Every finding on record at Majestic Care of Perrysburg

Based on review of personnel files, staff interview and policy review, the facility failed to ensure newly hired staff were checked on the nurse aide registry to verify eligibility for employment prior to working with residents in the facility. This had the potential to affect all 52 residents in the facility. The facility census was 52.Findings include:Review of the personnel file for Licensed Practical Nurse (LPN) #152 revealed a hire date of 02/18/26. Further review revealed no evidence LPN #152 was searched on the nurse aide registry prior to working in the facility.Interview on 04/20/26 at approximately 12:40 P.M. with Human Resources Manager (HRM) #125 revealed he did not perform nurse aide registry searches for applicants prior to hiring into the facility. HRM #125 stated he believed the registry was checked through the corporation's comprehensive background check. HRM #125 stated he performed nurse aide registry searches during his previous employment elsewhere, but did not receive direction to do so in his current position.Interview on 04/20/26 at approximately 4:00 P.M. with the Administrator confirmed HRM #125 had not completed any nurse aide registry searches for staff, except for Certified Nursing Assistants (CNAs), hired since HRM #125 began the position on 10/06/25. Additionally, the Administrator provided a list of 22 staff, not including CNAs, who were hired since HRM #125 began at the facility. Review of the facility provided list of staff hired, excluding CNAs, since 10/06/25 revealed 22 staff, including Assistant Director of Nursing (ADON) #153, seven Registered Nurses (RNs) (#109, #118, #120, #132, #133, #146, and #158), five LPNs (#139, #142, #143, #152, and #172), Maintenance Director (MD) #161, Activities Director (AD) #167, Director of Nutritional and Food Services (DNFS) #102, Administrative Assistant (AA) #116, Housekeeping Aide (HA) #163, two Dietary Cooks (DCs) (#141 and #169) and two Dietary Aides (DAs) (#108 and #112).Interview on 04/21/26 at 8:06 A.M. with the Administrator confirmed all staff, except dietary, who had been hired since 10/06/25, worked on all units in the facility.Interview on 4/21/26 at 9:10 A.M. with DNFS #102 revealed DA #108 and DA #112 would take meal trays into resident areas, but DC #141 and DC #169 had not taken trays to resident care areas since hire. Additionally, DNFS #102 confirmed interacting with residents throughout the facility. Nurse aide registry searches for the above 22 employees was completed by the facility on 04/20/26. Review of the findings revealed no staff had findings of abuse, neglect or misappropriation on the nurse aide registry.Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, revised 06/05/25, revealed it was the facility's policy to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks and to screen prospective residents/patients for appropriateness of admission. Additionally, the facility would do the following prior to hiring a new employee: check the nurse aide registry (and attempt to check other state registries if the individual was known to have worked in another state) for all potential new employees (licensed and unlicensed) and new volunteers to determine if there was a finding of abuse, neglect or misappropriation of property against the individual prior to the use of that individual.

Based on observation, staff interview, medical record review, policy review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and monitor Legionella control measures. This had the potential to affect all residents. Additionally, the facility failed to ensure enhanced barrier precautions (EBP) were implemented. This affected three (#1, #3 and #47) of three residents reviewed for transmission-based precautions (TBP). The facility census was 52. Findings include:1. Review of the facility's Legionella Water Management Plan, dated 12/01/25, revealed the Legionella prevention and monitoring tasks were to include flushing hot and cold water for three to five minutes each in empty rooms and in less frequently used outlets, including soiled utility rooms, medication rooms, shower stalls, private room showers and all eyewash stations. Furthermore, the Legionella Water Management Plan included a prevention task of cleaning and disinfecting or replacement of shower heads on a six-month cycle. Review of the facility documentation revealed no evidence the prevention and monitoring tasks of flushing water in less frequently used outlets/empty rooms or shower head cleaning or replacement was completed. Interview on 04/15/26 at 9:40 A.M. with Maintenance Director (MD) #161 revealed the facility performed flushing of less frequently used water outlets and this was tracked through The Equipment Lifecycle System (TELS); however, he was unaware he needed to maintain documented evidence that the task was completed. Additionally, MD #161 verified the shower heads were not cleaned/disinfected or replaced every six months as indicated in the facility's Legionella Water Management Plan. Review of the CDC guidelines titled, Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit), dated 02/17/26, revealed recommendations to store hot water at temperatures above 140 degrees Fahrenheit (F) and flushing low-flow piping at least weekly and flush infrequently used fixtures (for example, eye wash stations and emergency showers) regularly as-needed to maintain quality parameters within control limits. 2. Review of the medical record for Resident #1 revealed she was admitted on [DATE] with diagnoses including subsequent encounter of bladder injury, septic shock, ascites, Type II diabetes mellitus, polyneuropathy, irritable bowel syndrome, cystocele, peritonitis, and stage three chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment, dated 03/19/26, revealed Resident #1 was cognitively intact and did not display any behaviors nor refusals of care at the time of this assessment. She required maximal assistance to full dependence with activities of daily living (ADLs), bed mobility, and transfers. Resident #1 utilized a wheelchair and was dependent for mobility. Review of the care plan for Resident #1 revealed interventions initiated on 03/12/26 for impaired skin integrity related to her abdominal wound, heels, sacrum, and panniculitis. Interventions included wound care as ordered. Review of the physician orders for Resident #1 revealed an order dated 03/15/26 for EBP to be utilized during wound care for infection control. Observation on 04/15/26 at 9:15 A.M. of Licensed Practical Nurse (LPN) #158 providing wound care to Resident #1's abdomen and closed-suction bulb drain site revealed she did not don a gown, did not disinfect the bedside tabletop prior to utilizing it for wound care supplies, nor did she complete hand hygiene between a glove change. Interview on 04/15/26 at 9:30 A.M. with Assistant Director of Nursing (ADON) #153 and LPN #158 confirmed the above observations and verified a gown should have been worn during wound care, the bedside table should have been disinfected before placing clean wound supplies on the table, and hand hygiene should have been performed between each glove change. 3. Review of the medical record for Resident #3 revealed he was admitted on [DATE] with diagnoses including acquired deformity of head, disorders of the meninges, cognitive communication deficit, chronic respiratory failure with hypoxia, and tracheostomy status. Review of the quarterly MDS assessment, dated 03/03/26, revealed Resident #3 was cognitively impaired and did not display any behaviors nor refusals of care at the time of this assessment. He was dependent for all care, transfers, and mobility. Resident #3 required oxygen therapy, suctioning and tracheostomy care. Review of the care plan for Resident #3 revealed focus areas for the management of his tracheostomy and altered respiratory status. Interventions included the use of EBP dated 05/22/25. Review of the physician orders dated 02/07/26 revealed Resident #3 had orders for EBP to be utilized every shift for infection control and tracheostomy care every 12 hours. Observation on 04/16/26 at 9:20 A.M. of Registered Nurse (RN) #106 performing tracheostomy care for Resident #3 revealed she did not perform hand hygiene prior to entering the room nor between glove changes, did not don a gown and did not disinfect the bedside tabletop prior to using it for sterile tracheostomy care supplies. Interview on 04/16/26 at 9:40 A.M. with RN #106 confirmed the above observations and verified she should have performed hand hygiene prior to entering the room and between glove changes, worn a gown and disinfected the bedside tabletop before placing sterile supplies on it. 4. Review of Resident #47's medical record revealed an admission date of 05/20/20. Diagnoses included schizoaffective disorder, Type II diabetes mellitus, dementia, peripheral vascular disease, hypertension, chronic pain syndrome, insomnia, and hypothyroidism. Review of the MDS assessment, dated 03/12/26, revealed Resident #47 was assessed with moderately impaired cognition and was not at risk for developing pressure ulcers with a diabetic foot ulcer present. Review of a progress note dated 02/26/26 at 4:25 P.M. revealed Resident #47's left great toe had a black scab and the left second toe and heel scarred. Review of the physician orders revealed wound treatment was initiated on 02/26/26 and included Betadine Swabsticks External Swab 10 percent (%) (povidone-iodine), apply to left great and second toe topically every shift. Further review revealed on 03/05/26 the treatment was modified to the left heel to include cleanse with normal saline, pat dry then apply skin prep every shift for wound care. Lastly, on 04/01/26, wound treatment was changed to include left great toe, cleanse with normal saline, pat dry. apply hydrogel and cover with border gauze. Change every day shift for wound care and every 24 hours as needed for dislodgement/soilage. Observation on 04/13/26 at 8:32 A.M. revealed Resident #47 was seated in bed and eating the breakfast meal. No EBP were observed to be in place. Observation on 04/13/26 at 11:37 A.M. revealed Certified Nursing Assistant (CNA) #149 and CNA #159 provided Resident #47 with assistance with activities of daily living (ADLs), including transfer to the wheelchair using a standing lift. No personal protective equipment (PPE) was donned by CNA #149 and CNA #159 prior to providing care for Resident #47. Interview on 04/13/26 at 11:42 A.M. with LPN #145 verified Resident #47 had a current wound. LPN #145 confirmed there was no instruction signage or PPE accessible before entering Resident #47's room and the resident should have EBP in place. Interview on 04/13/26 at 2:11 P.M., during observation of Resident #47's left foot wound, with LPN #145 verified a second time that Resident #47 should be on EBP and they were not in place. Interview on 04/14/26 at 7:05 A.M. with ADON #153 verified EBP were not in place for Resident #47 until yesterday and the resident had been treated for a wound since 02/26/26. Review of the facility policy titled, Contact Precautions (EBP), revised 03/05/25, revealed an order for EBP would be obtained for resident's with any of the following: wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers) and/or indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident was not known to be infected or colonized with a multidrug-resistant organism (MDRO). Implementation of EBP included making gowns and gloves available immediately near or outside of the resident's room and face protection may also be needed if performing activity with risk of splash or spray. High-contact resident care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, and wound care (any skin opening requiring a dressing). Review of the facility policy titled, Handwashing-Hand Hygiene, dated 03/05/25, revealed hand hygiene would occur after removing gloves. This deficiency represents non-compliance investigated under Complaint Number 2796491.

Based on medical record review, observations, staff interviews, review of an equipment compliance report, review of the user manual and review of facility policy, the facility failed to ensure emergency respiratory equipment was at the bedside for a tracheostomy. This affected one (#3) of one resident reviewed for tracheostomy care. Additionally, the facility failed to ensure physician orders for the administration of oxygen. This affected two (#30 and #40) of five residents reviewed for oxygen therapy. Lastly, the facility failed to ensure Bilevel Positive Airway Pressure (BIPAP) therapy was initiated as ordered and BIPAP machine maintenance was completed. This affected one (#4) of one resident reviewed for BIPAP therapy. The facility census was 52. Findings include:1. Review of the medical record for Resident #3 revealed he was admitted on [DATE] with diagnoses including acquired deformity of head, disorders of the meninges, cognitive communication deficit, chronic respiratory failure with hypoxia, and tracheostomy status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/03/26, revealed Resident #3 was cognitively impaired and did not display any behaviors nor refusals of care at the time of this assessment. He was dependent for all care, transfers, and mobility. Resident #3 required oxygen therapy, suctioning, and tracheostomy care. Review of the care plan for Resident #3 revealed interventions for the management of his tracheostomy and altered respiratory status. Interventions dated 06/12/24 included keeping an extra tracheostomy tube and obturator at the bedside. Review of physician orders for Resident #3 revealed orders dated 02/07/26 for oxygen to be delivered at five liters per minute (lpm) through a tracheostomy collar and an order to keep a spare tracheostomy tube of the same size and one size smaller at the bedside. Additionally, Resident #3 had an order dated 02/08/26 to change oxygen and nebulizer tubing every week. Observation on 04/13/26 at 9:25 A.M. of Resident #3's room revealed the absence of an extra tracheostomy tube and obturator, nor one sized smaller, at the bedside. Interview on 04/13/26 at 10:00 A.M. with Licensed Practical Nurse (LPN) #145 verified there was not an extra tracheostomy tube and obturator, nor one sized smaller, at Resident #3's bedside and there should have been. Interview on 04/14/26 at 8:15 A.M. with Assistant Director of Nursing (ADON) #153 confirmed Resident #3's extra tracheostomy supplies were not at the bedside and should have been. Review of facility policy titled, Tracheostomy Care, dated 01/02/24, revealed the facility would provide tracheostomy care in a manner consistent with professional standards of practice. 2. Review of the medical record for Resident #30 revealed she was admitted on [DATE] with diagnoses including peptic ulcer, schizoaffective disorder, bipolar disorder, rheumatoid arthritis, anxiety disorder, chronic obstructive pulmonary disease, and lung cancer. Review of the social services progress review for the MDS assessment, dated 04/02/26, revealed Resident #30 was cognitively intact, had adequate vision and hearing, was able to be understood, and did not display any behaviors nor refusals of care. Review of the physician orders for Resident #30 revealed the absence of orders for the administration of oxygen. Observation on 04/13/26 at 8:15 A.M. revealed Resident #30 was wearing an oxygen nasal cannula connected to an oxygen concentrator running at four lpm. Interview on 04/13/26 at 10:05 A.M. with LPN #145 verified Resident #30 was receiving oxygen administration via nasal cannula. Interview on 04/16/26 at 12:45 P.M. with the Administrator confirmed Residents #30 did not have a physician order for oxygen administration. 3. Review of the medical record for Resident #40 revealed he was admitted on [DATE] with diagnoses including neurogenic bladder, cancer of the choroid, gallbladder cancer, liver cancer, and lung cancer. Review of the admission MDS assessment, dated 04/07/26, revealed Resident #40 was cognitively intact and did not display any behaviors nor refusals of care. The assessment indicated he did not utilize oxygen therapy. Review of the physician orders for Resident #40 revealed the absence of orders for the administration of oxygen. Observation on 04/13/26 at 9:45 A.M. revealed Resident #40 was wearing an oxygen nasal cannula connected to an oxygen concentrator running at four lpm. Interview on 04/13/26 at 10:05 A.M. with LPN #145 verified Resident #40 was receiving oxygen administration via nasal cannula. Interview on 04/16/26 at 12:45 P.M. with the Administrator confirmed Residents #40 did not have orders for the administration of oxygen. Review of facility policy titled, Oxygen Administration, dated 08/01/25, revealed the facility would administer oxygen under the orders of a physician. 4. Review of the medical record revealed Resident #4 admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus, bipolar disorder, major depression, anxiety disorder, neuropathy, restless leg syndrome, anemia, chronic viral hepatitis c, transient ischemic attack, and hypertension. Review of the MDS assessment, dated 03/26/26, revealed Resident #4 was assessed with intact cognition. Review of physician orders dated 11/19/25 revealed BIPAP (13/4) setting orders, change BIPAP tubing monthly every day shift starting on the 20th and ending on the 21st every month, and cleanse mask and machine weekly by wiping using a cloth dampened with warm soapy water and allow to dry every day shift every Monday. Review of the care plan dated 02/16/26 revealed Resident #4 had altered respiratory functioning and/or difficulty breathing related to COPD and was at risk for shortness of breath (SOB) while flat, BIPAP. Interventions included: administer medication(s) as ordered by doctor; refer to physician orders or electronic Medication Administration Record (eMAR) for current; monitor/document for side effects and effectiveness; adjust as directed by physician; assess respiratory status, including respiratory observation, lung sounds, skin color, pulse oximetry, as directed and as needed (PRN); report changes and/or abnormals to physician; adjust plan of care as directed; BIPAP 13/4 per orders; keep head of bed (HOB) elevated at all times due to SOB when lying flat related to related to COPD; maintain a clear airway by encouraging resident to clear own secretions with effective coughing; and if secretions could not be cleared, suction as ordered/required to clear secretions. Observation on 04/13/26 at 9:08 A.M. revealed Resident #4's BIPAP machine was located at the bedside. Concurrent interview with Resident #4 revealed the BIPAP machine had not be placed on her in approximately two months and when she used the machine, she got better sleep. Additional observation at the time identified no date was indicated (marked) on the tubing and no water was observed in the humidification chamber. Resident #4 stated the BIPAP machine had not been cleaned or had circuits or the filter changed in approximately two months and was missing parts. Observation on 04/14/26 at 5:02 A.M. revealed Resident #4 was seated in a recliner. The BIPAP machine was not applied. Interview on 04/14/26 at 5:08 A.M. with LPN #152 confirmed she assumed care of Resident #4 between 6:00 P.M. and 6:00 A.M. LPN #152 verified Resident #4's BIPAP was not applied during the night due to equipment not available in the room. LPN #152 verified the tubing was undated and Resident #4 had not worn the BIPAP machine for two months. Interview on 04/15/26 at 10:19 A.M. with Sleep Center Representative Staff (SCRS) #202 via telephone verified Resident #4's BIPAP had Bluetooth capability and results from the machine were periodically reviewed. SCRS #202 stated the center would provide machine readings via electronic mail (email). Interview on 04/16/26 at 5:34 A.M. with LPN #101 revealed she assumed care of Resident #4 the previous night at 6:00 P.M. until 6:00 A.M. this morning. LPN #101 stated she did not place or assess Resident #4's settings or placement of the BIPAP equipment during her shift. LPN #101 stated Resident #4 conducted this process herself and further stated she was unaware of how to operate the BIPAR or verify settings. Review of Resident #4's BIPAP machine usage report revealed the BIPAP was used from 12/05/25 to 02/15/26. No use had been recorded since 02/15/26. Further review revealed the compliance summary recorded use on 44 of 90 day, resulting in a percentage of 48.9 percent (%) of machine application. Review of facility Bilevel and Continuous positive airway pressure (BIPAP/CPAP) respiratory therapy policy, effective 08/01/25, revealed the nurse or respiratory therapist would provide CPAP/BIPAP only as ordered by the physician. Resident/patient settings should be re-evaluated when there was a change in resident's/patient's physiological condition. Review of BiPAP machine (DreamStation BiPAP Pro) user manual dated 2021 revealed the prescription and other device settings should only be changed on the order of the supervising physician. The operator should read and understand the entire manual before using the device. Inspect the tubing for damage or wear. Discard and replace tubing as necessary. Never operate the device if any parts were damaged or it was not working properly. Replace damaged parts before continuing use. Humidification could increase the resistance of bacteria filter and operator must monitor the bacteria filter frequently for increased resistance and blockage to ensure the delivery of therapeutic pressure.

Based on review of open and closed medical records, observations, resident and staff interviews and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments. This affected four (#29, #40, #55 and #62) of nine residents reviewed for MDS assessments. The facility census was 52.Findings include:1. Review of the medical record for Resident #29 revealed an admission date of 03/14/25 with diagnoses including traumatic subdural hemorrhage, Type Two diabetes mellitus, alcohol use, dysphagia, cognitive communication deficit, slurred speech, and unsteadiness on his feet.Review of the annual MDS assessment, dated 03/20/26, revealed Resident #29 had moderate cognitive impairment and did not exhibit aggressive behaviors, refusals of care, nor wandering behaviors.Review of Section E of the MDS assessment, dated 03/20/26, revealed the point of care documentation during the lookback period for this assessment indicated Resident #29 exhibited wandering behaviors on 03/19/26.Review of care plans dated 03/15/25 and 05/16/25 revealed Resident #29 exhibited exit-seeking behaviors and was an elopement risk. Interventions included the application of, and checking the placement and function of, his wander management device, redirection, and providing structured activities.Review of a physician order dated 08/04/25 revealed Resident #29 had an order for a wander management device to be placed on his left ankle.Review of the elopement risk assessments for Resident #29, completed between 03/15/25 and 03/29/26, revealed he was at risk for elopement. There were no elopement risk assessments indicating Resident #29 was not at risk for elopement.Review of a facility incident report revealed Resident #29 had an elopement from the facility on 03/29/26.Interview on 04/16/26 with Regional Registered Nurse (RRN) #177 verified Resident #29 was inaccurately assessed as not being an elopement risk on the MDS assessment dated [DATE].Interview on 04/20/26 at 9:30 A.M. with the Administrator revealed Resident #29 had a second elopement from the facility on 04/17/26.2. Review of the medical record for Resident #40 revealed an admission date of 03/31/26 with diagnoses including neurogenic bladder, cancer of the choroid, gallbladder cancer, liver cancer, and lung cancer.Review of the admission MDS assessment dated [DATE] for Resident #40 revealed he was cognitively intact and did not display any behaviors nor refusals of care. The assessment indicated he did not utilize oxygen therapy and was not a hospice patient. Further review of the medical record for Resident #40 revealed the absence of any subsequently completed MDS assessments.Observation on 04/13/26 at 9:45 A.M. revealed Resident #40 was wearing an oxygen nasal cannula connected to an oxygen concentrator running at four liters-per-minute (lpm).Interview on 04/16/26 at 12:45 P.M. with the Administrator confirmed Resident #40 utilized oxygen as needed.Review of hospice admission paperwork revealed Resident #40 elected hospice benefits on 03/31/26. Interview on 04/21/26 at 2:15 P.M. with the Administrator confirmed Resident #40 was admitted to hospice services on 03/31/26, after his admission to the facility, and his hospice services had not been interrupted throughout his stay at the facility. Continued interview confirmed Resident #40's MDS dated [DATE] was inaccurate regarding his use of oxygen and his status as a hospice patient.3. Review of the medical record for Resident #55 revealed an admission date of 02/27/26 with diagnoses including chronic heart failure, thrombophilia, atrial fibrillation, anxiety, depression, cellulitis of left lower extremity, venous insufficiency, lymphedema, and chronic respiratory failure with hypoxia.Review of the admission MDS assessment dated [DATE] revealed Resident #55 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a walker and wheelchair and was dependent for transfers and mobility. Resident #55 required maximal assistance to dependence with activities of daily living (ADLs). This assessment did not indicate Resident #55 had any existing wounds.Review of the admission orders for Resident #55, dated 02/27/26, revealed she had a wound to her right lower extremity with wound care orders, and required treatments to her left lower extremity and coccyx.Review of the care plan for Resident #55 revealed interventions initiated on 02/28/26 for wound management to her right and left lower extremities.Review of the admission assessment progress note dated 02/28/26, documented by Licensed Practical Nurse (LPN) #101, revealed Resident #55 had a wound to her right lower extremity measuring 6.5 centimeters (cm) by 5.8 cm by 0.1 cm, and treatment was provided during the admission.Observation on 04/13/26 at 10:15 A.M. revealed Resident #55 resting in bed with an elastic compression bandage to her right lower extremity. Continued observation revealed redness to her left lower extremity. Both extremities were elevated on pillows.Interview on 04/13/26 at 10:15 A.M. with Resident #55 revealed she had a wound to her right lower extremity, the wound was there when she was admitted to the facility, and she saw an off-site wound care provider weekly. Further interview revealed daily wound care was provided by the facility nurses as ordered by her wound care provider.Review of wound care visit notes for Resident #55 revealed the facility was to provide daily wound care to her right lower extremity.Review of the treatment administration record (TAR) for March 2026 for Resident #55 revealed a treatment order dated 03/06/26 for a skin tear to her left lower extremity.Interview on 04/21/26 at 10:05 A.M. with RRN #177 confirmed Resident #55 had a wound to her right lower extremity, present upon admission, to the facility and the MDS dated [DATE] did not reflect a wound was present.4. Review of the closed medical record for Resident #62 revealed he was admitted on [DATE] and discharged on 03/05/26. His diagnoses included chronic obstructive pulmonary disease, arthritis, cutaneous abscess of right lower extremity, bacteremia, hypertension, difficulty walking, and gastro-esophageal reflux disease.Review of the admission MDS assessment dated [DATE], and the discharge MDS assessment dated [DATE], revealed Resident #62 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment.Review of progress notes for Resident #62 revealed he refused care on 02/11/26, 02/12/26, 02/14/26, 02/16/26, 02/18/26, 02/19/26, three times on 02/23/26, twice on 02/25/26, 02/27/26, 02/28/26, twice on 03/04/26, and 03/05/26.Interview on 04/15/26 at 3:00 P.M. with MDS Coordinator #127 confirmed section E of Resident #62's admission MDS assessment dated [DATE], and his discharge MDS assessment dated [DATE], were incorrectly coded indicating he did not refuse care.A follow-up interview on 04/15/26 at 3:00 P.M. with MDS Coordinator #127 revealed there was no facility policy regarding the accurate completion of the MDS assessments. Continued interview revealed the facility followed the most recent edition of the LTC Facility RAI User's Manual, provided by CMS, for guidelines regarding the accurate completion of MDS assessments.Review of the LTC Facility RAI User's Manual revealed facilities would ensure MDS assessments accurately reflected residents' status.

Based on observation, open and closed medical record review, staff interview, resident interview, review of the facility elopement investigation files and review of facility policies, the facility failed to ensure adequate supervision was provided for residents assessed to be at risk for elopement. This affected one (#29) of one resident reviewed for elopement. Additionally, the facility failed to ensure smoking materials were properly stored. This affected one (#56) of two residents reviewed for smoking. Lastly, the facility failed to ensure neurological assessments were thoroughly completed following falls. This affected one (#63) of two residents reviewed for falls. The facility census was 52. Findings include:1. Review of the medical record for Resident #29 revealed he was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage, Type II diabetes mellitus, alcohol use with withdrawal, dysphagia, cognitive communication deficit, slurred speech, anxiety, and unsteadiness on his feet. Review of the annual Minimum Data Set (MDS) assessment, dated 03/20/26, for Resident #29 revealed he had moderate cognitive impairment, did not exhibit aggressive behaviors, refusals of care, nor wandering behaviors. Further review of the point of care documentation during the lookback period revealed Resident #29 exhibited wandering behaviors on 03/19/26. Review of care plans dated 03/15/25 and 05/16/25 for Resident #29 revealed he exhibited exit-seeking behaviors and was an elopement risk. Interventions included application of, and checking the placement and function of, his wander management device, redirection, and providing structured activities. Review of physician orders for Resident #29 revealed two physician orders, each dated 08/04/25, for a wander management device to be placed on his left ankle, and a functional test of the device to occur every day shift. Review of the elopement risk assessments for Resident #29, completed between 03/15/25 and 03/29/26, revealed he was at risk for elopement. Review of the facility incident report dated 03/29/26 revealed Resident #29 had an elopement incident on 03/29/26. Review of the elopement investigation file for the incident on 03/29/26 revealed a written and signed statement from Dietary [NAME] (DC) #169 indicating she arrived at the facility at 5:22 A.M. and observed Resident #29 outside the employee access door walking toward the smoking area. DC #169 stated another staff member opened the employee access door and was looking for Resident #29 when she arrived at the facility. Review of a progress note documented on 03/29/26 at 5:29 A.M., written by Licensed Practical Nurse (LPN) #143, revealed Resident #29 was observed in the hallway at 5:15 A.M. Sometime after 5:15 A.M. door alarms were activated and Resident #29 was found outside. Resident #29 was returned inside, assessed, and found to be physically unharmed. Review of the elopement investigation file for Resident #29, dated 04/17/26, revealed a written and signed statement from Registered Nurse (RN) #106 indicating the front door alarm was activated at 5:22 P.M. on 04/17/26. Continued review revealed staff began looking for Resident #29 first in his room then expanded the search to both inside and outside the facility. RN #106 stated Resident #29 was found on the lawn across a two-lane street adjacent to the facility property. Resident #29 was returned to the facility, assessed, and found to be physically unharmed. Further review of the investigation file revealed a written timeline of events by the Administrator indicating she received a phone call from RN #106 at 5:23 P.M. indicating Resident #29 had eloped, and another phone call from RN #106 at 5:34 P.M. indicating Resident #29 had been found. Observation on 04/20/26 at 9:00 A.M. revealed a staff member stationed outside Resident #29's door. Observation on 04/20/26 at approximately 9:10 A.M. revealed the location where Resident #29 was found when he eloped from the facility on 04/17/26 was west of the facility, across a two-lane street with a grassy median approximately 210 yards away from the front door of the facility. Additionally, the location where Resident #29 was found was approximately 35 yards south of a four-lane state route with a speed limit of 55 miles per hour. Interview on 04/20/26 at 9:30 A.M. with the Administrator revealed Resident #29 had successfully eloped from the building on 04/17/26 and was placed on one-on-one (1:1) staff observation. Continued interview revealed Resident #29 would remain on 1:1 observation until he could move to his new facility, which had been secured. The Administrator stated the current facility staffing was not adequate to provide continued supervision levels necessary to ensure the safety of Resident #29. A follow-up interview on 04/20/26 at 12:00 P.M. with the Administrator revealed the initial intervention for Resident #29's elopement that occurred on 03/29/26 was to relocate him to the memory care unit; however, there was an incident between Resident #29 and another resident on the memory care unit and Resident #29 was relocated back to his original room the same day and placed on 15-minute checks. It was determined the facility would seek alternative placement for the resident. The Administrator stated Resident #29 was back to his baseline with decreased exit-seeking behaviors and she discontinued the 15-minute checks at midnight on 04/08/26 without any additional interventions implemented. Review of facility policy titled Elopement Risk Management Guide, dated 04/15/24, revealed the facility would ensure the safety and wellbeing of their residents. 2. Review of the medical record for Resident #56 revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to thrombosis, dilated cardiomyopathy, hypertension, subcortical and intraventricular intracerebral hemorrhage, hemiplegia affecting the left side, and wheezing. Review of the quarterly MDS assessment, dated 03/09/26, for Resident #56 revealed he was cognitively intact and did not display any behaviors at the time of the assessment. He refused care on one to three days of the assessment period. Resident #56 utilized a manual wheelchair with supervision assistance and required maximal assistance with transfers and activities of daily living (ADLs). Review of the care plan for Resident #56 revealed a focus area for smoking with interventions dated 01/21/26 to orient resident to smoking policies, procedures and times. Review of the smoking assessment dated [DATE] for Resident #56 revealed he was safe to smoke with supervision. Review of progress notes for Resident #56 revealed documentation dated 04/13/26 at 12:26 P.M. created by Licensed Practical Nurse #145 indicating a vape pen was found in Resident #56's bed and the nurse practitioner (NP) was notified. Observation on 04/14/26 at 10:52 A.M. of Resident #56's room revealed he was not in his room and there was a red vape pen on his bed. Interview on 04/14/26 at 10:54 A.M. with Certified Nursing Assistant (CNA) #149 verified a red vape pen was on Resident #56's bed. Interview on 04/14/26 at 11:18 A.M. with Assistant Director of Nursing (ADON) #153 and Licensed Practical Nurse (LPN) #145 confirmed the red vape pen found in Resident #56's bed was not allowed to be stored in his room and should have been secured with all other smoking supplies. LPN #145 confirmed the red vape pen had been temporarily relocated to her locked medication cart. Interview on 04/14/26 at 2:00 P.M. with Resident #56 revealed he was aware of the facility's rules regarding smoking and all smoking materials. He indicated smoking materials, including vape pens, were required to be stored in a locked box maintained by the facility. Review of facility policy titled, Smoking, dated 02/14/25, revealed smoking included the use of electronic cigarettes, smoking was only permitted in designated areas at designated times, and smoking supplies would be stored by the facility. 3. Review of the closed medical record for Resident #63 revealed an admission date of 03/10/26 with diagnoses of chronic obstructive pulmonary disease, anxiety, Type II diabetes mellitus, heart disease and restless legs. Resident #63 discharged to another facility on 03/26/26. Review of the admission comprehensive MDS assessment, dated 03/17/26, revealed Resident #63 had intact cognition required substantial/maximal assistance for toileting hygiene and showering/bathing, upper body dressing, and was dependent for lower body dressing and personal hygiene. Additionally, Resident #63 required substantial/maximal assistance for rolling to the left and right, lying to sitting, sitting to standing, and chair to bed transfers and toilet transfers. Walking was not attempted due to medical condition or safety concerns. Review of the incident log from 01/15/26 through 04/20/26 revealed Resident #63 had an unwitnessed fall on 03/22/26. No additional fall incidents were identified for the resident. Review of the Neurological Assessment Flow Sheet, completed 03/22/26 at 9:30 P.M. through 03/24/26 at 4:15 A.M. revealed hand grasps and motor functions were not completed during the assessments on 03/22/26 at 9:30 P.M., 03/22/26 at 9:45 P.M., on 03/22/26 at 10:00 P.M., on 03/22/26 at 10:15 P.M., on 03/22/26 at 11:15 P.M., on 03/23/26 at 12:15 A.M., on 03/23/26 at 1:15 A.M., and on 03/23/26 at 5:15 A.M. Further review of the assessments during these dates and times revealed Resident #63 was alert and his pupils were equal and reactive to light. Interview on 04/16/26 at 3:03 P.M. with the Administrator, and concurrent review of the neurological assessment flowsheet verified the assessments were completed inaccurately and should have included an assessment of hand grasps and motor functions for all assessment timepoints. The deficiency represents non-compliance investigated under Complaint Number 2975430.

Based on observation, staff and resident interviews, review of open and closed medical records, review of the facility water temperature logs and policy review, the facility failed to ensure shower water temperatures in the East Hall shower room were adequately warm. This affected four (#19, #24, #55 and #63) of four residents reviewed for comfortable and homelike environment. The facility identified 15 (#4, #11, #14, #26, #28, #29, #30, #31, #37, #39, #41, #47, #48, #50 and #56) additional residents who used the East-hall shower room. The facility census was 52.Findings include:1. Review of the medical record for Resident #19 revealed an admission date of 02/27/25 with diagnoses of congestive heart failure, weakness, and parkinsonism. Review of the significant change comprehensive Minimum Data Set (MDS) assessment, dated 02/18/26, revealed Resident #19 had impaired cognition and was dependent on staff for showers/bathing.Interview on 04/16/26 at 11:11 A.M. with Resident #19 revealed he rarely used the shower. Resident #19 stated the water in the shower room was too cold, but staff provided bed baths for him.2. Review of the medical record for Resident #24 revealed an admission date of 08/25/25 with diagnoses of Parkinson's disease, asthma, and depression. Review of the quarterly MDS assessment, dated 04/02/26, revealed Resident #24 had intact cognition and required partial/moderate assistance for shower/bathing.Interview on 04/16/26 at 10:50 A.M. with Resident #24 confirmed she received a shower. Resident #24 stated the water was chilly but bearable. Resident #24 stated she had refused showers in the past because the water was cold.3. Review of the medical record for Resident #55 revealed an admission date of 02/27/26 with diagnoses of congestive heart failure, anxiety, and atrial fibrillation. Review of the MDS assessment, dated 03/06/26, revealed Resident #55 had intact cognition and was dependent on staff for showers/bathing.Interview on 04/16/26 at 11:14 A.M. with Resident #55 revealed the East Hall shower room was so cold she felt like she had icicles coming off her body. Resident #55 stated she avoided showers because it was so cold. Resident #55 stated she received bed baths in her room.4. Review of the closed medical record for Resident #63 revealed an admission date of 03/10/26 with diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, Type II diabetes mellitus, and restless legs. Resident #63 discharged from the facility on 03/26/26. Review of the admission comprehensive MDS assessment, dated 03/17/26, revealed Resident #63 had intact cognition and required substantial/maximal assistance for showering/bathing.Review of Resident #63's shower sheet, dated 03/23/26, revealed a written statement water in the shower room was too cold so [Resident #63] wanted to wash up at the sink.Interview on 04/14/26 at 10:04 A.M. with Medical Records (MR) #164 verified the statement written on Resident #63's shower sheet dated 03/23/26 related to the shower water being too cold to shower.Interview on 04/14/26 at 3:29 P.M. with Certified Nursing Assistant (CNA) #149 revealed water in the East Hall shower room was cold and residents complained about it. Interview on 04/15/26 at 11:25 A.M. with CNA #119 revealed she assisted Resident #63 with showers. CNA #119 confirmed Resident #63 used the East Hall shower room. Interview on 04/16/26 10:35 A.M. with Licensed Practical Nurse (LPN) #101 revealed she was aware the East Hall showers had cold water and stated the stall closest to the door was cold and the stall farthest from the door was barely warm. Observations on 04/16/26 from 10:39 A.M. until 10:47 A.M., with Maintenance Director (MD) #161, of the East Hall shower room water temperatures revealed stall number one (closest to the door) had a temperature of 83 degrees Fahrenheit (F) after running for six minutes, and stall number two had a temperature of 88 degrees F after running for five minutes. Additional observation revealed the sink in the East Hall shower room reached a temperature of 90 degrees F after three minutes. Concurrent interview with MD #161 verified the low water temperatures and stated he intended to keep hot water temperatures between approximately 109 degrees F and 115 degrees F. MD #161 stated cold shower water temperatures were never reported to him as a concern. MD #161 confirmed the water temperatures did not meet the minimum requirement of 105 degrees F and further stated the water pressure was low and a shower at those temperatures would be cold.A follow-up interview on 04/16/26 at 1:28 P.M. with MD #161, and concurrent review of the facility's water temperature logs from 02/02/26 through 03/11/26, revealed the East Hall shower room water temperatures should be monitored weekly, and no water temperatures were logged. Additionally, no water temperatures were recorded between 03/11/26 and 03/30/26. Further review revealed the East Hall shower room water temperature was 112 degrees F on 03/31/26 and was 109 degrees F on 04/06/26. MD #161 stated he began his position at the facility mid-March 2026. Review of the facility policy titled, Water Supply Management, Water Temperature Control, and Water System Maintenance, revised 02/26/26, revealed water temperatures were maintained within state-allowed limits. The deficiency represents non-compliance investigated under complaint number 2975430.

Based on observation, medical record review, staff interviews and review of facility policy, the facility failed to ensure dependent residents received appropriate bathing, showers, grooming and fingernail care. This affected four (#14, #57, #62 and #63) of five residents reviewed for activities of daily living (ADLs). The facility census was 52. Findings include:1. Review of Resident #14's medical record revealed an admission date of 05/06/21 with diagnoses including, malignant neoplasm of bronchus or lung, metabolic encephalopathy, schizophrenia, dementia, pulmonary embolism, malnutrition, pain, esophagitis, intellectual disability, anemia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 02/18/26, revealed Resident #14 was severely cognitively impaired, utilized a wheelchair for mobility, required substantial to maximal assistance with ADLs, was incontinent of bowel and bladder, received a mechanically altered diet, was at risk for pressure ulcer development, and received Hospice care. Review of a physician order dated 01/21/25 revealed Resident #14 admitted to Hospice services. Review of the plan of care, dated 12/03/25, revealed Resident #14 had an ADL self-care performance deficit related to (r/t) decline in functional mobility, diagnosis of lung cancer, dementia, hypertension, schizophrenia, dysphagia, anemia, low back pain, restlessness/agitation, anxiety, tremor, constipation, esophagitis, use of psychotropic medications, incontinence, and weakness. Resident #14 received end of life care through Hospice. Interventions included the following: assist with bathing as needed; provide the resident with short, simple instructions such as hold your washcloth in your hand, put soap on your washcloth, and wash your face to promote independence; partial to maximum assistance; provide supportive care; assistance with mobility as needed; document assistance as needed; and showers on Wednesday and Friday during day shift. Review of skin observation shower sheets revealed bed baths were provided to Resident #14 on 03/20/26, 03/24/26, 03/26/26, 04/03/26, 04/07/26 and 04/10/26. Further review revealed no documentation of the resident having his hair washed, fingernails clipped or beard groomed. None of the skin observation shower sheets documented resident refusals of care. Review of the electronic medical record (EMR) shower task charting revealed Resident #14 was provided with a bed bath on 03/31/26 and 04/10/26. Showers were documented on 03/17/26, 03/20/26 and 04/07/26. No refusals of care were documented. Observation on 04/14/26 at 5:33 A.M., during concurrent interview with Certified Nursing Assistant (CNA) #105 and CNA #136, revealed Resident #14 had greasy long hair, unkept facial hair/beard growth and long jagged fingernails. CNA #105 and CNA #136 verified the findings and stated Hospice was responsible for washing the resident's hair and providing showers. Interview on 04/15/26 at 1:00 P.M. with Hospice CNA (HCNA) #201 revealed the facility CNAs were to provide Resident #14 with showers and grooming. HCNA #201 verified Resident #14 had long greasy hair, unkept beard growth, and long jagged fingernails. 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of colon, anemia, muscle weakness, cognitive communication deficit, colostomy, depression and moderate protein calorie malnutrition. Review of the admission MDS assessment, dated 02/24/26, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. Resident #57 was dependient on others for toileting hygiene, showering, upper and lower body dressing and personal hygiene. Review of the admission care plan dated 02/17/26 revealed Resident #57 required assistance with ADLs with the goal of staff assistance with daily care needs. Interview on 04/13/26 at 9:55 A.M. with Resident #57 revealed the resident requested to shower more than once a week. Resident #57 stated he was unsure when his shower days were but knew he had only been getting showered once a week. Review of the facility Skin Observation Shower Sheets ([NAME]) for Resident #57 revealed shower days were scheduled for Mondays and Thursdays. Further review of the [NAME] for Resident #57 revealed showers sheets were completed on the following days: 02/19/26, 03/05/26, 03/09/26, 03/12/26, 03/19/26, 03/26/26, 03/30/26, 04/02/26 and 04/06/26. Review of the nurse aide task checklist for Resident #57 revealed showers were completed on the following days: 03/19/26, 03/30/26, 04/02/26, 04/06/26, 04/09/26 and 04/16/26. Further review of nurse aide task checklist revealed Resident #57 refused a shower on 03/26/26. No other refusals were noted in the nurse aid task checklist or on the [NAME]. Interview on 04/16/26 at 2:03 P.M. with the Interim Director of Nursing (IDON) confirmed the facility's expectation was for staff to complete shower sheets for each scheduled shower day, whether the resident refused to be showered or accepted a shower or bed bath. A follow- up interview on 04/16/26 at approximately 3:00 P.M. with IDON verified the facility had no evidence Resident #57 received scheduled showers on 02/23/26, 02/26/26, 03/02/26, 03/16/26, 03/23/26, 04/09/26 and 04/13/26. 3. Review of the closed medical record for Resident #62 revealed he was admitted on [DATE] and discharged on 03/05/26. His diagnoses included chronic obstructive pulmonary disease, arthritis, cutaneous abscess of right lower extremity, bacteremia, hypertension, difficulty walking, and gastro-esophageal reflux disease. Review of the admission MDS assessment, 02/12/26 revealed Resident #62 revealed was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. He utilized a wheelchair and was dependent for mobility. Resident #62 required maximal to dependent levels of assistance with ADLs. Interview on 04/15/26 at 2:00 P.M. with the Administrator revealed shower sheets were completed for each resident when bathing occurred. Continued interview revealed Resident #62 was scheduled for bathing on Wednesdays and Fridays. Review of shower sheets for Resident #62 revealed bathing occurred on 02/20/26, 02/28/26 and 03/04/26 (three of eight opportunities). Review of the nursing progress notes for Resident #62 from 02/05/26 to 03/05/26 revealed no evidence he refused bathing. Interview on 04/15/26 at 3:35 P.M. with the Administrator confirmed the only shower sheets completed for Resident #62 were on 02/20/26, 02/28/26 and 03/04/26. Continued interview confirmed there was no documentation indicating Resident #62 refused bathing or received showers as scheduled. 4. Review of the closed medical record for Resident #63 revealed an admission date of 03/10/26 with diagnoses of chronic obstructive pulmonary disease, anxiety, Type II diabetes mellitus, and restless legs. Resident #63 discharged from the facility on 03/26/26. Review of the admission comprehensive MDS assessment, dated 03/17/26, revealed Resident #63 had intact cognition and required substantial/maximal assistance for showering/bathing. Review of the shower sheets from 03/10/26 through 03/26/26 revealed no evidence of showers from 03/10/26 through 03/15/26. Interview on 04/14/26 at 9:52 A.M. with CNA #126 confirmed paper shower sheets should be completed for all residents, whether the shower was refused or not. Interview on 04/14/26 at 9:59 A.M. with Registered Nurse (RN) #158 confirmed staff should complete paper shower sheets for all residents' showers, bed baths, or refusals of care. Interview on 04/14/26 at 10:04 A.M. with Medical Records (MR) #164 revealed Resident #63 was to receive showers on Mondays and Thursdays. MR #164 confirmed Resident #63 should have received a shower on 03/12/26 (Thursday) and the facility had no evidence the shower was provided for the resident. Interview on 04/16/26 at 2:03 P.M. with the IDON confirmed the facility's expectation was for staff to complete shower sheets for each scheduled shower day, whether the resident refused to be showered or accepted a shower or bed bath. Follow-up interview on 04/16/26 at 2:12 P.M. with the IDON confirmed no additional shower sheets were available between 03/10/26 and 03/15/26 and, therefore, the facility could not provide evidence Resident #63 was offered a shower and/or bed bath during that time. Review of the facility policy titled, Activities of Daily Living, dated 01/02/24, revealed care and services would be provided for the following ADLs: bathing, dressing, grooming and oral care. This deficiency represents non-compliance investigated under Master Complaint Number 2979608 and Complaint Numbers 2975430, 2796491 and 2799367.

Based on observations, staff interview, and review of facility policy, the facility failed to store food in a safe and sanitary manner. This had the potential to affect 50 residents, Residents #3 and #37 received no food by mouth and thus received no food from the kitchen. The facility census was 52.Findings include:Observation on 04/13/26 at 8:05 A.M. of the dry food storage area revealed an opened box on the floor containing six 104-ounce cans of applesauce. On top of the applesauce was an unopened box containing six five-pound pouches of cornbread mix. On top of the cornbread mix was an opened box containing two sealed 10-pound bags of elbow macaroni. On the floor next to the applesauce was an unopened box containing six 57-ounce cartons of mashed potato flakes. On the floor next to the mashed potato flakes was an unopened box containing four 35-ounce bags of frosted flakes.Observation on 04/13/26 at 8:15 A.M. of the walk-in freezer revealed a box on the floor containing cracked wheat pull-apart rolls. On top of the rolls were two boxes labeled chicken breast fillets. On top of the chicken breast fillet boxes was a box labeled pork breakfast sausage crumbles. On top of the sausage crumbles was a box labeled buttermilk biscuits. On the floor next to this stack of boxes was an unopened box labeled chocolate protein shakes. On top of the protein shakes was a box labeled [NAME] Creek Meats. On the floor next to the protein shakes was a box of sliced strawberries.Observation on 04/13/26 at 8:20 A.M. of the walk-in cooler revealed two oval red colored stains, each approximately 12 inches wide, on the floor below boxes of meat stored on a bottom shelf to the left. Expired food on the shelving unit to the right included: a half full plastic container with a lid labeled beef stew with an expiration date of 04/10/26, a half full metal container with clear plastic film covering the top labeled pork with an expiration date of 04/11/26, a full black plastic bowl with clear plastic film covering the top labeled egg with an expiration date of 4/10/26, a three-quarters full plastic container with a lid labeled orange pineapple with an expiration date of 04/12/26, a half full plastic container with a lid labeled ham slices with an expiration date of 04/11/26, and a one-quarter full plastic container with a lid labeled fresh fruit with a prepared date of 04/05/26.Interview on 04/13/26 at 8:25 A.M. with Director of Nutritional and Food Services (DNFS) #102 confirmed the above observations of the dry food storage area, the walk-in freezer and the walk-in cooler. Continued interview confirmed food should not be stored on the floor and the items on the floor of the dry storage area and the walk-in freezer had been there since the food was delivered late afternoon on 04/10/26.Review of facility policy titled, Kitchen Sanitation, dated 12/01/25, revealed storage areas would be free of spills and all food would be stored at least six inches off the floor.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure resident respect and dignity was maintained. This affected one (#5) of three residents reviewed for respect and dignity. The facility census was 52.Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia and dementia without behavioral disturbance.Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/15/26, revealed Resident #5 was rarely/never understood. Resident #5 was dependent on staff for eating. Review of revised care plan dated 04/01/26 revealed Resident #5 had an Activities of Daily Living (ADL) self-care performance deficit. Interventions included partial assistance of one staff member to eat. Observation on 04/14/26 at 8:22 A.M. revealed approximately 13 residents were in the secured unit dining area awaiting breakfast. Certified Nursing Assistant (CNA) #110 assisted with passing out breakfast trays to the residents in the dining area. CNA #110 was exiting the secured unit, turned back and yelled from the hallway to another CNA, who was in the dining room assisting with breakfast, that Resident #5 was a feeder (meaning Resident #5 required assistance with eating). Interview on 04/14/26 at 8:35 A.M. with CNA #110 verified she yelled out that Resident #5 was a feeder. CNA #110 confirmed referring to the resident as a feeder was not dignified and respectful and apologized. Review of the facility policy titled, Residents Rights, dated 02/20/26, revealed care team members would treat each resident/patient with kindness, respect and dignity. This deficiency represents non-compliance investigated under Master Complaint Number 2979608 and Complaint Numbers 2975430 and 2799367.

Based on open and closed medical record review, staff interviews, and review of facility policy and procedures, the facility failed to ensure a baseline care plan was developed and provided to Resident #63's representative and further failed to ensure a baseline care plan for Resident #30 addressed the resident's care needs. This affected two (#63 and #30) of two residents reviewed for baseline care plans. The facility census was 52.Findings include:1. Review of the closed medical record for Resident #63 revealed an admission date of 03/10/26 with diagnoses of chronic obstructive pulmonary disease, anxiety, Type II diabetes mellitus, heart disease and restless legs. Resident #63 discharged from the facility on 03/26/26. Review of the admission comprehensive Minimum Data Set (MDS) assessment, dated 03/17/26, revealed Resident #63 required substantial/maximal assistance for toileting hygiene, showering/bathing and upper body dressing and was dependent for lower body dressing and personal hygiene. Additionally, Resident #63 required substantial/maximal assistance for rolling to the left and right, lying to sitting, sitting to standing, and chair to bed transfers and toilet transfers. Walking was not attempted due to medical condition or safety concerns. Review of the Nursing Admission/readmission Evaluation, dated 03/10/26, revealed Resident #63 needed physical assistance for ambulation, transfers, toileting and bathing. Additionally, Resident #63 used a walker and manual wheelchair for mobility. Further review revealed no baseline care plan was initiated. Interview on 04/15/26 at 8:38 A.M. with MDS Coordinator (MDSC) #127 confirmed no baseline care plan was initiated for Resident #63. Additionally, MDSC #127 stated she developed Resident #63's activities of daily living (ADLs) comprehensive care plan on 03/24/26. MDSC #127 further confirmed, along with concurrent review of Resident #63's comprehensive care plan, that monitoring for diabetes mellitus was not initiated until 03/24/26. MDSC #127 verified the first care area was initiated on 03/23/26 and no care plan was in place from Resident #63's admission on [DATE] until 03/23/26. 2. Review of the medical record for Resident #30 revealed an admission date of 04/01/26 with diagnoses including peptic ulcer, schizoaffective disorder, bipolar disorder, rheumatoid arthritis, anxiety disorder, chronic obstructive pulmonary disease, and lung cancer. Review of the social services progress review for the MDS assessment, dated 04/02/26, revealed Resident #30 was cognitively intact, had adequate vision and hearing, was able to be understood, and did not display any behaviors nor refusals of care. Review of the baseline care plan dated 04/01/26 for Resident #30 revealed she did not have a care plan for the administration of oxygen. Observation on 04/14/26 at 8:15 A.M. of Resident #30 revealed she was wearing an oxygen nasal cannula connected to an oxygen concentrator running at four liters-per-minute (lpm). Interview on 04/16/26 at 12:45 P.M. with the Administrator confirmed Resident #30 did not have a care plan developed to include the administration of oxygen and this resident utilized oxygen as needed. Review of facility procedures regarding the 72-hour care conference revealed the baseline care plan would be initiated by the nurse conducting the admission assessment. Review of facility policy titled Comprehensive Care Plan, dated 11/01/24, revealed care plans would include objectives to meet residents' medical needs. The deficiency represents non-compliance investigated under complaint number 2975430.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure non-pressure ulcer wound care was initiated timely upon admission and completed as ordered. This affected two (#1 and #55) of three residents reviewed for wound care. The facility census was 52.Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 03/12/26 with diagnoses including subsequent encounter of bladder injury, septic shock, ascites, Type Two diabetes mellitus, polyneuropathy, irritable bowel syndrome, cystocele, peritonitis and stage three chronic kidney disease.Review of the admission Minimum Data Set (MDS) assessment, dated 03/19/26, revealed Resident #1 was cognitively intact and did not display any behaviors nor refusals of care at the time of this assessment. She required maximal assistance to full dependence with activities of daily living (ADLs), bed mobility, and transfers. Resident #1 utilized a wheelchair and was depended for mobility.Review of the current care plan for Resident #1 revealed interventions for skin integrity related to her abdominal wound, heels, sacrum, and panniculitis (inflammatory condition affecting the subcutaneous fat layer resulting in painful, tender nodules or plaques). Interventions included wound care as ordered.Review of admission orders dated 03/12/26 for Resident #1 revealed wound care orders to her abdominal surgical incision and treatment of her closed-suction bulb drain site.Review of the facility physician orders revealed Resident #1 had no wound treatment orders in place until 03/23/26 (11 days after admission) to cleanse the insertion site of the closed-suction bulb drain site daily and to perform wound care to her abdominal surgical incision daily. Additionally, there was a treatment order dated 03/24/26 to record closed-suction bulb drain output on each shift.Review of the treatment administration records (TAR) for March 2026 and April 2026 for Resident #1 revealed wound care to her abdominal surgical incision was not performed until 03/17/26 (five days after admission). Further review revealed treatments to cleanse the insertion site of her closed-suction bulb drain were not performed until 03/24/26 (12 days after admission). Additional review revealed the closed-suction bulb drain output was not completed on 03/12/26, 03/14/26, 03/15/26, 03/17/26 through 03/19/26, 03/24/26 first shift, 03/27/26 second shift, 03/30/26 second shift, 03/31/26, 04/01/26 second shift, 04/07/26 second shift, 04/14/25 second shift, and 04/15/26 first shift.Interview on 04/16/26 at 3:45 P.M. with Regional Registered Nurse (RN) #177 verified Resident #1's wound and drain care were not initiated timely. 2. Review of the medical record for Resident #55 revealed an admission date of 02/27/26 with diagnoses including chronic heart failure, thrombophilia, atrial fibrillation, anxiety, depression, cellulitis of left lower extremity, venous insufficiency, lymphedema, and chronic respiratory failure with hypoxia.Review of the admission MDS assessment, dated 03/06/26, revealed Resident #55 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a walker and wheelchair and was dependent for transfers and mobility. Resident #55 required maximal assistance to dependence with ADLs. This assessment did not indicate Resident #55 had any existing wounds.Review of the care plan for Resident #55 revealed interventions were initiated on 02/28/26 for wound management to her right and left lower extremities including completing wound care as ordered.Review of admission orders dated 02/27/26 for Resident #55 revealed wound care orders to her right lower extremity.Review of physician orders revealed a treatment order dated 04/02/26 (34 days after admission) for wound care to be completed daily to Resident #55's right lower extremity.Review of the TAR for February 2026 through April 2026 revealed wound care to Resident #55's right lower extremity was not initiated until 03/26/26 (30 days after admission). Additionally, wound care was not completed on 04/01/26, 04/02/26, 04/03/26, 04/07/26, and 04/16/26.Interview on 04/21/26 at 10:05 A.M. with Regional RN #177 confirmed wound care for Resident #55 was not initiated timely. Review of facility policy titled, Wound Management, dated 05/30/24, revealed the facility would assess for resident specific skin impairment upon admission and timely treat those residents identified with impaired skin integrity.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure timely assessment and preventative interventions were implemented for a diabetic foot ulcer. This affected one (#47) of one resident reviewed for diabetic foot care. The facility census was 52. Findings include:Review of Resident #47's medical record revealed an admission date of 05/20/20 with diagnoses including schizoaffective disorder, Type II diabetes mellitus, history of diabetic ulcers, dementia, peripheral vascular disease, hypertension, chronic pain syndrome, insomnia, and hypothyroidism.Review of the Minimum Data Set (MDS) assessment, dated 03/12/26, revealed Resident #47 was assessed with moderately impaired cognition, no recorded resistive behaviors, required setup or clean-up assistance with eating, was dependent for activities of daily living (ADLs), required substantial to maximal assistance with bed mobility and was not at risk of developing pressure ulcers with a diabetic foot ulcer present.Review of a physician order dated 06/15/22 revealed to encourage offloading heel boots/protectors every shift. Further review revealed an order dated 11/19/25 for a weekly skin observation on every day shift, every Wednesday.Review of the care plan, initiated on 10/26/23 and revised on 04/22/25 and 03/19/26, revealed Resident #47 had potential for impairment to skin integrity related to decline in functional mobility, incontinence, peripheral vascular disease, diabetes mellitus Type II and diabetic foot ulcer. Interventions included the following: encourage and assist to off-load heels as tolerated; encourage and assist with turn and repositioning as tolerated; low air loss mattress to bed; monitor/document location, size and treatment of skin injury; report abnormalities, failure to heal, signs/symptoms of infection and maceration to the physician; and treatment to foot ulcer per orders.Further review of the care plan revealed on 10/30/23, the plan was revised to address Resident #47's diabetes mellitus Type II with long term insulin use. Interventions included: diabetes medication as ordered by doctor; monitor/document for side effects and effectiveness; educate resident/family/caregiver that diabetes is a chronic disease and compliance was essential to prevent complications of the disease, review complications and prevention with the resident/family/caregiver, elicit a verbal understanding from the resident/family/caregiver; nails should always be cut straight across, never cut corners, file rough edges with emery board; identify areas of non-compliance or other difficulties in resident's diabetic management; modify the problem area so that it may be more manageable for the resident/family; provide and document teaching to resident/family/caregiver; address identified roadblocks to compliance; monitor compliance with diet and document any problems; monitor/document/report to physician (MD) as needed (PRN) signs and symptoms of hypoglycemia; monitor/document/report to MD PRN signs and symptoms of hyperglycemia; monitor/document/report to MD PRN for signs and symptoms of infection to any open areas; and refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Review of a skin risk assessment, dated 01/16/26, revealed Resident #47 was at risk for skin breakdown due to age greater than [AGE] years old and dementia or Alzheimer's disease. Review of the weekly skin observation documentation revealed Resident #47 had no new skin alteration on 02/19/26. Further review of the medical record revealed no evidence that the next scheduled skin observation was completed on Wednesday, 02/25/26. Review of a change in condition evaluation form dated 02/26/26 at 4:28 P.M. and completed by Licenses Practical Nurse (LPN) #130 revealed Resident #47 had a skin wound or ulcer that started on 02/26/26 during the afternoon to the left great toe and second toe. The wound was described as a new onset grade two or higher pressure ulcer/injury, or progression of pressure ulcer/injury despite interventions. Apparently, minor recent wound was now developing redness, swelling, or pain. In addition, a wound/scab was described to the left heel. Narrative documentation noted LPN #130 was notified by the aide to come and observe Resident #47's left great and second toe and heel. LPN #130 observed the left great toe with a black scab and left second toe and heel scarred. A new order was initiated to apply betadine every (q) shift until assessed by the Nurse Practitioner (NP) with bilateral arterial doppler of lower extremities. The resident representative was notified on 02/26/26 with no time listed. No wound measurements were documented. Review of the skin condition evaluation dated 03/03/26 at 3:48 P.M. revealed Resident #47 had an in-house acquired diabetic foot ulcer to the left great toe measuring five centimeters (cm) long by (x) four cm wide with undetermined depth, 20 percent (%) of the wound was covered with epithelialization tissue and 80% of the wound was filled with eschar. No exudate was identified. A second area identified as a diabetic foot ulcer was noted to the left heel measuring one cm x one cm x undetermined depth. The wound tissue was noted with 50% of the wound covered with epithelialization and 50% of the wound was filled with eschar. No exudate was identified. Review of a late entry progress note, dated 02/27/26 at 9:30 A.M. and entered on 03/06/26 at 9:32 A.M., revealed Certified Nurse Practitioner (CNP) #01 documented that Resident #47 was resting in bed during exam. The resident was seen for a routine visit. Nursing reported concern for new foot ulcer to her left toe. The left great toe with scab, left heel dry/cracked. Skin was appropriate for ethnicity, warm and dry. CNP #01 ordered betadine twice daily (BID), notify provider of any changes and pending order for arterial doppler to rule out (r/o) vascular cause.Review of the Arterial Bilateral Lower Extremity Duplex Scan Doppler Studies, dated 02/27/26, revealed mild diffuse femoral arterial disease. There was no focal critical stenosis or occlusion. Review of an interdisciplinary team (IDT) note dated 03/02/26 at 1:08 P.M. revealed the IDT met to review and discuss the resident's skin integrity. A root cause analysis was completed and determined that Resident #47's socks were improperly sized and too small for her feet, contributing to the diabetic foot ulcer. The interventions implemented included: replacement of socks, new treatment orders, care plan would be updated as indicated and resident plan of care continued to be ongoing. Review of a progress note dated 03/04/26 at 1:00 P.M. revealed CNP #01 saw Resident #47. The resident was resting in bed during the exam. Resident #47 was seen for a follow-up visit and was recently diagnosed with a foot ulcer. The arterial doppler was negative for acute findings. Left great toe with scab, left heel dry/cracked and skin was pink, warm and dry. Diabetic foot ulcer noted to left great toe, no change from previous visit. Continue betadine treatment every shift.Additional review of the physician orders revealed on 03/05/26, the treatment was modified to the left heel diabetic foot ulcer, to include cleanse with normal saline, pat dry then apply skin prep, monitor for signs and symptoms of infection, notify MD of any changes and apply every shift for wound care. An additional physician order was initiated on 03/20/26 to elevate/float heels when resting in bed every shift for diabetic foot ulcer. Review of a nursing progress note dated 04/01/26 at 4:13 P.M. revealed Assistant Director Of Nursing (ADON) #153 spoke with Resident #47's Power Of Attorney (POA) regarding the resident's sore on her left great toe. ADON #153 informed the POA that the provider was in today to observe the sore and changed the treatment plan as well, adding an antibiotic to treat cellulitis that had started in the toe. The POA was also concerned about the resident's heel, as the resident was complaining of it feeling sore from time to time. It was explained that the resident's foot could be offloaded, as well as a tent placed over the top of the foot, to keep the sheet and/or covers off the area to promoted healing. Further review of the physician orders revealed on 04/01/26, wound treatment was changed to include: left great toe, cleanse with normal saline, pat dry, apply hydrogel, cover with border gauze, monitor for signs and symptoms of infection and notify MD/NP with concerns, change every day shift for wound care and every 24 hours as needed for dislodgement/soilage. In addition, doxycycline hyclate oral tablet 100 milligrams (mg), give one tablet by mouth two times a day for cellulitis of the great toe for seven days. Review of skin condition evaluation dated 04/07/26 at 2:59 P.M. revealed Resident #47 had a diabetic foot ulcer to the left heel. It was described as boggy with fragile skin that was at risk for breakdown with normal color. The left great toe measured one cm x 1.4 cm x undetermined depth with 10% granulation to the wound bed and non-attached edge appearing as cliff. No exudate was identified. Review of a physician order dated 04/11/26 revealed Resident #47's antibiotic was changed to cephalexin tablet 500 mg, give one tablet by mouth two times a day for wound infection for seven days. Observation on 04/13/26 at 8:10 A.M. revealed Resident #47 was in bed. Both feet had socks on and were resting on the mattress. No pressure relief boots or elevation were in place. In addition, no tent was observed to keep bed linen off of Resident #47's lower extremities. Continued observation on 04/13/26 at 9:14 A.M. revealed Resident #47 remained in bed with bilateral feet with socks on and resting on the mattress. No pressure relief boots or elevation were in place and no tent was observed to keep bed linen off the lower extremities. Observation on 04/13/26 at 11:37 A.M. revealed Certified Nursing Assistant (CNA) #149 and CNA #159 provided care to Resident #47, which included transferring the resident to the wheelchair using a standing lift. Resident #47 had socks on both feet and slip on shoes. The resident's feet were resting on the floor. Concurrent interview with CNA #149 and CNA #159 verified Resident #47 did not have heel elevation or pressure relief boots in place when she was in bed. CNA #159 stated she had not observed pressure relief boots in place at any time. Observation on 04/13/26 at 2:11 P.M. of Resident #47's left foot, with LPN #145, revealed the resident was seated in a wheelchair in her room with bilateral shoes to her feet. LPN #145 removed Resident #47's left sock and exposed a dressing to the left great toe. The dressing was dated 04/12/26 at 11:00 A.M. The dressing was removed and a moderate amount of yellow/green drainage was observed. Interview on 04/16/26 at 1:37 P.M. with the Director of Nursing (DON), and concurrent review of Resident #47's medical record, verified there was no evidence a weekly skin assessment was completed on 02/25/26. Interview on 04/16/26 2:20 P.M. with the DON and ADON #153, and concurrent review of Resident #47's medical record, verified no weekly skin assessment was completed on 02/25/26. Further interview confirmed that upon discovery of the toe wound on 02/26/26, LPN #130 did not document a description or obtain measurements of the toe wound. The DON and ADON #153 verified no description or measurements of the wound were obtained until 03/03/26. Review of facility policy, Wound Management, effective 05/30/24, revealed residents with impaired skin integrity were recognized by the facility team, treated timely and interventions to heal were not exhausted until the skin was healed. The facility would have a system in place to monitor the resident's skin for early symptoms of the development of a new skin impairment. Preventative skin monitoring may identify a new symptom or risk factor. The resident's care team will assess the skin, care plan any new care initiative, monitor the care initiative and evaluate care initiatives for effectiveness. The facility would have a system in place to identify impaired skin integrity development early to prevent further damage and treat the condition as soon as it was identified. This deficiency represents non-compliance investigated under Complaint Number 2796491.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure hemodialysis access sites were properly assessed and monitored. This affected one (#7) of one resident reviewed for dialysis care. The facility census was 52. Findings include:Review of Resident #7's medical record revealed an admission date of 10/06/20. Diagnoses included end stage renal disease, dependence on renal dialysis, arteriovenous fistula, hypertension, malnutrition, hydronephrosis, hypotension, major depression, malignant neoplasm of prostate, and anemia.Review of the Minimum Data Set (MDS) assessment, dated 01/14/26, revealed Resident #7 was assessed with intact cognition and received dialysis. Review of the care plan, dated 01/15/24, revealed Resident #7 received hemodialysis related to (r/t) end stage renal disease (ESRD). Interventions included: left arm fistula; hemodialysis on Tuesday, Thursday and Saturday with usual chair time at 6:00 A.M.; will have no signs/symptoms of complications from dialysis treatments through the review date; monitor left arm fistula thrill/bruit; monitor/document/report as needed (PRN) any signs/symptoms of infection to the access site; monitor/document/report PRN for signs and symptoms of bleeding, hemorrhage, bacteremia and septic shock. Review of the physician orders revealed Resident #7 had the following orders: 07/12/24, assess dialysis site for bruit/thrill if applicable every shift; 05/13/25, monitor hemodialysis site for signs/symptoms of complications (bleeding, swelling, pain, drainage, odor, hardness or redness at site), notify the physician and dialysis center immediately with any urgent problems and complete every shift; 10/14/25, complete pre/post dialysis assessment two times a day every Tuesday, Thursday and Saturday; 10/16/25, check dialysis access site (left upper arm) dressing post dialysis in the morning every Tuesday, Thursday and Saturday, document exceptions in progress note and notify physician. Observation on 04/14/26 at 12:45 P.M. revealed Resident #7 returned from hemodialysis and was seated on the bedside. Resident #7 stated he had not been assessed by a nurse since returning from dialysis. Review of Resident #7's treatment administration record (TAR) on 04/14/26 at 12:47 P.M. revealed Licensed Practical Nurse (LPN) #130 signed off on check dialysis access site (left upper arm) dressing post dialysis and monitor hemodialysis site for signs/symptoms of complications (bleeding, swelling, pain, drainage, odor, hardness or redness at site), indicating LPN #130 completed the orders. Interview on 04/14/26 at 12:51 P.M. with LPN #130, and concurrent review of Resident #7's medical record, verified the resident's dialysis access site had not been assessed since the resident returned from the dialysis center; however, LPN #130 documented the task had been completed.Observation on 04/14/26 at 1:40 P.M. revealed LPN #130 proceeded to Resident #7's room. LPN #130 lifted Resident #7's sleeve and exposed the left upper extremity with a white dressing in place, which was covering the fistula. LPN #130 placed her fingers on the dressing and concluded the assessment. No attempt to observe the fistula site or assess the fistula for a bruit were attempted. A follow-up interview on 04/14/26 at 1:46 P.M. with LPN #130 verified Resident #7's fistula site was not properly assessed. Review of facility's Dialysis Policy, dated 01/02/24, revealed the nurse would monitor and document the status of the resident's access site upon return from dialysis treatment to observe for bleeding or other complications. The nurse would ensure the dialysis site was checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse would immediately notify the attending physician, dialysis facility and /or nephrologist.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames for five of 32 observed medications administered, resulting in a 15.63% medication error rate. This affected one (#47) of four residents reviewed for medication administration. The facility census was 52. Findings include:Observation on 04/13/26 at 11:22 A.M. revealed Licensed Practical Nurse (LPN) #145 prepared Resident #47's medications for administration. Medications included the following: cephalexin 500 milligrams (mg) one tablet, Austedo 12 mg one tablet, Risperdal 0.25 mg one tablet, metoprolol tartrate 50 mg one tablet, and an insulin glargine pen set with 10 units. Continued observation revealed LPN #145 entered Resident #47's room at 11:25 A.M. and administered the medications, including 10 units of insulin via subcutaneous injection to the resident's right upper extremity.Review of Resident #47's medical record revealed the resident had the following physician medication orders: cephalexin 500 mg, give one tablet by mouth two times a day for wound infection seven days with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M.; Austedo 12 mg, give one tablet by mouth two times a day for tardive dyskinesia with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M.; Risperdal 0.25 mg by mouth two times a day for schizophrenia with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M.; metoprolol tartrate 50 mg two times a day for hypertension with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M.; and insulin glargine solution pen, inject 10 units subcutaneously every morning, hold if blood sugar was less than 100 mg/decaliter, with an administration time between 7:00 A.M. and 10:00 A.M. Interview on 04/13/26 at 11:38 A.M. with LPN #145 verified Resident #47's medications were administered outside the physician ordered time frames. In addition, LPN #145 verified she did not check Resident #47's blood sugar prior to insulin administration. Interview on 04/14/26 at 11:28 A.M. with Regional Registered Nurse (RRN) #177, during a review of the facility's medication administration policy, verified medications were not administered to Resident #47 in accordance with physician orders or within prescribed time frames. Review of the facility policy titled, Medication Administration, dated 01/02/24, revealed to compare medication source with the Medication Administration Record (MAR) to verify resident name, medication name, form, dose, frequency, route, and time. Administer medications within 60 minutes prior to or after scheduled times unless otherwise ordered by the physician or if the facility adopted open medication pass time.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure insulin was administered in accordance with physician orders. This affected one (#47) of four residents reviewed for medication administration. The facility census was 52. Findings include:Observation on 04/13/26 at 11:22 A.M. revealed Licensed Practical Nurse (LPN) #145 prepared Resident #47's medications for administration. Medications included the following: cephalexin 500 milligrams (mg) one tablet, Austedo 12 mg one tablet, Risperdal 0.25 mg one tablet, metoprolol tartrate 50 mg one tablet, and an insulin glargine pen set with 10 units. Continued observation revealed LPN #145 proceeded to Resident #47's room at 11:25 A.M. and administered the medications, including 10 units of insulin via subcutaneous injection to the right upper extremity. Review of Resident #47's medical record revealed the resident had the following physician medication orders: cephalexin 500 mg, give one tablet by mouth two times a day for wound infection seven days with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M.; Austedo 12 mg, give one tablet by mouth two times a day for tardive dyskinesia with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M.; Risperdal 0.25 mg by mouth two times a day for schizophrenia with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M.; metoprolol tartrate 50 mg two times a day for hypertension with administration times between 7:00 A.M. to 10:00 A.M. and 8:00 P.M. to 11:00 P.M.; and insulin glargine solution pen, inject 10 units subcutaneously every morning, hold if blood sugar was less than 100 mg/decaliter, with an administration time between 7:00 A.M. and 10:00 A.M. Interview on 04/13/26 at 11:38 A.M. with LPN #145 verified medications were administered outside physician prescribed time frames. In addition, LPN #145 verified she did not check Resident #47's blood sugar prior to insulin administration to determine if the medication should have been held per physician order. LPN #145 proceeded to obtain a blood sugar result of 167. Interview on 04/14/26 at 11:28 A.M. with Regional Registered Nurse (RRN) #177, during a review of the facility's medication administration policy, verified medications were not administered to Resident #47 in accordance with physician orders or within prescribed time frames.Review of the facility policy titled, Medication Administration, dated 01/02/24, revealed to compare medication source with the Medication Administration Record (MAR) to verify resident name, medication name, form, dose, frequency, route, and time. Administer medications within 60 minutes prior to or after scheduled times unless otherwise ordered by the physician or if the facility adopted open medication pass time.

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure medications were not left unattended at bedside. This affected one (#4) of four residents reviewed for medication administration. The facility census was 52.Findings include:Review of Resident #4's medical record revealed an admission date of 01/25/21 with diagnoses including peripheral vascular disease, chronic obstructive pulmonary disease, Type II diabetes mellitus, bipolar disorder, major depression, anxiety disorder, neuropathy, restless leg syndrome, anemia, chronic viral hepatitis c, transient ischemic attack, and hypertension.Review of the Minimum Data Set (MDS) assessment, dated 03/26/26, revealed Resident #4 was assessed with intact cognition and required setup/clean-up assistance with activities of daily living. Resident #4 received antianxiety, antidepressant, anticoagulant, diuretic, opioid, antiplatelet, hypoglycemic and anticonvulsant medications. Observation on 04/14/26 at 7:42 A.M. revealed Licensed Practical Nurse (LPN) #130 prepared Resident #4's medications for administration. Medications included spironolactone tablet 25 milligrams (mg), senna tablet 8.6 mg two tablets, hydrochlorothiazide tablet 25 mg, ropinole tablet one mg, Norvasc tablet 10 mg, Plavix tablet 75 mg, Pristiq tablet 25 mg, Eliquis tablet five mg, gabapentin tablet 300 mg, metformin tablet 750 mg, metoprolol tartrate tablet 100 mg and Protonix tablet 20 mg. Continued observation revealed LPN #130 entered Resident #4's room and placed the medications on the over bed table in front of the resident. LPN #130 proceeded to exit the room without observing Resident #4 to take the medications. Concurrent interview with LPN #130 verified she left Resident #4's medications unattended at bedside, without observing him take them, and stated the resident was independent with medications and she was not required to stay with the resident during medication administration. Interview on 04/15/26 at 7:45 A.M. with the Director of Nursing (DON), and concurrent review of Resident #4's medical record, verified Resident #4 was not assessed as independent with medication administration. Review of facility policy, Medication Administration, dated 01/02/24, revealed that unless the resident had been assessed for safe self-administration of medications, medications were not to be left unattended for the resident to consume at a later time.

Based on closed medical record review, staff interviews and review of facility policy, the facility failed to ensure complete and accurate documentation in the medical record. This affected one (#59) of three residents reviewed for accurate medical records. The facility census was 52. Findings include:Review of the closed medical record for Resident #59 revealed an admission date of 11/21/25 and a discharge date of 02/10/26. Diagnoses included traumatic subdural hemorrhage, intracranial abscess and granuloma and dependence on respirator (ventilator) status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/06/26, revealed Resident #59 had impaired cognition. Further review revealed a Discharge Return Anticipated MDS was completed on 02/10/26. Review of the facility's Admission, Discharge, and Transfer Report, from 02/01/26 through 02/28/26, revealed Resident #59 was discharged to the hospital on [DATE]. Interview on 04/15/26 at 12:10 P.M. with the Interim Director of Nursing (IDON) and Assistant Director of Nursing (ADON) #153 revealed the IDON had worked at the facility for approximately two weeks and ADON #153 had worked at the facility for approximately three weeks. Continued interview with the IDON and ADON #153 revealed they were unfamiliar with Resident #59 and the circumstances of the discharge. Concurrent review of Resident #59's progress notes from 02/05/26 through 02/11/26 with the IDON and ADON #153 verified there was no information regarding the resident's discharge contained in the electronic medical record (EMR) and the 02/10/26 MDS was completed as a Discharge Return Anticipated. ADON #153 stated a change in condition assessment and alert charting should have been completed if Resident #59 left the facility emergently. ADON #153 confirmed there was no evidence of alert charting or a change in condition in Resident #59's EMR. The IDON and ADON #153 verified there was no information contained in Resident #59's medical record regarding the reason for the resident's discharge. A follow-up interview on 04/15/26 at 12:15 P.M. with the IDON revealed the Administrator explained Resident #59 had a scheduled surgical appointment at the hospital on [DATE] and discharged to another long-term care facility from the hospital. Review of facility policy titled, Documentation in the Medical Record, dated 01/02/24, revealed the facility would ensure each medical record would present an accurate representation of the resident's experience and progress through complete and accurate documentation. This deficiency represents non-compliance investigated under complaint number 2799367.

Based on record review, observation, interview, and policy review, the facility failed to ensure a call light was within reach. This affected one (#46) of six residents reviewed for call lights. The facility census was 55.Findings include:Review of the medical record for Resident #46 revealed an admission date of 01/13/25 with diagnoses including but not limited to adult failure to thrive, hemiplegia/hemiparesis affecting non-dominant left side, and major depressive disorder.Review of The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for activities of daily living with the exception of eating.Review of the care plan dated 10/08/25 revealed the resident is at risk for falls related to decline in functional mobility, stroke with left sided weakness, and non-ambulatory status. Interventions included ensure call light is within reach and encourage resident to use it for assistance as needed.Observation and interview on 12/09/25 at 1:19 P.M. with Resident #46 revealed the resident stated he did not have a call light most times. Call light was observed to be on the floor behind the headboard of his bed out of his reach. Resident #46 was up in his wheelchair sitting beside the bed. Resident #46 stated he could use his call light if he was able to reach it.Interview on 12/09/25 at 1:14 P.M. with Certified Nursing Assistant (CNA #200) verified that Resident #46 call light was not in reach of the resident and it should be.Further observation on 12/10/25 at 8:58 A.M. of Resident #46's call light revealed the call light was on the floor out of reach of the resident. Resident #46 was resting in bed.Interview on 12/10/25 at 8:59 A.M. with CNA #116 verified the call light was on the floor out of reach of the resident.Review of policy titled, Call Lights, dated 01/02/24 revealed staff will ensure the call light is within reach of resident and secured as needed.This deficiency represents an incidental finding during the complaint investigation.

Based on record review, interview, and policy review, the facility failed to investigate a injury of unknown origin. This affected one (#31) of three residents reviewed for abuse. The facility census was 55.Findings include:Review of the medical record for Resident #31 revealed an admission date of 03/27/25 with diagnoses including but not limited to anoxic brain damage, gastrostomy status, tracheostomy status, anxiety, cognitive communication deficit, and dysphagia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had severe cognitive impairment. The resident was dependent on staff for all activities of daily living.Review of the care plan dated 11/10/25 revealed the resident had the potential/actual impairment to skin integrity. Interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces.Review of the skin evaluation dated 10/25/25 marked incomplete, revealed multiple scratches to left arm. Incident report opened in error.Review of progress notes revealed no documentation regarding any scratches to left arm.Review of physician orders for October 2025 revealed no orders for scratches to left arm.Interview on 12/10/25 at 2:07 P.M. with the Director of Nursing (DON) revealed he did not strike out the skin evaluation dated 10/25/25. The DON stated two events were opened on a Saturday and he only struck out one of them. DON verified they could not locate any nurse's notes or other documentation to support where the scratches came from or that the resident had scratches.Interview on 12/10/25 at 2:11 P.M. with Registered Nurse (RN #142) revealed that they were called into the resident's room and assessed the scratches to the residents left arm. RN #142 verified they did not put in an order for treatment to the scratches. RN #142 stated they completed a Risk Management and notified the family who already knew about them. RN #142 stated they did not know how the scratches happened so they did not fill out the predisposing factors on the risk.Interview on 12/10/25 at 2:18 P.M. with DON verified Resident #31's scratches were not investigated as to how they obtained them. DON verified it would be an injury of unknown origin if there was no supporting documentation as to where they came from and should have been investigated.Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation dated 07/01/25 revealed all incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident/patient property and all injuries of unknown source must be reported immediately to the Administrator or designee. Injury of unknown source is an injury when all the following are met: the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Once the Administrator and Department of Health are notified, an investigation of the allegation violation will be conducted.This deficiency represents non-compliance investigated under Complaint 2655109.

Based on record review, interview, and policy review, the facility failed to report an allegation of an injury of unknown origin to the State Agency. This affected one (#31) of three residents reviewed for abuse. The facility census was 55.Review of the medical record for Resident #31 revealed an admission date of 03/27/25 with diagnoses including but not limited to anoxic brain damage, gastrostomy status, tracheostomy status, anxiety, cognitive communication deficit, and dysphagia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had severe cognitive impairment. The resident was dependent on staff for all activities of daily living.Review of the care plan dated 11/10/25 revealed the resident had the potential/actual impairment to skin integrity. Interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces.Review of the skin evaluation dated 10/25/25 marked incomplete, revealed multiple scratches to left arm. Incident report opened in error.Review of progress notes revealed no documentation regarding any scratches to left arm.Review of physician orders for October 2025 revealed no orders for scratches to left arm.Review of the facility's Self-Reported Incidents (SRI) revealed no SRI was completed for this incident. Interview on 12/10/25 at 2:07 P.M. with the Director of Nursing (DON) revealed he did not strike out the skin evaluation dated 10/25/25. The DON stated two events were opened on a Saturday and he only struck out one of them. DON verified they could not locate any nurse's notes or other documentation to support where the scratches came from or that the resident had scratches.Interview on 12/10/25 at 2:11 P.M. with Registered Nurse (RN #142) revealed that they were called into the resident's room and assessed the scratches to the residents left arm. RN #142 verified they did not put in an order for treatment to the scratches. RN #142 stated they completed a Risk Management and notified the family who already knew about them. RN #142 stated they did not know how the scratches happened so they did not fill out the predisposing factors on the risk.Interview on 12/10/25 at 2:18 P.M. with DON verified Resident #31's scratches were not investigated as to how they obtained them. DON verified it would be an injury of unknown origin if there was no supporting documentation as to where they came from and should have been investigated. Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation dated 07/01/25 revealed all incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident/patient property and all injuries of unknown source must be reported immediately to the Administrator or designee. Injury of unknown source is an injury when all the following are met: the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Once the Administrator and Department of Health are notified, an investigation of the allegation violation will be conducted.This deficiency represents non-compliance investigated under Complaint 2655109.

Based on medical record review, review of hospital documentation, staff interview, and review of facility policy, the facility failed to complete on-going monitoring of a resident's condition to potentially prevent a decline. This resulted in actual harm when Resident #07 had a change in condition and was admitted to the hospital and subsequently diagnosed with urosepsis and required Intravenous (IV) intervention. This affected one (Resident #07) of three residents reviewed for monitoring. The facility census was 60. Findings include: Review of the closed medical record for Resident #07 revealed an admitted [DATE]. Diagnoses included cerebral infarction, dysphagia, type two diabetes mellitus, chronic diastolic heart failure, severe protein calorie malnutrition, dementia, anxiety, hypertension, fibromyalgia, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #07 had moderately impaired cognitive skills for daily decision making. The resident was rarely/never understood. Resident #07 required the extensive assistance of one staff for bed mobility and toileting and the extensive assistance of two staff for transfers. The resident was always incontinent of bowel and bladder. Review of the nurse's note dated 01/01/23 at 12:27 P.M. revealed the nurse was notified by an aide that Resident #07 was erratic and confused. The nurse went to assess the resident and found the resident sitting in bed, banging her remote on her tray table and shaking her head. When asked what her name was, she said her name and kept repeating it. When asked if she was in pain, the resident kept saying her name. Resident #07 had a fever of 102.4 Fahrenheit, blood pressure of 178/87 millimeters of mercury (mmHg), pulse of 82 beats per minute and oxygen saturation of 83-87 percent (%). Resident #07 was tested for Coronavirus 2019 (COVID-19) and was positive. The resident was moved to a private room for isolation purposes and two liters per minute of oxygen was initiated. The on-call physician was notified, and orders were received for Paxlovid (used for treatment of COVID-19) one time a day for five days, urinalysis with culture and sensitivity (UA C&S), complete blood count (CBC) with differential and a chest x-ray (CXR). The on-call manager and family were also notified. Review of the laboratory requisition slip dated 01/01/23 revealed Resident #07 was ordered a UA C&S for 01/02/23 due to altered mental status. Review of the medical practitioner progress note dated 01/05/23 at 11:30 A.M. revealed Resident #07 was seen for decreased respiratory status. The resident was noted as lethargic and reported increased weakness. Review of a nurse's note dated 01/18/23 at 12:34 P.M. revealed Resident #07 had a decline from her baseline (normal) status. The resident was sweating profusely and cool to the touch. Resident #07 was now requiring three liters per minute of oxygen to maintain normal oxygen saturation. Blood pressure was 96/53 mmHg. The on-call physician was notified of the change in condition and family chose to send the resident to the emergency room . Further review of Resident #07's medical record, including progress notes from 01/01/23 through 01/18/23 revealed there was no documented evidence staff were monitoring Resident #07's condition between 01/01/23 to 01/05/23, when Resident #07 was noted to be lethargic and complained of increased weakness. Additionally, there was no documented evidence staff monitored Resident #07's condition between 01/05/23 to 01/18/23 when Resident #07 was sent to the hospital. Additionally, Resident #07's vital signs, including temperature, were not monitored regularly. There was no evidence contained in the medical record showing Resident #07 was monitored for signs or symptoms of a urinary tract infection. Review of the transfer form dated 01/18/23 at 7:15 A.M. revealed Resident #07 was transferred to the hospital for altered mental status. Review of the hospital documentation dated 01/18/23 revealed while in the emergency department (ED), Resident #07 was found to be hypoxic (having too little of oxygen), hypotensive (low blood pressure), tachycardic (fast heart rate) and was diagnosed with urosepsis (an untreated urinary tract infection which spreads to the kidneys and causes sepsis [infection]). Resident #07 received a one-liter bolus (Intravenous Fluids [IV]) while in the ED. Resident #07's Lactate was not elevated, so she did not get full sepsis protocol fluid. The resident tested positive for Influenza A, had intermittent nonproductive cough, and a chest x-ray was completed and essentially unremarkable. The resident was on two liters of oxygen via nasal cannula with oxygenation rate of 94%. A urinalysis was completed showing a urinary tract infection (UTI) and the resident was started on Rocephin (antibiotic) two grams daily for urosepsis. Resident #07's white blood cell count was elevated at 21K (normal 4 to 10.6) with moderate abdominal pain during exam, CT (computerized tomography) pending. Also, troponin was elevated at 0.17, EKG (electrocardiogram) pending, she was not complaining of chest pain. This may be 2/2 sepsis. Interview on 02/09/23 at 11:07 A.M. with Nurse Practitioner (NP) #400 revealed an untreated UTI can cause sepsis. Interview on 02/16/23 at 9:07 A.M. with the DON revealed from 01/01/23 through 01/17/23 Resident #07 had a head-to-toe skin assessment, a quarterly nutritional assessment, a quarterly social service assessment and a pain assessment. The DON verified from 01/05/23 through 01/17/23 the resident had one blood pressure taken on 01/14/23. No other vital signs were obtained until 01/18/23. The DON verified there was no documentation from 01/02/23 through 01/18/23 staff were monitoring Resident #07 for signs and symptoms of a urinary tract infection. This deficiency represents non-compliance investigated under Complaint Number OH00139559.

Based on medical record review, review of hospital documentation, staff interview, and review of facility policy, the facility failed to complete an ordered urinalysis for Resident #07. This resulted in actual harm when Resident #07 had a change in condition and was admitted to the hospital and subsequently diagnosed with urosepsis and required Intravenous (IV) intervention. This affected one (Resident #07) of three residents review for timely completion of laboratory (lab) orders. The facility census was 60. Findings include: Review of the closed medical record for Resident #07 revealed an admitted [DATE]. Diagnoses included cerebral infarction, dysphagia, type two diabetes mellitus, chronic diastolic heart failure, severe protein calorie malnutrition, dementia, anxiety, hypertension, fibromyalgia, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #07 had moderately impaired cognitive skills for daily decision making. The resident was rarely/never understood. Resident #07 required the extensive assistance of one staff for bed mobility and toileting and the extensive assistance of two staff for transfers. The resident was always incontinent of bowel and bladder. Review of the nurse's note dated 01/01/23 at 12:27 P.M. revealed the nurse was notified by an aide that Resident #07 was erratic and confused. The nurse went to assess the resident and found the resident sitting in bed, banging her remote on her tray table and shaking her head. When asked what her name was, she said her name and kept repeating it. When asked if she was in pain, the resident kept saying her name. Resident #07 had a fever of 102.4 Fahrenheit, blood pressure of 178/87 millimeters of mercury (mmHg), pulse of 82 beats per minute and oxygen saturation of 83-87 percent (%). Resident #07 was tested for Coronavirus 2019 (COVID-19) and was positive. The resident was moved to a private room for isolation purposes and two liters per minute of oxygen was initiated. The on-call physician was notified, and orders were received for Paxlovid (used for treatment of COVID-19) one time a day for five days, urinalysis with culture and sensitivity (UA C&S), complete blood count (CBC) with differential and a chest x-ray (CXR). The on-call manager and family were also notified. Review of the laboratory requisition slip dated 01/01/23 revealed Resident #07 was ordered a UA C&S for 01/02/23 due to altered mental status. Review of the medical practitioner progress note dated 01/05/23 at 11:30 A.M. revealed Resident #07 was seen for decreased respiratory status. The resident was noted as lethargic and reported increased weakness. Review of a nurse's note dated 01/18/23 at 12:34 P.M. revealed Resident #07 had a decline from her baseline (normal) status. The resident was sweating profusely and cool to the touch. Resident #07 was now requiring three liters per minute of oxygen to maintain normal oxygen saturation. Blood pressure was 96/53 mmHg. The on-call physician was notified of the change in condition and family chose to send the resident to the emergency room . Review of the transfer form dated 01/18/23 at 7:15 A.M. revealed Resident #07 was transferred to the hospital for altered mental status. Review of the hospital documentation dated 01/18/23 revealed while in the emergency department (ED), Resident #07 was found to be hypoxic (having too little of oxygen), hypotensive (low blood pressure), tachycardic (fast heart rate) and was diagnosed with urosepsis (an untreated urinary tract infection which spreads to the kidneys and causes sepsis [infection]). Resident #07 received a one-liter bolus (Intravenous Fluids [IV]) while in the ED. Resident #07's Lactate was not elevated, so she did not get full sepsis protocol fluid. The resident tested positive for Influenza A, had intermittent nonproductive cough, and a chest x-ray was completed and essentially unremarkable. The resident was on two liters of oxygen via nasal cannula with oxygenation rate of 94%. A urinalysis was completed showing a urinary tract infection (UTI) and the resident was started on Rocephin (antibiotic) two grams daily for urosepsis. Resident #07's white blood cell count was elevated at 21K (normal 4 to 10.6) with moderate abdominal pain during exam, CT (computerized tomography) pending. Also, troponin was elevated at 0.17, EKG (electrocardiogram) pending, she was not complaining of chest pain. This may be 2/2 sepsis. Further review of Resident #07's medical record from 01/01/23 through 01/18/23 revealed the UA C&S was never completed. Interview on 02/07/23 at 7:30 A.M., the Director of Nursing (DON) reported the verbal physician order on 01/01/23 for the urinalysis for Resident #07 was never entered into the system. The DON stated the nurse who filled out the laboratory requisition form should have also filled out an order for the UA. The DON verified the urinalysis did not get completed because the order did not get entered in the system as it should have. Interview on 02/09/23 at 11:07 A.M. with Nurse Practitioner (NP) #400 revealed a UA was usually ordered to rule out infection. NP #400 revealed the UA should have been completed in the first 24 hours as it can take another 24 hours to result. NP #400 revealed an untreated UTI can cause sepsis. Review of facility policy titled, Laboratory Order Processing, dated 06/2018, revealed it was the responsibility of the center nurse to process all laboratory orders for each resident in their care. The procedure included to receive the lab order from the physician, process lab order in the electronic medical record on the scheduled day and place the lab order in the lab portal and print the laboratory requisition. This deficiency represents non-compliance investigated under Complaint Number OH00139559.

Based on medical record review, resident interview, interview with resident's emergency contact, staff interview, physician interview, wound care staff interview, Adult Protective Services interview, Ombudsman interview, and review of facility policy, the facility failed to ensure adequate preparation for a community discharge to ensure the resident's safety. This resulted in Immediate Jeopardy when Resident #54 was placed at risk for potential imminent danger of serious physical harm, injury and/or death when the facility discharged him to a motel without providing information on how to take medications, any notification to the physician of the discharge, lack of follow up physician appointments, no services in place to provide daily wound care for a Stage IV pressure ulcer and to assist with personal care, without ensuring any interested community persons were notified of the resident's location, and without ensuring the resident had access to food. This affected one (#54) of six (#53, #54, #59, #60, #64 and #67) residents reviewed for discharge. The facility census was 46. On 06/09/22 at 11:37 A.M., the Administrator, Director of Nursing (DON) and Regional Clinical Support (RCS) #175 were notified that Immediate Jeopardy began on 06/02/22 at 10:00 A.M. when Resident #54 was discharged and transported by an ambulette service, arranged for by the facility, to a motel without the facility making arrangements to ensure the resident's needs were met. The resident was left at the motel with medications provided by the facility and no instructions on what medications to take or when to take them. The resident was discharged with no wound care supplies, no instructions on how to care for his wound, and no services in place to perform the daily dressing changes. The resident's physician was not notified of the discharge and there were no follow up appointments set up with the physician. The facility did not set up any services to provide assistance with Resident #54's activities of daily living. The facility did not verify the resident had any access to food upon discharge and no assessment of the safety of the motel for Resident #54's limited mobility was completed. The Immediate Jeopardy was removed on 06/14/22 at 11:22 A.M. when the facility implemented the following corrective action: · On 06/09/22 at 11:53 A.M., the Administrator contacted Resident #54. The resident informed the Administrator he was fine and had everything he needs. He reported getting meals delivered once a day, which he splits into two meals. He is also able to order food to be delivered. Resident #54 reported he felt safe. · On 06/09/22 at 2:30 P.M., the Unit Manager notified Medical Director #225 that Resident #54 had been discharged by the facility to a motel on 06/02/22. Medical Director #225 was notified the facility had reached out to Resident #54 and he was safe. · On 06/09/22 at 3:04 P.M., the Administrator spoke with Adult Protective Services (APS) #250 about Resident #54 returning to the facility. APS #250 stated the resident declined to return to the facility, instead wishing to remain in the community with assistance from APS and his emergency contact. · On 06/09/22 at 4:15 P.M., RCS #175 provided education to the Administrator to ensure any resident who discharges has their safety maintained and everything is in place for a safe discharge. · On 06/09/22 at 4:17 P.M., the Administrator provided education to Social Service Director (SSD) #185 regarding the need to provide safe and orderly discharges. · On 06/09/22 at 4:19 P.M., the Administrator educated all staff, including the administrative team, via the facility's electronic communication system, regarding when a resident is scheduled for a discharge, whether it be home or another nursing facility, to ensure the resident has everything he/she needs in place and safety is always maintained. · On 06/09/22 at 4:24 P.M., the Administrator educated the nursing staff via the facility's electronic communication system, that if a resident voices they do not feel safe, does not wish to discharge, or does not have everything in place for the discharge to notify the facility administrator immediately. · On 06/09/22, the facility implemented the use of a Discharge Planning Checklist. The checklist includes the date the discharge order was obtained, the date a care conference was held to discuss the discharge, when the service agency referral was made and confirmation the agency can meet the resident's needs, the date nursing provided education to the resident regarding medications, treatments and care needs, and the date follow-up appointments were scheduled. · On 06/09/22, SSD #185 reviewed the current residents and identified no current residents with upcoming discharges. · Interviews on 06/09/22 between 9:58 A.M. and 10:03 A.M. with Licensed Practical Nurse (LPN) #305, the Activities Director, Admission Director #400 and SSD #185 verified they had been educated on 06/09/22 regarding resident discharges. · Beginning 06/13/22, the social worker/designee will complete audits weekly for four weeks and then monthly for two months to ensure safe and orderly discharges are occurring. · On 06/14/22 at 9:12 A.M., the facility notified Resident #54's attending physician #425 of the resident's discharge and provided an update on the resident's contact information. · On 06/14/22 at 9:30 A.M., the Administrator contacted Resident #54 and offered to bring him snacks and supplements. The resident declined the offer. The resident was asked if there was anything the facility could bring him, and he declined. Resident #54 was instructed to reach out to the facility if he needed anything. · On 06/14/22 at 11:22 A.M., the Administrator and SSD #185 contacted the home health agency that was providing dressing changes for Resident #54. The agency verified the staff are doing daily dressing changes for Resident #54 for 21 days, then they will re-evaluate the need for dressing changes and obtain a new order at that time. · Medical record reviews for five additional closed resident records (#53, #59, #60, #64 and #67), reviewed for safe discharge, revealed proper discharge planning occurred and no additional concerns were identified. Although the Immediate Jeopardy was removed on 06/14/22, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: Review of the medical record for Resident #54 revealed an admitted [DATE], a readmitted [DATE], and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/09/22, revealed Resident #54 was cognitively intact. The resident required set up assistance with toilet use, eating and bathing, one-person physical assistance with ambulation, and was independent with bed mobility, transfers, dressing and personal hygiene. Resident #54 had one unhealed Stage IV pressure ulcer. Review of the plan of care, initiated 12/21/21, revealed Resident #54 had a goal to return to his prior level of living. Interventions included social services to assist Resident #54 in finding appropriate living arrangements in the community. Resident #54 had an activities of daily living (ADLs) self-care performance deficit related to right fractured humerus, fatigue, decreased motivation, and pressure ulcers. Interventions included encourage and/or assist resident to meet toileting needs, completion of perineum care after each void/defecation, and assistance with daily care needs as needed. Resident #54 also had limited physical mobility related to non-weight bearing to the right arm. Interventions included provide assistive devices for mobility, provide supportive care and assistance with mobility. Resident #54 had actual impairment to skin integrity related to wounds on the right heel. Interventions included follow physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included administer treatments as ordered and avoid positioning on the affected area. Lastly, Resident #54 had a nutritional problem or potential nutritional problems related to pressure areas and other wounds, bone injuries, and history of [CONDITION(S)]. Resident #54 was of low-normal body weight with thin appearance. Interventions included provide and serve supplements as ordered and provide and serve diet as ordered. Review of the Skin Grid Pressure assessment, dated 05/25/22, revealed Resident #54 had one Stage IV pressure ulcer to the right heel and had recently been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . No other skin issues were identified. Review of the June 2022 physician orders revealed wound care orders for Resident #54 included to cleanse the right medial heel with Dakins solution ¼ strength, apply collagen to wound, cover with ABD pad (provides padding and protection for wounds), apply Kerlix wrap (used to secure and prevent movement of the primary dressing), and secure with an ace wrap every night shift. Resident to be non-weight bearing to the right foot and non-weight bearing to the right arm. Review of the June 2022 physician orders revealed MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 30-Day Discharge Notice, dated 05/23/22, revealed Resident #54 would be discharged on [DATE], unless the facility and the resident agreed to an earlier date. The notice identified a motel in another city as the address Resident #54 would be discharged to. The reason for discharge was identified as Resident #54 failed, after reasonable and appropriate notice to pay, or to have the Medicare or Medicaid program pay on his behalf, for the care provided by the facility. Review of a nursing progress note dated 06/01/22 at 6:25 A.M. revealed Resident #54 stated he could not breathe. Resident #54's oxygen saturation was 70% (normal greater than 90%) and his blood pressure was elevated at 250/176 millimeters/mercury (mm/Hg). The resident was started on 7 liters (L) oxygen via nasal canula, given [MEDICATION(S)], and emergency transport was called. Resident #54 was transported to the hospital. Review of a nursing progress note dated 06/01/22 at 12:00 P.M. revealed Resident #54 returned from the hospital with new orders for breathing treatments. Review of a nursing progress note dated 06/02/22 at 10:30 A.M., documented by Licensed Practical Nurse (LPN) #182, revealed Resident #54 was discharged against his wishes. Resident #54 stated he would be staying in a motel and did not know what would happen when he ran out of money. Resident #54 was picked up by transport and left with all belongings. Review of the medical record did not contain a physician's order for the discharge on 06/02/22 or any notification of the physician being notified of the discharge. There was no documentation of any discharge planning having occurred at the time Resident #54 was transported to the motel. The record did not have any evidence any medications or a list of medications with instructions was sent with the resident upon discharge. There was no documentation of any outside services being set up to provide wound care to Resident #54's pressure ulcer or to provide assistance with ADL's. There was no documentation the resident's emergency contact, or the Ombudsman was notified of the discharge. Review of a Discharge Summary, dated 06/02/22, revealed Resident #54 was discharged to a motel in another city. The resident had wounds to his right heel and ankle, was non-ambulatory, and required a wheelchair. The summary documented a list of follow up appointments was provided to the resident, but specific information related to the dates of the appointments was not documented in the summary. The summary documented Resident #54 was not happy about the discharge and notified the Ombudsman. Interview on 06/08/22 at 7:56 A.M., Registered Nurse (RN) #151 revealed the day prior to his discharge, Resident #54 had stated he was nervous because he was being discharged due to non-payment of his bill. RN #151 stated Resident #54 did not want to go. RN #151 stated Resident #54 told her the facility was discharging him to a motel, but he did not know when. The resident was able to do minimal care for himself, but he could transfer into a wheelchair. Interview on 06/08/22 at 8:03 A.M., State tested Nurse Aide (STNA) #134 revealed she was working the day Resident #54 was discharged . STNA #134 stated Resident #54 had nothing packed and was not ready to go. STNA #134 stated Resident #54 could get himself dressed and go to the bathroom, but he required assistance with care due to limited mobility. Interview on 06/08/22 at 8:40 A.M., Social Services Designee (SSD) #185 revealed Resident #54 was issued a 30-day notice by the Administrator. SSD #185 stated in planning this discharge Resident #54 had money in his bank account to pay for a motel, she provided him with a facility wheelchair, and provided him with shoes at discharge because he did not have any. Interview on 06/08/22 at 8:55 A.M., the Director of Nursing (DON) verified the facility had no documentation of what medications were provided to Resident #54 at the time of discharge. Interview on 06/08/22 at 9:41 A.M. with Home Health Agency (HHA) staff #202 revealed the agency did not receive a referral for home health services for Resident #54 until the afternoon of 06/06/22. HHA #202 stated Resident #54 was scheduled for his first home health visit the day of 06/08/22. HHA #202 stated typically wound care is only provided three days a week by a home health agency. Interview on 06/08/22 at 10:12 A.M., SSD #185 verified the Ombudsman was not notified of Resident #54's discharge. Interview on 06/08/22 at 10:50 A.M., SSD #185 stated Resident #54 was sent to the hospital on 06/01/22. She was instructed at that time to contact the hospital and tell them Resident #54 could not return to the facility and the resident needed to be discharged to the motel. SSD #185 stated she was not comfortable doing this and did not contact the hospital. Resident #54 returned to the facility the same day. SSD #185 revealed on 06/02/22 facility management instructed her to discharge Resident #54. SSD #185 stated it was not one specific person who gave her the instruction, but it was a management team decision. SSD #185 verified Resident #54 did not want to leave. SSD #185 stated Resident #54 was not able to return to his previous residence because it was located on the second floor and the resident could not go up and down stairs. SSD #185 stated Resident #54 went to a motel he identified as having stayed at in the past. SSD #185 verified the referral for home health services was not sent to the home health agency until late in the day on 06/03/22. SSD #185 stated the facility's Medical Director #225, not Resident #54's attending physician #425, wrote the order for discharge because Medical Director #225 was easier to get into contact with. SSD #185 stated Resident #54 was discharged with medication. SSD #185 verified Resident #54 was not provided with discharge paperwork, discharge information was not communicated to his primary care physician #425, and the facility did not have documentation of what medications were sent with Resident #54 at discharge. SSD #185 stated she did not know why Resident #54 was discharged on [DATE], just that she was instructed that morning by the management team to get him discharged . SSD #185 verified she did not arrange any home delivered meals for Resident #54, stating he said he could order out. Interview on 06/08/22 at 11:30 A.M., Physical Therapy Assistant (PTA) #147 verified Resident #54 was non-weight bearing due to wounds on his right heel and a dislocated right shoulder. PTA #147 stated they were limited in what they could do with the resident in therapy because they could not even do range of motion exercises due to a concern it would cause further injury to his shoulder. PTA #147 stated Resident #54 had limited hand dexterity, especially with his right hand and she did not believe he could do wound treatments himself. Interview on 06/08/22 at 11:50 A.M., with Resident #54's Emergency Contact #202, his former landlord, revealed he was with Resident #54 and taking him to a wound care clinic appointment. Emergency Contact #202 stated Resident #54 was dropped off at the motel the prior week with no food. Resident #54 telephoned Emergency Contact #202 after he was at the motel to let him know where the resident was now staying. Emergency Contact #202 had assisted with setting up meals to be delivered to the resident by the senior center. Emergency Contact #202 relayed from Resident #54, who was with him, that he had not received wound care since being discharged from the facility on 06/02/22. Emergency Contact #202 described the wound dressing as bloody. Interview on 06/08/22 at 12:15 P.M., Medical Director #225 revealed he recalled some discussion about Resident #54's discharge but he did not recall seeing any paperwork related to the discharge. Medical Director #225 stated he did not assess or evaluate Resident #54. Since he was not Resident #54's attending physician, he would not have written discharge orders unless there was some extenuating circumstance preventing the attending physician (#425) from doing it. An additional interview initiated by Medical Director #225 on 06/08/22 at 1:31 P.M., revealed he had returned to his office since the prior interview. Medical Director #225 stated the facility had sent orders to his office that day for him to sign to discharge Resident #54 to a motel. Medical Director #225 stated he did not agree with signing the orders and would not ever agree to discharging a resident to a motel. Medical Director #225 again verified he did not provide orders for Resident #54's discharge of 06/02/22. Interview on 06/08/22 at 1:39 P.M., Wound Care Nurse (WCN) #275 verified Resident #54 was assessed at the wound care clinic on this day. WCN #275 stated Resident #54's wound dressing was soiled and saturated with blood and wound drainage. WCN #275 noted the outer layer of the dressing was not intact. The wound appeared to not have been cleaned in several days and was redder than it had been the previous week. WCN #275 verified Resident #54 was to receive daily wound care for a Stage IV pressure ulcer to his right foot and was unable to provide his own wound care. The resident was to be non-weight bearing to aide in healing of the ulcer. Interview on 06/08/22 at 1:52 P.M. with the DON verified the facility had no evidence Resident #54 was provided with education on his wound care prior to discharge. She stated Resident #54 had been given a 30-Day Discharge Notice due to non-payment. The DON stated she was unsure why Resident #52 was discharged on [DATE], stating the resident must have wanted to leave that day. Interview on 06/08/22 at 1:53 P.M., the Ombudsman revealed she was provided a copy of Resident #54's 30-day discharge notice when she arrived at the facility that day. The facility had not informed her Resident #54 had already been discharged when she was provided a copy of the notice. Interview on 06/08/22 at 2:22 P.M. with APS #250 revealed she had worked with Resident #54 for about one year and the facility was aware she had been involved with the resident. APS #250 stated she initially became involved with Resident #54 after Emergency Contact #202 called in a referral because Resident #54 was not able to care for himself. APS #250 stated Resident #54 was unable to care for himself and her goal had been for Resident #54 to remain at the facility long term. APS #250 stated it had been a couple of months since she had contact with the facility and she had assumed the resident's issue with non-payment of his bill was resolved and Resident #54 was safe. She could have resolved the issue of non-payment of the resident's bill for the facility. APS #250 stated on 06/06/22 Emergency Contact #202 had notified her Resident #54 had been discharged from the facility on 06/02/22 to a motel. APS #250 stated she did see Resident #54 on 06/06/22 and verified Resident #54 had medications. However, Resident #54 did not know what his medications were or what to do with them. APS #250 stated she looked through the resident's belongings in the motel room and was unable to locate any discharge paperwork and Resident #54 told her he was not given any. APS #250 verified Resident #54's wound bandages were bloody, and she was uncertain when he had last received wound care treatment. APS #250 stated she did not see any wound care supplies in the motel room. APS #250 stated Resident #54 was unkempt, and his hair was greasy. APS #250 verified Resident #54 began receiving delivered meals from the senior center on 06/06/22, but the senior center only provides one meal per day on Monday through Friday. APS #250 stated there was a carryout down the street and Resident #54 had been using the motel office phone to call the carryout to have deli sandwiches delivered to him. APS #250 stated she contacted Resident #54's attending physician #425 and no follow-up appointments had been scheduled, so APS #250 arranged for physician follow-up for Resident #54. APS #250 stated she was going to be working on getting Resident #54 into another facility because he was not able to care for himself. Interview on 06/08/22 at 4:10 P.M., Medical Assistant (MA) #232, with Resident #54's attending physician's office, verified neither the attending physician #425 nor his Nurse Practitioner (NP) #426 wrote orders for Resident #54's discharge. Additionally, MA #232 stated NP #426 was scheduled to see Resident #54 at the facility that day and was unaware the resident had been discharged . Interview on 06/09/22 at 8:27 A.M., SSD #185 verified she was aware of Resident #54's involvement with APS and did not notify APS of Resident #54's discharge from the facility. SSD #185 stated the facility did not do all of the right steps to discharge Resident #54, but they did what they could to make sure it was a safe discharge. Interview on 06/09/22 at 8:59 A.M., LPN #182 revealed on 06/02/22 at approximately 9:00 A.M., she was approached by SSD #185 and told Resident #54 was being discharged and transportation was going to be there at 10:00 A.M. to pick him up. LPN #182 stated she told SSD #185 Resident #54 had a wound care clinic appointment that morning and transportation was going to be there to pick him up for the appointment. LPN #182 stated she was told by SSD #185 to cancel the appointment because the resident was leaving. LPN #182 stated Resident #54 was not comfortable with the discharge, but stated he was not staying somewhere he was not wanted. LPN #182 stated she saw no orders for discharge and was told SSD #185 was taking care of the orders. Since she did not have physician orders, LPN #182 stated she approached LPN #109 and asked what medications were to be sent with Resident #54. LPN #182 stated she was told by LPN #109 that Resident #54 owed the facility $43,000 and they were not sending any medications with the resident. LPN #182 stated she bagged the medications that were in the medication cart for Resident #54 and hid them in his belongings so that he had some medications to take. LPN #182 verified there was no documentation of what medications she had sent with the resident. She did not provide a list of upcoming follow-up appointments and she was not aware of any appointments that had been made. LPN #182 also verified no education had been provided to Resident #54 on wound care and she was unaware of any wound care supplies being sent with the resident. LPN #182 stated there was no prior notice and no planning for Resident #54's discharge, stating the way Resident #54 was discharged was spur of the moment. Interview on 06/09/22 at 11:13 A.M., the Administrator revealed it was decided between the facility management team and at the corporate level that Resident #54 would be issued a 30-day discharge notice due to non-payment for services. The Administrator stated the 30-day discharge notice was given to Resident #54 on 05/23/22. The Administrator stated facility staff had informed Resident #54 he was unable to return to his previous apartment and the facility offered to assist the resident with finding placement at the time of discharge. The Administrator stated on 05/30/22, SSD #185 found a motel and Resident #54 wanted to go there so discharge planning began. The Administrator stated discharge was planned for 06/02/22. Resident #54 went out to the hospital on 06/01/22 and they were unsure if he was going to return that day, so his discharge transportation was cancelled for 06/02/22. Resident #54 returned from the hospital on 06/01/22 and the facility was able to arrange transportation again for 06/02/22, so the facility proceeded with discharge. The Administrator stated she was unaware home health would not be able to provide care to Resident #54 daily. Interview on 06/09/22 at 12:09 P.M. with Resident #54 revealed he did not receive discharge instructions for medications and wound care, wound care supplies were not sent with him, no follow-up medical appointments were made, and he was provided no assistance with obtaining meals. Resident #54 stated he was given some medication but was unsure of what was given to him or when to take it. Interview on 06/10/22 at 12:00 P.M., LPN #201 stated at approximately 9:00 A.M. on 06/02/22 she was informed by SSD #185 that Resident #54 was being discharged and his ride would be there at 10:00 A.M. LPN #201 stated it was a very disorganized discharge. LPN #201 stated there were no physician orders for discharge and no order for a wheelchair. LPN #201 stated Resident #54 needed a wheelchair because he could not bear weight. LPN #201 stated she sent Resident #54 with a facility wheelchair because she could not let him leave without one. LPN #201 stated Resident #54 was non-weight bearing, had limited mobility with his right arm, and was not able to provide care for himself without assistance. LPN #201 stated Resident #54 could not physically care for his wound, and they had no time to provide wound care education to the resident. LPN #201 stated the discharge was not planned, was not thought out, and the staff had to rush to get him out of the building. LPN #201 stated Resident #54 was dumped, and she was not able to stop it. Resident #54 expressed concern about being discharged and LPN #201 stated nobody cared. Interview on 06/14/22 at 8:50 A.M., the Administrator stated she thought the facility's Medical Director #225 was Resident #54's attending physician. She was unaware the resident had a different attending physician. Interview on 06/14/22 at approximately 10:10 A.M., the Administrator stated she thought the home health agency was doing the dressing changes to Resident #54's pressure ulcer three times a week, with Emergency Contact #202 doing them the other days. The Administrator verified she had not spoken to APS, the emergency contact, or the home health agency to find out who was doing the dressing change on what days. Review of the facility policy titled Transfer or Discharge Documentation, dated 2018, revealed all necessary information, including a copy of the resident's discharge summary, and any other documentation, to ensure a safe and effective transition of care would be communicated to the receiving provider. This deficiency substantiates Complaint Control Number OH 171.

Based on observation, medical record review, staff interview, review of personnel files, and review of facility policy, the facility failed to ensure a resident was provided with appropriate assistance during transfers resulting in an avoidable fall. This resulted in actual harm for one resident (#23) when staff utilized a two person pivot/turn transfer instead of a mechanical lift as directed per the resident's plan of care. Consequently, Resident #23 fell and sustained a right femur fracture. Additionally, the facility failed to ensure two residents (#37 and #50) were provided with appropriate provisions of care and fall interventions per the residents care plans. This affected three (#23, #37, #50) of seven residents reviewed for falls. The facility identified 10 residents who required two-person physical assistance for transfer and/or bed mobility. The facility census was 62. Findings include: 1. Medical record review for Resident #23 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most current annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident was unable to complete the Brief Interview for Mental Status due to [MEDICAL CONDITION]. The Functional Status assessment revealed the resident required two-person physical assistance for bed mobility and surface to surface transfers. The resident was nonambulatory. Continued medical record review for Resident #23 revealed an assessment dated [DATE] indicating the resident required use of a mechanical lift for safe transfers. Review of the current plan of care revealed the identified risk for falls due [MEDICAL CONDITION](stroke), impaired mobility, behaviors and [MEDICAL CONDITION] medications. The first intervention listed was two person assist with transfers (using mechanical lift). Further review of the medical record revealed the Resident #23 experienced a fall in the afternoon of 02/27/18 at approximately 1:15 P.M. Nursing documented the resident sustained [REDACTED]. Documentation of the incident stated, (MONTH) have twisted her right knee. The resident was noted to have some redness, swelling and complaints of pain to the right knee at that time. The physician was notified and an X-ray was ordered. Review of the radiology report received at 11:02 P.M. via fax identified an acute minimally displace [MEDICAL CONDITION] femur. No dislocation was noted at that time. The physician was notified. Attempts to contact the responsible party continued to be unsuccessful. Resident #23 was transported to the emergency room (ER) for treatment. Resident #23 returned to the facility from theER on [DATE] at 6:00 P.M. The resident returned with a brace to the right leg for stabilization related to a right femur fracture. The resident was non-weight bearing and to follow up with orthopedics in two to four weeks. Observation of Resident #23 on 05/14/18 at 11:55 A.M. revealed the resident to be seated in a wheelchair in the dining room with her right leg elevated on a padded foot rest. A protective boot and knee brace were observed to be in place. The resident was noted to have a right-hand contracture with the arm lying on a padded arm rest. Attempts to interview were unsuccessful due to [MEDICAL CONDITION]. The resident would smile, and laugh inappropriately; could not provide meaningful information during interview. Staff interview with State tested Nursing Assistant (STNA) #200 was conducted on 05/15/18 at 3:20 P.M. STNA #200 was involved with the transfer of the resident on 02/28/18. During the interview, STNA #200 revealed the normal procedure was to use a stand-up lift to transfer Resident #23. STNA #200 stated STNA #202 was the second staff member present that assisted the transfer of Resident #23 to bed from her wheelchair. STNA #200 stated there were a lot of call lights going off and they (staff) were rushed on that evening. STNA #200 explained STNA #202 suggested they do a two-person stand/pivot assist to put Resident #23 in bed, as it would be quicker. STNA #200 said the resident was unhappy with the delay getting to bed, therefore STNA #200 agreed to transfer without the use of a stand-up lift. As the staff members assisted the resident up, the resident's legs went 'limp'. STNA #200 stated the resident was angry at the staff and refused to help stand up. The nursing assistants lowered the resident to the floor. STNA #200 stated, That was the worst decision I ever made. Review of personnel file for STNA #200 revealed an Individual Performance Improvement Plan (IPIP) initiated with the employee on 02/28/18. The IPIP indicated counseling was conducted by a nurse manager for an event concern on 02/27/18. Description of the event revealed, STNA did not follow plan of care for a resident. Resident was recommended to be sit-to-stand lift and the STNA attempted pivot transfer. The Policy Violation on the IIP was documented, Failure to follow resident plan of care. Staff interview was conducted with Licensed Practical Nurse (LPN) #210 on 05/16/18 at 10:29 A.M. who was on duty at the time of the fall for Resident #23. LPN #210 reported two STNA's (#200 and #202) attempted a two person stand and pivot transfer with the resident at the time of the incident. LPN #210 verified the order for transfer of Resident #23 at that time was to use a standing lift. The LPN reported the resident sustained [REDACTED]. Resident #23 was not a candidate for surgical repair. Therefore, non-weight bearing and immobilization with a brace during healing was the treatment prescribed. Staff interview with Occupational Therapy Assistant (OTA) #212 was conducted on 05/16/18 at 11:12 A.M. OTA #212 explained the strength and assistance needs for Resident #23 from therapy evaluations. Prior to the fall, Resident #23 was able to bear some weight on the right leg. However, staff were to use a sit-to-stand mechanical lift for transfers. The resident had not been cleared for a stand and pivot transfer by staff prior to the fall incident, due to instability. Resident #23 was currently non-weight bearing status following the fall/[MEDICAL CONDITION] femur. Review of the facility Event Summary Report, fall investigation revealed the facility documented the fall prevention measures were to include a two person assist, using a mechanical lift, with transfers. 2. Medical record review of Resident #37 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION], was dependent on supplemental oxygen and liquid nutrition via gastric tube. Resident #37 was nonverbal. Review of the most current annual MDS assessment dated [DATE] revealed the resident was totally dependent for bed mobility, transfer and hygienic care. The resident was identified as at risk for falls. The plan of care included the intervention of Mandatory two assist for all provision of direct care and transfers. Not to include med pass, tube [MEDICAL CONDITION]. Dated as initiated 11/06/17. Further review of the medical record revealed a fall occurrence dated 04/19/18 at 9:30 P.M. The nurses note revealed no information regarding the fall apart from a follow-up assessment. No injuries resulted from the fall. Review of the facility investigation Event Summary Report revealed on 04/19/18 at 9:30 P.M. reavealed Resident (#37) was being changed. When the nurse's aide (STNA #204) rolled Resident #37, STNA #204 lost her grip and the resident rolled out of the bed on the floor. Resident #37 did not hit her head and no injuries were noted at the time. No non-verbal symptoms of pain noted. Family and physician were informed, as well as, management. Observation of Resident #37 was conducted on 05/14/18 at 10:13 A.M. The resident was observed to be in a total vegetative state. Bilateral hand/arm contractions with splints in place were noted. A tube feeding was providing liquid nutrition to a gastric tube. The resident had a [MEDICAL CONDITION] with oxygen providing respiratory needs. The resident did not respond to verbal stimuli and was non-verbal. Staff interview with the DON on 05/15/18 at 9:08 A.M. verified STNA #204 had been providing care unassisted for Resident #37. When rolling the resident over on the side, STNA #204 lost her grip and Resident #37 rolled off the bed on to the floor. Review of the personnel file for STNA #204 revealed an IPIP for concern event date of 04/19/18. Description of the event stated, STNA independently provided care for a resident that has a plan of care that indicates requirement of two assist for all personal care excluding medication administration and tracheotomy care. The Policy Violation was noted, Failure to follow resident plan of care. Staff interview with STNA #204 on 05/16/18 at 3:15 P.M. verified on 04/19/18 they provided incontinence care on Resident #37 unassisted. Review of the facility Event Summary Report, fall investigation revealed the fall prevention measures were to include a two person assist with bed mobility. The staff member (STNA #204) was educated on requirement of two for all personal care. 3. Review of Resident #50's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #50's quarterly MDS dated [DATE] revealed the resident to have severe cognitive impairment. Further review revealed the resident to be totally dependent with one assist for bed mobility, transfers, ambulation and locomotion with use of a walker. Review of Resident #50's care plan revealed the resident to be at risk for falls. Interventions included to encourage the resident to lay down when fatigued, helmet for safety when ambulating, and hip protectors. Review of Resident #50's monthly physician orders dated (MONTH) (YEAR) revealed orders for a bed alarm, scoop mattress to bed, encourage use of hip protectors when out of bed and encourage resident to wear gait belt when up ambulating. Observation on 05/15/18 at 3:10 P.M. revealed the resident lying on a floor mat by the nurse's station without hip protectors in place. Observation on 05/17/18 at 8:43 A.M. revealed the resident sitting up in the wheelchair and did not have hip protectors or helmet in place. Interview on 05/15/18 at 3:11 P.M. with Registered Nurse (RN) #7 verified Resident #50 did not have hip protectors on as ordered. RN #7 stated the resident's helmet was broken and they are waiting on a new one to arrive. Interview on 05/17/18 at 8:44 A.M. with state tested nursing assistant (STNA) #214 verified Resident #50 did not have his hip protectors in place and that they were probably in the laundry. STNA #214 was unsure why the resident did not have his helmet on. Review of the facility policy Falls Management, dated as revised 03/15/16 revealed the policy to assess patients for fall risk. Those determined to be at risk were to receive appropriate interventions to reduce risk and minimize injury.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital documentation, review of an incident summary, review of the facility Self-Reported Incident (SRI) investigation, staff interview and policy review, the facility failed to ensure Resident #1 received a shower with the appropriate shower chair resulting in an avoidable fall. This resulted in actual harm when Resident #1 sustained a fall from an improper shower chair, the resident suffered a right hip fracture and was admitted to the hospital. This affected one (#1) out of three residents reviewed for falls. The facility identified 31 residents that utilize a shower chair for showers. The facility census was 68. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was readmitted on [DATE] after returning from the hospital for surgical repair of a right hip fracture. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed his Brief Interview for Mental Status (BIMS) score was 99 indicating he was rarely or never understood. Section G revealed Resident #1 required extensive assistance of two persons for transfers and one person for locomotion on and off the unit. Resident #1 required two persons extensive assistance with dressing and personal hygiene. For bathing Resident #1 required physical help in part of the bathing activity from one person. Section J revealed Resident #1 had no history of falls since his last assessment. Review of the Plan of Care (P(NAME)) revealed Resident #1 is dependent for Activities of Daily Living (ADL) care in bathing, grooming, dressing, eating, bed mobility, transfer, locomotion and toileting due to cognitive loss, dementia and quadriplegia. The P(NAME) was revised on 10/03/17 which indicated Resident #1 is to be placed in a reclining shower chair for all showers. Resident #1 was at risk for falls and required assistance of two with all showers. He used a mechanical lift for all transfers with two staff members. Review of the Nurse Notes dated 09/10/17 at 2:15 A.M. revealed Resident #1 had a fall. No injuries were noted at the time of his fall and assessment. His vital signs were normal. His guardian and the physician were notified of the fall. Review of the Change in Condition Evaluation Assessment completed on 09/10/17 at 2:15 A.M. revealed Resident #1 had a fall in the shower. Resident had no apparent injuries and no complaints of added pain at that time. Follow up condition change assessments were completed on 09/11/17 at 12:12 A.M., 8:00 A.M., and 4:00 P.M. with no change in condition and no complaints of increased pain. On 09/12/17 at 12:00 A.M., 3:00 A.M., and 8:00 A.M. revealed no change in condition and no complaints of increased pain. Further review of the Nurses Notes revealed no complains of hip pain until 09/22/17 at 9:19 P.M. which revealed an order for [REDACTED]. When writer was palpating his hips and legs, resident grimaced and began to punch at writer saying that his legs were extremely painful and sensitive. Review of the Mobilex Radiology Report dated 09/22/17 revealed the conclusion of the right hip x-ray was acute right hip fracture. Review of Nurses Notes on 09/23/17 at 4:11 A.M. revealed Resident #1 was transferred to the hospital. Review of Nurses Notes on 09/23/17 at 5:43 A.M. revealed Resident #1 had x-rays done to lower extremities due to excessive amounts of pain. X-rays came back positive for right hip and femur fracture. The physician was contacted and writer was instructed to send Resident #1 to the hospital. Management was contacted as well as residents Power of Attorney (POA). Review of the Imaging Results dated 09/23/17 at 7:06 A.M. revealed the findings included the right hip had an acute comminuted displaced intertrochanteric fracture of the proximal right femur. The right femoral head remains properly located in the right acetabulum. There was moderate to severe narrowing of the right hip joint space and associated osteophyte spur formation, underlying diffuse osteopenia. The impression revealed Resident #1 had an acute comminuted displaced intertrochanteric fracture the proximal right femur with moderate to severe underlying right hip osteoarthrosis and diffuse osteopenia. Review of the Hospital History and Physical dated 09/25/17 revealed Resident #1 presented to the hospital for evaluation of hip pain after a fall. Per the facility Resident #1 fell approximately 12 days ago. An x-ray last night revealed a right hip fracture. Resident #1 was also a paraplegic. He fell three to five feet onto a hard floor. The point of impact was the right hip. Moderate pain was present at the right hip. Review of the Event Summary Report dated 09/10/17 at 2:15 A.M. revealed Resident #1 had a fall in the shower room. The physician and his guardian were notified. State tested Nurse Aid (STNA) #231 was a witness to the fall. Resident #1 was lowered to the floor. The Fall Investigation revealed the fall was related to use of inappropriate shower seating. Analysis of the fall revealed the root cause was Resident #1 had slipped from his shower chair. Corrective action included to have two assistants for Resident #1 for all showers and to use of a reclining shower chair for all showers. Review of a facility SRI dated 09/23/17 revealed Resident #1 offered a new complaint of pain at his right hip on 09/22/17. The nurse immediately notified the physician and received an order for [REDACTED]. The x-ray was positive for fracture of Resident #1's right hip and femur. The nurse called the physician again and obtained an order to send Resident #1 to the emergency room (ER) for evaluation. Review of Resident #1's chart showed he was lowered to the floor in the shower room on 09/10/17. At the time of the fall Resident #1 did not offer any new complaints of pain when assessed. Resident #1's first complaint of new pain occurred on 09/22/17. STNA #231 reported that she lowered the resident to the floor on 09/10/17, the aide was immediately suspended pending investigation of the incident due to x-ray results. STNA #231 and other staff interviews were conducted. Through these interviews it was determined the STNA #231 had placed the Resident #1 in an improper shower chair and he slipped out of chair to the floor. STNA #231 attempted to lower resident to the floor to lessen the impact but was unsuccessful. Through investigation facility does not suspect abuse or neglect occurred. Interview with the Director of Nursing (DON) and Administrator on 10/12/17 at 2:20 P.M. regarding the SRI involving Resident #1. The DON verified Resident #1 had a fall on 09/10/17. Resident #1 was thoroughly assessed and found to have no injuries at the time of the fall. A fall investigation was completed at the time of the fall which resulted in a determination that Resident #1 was lowered to the floor by STNA #231 on the night of 09/10/17. Resident #1 had a history of [REDACTED]. Additionally, Resident #1 had poor communication ability and never indicated he had hip pain until 09/22/17. After the discovery of the hip fracture, the facility determined the fracture must have occurred during the fall dated 09/10/17 because there was no other incident which might have caused the fracture during the interim timeframe. The SRI investigation was initiated and the fall dated 09/10/17 was reviewed. STNA #231 was suspended pending investigation. DON learned additional information including that Resident #1 had been assisted to the shower chair per Hoyer lift by STNA #231 and the unit nurse. Once he was in the shower, assisted by STNA #23, Resident #1 slid from the shower chair. During the initial fall investigation STNA #231 had stated she lowered Resident #1 to the floor. After discovering the hip fracture and conducting additional interviews with STNA #231, the facility determined that the wrong shower chair had been in use on the night of his fall and determined Resident #1 had a harder fall than STNA #231 had portrayed on 09/10/17. The DON explained that Resident #1 had no trunk control and was not able to support himself in an up-right position. He was supposed to be using a reclining shower chair. The DON verified the reclining shower chair was not in his care plan at the time. The DON stated STNA #231 has been providing care for Resident #1 for years and always used the reclining shower chair. All the STNA's understood and used the reclining shower chair for Resident #1. During the initial fall investigation, it was not immediately clear STNA had used the bariatric shower chair on the night he fell . STNA #231 admitted during the SRI investigation that she had used the bariatric shower chair instead of the reclining shower chair. The DON determined STNA #231's original story had not been truthful regarding her statement she had assisted Resident #1 to the floor on 09/10/17. The DON and Administrator determined STNA #231 used poor judgment while showering Resident #1 on 09/10/17. STNA #231 was terminated for poor job performance on 09/28/17. The alleged neglect was unsubstantiated. Review of the facility policy titled Falls Management revised 03/15/16 revealed residents will be assessed for falls risk as part of the nursing assessment process. Residents at risk of falls will receive appropriate interventions to reduce the risk and minimize injury. As a result of the incident the facility took the following action to correct the deficient practice by 10/10/17: · On 09/12/17 the Nurse Practice Educator began in-service training of all licensed nurses and STNA's regarding following resident's plans of care for showers, equipment and level of assistance needed. The in-service training was completed on 10/03/17. · On 09/23/17 Resident #1 was sent to the hospital for evaluation and treatment of [REDACTED]. · On 09/23/17 STNA #231 was suspended and an investigation was started regarding the incident involving Resident #1. On 09/28/17 STNA #231 was terminated related to job performance specifically regarding the failure to follow Resident #1's plan of care. · On 09/25/17 the DON completed a full review of Resident #1's condition and care plan to ensure the care plan reflected the residents care needs. · On 09/25/17 the DON audited the 31 Resident's who utilize shower chairs to ensure correct shower chairs/safety interventions were care planed and implemented. No other residents were found to be affected. · On 09/25/17 the facility held a Performance Improvement Committee meeting to discuss shower chair safety. · On 09/25/17 the facility implemented weekly monitoring of five random residents that require assistance and use a shower chair with showering. These audits were completed on 09/26/17, 10/03/17 and 10/10/17 without any concerns identified. The audits will continue weekly for three months and results of the audits will be reviewed by the Performance Improvement Committee. · During the survey on 10/12/17 two (#2 and #3) additional residents were reviewed for the use of shower chair/safety and no concerns were identified. This deficiency substantiates Complaint Number OH 782.