Every finding on record at Majestic Care of Cedar Village.

Based on record review, staff and resident interview, observation, and policy review, the facility failed to ensure a resident was provided adequate supervision during incontinence care resulting in a fall from the bed. This resulted in Actual Harm to Resident #20 when Certified Nursing Assistant (CNA) #224 rolled the resident on her side and left the bedside to gather incontinence supplies. Resident #20 fell out of bed resulting in a laceration to her forehead and one broken toe. This affected one (Resident #20) of three residents reviewed for falls. The facility census was 152.Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included muscular dystrophy, chronic obstructive pulmonary disease (COPD) and spinal stenosis. Review of the care plan dated 10/25/22 and revised 06/11/26 revealed Resident #20 was at risk for falls or fall related injuries related to impaired mobility, history of falls, COPD and muscular dystrophy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was alert and oriented. She required partial assistance from one staff member for bed mobility. Review of Resident #20's Morse fall scaled completed 06/10/26 revealed she was at high risk for falls. Review of a nursing progress note dated 08/10/26 revealed Resident #20 fell out of bed onto the floor and hit her head resulting in a laceration above the right eyebrow. CNA #224 was in the bathroom during the fall and alerted the nurse in the hallway who entered the room and applied pressure to the resident's wound. Resident #20 was sent to the emergency room for evaluation and treatment. Resident #20 returned to the facility on [DATE] with 16 stitches to the forehead.Review of the nursing progress notes dated 08/14/26 revealed Resident #20 complained about right foot pain. The CNA removed the sock and noted bruising to the top of the right foot and second and third toe. The nurse practitioner was notified and an order for an x-ray was obtained along with instructions to elevate, apply cool compresses and wrap as tolerated. Review of the x-ray results dated 08/14/26 for Resident #20 revealed an acute fracture head of the second proximal phalanx. Review of the Nurse Practitioner note dated 08/14/26 revealed that a CNA had been providing care for Resident #20 when the CNA stepped into the bathroom. Resident #20 was unaware of her orientation and rolled out of bed striking her forehead. Review of the facility investigation revealed a statement dated 08/10/26 by CNA #224 that Resident #20 was changed but was adamant about getting her left side wiped off again due to itching. CNA #224 went to re-wet the towel and as she was coming out of the bathroom the resident was hitting the floor. During an interview on 08/25/26 at 10:20 A.M., Assistant Director of Nursing (ADON) #262 stated CNA #224 was giving Resident #20 a bath in bed when she walked away to get more soapy water. During this time, the resident rolled out of bed. During an interview on 08/25/26 at 1:19 P.M., Registered Nurse (RN) #308 stated she received a call from a staff nurse asking for help. When she got upstairs, Resident #20 was on the floor with the nurse applying pressure to the forehead laceration. RN #308 was told CNA #224 was changing Resident #20 and CAN #224 went into the bathroom. While CAN #224 was gone, Resident #20 reached down and rolled out of bed. RN #308 stated CNA #224 was not supposed to walk away from the bedside while providing care if residents were in unsafe positions. During an interview on 08/26/26 at 8:42 A.M., CAN #224 stated on 08/10/26 she had just finished changing Resident #20. Resident #20 was lying on her right side facing away from her and holding onto the grab bar with her strong hand. Resident #20 was adamant she needed cleaned better due to an itch that was bothering her. CNA #224 went to the bathroom to get fresh towels and water and while in the bathroom she heard a noise. When she exited the bathroom, she found Resident #20 had rolled out of bed and had a laceration on her forehead that was bleeding. CNA #224 called for the nurse who came and held pressure to the bleeding laceration on Resident #20's forehead. During an observation on 08/26/26 at 11:25 A.M., CNA #368 provided incontinence care to Resident #50. CNA #368 rolled Resident #50 away from her to perform care and while the resident was lying on her left side, CAN #368 left the bedside to go into the restroom and change gloves, which left the resident unattended. During an interview on 08/10/26 at 2:38 P.M., Resident #20 stated she was receiving incontinence care on 08/10/26 when CNA #224 asked her to roll onto her right side with her feet hanging over the edge of the bed. CNA #224 walked away from the bedside into the bathroom and during this time her feet fell the rest of the way off the bed and pulled the rest of her body with her. Resident #20 verified that she had 16 stitches placed in her forehead and her toe was broken with bruising on the foot. Review of the facility policy titled Incidents, Accidents, and Supervision, dated 12/01/25 revealed that each resident will receive adequate supervision and assistive devices to prevent accidents. It also states that supervision is an intervention and means of mitigating accident risk - the facility will provide adequate or increased supervision to prevent accidents. This deficiency represents noncompliance investigated under Complaint Number 3168467.

Based on medical record reviews, staff and resident representative interviews, and policy reviews, the facility failed to ensure a resident was appropriately discharged from the facility. This affected one (#150) out of three residents reviewed for discharge planning. The facility census was 144. Findings include: Review of the medical record for Resident #150 revealed an admission date of 07/03/26 with medical diagnoses of Parkinson's disease, unspecified psychosis, and hypothyroidism. The medical record indicated Resident #150 discharged to the hospital on [DATE] and had not returned to the facility. Review of Resident #150's admission Minimum Data Set (MDS) assessment, dated 07/10/26, indicated Resident #150 was cognitively intact and required substantial/maximum staff assistance with showers/baths, partial/moderate staff assistance with bed mobility, transfers, and wheelchair mobility, and set-up assistance with eating. The MDS indicated Resident #150 did not have any behaviors. Review of Resident #150's elopement risk assessment dated [DATE] indicated Resident #150 was at risk for elopement. Review of Resident #150's physician orders revealed an order dated 07/11/26 for a wanderguard to right ankle and to check function every day. Review of Resident #150's nurse's notes revealed a note dated 07/18/26 which stated Resident #150 stayed at the nurse's station area between 3:30 P.M. and approximately 6:15 P.M. While in supervision, was offered snacks, was interacted with, was observed rolling up and down the hallway. Resident #150's wanderguard ankle activated the elevator, alarm was cancelled by nurse. Resident #150 was returned from a different unit by an aide around dinner time, remained in front of the nurse's station throughout dinner until nurse observed CNA roll Resident #150 to his room in a wheelchair around 6:15 P.M. At 6:20 P.M. the nurse got on the phone with hospice agency for another resident then went to the room with hospice resident to provide comfort care as the visitor was in tears. While in that room, this nurse observed ambulance with no lights pull up the drive circle, then proceeded further down towards Assisted Living. The nurse finished care for hospice resident, walked out of the room when was called by CNA who stated Resident #150 got outside. When asked if Resident #150 could be safely retrieved, CNA stated, they want you outside on a side of the front door - Who wants me outside? -Medics. This CNA and this writer walked out, and the aide guided this writer to the front door courtyard between front door and Assisted Living. Resident #150 was observed sitting on the bench with three medics standing around him, ambulance parked next to the with no light on. The nurse pointed out to the medics that the wanderguard still remained in place on his right ankle, therefore, we were uncertain at this time how Resident #150 got outside. The nurse asked the medics who called them, received an answer one of this facility's resident's probably more confused than this one here said that he fell out the window. Resident #150 was able to state his name, recalled the nurse's name but was not able to state how he got outside. Resident #150 denied pain on assessment with medics present. A scratch was noted below the left knee. Resident #150 was able to ambulate with no grimacing, no complaint of pain on repeat assessment. Nurse Practitioner (NP) was contacted at 6:41 P.M. on the spot via phone, with no answer. Supervisor on call contacted next and was instructed to send Resident#150 out to the hospital at 6:45 P.M. for evaluation. DON, Assistant Director of Nursing notified next. NP was notified of transfer by the Social Worker. Son was notified of incident by DON. The hospital staff were contacted by the Admissions Director. Upon returning to the unit CNAs and nurse went to assess the room where Resident #150 was observed last (about 6:15 P.M.) and noted window missing on the right side (frame with the glass missing). Unbroken window observed on the grass below the window. DON and management team updated on new findings. Review of a nurse's note dated 07/20/26 stated Resident #150 remained at the facility and alternate placement was discussed with the family. Review of Resident #150's medical record revealed no documentation to support a notice of discharge was provided to Resident #150 or representative. Interview on 07/21/26 at 2:12 P.M. with Director of Nursing (DON) stated the facility informed Resident #150's son on 07/18/26 that the resident could not return to the facility because of safety concerns. DON stated all skilled nursing home rooms are located on the second and third floors and the wandergaurds only work for the elevator. DON confirmed the facility had not provided Resident #150 or representative with a notice of discharge. Interview on 07/22/26 at 10:23 A.M. with Resident #150's son stated the family was notified by the facility on 07/18/26 that the resident would not be able to return to the facility because the facility could not ensure Resident #150's safety. Resident #150's son stated the facility did not provide Resident #150 or the family with a notice of discharge. Resident #150's son stated Resident #150 remained in the hospital on medical hold until another facility could be found for placement. Resident #150's son further stated the family expected the resident to return to facility from the hospital on [DATE] until alternative placement was found but the facility informed the family they would not allow the resident to return. Review of the facility policy titled, Discharge planning, revised 03/16/26 stated the purpose was to ensure a safe, coordinated, and person-centered discharge planning process that promotes continuity of care, reduces readmissions, and supports successful transitions. The policy stated the discharge planning framework included facilitating a safe transition to post-discharge care and that appropriate and safe discharge options are explored and discussed. The policy also stated a comprehensive discharge summary was provided to support continuity of care and prevent delays or complications during transition. Review of the facility policy titled, Transfer and Discharges-including Against Medical Advice (AMA), revised 04/22/25 stated in situations where the facility has decided to discharge the Resident/Patient while the Resident/Patient is still hospitalized , the facility would send a notice of discharge to the Resident/Patient and the representative before the discharge and must also send a copy of discharge notice to a representative of the Office of the State Long-Term Ombudsman. The notice to the Ombudsman will occur at the same time as the notice of discharge is provided to the Resident/Patient and representative, even though at the time of initial emergency transfer, sending a copy of the transfer notice to the Ombudsman only needed to occur as soon as possible. The Resident/Patient has the right to return to the facility pending an appeal of any discharge unless the return would endanger the health or safety of the Resident/Patient or other individuals in the facility. This deficiency represents non-compliance investigated under Master Complaint Number 3105205 and Complaint Number 3076040.

Based on medical record reviews, staff and resident representative interviews, and policy reviews, the facility failed to provide a notice of discharge for Resident #150 and failed to complete a discharge summary/recapitulation of stay for Resident #155. This affected two (#150 and #155) out of three residents reviewed for discharge planning. The facility census was 144. Findings include: 1. Review of the medical record for Resident #150 revealed an admission date of 07/03/26 with medical diagnoses of Parkinson's disease, unspecified psychosis, and hypothyroidism. The medical record indicated Resident #150 discharged to the hospital on [DATE] and had not returned to the facility. Review of Resident #150's admission Minimum Data Set (MDS) assessment, dated 07/10/26, indicated Resident #150 was cognitively intact and required substantial/maximum staff assistance with showers/baths, partial/moderate staff assistance with bed mobility, transfers, and wheelchair mobility, and set-up assistance with eating. The MDS indicated Resident #150 did not have any behaviors. Review of Resident #150's elopement risk assessment dated [DATE] indicated Resident #150 was at risk for elopement. Review of Resident #150's physician orders revealed an order dated 07/11/26 for a wanderguard to right ankle and to check function every day. Review of Resident #150's nurse's notes revealed a note dated 07/18/26 which stated Resident #150 stayed at the nurse's station area between 3:30 P.M. and approximately 6:15 P.M. While in supervision, was offered snacks, was interacted with, was observed rolling up and down the hallway. Resident #150's wanderguard ankle activated the elevator, alarm was cancelled by nurse. Resident #150 was returned from a different unit by an aide around dinner time, remained in front of the nurse's station throughout dinner until nurse observed CNA roll Resident #150 to his room in a wheelchair around 6:15 P.M. At 6:20 P.M. the nurse got on the phone with hospice agency for another resident then went to the room with hospice resident to provide comfort care as the visitor was in tears. While in that room, this nurse observed ambulance with no lights pull up the drive circle, then proceeded further down towards Assisted Living. The nurse finished care for hospice resident, walked out of the room when was called by CNA who stated Resident #150 got outside. When asked if Resident #150 could be safely retrieved, CNA stated, they want you outside on a side of the front door - Who wants me outside? -Medics. This CNA and this writer walked out, and the aide guided this writer to the front door courtyard between front door and Assisted Living. Resident #150 was observed sitting on the bench with three medics standing around him, ambulance parked next to the with no light on. The nurse pointed out to the medics that the wanderguard still remained in place on his right ankle, therefore, we were uncertain at this time how Resident #150 got outside. The nurse asked the medics who called them, received an answer one of this facility's resident's probably more confused than this one here said that he fell out the window. Resident #150 was able to state his name, recalled the nurse's name but was not able to state how he got outside. Resident #150 denied pain on assessment with medics present. A scratch was noted below the left knee. Resident #150 was able to ambulate with no grimacing, no complaint of pain on repeat assessment. Nurse Practitioner (NP) was contacted at 6:41 P.M. on the spot via phone, with no answer. Supervisor on call contacted next and was instructed to send Resident#150 out to the hospital at 6:45 P.M. for evaluation. DON, Assistant Director of Nursing notified next. NP was notified of transfer by the Social Worker. Son was notified of incident by DON. The hospital staff were contacted by the Admissions Director. Upon returning to the unit CNAs and nurse went to assess the room where Resident #150 was observed last (about 6:15 P.M.) and noted window missing on the right side (frame with the glass missing). Unbroken window observed on the grass below the window. DON and management team updated on new findings. Review of a nurse's note dated 07/20/26 stated Resident #150 remained at the facility and alternate placement was discussed with the family. Review of Resident #150's medical record revealed no documentation to support a notice of discharge was provided to Resident #150 or representative. Interview on 07/21/26 at 2:12 P.M. with Director of Nursing (DON) stated the facility informed Resident #150's son on 07/18/26 that the resident could not return to the facility because of safety concerns. DON stated all skilled nursing home rooms are located on the second and third floors and the wandergaurds only work for the elevator. DON confirmed the facility had not provided Resident #150 or representative with a notice of discharge. Interview on 07/22/26 at 10:23 A.M. with Resident #150's son stated the family was notified by the facility on 07/18/26 that the resident would not be able to return to the facility because the facility could not ensure Resident #150's safety. Resident #150's son stated the facility did not provide Resident #150 or the family with a notice of discharge. Resident #150's son stated Resident #150 remained in the hospital on medical hold until another facility could be found for placement. Resident #150's son further stated the family expected the resident to return to facility from the hospital on [DATE] until alternative placement was found but the facility informed the family they would not allow the resident to return. 2. Review of the medical record for Resident #155 revealed an admission date of 06/29/26 with medical diagnoses of aftercare following a joint replacement, diabetes mellitus, atrial fibrillation, and arthritis. Review of the medical record indicated Resident #155 discharged home on [DATE]. Review of Resident #155's admission MDS assessment, dated 07/06/26, indicated Resident #155 was cognitively intact and required supervision with toilet hygiene, bathing, and transfers and supervision with bed mobility and eating. Review of Resident #155's medical record revealed no documentation to support the facility completed a discharge summary/recapitulation of stay upon discharge on [DATE]. Interview on 07/22/26 at 8:19 A.M. with DON confirmed Resident #155 discharged home on [DATE] and the facility had not completed a discharge summary/recapitulation of stay. Review of the facility policy titled, Discharge planning, revised 03/16/26 stated the purpose was to ensure a safe, coordinated, and person-centered discharge planning process that promotes continuity of care, reduces readmissions, and supports successful transitions. The policy stated the discharge planning framework included facilitating a safe transition to post-discharge care and that appropriate and safe discharge options are explored and discussed. The policy also stated a comprehensive discharge summary was provided to support continuity of care and prevent delays or complications during transition. Review of the facility policy titled, Transfer and Discharges-including Against Medical Advice (AMA), revised 04/22/25 stated in situations where the facility has decided to discharge the Resident/Patient while the Resident/Patient is still hospitalized , the facility would send a notice of discharge to the Resident/Patient and the representative before the discharge and must also send a copy of discharge notice to a representative of the Office of the State Long-Term Ombudsman. The notice to the Ombudsman will occur at the same time as the notice of discharge is provided to the Resident/Patient and representative, even though at the time of initial emergency transfer, sending a copy of the transfer notice to the Ombudsman only needed to occur as soon as possible. The Resident/Patient has the right to return to the facility pending an appeal of any discharge unless the return would endanger the health or safety of the Resident/Patient or other individuals in the facility. This deficiency represents non-compliance investigated under Master Complaint Number 3105205 and Complaint Number 3076040.

Based on observation, resident interview, and staff interview, the facility failed to ensure food was served at appropriate and safe temperatures. This had the potential to affect 149 residents who received food from the kitchen. The facility identified two residents (#02 and #03) who did not receive food from the kitchen. The facility census was 151. Findings include: Observation on 06/10/26 at 7:49 A.M. revealed a large pan of individually scooped and covered plastic cups sitting on the counter in the tray line area. There was no ice nor any other method used to keep the contents cold. Further observation revealed the pan of plastic cups remained in the tray line area through the entire tray line service. Interview at the same time, Dietary Aid (DA) #690 stated the plastic cups contained yogurt. Review of a test tray on 06/10/26 at 9:32 A.M., after all residents had been served, revealed the eggs were 110 degrees Fahrenheit (F) and the yogurt was 64 degrees F. Interview at the time of the observation Director of Nutrition and Food Service (DNFS) #605 verified the eggs were 110 degrees F and the yogurt was 64 degrees F. DNFS #605 stated his expectation was for the eggs to be a minimum of 135-140 degrees F and the yogurt to be 45 degrees F or less at the time it reached the residents. Interview on 06/10/26 at 11:44 A.M., Resident #39 stated her eggs at breakfast were not hot enough and the food tends to not be served very hot. Review of the facility policy titled, Food Production, dated 10/06/25, revealed food would be served at the appropriate temperatures. This deficiency represents non-compliance investigated under Complaint Number 3042667, Complaint Number 2743663 and Complaint Number 2731043.

Based on observation, staff interview, the facility failed to prepare, serve, and store food in a manner to prevent against the potential spread of foodborne illness. This had the potential to affect 149 rresidents who received food from the kitchen. The facility identified two residents (#02 and #03) who did not receive food from the kitchen. The facility census was 151. Findings include: 1. Observation on 06/08/26 at 12:49 P.M. revealed a cart, which contained approximately 25 cups of juices, in the hallway in front of the nurse station of the [NAME] unit, the cups of juice were covered with several loose paper towels. Certified Nursing Assistants (CNA) #410 and #630 were observed taking cups of juice off the cart, placing them on resident lunch trays, and carrying the trays down the hall with the juice cups uncovered, to deliver to resident rooms. Interview on 06/08/26 at 12:50 P.M., CNA # 410 verified the cups of juice were covered with paper towels in the hallway and were not being covered once removed from the cart and being delivered to resident rooms. Interview on 06/09/26 at 9:49 A.M., Registered Dietitian (RD) #699 verified beverages should be covered when being taken down to hall to deliver to resident rooms. 2. Observation on 06/10/26 at 7:13 A.M. revealed Dietary Aid (DA) #600 stirring and serving hot cereal into individual containers. DA #600 had her hair tied back in a ponytail, which extended several inches down her back, and was not wearing a hairnet. Interview completed during the observation with DA #600 verified she was not wearing a hairnet while preparing food. 3. Observation on 06/10/26 at 8:46 A.M. revealed an unidentified person wearing scrubs enter the kitchen next to the tray line area, which was actively serving breakfast. The unidentified person had multiple braids, approximately six inches in length each and did not apply a hair restraint upon entering the kitchen. Director of Nutrition & Food Service (DNFS) #605 was observed telling the unidentified person to put on a hairnet, however the unidentified person kept walking and did not acknowledge DNFS #605. DA #690 then approached the unidentified person and directed the person to the other end of the kitchen, to obtain a hairnet. Interview at the time of the observation, DNFS #605 verified the unidentified person did not don a hairnet. DNFS #605 stated the person was a nursing assistant from the assisted living, however, was unsure of her name. 4. Observation on 06/10/26 at 8:50 A.M. revealed DA #600 removed an empty pan of pancakes from the steam table, placed it on top of the hot holding cart, opened the hot holding cart with her gloved hand, retrieved a new/full pan of pancakes from the hot holding cart, and placed the pan in the steam table. DA #600 then continued plating food and utilized the same gloved hand to handle the pancakes directly and placed them on plates. Interview on 06/10/26 at 8:52 A.M., DA #600 verified she touched a potentially soiled surface with her gloved hand and then directly handled food with the same gloved hand. Further observation on 06/10/26 at 8:53 A.M., DA #600 removed her gloves and applied a clean pair of gloves. DA #600 was not observed to perform hand hygiene between the glove changes. Interview on 06/10/26 at 8:54 A.M. DA #600 verified she did not perform hand hygiene between the glove changes. When queried, DA #600 stated she did not have anything available to sanitize her hands between the glove changes. 5. Observation on 06/10/26 at 8:57 A.M. revealed a fan resting on stacks of milk crates blowing directly into the tray line area. The intake vent of the fan was coated in a grey, fuzzy material. Interview on 06/10/26 at 9:42 A.M., DNFS #605 verified the fan was dirty and directed toward the tray line area. 6. Observation on 06/10/26 at 9:32 A.M. of the pantry refrigerator on the Peach unit revealed a yellow liquid in the drawers and bottom of the inside of the refrigerator. Interview at the same time, DNFS #605 verified the yellow liquid in the drawers and bottom of the inside of the refrigerator and verified the refrigerator needed to be cleaned. DNFS #605 stated he was unsure who was responsible for ensuring unit refrigerators were maintained in a clean and sanitary manner. 7. Observation on 06/10/26 at 11:03 A.M., [NAME] #615 retrieved a stock pot from storage, placed it directly on the floor below the grill and began filling it with water from the spigot above. Continued observation on 06/10/26 at 11:04 A.M., [NAME] #615 picked the pot, now full of water, off the floor and placed it on the stove and took another pot that was on the stove and placed it directly on the floor and filled it with water, and placed it on the stove. Interview on 06/10/26 at 11:05 A.M., [NAME] #615 verified he placed the clean pots on the floor to fill them with water, and then placed them back on the stove. 8. Observation 06/11/2026 at 8:58 A.M. revealed Certified Nursing Assistant (CNA) #325 setting up the breakfast tray for Resident #8. CNA #325 unpeeled the half banana and used her bare hands to place the fruit on the resident's plate. During an interview on 06/11/2026 at 9:00 A.M. CNA #325 confirmed she had used her bare hands to unpeel Resident #8's half banana and place fruit on plate. Review of the facility policy titled, Kitchen Sanitation, dated 10/06/25, revealed the facility would ensure sanitary food handling practices would be maintained in the preparation and service areas at all times. Equipment would be clean and free of spills. Food would be covered. Review of the facility policy titled, Food Production, dated 10/06/25, revealed food will be served with clean utensils or gloves worn for a single use task with hand hygiene performed. Review of the facility policy titled, Safe Food Handling, dated 03/02/26, revealed staff should wear hair restraints to effectively keep their hair from contacting exposed food.

Based on record review, observations, staff interviews, review of online resources from the Centers for Disease Control and Prevention (CDC), and facility policy review, the facility failed to ensure a comprehensive Water Management Plan was implemented to minimize the risk of waterborne pathogens including Legionella. This had the potential to affect all residents living in the facility. The facility also failed to ensure enhanced barrier precautions (EBP) were in place and failed to ensure staff utilized proper personal protective equipment (PPE) this affected two (#80 and #162) of three residents reviewed for EBP. The facility census was 151.Findings include: 1. Review of the Water Management Plan with Maintenance Director #200 revealed the facility's water management plan expired on [DATE] and had not been updated to include the current Administrator, Director of Maintenance and Infection Control Preventionist. Review of the water management implementation plan revealed no documentation from 05/2025 through current. Interview on [DATE] at 3:14 P.M. with Maintenance Director #200 verified the facility did not have a current Water Management Plan in place to prevent the growth of Legionella, and verified the facility had no documentation of the prior water management plan being implemented from 05/2025 to present. 2. Review of the medical record of Resident #80 revealed an admission date of [DATE]. Diagnoses included osteomyelitis and chronic obstructive pulmonary disease. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required setup/cleanup assistance with eating, supervision with bed mobility, and partial/moderate assistance with toileting, bathing, and transfers. Review of physician orders revealed an order dated [DATE] to follow contact isolation protocols for right foot MRSA (methicillin-resistant staphylococcus aureus). Observation on [DATE] at 12:43 P.M. revealed Registered Nurse (RN) #620 in the room of Resident #80 with no personal protective equipment (PPE) on. Further observation revealed the door to Resident #80's room had the Centers for Disease Control (CDC) contact precautions sign and instructions for donning and doffing PPE. The signs indicated the need for a gown, gloves, mask, and eye protection. Interview on [DATE] at 12:45 P.M., RN #620 verified she did not don the appropriate PPE upon entering Resident #80's room. RN #620 stated she went in to answer the call light and verified PPE should be donned with any entrance into the room. Interview on [DATE] at approximately 3:00 P.M., the Director of Nursing (DON) verified full PPE should be applied prior to entering the room. 3. Review of the medical record revealed Resident #162 was admitted to the facility on [DATE]. Diagnoses included infection and inflammatory reaction to internal left knee prosthesis, hypertensive heart disease with heart failure, malignant neoplasm of the prostate, unspecified anxiety disorder, and secondary neoplasm of the bone. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #162 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #162 a physician order dated [DATE] for Enhanced Barrier Precautions when engaging in high contact resident care activities for open wound, every shift. Observation on [DATE] at 3:16 PM revealed Resident #162 had no sign posted on or near his door to alert staff and visitors that he required Enhanced Barrier Precautions and there was no Personal Protective Equipment (PPE) bin located either in the room or near the outside of the room. During an interview on [DATE] at 2:46 P.M. Licensed Practical Nurse (LPN) #484 verified there was no EBP sign or PPE cart either in the room or outside of door for Resident #162. During an interview on [DATE] at 3:13 P.M. Assistant Director of Nursing (ADON) #380 verified Resident #162 had just returned from hospital on [DATE] and was moved to a new room. The ADON stated she usually did a walk through the facility every Monday morning to make sure all EBP signs were hung appropriately and PPE bins were in place but had not had time this morning while gathering items for the survey. During an interview on [DATE] at 4:33 P.M. ADON #380 confirmed the facility hung signs outside of resident rooms informing staff and visitors to the type of precautions a resident had and placed a PPE bin in or near the resident's room. Review of the policy titled, Infection Prevention & Control Program, dated [DATE], revealed a water management program has been established as part of the overall infection prevention and control program and control measures and testing protocols are in place to address potential hazards. The Maintenance Director serves as the leader of the water management program. Review of the facility policy titled, Transmission-Based Precautions, dated [DATE], revealed PPE should be donned upon room entry and discarded before exiting the room.

Based on record review and staff interview, the facility failed to consider and timely resolve resident concerns. This affected twelve residents who regularly attended resident council meetings. The facility census was 151. Findings include: During the Resident Council discussion task on 06/10/2026 at 10:30 A.M., with three residents (#01, #62 and #79) revealed the Administrator attended and ran the Resident Council meetings and the residents felt their concerns were not addressed. The residents reported there was no follow-up to the concerns and issues brought up in the meetings were never included in the following meetings with information on resolution. Review of the Resident Council meeting minutes for the from May 2025 through May 2026, revealed no documented old business and no documented evidence of discussion or resolutions to concerns which had been brought up. During an interview on 06/11/26 at 9:28 A.M., Activity Director (AD) #315 stated the Administrator ran the meetings and documented the minutes. AD #315 stated there should be documented evidence of the residents' concerns and resolution in the minutes. AD #315 verified there was no old business documented and there was no documented resolution of the residents' concerns. During an interview on 06/11/26 at 1:14 P.M., the Administrator stated he attended the Resident Council Meetings and compiled the minutes of the meetings. The Administrator verified there was no documented evidence of resolutions from the resident concerns brought up in the meetings. This deficiency represents non-compliance investigated under Complaint Number 2674967.

Based on observation, interview, and policy review, the facility failed to maintain environmental temperature at a comfortable level on the Apple nursing unit. This affected six residents (#1, #71, #108, #114, #130, and #6) and had the potential to affect all 24 residents residing on the Apple nursing unit. The facility census was 151.Observation during facility tour on 06/11/26 between 5:46 P.M. and 6:20 P.M. with Maintenance Director #200 revealed the Apple nursing unit main corridor was 84.9 degrees Fahrenheit, Apple dining room was 89.8 degrees Fahrenheit, resident room for Resident #1 was 84.7 degrees Fahrenheit, Resident # 71 was 85.6 degrees Fahrenheit, Resident #108 was 83.3 degrees Fahrenheit, Residents #114 and #130 was 84.4 degrees Fahrenheit, and Resident #6 was 84.4 degrees Fahrenheit. All temperatures were taken and verified by Maintenance Director #200 who utilized the facility's infrared thermometer. Interviews on 06/11/26 between 5:46 P.M. and 6:14 P.M. with Residents #6, #108 and #114 revealed it was terribly hot.Interview on 06/11/26 at 6:14 P.M. with Maintenance Director #200 verified environmental temperature for the Apple nursing unit and the room temperatures for Residents #1, #6, #71, #108, #114 and #130 was not homelike or comfortable for the residents. Maintenance Director #200 also verified the ambient air temperatures had not been documented on the Apple nursing unit or the other four potentially affected nursing units.Interview on 06/12/26 at 3:14 P.M. with the Administrator revealed Apple nursing unit temperature concerns started on 06/07/26 at 2:00 P.M. when he was notified by the facility that the air conditioning was not operating. The Administrator stated he requested Maintenance Director #200 to assess the situation. On 06/08/26 portable air conditioning units were brought in along with some fans to circulate air. The Administrator stated Maintenance Director #200 did not monitor and document environmental temperatures, which was an integral part of the Extreme Temperature response plan. The Administrator also stated he did not report the situation in the facility to the Regional [NAME] President of Operations until 06/10/26 at 5:00 P.M. Review of the facility's Extreme Temperature Emergency Response Action Plan revealed ambient air temperatures will be monitored and documented on all impacted units/areas Review of the policy titled, Physical Environment, dated 01/01/26, revealed a purpose to ensure our facilities are designed, constructed, equipped, and maintained in a manner that provides a safe, functional, sanitary, and comfortable environment for residents/patients, Care Team Members, and the public. Resident/patient rooms and activity areas must be maintained at a temperature comfortable for residents/patients not Care Team Members. Review of the policy titled, Safe and Homelike Environment, dated 01/01/26, revealed a purpose to provide a safe, clean, comfortable, and homelike environment that supports resident/patient independence, enables the use of personal belongings, and ensures the delivery of care and services in a manner that minimizes safety risks and promotes well-being. The facility will strive to maintain comfortable and safe temperature levels in common resident/patient areas between 71 and 81 degrees Fahrenheit.This deficiency represents non-compliance investigated under Complaint Number 3043920 and Complaint Number 2731043.

Based on record review, interview and facility policy review, the facility failed to ensure care plans were timely reviewed and revised for one resident (#42), and failed to conduct quarterly care conferences for three residents (#5, #7 and #12) of eight reviewed for care plans. The facility census was 151. Findings include: 1. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, chronic obstructive pulmonary disease, non-traumatic subarachnoid hemorrhage, hypertensive heart disease and acute respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition and was occasionally incontinent bowel and always incontinent bladder. The resident required set up assistance for eating, moderate assistance for oral hygiene, bed mobility and transfers, maximal assistance for personal hygiene, and was dependent for toileting, bathing and dressing. Review of Section K. Swallowing/Nutritional Status, K0300 revealed Resident #42 triggered for a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Review of the care plan for Resident #42 dated 01/15/26 revealed Resident #42 presented with potential for nutritional risk related to hypertension, anemia, major depressive disorder, cardiac pacemaker, hypothyroidism and medications with nutritionally adverse side effects with the goal the resident would not exhibit significant weight change. Interventions were to document food/fluid intakes, honor food/fluid preferences as possible, lab/diagnostic work as ordered and report results to physician (MD) and follow up as indicated, provide and serve diet as ordered, provide and serve supplements as ordered, Registered Dietician (RD) to evaluate and make diet change recommendations as needed, therapy to screen quarterly and as needed, and weights as ordered/indicated with notification to physician of significant weight changes. Review of weights for Resident #42 revealed on 03/05/26 Resident #42 weighed 162.9 pounds and on 04/10/26 weighed 138.4 pounds. This represented a weight loss of 15.04 percent. Review of physician orders for Resident #42 revealed an order dated 03/18/26 for Resident #42 to be administered Mirtazapine (antidepressant) tablet 7.5 milligrams (mg), give 1 tablet by mouth at bedtime for depression/appetite. This was ordered prior to Resident #42's 15.04 percent weight loss between 03/05/26 and 04/10/26. Review of Resident Care Team Review document for Resident #42 dated 04/16/26 and authored by Registered Dietician (RD) #699 verified Resident #42's significant weight loss and revealed the resident was not receiving a dietary intervention. The RD's recommendations included a depression screening, weekly weights and an appetite stimulant. Weekly weights for Resident #42 were initiated on 05/06/26. Review of Resident Care Team Review document for Resident #42 dated 05/08/26 and authored by Registered Dietician Assistant (RDA) #695 revealed the resident did not have any new dietary interventions. The RDA's recommendations included changing the diet consistency to pureed, administering Ensure Clear three times a day, and fortified potatoes. Review of the care plan for Resident #42 dated 01/15/26 revealed it was not updated to include the RD's recommendations for a depression screening, weekly weights, appetite stimulant, pureed diet consistency, Ensure Plus, and fortified potatoes. Interview on 06/10/26 at 10:30 A.M. with the Director of Nursing verified Resident #42's care plan had not been updated/revised to include the 04/16/26 and 05/08/26 RD recommendations that were implemented. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes with chronic kidney disease, fibromyalgia, and hypertensive heart disease. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, had no behaviors, did not wander, and occasionally rejected care. Review of the medical record revealed Resident #5 had two care conferences in the last 12 months documented on 04/08/26 and 11/18/25. During an interview on 06/10/2026 at 12:26 P.M. Licensed Social Worker (LSW) #385 verified Resident #5 did not have quarterly care conferences in the last 12 months LSW #385 verified the resident should have had a care conference in February 2025 and May 2025. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes, Chronic Obstructive Pulmonary Disease (COPD), chronic diastolic heart failure, unspecified anxiety disorder, unspecified chronic kidney disease, and unspecified anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, had no behaviors, did not wander, and frequently rejected care. Review of the medical record revealed since admission, Resident #7 had care conferences on 09/24/25 and 01/20/26. During an interview on 06/10/2026 at 12:23 P.M. LSW #385 verified Resident #7 should have had a care conference in March or April 2026 and was due fo another care conference either this month or next month. 4. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included unspecified cerebrovascular disease, chronic pulmonary embolism, paranoid schizophrenia, mild vascular dementia with psychotic disturbance, and unspecified seizures. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #12 had adequate vision and did not use corrective lenses. Review of the medical record revealed Resident #12 had two care conferences in the last 12 months on 10/17/25 and 04/08/26. During an interview on 06/10/2026 at 12:25 P.M. LSW #385 stated Resident #12 had an annual MDS in December 2025, and a quarterly MDS in February 2026 and should have had care conferences at those times. Review of policy titled Comprehensive Care Plan dated 05/16/24 revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team (IDT) after each comprehensive and quarterly MDS assessment. Review of policy titled Care Conferences dated 05/16/2024 revealed care conferences were scheduled to include the resident, representative, and IDT team as soon as possible after admission, routinely, and with a change in condition.

Based on medical record review, staff interviews, and facility policy review, the facility failed to develop comprehensive care plans. This affected one (Resident #12) of eight residents sampled for care plans. The facility census was 151. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included unspecified cerebrovascular disease, chronic pulmonary embolism, paranoid schizophrenia, mild vascular dementia with psychotic disturbance, and unspecified seizures. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #12 had adequate vision and did not use corrective lenses. Review of eye examination summary dated 02/04/26 revealed Resident #12 had a diagnosis for mild, incipient cataracts to both eyes. Resident #12 had new eyeglasses prescribed, but they needed to wait to order new glasses related to new insurance. She was due to be re-evaluated for eyeglasses on 02/11/26 for further evaluation and testing to guide diagnosis and therapy. Review of the medical record revealed Resident #12 did not have a care plan for vision needs. During an interview on 06/10/2026 at 3:53 P.M. (Assistant Director of Nursing) ADON #380 verified Resident #12 did not have a care plan for vision services related to her diagnosis of cataracts Review of policy titled Hearing and Vision Services dated 08/04/26 revealed the facility provided ongoing monitoring of sensory problems, reviewed factors and history regarding vision abilities from medical records, and developed and implemented care plans including assistive devices used, adaptive equipment used, and communication strategies. Review of policy titled Comprehensive Care Plans dated 05/16/24 revealed the facility developed and implemented a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.

Based on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure bed rails were adequately secured to the bed. This affected one (#23) of one resident reviewed for bed rails. The facility census was 151. Findings include: Review of the medical record of Resident #23 revealed an admission date of 08/20/25. Diagnoses included heart failure, Type II Diabetes Mellitus, and ischemic cardiomyopathy. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision for bed mobility. Review of physician orders revealed an order dated 08/20/25 for 1/4 side rails on both sides of the bed. Review of the plan of care dated 08/27/25 revealed the resident required assistance with activities of daily living related to impaired mobility, weakness, debility, and edema. Interventions included to provide 1/4 side rails to aid in bed mobility. Interview on 06/08/26 at 11:22 A.M., the resident stated his side rails kept falling down because they were so loose. The resident stated the side rails had been tightened several times but kept coming loose. Observation at the time of the interview revealed, the resident pulled the side rail and it was not secure. The rail moved approximately four inches from center on each side of the rail. Interview on 06/09/26 at 9:08 A.M., Registered Nurse (RN) #620 verified Resident #23's side rails were not adequately secured. Interview on 06/09/26 at 9:26 A.M., Maintenance Director (MD) #200 stated he had tightened Resident #23's side rails several times, however the locking nut kept getting loose. Review of the facility policy titled, Bed Rails, dated 03/23/26, revealed, if bed rails are used, the facility ensures correct installation, use, and maintenance of the rails.

Based on medical record review, interviews, and facility policy review, the facility failed to provide timely services to maintain vision. This affected one (Resident #12) of two residents sampled for vision services. The facility census was 151. Findings include:Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included unspecified cerebrovascular disease, chronic pulmonary embolism, paranoid schizophrenia, mild vascular dementia with psychotic disturbance, and unspecified seizures. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #12 had adequate vision and did not use corrective lenses. Review of eye examination summary dated 04/04/26 revealed Resident #12 had a diagnosis for mild, incipient cataracts both eyes. Resident #12 had new eyeglasses prescribed, but they needed to wait to order new glasses related to new insurance. She was due to be re-evaluated for eyeglasses on 02/11/26 for further evaluation and testing to guide diagnosis and therapy. During an interview on 06/08/2026 at 11:33 A.M. Resident #12 stated her glasses were broken and she cannot read without them. She stated she cannot read her bills. During an interview on 06/10/2026 at 4:20 P.M. Licensed Practical Nurse (LPN)#419 verified Resident #12 had prescription for glasses since February 2026 and still did not have glasses due to concerns with insurance. 06/11/2026 10:37 AM Assistant Director of Nursing (ADON) #380 verified she was unaware Resident #12 had concerns with broken glasses, she verified the resident had a prescription since February and had insurance issues with getting glasses. ADON #380 stated the expectation would be that the clinic nurse would communicate there was a delay in getting glasses so the facility could determine the best course of action as a team. During an interview on 06/11/2026 at 10:50 A.M. LPN #419 stated she followed up the ophthalmologist who said insurance can and will pay for glasses but Resident #12 or family would have to go to Walmart to get them. Review of policy titled Hearing and Vision Services dated 08/04/25 revealed the facility ensured residents received timely services to maintain their highest practicable level of well-being.

Based on medical record review, interview and facility policy review, the facility failed to provide quarterly screening for therapy services. This affected one (Resident #7) of three residents sampled for therapy services. The facility census was 151. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes, Chronic Obstructive Pulmonary Disease (COPD), chronic diastolic heart failure, unspecified anxiety disorder, unspecified chronic kidney disease, and unspecified anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, had no behaviors, did not wander, and frequently rejected care. Review of care plan dated 09/28/25 revealed Resident #7 required assistance with (activities of daily living) ADL's. Interventions included assisting with ADLs as needed, encouraging resident to participate to the fullest extent, and for therapy to screen routinely, evaluate, and treat as ordered. During an interview on 06/08/2026 at 11:22 A.M. Resident #7 stated his arms were getting weaker from being in bed, and he could use therapy. Review of the medical record revealed Resident #7 received Physical and Occupational Therapies from 09/23/25 to 10/16/25 and was discharged due to lack of progress and lack of compliance/participation in therapy. During an interview on 06/11/2026 at 9:14 A.M. Director of Therapy Services #800 confirmed Resident #7 had not been evaluated for therapy services since he was discharged in October 2025. He confirmed each resident was supposed to be screened quarterly. Review of policy titled Therapy Screen For Rehabilitation Needs dated 12/05/25 revealed quarterly facility-wide screens were conducted to identify residents who might benefit from skilled therapy. This deficiency represent noncompliance investigated under Complaint Number 2787374, Complaint Number 2785032 and Complaint Number 2743663.

Based on medical record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure residents received routine dental services. This affected two (Resident #12 and Resident #55) of two residents sampled for dental services. The facility census was 151. Findings include: 1.Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included unspecified cerebrovascular disease, chronic pulmonary embolism, paranoid schizophrenia, mild vascular dementia with psychotic disturbance, and unspecified seizures. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #12 had adequate vision and did not use corrective lenses. Review of care plan dated 02/03/25 revealed Resident #12 has oral/dental health problems due to missing teeth and history of mouth pain. Interventions included administering medications as ordered, coordinating arrangements for dental care and transportation needs, observe and report dental problems, and encourage mouth care twice daily. Review of the medical record revealed Resident #12 revealed the resident had no progress notes regarding dental visits in last 12 months. Review of dental health services treatment record revealed Resident #12 had records for dental examinations provided on 07/20/22, 01/31/23, and 03/20/24. During an interview on 06/08/2026 at 11:35 A.M. Resident #12 stated she can't remember the last time she saw a dentist. Resident #12 denied dental pain but stated she had difficulty chewing. During an interview on 06/10/2026 10:18 at A.M. the Director of Nursing (DON) verified Resident #12 had not had dental services since 03/20/24. 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes, peripheral vascular disease, unspecified kidney disease, chronic pain syndrome, and unspecified anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, had verbal behaviors, did not wander, and occasionally rejected care. Review of care plan dated 04/17/25 revealed Resident #55 had oral/dental problems due to missing teeth. Interventions included coordinating appointments and transportation for dental care, observe/report dental concerns, and encouraging mouth care twice daily. Review of the medical record revealed Resident #55 had a dental examination through the facility clinic on 11/05/25. At the time, the resident reported no dental pain, had multiple missing teeth, existing restorations, and moderate bone loss. Recommendations for care were illegible. On 04/02/26, Resident #55 refused dental services through the clinic at the facility, and there were no additional notes regarding attempts to schedule dental services. During an interview on 06/08/2026 at 3:50 P.M. Resident #55 stated he did not want dental services provided through the facility and had been trying to get an appointment at an outside dental provider for months. Staff told him the only dentist in the area who accepted Medicaid was all booked up for five months. During an interview on 06/10/2026 at 2:37 P.M. Licensed Practical Nurse (LPN) #419 stated Resident #55 refused to come down to the clinic because he did not like the dentist that provided services at the facility. She called the dentist's office and found out the dentist he did not like was not with the dental service anymore and a different dentist came last week. He said he did not want to see any dentist in the facility clinic. LPN #419 stated Medical Records #311 made appointments with outside providers. 06/11/2026 1:52 PM Medical Records #311 confirmed she had not become aware that Resident #55 needed a dental appointment scheduled with an outside provider until Resident #55 approached her at the beginning of the June 2026 and asked to have a dental appointment scheduled. The provider she contacted did not have an appointment available in June, and the provider said they would call the facility if they had any cancellations. Medical Records #311 confirmed she did not schedule an appointment for the first-available time while she had the opportunity. Resident #55 was upset there were no appointments available in June 2026. Medical Records #311 stated she had since called the provider multiple time to schedule the next available appointment, but the provider did not answer. She left messages requesting a return call. Review of policy titled Dental Services dated 11/17/25 revealed the facility ensured residents received timely, appropriate, and safe dental care to maintain oral health, prevent complications, and support overall well-being. This deficiency represents noncompliance investigated under Complaint Number 2993750.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure antipsychotic medication had an adequate clinical indication for use. This affected three residents (#2, #20 and #156) of five residents reviewed for unnecessary medications. The facility census was 151.Findings include: 1. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of unspecified dementia and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had severe cognitive impairment and was frequently incontinent bowel and always incontinent of bladder. The resident required set up assistance for eating and oral hygiene, supervision for bed mobility, moderate assistance for toileting and transfers, and maximal assistance for personal hygiene, bathing and dressing. Review of physician orders for Resident #20 revealed an order dated 02/27/26 for Risperidone (antipsychotic) oral tablet 0.25 milligrams (mg), give 0.25 mg by mouth two times a day for dementia. Review of 2021 [NAME] Pocket Drug Guide for Nurses revealed Risperidone was classified as an antipsychotic and had a Black Box Warning (BBW) that stated not for use in elderly patients with dementia; there was an increased risk of cardiovascular mortality; not approved for this use. Indications included treatment of schizophrenia and treatment of bipolar disorder. Interview on 06/09/2026 at 3:48 P.M. with the Director of Nursing (DON) verified dementia was not an acceptable diagnosis for Resident #20 to be administered Risperidone. 2. Review of the medical record for Resident #156 revealed an admission date of 06/04/26. Diagnoses included left femur fracture, left humerus fracture, left wrist fracture, Alzheimer's disease, and dementia without behavioral disturbance. Review of the activities of daily living (ADL) care plan, dated 06/05/26, revealed the resident required assistance with Activities of Daily Living (ADLs) related to left femur, humerus, ulna, and wrist fractures. The resident was dependent on staff for bed mobility, dressing, transfers, and toileting. Review of physician orders revealed an order dated 06/08/26 for Haloperidol (antipsychotic) 0.5 milligrams (mg), 1 tablet by mouth every six hours as needed for agitation. Interview on 06/09/26 at 3:27 P.M., the Director of Nursing (DON) verified agitation is not an appropriate diagnosis for Haloperidol. 3. Review of records for Resident #2 revealed an admission date of 05/01/26 with diagnoses including Alzheimer's disease, Type Two Diabetes mellitus (DM2), and dementia with other behavioral disturbance. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had moderate cognitive impairment, and no identified mood issues. Resident #2 exhibited the following behaviors daily: delusions, verbal behaviors directed towards others, and other behaviors not directed at others. Resident #2 also significantly intruded on the privacy and activities of others, significantly disrupted care, rejected care, and wandered daily. Resident #2's list of active diagnoses revealed no identified psychiatric or mood disorder diagnoses. Review of Preadmission Screening and Resident Review (PASRR) dated 05/08/26 revealed Resident #2 had a diagnosis of Alzheimer's disease, and no other indications of serious mental illnesses were noted. The PASRR noted Resident #2 was receiving anti-psychotic medications. Review of physician's orders revealed an order dated 05/01/26 for Seroquel 50 milligrams (mg) twice a day for mood changes and dated 05/18/26. During an interview on 06/09/26 at 3:30 P.M. the Director of Nursing (DON) stated whoever put the orders in the electronic system would put in a diagnosis for a medication if one was not specified by physician. DON verified mood changes was not an appropriate diagnosis for Seroquel. Review of policy titled, Psychotropic Medication Use, effective 08/01/25, revealed the purpose of the policy was to ensure the safe, appropriate, and ethical use of psychotropic medications in the treatment of individuals served by our organization, in accordance with clinical standards, regulatory requirements, and person-centered care principles promoting the health and well-being of individuals while preventing unnecessary use and chemical restraints. Diagnosis and targeted symptoms must be documented in the medical record for any psychotropic medication use.

Based on medical record review, resident interviews, staff interviews, facility investigation review, and facility policy review, the facility failed to report concerns for misappropriation to the State Agency in a timely manner. This affected one (Resident #55) of three residents sampled for abuse. The facility census was 151. Findings include:Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes, peripheral vascular disease, unspecified kidney disease, chronic pain syndrome, and unspecified anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, had verbal behaviors, did not wander, and occasionally rejected care. Review of document titled (Resident #55)- Interview/Investigation, Missing $30, not dated, revealed Resident #55 informed the Administrator that $30.00 was missing from under the lamp in his room. The resident stated he had 25 one-dollar bills and one five dollar bill in a wad under his lamp. Resident #55 stated his friend outside the facility knew about the money, but this could not be confirmed. The Administrator offered a safe alternative for storing his personal belongings, but the resident refused. The Administrator stated explained he could not replace the $30.00 because he could not confirm Resident #55 had it. The Administrator offered to purchase some of the resident's favorite snacks along with some healthier snack alternatives in the equivalent of $30.00, and the resident agreed. The Administrator purchased and delivered the snacks to Resident #55. Additional review revealed the facility interviewed staff, and none were aware of the missing money. During an interview on 06/08/2026 at 3:33 P.M. Resident #55 stated he reported concerns, date not specified, to the Administrator and Social Service Designee when he discovered upon return from the hospital in either July or August 2025 that the $30.00 he had stored under the lamp in his room was missing. Resident #55 stated he had one $5.00 bill and 25-$1.00 bills for the vending machine. Resident #55 stated he a had a meeting with the social service designee and three other unidentified staff, during which staff stated they would refund him his money. The administrator asked Resident #55 what kind of snacks he liked and provided snacks in place of refunding the money. During an interview on 06/10/2026 at 1:46 P.M. the Administrator stated Resident #55's allegation of missing money was brought to his attention much later than the date of the incident. The Ombudsman sent an email in February 2026 asking the Administrator to address it. Prior to her notification, date not specified, the resident had not made any complaints about missing money. Resident #55 was hospitalized in October 2025, but the Administrator did not become aware of the incident until February 2026. The Administrator stated he did not report it because the Ombudsman asked him to report directly to her. The Administrator verified he did not file an SRI because it had been so long since the alleged event had occurred. The administrator stated he purchased and delivered snacks on 02/06/26 to replace the $30 that was allegedly missing. Review of policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation dated 06/05/25 revealed the facility investigated and reported all alleged violations involving misappropriation to the Department of Health with 24 hours of the care team being notified of the allegation. This deficiency represents noncompliance investigated under Complaint Number 2993750.

Based on record review, observation, staff interview, and policy review, the facility failed to provide dignified care to a resident with an external catheter. This affected one (Resident #162) of eight residents sampled for dignity. The facility census was 151. Findings include:Review of the medical record revealed Resident #162 was admitted to the facility on [DATE]. Diagnoses included infection and inflammatory reaction to internal left knee prosthesis, hypertensive heart disease with heart failure, malignant neoplasm of the prostate, unspecified anxiety disorder, and secondary neoplasm of the bone. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #162 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #162 had physician orders dated 06/01/26 for condom catheter output every shift. Observation on 06/08/2026 at 2:43 P.M. revealed Resident #162 lay in bed. A urinary catheter drainage bag was hanging on the side of the bed facing the hallway and urine content was visible from hallway. There was no dignity cover. During an interview on 06/08/2026 at 2:47 P.M. Licensed Practical Nurse (LPN) #433 verified Resident #162's urinary catheter drainage bag was visible from hallway and did not have a dignity cover. Review of policy titled Resident-Patient Rights dated 02/20/2026 revealed care members treated residents with kindness, respect, and dignity, and provided care the enhanced and promoted quality of life, patient preferences, and individuality.

Based on record review and staff interview, the facility failed to ensure staff was qualified to complete resident care. This had the potential to affect all 142 residents residing in the facility. The facility census was 142. Findings include: Review of the employee record for Nursing Assistant (NA) #540 revealed a hire date of 11/23/24 as a NA. Further review of NA #540's employee record revealed the staff member had not completed the state test to be a Certified Nursing Assistant (CNA). Review of the Detailed Hours Report with Training Category and Pay Category dated 08/14/25 revealed CNA #540 worked 11/28/25 through 04/18/25 as a CNA. Interview on 08/14/25 at 11:54 A.M. with Human Resource #434 confirmed NA #540 was hired on 01/23/24 as a NA for both assisted living and long-term care. Interview also confirmed when NA #540 was hired, she had completed the course for the CNA program but had not passed her state test. Interview also confirmed NA #540 worked for [NAME] Care of Cedar Village on 11/28/24 and was eligible to work for a total of four months with her nursing certificate. Interview also confirmed NA #540 should not have worked as a NA past 03/27/25. Interview confirmed NA #540 worked through 04/18/25. This deficiency represents non-compliance investigated under Complaint Numbers 1359585 (OH00162141) and 1359585 (OH00162141) .

Based on observation, staff and resident interviews and record review, the facility failed to ensure the facility was free from pests. This had the potential to affect all 142 residents residing in the facility. The facility census was 142. Findings include: Initial tour completed on 08/13/25 from 8:28 A.M. through 8:50 A.M. with the Director of Nursing (DON) revealed four dinner trays dated 08/12/25 were setting on the tables in the Gardenia dining area. Gnats were present on the trays and flying around the trays. There was two trays located on the windowsill in the Gardenia dining area. One of the trays had a couple gnats on the food, the other tray had approximately twenty ants on the plate and food. Observation of the Apple unit dining area had three dinner trays dated 08/12/25 with gnats on the food and gnats flying above the food. Observation on the Peach unit dining area had two trays dated 08/12/25 with gnats on the food of one of the trays. The DON was present during observation and confirmed the presence of gnats and ants on food and food dishes in the dining areas on Gardenia Unit, Apple Unit, and Peach Unit. Observation and interview on 08/13/25 at 10:15 A.M. with Resident #80 in dining room of Gardenia. Observations revealed gnats present on tray while resident is eating breakfast. Resident #80 reports they are there often. Interview on 08/13/25 at 10:16 A.M. with Licensed Practical Nurse (LPN) #414 confirmed the gnats were present on Resident #80's meal tray while eating and confirmed there are gnats present often. Observation on 08/14/25 at 6:09 A.M. with LPN #305 revealed the juice machine on Peach unit had multiple gnats on all four of the spouts on the machine. Interview on 08/14/25 at 6:09 A.M. with LPN #305 present during the observation and confirmed the presence of gnats on all four of the spouts on the machine. Review of the Pest Control #09's work order dated 08/04/25 revealed treated deli for gnats, and treated for ants didn't see any ant activity, light gnats. Review of the Cleaning Schedules, undated revealed all dining rooms are cleaned after each meal and dining aides are to take trays to the kitchen after each meal. Review of the Pest Control Program, dated 12/12/23 revealed it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. This deficiency represents non-compliance investigated under Complaint Numbers 2580789, 1359585 (OH00162141) and 1359582 (OH00162827).

Based on medical record review, observations, staff interviews and policy reviews, the facility failed to ensure staff completed hand hygiene after removing soiled incontinent brief and before donning new gloves. This affected one (#104) out of three residents observed for incontinence care. Additionally, the facility failed to ensure medications were administered in a way to avoid transmission of communicable diseases. Specifically, the facility staff touched resident medications with their bare hands when administering medications and failed to clean a multi resident blood glucometer between residents. This affected three (#125, #139, and #140) out of three residents observed for medications/glucometer checks. Lastly, the facility failed to provide a sanitary environment for resident dining and storage of medications in the medication cart. This had the potential to affect the 26 residents residing on the Peach Unit. The facility census was 142. Findings include: 1. Medical record review for Resident #104 revealed an admission on [DATE] with diagnoses including but not including type two diabetes mellitus, ulcerative colitis, morbid obesity, venous insufficiency and hypertensive heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #104 revealed an intact cognition. Resident #104 required maximum assistance with toileting tasks, transfers and bed mobility. Resident #104 was incontinent of bowel and bladder. Review of the plan of care for Resident #104 dated 02/04/25 revealed resident required assistance with activities of daily living (ADL) related to impaired mobility, weakness and disease progression. Interventions included mechanical lift for transfers from two staff members and a geriatric chair for locomotion. Observation on 08/18/25 at 10:35 A.M. of Resident #104 incontinent care by Certified Nurse Assistant (CNA) #374 and Licensed Practical Nurse (LPN) #455 revealed CNA #374 advised resident of task to be completed in preparation of transportation to the shower room. CNA #374 donned gloves and provided incontinent care to Resident #104 who was incontinent of both bladder and bowel without concerns. CNA #374 removed the incontinent brief and discarded the item into the trash can. CNA #374 applied clean gloves from box located on the resident's nightstand and applied them without completing hand hygiene. CNA #374 then assisted Resident #104 to roll from one side to side to position resident onto Hoyer sling pad. CNA #374 retrieved the Hoyer lift positioning the lift arms over Resident #104 and proceeded to attach Hoyer Sling pad to Hoyer lift with LPN #455 assisting. CNA #374 using the lift controller hanging on the hoyer lift bar to lift and transfer Resident #104 to a shower chair. LPN #455 and CNA #374 then disconnected the Hoyer lift arms from the Sling pad and moving the lift into the resident's bathroom. CNA #374 covered Resident #104 with shower sheet, removed gloves discarding them into the trash can in Resident #104's room, opening the door to the hallway and exited to room without completing hand hygiene. CNA #374 pushed Resident #104 to the shower room, unlocked the door with a keypad code and assisted the resident into the shower room. Interview on 08/18/25 at 10:55 A.M. with LPN #455 verified the CNA #374 removed gloves after completing incontinent care and did not complete hand hygiene prior to donning new gloves. Additionally, LPN #455 verified CNA #455 did not complete hand hygiene after removing gloves a second time and exiting the room to provide Resident #104 a shower. Review of the facility policy titled “Handwashing-Hand Hygiene”, dated 03/01/25 states care team members must wash their hands for twenty seconds using antimicrobial or non-antimicrobial soap before and after direct contact with residents/patients and after removing gloves. 2. Observation on 08/18/25 at 12:24 P.M. of medication cart located on the Peach Unit with LPN #455 revealed medications were provided to the facility from the pharmacy in a numbered card style unit dose package sealed with a foil type backing. The medication cart stored all medication for the 26 residents residing on the unit. Further observation revealed each section storing the medication cards had loose and broken tablets with a heavy accumulation of multiple colors of sand sized material under the medication cards. Interview on 08/18/25 at 12:30 P.M. with LPN #455 verified the medication carts were not clean and the number of medications in pill and capsule form in the bottom of the drawers in direct contact with the resident's medication cards exceeded one hundred in number. LPN #455 stated the facility has cleaning tasks assigned to each shift and night shift was assigned to clean the cart at regular frequency. Interview on 08/18/25 at 1:45 P.M. with the Director of Nursing (DON) verified the unit managers are supposed to conduct observations to ensure cleaning tasks are completed. DON verified the medication carts are to be cleaned on a routine basis and should not have any accumulation or loose tablets in the bottom of the drawers. Review of the facility policy titled “Medication Storage”, dated 01/02/24 stated it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation. 3. Review of the medical record for Resident #125 revealed an admission date of 01/06/24 with diagnoses of malignant neoplasm of unspecified part of unspecified bronchus r lung, neoplasm of uncertain behavior of spinal cord, anxiety, chronic obstructive pulmonary disease, and panic disorder. Review of the physician orders revealed an order for Drizama 60 mg 1 tablet (tab), Gabapentin 600 mg 1 tab, Tamsulosin 0.4 mg 1 cap, Oxycodone 30 mg 1 tab as needed, Trazadone 50 mg 1 tab, and Finasteride 6 mg 1 tab by mouth. Observation on 08/14/25 8:10 A.M. with Licensed Practical Nurse (LPN) #336 revealed LPN #336 removed Drizama 60 mg 1 tab, Gabapentin 600 mg 1 tab, Tamsulosin 0.4 mg 1 cap, Oxycodone 30 mg 1 tab as needed, Trazadone 50 mg 1 tab, and Finasteride 6 mg 1 tab from the pill cards with her bare hands, physically touching each pill. LPN #336 administered the medication to Resident #125. Interview on 08/14/25 at 8:38 A.M. with LPN #336 confirmed she touch each pill she pulled, she touched with her bare hands. 4. Review of the medical record for Resident #139 revealed an admission date of 05/19/22 with diagnoses of chronic venous hypertension (idiopathic) with ulcer of right lower extremity, type 2 diabetes mellitus without complications polyneuropathy, peripheral vascular disease, and generalized anxiety disorder. Review of the physician orders revealed an order for Aspirin 81 mg Chewable 1tab, Escitalopram 10 mg 1 tab, Carvedilol 3.125 mg 1 tab, Allopurinol 100 mg 1 tab, Furosemide 20 mg 3 tabs, Januvia 25 mg 1 tab, Levothyroxine 100 mcg 1 tab, Potassium Cl Micro 20 meq 200 mg ER 1 tab, Mag Ox 400 mg 1 tab, Ferrous Sulfate 325 mg 1 tab, Multi-Vitamin 1 tab, Vitamin B-12 1000 mcg 1 tab, Vitamin D 25 mcg 2 tabs, and finger stick blood sugar (FSBS). Observation on 08/14/25 at 7:53 A.M. with Licensed Practical Nurse (LPN) #336 revealed LPN #336 removed Aspirin 81 mg Chewable 1tab, Escitalopram 10 mg 1 tab, Carvedilol 3.125 mg 1 tab, Allopurinol 100 mg 1 tab, Furosemide 20 mg 3 tabs, Januvia 25 mg 1 tab, Levothyroxine 100 mcg 1 tab, Potassium Cl Micro 20 meq 200 mg ER 1 tab, Mag Ox 400 mg 1 tab, Ferrous Sulfate 325 mg 1 tab, Multi-Vitamin 1 tab, Vitamin B-12 1000 mcg 1 tab, Vitamin D 25 mcg 2 tabs from the pill cards with her bare hands, physically touching each pill. Observation also revealed LPN #336 administered the medication the Resident #139, then washed her hands, applied gloves, and checked the residents FBSB with a glucometer, then placed the glucometer back in the case. LPN #336 removed her gloves, washed her hands, then picked up the glucometer case and placed it in the medication cart. Interview on 08/14/25 at 8:38 A.M. with LPN #336 confirmed on 08/14/25 at 8:38 A.M. confirmed she touched each pill she pulled; she touched with her bare hands. Interview also confirmed LPN #336 did not clean the glucometer between using on multiple residents. Interview also confirmed she is supposed to clean the glucometer after each resident use with a sanitizing wipe. 5. Review of the medical record for Resident #140 revealed an admission date of 04/17/25 with diagnoses of type 2 diabetes mellitus with diabetic neuropathy, hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4, major depressive disorder, anxiety disorders, chronic pain syndrome, anemia, and primary osteoarthritis, right shoulder. Review of the physician orders revealed an order for Aspirin 81 mg chewable 1 tab, Sodium Bicarb 5.02 gr 1 tab, Bisacodyl 5 mg 2 tabs, Senna Plus 8.6mg – 50 mg 2 tabs, Buspirone 7.5 mg 1 tab, Amlodipine 19 mg 1 tab, Duloxetine 30mg 1 tab, Multi-Vitamin 1 tab, Duloxetine DR 60 mg 1 tab, Cetirizine 10 mg 1 tab, Gabapentin 100 mg 1 tab, and Propranolol 80 mg 1 tab. Observation on 08/14/25 at 8:21 A.M. with LPN #336 revealed Aspirin 81 mg chewable 1 tab, Sodium Bicarb 5.02 gr 1 tab, Bisacodyl 5 mg 2 tabs, Senna Plus 8.6mg – 50 mg 2 tabs, Buspirone 7.5 mg 1 tab, Amlodipine 19 mg 1 tab, Duloxetine 30mg 1 tab, Multi-Vitamin 1 tab, Duloxetine DR 60 mg 1 tab, Cetirizine 10 mg 1 tab, Gabapentin 100 mg 1 tab, and Propranolol 80 mg 1 tab was pulled from the pill cards with her bare hands, physically touching each pill. LPN #336 administered the medication to Resident #140, then washed her hands, applied gloves, and checked the residents FBSB with a glucometer, then placed the glucometer back in the case. LPN #336 removed her gloves, washed her hands, then picked up the glucometer case and placed it in the medication cart. Interview on 08/14/25 at 8:38 A.M. with LPN #336 confirmed on 08/14/25 at 8:38 A.M. confirmed she touch each pill she pulled; she touched with her bare hands. Interview also confirmed LPN #336 did not clean the glucometer between using on multiple residents. Interview also confirmed she is supposed to clean the glucometer after each resident use with a sanitizing wipe. This deficiency represents non-compliance investigated under Complaint Number 1359585 (OH00162141).

Based on medical record review, hospital record review, staff interview, and facility policy review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent infections for a pressure ulcer. This resulted in Actual harm when Resident #20 ' s weekly skin assessments were not completed and subsequently led to hospitalization for a wound infection and possible osteomyelitis. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 132. Findings include: Review of the medical record for Resident #20 revealed an admitted to the facility on [DATE] and a discharge date to the hospital on 04/09/24, and as of 04/16/24 Resident #20 is still hospitalized . Resident #20 had a hospital diagnosis of right large heel pressure ulcer with wet necrosis with suspected superimposed infection/osteomyelitis. The resident had pertinent diagnoses of cellulitis of right upper limb, atherosclerotic heart disease of native coronary artery, type two diabetes mellitus with diabetic neuropathy, atrial fibrillation, hypertensive heart disease with heart failure, congestive heart failure, anxiety disorder, asthma, chronic kidney disease stage three, attention deficit hyperactivity disorder, restless legs syndrome, hyperlipidemia, syncope and collapse, sleep apnea, left bundle branch block, hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, insomnia, depression, and gastroesophageal reflux disease. Review of a [NAME] scale for predicting pressure sore risk assessment dated [DATE] revealed the resident had a score of 18 and was categorized as at risk for pressure ulcers. Review of a plan of care dated 01/02/24 revealed Resident #20 had impaired skin integrity to right heel with a goal of tissue injury will heal and be free from complications. Interventions included: Assess and document skin condition, notify doctor of signs of infection (redness, drainage, pain, fever), assess for pain and treat as indicated, notify physician of worsening or no improvement in wound, pressure reducing/redistributing mattress on bed, wound location: right heel and wound treatment as ordered. Review of the 03/26/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #20 was cognitively intact and rejected care one to three days during the look back period. Resident #20 used a walker and wheelchair to aid in mobility and was dependent for toileting hygiene, and showering. Resident #20 required substantial to maximal assist for rolling left to right, sit tolying and lying to sitting, and sit to stand. Resident #20 had treatments in place to include pressure reducing device for chair and bed, and applications of ointments and dressings. Review of outside wound clinic assessment notes dated 03/05/24 revealed multiple wounds including an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed) right calcaneus pressure ulcer injury that was open and was acquired 12/31/23 with wound measurements of 6.5 centimeters (cm) in length, 6.5 cm in width with a depth of 0.3 cm. Review of a Physician Order dated 03/06/24 revealed to cleanse right heel wound with normal saline, apply Exufiber dressing (no silver), cover with abdominal pad and wrap with kerlix every other day and as needed per wound clinic every night shift, every other day for wound care, and as needed for wound care. Review of the outside wound clinic assessment notes dated 03/12/24 revealed an unstageable right calcaneus pressure ulcer injury with wound measurements of 6.5 cm in length, 6 cm in width, with a depth of 0.3 cm. The next appointment date was scheduled for 03/26/24. Review of the medical record revealed there were no wound measurements or assessments from 03/13/24 until a wound assessment was completed on 04/08/24. Review of the medical record revealed there was no information on the appointment for the date of 03/26/24. Review of a progress note dated 04/02/24 revealed tried to get resident ready for wound care appointment, resident too weak to sit up straight in bed, bed bath and sheets changed by aide, and educated resident on needing a stretcher for appointments. Review of the wound assessment report from the in-house wound nurse practitioner dated 04/08/24 revealed the right heel wound was unstageable 8 cm in length, by 6.5 cm in width, with a depth of 0.5 cm. There was slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) from 1-24% with a moderate amount of seropurulent exudate. Review of the Nurse Practitioner progress note dated 04/08/24 at 11:37 A.M. revealed spoke with nurse to confirm appointment at outside wound clinic for 04/09/24. Updated her on concerns for possible wound infection. Review of a progress note dated 04/09/24 at 5:45 P.M. revealed Resident #20 was being admitted to the hospital for wound infection per emergency room nurse. Interview with Registered Nurse (RN) #10 on 04/10/24 at 3:00 P.M. revealed Resident #20 did not go out to his wound clinic appointment on 03/26/24 and 04/02/24 because he was not feeling well. Interview with Director of Nursing (DON) on 04/15/24 at 12:05 P.M. verified there were no wound measurements or wound assessments from 03/13/24 until 04/08/24. Interview with Licensed Practical Nurse (LPN) #11 on 04/15/24 at 12:18 P.M. revealed she was wound certified and rounded with the wound Nurse Practitioner on Mondays. She stated they see patients weekly if they are on the caseload on her rounds. She stated she was notified on 04/08/24 that Resident #20 had missed the 04/02/24 wound appointments and was not notified of missing the 03/26/24 wound appointment. Residents usually have an order to measure wounds weekly. She verified she had not measured Resident #20 ' s wound from 03/13/24 to 04/08/24. LPN #11 stated if a new wound pops up and whoever does the treatment would measure it and assess the wound. She stated they quit following Resident #20 ' s wound back in February when they realized he was going out to a podiatrist at a wound clinic, and then switched over to a different wound provider. She revealed they called the wound clinic on 04/08/24 and talked to a nurse and the doctor, because the Nurse Practitioner was thinking the right heel had osteomyelitis and it had an odor. Review of the hospital records from admitted on 04/09/24 revealed Resident #20 had a wound culture that showed Methicillin Resistant Staphylococcus Aureus, Escherichia coli, and possibly extended spectrum beta lactamase. A fungus culture grew Candida Albicans. There was a right heel pressure ulcer with wet necrosis with suspected superimposed infection/osteomyelitis. The right foot x-ray showed erosion of the posterior right calcaneus compatible with osteomyelitis. Resident #20 was receiving intravenous daptomycin antibiotic. The MRI (Magnetic Resonance Imaging) for osteomyelitis was still pending. Review of the facilities skin management policy dated 10/01/19 revealed residents will have a skin assessment completed upon admission and no less than weekly by the licensed nurse in an effort to assess overall skin condition, integrity, and skin impairment. This deficiency represents non-compliance investigated under Complaint Number OH00152801.

Based on record review, observation, resident and staff interview, review of facility documents and review of the facility policy titled Abuse Prevention Program, the facility failed to ensure residents were protected from abuse during an investigation and failed to conduct a thorough abuse investigation. This resulted in psychosocial harm for Resident #94 after the facility failed to protect and thoroughly investigate Resident #94's allegation of emotional and verbal abuse resulting in Resident #94 being afraid to leave her room, was agitated, and tearful. This affected one (Resident #94) of three residents reviewed for abuse. The facility census was 148. Findings include: Review of the medical record for Resident #94 revealed an admitted [DATE]. Diagnoses included chronic pain syndrome, bipolar disorder, and chronic respiratory failure (CRF) with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the nursing progress note for Resident #94 dated 05/01/23 written by Unit Manager (UM) #236 revealed resident refused care when resident's call light was answered. The Director of Nursing (DON) and Social Worker (SW) #347 were made aware. Review of the concern form dated 05/02/23 revealed Resident #94 did not want UM #236 to answer her call light or be part of her care team. Further review of the form revealed the resident's request was granted and UM #236 would not be part of resident's care team. The form was signed by SW #347 and Resident #94. Review of interview statements of residents on the unit where Resident #94 resided dated 05/02/23 revealed the residents were asked if they ever had a negative encounter with a staff member, and if they had any issues regarding the nurses' approach. All residents interviewed answered no to the questions. Observation and interview on 05/17/23 at 10:13 A.M. revealed Resident #94's door was shut upon arriving to her room. Resident #94 was alert and oriented to person, time and place. Resident #94 became tearful during the interview. Resident #94 stated she stayed in her room and kept her door shut so she would not have to interact with UM #236. Resident #94 stated she was afraid of UM #236, and she thought she was a bully, that she was aggressive in her approach and that she talked to her like she was a child. Resident #94 confirmed things got worse between her and UM #236 when the nurse came into her room sometime back in April 2023 and told her that she wasn't allowed to have a catheter and that she didn't need it. Resident #94 stated she felt the nurse was disrespectful to her and she told the nurse to get out of her room and that she didn't want the nurse to ever come into her room again. Resident #94 confirmed that early in May 2023, UM #236 came into her room to answer her call light and she asked her to leave. Resident #94 confirmed UM #236 argued with her about how she had to answer the call light and the resident told UM #236 to leave and to get someone else to help her. Resident #94 reported her concerns to Licensed Practical Nurse (LPN) #356. Resident #94 confirmed she was afraid UM #236 might retaliate against her for complaining and she was upset UM #236 did not honor her request to stay out of her room. Resident #94 confirmed she could still hear UM #236 talking in the hallway, so she knew she was around, and it made her uneasy. Resident #94 confirmed SW #347 and the DON met with her and told her they would move UM #236 to another unit. Interview on 05/17/23 at 10:27 A.M. with LPN #356 confirmed early in May 2023, Resident #94 reported to her that she was afraid of UM #236, and Resident #94 called UM #236 a bully. Resident #94 had asked UM #236 back in April 2023 to never come in her room again. LPN #356 confirmed Resident #94 was upset because UM #236 did not honor her request and came in her room anyway when Resident #94 put her call light on. UM #236 said she had to answer the light. LPN #356 confirmed she reported Resident #94's concerns to the DON. LPN #356 confirmed Resident #94 did not accuse UM #236 of verbal or emotional abuse, but calling someone a bully could be considered an allegation of possible abuse. Interview on 05/17/23 at 11:54 A.M. with the DON confirmed LPN #356 reported to her by phone on 05/01/23 that Resident #94 complained she didn't want UM #236 to be part of her care team anymore and she didn't like her personality or her customer service approach. The DON confirmed LPN #356 did not use the word abuse nor did she share that the resident called UM #236 a bully. The DON confirmed if a resident reported a staff member was a bully, she would consider it an abuse allegation and would handle the situation per the facility's abuse protocol. The DON confirmed SW #347 and the DON met with Resident #94 on 05/01/23 or 05/02/23. The DON confirmed Resident #94 told them she did not want UM #236 to enter her room again for any reason and if her call light was on, someone else should answer it. The DON stated the facility made the decision to move UM #236 to be manager of a different unit in the facility and the switch was made a week ago. The DON confirmed as the facility was coordinating the switch, UM #236 continued to work on Resident #94's unit, but LPN #229 was asked to respond to any nurse management needs for Resident #94 which involved direct interaction with the resident. The DON confirmed she had not obtained written statements from the resident and/or staff who may have had first-hand knowledge of the incident. The DON confirmed the facility had not initiated an abuse investigation and UM #236 was not suspended at any time in April or May of 2023. Interview on 05/17/23 at 1:51 P.M. with SW #347 confirmed the DON and herself interviewed Resident #94 on 05/01/23 or 05/02/23. SW #347 stated Resident #94 was agitated during the interview and said she didn't like UM #236's personality towards her and didn't feel comfortable with her providing care and didn't want the nurse to enter her room for any reason. SW #347 confirmed Resident #94 was reluctant to elaborate any further but said she felt UM #236 was gruff in her mannerisms and speech. Interview on 05/17/23 at 2:24 P.M. with UM #236 stated her relationship with Resident #94 was fine until she went into her room and told her she needed to stop refusing her diuretics and the risk this could cause to her health. UM #236 confirmed Resident #94 was unhappy with her because she got her indwelling catheter discontinued. In April 2023, Resident #94 told her she thought her approach was aggressive and she didn't want UM #236 to answer her call light, come in her room, or even speak to her. UM #236 confirmed she went to Resident #94's room sometime in May 2023 and the resident was very upset and told her to leave the room. UM #236 confirmed she told Resident #94 she was obligated to answer call lights, and Resident #94 told her to find someone else to assist. UM #236 confirmed she was not suspended at any time in April or May of 2023. Review of the facility policy titled Abuse Prevention Program, dated March 2021, revealed the facility should protect residents during abuse investigations. The facility would ensure timely and thorough investigation of all reports and allegations of abuse. Abuse included verbal abuse-oral or written or gestured language that willfully includes disparaging and derogatory terms to residents or their families and mental abuse which included humiliation, harassment, and threats of punishment or withholding treatments or services. The facility should also ensure the reporting and filing of accurate documents relative to incidents of abuse. Employees of the facility who have been accused of resident abuse shall be suspended from duty immediately until the results of the investigation have been reviewed by the Administrator. This deficiency represents non-compliance investigated under Complaint Number OH00142514.

Based on record review, staff interviews, review of Emergency Medical Services (EMS) run report, review of hospital records, review of facility investigation, and review of facility policy, the facility failed to provide necessary supervision for Resident #108, who was assessed by the facility to be a moderate fall risk. Actual harm occurred on 12/03/22 when Resident #108 sustained an unwitnessed fall with injury. Facility staff failed to provide adequate supervision during the overnight hours, resulting in Resident #108 not being found on the floor until 12/04/22 (EMS arrived on 12/04/22 at 6:35 A.M.). Subsequently, the resident was transferred to a local emergency department (ED) where she was diagnosed with acute fractures of her thoracic (T-7) (vertebrae in back) and cervical (C-7) (vertebrae in neck) areas. This affected one resident (#108) of three residents reviewed. The facility census was 151. Findings include: Review of the medical record for Resident #108 revealed an admitted [DATE] with a hospital stay from 11/30/22 to 12/03/22. The resident had diagnoses including, but not limited to, Crohn's Disease, wedge compression fracture of T-7 and T-8 vertebra, wedge compression fracture of lumbar (L-4) vertebra, diverticulosis of intestine, anemia, hyperlipidemia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #108 dated 11/11/22, revealed resident was cognitively intact. Resident #108 required supervision with transfers and bed mobility. The resident was noted to be independent with walking in her room. Review of the Morse Fall Scale assessment for Resident #108 dated 07/21/22, revealed the resident was at moderate risk for falling. Review of the plan of care for Resident #108 dated 07/22/22, revealed the resident was at risk for falls or fall related injuries related to weakness, Crohn's disease, and pain. Interventions included assisting resident with transfers, encouraging resident to use call light for assistance, and keeping the pathways clear and well lit. Review of the Morse Fall Scale assessment for Resident #108 dated 11/19/22, which was completed after a previous fall, revealed the resident was assessed to be at a high risk for falling. Review of the hospital paperwork for Resident #108, revealed the resident was admitted to the hospital on 11/30/22 related to stomach pain and bloating and released back to the facility on [DATE]. Review of the nursing notes for Resident #108 dated 12/03/22 at 6:43 P.M., revealed the resident returned to the facility from the hospital via private transportation and resident reported she felt a lot better. Notes indicated Resident #108 reported she had pain in her shoulder and back, was noted to have eaten her dinner in her room and orders were verified with the physician as well as admission vital signs and weight were obtained. Review of the aide charting for Resident #108 dated 12/03/22, revealed no documented entries from 7:00 P.M. to 7:00 A.M. Review of the EMS run report for Resident #108 dated 12/04/22 at 6:35 A.M., revealed EMS responded to the nursing home related to injuries from a fall for Resident #108. EMS report indicated resident stated she had been on the floor since 12/03/22 at 9:45 P.M. after falling while turning off her lights. EMS report indicated Resident #108 reported tenderness to her neck region, denied back pain and had a laceration to the back of her which was difficult to visualize due to matted hair. The resident was able to stand with assistance from EMS staff and Resident #108 was taken to a local emergency room for further evaluation. Review of the hospital paperwork for Resident #108 dated 12/04/22 at 6:56 A.M., revealed the resident arrived at the hospital ED after a fall at the nursing home. Notes indicated Resident #108 stated she fell on [DATE] around 10:00 P.M. and remained on the floor until she was checked on the next morning. Notes indicated the resident fell while trying to turn off her Christmas lights. Notes indicated the resident reported she turned too quickly, lost her balance, and fell on the floor. Notes indicated resident had an acute closed wedge compression fracture of the T-7 vertebra and a compression fracture of the C-7 vertebra. Review of the nursing notes for Resident #108 dated 12/04/22 at 8:11 A.M., revealed the resident was found in the supine position on the floor of her room and next to her couch with her walker next to her. Notes indicated the resident stated she fell trying to walk to bed from the window area and there was blood was noted to the back of resident's head. Resident was sent to a local hospital via EMS and the physician and family were notified of the incident. Review of the nursing notes for Resident #108 dated 12/04/22 at 11:47 A.M., revealed the facility received a report from the hospital stating the resident would be returning to the facility. Notes indicated resident had T-7 lumbar compression fracture, head injury, and a cervical collar was to be worn at all times except during bathing. Notes indicted resident was ordered to follow up with neurosurgeon. Notes indicated there were orders to cleanse head wound daily and apply antibiotic ointment daily until healed. Review of the Interdisciplinary Team (IDT) notes for Resident #108 dated 12/04/22 at 1:09 P.M., revealed the resident was observed on the floor during night shift and sent to the ED. Notes indicated resident reported she was turning her Christmas tree lights off and when she turned around and lost her balance. Notes indicated the resident reported she did not get dizzy or lightheaded and she had her gym shoes on. Notes indicated staff would encourage the resident to allow staff members to turn off Christmas lights or they could remain on if the resident wishes. The Family was made aware of all new orders. Review of the nursing notes for Resident #108 dated 12/04/22 at 3:26 P.M., revealed the resident returned from the hospital after the fall. Notes indicated the resident had cervical collar in place related to her compression fracture and the cervical collar was to stay in place at all times until the resident saw the neurologist. Notes indicated Resident #108 was re-educated about the use of call light and resident voiced her understanding. The resident continued on neurological (neuro) checks per facility policy. Review of the nursing notes for Resident #108 dated 12/04/22 at 6:20 P.M., revealed the nursing staff spoke with family to notify them the resident would be placed on frequent checks throughout the night. Review of the untitled facility documentation for Resident #108 revealed the resident was placed on 15-minute checks from 12/04/22 at 7:00 P.M. through 12/05/22 at 7:00 A.M. Review of the facility interviews dated 12/05/22 with Licensed Practical Nurse (LPN) #35 confirmed she was the nurse taking care of Resident #108 on 12/03/22 from 7:00 P.M. to 7:00 A.M. Notes indicated LPN #35 reported she gave the resident her nighttime medication around 9:30 P.M. and the nurse reported she did not go back into resident's room until around 6:00 A.M. on 12/04/22 when State tested Nursing Aide (STNA) #23 alerted her that Resident #108 was on the floor at which time LPN #35 called 911. Notes indicated LPN #35 confirmed she did not do rounds that evening and thought the aide was completing rounds. Additionally, LPN #35 verified she knew Resident #108 had just returned from the hospital and the resident was feeling weak. Notes indicated LPN #35 did not check on resident because she had said before that she did not want to be disturbed during nighttime hours because she liked her sleep. Notes indicated resident was usually self-sufficient. Review of the updated care plan dated 12/14/22 for Resident #108, revealed new interventions to allow staff to turn off Christmas lights or leave them on and encouraging the resident to use the call light for assistance. Care plan revealed no documentation regarding checking on the resident at night. The surveyor attempted to call LPN #35 on 02/11/23 at 10:45 A.M. and 11:30 A.M. with no success. The mailbox to the phone number was full and no call back was received. Review of the facility witness statement provided by STNA #23 dated 12/05/22 at 9:36 A.M. confirmed that she was taking care of Resident #108 on 12/03/22 from 7:00 P.M. to 7:00 A.M. The statement indicated STNA #23 last observed Resident #108 on 12/03/22 around 10:00 P.M. when resident took her nighttime medications. Notes indicate the resident said goodnight and was going to bed. Notes indicated the resident had reported in the past, she did not like to be disturbed in the middle of the night, because she does everything for herself. Notes indicated STNA #23 went into the room on 12/04/22 at 6:00 A.M. to get the residents morning weight and Resident #108 was lying on the floor next to her wardrobe and couch. The statement went on to say the resident's walker was near her, and resident said she was turning off her Christmas lights when she fell . Notes indicated the resident reported she could not reach her call light or phone for help. Notes indicated the nurse called 911. Review of an additional interview dated 02/10/23 and completed by the Director of Nursing (DON) with STNA #23, confirmed she he went into resident's room on 12/04/22 at around 6:00 A.M. to get resident's weight when she found Resident #108 on the floor. Notes indicated STNA #23 reported she knew about rounding two hours, but the resident had told her before that she did not want to be disturbed during the night. Phone interview on 02/11/23 at 10:50 A.M. with STNA #23 confirmed she was the aide taking care of Resident #108 on the night shift of 12/03/22 from 7:00 P.M. to 7:00 A.M. STNA #23 confirmed the last time she saw Resident #108 was on 12/03/22 at 10:00 P.M. and she did not see the resident again until 12/04/22 at 6:00 A.M. when she was going to obtain the residents weight. STNA #23 indicated she never heard any yelling or crying from the resident's room while taking care of other residents around Resident #108's room. STNA #23 also confirmed she never opened the door to Resident #108's room from 10:00 P.M. to 6:00 A.M. because resident would hit the call light if she needed anything. Review of the call light logs dated 12/03/22 and 12/04/22 for Resident #108, revealed the call light was never activated during the night shift on 12/03/22 from 7:00 P.M. to 7:00 A.M. Interview on 02/11/23 at 6:30 A.M. with the Director of Nursing (DON), confirmed there was no aide charting for Resident #108 on 12/03/22 from 7:00 P.M. to 12/04/22 at 7:00 A.M. The DON also confirmed there was no documentation of the resident being checked on from 12/03/22 at approximately 10:00 P.M. until 12/04/22 at about 6:00 A.M. The DON stated that staff were expected to make regular rounds on each resident regardless of how much assistance they needed. The DON additionally stated the resident had stated in the past, she did not want to be bothered at night, however, also verified this reported information was not documented anywhere in resident's medical records. Review of the facility policy titled Fall Management dated 01/2023, revealed the resident would be assessed immediately and necessary treatment would be provided. Policy indicated the physician would be contacted immediately to receive any orders, This deficiency was an incidental finding discovered during the complaint investigation completed on 02/21/23.

Based on medical record review, staff interview, and review of facility policy, the facility failed to conduct thorough root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when a resident experienced repeated falls resulting in fracture and closed head injury. This affected one (#104) of three residents reviewed for falls. Facility census was 160. Findings include: Review of the medical record for Resident #104 revealed an admitted [DATE] with a diagnosis of [CONDITION(S)] with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #104 dated 02/12/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with bed mobility, transfers, and toilet use. Review of fall risk assessment for Resident #104 dated 06/07/22 revealed the resident was at high risk for falls. Review of the care plan for Resident #104 initiated on 11/29/21 revealed the resident was at risk for falling and fall related injuries related to impaired mobility, weakness and history of falls. Interventions included the following: visual reminder for resident not to walk without assistance from staff, assure floor is free of glare, liquids, encourage resident to assume a standing position slowly, encourage resident to use environmental devices such as hand grips hand rails, verbal reminders not to ambulate and transfer without assistance, keep bed in lowest position, call light in reach at all times, keep personal items in reach, night light in room, proper well maintained footwear, environment free of clutter, provide toileting assistance. Review of the nurse practitioner (NP) note for Resident #104 dated 05/11/22 revealed staff asked the nurse practitioner (NP) to evaluate the resident because the resident had fallen earlier in the day. Further review of note revealed the NP palpated resident's head and noted a large fist-sized hematoma to the resident's head. Resident #104 cried out in pain with light palpation. The NP gave order for resident to go the hospital for an evaluation. Review of skilled nursing facility (SNF) to hospital transfer form for Resident #104 dated 05/11/22 revealed the resident complained of pain to the back of her head and exhibited altered mental status and was transferred to the hospital for evaluation on 05/11/22 at 12:45 P.M. per ambulance. Review of MDS for Resident #104 dated 05/11/22 revealed the resident was discharged from the facility to the hospital. Review of MDS for Resident #104 dated 05/12/22 revealed resident returned to the facility. Review of hospital notes for Resident #104 dated 05/11/22 revealed a computed tomography (CT) scan of the resident's head showed an occipital bone fracture, subdural hematoma, a subarachnoid hemorrhage following fall. Plan was for nursing staff to conduct neurological (neuro) checks every two hours while in the hospital. Surgeon recommended follow up with outpatient traumatic brain injury (TBI) clinic. Review of medical record for Resident #104 revealed there were no neurological check sheets completed for resident upon her return from the hospital on 05/12/22. Review of progress notes for Resident #104 revealed the record did not include a description of resident's fall on 05/11/22. Interview on 07/13/22 at 2:00 P.M. with the Director of Nursing (DON) confirmed Resident #104's record did not include a description of the fall nor did the record include neuro checks upon resident's return from the hospital on 05/12/22. The DON confirmed the facility had not completed an investigation regarding resident's fall. The DON confirmed Licensed Practical Nurse (LPN) #107 was the nurse on duty at the time of Resident #104's fall on 05/11/22. Interview on 07/13/22 at 5:14 P.M. with LPN #107 confirmed she was the nurse on duty when Resident #104 fell on [DATE]. LPN #107 further confirmed she did not document Resident #104's fall in the medical record. LPN #107 confirmed Resident #104 was found on the floor in her bedroom sitting on her buttocks at approximately 10:00 A.M. on 05/11/22. LPN #107 confirmed she cannot recall if Resident #104 had on footwear, but she thought her walker was nearby. LPN #107 confirmed she was unsure if other fall prevention measures such as call light within in reach were in place per the resident's care plan prior to Resident #104's fall on 05/11/22. Review of the nurse progress note for Resident #104 dated 07/01/22 per Registered Nurse (RN) #39 revealed the resident was toileted with assist of one staff using resident's wheelchair. Staff was in Resident #104's room changing her glove due to the glove being soiled when the resident got up and tried to transfer herself back into bed and fell hitting the left side of her head on the bed which caused a laceration and bleeding. Resident #104 was sent to the hospital via 911. Review of the nurse progress note for Resident #104 dated 07/02/22 revealed the resident returned from the hospital in the morning of 07/02/22. Findings from hospital show no changes in size or severity of previous injury (from the fall on 05/11/22.) Review of the hospital notes for Resident #104 dated 07/02/22 revealed the resident had a CT scan at the hospital which showed a subdural hematoma. Resident #104 stayed overnight in the hospital and was returned to the facility on [DATE]. The hospital physician determined the subdural hematoma was chronic in nature, related to Resident #104's prior fall in the facility on 05/11/22. Interview on 07/13/22 at 2:00 P.M. with the DON confirmed the facility had not completed an investigation of Resident #104's fall on 07/01/22. The DON confirmed the progress note suggested Resident #104 was left unattended momentarily while staff changed gloves and during that time resident got up and attempted a self transfer and fell . The DON was unsure which staff member was assisting Resident #104 with toileting. The DON confirmed it was either RN #39 or one of the State tested Nursing Assistants (STNA's) #130 or #159. Interviews on 07/13/22 at 2:15 P.M. with STNA #159 and at 2:38 P.M. with STNA #130 confirmed they were not involved with Resident #104's fall on 07/01/22 and had no knowledge of how the fall occurred. Interview attempts by telephone for RN #39 on 07/13/22 at 4:54 P.M., 5:21 P.M. and on 07/14/22 at 11:49 A.M. were unsuccessful. Review of the facility policy titled Managing Falls and Fall Risk dated March 2018 revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency substantiates Complaint Number OH 816.

Based on observations, record review, policy review, staff interviews and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to comprehensively assess and implement nutritional interventions when a resident developed a Stage 2 pressure ulcer and was diagnosed with [REDACTED].#58's Stage 2 pressure ulcer worsened to a an unstageable pressure ulcer. This affected one (#58) of three residents reviewed for pressure ulcers. The facility identified four residents currently with pressure ulcers. The census was 133. Findings included: Review of Resident # 58's medical record revealed an admitted d of 02/07/18. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely cognitively impaired, required extensive assistance with activities of daily living including bed mobility, transferring, toileting and personal hygiene. The MDS assessment indicated the resident was frequently incontinent of bowel and bladder, and was at risk for pressure ulcers but currently had none. Braden Scale for Predicting Pressure Score Risk assessments were completed on 02/07/18 and 03/04/18, both assessments revealed the resident was assessed at low risk. Review of the admission nutrition assessment dated [DATE], indicated the resident had no recent weight loss. The resident's weight on admission was 180.8 pounds. Review of a quarterly MDS dated [DATE] revealed Resident #58 had a brief interview for mental status of four out of 15 indicating cognitive impairment. The resident required extensive assist of staff for bed mobility and transfers and the resident did not walk in the room or the corridor. The resident was at risk for pressure ulcers and was documented as having a Stage 3 (full thickness skin loss) pressure ulcer. The resident has experienced a significant weight loss and the current weight was 160 pounds. Review of Resident #58's care plan dated 02/07/18, indicated the resident was at risk for skin alterations related to decrease in mobility, dementia and incontinence. Interventions to prevent skin alterations included weekly skin checks by the charge nurse. Review of the medical record revealed no documentation of weekly skin checks of Resident #58 from admission, until 04/10/18 when a pressure area was discovered on her coccyx. Review of a progress note dated 04/10/18, documented the resident was noted with a fluid filled blister approximately 1 centimeter (cm) by 0.5 centimeter in her gluteal fold area. A treatment was started on 04/10/18. On 04/12/18, Wound Consultant Certified Nurse Practitioner (CNP) #300 examined the resident, verified the area was a stage two pressure ulcer and gave her the [DIAGNOSES REDACTED]. The wound measures 2 cm in length x 2 cm in width x 0.1 cm in depth. The wound was limited to skin breakdown. No drainage was noted. The wound margin is distinct with the outline attached to the wound base. The periwound skin appearance exhibited maceration and was 100 % pink partial thickness. The plan included starting barrier cream twice a day and as needed, offloading, pressure redistribution surface, encourage protein for healing and follow up next week. Review of the nutritional assessments and dietary notes revealed there was no assessments or new interventions implemented as the CNP #300 recommended for wound healing. There was no indication a protein or nutritional supplement was started for Resident #58 following CNP # 300's 04/12/18 consult. The resident's weight on 04/07/18 was 171.6 pounds. The resident's weight on 04/20/18 was 167.8 pounds. Review of a progress note dated 04/23/18, indicated Registered Dietitian (RD) #400 spoke with the resident's family member, when the family member had called with concerns related to the resident's weight loss and poor intakes. The resident was started on a nutritional supplement three times per day. RD #400's note did not indicate the resident had a pressure ulcer or had increased needs for wound healing. Review of a wound note by CNP #300 dated 04/19/18 and 04/24/18 revealed the wound remained assessed as a stage two. Review of a wound note dated 05/03/18, revealed CNP #300 assessed the wound and staged the wound as an unstageable. The wound measured 3.5 cm in length by 4 cm in width and 0.2 cm in depth with red, brown serosanguieous exudates. There was a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough. The periwound skin appearance exhibited maceration. The CNP's note further stated the ulcer declined due to a urinary tract infection and poor nutritional intake. Plans included discontinuing barrier cream, starting [MEDICATION NAME] gauze daily and as needed, starting mist therapy three times a week, low air loss mattress and a dietitian consult. Review of physician orders [REDACTED]. RD #500 assessed the patient on 05/07/18, noted the resident had an open area to her coccyx and recommended prostat (protein drink) three times per day for wound healing and a high calorie nutritional supplement drink three times per day for weight loss. The resident's weight on 05/02/18 was 167.8 pounds. Review of the wound note dated 10/02/18, documented CNP # 300 again assessed the wound and staged it as stage 4. The wound measured 1.5 cm in length by 0.5 cm in width and 1.5 cm in depth with undermining starting at 10 o'clock (10:00) and ending at one o'clock (1:00) with a maximum distance of 1.6 cm. There was a Fat Layer (Subcutaneous Tissue) exposed. There was a small (1-33%) amount of necrotic tissue within the wound bed including adherent slough. Review of the resident's laboratory results revealed there was no [MEDICATION NAME] or [MEDICATION NAME] levels obtained for Resident #58 to help assess nutritional status. Observations on 11/07/18 at 10:28 A.M., revealed Resident #58 was observed in the common area. The resident was seated in a wheelchair with a roho cushion in the chair. On 11/08/18 at 8:51 A.M., Resident #58's wound was observed when CNP #300 and Licensed Practical Nurse (LPN) #80 completed the resident's wound treatment. The wound was a stage 4 and measured 1.8 cm in length by 1.2 cm in width and 0.3 cm in depth with undermining. CNP #300 stated the wound had no significant changes since it was last examined. Interview on 11/08/18 at 11:52 A.M., with LPN #214 stated on admission the resident had care planned interventions which included a pressure reduction mattress, pressure reduction cushion to her chair and for weekly skin checks to be completed by the nurse. LPN #214 verified the facility had no evidence the weekly skin checks had been completed. LPN #214 stated a stage 2 pressure ulcer was found on Resident #58 on 04/10/18 and stated she did not know who had discovered the wound. LPN #214 further verified no nutritional intervention to promote wound healing were started until a nutritional supplement was started on 04/23/18 for weight loss and the pressure relieving devices were not ordered until 05/03/18. LPN #214 verified prostat (a protein supplement) was not ordered until 05/07/18. Interview on 11/08/18 at 1:56 P.M., with the Director of Nursing (DON) stated the facility's policy is for the nurse to complete skin checks weekly on every resident and verified Resident #58's weekly skin checks had been missed because of an error made in the resident's electronic health record on admission. Interview on 11/08/18 at 3:19 P.M., with CNP #300 stated he could not say if Resident #58's pressure area was avoidable or unavoidable. When Resident #58's pressure score was first found, the resident had significant issues with her nutritional status, was not eating well and had weight loss. Therefore, the resident was diagnosed on [DATE], with mild protein calorie malnutrition. CNP #300 verified the resident needed to improve her nutritional intake. He further stated he did not order a nutritional supplement or nutritional labs. CNP #300 stated nutritional labs, such as [MEDICATION NAME] or [MEDICATION NAME], are not always reflective of nutritional status in the elderly. RD #400 was no longer employed at the facility and was unavailable for interview. Review of the undated facility's policy titled Prevention of Pressure Ulcers, indicated as interventions and preventive measures the facility would routinely assess and document the condition of the resident's skin weekly on shower days for any signs and symptoms of irritation or breakdown. Review of information from the NPUAP revealed a Stage 2 Pressure Injury is partial-thickness skin loss with exposed dermis. An Unstageable Pressure Injury is obscured full-thickness skin and tissue loss as the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. A Stage 4 Pressure Injury is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Further review of the NPUAP revealed the staff should develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Refer all individuals at risk for pressure injury from malnutrition to a registered dietitian/nutritionist.

Based on observations, record review, policy review, staff interviews and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement interventions to prevent the worsening of a pressure ulcer. This resulted in actual harm when a Stage 2 pressure ulcer progressed to a an unstageable pressure ulcer. This affected one (#58) of three residents reviewed for pressure ulcers. The facility identified four residents currently with pressure ulcers. The census was 133. Findings included: Review of Resident # 58's medical record revealed an admitted d of 02/07/18. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely cognitively impaired, required extensive assistance with activities of daily living including bed mobility, transferring, toileting and personal hygiene. The MDS assessment indicated the resident was frequently incontinent of bowel and bladder, and was at risk for pressure ulcers but currently had none. Braden Scale for Predicting Pressure Score Risk assessments were completed on 02/07/18 and 03/04/18, both assessments revealed the resident was assessed at low risk. Review of the admission nutrition assessment dated [DATE], indicated the resident had no recent weight loss. The resident's weight on admission was 180.8 pounds. Review of a quarterly MDS dated [DATE] revealed Resident #58 had a brief interview for mental status of four out of 15 indicating cognitive impairment. The resident required extensive assist of staff for bed mobility and transfers and the resident did not walk in the room or the corridor. The resident was at risk for pressure ulcers and was documented as having a Stage 3 (full thickness skin loss) pressure ulcer. The resident has experienced a significant weight loss and the current weight was 160 pounds. Review of Resident #58's care plan dated 02/07/18, indicated the resident was at risk for skin alterations related to decrease in mobility, dementia and incontinence. Interventions to prevent skin alterations included weekly skin checks by the charge nurse. Review of the medical record revealed no documentation of weekly skin checks of Resident #58 from admission, until 04/10/18 when a pressure area was discovered on her coccyx. Review of a progress note dated 04/10/18, documented the resident was noted with a fluid filled blister approximately 1 centimeter (cm) by 0.5 centimeter in her gluteal fold area. A treatment was started on 04/10/18. On 04/12/18, Wound Consultant Certified Nurse Practitioner (CNP) #300 examined the resident, verified the area was a stage two pressure ulcer and gave her the [DIAGNOSES REDACTED]. The 04/12/18, note stated the wound was classified with etiology of pressure ulcer and is located on the coccyx. The wound measures 2 cm in length x 2 cm in width x 0.1 cm in depth. The wound was limited to skin breakdown. No drainage was noted. The wound margin is distinct with the outline attached to the wound base. The periwound skin appearance exhibited maceration and was 100 % pink partial thickness. The plan included starting barrier cream twice a day and as needed, offloading, pressure redistribution surface, encourage protein for healing and follow up next week. Review of the nutritional assessments and dietary notes revealed there was no assessments or new interventions implemented as the CNP #300 recommended for wound healing. There was no indication a protein or nutritional supplement was started for Resident #58 following CNP # 300's 04/12/18 consult. The resident's weight on 04/07/18 was 171.6 pounds. The resident's weight on 04/20/18 was 167.8 pounds. Review of a progress note dated 04/23/18, indicated Registered Dietitian (RD) #400 spoke with the resident's family member, when the family member had called with concerns related to the resident's weight loss and poor intakes. The resident was started on a nutritional supplement three times per day. RD # 400's note did not indicate the resident had a pressure ulcer or had increased needs for wound healing. Review of a wound note by CNP #300 dated 04/19/18 and 04/24/18 revealed the wound remained assessed as a stage two. Review of a wound note dated 05/03/18, revealed CNP #300 assessed the wound and staged the wound as an unstageable. The wound measured 3.5 cm in length by 4 cm in width and 0.2 cm in depth with red, brown serosanguieous exudates. There was a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough. The periwound skin appearance exhibited maceration. The CNP's note further stated the ulcer declined due to a urinary tract infection and poor nutritional intake. Plans included discontinuing barrier cream, starting [MEDICATION NAME] gauze daily and as needed, starting mist therapy three times a week, low air loss mattress and a dietitian consult. Review of physician orders [REDACTED]. RD #500 assessed the patient on 05/07/18, noted the resident had an open area to her coccyx and recommended prostat (protein drink) three times per day for wound healing and a high calorie nutritional supplement drink three times per day for weight loss. The resident's weight on 05/02/18 was 167.8 pounds. Review of the wound note dated 10/02/18, documented CNP # 300 again assessed the wound and staged it as stage 4. The wound measured 1.5 cm in length by 0.5 cm in width and 1.5 cm in depth with undermining starting at 10 o'clock (10:00) and ending at one o'clock (1:00) with a maximum distance of 1.6 cm. There was a Fat Layer (Subcutaneous Tissue) exposed. There was a small (1-33%) amount of necrotic tissue within the wound bed including adherent slough. Review of the resident's laboratory results revealed there was no [MEDICATION NAME] or [MEDICATION NAME] levels obtained for Resident #58 to help assess nutritional status. Observations on 11/07/18 at 10:28 A.M., revealed Resident #58 was observed in the common area. The resident was seated in a wheelchair with a roho cushion in the chair. On 11/08/18 at 8:51 A.M., Resident #58's wound was observed when CNP #300 and Licensed Practical Nurse (LPN) #80 completed the resident's wound treatment. The wound was a stage 4 and measured 1.8 cm in length by 1.2 cm in width and 0.3 cm in depth with undermining. CNP #300 stated the wound had no significant changes since it was last examined. Interview on 11/08/18 at 11:52 A.M., with LPN #214 stated on admission the resident had care planned interventions which included a pressure reduction mattress, pressure reduction cushion to her chair and for weekly skin checks to be completed by the nurse. LPN #214 verified the facility had no evidence the weekly skin checks had been completed. LPN #214 stated a stage 2 pressure ulcer was found on Resident #58 on 04/10/18 and stated she did not know who had discovered the wound. LPN #214 further verified no nutritional intervention to promote wound healing were started until a nutritional supplement was started on 04/23/18 for weight loss and the pressure relieving devices were not ordered until 05/03/18. LPN #214 verified prostat (a protein supplement) was not ordered until 05/07/18. Interview on 11/08/18 at 1:56 P.M., with the Director of Nursing (DON) stated the facility's policy is for the nurse to complete skin checks weekly on every resident and verified Resident #58's weekly skin checks had been missed because of an error made in the resident's electronic health record on admission. Interview on 11/08/18 at 3:19 P.M., with CNP #300 stated he could not say if Resident #58's pressure area was avoidable or unavoidable. When Resident #58's pressure score was first found, the resident had significant issues with her nutritional status, was not eating well and had weight loss. Therefore, the resident was diagnosed on [DATE], with mild protein calorie malnutrition. CNP #300 verified the resident needed to improve her nutritional intake. He further stated he did not order a nutritional supplement or nutritional labs. CNP #300 stated nutritional labs, such as [MEDICATION NAME] or [MEDICATION NAME], are not always reflective of nutritional status in the elderly. RD #400 was no longer employed at the facility and was unavailable for interview. Review of the undated facility's policy titled Prevention of Pressure Ulcers, indicated as interventions and preventive measures the facility would routinely assess and document the condition of the resident's skin weekly on shower days for any signs and symptoms of irritation or breakdown. Review of information from the NPUAP revealed a Stage 2 Pressure Injury is partial-thickness skin loss with exposed dermis. An Unstageable Pressure Injury is obscured full-thickness skin and tissue loss as the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. A Stage 4 Pressure Injury is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Further review of the NPUAP revealed the staff should develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Refer all individuals at risk for pressure injury from malnutrition to a registered dietitian/nutritionist.