Every finding on record at Main Street Terrace Care Center

Based on record review, review of policy, interview with the State Long Term Care Ombudsman and staff interview, the facility failed to notify the state long term care ombudsman of the transfer and/or discharge of three residents. This affected three (#60, #61, and #62) of three residents sampled for discharges/ hospitalizations. The facility census was 50.Findings include: 1. Review of Resident #60's medical record revealed an admission date of 07/01/25, transfer to the hospital on [DATE] and a discharge date of 06/11/26. Diagnoses included metabolic encephalopathy, encounter for surgical aftercare following surgery on the digestive system, acute respiratory failure with hypoxia, colostomy status and dementia.Review of Resident #60's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was severely cognitively impaired. Further review of Resident #60's MDS revealed the resident was dependent on oral hygiene, toileting hygiene, showering/bathing, dressing, personal hygiene, bed mobility, wheelchair mobility and transfers. The MDS indicated her overall goal was to remain at the facility.Interview on 07/08/26 at 9:42 A.M. with the State Long Term Care Ombudsman (SLTCO) #1 verified no notification was made to her for Resident #60.Interview on 07/08/26 at 2:30 P.M. with the Administrator verified SLTCO #1 was not notified of Resident #60's discharge.2. Review of Resident #61's medical record revealed an admission date of 01/15/26, and a discharge date of 05/01/26. Diagnoses included Type 2 Diabetes Mellitus, presence of cardiac pacemaker, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia and nicotine dependence.Review of Resident #61's most recent MDS assessment dated [DATE] revealed the resident was cognitively intact. Further review of Resident #61's MDS revealed the resident was independent for toileting hygiene, showering/bathing, dressing, personal hygiene, bed mobility, transfers and ambulation.Review of Resident #61's progress notes revealed a note written by Admissions Director/Social Services #105 on 05/01/26 at 11:56 A.M., indicating the resident was discharging from the facility against medical advice (AMA), due to not wanting to pay her patient liability.Interview on 07/08/26 at 9:42 A.M. with the SLTCO #1 verified no notification was made to her for Resident #61.Interview on 07/08/26 at 2:30 P.M. with the Administrator verified SLTCO #1 was not notified of Resident #61's discharge.3. Review of Resident #62's medical record revealed an admission date of 04/10/26, and a discharge date of 05/01/26. Diagnoses included pneumonia, sepsis, Parkinson's Disease, difficulty in walking and facial weakness following cerebral infarction.Review of Resident #62's most recent MDS assessment dated [DATE] revealed the resident was cognitively intact. Further review of Resident #62's MDS revealed the resident required partial to moderate assistance with showering/bathing, bed mobility and transfers.Review of Resident #62's progress notes revealed a note written by Licensed Practical Nurse (LPN) #120 on 05/01/26 at 1:27 P.M., indicating Resident #62 was discharged home.Interview on 07/08/26 at 9:42 A.M. with the SLTCO #1 verified no notification was made to her for Resident #62.Interview on 07/08/26 at 2:30 P.M. with the Administrator verified SLTCO #1 was not notified of Resident #62's discharge.Review of the policy titled Transfer and Discharge (including AMA) dated 09/09/25, revealed for emergency transfers/discharges, the social services director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as it meets all requirements for content of such notices.This deficiency represents non-compliance investigated under Complaint Number 3066180.

Based on observation and staff interviews, the facility failed to ensure daily nurse staffing information was posted. This had the potential to affect 50 of 50 residents residing in the facility. The facility census was 50.Findings include: Observation and interview on 07/08/26 at 9:35 A.M. with the Administrator of the daily posted staffing revealed the last posted staffing information was dated 07/01/26. Administrator verified daily staffing was not posted for the last seven days. Interview on 07/08/26 at 10:00 A.M. with the Director of Nursing (DON) revealed she was responsible for posting the daily nurse staffing. She stated she had been in the facility working night shift and had not posted them. This is an incidental finding while investigating Complaint #3066180.

Based on observation, interview, and review of service report and email, the facility failed to maintain a clean stove hood in the kitchen. This had the potential to affect all 45 residents residing in the facility. The facility census was 45.Findings include:Observation of the kitchen on 12/30/25 at 10:20 A.M. revealed the kitchen hood above the stove to be dusty. Observation of the inspection and cleaning sticker on the kitchen hood revealed it was last cleaned 08/27/25 and due again after 90 days. Interview with the Dietary Manager on 12/30/25 at 10:22 A.M. confirmed the kitchen hood above the stove was dusty and should have been cleaned and confirmed the kitchen hood was supposed to be cleaned every 90 days. The Dietary Manager further confirmed having paperwork to show inspections were completed but reported they were not the most current reports. Review of the service report revealed a date of 02/13/25. Review of an email dated 02/28/25 from Silco Fire and Security revealed the next inspection was scheduled for 03/06/25. There were no further service reports or documentation able to be provided.

Based on closed record review, interview, and review of the facility's Beneficiary Notices, the facility failed to provide notification to residents and/or representative within 48 hours. This affected one resident, (#53), of three residents reviewed for Beneficiary Notification. The facility census was 45.Findings include:Review of the closed record for Resident #53 revealed an admission date of 08/23/25 and discharge date of 09/13/25. Diagnoses for Resident #53 included, but were not limited to, dementia (9/9/25), obstructive and reflux uropathy (8/26/25), GERD (8/23/25), osteoarthritis (8/23/25), HTN (8/23/25), anxiety disorder (8/23/25), adult failure to thrive (8/23/25), anemia (8/23/25), altered mental status (8/23/25), pain (8/23/25), tachycardia (8/23/25), atherosclerotic heart disease (8/23/25), and obesity (8/23/25). BIMS for Resident #53, according to Minimum Data Set (MDS) section C, signed 09/15/25, was 11. Review of the facility's Beneficiary Notice revealed the notice for Resident #53 had an effective date of 09/11/25 for coverage to end. Further review revealed the telephone notice to Resident #53's representative was dated for 09/11/25 and signed by the Admissions Director 09/12/25. Interview with the admission Director 12/31/25 at 11:40 A.M. revealed Resident #53 no longer wished to reside at the facility as he wanted hospice through Veteran Affairs (VA), whom the facility did not contract with, and wanted to discharge as soon as possible. The admission Director reported the Notice of Medicare Non-Coverage (NOMNC) was issued as soon as possible, and confirmed the notification was signed on 09/12/25. The admission Director confirmed there was no documentation to confirm Resident #53's discharge was resident/family initiated and confirmed 48-hour notice was not given to Resident #53's representative.

Based on record review, interview, review of a facility Self-Reported Incident (SRI), review of December 2025 In-service Sign Off, and review of the facility's Resident Safety policy, the facility failed to complete resident abuse in-service reeducation for an agency aide involved in an abuse allegation following the investigation. This affected one, (#06), of three residents reviewed for abuse. The facility census was 45.Findings include:Review of Resident #06's record revealed an admission date of 11/11/25 with diagnoses of, but not limited to, muscle weakness (11/11/25), difficulty in walking (11/11/25), other lack of coordination (11/11/25), cognitive communication deficit (11/11/25), low back pain (11/11/25), chronic pain syndrome (11/11/25), weakness (11/7/25). Review of Resident #06's Minimum Data Set (MDS) signed 11/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 14. Interview with Resident #06 on 12/29/25 at 1:50 P.M. revealed the resident had an incident with an aide, believed to have occurred a few weeks ago. Resident #06 reported the aide had been behind her and shoved her. Resident #06 reported having pain in her back following the incident to which she informed the aide, and the aide responded, you cry even when we touch your pinky finger. Resident #06 explained that she reported the incident to the facility Social Worker and was unsure of the outcome, but knew the aide was working at the facility still as the aide assisted another aide with changing her Depends this morning. Resident #06 reported she still felt safe at the facility. Interview with the Director of Nursing (DON) on 12/31/25 at 9:25 A.M. revealed the facility's response to unsubstantiated investigations of abuse/neglect is to re-educate staff on their Resident Safety policy. The DON reported that the aide involved in the incident with Resident #06 was an agency aide that picked up shifts as desired. The DON explained if an agency aide is involved in an incident and re-education is required the facility would have a one-on-one meeting with that staff person to complete the re-education. The DON reported being unable to provide documentation showing the re-education was completed with the agency aide involved in the incident with Resident #06, following the incident. Review of SRI ID #268464 created 12/10/25 confirmed an incident occurred with Resident #06 and a staff person where the resident reported being shoved by an aide. Review of the SRI revealed the facility completed an investigation and reported education would be provided to all staff providing care. The allegation was unsubstantiated. Review of the In-service Sign Off for topic Respiratory Assessment/Lung Sounds, Nebulizer Treatments, Trach Care/Oxygen Equipment Storage and Nebulizer and Tubing Equipment Checks/Abuse and Neglect, dated December 2025, revealed the agency aide listed on the SRI as the perpetrator had not been signed off as completing the re-education. Review of the facility's Resident Safety Policy, not dated, revealed all employees will have training at initial orientation and at ongoing sessions on issues related to resident safety.

Based on medical record review and staff interview, the facility failed to ensure preadmission screening resident review (PASARR)'s were up dated with additional mental illness diagnoses. This affected three residents (#5, #8 and #23) of three residents reviewed for PASARR. The census was 45.Findings include:1. Review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes, metabolic encephalopathy, emphysema, chronic respiratory failure, psychosis, depression, and anxiety disorder. Review of the quarterly MDS dated [DATE] revealed his cognition was not intact. He required set up or clean up assistance with eating, oral hygiene, dependent on toileting, personal hygiene, substantial/maximal assistance for shower/bathing and partial/maximal assistance with turning and repositioning. Always incontinent of bladder and always continent of bowel. Further review revealed a PASARR completed on 08/17/23. On 12/24/24 Resident #5 received a new diagnosis of anxiety disorder. There was no documented evidence a new PASAAR was completed after the new diagnosis. On 12/30/25 at 4:18 P.M. this was verified during interview with admission Director #201. 2. Review of Resident #8's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, COPD, diabetes, mild protein calorie malnutrition, unspecified psychosis, PTSD, anxiety and major depression. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact (BIMS 15), she required set up or clean up assistance with meal set up, oral hygiene, substantial/maximal assistance for toileting, shower/bathing, personal hygiene and turning and repositioning. The resident was frequently incontinent of bowel and bladder. The resident's vision was impaired with no corrective lenses. Further review revealed a PASARR completed on 06/30/25 that did not include her anxiety disorder of Post Traumatic Stress Disorder (PTSD). On 12/30/25 at 4:18 P.M. this was verified during interview with admission Director #201. 3. Review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included COPD, severe protein calorie malnutrition, major depression, emphysema, peripheral vascular disease, PTSD and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed her cognition was intact, she was independent with eating, toileting, dressing, and personal hygiene, she requires set up or clean up assistance with oral hygiene, supervision or touching assistance with shower/bathing. Always continent of bowel and bladder. Has had a fall since admission. Further review revealed a PASARR completed on 08/22/25 which did not include her PTSD diagnosis. On 10/09/25 new diagnoses of anxiety disorder and major depression was added. There was no documented evidence to include the PTSD or the new diagnoses were added. On 12/30/25 at 4:18 P.M. this was verified during interview with admission Director #201.

Based on record review, review of care plan, and interview, the facility failed to ensure monitoring was in place for the side effects of opioid medications. This affected one (#4) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include:Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, fracture of right fibula and fracture of shaft of left femur. Review of a care plan dated 06/18/25 revealed no evidence of monitoring for side effects of taking opioid medications. Review of an order dated 10/30/25 revealed Resident #4 had hydrocodone-acetaminophen oral tablet 5-325 milligrams (mg) one tablet by mouth every four hours as needed for pain. There was no evidence of an order for monitoring side effects for opioid medications. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, she had no behaviors, she had frequent pain of two, and she took an opioid medication. Interview on 12/31/25 at 1:41 P.M. with the Director of Nursing (DON) confirmed there was not a care plan or an order to monitor Resident #4 for side effects related to taking an opioid medication.

Based on record review and interview, the facility failed to ensure residents were provided a care conference quarterly. This affected one resident (#7) of one resident reviewed for care conferences. The facility census was 45. Findings include:Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, asthma, and depression. Review of the medical record revealed there had been no quarterly care conferences since 01/21/25. Review of minimum data set (MDS) assessment records revealed Resident #7 had MDS' completed on 03/26/25, 06/26/25, and 09/26/25. Review of a MDS dated [DATE] revealed Resident #7's cognition remained intact and she had no behaviors. Interview on 12/29/25 at 1:30 P.M. with Resident #7 revealed she could not recall having a care conference. Interview on 12/30/25 at 1:21 P.M. with Social Worker (SW) #201 revealed the Director of Nursing (DON) is who usually documents care conferences. SW #201 stated care conference should be completed quarterly, with significant change, or as needed. SW #201 stated residents and family are invited to participate. SW #201 stated the schedule for care conferences is based on the scheduling of MDS'. SW #201 confirmed she was unable to provide documentation of Resident #7 being invited to or staff having a care conference for Resident #7 near 03/26/25, 06/26/25, or 09/26/25.

Based on medical record review, observation, and staff interview, the facility failed to ensure resident nebulizer equipment was stored in a safe and sanitary manner and not laying directly on their bed surface or bedside tablet. This affected two residents (Resident #01 and #23) of the three residents reviewed for oxygen. The facility census was 45. Findings include:1. Review of the medical record for Resident #01 revealed an admission date of 11/22/22 with a re-entry date of 12/05/23. Diagnoses included chronic obstructive sleep apnea, pulmonary disease, respiratory disorder, and malignant neoplasm of the pancreas and left lower right lung lobe. Review of Resident #01's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Review of Resident #01's current physician orders revealed an order for Albuterol Sulfate inhalation 2.5 milligram (mg) per every 3 milliliter (ml), 0.083%, inhale 3 ml orally via nebulizer at twice a day for chronic obstructive pulmonary disease. Review of Resident #01's care plan dated 02/20/23 revealed this resident receives oxygen therapy related to respiratory illness related to COPD and a history of malignant neoplasm to right lower lobe. Interventions include to check oxygen saturations as needed and per nursing judgement, administer medication as ordered, give 2 liters of supplemental oxygen continuous with humidifier when using concentrator. Observation completed on 12/29/25 at 9:30 A.M. and on 12/31/25 at 2:00 P.M. revealed Resident #01's nebulizer mask laying on his bed surface without being placed in a protective bag. Interview with the DON on 12/30/25 at 4:12 P.M. confirmed Resident #01's nebulizer mask was not in the proper bag and was laying on this resident's bed. Even though this resident is able to take this mask off himself and turn the machine off, the nurse should still be making sure everything is put away properly. 2. Review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included COPD, severe protein calorie malnutrition, major depression, emphysema, peripheral vascular disease, PTSD and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed her cognition was intact, she was independent with eating, toileting, dressing, and personal hygiene, she requires set up or clean up assistance with oral hygiene, supervision or touching assistance with shower/bathing. Always continent of bowel and bladder. Has had a fall since admission. On 12/29/25 at 4:00 P.M. observation revealed the resident's nebulizer mask lying on the bedside table uncovered. Observations on 12/30/25 at 9:59 A.M., 3:43 P.M. and 4:11 P.M. revealed the nebulizer mask was on the bedside stand uncovered. This was verified during interview with the Director of Nursing at the time of the observation.

Based on medical record review, staff interview, and observation the facility failed to ensure residents' pulse was monitored prior to administration of medication as well as pain medication had parameters in place related to the numeric pain scale. This affected two residents (#12 and #4) of the five residents reviewed for unnecessary medication. The facility census was 45. Findings include: 1.Review of the medical record for Resident #12 revealed an admission date of 02/22/21. Diagnoses included anxiety disorder, acute respiratory failure, hypertension, and Alzheimer's disease. Review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating a severely impaired cognition for daily decision-making abilities. Review of Resident #12's current physician orders revealed an order for Atenolol (beta blocker) oral tablet 50 milligrams (mg) give one tablet in the morning. Hold for pulse less than 55. Review of Resident #12's medication administration record from 06/25 through 12/25 revealed on 06/03/25,06/06/25, 07/12/25, 07/31/25, and 08/11/25 the Atenolol medication was documented as held due to outside of vital sign parameter, but the actual pulse reading was not documented. Also, this medication was noted to have been administered on 08/15/25, 08/17/25, and 08/20/25 with pulse readings below 55. Interview on 12/30/25 at 4:50 P.M with the Director of Nursing (DON) confirmed there was multiple days where Resident #12's Atenolol medication was held due to the pulse (heart rate) being too low and the results were not documented. The DON also verified there were a few days that were marked with a VS indicating the pulse reading was below or above the ordered parameter and there were a few days noted where this resident was documented as receiving this medication when the resident's pulse was below 55. 2. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, fracture of right fibula and fracture of shaft of left femur. Review of an order dated 06/18/24 revealed Resident #4 had acetaminophen tablet 325 milligrams (mg) give two tablets by mouth every eight hours as needed for general discomfort, not to exceed 3,000 mg in 24 hours. Review of an order dated 10/30/25 revealed Resident #4 had hydrocodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every four hours as needed for pain. There was no evidence of either as needed pain medications having parameters to determine which medication to give based on the level of pain Resident #4 was expressing. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, she had no behaviors, she had frequent pain of two, and she took an opioid medication. Interview on 12/31/25 at 1:41 P.M. with the Director of Nursing (DON) confirmed there were not parameters on as needed pain medications to guide nurses in determining which medication to give based on Resident #4's level of pain.

Based on observation, food taste testing, and interview, the facility failed to prepare pureed foods in a way to maintain nutritious value and palatability. This affected three residents (#30, #35, and #42) of three residents on pureed diets. The facility census was 45.Findings include:Observation of puree lunch preparation on 12/30/25 at 10:30 A.M. revealed Dietary [NAME] (DC) #266 to be preparing barbeque pork and mixed vegetables. While pureeing the mixed vegetables, DC #266 added about 3/4ths a cup of water and three unmeasured portions of thickener throughout the puree process. Post pureeing the mixed vegetables, this surveyor tasted them and noted the flavor to be bland with little to no flavor. The Dietary Manager tasted the mixed vegetables as well and confirmed them to have little to no flavor. Interview with the Dietary Manager on 12/30/25 at 10:35 A.M. confirmed DC #266 used water and unmeasured amounts of thickener to prepare the pureed mixed vegetables. Dietary Manager confirmed DC #266 should have used broth to maintain nutritious value and palatability of the pureed vegetables instead of using water.

Based on observation, record review, and interview, the facility failed to ensure residents were provided assistive devices as ordered. This affected one resident (#7) of one resident reviewed for assistive devices. The facility census was 45. Findings include:Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, asthma, and depression. Review of an order dated 10/04/21 revealed Resident #7 was to receive plastic tumblers with lids for all drinks. Review of a minimum data set (MDS) dated [DATE] revealed Resident #7's cognition remained intact, she had no behaviors, and she received a mechanically altered diet. Review of a care plan initiated on 06/26/19 and revised on 12/26/25 revealed Resident #7 was at risk for altered nutrition and hydration related to body mass index, mechanically altered diet, and prone to edema. The goals were to consume adequate nourishment to achieve optimal nutrition with no signs or symptoms of dehydrations, aspirations or significant weight changes. Interventions included but were not limited to administer supplements as ordered, honor food preferences, offer 240 milliliters of water three times daily, and use only plastic tumblers with lids and no straws. Observation and interview on 12/30/25 at 3:55 P.M. with Certified Nursing Assistant (CNA) #260 confirmed Resident #7 had a plastic cup/tumbler with no lid in her room. Observation on 12/31/25 at 10:32 A.M. revealed Resident #7 was seated in her wheelchair with her head resting on the over the bed table, sleeping. There were two plastic cups on her table with no lids noted. Observation on 12/31/25 at 12:26 P.M. revealed Resident #7 was sitting in her wheelchair eating lunch in her room. She had six plastic cups on her tray with no lids. A policy for assistive devices was requested, but the facility did not have one.

Based on medical record review, review of the facility policy, review of information from the National Pressure Ulcer Advisory Panel (NPUAP) and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to prevent the deterioration of a pressure ulcer for Resident #45. Actual Harm occurred on 10/03/24 when Resident #45, who was admitted to the facility with a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) sacral pressure ulcer was assessed to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer with the presence of slough and necrotic tissue to the area. The deterioration of the pressure ulcer was a result of the facility not implementing effective and timely treatment. This affected one resident (#45) of one resident reviewed for pressure ulcers. The facility census was 49 residents. Findings include: Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses including cerebral infarction, encounter for surgical aftercare following surgery on the digestive system, hemiplegia and hemiparesis, and history of pulmonary embolism. Review of the baseline care plan for Resident #45 dated 09/25/24 revealed the resident had a stage III pressure ulcer to the sacrum with the intervention to provide wound care/treatment per physician order. Review of the monthly physician's orders for Resident #45 revealed an order dated 09/25/24 to apply house barrier cream to buttocks and peri area every shift. Review of the pressure ulcer risk assessment for Resident #45 dated 09/26/24 revealed the resident was at high risk for skin breakdown. Review of the admission assessment for Resident #45 dated 09/26/24 revealed the resident had a Stage III pressure ulcer to the sacrum which measured 5.0 centimeters (cm) length by 5.0 cm width with 0.1 in depth with a scant amount of sanguineous (bloody) drainage and a pink, healthy wound bed. There was no dressing or wound treatment ordered for the pressure ulcer. The resident only had an order to apply house barrier cream to the buttocks and peri area. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 10/01/24 revealed the resident was cognitively intact, was totally dependent on staff for bathing, hygiene, bed mobility, and transfers, and was coded for the presence of stage III pressure ulcer upon admission to the facility. Review of the weekly skin assessment for Resident #45 dated 10/03/24 revealed the resident's pressure ulcer to the sacrum was now classified as an unstageable pressure ulcer and measured 4.8 cm length by 3.0 cm width with 0.2 cm in depth with a moderate amount of sanguineous drainage and the presence of slough wound bed. The new treatment order was to cleanse the wound with normal saline and apply Mesalt and a dry dressing to the wound bed. Review of the wound physician note for Resident #45 per Wound Physician (WP) #81 dated 10/03/24 revealed the resident had an unstageable (due to necrosis) sacral full thickness pressure ulcer which measured 4.8 cm length by 3.0 cm width with 0.2 cm in depth with a moderate amount of serous exudate, 20 percent (%) thick adherent devitalized necrotic tissue and 30 % slough (yellow/white material which consists of dead cells that accumulate in the wound bed). The new treatment order was to cleanse the wound with normal saline, apply Mesalt, and cover with a dry dressing. Review of the monthly physician's orders for Resident #45 revealed an order dated 10/03/24 to cleanse the sacral wound with normal saline, apply Mesalt, and cover with a dry dressing daily and as needed. Interview on 10/22/24 at 11:41 AM with the Resident #45 confirmed she had a pressure ulcer to her sacrum which required daily wound care. At the time of the interview, Resident #45 declined observation of wound care because the wound was located on the sacrum/buttocks area. Interview on 10/22/24 at 3:19 P.M. with the Director of Nursing (DON) confirmed Resident #45 was admitted with a Stage III pressure ulcer to the sacrum on 09/25/24. The DON confirmed the facility nurse did not contact the physician to obtain an appropriate treatment order, and the wound was noted to have worsened/deteriorated on 10/03/24 to an unstageable pressure ulcer with the presence of slough and necrotic tissue. Interview on 10/22/24 at 4:09 P.M. with the Assistant Director of Nursing (ADON) revealed she completed the wound assessment for Resident #45 on 09/26/24 and she did not contact the physician to obtain an appropriate treatment order for the resident's sacral ulcer which she had classified as a Stage III upon admission. The ADON confirmed there was no order implemented upon admission to cleanse Resident #45's pressure ulcer and/or to apply a treatment to promote wound healing and a dressing to cover the wound. Interview on 10/23/24 at 9:56 A.M. with State tested Nursing Assistant (STNA) #7 revealed if a resident had a pressure ulcer, she would not apply house barrier cream to the ulcer but would notify the nurse so the nurse could assess the wound and see if it needed a dressing and/or a treatment to be done by the nurses. Interview on 10/23/24 at 10:05 A.M. with Registered Nurse (RN) #1 revealed she completed skin assessments on residents admitted to the facility over the weekends and after hours. RN #1 confirmed she was able to stage pressure ulcer injuries and utilized the resources provided in the medication room which included a staging chart. RN #1 revealed she reviewed the wound measurements and descriptions for Resident #45's admission skin assessment dated [DATE] and verified she would have staged the resident's wound as a Stage III pressure ulcer on 09/26/24, but she then would have notified the physician for an appropriate treatment to promote healing of the wound. RN #1 confirmed house barrier cream was not an appropriate wound treatment for a Stage III pressure ulcer. Interview on 10/24/24 at 6:46 A.M. via telephone with WP #81 revealed he would have ordered triad hydrophilic for Resident #45's Stage III pressure ulcer upon admission, and house barrier cream utilized by the facility was not an appropriate treatment order. WP #81 further confirmed when he first saw the wound on 10/03/24, it presented as unstageable pressure ulcer with slough and necrotic tissue and he ordered a more aggressive treatment, cleanse with normal saline, apply Mesalt, and cover with a dry dressing, because the wound had worsened. Review of the facility undated policy titled Skin Protocol revealed house barrier cream would be used as a preventative measure on the buttocks or peri area to prevent rashes or excoriation due to incontinence. Staff should contact the wound physician for wound orders and treatment for actual pressure ulcers. Review of online information from the NPUAP at chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://cdn.ymaws.com/npiap.com/resource/resmgr/2014_guideline.pdf on 10/28/24 on page 93 revealed the facility staff should implement treatments to prevent contamination of the pressure ulcer. Pressure ulcers near the anus were subject to contamination, especially by bacteria from the colon. Meticulous skin cleansing and use of dressings or topical agents to prevent exposure to fecal matter were needed. Further review on page 588 revealed wound dressings were a central component of pressure ulcer care and wound healing was optimized when the wound was kept in a moist environment. Occlusive or semi-occlusive wound dressings that maintained wound bed moisture promoted re-epithelialization and wound closure. Wound dressings for pressure ulcers would improve wound healing time, absorb blood and tissue exudate, minimize pain associated with application and removal, absorb and control malodor, reduce injury to periwound skin.

Based on medical record review, staff interview and review of the facility policy, the facility failed to complete comprehensive resident care plans. This affected four (Residents #9, # 15, #18, and #20) of 15 residents sampled. The facility census was 49 residents. Findings include: 1.Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis affecting right dominant side, major depressive disorder, dysphagia, aphasia, Parkinson's disease, and anxiety disorder. Review of the care plan for Resident #18 initiated 01/06/18 revealed it did not include a care plan for wandering, exit-seeking, or high risk for elopement. Review of the physician's orders for Resident #18 revealed an order dated 07/01/24 revealed for a Wanderguard to the right ankle for exit seeking. Review of the progress note for Resident #18 dated 07/01/24 revealed the resident had been attempting to exit seek out of the doors and a new order for a Wanderguard was received. Review of the progress notes for Resident #18 dated 08/31/24 and 09/03/24 revealed the resident was exit seeking but was redirected by staff. Review of the Minimum Data Set (MDS) assessment for Resident #18 dated 09/05/24 revealed the resident had severely impaired cognition and was coded for the presence of wandering during one to three days of the review period. Review of the progress notes for Resident #18 dated 09/28/24, 10/08/24, and 10/11/24 revealed the resident was wandering, but was redirected by staff. Interview on 10/23/24 at 7:47 A.M. with the Director of Nursing (DON) confirmed Resident #18's care plan did not address the resident's risk for elopement and/or wandering and exit-seeking behaviors. 2. Review of the medical record for Resident #15's medical revealed an admitted [DATE] with diagnoses including dementia, expressive language disorder, major depressive disorder, gastro-esophageal disease, and chronic kidney disease. Review of the care plan for Resident #15 initiated 08/10/23 revealed it did not include a care plan for use of TED hose and/or a care plan for activities. Review of the physician's orders for Resident #15 revealed an order dated 03/15/24 for TED hose to be applied in the morning and removed at bedtime. Review of the MDS assessment for Resident #15 dated 07/25/24 revealed the resident had impaired cognition. Review of the activity assessment for Resident #15 dated 09/20/24 revealed the resident felt it was somewhat important for her to read and it was very important for her to listen to music, see animals, keep up with the news, participate in groups, do her favorite activities, go outside when the weather is good, and participate in religious services. Interview on 10/23/24 at 2:00 P.M. with the DON confirmed Resident #15's TED hose were not addressed in the plan of care. Interview on 10/23/24 at 2:40 P.M. with Activities Director (AD) #45 confirmed Social Services Director (SSD) #15 had been completing the activity care plans for the residents. Interview on 10/23/24 at 2:43 P.M. with SSD #15 confirmed there was no activity care plan for Resident #15. 32654 3. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including congestive heart failure, chronic kidney disease, major depressive disorder, chronic obstructive pulmonary disease, depression, atrial fibrillation and chronic respiratory failure with hypercapnia. Review of the MDS assessment for Resident #20 dated 08/30/24 revealed the resident had a moderate cognitive deficit and received oxygen. Review of physician's orders for Resident #20 revealed an order dated 01/11/23 for oxygen at two liters per nasal cannula to keep oxygen saturation above 90 percent (%) as needed for shortness of breath and to change oxygen tubing and water weekly. Review of the care plan for Resident #20 initiated 12/14/22 revealed it did not include a care plan which addressed the resident's use of supplemental oxygen. Interview on 10/22/24 at 10:49 A.M. with Registered Nurse (RN) #18 confirmed Resident #20 the facility had not developed a care plan regarding the resident's supplemental oxygen use as ordered by the physician. 4. Review of the medical record for Resident # 9 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus (DM), osteoarthritis, osteoporosis, anemia, dysphagia, anxiety disorder, major depressive disorder, Parkinson's disease, hypertension, and congestive heart failure. Review of the care plan for Resident #9 initiated 03/05/24 revealed the care plan did not address the resident's DM diagnosis and/or the resident's use of daily insulin. Review of the MDS assessment for Resident #9 dated 09/07/24 revealed the resident had no cognitive deficit, had DM as a current diagnosis, and received daily insulin injections. Interview on 10/22/24 at 4:35 P.M. with Licensed Practical Nurse (LPN) #14 confirmed Resident #9's care plan did not address the resident's DM diagnosis, nor did it address the resident's daily use of insulin. Review of the facility policy titled Comprehensive Person-Centered Care Plans dated March 2022 revealed the facility should develop and implement a comprehensive person-centered care plan for each resident that included measurable goals and timetables to meet the resident's physical, psychosocial and functional needs.

Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to properly clean and disinfect glucometers after use. This affected one (Resident #9) of 12 facility-identified diabetic residents (#1, #7, #8, #9, #17, #19, #22, #23, #25, #27, #38, #45) who resided on the front hallway. The facility also failed to ensure staff practice proper infection control practices to prevent the potential spread of infection during wound care. This affected one (Resident #23) of one resident observed for wound care. The facility census was 49 residents. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE] with the diagnoses including chronic obstructive pulmonary disease, diabetes mellitus (DM), and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 09/07/24 revealed the resident had no cognitive deficit, had DM as a current diagnoses and received daily insulin injections. Review of the physician's orders for Resident #9 revealed an order dated 03/12/24 for the resident to receive Lantus insulin 20 units daily for DM via subcutaneous injection. Observation on 10/22/24 at 8:20 A.M. of insulin administration for Resident #9 per Registered Nurse (RN) #1 revealed the nurse checked the resident's blood sugar using a glucometer prior to insulin administration. RN #1 cleansed the resident's finger with an alcohol wipe and pierced the resident's finger with a lancet and obtained a drop of blood. RN #1 [NAME] cleansed the multi-use glucometer with an alcohol swab and placed the glucometer on the resident's dresser. RN #1 then exited the room to obtained the resident's insulin, returned to the room and injected the insulin, and then left the room and placed the glucometer inside the medication cart. Interview on 10/22/24 at 8:25 A.M. with RN #1 confirmed she cleaned the glucometer following obtaining Resident #9's blood sugar with an alcohol swab instead of using an approved disinfectant wipe. Review of the facility policy titled Glucometer Cleaning undated revealed after using the glucometer staff should clean and disinfect using a germicidal disinfectant wipe. 2. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses cerebrovascular accident with left sided hemiplegia, diabetes mellitus, severe morbid obesity, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 09/24/24 revealed the resident had a severe cognitive deficit and required extensive assistance of two staff for bed mobility, transfers and toilet use. Review of the physician's orders for Resident #23 revealed an order dated 09/12/24 to cleanse wound to the left calf wound with normal saline (NS), apply calcium alginate the wound bed and wrap with Kerlix every shift and an order dated 10/04/24 to cleanse the left heel with normal saline, apply a crushed 500 milligram (mg) Flagyl tablet to the wound bed, apply calcium alginate to the wound bed, and wrap with Kerlix every shift. Observation of wound care on 10/23/24 at 11:18 A.M. for Resident #23 per RN #2 and the Director of Nursing (DON) revealed the nurses washed their hands and donned gloves. The DON held the resident's left leg while RN #2 removed the soiled dressings from the resident's leg exposing a left calf wound and a left heel wound. RN #2 attempted to pulled the calcium alginate off the left calf wound, but the calcium alginate was adhered to the wound and RN #2 doffed gloves, washed her hands and exited the room. RN #2 returned to Resident 23's room, washed hands and donned clean gloves. RN #2 used a syringe of NS to soak the calcium alginate to the resident's left calf and removed it. The DON instructed RN #2 to wash her hands. RN #2 removed her gloves, washed her hands, and donned clean gloves. RN #2 then used the same NS-soaked gauze which she had used on the left calf wound and cleansed the resident's left heel. RN #2 then washed her hands, donned clean gloves, applied crushed Flagyl and calcium alginate to the resident's left heel. RN #2 then washed her hands and donned a clean pair of gloves. The DON then washed her hands and donned a clean pair of while RN #2 wearing the same gloves opened three pieces of 2 X 2 calcium alginate and placed them on an ABD pad and placed over the left calf wound. RN #2 then wrapped the resident's left heel with Kerlix gauze and then used another roll of Kerlix to wrap the left calf. Interview on 10/23/24 at 11:47 A.M. with the DON confirmed RN #2 had not practiced proper control practices to prevent the spread of infection because she treated the two separate wounds as one wound and used contaminated gauze to cleans the resident's left heel. The DON further confirmed each wound should be treated separately to prevent cross-contamination.

Based on medical record review and staff interview the facility failed to notify the physician of significant weight changes for a resident with congestive heart failure and failed to notify the physician of abnormal urinalysis results. This affected two (Residents #38 and #46) of 15 residents sampled. The facility census was 49 residents. Findings include: 1.Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia, morbid obesity, and congestive heart failure. Review of the care plan for Resident #38 initiated 04/10/24 revealed the resident had a potential for fluid volume deficit related to diuretic use. Interventions included to monitor and document the resident's weight and report weight changes to the physician. Review of the weight record for Resident #38 revealed the resident weighed 289 pounds (lbs) on 04/10/24 and on 04/17/24 the resident weighed 294.8 lbs. Review of the weight record for Resident #38 revealed on 05/07/24 the resident weighed 304 lbs. and on 05/17/24 the resident weighed 296.4 lbs. Review of the weight record for Resident #38 revealed on 06/04/24 the resident weighed 309.4 lbs. and on 06/11/24 the resident weighed 302 lbs. Review of the weight record for Resident #38 revealed on 07/11/24 the resident weighed 303.2 lbs. and on 08/02/24 the resident weight 313.6 lbs. Review of the weight record for Resident #38 revealed on 08/02/24 the resident weighed 313.6 lbs. and on 09/04/24 the resident weighed 301.5 lbs. Review of the progress notes for Resident #38 dated 04/10/24 to 09/04/24 revealed the notes did not include documentation of physician notification of the resident's weight fluctuations. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 08/29/24 revealed the resident was cognitively intact. Interview on 10/23/24 at 7:49 A.M. with Director of Nursing (DON) confirmed Resident #38's weight fluctuations had not been reported to the resident's attending physician. Interview with the DON further confirmed Resident #38's weight changes should be reported to the physician particularly due to the resident's diuretic use and diagnosis of congestive heart failure. 50536 2. Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses including metabolic encephalopathy, type two diabetes, obstructive uropathy, and benign prostatic hypertrophy (BPH.) Review of the care plan for Resident #46 initiated 02/07/24 revealed the resident had the potential for infection related to the presence of an indwelling urinary catheter. Interventions included to monitor lab results by obtaining urinalysis, culture, and sensitivity specimens for testing per physician's order, and reporting results to the physician. Review of a laboratory report for Resident #46 dated 07/25/24 revealed the urinalysis was abnormal and indicated a level greater than 100,000 mixed pathogens and was probably a contaminated sample. Review of the progress notes for Resident #46 for July 2024 revealed they did not include notification to the physician of the abnormal urinalysis result dated 07/25/24. Interview on 10/23/24 at 9:38 A.M. with Registered Nurse (RN) #18 confirmed Resident #46 had abnormal urinalysis test resulted on 07/25/24 and the facility failed to notify the resident's physician.

Based on medical record review, family interview, and staff interview, the facility failed to assist all dependent residents with oral hygiene. This affected one (Resident #22) of one residents reviewed for activities of daily living (ADL) care. The facility census was 49 residents. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including dementia, major depressive disorder, type two diabetes, atherosclerotic heart disease, hypertension, and hypothyroidism. Review of the care plan for Resident #22 initiated 06/01/23 revealed the resident required the assistance of one staff with personal hygiene and oral care. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 08/16/24 revealed the resident had mild cognitive impairment and was to receive supervision/touching assistance with oral care. Review of the physician's orders for Resident #22 revealed an order dated 10/01/24 for denture care completed after each meal and at bedtime. The dentures were to be cleaned with a denture brush and antibacterial soap, four times daily. Review of the ADL Task Log for Resident #22 dated 10/01/24 to 10/22/24 revealed the resident had a total of 88 opportunities that staff were to assist with denture care. Of those 88 opportunities for denture care, there were only 43 times that the resident's dentures were documented as being cleaned. Resident #22 was not interviewable. Interview on 10/21/24 at 12:16 P.M. with Resident #22's representative confirmed they had to speak with the facility management because the resident's dentures were not not always clean when they came to visit. Interview on 10/24/24 at 9:46 A.M. with State tested Nurse Aide (STNA) #8 confirmed the aides recorded ADL care on the ADL Task Log in the electronic medical record. STNA #8 confirmed if Resident #22's denture care was not signed off in the ADL Task Log it wasn't done. Interview on 10/24/24 at 9:57 A.M. with Director of Nursing (DON) confirmed the ADL Task Log in the electronic medical record would be the only location in which ADL care was documented. The DON confirmed the facility had no documentation that staff cleaned Resident #22's dentures four times daily as ordered.

Based on medical record review, staff interview, and observation, the facility failed to perform regular resident blood pressure checks and failed to apply thromboembolic deterrent (TED) hose as ordered. This affected two (Resident #38 and #29) of 15 residents sampled. The facility census was 49 residents. Findings include: 1. Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia, hypertension, morbid obesity, and congestive heart failure. Review of the monthly physician's orders for Resident #38 revealed an order dated 06/12/24 for lisinopril (an anti-hypertensive medication) 2.5 milligrams (mg) once daily and an order dated 06/12/24 for spironolactone (a diuretic medication), and an order dated 10/06/24 to take full vital signs on a monthly basis, which included measuring blood pressure. Review of the vital sign records for Resident #38 dated 04/14/24 to 10/08/24 revealed monthly blood pressure checks were not completed in June, July, and August of 2024. There were no blood pressures completed from 05/10/24 to 09/10/24. Interview on 10/23/24 at 7:49 A.M. with the Director of Nursing (DON) confirmed the facility should have checked Resident #38's blood pressure at least monthly at a minimum but they had not checked the resident's blood pressure from 05/10/24 to 09/10/24. 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including Parkinson's disease, major depressive disorder, schizophrenia, depression, respiratory disorders, dysphagia, and hypertension. Review of the physician's orders for Resident #29 revealed an order dated 05/03/23 for the resident to have TED hose on in the morning and off at bedtime. Review of the care plan for Resident #29 dated 04/24/24 revealed the resident had impaired breathing problems and altered cardiac output related to atrioventricular block, bradycardia, hypertension, atrial fibrillation, asthma, and shortness of breath with exertion and sitting at rest at times. Interventions included the following: administer medications as ordered, allowing resident to perform activity at own rate, encourage fluid intake, labs as ordered, TED hose to lower bilateral extremities on in morning and off at bedtime. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 07/24/24 revealed the resident had intact cognition. Review of the Medication Administration Record (MAR) for Resident #29 revealed the MAR dated 10/22/24 was marked to indicate the resident's TED hose were in place. Observations on 10/21/24 at 11:43 A.M. and on 10/22/24 at 3:09 P.M. and 3:37 P.M. revealed Resident #29 did not have TED hose in place. Interview on 10/22/24 at 3:37 P.M. with State tested Nursing Aide (STNA) #7 confirmed Resident #29 was not wearing her TED hose and had refused to wear them for a long time. STNA #7 could not recall the last time the resident wore the TED hose. Interview on 10/22/24 at 3:41 P.M. with Licensed Practical Nurse (LPN) #5 confirmed Resident #29 had a physician's order for TED hose, and she had marked Resident #29's MAR to indicate the resident was wearing the TED hose, but the resident was not wearing them.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to assess residents for elopement risk. Additionally, the facility failed to ensure residents were properly supervised to prevent falls. This affected two (Residents #15 and #20) of six residents reviewed for accidents. The facility census was 49 residents. Findings include: 1.Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including dementia, expressive language disorder, major depressive disorder, gastro-esophageal disease, and chronic kidney disease. Review of the care plan for Resident #15 initiated 08/10/13 revealed it did not include the resident's risk for elopement or wandering behaviors. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/25/24 revealed the resident had impaired cognition and had no wandering behaviors during the review period. Review of the progress note for Resident #15 dated 10/08/24 revealed the resident had increased confusion and was standing by exit doors. Staff redirected the resident back to her room and new orders were obtained for a Wanderguard to the right ankle due to exit seeking. Review of the physician's orders for Resident #15 revealed an order dated 10/08/24 for Wanderguard bracelet to the right ankle. Review of the medical record for Resident #15 revealed it did not include an assessment of the resident's risk for elopement. Interview on 10/23/24 at 8:34 A.M. with the Director of Nursing (DON) confirmed elopement risk assessments should be completed upon admission, quarterly, and with significant changes for all residents. The DON further confirmed the facility had not completed an elopement risk assessment for Resident #15 and the resident had exhibited recent exit-seeking behavior. Review of the facility policy titled Elopement undated revealed the facility would maintain the safety of all residents, minimize the potential of residents eloping from the facility, would determine which residents were at risk for elopement, and would prevent reoccurring elopements. The facility would assess all residents for elopement upon admission, quarterly, and with any significant changes. 32654 2. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including congestive heart failure, chronic kidney disease, and hypertensive heart disease. Review of the care plan for Resident #20 dated 03/12/24 revealed the resident had the potential for falls related to balance deficit, history of falls and noncompliance. Interventions included the following: half side rails to enhance independent bed mobility, assist in position for comfort as needed, anticipate needs as able, bed against wall, Dycem to reclining chair on top and under the pad to decrease the risk of sliding off seat, encourage non-skid footwear at all times, encourage to ask/use call light for assistance, call light within reach, low bed in low position while occupied, maintain uncluttered environment, mat to floor bedside bed, pressure alarm to chair to remind resident of need for assistance and alert staff resident may need assistance. Review of the Minimum Data Set (MDS) assessment for Resident #20 dated 08/30/24 revealed the resident had a moderate cognitive deficit. Review of the fall risk evaluation for Resident #20 dated 09/23/24 revealed the resident was at risk for falls. Review of the late entry progress note for Resident #20 dated 09/27/24 timed at 6:38 P.M. revealed on 09/23/24 at 10:00 A.M. a State tested Nursing Assistant (STNA) notified the nurse the resident was on the floor in the shower room. Review of the Interdisciplinary Team (IDT) progress note for Resident #20 dated 09/30/24 at 9:38 A.M. revealed the fall on 09/23/24 occurred in the shower room when STNA #28 took Resident #20 into the shower room, transferred the resident to the commode and then left the shower room. Resident #20 stated she fell when trying to transfer herself off the commode. Resident #20 sustained no injuries and all staff were reeducated that residents cannot be left in the shower room without a staff member present. Interview on 10/22/24 at 11:51 A.M. with the Director of Nursing (DON) confirmed on 09/23/24 STNA #28 took Resident #20 to the shower room, transferred the resident to the commode and then left the shower room. The DON confirmed Resident #20 had an unwitnessed fall without injury while trying to self-transfer off the commode. The DON confirmed Resident #20, and all residents should not be left alone in the shower room. Review of the facility policy titled Managing Falls and Fall Risk dated March 2018 revealed the staff would identify interventions related to the resident's specific risks to try to prevent the resident from falling.

Based on medical record review, observation, staff interview and manufacturer's instructions, the facility failed to ensure staff primed insulin needles prior to insulin administration. This affected one (Resident #9) of five residents observed for medication administration. The facility census was 49 residents. Findings Include: Review of the medical record for Resident #9 revealed an admitted [DATE] with the diagnoses including chronic obstructive pulmonary disease, diabetes mellitus (DM), and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 09/07/24 revealed the resident had no cognitive deficit, had DM as a current diagnoses and received daily insulin injections. Review of the physician's orders for Resident #9 revealed an order dated 03/12/24 for the resident to receive Lantus insulin 20 units daily for DM via subcutaneous injection. Observation on 10/22/24 at 8:20 A.M. of insulin administration for Resident #9 per Registered Nurse (RN) #1 revealed the nurse dialed the pen to 20 units, cleansed the resident's abdomen, and injected the insulin. The nurse did not prime the insulin pen prior to administration. Interview on 10/22/24 at 8:25 A.M. with RN #1 confirmed she did not prime the insulin pen prior to insulin administration for Resident #9 and she should have done so according to the manufacturer's instructions. Review of the Lantus pen instructions for use last revised October 2021 revealed the nurse should remove the seal from the safety pen needle, attach the safety pen needle securely to the pen injector device by twisting clockwise until it stops, and then prime the pen injector device prior to administration.

Based on record review, interview and policy review the facility failed to ensure Resident #49 was free from an avoidable fall and failed to ensure a thorough fall investigation was completed. This affected one resident (Resident #49) of three residents reviewed for accidents. Actual Harm occurred to Resident #49 when the nurse recognized the resident appeared tired and was attempting to lay his head down but did not assist or offer the resident to lay down. The resident was subsequently discovered on the floor, face down in a pool of blood, transferred to the hospital and diagnosed with [REDACTED]. Findings include: Review of Resident #49's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the 60 day Minimum Data Set (MDS) 3.0 assessment, dated 12/21/17 revealed the resident had severe cognitive impairment and required extensive assistance from one staff member with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. Review of the fall risk assessment dated [DATE] identified the resident as a high risk for falls. Review of the fall investigation dated 11/19/17 revealed the resident was found on the floor and it appeared he fell face first out of his wheelchair and hit his face on the floor. The resident was found in front of his wheelchair with blood coming out of his nose. The resident rated his pain a four on a numerical pain scale of one to ten with ten being the most severe pain. The fall investigation did not indicate what fall interventions were in place at the time of the fall. Further review revealed predisposing environmental factors were listed as other and predisposing situation factors were indicated as other. No further explanation of the other factors was provided. Review of the nursing progress notes, dated 11/19/17 revealed at approximately 5:15 P.M. the resident was sitting in his wheelchair in the sitting area. The resident looked tired and was trying to lay his head down. The nurse asked the resident if he was alright and he replied yes. The nurse went upstairs to finish medication administration when the other nurse alerted her a male resident was on the floor. The resident was lying on the floor in front of his wheelchair with blood coming from his nose. The resident was transferred to the emergency room at approximately 5:25 P.M. Review of the emergency room discharge instructions dated 11/19/17 revealed the resident sustained [REDACTED]. On 01/31/18 at 12:45 P.M. interview with the Director of Nursing (DON) verified the resident sustained [REDACTED]. The DON verified the nurse identified the resident appeared tired and was laying his head down but did not offer the resident to lay down or assist the resident with lying down. The DON stated she would expect staff to offer the resident to lay down and not leave them unsupervised in a wheelchair if they were a fall risk and had a history of [REDACTED]. The DON also verified the fall investigation was not thorough and did not indicate the root cause or what fall interventions were in place at the time of the fall. On 01/31/18 at 1:20 P.M. interview with State tested nursing assistant (STNA) #104 revealed the resident was a high fall risk meaning if the resident appeared tired he should have been laid down in bed or brought to a more closely supervised area if he didn't wish to lay down. Review of the Falls-Clinical Protocol dated 2001 and revised 09/12 revealed the nurse should assess and document/report precipitating factors and details on how the fall occurred. For an individual who has fallen, staff would attempt to define possible causes within 24 hours of the fall. This deficiency substantiates Complaint Number OH 775.