Every finding on record at Magnolia Creek Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to provide toenail care for 1 (#7) of 1 sampled resident reviewed for foot care.The administrator identified 72 residents resided in the facility. Findings:On 01/20/26 at 1:49 p.m., Resident #7's toenails were observed to be thick, overgrown, and were half an inch long.A significant change assessment, dated 12/03/25, showed Resident #7's cognition was intact with a brief interview for mental status score of 13. The assessment showed the resident was admitted to the facility on [DATE] with diagnosis which included diabetes mellitus and required partial to moderate assistance from staff for most activities of daily living.The facility did not have a policy related to nail care.Nurse notes, dated 08/30/25 through 01/20/26, did not show Resident #7's toenails needed to be cut or a referral to the podiatrist was needed.On 01/20/26 at 1:49 p.m., Resident #7 stated their toenails were long and needed to be cut. Resident #7 stated their toenails had needed to be cut since admission to the facility and had told staff on various occasions they needed to be cut.On 01/23/26 at 10:51 a.m., the podiatrist stated, Services were last conducted in the facility on 08/07/25.On 01/23/26 at 11:45 a.m., the director of nursing stated toenails were to be looked at by licensed practical nurses weekly and were part of the skin assessment. They stated nursing and social services signed up the residents who needed podiatry services.On 01/23/26 at 12:10 p.m., the assistant director of nursing stated staff tried to cut Resident #7s toenails, but it was not documented.

Based on record review and interview, the facility failed to investigate an incident of alleged resident-to-resident abuse for one (#1) of three sampled residents reviewed for abuse. The administrator identified 72 residents resided in the facility. Findings: A Resident Abuse, Neglect and Misappropriation of Property policy, dated 11/01/22, read in part, The licensed nurse in charge of the unit shall then complete an incident report reflecting any and all findings from the assessment of the resident following the incident. The policy read in part, A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283. The policy also read in part, Mental abuse is the use of verbal or nonverbal conduct which cause or has the potential to cause the resident to experience humiliation, intimidation, fear, agitation, or degradation. Resident #1 had diagnoses which included cerebral infarction, insomnia, and depressive disorder. A comprehensive assessment, dated 10/05/24, documented Resident #1's cognition was intact, and they required substantial/maximal staff assistance with most activities of daily living. An Incident/Offense report from the [name removed] police department, dated 10/30/24 at 6:30 p.m., documented the officer was dispatched to [address removed] room [ROOM NUMBER] for threats being made. The report documented Resident #1 reported that Resident #2 had been threatening them. The report documented Resident #2 went into Resident #1's room while they were trying to sleep and began shaking the bed. The report documented Resident #1 told Resident #2 to leave the room a total of three times. The report documented Resident #1 reported being afraid. The report documented Resident #1 told Resident #2 that if Resident #2 did not leave the police would be called. The reported documented Resident #2 made a fist and started shaking it at Resident #2. The report documented Resident #2 told Resident #1 they would be sorry while a fist at Resident #1. The report documented the officer spoke with the head nurse about Resident #2 threatening Resident #1. The report also documented the officer advised the administrator and head nurse it would be a good idea to keep both residents separated as much as possible. A Grievance form, dated 10/30/24, documented Resident #2 rolled into Resident #1's room and startled them. The form documented the DON sat at Resident #1's bedside to make sure the resident was okay. The form documented Resident #1's family member called the police and asked the administrator and DON to exit the room. The form documented the police officer reported to the administrator no harm was done and an information report would be completed. The form documented the DON and administrator assured Resident #1 that Resident #2 would be kept from wandering into their room. The form documented staff were educated to put stop signs across Resident #1's door as well as being vigilant if Resident #2 started going down that hallway. The form documented the ombudsman was notified. The form documented to educate staff on Resident #2 roaming on the wrong halls. On 11/04/24 at 12:45 p.m., Resident #1 reported fear of Resident #2. The resident reported this was reported to the DON and the administrator. The resident reported on 10/30/24 Resident #2 came into their room while they were sleeping and shook the end of their bed startling them awake, then started going through their personal belongings. Resident #1 reported Resident #2 was asked to leave the room which they would not do. Resident #1 pushed their call light for assistance and hollered for staff to get the Resident #2 out of their room. Resident #1 reported Resident # 2 came up to the bed and shook a fist at them. Resident #1 reported no staff had come to assist. Resident #1 reported they then told Resident #2 they were going to call the police. They reported Resident #2 told them they would pay for it. Resident #1 reported a staff member finally removed Resident #2 from the room. On 11/05/24 at 10:17 a.m., the DON reported Resident #1 had reported to them on 10/30/24 Resident #2 rolled into the resident's room and grabbed the end of their bed while they were sleeping. The DON reported Resident #1 reported the incident scared them because they were asleep. The DON reported Resident #1 reported Resident #2 had shaken a fist at them. The DON reported not feeling like the incident was an abuse situation. On 11/05/24 at 10:29 a.m., the administrator reported no abuse was reported to them by the police officer. The administrator reported after talking to the resident they did not feel like the incident was an abuse allegation. The administrator reported they conducted a grievance investigation. The administrator reported staff were educated on putting up stop signs on the Resident #1's door to keep Resident #2 from wandering in and educated staff on Resident #2 wandering onto the wrong hallways. The administrator reported no other residents or staff were interviewed related to the incident.

Based on observation, interview, and record review, the facility failed to update a resident's care plan for wandering behavior for one (#2) of three sampled residents reviewed for abuse. The administrator reported 72 residents resided in the facility. Findings: Resident # 2 had diagnoses which included depression. A Behavior note, dated 08/06/24, read in part, Res has had an increase in wandering and exit seeking .Elopement band in place and functioning .Staff continue to redirect. A care plan, dated 09/06/24, documented no care areas related to wandering or elopement behaviors. A comprehensive assessment, dated 09/23/24, documented the resident had severely impaired cognition and no behaviors. A Behavior note, dated 10/30/24, read in part, Resident keeps roaming the halls and entering resident's rooms, resident keeps being redirected to her hallway. On 11/04/24 at 12:30 p.m., Resident #2 was observed in their wheelchair going down the 400 hall looking into other resident's rooms. On 11/04/24 at 12:45 p.m., Resident #1 reported Resident #2 would enter their room uninvited and go through their personal items. On 11/04/24 at 1:30 p.m., Resident #2 was observed sitting behind the nurse's station with the charge nurse. On 11/05/24 at 1:15 p.m., LPN #2 reported wandering and elopement behaviors should be included on a resident's care plan.

Based on record review and interview, the facility failed to ensure wound care was performed, following physician orders, for one (#5) of three residents reviewed for wound care. The DON reported 82 residents resided in the facility. Findings: A policy Skin and Wound Care Guidelines, not dated, documented Medical treatments will be ordered by a physician or their designee and transcribed onto the treatment record. The licensed nurse will document each time the treatment is completed. Resident #5 had diagnoses which included right femur fracture. The resident was admitted to the facility on [DATE]. A physician order for resident #5, dated 08/13/24, documented Cleanse surgical wound to right hip with wound cleanser, pat dry with 4 X 4' s', apply silver dressing to site every 5 days/PRN until healed. Resident #5's treatment administration record documented silver dressing was applied to right hip on 08/13/24. Resident #5's medical record was reviewed and documented no new wound care order for 08/15/24. The medical record documented no reason the silver dressing was not used for resident #5's right hip surgical incision on 08/15/24. A comprehensive assessment, dated 08/18/24, documented resident #5's cognition was intact and required substantial/maximal assistance from staff for most activities of daily living. A physician visit note, dated 08/16/24, read in part, .Patient (resident #5) is here for evaluation of right hip drainage for possible post-op infection .Date of surgery was 08/09/24 .Patient presents with saturated bordered gauze dressing over main incision .Drainage is serous in color .Patient states they have only changed the dressing twice since surgery .They are not using the ordered silver dressing due to cost .The bordered gauze dressing are causing severe skin breakdown around the surgical site.,,Plan: There are no signs or indications of any active infections .Patient was told they were unable to use Optifoam silver dressings due to cost at their facility .Facility called and spoke with the director of nursing at [name removed]. The DON informed that they do have the Optifoam sliver dressings and that moving forward the will only be using the dressings. On 09/10/24 at 9:45 a.m., resident #5 reported the hospital sent her with the silver dressings for wound care to the surgical site. The resident reported the nurses would not use the silver dressing, they told her the dressings were too expensive. The resident reported making the nurses aware the silver dressing had been brought from the hospital for the facility to use. The resident reported the dressing the staff used stuck to the surgical wound and at the first post op visit with the physician, the skin pulled off around the staples. On 09/10/24 at 12:29 p.m., LPN #1 reported the facility did use the Optifoam silver dressing for residents when ordered by a physician. The LPN reported the hospital usually sent some with residents for use by the facility. The LPN reported if the ordered dressing was not used for a dressing change, it should have been charted why and what was used. The LPN reported wound care should be performed following physician orders. On 09/10/24 at 2:53 p.m., the DON reported the nurse that performed resident #5's wound care on 08/15/24, before the doctors appointment on 08/16/24, was not aware the resident had the Optifoam silver dressings available and applied a telfa dressing until the resident could see the doctor on 08/16/24.

Based on record review and interview, the facility failed to accurately dispense medication to a resident discharging from the facility for one (#6) of one resident reviewed for discharge. The DON reported 82 resident resided in the facility. Findings: The Administrator reported no facility policy related to discharge or dispensing medication at discharge. Resident #6 had diagnoses which included right artificial hip replacement. The resident was admitted to the facility on [DATE]. A comprehensive assessment, dated 08/09/24, documented resident #6's cognition was intact. A discharge summary, dated 08/22/24, documented the resident's medications were given to the resident and their husband, and education was given on the importance of administration time. A form medications released on leave of absence or dismissal for resident #6, dated 08/22/24, documented the following medication and amounts sent home with the resident: Morphine 15 mg - 34 Oxycodone 10 mg - 28 Lomotil - 8 Venlafaxine 75 mg - 4 Multivitamin - 14 Pravastatin 20 mg - 13 Lisinopril 20-25 mg - 13 Folic Acid 1 mg - 14 Aspirin Low 81 mg - 13 Eliquis 5 mg - 13 Tizandine 4 mg - 18 Vitamin D 1.25 mg - 3 Levothyroxine 50 mcg - 10 Hydralazine 10 mg - 30 Promethazine 25 mg - 9 Colace 100 mg - 20 Loperamide 2 mg - 10 Atarax 10 mg - 30 Miralax PEG 3350 - 2. Resident #6's physician orders, dated 08/22/24, documented no order for the following medication: Eliquis 5 mg Levothyroxine 50 mcg Hydralazine 10 mg, Loperamide 2 mg Atarax 10 mg On 09/09/24 at 3:40 p.m., complaintant #1 reported the facility sent resident #6 home with another resident's medication on 08/22/24. The complaintant reported resident #6 called the facility and reported being given another resident's medication, along with their own medication, at discharge. The complaintant reported resident #6 was told the facility would send someone to pick up the medication. The complaintant reported resident #6 called back to the facility on [DATE] because the medication had not been picked up. On 09/10/24 at 4:45 p.m., the Administrator and DON reported they were not aware a resident had been sent home with another resident's medication. On 09/10/24 at 4:50 p.m., CMA #2 reported resident #6 was discharged home with their current prescribed medications and accidentally received some medication that belonged to another resident. The CMA reported resident #6 was discharged home with current medications left in stock and another resident's medication was in the same bin. The CMA reported each package of medication should have been checked for the resident's name and compared to the resident's discharge orders. On 09/10/24 at 5:00 p.m., the DON reported resident #6 called the facility to inform staff of having another resident's medication. The DON stated the charge nurse called transportation and the medication was picked up. The DON reported resident #6 did not take any of the other resident's medication. The DON reported the medication should have been checked by the discharge nurse and reconciled before the resident left the facility with the medication. The DON reported the error should have been reported to the DON and the Administrator as soon as the error was found.

Based on observation and interview, the facility failed to ensure the call light was in reach for one (#2) of three sampled residents reviewed for timely call lights. The DON identified 82 residents resided in the facility. Findings: Resident #2 had diagnoses which included legal blindness. Resident #2's annual assessment, dated 02/22/24, documented the resident's vision was severely impaired and required moderate assistance with activities of daily living. On 09/05/24 at 7:10 p.m., Resident #2's call light was observed by the side of their drawer. The resident was sitting in a recliner. Resident #2 stated they used their call light when they needed assistance. They tried to locate the call light and could not find it. They stated, now this makes me mad. The call light was out of reach of the Resident. On 09/05/24 at 7:29 p.m., CMA #1 stated resident #2 used their call light and sometimes came to the door and yelled if they needed assistance. They stated the resident is blind and only able to see shadows. They stated the resident is a fall risk. On 09/05/24 at 7:29 p.m., CMA #1 made observation of resident #2's room and reported the resident's call light was out of their reach.

Based on observation and interview, the facility failed to ensure a resident's bed was made and an extra mattress was store appropriately for one (#2) of three residents reviewed for homelike environment. The DON identified 82 residents resided in the facility. Findings: Resident #2 had diagnoses which included legal blindness. On 09/05/24 at 7:00 p.m., Resident #2 stated their bed was not made. They stated it had been like that for days. There were two pillows without pillowcases and two personal pillows. There was a spare mattress in the resident's room by a wall table. On 09/05/24 at 7:33 p.m., CMA #1 made observation of Resident #2's room. On 09/05/24 at 7:38 p.m., CMA #1 stated the resident's bed was not made. They stated beds were supposed to be always made. They stated they were not sure why the extra mattress was in the resident's room and the resident was a fall risk.

Based on observation record review and interview, the facility failed to provide assistance with care in a timely manner for three (#12, 18 and #36) of three sampled residents reviewed. The director of nursing identified 25 residents who were totally dependent on two staff for care. Findings: 1. Resident #12 had diagnosis to include dementia, anxiety, major depression, hypertension and hyperlipidemia. Resident #12 care plan, last revised 01/24/24, read in part, .I am at risk for pressure ulcer D/T my incontinence .provide incontinent care every 2 hours as needed . A quarterly assessment, dated 04/2024, documented Resident #12 was not able to complete the brief interview for mental status interview to determine cognition, and was always incontinent of bowel and bladder. Resident #12 was dependent on staff for toileting and hygiene and required two or more staff were required to complete the activity. On 06/20/24 at 5:00 a.m., Resident #12, was observed up in their geri-chair in the lobby near the nurses station. On 06/20/24 from 5:00 a.m. through 8:05 a.m. direct observation was made of Resident #12. No staff was observed checking on the residents and/or providing any care to them. On 06/20/24 at 8:05 a.m., CNA #2 was observed transferring Resident #12 from the lobby directly into the dining room without providing any care. On 06/20/24 at 9:03 a.m., Resident #12 was observed being brought out of the dining room by LPN#3. LPN #3 placed Resident #12 near the nurses station in the lobby On 06/20/24 at 9:08 a.m., CNA # 1 and CNA #2 was observed taking Resident #12 to their room. On 06/20/24 at 9:10 a.m., CNA # 1 and CNA #2 was observed transferring Resident #12 to the bed from the geri-chair and provided incontinent care. Resident #12 was observed up in her geri-chair from 5:00 a.m. through 9:10 a.m. (four hours and ten minutes) without any care being provided. 2. Resident #18 had diagnosis to include Alzheimer's, history of falling, osteoarthritis, chronic atrial fibrillation, and dysphagia. Resident #18 care plan, last revised 04/10/2023, read in part, .has an ADL Self Care Performance Deficit and is dependent on staff for care r/t Alzheimer's Disease and Decreased Mobility toileting requires extensive total dependence X 2 staff .uses geri-chair for mobility . An annual assessment, dated 06/02/24, documented Resident #18 had short and long term memory problems, and was always incontinent of bowel and bladder. Resident #18 was dependent on staff for toileting, hygiene and required two or more staff were required to complete the activity. On 06/20/24 at 5:00 a.m., Resident #18, was observed up in their geri-chair in the lobby near the nurses station. On 06/20/24 from 5:00 a.m. through 8:05 a.m. direct observation was made of Resident #18. No staff was observed checking on the residents and/or providing any care to them. On 06/20/24 at 8:05 a.m., CNA #1 was observed transferring Resident #18 from the lobby directly into the dining room without providing any care. On 06/20/24 at 8:41 a.m., Resident #18 was observed being brought out of the dining room by LPN#3. LPN #3 placed Resident #18 near the nurses station in the lobby. On 06/20/24 at 9:27 a.m., Resident #18 was observed being taken back to their room for care by CNA #4. CNA #4 was observed providing care to Resident #18. CNA #4 confirmed Resident #18 was incontinent of urine only. CNA #4 stated they did not know how long it had been since care was provided to Resident #18 since they arrived at work around 8:30 a.m. Resident #18 was observed up in her geri-chair from 5:00 a.m. through 9:27 a.m. (four hours and 27 minutes) without any care being provided. 3. Resident #36 had diagnosis to include anemia, congestive heart failure, depression, anxiety and dementia. Resident #36 care plan, last revised 02/21/24, read in part, .has an ADL Self Care Performance Deficit and is dependent on staff r/t dementia and decreased mobility .transfers requires extensive-total dependence x 2 staff assist .toileting requires extensive total dependence X 2 staff . A quarterly assessment, dated 04/19/24, documented Resident #36 had severly impaired cognitive skills, and was always incontinent of bowel and bladder. Resident #36 was dependent on staff for toileting and hygiene and required two or more staff were required to complete the activity. On 06/20/24 at 5:00 a.m., Resident #36 was observed up in their geri-chair in the lobby near the nurses station. On 06/20/24 from 5:00 a.m. through 8:05 a.m. direct observation was made of Resident #36. No staff was observed checking on the residents and/or providing any care to them. On 06/20/24 at 8:10 a.m., CNA #1 was observed transferring Resident #36 from the lobby directly into the dining room without providing any care. On 06/2024 at 8:54 a.m., Resident #36 was observed being brought out of the dining room by LPN#3. LPN #3 placed Resident #36 near the nurses station in the lobby next to Resident #18. On 06/20/24 at 9:05 a.m., Resident #36 was observed being taken to her room at 9:05 a.m., and placed next to her bed in the geri-chair. The resident was not provided any care and left up in the geri-chair. On 06/20/24 from 9:05 a.m. through 10:10 a.m., Resident #36 remained up in her geri-chair without any care being provided. On 06/20/24 at 10:10 a.m., CNA #1 and CNA #2 was observed transferring Resident #36 to the bed and provided incontinent care. Resident #36 had been incontinent of bowel and bladder with a ring of dried feces on their buttocks. Resident #36 was observed up in her geri-chair from 5:00 a.m. through 10:10 a.m. (five hours and ten minutes) without any care being provided. On 06/20/24 at 7:45 a.m., CNA #5 stated they and CNA #6 got Resident #36 up at 4:10 a.m., Resident #12 up at 4:20 a.m., and Resident #18 up at 4:00 a.m. CNA #5 stated all the residents were up and out to the lobby after they were provided care. CNA #5 stated that was the last care that they provided the residents for their shift. CNA #5 stated all residents were required to be checked and provided care every two hours. On 06/20/24 at 8:15 a.m., CNA #6 was asked what times Resident #12, Resident #18 and Resident #36 were up out of bed. CNA #6 stated all the residents on the get up list, which included Resident #12, Resident #18 and Resident #36, were up and out of their room between 4:00 a.m. and 4:20 a.m. The certified nurse aide was asked when care was last provided to the residents. CNA #6 stated care was provided to them prior to being brought out by the nurses station. CNA #6 stated all residents were required to be checked and provided care every two hours. On 06/20/24 at 1:04 p.m., CNA # 1 stated residents were required to be checked on and provided care every two hours. CNA #1 stated Resident #12 and Resident #36 required two people to provide care and transfer them to bed. She was asked when care was provided to Resident #12 and Resident #36. CNA #1 stated they did not provide care to Resident #36 until after 10:00 a.m. and Resident #12 was provided at about 9:10 a.m. CNA #1 stated care was to be provided every two hours and no care was provided since starting work at 6:00 a.m On 06/20/24 at 1:29 p.m., CNA #2 confirmed Resident #12 and #36 was in the lobby when they arrived, went to the dining room and back to the lobby after breakfast. CNA #2 stated neither her or CNA #1 provided care prior to the observations being made at 9:10 a.m. and 10:10 a.m. CNA #2 stated all residents should be provided care every two hours and being up since 4:30 a.m., without any care was not good. On 06/21/24 at 8:35 a.m., the DON stated night staff get residents up that require two people assists with a lift. The DON stated the residents should be up at 5:30 a.m., and the day shift will finish getting everyone else up. The DON stated all residents need care every two hours and as needed. The DON stated, That's not good when describing the observations on Resident #12, Resident #18 and Resident #36 being up at 5:00 a.m. and not receiving care for four and five hours.

Based on observation, record review, and interview, the facility failed to ensure they had sufficent staff to provide care to residents. The facility ceneus was 77. Findings: A review of the stafing sheets for 06/07/24 through 06/21/24 documentd the 6:00 p.m. to 6:00 a.m., shift had one nurse and two aides for the long term care side on the following dates: 06/15/24; 06/16/24; 06/18/24, 06/19/24, and 06/20/24. 1. Resident #12 had diagnosis to include dementia, anxiety, major depression, hypertension and hyperlipidemia. Resident #12 care plan, last revised 01/24/24, read in part, .I am at risk for pressure ulcer D/T my incontinence .provide incontinent care every 2 hours as needed . A quarterly assessment, dated 04/2024, documented Resident #12 was always incontinent of bowel and bladder, was dependent on staff for toileting and hygiene, and required two or more staff were required to complete the activity. On 06/20/24 at 5:00 a.m., Resident #12, was observed up in their geri-chair in the lobby near the nurses station. On 06/20/24 from 5:00 a.m. through 9:10 a.m., direct observation was made of Resident #12. No staff was observed checking on the residents and/or providing any care to them. On 06/20/24 at 9:10 a.m., CNA #1 and CNA #2 was observed transferring Resident #12 to the bed from the geri-chair and provided incontinent care. Resident #12 was observed up in her geri-chair from 5:00 a.m. through 9:10 a.m. (four hours and ten minutes) without any care being provided. 2. Resident #18 had diagnosis to include Alzheimer's, history of falling, osteoarthritis, chronic atrial fibrillation, and dysphagia. Resident #18 care plan, last revised 04/10/23, read in part, .has an ADL Self Care Performance Deficit and is dependent on staff for care r/t Alzheimer's Disease and Decreased Mobility toileting requires extensive total dependence X 2 staff .uses geri-chair for mobility . An annual assessment, dated 06/02/24, documented Resident #18 had short and long term memory problems, was always incontinent of bowel and bladder, dependent on staff for toileting and hygiene and required two or more staff were required to complete the activity. On 06/20/24 at 5:00 a.m., Resident #18, was observed up in their geri-chair in the lobby near the nurses station. On 06/20/24 from 5:00 a.m. through 9:10 a.m., direct observation was made of Resident #18. No staff was observed checking on the residents and/or providing any care to them. On 06/20/24 at 9:27 a.m., Resident #18 was observed being taken back to their room for care by CNA #4. CNA #4 was observed providing care to Resident #18. CNA #4 confirmed Resident #18 was incontinent of urine only. CNA #4 stated they did not know how long it had been since care was provided to Resident #18 since they arrived at work around 8:30 a.m. Resident #18 was observed up in her geri-chair from 5:00 a.m. through 9:27 a.m. (four hours and 27 minutes) without any care being provided. 3. Resident #36 had diagnosis to include anemia, congestive heart failure, depression, anxiety and dementia. Resident #36 care plan, last revised 02/21/24, read in part, .has an ADL Self Care Performance Deficit and is dependent on staff r/t dementia and decreased mobility .transfers requires extensive-total dependence x 2 staff assist .toileting requires extensive total dependence X 2 staff . A quarterly assessment, dated 04/19/24, documented Resident #36 had severly impaired cognitive skills, was always incontinent of bowel and bladder, dependent on staff for toileting and hygiene, and required two or more staff. On 06/20/24 at 5:00 a.m., Resident #36 was observed up in their geri-chair in the lobby near the nurses station. On 06/20/24 from 5:00 a.m. through 10:10 a.m., direct observation was made of Resident #36. No staff was observed checking on the residents and/or providing any care to them. On 06/20/24 at 10:10 a.m., CNA #1 and CNA #2 was observed transferring Resident #36 to the bed and provided incontinent care. Resident #36 had been incontinent of bowel and bladder with a ring of dried feces on their buttocks. Resident #36 was observed up in her geri-chair from 5:00 a.m. through 10:10 a.m. (five hours and ten minutes) without any care being provided. On 06/20/24 at 7:45 a.m., CNA #5 stated they and CNA #6 got Resident #36 up at 4:10 a.m., Resident #12 up at 4:20 a.m., and Resident #18 up at 4:00 a.m. CNA #5 stated all the residents were up and out to the lobby after they were provided care. CNA #5 stated that was the last care that they provided the residents for their shift. CNA #5 stated all residents were required to be checked and provided care every two hours. CNA #5 stated care can not be provided with only two aides working. They stated they had to provide care to other residents and not able to provide the care as needed. On 06/20/24 at 8:15 a.m., CNA #6 was asked what times Resident #12, Resident #18 and Resident #36 were up out of bed. CNA #6 stated all the residents on the get up list, which included Resident #12, Resident #18 and Resident #36, were up and out of their room between 4:00 a.m. and 4:20 a.m. The certified nurse aide was asked when care was last provided to the residents. CNA #6 stated care was provided to them prior to being brought out by the nurses station. CNA #6 stated all residents were required to be checked and provided care every two hours. CNA #6 stated they with only two aides working care can not be provided every two hours. On 06/20/24 at 1:04 p.m., CNA # 1 stated residents were required to be checked on and provided care every two hours. CNA #1 stated Resident #12 and Resident #36 required two people to provide care and transfer them to bed. She was asked when care was provided to Resident #12 and Resident #36. CNA #1 stated they did not provide care to Resident #36 until after 10:00 a.m. and Resident #12 was provided at about 9:10 a.m. CNA #1 stated care was to be provided every two hours and no care was provided since starting work at 6:00 a.m. CNA #1 stated that there were two aides for hall 200 and 300, and with all the residents that require two person asssits, answering the call lights and providing showers care can not be provided like it should. The CNA stated the priority was to answer call lights and others would have to wait. CNA #1 stated Resident #36 had to wait until 10:00 a.m. for care because CNA #2 was providing showers and call lights were being answered. On 06/20/24 at 1:29 p.m., CNA #2 confirmed Resident #12 and #36 was in the lobby when they arrived, went to the dining room and back to the lobby after breakfast. CNA #2 stated neither her or CNA #1 provided care prior to the observations being made at 9:10 a.m. and 10:10 a.m. CNA #2 stated all residents should be provided care every two hours and being up since 4:30 a.m., without any care was not good. CNA #2 stated with only two aides appropriate care can not be provided. The CNA stated we have to answer call lights and those needing two staff for care have to wait. On 06/21/24 at 9:29 a.m., the DON stated the facility followed state guidelines for staff and that was all they did. The DON stated the facility had no policy for staffing just that it needs to meet the needs of the residents. The DON then stated based on what was observed the standard of quaility of care was not being followed. 4. On 06/18/24 at 10:1 a.m., Resident #52 stated there was not enough staff to assist when needed and call lights can take up to 45 minutes or longer to respond. Resident #52 stated it took two hours to recieve water. 5. On 06/18/24 at 8:22 a.m., Resident #41 stated there were not enough staff and when she dropped their oxygen tubbing on the floor staff never came in to asssit with getting it. Resident #41 then stated staff came to help reposition them and left after turning off the call light. They stated staff said the would be right back and they had to wait over 20 minutes to be positioned up in bed. 6. On 06/18/24 at 10:36 a.m., a confidential family interview was conducted. The family member stated there were only two aides and one nurse for all four wings and that was not enough to provide the care for all the residents. 7. On 06/19/24 at 1:00 p.m., a resident group meeitng was held with eight alert and oriented residents. When asked about staffing seven out of eight residens stated it took a long time for call lgiths to be answered and care provided. The residents stated that it was bad at nights but it happens on the day because there were not enough staff to respond and provide the care.

Based on observation, record review, and interview, the facility failed to assess and monitor a resident with a severe weight gain of 36 pounds (17.24 %) for one (#45) of two sampled residents reviewed for weights. The facility census was 77. Findings: A Dining Services Policies and Procedures Weight List, revised 07/09/08, read in part .Residents' weights are routinely and systematically monitored .Residents with a weight loss or gain of five percent or more, within one month, should be re-weighed and entered into PCC by the 15th of the month. The resident's physician should be notified of any Significant Weight Change in PCC A Resident's Family or Physician Notification of Change Guideline policy, dated 12/01/09, read in part The facility will inform the resident; consult with the resident's physician .of the following events .A significant change in the resident's physical, mental, or psychosocial status. (i.e. a deterioration in health, mental or psychosocial states in either life-threatening conditions or clinical complications . a need to alter treatment significantly . Resident #45 had diagnosis to include congestive heart failure and edema. A quarterly assessment, dated 03/24/24, documented Resident #45 was cognitively impaired, was dependent on staff for showers, lower body dressing, putting on and taking off footwear and required substantial/maximal assistance with toileting and upper body dressing. A review of the weight record for Resident #45 documented the resident weighed 208.8 pounds on 05/23/24 and weighed of 244.8 pounds on 06/07/24. Resident #45 had a 36 pound (17.24%) weight gain in 15 days. There was no documentation Resident #45's physician had been notified of the severe weight gain on 06/07/24. A Skin Evaluation, dated 06/07/24 did not identify any new skin issues. There was no vital signs, lung sounds or edema assessment completed. A review of the restorative weight record, dated 06/12/24, documented Resident #45 weighed 240.2 pounds. Resident #45 continued to have a severe weight gain of 31.4 pounds (15.04%) since 05/23/24. A physician visit note, dated 06/13/24, read in part, .The patient presents for a follow-up visit at the nursing home per the request of the nursing staff. [The residents] complaint is persistent bilateral leg pain, which he describes as feeling like there is a fire inside. [The resident] reports having significant peripheral edema .Congestive Heart Failure .Continue current heart failure medications and monitor for any signs of worsening symptoms . A physician order, dated 06/13/24 documented to administer Lasix 20 milligrams by mouth two times per day. The nurse's progress notes did not contain documentation Resident #45 had been assessed by a nurse on 06/13/24 and 06/14/24 for worsening of symptoms. A Skin Evaluation dated 06/14/24, did not identify any new skin issues. There was no vital signs, lung sounds or edema assessment completed. A Nurses Progress Note, dated 06/15/24 at 12:46 a.m., read in part Focuses assessment r/t increase lasix 20 mg to twice daily and N.O. Neurontin 100mg TID. No c/c discomfort. No s/sx of adverse effects .vs-140/87 75 18 97.8 98%RA . ANurse Progress Note, dated 06/15/24 at 1:45 p.m., read in part .Focuses assessment r/t resident recent increase in Lasix to 20mg BID d/t increased edema, and n/o of Neurontin 100mg BID for poyneuropathy. Resident has no complaints at this time .vs wnl - 146/92, 73, 97.3, 18, 98% RA, 5 pain in feet . A Nurses Progress Note, dated 06/15/2024 at 9:45 p.m., read in part .vs 153/64-69-20-98.2 resident in bed high [NAME] position. awake and alert. resp even and unlabored. 4+pitting edema to bil lower ext. bil fa noted to have slight edema. no order for Lasix bid and Neurontin 100mg tid for lower leg pain. tolerating well no s/s of adverse reaction voiced. continuing with plan of care . A Nurses Progress Note, dated 06/16/24 at 5:21 p.m., read in part .Focuses assessment r/t resident recent increase in Lasix to 20mg BID and n/o of Neurontin 100mg TID for europathy. Resident c/o discomfort to legs. Resident currently in bed with feet propped on pillow . No v/s or edema observation was noted. A Nurses Progress Note date 06/16/24 at 10:19 p.m., read in part .VS 136/65-84-18-97.9 pox94% RA. Resting in bed. high [NAME] position. Resp even and unlabored. Edema remains to bil lower extremities 3+ pitting. Decreasing in arms bil. Lasix changed to bid. New order for Neurontin 100mg po bid. [resident] tolerating med changes without s/s of adverse reaction. Continuing with plan of care . A Nurses Progress Note, dated 06/17/24 at 1:14 p.m., read in part .Focuses nursing assessment r/t starting Neurontin and increase of Lasix. No s/e or a/r noted. Sitting up in chair eating lunch at this tie. no distress noted .vs stable. 97.9, 96, 150/73, 76, 18 . A Nurses Progress Note, dated 06/18/24 at 4:39 a.m., read in part .focused assessment r/t n/o Neurontin 100mg TID, Increase Lasix from 20 mg qday to 20mg BID. No adverse reaction noted this shift. Resident continues to c/o burning in bilateral feet and BLE. Resident has order for 5mg Roxicodone QID PRN for pain relief. Resident resting in bed, call light within reach. POC ongoing . No v/s or edema assessment was documented. There was no documentation in the progress notes Resident #45 had been assessed on 06/19/24. On 06/19/24 at 1:13 p.m., Resident #45 was sitting in their wheelchair, both feet were observed to have edema. On 06/20/24 at 5:29 a.m., Resident #45 was observed in their bed in the high [NAME] position. On 06/20/24 at 2:01 p.m., the DON was asked when the physician had been notified of the 36 pound weight gain. They stated, I don't think the restorative aide put that weight in right or didn't report it to the nurse. They were asked if the physician had been notified in a timely manner. They stated depends on what timely means but they would have notified the physician as soon as they were aware. On 06/20/24 at 2:01 p.m., LPN #2 was asked what had been done when the resident had been seen by the physician on the 13th. They stated the doctor gave an order to increase the Lasix to twice a day. A Nurses Progress Note dated 06/20/24 at 4:16 p.m., read in part .[Doctor] notified of cont weight gain. Physician reviews recent PO Lasix as intervention for weight gain, ineffective. Received n/o to send res to ER for eval and tx. A Nurses Progress Note, dated 06/20/24 at 4:44 p.m., read in part .Resident assessed VS wnl - 140/62, 71, 20, 97%RA, 97.4, 9 pain. Resident c/o 3+ edema to BLE being painful, +1 edema to BUE also uncomfortable. Resident states [they] had some SHOB last night and some this day. Lungs clear to all lobes. EMS arrived to transfer resident to [name of hospital], report given to nurse at ER. A Nurses Progress Note , dated 06/21/24 at 12:39 a.m., read in part . resident admitted to [name of hospital] for CHF Exacerbation . On 06/21/24 at 8:38 a.m., the DON was asked what the Resident #45s weight was when they had been weighed. They stated it was 249 pounds, the resident was sent to the hospital and admitted for CHF. On 06/21/24 at 10:44 a.m., the DON was asked what was Resident #45's diagnosis. They stated heart failure. They were asked to review the weights on 05/23/24 and 06/07/24 and asked how did the facility respond. They stated they had reweighed the resident by the fifteenth of the month according to policy. The DON was asked if the physician had been notified on 06/15/24 when the nurse progress note documented 4+ pitting edema and edema to forearm. They stated No. They were asked if the physician had been notified when the nurse progress note documented the resident had 3+ edema to their lower legs and edema to their arms. They stated No. The DON was asked when the physician was notified. They stated the physician was asked to see the resident on 06/13/24. The swelling had been noticed during skin observations. The DON was asked did the physician give orders. They stated to increase the resident's Lasix 20 mg from one time a day to two times per day. They were asked what the rationale for increasing the Lasix. They stated for congestive heart failure. The DON was shown the physician note, dated 06/13/24, and asked what did monitoring for any signs of worsening symptoms mean. They stated To complete assessments. On 06/21/24 at 11:40 a.m., the pharmacy consultant was asked for a policy related to monitoring for the use of diuretics. They stated they were unsure if they had one. The facility did not provide a policy related to monitoring a resident with congestive heart failure.

Based on observation, record review, and interview, the facility failed to maintain infection control measures: a. during provision of wound care and incontinent care for one (#4) of four sampled residents reviewed for infection control; b. to alert staff of enhanced barrier precautions when providing care for one (#9) of four sampled residents reviewed for infection control; and c. during provision of peri care for one (#32) of four sampled residents reviewed for infection control; and d. when emptying a catheter for a resident on enhanced barrier precautions for one (#42) of four sampled residents reviewed for infection control. Facility census: 77 Findings: The facility's Infection Control and Isolation Policy, revised 03/28/24, read in part, Gloves are used to prevent contamination of healthcare personnel hands when . anticipating direct contact with blood, or bodily fluids, mucous membranes, non-intact skin and other potentially infectious materials. The policy also read, infectious organisms can be reduced by adhering to the principles of working from clean to dirty, and confining or limiting contamination to surfaces that are directly needed for patient care. It may be necessary to change gloves during the care of a single patient to prevent cross contamination of body sites. The policy also read, Hand hygiene following glove removal further ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hands during glove removal. The policy also read, Enhanced Barrier Precautions. Examples of high contact resident activities requiring gown and glove use for enhanced barrier precautions include device care or use: central line, urinary catheter. 1. Resident #4 had diagnoses which included an unstageable pressure ulcer to the left buttock, a deep tissue injury to the right buttock and Alzheimer's. Resident #4's care plan for pressure ulcers, dated 01/18/23 through 01/19/24, documented, a. assess/record/monitor wound healing. b. enhanced barrier precautions related to peg tube/foley catheter. May discontinue if peg tube and foley removed. c. ROHO mattress in place. d. wound consultant to screen, evaluate and treat as indicated. e. turn and reposition resident from side to side only every 2 hours and prn. A physician order, dated 04/02/24, documented enhanced barrier precautions related to peg tube/foley catheter. May discontinue if peg tube and foley removed, every shift gown and gloves for activities of daily living and foley/peg tube care. A quarterly assessment, dated 04/13/24, documented Resident#4 had severe cognitive impairment, and was dependent on staff for activities of daily living. A physician order, dated 06/18/24, documented to cleanse the right buttock, with wound cleanser, pat dry, apply Medi honey, Durafiber Ag and a bordered foam dressing every Monday, Wednesday, and as needed for a deep tissue injury. A physician order, dated 06/18/24, documented to cleanse the left buttock with wound cleanser, pat dry, apply Medi honey, Durafiber Ag and cover with a bordered foam dressing every Monday, Wednesday, Friday and as needed for an unstageable pressure ulcer of the left buttock. On 06/19/24 10:52 a.m., lying in bed on left side with heel protectors in place and an indwelling catheter flowing to gravity with clear yellow urine. No gowns or gloves behind resident's door at this time for enhanced barrier precautions. On 06/19/24 at 1:38 p.m., LPN #2 was observed to prepare wound care supplies to perform wound care for Resident #4. LPN #2 was observed to put multiple clean gloves in their pocket. LPN #2 donned gloves and brought the supplies into the room and placed the supplies on a clean surface then removed the gloves from their pocket and placed on the clean surface. LPN #2 removed their gown and gloves and went out to the cart to get tongue depressors for wound care. Resident #4 was observed to be incontinent of bowel before and during wound care. LPN #2 was observed to cleanse the two wounds on the residents' buttocks, and remove their gloves. They were not observed to sanitize their hands between changing their gloves. They applied the Medi honey and dressings, then covered the areas with dressings and dated the dressings. LPN #2 then provided incontinent care then placed a new bed pad underneath the resident, repositioned the resident then covered the resident up with a sheet and blanket. LPN #2 was not observed to change their gloves after provision of incontinent care and repositioning the resident. On 06/19/24 at 1:53 p.m., LPN #2 was asked if they had sanitized their hands between glove changes during wound care. They stated No. They were asked if they had changed their gloves after they provided incontinent care and repositioned the resident. They stated No. 2. Resident #9 had diagnosis which included urinary tract infection in the last 30 days and diabetes mellitus. An annual assessment, dated 05/13/24, documented Resident #9 had no cognitive impairment and an indwelling catheter. On 06/20/24 at 7:30 a.m., observed LPN #3 perform catheter care for Resident #9. They reported they kept gowns on the medication cart just in case. The door was not marked to alert staff to use enhanced barrier precautions when providing care and no gowns/gloves were supplied on the back of door. On 06/20/24 at 8:05 a.m., IP nurse reported Resident #9 was not on enhanced barrier precautions and upon entering the room they realized the resident had an indwelling catheter in place. On 06/20/24 at 6:50 a.m., CNA #5 was asked how do they know when they need to wear PPE. They stated there would be a sign on the door and PPE outside the door. On 06/20/24 at 8:11 a.m., IP nurse reported they found out what why the door was not marked for enhanced barrier precautions. Resident #9 went to the hospital and they were on enhanced barrier precautions and when they returned from the hospital on 06/05/24, they did not put the enhanced barrier precautions signs back up. The IP nurse reported they were out on vacation from 06/06/24 and returned on 06/13/24. On 06/20/24 at 8:36 a.m., IP nurse posted a sign on Resident #9's door for enhanced barrier precautions and reported that it just slipped by them. On 06/20/24 at 8:27 a.m., IP nurse reported there was a breakdown in the process for enhanced barrier precautions. 3. Resident #32 had diagnosis which included cerebrovascular accident, heart failure, and high blood pressure. A quarterly assessment, dated 04/17/24, documented Resident #32's cognition was intact, always incontinent of urine, and frequently incontinent of bowel. A care plan, documented Resident #32's bladder incontinence: a. will remain free from skin breakdown due to incontinence and use brief through the review date. b. monitor/document for sign and symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. c. monitor/document/report to physician as needed for possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects On 06/20/24 at 5:54 a.m., CNA #5 and CNA #6 were observed to provide incontinent care to Resident#32. Both staff were wearing gloves, they uncovered the resident and pulled the brief down from between the resident's legs. CNA #6 cleansed the buttocks area then placed a new brief under the resident they were not observed to change their gloves. CNA #6 then applied ointment to the Resident's buttocks and wiped the remaining ointment from their glove on the clean brief. They removed their right glove and left the other glove on. CNA #6 used their gloved hand to reposition the resident then reached into their pocket and retrieved a glove then donned it on their right hand. CNA #5 provided peri care to the residents' vaginal area, applied ointment to the peri area then used a wipe to clean their gloves. CNA #5 and CNA #6 were then observed to position the resident and pull up the brief between the residents' legs and reposition the resident to their left side, then pulled the resident up in the bed. CNA #6 got a cover from the resident's chair, and covered the resident. CNA #6 was not observed to change their left glove at any time during the provision of care. On 06/20/24 at 6:31 a.m., CNA #6 was asked to describe handwashing and glove usage. They stated before they change, they wash their hands and after they change they wash their hands then sanitize. They were asked if they change their gloves when providing care. They stated they do not change their gloves. They were asked if they should wash their hands and put on clean gloves. CNA #6 stated they did not take off the gloves and wash their hands and put on clean gloves. They were asked if Resident #32 was soiled when they provided incontinent care. They stated the resident was incontinent of urine. CNA #6 stated they kept their gloves in their pocket and when they ran out they went to get more. They stated not all rooms had gloves. They stated they had applied ointment and after cleaning the buttocks they would be considered dirty and should have washed their hands. On 06/20/24 at 6:50 a.m., CNA #5 was asked how do they know when they need to wear PPE. They stated there would be a sign on the door and PPE outside the door. They were asked what PPE should be worn when emptying a catheter. They stated gloves, a gown and eye protection. They were informed of the observation when emptying the catheter and they stated they should have worn a gown and not just gloves. 4. Resident #42 had diagnoses which included neurogenic bladder and multiple sclerosis. A physician order, dated 04/02/24, documented to provide enhanced barrier precautions related to indwelling catheter. Use gown and gloves for activities of daily living and catheter care. Resident #42's, care plan, dated 08/04/20 through 07/09/24, documented, a. has an indwelling catheter related to: Neurogenic bladder. b. enhanced barrier precautions related to indwelling catheter, may discontinue when indwelling catheter removed. On 06/18/24 at 10:21 a.m.,Resident #42 was observed lying in their bed. Enhanced barrier precautions sign was posted on the door outside of the room. Resident #42 has an indwelling catheter and reported the staff put the sign up outside the door recently. On 06/19/24 at 10:55 a.m., lying in bed, enhanced barrier precautions placed on door (magnet) and supplies were located on the back of door to include gowns and gloves. On 06/20/24 at 5:50 a.m., CNA #5 was observed to enter Resident #42's room. CNA #5 donned gloves and was observed to empty the residents catheter using a urinal, then emptied the urine into the toilet, rinsed the urinal in the sink, and poured it into the toilet, placed the urinal into a trash bag in the bathroom. CNA #5 was not observed to don a gown. PPE was observed in a yellow cloth bin on the back of the resident door. A sign for EBP precautions was observed on the door frame on the outside of the door. On 06/20/24 at 8:37 a.m., the IP nurse was asked what the process was for getting gloves to prepare for providing care. They stated staff should have those things readily available on a clean spot or bedside table. If performing peri care or catheter care all supplies should be readily available. They were asked when should staff change their gloves during provision of peri care. They stated staff should change gloves after they clean the resident. They should remove the dirty gloves, sanitize their hands then put new gloves on. On 06/20/24 at 8:45 a.m., the IP nurse was informed of CNA #5 not donning a gown when emptying Resident #42's catheter. They were asked if they should have worn a gown. They stated, Yes. The IP nurse was informed of the observations made during provision of wound care provided by LPN #2. They stated that was not acceptable. 41872

Based on observation, record review, and interview, the facility failed to notify the physician of a severe weight gain of 36 pounds (17.24 %) for one (#45) of two sampled residents reviewed for weights. The facility census was 77. Findings: A Dining Services Policies and Procedures Weight List, revised 07/09/08, read in part .Residents' weights are routinely and systematically monitored .Residents with a weight loss or gain of five percent or more, within one month, should be re-weighed and entered into PCC by the 15th of the month. The resident's physician should be notified of any Significant Weight Change in PCC A Resident's Family or Physician Notification of Change Guideline policy, dated 12-01-09, read in part The facility will inform the resident; consult with the resident's physician .of the following events .A significant change in the resident's physical, mental, or psychosocial status. (i.e. a deterioration in health, mental or psychosocial states in either life-threatening conditions or clinical complications . a need to alter treatment significantly . Resident #45 had diagnosis to include congestive heart failure and edema. A review of the weight record for Resident #45 documented the resident weighted 208.8 pounds on 05/23/24 and weighted 244.8 pounds on 06/07/24. Resident #45 had a 36 pound (17.24%) weight gain in 15 days. There was no documentation Resident #45's physician had been notified of the severe weight gain on 06/07/24. A review of the restorative weight record, dated 06/12/24, documented Resident #45 weighed 240.2 pounds. The Resident #45 continued to have a severe weight gain of 31.4 pounds (15.04%) since 05/23/24. A physician visit note, dated 06/13/24, read in part, .The patient presents for a follow-up visit at the nursing home per the request of the nursing staff. [The resident] complaint is persistent bilateral leg pain, which he describes as feeling like there is a fire inside. [The resident] reports having significant peripheral edema. On 06/20/24 at 2:01 p.m., the DON was asked when the physician had been notified of the 36 pound weight gain. They stated, I don't think the restorative aide put that weight in right or didn't report it to the nurse. They were asked if the physician had been notified in a timely manner. They stated depends on what timely meant but they would have notified the physician as soon as they were aware. On 06/21/24 at 10:44 a.m., the DON was asked what was Resident #45's diagnosis. They stated heart failure. They were asked to review the weights on 05/23/24 and 06/07/24 and asked how did the facility respond. They stated they had reweighed Resident #45 by the fifteenth of the month according to policy. The DON was asked if the physician had been notified on 06/15/24 when the nurse progress note documented 4+ pitting edema and edema to forearm. They stated No. They were asked if the physician had been notified when the nurse progress note documented the Resident #45 had 3+ edema to their lower legs and edema to their arms. They stated No. The DON was asked when the physician was notified. They stated the physician had been asked to see the Resident #45 on 06/13/24. 41872

Based on record review and interview, the facility failed to complete a significant change assessment for one (#52) of 15 sampled residents reviewed for assessments. The facility census was 77. Findings: Resident #52 had diagnoses which included, paraplegia, and high blood pressure. An annual assessment, dated 12/25/23, documented the Resident #52 was independent with oral hygiene, needed setup or clean up assistance with shower/bathing, supervision or touching assistance with upper body dressing and partial to moderate assistance with lower body dressing. A quarterly assessment, dated 03/19/24, documented the Resident #52 required setup or clean up assistance with oral hygiene, needed partial/moderate assistance with shower/bathing and upper body dressing and needed substantial maximal assistance with lower body dressing. On 06/19/24 at 3:37 p.m., the ADON was asked to review the last two assessments dated 12/25/23 and 03/19/24 for ADL assistance. They were asked if there should have been a significant change assessment completed with the decline in two or more areas. They stated, a significant change assessment should have been completed.

Based on record review and interview, the facility failed to allow a resident to return to the facility after a hospitalization for one (#3) of two sampled residents reviewed for discharge. The facility failed to have a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The DON reported 81 residents resided in the facility. Findings: Res #3 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease, chronic venous hypertension with ulcers to bilateral lower extremities, general anxiety, and depressive disorder. A quarterly assessment, dated 10/26/23, documented the resident was cognitively intact and no behaviors were exhibited. A physician phone order, dated 12/26/23, documented, Discharge res to [hospital name withheld] ER for harmful behaviors towards self and others. A nurse progress note, dated 12/26/23 at 10:10 p.m., documented, The resident combative, throwing things at staff and other residents. Lighting various things in his room on fire as well as smoking in his room. Resident believes facility staff are holding his daughter hostage in the attic and also in the basement. He called 911 multiple times, tying up the emergency number. When confronted with information that what he was doing was against the law, he started throwing things at staff members. Swearing at us and yelling really loudly. He has had multiple resent lab draws showing critical levels for HGB and HCT. Resident refuses medical care. Corporate ordered to have resident emergency discharged from facility d/t him being a danger to himself as well as other residents and staff members. [Police department name withheld] escorted resident to [hospital name withheld] for medical evaluation. Resident agreed to go and left without incident. An emergency involuntary transfer/discharge notice, dated 12/26/23, was not signed by Res #3. A summary order overruling involuntary discharge, signed by the Administrative Law Judge, dated 01/10/24, read in part, .The court finds an involuntary discharge hearing is not required because the facilty failed to comply with the previsions of 42 C.F.R. 483.15(c)(5), regarding a written notice . No discharge summary signed by the physician was available in the resident's medical record. On 01/17/24 at 10:45 a.m., the administrator reported Res #3 was EOD to the hospital by the police department due to being a harm to himself and others. The administrator reported the nurse signed a third party statement because the resident would not agree to go to the ER until the police arrived to the facility. The administrator reported the resident was involuntarily discharged due to the EOD and the facility not being able to meet his needs. The administrator reported the facility did not have a policy related to involuntary discharges. On 01/17/24 at 2:58 p.m., the case manager with [hospital name withheld] reported the hospital was not aware Res #3 had been discharged and was not able to return to the facility. The case manager reported they contacted the facilty to notify them that the resident had been evaluated and cleared to return to the facility. The case manager reported being told by the facility that the resident was discharged and was not allowed to return d/t the facility not being able to meet his needs. The case manager reported not being able to find placement for the resident. The case manager reported no knowledge that the resident had not been given a discharge notice. The case manager reported the resident had voiced missing the other residents at the facility and was ready to return.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing and humidifier bottles were dated for three (#10, 40, and #78) of three residents reviewed for oxygen therapy. The Resident Census and Conditions of Residents report, dated 05/01/23, documented 36 residents received respiratory treatments. Findings: The facility's Respiratory Equipment Changeout Schedule policy, dated 11/11/19, read in parts, .Each facility will stock disposables necessary to provide respiratory therapy treatments to residents .When this equipment is changed out the equipment needs to be dated .Changeout schedule: O2 humidifier one time per month, Cannula one time a month . 1. Res #10 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease. A Physician Order, dated 03/09/23, documented O2 at three liters via nasal cannula. An Admission MDS assessment, dated 03/15/23, documented oxygen therapy while a resident. On 05/01/23 at 3:30 p.m., Resident #10 was observed with O2 at three liters via nasal cannula in use. The oxygen tubing was not labeled with a date. A Care Plan, revised 05/02/23, read in parts, .Res #10 has respiratory problems related to diagnoses of chronic obstructive pulmonary disease, shortness of breath, and allergies .O2 at 3 liters via nasal cannula as physician ordered . 2. Resident #40 was admitted with diagnoses which included chronic obstructive heart disease. An Admission MDS assessment, dated 04/13/23, documented oxygen therapy while a resident. On 05/02/23 at 10:17 a.m., Resident #40 was observed with oxygen in use at five liters via nasal cannula. The oxygen tubing and humidifier bottle was not dated. A Physician Order, dated 05/03/23, documented oxygen at two to four liters via nasal cannula if O2 sats are less than 90%. A Care Plan, revised 05/03/23, read in parts, .Res #40 has altered respiratory status, and difficulty breathing related to chronic obstructive pulmonary disease . Change nasal cannula on the 15th of every month and as needed . Oxygen at 2-4 liters via nasal cannula if O2 sats are less than 90% . 3. Resident #78 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease. A Physician Order, dated 03/31/23, documented O2 at two liters with no directions specified for order. An Admission MDS Assessment, dated 04/06/23, documented the resident's cognition was intact. On 05/01/23 at 4:00 p.m., the resident was observed in bed with O2 in use at two liters via nasal cannula. The O2 tubing and humidifier bottle were not labeled with a date. A Care Plan, revised 05/03/23, read in parts, .Res has respiratory problems related to diagnoses of chronic obstructive pulmonary disease .O2 at 2 liters via nasal cannula as physician ordered . On 05/03/23 at 4:42 p.m., the RN regional nurse consultant reported oxygen tubing and humidifier bottles should be labeled with a date.

Based on observation, record review, and interview, the facility failed to provide assistance with incontinence for dependent residents, in a timely manner, for two (#3 and #70) of two dependent residents reviewed for assistance with activities of daily living. The Resident Census and Conditions of Residents report, dated 05/01/23, documented 91 residents resided in the facility. Findings: 1. Resident #3 had diagnoses which included congestive heart failure, diabetes, chronic pain, anxiety, and depression. An Annual MDS Assessment, dated 03/21/23, documented the resident was cognitively intact. The assessment documented the resident required extensive assistance with bed mobility, transfers, and most activities of daily living. A Care Plan, dated 04/06/23, documented the resident had a self-care deficit related to limited mobility and weakness. Physician Orders, dated May 2023, documented the resident required a transfer/grab bar in place on the bed to promote independence with repositioning and transfers while in bed due to muscle weakness. On 05/01/23 at 3:21 p.m., Resident #3's room was observed to smell strongly of BM and urine. The resident's call light was observed to be on. Two unidentified staff members were observed to walk by the resident's room without responding to the resident or acknowledging the resident's call light. The resident was observed to yell out loudly to request assistance. On 05/01/23 at 3:26 p.m., the same two unidentified staff members were observed to walk by Resident #3's room again. The resident's call light remained on and the staff members did not acknowledge the resident or respond to the resident in any way. On 05/01/23 at 3:37 p.m., Resident #3's call light remained on and the resident was observed to yell out for assistance. Several staff members were observed down the hall standing around the nurse's station without responding to the resident's call light. On 05/01/23 at 3:52 p.m., two CNAs were observed to take a resident into a room a couple of doors down from Resident #3's room but did not respond to Resident #3 or acknowledge him yelling out. On 05/01/23 at 3:59 p.m., CNA #1 was observed to walk into Resident #3's room briefly, the call light was observed to go off, and the aide left the resident's room. On 05/01/23 at 4:02 p.m., Resident #3 was asked if the aide took care of his needs. The resident reported the aide said she would come back. The resident was asked what he needed and he reported he needed assistance with incontinent care. On 05/01/23 at 4:07 p.m., CNA #1 and other staff were observed standing at the nurse's station. Resident #3's call light was no longer on and no one had returned to the resident's room. On 05/01/23 at 4:24 p.m., Resident #3 was asked if he was still waiting on assistance. The resident stated, Yes, this happens every day, it's nothing new. On 05/01/23 at 4:27 p.m., CNA #1 was overheard discussing resident care with other staff members, which residents needed to get up, who needed to be changed, etc. The CNA was asked if Resident #3 was on their list and she stated yes, and reported the resident usually called when he needed assistance. The surveyor pointed out the resident had already called and the CNA was observed to respond to the resident's call light, but had not returned to provide care. The CNA stated they would take care of the resident. 2. Resident #70 had diagnoses which included hemiplegia/hemiparesis, chronic kidney disease, and chronic pain. A Care Plan, dated 03/16/23, documented Resident #70 had decreased mobility and required extensive assistance with activities of daily living. On 05/02/23 at 11:55 a.m., Resident #70 reported it took staff a long time to answer the call light when the resident needed to use the restroom. The resident stated it usually took 30 minutes or longer for staff to respond. On 05/04/23 at 8:30 a.m., the Administrator and DON reported corporate had recently established an academy to train CNAs, and this was currently being done remotely at this facility. The Administrator reported his expectation was for call lights to be answered promptly and was hopeful additional CNAs would help with this situation.

Based on record review and interview, the facility failed to complete a significant change assessment for one (#68) of one resident reviewed for hospice services. The facility Resident Census and Conditions of Residents report, dated 05/01/23, documented three residents received hospice services. Findings: Resident #68 was admitted with diagnoses which included diabetes mellitus and dementia. A hospice Certification of Terminal Illness Statement, dated 01/18/23, read in parts, .I certify that this patient is terminally ill, with a life expectancy of six months or less .admitted to hospice with terminal dx of Alzheimer's disease .physician signature, dated 02/07/23 . Resident #68's Quarterly MDS Assessment, dated 02/10/23, documented the resident required staff assistance with ADLs and contained no documentation related to hospice services. A Significant Change MDS Assessment, dated 03/14/23, documented Resident #68 received hospice services. On 05/03/23 at 4:42 p.m., the RN regional nurse consultant reported hospice services should have been captured on a MDS significant change assessment within 14 days of receiving hospice services. She reported the MDS coordinator had identified hospice services and completed the significant change assessment, but it was completed late and past the 14 day requirement.

Based on record review, observation, and interview, the facility failed to thoroughly investigate an allegation of sexual abuse, and prevent further potential abuse, for one (#3) of four residents reviewed for abuse. The Resident Census and Conditions of Residents form documented 91 residents resided in the facility. Findings: A facility policy, Resident Abuse, Neglect and Misappropriation of Property, revised 12/28/17, documented in parts .The facility will not tolerate mistreatment, neglect, or abuse of residents. Verbal, mental, sexual, or physical abuse .will not be tolerated. Abuse is never expected of an employee and abusive acts are outside the scope of employment .Report the incident to the highest-ranking person working in the facility at the immediate time of the allegation .The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation .The licensed nurse should report his/her findings to the administrator and/or physician as soon as possible after the assessment .The nurse should take immediate steps to protect the resident from further incident during this time .The licensed nurse in charge of the unit shall then complete an incident report reflecting any and all findings from the assessment of the resident following the incident .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 . Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Assessment for resident #3, dated 09/19/22, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with activities of daily living and was incontinent of bowel and bladder. A handwritten note, written and provided by the DON but not signed or dated, documented in parts .It was reported to me by LPN #1 [name deleted] that this CNA (CNA #1) reportedly fondles pts genitals to stimulate them to urinate .Upon investigation I interviewed the RN on duty [name deleted] .reports she has never been told this before .I questioned [name deleted-CNA #1] .She states the only thing she does in that manner is one pt, a female, has difficulty starting her stream .The CNA has found that if she uses a clean wet wipe prior to toileting it will stimulate that res to void .I spoke with this particular res regarding this intervention and she reports that is the truth. On 10/28/22 at 5:37 p.m., CNA #2 reported a few months back she turned in a complaint related to an incident she witnessed involving CNA #1. CNA #2 reported she walked by resident #3's room and observed CNA#1 rubbing the resident's vagina. CNA #2 stated CNA #1 was training CNA #3 and she was also in the resident's room. CNA #2 stated she asked CNA #1 what she was doing because it didn't look appropriate to her, and CNA #1 responded she was trying to help the resident urinate. CNA #2 stated CNA #1 was observed to use her bare hand while touching the resident, without a glove or wash cloth. On 10/28/22 at 7:00 p.m., resident #3 was observed to be receiving her evening medications. The resident was observed lying in bed, covered with a blanket. The resident had her eyes open and responded to the CMA but was not capable of answering interview questions. On 10/28/22 at 7:44 p.m., CNA #1 was interviewed by telephone about the incident involving resident #3. The CNA stated the DON asked her if she had ever fondled a resident's genitals and she stated, no. The CNA reported there was one resident (resident #3) who had trouble voiding. The CNA stated she placed a washcloth on the resident's leg and it helped her go. The CNA was asked if any other charge nurse or administrative staff had talked to her about the allegation related to resident #3 and she reported the DON was the only one to question her. On 10/28/22 at 7:55 p.m., the DON stated LPN #1 had reported the allegation of abuse to her when the LPN was being counseled related to a separate matter. The DON stated the LPN didn't give her a resident name, or specific date of the incident, when she initially informed her that CNA #1 was fondling residents. The DON was asked if she recognized the incident as a sexual abuse allegation. The DON stated, yes, and because of this she started monitoring CNA #1 on the nightshift. The DON stated she interviewed other staff members and no one voiced concerns related to CNA #1. The DON was asked if she had documented her observations or interviews and she reported she had not. The DON was asked if anyone had completed an incident report or started an investigation related to the allegation of sexual abuse. The DON stated an incident report had not been completed and she did not have any documentation related to her investigation. The DON was asked if other residents had been interviewed related to CNA #1 and she reported no other residents had been interviewed. On 10/28/22 at 7:56 p.m., CNA #3 was interviewed by telephone and reported she had not worked in the facility for at least a month. The CNA was asked if she had witnessed anything inappropriate during the time she was in training at the facility and she stated, no, not at all. The CNA was asked if she had any concerns about any of the staff she worked with or if she had witnessed resident abuse of any kind. The CNA reported no, she had not witnessed anything of concern related to resident care or abuse of any kind. On 10/28/22 at 8:36 p.m., the Administrator reported the DON had been informed of the allegation of abuse from LPN #1. The Administrator stated when he was informed of the abuse allegation, he told the DON to investigate the reported incident. The Administrator stated the DON interviewed staff members and determined CNA #1 was not doing anything wrong or inappropriate. The Administrator was not aware of any residents being interviewed related to CNA #1 and potential sexual abuse.

Based on record review, observation, and interview, the facility failed to implement the abuse policy to ensure a resident was free from sexual abuse for one (#3) of four residents reviewed for abuse. The Resident Census and Conditions of Residents form documented 91 residents resided in the facility. Findings: A facility policy, Resident Abuse, Neglect and Misappropriation of Property, revised 12/28/17, documented in parts .The facility will not tolerate mistreatment, neglect, or abuse of residents. Verbal, mental, sexual, or physical abuse .will not be tolerated. Abuse is never expected of an employee and abusive acts are outside the scope of employment .All employees of a nursing facility are mandated reporters of resident abuse .and must report any and all incidents .Report the incident to the highest-ranking person working in the facility at the immediate time of the allegation .The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation .The licensed nurse should report his/her findings to the administrator and/or physician as soon as possible after the assessment .The nurse should take immediate steps to protect the resident from further incident during this time .The licensed nurse in charge of the unit shall then complete an incident report reflecting any and all findings from the assessment of the resident following the incident .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 . Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Assessment for resident #3, dated 09/19/22, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with activities of daily living and was incontinent of bowel and bladder. A handwritten note, written and provided by the DON but not signed or dated, documented in parts .It was reported to me by LPN #1 [name deleted] that this CNA (CNA #1) reportedly fondles pts genitals to stimulate them to urinate .Upon investigation I interviewed the RN on duty [name deleted] .reports she has never been told this before .I questioned [name deleted-CNA #1] .She states the only thing she does in that manner is one pt, a female, has difficulty starting her stream .The CNA has found that if she uses a clean wet wipe prior to toileting it will stimulate that res to void .I spoke with this particular res regarding this intervention and she reports that is the truth. On 10/28/22 at 5:37 p.m., CNA #2 reported a few months back she turned in a complaint related to an incident she witnessed involving CNA #1. CNA #2 reported she walked by resident #3's room and observed CNA#1 rubbing the resident's vagina. CNA #2 stated CNA #1 was training CNA #3 and she was also in the resident's room at the time of the incident. CNA #2 stated she asked CNA #1 what she was doing because it didn't look appropriate to her, and CNA #1 responded she was trying to help the resident urinate. CNA #2 stated CNA #1 was observed to use her bare hand when touching the resident, without a glove or wash cloth. On 10/28/22 at 7:00 p.m., resident #3 was observed to be receiving her evening medications. The resident was observed lying in bed, covered with a blanket. The resident had her eyes open and responded to the CMA but was not capable of answering interview questions. On 10/28/22 at 7:44 p.m., CNA #1 was interviewed by telephone about the incident involving resident #3. The CNA stated the DON had asked her if she had ever fondled a resident's genitals and she stated, no. The CNA reported there was one resident (resident #3) who had trouble voiding. The CNA stated she placed a washcloth on the resident's leg and it helped her go. The CNA was asked if any other charge nurse or administrative staff had talked to her about the allegation related to resident #3 and she reported the DON was the only one to question her. On 10/28/22 at 7:55 p.m., the DON stated LPN #1 had reported the allegation of abuse to her when the LPN was being counseled related to a separate matter. The DON stated the LPN didn't give her a resident name or specific date of occurrence when she initially informed her that CNA #1 was fondling residents. The DON was asked if she recognized the incident as a sexual abuse allegation. The DON stated, yes, and because of this she started monitoring CNA #1 on the nightshift. The DON stated she interviewed other staff members and no one voiced concerns related to CNA #1. The DON was asked if she had documented her observations or interviews and she reported she had not. The DON was asked if anyone had completed an incident report or started an investigation related to the allegation of sexual abuse. The DON stated an incident report had not been completed and she did not have any documentation related to her investigation. The DON was asked if other residents had been interviewed related to CNA #1 and the allegation of her fondling residents. The DON reported no other residents had been interviewed. On 10/28/22 at 7:56 p.m., CNA #3 was interviewed by telephone and reported she had not worked in the facility for at least a month. The CNA was asked if she had witnessed anything inappropriate during the time she was in training at the facility and she stated, no, not at all. The CNA was asked if she had any concerns about any of the staff she worked with or if she had witnessed resident abuse of any kind. The CNA reported no, she had not witnessed anything of concern related to resident care or abuse of any kind. On 10/28/22 at 8:36 p.m., the Administrator reported the DON had been informed of the allegation of abuse from LPN #1. The Administrator stated when he heard about the allegation, he told the DON to investigate the reported incident. The Administrator stated the DON interviewed staff members and it was determined that CNA #1 was not doing anything wrong or inappropriate.

Based on record review, observation, and interview, the facility failed to report an allegation of sexual abuse to the State Agency (OSDH) for one (#3) of four residents reviewed for abuse. The Resident Census and Conditions of Residents form documented 91 residents resided in the facility. Findings: A facility policy, Resident Abuse, Neglect and Misappropriation of Property, revised 12/28/17, documented in parts .The facility will not tolerate mistreatment, neglect, or abuse of residents. Verbal, mental, sexual, or physical abuse .will not be tolerated .All employees of a nursing facility are mandated reporters of resident abuse .and must report any and all incidents .Report the incident to the highest-ranking person working in the facility at the immediate time of the allegation .The licensed nurse should report his/her findings to the administrator and/or physician as soon as possible after the assessment .The licensed nurse in charge of the unit shall then complete an incident report reflecting any and all findings from the assessment of the resident following the incident .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 . A facility policy Allegation of Abuse Guideline to be Reported Within 2 Hours, dated 07/31/18, documented in parts .All types of abuse fall under this: resident to resident, verbal, physical, sexual .Call the Administrator, Director of Nursing .Director of Nursing/Administrator do initial state report, send in any staff to Nursing/CNA Board if applicable within 2 hours .Complete investigation and do final state report within 5 working days . Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Assessment for resident #3, dated 09/19/22, documented the resident was severely impaired with cognition. The assessment documented the resident required extensive assistance with activities of daily living and was incontinent of bowel and bladder. A handwritten note, written and provided by the DON but not signed or dated, documented in parts .It was reported to me by LPN #1 [name deleted] that this CNA (CNA #1) reportedly fondles pts genitals to stimulate them to urinate .Upon investigation I interviewed the RN on duty [name deleted] .reports she has never been told this before .I questioned [name deleted-CNA #1] .She states the only thing she does in that manner is one pt, a female, has difficulty starting her stream .The CNA has found that if she uses a clean wet wipe prior to toileting it will stimulate that res to void .I spoke with this particular res regarding this intervention and she reports that is the truth. On 10/28/22 at 5:37 p.m., CNA #2 reported a few months back she turned in a complaint related to an incident she witnessed involving CNA #1. CNA #2 reported she walked by resident #3's room and observed CNA#1 rubbing the resident's vagina. CNA #2 stated she asked CNA #1 what she was doing because it didn't look appropriate to her, and CNA #1 responded she was trying to help the resident urinate. CNA #2 stated CNA #1 was observed to use her bare hand with no glove or wash cloth. CNA #2 stated she reported the incident to the charge nurse on duty but couldn't remember for sure which nurse she reported to. On 10/28/22 at 7:00 p.m., resident #3 was observed to be receiving her evening medications. The resident was observed lying in bed, covered with a blanket. The resident had her eyes open and responded to the CMA but was not capable of answering interview questions. On 10/28/22 at 7:44 p.m., CNA #1 was interviewed by telephone about the incident involving resident #3. The CNA stated the DON asked her if she had ever fondled a resident's genitals and she stated, no. The CNA reported there was one resident (resident #3) who had trouble voiding. The CNA stated she placed a washcloth on the resident's leg and it helped her go. The CNA was asked if any other charge nurse or administrative staff had talked to her about the allegation related to resident #3 and she reported the DON was the only one to question her. On 10/28/22 at 7:55 p.m., the DON stated LPN #1 had reported the allegation of abuse to her when the LPN was being counseled related to a separate matter. The DON stated the LPN didn't give her a resident name, or specific date of the incident, when she initially informed her that CNA #1 was fondling residents. The DON was asked if she recognized the incident as a sexual abuse allegation and she stated, yes. The DON was asked if anyone had completed an incident report or started an investigation related to the allegation of sexual abuse. The DON stated an incident report had not been completed and she did not have any documentation related to her investigation. On 10/28/22 at 8:36 p.m., the Administrator reported the DON had been informed of the allegation of sexual abuse from LPN #1. The Administrator stated when he was made aware of the allegation, he told the DON to investigate the reported incident. The Administrator stated the DON interviewed staff members and determined CNA #1 was not doing anything wrong or inappropriate. The Administrator stated an incident report had not been completed and the allegation of sexual abuse was not reported to the State Agency.

Based on record review and interview, it was determined the facility failed to provide supervision to prevent resident to resident altercations for one (#2) of four residents who were reviewed for supervision. Resident #2 had hit another resident in the face causing an abrasion and bruising. The facility did not ensure continuous supervision was in place after this incident. The resident attempted to hit another resident while left unsupervised. This had the potential to affect all 78 residents. Findings: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 10/24/17, documented the resident's cognition was modified independence. It documented the resident needed supervision with transfer, ambulation, and eating with set up only. It documented he needed extensive assistance with dressing, hygiene, and physical help in part with one person assistance, no range of motion limitations, and was occasionally incontinent of bowel and bladder. A care plan, dated 10/17/17, documented a resident to resident event had occurred on 10/23/17 with interventions which included redirect resident and 1:1 with personal sitter. A nurse's note, dated 10/23/17, documented the resident was standing by a female resident. The female resident tried to shoo him away and he hit her with his fist on the right side of her forehead. On 10/26/17 at 1:47 p.m., licensed practical nurse (LPN) #1 was asked if the resident had been supervised 1:1 since the incident on 10/23/17. She stated on 10/25/17 around 4:30 p.m., she observed the resident wander into the dining room. She stated he had approached a couple of different dining tables and then went toward resident # 5's table. She stated resident #5's daughter called out for assistance and she went and re-directed resident #2 out of the dining room. She stated resident #2 had not been monitored. She stated she had found out later the sitter for resident #2 had left around 2:30 p.m. At 2:29 p.m., resident #5 and resident #6 asked to speak with this surveyor. They stated resident #2 had been involved in an altercation with resident #1. Resident #5 stated on 10/25/17 at around 4:30 p.m. resident #2 had been in the dining room and began to approach the table where she had been eating. She stated her daughter called for help to redirect resident #2. She stated there was no one with resident #2. She also stated she had heard he had punched another resident. She identified the resident as resident #12 and certified medication aide (CMA) #1 knew all about it. At 2:39 p.m., CMA #1 was asked if resident #2 had been supervised after the incident on 10/23/17. She stated the resident's sitter had left around 2:30 p.m. on 10/25/17. She was asked if she had told anyone the sitter had left. She stated she had not remembered if she had or not. She was asked if the resident had exhibited aggressive behaviors since 10/23/17. She stated on 10/25/17 about 6:30 p.m., she had been giving medications. She saw resident #2 follow resident #12 down the hall. When resident #12 had stopped at her cart resident #2 had punched toward resident #12. She stated resident #2 had been too far away to have made contact with the other resident. She stated she redirected resident #2 and he left. She was asked if anyone had been observing resident #2. She stated not that she knew of. She was asked if she notified anyone of resident #2's aggressive behavior. She stated she notified the assistant director of nurses (ADON). She was asked if anyone was monitoring the resident after the altercation. She stated the wife came up here around 7:00 p.m. and stayed with him. At 2:41 p.m., a family member of resident #5 wanted to speak with this surveyor. She stated that on 10/25/17 resident #2 had wandered into the dining room. She stated he had begun to approach the table where her and her mother were seated. She stated she was concerned that the resident would have been aggressive because she had heard he had punched another resident. She stated she called out for staff to help. She stated a nurse came in and redirected the resident. She was asked if she had observed resident #2 to have been aggressive. She stated she had not. She was asked if she had heard of any other altercations with any other residents She stated she had not seen or heard of any other incidents. At 3:24 p.m., the director of nurse (DON) was asked what interventions were put in place for resident #2 after his altercations with resident #1. She stated they had him put on 1:1 monitoring. She was asked who provided the 1:1 care. She stated the family was contacted and was asked to provide the 1:1 care. She was asked what was put in place as a facility. She stated the staff was told to watch him and redirect him if needed. She was asked what type of interventions were put in place after the sitter had left. She stated the resident had not exhibited any aggressive behaviors for 48 hours after the incident and therefore they had not thought they needed anything specific other than informing the staff to monitor him. She was asked when resident #2 had approached resident #12 and punched at her, how was the staff supervising him. She stated the staff had been instructed to watch him. At 3:39 p.m., the ADON was asked about the incident on 10/25/17 with resident #2 and resident #12. She stated CMA #1 had contacted her about resident #2 punching toward resident #12. She stated she contacted the family and told them resident #2 needed 1:1 monitoring. She stated the wife came up a little before 7:00 p.m., and stayed with him. She stated the physician was notified and ordered Risperdal 1 milligram one time to be given to the resident for agitation. Resident #2 was observed to have 1:1 supervision during the survey on 10/26/17. The resident was transferred to a geriatric psychiatric facility on 10/27/17 at 5:29 p.m.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care to prevent the development of and promote the healing of pressure ulcers for one (#116) of two sampled residents who were reviewed for pressure ulcers. This resulted in actual harm for resident #116, when his pressure ulcer failed to progress towards healing. This had the potential to affect 7 residents with a pressure ulcer according to the facility's Resident Census and Conditions of Residents Form. Findings: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, dated 11/25/14, documented the resident's cognition was severly impaired. He required extensive assistance with transfers, dressing, eating and hygiene. The resident had a catheter and was always continent of bowel. He used a motorized wheelchair for mobility. He had not ambulated in the last 7 days. It was documented he was at risk for developing pressure ulcers. A care plan, dated 11/18/14, for skin integrity was reviewed. Documented interventions included: 1. Obtain pressure reduction mattress 2. Obtain pressure cushion for chair and or wheelchair. 3. Assist with turning and repositioning to meet residents needs. 4. Use pillows as needed to float heels and for positioning. 5. Perform head to toe skin assessment. 6. Monitor/document location, size and treatment of [REDACTED]. to the physician. On 12/02/14, a wound care nurse's note documented the right heel had a blister measuring 5 centimeters (cm) width, 5.5 cm length and < 0.1 cm in depth. It was described as clear fluid filled. The note documented the treatment to the heel was skin prep every shift and as needed. A physician's orders [REDACTED]. [MEDICATION NAME] cover with allevyn heel netting to keep in place. change daily and as needed, Diagnosis: [REDACTED]. On 12/09/14, a wound care nurse's note documented, "Right heel blister popped treatment changed: clean with wound cleanser, pat dry with 4x4's, apply [MEDICATION NAME], cover with allevyn, change daily and as needed." The treatment had not changed as the nurse's note documented. No characteristics and no measurements of the wound were documented. On 12/16/14, a wound care nurse's note documented the right heel had no changes. No characteristics and no measurements of the wound were documented. On 12/23/14, a wound care nurse's note documented the right heel had no changes to treatment, no signs and symptoms of infection. No characteristics of the wound and no measurements were documented. On 12/30/14, a wound care nurse's note documented the right heel had no changes. No characteristics of the wound and no measurements were documented. A physician's orders [REDACTED]. Discontinue [MEDICATION NAME] treatment to right heel." The December 2014 treatment sheet documented the new treatment was done on 12/31/14. The January treatment sheet documented the treatments were done only on the 7th. 9th, 11th, and 13th. On 01/14/15 at 10:50 a.m., the wound care nurse unwrapped the resident's right heel. The right heel was observed to be completely black. The wound care nurse was asked if she felt the heel ulcer was from pressure. She stated, "Yes." At 10:55 a.m., the wound care nurse stated she had found another pressure ulcer on the resident's left heel on 01/13/15. She was asked if she felt it was from pressure. She stated, "It's from pressure, It's on the outer side of the heel right where his heel lays on the bed." At 3:34 p.m., the director of nurses was asked if she had seen resident #116's right heel. She stated, "No, I haven't, I don't no anything about wounds." She was in agreement that weekly measurements and wound characteristics should have been documented. On 01/15/15 at 8:43 a.m., the resident was observed in bed. The wound care nurse pulled the cover back off his legs. There was a pillow under his legs right below the knees, both heels were on the bed. The wound care nurse was asked if the pillow was working to keep his heels off the bed. She stated, "No, it's not working. We need to do something different." At 8:46 a.m., the wound on the right heel was observed being measured by the wound care nurse. It measured 4.6 cm by 6 cm. It was black and unstageable. The wound on the left heel was 1.0 cm by 0.7 cm by 0.1 cm. The wound care nurse stated it was a stage 2. At 9:18 a.m., the resident's physician was interviewed. He was asked if he had seen the wound. He stated he saw the wound for the first time on 01/08/15. He stated he was really worried about it and felt like he needed to make a referral for it. The physician was asked if he was aware there was another pressure ulcer on the resident's left heel. He stated he was not aware of any other ulcer on the left foot. At 10:33 a.m., the resident stated no one had informed him about the condition of his right heel wound. At 4:50 p.m., the administrator stated the resident was very independent and at times didn't like to be bothered, "But I know that's no excuse."