on [DATE] and additional fractures were identified. Resident #17 was not a surgical candidate and expired on [DATE] due to complications from the fractures.The immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 10:00 A.M. a Quality Assurance Performance Improvement (QAPI) meeting was held at the facility, with some participants via phone. This meeting included a root cause analysis and developed a plan of correction. Participants included the Medical Director (via phone), Regional Director of Operations #404 (via phone), Director of Nursing, Assistant Director of Nursing, Unit Manager, Minimum Data Set (MDS) Nurse #129, Regional Nurse #411 (via phone), and the Regional Director of Clinical Services #403 (via phone). The root cause of the resident's injuries was related to an improper transfer, a breakdown in communication, including lack of Point Click Care (PCC) (the software used by the facility to maintain the electronic medical record) access, and inadequate accountability and supervision by Licensed Practical Nurse (LPN) #300. The facility Administrator and DON were educated by the Regional Director of Clinical Services #403 on ensuring staff are knowledgeable and have access to medical records to provide care, ensuring all incidents and changes in condition are reported timely to the provider, and ensuring residents are transferred safely per the plan of care. The plan was approved by the Facility Medical Director and Interdisciplinary Team (IDT) at 11:00 A.M. on [DATE]. On [DATE] at 11:00 A.M. Resident #17 was transferred to the emergency room and returned to the facility on [DATE] at 6:09 P.M. Orders were given for an elastic wrap to the left leg and an immobilizer on the right leg. The resident was monitored for pain, and circulation checks to lower extremities were completed daily by the nurses. Tylenol was given as needed for pain. On [DATE] at 11:15 A.M. the DON, ADON, UM #203, and the Director of Rehabilitation evaluated the following 41 residents #11, #78, #55, #181, #35, #18, #123, #199, #129, #3, #178, #24, #131, #71, #59, #45, #47, #46, #152, #161, #143, #65, #84, #95, #186, #177, #175, #146, #50, #37, #162, #200, #23, #168, #197, #88, #151, #163, #134, #19, and #16 for injuries such as skin alterations and range of motion (ROM) concerns. The identified residents either required a mechanical lift transfer or resided on the same hall as Resident #17. The audit/evaluation was completed at 3:30 P.M. and no injuries were noted. Immediate education began on [DATE] at 2:00 P.M. for all facility Registered Nurses (RN) (12), LPNs (24), and CNAs (51) by the DON in person and via phone. Education included transfers using a mechanical sling lift, orthostatic vitals, skin integrity, pain management , following the care plan, following the Kardex, mechanical sling lift protocols, staff responsibilities for reviewing the care plan and Kardex, following transfer and care instructions, reporting changes or concerns, immediately reporting changes to the appropriate medical providers, and ensuring resident/ family concerns are addressed, who to notify if you are unable to log into PCC, communicating changes in residents to RN's and LPN's , monitoring compliance with transfers and safety orders, falls and incidents, neuro checks, the new shift to shift report sheet to assist the nurse as a quick reference guide with who is a mechanical sling lift , and nurses supervision of CNA's. On [DATE] at 4:30 P.M. the Assistant DON placed the same education into a binder for the agency staff to review. When agency call the DON/designee for their PCC access (every shift worked requires a new PCC log in for agency staff) the education will be provided verbally, and they will be reminded to review the binder as well. The DON/designees will monitor the agency staff to ensure they are receiving the education prior to their shift. On [DATE] at approximately 6:00 P.M. the DON contacted Agency CNA #306 and provided education regarding safe resident transfers utilizing a mechanical sling lift and protocols, staff responsibilities for reviewing and following the resident's care plan and Kardex, adherence to transfer instructions, prompt reporting of changes in resident condition or concerns, appropriate notification procedures when unable to access PCC, communication of resident changes to licensed nursing staff and ensuring resident and family concerns are addressed in a timely manner. The DON placed the Agency CNA on suspension pending outcome of the investigation. On [DATE] at approximately 6:10 P.M. the DON contacted LPN #300 and CNA #302 by telephone regarding safe mechanical sling lift transfers, orthostatic vital signs, skin integrity monitoring, pain assessment and management, compliance with the resident's care plan and Kardex, mechanical sling lift protocols, staff responsibilities for reviewing and following transfer instructions, prompt reporting of changes in condition to appropriate medical providers, addressing resident and family concerns, procedures for reporting inability to access PCC, effective communication with licensed nursing staff, monitoring compliance with transfer and safety orders, fall and incident reporting, neurological checks, and utilization of the newly implemented shift-to-shift report sheet identifying residents requiring mechanical sling lift transfers. Education also included the licensed nurse's responsibility to supervise nursing assistants and ensure care is provided in accordance with the resident's plan of care and physician orders. The DON also placed them on suspension pending outcome of the facility investigation. Beginning [DATE] the shift-to-shift report was implemented for quick access to resident transfer status. This form is updated/reviewed daily (Monday through Friday) by the DON/designee to ensure accuracy. Ongoing, education will be provided by the DON/designee on the above topics for newly hired staff. The DON/designee performed weekly audits beginning the week of [DATE] for four weeks, the audits ended [DATE]. The audits included observation and review of five residents per week for four weeks with observation of residents being transferred, observation of the correct number of staff in assistance, validation the staff having access to PCC, and the medical record reviewed for a mechanical sling lift order and care plan to Kardex. Also, an audit for change of condition, pain and residents' concerns being addressed with a physician was started the week of [DATE] and completed [DATE]. Ad hoc education will be provided by the DON/ designee to any person who is not correctly implementing the plan of correction. On [DATE] at 2:00 P.M. Resident #17 was transported to a follow-up appointment with the orthopedic provider. The resident remained a non-surgical candidate and was to return for another follow-up on [DATE]. On [DATE] at 12:40 P.M. Resident #17 was discharged to a Hospice facility due to decline in her over-all condition since the fractures. The QAPI committee will review the results of these audits weekly x 4 weeks, ending on [DATE]. Findings include:Review of the closed medical record for Resident #17 revealed an admission date of [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypocalcemia, dementia, pain, osteochondrodysplasias (a vast, heterogeneous group of over 450 rare genetic disorders that disrupt the normal development and growth of bone and cartilage), reduced mobility, Parkinson's Disease without dyskinesia, osteoarthritis, and unstageable pressure ulcer of sacral region.Review of the Activities of Daily Living (ADL) care plan dated [DATE] revealed Resident #17 had a performance deficit related to decline in health, decreased mobility, shortness of breath, bilateral lower extremity swelling with hematemesis and increased confusion. Interventions include but are not limited to mechanical sling lift for all transfers with two assists, initiated [DATE]. Review of the Physician's orders dated [DATE] revealed an order for a mechanical sling lift for all transfers with two assists. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was dependent on care and walking was not attempted due to medical condition or safety concern, no impairment to the upper or lower extremities and the resident had severely impaired cognition. The use of a mechanical lift was not answered on the assessment.Record review for Resident #17 revealed an e-Interact change in condition evaluation dated [DATE] at 3:15 A.M., authored by LPN #139, identifying edema/swelling and new or worsening pain to Resident #17's bilateral lower extremities and the change of condition was not reported to the primary care clinician and ice was applied per family request.Record review revealed a progress note dated [DATE] at 3:15 P.M. authored by LPN #139 documented Resident #17's daughter reported the resident's leg was hurting when touched. LPN #139 assessed and mild swelling was observed to the knee, ice pack was applied for comfort and the provider was notified. Review of the progress notes dated [DATE] at 5:59 P.M. authored by LPN #160 revealed Resident #17's daughter asked LPN #160 to assess the resident and increased swelling and warmth was found to the knee. Resident #17's daughter declined to have a physician notified and requested ice to be applied.Record review for Resident #17 revealed an e-Interact change in condition evaluation dated [DATE] at 10:30 P.M. authored by LPN #153 identifying new or worsening pain and the change of condition was not reported to the primary care clinician. Review of progress notes revealed the results of the obtained X-ray were received on [DATE] at 9:45 A.M. identifying a right femur fracture and Nurse Practitioner (NP) #415 was notified and the resident was sent to the emergency room (ER) for further evaluation and treatment. Review of the facility investigation dated [DATE] at 9:45 A.M. revealed staff did not transfer Resident #17 according to the plan of care. During the transfer, the resident's right leg became positioned under the wheelchair, and a CNA gently removed the leg from under the chair. Review of the hospital records dated [DATE] revealed a computed tomography (CT) scan of the right lower extremity with findings of an impacted fracture of the distal femur and the left lower extremity revealed an impacted fracture of the lateral tibial plateau/metaphysis. Review of the hospital care coordination summary revealed a progress note documenting Resident #17's family was advised of injury including right distal femur fracture, right shinbone and left tibial plateau fracture which is concerning considering the non-ambulatory status. The resident was not a surgical candidate.Review of the SRI initiated [DATE] at 7:00 P.M. revealed due to continued concerns, an X-ray was ordered for Resident #17's right leg. The resident's family voiced concerns regarding the resident's care and used the word neglect. Facility Administration notified and an investigation was initiated. On [DATE] at approximately 6:00 P.M. Resident #17 required the replacement of the air mattress on her bed and LPN # 401 and CNA #400 entered Resident #17's room to assist with getting the resident out of bed. She was assisted into a seated position and then CNA #402 entered the room. LPN #401 exited the room and CNAs #400 and #402 manually transferred the resident from the bed to the wheelchair and the resident's right leg became positioned underneath the wheelchair during the transfer. Both staff reported the resident's leg was gently moved and repositioned.Review of the progress notes dated [DATE] at 12:00 P.M, revealed Resident #17 was transferred to the emergency room due to a change in condition; decreased appetite, fluid intake and distended abdomen. She later returned to the facility at 8:50 P.M. with no new orders per the progress note authored by LPN #153.Review of the hospice consultation progress notes dated [DATE] revealed since Resident #17's her emergency department evaluation and fractures were identified she has notably declined. Resident #17 has not been eating, drinking or taking pills. She was eligible for hospice admission due to recent fractures and ongoing decline and appeared to be end of life. A progress note dated [DATE] authored by LPN #203 revealed Resident #17 was scheduled to be admitted to hospice. Resident #17 was unable to swallow and speech therapy recommended nothing by mouth. Resident #17's family stated she would sign up with hospice on [DATE] and admit to in-patient hospice. On [DATE] at 12:48 P.M. Resident #17 was discharged from the facility to the inpatient hospice unit. Review of the death certificate revealed Resident #17 expired on [DATE] due to complications from multiple fractures and unwitnessed fall to floor. During an interview on [DATE] at 2:26 P.M., Family member #410 Yes and she is #410. stated Resident #17 started to complain of the right leg pain while the family member was visiting at the facility. The facility called the police and made her leave, stating she was causing a commotion, but she was unsure of the nurse's name who called the police or why the police were needed. On [DATE], when she came in around 2:00 P.M., Resident #17's legs were swollen. Family member #410 reported it to the nurse and the nurse said she probably pulled a muscle. Then on [DATE] both legs were red, hot and swollen. The right leg was swollen from the hip down. Family Member #410 mentioned it again and the facility said they would get an X-ray, but it did not get done until Sunday [DATE]. Family Member #410 confirmed the resident was discharged to a hospice provider for in-patient care on [DATE] due to a decline in her condition. Resident #17 was not eating or drinking after she sustained the multiple fractures. Family Member #410 confirmed the resident died at the hospice facility. During an interview on [DATE] at 2:32 P.M., LPN #203 stated the facility noticed the X-ray results in the morning on [DATE] and notified the Nurse Practitioner #415 and got Resident #17 sent out. LPN #203 stated the facility did not know what happened and they started an investigation. They found out the two CNAs transferred the resident, and she required a mechanical sling lift for transfers. At the hospital, additional fractures were identified. During an interview on [DATE] at 11:32 A.M., LPN #401 stated she was the nurse on duty on [DATE] and no incident was reported to her. LPN #401 stated she was initially going to assist with transferring Resident #17 to the wheelchair then another staff member showed up. The nurse exited the room and CNA #400, and CNA #402 manually transferred the resident from the bed to the wheelchair and the resident's right leg became positioned underneath the wheelchair during the transfer but there was nothing concerning to report at the time.During an interview on [DATE] at 12:19 P.M., CNA # 400 stated she did not get report from the previous shift when she arrived and did not have access to the computer to complete any charting. Towards the end of the shift, a man came up the hallway and told the aide he was there to bring a mattress (a new air mattress for Resident #17). He said he needed Resident #17 out of bed. The aide and the nurse were going to transfer her, but the CNA stated she had no idea she used a mechanical sling lift. The nurse said she would help transfer and the CNA said she assumed the nurse knew how the resident transferred. The nurse and the CNA sat her up at the side of the bed and at that time CNA #400's relief came to the room (CNA #402). She asked if she could help. She replaced the nurse and nothing was said. We lifted Resident #17 under the arms and by the back of her pants and stood her up. CNA #400 was on the right side, and the other aide was on the left side. The CNA reported they sat her down and backed up the wheelchair. Her right leg was underneath her wheelchair, and the other aide repositioned her leg. Resident #17 seemed fine, she did not appear uncomfortable. The other aide wheeled her out into the hallway and CNA #400 gave report. The CNA stated she did not know there was an issue until a few days later when she had to send the facility an email with her statement. She stated she did not have access to point click care but did try multiple times to notify someone (but did not specify who). During an interview on [DATE] at 1:14 P.M., CNA #402 stated she was coming on for her shift that evening when she entered the resident's room (Resident #17). An agency aide and an agency nurse (later identified to be facility LPN #401) were in the room. CNA #402 and the other aide got Resident #17 up in the wheelchair. CNA #402 stated she was just trying to make sure Resident #17 did not fall. There was not a lift pad in the room nor was there a mechanical sling lift in the hall. And the mattress guy was waiting in the hallway. The resident did not yell out in pain or say anything during the transfer. She appeared to be fine. Afterwards CNA #402 reported she went out and told the nurse to go and assess Resident #17. The daughter came in and was upset that her mom did not have her oxygen on and the nurse ended up calling the police, so I don't think she assessed her. I also told the night shift nurse what happened when she came in and I don't believe she assessed her either. CNA #402 reported someone from the facility called her four days later and asked her to come in and write a statement and suspended her, then she was terminated. The resident seemed fine through the night. She didn't sleep that well but did not have any complaints either. During an interview on [DATE] at 12:00 P.M., the DON stated initially the QAPI stated she had a fall because when the facility received the X-ray results, they assumed there was a fall and immediately started the QAPI. During the investigation they discovered the two CNAs involved transferred her without the use of the lift. There was no reason why they should have, they had access to her plan of care and the DON stated she and HR verified the two staff had access to the resident's care plan to know the resident's transfer abilities. They were immediately suspended pending investigation, then terminated. The nurse who was initially assisting was brand new but was responsible to ensure the aides followed the resident's care plan. The DON verified there was no notification made to the medical provider with the multiple complaints of pain or change in assessment and the staff should report changes in resident condition when it occurs. Review of the policy titled Change in condition policy dated [DATE] revealed the facility will promptly identify, assess, and respond to any significant change in a resident's physical, mental, or psychosocial condition. The licensed nurse will ensure timely notification of the physician and resident representative and implement appropriate interventions to maintain the resident's health and safety. All staff are responsible for observing resident's and immediately reporting any change in condition to the licensed nurse. This violation is a recite to the complaint survey completed [DATE].

Based on observation, resident interviews, staff interviews, work orders, and facility policy review, the facility failed to ensure temperatures in the facility were at a comfortable level. This affected twenty-five residents (#13, #22, #30, #31, #35, #36, #41, #47, #48, #51, #54, #56, #57, #58, #61, #62, #63, #64, #66, #67, #81, #105, #106, #140 and #145) of 142 residents. Facility census was 142.Findings include: Interview and observation on 06/11/26 from 11:55 A.M. to 12:45 P.M. with Maintenance Director #182 of all occupied rooms, common areas and hall temperatures. Maintenance Director #182 stated there are two air conditioning units (AC) out and have been for a couple of weeks. It was going to be repaired in the next few days.During the observations on 06/11/26 temperatures ranged from 68 degrees to 80.4 degrees in resident rooms. The temperatures for resident rooms at 80 degrees did not have window AC units.Review of invoices dated 06/05/26 from (named supplier) for the purchase of two commercial AC units, invoices dated 06/05/26 from for the purchase of seven window AC units, and an invoice dated 06/08/26 from (named supplier) for the purchase of two window AC units.Review of daily facility temperature logs from 06/01/26 to 06/11/26 revealed unit hallway temperatures from 71 degrees to 78 degrees. No room temperatures were taken by Maintenance. Verified with Maintenance Director #182.Review of the maintenance logs from April 2026 through June 2026 revealed no concerns with the air conditioning.Observations and interviews on 06/11/26 from 11:55 A.M. to 12:45 P.M. with Residents #13, #22, #30, #31, #35, #36, #41, #47, #48, #51, #54, #56, #57, #58, #61, #62, #63, #64, #66, #67, #81, #105, #106, #140 and #145 stated it was hot in their rooms. On 06/11/26 room temperatures were conducted with Maintenance Director #182 revealed the following temperatures and interviews revealed:At 12:00 P.M. Resident #22's room was 74.5 degrees, and the resident stated it was too warm.At 12:03 P.M. Resident #13's room was 80.4 degrees, and he stated it was too hot.At 12:05 P.M. Resident #30's room was 74.8 degrees, and the resident stated it was too hot.At 12:05 P.M. Resident #31's room was 74.8 degrees, and the resident stated it was too hotAt 12:10 P.M. Resident #35's room was 72.7 degrees, and the resident stated it was too hot in the evenings.At 12:10 P.M. Resident #36's room was 72.7 degrees, stated it was too hot in the evenings.At 12:13 P.M. Resident #41's room was 76.3 degrees, stated it was hot as hell, had a fan on and was told the air was broken.At 12:15 P.M. Resident #47's room was 76.8 degrees, stated it was too warm.At 12:15 P.M. Resident #48's room was 76.8 degrees, stated it was too warm.At 12:18 P.M. Resident #51's room was 75.8 degrees, stated it was pretty hot in the room. At 12:20 P.M. Resident #56's room was 76.1 degrees, stated it is too warm, has a fan on, in the evenings it gets even hotter, has to go in the hallway to get cooled off.At 12:20 P.M. Resident #57's room was 76.1 degrees, stated it is too warm.At 12:23 P.M. Resident #58's room was 75.2 degrees, stated it is too warm.At 12:24 P.M. Resident #61's room was 79.1 degrees, had a fan on and stated it was too hot.At 12:24 P.M. Resident #62's room was 79.1 degrees, stated it was too hot.At 12:25 P.M. Resident #63's room was 78.7 degrees, stated it was too warm.At 12:25 P.M. Resident #64's room was 78.7 degrees, stated it was too warm.At 12:26 P.M. Resident #66's room was 80.1 degrees, stated it was too warm and had a fan turned on.At 12:26 P.M. Resident #67's room was 80.1 degrees, stated it was too warm and had a fan turned on.At 12:30 P.M. Resident #81's room was 79.3 degrees, stated it was too hot, had a fan on and windows open.At 12:30 P.M. Resident #54's room was 79.3 degrees, stated it was too hot.At 12:35 P.M. Resident #105's room was 73.8 degrees, stated it was too hot.At 12:35 P.M. Resident #106's room was 73.8 degrees, stated it was too hot. At 12:40 P.M. Resident #140's room was 76.6 degrees, stated it was too warm and the windows were open.At 12:43 P.M. Resident #145's room was 75.9 degrees, stated it was too hot.Interview on 06/15/26 at 2:32 PM with Licensed Practical Nurse (LPN) #203 revealed the air conditioning has been an ongoing issue, it went out last year also. It has been very hot and the staff is complaining.Interview on 06/15/26 at 4:43 P.M. with Certified Nursing Assistant (CNA) #133 revealed the resident's assigned to her did complain about the heat, but they had fans in their rooms. she did not think it was exceedingly hot in their rooms. I did not notice the temperature in the resident rooms to be 81 degrees.Interview on 06/15/26 at 2:45 P.M. with CNA #252 revealed the residents have complained about the heat. It has been very hot in the facility, worse in the evenings. The air conditioning has been broke for a few weeks.Review of facility policy titled Homelike Environment revised February 2021 revealed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe temperatures (71 degrees Fahrenheit (F) and 81 degrees F). This deficiency represents non-compliance investigated under Complaint Number 3039180 and 3040812.

Based on observation, medical record review, policy review and interview, the facility failed to maintain resident dignity for Resident #15. This affected one resident (#15) of three sampled residents. The facility census was 142.Findings include: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including dementia need for assistance with personal care, reduced mobility, epilepsy, and anxiety disorder.Review of the most recent Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 0 indicating severe cognitive impairment. The resident was assessed to require substantial/maximal assist for showering/bathing, personal hygiene, and transfers.Observation on 06/15/26 at 9:51 A.M. revealed Resident #15 being assisted out of her room in a shower chair by Certified Nursing Assistant (CNA) #172. The resident was wearing a nightgown exposing her body from her waist down.Interview on 06/15/26 at 9:51 A.M. with CNA #172 verified Resident #15 hips and lower body was exposed in the hallway in front of other residents and stated she was going to cover the resident up with a sheet since her lower body was exposed.Review of facility policy titled Dignity, dated August 2024 revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.This deficiency represent non-compliance investigated under Complaint Number 3039180.

Based on medical record review, staff interview, observations, and facility policy review, this facility failed to provide activities to meet the interest or needs of each resident residing on the facility's memory care units. This affected all 29 resident's (Resident # 11, 13, 19, 23, 29, 40, 43, 50, 59, 61,67, 69, 71, 74, 83, 90, 91, 99, 102, 121, 122, 125, 126, 128, 135, 136, 142, 149, 150) residing on the 200 and 300 unit in the [NAME] Wing. The facility census was 148. Findings include: 1 The facility had a secured memory care unit on 200 hall of [NAME] wing where 13 residents resided: Residents #11, 13, 19, 23, 50, 59, 74, 83, 90, 99,121, 122, 135. Review of the activity calendar for the memory care unit revealed on 03/25/26 chats were scheduled for 10:00 A.M. No activity was observed at 10:00 A.M. Observations on 03/25/26 at 11:30 A.M. on the 200 hall memory care unit revealed direct care staff actively assisting residents with Activity of Daily Living (ADL) care. Multiple residents were observed ambulating independently on the 200 unit. Interview with Nursing Assistant #249 on 03/25/26 at 2:36 P.M. revealed she had worked at the facility for 5-6 months and normally works dayshift. She stated there was no activity schedule or plan for the unit. She stated the activity aides were supposed to provide the activities for residents on the unit. Observations on 03/25/26 at 2:45 P.M. revealed no activities occurring on the 200 hall memory care unit. (2:00 P.M. was to be snack and chat and 2:30 P.M. was to be bible study per activity calendar). Interview with Activity Assistant #264 on 03/25/26 at 3:00 P.M. revealed that the activity scheduled every day of March 2026 at 10:00 A.M. called chats for the memory care units was done by someone else other than activities. She stated it was not a group activity. She stated someone just walks through and says hey. Interview with Activity Director #326 on 03/25/26 at 3:06 P.M. revealed the memory care units (200 and 300 halls on [NAME] Wing) have different activity schedules than the rest of the facility. She confirmed there are four staff who work in activities. She stated two of those staff do primarily memory care and work either 11:00 A.M. to 7:30 P.M. or 12:00 P.M. to 8:30 P.M. She stated most days through the week there are a total of three staff in activities for the whole building and two on the weekends. She confirmed that the memory care activity calendar has the same four activities scheduled every day of the month of March: 10:00 A.M. Chats; 11:00 A.M. Lunch and tunes; 12:30 P.M. exercise; and 2:00 P.M. snack and chat. She stated the aides on the unit do the 10:00 A.M. chats. She stated no one did the 11:00 A.M. lunch and tunes today. She stated the activity aide did not come on duty until noon. She stated she just took over as activity director four weeks ago and did not make the calendars. She stated if an activity does not work, the staff should try a different one. She stated the memory care units should have a lot of engagement with residents to keep them busy and occupied. She stated they should have a variety of activities. She stated that she knew that the residents on the units liked music, puzzles, coloring, and movies. Interview with Activity Director #326 on 03/25/26 at 3:06 P.M. revealed current events and room visits are done simultaneously and last about 5-10 minutes. Observations completed 03/30/26 from 4:10 P.M. through 4:40 P.M. of the 200 unit on the [NAME] Wing revealed no activity was being completed. Per review of the activity Calander, karaoke was supposed to be completed at 4:00 P.M. Interview with the Activity Director #326 on 03/30/2026 at 4:43 P.M. revealed there was two evening aides one for each of the memory care units. The Activity Director #326 claimed one of the activity aides were supposed to be on the 200 unit doing Karaoke and could not provide an explanation why this activity was not completed or where that activity aide was during that time. 2. The facility had a secured memory care unit on 300 hall of [NAME] wing where 16 residents resided: Residents # 29, 40, 43, 61, 67, 69, 71, 91, 102, 125, 126, 128, 136, 142, 149, and 150. Review of the record for Resident #29 revealed an admission date of 02/09/26 and diagnoses including vascular dementia and cerebral infarction. A Minimum Data Set assessment completed 02/15/26 revealed a score of 00 for the brief interview for mental status, indicating severe cognitive impairment. It indicated he required set up assistance only with eating and was independent with mobility. Review of an Activity Interview Form completed 02/09/26 revealed Resident #29 wished to participate in group and independent activities and go on outings. It stated he had present interests in: reading/books, religion/bible study, reminiscing, tv/radio. movies/videos, cooking/food, sports, and bingo. It stated he wished for visits by clergy in the facility. Review of a daily preference evaluation completed 02/09/26 revealed that it was very important to him to be around animals such as pets, go outside to get fresh air, and participate in religious activities. Observations on 03/24/26 at 9:54 A.M. Resident #29 was observed sitting in the lounge with two other residents. There were no staff in the room and no activities going on. The aide was sitting across the hall in the dining room looking at her phone screen. Review of the memory care activity schedule revealed on 03/24/26 at 10:00 A.M. AM chats were scheduled. There was no activity observed at 10:00 A.M. on 03/24/26. Observations on 03/24/26 at 4:23 P.M. revealed Resident #29 to be sitting in the dining room on the secured unit. A staff person was doing one female resident's nails. No other activity going on. Review of the memory care activity schedule revealed on 03/24/26 at 4:00 P.M. nails was scheduled. Observations on 03/25/26 at 9:03 A.M. revealed Resident #29 was laying in bed awake. The television was on in the room but you could not see the screen from his bed due to the bathroom door being open. There were no activities going occurring on the 300 hall secured unit. Two male residents were observed sitting quietly in the dining room (no staff and no activities). One of the male residents then started raising his voice to the other resident and said get out of here. He said the resident was making noise and that he agitated him. A staff person came in and took one of the residents out of the dining room. Observations on 03/25/26 at 9:58 A.M. revealed Resident #29 to be in bed with eyes closed. There were no activities occurring on the 300 hall unit. There was one aide working on the 300 hall unit and she was standing in the hall leaning up against the wall. The nurse was observed sitting in the nurses station room. There were no activity staff on the unit. Review of the activity calendar for the memory care unit revealed on 03/25/26 chats were scheduled for 10:00 A.M. No activity was observed at 10:00 A.M. Observations on 03/25/26 at 11:30 A.M. on the 300 hall memory care unit revealed a nursing assistant sitting in the lounge alone looking at her phone screen. Another aide was in the dining room with five residents. As soon as the surveyor walked in, the aide moved quickly and started asking residents if they wanted to color a paper heart. Resident #29 was not present. He was observed in bed at 11:33 A.M. with his eyes closed. Observations on 03/25/26 at 2:23 P.M. on the 300 hall secured unit revealed Resident #29 to be standing in the hallway. There were no activities occurring. Review of the activity calendar for the memory care unit for 03/25/26 revealed snack and chat was to occur at 2:00 P.M. and bible study was to occur at 2:30 P.M. Interview with Nursing Assistant #249 on 03/25/26 at 2:36 P.M. revealed she had worked at the facility for 5-6 months and normally works dayshift. She was working on the 300 hall memory care unit. She stated there was no activity schedule or plan for the unit. She stated the activity aides were supposed to provide the activities for residents on the unit. She stated there was an activity aide on the unit now (was sitting in the lounge talking with her prior to the interview) but she had not done any activities. She stated there had not been any activities on the 300 hall memory care unit that day. Observations on 03/25/26 at 2:45 P.M. revealed no activities occurring on the 300 hall memory care unit. (2:00 P.M. was to be snack and chat and 2:30 P.M. was to be bible study per activity calendar). Interview with Activity Assistant #201 on 03/25/26 at 2:45 P.M. revealed activities scheduled for the 300 hall memory care unit that day included: 10:00 A.M. chats. She stated she did not know who did that activity. She stated she did snack and chat at 2:00 P.M. (however, observations did not reveal any activity going on at 2:23 P.M.). She stated she was supposed to do bible study at 2:30 P.M. which would include watching a video or praying. She stated that activity had not occurred yet. She stated there are four staff who work in activities (for the whole 172 bed facility). She stated some days there are only three staff in activities, due to days off. She stated she and another activity aide provide the activities for the two secured memory care units on [NAME] wing (200 and 300 halls). She stated the other 1-2 staff provide the activities for the rest of the facility. She stated there are only two staff scheduled on the weekends for activities from 8:00 A.M. to 4:30 P.M. She stated Resident #29 will participate in activities such as exercises or painting. Interview with Activity Assistant #264 on 03/25/26 at 3:00 P.M. revealed that the activity scheduled every day of March 2026 at 10:00 A.M. called chats for the memory care units was done by someone else other than activities. She stated it was not a group activity. She stated someone just walks through and says hey. Interview with Activity Director #326 on 03/25/26 at 3:06 P.M. revealed the memory care units (200 and 300 halls on [NAME] Wing) have different activity schedules than the rest of the facility. She confirmed there are four staff who work in activities. She stated two of those staff do primarily memory care and work either 11:00 A.M. to 7:30 P.M. or 12:00 P.M. to 8:30 P.M. She stated most days through the week there are a total of three staff in activities for the whole building and two on the weekends. She confirmed that the memory care activity calendar has the same four activities scheduled every day of the month of March: 10:00 A.M. Chats; 11:00 A.M. Lunch and tunes; 12:30 P.M. exercise; and 2:00 P.M. snack and chat. She stated the aides on the unit do the 10:00 A.M. chats. She stated no one did the 11:00 A.M. lunch and tunes today. She stated the activity aide did not come on duty until noon. She stated she just took over as activity director four weeks ago and did not make the calendars. She stated if an activity does not work, the staff should try a different one. She stated the memory care units should have a lot of engagement with residents to keep them busy and occupied. She stated they should have a variety of activities. She stated that she knew that the residents on the units liked music, puzzles, coloring, and movies. Review of the activity participation records for Resident #29 since admission [DATE]) revealed that he had only current events and room visits marked for 23 of 30 days. There was no evidence of any activities that included his preferences: pets, clergy visits, going outside, or bingo. Interview with Activity Director #326 on 03/25/26 at 3:06 P.M. revealed current events and room visits are done simultaneously and last about 5-10 minutes. Review of the facility policy dated 2001 and revised June 2018 titled Activity Programs revealed activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. All activities are documented in the resident's medical record. Our activity programs consist of individual, small group, and large group activities that are designed to meet the needs and interests of each resident.

Based on medical record review, staff interview, observations, and facility policy review, this facility failed to provide care and services related to pressure ulcer care. This affected 5 residents (Resident #11, #57, #108, #138, and #157) of the 7 residents reviewed for wound care. The facility census was 148. Findings include: 1 Review of the medical record for Resident #11 revealed an admission date of 12/19/2025. Diagnoses included rhabdomyolysis, wedge compression fracture of the thoracic vertebra, and Dementia. Review of plan of care dated 12/28/2025 revealed Resident #11 was noted to have impaired skin integrity as evidenced by a unstageable pressure to the coccyx, and wound to the right and left heels. Interventions include to apply protective barrier cream after each incomitance episode, turn and reposition as needed, provide medication as ordered. notify nurse of any new pressure areas, apply a pressure redistribution device to the bed and chair. Review of the skin assessment dated [DATE] revealed Resident #11 was admitted to the facility with a pressure wound to the coccyx. Review of the skin assessment dated [DATE] revealed Resident #11 was noted to still only have a pressure wound to the coccyx. Review of the skin assessment dated [DATE] revealed Resident #11 had a pressure wound to the coccyx which was noted upon admission to the facility. Resident #11 was also noted to have a pressure wound to the right and left heel. Original date identified for the right and left heel was dated 12/28/2025. Review of Resident #11's physician orders for December 2025 revealed no evidence that treatments orders were implemented when the pressure wounds were noted to this resident's right and left heels. Treatments for both heels were not noted to be implemented until 12/30/2025. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating a severely impaired cognition for daily decision-making abilities. Resident #11 was noted to be free from any upper or lower extremity impairment and was independent for bed mobility. Interview on 03/25/2026 at 10:14 A.M. with the Director of Nursing (DON), Licensced Practical Nurse (LPN) Wound Nurse #388, and LPN #284 revealed Resident #11 admitted to this facility with only the coccyx wound. The heel wounds were identified on 12/28/25. LPN #284 was working the weekend this resident's heel wounds were identified and contacted the on-call physician who provided treatment orders. These orders were never implemented into this resident's medical record. LPN Wound Nurse #388 was interviewed and verified Resident #11 did not have any actual preventive interventions in place to protect her heels other than a pressure relieving mattress. When asked why the moon boots which were not ordered until March 2026 were not implemented upon wounds to the bilateral heels being identified, no answer was provided. 2. Review of Resident #57's physicians orders, revealed an order dated 04/23/2024 for an air mattress to bed, check placement and function every shift for pressure relief. Review of the MDS assessment dated [DATE] revealed that Resident #57 had cognitive loss and was mobile with a wheelchair but dependent with showering/bathing, dressing, rolling, sitting to lying/lying to sitting, sitting to stand and all transfers. Review of Resident #57's care plan revealed that the resident had a potential for skin integrity/pressure ulcer development related to reduced mobility, incontinence, chairbound, terminal illness and hospice status. Interventions noted the resident required an air mattress to the bed for skin integrity, pressure relieving/reducing device on bed and/or chair, and assistance with activities of daily living (ADL) and mobility needs. Review of the progress noted dated 12/26/2025 for Resident #57 revealed a Braden Scale for predicting pressure ulcer risk of 12.0. Observation of Resident #57 on 03/23/2026 at 11:27 A.M. revealed Resident #57 resting in bed with air mattress settings of normal and 140 pounds. Review of Resident #57's chart revealed a weight of 85.9 pounds on 03/04/2026. Interview with Licensed Practical Nurse (LPN) #219 revealed that Resident #57's air mattress was set to the wrong weights, but that hospice provides the air mattresses and maintains them. Observation of Resident #57's air mattress on 03/24/2026 at 11:17 A.M. revealed that the settings were corrected to appropriate weight. 3. Record review revealed Resident #138 was admitted on [DATE] with diagnoses including but not limited to dementia, major depressive disorder, psychotic disorder with hallucinations, anxiety disorder, morbid obesity and quadriplegia. Review of Resident #138's physician orders dated 10/08/2024 revealed a Braden scale for predicting pressure ulcer risk of 12.0. Review of Resident #138's MDS assessment dated [DATE] revealed cognitive intact with impairment on bilateral upper and lower extremities. Resident was dependent with rolling side to side, sitting to lying, lying to sitting and all transfers. Review of Resident #138's care plan revealed that the resident has a potential for pressure ulcer development and the potential for impairment to skin integrity related to immobility, quadriplegia and incontinence. Interventions included an air mattress with bolsters – check function every shift and requirement of pressure relieving/reducing device on bed and/or chair. Review of Physicians orders for Resident #138 revealed an order dated 02/11/2026 for a low air loss mattress on bed for pressure reduction, monitor low air-loss mattress functioning and check that the settings are appropriate for the patient every shift. Review of Resident #138's medical records reviewed a weight of 216.1 pounds on 03/04/2026. Observation of Resident #138 on 03/23/2026 at 1:28 P.M. revealed resident in bed on back with air mattress settings of alternate and 600 pounds to 1,000 pounds. Interview with Licensed Practical Nurse (LPN) #219 revealed that Resident #138's air mattress was set to the wrong weight, but that hospice provides the air mattresses and maintains them. Observation of Resident #138's on 03/24/2026 revealed air mattress settings at appropriate weight for resident. 4. Review of the medical record for Resident #157 revealed an initial admission date of 03/19/26 with the diagnoses including but not limited to dementia, anxiety disorder, abnormal weight loss, urinary tract infection, fracture of lower leg and senile degeneration of brain. Review of the resident's admission assessment with baseline care plan dated 03/19/26 revealed the resident was admitted to the facility with a stage III pressure ulcer to her sacrum measuring 11 centimeters (cm) by 0.5 cm by 0.1 cm and an unstageable pressure ulcer to the left gluteal fold that measured 0.5 cm by 1.0 cm. Further review revealed no description of the either wound. The assessment indicated the resident weighed 132.8 pounds. Review of the resident's Braden scale dated 03/19/26 revealed a score of 16 indicating the resident was at risk for skin breakdown. Review of the plan of care dated 03/19/26 revealed the resident has impaired skin integrity as evidenced by stage III pressure ulcer to sacrum and an unstageable pressure to left gluteal fold. Interventions included low air loss mattress in place and pressure redistribution device in chair. Review of the progress note dated 03/19/26 revealed the admission head to toe assessment was completed and the resident was admitted to the facility with a stage III pressure ulcer to her sacrum and an unstageable to her left gluteal fold. Review of the brief interview for mental status (BIMS) evaluation dated 03/20/26 revealed a score of six out of 15 indicating the resident had a severe cognitive deficit. Review of the resident's monthly physician orders for March 2026 identified an order dated 03/24/26 low air loss mattress on bed for pressure reduction, monitor low air loss mattress functioning and check that the settings are appropriate for the resident every shift. On 03/24/26 at 8:36 A.M., observation of Resident #157 revealed she was positioned on her back with no off-loading to the stage III pressure ulcer to the sacrum and the unstageable pressure ulcer to the left gluteal fold. Further observation revealed the low air loss mattress was set to firm. On 03/24/26 at 8:44 A.M., an interview with Registered Nurse (RN) #237 verified the mattress was set on firm and providing no off-loading to the stage III and the unstageable pressure ulcer. The RN revealed the resident weighed 132.8 pounds and should be set between 100 to 150 pounds. 5. Review of the medical record for Resident #108 revealed an initial admission date of 08/23/23 with the latest readmission date of 03/02/26 with the diagnoses including but not limited to hypoxemia, diabetes mellitus, chronic kidney disease, disappearance and death of family member, open wound to right hip, post-traumatic stress disorder, insomnia, anemia, paraplegia, hyperlipidemia, retention of urine, diabetes mellitus, mild intellectual disabilities, chronic pain, end stage renal disease, paranoid schizophrenia, major depressive disorder, benign prostatic hyperplasia, bladder neck obstruction, obstructive and reflux uropathy, kidney transplant status, spinal stenosis, need for assistance with personal care and chronic obstructive pulmonary disease. Review of the plan of care dated 12/18/24 revealed the resident required the use of an air mattress due to potential and history of pressure ulcers and impaired skin integrity. Interventions included adjust settings when weights obtained by utilizing the setting graph on the air mattress pump. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required substantial/maximal assistance with bed mobility. The assessment indicated the resident was at risk for skin breakdown and had no unhealed pressure ulcers. The facility implemented the interventions pressure reducing device bed/chair, nutrition or hydration intervention to manage skin problems, surgical wound care and application of ointments/medications other than to feet. Review of the resident's monthly physician orders for March 2026 identified orders dated 03/02/26 low air loss mattress. On 03/24/26 at 9:11 A.M., observation of the resident revealed his air mattress was set on the weight setting of 318 pounds. On 03/24/26 at 9:15 A.M., an interview with Registered Nurse (RN) #415 verified the resident air mattress was not set at the correct setting for the resident's weight. Review of the facility policy titled, Skin and Wound Management, dated 01/25 revealed nurses will ensure orders, interventions and treatments for skin and wounds are implemented as ordered.

Based on interview, record review and policy review, the facility failed to complete required minimum data set (MDS) assessments in a timely manner for Residents #7, #15, #60, and #147, failed to ensure the initial wound assessment accurately reflected wound characteristic for Resident #157, and failed to ensure the comprehensive assessment was accurate for Resident #8. This affected six ( Resident #7,#8,#15,#60,#147, and #157) of the 36 residents sampled for the annual survey. The facility census was 148. Findings include: 1. Review of Resident #7's medical record revealed an admission date of 05/30/25, a re-entry date of 02/11/26 and diagnoses including but not limited to cerebral infarction, anxiety disorder, chronic kidney disease stage four, major depressive disorder, diabetes, and dementia. Review of Resident #7's admission MDS dated [DATE] revealed a completion date of 03/02/26. In an interview on 03/30/26 at 1:10 P.M. MDS Coordinator #292 confirmed Resident #7's admission MDS was not completed until 03/02/26. 2. Review of Resident #15's medical record revealed an admission date of 09/02/25 and diagnoses including but not limited to alcohol abuse, cannabis dependence, and hypertension. Review of Resident #15's quarterly MDS dated [DATE] revealed a MDS completion date of 03/02/26. In an interview on 03/26/2026 at 11:45 A.M. MDS Coordinator #292 confirmed Resident #15's quarterly MDS was not completed until 03/02/26. 3. Review of Resident #60's medical record revealed an admission date of 12/19/25, a re-entry date of 01/17/26 and diagnoses including but not limited to end stage renal disease, diabetes, and hypertension. Review of Resident #60's admission Minimum Data Set (MDS) dated [DATE] revealed a completion date of 01/12/26. In an interview on 03/26/26 at 11:45 A.M. MDS Coordinator #292 confirmed Resident #60's admission MDS was not completed until 01/12/26. 4. Review of Former Resident #147's medical record revealed an admission date of 11/02/25, a discharge date of 02/28/26 and diagnoses including but not limited to paraplegia, unspecified, depression, and hypertension. Review of Former Resident #147's quarterly MDS dated [DATE] revealed a MDS completion date of 01/23/26. In an interview on 03/31/2026 at 10:53 A.M. MDS Coordinator #292 confirmed Former Resident #147's quarterly MDS was not completed until 01/23/26. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 revealed the MDS completion date for a quarterly assessment must be no later than 14 days after the Assessment Reference Date (ARD) (ARD + 14 calendar days). Further review revealed the MDS admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. Review of the policy titled MDS Completion and Submission Timeframes, revised July 2024 revealed the timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. 5. Review of the medical record for Resident #157 revealed an initial admission date of 03/19/26 with the diagnoses including but not limited to dementia, anxiety disorder, abnormal weight loss, urinary tract infection, fracture of lower leg and senile degeneration of brain. Review of the resident's admission assessment with baseline care plan dated 03/19/26 revealed the resident was admitted to the facility with a stage III pressure ulcer to her sacrum measuring 11 centimeters (cm) by 0.5 cm by 0.1 cm and an unstageable pressure ulcer to the left gluteal fold that measured 0.5 cm by 1.0 cm. Further review revealed no comprehensive assessment reflecting the condition of the wound, type of dressing and a description of the wound. Review of the plan of care dated 03/19/26 revealed the resident has impaired skin integrity as evidenced by stage III pressure ulcer to sacrum and an unstageable pressure to left gluteal fold. Interventions included low air loss mattress in place and pressure redistribution device in chair. Review of the progress note dated 03/19/26 revealed the admission head to toe assessment was completed and the resident was admitted to the facility with a stage III pressure ulcer to her sacrum and an unstageable to her left gluteal fold. Review of the resident's monthly physician orders for March 2026 identified orders dated 03/19/26 barrier cream after each incontinence episode, cleanse stage III pressure ulcer to sacrum with normal saline (NS), pat dry, apply triad paste and cover with foam dressing, cleanse unstageable pressure ulcer to left gluteal fold with normal saline, pat dry, apply triad past and leave open to air twice daily, 03/20/26 enhanced barrier precautions (EBP) due to wounds every shift, 03/24/26 low air loss mattress on bed for pressure reduction, monitor low air loss mattress functioning and check that the settings are appropriate for the resident every shift. On 03/25/26 at 10:07 A.M., an interview with the Director of Nursing (DON) verified the stage III pressure ulcer and the unstageable pressure ulcer was not comprehensively assessed on admission. Review of the facility policy titled, Skin and Wound Management, dated 01/25 revealed the nurse will conduct a comprehensive skin assessment upon admission including skin integrity. In addition, the nurse shall describe and document/report the following, full assessment of pressure injury including location, state, length, width, and depth, presence of exudates or necrotic tissue, pain assessment, resident's mobility status and current treatments, including support surfaces. 6. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension, and post-traumatic stress disorder (PTSD). Review of the Trauma Informed Care Assessment verified PTSD screen was marked no for Resident #8 on 08/26/26, 11/26/25 and 02/27/26. The Minimum Data Sheet Assessment (MDS) dated [DATE] indicated PTSD as an active diagnosis. Interview with Social Services Director #366 on 03/26/26 at 12:10 P.M. verified the Trauma Informed Care Assessment PTSD screen was marked no for Resident #8 on 08/26/25, 11/26/25 and 02/27/26. Social Services Director #366 confirmed Resident #8 had diagnosis of PTSD upon admission.

Based on medical record review, staff interview, and observations, the facility failed to maintain comfortable hot water temperatures and homelike environment. This affected 13 residents (Resident #11, #13, #19, #23, #50, #59, #74, #83, #90, #99, #121, #122, #135) residing on the 200 unit and 16 residents (Resident #29, #40, #43, #61, #67, #69, #71, #91, #102, #125, #126, #128, #136, #142, #149, #150) on the 300 unit located in the facility's [NAME] home due to uncomfortable hot water temperatures and room [ROOM NUMBER] located in the facility's [NAME] home affecting Resident #14 due to hot water not working properly and to ensure room [ROOM NUMBER] where Resident #155 resided was free of deep black gouges on the floor. The facility census was 148. Findings include: 1. Interview on 03/30/2026 at 9:35 A.M. with Certified Nursing Assistant (CNA) #254 revealed the hot water tank located on the 200 unit on the [NAME] Wing has been turned off to the resident's rooms due to there being a leak. CNA #254 claimed that per her knowledge this leak has not been addressed or fixed yet. The shower room located on this unit still had hot water and did not affect their ability to provide bathing care for residents. Interview on 03/30/2026 at 9:40 A.M. with Environmental and Safety Director (ESD) #225 revealed the hot water for the 200 unit on the [NAME] Wing has been turned off for about two weeks due to a leak. There was a leak in the plumbing a while ago and they had to areas of the concrete floor up to fix it and now there has been another leak in the flooring. Due to having to dig up the concrete flooring, they were trying to get in touch with a plumbing company that had the special equipment to see the plumbing through the concreate floor so they could locate the exact area where the leak is at. ESD #225 claimed he has reached out to two different placed to see if they can find someone who has specific equipment. According to the two companies ESD #225 had reached out to, they are booked out and could not give a timeframe to come in and evaluate the leak. Call placed on 03/30/2026 at 10:35 A.M. to one of the plumbing companies which ESD #225 had reached out to and provided the contact number for claimed 03/30/2026 was the first time they received a phone call from ESD #225. This company owner claimed the contact number listed online for customers was directly to his personal cell phone and he was the only one who answered this phone. Anyone who called had the ability to leave a voice message and this mailbox was checked frequently. Observation completed on 03/30/2026 at 11:00 A.M. of the 200 hall located on the [NAME] Wing confirmed there was no hot water being delivered to residents' room [ROOM NUMBER]-212. The 200 hall on [NAME] wing was a secured memory care unit (for residents with memory impairment) where 13 residents lived including Rooms 201-212 and Residents #11, #13, #19, #23, #50, #59, #74, #83, #90, #99, #121, #122, #135. 2. Observations on 03/24/26 at 8:07 A.M. in room [ROOM NUMBER] on [NAME] Wing (Resident #40) and on 03/24/26 at 8:20 A.M. in room [ROOM NUMBER] on [NAME] Wing (Resident #29) revealed the hot water felt cool to touch in the sinks in the resident bathrooms. On 03/30/26 at 8:20 A.M. interview with Environmental and Safety Director (ESD) #225 revealed he was not aware of any issues with the hot water on the 300 hall on [NAME] wing. He stated the hot water in the resident rooms and the hot water in the shower room on the 300 hall were controlled by two different hot water tanks. A check of the hot water in the sink in room [ROOM NUMBER] (Resident #40) on 03/30/26 at 8:35 A.M. verified with ESD #225's thermometer and the surveyor's thermometer revealed the hot water was 71 degrees and the hot water in the sink in room [ROOM NUMBER] (Resident #29) at 8:36 A.M. was 73.4 degrees with ESD #225's thermometer and between 72 and 74 degrees with surveyor thermometer. A check of the hot water in the shower in the shower room on the 300 hall [NAME] wing at 8:40 A.M. revealed the hot water was 91.4 degrees with ESD #225's thermometer. (The sink in the shower room had hot water). A check of the hot water in room [ROOM NUMBER] on [NAME] wing on 03/30/26 at 8:55 A.M. with surveyor thermometer revealed the hot water in the sink was 72 degrees. ESD #225 stated the hot water should be between 105-120 degrees. He further stated that it was either a bad element or a bad fuse in the hot water tank causing the resident rooms not to have hot water. Interview with Nursing Assistant #252 on 03/30/26 at 8:45 A.M. revealed she had worked on the 300 hall [NAME] wing the prior week on 03/25/26 and the hot water was just luke warm. Resident #40 and #29 had impaired cognition and were not able to be interviewed to determine if they had concerns from the lack of hot water. The 300 hall on [NAME] wing was a secured memory care unit (for residents with memory impairment) where 16 residents lived including Rooms 300-314 and Residents #29, #40, #43, #61, #67, #69, #71, #91, #102, #125, #126, #128, #136, #142, #149, and #150. Interview with ESD #225 on 03/30/26 at 9:00 A.M. revealed that, after checking, there was a blown element and a popped fuse that was the cause of no hot water in the resident rooms on 300 hall [NAME] wing. On 03/30/26 at 9:40 A.M. he stated that, after adjusting the mixing valve for the shower unit on 300 hall [NAME] wing, he was able to get the hot water up to 101 degrees. 3. Observations on 03/23/26 at 2:14 P.M. revealed the floor in room [ROOM NUMBER] (Resident #155) on [NAME] Wing had multiple dark dirty looking areas upon entering the room and by the resident's recliner. It looked at though someone had used a black marker and made long, black marks on the tile flooring. Observations on 03/30/26 at 10:10 A.M. with ESD #225 in room [ROOM NUMBER] on [NAME] wing revealed ESD #225 confirmed there were multiple black marks covering at least six of the one foot tiles in the center of the room. He stated these marks were actually cuts in the tile in the floor caused by moving the bed around in the room. It was observed that the black marks were actually cuts in the tile and were not cleanable. ESD #225 stated that, due to the amount of tiles affected, the whole flooring needed to be replaced in the room. He stated he was not aware of how long the floor had been that way. 4. Review of Resident #14's medical record revealed the resident was admitted [DATE] and had diagnoses that included quadraplegia, depression, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. Observation of Resident #14's bathroom sink on 03/26/2026 at 9:15 A.M. revealed water barely trickled from the faucet when hot water was turned on. Interview with Environmental and Safety Director (ESD) #225 on 03/26/2026 at 9:18 A.M. confirmed the hot water in Resident #14's bathroom sink did not work.

Based on observations, staff interview, and facility policy review, this facility failed to ensure a food steam table located on the [NAME] Wing was free from buildup, ensure the snack fridge located at the [NAME] nurses station had open food items that were properly dated and failed to prepare food in a sanitary manner in the [NAME] Wing. This had to potential to affect 147 residents residing at this facility as one resident who was noted to receive nothing by mouth (NPO). The facility census was 148. Findings include:Observations completed on 03/30/2026 at 10:30 A.M. of Dietary Manager #211 preparing pureed food for lunch revealed multiple concerns related to handling food in a safe and sanitary manner. Dietary Manager #211 was observed placing a pair of gloves on after completing hand hygiene. Three breadsticks were torn into smaller pieces by this same staff member with gloves hands then placed in [NAME] to be blended into a pureed texture. Dietary Manager #211 proceeded to walk over to the storage closet located in the kitchen to obtain a 2-ounce (oz) spoon to measure each breadstick serving. After letting the blender run for a few moments, Dietary Manager #211 removed the lid and used the 2 oz spoon to scrape food from the upper side of the blender container. A large amount of pureed bread was stuck to the spoon and Dietary Manager #211 was observed using her gloved hand to remove this bread from the spoon. Continued observation revealed Dietary Manger #211 completed hand hygiene then placed on a new pair of gloves. Dietary Manager #211 was then observed picking up multiple bowls of salad, uncovering each bowl and then using her gloved hands to scrap the salad into the blender container. After turning on the blender for a few moments, Dietary Manager #211 used a spoon to scrape the sides of the container and then placed the spoon back onto a metal table. This action was completed two additional times until the salad was at the appropriate pureed texture. Interview on 03/30/2026 at 10:50 A.M. with Dietary Manager #211 confirmed she had initially completed hand hygiene and placed a new pair of gloves on before she tore the breadsticks into smaller pieces but did not complete hand hygiene after touching multiple surfaces in the kitchen including a storage room door handle, and the door itself. Also confirmed after touching multiple surfaces, hand hygiene was not completed prior to using her gloved hand to scrap pureed bread of a spoon. Dietary Manager #211 also confirmed that she had used gloved hands to scrape the salad out for multiple bowl after touching different surfaces while obtaining the salad bowels along with using a spoon that was placed on a bare table to scrap purees salad off the side of the blander container. A barrier should have been placed on the table prior to placing the spoon on the tablet and she should not have used her gloved hands to scrape the salad out of each bowel. Observation of the [NAME] kitchen on 03/23/26 at approximately 8:45 A.M. and on 03/25/26 at 10:17 A.M. revealed the four empty water pans on the steam table had a heavy build up of tan limescale or mineral deposits. (water pans hold the water to create steam to keep food hot). Interview with Dietary Manager #211 on 03/23/26 at approximately 8:45 A.M. confirmed the build up of mineral deposits in the steam table pans. She stated they needed to be cleaned with a de-[NAME] that they would need to get from maintenance. Interview on 03/30/26 at 7:20 A.M. with Licensed Practical Nurse (LPN) #287 identified the refrigerator at the nurses station on [NAME] Wing as being a refrigerator used to store resident snacks/food items. Observations on 03/30/26 at 7:20 A.M. of the refrigerator revealed a large, unlabeled, plastic container of applesauce that was dated 01/04/26 (written on). It did not have a use by date or expiration date. The applesauce was then thrown away by LPN #287. There was also a plastic storage bowl full of spaghetti with room [ROOM NUMBER] written on it (Resident #153). The spaghetti was not dated. LPN #287 stated the resident's family had brought it in. He confirmed it was not dated to determine when it should be used by. There was also a sticky substance spilled inside the refrigerator on the shelves that items on the shelves were stuck to. All of the above was confirmed by LPN #287 at the time of the observation. Review of the facility policy dated 2001 and revised March 2022 and titled Foods Brought by Family/Visitors revealed food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility prepared food. The nursing staff will discard perishable foods on or before the use by date.

Based on observation, medical record review, interview and facility policy review, the facility failed to provide privacy during wound care. This affected one resident (#157) of one resident reviewed for privacy. The facility census was 148. Findings Include: Review of the medical record for Resident #157 revealed an initial admission date of 03/19/26 with the diagnoses including but not limited to dementia, anxiety disorder, abnormal weight loss, urinary tract infection, fracture of lower leg and senile degeneration of brain. Review of the resident's admission assessment with baseline care plan dated 03/19/26 revealed the resident was admitted to the facility with a stage III pressure ulcer to her sacrum measuring 11 centimeters (cm) by 0.5 cm by 0.1 cm and an unstageable pressure ulcer to the left gluteal fold that measured 0.5 cm by 1.0 cm. Further review revealed no description of the either wound. Review of the plan of care dated 03/19/26 revealed the resident has impaired skin integrity as evidenced by stage III pressure ulcer to sacrum and an unstageable pressure to left gluteal fold. Interventions included low air loss mattress in place and pressure redistribution device in chair. Review of the resident's monthly physician orders for March 2026 identified orders dated 03/19/26 barrier cream after each incontinence episode, cleanse stage III pressure ulcer to sacrum with normal saline (NS), pat dry, apply triad paste and cover with foam dressing, cleanse unstageable pressure ulcer to left gluteal fold with normal saline, pat dry, apply triad past and leave open to air twice daily, 03/20/26 enhanced barrier precautions (EBP) due to wounds every shift, 03/24/26 low air loss mattress on bed for pressure reduction, monitor low air loss mattress functioning and check that the settings are appropriate for the resident every shift. On 03/24/26 at 12:51 P.M., an observation of Registered Nurse (RN) #237 provide the physician ordered wound care for Resident #157 revealed the RN provided the wound care to the resident's with the window blind open, facing another wing of the facility withing view of other resident's windows with open blinds. RN #287 verified privacy was not provided during wound care. Review of the facility policy titled, Resident Rights, dated 02/21 revealed federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right of privacy and confidentiality.

Based on medical record review, interviews and facility policy review, the facility failed to honor bathing preferences. This affected one resident (#108) of one resident reviewed for choices. The facility census was 148. Findings Include: Review of the medical record for Resident #108 revealed an initial admission date of 08/23/23 with the latest readmission date of 03/02/26 with the diagnoses including but not limited to chronic kidney disease, post-traumatic stress disorder, paraplegia, retention of urine, diabetes mellitus, mild intellectual disabilities, chronic pain, end stage renal disease, paranoid schizophrenia, major depressive disorder, spinal stenosis, need for assistance with personal care and chronic obstructive pulmonary disease. Review of the plan of care dated 12/18/24 revealed the resident required assistance with showering and the resident was to be showered per facility protocol weekly. Review of the resident's admission assessment with baseline plan of care dated 11/19/25 revealed the resident preferred showers in the morning. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated it was very important to choose between a tub bath, shower, bed bath or sponge bath. On 03/25/26 at 3:20 P.M., an interview with Certified Nursing Assistant (CNA) #306 revealed the resident was scheduled for a shower every Tuesday and Friday. He said all residents who reside on the hallway were capable of being assisted to the central shower room for a shower. CNA #306 verified the facility only staffed one CNA for the 400 hallway and had to go to another hallway and get assist for those residents who require two staff members. CNA #306 verified those residents who required two staff members had longer wait times for assistance and at times showers are not provided due to the lack of staff assigned to the hallway. Review of the resident's bath and skin report from January 2026 revealed the resident had nine opportunities for a shower. Further review revealed the resident had a shower on 01/03/26, 01/20/26 and 01/24/26 and on 01/06/26, 01/10/26, 01/13/26, 01/17/26, 01/27/26 and 01/31/26 the resident received a bed bath. Review of the resident's bath and skin report from February 2026 revealed the resident had eight opportunities for a shower. Further review revealed the resident was given a bed bath on all dates scheduled for a shower. Review of the resident's bath and skin report from March 2026 revealed the resident had seven opportunities for a shower to date. Further review revealed the resident was given a bed bath on all dates scheduled for a shower. On 03/24/26 at 9:03 A.M., an interview with Resident #108 revealed he prefers a shower, however since he was bed bound and requires two assist he was provided bed baths. On 03/26/26 at 11:41 A.M., an interview with Licensed Practical Nurse (LPN) #287 verified the resident was given a bed bath instead of his preferred shower. Review of the facility policy titled, Resident Rights, dated 02/21 revealed federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right of self-determination.

Based on closed record review, interview and facility policy review, the facility failed to notify the resident's representative of a change in condition. This affected one resident (#12) of 36 sampled residents. The facility census was 148. Findings Include:Review of the closed medical record for Resident #12 revealed an initial admission date of 02/03/26 with the diagnoses including but not limited to anemia, cystocele, osteoarthritis, diabetes mellitus, overactive bladder, chronic kidney disease, dementia, urinary tract infection, uterovaginal prolapse, spinal stenosis, osteoporosis, Alzheimer's disease and adult failure to thrive. Review of the resident's admission assessment with baseline plan of care dated 02/03/26 revealed the resident was alert and oriented to her name only. The resident was admitted to the facility with an indwelling urinary catheter for urinary obstruction and cystocele with prolapse. Review of the resident's bowel and bladder evaluation dated 02/05/26 revealed the resident had a urethral catheter due to cystocele with prolapse. The assessment indicated the resident was always continent of bowel and required extensive assistance from one staff member for toileting needs. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident required substantial/maximal assistance with toileting. The resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the progress note dated 02/10/26 at 4:30 A.M. revealed the resident removed her indwelling urinary catheter and stated, I didn't want this in me anymore. The physician was notified and a new indwelling urinary catheter was reinserted. Review of the medical record revealed no documented evidence the resident's power of attorney (POA) was notified of the removal of the indwelling urinary catheter by the resident. Review of the progress noted dated 02/22/26 revealed the resident removed her indwelling urinary catheter. The physician was notified and ordered to leave the catheter out and monitor. Review of the medical record revealed no evidence the POA was notified the catheter was ordered to be left out. On 03/26/26 at 4:30 P.M., an interview with the Administrator verified the resident's POA was not notified the resident had pulled her indwelling urinary catheter out on 02/10/26 and the discontinuation of the indwelling urinary catheter on 02/22/26. Review of the facility policy titled, Change in Condition Policy, dated 09/24 revealed the facility will promptly identify, assess and respond to any significant change in a resident's physical, mental or psychosocial condition. The licensed nurse will ensure timely notification of the physician and resident representative and implement appropriate interventions to maintain the resident's health and safety. This deficiency represents non-compliance investigated under Complaint Number 2799805.

Based on record review and staff interview, the facility failed to provide notice to the office of the state long-term care Ombudsman for resident transfers or discharges. This affected two (Residents #144 and #146) of three closed records reviewed. The facility census was 148. 1. Review of the closed record for Resident #146 revealed an admission date of 02/17/26 with diagnoses including alcoholic cirrhosis, peptic ulcer, hepatic encephalopathy, and protein/calorie malnutrition. The resident was at the facility for two days before being transferred to the hospital on [DATE]. The resident did not return to the facility. (The family requested the resident go to a different facility). Review of an email dated 03/03/26 at 5:48 P.M. from Human Resources Director #274 revealed it stated please find the February transfers and discharges notice from the facility. Resident #146's name was on the list. The email was sent to the State legal department. There was no evidence the State long-term care Ombudsman office was notified of the transfers or discharges. 2. Review of the closed record for Resident #144 revealed an admission date of 01/13/26 with diagnoses including diabetes, alcohol induced pancreatitis, malignant neoplasm of the glottis, congestive heart failure, and acute and chronic respiratory failure. Record review revealed the resident went out to a physician appointment on 01/30/26 and was sent to the hospital from the physician's office for further evaluation. The resident did not return to the facility. Hospital records revealed the resident remained in the hospital until 03/02/26 and was then transferred to another nursing facility. The facility provided a list of residents who were transferred or discharged in January 2026. Resident #144's name was on the list. There was no evidence the list was provided to the State long-term care Ombudsman. Interview with Human Resources Director #274 on 03/30/26 at 9:00 A.M. revealed she thought she was sending the monthly list of resident transfers/discharges to the State long-term care Ombudsman office but did not realize that the email address she was using was for the State legal department. She stated she had been emailing only the State legal department since at least August 2025.

Based on medical record review and staff interview, the facility failed to ensure resident assessments accurately reflected the number of pressure wounds present upon admission to the facility. This affected one (Resident #11) for wound care out of the 36 total sampled residents reviewed for accurate assessments. The facility census was 148. Findings include:Review of the medical record for Resident #11 revealed an admission date of 12/19/2025. Diagnoses included generalized anxiety, dementia, and wedge compression fracture of the thoracic vertebra. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating a severely impaired cognition for daily decision-making abilities. Per this assessment, Resident #11 was noted to have three stage III pressure ulcers (full-thickness skin loss forming a deep, crater-like wound where subcutaneous fat is visible, but muscle, tendons, or bone are not) where two of these three pressure ulcers were present upon admission to the facility. Review of a Skin Observation assessment dated [DATE] revealed Resident #11 had a pressure wound located on the coccyx measuring 5 centimeters (cm) in length by 7 cm in width and unable to determine the depth. Review of a Skin Observation assessment dated [DATE] revealed Resident #11 had a pressure wound to the coccyx which was present upon admission to the facility. Resident #11 was also noted with a pressure wound to the left heel measuring 3 cm in length by 3 cm in width by 0.1 cm in depth, which was not present upon admission to this facility. Resident #11 was also noted a pressure wound to the right heel measuring 3.5 cm in length by 3 cm in width by 0.1 cm in depth. This wound was also not noted to be present upon admission to the facility. Interview on 03/25/2026 at 9:37 A.M, with the Director of Nursing (DON) revealed when a new resident arrives to the facility, it is the responsibility of the floor nurse to complete nursing assessments which include whole body and skin assessments. This assessment is to be completed ASAP but at least within 24 hours post admission. The DON confirmed Resident #11 was admitted to the facility with one pressure wound to the coccyx and this resident's MDS assessment did not accurately reflect this when it indicated this resident had two pressure wounds upon admission, there was only one.

Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) was completed accurately for a resident. This affected one (#8) of five residents reviewed for PASARR. The facility census was 148.Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension, and post-traumatic stress disorder (PTSD). Diagnoses of major depressive disorder and generalized anxiety were added 01/22/26 by the nurse practitioner. Review of the most recent PASARR documentation dated 01/26/26 revealed diagnoses of generalized anxiety and PTSD were not listed for Resident #8.Interview with Social Services Director #366 on 03/25/26 at 11:10 A.M. verified the PASARR dated 01/26/26 was missing additional diagnoses.

Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) was completed timely for a resident. This affected one (#8) of five residents reviewed for PASARR. The facility census was 148. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension and post-traumatic stress disorder (PTSD). Medical record review indicated Resident #8 had diagnosis of PTSD upon admission to facility. The PASARR was completed 10/31/25.Interview with Social Services Director #366 on 03/26/26 at 12:10 P.M. verified the PASARR dated 10/31/25 was not completed within 30-day timeframe from admission to the facility.

Based on record review, observations, family interview, and staff interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care for each resident in the area of pain. This affected one (Resident #155) of four residents reviewed for pain. The facility census was 148.Review of the record for Resident #155 revealed an admission date of 03/17/26 and diagnoses including osteoporosis, chronic kidney disease, hypertension, depression, and anxiety disorder. A brief interview for mental status assessment conducted on 03/18/26 indicated a score of 15, intact cognition. Review of hospital records revealed the resident had a hospital stay from 03/03/26 to 03/17/26. The discharge summary stated the resident was admitted after a fall. She presented with a head hematoma, altered mental status, and left sided weakness. She was diagnosed with an acute traumatic subarachnoid hemorrhage enhanced by aspirin and an acute traumatic glenoid fracture (an injury to the shoulder socket). At the time of discharge to the facility she was afebrile, hemodynamically stable, breathing comfortably, eating a regular diet with oral pain medication, and tolerating therapies. Tylenol 1000 milligrams three times daily was ordered upon discharge. Review of physician's orders revealed an order on 03/17/26 to monitor pain every shift and record pain number on a 0-10 scale. The resident started receiving Tylenol 1000 milligrams three times daily on 03/18/26 at 8:00 A.M. Review of nursing progress notes on 03/19/26 at 12:36 P.M. revealed the resident was found laying on the floor in her room. Alert and oriented x 2. Denied pain. Resident reports mild pain to left shoulder. A left shoulder x-ray was ordered. Review of a progress note by the nurse practitioner on 03/19/26 revealed a fall on this day of visit. Shoulder x-ray reviewed and non-acute. On 03/19/26 a lidocaine patch was ordered daily as needed. (a topical patch to relieve pain). Review of a progress note by the nurse practitioner on 03/20/26 revealed resident reported pain at 5/10 but managed well. (Only Tylenol given. No Lidocaine patches documented as given). Interview with Resident #155's daughter on 03/23/26 at 1:51 P.M. revealed that she felt that after the fall on 03/19/26 the resident was sleeping more, more confused, more delirium towards evening. She stated the resident was not like that at the hospital. She felt she had slowly gotten worse since the fall at the facility 03/19/26. She stated she stays until late evening because she is afraid the resident is going to get up by herself and fall again. She stays until she is asleep. She further stated she did not feel the facility was managing the residents chronic back pain. She stated the resident took Tylenol at home but was having more pain now. During the interview, Resident #155 was in bed and kept fidgeting around in the bed and acted as if she was uncomfortable. Observations on 03/24/26 at 8:28 A.M. revealed the nursing assistant to deliver the residents breakfast tray to the room. The resident was flat in bed. The nursing assistant asked the resident if she wanted to eat and she responded no. The resident was complaining of back pain and was left flat in the bed. The nursing assistant said she would leave the tray in case the resident got hungry. The resident remained in bed with her eyes closed. Observations on 03/24/26 at 10:03 A.M. revealed the resident's son was visiting. The resident was up in a recliner in the room. He stated he felt the resident's cognition had declined since being at the facility. The resident was observed to be moaning out in pain. She was stating that the pain was in her upper back. He stated that she is not usually like this and this pain level is not consistent with what she has had prior. He stated for the last two days she just wants to lay in bed. (The resident's yelling and moaning out in pain could be heard in the hallway). No staff responded. On 03/24/26 at 10:14 A.M. the surveyor summoned the unit nurse (LPN #404) and Corporate Nurse #401 to come to the room due to the resident repeatedly yelling out in pain over and over again. The resident continued to yell out in pain when they entered the room. Interview with LPN #404 on 03/24/26 at 10:16 A.M. revealed she was an agency nurse and this was the first time she had ever worked on that hallway. She confirmed that Resident #155 had been hollering out in pain this morning and she gave her the scheduled Tylenol around 8:50 A.M. She stated she went back to the room around 9:30 A.M. and the resident was still in pain so they got her up in the recliner. She stated she had not been back to assess the resident since around 9:30 A.M. Observations on 03/24/26 at 10:20 A.M. revealed the nurse practitioner to enter Resident #155's room. He stayed in the room approximately 3-5 minutes. Review of the nurse practitioner note on 03/24/26 revealed in obvious discomfort on exam. Reports neck, low back, and sacral pain. Uncontrolled with conservative treatments. (Review of medication administration record revealed the Lidocaine patch ordered on 03/19/26 was never documented as being administered prior to 03/24/26). Review of a nursing progress note on 03/24/26 at 10:30 A.M. revealed resident noted to be sitting up in reclining chair yelling out. This nurse assessed resident. Resident stated she had pain in spine. Floor nurse stated resident was given Tylenol around 8:30 A.M. Resident voiced lying flat helps with the pain. Resident transferred to bed and repositioned. Nurse practitioner in house and assessed resident at bedside. New orders received. The next nursing progress note on 03/24/26 at 10:35 A.M. stated Oxycodone 2.5 milligrams (narcotic pain medication) was ordered due to an increase in pain to left shoulder, neck, and mid back that was unrelieved with non-pharmacological interventions. None of the progress notes indicated the residents level of pain on a scale of 0-10. Observations on 03/24/26 at 10:32 A.M. revealed the resident to be in bed. The resident was moaning out repeatedly in pain. Her son asked her what month it was and she said April, then July (it was March). He asked her what day it was and she said Thursday (it was Tuesday). Observations on 03/24/26 at 10:37 A.M. revealed the resident to still be moaning out repeatedly in pain. Review of the medication administration record revealed the Oxycodone pain medication ordered by the nurse practitioner was given on 03/24/26 at 10:46 A.M. Review of a nursing progress note on 03/24/26 at 10:46 A.M. revealed the Oxycodone was given due to complaints of pain and resident is calling out. The nurse attempted to resolve pain with Tylenol (given around 8:30 A.M. per previous note) and attempt was unsuccessful. Observations on 03/24/26 at 11:10 A.M. revealed the resident to be in bed, moaning repeatedly and saying help. (no staff in room). Observations on 03/24/26 at 11:13 A.M. revealed Nursing Assistant #246 to be walking down the hall with another resident towards the shower room. She stated she was the only aide on the hall. She walked by Resident #155's room where the resident could be heard in the hallway moaning and yelling out. Nursing assistant #246 walked on by the room and went into the shower room with the other resident. (There was no other staff in Resident #155's room). Observations on 03/24/26 at 11:15 A.M. revealed Registered Nurse (RN) #500 to enter the resident's room. The resident was still complaining of pain. RN #500 said she would get the resident a Lidocaine patch. Review of a nursing progress note on 03/24/26 at 11:16 A.M. revealed the resident reported pain at 4 out of 10. The note indicated the medication was effective. Observations on 03/24/26 at 11:18 A.M. revealed Director of Therapy Services #336 enter the room. The resident was in bed. Director of Therapy Services #336 asked the resident if she wanted to sit in a chair, even though she had just been placed in bed at 10:30 A.M. due to pain while up in the chair. Observations on 03/24/26 at 11:20 A.M. revealed a Lidocaine patch was applied to the residents shoulder. Review of a nursing progress note on 03/24/26 at 11:20 A.M. revealed the nurse assessed resident after administering pain medication. Resident reported pain level 4 out of 10 after receiving. Nurse to put lidocaine patch on resident per her request. Although resident says pain medication was effective, she still continues to yell out. Review of a nursing progress note on 03/24/26 at 11:29 A.M. revealed the resident had a change in condition of pain (uncontrolled). An order was received to send the resident to the hospital for evaluation. Review of a change in condition evaluation form for 03/24/26 at 11:29 A.M. completed by Licensed Practical Nurse (LPN) #223 revealed the resident had acute, uncontrolled pain of the back. It stated the resident was not cognitively able to rate pain scale. It stated the pain started on the night of 03/23/26. It stated she had memory loss-new or worsening, an abrupt decline in memory or mental status without other apparent symptoms and needs more assistance with activities of daily living including ambulation, bathing, bowel and bladder management, dressing, and transferring. Observations on 03/24/26 at 11:50 A.M. revealed emergency personnel entering Resident #155's room to transfer her to the hospital. The resident did not have a plan of care for pain. This was confirmed by the Director of Nursing on 03/30/26 at 8:25 A.M.

Based on medical record review and staff interview, the facility failed to develop and implement a person-centered comprehensive care plan. This affected one (#8) of 36 residents reviewed for care planning. The facility census was 148. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension, and post-traumatic stress disorder (PTDS). Diagnoses of major depressive disorder and generalized anxiety were added 01/22/26 by the nurse practitioner. Medical record review of the most recent Minimum Data Set (MDS) assessment dated [DATE] validated diagnoses of major depressive disorder, generalized anxiety and PTSD. Recent care plan dated 03/11/26 revealed anxiety, depression and PTSD were not addressed in plan of care. Interview with Social Services Director #366 on 03/26/26 at 12:10 P.M. verified the care plan did not address anxiety, depression and PTSD for Resident #8.

Based on closed medical record review, hospital record review, interview, and facility policy review, the facility failed to ensure Resident #139, who was admitted to the facility on [DATE] was provided antibiotics timely and as ordered at the time of hospital discharge and failed to ensure laboratory testing associated with the antibiotic use was completed as required to properly treat the resident's osteomyelitis and to prevent complications. Actual harm occurred on 10/01/24 when Resident #139 was transferred to the hospital for treatment of Vancomycin toxicity and acute kidney injury after the facility failed to monitor the antibiotic through laboratory testing. This affected one resident (#139) of eight residents reviewed for laboratory monitoring/testing. The facility census was 137. Findings include: Review of the closed medical record for Resident #139 revealed an admitted [DATE] with diagnoses including Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer of the sacral region, osteomyelitis of vertebra sacral and sacrococcygeal region, and the use of antibiotics. Record review revealed the resident was discharged to the hospital on 10/01/24. Review of Resident #139's Clinical Discharge Instructions from the hospital dated 09/18/24 revealed under section titled Discharge Diagnosis and Plan revealed the resident was receiving intravenously (IV) Cefepime (antibiotic) and Vancomycin (antibiotic) which would be continued for 6 to 8 weeks. Weekly labs. Labs ordered included C-Reactive Protein, CBC with Diff, Erythrocyte Sedimentation Rate, Renal Function Panel, and Vancomycin Trough level. However, review of the resident's physician admission orders, dated 09/18/24 revealed no orders were written for the resident to continue/receive the IV Cefepime or IV Vancomycin at the facility. In addition, there were no admission orders written for weekly labs as noted in the resident's clinical discharge instructions from the hospital dated 09/18/24. Record review revealed no evidence facility staff obtained clarification of these orders at the time of admission. Review of a progress note dated 09/18/24 at 9:55 P.M. created by Licensed Practical Nurse (LPN) #250 revealed Resident #139 was admitted to the facility at 8:00 P.M. via ambulance on a stretcher. The resident was a full code (advance directives), had no known allergies and was a diabetic. The resident was noted to have a peripherally inserted central catheter (PICC) line, had a Foley catheter and feeding tube. Review of the nursing progress note revealed no documentation was noted related to the resident's antibiotics or laboratory testing. Review of a progress note dated 09/20/24 at 2:05 P.M. (two days after admission) created by LPN #238 revealed a new order for IV antibiotics Vancomycin and Cefepime for six weeks due to osteomyelitis. Resident and pharmacy made aware of new orders. Labs also ordered weekly every Monday and to report labs (to physician) every Monday for six weeks. Review of Resident #139's physician orders for September 2024 revealed an order written on 09/20/24 for Vancomycin 1000 milligrams (mg)/200 milliliter (ml) every 12 hours. The resident had an order, dated 09/20/24 for Cefepime 2 grams (gm)/100 ml three times a day. Resident #139 also had labs orders written on this date for a Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), test and a pre Vanco level every Monday with the start date of 09/23/24. The order noted for the lab results to be faxed to the physician. Review of the medication administration record for September 2024 revealed the resident received his first dose of Cefepime in the facility on 09/21/2024 at 6:00 A.M. (three days after admission) and his first dose of Vancomycin on 09/20/2024 at 9:00 P.M. (two days after admission). Record review revealed Registered Nurse (RN) #241 documented on the treatment administration record that the ordered laboratory testing was completed on both 09/23/24 and 09/30/24; however, there was no additional information contained in the resident's medical record to support this laboratory testing was actually completed. Review of a progress note dated 09/23/24 at 9:52 A.M. created by Unit Manger #118 revealed, called Nurse Practitioner #501 with infectious Disease for clarification of labs. Review of a progress note dated 09/24/24 at 1:22 P.M. created by Unit Manager #118 revealed, the unit manager spoke with Nurse Practitioner #501 with infectious disease, a new order was received for labs to start on 09/30/24. The note also included there was an order to fax to infectious disease. Review of a progress note dated 10/01/24 at 12:01 P.M. created by RN #241 revealed the lab was in to draw the resident's Vanco trough level. Lab drawn and taken to lab. Review of a progress note dated 10/01/24 at 2:07 P.M. created by RN #241 revealed critical lab called to this nurse for Vanco trough of 30.3 (elevated). Nurse Practitioner #501 with infectious disease notified. New order received to transfer resident to the emergency room . Nurse Practitioner #501 notified the local hospital. Review of the completed laboratory testing for Resident #139 (from admission through discharge) revealed the only lab that was completed was dated 10/01/24 which was for the Vanco trough level. The lab result was critically high with a reading of 30.3. Per information contained on the lab paperwork the normal range for a Vanco trough was between 10.0-20.0 microgram per milliliter. Review of the hospital paperwork for Resident #139 dated 10/01/2024 revealed this resident had diagnoses of acute kidney injury (AKI), Vancomycin overdose, and PICC line complications. Continue review revealed the resident's creatinine level was elevated at 1.6 with a normal range between 0.7-1.3 mg/ml. (An elevated creatinine level indicated your kidneys weren't working properly). The resident's Vancomycin level was 30.9 and with the elevated creatinine level and monitoring needed to be completed. As of 10/06/24 the assessment and plan for the resident's osteomyelitis of the vertebra, sacral and sacrococcygeal region was that the patient was at a high risk due to requiring drug therapy, IV Vancomycin that required intense monitoring for toxicity, monitoring trough levels. Trough level noted to be at 30.9. Recommendations to discontinue Vancomycin due to toxicity and renal failure. Patient was stared on IV Daptomycin (antibiotic) in addition to continuing the IV Cefepime. For the AKI, the resident's renal function continued to worsen despite being on IV fluids with a creatinine level this morning of 3.12 from 2.95 and a Glomerular Filtration Rate (GFR) (blood test used to measure how well kidneys are filtering waste and extra fluid from the blood) rate from 21 to now 20. A GFR of 60 or higher was in the normal range. Below 60 may indicate kidney disease and below 15 may indicate kidney failure. This was suspected secondary to Vancomycin toxicity. The resident remained hospitalized as of 10/09/24. Interview on 10/07/24 at 10:40 A.M. with the DON revealed the facility contacted the infectious disease office to clarify the lab orders however, this was not done until 09/23/2024. The DON revealed she believed the facility had drawn labs on 09/30/24 and it resulted with a critical high Vanco trough level. The facility then received the order to send Resident #139 to the hospital and the rest of his ordered labs would be drawn there. A follow-up interview with the DON on 10/07/24 at 11:04 A.M. revealed when she reviewed the resident's hospital discharge instructions related to labs being completed weekly, the DON claimed they did not complete labs prior to 09/30/24 because they didn't have any orders to draw labs. When asked why staff did not call/obtain clarification prior to 09/23/24, the DON indicated she was not sure why no one called prior to that. The DON then verified the lab was not actually drawn on 09/30/24 as scheduled but was drawn on 10/01/2024. The DON also verified not all the scheduled labs were drawn for the resident following the hospitalization and she was not sure why only the Vanco trough was drawn on 10/01/24. Interview on 10/07/24 at 12:02 P.M. with RN #241 revealed she worked on 09/23/24 and marked the laboratory testing as completed because Resident #139 had a bandage that appeared like he had blood drawn and when she asked him if someone came and drew his labs, he said yes. RN #241 confirmed she had not received any resulted labs for 09/23/24 which normally results would come the same day. RN #241 also stated she had not drawn Resident #139's blood for lab work on 09/30/24 because she stated there was nothing in the system popping up to inform her this was scheduled to be done that day. Lab was contacted and they came to the facility and obtained the blood work on 10/01/2024 which resulted in the critical Vanco trough level. Interview with Hospital Staff #500 on 10/07/24 at 3:12 P.M. revealed Resident #139 was discharged from the hospital to the skilled nursing facility on 09/18/24. On that day, the hospital nurse explained all the discharge orders to the facility nurse. The expectation was that the Vancomycin lab order (along with the other labs) were to be completed on Monday, 09/23/24. She stated she called the facility on 09/24/24 to find out what the Vancomycin lab results were. She spoke with Unit Manager #118, who confirmed the labs were not taken and stated she was told they would get them when the labs were due again on Monday, 09/30/24. She told Unit Manager #118 they would like the labs to be done the next day or Thursday (09/25/24 or 09/26/24); she stated they would get it done. There was also an order for the routine Vancomycin trough level (along with all the other labs ordered) to be done on Monday, 09/30/24. They first received lab results from the Vancomycin testing on 10/01/24 which was a critically high number, which was why they stated Resident #139 needed to go to the hospital. Hospital Staff #500 confirmed there were multiple dates in which the facility was to get labs completed, and they were not done. Interview with LPN #238 on 10/08/24 at 12:17 P.M. revealed she was going through the resident's discharge paperwork from the hospital for Resident #139 on 09/20/2024 and then contacted the hospital/physician (at that time) to discuss the resident's Vancomycin orders. She stated she wasn't sure if the resident was to continue the Vancomycin, so she called to clarify. The LPN stated she put the new order in for Vancomycin to continue and for the lab work to be done on each Monday. She stated she put the order in for lab work to be done on 09/23/24. When asked again why she made the call to clarify the orders (on 09/20/24), she stated she was looking at the discharge paperwork from the hospital. She stated she didn't know why the orders were not clarified on 09/18/24 when the resident was admitted . Attempts to reach LPN #250, the nurse who admitted the resident on 09/18/24, by telephone on 10/07/24 and 10/08/24 were unsuccessful. Review of the facility policy titled, Lab and Diagnostic Test Results-Clinical Protocol, revised 09/2012 revealed the physician would identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff would process the test requisitions and arrange for the test. A nurse would review all results and the person who was to communicate results to the physician would review and be prepared to discuss any concerns or issues the physician will be expected to address upon receiving the results. This deficiency represents non-compliance investigated under Complaint Number OH00158452. This deficiency is also an example of continued non-compliance to the survey dated 08/29/24.

Based on interviews, observations, record reviews, and facility policy review, the facility failed to complete vital signs and a transfer form when change of condition was required for Resident #115. This affected one resident (#115) for change of condition and the facility also failed to order daily weights for Resident #442 after surgery upon readmission affecting one resident (#443) reviewed. The facility census was 140. Findings include: 1. Review of Resident #115's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a chronic or unspecified gastric ulcer with hemorrhage, long term (current) use of aspirin, acute post hemorrhagic anemia, Barrett's Esophagus without dysplasia, gastrostomy status, hematemesis, and unspecified dementia. Review of Resident #115's progress notes revealed a nurses note dated 07/23/24 at 6:08 A.M. that indicated the resident was throwing up black stuffs and was given Zofran (anti-emetic). The resident continued throwing up and the nurse notified an on call nurse practitioner. Directive was given to send the resident to the emergency department (ED). There was no documented evidence of the nurse obtaining vital signs on the resident upon his change in condition. Further review of Resident #115's progress note revealed a nurse's note dated 07/23/24 at 1:47 P.M. that indicated an update was received from the hospital and the facility was informed the resident had been admitted to the hospital for a gastrointestinal (GI) bleed and blockage. Review of Resident #115's transfer records from the facility that was provided to the receiving hospital revealed the only forms sent with the resident to the hospital was a copy of his admission record (face sheet) that included the resident's personal information, contacts, code status, and diagnoses and a copy of the resident's active physician's orders. There was no evidence of a transfer form being sent with the resident that included vital signs or other relevant information needed for purposes of continuity of care. Review of Resident #115's vital signs recorded under the vital sign tab of the electronic medical record (EMR) revealed there was no evidence of the resident's vital signs being obtained at the time of his change in condition on 07/23/24 around 6:00 A.M. The last vital signs that had been recorded (prior to the resident's hospital transfer) was on 07/22/24 at 11:23 P.M. as recorded by the night shift nurse that sent the resident out the morning of 07/23/24. Review of Resident #115's hospital records for his transfer to the ED on 07/23/24 revealed the resident was found to have a low blood pressure when he arrived at the ED on 07/23/24 at 7:05 A.M. His blood pressure was recorded as being 90/57 mm/hg and he had been given a liter of intravenous fluid in the ER raising his blood pressure to 120 systolic (top number of a blood pressure reading). He was admitted to the hospital with a GI bleed. On 08/22/24 at 11:05 A.M., an interview with Registered Nurse (RN) #140 revealed she could not find any evidence of a transfer form (eINTERACT Transfer Form) being completed for Resident #115's transfer to the hospital on 07/23/24. She stated their transfer paperwork should have included the eINTERACT Transfer Form, in addition to the face sheet and active physician's orders, for continuity of care purposes. She was asked what should be included as part of an assessment when a resident had a change in condition. She confirmed the assessment should have included obtaining the resident's vital signs. She verified there was no evidence the nurse, that assessed the resident and transferred him to the hospital, obtained vital signs as part of the assessment. She acknowledged the hospital records indicated the resident was found to be hypotensive, while at the hospital, and was given intravenous fluids. She initially indicated the nurse may not have obtained vital signs due to the resident having hematemesis and the nurse already knew he needed to be transferred to the hospital. She then acknowledged that vital signs should have been part of an assessment with a change in condition and the nurse would have had time to obtain them prior to EMS services arriving for transport. Review of the facility's policy on Change in a Resident's Condition or Status revised May 2017 revealed the nurse would record in the resident's medical record information relative to the changes in the resident's medical condition or status. The facility denied having a policy specific to hospital transfers and provided an Acute Care Transfer Document Checklist in it's place. Documents recommended to accompany the resident to the receiving acute care facility included a resident transfer form. 2. Review of Resident #443's medical record revealed the resident was admitted to the facility on [DATE]. His diagnosis included surgical aftercare following surgery on the circulatory system (Coronary Artery Bypass Graft x 5). Review of Resident #443's Patient Discharge Instructions dated 07/26/24 from the transferring acute care facility revealed the resident was to have a daily weight obtained. The cardio-thoracic surgery discharge instructions provided in addition to the patient discharge instructions indicated the resident was to be weighed daily. It further indicated they were to call the cardio-thoracic surgeon's office to report any sudden weight gains of three or more pounds in one day or five pounds over one week. Review of Resident #443's physician's orders from his date of admission on 07/26/24 until his discharge on 08/20/24 revealed the resident did not have an order for obtaining a daily weight until 08/01/24. The order added on 08/01/24 included the need to notify the provider if there was a two pound weight gain over night or a five pound weight gain in one week. Review of Resident #443's weights recorded under the vital sign tab of the electronic medical record (EMR) revealed the resident was not being weighed daily as per the patient discharge instructions provided to the facility on [DATE], at the time of his admission. He had a weight of 269.8 pounds on 07/26/24 and a weight of 267.8 pounds on 07/27/24. He was then not weighed again until 07/30/24, when he weighed 269.4 pounds. Weights recorded after that were sporadic and were not obtained daily as ordered, even after the daily weight was ordered on 08/01/24. Review of Resident #443's medication administration record (MAR) revealed there was no daily weights recorded between 07/26/24 and 07/31/24. The August 2024 MAR did add the order to obtain daily weights beginning on 08/01/24, after another order was given to obtain daily weights. There was no weights recorded for 08/05/24 or 08/11/24, even after another order for daily weights was obtained on 08/01/24. Review of Resident #443's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors nor was he indicated to reject care. On 08/19/24 at 2:28 P.M., an interview with Resident #443 revealed he was told by his heart doctor that his weight should be monitored daily. He denied the facility staff were checking his weights daily and indicated he had to do it on his own. On 08/22/24 at 4:25 P.M., an interview with RN #140 confirmed Resident #443's order for him to be weighed daily that was included on his patient discharge instructions from the hospital was not carried over when the resident was admitted to the facility on [DATE]. She stated it was not until 08/01/24 that they noted the order for the daily weight was missed. They obtained an order for the daily weight on 08/02/24 and the order also included parameters on when to notify the physician if a weight gain of 2 or more pounds were noted in a day or five pounds were noted in a week. She further confirmed, even after the daily weight was ordered, there were two days in which a daily weight had still not been obtained and recorded. She acknowledged the importance of monitoring a resident's daily weight following cardio-thoracic surgery in which a quintuple bypass procedure was done.

Based on observation, record review, fall investigation review, staff interview and safety belt installation instructions, the facility failed to properly secure one resident (Resident #38) during a transport in the facility's bus. Actual harm occurred on 05/06/24 when Resident #38 who was in a manual wheelchair was placed in the facility bus for transport. The wheelchair was secured with the wheelchair tie down and belts, however, the resident was not secured as recommended with both a torso and pelvic seat belt. The resident slid out of the wheelchair onto the floor of the bus and sustained a left femoral shaft fracture and left great toe fracture. This affected one (Resident #38) of six residents reviewed for falls. The facility census was 140. Findings Include: Review of the medical record for Resident #38 revealed an initial admitted [DATE] with the latest readmission of 04/08/24 with diagnoses including but not limited to retention of urine, acute kidney failure, severe sepsis, speech disturbances, dysphagia, urinary tract infection, cerebral infarction, psychotic disorder with hallucinations, chronic coronary microvascular dysfunction, Parkinson's disease, anxiety disorder, hypothyroidism, diabetes mellitus, major depressive disorder, severe morbid obesity, Rheumatoid arthritis, congestive heart failure, lymphedema, metabolic encephalopathy, hypertension, osteoarthritis, chronic kidney disease, obstructive sleep apnea, hyperlipidemia, peripheral vascular disease, right above the knee amputation, chronic obstructive pulmonary disease, dementia, anemia, gastro-esophageal reflux disease, chronic pain, obstructive and reflux neuropathy, neuromuscular dysfunction of bladder and benign prostatic hyperplasia. Review of the plan of care dated 08/31/19 revealed the resident was at risk for falls related to deconditioning, unaware of safety needs, Parkinson's disease, decreased mobility, activity tolerance, muscle weakness, CHF and COPD with shortness of breath. Interventions included bed against wall per resident preference, bilateral mobility bars to bed, encourage the resident to attend activities that minimize the potential for falls while providing diversion and distraction, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, keep the resident's call light within reach and encourage the resident to use it for assistance as needed, mechanical lift required for transfers due to advanced Parkinson's disease, provide resident with a safe environment, therapy to evaluate and treat as ordered and as needed and resident/family/legal representative has been educated to call for assistance by using call light for mobility needs to reduce risk for falls. Review of the resident's falls risk evaluation dated 04/12/24 revealed a score of 10 indicating the resident was at risk for falls. Review of the progress note dated 05/06/24 at 4:00 P.M. revealed the resident was returning from transport at an area hospital when the facility Former Transport Driver (FTD) #274 turned the corner, the resident slid from his wheelchair and landed on the floor of the transport vehicle. The transport driver and State tested Nursing Assistant (STNA) #179 were unable to get the resident up so 911 was called. The medics arrived on scene and were able to get the resident from the bus to their cot and suggested the resident be transported to the local emergency department (ED) for an evaluation. At the ED the resident was found to have a left broken great toe. The resident was discharged and transported back to the facility. Review of the discharge summary from the ED visit dated 05/06/24 revealed the resident was treated for fall from wheelchair, laceration and hematuria. Review of the facility fall investigation dated 05/06/24 at 1:40 P.M. revealed the facility was notified the resident sustained a fall while being transported back from an appointment in the facility bus. The incident revealed the resident slid from his wheelchair onto the floor of the facility bus. The resident stated he slid from his wheelchair when FTD #273 turned a corner. The resident was transported to a local ED by 911 and found to have a broken left great toe. Review of the medical record revealed no documented evidence the resident was assessed following the fall including the broken left great toe. Review of the resident's progress note dated 05/08/24 at 12:42 P.M. a new order was obtained for X-ray of left hip, knee, tibia and fibula. The facility's contracted X-ray company was made aware of the need for the X-ray. Review of the progress note dated 05/09/24 at 8:40 A.M. revealed the resident was complaining of pain to his left knee and the pain was getting worse after the Certified Nurse Practitioner (CNP) had prescribed him the medication Prednisone for swelling. The resident's knee was swollen and painful to touch. The resident stated nothing really made the pain better and medication helps a little bit, but it's still quite painful. The resident stated being mobile increased the pain. The physician was notified and an order for X-ray was obtained. Review of the resident's May 2024 Medication Administration Record (MAR) revealed no documented evidence the resident was given an analgesic for the reports of pain to the left knee. Review of the X-ray results dated 05/09/24 revealed the results of the X-ray were reported on 05/09/24 at 1:15 P.M. Further review revealed the resident had a supracondylar knee fracture (also called distal femur fracture). Review of the resident's progress note dated 05/10/24 at 10:20 P.M. revealed the resident returned from the local ED with diagnosis of left femoral shaft fracture and was treated with immobilization, Hydrocodone-acetaminophen 5-325 milligrams (mg) with the special instructions to administer two tablets by mouth every for hours as needed for pain and follow up appointment with ortho scheduled for 05/17/24. Review of the acute care hospital discharge summary dated 05/10/24 revealed the resident was treated for a left femoral shaft fracture (a break in the long straight part of the thigh bone.). The resident was treated with an immobilizer to the left leg, pain medication and a follow up appointment with orthopedics on 05/17/24. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident has an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated the resident has not had any falls since the prior assessment. The resident's weight was 255 pounds and had no know weight loss. Review of the state optional MDS assessment dated [DATE] reveled the resident was dependent on two staff for bed mobility, transfers, and toilet use. On 08/21/24 at 10:04 A.M., observation of Resident #38 revealed his left leg was externally rotated outward causing the outer part of the left foot to rest on the bed. 08/21/24 12:28 PM interview with STNA #179 revealed she was riding in the back of the bus with Resident #38. STNA #179 revealed FTD #179 failed to ensure the resident was secured with the pelvic and chest belts. She said when they pulled out of the parking lot the resident slid from his wheelchair onto his buttocks. STNA #179 revealed she was not trained in securing a resident in the bus. She revealed it was a new facility bus and it was her first time on the bus. STNA #179 revealed transport staff received training on the bus seat belt following the incident. On 08/22/24 at 3:53 P.M., interview with Regional Director of Operations (RDO) #274 verified the resident's manual wheelchair was tied down with the four-point system, however the resident was not secured as recommended with the chest and pelvic belts. RDO #274 revealed FTD #273 received training on the securing a resident on the bus prior the incident. RDO #273 revealed FTD #273 was terminated from employment with the facility due to not securing a resident properly following the additional training. Review of the statement dated 05/07/24 revealed FTD #273 received training and provided a return demonstration regarding safety protocol that must be followed when transporting residents in facility vehicles or bus. The training included how to properly secure safety belts to the wheels of the wheelchair, how to properly secure the safety belt that is positioned across the resident. Review of the four-point wheelchair securement system instructions revealed the four point wheelchair and occupant securement systems, when used as recommended, provide the safest means of transportation for wheelchair passengers unable to transfer from their wheelchairs when traveling in motor vehicles. Each component has been designed, engineered and tested to work as one comprehensive system.

Based on observation, record review, staff interviews, review of wound notes, and facility policy review, the facility failed to accurately assess an identified pressure area and implement interventions to prevent a stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling pressure ulcer to the interdigit of the left fourth and fifth toe and the left fifth toe) for Resident #38. In addition, the facility failed to accurately assess an identified pressure area and implement interventions to prevent worsening of a right heel pressure ulcer for Resident #49. Actual harm occurred on 06/06/24 when Resident #38 who required extensive assistance from two staff and was incontinent, had a Stage III pressure ulcer interdigit of the left fourth and fifth toe and the outer fifth toe was not comprehensively assessed, not providing implementation of appropriate prevention interventions, and treatment or adequate assessments of the wound area. Actual harm occurred on 08/19/24 when Resident #49 who required assistance with mobility, had a suspected deep tissue injury (SDTI), (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 his right heel that deteriorate to an unstageable (full thickness tissue loss in which the base of the ulcer was covered by slough and/ or eschar in the wound bed) pressure ulcer and was not being accurately assessed, not providing implementation of appropriate prevention interventions, and treatment or adequate assessments of the wound area. This affected two (Resident #38 and Resident #49) of five reviewed for pressure ulcers. The facility census was 140. Findings Included: 1. Review of the medical record for Resident #38 revealed an initial admitted [DATE] with the latest readmission of 04/08/24 with diagnoses including but not limited to retention of urine, acute kidney failure, severe sepsis, speech disturbances, dysphagia, urinary tract infection, cerebral infarction, psychotic disorder with hallucinations, chronic coronary microvascular dysfunction, Parkinson's disease, anxiety disorder, hypothyroidism, diabetes mellitus, major depressive disorder, severe morbid obesity, Rheumatoid arthritis, congestive heart failure, lymphedema, metabolic encephalopathy, hypertension, osteoarthritis, chronic kidney disease, obstructive sleep apnea, hyperlipidemia, peripheral vascular disease, right above the knee amputation, chronic obstructive pulmonary disease, dementia, anemia, gastro-esophageal reflux disease, chronic pain, obstructive and reflux neuropathy, neuromuscular dysfunction of bladder and benign prostatic hyperplasia. Review of the plan of care dated 07/28/23 revealed the resident had a potential for pressure ulcer development related to reduced mobility and activity intolerance. Interventions included administer medications as ordered, dietary supplements as ordered, labs as ordered, observe for changes in skin status, observe nutritional status for adequate intake, skin assessment as indicated, the resident required assistance with activities of daily living (ADL) and mobility needs, the resident requires pressure relieving/reducing device on bed and/or chair and treatments as ordered and observe for effectiveness. Review of the resident's readmission assessment with baseline care plan dated 04/09/24 revealed the resident was not admitted to the facility with any pressure ulcers to his left foot. Review of the resident's Braden scale dated 04/09/24 revealed a score of 12 indicating the resident was at high risk for skin breakdown. Review of the plan of care dated 04/09/24 and last revised on 07/30/24 revealed the resident had an actual area of skin impairment, skin tear to left buttocks and deep tissue pressure injury (DTPI) to left fifth toe. Interventions included evaluate for pain and provide pain relieving interventions as ordered, initiate wound treatment, continue treatment as ordered by the physician, nursing to observe the wound dressing daily to ensure the dressing remains intact and there are no signs/symptoms of infection or increased drainage, observe for clinical changes such as infection and/or worsening of wound, refer to dietician to determine need/no need for dietary intervention and skin observation and document on bath/shower days, charge nurse to notify the wound nurse, physician and family of any new areas. Review of the weekly non-pressure skin grid dated 06/06/24 revealed the facility identified the resident had a wound to the left third toe measuring 1.5 centimeters (cm) by 0.8 cm with 70% granulation and 30% eschar. The facility also identified a wound to the left great toe measuring 1.8 cm by 1.0 cm with 100% eschar. The wounds had no staging or presence of exudate. Review of the weekly non-pressure skin grid dated 06/13/24 revealed the facility corrected the locations of the left interdigit between toes fourth and fifth and the left fifth toe. The left interdigit between the fourth and fifth toes measured 1 cm by 0.5 cm and was 100% granulation tissue. The left fifth toe measured 1.5 cm by 1.0 cm and was 100% eschar. The assessment contained no staging, presence of exudate or determination if the wound had improved, deteriorated or remained unchanged. Review of the weekly non-pressure skin grid dated 06/20/24 revealed the left interdigit between the fourth and fifth toes measured 0.3 cm by 0.5 cm by less than 0.1 cm with 100% granulation. The left fifth toe measured 1.5 cm by 1.0 cm and was 100% eschar. The assessment contained no staging, presence of exudate or determination if the wound had improved, deteriorated or remained unchanged. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident has an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had one stage III pressure ulcer and one deep tissue injury (DTI) [purple or maroon localized area of discolored intact skin or blood filled blister] that were not present on admission. The facility implemented pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of non-surgical dressing other than to feet, application of ointments/medications other than to feet and application of dressing to feet. Review of the state optional MDS assessment dated [DATE] reveled the resident was dependent on two staff for bed mobility, transfers, and toilet use. Review of the weekly non-pressure skin grid dated 06/27/24 revealed the left interdigit between the fourth and fifth toes measured 0.3 cm by 0.5 cm by less than 0.1 cm with 100% granulation. The left fifth toe measured 1.5 cm by 1.0 cm and was 100% eschar. The assessment contained no staging, presence of exudate or determination if the wound had improved, deteriorated or remained unchanged. Review of the weekly non-pressure skin grid dated 07/02/24 revealed the left interdigit between the fourth and fifth toes measured 0.3 cm by 0.3 cm by less than 0.1 cm with 100% granulation. The left fifth toe measured 1.5 cm by 0.8 cm and was 100% eschar. The assessment contained no staging, presence of exudate or determination if the wound had improved, deteriorated or remained unchanged. Review of the weekly non-pressure skin grid dated 07/08/24 revealed the left interdigit between the fourth and fifth toes and left fifth toe was not measured due to the resident refused to lay down. Review of the medical record revealed no documented evidence the facility attempted to assess the wound at a later time and/or date. Review of the weekly non-pressure skin grid dated 07/15/24 revealed the left interdigit between the fourth and fifth toes measured 0.3 cm by 0.3 cm by less than 0.1 cm with 100% granulation. The left fifth toe measured 0.8 cm by 0.8 cm and was 100% eschar. The assessment contained no staging, presence of exudate or determination if the wound had improved, deteriorated or remained unchanged. Review of the weekly pressure skin grid dated 07/22/24 revealed the facility staged the wound as a stage III pressure ulcer to the left interdigit of the fourth and fifth toes measuring 0.2 centimeters (cm) by 0.3 cm by less than 0.1 cm with 100% granulation tissue. The wound had a moderate amount of drainage. The facility determined the wound had improved. Review of the medical record revealed no documented evidence the facility assessed the wound to the resident's left fifth toe on 07/22/24. Review of the weekly pressure skin grid dated 07/29/24 revealed the Stage III pressure ulcer to the left interdigit of fourth and fifth left toes was healed. Review of the weekly pressure skin grid dated 07/29/24 revealed the stage III pressure ulcer to the left fifth metatarsal was identified on 06/06/24. The wound measured 1.5 cm by 0.8 cm by 0.1 cm with 80% granulation tissue and 20% slough. The wound had no drainage. The facility determined the wound had improved. Review of the weekly pressure skin grid dated 08/05/24 revealed the stage III pressure ulcer to the left fifth metatarsal measured 1.0 cm by 0.5 cm by 0.1 cm and was 80% granulation and 20% eschar. The wound had no drainage. The facility determined the wound had improved. Review of the weekly pressure skin grid dated 08/12/24 revealed the stage III pressure ulcer to the left fifth metatarsal measured 0.5 cm by 0.5 cm by and was 80% granulation and 20% eschar. The wound had no drainage. The facility determined the wound had improved. Review of the weekly pressure skin grid dated 08/19/24 revealed the stage III pressure ulcer to the left fifth metatarsal measured 0.3 cm by 0.5 cm by and was 80% granulation and 20% eschar. The wound had no drainage. The facility determined the wound had improved. Review of the resident's monthly physician orders for August 2024 identified orders dated 04/12/24 Barrier cream to buttocks, 07/26/24 monitor wounds for signs/symptoms of infection or decline, notify physician of if noted, 08/05/24 cleanse left fifth toe, pat dry, apply skin prep to wound bed and leave open to air daily and as needed, 08/15/24 cleanse right buttocks skin tear with wound spray, pat dry, apply zinc ointment to wound and leave open to air every shift and as needed. On 08/21/24 at 10:04 A.M., observation of Resident #38 revealed the resident's left foot was externally rotated outward allowing the fifth digit to resident directly on the bed. On 08/21/24 at 2:58 P.M., interview with Licensed Practical Nurse (LPN) #231 revealed the stage III pressure ulcer to the left interdigit fourth and fifth toes and the stage III pressure ulcer to the left fifth digit was caused by a boot being applied to tight to his left foot. LPN #231 verified the lack of off-loading to the left foot. On 08/21/24 at 3:05 P.M., observation of Resident #38 revealed he was being transferred from the shower room to his room via two assists on a shower chair. The resident was noted to have no dressing to the left foot and the foot was dragging the carpet while being pushed down the hallway. On 08/21/24 at 3:28 P.M., interview with LPN #231 verified the wounds were not comprehensively assessed, no evidence comprehensive, effective and individualized interventions were implemented to prevent the development of the pressure ulcers. On 08/21/24 at 3:37 P.M., observation of the resident's wound revealed the wound was covered with a light tan scab. The left foot had no off-loading to the pressure ulcer. On 08/22/24 at 9:32 A.M., observation of Resident #38 revealed the resident's left foot was laying directly on the bed with no off-loading observed. 28923 2. Review of Resident #49's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included paraplegia, severe intellectual disabilities, reduced mobility, muscle weakness, protein- calorie malnutrition, adult onset diabetes mellitus, anemia, osteomyelitis, chronic pain, and need for assistance with personal care. He was hospitalized between 01/26/24 and 02/02/24. Review of Resident #49's re-admission assessment dated [DATE] revealed he was noted to have stage IV pressure ulcers to his coccyx and right buttock and a suspected deep tissue injury to the right heel. Review of Resident #49's skin grid pressure assessment completed on 02/08/24 revealed the suspected deep tissue injury (SDTI) to the right heel originated on 02/02/24. The area measured 3 centimeters (cm) x 2.5 cm. No description of the general appearance of the area was provided. Review of a subsequent skin grid pressure assessment of Resident #49's pressure ulcer to the right heel revealed it deteriorated from a SDTI to an unstageable (full thickness tissue loss in which the base of the ulcer was covered by slough and/ or eschar in the wound bed. The description of the general appearance of the area indicated it had 100% eschar. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired. He was not known to have displayed any behaviors, nor was he known to reject care during the seven day assessment period. He had a functional limitation in his range of motion of his bilateral lower extremities. He was identified as having been at risk for pressure ulcers and was also identified as having an unhealed pressure ulcer. The MDS indicated that he was known to have one stage IV pressure ulcer and one unstageable pressure ulcer that was not present upon admission. Review of Resident #49's care plans revealed he had a care plan in place for having the potential for and having an actual pressure ulcer development related to reduced mobility and activity intolerance. The care plan was revised on 02/02/24 to reflect the presence of a pressure ulcer to the right heel. The goal was for the resident's pressure ulcer to decrease or heal through the review date. The interventions included the need to perform treatments as ordered. The interventions also included the use of pressure reduction devices to the chair/ bed and placing a pillow between the resident and his mobility bars when turned to that side. The interventions did not include the need to elevate his heels on pillows or to use some other off-loading device despite the resident being known to have an existing pressure ulcer to his right heel. Review of Resident #49's physician's orders revealed he had treatment orders in place for the right heel to cleanse the pressure ulcer with normal saline solution and pat dry. They were then to apply skin prep covering with an ABD dressing and secure by wrapping it with Kerlix (gauze wrap). The dressing was to be changed every two days and as needed (prn). That order was last updated on 08/05/24. Review of Resident #49's weekly wound assessments revealed the resident's pressure ulcer to the right heel was last assessed on 08/19/24. The pressure ulcer to the right heel was assessed and staged as a SDTI measuring 0.5 cm x 0.8 cm with a depth that was not able to be determined. A description of the general appearance of the area was provided and indicated the wound bed had 100% eschar, which should have resulted in the pressure ulcer being staged as an unstageable pressure ulcer. Review of Resident #49's treatment administration record (TAR) for August 2024 revealed the resident's treatment to his pressure ulcer on the right heel was last documented as having been completed on 08/19/24 on day shift (7:00 A.M. to 7:00 P.M.). There was no documentation showing the treatment to the right heel had been provided on a prn basis that month as ordered. The TAR's did not include documentation of any skin prevention interventions being implemented that involved off-loading the resident's heels. On 08/20/24 at 3:30 P.M. and again on 08/21/24 at 8:45 A.M., observations of Resident #49 noted him to be lying in bed. His right heel, where he was known to have an existing pressure ulcer, was noted to be in direct contact with the mattress on the bed. On 08/21/24 at 9:29 A.M., an observation was made of State tested Nursing Assistant (STNA) #168 noted her to bring in Resident #49's breakfast tray and provided him with set up help. He was noted by the STNA to be down in his bed. She asked the resident if he wanted pulled up in bed and assisted him in doing so by grabbing his draw sheet that was under him pulling him up in bed. The resident's right heel was noted to still be in contact with the mattress and the movement of the resident while pulling him up in bed caused friction against his right heel as it was dragged along the mattress on the bed. She did not offer to off-load his heels for him and left them in direct contact with the mattress. On 08/21/24 at 9:42 A.M., a treatment observation was made of Resident #49's pressure ulcer to his right heel. His treatment was provided by LPN #231, who was the facility's wound/ treatment nurse, and she was assisted by RN #108. The right heel was not noted to have a dressing on it as ordered. The treatment completed in accordance with the physician's orders. The right heel was observed and noted to be covered with an area of eschar that measured 2.2 cm x 2.5 cm. The scabbed area (eschar) was lifting at the edges. The resident tolerated the procedure with no complaints of pain. On 08/21/24 at 10:06 A.M., an interview with STNA #168 revealed she had only worked at the facility for about five days now. She was aware of the resident having a dressing on his left hip, but was not aware of the resident having any wounds on his right heel. She was asked what skin prevention interventions they were implementing for the resident to help existing pressure ulcers heal and to prevent new ones from developing. She stated they tried to keep him turned every couple of hours when they changed him and also placed a pillow between his knees and under his arm. She was asked what they were doing to offload heels. She again denied knowledge of the resident having anything on his right heel that she was aware of. She further denied they used any pillows or other off-loading devices to elevate his heels off the mattress when in bed. She acknowledged she had been observed pulling the resident up in bed when she positioned him for breakfast earlier that morning. She further acknowledged the resident's heel was not off-loaded and when she pulled him up in bed his heel was dragged against the mattress of the bed resulting in a friction force to his right heel. She denied that she had left the resident with his heels elevated, after she pulled him up in bed. On 08/21/24 at 10:12 A.M., an interview with LPN #231 confirmed Resident #49 did not have a dressing intact to his right heel that she had to remove when doing his dressing change. She suspected the dressing may have gotten loose and was taken off, but denied she had been informed that was the case. She acknowledged the resident had an order for the dressing to his right heel to be changed on a prn basis and if it had come off someone should have put a new one on him. She further acknowledged the staff should be informing the nurse when the dressing to the right heel was off so a new dressing could be applied. She also confirmed the resident did not have his heels offloaded while in bed, when she went to do his dressing changes. She was informed STNA #168 was not aware the resident had a pressure ulcer to his right heel and observed pulling him up in bed dragging his right heel against the mattress. She indicated they should be off-loading his heels and not to cause any shearing or friction forces to his skin when pulling him up in bed. On 08/21/24 at 11:53 A.M., a follow up interview LPN #231 was conducted to see why Resident #49's pressure ulcer to his right heel was staged as a SDTI, when the latest assessment and observations of the wound during the dressing change clearly showed it was an unstageable pressure ulcer. She reported the wound physician that followed the resident and assessed him weekly did not allow the nurses to stage pressure ulcers. The wound physician would not change a wound's staging from what it was when first noted, until it had been resolved. She was informed a pressure ulcer that was a stage IV pressure ulcer would remain a stage IV until it was healed. A stage III pressure ulcer would remain a stage III until it was healed, unless it deteriorated into a stage IV pressure ulcer and then should be classified as such. A SDTI could resolve or it could deteriorate into a stage III or IV pressure ulcer. She acknowledged, if a SDTI deteriorated to a stage III or IV, it should be reclassified as such as that was a deterioration in the wound. She confirmed the resident's SDTI did present as an unstageable pressure ulcer, as the wound bed was covered with 100% eschar. Review of the facility's policy on Prevention of Pressure Ulcers/ Injuries revised October 2018 revealed the facility was to review the resident's care plan and identify risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Prevention included mobility/ repositioning of the resident. They were to provide support devices and assistance as needed. They were also to select appropriate support surfaces based on the resident's mobility and overall risk factors. The purpose of the procedure was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, facility policy review, and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer treatment plan for Resident #7 who developed an in-house pressure ulcer. Actual Harm occurred on 01/05/24 when Resident #7, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for activities of daily living was transferred to the hospital due to family concerns with the resident's left heel wound, which was swollen and warm to touch and the resident was not acting right. The resident was admitted to the hospital and assessed to have a Stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) pressure ulcer to the left heel which required treatment with a wound vacuum and intravenous antibiotics due to the presence of infection/osteomyelitis. The resident was hospitalized until 01/13/24. Prior to the hospitalization , the facility had identified and was treating the ulcer as an arterial wound. This affected one resident (#7) of three residents reviewed for wounds. The facility identified nine residents with pressure wounds. The census was 120. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, atherosclerosis of native arteries of extremities with intermittent claudication of bilateral legs, chronic diastolic heart failure, major depressive disorder, dysphasia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/23, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The assessment indicated the resident had severely impaired cognitive skills for daily decision making. The resident was dependent upon staff for all of the effort with bed mobility, transfers, grooming, personal hygiene, and toileting. The assessment indicated there were no pressure, arterial, or venous ulcers present upon admission. Further review of the medical record revealed the resident was identified at moderate risk for pressure ulcer development. Review of the Care Plan, dated 12/07/23, revealed the resident had an arterial/ischemic ulcer located on the left heel. Interventions included an air mattress to the bed, monitor skin daily and report changes to the nurse, pressure reduction boot to the left heel when lying in bed, treat wound as ordered and observe for signs and symptoms of infection and report accordingly, and to turn and reposition every two hours. Review of Resident #7's Shower Sheet, dated 11/26/23, revealed The Nurse Body Examination section of the form indicated there were no open or red/discolored areas on the resident's feet or body. Review of the Shower Sheet, dated 11/28/23 and completed by a State-tested Nursing Assistant (STNA) revealed no new skin issues. The Nurse Body Examination section of the form was not completed and was blank. Review of the nursing progress note (authored by the previous Director of Nursing), dated 12/05/23 at 1:08 P.M., revealed the resident had skin impairment to the right heel that measured four centimeters (cm) x 3 cm x 0.1 cm. The resident has some light, serous (clear) drainage noted. No signs/symptoms of infection, skin intact. Pillow placed under feet in wheelchair. Physician to follow-up on 12/07/23. Resident has treatment in place. Power-of-attorney (POA) and physician notified. Review of the medical record did not provide evidence of an assessment, including Staging and type of the new wound, onset date 12/05/23, located on Resident #7's right heel. There was no evidence of a treatment order was given or initiated. Review of the nursing progress note, dated 12/06/23 at 10:40 A.M., revealed reclassified skin impairment is to the left heel, not the right. Review of the Interdisciplinary team (IDT) progress note, dated 12/07/23 at 9:45 A.M., revealed the team met to review an incident on 12/05/23. Resident #7 was found with a skin impairment to the left heel. The diagnosis was an arterial wound. The wound had some light, serous drainage, no infection, and the skin is intact otherwise. Treatment in place. Family and physician notified. Physician #400 will see the resident on Thursday. Place a pillow under both feet when in wheelchair. Plan of care updated. Review of the nursing progress note, dated 12/07/23 at 2:41 P.M., revealed upon assessment with Physician #400, a left arterial wound had necrotic tissue and no exudate (drainage). The wound measured 3.5 cm x 3.2 cm. Treatment was to cleanse with soap and water and apply Betadine. Review of physician order, dated 12/08/23, revealed the order to cleanse the left heel with soap and water (SW) and apply Betadine, once daily for wound care. Review of the Treatment Administration Record (TAR) revealed the treatment was completed on 12/08/23, 12/09/23, 12/11/23, 12/12/23, and 12/13/23. The TAR did not contain documentation of any wound treatment on 12/10/23 or 12/14/23. Further review of the medical record revealed there was no left heel wound treatment/dressing change between the onset on 12/05/23 until 12/07/23 (as evidenced in a nursing progress note and not documented on the TAR.) Review of the nursing progress note, dated 12/28/23 at 2:45 P.M., revealed a new treatment order received for the resident to receive a Mesalt (helps manage heavily discharging and discharging wounds in the inflammatory phase. It can also be used in for a deep cavity wound such as a pressure ulcer) dressing to the left heel. Sharps debridement performed per wound physician in hopes to improve wound healing. Resident tolerated well with no facial grimacing. Spouse aware and agreed with current treatment plans. Review of nursing skin assessment, dated 12/28/23, revealed observation of the arterial wound located on the left heel. The onset date was incorrect and documented as 12/28/23. The wound measurements were 3.4 cm x 3 cm x 0.3 cm. The wound had 100% necrosis with moderate, serous drainage, and was without odor or inflammation. Review of the wound physician progress note, dated 12/28/23, revealed an arterial wound of the left heel, measuring 3.4 cm x 3.0 cm x 0.3 cm, with moderate serous exudate and 100% necrotic tissue. The wound progress was described as improved as evidenced by decreased surface area. A surgical excision debridement procedure was performed to remove necrotic tissue and establish the margins of viable tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. As a result of the procedure the nonviable tissue in the wound bed decreased from 100% to 60%. Hemostasis (the mechanism to stop bleeding from a vessel) was achieved, and a clean dressing was applied. Treatment: Continue Mesalt Sheet once daily and apply a gauze island dressing with border daily. Review of the nursing progress note, dated 01/05/24 at 9:47 A.M., revealed Resident #7's spouse (Family Member #1) came to the nurse with concerns of her husband's left, lower extremity. Assessment revealed the site was swollen and warm to touch. There was no redness observed and the dressing was dry and intact. Family Member #1 stated that her husband wasn't acting right and asked for him to to be sent to the emergency room . The Nurse Practitioner was notified. Review of Resident #7's hospital discharge summary, dated 01/13/24, revealed the resident was hospitalized from 01/05/24 through 01/13/24. The resident was brought into the hospital by family due to concerns of a left heel ulcer. The hospital diagnoses include chronic osteomyelitis of the left foot and ankle. An x-ray of the left calcaneus (the large bone forming the heel) revealed soft tissue ulceration with loss of cortical definition of the posterior aspect concerning for osteomyelitis. Orthopedics was consulted and the resident was noted to have a pressure ulcer, Stage IV located on the left heel. The pressure ulcer was debrided on 01/07/24; the debridement included the removal of dead tissue and some of the calcaneus and a wound VAC (a device attached to the wound that decreases air pressure on the wound. This may help with the wound healing more quickly) was applied. Wound cultures were positive for proteus and pseudomonas (bacteria). Infectious Disease was consulted and intravenous (IV) antibiotics were administered, Zosyn and Vancomycin. Review of a wound clinic progress note, dated 01/22/24, revealed the resident had a pressure ulcer, Stage IV, located on the left heel. The wound bed had granulation tissue and slough, with exposed bone. The treatment plan was to cleanse wound with wound cleanser, apply white foam over exposed bone and then cover with GranuFoam to the wound and apply wound vac at 150 mmHg continuous pressure. Change dressing three times per week. During interview on 01/23/24 at 1:55 P.M. Unit Manager/RN #200 confirmed there was no weekly skin assessment completed by a nurse during the week preceding the onset of the left heel wound on 12/05/23 (shower sheet documentation). RN #200 further confirmed there was no treatment order/dressing change for the left heel wound initiated and completed until 12/07/23 (with the ulcer first being identified on 12/05/23). During interview on 01/23/24 at 2:06 P.M., Wound Physician #400 was contacted via phone by Unit Manager/RN #200 and agreed to be interviewed by this surveyor. Physician #400 stated he did not have Resident #7's medical records in front him, however, he did recall the resident and would answer any questions. Physician #400 stated that he believed the resident's left heel wound was a mixed etiology and not only one, and although the wound assessment (prior to the resident's hospitalization ) classified the wound as arterial, it was likely both arterial and pressure related. Physician #400 stated he identified the wound as arterial because for the resident's diagnosis of peripheral artery disease. The physician further stated that he would never debride an arterial wound and stated that if he did debride the resident's wound it was because it was no longer hard (the wound bed). During observation on 01/22/24 at 11:55 A.M., Resident #7 was lying in bed with his wife and another visitor present in the room. Resident #7's wife stated that her husband had been to the wound clinic earlier in the day. The resident was non-verbal and was unable to answer any questions due to his severely impaired cognition. Resident #7 appeared comfortable and was not exhibiting any signs or symptoms of pain. The Unit Manager/RN #200 stated the dressing to the resident's left heel wound had been changed earlier at the wound clinic. Observation of the left heel revealed the foam and adhesive dressing was clean and intact and the wound vacuum was applied to the wound at 150 mmHg, as ordered. The resident was wearing moon boots on both feet. During interview on 01/23/24 at 3:26 P.M., interview Certified Nurse Practitioner (CNP) #401 confirmed that she treated Resident #7 the previous day, 01/22/24, at the wound clinic, and the resident had a pressure ulcer, Stage IV to the left heel. The CNP stated she had reviewed all of the resident's hospital paperwork and was aware of the nursing home wound physician's diagnosis of the left heel wound being an arterial wound. CNP #402 stated she classified the wound as a pressure ulcer, however, the wound could have started as an arterial wound due to the decreased blood flow and then became a combination of a pressure wound and an arterial wound. CNP #401 stated that she was able to listen to Resident #7's pedal pulses with a doppler. During interview on 01/23/24 at 3:43 P.M., Regional Director of Clinical Operations RN #402 stated she had identified a concern after reviewing Resident #7's hospital discharge paperwork and noted the discrepancy between the diagnosis of an arterial wound by the facility's wound physician and the hospital physician's diagnosis of a pressure wound. RN #402 stated Wound Physician #400's services were terminated with the facility and staff in-services, audits, and quality assurance and performance improvement (QAPI) measures were initiated on 01/11/24. During interview on 01/24/24 at 12:55 P.M., the DON confirmed the left heel wound was diagnosed as a pressure ulcer, Stage IV, when the resident was hospitalized between 01/05/24 and 01/13/24. The DON further confirmed there was no treatment order/dressing change initiated and completed until 12/07/23 for Resident #7's left heel wound. Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 08/22/22, revealed the facility shall establish and utilize a systematic approach for pressure ulcer prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. The deficient practice was corrected on 01/12/24 when the facility implemented the following corrective actions: On 01/11/24 the facility implemented interventions to complete a whole house skin sweep completed by the Unit Manager/RN. On 01/12/24 all resident records were audited to ensure every resident had treatments completed as ordered and if the areas had improved or declined; all residents with wounds were audited for wound type and any discrepancies were noted. Three residents will be audited weekly for four weeks to ensure compliance. On 01/11/2024 admission and weekly skin assessments were added to the Quality Assurance Performance Improvement (QAPI) to audit all new admissions for two-step skin assessments and weekly skin assessments for four weeks through 03/04/24. On 01/11/24 all clinical staff were educated to policies on wound identification/prevention. On 01/12/24 the current wound physician's contract was terminated, and a new company was contracted for services. This deficiency represents non-compliance investigated under Complaint Number OH00150062.

Based on observations, interviews, and record reviews, the facility failed to properly manage Resident #1 and #3 pain. Actual harm occurred on 06/07/23 when Resident #3 verbalized pain during wound care treatment including yelling out, grimacing, and indicating the treatment felt like knives stabbing her foot and the nurse continued treatment without addressing the pain. This affected two residents (#1 and #3) out of the three residents reviewed for pain management. The facility census was 121. Findings include: 1. Record review for Resident #3, admitted on [DATE] diagnoses including type two diabetes mellitus, osteomyelitis, hypertension, dementia, and non-pressure chronic ulcer of the foot. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/18/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. This resident was assessed to require extensive assistance from two staff members for bed mobility, was dependent upon two staff members for transfers, was dependent upon one staff member for toileting, and required limited assistance from one staff member for eating. This resident was assessed to have a diabetic foot ulcer. Review of the active physicians order, dated 03/14/23, revealed Resident #3 had an order to be administered Oxycodone (an opioid medication) as needed for pain. Review of the care plan, dated 04/07/23, revealed this resident was on pain medication. Interventions included to provide medication as ordered. Review of Resident #3's active physicians order, dated 04/27/23, revealed to cleanse the left lateral diabetic foot wound with soap and water, apply calcium alginate with Santyl (a chemical debriding agent), apply an ABD pad, and wrap with a Kerlix gauze daily. Review of the Medication Administration Record (MAR), dated 06/07/23, revealed no documentation Resident #3 received as needed Oxycodone for pain. Observation on 06/07/23 at 10:10 A.M. of Licensed Practical Nurse (LPN) #294 providing wound care treatment to left diabetic foot wound of Resident #3 revealed as LPN #294 was attempting to clean the wound with soap and water using a gauze pad, Resident #3 began yelling out in pain, was grimacing, and voiced, that hurts. Resident #3 rated the pain as a six on a one to ten numerical pain scale and stated it felt like knives stabbing her in the foot when it was being cleaned. LPN #294 then continued the wound care treatment without stopping to address the resident's verbalization of pain during treatments. LPN #294 verified the resident experienced pain during the wound care. Review of the progress notes, dated 06/07/23, revealed no notification to the physician of pain experienced by Resident #3 during wound care treatments. Interview with the Director of Nursing (DON) on 06/07/23 at 4:05 P.M. revealed any resident observed to be experiencing pain during wound care treatment should be immediately assessed and the staff member performing the treatment should cease until addressing the resident's pain. Interview with Resident #3 on 06/08/23 at 1:48 P.M. revealed it always hurt bad and felt like knives were stabbing her foot when wound care was being provided by staff. 47059 2. Resident #1 was admitted on [DATE] with diagnoses that include compression of brain, intestinal and esophageal obstructions, disorder of skin and subcutaneous tissue, opioid use, rheumatoid arthritis, adult-onset Still's disease, anemia, hypothyroidism, major depressive disorder, insomnia, vitamin D deficiency, migraine, wheezing, and juvenile rheumatoid arthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, required extensive assistance of 2 people for mobility, transfer, walking, and activities of daily living (ADL), and was totally dependent for toileting and bathing. Review of Plan of Care revision date of 04/14/23 for Resident #1, revealed Resident #1 had pain due to weakness, juvenile rheumatoid arthritis with debility and chronic pain. Interventions included administering medications as ordered, attempting non-pharmacological interventions for pain relief, monitor for effectiveness of pain medication, observe for any changes in usual activity patterns, and observe for non-verbal signs of pain. Review of Resident #1's physician orders revealed the resident was ordered Norco (narcotic pain medication) 10-325 milligrams (mg) every four hours for rheumatoid arthritis. Review of Resident #1's Medication Administration Record (MAR) for May 2023 indicated all medications were available and given on time. Review of an audit printout of actual administrations times for May 2023 revealed Norco 10-325 mg ordered to be given every 4 hours was over 1 hours late for doses on 05/25/23 scheduled for 08:00 A.M. but given at 09:19 A.M.; 05/26/23 at 08:00 A.M. given at 09:33 A.M.; 05/26/23 at 08:00 P.M. given at 09:53 P.M.; 05/27/23 10:16 P.M., 05/28/23 midnight given at 01:01 A.M.; 05/28/23 08:00 P.M. given at 10:21 P.M., 05/29/23 noon given at 01:36 P.M.; 05/30/23 08:00 A.M. given at 10:46 A.M.; and 05/30/23 noon dose given at 06:15 P.M. Interview on 06/08/23 at 01:46 P.M. with Resident #1 revealed Resident #1 had some level of pain most of the time. He was aware that it was part of living with juvenile rheumatoid arthritis. Resident #1 stated it helped when he received his Norco every four hours. Resident #1 indicated that does not always happen. Interview on 06/08/23 at 02:00 P.M. with Registered Nurse (RN) #1 confirmed the date and time on the audit report are the actual administration times. The medication administration report reflects the scheduled medication was given, confirming Resident #1 did not receive pain medication timely.

Based on record review, review of hospital records and interview the facility failed to ensure timely and adequate monitoring and intervention was provided for Resident #5, who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Slough and/or eschar may be visible on some parts of the wound bed) pressure ulcer to the resident's left outer ankle. Actual harm occurred on 03/24/21 when Resident #5 was transferred from hemodialysis to the hospital and assessed to have a Stage IV pressure ulcer to the left outer ankle measuring 3.5 centimeters (cm) in length by 4.0 cm width with 0.5 cm depth. The ulcer was assessed to be foul smelling with purulent drainage and necrotic tissue present with bone involvement. The resident was subsequently diagnosed with [CONDITION(S)] and gangrene and underwent a left below the knee amputation. Hospital record review revealed the ulcer did not appear to have just started. However, the facility failed to identify the area of skin impairment prior to the resident's hospitalization . Findings include: Review of the medical record for Resident #5 revealed an original admitted [DATE] with the latest readmission of 10/09/20. The resident was discharged to an acute care hospital on 03/24/21 following a hemodialysis treatment. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident received hemodialysis three times per week at an outside hemodialysis center. Review of the plan of care, dated 05/09/19 revealed the resident had potential/actual impairment to skin integrity related to incontinence, limited mobility, [CONDITION(S)], diabetes mellitus, peripheral vascular disease and end stage renal disease. Interventions included to avoid skin to skin contact, diet as ordered by physician, encourage resident to keep nails trimmed to reduce risk of injury, encourage good nutrition and hydration in order to promote healthier skin, encourage to wear tubigrips (skin protection devices) to lower extremities on [CONDITION(S)] days for prevention, give medications as ordered, monitor skin integrity every shift and report abnormalities, observe for sign/symptoms of infection, padding to bed side table to reduce risk of skin injury, therapeutic mattress to bed and treatments as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/17/21 revealed Resident #5 had clear speech, understood others, made himself understood and had had no cognitive deficits. The Brief Interview for Mental Status (BIMS) score was 15, with scores of 13 to 15 indicating the person was alert, oriented and cognitively intact. The resident required extensive assistance of two staff for bed mobility and was dependent on two staff for transfers and was non-ambulatory. The assessment indicated the resident was at risk for skin breakdown and had no unhealed pressure ulcers or venous or arterial ulcers. The facility implemented interventions including pressure reducing devices to the bed, application of nonsurgical dressing and applications of ointments/medication. Review of the pressure ulcer risk assessment dated [DATE] revealed a score of 16 indicating the resident was at low risk for the development of pressure ulcers. Review of Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed there were no other physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's notes, dated 01/01/21 through 03/26/21 revealed no documented evidence the facility had identified any type of wound/pressure ulcer to the resident's left foot/ankle area during this time period. Review of Resident #5's medical record revealed no wound assessments related to the wound/pressure ulcer to his left foot/ankle. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/31/21 at 11:30 A.M. interview with Licensed Practical Nurse (LPN) #100 revealed she received a phone call from the local hospital emergency department (ED) (on 03/24/21) and was told Resident #5 had a seeping wound to his outer left ankle area. LPN #100 revealed the hospital staff was calling to obtain the current treatment order for the area. LPN #100 revealed she was unable to locate any documentation Resident #5 had a wound at the facility and no treatment orders were found for the wound to his left ankle. On 03/31/21 at 2:08 P.M. interview with [CONDITION(S)] Registered Nurse (DRN) #201 revealed as Resident #5 was leaving the [CONDITION(S)] center after his [CONDITION(S)] treatment, she overheard the paramedic state You can't hear. DRN #201 went back over to Resident #5 and started to assess the resident. DRN #201 revealed the resident was on a cot and she could smell a stagnate smell and observed serosanguineous drainage on the footrest. She stated she was unsure where it was coming from at that time and indicated Resident #5 was wearing a non-skid slipper sock on the left foot (no pressure relieving/reducing device). DRN #201 revealed the resident wanted to go to the emergency room at that time and subsequently left with the transport that was onsite to pick him up. The resident was admitted to the hospital. Review of Resident #5's hospital surgical report, dated 03/28/21 revealed the resident was taken to radiology for a left lower extremity angiogram. The resident was diagnosed with atherosclerosis of the left leg with gangrene. Further review of the surgical report revealed the resident was taken to the surgical room on 03/29/21 at which time a left below the knee amputation was preformed due to the [CONDITION(S)] from the Stage IV pressure ulcer. Review of documentation contained in Resident #5's acute care hospital records revealed a document, dated 04/01/21 which reflected the resident was transferred to the emergency department (ED) following a scheduled hemodialysis treatment with the chief complaint of hearing loss. Review of Physician #207's progress note revealed Resident #5 was found to have a large Stage IV (a full thickness tissue loss with exposed bone, tendon or muscle in which slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling) pressure ulcer to the left outer ankle with foul smelling purulent drainage while in the ED. The hospital record noted, apparently, according to the nursing facility staff, this pressure ulcer was not present the day before, but further evaluation revealed it was a Stage IV pressure ulcer. An MRI (magnetic resonance imaging) of the area showed acute [CONDITION(S)] (bone infection) involving the distal (lower) 4.0 cm of the lateral malleolus (outer ankle) adjacent to the ulcer. Hospital documentation continued and indicated, so, it does seem likely it probably had been going on for more than one day. The wound was measured to be 14.0 cm in length by 4.0 cm width with 0.5 cm depth. Further review revealed Physician #207 visited the resident while at [CONDITION(S)] in the acute care hospital and found the resident's left leg laying turned so the pressure ulcer wound was on the bed and he suspected that most of the time the left leg was rotated that way causing the really deep pressure ulcer with bone involvement. The physician documented that due to the resident's diabetes, peripheral vascular disease, [CONDITION(S)] and [CONDITION(S)] the [NAME] procedure to prevent the amputation of the resident's left lower leg would not be prudent, therefore the decision was made for a below the knee amputation for Resident #5's left leg. Review of the hospital records dated 04/01/21 revealed the physician documented the resident reported his aide at the nursing home washed his feet on Tuesday and she made no mention of the new ulcer on his left ankle. The resident said he had no sensation in his left lower extremity and had difficulty offloading the left leg while in bed. On 04/01/21 at 2:06 P.M. interview with Physician #206 revealed he was notified Resident #5 was being transferred to the local ED by the [CONDITION(S)] center on 03/24/21. He said he was notified of the left ankle wound by the hospital ED. Physician #206 revealed he was also aware the resident had been found to have gangrene and [CONDITION(S)] to the left foot/ankle area also. He said with the peripheral artery occlusion the hospital found following testing could occur with [CONDITION(S)] patients when their blood pressure drops. He said this could have happened weeks or days ago. He said when you have an ischemic leg with no blood flow, [CONDITION(S)] and gangrene could develop in a matter of days. Physician #206 proceeded to explain he felt the pressure ulcer could develop in a matter of days or weeks and with the resident's diabetic [CONDITION(S)] the resident did not feel pain that normally triggered a person to know something was wrong. Physician #206 revealed with the nursing facility staff changing the resident's sheets and providing care they should have recognized if the resident had a wound to that degree at an early onset. On 04/14/21 at 5:00 P.M. interview with Resident #5 revealed he returned from the hospital from having a left below the knee amputation. The resident shared he had been at hemodialysis (end of March 2021) and all of a sudden couldn't hear. He said when the nurse came over to see him, she found drainage coming from his left ankle and instructed the ambulance drivers to transport him to the emergency room . Resident #5 revealed he was unaware of any issue to the area and indicated he lacked sensation to the area. Resident #5 revealed the physician told him the wound had been there for quite some time as there was infection from the wound that had already eaten into the bone so there was no saving his lower leg. Resident #5 revealed he didn't have feeling in his legs due to the [CONDITION(S)]. The resident revealed his left leg wasn't deformed but it rotated outward resulting in direct pressure on the left outer ankle. Resident #5 revealed the facility had never implemented any interventions to offload the pressure to his left ankle. This deficiency substantiates Complaint Number OH 614, Complaint Number OH 494, Complaint Number OH 211 and Complaint Number OH 129.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), review of facility policy and procedures, review of daily census reports, review of the facility floor plan, observations, staff and local health department interviews, and record reviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy when the facility failed to implement adequate infection control measures following the identification of an Immediate Jeopardy in the area of infection control on [DATE] contributing to 36 additional residents (#2, #4, #7, #10, #12, #13, #18, #24, #32, #36, #38, #40, #42, #48, #52, #54, #56, #58, #67, #68, #69, #70, #73, #77, #81, #85, #87, #89, #97, #108, #110, #121, #122, #123, #130 and #131) testing positive for COVID-19 since [DATE]. Additionally, on [DATE] four additional residents, #28, #55, #59 and #75 tested positive for COVID-19. Five residents, #46, #49, #51, #84 and #100, who were COVID-19 positive expired. On [DATE] onsite observations revealed all eight units of the facility had both positive and negative COVID-19 residents residing on them with the same staff caring for both residents who were positive and negative for COVID-19. Staff were observed going into the rooms of those residents who were positive COVID-19 with N95 masks in place, exiting and entering the rooms of those residents who were negative for COVID-19 with the same N95 mask and lacking additional personal protective equipment (PPE). The facility corrective action plan, from the [DATE] Immediate Jeopardy survey indicated all residents would be placed on droplet isolation on [DATE]. Further observation revealed staff administering medications without proper hand hygiene and proper PPE use to positive COVID-19 residents and then entering negative COVID-19 resident's rooms without proper PPE and administering medications. The facility also failed to adequately monitor the spread of COVID-19 throughout the facility. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 116 residents at risk for the likelihood of harm, complications and/or death. The facility census was 116 residents. On [DATE] at 3:29 P.M. the Administrator was notified that Immediate Jeopardy began on [DATE] when all eight facility units had both positive and negative COVID-19 residents residing on them indicating the facility had no designated COVID-19 unit. The facility also had no designated units set up for quarantine residents or suspected COVID-19 positive residents, which resulted in the lack of designated staff to care for COVID-19 positive residents to prevent the transmission of COVID-19 to the negative residents. Based on the facility census and layout of the facility, the ability to designate a COVID-19 unit was determined to be impossible. Furthermore, staff were observed entering COVID-19 positive resident rooms without full PPE, providing care and then going into COVID-19 negative resident rooms without full PPE and wearing the same N95 mask providing care to the resident. The facility failed to provide sufficient evidence of a PPE crisis to support the use of N95 masks in both COVID-19 positive and COVID-19 negative resident rooms and failed to provide sufficient evidence of a staffing crisis. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] the facility participated in a Tele-ICAR with the State Agency Bureau of Infectious Disease and Local Health Department (LHD) Infectious Disease Coordinator. · On [DATE] at 4:00 P.M. the facility Medical Director approved all activities pertaining to the facility immediate action plan including the testing of residents and room placement for residents. · On [DATE] the facility began consulting with the QIO I-PRO regarding Infection Control. · On [DATE] from 8:45 A.M. to 10:15 A.M. all residents identified as potentially at risk for COVID-19 due to room assignment were tested through point of care testing by the Director of Nursing (DON) and Registered Nurse (RN) #245. A plan for residents who tested positive to be relocated to the COVID-19 designated units on the Sheridan Wing Unit 3 or Eckert Wing Unit 2 by the end of the day on [DATE] was developed. Four additional residents (#28, #55, #59 and #75) were identified as positive at this time. · On [DATE] at 12:00 P.M. a Quality Assurance Committee Meeting was held pertaining to the testing and placement of residents. Staff attending the meeting included, the Medical Director, Program Director #281, Process Improvement Director (PID) #304, Business Relations Manager #338, the Administrator, RN #245, RN #40, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), Dietary Supervisor #294, Maintenance Supervisor #204, Activity Director #302 and Consultant Pharmacist #349. · On [DATE] the facility identified the following designated care areas, which would be effective immediately with a plan for all room changes to be completed by the end of day [DATE]: Sheridan Wing Unit 1- All currently negative residents who may be at risk for contracting COVID-19 but show no signs or symptoms, have tested negative, and are not undergoing an observation/quarantine period. Sheridan Wing Unit 2- Observation/Quarantine Area Sheridan Wing Unit 3- COVID-19 Positive Area Sheridan Wing Unit 4- Residents who have fully recovered from COVID-19 and do not require transmission-based precautions. Eckert Wing Unit 1- Residents who have fully recovered from COVID-19 and do not require transmission- based precautions. Eckert Wing Unit 2- COVID-19 Positive Area Eckert Wing Unit 3- Residents who have fully recovered from COVID-19 and do not require transmission- based precautions. Eckert Wing Unit 4- Residents who have fully recovered from COVID-19 and do not require transmission- based precautions. · On [DATE] a plan for residents currently residing on Sheridan Wing Unit 1 to be relocated as determined by their current COVID-19 status by the end of day [DATE] was implemented. · On [DATE] a plan for all remaining negative residents identified by testing on [DATE] to be moved to Sheridan Wing Unit 1 by end of day on [DATE] was implemented. · On [DATE] a plan for all staff to be educated by RN #240, who functions as the facility's Education Director regarding appropriate PPE use as determined by each hallway's COVID-19 demonstration. The PPE requirements will be as follows: For halls with all negative residents not experiencing signs of COVID-19 (or halls that house residents who were previously positive for COVID-19 but have recovered and been cleared from isolation), staff will wear a surgical mask and eye protection at all times. Other PPE such as gloves and gown will be determined based upon other clinical needs. Eye protection will be sanitized at the beginning and end of each shift. For Sheridan Wing Unit 2, which holds residents under observation or quarantine for COVID-19, the staff will wear a respirator (such as a N95), with a gown, gloves and eye protection with each resident encounter. Over the respirator, staff will don a new surgical mask upon entering any resident rooms and then doff the surgical mask, which will then be discarded and not reused. Eye protection will be sanitized between each resident encounter and at the beginning and end of each shift. Staff working Unit 2 will not be shared between other hallways unless using critical staffing measures. For COVID-19 positive halls (Sheridan Wing Unit 3 and Eckert Wing Unit 2), staff will wear a respirator (such as a N95), gown, gloves and eye protection for all resident encounters. Eye protection will be sanitized at the beginning and end of each shift. Staff working this unit will also wear the respirator and eye protection at all times while working. Gowns and gloves must be changed between each resident encounter. Staff education was noted to be completed on [DATE]. As of this time 143 of 146 staff had been completed with three remaining staff being on leave of absence. · On [DATE] a plan for all residents who are undergoing observation for COVID-19 to be moved to the quarantine area by end of day [DATE] was implemented. · On [DATE] a plan for all residents who are currently COVID-19 positive to be moved to a COVID-19 isolation unit by end of day [DATE] was implemented. · On [DATE] a plan for the facility to provide consistent assignment of staff and put forth every effort to promote proper infection control was implemented. · To monitor further compliance, all room assignments must be approved by the Administrator in writing before finalized until further notice, beginning [DATE]. The Administrator will be held accountable and responsible to the Board of Directors for completion of this task. · The Education Director will continue to complete return demonstration audits of the donning and doffing of PPE and handwashing for 10 staff members, 5 days weekly for four weeks beginning [DATE]. The education director will be held accountable and responsible to the Administrator for completion of this task. · A summary of compliance audits for donning and doffing of PPE and approved room assignments will be submitted to the QAPI Committee in [DATE] for review with recommendations as appropriate. · On [DATE] by the end of the day all COVID-19 negative residents were moved on one of the following units, units 1, 3, and 4 in the Eckert wing and unit 4 in the Sheridan wing. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). The QSO memo revealed, Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). a. On [DATE] at 8:30 A.M. interview with the Administrator revealed the facility had no designated COVID-19 unit, quarantine unit or suspected COVID-19 unit. The Administrator indicated all eight facility units had both positive and negative residents residing on them. The Administrator confirmed additional residents had tested positive for COVID-19 since [DATE] but did not know the exact number or names of those residents who tested positive at the time of this interview. On [DATE] between 9:25 A.M. and 10:45 A.M. an initial tour of the facility revealed all four units in the Eckert home (Units 1, 2, 3 and 4) were being referred to as isolation units. In addition, all units in the Sheridan home (Units 1, 2, 3 and 4) were also considered to be isolation units. Tour of Unit 1 located in the Eckert home revealed resident rooms with three drawer carts located outside their doors in the hallway, containing PPE for staff. Rooms were noted to have a (+) or (-) symbol on the doorway entrance. A (+) symbol indicated the resident was COVID-19 positive and a (-) symbol indicated the resident was COVID-19 negative. Each unit was noted to have a room that was designated to serve as staff break room and another room which was designated to serve as a decontamination room. Review of the facility's floor plan provided by the Administrator also revealed all four units (Units 1, 2, 3, 4) of the Eckert building and all four units (1, 2, 3, 4) of the Sheridan building were identified as COVID-19 positive hallways. Review of the facility provided form titled, Residents with Positive COVID-19 Results, provided on [DATE] revealed Resident #36, #38, #40, #42, and #56 tested positive for COVID-19 on [DATE]. Further review revealed Resident #10 tested positive for COVID-19 on [DATE]. Review of the facility's mass COVID-19 testing dated [DATE] revealed the facility had 17 residents, Resident #2, #4, #7, #12, #18, #48, #52, #54, #58, #68, #70, #73, #85, #87, #97, #122 and #131 test positive for COVID-19 and one roommate (#32) of a COVID-19 positive resident test positive on [DATE]. Review of the facility's staff mass COVID-19 testing dated [DATE] revealed the facility had 11 staff, LPN #219, STNAs ##279, #296, #321, #322 and #341, Dietary Manager 294, Cook #210, Activity Director #267 and Housekeepers #255 and #264 test positive. Review of the facility's mass COVID-19 testing dated [DATE] revealed the facility had 12 additional residents, Resident #13, #24, #67, #69, #77, #81, #89, #108, #110, #121, #123, #130 test positive. Review of the facility's staff mass COVID-19 testing dated [DATE] revealed the facility had six staff members, STNAs #202, #226, #311 and #336, Housekeeper #250, and Office Personnel #205 test positive. Review of the COVID-19 point of care testing results conducted by the facility on [DATE] revealed four additional residents, Resident #28, #55, #59 and #75 of the remaining 20 previously negative residents tested positive for COVID-19. Review of the CDC guidelines revealed for residents with new-onset suspected or confirmed COVID-19 test results the facility should: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross- transmission. If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Interview on [DATE] at 10:00 A.M. with LPN #263 confirmed all eight facility units have COVID-19 positive residents residing on them and there was no dedicated unit for only those residents who were positive. Although, they did not share the same room, both positive and negative residents resided on the same units. The LPN stated their assignments were not consistent to a specific unit and she works multiple units in one shift. LPN #263 said a normal assignment included one full unit and half of another unit. The nurse said the assignment was the same for the STNAs as well and an STNA could float between all four units in one building during any given shift. LPN #263 said COVID-19 positive resident rooms were supposed to be completed last for care/medication administration but this was not realistic based on acuity and resident needs. The nurse said staff were supposed to decontaminate with a disinfectant after being in a COVID-19 positive room. However, LPN #263 revealed staff were unable to disinfect after providing care to residents. The LPN also revealed staff were only wearing PPE in COVID-19 positive rooms and wearing the same N95 mask when caring for residents who were both COVID-19 positive and COVID-19 negative. On [DATE] at 10:23 A.M. during an interview with RN #245, the RN revealed tracking of COVID-19 positive cases and contact tracing was not being completed in the facility due to the amount of resident room moves that had been completed (following the [DATE] survey). RN #245 revealed social service staff kept track of the room changes. On [DATE] at 11:00 A.M. interview with RN #347 revealed the nurse worked on all units of the building. The nurse confirmed the units had both negative and positive COVID-19 residents residing on them. The nurse also confirmed the facility had no dedicated COVID-19 unit. The RN confirmed staff were instructed to only wear PPE when caring for COVID-19 positive residents. RN #347 revealed staff were only given one N95 mask and had worn that mask in both COVID-19 negative and positive rooms. The nurse revealed a lack of knowledge regarding the disinfectant used in the decontamination room and the contact time needed to be affective against COVID-19. On [DATE] at 11:43 A.M. interview with RN #280 revealed the facility does not have a COVID-19 unit, quarantine unit or suspected COVID-19 unit. During the interview, the RN stated the lack of a COVID-19 unit contributed to the spread of COVID-19 in the facility. The RN revealed the facility had not designated staff to work with the COVID-19 positive residents as all units had residents who were positive residing on them. The RN revealed staff were to decontaminate between all residents by spraying their uniform and the bottoms of their shoes. The RN said face shields were to be cleansed after each resident as well. The RN said the same N95 mask is worn when caring for both COVID-19 negative and positive residents. On [DATE] at 1:45 P.M. interview with the Administrator revealed after consulting with the Medical Director and the Local Health Department (LHD) contact the decision was made to shelter in place, due to the number of COVID-19 positive cases the facility had. During the interview, the Administrator reported following the State Agency survey last week on [DATE] the facility had not yet implemented all the corrective actions to address the identified infection control concerns. The Administrator also indicated during this interview the facility was in crisis for PPE. The Administrator said the facility was working with the Emergency Management Agency (EMA) but were limited to what could be donated. The Administrator revealed 36 additional residents, Resident #2, #4, #7, #10, #12, #13, #18, #24, #32, #36, #38, #40, #42, #48, #52, #54, #56, #58, #67, #68, #69, #70, #73, #77, #81, #85, #87, #89, #97, #108, #110, #121, #122, #123, #130 and #131 had tested positive for COVID-19 since the [DATE] survey as of this date. At the time of the interview, the Administrator was asked to provide evidence to support a PPE crisis and evidence of an investigation related to the 36 additional residents who had contracted COVID-19 while residing in the facility. During the interview, there was no evidence provided that the facility was in a staffing crisis at the time of the survey. On [DATE] at 2:06 P.M. interview with the facility's LHD contact person revealed she referred the facility to CDC guidelines related to COVID-19 and didn't know what shelter in place meant. The LHD contact person revealed she was not aware the facility no longer had a designated COVID-19 unit and with the amount of positive COVID-19 cases she believed they had more than one COVID-19 unit. During the interview, the contact person revealed the facility had not relayed information regarding a PPE crisis to her and if they had she would have referred them to the local EMA. Review of the CDC guidelines revealed the facility should identify a space that could be dedicated to monitor and care for residents with COVID-19, such as a dedicated floor, unit or wing in the facility. The CDC considerations for establishing a designated COVID-19 unit for residents with confirmed COVID-19 included ideally the unit should be physical separated from other rooms/units housing residents without confirmed COVID-19, assign dedicated staff to work the COVID-19 care unit, the unit should have a restroom, break room and work area that are separate from staff working in other areas of the facility. Dedicated resident care equipment should be dedicated to the COVID-19 unit and should not leave the unit. Review of facility provided emails from [DATE] to [DATE] from the local EMA and facility vendor revealed the facility received requested PPE items such as gowns, surgical masks and N95 masks following each request that was made. None of the provided emails included evidence that requests for PPE could not be granted. On [DATE] at 12:30 P.M. observation and interview with Process Improvement Director (PDI) #304 of the facility supply of PPE (disposable gowns, gloves, surgical masks, N95 and face shields) revealed the facility had two separate storage areas for overflow of PPE outside the facility in two separate buildings. PDI #304 revealed the facility had roughly 20,000 disposable gowns, 15,000 surgical masks and 1,000 N95/K95 masks on hand. He said the facility receives shipments of gloves three times a week and is able to order PPE supplies from four different vendors. PDI #304 denied evidence of a PPE crisis or ability to get necessary PPE. Review of the facility undated COVID-19 Designated Staffing Plan (that was in place prior to the start of the survey) revealed the facility would have COVID-19 positive units located on Unit 2 in the Eckert Wing and Unit 3 in the Sheridan Wing. The facility Quarantine/Observation unit would be located on Unit 2 in the Sheridan Wing. COVID-19 negative residents and COVID-19 recovered residents would be located on Units 1, 3 and 4 in the Eckert Wing and Unit 4 on the Sheridan Wing. The plan revealed staff would be designated to work the following unit types and were not to be changed without the permission of the Administrator. b. Additionally, during the survey, the facility identified five residents, Resident #49, #52, #84, #86 and #100 who had passed away associated with COVID-19: Review of the facility's COVID-19 log revealed Resident #82 tested positive for COVID-19 on [DATE]. Resident #84 (roommate of Resident #82) tested negative on [DATE] and remained in the same room with Resident #82. On [DATE] Resident #84 was transferred to the hospital with a temperature and a low oxygen saturation rate. The resident tested positive for COVID-19 on admission to the hospital and expired on [DATE]. Review of the facility's COVID-19 log revealed Resident #102 tested positive for COVID-19 on [DATE]. Resident #100 (roommate of Resident #102) tested negative on [DATE] and remained in the same room with Resident #102. On [DATE] Resident #100 was transferred to the hospital with a temperature and a low oxygen saturation rate. The resident tested positive for COVID-19 on admission to the hospital and expired on [DATE]. Review of the facility's COVID-19 log revealed Resident #51 tested positive for COVID-19 on [DATE]. Resident #51 was transferred to the hospital the hospital on [DATE] due to being lethargic. The resident expired at the hospital on [DATE]. Review of the facility's COVID-19 log revealed Resident #46 tested positive for COVID-19 on [DATE]. Resident #46 expired at the facility on [DATE]. Review of the facility's COVID-19 log revealed Resident #49 tested positive for COVID-19 on [DATE]. The resident was transferred to the hospital with abnormal laboratory tests on [DATE]. The resident expired on [DATE] in the emergency department. c. Interview on [DATE] at 9:45 A.M. with Housekeeper #270 revealed she wears the same washable gown with an N95 mask and shield in the COVID-19 negative resident rooms. She said when she cleans a COVID-19 positive resident room she removes the washable gown and puts on a disposable gown. She said she wears the same N95 mask and face shield in both the COVID-19 negative and positive resident rooms. She said she walks to the decontamination room at the end of the hallway after she comes out of the positive COVID-19 resident rooms and will spray her shoes and clean her shield. She was unaware of the name of the solution spray used for decontamination or the contact time needed for the disinfectant to be effective. She denied the need to decontaminate her shoes or shield after leaving a COVID-19 negative resident room. On [DATE] at 10:15 A.M. LPN #263 was observed entering Resident #1's room. Resident #1 was identified to be positive for COVID-19. The LPN was wearing PPE including a disposable gown, gloves, face shield and an N95 mask and assisted the resident to reposition. After exiting Resident #1's room, LPN #263 was observed to enter Resident #90's room. Resident #90 was identified to be negative for COVID-19. LPN #263 entered the room without first going to the decontamination room to disinfect her shoes or face shield. Upon entering Resident #90's room, LPN #263 was wearing PPE including an N95 mask and a face shield. The LPN confirmed the lack of PPE in the COVID-19 negative resident room and the lack of decontamination between the positive COVID-19 resident's room and the COVID-19 negative resident's room. On [DATE] at 4:28 A.M. STNA #296 and another unidentified staff member were observed sitting in the nurse's station (on a unit with COVID-19 positive residents) with no N95 or face shield in place. Interview on [DATE] at 4:30 A.M. with STNA #296 revealed she was to be wearing her N95 and face shield while in the building. The STNA revealed she cares for both positive and negative COVID-19 residents on the hallway. During the interview, the STNA revealed as of [DATE] or [DATE] staff had been instructed to wear PPE (gown, gloves, N95 and shield) for all residents. The STNA revealed prior to that she only wore PPE when caring for COVID-19 positive residents. She said the facility was also now telling staff to place a surgical mask over their N95 masks when in a resident's room. The STNA said staff were supposed to disinfect their feet and leave the disinfectant on their shoes wet for five minutes. On [DATE] at 4:40 A.M. LPN #243 was observed walking down the 300 unit in the Sheridan wing where all 19 residents residing on the unit were COVID-19 positive without an N95 mask or a face shield on. The LPN stated it was, ridiculous that staff have to put PPE on in one unit, take it off, and then put new PPE on when they walk outside and around the building to go to another unit. Following the above observation and interview, LPN #243 was observed to administer medications. The LPN donned a disposable gown in the nurse's station and had an N95 mask on. The LPN had her own personal glasses on and no other eye protection. The LPN walked into Resident #4's room who was COVID-19 positive to administer her medications. The resident requested her medication be crushed. The LPN removed her disposable gown and left the room, walked to the nurse's station and punched in the code to the door's lock and then sanitized her hands following that. She then crushed the medications and donned a new disposable gown. She walked back to Resident #4's room and assisted the resident in taking her medication. She walked into the resident's bathroom and washed her hands. She then walked to the trash can located next to the door and removed the disposable gown and placed the soiled gown in the trash can. She then walked back to the nurse's station, punched the code in the door and began working on preparing Resident #8's medications who was COVID-19 negative. She then donned a disposable gown, walked down the hallway to Resident #8's room and assisted her with taking her medications. She then washed her hands, walked to the trash can located by the door and removed the disposable gown. The LPN then walked back to the nurse's station, punched the code into the lock and began preparing Resident #12's medication who was COVID-19 positive. She donned a disposable gown, walked to Resident #12's room and assisted her with taking medications. She then assisted the resident to clean up spilled water from her bedside table. The LPN removed her gown and exited the room and entered the nurse's station and sanitized her hands. She then prepared Resident #14's medication, donned a disposable gown, walked down the hallway to Resident #14's room and administered the medication. The LPN sanitized her hands, removed the gown and placed the soiled gown in the trash can located next to the door and walked back to the nurse's station. The LPN confirmed she had not worn gloves or a face shield while administering the medications to Resident #4, #8, #12 and #14. She verified she was supposed to administer the negative COVID-19 resident their medications prior to administering the positive COVID-19 resident their medications. The LPN also confirmed the disposable gown should have been removed and then she should have washed or sanitized her hands before leaving and having contact with other surfaces in the facility. On [DATE] at 3:30 P.M. interview with RN #240 revealed the facility utilized two disinfectant solutions. A bleach solution and a solution she was unsure of the name of. The RN said the contact time depended on the solution and staff were to read the bottle for contact times. The RN said she thought the contact time for the bleach solution was two to three minutes and the contact time for the unnamed solution was five minutes to be effective. Review of the facility undated policy titled, Disinfecting Your Shoes When Leaving Isolation Rooms revealed staff were to enter the decontamination area of the unit, remove their shoes and spray them with the disinfectant that has been provided and leave the shoes wet for the amount of time recommended by the manufacturer's guidelines. The policy revealed to check the bottle of the disinfectant for the recommended time frame. Place gloves on and wipe your shoes with a paper towel at this time if needed. Review of the Virex II 256 one step disinfectant cleaner and deodorant revealed for use as a one step cleaner and/or disinfectant apply/use solution to hard, non-porous environmental surfaces. To disinfect, all surfaces must remain wet for 10 minutes. Review of the CDC guidelines Sparkling Surfaces: Stop COVID-19's Spread revealed [MEDICAL CONDITION] that causes COVID-19 can be spread by indirect contact with contaminated surfaces. Surfaces that were touched frequently increase the chance that germs could be spread to residents and staff. On surfaces which look clean, pathogens might be present. The coronavirus causing COVID-19 has been shown to survive on surfaces from several hours to days. Review of the facility Revised Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) revealed droplet isolation precautions if a resident was confirmed positive or suspected positive for COVID-19, staff would wear an N95 mask. Eye protection would be donned. Reusable eye protection would be cleaned and disinfected according to manufacturer recommendation. Disposable eye protection would be discarded after each use. Disposable or reusable gowns/coverings would be used as necessary. Hand hygiene using alcohol based hand sanitizer before and after all patient contact, contact with infectious material and before and after removal of PPE, including gloves. If hands were soiled, washing hands with soap a (TRUNCATED)

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Center for Disease Control (CDC) review of the facility's policy and procedure, review of the facility's infection control log, review of daily resident census reports, Point of Care testing results, interview with the local health department staff, interview with the facility's Medical Director, and staff interview, the facility failed to implement infection control procedures to prevent the spread of infectious disease and move COVID-19 positive residents out of rooms with COVID-19 negative residents. With positive and negative residents cohorting, the likelihood exists for serious harm or death related to the spread of the COVID-19 virus. This resulted in Immediate Jeopardy on 10/14/20 when 16 residents tested positive for COVID-19 and ten (10) of the 16 newly positive residents remained in their room being shared with a COVID-19 negative resident. This has the potential to affect all residents in the facility and specifically affected (10) COVID-19 negative residents (Resident #21, #23, #41, #47, #85, #54, #80, #84, #98, and #100) residing with COVID-19 positive residents. The facility census is currently 125. On 10/20/20 at 4:50 P.M. the Administrator was notified of the Immediate Jeopardy that began on 10/14/20 when facility wide testing for COVID-19 was completed for all staff and residents following a facility outbreak. At this time 16 additional new cases were identified including Residents #51, #49, #39, #53, #45, #43, #25, #19, #96, #82, #102, #78, #76, #74, #83, #86. Ten residents (Residents #54, #21, #23, #41, #47, #85, #80, #84, #98, and #100) tested negative and remained in rooms with residents who had tested positive. Additional testing on 10/20/20 resulted in five of these residents, Residents #23, #41, #47, #98, and #100, now testing positive for COVID 19. The Immediate Jeopardy was removed on 10/22/20 when the facility completed the following corrective actions: · 10/20/20 at 5:00 P.M., Medical Director #1 was notified of the need for additional repeat COVID-19 testing of residents who reside in a room with a COVID-19 positive roommate. Medical Director #1 provided orders to test all residents (total of 10) who had COVID positive roommates and make room changes if results remain negative, if room changes were possible at the time of testing. · On 10/20/20 between 6:00 P.M. and 7:00 P.M. testing was completed and revealed of the residents who were previously negative for COVID-19, five residents have tested negative for COVID-19 (after having exposure and potential infection from a COVID positive roommate) and room changes were completed per Medical Director #1's orders to place them into private rooms (Residents #60, #80, #90, #21, and #85). These same residents received a PCR test on 10/21/20 to confirm their COVID-19 status. No room changes resulted in additional COVID positive residents to any units. Five residents (Residents #23, #41, #47, #98, and #100) tested positive. No room change was made due to these residents already residing in a room with another positive resident. MD #1 and family and/or representative was notified of the positive results. · On 10/20/20, the QAPI committee met to discuss the facility's current COVID-19 status and review for possible areas of improvement. · On 10/20/20 at 6:30 P.M., all nurse management and admissions staff were reeducated on the CDC's guidance for appropriate placement of COVID-19 positive, as well as presumptive positive residents, by the facility Administrator. This education states that COVID-19 positive residents should be isolated to a private room if possible. Presumptive positive residents should be isolated to a private room if possible. If cohorting is required because of unavailability of private rooms, residents should be appropriately placed by CDC guidelines, which includes not cohorting positive and confirmed negative residents together. · As of 10/21/20 the facility's licensed bed capacity is 180, with a current census of 127. In response to the facility's COVID-19 status, all 8 units have been converted into temporary isolation units and all residents are on droplet isolation. · On 10/21/20 at 12:00 P.M., all staff in all disciplines (including 26 nurses, 49 state tested nursing assistants, 16 therapy staff, 13 housekeepers, 8 laundry staff, 3 maintenance staff, 9 receptionist, 10 office personnel, 8 activity staff, 19 dietary staff, and 3 medical record staff) reported to the facility and were reeducated regarding the donning and doffing of PPE, hand washing, and signs and symptoms of COVID-19 by the facility's Education Director #4. No further facility staff require this education. · Beginning 10/21/20, to monitor further compliance, all room assignments must be approved by the Administrator in writing before finalized until further notice. The Administrator will be held accountable and responsible to the Board of Directors for completion of this task. · Beginning 10/21/20 Education Director #4 will complete return demonstration audits of the donning and doffing of PPE and handwashing for (10) staff members, 5 days weekly x4 weeks beginning 10/21/2020. The Education Director #4 will be held accountable and responsible to the Administrator for completion of this task. · On 10/22/20 between 10:00 A.M. and 10:30 A.M. a tour was completed of the facility that confirmed residents who had tested positive for COVID-19 were in rooms with other COVID positive residents and COVID negative residents were in rooms with other COVID negative residents. · On 10/22/20 between 1:50 P.M. and 2:30 P.M. interview with Nursing Services #79, State tested Nursing Assistant #145, Housekeeping #173, and Licensed Practical Nurse #147 revealed they had received education within the last two days in regards to the donning and doffing of PPE, hand washing, and signs and symptoms of COVID-19. On 10/22/20 at 3:00 P.M. Education Director #4 provided a sign in sheet for education provided to staff on 10/20/20 and 10/21/20 which contained all staff signatures. Although the Immediate Jeopardy was removed on 10/22/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/03/20, revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of Covid-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). Tour of the facility on 10/19/20 between 2:50 P.M. and 3:34 P.M. revealed all four units in the Eckert home (Units 1,2,3, and 4) were isolation units. All units in the Sheridan home (Units 1,2,3 and 4) were also considered to be isolation units. Tour of Unit 2 located in the Eckert home revealed resident rooms with three drawer carts located outside their doors in the hallway, containing personal protective equipment (PPE) for staff. Multiple rooms were noted to have both a (+) and (-) symbol on the doorway entrance. Staff were observed exiting residents' room after removing their PPE and using the hand sanitizer located by the door before exiting the room. Before entering another room, staff were observed putting on new, clean PPE items. Each unit was noted to have and room that was designated to serve as staff's breakroom and another room which was designated to serve as a decontamination room. Interview on 10/19/20 at 3:25 P.M. with Infection Control Director #8 and Assistant Director of Nursing #2 confirmed the (+) symbol on a resident's door indicated the resident was COVID-19 positive when tested and a (-) indicated a resident was COVID-19 negative when tested . Infection Control Director #8 confirmed there were COVID negative residents residing in the same room as COVID positive residents due to the two residents already being roommates prior to the positive COVID results. They felt as though the negative roommate had already been exposed to [MEDICAL CONDITION] and moving them out of the room would cause a greater outbreak of [MEDICAL CONDITION]. Review of the facility's bed board and resident daily census report for 10/19/20 confirmed the resident's location in the facility to be correct and COVID-19 positive residents were in the same room as COVID-19 negative residents. Review of the Infection Control log for 08/2020, 09/2020, and 10/2020, revealed the facility did not have any positive COVID cases until 10/06/20 when a staff member started to experience symptoms of [MEDICAL CONDITION] on 10/05/20 and tested positive for COVID-19 on 10/06/20. Due to this positive result, all residents residing in the facility were tested with a point of care (POC) COVID test method which provides results right away. This test resulted in five positive COVID tests for Residents #31, #33, #52, #60, and #62. Each of the five positive results test samples was sent to have a polymerase chain reaction (PCR) test completed which test for the COVID [MEDICATION NAME]. Of the five positive POC test completed three resulted in a positive PCR test. 1. Review of the facility's COVID-19 logs revealed Resident #52 tested positive for COVID 19 on 10/07/20. Resident #54 (roommate of Resident #52) tested negative on 10/07/20 and remained in the same room with Resident #52. On 10/20/20 Resident #54 was retested and remained negative for COVID-19. The family and residents wished to remain cohorted as they were husband and wife. 2. Review of the Facility's COVID-19 log revealed Resident #19 tested positive for COVID-19 on 10/14/20. Resident #21 (roommate of Resident #19) tested negative on 10/14/20 and remained in the same room with Resident #19. On 10/20/20 Resident #21 was retested and remained negative and was relocated to a private room. 3. Review of the Facility's COVID-19 log revealed Resident #25 tested positive for COVID-19 on 10/14/20. Resident #23 (roommate of Resident #25) tested negative on 10/14/20 and remained in the same room with Resident #25. On 10/20/20 Resident #23 was retested and was positive for COVID-19. 4. Review of the Facility's COVID-19 log revealed Resident #39 tested positive for COVID-19 on 10/14/20. Resident #41 (roommate of Resident #39) tested negative on 10/14/20 and remained in the same room with Resident #39. On 10/20/20 Resident #41 was retested and was positive for COVID-19. 5. Review of the Facility's COVID-19 log revealed Resident #45 tested positive for COVID-19 on 10/14/20. Resident #47 (roommate of Resident #45) tested negative on 10/14/20 and remained in the same room with Resident #45. On 10/20/20 Resident #47 was retested and was positive for COVID-19. 6. Review of the Facility's COVID-19 log revealed Resident #83 tested positive for COVID-19 on 10/14/20. Resident #85 (roommate of Resident #83) tested negative on 10/14/20 and remained in the same room with Resident #84. On 10/20/20 Resident #85 was retested and was negative for COVID-19 and moved to a private room. 7. Review of the Facility's COVID-19 log revealed Resident #78 tested positive for COVID-19 on 10/14/20. Resident #80 (roommate of Resident #78) tested negative on 10/14/20 and remained in the same room with Resident #78. On 10/20/20 Resident #80 was retested and was negative for COVID-19 and was moved to a private room. 8. Review of the Facility's COVID-19 log revealed Resident #82 tested positive for COVID-19 on 10/14/20. Resident #84 (roommate of Resident #82) tested negative on 10/14/20 and remained in the same room with Resident #82. On 10/20/20 Resident #84 was retested and was negative for COVID-19 and was moved to a private room. 9. Review of the Facility's COVID-19 log revealed Resident #96 tested positive for COVID-19 on 10/14/20. Resident #98 (roommate of Resident #96) tested negative on 10/14/20 and remained in the same room with Resident #96. On 10/20/20 Resident #98 was retested and was positive for COVID-19. 10. Review of the Facility's COVID-19 log revealed Resident #102 tested positive for COVID-19 on 10/14/20. Resident #100 (roommate of Resident #102) tested negative on 10/14/20 and remained in the same room with Resident #102. On 10/20/20 Resident #100 was retested and was positive for COVID-19. Interview on 10/19/20 at 3:40 P.M. with the Administrator revealed when the facility had the five residents who tested positive on 10/07/20, they ensured they were not with another resident who was negative other than for Resident #52 due to her roommate being her husband and both residents refusing to relocate. The Administrator also revealed the facility's Medical Director (MD) #1 was notified of the positive cases and MD #1 gave orders to start every resident who resided on the same unit and the COVID positive residents on a preventive cocktail of medication which included, [MEDICATION NAME] (an antibiotic used to treat various types of infections), [MEDICATION NAME] (an antibiotic used to treat and prevent infections), Zinc (a supplement), Vitamin C (a supplement), and Vitamin D (a supplement). Interview on 10/19/20 at 4:10 P.M. with the Administrator revealed when the facility made MD #1 aware of the new COVID positive cases, MD #1 advised the facility to keep all the residents in their current room and place the whole facility in isolation. MD #1 ordered the previously noted preventive cocktail for all residents residing in the facility. The Administrator indicated MD #1 informed him that it is already presumed that all residents who tested negative to COVID and are residing with a COVID positive resident have been exposed to [MEDICAL CONDITION] due to being in the same room and he did not want to move any residents around and have an even larger number of positive cases. Interview on 10/20/20 at 2:05 P.M. with MD #1 revealed the facility has been updating him on every positive staff and resident case. MD #1 claimed when the first five residents tested positive on 10/07/20 they were either already in a private room, moved into a room with another COVID positive resident, or refused to move rooms. MD #1 revealed he decided to start the COVID positive residents plus all other residents who resided on the same unit on a cocktail of medication to try to prevent them from contracting [MEDICAL CONDITION] and to help those who already have it, recover quicker. When the facility contacted him in regards to the new cases on 10/14/20, he decided there was just too large of a number of positive residents to try to move around so he instructed the facility to leave all residents where they currently were, place the whole facility in isolation, and start every resident on the cocktail of preventive medication who weren't already on it. MD #1 revealed he was not sure of any other facility that was using this cocktail but spoke with the Administrator and they decided they wanted to be aggressive with the resident's care and treatment. MD #1 claims that he felt the preventive cocktail was effective due to the facility currently having no deaths or hospitalization s due to COVID. MD #1 also revealed he decided to keep all the residents in their current location because he was not that confident in the test results. Most of the residents who tested positive were not experiencing any signs or symptoms of [MEDICAL CONDITION] which was very unusual for this population plus he strongly felt that since the positive and negative residents resided in the same room, it was presumed the negative resident had already been exposed and it was just a matter of time until they test positive. If the facility was to relocate them into another room with a negative resident, it would just cause more exposure to [MEDICAL CONDITION]. Interview on 10/21/20 at 11:33 A.M. with Communicable Disease Nurse (CDN) #1 for the Local Health Department revealed the facility was advised the ideal situation for COVID positive residents would be to place them in a private room if available. The facility informed the Health Department that due to having two rooms on each unit designated as a decontamination room and another room as a staff breakroom, there was not enough rooms to provide each positive resident with a private room. The facility was then advised to follow the Center for Disease Control guidelines which, per the Local Health Department's understanding, was to keep the residents in their current rooms since the likelihood of contamination had already occurred and it was not ideal to move residents around and cause a possible greater exposure. Follow-up interview with CDN #1 on 10/23/20 at 12:15 P.M. by the state agency survey administrator revealed the facility told CDN #1 they did not have any rooms available to separate Covid-19 positive residents and COVID-19 negative residents. CDN #1 stated it is not within her position to analyze the facility bed availability. In addition, the facility failed to provide the surveyor any information indicating they were in crisis capacity staffing. Review of facility policy titled Revised Interim Policy for suspected or Confirmed Coronavirus, revised on 08/26/20, revealed under section Emergency Preparedness and Response Plan Related to COVID-19 number 1. Place residents in private rooms on droplet isolation precautions OR cohort residents identified with same symptoms and/or COVID-19 confirmation. This deficiency substantiates Complaint Number OH 548 and OH 524.

Based on medical record review, review of hospital records, review of facility investigation, staff interview, resident interview, and family interview, the facility failed to ensure a safe transfer of one resident (Resident #116). The facility failed to complete a thorough investigation of a sustained injury to determine if the resident was transferred properly and if the equipment being used was safe. This resulted in actual harm when Resident #116 was transferred from his wheelchair to his bed and sustained a laceration to the outside of his right lower extremity (RLE) resulting in 26 staples and 11 sutures to close the area. This affected one of three residents reviewed for transfers. The facility census was 140. Findings include: Review of the medical record for Resident #116 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #116's care plan dated 9/10/19 revealed the resident had actual impairment to skin integrity with interventions including wound care treatments to the resident's right lateral and posterior calf. Review of Resident #116's physician orders [REDACTED]. Review of the PT plan of care dated 09/10/19 revealed Resident #116 was referred for PT due to a decline in transfers and gait due to amputation of his right toe. He required skilled therapy in order to improve safety and function. The resident was noted to be non-weight bearing (NWB) on his right foot. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 had intact cognition and required extensive assistance with two staff for transfers. Review of Resident #116's progress note dated 09/30/19 at 6:44 P.M. revealed the resident was complaining of increased shortness of breath, coughing up yellow sputum and requested to be sent to the hospital. The physician was notified, and the resident was sent to the hospital. Review of the hospital record revealed Resident #116 was discharged back to the facility on [DATE] after being treated for [REDACTED]. Review of Resident #116's documentation and measurements to skin areas form dated 10/11/19 upon his return to the facility revealed the area to the resident's outer side of his RLE was an open area measuring 2.3 centimeters (cm) x 1.7 cm, with no depth documented. Review of Resident #116's progress note dated 10/12/19 at 3:09 P.M. revealed the resident's dressing was changed to his RLE. Review of Resident #116's progress note, dated 10/13/19 and timed 1:08 P.M. written by Registered Nurse (RN) #4, revealed the receptionist notified her that a nurse was needed in Resident #116's room. At approximately 10:30 [NAME]M. RN #4 and the Unit Nurse, Licensed Practical Nurse (LPN) #55 immediately responded to the room. Upon arriving LPN #216, State tested Nursing Assistant (STNA) #215, and Physical Therapist Assistant (PTA) #207 were in the room as they had just transferred the resident from his wheelchair to his bed. LPN #216 had a towel placed against the resident's right lower leg, applying pressure. There was a gross amount of blood on the towel and the floor. A skin tear was noted to the right lateral calf measuring approximately 18 centimeters (cm) in length x 14 cm in width, and 1 cm in depth, with a gross amount of bleeding noted. The flap was intact with subcutaneous tissue exposed. The actual precise measurements were unable to be obtained due to the amount of bleeding. A moistened sterile gauze was used to assist to keep the flap in place on his leg. The area was covered with an abdominal gauze (ABD/used to absorb heavily draining wounds) pad and secured with Kerlix. The resident verbalized pain to the area, however was calm. Emergency Medical Services (EMS) arrived at 10:48 [NAME]M. and the resident was transferred to the hospital. New orders were put in place to pad the posterior ends of the resident's side rails on his bed, and to use a Hoyer lift for all transfers until PT/OT could further evaluate appropriate transfer techniques. Review of the hospital report dated 10/13/19 revealed Resident #116 arrived at the hospital with a large evulsion (injury of a body structure torn off by either trauma or surgery) to the right lower leg. The resident revealed his leg was hit on the bed rail at the nursing facility. The report noted the resident was currently on [MEDICATION NAME] (blood thinner) and his bleeding was controlled with a pressure dressing. His pain was noted to be a 9 out of 10, with 10 being the most severe pain. The wound was cleansed with normal saline. The wound measured 28 cm that extended to the muscle fascia (connective tissue beneath the skin). The wound was noted to be a complex laceration that required 10 sutures and 26 staples to close. He was discharged back to the facility the same day. The complete investigation was requested from the Administrator and was provided. The investigation completed by the facility consisted of three witness statements completed by staff, an incident/accident investigation completed by the Director of Nursing (DON), and one in-service training provided to therapy staff on 10/15/19. The areas covered during the in-service were to individualize all treatment plans and to listen to the residents about their bodies. The in-service was completed by the Licensed Occupational Therapist. The investigation did not include a statement from Resident #116, nor was there any inspection of the bed, bedrails, or the resident's wheelchair in order to try and determine what caused the injury. No additional investigation was provided. Review of the incident/accident investigation dated 10/13/19 at 10:35 [NAME]M., signed by the Director of Nursing (DON) revealed the nurse was notified by the receptionist that their assistance was needed in Resident #116's room. The RN supervisor and Unit Nurse responded. The resident was being transferred from his wheelchair to his bed when his lower leg scraped against the bed causing a large skin tear. First aid was administered, and the resident was sent to the emergency room . Review of the incident witness statement dated 10/13/19 at 10:35 [NAME]M., completed by LPN #216 revealed Resident #116 was in his wheelchair and asked to lay down. Therapy was notified because they wanted to watch him transfer. Three medical staff attempted to transfer the resident with a gait belt and his walker, however the resident sat back in the chair. Upon the second attempt, the resident requested to be moved closer to the rail in order to grasp upon it while standing. The resident was transferred with three staff members (LPN #216, STNA #215 and PTA #207) to his bed. Upon the resident sitting it was noted blood was coming from his right outer calf. Pressure was applied. Review of the incident witness statement dated 10/13/19 at 10:35 [NAME]M. completed by PTA #207 revealed she was called by STNA #215 for assistance for therapy to help transfer Resident #116 from his wheelchair to his bed. A stand pivot transfer was attempted with the resident and was unable to be completed safely. The resident requested his wheelchair be moved closer to the bed. The resident had a gait belt donned and non-skid foot wear with an off-loading shoe to the right foot. After the transfer was completed the resident stated, my foot. A skin tear was noted. STNA #215 acquired materials to assist with the skin tear. RN #4 was immediately notified. Constant pressure was applied to the skin tear on the resident's right lateral calf region. Review of the incident witness statement dated 10/13/19 at 10:35 [NAME]M. completed by STNA #215 revealed the STNA went in to Resident #116's room and the resident had asked to go back to bed. The STNA revealed herself, LPN #216 and PTA #207 assisted with the transfer. The STNA revealed she was standing behind the resident's wheelchair to lift his bottom. The resident asked to move closer to the bed rail. When moving to the bed, Resident #116 said, oh, my foot. We moved his foot and saw a large open spot. Interview with Resident #116's spouse on 11/07/19 at 12:13 P.M. revealed when staff transferred her spouse from the wheelchair to the bed, a gait belt was used. When the resident sat on the bed, his right leg was pressed up against the bed railing and split open. The resident's spouse shared a photo of the injury taken prior to the resident begin treated at the hospital. The photo revealed a deep gaping laceration to his outer RLE from the knee down to the ankle, with red beefy, bloody skin exposed. Interview with PTA #207 on 11/07/19 at 4:15 P.M. confirmed Resident #116 was transferred from his wheelchair by her, STNA #215 and LPN #216. PTA #207 revealed STNA #215 had informed her Resident #116's transfer from the wheelchair to the bed the previous day was not very good. The resident attempted to stand at his walker to complete a stand pivot transfer from his wheelchair to the bed, however the resident's legs started buckling and collapsing so the resident sat back down in the wheelchair. PTA #207 moved the resident's walker and she and LPN #216 were positioned in front of the resident and STNA #215 was positioned behind the resident when the transfer was attempted again. Resident #116 completed a stand pivot transfer from his wheelchair to the bed, however upon sitting on the bed, the resident yelled, my foot! STNA #215 pulled the wheelchair back away from the resident and the resident's outer right calf was pressed up against the bed railing. PTA #207 revealed she did not see any injuries, so she grabbed the resident's right foot and repositioned it and then noticed all the blood. She revealed something on the bed had to have caused the injury. Interview and observation with Resident #116 on 11/07/19 at 5:00 P.M. revealed his bed railing on his bed was wrapped with gauze as a preventative measure to reduce the risk of another incident. Resident #116 revealed it was the pressure against the bed that made his leg explode. He said his outer RLE was pressed up against the bed railing during a transfer and he yelled, oh, my foot, however LPN #216 and STNA #215 continued to pull him back toward the middle of the hospital bed, placing more pressure on his calf. The resident revealed he was frustrated because he wanted to be discharged back to home with his family, however he had not been able to bear any weight on his right leg again following the incident, which has delayed his progress. Interview with STNA #215 on 11/18/19 at 11:45 [NAME]M. revealed Resident #116 had been transferred from his bed to the wheelchair on 10/13/19 with no issues. After an hour of being up he requested to be returned to bed. The STNA revealed she stood behind the wheelchair while PTA #207 and LPN #216 was on either side of him. STNA #215 revealed when they sat him on the edge of the bed blood began gushing out of his lower right leg. STNA #215 was unsure what had hit his leg, the bed or the bedrail. STNA #215 revealed she notified RN #4 who came with LPN #55 to assess and treat the resident. Interview with LPN #55 on 11/18/19 at 11:45 [NAME]M. revealed she was the nurse who assisted RN #4 in treating Resident #116 after his injury to his right lower leg. LPN #55 revealed it was not possible to get an exact measurement of the wound due to the amount of blood. She revealed the flap of the wound was put back in the leg and a pressure dressing was applied. The resident was then transferred to the hospital for treatment. A follow up interview with PTA #207 on 11/18/19 at 12:10 P.M. revealed there was blood on Resident #116's side rail, mattress, and the floor. She was unsure of what the resident's RLE had hit, however said it had to hit the siderail or the bed. She further revealed she was unaware the resident had a wound to the right lower leg prior to the incident that was to be covered with a dressing. She confirmed the resident was wearing shorts and there was no dressing to the resident's leg when the transfer occurred. PTA #207 revealed if the resident had a compromised area to his outer RLE prior to the incident, it would have been more susceptible for injury due to his poor skin integrity. Interview with RN #234 on 11/18/19 at 4:05 P.M. revealed Resident #116 did have an open area to his outer RLE with a wound treatment in place prior to the incident on 10/13/19. The RN confirmed there was no evidence the area had a dressing on it prior to the incident on 10/13/19 and there should have been one. Attempts on 11/18/19 at 12:30 P.M., and 4:10 P.M. to interview LPN #216 via telephone were unanswered. A message was left, and no return call was received. This deficiency substantiates Complaint Number OH 037

Based on medical record review and staff interview, the facility failed to comprehensively assess Resident #83's bowel and bladder function and implement interventions and/or a program to restore function and prevent the decline in her bowel and bladder function. Actual harm occurred for Resident #83 when the facility failed to implement interventions to restore and/or prevent the decline from her being occasionally incontinent of bowel and bladder status to her always being incontinent of bowel and bladder. This affected one of one sampled residents reviewed for urinary incontinence. The facility census was 153. Findings include: Review of Resident #83's medical record revealed an original admission date of [DATE] with the latest readmission on 07/14/17 with the admitting [DIAGNOSES REDACTED]. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understands others, makes herself understood and was alert and oriented without cognitive deficits as documented on the Brief Interview for Mental Status (BIMS). The MDS Resident #83 was dependent on two staff members for toileting, was occasionally incontinent of both bowel and bladder. Occasional urinary incontinence is defined by having less than seven episodes of incontinence in the seven day review period Occasional bowel incontinence is defined as having one episode of incontinence in the seven day review period. This assessment indicated a toileting program had not been implemented or trialed to improve or manage the resident's bowel and bladder incontinence. Review of the resident's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #83 was dependent on two staff members for toileting and the resident's bowel and bladder function declined and she was now frequently incontinent of both bowel and bladder. Frequently incontinet of bowel is defined as two or more episodes with one continent episode in the seven day review period. Frequently incontinent of bladder is defined as seven or more incontinence episodes with at lease one continent episode in the seven day review period. This assessment indicated Resident #83 was not on a toileting program to improve or manage her bowel or bladder incontinence. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #83 was dependent on two staff members for toileting and the resident's bowel and bladder function declined and she was now always incontinent of both bowel and bladder. This is defined as her having no continent episodes for either bowel or bladder in the seven day review period. The MDS indicated the resident was not on a toileting program to improve or manage the resident's incontinence. Review of the resident's bladder incontinence plan of care dated 07/17/17 revealed the facility implemented the interventions for staff to encourage the resident to urinate while on the toilet and that she used disposable briefs. Review of the resident's elimination plan of care dated 07/17/17 revealed the resident was incontinent of bowel and bladder function and staff were to keep resident clean and dry every shift. Review of the baseline care plans dated 7/16 and 11/16 revealed the resident's bladder function was incontinent. The baseline plan of care did not address the resident's bowel function. Review of the medical record revealed no documented evidence of a completed bowel or bladder assessment or any interventions implemented to attempt to restore and/or prevent the decline in Resident #83's bowel and bladder status. On 02/09/18 at 2:20 P.M. interview with Licensed Practical Nurse (LPN) #137 revealed the baseline care plan is part of the Registered Nurses (RN) admission assessment and the RN assesses the resident's bowel and bladder status. On 02/09/18 at 3:25 P.M. interview with RN #245 revealed he provided an illustration of documentation and measurements of skin areas dated 07/14/17 and stated the resident was assessed on the admission by writing bladder incontinent on this skin assessment. On 02/09/18 at 5:25 P.M. interview with RN #7 verified the facility was unable to provide any assessments for Resident #83's bowel and bladder function. The RN said she was unable to provide any documentation or evidence the facility attempted any interventions to attempt to restore and prevent Resident #83's declines in bowel and bladder function.

Based on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to ensure Resident #71's personal alarm (an alarm device that gives an audible signal) was properly functioning resulting in an avoidable fall. The facility also failed to use two staff assists with a transfer for Resident #60 resulting in a laceration requiring sutures. Additionally the facility failed to serve Resident #46 beverages in a physician ordered therapeutic cup. Actual harm occurred when Resident #71, who was dependent on two staff members for transfers and was coded as being non-ambulatory, fell when her personal alarm failed to sound when she attempted to self ambulate, resulting in a left [MEDICAL CONDITION] requiring hospitalization and surgical repair. Actual harm occurred When Resident #60 was transferred with one staff resulting in a leg laceration requiring a visit to the hospital, stitches to to close the wound and ongoing dressing changes and antibiotics. Actual harm occurred when Resident #46 was served hot coffee in a regular coffee cup which caused the resident to spill hot coffee on her right hip resulting in a second degree burn (a burn marked by pain, blistering, and superficial destruction of dermis with [MEDICAL CONDITION] and hyperemia of the tissues beneath the burn). This affected three of six residents reviewed for accidents. The facility census was 153. Findings include: 1. Review of Resident #71's medical record revealed an original admission date of [DATE] with the latest admission on 10/16/17 with admitting [DIAGNOSES REDACTED]. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident understood others, made herself understood and was alert and oriented with no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS). This MDS indicated Resident #71 was dependent on two staff members for transfers, was non-ambulatory and had a history of [REDACTED]. Review of the resident's physician's orders [REDACTED].). Review of the resident's monthly physician's orders [REDACTED]. Review of the at risk for falls plan of care dated 08/01/17 revealed on 09/22/17 the facility implemented the intervention of a personal alarm to bed and chair and the staff were to check the placement and function of the alarm every shift. Review of the at risk for falls plan of care dated 10/17/17 revealed on 10/16/17 the facility implemented the intervention of a personal alarm to her bed and chair and the staff were to check the placement and function every shift. Review of the resident's fall risk assessment dated [DATE] revealed the resident was at risk for falls and the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the fall investigation report dated 10/13/17 at 6:45 P.M., revealed Resident #71 was ambulating in the hallway with a walker when she fell on her left side and complained of left hip pain. The investigation documented her sensor and personal alarms were not sounding at the time of the fall. The facility sent the resident to the local emergency room for evaluation of her left hip pain. Review of the resident's nursing progress notes dated 10/13/17 at 8:25 P.M. indicated the resident was ambulating in the hallway unassisted with a walker and the personal alarm was not sounding. The resident fell in the hallway on her left side. The resident reported pain and requested to be sent to the emergency room for an x-ray of her left hip. Review of the continuity of care form dated 10/16/17 from the acute care hospital revealed the resident's admitting [DIAGNOSES REDACTED]. The resident required a surgical procedure, an intramedullary nailing of the left intertrochanteric [MEDICAL CONDITION], to fix the [MEDICAL CONDITION]. Review of the resident's medical record failed to provide any documented evidence the staff checked the placement and function of Resident #71's alarms every shift. On 02/06/18 at 4:21 P.M., Resident #71 was observed sitting up in her wheelchair in her room without the sensor alarm in place to her wheelchair. On 02/07/18 at 9:50 A.M., Resident #71 was observed sitting up in her wheelchair in her room without the sensor alarm in place to her wheelchair. On 02/07/18 at 3:45 P.M., Resident #71 was observed sitting up in her wheelchair in her room without the sensor alarm in place to her wheelchair. On 02/09/18 at 9:58 A.M., Resident #71 was observed sitting up in her wheelchair in her room without the sensor alarm in place to her wheelchair. On 02/09/18 at 10:00 A.M. interview with Licensed Practical Nurse (LPN) #3 verified the resident did not have a sensor alarm in place as the physician ordered. On 02/09/18 at 2:56 P.M. interview with LPN #109 revealed the resident's personal alarm was attached by a primesnap, and said the resident was pretty weak but felt she did have the strength to remove the alarm. On 02/09/18 at 3:13 P.M. interview with Former State tested Nursing Assistant (STNA) #258 revealed the STNA witnessed the resident fall on 10/13/17 at approximately 6:45 P.M. The STNA said the primesnap was still attached to the resident and the personal alarm was not sounding. The STNA said the personal alarm was still in the resident's room. The STNA said the LPN on duty was summoned to the resident and she was sent to the emergency room . The STNA said the resident was admitted to the hospital that evening. On 02/09/18 at 4:35 P.M. interview with Registered Nurse (RN) #7 revealed the resident's personal alarm malfunctioned the day of the fall and was replaced at that time. Review of the facility's policy and procedure for falls and accidents, not dated, revealed it is the facility's policy to provide a safe environment for all residents, to reduce foreseeable accidents and falls, to assure quality of life in a controlled environment and to enhance and/or prevent deterioration in the resident's condition. High risk criteria are those residents with known history of falls/accidents, disorientation, sensory deficits or weakened/deteriorated condition due to disease or medical treatment. All residents will be assessed on admission, quarterly and as needed. The following implementations, such as personal monitors to alert staff of their needs, will be followed based on the resident's individual needs and the resident's plan of care will reflect the interventions. 2. Review of Resident #60's medical record revealed an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] indicated the resident had clear speech, usually understands others, makes herself understood and had severe cognitive deficit as indicated by a BIMS score of seven. Scores of zero to seven indicate severe cognitive impairment for decision making. This MDS indicated the resident was dependent on two staff members for transfers, was non-ambulatory and had no falls since the prior assessment completed on 12/30/17. Review of the resident's mobility plan of care dated 12/26/17 revealed the facility implemented an intervention for two staff to assist her with transfers. Review of the resident's self care deficit plan of care dated 12/26/17 also indicated the facility implemented two staff to assist her with transfers. Review of the resident's mobility plan of care dated 01/19/18 revealed on 01/24/17 the facility implemented the interventions that staff may use the Hoyer (mechanical) lift with all transfers. Review of the resident's monthly physician's orders [REDACTED]. Review of the resident's progress notes revealed an entry dated 02/01/18 at 8:30 A.M. that documented Occupational Therapy Assistant (OTA) #259 requested assistance with the resident at bedside. The OTA reported she was working with the resident at the bedside on transfer skills from the bed to the wheelchair when the resident was noted to have a laceration to her left shin. Review of the resident's progress note dated 02/01/18 at 8:32 A.M. revealed an order was obtained to send the resident to the local emergency room for an evaluation and treatment. Review of the discharge instructions from the local emergency room dated 02/01/18 revealed the resident's primary [DIAGNOSES REDACTED]. The discharge instructions described the laceration to the left shin as a 5.0 cm complex laceration, Y shaped, with a flap wound requiring 10 sutures to close the laceration. The discharge instructions indicated the sutures were to be removed in seven to 10 days. On 02/02/18 an order was written to change the treatment to the resident's left lower shin to cleanse with soap and water, apply an oil [MEDICATION NAME] dressing, cover with and a pad and wrap with Kerlix gauze daily and as needed to promote healing. also an order [REDACTED]. Review of the treatment progress note dated 02/06/17 at 7:47 A.M. revealed the laceration to the resident's left shin measured 3.4 cm by 0.4 cm and the wound bed was pale pink with a small amount of active bleeding. The periwound was bruised and deep maroon/purple in color with no signs of infection. The left shin proximal (closest to the knee) laceration was 4.2 cm by 2.7 cm by 0.4 cm and the wound was V shaped with 9 sutures intact. There was also an open area at the tip of the V with a depth of 0.4 cm. The wound bed was beefy red with a small amount of serosanguineous (clear to tan bloody) drainage noted. The periwound was bruised with no signs of infection. On 02/07/18 at 4:10 P.M. Registered Nurse (RN) #17 was observed completing the physician ordered treatment to the resident's left lower leg. The RN then removed the soiled dressing which had a moderate amount of reddish drainage to the soiled dressing. The RN cleansed the wound with soap and water using a gauze square. The wound had nine visible stitches in place. The wound edges were well approximated and was without any signs of infection. The surrounding tissue was dark purple in color. The RN applied the dressing as ordered. On 02/05/18 at 5:10 P.M., OTA #258 demonstrated and verified one assist was used during the transfer of Resident #60 at the time the laceration was sustained. 3. Review of Resident #46's medical record revealed a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#46 had an order dated 12/19/17 to use therapeutic cups. Review of an occupational therapy evaluation dated 01/04/18 revealed Resident #46 was referred to therapy due to difficulty handling utensils for self feeding. Review of admission MDS assessment dated [DATE] revealed Resident #46 had severe cognitive impairments and required staff supervision and set-up for meals. Review of nurse's progress note dated 02/01/18 at 12:15 P.M. revealed the nurse was summoned to Resident #46's room and the resident said, I spilled my coffee on me. Redness and blisters were noted to her right hip area. The area measured 9.0 centimeters (cm) by 13.0 cm with several blisters noted. Cold compresses were applied and treatment orders for staff to clean the area with soap and water and apply an Allevyn dressing every three to five days and as needed. Review of treatment progress notes dated 02/05/18 revealed Resident #46 had second [MEDICAL CONDITION] her hip and the upper part measured 7.0 cm by 17.0 cm and the blister to right hip had burst. She also sustained second [MEDICAL CONDITION] her right lower hip area which measured 2.0 cm by 7.0 cm and that blister had burst. Resident #46 denied pain. Review of the dietary coffee temperature log dated (MONTH) (YEAR) revealed on 02/01/18 coffee was measured at 166 degrees when it left the kitchen and was 162 degrees when it arrived to the dining room to be served. Review of the log revealed coffee temperatures for serving were between 155 degrees and 164 degrees. Interview was conducted on 02/08/18 at 8:56 A.M. with Resident #46 and she verified she did burn herself with coffee and stated it just happened. She was unable to tell any specifics due to her cognitive status. There was a therapeutic cup observed on her bedside table. Interview was conducted on 02/08/18 at 3:33 P.M. with Dietary Staff #170 and she stated coffee temperatures are logged every day and she verified Resident #46 was burned with hot coffee on 02/01/18. She stated it was within normal temperature range and they try to keep coffee at 160 degrees. She verified the temperature of the coffee logged for 02/01/18 at 162 degrees was correct. Interview was conducted on 02/08/18 at 5:19 P.M. with LPN #6 and she verified she was Resident #46's nurse on 02/01/18 and she stated she was called into resident's room per state tested nursing assistant (STNA) #177 who stated the resident had spilled her coffee. LPN #6 stated Resident #46's coffee was in a regular cup on her meal tray. She said Resident #46 got the cup of coffee off her tray before the STNA could pour it into her therapeutic cup. LPN #6 stated resident loves her coffee and grabbed it in a hurry. Interview was conducted on 02/08/18 at 5:26 P.M. with STNA #177 and she verified she was Resident #46's aide on 02/01/18. She stated she took Resident #46's tray to her at bedside and was getting ready to prepare it and Resident #46 got her coffee and spilled it on herself. STNA #177 verified the coffee was in a regular cup and that Resident #46 picked it up before she had the chance to pour the coffee it into her therapeutic cup. She stated she immediately got the nurse when resident stated she got burned. STNA #177 stated she was educated to prepare resident's trays before placing it within the reach of the resident. Interview was conducted on 02/08/18 at 5:30 P.M. with the Director of Nursing and she verified Resident #46 had sustained second [MEDICAL CONDITION] 02/01/18 from spilling hot coffee on herself. She stated they educated the STNA on preparing the tray before placing the tray within resident's reach. She stated the kitchen brings all liquids out in regular cups and it was the aides and the nurses responsibility to then pour the beverages into their appropriate and ordered cups or devices. She verified Resident #46 was to have liquids served in therapeutic cups. This deficiency substantiates Complaint Number OH 042.

Based on observation, closed medical record review, review of an accident/incident report, review of an investigation form, staff interviews, physician interview, family interview, and review of the facility undated policy and procedure for a missing resident, the facility failed to provide adequate supervision to prevent Resident #31 from eloping from the facility. This resulted in Immediate Jeopardy when Resident #31, who was at risk for elopement and had a history of [REDACTED]. The potential for serious harm, impairment, or death occurred as Resident #31 left the facility at night and was found by local police on a two lane road near a heavily traveled State route on a road adjoining the facility. This affected one of three residents (#31) reviewed for exit seeking behaviors. The facility identified thirty additional residents (Resident #2, #3, #5, #7, #9, #28, #32, #33, #34, #37, #38, #42, #50, #53, #56, #59, #60, #65, #77, #81, #98, #100, #118, #119, #122, #126, #129, #147, #148, and #153) who were at risk for elopement. The facility census was 158. On 11/09/17 at 10:38 A.M., the Administrator, the Director of Nursing (DON), the Administrative Assistant, and the Process Improvement Director were notified Immediate Jeopardy began on 10/31/17 at approximately 1:30 A.M. when Resident #31 exited the facility through a side exit door without staff knowledge. Resident #31 was returned to the facility by local police at approximately 3:00 A.M. after she was found walking near a heavily traveled State route. The facility policy on missing residents identified areas of high risk around the surrounding areas of the facility that included the farm field, parking areas, pond, and roads adjoining the facility. The Immediate Jeopardy was removed on 11/05/17 at 4:49 A.M. when the facility implemented the following corrective actions: · On 10/31/17 the Human Resources/In-service Director provided in-service training to all facility staff in all departments on the policy and procedure regarding missing residents and elopement with an emphasis on recognizing potential elopement risks upon admission and thereafter, re-directing wandering residents, steps to take in case of an unfortunate scenario and who must be notified. Review of the facility provided sign in sheets revealed all staff had received the training on 10/31/17. · On 10/31/17 at 5:00 P.M. the Human Resources/In-service Director provided in-service training to five of five facility receptionists. The content of the training included phone etiquette, customer service, first impression and elopement/missing resident. · On 10/31/17 Receptionist #160, who was responsible for monitoring the door exits via cameras located in the reception area and alarms on the exit doors was terminated. · On 10/31/17 Social Service Assistant #161 conducted an Elopement Book Quality Assurance Study to ensure all residents who were identified as being high risk for elopement had their pictures in the elopement book kept at the information desk on each wing and at the therapy entrance. · On 10/31/17 the Licensed Practical Nurse Medical Records Director completed an audit titled Elopement Risk Assessments. The audit reviewed the date of the last elopement risk assessment completed and ensured the risk assessment reflected the current status for all current facility residents. · Between 11/01/17 and 11/09/17 there were no identified resident elopements that had occurred in the facility. · On 11/05/17 at 4:49 A.M. Resident #31 was transferred to the hospital related to changes in her behavior and as of 11/16/17 had not returned. · On 11/08/17 interview with Registered Nurse (RN) #164 and RN #170, Licensed Practical Nurse (LPN) #162, LPN #163, LPN #165, LPN #168, State tested Nursing Assistant (STNA) #167, STNA/Receptionist #166, Central Supply Manager #169, and Receptionist #171 revealed the staff were knowledgeable of the facility's policy and procedure on elopement. Although the Immediate Jeopardy was removed on 11/05/17, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of placing elopement books at each of the facility's eight nursing stations, conducting ongoing monitoring of corrective actions as well as ensuring evidence that incidents of elopement were accurately documented in the electronic medical record progress notes to ensure staff were knowledgeable of incidents and aware of the ongoing care needs based on elopement. Findings include: Review of Resident #31's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident did not have a Minimum Data Set (MDS) 3.0 assessment completed as of 11/08/17. Record review revealed on 11/05/17 at 4:49 A.M. Resident #31 was transferred to the hospital related to changes in behavior. As of 11/16/17 the resident had not returned to the facility. Review of an elopement risk assessment, dated 10/25/17 revealed Resident #31 had recently experienced an admission within the last month and a change of roommate and caregiver. It stated her former lifestyle included frequent walking and indicated the resident was a known wanderer/history of wandering. The assessment concluded the resident was a high risk for wandering and was likely to attempt to leave the facility. Record review revealed a plan of care, initiated 10/26/17 that reflected Resident #31 was an elopement risk and had a history of [REDACTED]. The goal was for the resident's safety to be maintained through 01/21/18. Interventions on the plan of care included to place a red cardinal bird on the door frame to alert staff of elopement risk, redirect as needed and place resident's picture in elopement risk binder at the information center (front desk). Observation on 11/08/17 at 10:11 A.M. revealed there were two pictures of red cardinal birds on the room Resident #31 had resided in. Both the resident and her roommate, Resident #32, were identified by the facility to be at risk for elopement. Review of Resident #31's electronic nursing progress notes revealed a note, dated 10/30/17 at 6:36 P.M., authored by LPN #172 which indicated the resident was alert to name and time but confused to place. The resident had frequent outbursts of laughter and other noises. It further stated the resident walked with a steady gate. On 10/30/17 at 8:45 P.M. a nursing progress note, authored by RN #170 revealed the resident was aggressive and combative towards staff, pacing up and down the hallways and exit seeking. It was documented that RN #170 called the physician, left an urgent voicemail, and was awaiting a return call. There was nothing further documented on 10/30/17. There was nothing documented to indicate if the physician returned the call. The next entry, dated 10/31/17 at 3:33 A.M. revealed the resident was exit seeking and expressing self harm. The nurse called the physician who gave an order to send the resident to the emergency room for evaluation and treatment. Per the nursing progress note, the resident left the facility at 3:57 A.M. and returned to the facility on [DATE] at 2:13 P.M. with no new orders. Review of a facility accident/incident report dated 10/31/17 at 3:00 A.M. revealed the following information: Resident #31 was noted to walk outside of facility on her own accord with weather appropriate clothing and shoes on. Resident returned shortly to facility. Resident was assessed by RN #170 upon return with no new skin issues noted. Resident expressed she had feelings of wanting to harm self. The physician was notified and the resident was sent to the hospital at 10/31/17 at 4:05 A.M. The accident/incident report was completed by the DON. Review of the electronic nursing progress notes revealed no entry had been completed to reflect the resident was outside the facility, the time she left or the circumstances surrounding how she returned to the facility. Record review revealed no elopement risk assessment was completed following the resident's return and no new safety interventions were initiated to prevent elopement following the resident's return on 10/31/17 at 2:13 P.M. Review of an Investigation of Resident Grievance form, dated 10/31/17 at 3:00 A.M. and completed by the DON revealed Resident #31 was noted to walk outside of facility and returned stating she wanted to harm herself. The DON documented, per RN #170, Resident #31 had been aggressive towards staff around 8:00 P.M. but had no further episodes. The form noted the resident was pleasant and cooperative after the episode and was walking around the facility smiling and laughing, frequently in view of staff members and was not exit seeking. It stated that upon return from resident's walk, she expressed concerns to RN #170 of wanting to harm herself and was sent to the hospital per physician order. On 11/08/17 at 12:00 P.M. and 2:20 P.M. attempts to obtain information regarding this incident from the local police department were unsuccessful. Interview with Central Supply Manager (CSM) #169 on 11/08/17 at 3:50 P.M. revealed she was doing inventory during the night on 10/31/17. She stated between approximately 1:00 A.M.-1:30 A.M. Resident #31 told her that she wanted to sit on the porch outside. CSM #169 stated Resident #31 asked her to help her find her jacket as the resident didn't know where her room was. CSM #169 stated she helped her find her room and put her jacket on. CSM #169 stated she then went back to her office and did not see Resident #31 leave the building. She stated she did not believe Resident #31 was at risk for elopement. Interview with RN #170 on 11/08/17 at 4:00 P.M. revealed she was the supervisor on duty on night shift on 10/31/17. She stated Resident #31 had been previously identified as being at risk for elopement and she had her picture in the book at the information desk. She stated Resident #31 was not permitted to leave the facility alone. She stated, on that night, the resident was walking around inside the facility. She stated she did not know anything about Resident #31 being out of the facility until she got a telephone call from Resident #31's father sometime between 1:00 A.M. and 3:00 A.M. stating the resident had gotten out of the facility and the police were bringing her back. She stated she did not know when the resident was last seen in the facility. She stated when the police brought her back, they stated they had found Resident #31 walking on the road the facility was on. She stated Resident #31 told her she had went out the back exit door by the dining room. RN #170 stated Receptionist #160 was on duty and told her she thought it was staff going out the door. RN #170 further stated she was instructed by the DON not to document the incident of Resident #31 getting outside in the electronic nursing progress notes. Interview with Resident #31's father on 11/08/17 at 4:15 P.M. revealed he received a telephone call from the local police on 10/31/17 at 2:53 A.M. stating they had picked Resident #31 up walking down the road from the facility. He stated Resident #31 would only tell them to call her dad. He told them where she lived and that she must have slipped out. The police said they would take her back. Resident #31's father stated he then called the nursing facility and he thought staff did not even know she was gone and then staff stated the police were pulling up then. He further stated Resident #31 had eloped from the previous nursing facility she had resided at and had worn an ankle bracelet to prevent elopement for around eight years. Interview with STNA #167 on 11/08/17 at 4:46 P.M. revealed she was working as a nursing assistant on the hall where Resident #31 resided on the night of 10/31/17. She confirmed Resident #31 was an elopement risk and was not allowed to leave the facility on her own. She stated on the night of 10/31/17, Resident #31 was adamant on leaving the facility and had been making attempts to leave the facility. She stated Receptionist #160 was aware that Resident #31 was making attempts to leave the facility and had STNA #167 close a set of doors between the front entrance doors and the receptionist desk to try to deter the resident from going out the front door. STNA #167 stated she was not aware Resident #31 had left the facility until approximately 2:30-3:00 A.M. when Receptionist #160 asked her where Resident #31 was. STNA #167 stated the last time she saw Resident #31 was around 12:30 A.M.-1:00 A.M. She stated she felt Resident #31 had gone out an exit door that employee's used. She stated she felt Resident #31 got out because Receptionist #160 was careless with watching the monitors to see who was going out the doors. She stated shortly after Receptionist #160 asked where Resident #31 was, the police returned Resident #31 to the facility. Observation on 11/08/17 at 5:07 P.M. revealed the elopement book at the receptionist desk on the Sheridan wing contained a picture of Resident #31. Interview at that time with Receptionist #171 revealed the book contained the name and pictures of each resident at risk for elopement. She stated the residents in the book would not be permitted to go outside unsupervised. She stated they were confused and can't go outside. Interview with the Administrative Assistant on 11/08/17 at 5:20 P.M. confirmed that Resident #31's picture was included in the elopement book. He stated that anyone who was an elopement risk would be in the book. He further stated that just because a resident's assessment indicated they were at high risk for elopement did not mean that they did not have the right to go outside. On 11/08/17 during the entrance conference a request was made for a list of any residents who had eloped in the previous three months. A list provided by the facility revealed there had been no elopements during this time period. During an interview with the Administrative Assistant on 11/08/17 at 2:20 P.M. the assistant indicated the facility did not consider the incident of Resident #31 going outside during the night on 10/31/17 as an elopement. He stated that, even though she had been assessed as being at risk for elopement, had a plan of care in place for elopement, was found outside the facility and off facility grounds by local police, it was her right to go for a walk. Interview with the DON on 11/09/17 at 7:01 A.M. revealed the facility investigation of the incident regarding Resident #31 going outside on 10/31/17 did not include any written statements from staff who were working or who had knowledge of the incident. The DON stated the she had spoken to staff about the incident, but only to RN #170, STNA #167, and Central Supply Manager #169. She confirmed she had not spoken to LPN #168, who was assigned to care for Resident #31 on 10/31/17 or Receptionist #160 who was on duty on 10/31/17 when Resident #31 exited the building during the night. She confirmed there was no evidence of any further investigation related to how Resident #31 got out of the facility on 10/31/17. She also confirmed that Resident #31 leaving the facility and being returned by the police was not documented in the electronic nursing progress notes. Based on the investigation completed, the facility failed to conduct a thorough and comprehensive investigation to determine at what time the resident was last seen by staff in the facility on 10/31/17, what time the resident left the facility unattended, how the resident was able to exit the facility without staff knowledge, and what door the resident exited. Interview with LPN #168 on 11/09/17 at 7:30 A.M. revealed she was the nurse on duty on the hall where Resident #31 resided on 10/31/17. She stated Resident #31 was acting differently that night and was wanting to go on a walk. She confirmed Resident #31 was at risk for elopement and was not allowed to leave the facility on her own. She confirmed Resident #31's picture was in the book at the front desk identifying residents who were at risk for elopement. She confirmed staff had closed the set of doors by the front entrance to try to distract Resident #31 from leaving. She stated Receptionist #160, who was on duty that night, knew that Resident #31 was at risk for elopement and should not go out by herself. LPN #168 stated Resident #31 resided on Unit 2 but she was also covering Unit 4 on 10/31/17 and was on Unit 4 when STNA #167 came to her sometime between 1:00 A.M. and 3:00 A.M. and stated she could not find Resident #31. She stated as she was walking back to the front of the building, the police were bringing Resident #31 back into the facility. She stated the police stated they had found Resident #31 walking down the road between a nearby assisted living facility and a State route. LPN #168 stated she did not document anything regarding the incident because RN #170 was taking care of it. Record review revealed after Resident #31 returned to the facility from the hospital on [DATE] at 2:13 P.M. there was no evidence the facility reassessed the resident for elopement risk or made any changes to the plan of care to attempt to prevent further elopements. This was confirmed through interview with the DON and Administrator on 11/09/17 at 11:00 A.M. A progress note, dated 10/31/17 at 4:12 P.M. by Social Services #173 revealed she and the DON spoke with Resident #31's father about different options for the resident. She stated it was explained to him that there were facilities that had lock down units to help with residents that had exit seeking behaviors. It was documented this had been a past and present behavior for Resident #31. It stated Resident #31's father wanted to keep the resident in the facility but did like knowing the option of a possible lock down unit. A nurses progress notes, authored by LPN #174 on 11/01/17 at 4:02 A.M. documented Resident #31 had been having behaviors throughout the shift. It stated the resident was barking, trying to walk into hallways naked, and sat on the floor by the front desk to sort her books. A progress note by Social Services #173 on 11/02/17 at 12:27 P.M. stated that Resident #31 was packing up her books and stated that she was going home. A nurses progress note on 11/02/17 at 8:46 P.M. by LPN #175 stated that Resident #31 hit staff, was tearful and crying profusely stating that she was a baby. Was howling like a dog and licking her arm. Laughs and has conversations with herself. Making statements that she killed her baby. Kept removing her socks and trying to walk the halls. Alert and oriented to self only. A progress note on 11/03/17 at 6:59 P.M. by LPN #162 revealed that Resident #31 refused to wear socks and was noted walking throughout the facility with bare feet. A progress note on 11/04/17 at 2:46 A.M. by LPN #176 stated that Resident #31 was found with a self inflicted bite wound on her arm measuring 1.5 by 0.5 centimeters. On 11/04/17 at 3:37 A.M. RN #170 documented in the progress notes that Resident #31 was experiencing loose associations, hallucinations, fornication, restlessness, compulsiveness, excitability, and was physically and verbally abusive with staff. A progress note on 11/04/17 at 1:18 P.M. by LPN #175 stated that Resident #31 threw part of her book shelf across the room and ran around the hall naked. It stated she also hit staff, threw yogurt across the room, was trying to feed her roommate, threw a drink in another resident's face, called a resident fat, run through the halls multiple times, and stated she was going to kill her roommate. Resident #31 was sent to the hospital on [DATE] at 4:45 P.M. and returned on 11/04/17 at 9:54 P.M. A progress note on 11/05/17 at 1:30 A.M. by LPN #162 stated that Resident #31's top lip was noted swollen and the resident stated that she had bit it. A progress note on 11/05/17 at 4:36 A.M. by RN #170 stated that Resident #31 continued to exhibit disruptive behaviors, self harm, combativeness towards staff, walking in hallway nude, and refusing medications. Resident #31 was transferred to the hospital on [DATE] at 4:49 A.M. Resident #31 had not returned to the facility as of 11/09/17. On 11/09/17 at 8:20 A.M. interview with Resident #31's physician, Physician #177 revealed it was his belief the resident had a change in emotional status after being admitted to the facility. He stated he had seen her twice since her admission. He stated during the first visit she was still pretty good, but after that things started to unravel. (Record review revealed Resident #31 was first seen by her physician on 10/25/17). He stated Resident #31 did not have good judgement related to her psychiatric [DIAGNOSES REDACTED]. Physician #177 stated he did not feel Resident #31 was safe to be outside by herself especially in the middle of the night. Review of the undated facility policy and procedure for a missing resident revealed the facility was equipped with a buzzer system on all of its' outside doors. Each time an outside door was opened, the buzzer was activated and rings into the information center (front desk). The information center has a lighted panel which indicates which door has been opened. The policy indicated wandering residents had a higher potential for elopement than other residents. Wandering residents would be redirected as needed to prevent elopement. Safe designated areas would be provided for residents to wander. Halls and non-resident areas were available to these residents with close supervision of staff so as not to infringe on other resident's rights. The policy further stated all residents, upon admission, would be assessed with [REDACTED]. The assessment nurse would determine by the form and review of the resident if the resident would be at risk or not at risk for elopement (this information would become part of the resident's care plan). A photograph of the resident upon admission would be taken and become part of the medical record. This deficiency substantiates Complaint Number OH 486.