Every finding on record at Majestic Care of Clyde

Based on observation, review of the medical record, interview, and policy review, the facility failed to properly assess a pressure ulcer wound when specifically omitting accurate measurements, staging, and characterization of the wound. Additionally, the facility failed to implement physician-ordered treatments and failed to report changes in wound status. This lack of intervention resulted in actual harm on 07/01/26, as evidenced by the deterioration of the resident's stage three pressure ulcer when the resident's wound developed undermining on 07/01/26 and continued to deteriorate and increase in depth. This affected one (#21) of three (#21, #8, #33) residents reviewed for pressure ulcers. The facility identified four (#21, #8, #33, #11) residents with pressure ulcers. The facility census was 65.Findings include:Review of the medical record for Resident #21 revealed an admission date of 05/21/26. Diagnoses included pneumonitis, pleural effusion, atrial fibrillation, pulmonary hypertension, dementia, chronic kidney disease, peripheral vascular disease, respiratory failure, dysphagia, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was dependent on staff for bed mobility and transfers. The resident had a stage three pressure ulcer. The resident had an indwelling urinary catheter, and the resident was occasionally incontinent of bowel. The resident was at risk for skin breakdown. Review of the care plan initiated on 05/21/26 and last revised on 05/27/26 revealed the resident required assistance with activities of daily living due to impaired mobility, weakness, pneumonitis, peripheral vascular disease, tremors, osteoarthritis, and dementia. Interventions included total assistance with bed mobility. Review of physician orders dated 05/21/26 revealed an order for a regular diet with regular texture, thin consistency, with chopped meats. The resident had an order for house barrier cream to the buttocks, coccyx, and peri-area every shift with incontinent episodes and as needed. There was an order to encourage the resident to turn and reposition every two hours while in bed every shift to minimize risk of skin breakdown. The resident had an order for a pressure reduction mattress. There was an order to apply skin protectant to the toe scabs and bilateral heels every shift. There were no wound care treatment orders for the stage three pressure ulcer to the coccyx. Review of an admission skin evaluation completed on 05/21/26 revealed the resident was noted with a small slit to the lower spine from an old surgical incision measuring nine centimeters (cm) in length by three cm in width. A stage three pressure ulcer (full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling) to the coccyx measuring eight cm in length by eight cm in width, purple surrounding skin with moderate serous drainage. There was no documentation of the depth of the wound or the wound characteristics. The resident was noted with scabs on two toes on the right foot and one toe on the left foot. The resident was noted with a mushy right heel with a calloused area and a mushy left heel with no redness. Also, the resident had scarring on the bilateral knees and the right outer elbow. The resident had bruising on the right and left hand, and scattered bruising on the right arm and the left lower extremity. The evaluation further noted a treatment was applied but the type of treatment and location of the treatment were not specified. Review of the care plan initiated 05/22/26 revealed the resident was at risk for skin breakdown with interventions for a pressure reducing mattress and a chair cushion. Also, staff assessing the resident's skin would take additional time to ensure careful observation of the resident's skin to ensure healing and the prevention of a skin impairment developing. The care team would follow the treatment plan, medication regimen, perform diagnostic studies, and adhere to other health interventions to ensure optimal healing and skin prevention.Review of the nutrition care plan initiated 05/25/26 revealed the resident had a potential for having a nutritional risk related to congestive heart failure, chronic kidney disease, diuretic therapy, edema, history of aspiration pneumonia, and dysphagia. Interventions included to document the food/fluid intakes, provide and serve supplements as ordered, and for the dietitian to evaluate and make diet change recommendations as needed. Further review of the nutrition care plan revealed no nutritional interventions for Resident #21's wounds or pressure ulcers.Review of a dietitian review assessment completed on 05/26/26 at 9:39 A.M. revealed the resident was on a regular diet with regular texture and thin liquids. The resident weighed 159 pounds. The dietician noted the resident had no skin issues besides scars, bruising, and scabs. There was no documentation regarding the stage three pressure ulcer. The residents' food intakes were noted as fluctuating between 25 percent to 100 percent. The resident required extensive feeding assistance. The dietitian noted there were no new recommendations. Review of nine nursing daily skilled head to toe assessments completed from 05/22/26 through 05/27/26 revealed no documentation of the presence of the stage three pressure ulcer. Current skin conditions noted by the nurses included excoriation to the perianal area, open areas to the toes, scabs on the toes, and other with no further description. Review of a skin condition evaluation dated 05/27/26 revealed the resident had a stage four pressure ulcer (full thickness skin and tissue loss with exposed bone, tendon or muscle where slough or eschar may be present on some parts of the wound bed and often including undermining and tunneling) to the sacrum measuring eight cm in length and eight cm in width with an undetermined depth. The area was noted as stable with full thickness skin and tissue loss. There was no documentation regarding undermining or tunneling, and there was no description of the wound bed. There was moderate serosanguineous drainage, and the surrounding skin edges were attached. The surrounding tissue was noted as normal in color with no induration. There was no documentation that a wound treatment order was obtained from the physician and no documentation that a wound treatment had been applied. The resident was also noted with an old surgical incision wound to the middle upper vertebrae measuring nine cm in length by three cm in width which later resolved on 06/24/26. Review of a physician order dated 05/28/26 revealed to cleanse the coccyx with normal saline and pat dry. Apply collagen to the wound bed and cover with a foam dressing. Change daily and as needed for wound care. Review of the Treatment Administration Record (TAR) dated 05/21/26 through 05/31/26 revealed there were no wound care treatments administered for the stage three or stage four pressure ulcer until 05/29/26. Staff were applying barrier cream each shift.Review of a late entry nurses note created on 06/02/26 at 10:31 A.M. for 05/21/26 at 5:27 P.M. by a former interim Director of Nursing revealed a clarification noting the coccyx wound noted on admission was a stage three pressure ulcer. Review of a physician order dated 06/02/26 revealed the resident was ordered an alternating air mattress for skin integrity. Review of a skin condition evaluation dated 06/03/26 revealed the resident had a stage three full thickness skin loss pressure ulcer to the coccyx. The area measured eight cm in length by eight cm in width with an undetermined depth. There was no description of the wound bed. The wound was noted as improving. There was moderate serosanguineous drainage. The surrounding skin edges were attached and noted as normal in color. There was no documentation of undermining or tunneling.Review of a skin condition evaluation dated 06/10/26 revealed the resident had a stage three pressure ulcer to the sacrum measuring five cm in length by three cm in width with an undetermined depth. The wound was noted as improving. The wound bed contained 30 percent epithelization tissue. There was no documentation for the other 70 percent of the wound bed. There was moderate serosanguineous drainage. There was no documentation of undermining or tunneling. The surrounding skin was noted as normal in color. The resident also had a new stage two pressure ulcer to the right heel measuring 2.5 cm in length by 2.5 cm in width by 0.1 cm in depth. There was no documentation of the wound bed characteristics. The stage two pressure ulcer to the heel was noted as heeled on 07/08/26. Review of a nurse's note dated 06/12/26 at 5:03 P.M. revealed the nurse practitioner was updated on the wound to the resident's buttocks. The area had adhered slough. A new order was received, and the resident's family was notified. Review of the skin evaluations revealed a reassessment of the wound due to changes in the wound was not completed. Review of a physician order dated 06/12/26 revealed to cleanse the coccyx with wound wash, apply Medi-honey to the wound bed, cover with bordered foam every shift and as needed. Review of the care plan initiated on 06/12/26 and last revised on 06/26/26, revealed the resident had impaired skin integrity including a healed surgical incision to the upper middle back, a stage two pressure ulcer of the right heel, and a stage three sacral ulcer. Interventions included for staff to assess and document skin condition, notify the physician of worsening or no improvement in the wound and of signs of infection. Also, there were interventions to assist the resident with bed mobility to turn and reposition routinely and to complete the wound treatments as ordered.Review of a nutrition/dietary note dated 06/14/26 at 11:43 P.M. revealed the dietitian noted the resident had an area to the right heel, treatments in place, monitor skin integrity for improvement and assist with meals as needed. Further review of the documentation revealed there was no reassessment of the residents' nutritional needs with no new interventions or recommendations. Review of a physician order dated 06/16/26 revealed to cleanse the coccyx wound with wound wash, apply a Thera-honey sheet to the wound bed, cover with bordered foam every shift and as needed for wound care. Review of a skin condition evaluation dated 06/17/26 revealed the resident had a stage three pressure ulcer to the sacrum measuring 4.6 cm in length, 2.8 cm in width, with an undetermined depth. The wound was noted as improving. The wound bed had 40 percent granulation with no documentation for the other 60 percent of the wound bed. The wound had moderate serosanguineous drainage. The skin surrounding the wound was noted as normal in color. There was no documentation of tunneling or undermining. Review of a skin condition evaluation dated 06/24/26 revealed the resident had a stage three pressure area to the sacrum measuring 3.1 cm in length, three cm in width, and 0.3 cm in depth. The wound was noted as improving. The wound bed was noted with 50 percent granulation with no documented description of the other 50 percent of the wound bed. The wound had moderate serosanguineous drainage. The skin surrounding the wound was noted as normal in color. There was no documentation of undermining or tunneling. Review of a nutrition/dietary note dated 06/28/26 at 7:58 P.M. revealed the dietitian noted the stage three pressure ulcer to the sacrum and the stage two pressure ulcer to the heel were improving. No nutritional interventions were recommended. Review of the nurse's notes dated 06/25/26 through 06/30/26 revealed there was no documentation the resident's wound had developed undermining when observed during the wound treatments completed two times each day. Review of the TAR dated 06/01/26 through 06/30/26 revealed the wound treatments were not completed during day shift on 06/04/26, on night shift on 06/25/26, and no wound treatments were completed on 06/29/26 on either the day shift or night shift. There was no documentation the resident had refused care or treatment interventions.Review of the nutrition task for the amount eaten dated 06/10/26 through 07/04/26 revealed the resident had refused one meal. The resident consumed 26 percent to 50 percent for seven meals. The resident consumed 51 percent to 75 percent for 33 meals. The resident consumed 76 percent to 100 percent for 33 meals. There was no documentation for 11 meals. Review of a skin condition evaluation dated 07/01/26 revealed the stage three pressure ulcer to the sacrum measured four cm in length, three cm in width, and 0.3 cm in depth. The wound was noted as worsening due to undermining of one cm at 12 o'clock and 3 o'clock. There was no description of the wound bed and there was no documentation of any slough being present in the wound bed. The wound had moderate serosanguineous drainage. The skin surrounding the wound was noted as normal in color. There was no documentation the physician and family were notified. Review of the nursing notes dated 07/01/26 through 07/06/26 revealed no documentation the physician was notified regarding the continuing decline of the stage three pressure ulcer. The last documented update to the physician regarding the wound condition occurred on 06/12/26. There was no documentation the worsening wound was reassessed. There was also no documentation that the dietitian was made aware of the changes in the wound. There was no documentation the resident had refused care or treatment interventions. Review of the TAR dated 07/01/26 through 07/06/26 revealed the resident's wound treatment was documented as completed twice daily. Observation on 07/07/26 at 10:43 A.M. of wound care for Resident #21 with Registered Nurse (RN) #200 and Certified Nursing Assistant (CNA) #244 revealed the bed was raised and the resident was positioned on his right side leaning toward the grab bar (positioning aid) while CNA #244 assisted the resident with maintaining his position. The resident had an undated and unsigned wound dressing in place on the coccyx. RN #200 removed the dressing and there was approximately a six centimeter in length by three cm in width area of dark brown dried exudate on the wound dressing. RN #200 cleansed the wound. The wound was deep with full thickness skin loss and extensive tissue loss. There was no visible bone, muscle, or cartilage. Approximately 50 percent of the wound bed was covered in yellow slough with approximately 50 percent granulation tissue. RN #200 measured the wound. The wound was 4.5 cm in length, three cm in width, with a depth of two cm. There were no odors and no signs of infection. There was undermining from 11:00 o'clock through 3:00 o'clock with a depth of 1.3 cm. The surrounding skin had large areas of reddened blotchy skin extending from the bilateral buttocks up to the resident's lower back. RN #200 revealed the wound looked worse than a stage three pressure ulcer and the wound was not that deep last week. RN #200 completed the wound dressing change per physician orders and stated she was going to call the nurse practitioner. Review of a nurse's note dated 07/07/26 at 1:59 P.M. revealed the nurse practitioner was updated on the wound to the coccyx. New orders were received. Further review of the wound documentation and nurses note revealed RN #200 had not documented her assessment of the wound after completing the wound treatment. Review of a physician order dated 07/07/26 revealed to cleanse the coccyx with wound wash, apply skin protectant to the skin surrounding the wound, pack the wound with wet gauze, cover with dry gauze, and a bordered foam dressing every shift and as needed for wound care. Interview on 07/07/26 at 2:05 P.M., Unit Manager Licensed Practical Nurse (UMLPN) #202 revealed RN #213 had completed the resident's admission skin assessment and should have completed and documented the wound assessment and entered treatment orders. UMLPN #202 was asked by the surveyor if the resident's wound upon admission may have been unstageable. UMLPN #202 revealed she was not allowed to stage a wound. UMLPN #202 revealed one of several recent interim Directors of Nursing (DON) had staged the wound. UMLPN #202 revealed she just documented the stage she was told. UMLPN #202 verified she was not completing documentation of the wound bed assessment and also had not accurately documented other wound bed assessments to include 100 percent of the wound bed. UMLPN #202 revealed on 06/10/26 the wound bed was weird looking but had not looked like granulation tissue. UMLPN #202 revealed there was no one to reach out to. UMLPN #202 revealed another interim DON looked at the wound but was not here long. UMLPN #202 revealed on 06/17/26 she saw fatty tissue in the wound bed. UMLPN #202 revealed on 07/01/26 the wound had a little bit of undermining, but the full depth of the wound was 0.3 cm and verified there was no slough documented. UMLPN #202 revealed if there was slough, it was not a lot. UMLPN #202 revealed all the nurses who had cared for the resident had treated the wound and should have recognized the wound looked worse and they should have contacted the physician. Interview on 07/07/26 at 3:09 P.M., RN #213 revealed she completed the resident's admission. RN #213 revealed the resident had a stage three pressure ulcer upon admission. RN #213 verified she had not completed a full wound assessment and had not notified the physician to obtain treatment orders for the wound. RN #213 revealed she was not aware she needed to complete the skin wound evaluation as she thought the resident's nurse or unit manger would complete the evaluation. RN #213 revealed she had a conversation with UMLPN #202 regarding the wound the following day. Interview on 07/07/26 at 5:50 P.M., Licensed Practical Nurse (LPN) #206 stated she had a bad habit of signing off her treatments before completing them. LPN #206 revealed the undated dressing found during the wound care observation on 7/07/26 had not been completed by her. LPN #206 revealed on 07/06/26 she had documented completing the resident's wound treatment but never completed the treatment during the 12-hour evening shift. LPN #206 revealed she recalled during care with the nursing assistants, the resident had a wound dressing in place and could not recall seeing a date on the wound dressing. LPN #206 revealed the last time she had changed the wound dressing (06/29/26) the wound had a depth of about 0.5 cm and the wound looked like it was staying the same. Observation on 07/08/26 at 8:30 A.M. of wound care for Resident #21 with RN #213 and the new Director of Nursing (DON) revealed the resident was positioned on his left side and the resident was holding the bed grab bar trying to remain on his left side with no staff assisting the resident with maintaining his position. The resident's bed was not raised. The DON had a physician on the phone to look at the wound. The wound dressing was removed and the wound was cleansed. The wound bed was difficult to see due to how the resident was positioned and the low position of the bed. The DON measured the wound. The DON stated the wound measured four cm in length, 3.8 cm in width, with a depth of 1.4 cm. The DON was asked to measure the depth a second time as it appeared he was not measuring the deepest part of the wound. The DON stated again the wound depth was 1.4 cm with undermining from nine o'clock to three o'clock with a depth of 1.4 cm at 12 o'clock. The DON stated the wound had 40 percent granulation tissue and 60 percent slough with no exudate. UMLPN #202 entered the room during the wound care to look at the wound. UMLPN #202 revealed the wound was a lot deeper than when she had evaluated the wound on 07/01/26. UMLPN #202 revealed the deeper hole now present in the wound was not there when the wound was last assessed. Interview on 07/08/26 at 9:08 A.M., LPN #207 revealed she had completed the resident's wound treatments during the 12-hour dayshift on 07/04/26, 07/05/26, and 07/06/26. LPN #207 revealed the wound was a lot worse since she last saw the wound on 06/26/26. LPN #207 revealed she thought the wound should have been packed. LPN #207 revealed she told UMLPN #202 the resident's wound was a lot worse and UMLPN #202 said she would be taking a look at it. LPN #207 revealed she had not called the physician because she was not sure if someone had already notified the physician and she was not sure how long the wound had been looking like that. LPN #207 also revealed she had not always signed and dated the wound dressings but would try to before applying the dressing. LPN #207 revealed when she had changed the wound dressing on 07/06/26 the wound dressing was dated 07/05/26 from the previous shift. LPN #207 revealed discussing the wound with another nurse who told her the wound looked pretty bad but had not gone into detail. Interview on 07/08/26 at 9:28 A.M., UMLPN #202 revealed none of the nurses had notified her that Resident #21's wound had worsened after 07/01/26 until RN #200 notified her yesterday after the wound observation. UMLPN #202 revealed the nurses should have documented their assessment and notified the physician. Interview on 07/08/26 at 10:26 A.M., RN #216 revealed she had completed a wound treatment for the resident on 06/19/26 and on 07/02/26. RN #216 revealed on 07/02/26 that the resident's wound looked worse, the wound was a lot deeper and there was some slough in the wound bed. RN #216 revealed she had not documented any assessment of the wound and had not notified the physician regarding the wound. RN #216 revealed she worked prn (as needed) in the facility and assumed the other nurses had documented and reported the changes in the wound. Interview on 07/08/26 at 10:46 A.M., Clinical Resource Registered Nurse (CRRN) #277 verified no wound treatment orders had been obtained until 05/28/26 and no wound care treatments had been documented as completed for the stage three pressure ulcer until 05/29/26. CRRN #277 revealed the facility was in the process of contracting with a wound care provider. Interview on 07/08/26 at 2:26 P.M., UMLPN #222 verified there was no documentation the physician ordered wound treatments for the stage three pressure ulcer were completed on dayshift on 06/04/26, on nightshift on 06/25/26, and on both shifts on 06/29/26. UMLPN #222 also verified there were no wound treatments initiated for the stage three pressure ulcer until 05/29/26. Interview on 07/08/26 at 2:45 P.M., Registered Dietitian (RD) #302 revealed she was the dietitian in the facility until the change of ownership on 06/30/26. RD #302 revealed she was not aware the resident had a pressure ulcer when she completed the resident's nutritional assessment on 05/26/26. RD #302 revealed she was later notified the resident had a stage three pressure ulcer and a stage two pressure ulcer. RD #302 verified she had not recalculated the resident's nutritional needs. RD #302 revealed as far as she knew the resident was eating okay and would not have required nutritional supplementation. RD #302 revealed she had not been made aware of any decline in the residents' wounds. RD #302 revealed if she had been made aware of a decline in the wound then she may have added some type of nutritional supplement. Interview on 07/09/26 at 8:25 A.M., UMLPN #222 revealed she was not always able to complete the resident's wound dressing changes because he would not want to get back in bed for the dressing change if he was getting ready to eat his meals. UMLPN #222 revealed she was unable to describe the resident's wound except for stating it just looked bad. UMLPN #222 revealed she usually worked the day after the resident's wound care evaluations, so she assumed they were already aware of what the wound looked like. Interview on 07/09/26 at 9:26 A.M., the DON verified after reviewing the medical record there was no documentation in the medical record the resident had refused care or treatment. Further interview with the DON revealed the clarification progress note for the stage of the resident's pressure ulcer wound was a late entry completed on 06/02/26. Interview on 07/09/26 at 10:05 A.M., CRRN #277 verified the resident's stage three pressure ulcer wound should have been documented in the nurse's daily skilled nursing evaluations. CRRN #277 revealed an assessment of the entire wound bed was a standard of care. CRRN #277 revealed UMLPN #202 had been trained to assess wounds. CRRN #277 verified the previous facility ownership policies provided no guidelines on what to include in a wound assessment. CRRN #277 verified last week that the staff had not notified her of a decline in the resident's stage three pressure ulcer wound and had not requested information for the new dietitian. CRRN #277 verified the dietitian, and the physician should have been notified of the decline in the stage three pressure ulcer. CRRN #277 verified a nutritional reassessment, and a wound reassessment should have been completed. CRRN #277 verified the previous facility ownership policies were effective through 06/29/26 and the current policies were in effect when the new facility ownership began on 06/30/26.Interview on 07/09/26 at 11:13 A.M., UMLPN #202 revealed she had not contacted the physician regarding the wound decline on 07/01/26. UMLPN #202 revealed RN #200 had previously contacted the physician about the wound and had received the order for the new treatment on 06/12/26. UMLPN #202 revealed she had not thought to notify the dietitian. UMLPN #202 revealed the dietitian for the former ownership would have told her to address the wound decline during the weekly risk meeting. UMLPN #202 revealed the facility had no dietitian yet with the new ownership. Interview on 07/09/26 at 12:02 P.M., LPN #220 revealed she had not seen the resident's wound in several weeks. LPN #220 revealed she was quite stunned when she changed the resident's wound dressing on 07/03/26. LPN #220 revealed the wound previously was healing with little depth and was now considerably worse. LPN #220 estimated the wound depth was about one half inch (1.27 cm) deep. LPN #220 revealed she had not documented her assessment and had not notified the physician about the wound. LPN #220 revealed she was not aware if the worsening of the wound was new and wanted to talk to another nurse who knew the resident better. LPN #220 revealed the wound was discussed with the oncoming nurse during shift report who agreed the wound had gotten considerably worse. Interview on 07/09/26 at 12:18 P.M., RD #300 revealed she had not been notified by the facility of a decline in the resident's wound. RD #300 revealed she was currently covering the facility since the change in ownership on 06/30/26. RD #300 revealed the previous dietitian should have recalculated the resident's nutritional needs when she became aware of the pressure ulcer and then again when there was a decline in the wound. RD #300 revealed the dietitian should have reviewed the wound log. RD #300 revealed a stage three pressure ulcer required a lot of calories and nutrients to heal. RD #300 revealed she would have reviewed the resident's medical record, medications, labs, and discussed options with the resident and/or family. RD #300 revealed usually supplements or fortified foods would be recommended if the resident was not consuming 100 percent of the meals provided. Interview on 07/09/26 at 1:32 P.M., the DON revealed the wound may have gotten deeper because the wound treatment was debriding the slough in the wound bed. The DON stated the wound treatment would cause a change in the wound measurements. The DON revealed RN #200 had notified the physician of the wound decline and the slough in the wound bed on 06/12/26. The DON verified there was no slough documented in the wound bed for the weekly wound assessments completed on 06/17/26, 06/24/26, and 07/01/26. The DON also verified there was no documentation of the percentage of meal intakes for 11 of the residents' meals. Review of the facility policy Nutrition Assessment, revised 07/07/25 used by the previous facility ownership and in effect through 06/29/26, revealed a registered dietitian would assess the nutritional status of each resident upon admission, annually, and with a significant change in condition. The care plan would be updated as resident needs and interventions changed. Review of the facility policy Wound Management Policy, dated 05/20/24 used by the previous facility ownership and in effect through 06/29/26, revealed residents with impaired skin integrity would be treated timely, and interventions to heal would not be exhausted until the skin was healed. Further review of the policy revealed the resident's skin would be assessed at admission and evaluated routinely. The facility would have a system in place to prevent the condition of skin impairment from evolving and eroding the health of the resident affected. There were no guidelines for assessing a wound. Review of the facility policy Wound Program, dated 05/10/24 revealed at the time of admission the resident's skin would be assessed upon admission. Skin conditions would be assessed, measured, and documented with a treatment applied. There were no guidelines for conducting a wound assessment. Review of the facility policy Nutritional Management dated 06/30/26 revealed a comprehensive nutritional assessment would be completed by the dietitian within 72 hours of admission, annually, and upon significant change in condition. The assessment would clarify the resident's current nutritional status and individual risk factors for altered nutrition/hydration. Interventions would be individualized to address the specific needs of the residents. Monitoring of the resident's condition and care plan interventions would occur on an ongoing basis and would be updated when a resident's condition changes or interventions were determined to be ineffective, or if new causes of nutritional-related problems were identified. Review of the facility policy Documentation of Wound Treatments, dated 06/30/26 revealed wound assessments would be documented on admission, weekly, and as needed if the resident or wound condition deteriorates. A complete wound assessment included the type of wound, location of wound, stage of wound, measurements for length, width, depth, undermining, and tunneling. Also included in the wound assessment were the wound characteristics including the color of the wound bed, the type of tissue in the wound bed, the condition of the skin surrounding the wound, the amount and type of wound drainage, and the presence or absence of odor and pain. Additional documentation would include notification to the physician and to the responsible party regarding wound condition changes or wound treatment changes. Review of the facility policy Wound Treatment Management, dated 06/30/26 revealed the effectiveness of treatments would be monitored through ongoing assessment of the wound. Considerations for needed modifications included the lack of progression toward healing, and changes in the characteristics of the wound. This deficiency represents non-compliance investigated under Complaint Number 2990029.

Based on review of the medical record, interview, and policy review, the facility failed to ensure an accurate and complete medical record. This affected one (#21) of three residents reviewed for accuracy of the medical record. The facility census was 65. Findings include:Review of the medical record for Resident #21 revealed an admission date of 05/21/26. Diagnoses included pneumonitis, pleural effusion, atrial fibrillation, pulmonary hypertension, dementia, chronic kidney disease, peripheral vascular disease, respiratory failure, dysphagia, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was dependent on staff for bed mobility and transfers. The resident had a stage three pressure ulcer. The resident had an indwelling urinary catheter, and the resident was occasionally incontinent of bowel. The resident was at risk for skin breakdown.Review of an admission skin evaluation completed on 05/21/26 revealed the resident had a stage three pressure ulcer (full thickness tissue loss where subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling) to the coccyx measuring eight centimeters (cm) in length by eight cm in width, purple surrounding skin with moderate serous drainage.Review of nine nursing daily skilled head to toe assessments completed from 05/22/26 through 05/27/26 revealed no documentation of the presence of the stage three pressure ulcer. Current skin conditions noted by the nurses included excoriation to the perianal area, open areas to the toes, scabs on the toes, and other with no further description. Review of the nutrition care plan initiated 05/25/26 revealed the resident had a potential nutritional risk with an intervention to document food/fluid intakes. Review of the nutrition task for the amount eaten dated 06/10/26 through 07/04/26 revealed there was no documentation of the percentage of meal intakes for 11 meals.Review of a physician order dated 06/16/26 revealed to cleanse the coccyx wound with wound wash, apply a Thera-honey sheet to the wound bed, cover with bordered foam every shift and as needed for wound care.Review of the Treatment Administration Record (TAR) dated 07/01/26 through 07/06/26 revealed the resident's wound treatment was documented as completed twice daily. Interview on 07/07/26 at 5:50 P.M., Licensed Practical Nurse (LPN) #206 stated she had a bad habit of signing off her treatments before completing them. LPN #206 revealed on 07/06/26 she had documented completing the resident's wound treatment but never completed the treatment during the 12-hour evening shift.Interview on 07/09/26 at 10:05 A.M., Clinical Resource Registered Nurse (CRRN) #277 verified the resident's stage three pressure ulcer wound should have been documented in the nurse's daily skilled nursing evaluations. Interview on 07/09/26 at 1:32 P.M., the Director of Nursing (DON) verified there was no documentation of the percentage of meal intakes for 11 of the residents' meals.Review of the facility policy Documentation in Medical Record, dated 06/30/26 revealed the medical record would include complete, accurate, and timely documentation. False information would not be documented. This deficiency represents non-compliance investigated under Complaint Number 2990029.

Based on medical record review, staff interview, review of an audio recording and review of the facility policy, the facility failed to ensure residents were permitted privacy during telephone calls. This affected one (#20) of three residents reviewed for private communications. The facility census was 65.Findings include:Review of the medical record for Resident #20 revealed an admission date of 02/13/26. Diagnoses included schizophrenia, anxiety, adjustment disorder with mixed anxiety and depression, and emphysema.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact.Review of an audio recording, undated, revealed Resident #20's family called and requested to speak with the resident. Resident #20 accepted the telephone call and identified herself on the call, along with the resident's son and daughter-in-law. Further review revealed Resident #20 stated to her family, I am on speaker phone and there are a lot of people around and listening. Resident #20's son asked the resident if she could go to a private place and the resident stated, No, I cannot not. At this time, an unknown facility employee intervened on the telephone call and told Resident #20's family that if they wished to speak to the resident, they would need to come to the facility and speak to the Director of Nursing (DON) and abruptly hung up the telephone.Interview on 04/14/26 at 8:20 A.M. with the Administrator verified the audio recording was the result of family members who called the facility telephone and further confirmed those involved included Resident #20, her family members, and an unknown facility staff. Additionally, the Administrator verified privacy was not offered or provided for Resident #20's telephone call with her family and an unknown facility staff member abruptly ended the call. Interview on 04/14/26 at 8:45 A.M. with Social Services Designee (SSD) #510 revealed she received a call from the night shift nurse (date unknown) and inquired about Resident #20's family, who had called the facility to speak to the resident. SSD #510 stated she advised the staff if Resident #20 wanted to speak to her family, the facility staff could not stop her and it was the resident's decision. Continued interview with SSD #510 verified the audio recording was a telephone call between Resident #20, her son, and her daughter-in-law. SSD #510 verified Resident #20 was not provided a private place for the telephone call to occur and verified that an unknown facility staff member abruptly ended the phone call between Resident #20 and her family.Review of the facility policy titled, Resident-Patient Rights, revised February 2026, revealed every resident would be afforded and supported in exercising the full set of rights guaranteed under federal law and applicable state requirements. Residents would have access to a telephone, mail, and email and communicate in person my mail, email, and telephone with privacy.This deficiency represents non-compliance investigated under Complaint Number 2805129.

Based on observation, interview, and record review, the facility failed to ensure proper sanitation practices were maintained in the kitchen and failed to ensure canned food items were stored in accordance with facility policy and acceptable food safety standards. This deficient practice had the potential to affect all residents, as all residents were identified as receiving meals prepared by the facility kitchen. The facility census was 64. Findings Include: Observation of the kitchen on 12/30/25 at 6:57 A.M. revealed the facility kitchen floor was coated with unidentified brown and white substances and contained miscellaneous unidentified food and non-food debris. Concurrent interview with with Dietary Aide #143 confirmed the presence of the unidentified brown and white substances and miscellaneous unidentified food and non-food debris on the kitchen floor.Observation on 12/30/25 at 7:00 A.M. of the facility dry storage room revealed the following dented canned food items: two six-pound ten-ounce, cans of pineapple tidbits with large dents on the sides of the cans; one 98-ounce can of collard greens with a large dent in the top ring of the can; and one 110-ounce can of baked beans with a large dent in the top ring of the can.Interview on 12/30/25 at 7:02 A.M. with Dietary Aide #143 confirmed the dents observed on the canned food items.Review of the facility policy titled Kitchen Sanitation, dated 12/01/25, revealed the facility policy required that good sanitary food handling practices be maintained at all times and that sanitary conditions be maintained in food storage, preparation, and serving areas. The policy further required that equipment and areas be kept clean, organized, and free of contamination, spills, mold, or build up. Dented cans or contaminated food items must be separated, labeled Dented Cans - Do Not Use, and disposed of accordingly.

Based on review of the facility electronic medical record (EMR), observation, interview, and review of facility policy, the facility failed to ensure proper infection control practices were maintained for a resident on isolation precautions. This deficient practice affected one resident (Resident #8) and had the potential to affect 23 additional residents (#1, #2, #3, #5, #6, #9, #17, #22, #23, #25, #29, #32, #33, #34, #36, #38, #43, #45, #48, #49, #57, #59, and #65) who resided in the facility. The facility census was 64. Findings Include: Review of the Electronic Medical Record (EMR) for Resident #8 revealed an admission date of 05/24/25 with diagnoses that included cerebral infarction, aphasia, hemiplegia and hemiparesis following cerebral infarction, dysphagia, asthma, neuralgia and neuritis, lumbar disc displacement, hypertension, bicuspid aortic valve, nonrheumatic aortic valve stenosis, heart disease, obesity, bipolar disorder, cardiac arrhythmia, nicotine dependence, syncope and collapse, presence of a prosthetic heart valve, other psychoactive substance use, radiculopathy, depression, cardiac murmur, ascending aortic aneurysm, and mixed hyperlipidemia. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Review of the Electronic Medical Record EMR revealed Resident #8 tested positive for SARS CoV-2 (COVID-19) on 12/24/25 and had a physician order for droplet precautions 12/24/25 through 01/04/25. Observation on 12/30/25 at 8:43 A.M. of the wall outside Resident #8's room revealed signage indicating the resident was on contact precautions and droplet precautions. Review of the facility Contact Precaution signage revealed all individuals were required to perform hand hygiene before entering and upon exiting the room. The signage further required staff and providers to don gloves and a gown prior to room entry, discard gloves and gown prior to room exit, and use dedicated or disposable equipment, or clean and disinfect reusable equipment before use on another individual. Review of the facility Droplet Precaution signage revealed that, in addition to contact precaution requirements, individuals were required to ensure their eyes, nose, and mouth were fully covered with appropriate face protection prior to room entry and to remove face protection before exiting the room. Observation on 12/30/25 at 8:44 A.M. revealed Licensed Practical Nurse (LPN) #157 entered Resident #8's room to obtain vital signs and administer medications while wearing only a surgical mask and gloves and without wearing a gown or eye protection as required by the posted precaution signage. Interview on 12/30/25 at 8:47 A.M. with LPN #157 confirmed she provided care to Resident #8 without wearing the appropriate personal protective equipment (PPE) as outlined in the facility's Contact and Droplet Precaution signage. LPN #157 stated she did not believe PPE was required while providing care to Resident #8. LPN #157 further confirmed there was signage posted outside the resident's room indicating contact and droplet precautions. Review of the facility policy titled Infection Prevention and Control Program, dated 10/01/25, revealed residents with infections or communicable diseases were to be placed on transmission-based precautions in accordance with current CDC guidelines. Review of the facility policy titled Personal Protective Equipment, (PPE) dated 01/02/24, revealed the facility required the appropriate use of PPE to prevent the transmission of pathogens to residents, visitors, and staff.

Based on medical record review, review of facility self-reported incident (SRI) #267409, staff interviews, and review of facility policy, the facility failed to ensure adequate supervision was provided to ensure a resident on the secured memory care unit was free from sexual abuse. This affected one resident (#68) of three residents reviewed for abuse. The facility census was 64.Findings Include:Review of the medical record for Resident #68 revealed an admission date of 06/08/21 and a discharge date of 11/22/25 with diagnoses including vascular dementia, major depressive disorder, age-related osteoporosis, idiopathic peripheral autonomic neuropathy, abnormalities of gait and mobility, generalized muscle weakness, oropharyngeal dysphagia, constipation, iron deficiency anemia, sexual dysfunction, bunions of right foot, and anxiety. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 09/15/25, identified Resident #68 was rarely/never understood. Further review of this MDS assessment revealed Resident #68 was dependent for ambulation.Review of the medical record for Resident #68 revealed she had a guardian. Resident # 68 lived on the secured memory care unit at the facility. Review of the medical record for Resident #67 revealed an admission date of 05/26/22 and a discharge date of 12/09/25 with diagnoses including atherosclerotic heart disease of native coronary artery, schizoaffective disorder, type two diabetes mellitus (DM2), anemia, other sexual disorders, trans ischemic attack (TIA), dysphagia, dementia, urge incontinence, other abnormalities of gait and mobility, lipoprotein deficiency, generalized muscle weakness, deficiency of other specified B group vitamins, metabolic encephalopathy, pure hypercholesterolemia, nicotine dependence, constipation, pulmonary embolism, hypothyroidism, other signs and symptoms involving cognitive functions and awareness, and cognitive communication deficit. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #67 has severely impaired cognition. Further review of this MDS assessment revealed Resident #67 was independent for ambulation.Review of the medical record for Resident #67 revealed he had a guardian. Review of facility SRI #267409 revealed that on 11/11/25 at approximately 10:30 A.M., Resident #68 was in her wheelchair in the common area of the memory care (MC) unit, and Resident #67 had his hand down the front of her shirt. The residents were immediately separated, and Resident #67 was placed on one to one (1:1) monitoring that continued until his discharge on [DATE]. Resident #67 presents with a six out of 15 on brief interview of mental status (BIMs) assessment demonstrating a severe cognitive deficit; care plan review identifies a history of sexual behaviors and poor impulse control. Resident #68 presents with a zero out of 15 on BIMs assessment demonstrating a severe cognitive deficit, care plan review identifies a history of sexual behaviors and poor impulse control. The facility determined sexual abuse was unsubstantiated as the evidence of sexual abuse is inconclusive. The SRI documented both involved residents present with a severe cognitive impairment and did not act willfully, both residents also have a history of sexual behaviors and poor impulse control. Interview on 01/07/26 at 7:15 A.M. with the Administrator and the Director of Nursing (DON), both familiar with SRI #267409, confirmed Resident #67 ' s hand was inside the front Resident #68 ' s shirt while both were in the common area of the MC unit. Interview on 01/08/26 at 10:11 A.M. with the DON revealed Resident # 68 would become combative if she did not want another person in her space and the incident that occurred between her and Resident #67 there was no combative behavior from Resident #68. The DON stated the incident between Resident #68 and Resident #67 was consensual as Resident #68 was hypersexual at baseline. The DON further explained Resident #68 was not upset during or after the incident with Resident #67 and did not remember the incident approximately less than five minutes after it occurred. Telephone interview on 01/08/26 at 10:35 A.M. with Certified Nursing Assistant (CNA) #172 revealed she was returning to the unit and saw Resident #68 and Resident #67 in the common area of the MC unit and Resident #67 was standing over Resident #68 who was in her wheel chair. Resident #67 had one hand holding Resident #68's shirt open and the other hand was down her shirt. The CNA stated she reported it to the DON right away and does not feel this was a consensual incident. The CNA did state Resident #68 will say no or have a mean look or become combative if someone is in her space or touched her and she did not want it, but the CNA could not recall if Resident #68 behaved like that at the time of the incident. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 07/01/25, revealed residents/patients have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/patient property. Sexual abuse is a non-consensual sexual contact of any type with a resident/patient. This citation represents non-compliance investigated under Complaint Number 2671084.

Based on medical record review, resident interview, staff interview, review of self reported incident, review of facility investigation, and review of facility policy, the facility failed to prevent sexual abuse. This affected three (#12, #15, and #25) of four residents reviewed for abuse. The facility census was 57. Findings include: 1. Review of the medical record revealed Resident #25 was admitted on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, diabetes mellitus due to underlying condition with hyperglycemia, essential hypertension, hemiplegia affecting right dominant side, schizoaffective disorder, major depressive disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 04/21/25, revealed the resident was moderately cognitively impaired. Review of the medical record revealed Resident #25 had a guardian. Review of care plan, revised on 06/10/25, revealed Resident #25 had a history of aggressive/inappropriate behavior. Resident #25 has thrown chairs, urinated in the dining room, presented with verbal or physical aggression, acted impulsively, exposed himself, masturbated in public areas, wandered into female rooms and exposed himself, and moved to the secure unit for increased engagement. Review of care plan, revised on 06/17/25, revealed Resident #25 demonstrated cognitive impairment related to impaired decision making, poor logic, poor ability to understand cause and effect, and sexually inappropriate at times. Review of nursing progress note, dated 05/26/25 at 1:51 P.M., revealed Resident #25 was wandering in and out of female resident rooms. Resident #25 was found in Resident #12's room and when asked why he was in there, resident response was that he wanted to have sex. Resident #25 immediately removed and went to activities. Review of nursing progress note, dated 05/26/25 at 9:18 P.M., revealed Resident #25 was found in Resident #12's room, standing over the bed with his penis exposed. Resident was immediately removed and taken to the activities lounge. Review of Self-Reported Incident (SRI) #260924, dated 05/28/25, revealed during a clinical review it was noted in a progress note on 05/26/25 nursing staff found Resident #25 had been in Resident #12's room standing over the bed with his penis exposed. Staff interviews conducted revealed staff reporting they discovered Resident #25 feeling Resident #12's breasts over her clothing and his penis was exposed. Residents had been immediately separated and redirected with increased monitoring provided throughout the night. Staff reported the residents were upset about being separated but no behaviors were noted after the incident. Skin evaluations were conducted with no areas of concern. Resident #12's room was moved further from Resident #25's room to keep him from wandering into her room. Psychiatric services were consulted with medication review with recommendations. Both residents present with moderate impairment. All resident's observed on the secured unit were interviewed/observed with no concerns of abuse identified. Psychosocial support provided by contracted services and staff were educated. Review of witness statements, dated 05/28/25, revealed Certified Nursing Assistant (CNA) #108 verified she found Resident #25 in Resident #12's room. Resident #25's pants were down and he was facing towards Resident #12's bed. Review of witness statements, dated 05/28/25, revealed CNA #131 verified Resident #25 was next to the residents bed with his penis exposed. Resident #25 and Resident #12 were holding hands, looking at each other smiling. Resident #12 had her brief on and was laying in the bed while Resident #25 was touching her breast. When the residents were separated Resident #12 was upset stating that she liked it when he touched her. Review of nursing progress note, dated 06/09/25, revealed Resident #25 was observed touching himself in front of another resident (Resident #15). Resident #25 was calm before the incident, no other behaviors were observed. Resident effected was not harmed nor exhibited any behaviors before or after the incident. All necessary parties were notified. Interview on 06/17/25 at 9:43 A.M. with Licensed Practical Nurse (LPN) #109 verified Resident #25 has touched his penis under his clothing in front of other residents. Interview on 06/17/25 at 10:52 A.M. with Registered Nurse (RN) #128 verified Resident #25 has exposed himself during night shift. RN #128 stated she has not observed him expose himself but has observed him in the lounge with his hands in his pants masturbating. 2. Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included spontaneous rupture of extensor tendons right ankle and foot, unspecified dementia, and obsessive compulsive disorder. Review of the MDS assessment, dated 06/02/25, revealed the resident was moderately cognitively impaired. Review of the medical record revealed Resident #12 had a guardian. Review of the facility SRI #260924, dated 05/28/25, revealed during a clinical review it was noted in a progress note on 05/26/25 nursing staff found Resident #25 had been in Resident #12's room standing over the bed with his penis exposed. Staff interviews conducted revealed staff reporting they discovered Resident #25 feeling Resident #12's breasts over her clothing and his penis was exposed. Residents had been immediately separated and redirected with increased monitoring provided throughout the night. Staff reported the residents were upset about being separated but no behaviors were noted after the incident. revealed Resident #12 will lay in bed naked in view of others and refuses to don clothes. Interview on 06/17/25 at 12:50 P.M. with Resident #12 states she does not remember the incident and states she feels safe at the facility. 3. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included vascular dementia, major depressive disorder recurrent severe with psychotic symptoms, age related osteoporosis, essential hypertension, and muscle weakness. Review of the MDS assessment, dated 03/28/25, revealed the resident is rarely understood. Review of the medical record revealed Resident #15 had a guardian. Review of the care plan, initiated on 06/12/25, revealed Resident #15 exhibits behavior of inappropriate touching (attempting to rub another person's back, reaching for a leg, shoulder rubbing or bumping into others). History of making crude, sexually oriented profane, or suggestive remarks. Interview on 06/17/25 at 9:43 A.M. with Licensed Practical Nurse (LPN) #109 verified Resident #25 has touched his penis under his clothing in front of other residents. Interview on 06/17/25 at 9:59 A.M. with CNA #120 verified Resident #25 stood in front of Resident #15 and exposed his penis. Interview on 06/17/25 at 10:25 A.M. with CNA #200 verified Resident #25 has stood in front of Resident #15 and touch his penis under his shorts or expose himself to the resident. Interview on 06/18/25 at 3:15 P.M. with the DON verified the unidentified resident in Resident #15's nursing progress note date 06/09/25 was in reference to Resident #25 touching himself in front of Resident #15. Review of policy, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 09/06/24, verified residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes sexual abuse. Sexual abuse is a non-consensual sexual contact of any type with a resident. This deficiency represents non-compliance investigated under Master Complaint Number OH00166360.

Based on medical record review, staff interview, review of self reported incidents, and review of facility policy the facility failed ensure all allegations of abuse were reported and reported timely. This affected three (#12, #15, and #25) of four residents reviewed for abuse. The facility census was 57. Findings include: 1. Review of Self-Reported Incident (SRI) #260924, dated 05/28/25, revealed during a clinical review it was noted in a progress note on 05/26/25 nursing staff found Resident #25 had been in Resident #12's room standing over the bed with his penis exposed. Staff interviews conducted revealed staff reporting they discovered Resident #25 feeling Resident #12's breasts over her clothing and his penis was exposed. Residents had been immediately separated and redirected with increased monitoring provided throughout the night. Staff reported the residents were upset about being separated but no behaviors were noted after the incident. Skin evaluations were conducted on involved and like residents with no areas of concern. Resident #12's room was moved further from Resident #25's room to keep him from wandering into her room. Psychiatric services were consulted with medication review with recommendations. Both residents present with moderate impairment. All resident's observed on the secured unit were interviewed/observed with no concerns of abuse identified. Psychosocial support provided by contracted services and staff were educated. Review of the medical record revealed Resident #25 was admitted on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, diabetes mellitus due to underlying condition with hyperglycemia, essential hypertension, hemiplegia affecting right dominant side, schizoaffective disorder, major depressive disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 04/21/25, revealed the resident was moderately cognitively impaired. Review of nursing progress note, dated 05/26/25 at 9:18 P.M., revealed Resident #25 was found in Resident #12's room, standing over the bed with his penis exposed. Resident was immediately removed and taken to the activities lounge. Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included spontaneous rupture of extensor tendons right ankle and foot, unspecified dementia, obsessive compulsive disorder. Review of the MDS assessment, dated 06/02/25, revealed the resident was moderately cognitively impaired. Interview on 06/18/25 at 2:20 P.M. with the Director of Nursing (DON) verified SRI #260924 was not reported timely. The DON verified the incident occurred on 05/26/25 and was not reported until it was discovered on 05/27/25 after a clinical review meeting. 2. Review of nursing progress note, dated 06/09/25, revealed Resident #25 was observed touching himself in front of another resident. Resident #25 was calm before the incident, no other behaviors were observed. Resident effected was not harmed nor exhibited any behaviors before or after the incident. All necessary parties were notified. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included vascular dementia, major depressive disorder recurrent severe with psychotic symptoms, age related osteoporosis, essential hypertension, and muscle weakness. Review of the MDS assessment, dated 03/28/25, revealed the resident is rarely understood. Review of SRI's, dated June 2025, revealed there was no report of alleged abuse with Resident #25 and Resident #15. Interview on 06/17/25 at 9:59 A.M. with CNA #120 verified Resident #25 stood in front of Resident #15 and exposed his penis. Interview on 06/17/25 at 10:25 A.M. with CNA #200 verified Resident #25 has stood in front of Resident #15 and touch his penis under his shorts or expose himself to the resident. Interview on 06/17/25 at 12:07 P.M. with the DON verified an allegation of abuse was not reported as a SRI for all allegations of abuse including the incident on 06/09/25 when Resident #25 was observed touching himself in front if another resident as indicated in the progress note. Interview on 06/18/25 at 3:15 P.M. with the DON verified the unidentified resident in Resident #15's nursing progress note date 06/09/25 was in reference to Resident #25 touching himself in front of Resident #15. Review of policy, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 09/06/24, verified the care team members should immediately report all allegations to the Administrator and to the Department of Health in accordance with the procedures in this policy. All incidents and allegations of abuse must be reported immediately to the Administrator or designee. If abuse is alleged the Administrator or designee will notify the Department of Health immediately but not later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Master Complaint Number OH00166360.

Based on medical record review, staff interview, review of self reported incidents, and review of facility policy the facility failed ensure all allegations of abuse were investigated and thoroughly investigated. This affected three (#12, #15, and #25) of four residents reviewed for abuse. The facility census was 57. Findings include: 1. Review of Self-Reported Incident (SRI) #260924, dated 05/28/25, revealed during a clinical review it was noted in a progress note on 05/26/25 nursing staff found Resident #25 had been in Resident #12's room standing over the bed with his penis exposed. Staff interviews conducted revealed staff reporting they discovered Resident #25 feeling Resident #12's breasts over her clothing and his penis was exposed. Residents had been immediately separated and redirected with increased monitoring provided throughout the night. Staff reported the residents were upset about being separated but no behaviors were noted after the incident. Skin evaluations were conducted on involved and like residents with no areas of concern. Resident #12's room was moved further from Resident #25's room to keep him from wandering into her room. Psychiatric services were consulted with medication review with recommendations. Both residents present with moderate impairment. All resident's observed on the secured unit were interviewed/observed with no concerns of abuse identified. Psychosocial support provided by contracted services and staff were educated. Review of the medical record revealed Resident #25 was admitted on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, diabetes mellitus due to underlying condition with hyperglycemia, essential hypertension, hemiplegia affecting right dominant side, schizoaffective disorder, major depressive disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 04/21/25, revealed the resident was moderately cognitively impaired. Review of nursing progress note, dated 05/26/25 at 9:18 P.M., revealed Resident #25 was found in Resident #12's room, standing over the bed with his penis exposed. Resident was immediately removed and taken to the activities lounge. Review of nursing progress note, dated 06/09/25, revealed Resident #25 was observed touching himself in front of another resident (Resident #15). Resident #25 was calm before the incident, no other behaviors were observed. Resident effected was not harmed nor exhibited any behaviors before or after the incident. All necessary parties were notified. Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included spontaneous rupture of extensor tendon right ankle and foot, unspecified dementia, and obsessive compulsive disorder. Review of the MDS assessment, dated 06/02/25, revealed the resident was moderately cognitively impaired. Interview on 06/17/25 at 2:09 P.M. with the Director of Nursing (DON) verified the police were not notified of the alleged abuse involving Resident #12 and Resident #25 in SRI #260924. 2. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included vascular dementia, major depressive disorder recurrent severe with psychotic symptoms, age related osteoporosis, essential hypertension, and muscle weakness. Review of the MDS assessment, dated 03/28/25, revealed the resident is rarely understood. Interview on 06/17/25 at 9:59 A.M. with CNA #120 verified Resident #25 stood in front of Resident #15 and exposed his penis. Interview on 06/17/25 at 10:25 A.M. with CNA #200 verified Resident #25 has stood in front of Resident #15 and touch his penis under his shorts or expose himself to the resident. Interview on 06/17/25 at 12:07 P.M. with the DON verified an investigation was not conducted for an allegation of abuse related to the incident described in a progress note on 06/09/25 affecting Resident #15 and Resident #25. Review of policy, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 09/06/24, verified once the Administrator and the Department of Health are notified, an investigation of the allegation violation will be conducted. This deficiency represents non-compliance investigated under Master Complaint Number OH00166360.

Based on observation, staff interviews, and policy review revealed the facility failed to maintain a clean and sanitary environment for residents. This had the ability to affect all residents (#36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65) who resided on the west unit. The facility census was 56. Findings include: Observation of the west shower room on 03/12/25 at 11:22 A.M. with Certified Nurses Aide (CNA) #458 revealed the shower room was very hot and humid with a musty odor. Continued observation revealed the west wall, right side shower stall where the wall and ceiling joined, both the wall and ceiling had a black irregular shaped area with moist spots (on white wall) approximately two feet long and two inches wide. The spots resembled black dust. Interview with CNA #458 at the time of observation verified the musty odor, and the black irregular shaped area on the white wall and ceiling of the west shower room. Observation of the west shower room on 03/12/25 at 2:35 P.M. with Maintenance Director #469 verified the black irregular shaped area on the white wall and ceiling of the west shower room, in addition, a dinner plate size black stain on the ceiling near the window and also along the wall/ceiling area on the north wall of the shower room was identified. Maintenance Director #469 verified moisture was observed on all areas of the west shower room and he verified no knowledge of the mold, stating staff had failed to notify him. In verifying the findings, Maintenance Director #469 stated there failed to be an exhaust fan in the room which may have lead to the mold in addition to the left side shower on the west wall having constantly running water due to the inability of the water to be shut off. Review of the facility Infection Control information dated 01/01/25 through 03/12/25 revealed there was one respiratory illnesses in the facility which was diagnosed as pneumonia. Review of the facility policy titled Safe and Homelike Environment dated 01/02/24 revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. This violation represents non-compliance investigated under Complaint Numbers OH00163559 and OH00162562.

Based on review of the medical record, review of documented staff interviews, review of self-reported incidents, interview, and policy review, the facility failed to report and thoroughly investigate an allegation of abuse and immediately protect residents by removing the alleged perpetrator. This affected Resident #22 and had the potential to affect 22 resident residing on the memory care unit. Additionally, the facility failed to report and thoroughly investigate al allegation of misappropriation of the medication Ozempic. This affected three residents (#42, #39, #49) of five residents reviewed for misappropriation of medication. The facility identified five residents as receiving the medication Ozempic. The facility census was 56. Findings include: 1. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, hypertension, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. Review of the care plan initiated 10/19/24 revealed the resident had cognitive impairment and would yell out for assistance instead of using the call light. Further review of the care plan noted no behavioral symptoms of physical aggression or rejection of care. An intervention was revised on 02/25/25 if the resident was agitated during care then back off and try to calm the resident with soothing word. If the resident remained agitated then inform him care would be provided when he was feeling better. Assure the resident he was safe and protected. Review of an Investigation Collection Form, dated 01/19/25 revealed Certified Nurse Aide (CNA) #450 reported Alleged Perpetrator Certified Nursing Assistant (APCNA) #566 physically abused Resident #22 in his room on 01/19/25 around 4:30 A.M. APCNA #566 was suspended on 01/21/25. Review of the facility self-reported incidents revealed the allegation of abuse was not reported to the state agency. Review of the medical record including review of nurse progress notes dated 01/19/25 revealed no documentation of the incident or immediate assessment of the resident after the alleged incident. There was no documentation the resident was assessed for injuries until two days after the alleged incident. Review of a skin assessment dated [DATE] revealed the Director of Nursing (DON) completed a skin assessment for Resident #22 with no abnormal findings. Review of an interview statement dated 01/21/25, CNA #450 revealed Resident #22 began hitting APCNA #566 during care but not hard. APCNA #566 then grabbed Resident #22's arm and wrist and brought them up against his chest and threatened the resident. CNA #450 told APCNA #566 to leave the room. APCNA #566 then swore at the resident then walked back into the room and did the same thing to the resident's ankles. CNA #450 stated APCNA #566 and herself took the linen down and trash out and APCNA #566 kept following her so she told him she had to leave to speak to another nursing assistant then went and told Licensed Practical Nurse (LPN) #425 on the other unit what happened. LPN #425 then called and told LPN #455 to come down to the other unit and told her what happened. LPN #455 and CNA #450 then called the Administrator and reported the incident. Review of an interview statement dated 01/21/25 by APCNA #566 revealed Resident #22 freaked out about him coming in the room with the nurse. APCNA #566 revealed he was changing the resident and pushed the resident's arms away because he was swinging at him. APCNA #566 revealed he had not put the resident in a hold and had not sworn at the resident. Review of an interview statement dated 01/24/25 by the Administrator revealed on 01/19/25 at 4:42 A.M. CNA #450 reported APCNA #566 responded inappropriately to a combative resident by grabbing his arms and pushing them into the bed. CNA #450 was asked if this was abuse or the aide had overresponded. CNA #450 responded APCNA #566 had overreacted. CNA #450 was informed the Administrator would speak with APCNA #566 regarding his behavior. The Administrator revealed she followed up with the nurse of the unit (LPN #455) who reported Resident #22 was aggravated stating those two kept coming in all night. The nurse reported Resident #22 denied pain and no bruising or red marks were noted and the resident was comfortable. Review of an interview statement dated 01/24/25 LPN #455 revealed Resident #22 had denied pain. LPN revealed she was not looking for marks but had not seen any bruises or red marks. Further review of LPN #455's statement revealed no documentation when she was notified of the incident or what action was taken. Review of an interview statement on 01/24/25 with LPN #425 revealed no documentation if she was notified of the incident, when the incident occurred or the follow up actions taken if any. Review of a corrective action form dated 02/25/25 revealed the Administrator received coaching action for failure to report to the state board of health for an incident in January involving a nursing assistant and a resident. The nursing assistant was physically abusive to the resident and this allegation was not reported to the state board of health nor was a complete investigation done. The Administrator was educated on reporting guidelines by the regional nurse consultant to immediately notify supervisors of the occurrence of any unusual incident. Review of the employee timecard for APCNA #566 revealed the employee clocked in on Saturday 1/18/25 at 4:38 P.M. and clocked out on 01/19/25 Sunday at 5:07 A.M. APCNA #566 had not worked again and was terminated from the facility on 01/28/25 for violation of code of conduct and not performing job duties. Interview on 03/12/25 at 7:54 A.M., Resident #22 revealed the resident had confusion and was not oriented to time, date, or place. Resident #22 denied mistreatment by staff. Resident #22 had no recollection of the incident on 01/19/25. Interview on 03/12/25 at 10:29 A.M., the Administrator revealed CNA #450 reported on 01/19/25 Resident #22 was combative and APCNA #566 had grabbed his arms and put him on the bed. The Administrator revealed APCNA #566 denied the allegation. The Administrator revealed Resident #22 had no bruises and no red marks and no recollection of the event. The Administrator verified the incident alleging abuse was not reported to the state agency and a thorough investigation had not been completed timely. Interview on 03/13/25 at 12:45 P.M., the Regional Director of Operations (RDO) #700 verified the Administrator had failed to report and thoroughly investigate the allegation of physical abuse. Interview on 03/13/25 at 2:21 P.M., CNA #450 revealed she was working with APCNA #566 on 01/19/25 to care for Resident #22 around 4:00 A.M. and provided incontinence care for the resident. CNA #450 revealed a little later the resident was yelling out and she had asked APCNA #566 to check the resident. APCNA #566 reported the resident legs were hanging out of the bed like he was trying to get up. CNA #450 revealed they went around 4:25 A.M. or 4:30 A.M. to reposition the resident and the resident was calling APCNA #566 names and then hitting APCNA #566. CNA #450 told APCNA #566 he could leave and she would finish up with the resident. CNA #450 revealed APCNA #566 then grabbed Resident #22's arms and wrists with his hands, crossed the resident's arms over his chest and was pushing and pulling the resident up and down in the bed like he was trying to shake him. CNA #450 revealed she went around to the other side of the bed to stop APCNA #566 but he let go of the resident. CNA #450 told APCNA #566 to get out of the room now and she opened the door for him to leave. CNA #450 revealed APCNA #566 then went back to Resident #22 and grabbed the residents legs by the ankles with his hands and was pushing and pulling the resident's legs while holding his ankles. CNA #450 revealed she started yelling at APCNA #566 and he let go of the resident before she got to him. CNA #450 revealed she told APCNA #566 to get the expletive out of the room now. CNA #450 asked Resident #22 if he was okay. CNA #450 stated as APCNA #566 was leaving the room he was swearing at the resident and threatening him. CNA #450 revealed she apologized to Resident #22 for the APCNA #566's behavior and went to the nurses station where APCNA #566 was with the nurse. CNA #450 revealed she was trying to figure out how to report the incident since APCNA #566 was with the nurse. CNA #450 revealed she left the memory care unit and went and reported the incident to LPN 425. LPN #425 then called LPN #455 to come out of the unit. CNA #450 revealed we then called the Administrator to report the incident. CNA #450 verified APCNA #566 was left alone in the memory care unit with the vulnerable residents while they were on the phone with the Administrator around 4:45 P.M. reporting the abuse. CNA #450 revealed the Administrator felt APCNA #566 had just overreacted, provided no instruction on what to do or for APCNA #566 to leave the facility. CNA #450 revealed the Administrator never asked her to write a statement. Interview on 03/13/25 at 3:50 P.M., the Director of Nursing (DON) revealed Resident #22 was not assessed for injuries until 01/21/25 at which time no injuries were observed. The DON revealed APCNA #566 was not interviewed until 01/21/25 and claimed he was not rough with the resident. The DON revealed the witness CNA #450 was also not interviewed until 01/21/25. The DON revealed residents on the memory care unit had not received skin assessments for signs of abuse until 02/12/25 and were not interviewed until 02/26/25. The DON revealed she had not been notified of the incident until 01/20/25. The DON revealed she felt abuse occurred and told the Administrator she thought abuse occurred. The DON revealed the Administrator thought staff were embellishing the incident as they had not liked APCNA #566 as he could not care for the female residents. The DON revealed the Administrator thought it was a customer service concern and the staff needed education. The DON revealed she told the Administrator the incident needed reported and APCNA #566 needed suspended. The DON verified the residents in the memory care unit should not have been left unprotected in the care of APCNA #566 while LPN #455 and CNA #450 left the memory care unit to report the incident. Interviews by telephone on 03/13/25 at 10:28 A.M. and on 03/16/25 at 3:44 P.M. were attempted with APCNA #566. Interviews by telephone on 03/13/25 at 2:10 P.M. and on 03/16/25 at 3:38 P.M. were attempted with LPN #455. 2. Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, hypertension, peripheral vascular disease, and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 03/08/24 revealed the resident was ordered Ozempic (two milligram (mg)/dose) subcutaneous solution pen-injector eight mg/three milliliters (ml), inject two mg subcutaneously one time a day every Friday for diabetes mellitus. Review of a pharmacy receipt dated 01/02/25 revealed the facility received Ozempic two mg/dose (eight mg/three ml pen) for Resident #42. Each pen supplied one two mg dose per week for four weeks. Review of the medication administration record (MAR) revealed the resident was administered one dose of the medication on 01/03/25. The resident should have had three remaining doses from the pen. The resident was never administered the medication on 01/10/25, 01/17/25, and 01/24/25 and 01/31/25, and 02/07/25. The medication was noted as unavailable. Review of a pharmacy receipt dated 02/14/25 revealed the facility received Ozempic two mg/dose (eight mg/three ml pen) for Resident #42. Review of the MAR revealed Resident #42 was administered one dose on 02/15/25 with three remaining doses in the pen. Resident #42 was not administered the Ozempic on 02/22/25. Review of an administration note dated 02/22/25 at 11:18 A.M. revealed the box in the refrigerator was empty and the pen could not be found and delivery was on 02/14/25. Review of the medical record for Resident #39 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of physician orders dated 05/22/24 revealed the resident was ordered Ozempic eight mg/three ml solution pen-injector, two mg/dose, inject two mg weekly on Wednesdays. Review of a pharmacy receipt dated 02/08/25 revealed the facility received Ozempic two mg/dose (eight mg/three ml pen). Each pen supplied one two mg dose per week for four weeks. Review of the MAR revealed the resident was administered Ozempic on 02/12/25 and 02/19/25. There should have been two remaining doses left in the pen. Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, and atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a pharmacy invoice dated 02/01/25 revealed the facility received Ozempic four mg/three ml for Resident #49. Review of the physician orders dated 02/03/25 revealed an order for Ozempic (one mg/dose) subcutaneous solution pen-injector four mg/three ml, inject one mg subcutaneously one time a day every Friday related to type two diabetes mellitus. Review of the MAR revealed the resident was administered one dose on 02/07/25, and 02/14/25, and 02/21/25. There should have been one dose remaining in the pen. Review of an electronic communication dated 02/24/25 at 1:13 P.M. revealed the facility paid to replace one pen each for Resident #39 and Resident #42. The facility provided no documentation Resident #42 was reimbursed for the missing pen in January or Resident #49 was reimbursed for the one remaining dose left in the pen on 02/22/25 later found missing on 02/24/25. Interview on 03/12/25 beginning at 10:29 A.M., the Administrator revealed a nurse went to administer Ozempic for a resident and the resident's Ozempic pen was missing and later three Ozempic pens were discovered as missing. The Administrator revealed the facility paid to replace two Ozempic pens. The Administrator revealed the Director of Nursing (DON) handled the investigation with pharmacy. The Administrator revealed a self-report incident was not submitted to the state agency for the missing medications. Review of the facility self-reported incidents revealed the missing Ozempic pens were not reported. Interview on 03/12/25 at 2:33 P.M., Registered Nurse (RN) #434 revealed on 02/22/25 Licensed Practical Nurse (LPN) #427 reported Resident #42's Ozempic pen was missing and just the box was in the refrigerator. RN #434 revealed LPN #427 checked the Ozempic pens for four additional residents and the pens were present in the refrigerator on 02/22/25. RN #427 revealed she reported the missing Ozempic pen to the Director of Nursing on 02/22/25. RN #427 revealed when she returned to work on 02/24/25 two more Ozempic pens were missing for Resident #39 and Resident #49 and the empty boxes were in the refrigerator. RN #427 revealed three of five Ozempic pens were missing for three of the five residents with orders for Ozempic and the DON was notified again on 02/24/25 of the additional missing pens. RN #427 revealed none of the five residents were not scheduled for administration of Ozempic from 02/22/25 through 02/24/25. RN #427 revealed each pen administers four doses (one dose weekly.) RN #427 also revealed she had reported Resident #42 was missing her Ozempic pen in January. RN #427 revealed only the nurses and unit managers had keys to access the medication room refrigerator. RN #434 revealed all Ozempic pens and doses administered were now recorded and counted each shift. Interview on 03/12/25 at 03:29 P.M., LPN #427 revealed on 02/22/25 Resident #42's Ozempic pen and needles were missing but the empty box was in the refrigerator. LPN #427 revealed she checked the other boxes of Ozempic to see if the medication had been misplaced but the other boxes contained Ozempic pens on 02/22/25. LPN #427 revealed she notified RN #434 of the missing Ozempic pen and told her she thought someone took the Ozempic. LPN #427 revealed all Ozempic pens were now counted each shift. Interview on 03/13/25 at 8:50 A.M. and 3:50 P.M. the DON revealed she had no documentation of staff statements or interviews conducted with the nursing staff regarding the missing Ozempic pens. The DON revealed she had spoken with four nurses and had left a voicemail with a fifth nurse. The DON revealed she had not completed a thorough investigation and had not interviewed all the nurses as another abuse investigation was taking place at the same time. The DON revealed the nurses who were interviewed had no knowledge of the missing pens. The DON revealed she investigated as if someone took the pens but was not wanting to accuse anyone without concrete evidence. The DON revealed the missing Ozempic pens were reported to herself and the Administrator on 02/22/24 and 02/24/24. The DON could not recall with certainty but said it was possible RN #434 had reported Resident #42's Ozempic pen missing in January. Interview on 03/13/25 at 12:45 P.M., the Regional Director of Operations (RDO) #700 revealed the Administrator should have reported the missing Ozempic pens to the state agency. RDO #700 revealed it was not company practice to not report and moving forward the Administrator was educated to inform regional of what was going on in the building. Review of the facility policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, last revised 09/06/24 revealed all allegations involving neglect, exploitation, and misappropriation of resident property would be reported to the Department of Health immediately with the submission on an online Self-Reported Incident form, but no later than 24 hours from the time the incident/allegation was made known to the care team member. If the facility suspects a crime had been committed, it would report the suspicion to law enforcement. The nurse would perform an initial assessment of the resident including range of motion, full body assessment for signs of injury and vital signs. If a care team member was accused or suspected, the facility should immediately remove the care team member from the facility and the schedule pending the outcome of the investigation. Documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and resident representative and any treatment provided. Once the Administrator and Department of Health were notified, an investigation of the allegation would be conducted and completed within five working days and submitted to the Department of Health. The investigation should include interviews with the resident, the accused, and all witnesses and expanded to include care team members on the shift and residents on the unit. This violation represents non-compliance investigated under Complaint Number OH00162176.

Based on review of the medical record, interview, and policy review, the facility failed to notify the physician of medications not administered. This affected one resident (#42) of five residents reviewed for a change in condition. The facility census was 56. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 03/08/24 revealed the resident was ordered Ozempic (two milligram/dose) subcutaneous solution pen-injector eight milligrams/three milliliters, inject two mg subcutaneously one time a day every Friday for diabetes mellitus. Review of the medication administration record (MAR) dated 01/01/25 through 02/28/25 revealed Resident #42 was not administered the medication on 01/10/25, 01/17/25, 01/24/25, 01/31/25, 02/07/25, and 02/22/25 per physician orders. Review of the electronic medication administration record notes revealed the Ozempic was not available 01/10/25, 01/17/25, 01/24/25, 01/31/25, 02/07/25, and 02/22/25. The physician was not notified when the medication was not administered on 01/10/25, 01/24/25, 02/07/25, and 02/22/25. Interview on 03/13/25 at 8:50 A.M., the Director of Nursing (DON) verified Resident #42 was not administered the weekly Ozempic injections on 01/10/25, 01/17/25, 01/24/25, 01/31/25, 02/07/25, and 02/22/25. The DON verified the physician was not notified the medication was not administered on 01/10/25, 01/24/25, 02/07/25, and 02/22/25. Interview on 03/13/25 at 1:14 P.M., Resident #42 revealed she was aware the facility had not administered her weekly injections of Ozempic but they never told her why. Review of the facility policy Medication Administration, dated 01/02/24, revealed medications would be administered as ordered by the physician in accordance with professional standards of practice. The physician would be notified timely of medication omissions. Review of the facility policy Change in Condition Physician Notification, dated 01/02/24, revealed the nursing staff would notify the physician or nurse practitioner of medication omissions/errors. Notifications would be made within 24 hours and the nurse would document notifications.

Based on review of the medical record, review of documented staff interviews, review of self-reported incidents, interview, and policy review, the facility failed to report and thoroughly investigate an allegation of abuse and immediately protect residents by removing the alleged perpetrator. This affected Resident #22 and had the potential to affect 22 resident residing on the memory care unit. Additionally, the facility failed to report and thoroughly investigate al allegation of misappropriation of the medication Ozempic. This affected three residents (#42, #39, #49) of five residents reviewed for misappropriation of medication. The facility identified five residents as receiving the medication Ozempic. The facility census was 56. Findings include: 1. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, hypertension, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. Review of the care plan initiated 10/19/24 revealed the resident had cognitive impairment and would yell out for assistance instead of using the call light. Further review of the care plan noted no behavioral symptoms of physical aggression or rejection of care. An intervention was revised on 02/25/25 if the resident was agitated during care then back off and try to calm the resident with soothing word. If the resident remained agitated then inform him care would be provided when he was feeling better. Assure the resident he was safe and protected. Review of an Investigation Collection Form, dated 01/19/25 revealed Certified Nurse Aide (CNA) #450 reported Alleged Perpetrator Certified Nursing Assistant (APCNA) #566 physically abused Resident #22 in his room on 01/19/25 around 4:30 A.M. APCNA #566 was suspended on 01/21/25. Review of the facility self-reported incidents revealed the allegation of abuse was not reported to the state agency. Review of the medical record including review of nurse progress notes dated 01/19/25 revealed no documentation of the incident or immediate assessment of the resident after the alleged incident. There was no documentation the resident was assessed for injuries until two days after the alleged incident. Review of a skin assessment dated [DATE] revealed the Director of Nursing (DON) completed a skin assessment for Resident #22 with no abnormal findings. Review of an interview statement dated 01/21/25, CNA #450 revealed Resident #22 began hitting APCNA #566 during care but not hard. APCNA #566 then grabbed Resident #22's arm and wrist and brought them up against his chest and threatened the resident. CNA #450 told APCNA #566 to leave the room. APCNA #566 then swore at the resident then walked back into the room and did the same thing to the resident's ankles. CNA #450 stated APCNA #566 and herself took the linen down and trash out and APCNA #566 kept following her so she told him she had to leave to speak to another nursing assistant then went and told Licensed Practical Nurse (LPN) #425 on the other unit what happened. LPN #425 then called and told LPN #455 to come down to the other unit and told her what happened. LPN #455 and CNA #450 then called the Administrator and reported the incident. Review of an interview statement dated 01/21/25 by APCNA #566 revealed Resident #22 freaked out about him coming in the room with the nurse. APCNA #566 revealed he was changing the resident and pushed the resident's arms away because he was swinging at him. APCNA #566 revealed he had not put the resident in a hold and had not sworn at the resident. Review of an interview statement dated 01/24/25 by the Administrator revealed on 01/19/25 at 4:42 A.M. CNA #450 reported APCNA #566 responded inappropriately to a combative resident by grabbing his arms and pushing them into the bed. CNA #450 was asked if this was abuse or the aide had overresponded. CNA #450 responded APCNA #566 had overreacted. CNA #450 was informed the Administrator would speak with APCNA #566 regarding his behavior. The Administrator revealed she followed up with the nurse of the unit (LPN #455) who reported Resident #22 was aggravated stating those two kept coming in all night. The nurse reported Resident #22 denied pain and no bruising or red marks were noted and the resident was comfortable. Review of an interview statement dated 01/24/25 LPN #455 revealed Resident #22 had denied pain. LPN revealed she was not looking for marks but had not seen any bruises or red marks. Further review of LPN #455's statement revealed no documentation when she was notified of the incident or what action was taken. Review of an interview statement on 01/24/25 with LPN #425 revealed no documentation if she was notified of the incident, when the incident occurred or the follow up actions taken if any. Review of a corrective action form dated 02/25/25 revealed the Administrator received coaching action for failure to report to the state board of health for an incident in January involving a nursing assistant and a resident. The nursing assistant was physically abusive to the resident and this allegation was not reported to the state board of health nor was a complete investigation done. The Administrator was educated on reporting guidelines by the regional nurse consultant to immediately notify supervisors of the occurrence of any unusual incident. Review of the employee timecard for APCNA #566 revealed the employee clocked in on Saturday 1/18/25 at 4:38 P.M. and clocked out on 01/19/25 Sunday at 5:07 A.M. APCNA #566 had not worked again and was terminated from the facility on 01/28/25 for violation of code of conduct and not performing job duties. Interview on 03/12/25 at 7:54 A.M., Resident #22 revealed the resident had confusion and was not oriented to time, date, or place. Resident #22 denied mistreatment by staff. Resident #22 had no recollection of the incident on 01/19/25. Interview on 03/12/25 at 10:29 A.M., the Administrator revealed CNA #450 reported on 01/19/25 Resident #22 was combative and APCNA #566 had grabbed his arms and put him on the bed. The Administrator revealed APCNA #566 denied the allegation. The Administrator revealed Resident #22 had no bruises and no red marks and no recollection of the event. The Administrator verified the incident alleging abuse was not reported to the state agency and a thorough investigation had not been completed timely. Interview on 03/13/25 at 12:45 P.M., the Regional Director of Operations (RDO) #700 verified the Administrator had failed to report and thoroughly investigate the allegation of physical abuse. Interview on 03/13/25 at 2:21 P.M., CNA #450 revealed she was working with APCNA #566 on 01/19/25 to care for Resident #22 around 4:00 A.M. and provided incontinence care for the resident. CNA #450 revealed a little later the resident was yelling out and she had asked APCNA #566 to check the resident. APCNA #566 reported the resident legs were hanging out of the bed like he was trying to get up. CNA #450 revealed they went around 4:25 A.M. or 4:30 A.M. to reposition the resident and the resident was calling APCNA #566 names and then hitting APCNA #566. CNA #450 told APCNA #566 he could leave and she would finish up with the resident. CNA #450 revealed APCNA #566 then grabbed Resident #22's arms and wrists with his hands, crossed the resident's arms over his chest and was pushing and pulling the resident up and down in the bed like he was trying to shake him. CNA #450 revealed she went around to the other side of the bed to stop APCNA #566 but he let go of the resident. CNA #450 told APCNA #566 to get out of the room now and she opened the door for him to leave. CNA #450 revealed APCNA #566 then went back to Resident #22 and grabbed the residents legs by the ankles with his hands and was pushing and pulling the resident's legs while holding his ankles. CNA #450 revealed she started yelling at APCNA #566 and he let go of the resident before she got to him. CNA #450 revealed she told APCNA #566 to get the expletive out of the room now. CNA #450 asked Resident #22 if he was okay. CNA #450 stated as APCNA #566 was leaving the room he was swearing at the resident and threatening him. CNA #450 revealed she apologized to Resident #22 for the APCNA #566's behavior and went to the nurses station where APCNA #566 was with the nurse. CNA #450 revealed she was trying to figure out how to report the incident since APCNA #566 was with the nurse. CNA #450 revealed she left the memory care unit and went and reported the incident to LPN 425. LPN #425 then called LPN #455 to come out of the unit. CNA #450 revealed we then called the Administrator to report the incident. CNA #450 verified APCNA #566 was left alone in the memory care unit with the vulnerable residents while they were on the phone with the Administrator around 4:45 P.M. reporting the abuse. CNA #450 revealed the Administrator felt APCNA #566 had just overreacted, provided no instruction on what to do or for APCNA #566 to leave the facility. CNA #450 revealed the Administrator never asked her to write a statement. Interview on 03/13/25 at 3:50 P.M., the Director of Nursing (DON) revealed Resident #22 was not assessed for injuries until 01/21/25 at which time no injuries were observed. The DON revealed APCNA #566 was not interviewed until 01/21/25 and claimed he was not rough with the resident. The DON revealed the witness CNA #450 was also not interviewed until 01/21/25. The DON revealed residents on the memory care unit had not received skin assessments for signs of abuse until 02/12/25 and were not interviewed until 02/26/25. The DON revealed she had not been notified of the incident until 01/20/25. The DON revealed she felt abuse occurred and told the Administrator she thought abuse occurred. The DON revealed the Administrator thought staff were embellishing the incident as they had not liked APCNA #566 as he could not care for the female residents. The DON revealed the Administrator thought it was a customer service concern and the staff needed education. The DON revealed she told the Administrator the incident needed reported and APCNA #566 needed suspended. The DON verified the residents in the memory care unit should not have been left unprotected in the care of APCNA #566 while LPN #455 and CNA #450 left the memory care unit to report the incident. Interviews by telephone on 03/13/25 at 10:28 A.M. and on 03/16/25 at 3:44 P.M. were attempted with APCNA #566. Interviews by telephone on 03/13/25 at 2:10 P.M. and on 03/16/25 at 3:38 P.M. were attempted with LPN #455. 2. Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, hypertension, peripheral vascular disease, and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 03/08/24 revealed the resident was ordered Ozempic (two milligram (mg)/dose) subcutaneous solution pen-injector eight mg/three milliliters (ml), inject two mg subcutaneously one time a day every Friday for diabetes mellitus. Review of a pharmacy receipt dated 01/02/25 revealed the facility received Ozempic two mg/dose (eight mg/three ml pen) for Resident #42. Each pen supplied one two mg dose per week for four weeks. Review of the medication administration record (MAR) revealed the resident was administered one dose of the medication on 01/03/25. The resident should have had three remaining doses from the pen. The resident was never administered the medication on 01/10/25, 01/17/25, and 01/24/25 and 01/31/25, and 02/07/25. The medication was noted as unavailable. Review of a pharmacy receipt dated 02/14/25 revealed the facility received Ozempic two mg/dose (eight mg/three ml pen) for Resident #42. Review of the MAR revealed Resident #42 was administered one dose on 02/15/25 with three remaining doses in the pen. Resident #42 was not administered the Ozempic on 02/22/25. Review of an administration note dated 02/22/25 at 11:18 A.M. revealed the box in the refrigerator was empty and the pen could not be found and delivery was on 02/14/25. Review of the medical record for Resident #39 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of physician orders dated 05/22/24 revealed the resident was ordered Ozempic eight mg/three ml solution pen-injector, two mg/dose, inject two mg weekly on Wednesdays. Review of a pharmacy receipt dated 02/08/25 revealed the facility received Ozempic two mg/dose (eight mg/three ml pen). Each pen supplied one two mg dose per week for four weeks. Review of the MAR revealed the resident was administered Ozempic on 02/12/25 and 02/19/25. There should have been two remaining doses left in the pen. Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, and atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a pharmacy invoice dated 02/01/25 revealed the facility received Ozempic four mg/three ml for Resident #49. Review of the physician orders dated 02/03/25 revealed an order for Ozempic (one mg/dose) subcutaneous solution pen-injector four mg/three ml, inject one mg subcutaneously one time a day every Friday related to type two diabetes mellitus. Review of the MAR revealed the resident was administered one dose on 02/07/25, and 02/14/25, and 02/21/25. There should have been one dose remaining in the pen. Review of an electronic communication dated 02/24/25 at 1:13 P.M. revealed the facility paid to replace one pen each for Resident #39 and Resident #42. The facility provided no documentation Resident #42 was reimbursed for the missing pen in January or Resident #49 was reimbursed for the one remaining dose left in the pen on 02/22/25 later found missing on 02/24/25. Interview on 03/12/25 beginning at 10:29 A.M., the Administrator revealed a nurse went to administer Ozempic for a resident and the resident's Ozempic pen was missing and later three Ozempic pens were discovered as missing. The Administrator revealed the facility paid to replace two Ozempic pens. The Administrator revealed the Director of Nursing (DON) handled the investigation with pharmacy. The Administrator revealed a self-report incident was not submitted to the state agency for the missing medications. Review of the facility self-reported incidents revealed the missing Ozempic pens were not reported. Interview on 03/12/25 at 2:33 P.M., Registered Nurse (RN) #434 revealed on 02/22/25 Licensed Practical Nurse (LPN) #427 reported Resident #42's Ozempic pen was missing and just the box was in the refrigerator. RN #434 revealed LPN #427 checked the Ozempic pens for four additional residents and the pens were present in the refrigerator on 02/22/25. RN #427 revealed she reported the missing Ozempic pen to the Director of Nursing on 02/22/25. RN #427 revealed when she returned to work on 02/24/25 two more Ozempic pens were missing for Resident #39 and Resident #49 and the empty boxes were in the refrigerator. RN #427 revealed three of five Ozempic pens were missing for three of the five residents with orders for Ozempic and the DON was notified again on 02/24/25 of the additional missing pens. RN #427 revealed none of the five residents were not scheduled for administration of Ozempic from 02/22/25 through 02/24/25. RN #427 revealed each pen administers four doses (one dose weekly.) RN #427 also revealed she had reported Resident #42 was missing her Ozempic pen in January. RN #427 revealed only the nurses and unit managers had keys to access the medication room refrigerator. RN #434 revealed all Ozempic pens and doses administered were now recorded and counted each shift. Interview on 03/12/25 at 03:29 P.M., LPN #427 revealed on 02/22/25 Resident #42's Ozempic pen and needles were missing but the empty box was in the refrigerator. LPN #427 revealed she checked the other boxes of Ozempic to see if the medication had been misplaced but the other boxes contained Ozempic pens on 02/22/25. LPN #427 revealed she notified RN #434 of the missing Ozempic pen and told her she thought someone took the Ozempic. LPN #427 revealed all Ozempic pens were now counted each shift. Interview on 03/13/25 at 8:50 A.M. and 3:50 P.M. the DON revealed she had no documentation of staff statements or interviews conducted with the nursing staff regarding the missing Ozempic pens. The DON revealed she had spoken with four nurses and had left a voicemail with a fifth nurse. The DON revealed she had not completed a thorough investigation and had not interviewed all the nurses as another abuse investigation was taking place at the same time. The DON revealed the nurses who were interviewed had no knowledge of the missing pens. The DON revealed she investigated as if someone took the pens but was not wanting to accuse anyone without concrete evidence. The DON revealed the missing Ozempic pens were reported to herself and the Administrator on 02/22/24 and 02/24/24. The DON could not recall with certainty but said it was possible RN #434 had reported Resident #42's Ozempic pen missing in January. Interview on 03/13/25 at 12:45 P.M., the Regional Director of Operations (RDO) #700 revealed the Administrator should have reported the missing Ozempic pens to the state agency. RDO #700 revealed it was not company practice to not report and moving forward the Administrator was educated to inform regional of what was going on in the building. Review of the facility policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, last revised 09/06/24 revealed all allegations involving neglect, exploitation, and misappropriation of resident property would be reported to the Department of Health immediately with the submission on an online Self-Reported Incident form, but no later than 24 hours from the time the incident/allegation was made known to the care team member. If the facility suspects a crime had been committed, it would report the suspicion to law enforcement. The nurse would perform an initial assessment of the resident including range of motion, full body assessment for signs of injury and vital signs. If a care team member was accused or suspected, the facility should immediately remove the care team member from the facility and the schedule pending the outcome of the investigation. Documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and resident representative and any treatment provided. Once the Administrator and Department of Health were notified, an investigation of the allegation would be conducted and completed within five working days and submitted to the Department of Health. The investigation should include interviews with the resident, the accused, and all witnesses and expanded to include care team members on the shift and residents on the unit. This violation represents non-compliance investigated under Complaint Number OH00162176.

Based on observation, record review, staff interviews, and policy review the facility failed to provide adequate grooming care for a dependent resident (#45). This had the ability to affect all residents. The facility census was 56. Findings include: Review of Resident #45's medical record revealed an admitted [DATE]. Diagnosis included Parkinson's disease, bipolar disorder, peripheral vascular disease, and chronic obstructive pulmonary disease. Review of Resident #45's Minimum Data Set (MDS) regarding a significant change dated 02/28/25 revealed the resident had an intact cognitive function, was dependent on staff for activities of daily living, and was under hospice care. Review of Resident #45's most recent care plan revealed she had an activity of daily living self-care performance deficit related to Parkinson's disease and required a one person assist with all personal hygiene and care. Observation of Resident #45's toenails on 03/12/25 at 4:05 P.M. with Licensed Practical Nurse #427 revealed the residents right foot contained a long toenail on her second toe. The nail curved down around the top of her toe. Observation of Resident #45's left foot revealed all toenails except the small toe were long and in need of trimming. The large toenail grew straight out, the second, third, and fourth toe nails were curved around the tops of her toes. Interview with LPN #427 on 03/12/25 at 4:05 P.M. verified the resident was in need of a nail trim and that the care should have been completed on shower days. LPN #427 stated the resident was not diabetic. Interview with Resident #45 on 03/12/25 at 4:07 P.M. revealed she was in need of getting the toenails trimmed, and staff had failed to do so. Resident #45 also stated her daughter would attempt to complete nail trimming when she visited. Review of the facility policy titled Activities of Daily Living dated 01/02/24 revealed care and services would be provided for grooming. A resident who was unable to carryout the activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This violation represents non-compliance investigated under Complaint Numbers OH00162562.

Based on review of the medical record, staff and resident interview, and policy review, the facility failed to timely clarify incorrect medication orders before administration and failed to ensure medications were administered per physician orders. This affected two residents (#64 and #42) of five residents reviewed for medications. The facility census was 56. Findings include 1. Review of the medical record for Resident #64 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, hypertension, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. Review of the care plan last revised 01/21/25 revealed the resident had diabetes mellitus with an intervention to administer diabetes medication as ordered by the physician. Monitor/document side effects and monitor for effectiveness. Review of the physician orders dated 01/16/25 revealed an order for Ozempic (0.25 milligrams (mg) or 0.5 mg/dose) subcutaneous solution pen-injector two mg/three milliliter (ml), inject 0.25 mg subcutaneous one time a day every Saturday for diabetes mellitus for four weeks and inject 0.5 mg subcutaneously one time a day following four weeks of the 0.25 mg for diabetes mellitus. The order was incorrectly entered as a daily injection instead of a weekly injection. Review of the medication administration record (MAR) for 02/2025 revealed Resident #64 was administered Ozempic (0.25 or 0.5 mg/dose) subcutaneous solution Pen-Injector two mg/three ml, inject 0.5 mg subcutaneous one time a day for diabetes mellitus on 02/15/25, 02/16/25, 02/17/25, and 02/18/25. Review of an incident report dated 02/18/25 at 10:20 A.M. revealed the physician order for the Ozempic was put in daily instead of weekly. Resident stated, yeah I've been given that shot the last couple of days. The physician was notified and ordered for Ozempic to be administered weekly. Due to resident not having any side effects or other issues related to the medication, the physician gave no further orders. Review of an interdisciplinary (IDT) progress note dated 02/19/25 at 9:33 A.M. revealed the IDT team met to discuss event on 02/18/25. New orders from physician to change medication to once a week and not one a day. No new orders from the physician as he would see the resident when he came into the facility. Resident was evaluated and no signs or symptoms of side effect or adverse reactions to the medication. The resident and responsible party were notified. Interview on 03/12/25 at 2:42 P.M., Registered Nurse (RN) #434 revealed after checking the resident's order for Ozempic, realized the order had been entered into the electronic record as a daily injection instead of a weekly injection. RN #434 revealed she notified the physician and no new orders were given. Interview on 03/13/25 at 9:12 A.M., the Director of Nursing (DON) verified Resident #64 was administered daily doses of Ozempic instead of once a week injections. The DON revealed the pharmacy also had not questioned the daily dose. 2. Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Review of the care plan last revised 01/21/25 revealed the resident had diabetes mellitus with an intervention to administer diabetes medication as ordered by the physician. Monitor/document side effects and monitor for effectiveness. Review of a physician order dated 03/08/24 revealed the resident was ordered Ozempic (two milligram/dose) subcutaneous solution pen-injector eight milligrams/three milliliters, inject two mg subcutaneously one time a day every Friday for diabetes mellitus. Review of the medication administration record (MAR) dated 01/01/25 through 02/28/25 revealed Resident #42 was administered Ozempic on 01/03/25, 01/15/25, and 02/14/25. The resident was not administered the medication on 01/10/25, 01/17/25, 01/24/25, 01/31/25, 02/07/25, and 02/22/25 per physician orders. Review of the electronic medication administration record notes revealed the Ozempic was not available 01/10/25, 01/17/25, 01/24/25, 01/31/25, 02/07/25, and 02/22/25. The physician was notified the resident was not administered the medication on 01/10/25, 01/24/25, 02/07/25, and 02/22/25. Interview on 03/13/25 at 8:50 A.M., the Director of Nursing (DON) verified Resident #42 was not administered the weekly Ozempic injections on 01/10/25, 01/17/25, 01/24/25, 01/31/25, 02/07/25, and 02/22/25. The DON verified the physician was not notified the medication was not administered on 01/10/25, 01/24/25, 02/07/25, and 02/22/25. Interview on 03/13/25 at 1:14 P.M., Resident #42 revealed she was aware the facility had not administered her weekly injections of Ozempic but they never told her why. Review of the facility policy Medication Administration, dated 01/02/24, revealed medications would be administered as ordered by the physician in accordance with professional standards of practice. The physician would be notified timely of medication omissions.

Based on food sample, resident interview, staff interview, and policy review the facility failed to assure residents were served food at an acceptable temperature. This affected 20 residents (#32, #34, #35, #37, #38, #39, #40, #42, #43, #44, #46, #47, #50, #51, #52, #53, #56, #58, #61, and #62) who received meal trays on the 200 hall. The facility census was 53. Findings include: Interview with Residents #13 and #15 on 01/21/25 between 11:28 A.M. to 1:35 P.M. revealed meals on the hall trays were served cold at times. The residents stated sometimes they would ask staff to reheat the food, or they ate just ate the food cold. Observation of meal tray service on 01/21/25 on the 200 hall revealed the food cart arrived to the hall at 11:42 A.M. Staff began to serve the trays to residents within two minutes. A test tray was checked for food temperature at 11:51 A.M. with Dietary Assistant #535. The shrimp temperature was 100 degrees Fahrenheit and the french fries were 118 degrees Fahrenheit. The food tasted cold and the shrimp had no flavor. Interview with Director of Nutritional and Food Services #540 on 01/21/25 at 11:53 A.M. verified the food temperatures and acknowledged the food temperatures were below required temperatures for serving. Review of the facility policy titled Food Production dated 01/02/24 revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of injurious organisms and substances. This violation represents non-compliance investigated under Complaint Number OH00160861.

Based on observation, resident interview, staff interview, and facility policy, the facility failed to serve reasonably palatable food. This affected all residents who received spaghetti with the lunch meal. The facility identified 11 (#3, #10, #14, #17, #22, #29, #30, #31, #41, #46, and #50) residents who did not receive spaghetti. The facility census was 54. Findings include: Interviews on 11/04/24 between 8:33 A.M. and 3:29 P.M. with Residents #17, #18, #26, #31, #35, #42, #50, and #55 revealed concerns for food palatability. Observation on 11/05/24 at 12:03 P.M. revealed the lunch meal test tray included a four ounce spoodle of spaghetti noodles with marinara sauce. The spaghetti appeared appetizing but tasted sour and was gummy in texture. Interview on 11/05/24 with Corporate Dietary Manager #198 verified the spaghetti tasted acidity. Interview on 11/05/24 from 12:07 P.M. with Resident #1 revealed the spaghetti sauce was not good and could not eat it. Interview on 11/05/24 at 12:08 P.M. with Resident #9 revealed the spaghetti was yuck. Interview on 11/05/24 at 12:11 P.M. with Resident #16 reports the spaghetti was not good and mushy adding that it tasted like it came from a can. Interview on 11/05/24 at 12:13 P.M. with Resident #47 revealed the spaghetti did not taste good. Review of the policy, Palatability and Nutritive Value, dated 06/27/23, revealed food will be prepared, held, and served in a manner that preserves nutritive value and palatability. Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns.

Based on review of the medical record, observation, and interviews, the facility failed to ensure the memory care unit was maintained in good condition. This affected six (#43, #56, #44, #55, #21, #28,) of seven residents reviewed for environment and had the potential to affect all residents residing in the memory care unit. The facility census was 54. Findings include: 1. Review of the medical record for Resident #44 revealed an admitted [DATE]. Diagnoses included dementia, hypertension, and retinal disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had moderate cognitive impairment. Observation on 11/04/24 at 8:13 A.M. revealed there was an approximate ten inch wide by five inch tall spider web in the resident's window between the window and the screen. Interview on 11/06/24 at 8:54 A.M., the Director of Housekeeping (DOH) #158 verified the spider web in the window. 2. Review of the medical record for Resident #55 revealed an admitted [DATE]. Diagnoses included dementia, Alzheimer's disease, hypertension, and depressive disorder. Review of the admission MDS dated [DATE] revealed Resident #55 had severe cognitive impairment. Observation on 11/04/24 at 8:16 A.M., revealed the resident had a buildup of dust on the bathroom fan. Interview on 11/06/24 at 9:04 A.M., the DOH #158 verified the dust build up on the resident's bathroom fan. 3. Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included Parkinsonism, chronic obstructive pulmonary disease, bipolar disorder, and type two diabetes mellitus. Review of the admission MDS assessment dated [DATE] revealed Resident #56 had intact cognition. Observation on 11/04/24 at 8:34 A.M. revealed there was large scrapes in the wall next to the window. There was also patched areas on the bathroom door left not sanded or finished. Interview on 11/04/24 at 8:34 A.M., Resident #56 revealed the scrapes on the wall and patches on the bathroom door had been there since she moved into the room. Interview on 11/06/24 at 8:52 A.M., the Director of Maintenance (DOM) #107 and DOH #158 verified the scraped area on the walls and unfinished patches on the bathroom door. DOM #107 stated he had been out of paint for a long time. DOM #107 stated he thought paint had been ordered but was not sure when it would be received. 4. Review of the medical record for Resident #21 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included dementia, hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #21 had severe cognitive impairment. Observation on 11/04/24 at 8:50 A.M. revealed the resident had a build up of dust on his bathroom fan. Interview on 11/06/24 at 8:56 A.M. with the DOH #158 verified the dust buildup on the bathroom fan. 5. Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included vascular dementia and type two diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had severe cognitive impairment. Observation on 11/04/24 at 8:55 A.M. revealed there was a build up of dust on the resident's bathroom fan. Interview on 11/06/24 at 9:04 A.M., DOH #158 verified the build up of dust on the bathroom fan. 6. Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included vascular dementia, hypertension, peripheral vascular disease and depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severe cognitive impairment. The resident required set-up assistance/clean up assistance for toileting hygiene. Observation on 11/04/24 at 8:58 A.M. revealed there was a large puddle of urine on the bathroom floor and a brown substance smeared on the toilet. Interview on 11/04/24 at 8:58 A.M. State tested Nursing Assistant (STNA) #133 verified the puddle of urine and the brown substance on the toilet lid. STNA #133 revealed the prior shift should have cleaned up the area. 7. Observation on 11/04/24 at 8:59 A.M. revealed the floors in the dining room in the memory care unit were sticky and not clean. Interview on 11/04/24 at 8:59 A.M., Administrative Staff (AS) #161 verified the floors were sticky and not clean. Observation on 11/06/24 at 8:59 A.M., revealed the floor in the dining room felt tacky when walked on. Interview on 11/06/24 at 8:59 A.M., DOH #158 verified the floor was tacky. DOH #158 stated some peoples shoes stick to the floor and some do not. Review of the policy, Housekeeping, dated 04/2018, revealed resident rooms and common area would be cleaned and maintained.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents had access to their call lights. This affected three residents (#21, #40, and #42) in a facility with a census of 54. Findings include: 1. Review of the electronic medical record for Resident #40 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension, atherosclerotic heart disease, bipolar disorder, retention of urine, anemia, anxiety, insomnia, and major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #17 was cognitively intact. Resident #40 required assistance with her functional abilities and ambulated with a walker. Observation on 11/04/24 at 8:42 A.M. revealed Resident #40 needed to use the restroom and needed to use the call light to request assistance from facility staff, but was unable to locate her call light that was located out of her reach. Interview on 11/04/24 at 8:42 A.M. with Resident #40 revealed she did not know where her call light was, and it was frequently out of her reach. Interview on 11/04/24 at 8:45 A.M. with Administrative Staff #161 verified Resident #40's call light was out of her reach and Resident #40 was unable to locate it. 2. Review of the electronic medical record for Resident #42 revealed an admitted [DATE] with diagnoses of sepsis, osteomyelitis, acute kidney failure, chronic obstructive pulmonary disease, type two diabetes mellitus, osteoarthritis, constipation, depression, anxiety, hyperlipidemia, and hypotension. Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 08, indicating Resident #42 was moderately cognitively impaired. Resident #42 required partial to moderate assistance with his functional abilities and utilized a wheelchair. Observation on 11/04/24 at 8:36 A.M. revealed Resident #42's call light was not able to be located visually. Interview on 11/04/24 at 8:36 A.M. with Resident #42 revealed he was unable to locate his call light in his room. Interview on 11/04/24 at 8:40 A.M. with Administrative Staff #161 verified Resident #42 did not know where his call light was located in his room. Further interview on 11/04/24 at 8:40 A.M. with Administrative Staff #161 revealed the call light for Resident #42 was located out of his reach in his room. 51067 3. Review of the medical record revealed Resident #21 had an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, chronic obstructive pulmonary disease, anxiety disorder, type two diabetes mellitus with diabetic neuropathy, dementia, and hypertension. Review of the MDS assessment dated [DATE], revealed the resident had severe cognitive impairment. The resident had impairment to one side of the body and was dependent for toileting. Review of the care plan dated 04/19/23 revealed Resident #21 was at risk for falls and had a self-care performance deficit for activities of daily living (ADL). Interventions included for staff to ensure the call light was within reach and encourage Resident #21 to use it when assistance was needed. Observation on 11/05/24 at 7:18 A.M. revealed Resident #21's call light was out of reach positioned between the bed rail and mattress. Interview on 11/05/24 at 7:18 A.M., State tested Nursing Assistant (STNA) #151 and STNA #163 verified the call light was not in reach. Review of the undated policy, Answering the Call Light, revealed to ensure when a resident was in bed or confined to a chair to be sure the call light was within easy reach of the resident.

Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents received adequate hygiene and personal care. This affected one (#43) of six residents reviewed for Activities of Daily Living (ADLs). The facility census was 54. Findings include: Review of Resident #43's medical record revealed an admitted [DATE]. Diagnoses included vascular dementia, hypertension, and peripheral vascular disease. Review of Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment and required setup assistance with personal hygiene and oral care. Observation on 11/04/24 at 9:24 A.M. revealed Resident #43's bottom teeth were caked with a white residue. Observation on 11/05/24 at 7:26 A.M. revealed Resident #43's teeth were still had a white buildup of residue. Interview on 11/05/24 at 7:26 A.M., State tested Nursing Assistant (STNA) #163 verified the buildup on the resident's bottom dentures. STNA #163 stated the resident's teeth should get cleaned twice a day. Further interview with STNA #163 revealed she obtained oral care supplies for the resident. Interview on 11/06/24 at 7:59 A.M., STNA #176 revealed Resident #43 sometimes would refuse care and would have to approached again for care later. STNA #176 revealed if the resident refused care multiple times, then the nurse would be notified. STNA #176 revealed staff cleaned Resident #43's dentures for him. Review of Resident #43's progress notes revealed no documentation of Resident #43 refusing oral care or denture care. Review of policy, Personal Care, revised 01/2021, revealed staff were to assist residents with oral care including brushing teeth (or cleaning dentures) as needed. Some residents may need their mouth swabbed with a mouth swab.

Based on medical record review, review of a self-report incident investigation, staff and resident interviews and policy review, the facility failed to prevent resident to resident physical abuse resulting in Resident #1 sustaining two [MEDICAL CONDITION] and a neck abrasion requiring emergency room treatment. This affected one (Resident #1) of three residents reviewed for abuse. The facility census was 60. Findings include Medical record review for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly comprehensive assessment dated [DATE] revealed Resident #1 had mild cognitive impairment. Resident #1 required the extensive assistance of two staff members for transfers, bed mobility, dressing, toilet use and personal hygiene. He required supervision for locomotion on and off the unit. Review of the behavior assessment revealed Resident #1 had physical and verbal behaviors directed towards others during one to three days during the assessment look back period. Review of a facility Self-Reported Incident (SRI) report dated 03/18/19 revealed another resident struck Resident #1 in the head with a reacher device. Resident #1 sustained a [MEDICAL CONDITION] and was sent to the emergency room for treatment. Review of the incident log from 01/10/19 through 04/10/19 revealed a resident to resident altercation occurred on 03/18/19 between Resident #1 and another resident. Review of a nurse's note date 03/18/19 at 7:50 P.M. revealed Resident #1 was sent to the hospital for evaluation after an altercation with another resident resulting in a scalp laceration. Review of the hospital report dated 03/18/19 revealed Resident #1 sustained an assault with a grabber device which required a scalp laceration repair. Resident #1 sustained two small scalp lacerations measuring one centimeter in the posterior occipital aspect of his scalp. Resident #1 also had a two-centimeter superficial abrasion to the left lateral neck. Continued review of the hospital report revealed two staples were placed into the more proximal laceration and one staple was placed into the more lateral laceration. Review of a police report dated 03/18/19 revealed the police arrived at the facility at 7:51 P.M. Further review of the police report revealed Resident #1 admitted he made a comment about Resident #2's mother. Resident #2 stated Resident #1 tried to kick him and he struck him in the head with his cane. Resident #1 had a laceration on his head and paramedics advised he was going to the hospital. Interview on 04/10/19 at 10:04 A.M. with Resident #2 revealed on 03/18/19 Resident #1 was talking about his momma and Resident #1 started kicking him. Resident #2 revealed Resident #1 always had something smart to say and he was tired of his mouth. Resident #2 admitted he hit Resident #1 on the head with his reacher. Interview on 04/10/19 at 10:47 A.M. with Licensed Practical Nurse (LPN) #200 revealed on 03/18/19 Resident #2 attacked Resident #1 with his reacher. Resident #1 was bleeding from his head. LPN #200 revealed Resident #1 tried to go back after Resident #2. LPN #200 revealed the residents were separated but continued yelling at each other. LPN #200 revealed she called for an ambulance and the police. LPN #200 revealed there were prior verbal exchanges between the two residents. LPN #200 revealed Resident #1 would usually start the verbal exchanges. Telephone interview on 04/10/19 at 11:19 A.M. with the former Director of Nursing (FDON) revealed Resident #2 hit Resident #1 with his reacher. Resident #1 had a laceration to his head. FDON revealed the residents were separated and the police were notified. FDON #2 revealed she educated Resident #2 and gave him a final warning. FDON revealed she was unaware of any prior incidents between Resident #1 and Resident #2. Interview on 04/10/19 at 1:24 P.M. with State tested Nursing Assistant (STNA) #103 revealed on 03/18/19 we were in a room with a resident who had fallen. STNA #103 revealed they heard yelling in the hall. Resident #1 was going down the hall into his room and another resident was behind him hitting him over the head with his reacher. STNA #103 revealed Resident #1 was bleeding. STNA #103 revealed the two residents were separated. Interview on 04/10/19 at 1:55 P.M. with Resident #1 revealed on 03/18/19 Resident #2 hit him over the head with his reacher . Resident #1 revealed he had to go to the hospital and get staples in his head. Review of the policy Abuse, Neglect, and Misappropriation, dated (MONTH) (YEAR), revealed residents would be free from abuse, coercion and retaliation.

Based on observations, medical record review, device manufacturer's instructions review, facility policies review and staff interviews, the facility failed to maintain the positioning of Foley catheters to prevent personal injury from the use of an indwelling urinary catheter and failed to ensure immediate medical treatment was provided for the injury. This resulted in actual harm when Resident #46 received a severe painful penile tear, when a Foley catheter was not secured to prevent potential dislodgement and when treatment was not initiated until fourteen days later. This affected two (#46 and #32) of two residents reviewed for indwelling urinary catheters. The facility identified three current residents utilizing indwelling urinary catheters. The facility census was 55. Findings include: 1. Review of Resident #46's medical record revealed an admission date of [DATE], with medical [DIAGNOSES REDACTED]. Review of the most recent comprehensive minimum data set (MDS) assessment dated [DATE], assessed Resident #46 as requiring extensive assistance of two persons with bed mobility, transferring; was dependent for locomotion and dressing. Review of the progress notes dated 10/20/16, identified Resident #46 required the use of an indwelling Foley catheter for bladder emptying. Progress note dated 11/21/16 at 1:38 A.M., documented foreskin to the penis extremely distorted by irregular skin swelling. A progress note dated 12/14/16 at 5:19 A.M., revealed Resident #46 was noted with an open pressure area on the shaft of the penis, appeared to be from the catheter tubing, an incident report was completed, the wound team was notified for treatment orders, and primary care physician (PCP) was notified via fax. A progress note dated 12/14/16 at 1:30 P.M., documented the resident's urethra opening larger from Foley, and small amount of greenish/yellow drainage noted from the site. The Registered Nurse (RN) was going to speak with the case manager about a family meeting to see if the family would like a urology consult for a supra-pubic (through abdominal wall) or possible removal with family notification. Review of the treatment administration record (TAR) dated December 2016, identified no evidence of any anchoring devices in place to prevent trauma. The record further lacked treatment to Resident #46's penile tear from 12/14/16 through 12/28/16. Review of a physician order [REDACTED]. Resident #46's TAR confirmed the facility staff started the treatment to the area on 12/28/16, 14 days following initial identification of penile tear. Review of a physician's progress note dated 01/02/17, identified Resident #46's penile tear to measure 3 centimeters (cm) in length by 5 cm in width, with [DIAGNOSES REDACTED] (abnormal redness) and [MEDICAL CONDITION] (swelling) noted. Observation of Resident #46 occurred on 04/12/17 at 8:40 A.M. with State tested Nursing Assistant (STNA) #225. Resident #46 was observed to have a penile tear that extended down on the entire length of the ventral aspect of the penile shaft. Resident #46 was observed to grimace when STNA #225 was touching the catheter tubing during the observation. Resident #46's skin and urethra was completely damaged from the tip to the penoscrotal junction with urethral mucosa exposed along the length of the damaged area. Resident #46 was observed with a loosely placed elastic leg band (anchor) on the left leg. The label was pointing towards the outside of Resident #46's leg and the elastic band was easily moving about Resident #46's leg. STNA #225 stated Resident #46 frequently complains of pain in the area and was treated with a numbing cream. STNA #225 confirmed the leg band was not placed snuggly on Resident #46's leg and was moving freely. STNA #225 denied ever receiving education on placement of urinary catheter anchors. Interview with Licensed Practical Nurse (LPN) #219 on 04/12/17 at 8:43 A.M., stated Resident #46 receives [MEDICATION NAME] ointment to the penis often due to pain and discomfort. Interview with STNA #710 on 04/12/17 at 9:03 A.M., revealed she was working in the facility around the time Resident #46 suffered the penile tear. STNA #710 confirmed the facility was not using any leg straps in December 2016 when Resident #46 was injury occurred. STNA #710 also confirmed no education was provided to the nursing staff regarding the use of leg anchors prior to using them. Review of the undated manufacture's instructions of the Dale Hold-MN-place (Foley catheter holder), revealed application instructions included: position leg band high around patient's thigh with Dale product label pointing to inside of leg. Stretch leg band in place and fasten hook and loop tab. Proper compression has been achieved when two fingers fit snuggly under the band. Review of the facility policies titled, Use and Care of Urinary Catheter Guidelines, dated 04/2012 and Foley Care Procedure, dated 04/2014, revealed no indication on how staff was to prevent catheter pain, urethral tears and or erosion complications. Interview with the Director of Nursing on 04/13/17 at 11:06 A.M. verified the policies lacked instruction or procedures to prevent catheter pain, urethral tears and or erosion complications. 2. Review of Resident #32's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #32's minimum data set (MDS) assessment revealed the resident to be cognitively intact and having an indwelling urinary catheter. Review of Resident #32's care plan revealed the resident to have an indwelling urinary catheter. Review of Resident #32's physicians order dated April 2017, revealed an order for [REDACTED]. Observation on 04/11/17 at 1:03 P.M. of Resident #32, revealed the resident to have a urinary catheter in place without an anchor device in place. Resident #32 stated he did have a suprapubic catheter and now has an indwelling urinary catheter. Observation on 04/12/2017 at 9:22 A.M. of Resident #32, revealed State tested Nursing Assistants (STNA's) #224 and #225 provided catheter care for the resident. Resident #32's catheter was observed not to be anchored in place. Interview with STNA #224 and #225, at the time of the observation, verified they do not use any kind of anchoring device to secure the resident's catheter in place. Interview on 04/12/2017 at 10:15 A.M. with Licensed Practical Nurse (LPN) #219, verified Resident #32 did not have a urinary catheter anchor in place.

Based on review of medical records, policy review, surveyor observation, and interview with staff and residents, the facility failed to prevent development of avoidable pressure ulcers in one (#3) of four dependent residents with in-house acquired pressure ulcers. This resulted in actual harm to Resident #3, who developed four avoidable, unstageable black/necrotic pressure sores. Additionally, the facility failed to provide care and services to promote healing for three residents (#18, #50 and #24) with wounds. The facility identified a total of ten residents with pressure sores. Findings include: 1. Review of the medical record for Resident #3 revealed the alert and oriented resident was admitted on [DATE] after a coronary bypass surgery. Other [DIAGNOSES REDACTED]. The resident was assessed to require extensive assistance of two persons with bed mobility, transfers, hygiene and dressing. The admission form entitled "Admission Skin Assessment," dated 11/05/10, indicated the resident had bilateral soft mushy heels, indicating high potential for pressure ulcer development. However, a form entitled "Braden Risk Assessment Scale," dated 11/12/10, indicated that the resident was at "minimal" risk of development of a pressure ulcer with a score of 17 points. A prevention plan of care for potential development of pressure ulcers was documented on 11/05/10, but failed to address specific care to the heels. The plan did instruct staff to assess the skin for signs of breakdown. No physician orders or notification were obtained for preventive treatment to the "mushy heels". Review of the Treatment Administration Records (TAR) for 11/10/10, revealed that weekly skin assessments were to be done. The unit charge nurses were to perform a head to toe assessment. The assessments were documented 11/12/10, 11/19/10 and 11/26/10. These assessments indicated there were no skin impairments discovered. On 11/27/10, the form entitled "Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other," indicated the discovery of a black left heel ulcer. The staging descriptions on the form indicated that unstageable ulcers present as eschar (tan, black, brown) in the wound bed. The wound was assessed in both inches and centimeter calibrations as "1 1/2 inches in length, 1 1/2 inches width, and 4 centimeter in diameter." No treatment order for the ulcer was documented until 12/03/10, at which time a dry dressing change daily was ordered. The Pressure Ulcer care plan was not revised to address specific care to relieve pressure or treat the left heel ulcer. No further assessment of the area was documented until 12/20/10, which described the left heel ulcer as 3.3 centimeter (cm) length, 4.3 cm. width, and unstageable depth with black color. The wound was then not assessed again until 01/11/10, when it was described as "2.0 cm width, black color". The wound was not assessed again until 01/25/11, when it was noted as 3.0 cm. in diameter and black in color. The wound was not assessed again until 02/07/11, when it was described as 2.0 cm length by 1.5 cm. width, by 0.1 cm. depth with black eschar. There were no documented assessments between 02/28/11 and 03/15/11 of the left heel ulcer. The ulcer was described on 03/15/10 as 1.8 cm length, by 0.8 cm. width, and 0.1 cm. depth. However, during observation of the wound with the East Unit Manager on 03/16/11, there was noticeable black necrotic tissue in the wound bed. Interview with the director of nursing (DON) and Unit Manager #1 of East Unit, on 03/16/11 at 6:15 P.M., revealed that they could not attest as to why there was no preventive skin care interventions initiated on the plan of care or physician orders on admission to address potential breakdown of the "mushy" heels. The DON and Unit Manager could not attest as to why the left heel ulcer was not discovered until at an unstageable necrotic ulcer, given no evidence of severe vascular disease or co-morbidity, and, a negative skin assessment the previous day. They could not attest to whether the nurse had removed stockings to check the heels. Unit Manager #1 stated the nurse had inaccurately assessed the wound initially using both inches and centimeters. The DON nor the East Unit Manager could attest as to why the ulcer was not measured weekly as per policy on the Weekly Skin Grid forms. They verified that a weekly skin assessment, which is to be conducted by the unit managers and documented on the Treatment Administration Records, was blank on 12/01/10, 12/07/10, 12/14/10, 12/28/10, 01/04/11, 01/11/11, 01/25/11, 02/01/11, and 02/15/11. It was not until 01/10/11, 44 days after the discovery of the necrotic left heel ulcer, that a physician order was obtained for elevation of the heels to promote healing and prevention of further ulcers. A bed cradle was ordered. These interventions were not brought forward to the plan of care. No weekly skin assessment was documented on the TAR on 01/25/11 and 02/01/11. On 02/07/11, an ulcer was discovered on the right heel. It was described as 1 cm. in length, 1 cm. in width, and less than "0.1 in depth". The staging assessment was blank, but the ulcer was described as "black", indicating necrosis and likely unstageable status. There were no new physician orders or plan of care to address the new right heel ulcer. On 02/09/11, the care plan documentation stated "venous stasis ulcers left and right heel". There was no documentation to substantiate assessment of the wound between 02/28/11 and 03/15/11. On 03/15/11, the wound measured 1 cm. in diameter and 0.1 cm depth. The ulcer was observed with Unit Manager #1 as unstageable with black eschar on 03/16/11 at 5:00 P.M. The weekly skin assessment on the TAR was negative for impairment on 02/08/11. On 02/14/11, another area was discovered on the right heel. It was documented as 1.5 cm. length, by 1.0 cm. width, by 0.1 cm. depth. No staging was assessed. However, it also stated that the wound had a black color, indicating that it was necrotic and likely unstageable. There was no documented evidence that the physician was notified for a treatment order. The plan of care was not revised to address the new right heel ulcer. The wound was not assessed between 02/28/11 and 03/15/11. On 03/15/11 it was described as 1 cm diameter with black color. The wound was observed with Unit Manager #1 on 03/16/11 as being necrotic. On 02/28/11, another area was discovered on the left heel and described as 1 cm. diameter with black color. There was no further assessment documented until 03/15/11. There was no documented evidence that the physician was notified for treatment orders. The plan of care was not revised to address the new left heel pressure ulcer. The area was observed as necrotic on 03/16/11 when observed with Unit Manager #1 at 5:00 P.M. On 03/15/11, the assessments of the two right heel ulcers and one left heel ulcer described a mild odor with yellow brown drainage, indicating infection. [MEDICATION NAME](an oral antibiotic) and Silver [MEDICATION NAME] (a topical antibiotic) were ordered on [DATE]. At 6:00 P.M. on 03/16/11, the DON and Unit Manager #1 could not attest as to why the new ulcers on 02/07/11, 02/14/11 and 02/28/11 were not discovered until they were necrotic. They verified that staff should have been monitoring the resident's feet daily during bathing and dressing. They verified the failure to document notification to the physician regarding the 02/14/11 and 02/28/11 necrotic ulcers of the heels. They verified that there were no physician orders for treatment of [REDACTED]. They verified that there was no treatment ordered to address the heels until 03/10/11, at which time dressing change orders were received. They could not attest as to why there were no documented wound assessments on the Skin Grid forms between 02/28/11 and 03/15/11. They verified that the plan of care was revised in 02/11 to note "venous stasis ulcer on left heel/right heel". They verified that the plan of care did not address each individual pressure ulcer on both heels nor have revised interventions to treat, promote healing and further prevention of pressure ulcers. They verified that the physician had ordered tests of the arterial flow of both legs on 01/27/11 which revealed that blood flow was normal in the right leg and had only mild obstruction in the left leg. They could not attest as to how their statement of "venous stasis ulcers" was documented on the plan of care when no such [DIAGNOSES REDACTED]. During observation of the wounds of Resident #3, with Unit Manager #1, on 03/16/11 at 5:00 P.M., the nurse verified that the only pressure relieving intervention that she was aware of was to apply two bed pillows under the resident's legs when in bed. No bed cradle was present as ordered in 01/11. Interview with Resident #3 during this observation revealed that she was aware that her heels were mushy on admission. She stated that she also had [MEDICAL CONDITION] to both lower extremities at that time, which appeared after her heart surgery shortly before admission. She stated that the ulcers developed as a result of wearing her shoes. She stated that she "had to wear shoes to go to therapy". She said the shoes were tight due to the swelling and hurt her feet. She stated that it was several weeks after the left heel broke down that they started putting my feet up on pillows when in bed. She stated that she had been weakened with the heart surgery and needed help to reposition in bed. She stated that she laid most of the time on her back with her heels on the mattress, unable to turn independently. She said "someone brought boots in once, but they are in my closet because I am unable to put them on myself". Unit Manager #1 opened the closet during our observation and found the boots designed for pressure relief. She verified that there was no order for the boots, the boots were not mentioned on the plan of care, and she was not aware of this intervention. She verified that the resident was certainly unable to apply the pressure relieving boots by herself. She verified that there was no mention of tight shoes being discontinued on the plan of care. The resident was observed on 03/16/11 and 03/17/11 up in the wheelchair with gripper socks and bilateral heel dressings intact. Interview with the resident's physician, on 03/18/11, at 12:45 P.M., revealed that he was not made aware of the mushy heels upon admission. He stated that he was aware that the resident developed several necrotic pressure sores "rather rapidly". He verified that he had tested the resident for arterial flow as a potential cause, but the resident did not have significant circulatory issues related to pressure ulcer formation. He verified that no interventions were put in place for prevention on admission and that he and the facility should have made more rapid response to the prevention and treatment of [REDACTED]. Review of the policy entitled "Wound Prevention and Treatment," dated 04/09, revealed that staff are to ensure that pressure ulcers do not develop unless the resident's condition demonstrates unavoidable skin breakdown. The policy directed staff to prevent the development of pressure ulcers by reducing pressure over bony prominences, protecting against external pressure/friction/sheering, and increasing awareness of pressure prevention through education. The policy indicated that intensive efforts should be directed at managing risk factors, providing preventive interventions, and providing treatment. The policy stated that a resident with pressure ulcers is to receive preventive interventions to promote healing and prevent infection. The policy indicated that assessment of the length, width, depth, color, location, and other characteristics are to be assessed weekly. Interview with the administrator, on 03/18/11 at 11:30 A.M. verified that the Unit Managers are to be assessing all residents weekly from head to toe and documenting findings on the TAR. He stated that Unit Managers are to inform the DON of any skin issues every morning during report, and, that those issues are to be discussed at the morning meeting with department heads to assure preventive and interventions to promote healing are being addressed. He verified that the facility failed to implement their policy for prevention and care of Resident #3 regarding the development of avoidable pressure ulcers. 2. Review of the medical record for Resident #50 revealed that the resident was admitted on [DATE] free of pressure ulcers. The resident's [DIAGNOSES REDACTED]. The resident was assessed to require extensive assistance with mobility, dressing, and hygiene. The resident had been assessed as having gradual weight loss, but remained within ideal weight limits at 158 pounds, at 5 foot 9 inches height. The resident was assessed at moderate risk for pressure ulcer development due to sensory impairment, incontinence, being chairfast, and impaired ability to move. A preventive care plan for pressure ulcers was developed 08/21/10. Further review revealed that on 03/02/11 at 2:31 A.M., State tested Nurse Aide (STNA) #39 reported a new skin problem to the nurse as documented on the "EHSI-CNA Skin Detail Report." On 03/02/11 at 6:30 A.M., the nurse documented discovery of a "blood blister to the right outer foot". She applied "Skin Prep" solution treatment every shift. At 2:30 P.M., the nurse documented "blister intact". There was no documentation to evidence that the physician and family were notified of the blister developing on 03/02/11. There was no documented assessment of the characteristics and size of the area until 24 hours later, on 03/03/11. The area on the right foot was then described as 2.0 centimeter (cm) length by 3.0 cm. width, no depth due to black eschar. The wound was necrotic and unstageable. West Unit Manager #1 then wrote a treatment order on 03/03/11 for the Skin Prep treatment, keeping the heels elevated, and ordered Diabetic shoes. She also documented on the Treatment Administration Record stating "No shoes bilateral heels for one week". None of these interventions were revised on the care plan on 03/03/11. On 03/14/11, the wound was assessed as a "diabetic ulcer" with the same measurements/description as 03/03/11. Observations of Resident #50 on 03/15/11 revealed the resident to be up in a wheelchair at 8:50 A.M., 12:30 P.M., and 2:15 P.M. with tennis shoes applied. On 03/16/11, Resident #50 was observed at 9:15 A.M. in the wheelchair with the tennis shoes on. At 2:45 P.M., the resident was observed in bed without the shoes, but with bilateral heels directly resting on the mattress. On 03/16/11 at 3:00 P.M., the surveyor spoke with the DON regarding the cause of the wound. She verified that it was most likely caused from ill-fitting shoes. She verified that the resident was wearing the same shoes the past two days and that he had been observed with the heels directly on the mattress on 03/16/11 despite the necrotic ulcer on the right outer foot. At 4:00 P.M., West Unit Manager #1 documented a physician's telephone order for off-loading splints to both feet at all times until diabetic shoes were available. On 03/17/11 at 7:52 A.M., Resident #50 was observed up in the wheelchair with the ill-fitting tennis shoes applied. The observation was verified and West Unit Manager #1 removed the shoes. On 03/17/11, at 9:50 A.M., the surveyor observed the wound with West Unit Manager #1. The wound appeared as a 2 cm. length by 3 cm. width round, thick black necrotic scab on the outer right foot near the ankle bone. The Unit Manager stated that the wound was most likely caused from ill-fitting tennis shoes. She stated that she had diagnosed it as a "diabetic ulcer" because he had Diabetes Mellitus. Interview with the DON on 03/18/11 at 2:00 P.M., verified that the shoes had been sent home with the family to prevent staff from reapplying the ill-fitting shoes. She stated that she felt that the shoes rubbed a blister and that the Skin Prep application for a period of 24 hours had caused the blood blister to harden into the necrotic scab. She verified that the initial documentation of the assessment of the size and characteristics of the blister was not documented for a period of approximately 24 hours after discovery and then not again for a period of 11 days. She verified that there was a failure to revise the care plan to address the acute ulcer of the right foot until brought to the attention by the surveyor 03/16/11. 3. Review of the medical record for alert and oriented Resident #18 revealed that the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident required the extensive assistance of two persons for turning, repositioning, and transfer due to the application of a left knee immobilizer at all times. The plan of care developed on 02/03/11 instructed staff to inspect the skin. On 02/03/11 and 02/10/11, the nurses documented on the Treatment Administration Record that a weekly skin assessment was performed. A daily dressing change was documented to the left leg surgical site which was above the left knee. On 02/12/11, during the dressing change to the left leg, the nurse discovered two necrotic ulcers to the upper left and lower left ankle. The upper ulcer measured 2.0 cm. length by 0.7 cm. width with black eschar. The lower ulcer measured 1.4 cm. length by 0.6 cm. width with black eschar. There was no revision of the care plan to address the two ulcers for interventions or monitoring. There were no further assessments documented until 31 days later, on 03/15/11. The upper ulcer was now 2 cm. length by 1.2 cm. width and 0.1 cm depth, with a "brown scab". The lower ulcer was 0.9 cm. length by 0.6 cm. width, by 0.1 cm depth, with a "brown scab". Observation of the areas with the treatment nurse on 03/16/11 revealed the same. The areas were in accordance with the lower edge of the knee immobilizer, thought to be the cause, as stated by the treatment nurse. Interview with the DON, on 03/15/11 at 3:30 P.M., verified that the surgeon who ordered the knee immobilizer was consulted on 02/21/11 and ordered that the knee immobilizer be continued despite the ulcers, and ordered a new topical treatment. She could not attest as to why there was no documented assessment of the ulcers between 02/12/11 and 03/15/11. She verified that the care plan was not revised to address the two acute ulcers or care interventions. On 03/18/11, the DON contacted the surgeon regarding the ulcers, and, who, again, ordered no change in application of the knee immobilizer. 4. Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE] with a re-admission on 12/23/10. [DIAGNOSES REDACTED]. Although documented on the transfer sheet from the hospital that the coccyx was dry and intact, review of the admission skin assessment revealed the presence of a reddened area at the coccyx with a 1/2 inch scratch and a 2 inch crack in the skin tissue in the crease between the buttocks. The facility noted the presence of a rectal fistula on the right buttock which was documented as a 0.4 centimeter deep and 1 inch long hole as well as a pressure area on the right buttock which was documented as a 1 inch deep and 2 inch long hole. Despite these findings, Resident #24 was determined according to the "Braden Risk Assessment Scale" to be at minimal risk for pressure sore development with a score of 17 on the date of admission. Review of the medical record from the date of the admission on 11/15/10 until discharge on [DATE] failed to show evidence of any further assessment and monitoring of the wounds documented on admission. Resident #24 returned to the facility on [DATE]. The admission skin assessment form noted that the resident had excoriation under the abdominal fold, an open wound on the right buttock, bruising on the right side of the neck and [MEDICAL CONDITION] of both arms. The facility's "Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other," form initiated on 12/23/10, noted a Stage IV pressure sore on the right buttock measuring 10 cm by 12 cm by 1.7 centimeters. The document noted no further assessment of this large wound until 1/13/11, which revealed the wound to measure 3 cm in length by 5 cm width by 3 centimeters depth. The wound showed slight improvement when measured on 01/20/11 and 01/27/11 decreasing on 02/01/11 to 3 by 4 by 3 centimeters. The wound was then not assessed until 2/16/11, again with improvement at 2 by 0.2 by 2.5 centimeters and then again on 02/23/11 at 3 by 1 by 2 centimeters. Measurements of 02/28/11 revealed the wound to measure 2.7 by 0.8 by 3.0. The facility was unable to provide any evidence of further assessment after 02/28/11. Observation of the treatment with wound measurements on 03/17/11 revealed it to currently measure 1.5 by .3 by 2.2 centimeters. Additionally, a skin grid dated 02/03/11 noted the presence of an area in the crease between the buttocks at the coccyx which measured 0.5 by 0.7 by less than 0.1 centimeters. There was no further assessment until 02/17/11 when the wound was noted to measure 1.5 by 0.2 by 0.1 centimeters. On 02/23/11 the wound had increased in size to 3 by 1 by 0.1 centimeters and then there was no additional assessment until 03/14/11 when the wound was noted to have separated into two separate wounds, the upper measuring 0.3 by 0.1 by 0.1 centimeters and the lower measuring 1.5 by 0.2 by 0.2 centimeters. Observation of the treatment with wound measurements revealed the wound is currently one Stage II pressure area measuring 1.2 by 0.5 by 0.1 centimeters. These assessments were to be completed weekly per direction of the facility policy entitled "Wound Prevention and Treatment." During interview with Registered Nurse (RN) #8 on 03/17/11 at 10:30 A.M., she was unable to explain why there were lapses in the assessment and documentation of the ulcers. She verified that the wounds are to be assessed weekly and the findings documented on the Skin Grid form. Review of the medical record revealed physician orders of 03/01/11 directing staff to use a specialty mattress, turn Resident #24 side to side every three hours and to off load her heels with pillows at the calves. Review of the document, "Skin Integrity Assessment: Prevention and Treatment Plan of Care," initiated 01/03/11, which identified the resident as high risk. Interventions included implementing an individualized turning schedule if applicable; provide a pressure reduction or pressure relief surface for bed and/or wheelchair, and position calves on pillows to elevate heels off of the bed. Observation revealed the presence of a low air loss mattress on the bed which was functional. When up in the wheelchair, Resident #24 was observed to have a pressure relieving cushion in the seat of the chair. Observation when in bed on 03/15/11 at 6:35 A.M., 9:50 A.M. and 11:10 A.M. revealed her to be positioned on her back in bed. On 03/16/11, Resident #24 was observed to remain up in her wheelchair between 6:30 A.M. and 10:00 A.M. On 03/16/11 at 2:00 P.M. she was observed laying in bed on her back with her feet resting directly on the mattress. She remained on her back when observed at 3:30 P.M. The plan of care and nurses' notes were silent to any indication of the resident being non-compliant with turns.