Every finding on record at Majestic Care of Point Place

Based on medical record review, observation, staff interview, Ohio Department of Health (ODH) Environmental Specialist (ES) interview, review of an electronic mail (email) correspondence from the local health department (LHD) epidemiologist, review of the facility's water management program and review of the facility policy, the facility failed to ensure a comprehensive water management plan was developed to include all required elements and further failed to ensure the plan was updated annually. Furthermore, the facility failed to ensure all recommended control measures were implemented when the facility was notified of a presumptive legionella pneumonia case. This had the potential to affect all residents. The facility census was 75.Findings include: Review of the medical record revealed Resident #60 was admitted on [DATE] with diagnoses of cauda equina syndrome, pressure ulcer stage IV, Type Two diabetes mellitus with diabetic chronic kidney disease, hypertensive heart and chronic kidney disease, chronic or unspecified duodenal ulcer with hemorrhage, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment, dated 07/19/26, revealed the resident was cognitively intact, required partial/moderate assistance for bathing, and set-up assistance for personal hygiene.Further review of the medical record revealed Resident #60 admitted to the hospital on [DATE] and returned to the facility on [DATE]. On 08/06/26, the resident experienced a change in condition and was transferred to the hospital for further evaluation and treatment. On 08/07/26, Resident #60 was diagnosed with right middle lobe legionella pneumonia in the hospital. The facility was notified by the LHD on 08/10/26 of the presumptive legionella case. Resident #60 returned to the facility on [DATE].Review of an email dated 08/10/26 at 2:14 P.M. from Epidemiologist #501 with the LHD to the facility's Administrator and Director of Nursing (DON), with the subject noted as Presumptive Healthcare- Associated Legionella Exposure, revealed eight numbered items to be completed by the facility. Item #2 instructed the facility to implement water-use restrictions throughout the facility using point-of-use filters (0.2 microns). ODH recommends using filters graded for at least 60 days during investigations. Working with their consultant, they may either install these filters on all fixtures in the building or on key locations and restrict water access everywhere else. Item #3 instructed the facility to communicate to staff and residents about water restrictions and post signage near each fixture with a filter for people to contact maintenance staff if a filter is damaged or removed. Center for Disease Control and Prevention (CDC) provides communication resources on their website. Review of the facility's Water Management Risk Assessment and Analysis, updated February 2025, revealed the water management plan had not been updated and did not include a diagram of the system, dead zones, and exits/entrance of the systems.Observation on 08/20/26 from 9:12 A.M. to 11:20 A.M. revealed resident room bathroom sinks were operational and did not have a filter, were not covered to deter use, and no signage was posted to alert residents, staff, and visitors to not use the sinks. Interview on 08/20/26 at 12:55 P.M. with the Administrator verified resident sinks were operational and were not covered to deter use and there was no signage posted to instruct residents, staff, and visitors to not use the sinks. Additionally, the Administrator verified the facility provided no formal notification to the residents or resident representatives regarding the potential legionella concern due to not wanting to induce alarm. The Administrator stated residents were notified by staff on all shifts that the water was unsafe. A telephone interview 08/20/26 at 2:04 P.M. with Environmental Specialist (ES) #502 with the ODH verified they were working with the facility related to the presumptive legionella case and interventions to implement. ES #502 confirmed there should be no water access from any fixture that did not have a filter on it while the investigation continued. A follow-up interview on 08/24/26 at 12:45 P.M. with the Administrator verified the facility's water management plan had not been updated since February 2025 and did not include all the required elements. Review of the facility policy titled, Water Management, reviewed 12/12/23, revealed the water management program included the following elements: an interdisciplinary water management team, a detailed description and diagram of the water system in the facility (receiving, cold water distribution, heating, hot water distribution, and waste), the identification of areas in the water system that could encourage the growth and spread of legionella or other waterborne bacteria, identifications of situations that could lead to legionella growth, specific measures used to control the introduction and or spread of legionella, control limits or parameters that were acceptable and monitored, a diagram of where control measures were applied, a system to monitor control limits and the effectiveness, a plan for when control limits were not met and/or not effective, and documentation of the program. The water management program would be reviewed at least once a year, or sooner if the following occurred: control limits were consistently not met, there was a major maintenance or water service change, there were any disease cases associated with the water management system, or there were changes in laws, regulations, standards, or guidelines. This deficiency was an incidental finding discovered during the complaint survey.

Based on observation, resident interview, staff interview, and review of electronic medical record (EMR), the facility failed to maintain a safe, clean, sanitary, comfortable, and homelike environment for residents. This affected two residents (#17 and #25) reviewed for homelike environment. This had the potential to affect all facility residents. The facility census was 73. Findings Include: 1.Review of the EMR for Resident #17 revealed an admission date of 10/08/20 with diagnoses including asthma, breast cancer, atrial fibrillation (a. fib), generalized muscle weakness, hypertension (HTN), congestive heart failure (CHF), hyperlipidemia, oral dysphagia, osteoarthritis, diaphragmatic hernia, cardiomyopathy, depression, and hearing loss. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 06/22/26, revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating Resident #17 was severely cognitively impaired. Further review of this MDS assessment revealed Resident #17 required substantial to maximal assistance with all functional abilities including, but not limited to, dressing, hygiene, toileting, repositioning, grooming, and ambulation. Observation on 08/06/26 at 9:11 A.M. revealed CNA #264 tell a resident she is unable to accommodate a request for linen as the facility has no clean linen at that time. Observation on 08/06/26 at 9:15 A.M. of the clean linen supply room for rooms 208-308 revealed no pillowcases, bath towel, or washcloths were available. Interview on 08/06/26 at 9:15 A.M. with Licensed Practical Nurse (LPN) #278 verified the clean linen supply room for rooms 208-308 had no pillowcases, bath towel, or washcloths available for resident use. Observation on 08/06/26 at 9:20 A.M. of the clean linen supply room for the 200-hall revealed it contained no linens for resident use. Interview on 08/06/26 at 9:20 A.M. with CNA #264 verified the clean linen supply room for the 200-hall contained no linens for resident use. Observation on 08/06/26 at 9:36 A.M. revealed Resident #17 was sitting on the side of her bed with her back to the room door looking out the window. Further observation revealed there were no sheets on her bed and her pillow did not have a pillowcase. An interview on 08/06/26 at 9:36 A.M. with Resident #17 was attempted but was unsuccessful due to Resident #17's severe cognitive impairment.Interview on 08/06/26 at 9:36 with Certified Nursing Assistant (CNA) #264 verified Resident #17 did not have sheets or a pillowcase in place on her bed. CNA #264 stated she would not prefer to have a bed with no linens. CNA #264 further stated there are no clean sheets and the facility is very low on all linen. Observation on 08/06/26 at 9:42 A.M. of the facility laundry room revealed no reserve of clean towels, sheets, or other linens. Interview on 08/06/26 at 9:44 A.M. with Laundry Aide #208 verified there was no reserve of clean towels, sheets, or other linens in the facility laundry room. Laundry Aide #208 stated the facility does not have enough linen. Laundry Aide #208 also stated she had been told by the facility more linen had been ordered but she is not sure of when it is to be delivered. 2. Review of the EMR for Resident #25 revealed an admission date of 09/14/24 with diagnoses including hemiplegia, type two diabetes (DM2), dementia, spinal stenosis, apashia, seizures, lumbar spinal fusion, oropharyngeal dysphagia, depression, myocardial infarction, cognitivie communication deficit, generalized muscle weakness, dorsalgia, HTN, hyperlipidemia, insomnia, constipation, and osteoarthritis. Review of Resident #25's most recent annual MDS assessment revealed a BIMS score of two, indicating Resident #25's was severely cognitively impaired. Further review of this MDS assessment revealed Resident #25 was dependent for toileting and required substantial to maximal assistance with all other functional abilities including, but not limited to, eating, dressing, hygiene, turning and repositioning, and ambulation. Observation on 08/06/26 at 9:20 A.M. revealed the toilet in Resident #25's in-room restroom was broken. Interview on 08/06/26 at 9:20 A.M. with CNA #264 verified the toilet in Resident #25's in-room restroom was broken. Interview on 08/06/26 at 9:22 A.M. with LPN #278 revealed Resident #25 does not use his in-room restroom for toileting as he is incontinent and utilized a brief. An interview on 08/06/26 at 9:28 A.M. was attempted with Resident #25 but was unsuccessful due to his cognitive status. Interview on 08/06/26 at 1:33 P.M. with Director of Maintenance (DOM) #120 and the Administrator verified the toilet in Resident #25's in-room restroom is not working. DOM #120 states that the toilet has not been operational since 07/20/26. Review of the facility policy titled Physical Environment, dated 06/30/26, revealed the facility will maintain all equipment in safe operating condition. Review of the facility policy titled Safe and Homelike Environment, dated 06/30/26, revealed the facility will provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortably environment. This deficiency represents non-compliance investigated under Complaint Number 3136529.

Based on observation, resident interview, staff interview, record review medical record, and review of facility policy, the facility failed to ensure residents medications were routinely available for Resident #71. The facility census was 73. Findings Include: Review of the electronic medical record (EMR) for Resident #71 revealed an admission date of 02/06/25 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus (DM2), hypertensive heart disease with heart failure, congestive heart failure (CHF), gastroesophageal reflux disease (GERD), hypothyroidism, anxiety, history of SARS CoV-2 (COVID-19), low back pain, generalized muscle weakness, myocardial infarction (MI), personal history of other venous thrombosis and embolism, depression, asthma, obesity, repeated falls, chest pain, hyperlipidemia, anemia, and osteoarthritis. Review of Resident #71's most recent quarterly Minimum Data Set (MDS) assessment, dated 06/02/26, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #71 was cognitively intact. Further review of the MDS assessment revealed Resident #71 required setup or clean-up assistance with all assessed functional abilities, including, but not limited to, hygiene, dressing, toileting, repositioning, and ambulation. Review of the EMR revealed a physician order, dated 07/08/26, for two tablets of Percocet (opioid) 5-325 milligrams (mg) to be administered by mouth (PO) every six hours (Q6H) for chronic pain syndrome. Review of Resident #71's August 2026 Medication Administration Record (MAR) revealed that on 08/06/26, Resident #71 did not receive the scheduled doses of two tablets of Percocet 5-325 mg at 12:00 A.M. and 6:00 A.M. Further review of the EMR revealed progress notes documenting that Resident #71's Percocet was not available for administration at the scheduled times.Interview on 08/06/26 at 8:40 A.M. with Resident #71 revealed she did not receive her physician-ordered doses of two tablets of Percocet 5-325 mg at 12:00 A.M. and 6:00 A.M. Resident #71 stated the medication was not available for administration. Interview on 08/06/26 at 9:09 A.M. with Licensed Practical Nurse (LPN) #278 verified Resident #71 did not receive her physician-ordered doses of two tablets of Percocet 5-325 mg at 12:00 A.M. and 6:00 A.M. LPN #278 stated the medication was not available for the resident and that she was awaiting the pharmacy to deliver the medication. Review of the facility policy titled Medication Reordering, dated 06/30/26, revealed the facility's policy was to accurately and safely provide or obtain pharmaceutical services, including routine and emergency medications, in a timely manner to meet each resident's needs. The policy further indicated the facility would utilize a systematic approach to provide or obtain routine and emergency medications and that acquisition of medications should be completed in a timely manner to ensure medications were administered as ordered. The policy specified that when a nurse administering medications observed six or fewer doses of a medication remaining, the nurse would reorder the medication, time permitting. The policy also required the nurse assigned to each medication cart to perform a medication cross-match every Thursday night.

Based on observation, resident interview, staff interview, review of electronic medical record (EMR), review of facility maintenance documents, and facility policy review, the facility failed to maintain a safe, clean, sanitary, comfortable, and homelike environment for three residents (#34, #70, and #71). The facility census was 73. Findings Include: 1.Review of the EMR for Resident #71 revealed an admission date of 02/06/25 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus (DM2), hypertensive heart disease with heart failure, congestive heart failure (CHF), gastro-esophageal reflux disease (GERD), hypothyroidism, anxiety, history of SARS-CoV2 (COVID-19), low back pain, generalized muscle weakness, myocardial infarction (MI), personal history of other venous thrombosis and embolism, depression, asthma, obestity, repeated falls, chest pain, hyperlipidemia, anemia, and osteoarthritis.Review of Resident #71's most recent quarterly Minimum Data Set (MDS) assessment, dated 06/02/26, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #17 was cognitively intact. Further review of this MDS assessment, revealed Resident #71 required setup or clean-up assistance for all functional abilities including, but not limited to, hygiene, dressing, toileting, repositioning, and ambulation.Interview on 08/06/26 at 8:40 A.M. with Resident #71 revealed the toilet in her resident in-room restroom was leaking and the water forms a puddle on the floor. Further interview with Resident #71 revealed the leaking toilet causes her distress as she does not feel this is safe, comfortable, nor homelike. Observation on 08/06/26 at 8:45 A.M. of Resident #71's in-room restroom, revealed the resident's toilet was leaking and a puddle of water had formed on the floor immediately adjacent to her toilet.Interview on 08/06/26 at 8:46 A.M. with Licensed Practical Nurse (LPN) #278 verified Resident #71's toilet was leaking and a puddle of water had formed immediately adjacent to the toilet. Interview on 08/06/26 at 1:33 P.M. with Director of Maintenance (DOM) #120 and the Administrator revealed the toilet in Resident #71's in-room restroom was leaking. DOM #120 stated the leak was a result of a water line that needed to be tightened.2.Review of the EMR for Resident #34 revealed an admission date of 04/12/26 with diagnoses including CHF, stage three chronic kidney disease (CKD3), DM2 with foot ulcer, anemia, peripheral vascular disease (PVD), hyperlipidemia, GERD, bipolar disorder, difficulty in walking, generalized muscle weakness, calculus in the bladder, benign prostatic hyperplasia (BPH), acquired absence of other genital organs, abnormalities of gait and mobility, and Schizoaffective disorder.Review of Resident 34's most recent annual MDS assessment, dated 07/02/26 revealed a BIMS score of 15, indicating Resident #34 was cognitively intact. Further review of this MDS assessment revealed Resident #34 required assistance with functional abilities, including, but not limited to, hygiene, dressing, toileting, repositioning, and ambulation.3.Review of the EMR for Resident #70 revealed an admission date of 08/05/24 with diagnoses including obesity, CKD3A, osteoarthritis, hyperlipidemia, MI, hydrocele, need for assistance with personal care, insomnia, DM2, generalized muscle weakness, depression, anemia, heartburn, erythema intertrigo, tinea unguium, cellulitis of bilateral lower limbs, dyspnea, and inflammatory disorders of the scrotum.Review of Resident #70's most recent significant change MDS assessment, dated 07/17/26 revealed a BIMS score of 15, indicating Resident #70 was cognitively intact. Further review of this MDS assessment revealed Resident #70 required assistance with functional abilities, including, but not limited to, hygiene, dressing, toileting, repositioning, and ambulation.Observation on 08/06/26 at 9:08 A.M. of the toilet in the room shared by Resident #34 and Resident #70 revealed it was non-functional. Further observation of this in-room resident restroom, revealed it contained a bedside commode (BSC) (A movable toilet that does not require running water. It typically resembles a chair with a toilet seat, and has a removable bucket or pail underneath to collect urine and feces, which must be emptied and cleaned after each use). The collection bucket of the BSC was approximately three-quarters full of an unidentified yellowish-brown liquid that contained an unidentified solid and semi-solid brown substance. Additionally, the toilet seat, lid, and handles of the BSC contained multiple widespread areas which were contaminated with an unidentified brown substance that was dried on, and adhered to, the surface. Additional observation revealed a very strong, very foul odor was emanating from the BSC of urine and feces. Interview on 08/06/26 at 9:17 A.M. with LPN #278 verified the toilet in the room shared by Resident #34 and Resident #70 was non-functional. LPN #278 also verified this in-room resident restroom, contained a BSC. LPN #278 verified the collection bucket of the BSC was approximately three-quarters full of an unidentified yellowish-brown liquid that contained an unidentified solid and semi-solid brown substance. LPN #278 also verified the toilet seat, lid, and handles of the BSC contained multiple widespread areas which were contaminated with an unidentified brown substance that was dried on, and adhered to, the surface. LPN #278 also verified there was a very strong, very foul odor emanating from the BSC of urine and feces. Interview on 08/06/26 at 1:33 P.M. with DOM #120 and the Administrator verified the toilet in Resident #34 and Resident #70's shared in-room restroom is not working. DOM #120 states that the toilet has not been operational since 07/20/26. Interview on 08/12/26 at 7:20 A.M. with Resident #34 revealed he did not enjoy it when he and Resident #70's shared in-room restroom was not working. Resident #34 stated he did not feel that the broken toilet and dirty BSC were safe, clean, sanitary, comfortable, or at all homelike.Interview on 08/12/26 at 7:23 A.M. with Resident #70 revealed it was not ideal when he and Resident #70's shared in-room restroom was not working. Resident #70 stated he did not feel that the broken toilet and dirty BSC were safe, clean, sanitary, comfortable, or at all homelike. Review of the facility policy titled Routine Cleaning and Disinfection, dated 06/30/26, revealed the provision of routine cleaning and disinfection is to provide a safe, sanitary environment, and to prevent the development and transmission of infections. Routine cleaning and disinfection of visibly soiled surfaces will be performed in resident rooms. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high-touch areas including toilet handles. Review of the facility policy titled Physical Environment, dated 06/30/26, revealed the facility will maintain all equipment in safe operating condition. Review of the facility policy titled Safe and Homelike Environment, dated 06/30/26, revealed the facility will provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortably environment. This deficiency represents non-compliance investigated under Complaint Number 3136529.

Based on observation, record review, review of emergency medical services (EMS) run reports, review of crash cart audit logs, review of cardiopulmonary resuscitation certification documentation, review of a medication administration audit report, review of a vital documentation audit report, review of the American Heart Association (AHA) guidance for adult Cardiopulmonary Resuscitation (CPR), staff interview, EMS staff interviews, and review of facility policy, the facility failed to provide Resident #77, who had a full code status (advance directives), with basic lifesaving interventions on [DATE] by not immediately initiating rescue breathing or ventilations while performing chest compressions. Licensed Practical Nurse (LPN) #200 failed to immediately call 911 and/or instruct another staff member to call 911 until after the resident was assessed with an absence of vital signs, after checking code status, after taking the crash cart to the resident's room and after beginning chest compressions. After beginning chest compressions, LPN #200 then instructed Certified Nursing Assistant (CNA) #309 to call 911. Review of the EMS run report revealed the 911 call was received at 8:06 P.M. and EMS arrived at the resident at 8:18 P.M. When EMS arrived, they found staff administering chest compressions without ventilations. Resident #77 was without ventilations for greater than 12 minutes. EMS continued chest compressions and initiated ventilation and continued life-sustaining efforts. After collaboration with the off-site physician, the resident was pronounced deceased by EMS at 8:57 P.M. This affected one (Resident #77) of three residents reviewed for death. The facility identified 52 residents with a full code status. The facility census was 76.On [DATE] at 11:35 A.M., the Administrator, the Director of Nursing (DON), and the Regional Quality Assurance Registered Nurse (RQARN) #730 were notified Immediate Jeopardy began on [DATE] at 7:30 P.M. when the facility failed to provide Resident #77, who had a full code status, with basic lifesaving interventions by not immediately initiating rescue breathing or ventilations while performing chest compressions and failed to immediately call 911 and/or instruct another staff member to call 911 until after the resident was assessed with an absence of vital signs, after checking code status, after taking the crash cart to the resident's room and after beginning chest compressions. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at a Severity Level 2 (no actual Harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. On [DATE] at 3:45 P.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, DON, Medical Director #700, [NAME] President of Operations (VPO) #712, and RQARN #730. On [DATE], the DON and/or designee audited the code status of all residents. On [DATE], the DON and/or designee audits code status with physician orders and resident care plans for all residents. On [DATE], the Human Resource Director (HRD) #343 audited CPR certifications for facility nursing staff. On [DATE], the DON and/or designee re-educated the facility nurses on where to find resident code status and appropriate response in code situations. No nurse would be permitted to work after this date until the education was completed. Beginning [DATE], the DON and/or designee would audit all new admission to ensure their code status was accurate, appropriate physician orders were in place, and care plans matched. This would be completed weekly for four weeks then as needed thereafter. All findings would be reported to the Quality Assurance (QA) committee. Beginning on [DATE], the DON and/or designee would perform a mock code on each shift at random weekly for four weeks, then as needed thereafter. All findings will be reported to the QA committee for review. Beginning on [DATE], the DON and/or designee would interview five nurses per week to ensure they knew where to find resident's code status and how to conduct a code blue. The interviews would be completed weekly for four weeks then as needed thereafter. Findings would be reported to the QA committee for review. Beginning on [DATE], unexpected resident deaths and their circumstances would be analyzed and assess for compliance by the interdisciplinary team (IDT) at the next IDT meeting following the event. IDT finding would be provided to the medical director for further review. Findings would be reported to the QAPI committee for review and guidance. On [DATE], the Administrator and DON were assigned responsibility for ensuring compliance with the plan of correction. Interviews on [DATE] at 11:37 A.M., Registered Nurse (RN) #265, LPN #236 and RN #300 revealed they had received education on [DATE] regarding the proper use of a bag valve mask, locating resident code status and appropriate response in a code situation. Findings include:Review of the medical record for Resident #77 revealed an admission date of [DATE] and a discharge date of [DATE] when the resident expired in the facility. Diagnoses included Huntington's disease, dysphagia, anxiety, and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had severe cognitive impairment and was dependent on staff for all activities of daily living.Review of the care plan dated [DATE] and last revised on [DATE] revealed the resident had chosen a full code status (cardiopulmonary resuscitation would be initiated in the event of a cardiac or respiratory event) with a goal to honor the resident's decisions regarding healthcare choices. Only one intervention was in place stating for staff to activate the resident's advanced directive as indicated. Review of the physician orders dated [DATE] revealed the resident had elected a full code status. Review of a vital sign report dated [DATE] at 7:20 P.M. for Resident #77 revealed the resident's blood pressure was 113 systolic over 71 diastolic, with a pulse of 58 beats per minute. The resident's oxygen saturation level was 96 percent on room air and the resident's respiratory rate was 16 breaths per minute. Review of a vital sign audit report dated [DATE] revealed the vital signs documented on [DATE] at 7:20 P.M. were not entered into the electronic medical record until [DATE] at 7:50 A.M.Review of a late entry nurses note dated [DATE] at 11:30 A.M. (documented on [DATE] at 7:55 A.M.) revealed the funeral home picked up the resident's body on [DATE] at 11:30 P.M. Review of a late entry nurse's note dated [DATE] at 11:40 A.M. (documented on [DATE] at 7:54 A.M.) revealed LPN #200 was notified by a nursing assistant that Resident #77 was unresponsive. LPN #200 checked the resident's vital signs and they were absent. Resident #77 was a full code and CPR was initiated. Another staff nurse was notified and called 911. The crash cart was present, and the AED (automated external defibrillator) was applied. EMS arrived and took over life sustaining measures. The resident's pronounced time of death was 8:50 P.M. The physician, family, and funeral home were notified. There was no documentation Resident #77 was not provided ventilations during CPR. Review of a late entry SBAR (situation, background, assessment and recommendation) summary for providers progress note dated [DATE] at 11:41 A.M. (documented on [DATE] at 7:48 A.M.) revealed Resident #77 had a respiratory arrest and was unresponsive. At the time of the evaluation, no vital signs had been documented. Review of the EMS incident run reports dated [DATE] revealed the nursing home staff called 911 at 8:06 P.M. EMS arrived on scene at 8:16 P.M. and were at Resident #77's bedside at 8:18 P.M. The resident had a presumed cardiac arrest. EMS noted CPR was initiated by the facility staff beginning at an estimated time of 8:00 P.M. with hands-only compressions with an AED machine applied to the resident. The initial electrocardiogram (ECG) rhythm was asystole (flatline, no cardiac activity). The resident was unresponsive, without a pulse, and had no respirations. EMS took over manual chest compressions, changed out the AED, and initiated ventilations with a bag valve mask with supplemental oxygen at 15 liters per minute. A second EMS crew responded and started Advanced Life Support (ALS) Cardiac Arrest Protocols and the resident was placed on the auto ventilator. The resident was too small for the LUCAS (portable mechanical device for automatic chest compressions). Resident #77 was given four rounds of epinephrine every 10 minutes, and one dose of sodium bicarbonate. The resident was in asystole through the entire event. Manual compressions continued on the resident with EMS changing personnel every two minutes. EMS noted the facility staff had stated the resident's last known well time was approximately 6:30 P.M. EMS noted Resident #77 had an unwitnessed arrest with an approximate onset time of 6:45 P.M. The physician was contacted and later directed EMS to stop lifesaving efforts. The resident was pronounced dead at 8:57 P.M.Review of the crash cart audit logs for the crash cart located on the 100 hall and for the crash cart located on the 200/300 halls revealed there were three CPR mouth shields located in each cart and each cart contained a bag valve mask. Review of a medication audit time report dated [DATE] revealed LPN #200 last administered medication to Resident #7 on [DATE] at 8:01 P.M. and viewed Resident #25's medication record before being logged out of the electronic medical record program at 9:18 P.M. During an observation on [DATE] at 9:27 A.M. the 100-hall crash cart and the 200/300 hall crash cart with each had a bag valve mask on the crash cart and three CPR mouth shields which could be used for rescue breathing during CPR. During an interview on [DATE] at 12:52 P.M., LPN #200 stated on [DATE] after completing the shift-to-shift report, she had checked Resident #77's vital signs then went down the hall and started the evening medication pass. LPN #200 stated she was unsure of the time but estimated a few minutes later around 7:30 P.M., a nursing assistant reported Resident #77 had coded. LPN #200 thought the nursing assistant was talking about a door code then realized the nursing assistant was saying Resident #77 had coded, but it had not registered immediately because she had just seen the resident. LPN #200 grabbed the crash cart and went to the resident's room. She attempted to get Resident #77's vital signs but there were none. She had applied her personal pulse oximeter, but it was reading dash, dash, dash and she kept pushing the button on the pulse oximeter every couple of minutes trying to get a reading. She started chest compressions and told another staff member to call 911. LPN #216 went and got the AED machine and applied the AED pads to the resident. LPN #200 stated only chest compressions were administered until EMS arrived. The AED pads were too close together and they had to be moved around. LPN #200 stated we just followed the prompts. LPN #200 stated they did not provide ventilations to Resident #77 with the bag valve mask and did not provide rescue breathing. LPN #200 stated the bag valve mask was not on the crash cart and must have fallen off when bringing the crash cart to the room. LPN #200 stated the mask was later located on the floor in the room but never used. LPN #200 stated the bag valve mask looked different than ones she had seen before as it had a tube coming out of it and LPN #216 and herself did not know how to use it. It took about 15 minutes or more for EMS to arrive. By the time the bag valve mask was found on the floor, and they figured out how to put together the bag valve mask to use, EMS had arrived and took over the code. LPN #200 revealed she was not sure when the code started or when EMS arrived. LPN #200 stated she had not been trained on using the facility's bag valve mask. She did not document anything in the medical record until the following day because she was unsure what she needed to do and what needed documented. LPN #200 stated she called the DON, but she never answered so she then notified the on-call manager, RN #513 about Resident #77. LPN #200 stated she charted the incident the following day and verified the documented times were not accurate. During an interview on [DATE] at 1:30 P.M., LPN #216 stated she was notified by LPN #200 that Resident #77 had coded. LPN #216 stated chest compressions were initiated, and the AED was applied and an unknown staff member called 911. Chest compressions continued for about 15 minutes until EMS arrived and took over. LPN #216 stated LPN #200 and herself had only completed chest compression and had not provided ventilations for the resident with the bag valve mask or rescue breathing. LPN #216 denied any problems with the bag valve mask. LPN #216 stated CPR was performed with the resident on the bed with the [NAME] board underneath her. She could not recall what time the code was called but the shift started at 6:45 P.M. and shift to shift report ended around 7:15 P.M. LPN #216 staed the code was called sometime after the end of report fairly early into the shift. During an interview on [DATE] at 2:05 P.M., the DON stated she had not obtained staff statements regarding Resident #77's death and had not documented interviews with the staff regarding Resident #77's death. She had talked to the staff that night and the next morning. The DON stated LPN #200 and LPN #216 had told her EMS was there, what supplies they had used on the crash cart, and what notifications were made. She had asked staff if they had used the [NAME] board under the resident while performing CPR and they had indicated they had. The nurses were asked when the last time the resident was checked and the nurse told her vitals were obtained on [DATE] at 7:20 P.M. The DON stated Resident #77 had yet to be administered any of her evening medications on [DATE]. The DON stated if a code was called then staff should check code status, check vital signs, call 911, grab the crash cart and [NAME] board, apply the AED, throw the pulse oximeter on, notify the physician and family. One nurse should be giving ventilations with the bag valve mask, and the other nurse should be doing the chest compressions, and the two nurses should switch as needed. If a bag valve mask was not available or functioning, then staff should provide rescue breathing. The DON verified there were CPR mouth shields in the crash cart. The DON also revealed the nursing staff had not reported failure to provide ventilations and/or rescue breathing for Resident #77. Attempts were made to interview LPN #316 on [DATE] at 11:19 A.M. and on [DATE] at 2:32 P.M. but were unsuccessful. During an interview on [DATE] at 11:23 A.M., CNA #222 stated Resident #77 was checked on sometime after dinner and the resident was not moving and not breathing. CNA #222 stated the resident's call light was not on. CNA #222 was unsure of the resident's assigned CNA's name. CNA #222 stated the nurse was notified but CNA #222 could not recall the nurse's name. Someone called 911 but she was unsure who had placed the call. During an interview on [DATE] at 1:21 P.M., CNA #309 stated she was assigned to Resident #77 on [DATE]. She had provided incontinence care for the resident around 4:50 P.M. then checked on the resident sometime after dinner time and repositioned the resident. CNA #309 stated Resident #77 was sweaty like usual, and she removed the blanket and covered the resident with the sheet. CNA #309 asked a coworker to check the resident as she was finishing up with other residents. CNA #309 said CNA #222 told her Resident #77 had coded. CNA #309 said she yelled for the nurse and told her the resident coded but the nurse was not understanding what she was saying. She yelled for the nurse to come now to the resident's room. Another nurse came down the hallway, and it took the nurses about 10 minutes to find the resident's code status. They went to the resident's room and LPN #200 started chest compressions. CNA #309 stated she ran and got another nurse. LPN #216 went and got the AED machine and hooked it up. LPN #200 told her to call 911. CNA #309 stated she was not sure what time she called 911. The nurses administered chest compression until EMS arrived but did not administer ventilations. During an interview on [DATE] at 10:19 A.M., Emergency Medical Technician (EMT) #500 stated they arrived at 8:18 P.M. and Resident #77 was not responsive. The resident was in her bed, and staff were performing chest compressions only. EMT #500 revealed staff were not providing ventilations with the BVM. EMT #500 revealed there was a [NAME] board under the resident. EMT #500 could not recall if there was a pulse oximeter applied to the resident. EMT #500 revealed there were three staff in the room who had not identified themselves. EMT #500 revealed the staff provided a last known well time of 5:30 P.M. then another staff stated a last known well time of 6:30 P.M. EMT #500 stated the nursing staff had not reported obtaining vital signs on the resident at 7:20 P.M. A new AED was attached to the resident, and compressions began with another EMT getting the airway ready and providing ventilation with bag valve mask with supplementing oxygen at 15 liters per minute. The ALS team arrived shortly after and started an intraosseous (IO) line and administered medications. EMT #500 stated the resident was too small for the LUCAS device to give automatic compressions. EMT #500 revealed CPR continued until the physician authorized ending resuscitation attempts.During an interview on [DATE] at 10:47 A.M., EMT #502 stated EMT #500 was first on scene performing CPR on the resident. EMT #502 stated the facility staff were poor historians and had difficulty establishing the resident's last known well time. EMT #502 revealed the nursing staff never reported the resident's vitals were last obtained at 7:20 P.M.Review of the CPR Certification documentation revealed LPN #200 had received certification for Basic Life Support (BLS) and CPR on [DATE] with a renewal date of [DATE]. LPN #216 had also received certification for BLS and CPR on [DATE] with a renewal date of 04/2028.Review of the facility policy titled Documentation in the Medical Record, dated [DATE], revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed Staff and interdisciplinary team members would document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.Review of the facility policy titled CPR-Medical Emergency, dated [DATE], revealed if a resident experienced a cardiac arrest, the facility must provide basic life support, including CPR prior to the arrival of EMS. The employee who first witnessed or who was first on site of the medical emergency that was trained would initiate immediate action, including CPR as appropriate, basic first aid, and summon for assistance. The nurse would assess the situation, stay with the resident, designate a staff member to announce a Code Blue, notify the physician and call 911 as needed. Further review of the policy revealed no procedure for performing CPR and providing ventilations with a BVM or rescue breaths. Review of the American Heart Association (AHA) 2025 guidance for adult CPR included the following: Check for breathing, if the person is not breathing or only gasping, begin CPR; Chest compressions included to push down hard and fast at a rate of 100 to 120 compressions per minute; After every 30 compressions, give two rescue breaths; and make sure the person is on a firm surface. In 2008, after the publication of several studies looking at the rates of bystander CPR and public attitudes toward it, the AHA updated their guidance and decided to take out rescue breathing (mouth to mouth) for untrained or lay responders as a way to encourage and focus on hands only CPR. This updated guidance did not apply to trained healthcare professionals. AHA guidelines clearly state that CPR must continue until a licensed provider with higher authority assumes care, the patient shows signs of life, the rescuer is physically unable to continue or an advanced directive/valid do not resuscitate (DNR) is present. Conditions under which CPR should not be started included decapitation, dependent lividity (pooling of blood in the lowest parts of the body) and rigor mortis (post-mortem muscle stiffening typically beginning two to four hours after death). Further review of the guidelines revealed chest compressions with ventilation improved outcomes for adults in cardiac arrest. Delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than compression plus ventilation because arterial oxygen content decreased as CPR duration increased.This deficiency was an incidental finding investigated during the course of a complaint investigation.

Based on observation, review of the crash cart checklist logs, staff interview, and policy review, the facility failed to ensure the two facility crash carts were properly maintained. This had the potential to affect all residents. The facility census was 76. Findings include:Review of the facility crash cart checklist for the 200/300 hall dated [DATE] through [DATE] revealed facility staff checked the contents of the cart on the first of the month. If the cart had not been used then the intact lock tag number was verified and signed off daily as intact by staff. The contents of the cart were last verified on [DATE] and signed off daily through [DATE]. There were no directions on the crash cart checklist alerting staff to check for expired items. Review of the facility crash cart checklist for hall 100 dated [DATE] through [DATE] revealed the facility staff checked the contents of the cart on the [DATE]. No lock number was noted on the checklist from [DATE] through [DATE]. On [DATE] the crash cart lock tag number was identified, and the content check was noted as complete. There were no directions on the crash cart checklist alerting staff to check for expired items. Observation on [DATE] beginning at 9:27 A.M. with Licensed Practical Nurse (LPN) #330 of the crash cart located on hall 100 revealed the bag valve mask (BVM) used during cardiopulmonary resuscitation had expired on [DATE]. Interview on [DATE] at 9:28 A.M., LPN #330 verified the BVM expired on [DATE]. LPN #330 revealed staff were required to check the contents of the crash cart monthly and after each use. LPN #330 revealed there were no directions on the crash cart logs for staff to check the items in the crash cart for expiration dates. Observation on [DATE] at 9:30 A.M. of the crash cart located on the 200/300 hall revealed there were two Yankauer suction tip catheters (oral suction tool) with expiration dates of [DATE]. Additionally, there were three intravenous (IV) start kits with expiration dates of [DATE], [DATE], and [DATE], suction tubing with an expiration date of [DATE], and a nebulizer mask with an expiration date of [DATE].Interview on [DATE] at 9:33 A.M., LPN #330 verified the expiration dates of the IV start kits, Yankauer catheters, suction tubing, and nebulizer mask. Interview on [DATE] at 2:31 P.M., the Administrator revealed it was her expectation that the central supply staff would check medical equipment monthly for expiration dates. The Administrator revealed the crash carts should be audited monthly. The Administrator revealed she was unaware if there was a formal process for checking the expiration dates of the supplies in the crash carts. The Administrator revealed she was unaware if staff had been educated on checking for expiration dates. Interview on [DATE] at 7:35 A.M., the Director of Nursing (DON) verified the facility had no policy on maintaining the crash carts or checking for expired medical supplies. Review of the facility policy Safe and Homelike Environment, dated [DATE] revealed the facility would provide a safe, clean, comfortable, and homelike environment ensuring the delivery of care and services in a manner that minimized safety risks and promoted well-being. This deficiency represents noncompliance investigated under Complaint Number 3038257.

Based on observation, medical record review, staff interview, and policy review, the facility failed to maintain required infection control standards during a dressing change. This affected one (#49) of three residents reviewed for wounds. Additionally, the facility failed to ensure bedpans and basins were properly stored in a sanitary manner. This affected one (#34) of three residents reviewed for activities of daily living. The facility identified eight residents utilizing bedpans. The facility census was 76.Findings include:Review of Resident #49's medical record revealed an admission date of 12/14/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, and dysphagia. Review of Resident #49's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. Furthermore, Resident #49 was at risk for developing pressure ulcers and required set up or clean up help with bed to chair and chair to bed transfers. Review of Resident #49's care plan dated 04/17/26 revealed Resident #49 was at risk for skin breakdown related to incontinence and type II diabetes mellitus. Interventions included pressure reducing/redistributing cushion to chair and bed, preventive skin care as ordered, skin inspections weekly and as needed, document skin inspections and report any abnormalities to the provider and to follow the treatment plan. Resident #49 was also care planned for being at risk for complications and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Interventions included to observe for signs or symptoms of hypo/hyperglycemia such as poor wound healing, and to perform skin inspections weekly and as needed, paying particular attention to the feet. Review of a nursing progress note dated 06/09/26 revealed Resident #49 had an abrasion to the right great toe. The provider was notified and order was received to cleanse the right great toe with soap and water, then cover with calcium alginate and a dry dressing daily and as needed until healed. Observation on 06/16/26 at 8:04 A.M. of wound care completed by Licensed Practical Nurse (LPN) #308 for Resident #49 revealed Resident #49 had an abrasion to his right great toe. LPN #308 washed her hands prior to beginning the dressing change. LPN #308 donned gloves and removed the previous dressing. LPN #308 discarded the old dressing and with the same gloves, LPN #308 washed the wound with soap and water per the physician's orders. After washing and rinsing the wound with soap and water, LPN #308 discarded her gloves, performed hand hygiene, and donned a new pair of gloves to apply the new dressing. Interview on 06/16/26 at 8:15 A.M. with LPN #308 verified she used the same gloves to take off the old dressing and to wash and rinse the wound. Review of the facility validation checklist for wound care with a copyright date of 2022 revealed the nurse should remove a dressing and place it in an appropriate receptacle, perform hand hygiene and don clean gloves, and then cleanse the wound thoroughly with the prescribed cleansing agent. 2. Review of the medical record for Resident #34 revealed an admission date of 02/25/26. Diagnoses included chronic respiratory failure, type two diabetes mellitus, hypertension, and atrial fibrillation. Review of the significant change MDS assessment dated [DATE] revealed the resident had intact cognition. The resident was always incontinent of bowel and bladder. The resident was dependent on staff for toileting. Review of the physician orders dated 04/27/26 revealed the resident had orders for enhanced barrier precautions due to a multi-drug resistant organism. Observation on 06/16/26 at 2:50 P.M. revealed a bath basin and a bed pan were in direct contact with the floor underneath the sink in the resident's bathroom. Interview on 06/16/26 at 2:50 P.M., Resident #34 revealed she was incontinent of urine and would use the bedpan if she knew timely she needed toileting. Interview on 06/16/26 at 2:52 P.M., Registered Nurse (RN) #265 verified the bath basin and bedpan had been placed directly on the floor in the bathroom. Interview on 06/16/26 at 2:55 P.M., the Director of Nursing (DON) revealed bed pans should be stored in a bag if reused. Follow-up interview with the DON revealed that the facility had no specific infection control policy regarding the reuse and storage of bed pans. Review of the facility policy Safe and Homelike Environment, dated 01/01/26, revealed the facility would prevent the spread of disease-causing organisms by keeping resident/patient care equipment clean and properly stored. This deficiency represents noncompliance investigated under Complaint Number 3038257.

Based on review of the medical record, review of a facility statement, review of Emergency Medical Services incident run reports, interview, and policy review, the facility failed to ensure accurate and thorough documentation in the medical record. This affected two (#14, #77) of three residents reviewed for medical documentation. The facility census was 76.Findings include:1. Review of the medical record for Resident #14 revealed an admission date of [DATE]. Diagnoses included dementia, anxiety, hypertension, and spinal stenosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident used a walker for ambulation with staff supervision. The resident required substantial/maximal assistance for toileting and partial/moderate supervision for transfers. The resident wore a wander/elopement alarm daily. Review of the elopement risk assessment completed [DATE] and [DATE] revealed the resident was at risk for elopement. Review of the care plan dated [DATE] revealed the resident was at risk for elopement due to confusion and attempts to leave the facility unattended. Interventions included for staff to assess for unmet needs, assess elopement risk quarterly and as needed, place resident profile in elopement book, redirect the resident when wandering or exit seeking, and wander guard to the left ankle, check function and placement daily. Review of an undated and unsigned statement from the facility revealed on [DATE] Resident #14 was observed walking up the driveway toward the main driveway by therapy staff who notified Licensed Practical Nurse (LPN) #330. LPN #330 notified the Director of Nursing (DON) and went outside and brought the resident into the facility. Resident #14 reported she had returned from a leave of absence with a friend and wanted to smoke a cigarette before she came back into the facility. LPN #330 and the DON noted the wander guard alarm was working properly when they brought the resident back into the facility. The DON noticed Resident #14's friend sitting in her vehicle in the first row of the parking lot. The DON checked the sign out book and noted Resident #14's friend had signed the resident out for a leave of absence. Review of electronic communication (email) dated [DATE] revealed Social Worker #254 notified the resident's guardian about the resident not being escorted back inside the building by her friend after a leave of absence. Review of the nursing progress notes dated [DATE] through [DATE] revealed no documentation about the resident being found unattended in the parking lot. Further review of the medical record revealed no documentation the resident's guardian was notified. Interview on [DATE] at 10:39 A.M., LPN #330 at first was unable to recall finding Resident #14 outside unattended. LPN #330 then revealed she was walking through the therapy gym and noticed the resident outside and she notified the DON and went out and got the resident. LPN #330 revealed the resident had gone out to smoke and was not supposed to. LPN #330 stated the incident that occurred two to three weeks ago. LPN #330 revealed she thought the resident's sister was somewhere in the parking lot. Interview on [DATE] at 10:45 A.M., the DON revealed the resident was allowed to leave with supervision. The DON revealed the incident occurred about two to three weeks ago. The DON verified the incident was not documented in the medical record because the resident was within eyesight. Interview on [DATE] at 10:52 A.M., the Administrator revealed the resident would go on leave of absence with her sister and a friend. The Administrator revealed she was not aware of the resident getting out of the building. The Administrator then stated the resident was outside in the parking lot but was not unsupervised because her friend was parked in the parking lot. The Administrator verified there was no documentation of the incident in the medical record. The Administrator stated there was a conversation with the resident's guardian but verified it was not documented in the medical record. The Administrator revealed maybe the notification was in an email.Interview on [DATE] at 2:07 P.M., Regional Registered Nurse (RRN) #526 verified the staff should have created a risk report regarding the incident. RRN #526 stated while there was no documentation in the medical record, the incident was not dismissed, and staff had followed up with the guardian regarding the incident. RRN #526 was informed during surveyor interviews, several staff had varying accounts of how and when the incident occurred. RRN #526 revealed the team put their heads together and were able to recall the incident had happened on [DATE]. Review of facility policy Incidents, Accidents, and Supervision, dated [DATE], revealed an incident was an occurrence or situation not consistent with the routine care of a resident or with any routine operation. This could involve a visitor, vendor, or Care Team Member. The purpose of incident reporting includes assuring appropriate and immediate interventions were implemented and corrective actions were taken to prevent reoccurrences and improve the management of resident care. A resident would be assessed for elopement risk and interventions would be documented. A timeline, search efforts and notification would also be recorded. Care plans would be updated, and environmental/system changes would also be documented. 2. Review of the closed medical record for Resident #77 revealed an admission date of [DATE] and a discharge date of [DATE] when the resident expired in the facility. Diagnoses included Huntington's disease, dysphagia, anxiety, and gastrostomy status. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for all activities of daily living.Review of the care plan dated [DATE] and last revised on [DATE] revealed the resident had chosen a full code status (cardiopulmonary resuscitation (CPR) would be initiated in the event of a cardiac or respiratory event) with a goal to honor the resident's decisions regarding healthcare choices. Only one intervention was in place stating for staff to activate the residents' advanced directive as indicated. Review of the physician orders dated [DATE] revealed the resident had elected a full code status. Review of a vital sign report dated [DATE] at 7:20 P.M. for Resident #77 revealed the resident's blood pressure was 113 systolic over 71 diastolic, with a pulse of 58 beats per minute. The resident's oxygen saturation level was 96 percent on room air and the resident's respiratory rate was 16 breaths per minute. Review of a vital sign audit report dated [DATE] revealed the vital signs documented on [DATE] at 7:20 P.M. were not entered into the electronic medical record until [DATE] at 7:50 A.M.Review of a late entry nurses note dated [DATE] at 11:30 A.M. (documented on [DATE] at 7:55 A.M.) revealed the funeral home picked up the resident's body at 11:30 P.M. Review of a late entry nurse's note dated [DATE] at 11:40 A.M. (documented on [DATE] at 7:54 A.M.) revealed LPN #200 was notified by a nursing assistant that the resident was unresponsive. LPN #200 checked the residents' vital signs and they were absent. The resident was a full code and CPR was initiated. Other staff nurse notified and called 911. The crash cart was present, and the AED (automated external defibrillator) was applied. Emergency Medical Services (EMS) arrived and took over life sustaining measures. The resident's pronounced time of death was 8:50 P.M. The physician, family, and funeral home were notified. Further review of the nurse's notes dated [DATE] and [DATE] revealed no documentation the resident was not provided ventilations during CPR. Review of a late entry SBAR summary for providers progress note dated [DATE] at 11:41 A.M. (documented on [DATE] at 7:48 A.M.) revealed the resident had a respiratory arrest and was unresponsive. At the time of the evaluation, no vital signs had been documented.Review of the EMS incident run reports dated [DATE] revealed the nursing home staff called 911 at 8:06 P.M. EMS arrived on scene at 8:16 P.M. and at Resident #77's bedside at 8:18 P.M. EMS continued life saving measures until the physician later directed EMS to cease efforts. The resident was pronounced expired at 8:57 P.M. Interview on [DATE] at 12:52 P.M., LPN #200 verified she had not documented the Resident #77's code in the medical record until the following day. LPN #200 also verified the incident events were also documented at the incorrect times. Interview on [DATE] at 10:49 A.M., the DON verified LPN #200 had inaccurately documented the time of Resident #77's code and the subsequent events. Review of the facility policy Documentation in the Medical Record, dated [DATE], revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members would document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.This deficiency represents noncompliance investigated under Complaint Number 3038257.

Based on observation, record review, review of weekly skin assessments, resident interview, staff interview, and review of facility policy the facility failed to ensure routine skin assessments were completed and physician ordered wound interventions were implemented. This affected two (#29 and #12) of three residents reviewed for wounds. The facility identified a total of 18 residents as having wounds. The facility census was 76.Findings include:1. Review of Resident #29's medical record revealed an admission date of 11/04/25. Diagnoses included chronic kidney disease stage four, vascular dementia, major depressive disorder, dysphagia, chronic or unspecified peptic ulcer with hemorrhage, vitamin D deficiency, hypertension, and hypothyroidism.Review of the significant change Minimum Data Set (MDS) assessment revealed Resident #29 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of three. Resident #29 was dependent on staff Furthermore, Resident #29 did not have any wounds, but was at risk for pressure ulcers.Review of Resident #29's care plan dated 03/27/25 revealed the resident was at risk for skin breakdown due to impaired mobility, chronic kidney disease and type II diabetes mellitus. Interventions included for staff to apply advanced skin protectants, barriers, cleansers, and moisturizers, assist with bed mobility and to turn and reposition frequently, assist with toileting, preventive skin care as ordered, skin inspections weekly and as needed with findings documented and the provider notified of any abnormal findings, clinical assessments for any deteriorating symptoms or characteristics will be documented, reported to the provider, treated timely, and provider prescribed or recommended nutritional provided each shift and documented. The care plan updated on 05/04/26 revealed Resident #29 had impaired skin integrity related to diabetic foot ulcers to the left heel, and the right fourth and fifth digits. Interventions included to complete wound treatments as ordered, provide supplements as ordered, use heel protector boots as tolerated, assess for pain and treat as indicated, assess and document skin condition, notify the provider of signs of infection, of worsening or no improvement of the wound.Review of Resident #29's physician visit notes revealed Resident #29 was seen by the house physician on 04/23/26 with no new skin areas were noted. Review of Resident #29's weekly skin evaluations from 03/11/26 to 05/03/26 revealed weekly skin evaluations were completed on 03/11/26, 03/18/26, 04/03/26, and 05/03/26.Review of Resident #29's shower sheets dated 04/29/26 and 04/30/26 the resident had a bed bath and there was redness due to the resident picking at a scab on the left shoulder area, the resident had no noted open areas. The shower sheet dated 4/30/26 revealed the resident had bruising but there were not any areas indicated. Review of Resident #29's nursing progress notes revealed on 05/03/26 at 4:01 P.M. the nurse was called into Resident #29's room to check Resident #29's skin due to an open wound on the left heel. The nurse notified the Nurse Practitioner (NP), and an order was received to send the resident to the hospital emergency department for evaluation. Review of Resident #29's ED emergency room encounter document dated 05/03/26 and timed 5:38 P.M. revealed Resident #29's chief complaint was a wound infection of the left heel. Review of the history of present illness note revealed per the Emergency Medical Services (EMS) report the resident had been complaining of left heel pain for approximately two months however the nursing facility found the wound today with no reported injuries or trauma. The resident was alerted to self, was complaining of pain and asking for pain medication. Upon assessment the wound appeared deep with a differential diagnosis of pressure ulcer verses diabetic foot wound. After a workup that included laboratory testing and x-ray to rule out osteomyelitis Resident #29 was discharged back to the nursing home with an open wound and soft tissue swelling to the left heel with oral antibiotics and an order with a start date of 05/04/26 for the left heel to be cleansed with normal saline or wound wash then patted dry, followed by an application of collagen and then wrapped with rolled gauze. Resident #29 had a follow up appointment scheduled for 05/12/26 with wound care. Review of the wound care note dated 05/12/26 and timed 3:49 P.M. revealed Resident #29 had an injury of the left heel with unknown etiology. The wound eschar was unable to be removed. An order for the left heel included for the wound to be cleansed with liquid antibacterial soap and water and rinsed well followed by Santyl ointment, nickel thickness applied to the wound bed, covered with saline moistened gauze, an abdominal wound dressing and wrapped with rolled gauze was written with a follow up appointment scheduled in one week. Resident #29 was also ordered Doxycycline 100 milligrams twice a day for 10 days, an increased protein diet (meat, cheese egg, fish, peanut butter, nuts and beans), a multivitamin daily, foam offloading boots, frequent turns and a had a referral sent to vascular surgery. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for May 2026 revealed Resident #29 had wound care treatments completed as ordered, Doxycycline was administered as ordered and the resident was scheduled to see vascular surgery on 05/22/26 at 10:!5 A.M. Further review of the MAR or TAR for May 2026 revealed Resident #29 did not receive an increased protein diet, a daily multivitamin, off-loading boots or frequent turns. Interview on 06/15/26 at 10:23 A.M. with the Director of Nursing (DON) verified that skin evaluations should be completed weekly. Furthermore, the DON verified for Resident #29, there were no weekly skin evaluations completed between 04/03/26 and 05/03/26. Interview on 06/15/26 at 10:49 A.M. with Culinary Manager (CM) #274 verified Resident #29 was on a regular diet, regular texture, and honey/moderately thick consistency for liquids. CM #274 stated if a resident has a diet change nursing needs to enter the dietary order into the electronic medical record (EMR) at which time the dietary department would implement the diet order as ordered. CM #274 verified they do not have an order for Resident #29 to receive increased proteins and further verified the increased protein would be listed on the diet if ordered. Observation of Resident #29's diet card at the time of the interview stated the resident was on a regular diet, regular texture, honey/moderately thick consistency for liquids, there was nothing regarding an increased protein diet.Follow up interview with the DON on 06/16/26 at 11:29 A.M. verified the diet order and the daily multivitamin that was ordered by wound care had not been implemented for Resident #29. Interview on 06/16/26 at 2:46 P.M. with Resident #29 revealed the resident could not recall how the wound on her heel was obtained. Resident #29 denies being turned and repositioned on a regular scheduled basis. 2. Review of the medical record for Resident #12 revealed an admission date of 06/05/25. Diagnoses included bipolar disorder, fibromyalgia, hypertension, type II diabetes mellitus, hemiplegia and hemiparesis following a cerebral infarction affecting the right (dominant) side. Resident #12 had a stage 4 pressure ulcer to the sacral region and a pressure ulcer to the right heal. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and was rarely or never understood. Furthermore, Resident #12 had a stage three and stage four pressure ulcer and was dependent on staff for rolling left and right. Review of Resident #12's care plan dated 06/06/25 revealed the resident was at risk for further skin breakdown due to current pressure areas, COPD, type II diabetes mellitus, hemiplegia, ADL dependence and use of supplemental oxygen. Interventions included the use of advanced skin protectants, barriers, cleansers, moisturizers, check for incontinence and provide incontinence care as needed, low air mattress on bed, preventative skin care as ordered, reposition frequently, skin inspections weekly and as needed, document and notify the provider of any abnormal findings. The care plan updated 03/27/26 revealed the resident had impaired skin integrity related to pressure ulcers on the right heel and sacrum, and a vascular ulcer on the right shin. Interventions included to provide wound treatments as ordered and to assist with bed mobility to turn and reposition routinely. Review of a physician order dated 10/13/25 revealed Resident #12's skin was to be assessed weekly every night shift on Wednesdays. Review of weekly skin assessments for Resident #12 from 03/09/26 until 06/01/26 revealed skin assessments were completed on 03/09/26, 03/20/26, 04/15/26, 04/30/26, 05/07/26, 05/21/26, 06/01/26. Further review of the skin assessment dated [DATE] revealed Resident #12 had an open blister to the right side of the middle back measuring 5 centimeters (cm) long by 1.5 cm wide. Observation on 06/16/26 at 7:50 A.M. of Resident #12 revealed the resident was observed lying in bed positioned on her back. The resident had a functioning low air loss mattress in place.Observation on 06/16/26 at 9:55 A.M. of Resident #12 revealed the resident was observed lying in bed positioned on her back.Interview on 06/16/26 at 9:56 A.M. with Certified Nursing Assistant (CNA) #346 verified he began his shift on Resident #12's hall at 6:15 A.M When asked when the last time Resident #12 was repositioned, CNA #346 stated not yet today. Furthermore, CNA #345 stated the previous shift would have been the last people who would have turned and repositioned Resident #12.Interview on 06/16/26 at 1:43 P.M. with the DON verified residents should be turned and repositioned every two hours, aides know to do two hours checks. The DON reported that no staff had reported to her that turning and repositioning was not completed or that they needed help to turn and reposition the residents. Review of the facility policy titled Activities of Daily Living, revised 03/19/26 stated each resident will receive the necessary care and services to maintain or improve ADLs, and those that are unable to perform ADLs will receive the necessary services to prevent avoidable decline. Care will be individualized, assessment-driven, person centered support consistent with the residents' needs. Review of the facility policy titled Wound Care Policy, with a revision date of 03/17/26 stated it is the responsibility of every care team member to ensure residents who do not have skin integrity impairments do not develop a new condition affecting the skin and residents with impaired skin integrity are treated timely, and interventions to heal are not exhausted until the skin is healed. Furthermore, residents will have their skin assessed at the time of admission/re-admission and evaluated routinely to ensure the skin is intact. Routine skin monitoring is completed to recognize any early symptoms of the development of a new skin impairment. If a risk factor or new symptom is discovered the care team member will assess the resident's skin, care plan any near care initiative, operationalize care initiative, and monitor and evaluate those care initiatives.This deficiency represents non-compliance investigated under Complaint Number 3038257.

Based on review of the daily posted staffing information, review of staff time cards, interview, and policy review, the facility failed to ensure a Registered Nurse (RN) was present for eight consecutive hours in the facility. This had the potential to affect all residents. The facility census was 76. Findings include:Review of the daily posted staffing information dated 06/06/26 revealed one Registered Nurse (RN) was scheduled to work 5.25 hours. A second RN with administrative duties was scheduled to work 7.5 hours. Review of the employee timecard dated 06/06/26 for RN #354 revealed a start time of 6:40 A.M. and an ending time of 12:12 P.M. Review of the handwritten and unsigned employee timecard dated 06/06/26 for the former RN#513 revealed a start time of 1:00 A.M. and an ending time of 2:15 A.M. then another start time of 7:00 P.M. and an ending time of 11:00 P.M. Further review of the timecards revealed no other RNs worked on 06/06/26 and no RN worked for eight consecutive hours. Interview on 06/15/26 at 12:32 P.M., the Administrator verified there was not an RN working in the facility for eight consecutive hours on 06/06/26. Review of the facility policy Staffing, last revised 09/19/24, revealed the facility would utilize the services of an RN for at least eight consecutive hours a day, seven days per week. This deficiency represents noncompliance investigated under Complaint Number 3038257.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, resident interview, observation of the 100-hall medication cart, and policy review, the facility failed to administer an as needed seizure medication for a resident having a seizure. This affected one (#17) of three residents reviewed for as needed seizure medications. The facility census was 64. Findings include:Review of Resident #17's medical record revealed an admission date of 08/06/25. Diagnoses included epilepsy, intractable without status epilepticus, type two diabetes mellitus, moderate persistent asthma, anxiety, orthostatic hypotension and peripheral vascular disease.Review of Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14. Furthermore, Resident #17 was noted to take anticonvulsant medication.Review of Resident #17's current physician orders revealed an order for Divalproex Sodium oral tablet delayed release 500 milligrams (mg) with instructions to give three tablets by mouth every morning and at bedtime for seizures. An order for Levetiracetam oral tablet 1000 mg with instructions to give one and a half tablets by mouth two times a day for seizures. An order for Levetiracetam oral tablet 750 mg with instructions to give one tablet by mouth every morning and at bedtime for seizures. An order for Primidone oral tablet 50 mg with instructions to give one tablet by mouth three times a day for anticonvulsant. An order for Topiramate oral tablet 200 mg with instructions to give one tablet by mouth every morning and at bedtime for seizures. An order for Midazolam nasal solution 5 mg/0.1 milliliter (ml) with instructions to give one spray in the left nostril as needed for a seizure lasting greater than two minutes, may repeat dose in alternate nostril if seizure continues. Do not repeat dose if the resident is having trouble breathing or sedation.Review of Resident #17's care plan dated 01/28/26 revealed Resident #17 received anticonvulsant medication and was at risk for adverse side effects with interventions that included to administer medications as ordered by the physician and to observe Resident #17 closely for significant side effects of anticonvulsant medication use that included but is not limited to dizziness, nausea, jaundice, and blurred vision.Review of Resident #17's Medication Administration Record (MAR) for the month of January 2026 revealed prior to Resident #17's seizure on 01/29/26, Resident #17 received all her scheduled seizure medications as ordered. On 01/29/26 when Resident #17 had her seizure, the as needed seizure medication was not documented as administered.Interview and concurrent observation on 02/05/26 at 2:40 P.M. of the 100-hall medication cart with Registered Nurse (RN) #112 revealed Resident #17 had four doses of the as needed Midazolam in the medication cart in the event of a seizure. RN #112 stated she had been educated about leaving the keys to the medication cart with another nurse when going on break.Interview on 02/05/26 at 3:03 P.M. with Certified Nursing Assistant (CNA) #163 revealed he had just started his shift and noticed Resident #17's call light was on. CNA #163 stated he answered the call light and Resident #17 told him she was going to have a seizure. CNA #163 reported after ensuring Resident #17 was safe in her bed he ran to get the nurse and when he could not find the nurse on duty, he ran to the Director of Nursing's (DON) office for help. CNA #163 stated Resident #17 convulsed for approximately 10 to 12 minutes.Interview on 02/05/26 at 3:25 P.M. with the DON verified Resident #17 did not receive the as needed dose of Midazolam when she had the seizure on 01/29/26 due to not having access to the medication cart as the nurse on duty went to break and took the medication cart keys with her. The DON stated CNA #163 came running into her office to get help for Resident #17 at which time she ran back to Resident #17's room with CNA #163 and found Resident #17 convulsing in bed. The DON stated she immediately turned Resident #17 onto her side and stated the resident's airway was clear for the entirety of the seizure, which lasted about five minutes. The DON called the Unit Manager for assistance, the physician was notified and an order was received to send Resident #17 to the hospital. Interview on 02/05/26 at 3:40 P.M. with Resident #17 revealed she had an aura and could tell a seizure was going to start. Resident #17 stated she put on her call light and CNA #163 answered it and which time she told CNA #163 she was about to have a seizure. Resident #17 stated CNA #163 went running for the nurse, and other than that Resident #17 stated she does not remember anything else until waking up when she was being transported out of the facility. Resident #17 stated she was not harmed in any way and had no deficits from the seizure.Review of the facility policy titled Medication Administration dated 01/02/24 revealed medications are administered by nurses as ordered by the physician and in accordance with professional standards of practice.As a result of the incident, the facility took the following actions to correct the deficient practice by 01/31/26:On 01/29/26 Resident #17 was immediately sent to the hospital for evaluation and treatment. The resident returned to the facility with no new orders.On 01/29/26 the problem was identified as Resident #17's Midazolam was unable to be obtained from the medication cart for administration during a seizure as no one was able to access the medication cart.On 01/30/26 an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with a root cause analysis completed. Results of the root cause analysis identified no nursing unit should be left unattended with medication cart key handed off to another nurse when going on break. On 01/30/26 all nurses were educated on the process of handing off the medication cart keys to another nurse when going on break. Review on 02/05/26 of the in-service attendance sign-in sheet dated 01/30/26 verified all facility nurses were educated. On 01/31/26, 02/02/6 and 02/05/26 audits were conducted on each shift and verified all nurses handed the medication cart keys to another nurse when going on break. Audits are to continue three times weekly for one more week, then twice weekly for two weeks, then as needed. All results will be reviewed by the Director of Nursing and reported to QAPI. This deficiency represents non-compliance investigated under Complaint Number 2734255.

Based on medical record review, staff interview, and policy review the facility failed to accurately and timely document in the medical records. This affected one Resident (Resident #37) out of ten residents reviewed for documentation. Additionally, the facility failed to transcribe physician orders. This affected four residents (#04, #37, #05, and #63) out of six reviewed for physician orders. The facility census was 63. 1. Review of the medical record for Resident #04 revealed an admission date of 07/27/22, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left side, gastrostomy status, and acquired absence of left leg above the knee. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/19/25 revealed Resident #04 had moderate cognitive impairment and required staff assistance for all activities of daily living (ADL's), was always incontinent for bowel and bladder. Review of the provider notes revealed Resident #04 had left shoulder pain related to a fall with an order for Lidocaine External Patch 4% apply to left shoulder topically every morning and at bedtime for pain remove every 12 hours. On 09/30/25 the order was corrected to Lidocaine External Patch 4% apply to left shoulder topically in the morning for pain on for 12 hours, off for 12 hours. Interview on 09/30/25 at 1:36 P.M. with Director of nursing (DON) revealed that the order for Lidocaine External Patch dated 07/31/25 was inaccurately ordered. 2. Review of the medical record for Resident #05 revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, bipolar disorder, obsessive-compulsive disorder, depression, anxiety, coronary angioplasty implant and graft, toxic liver disease, irritable bowel syndrome, and hepatitis C. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] for Resident #05 revealed she was cognitively intact. Resident #05 displayed no behaviors at the time of the assessment. She was incontinent, used a walker for mobility, and required substantial assistance with toileting hygiene, personal hygiene, dressing, bathing, bed mobility and transfers. At the time of the assessment, Resident #05 had scheduled and as-needed pain regimens in place to manage frequent pain, rated five out of ten, that interfered with her daily activities. Review of the pharmacy recommendations dated 09/15/25 for Resident #05 revealed lidocaine patches should be removed for 12 hours each day, per manufacturer recommendations. This pharmacy recommendation was signed and ordered by the attending provider on 09/16/25 indicating the lidocaine patch be applied for 12 hours then removed and kept off for 12 hours. Review of physician orders dated 09/16/25 for Resident #05 revealed an order for a lidocaine patch to be applied to the left ribs topically every 12 hours as needed for pain. Interview on 09/30/25 at approximately 11:30 A.M. with the DON and Corporate Registered Nurse #206 revealed the lidocaine order for Resident #05 dated 09/16/25, generated from the pharmacy recommendation form dated 09/15/25, was inaccurately transcribed. 3. Review of the medical record for Resident #63 revealed an admission date of 02/06/25 with diagnoses of type 2 diabetes mellitus, hypertensive heart disease, and congestive heart failure. Review of the quarterly MDS assessment, dated 12/08/25, revealed Resident #63 had intact cognition. Review of the current physician orders for Resident #63 revealed an order dated 03/20/25 for Percocet oral tablet 5-325 milligram (mg) (oxycodone with acetaminophen), give two tablets by mouth every four hours as needed for moderate to severe pain, no more than eight tablets in 24 hours. Further review revealed an active order initiated 09/25/25 for Percocet oral tablet 5-325 mg (oxycodone with acetaminophen), give one tablet by mouth every four hours as needed for mild pain. Additional review revealed an active order initiated 09/25/25 for Percocet oral tablet 5-325 mg (oxycodone with acetaminophen), give two tablets by mouth every four hours as needed for severe pain. Interview on 09/30/25 at 4:30 P.M. with the DON confirmed Resident #63 had redundant orders for Percocet; specifically one order to provide two tablets as needed for moderate/severe pain and an additional order to provide two tablets for as needed for severe pain. The DON stated an order was pending to consolidate the three Percocet orders, but the provider had difficulty accessing the electronic medical record and had not revised the order at the time of the interview. Follow-up interview on 12/18/25 at 11:50 A.M. with the DON and concurrent review of the Medication Administration Record (MAR) for September 2025 revealed Resident #63 received Percocet, two tablets, from both active orders on 09/26/25, 09/27/25, 09/29/25 and 09/30/25. Resident #63 did not exceed eight tablets in 24 hours. Review of the policy Medication Administration, dated 01/02/24, revealed the facility would administer medication as ordered by the physician. 4. Review of the medical record for Resident #37 revealed an admission date of 08/07/24, diagnoses included orthopedic aftercare following amputation, major depressive disorder, and chronic pain syndrome. Review of the quarterly MDS 3.0 assessment revealed Resident #37 was cognitively intact and required substantial staff assistance with ADL's. Resident #37 was always incontinent for bowel and bladder. Interview with Resident #37 revealed on 11/26/25 Licensed Practical Nurse (LPN) #160 was changing the wound dressing on her left second toe when she noticed the area to have significant discharge, pain, redness, and swelling. After LPN #160 contacted the physician Resident #37 was sent out to the hospital for further evaluation. No progress note was entered by LPN #160 in regards to the wound or for the send out to the hospital. Resident #37 indicated she was sent out sometime between 12:00 and 1:00 A.M. Review of progress notes for Resident #37 from 11/21/25 through 12/02/25 revealed that on 11/26/25 at 9:50 A.M. a note was entered by LPN #146 stating Resident #37 was sent out to hospital due to wound on left second toe red and swollen. No progress note regarding wound or wound care were entered between 11/21/25 and 11/25/25. Interview on 12/17/25 at 6:01 A.M. with LPN #160 revealed that on 11/26/25 resident #37 came to her with reports of pain and bleeding from the wound area on her left second toe. When LPN #160 was removing the dressing on Resident #37's left second toe she noted excessive discharge, an odor, all toes and top of foot swollen, and redness covering entire foot and very bottom of left leg. LPN #160 called physician on duty and was ordered to send Resident out to hospital emergency room (ER) for further evaluation. Resident #37 was admitted to hospital with a wound infection LPN #160 further stated she did not put any progress notes in related to resident #37's condition or hospital send out because she was busy and never got around to it. Review of policy titled Documentation In The Medical Record dated 01/02/24 revealed that documentation shall be completed at the time of service, but no later than the shift in which the services provided in the Resident's care service occurred. Additionally, the policy stated that the documentation must record descriptive and objective information based on first-hand knowledge of the assessment, observation, or services provided.

Based on observation, staff interview, and review of the menu spreadsheet, the facility failed to provide appropriate portions and all menu items for residents on a pureed diet. This affected two (#4 and #64) of two residents identified on a pureed diet. The facility census was 63.Observation in the kitchen on 09/30/25 at 4:05 P.M. revealed [NAME] #195 preparing pureed meals for the evening meal. [NAME] #195 used an 8-ounce scoop to portion out turkey and dumplings for preparation. Concurrent interview with [NAME] #195 confirmed he only needed one 8-ounce scoop for two pureed portions of turkey and dumplings. [NAME] #195 stated only two residents, Resident #4 and Resident #64, were on pureed diets.Continued observation revealed [NAME] #195 prepared pureed turkey and dumplings and pureed green beans. [NAME] #195 placed a 4-ounce portion of pureed turkey and dumplings and a 4-ounce portion of pureed green beans onto Resident #4's plate and Resident #64's plate. Concurrent interview with [NAME] #195 confirmed the two items on the plate were the only items residents on a pureed diet would receive, except for dessert.Observation on 09/30/25 at 5:05 P.M. revealed Certified Nursing Assistant (CNA) #114 pulling Resident #4's meal tray from the cart and preparing to take it to his room. Concurrent interview with CNA #114 revealed there were only two items on Resident #4's plate, a main dish and the vegetable. CNA #114 identified Resident #4 also had nutrition supplements on his tray, but did not have a bread serving.Observation on 09/30/25 at 5:07 P.M. revealed Medical Records (MR) #172 passing meal trays. MR #172 removed Resident #64's tray from the tray cart on the hall. Concurrent interview with MR #172 confirmed no bread was on Resident #64's meal tray.Interview on 09/30/25 at approximately 5:09 P.M. with [NAME] #195 and Dietary Manager (DM) #186 confirmed [NAME] #195 provided a 4-ounce pureed portion of turkey and dumplings to Resident #4 and Resident #64. Further interview and concurrent review of the menu spreadsheet revealed residents on a pureed diet should have received a portion size of two #10 scoops (a total of six and a half ounces) rather than the four ounces provided. Additional interview with review of the menu spreadsheet revealed residents on a pureed diet should receive one slice of pureed white bread. [NAME] #195 and DM #186 confirmed no pureed bread was prepared or provided to Resident #4 and Resident #64.

Based on record review and staff interview, the facility failed to timely respond to pharmacist recommendations. This affected one (#63) of five residents reviewed for pharmacist recommendations. The facility census was 63.Review of the medical record for Resident #63 revealed an admission date of 02/06/25 with diagnoses of type II diabetes mellitus, hypertensive heart disease, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/08/25, revealed Resident #63 had intact cognition and received hypoglycemic medications.Review of the pharmacy recommendation to prescriber, dated 08/10/25, revealed a recommendation to check Resident #63's hemoglobin A1c (HbA1c) laboratory value. Further review revealed the physician responded 08/15/25 with a statement ok to draw lab. Review of the laboratory test results for Resident #63 revealed a HbA1c test was drawn 10/02/25.Interview on 12/17/25 at 2:59 P.M. with the Director of Nursing (DON) confirmed no HbA1c was drawn for Resident #63 between 08/15/25 and 10/02/25. The DON further stated Resident #63's HbA1c laboratory test should have been completed within seven days of the physician signing the recommendation on 08/15/25.

Based on observation, resident interview, staff interview, and policy review revealed the facility failed to ensure one Resident (#18) was showered and received haircuts timely. This had the ability to affect all residents. The facility census was 63.Review of Resident #18's medical record revealed an admission date of 08/25/22. Diagnoses included vascular dementia, convulsion, chronic kidney disease, and transient ischemic attack.Review of Resident #18's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderately intact cognition. He required supervision or touching assistance for showers.Review of the most recent care plan revealed Resident #18 required minimal assistance with activities of daily living related to dementia and a history of falls. Nail care was to be completed on bath days and as necessary. Supervision and touch assist was required for shower and bathing.Review of Resident #18's skin observation shower sheets revealed the resident received a shower on 09/10/25 and not another shower until 09/20/25.Review of Resident #18 's shower/bathing task in the electronic medical record revealed the resident received no shower from 08/31/25 until 09/07/25. The resident received a shower on 09/10/25 and not again until 09/20/25.Review of Resident #18's progress notes from 08/31/25 through 09/20/25 revealed no documentation associated to showers nor shower refusals.Review of the shower schedule revealed Resident #18 was to receive a shower every Wednesday and Saturday.Observation of Resident #18 on 09/29/25 at 9:10 A.M. revealed the resident had long, unkempt hair. Interview with Resident #18 at the time of the observation revealed the resident failed to receive showers timely and would like to be showered regularly. Resident #18 also stated he was in need of a haircut.Interview with Certified Nursing Assistant (CNA) #123 on 09/30/25 at 1:40 P.M. revealed she worked first shift, but the second shift staff failed to complete showers timely.Review of the facility policy titled Activities of Daily Living (ADLs) dated 12/12/23 revealed a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, resident interview, staff interview, and policy review the facility failed to ensure a residents were care planned for hearing aids which resulted in the facility failing to ensure resident hearing aids were maintained and in good working order. This affected one (#61) of two residents reviewed for comprehensive care planning. The facility census was 63.Review of Resident #61's medical record revealed an admission date of 02/14/25. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, atrial fibrillation, dementia, Parkinson's, and transient ischemic attack.Review of Resident #61's significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition, had moderate hearing loss and required the use of hearing aids.Review of Resident #61's most recent care plan revealed the care plan failed to address hearing loss nor the need for hearing aids.Review of Resident #61's physician order dated 02/14/25 revealed the resident should be seen by the audiologist.Interview with Resident #61 on 09/29/25 at 10:03 A.M. revealed he was unable to wear his hearing aids because they needed new batteries. Resident #61 stated he had let the nurses know that he needed new batteries for his hearing aids. Interview with Nurse #206 and MDS Coordinator #163 on 09/30/25 at 9:33 A.M. revealed the resident's family had requested the resident to be seen by the audiologist. Nurse #206 and MDS Coordinator #163 were unaware Resident #61 needed new batteries for his hearing aids.Interview with Certified Nursing Assistant (CNA) #158 on 09/30/25 at 10:34 A.M. verified she was unaware the resident required hearing aides.Review of the facility policy titled Comprehensive Care Plan revised 05/16/25 revealed the comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care.

Based on observation, medical record review, staff interviews, and review of facility policies, the facility failed to ensure infection prevention measures were correctly utilized when providing care to residents. This affected three (Residents #03, #22, and #71) of six resident reviewed for infection control. The facility census was 63. 1. Review of the medical record for Resident #22 revealed she was admitted on [DATE]. Diagnoses included hemiparesis to the right side following a stroke, type two diabetes mellitus, dysphagia, aphasia, hypertension, neurogenic bladder, colostomy, and stage three pressure ulcer. Review of the Minimum Data Set 3.0 assessment dated [DATE] for Resident #22 revealed the resident was unable to communicate and was severely cognitively impaired, displayed no behaviors at the time of the assessment and was dependent for all care. Resident #22 was at risk for pressure ulcers and three were present on admission to her right heel, scapula, and sacrum. Review of a physician order for Resident #22 dated 09/25/25 revealed a wound treatment was ordered twice daily to her sacrum. The wound order stated to cleanse the sacral wound with wound cleaner, pat dry, apply skin-prep around the wound, allow the kin prep to dry, pack wound with gauze moistened with pure hypochlorous acid solution, and cover with a dry dressing. Observation on 09/30/25 at 11:45 A.M. of sacral wound care for Resident #22 revealed Licensed Practical Nurse (LPN) #169 performed hand hygiene and applied clean gloves. LPN #169 removed the old dressing from Resident #22's sacrum, disposed of the dressing in the trash and removed her gloves. LPN #169 put on new clean gloves, obtained scissors from her pocket, picked up a gauze, cut the gauze with the scissors, moistened the gauze with hypochlorous acid solution, and then placed the moistened gauze in Resident #22's sacral wound. Subsequent interview with LPN #169 and Infection Control LPN #146, who was also present during this observation verified LPN #169 did not perform hand hygiene before putting on new clean gloves and did not clean the scissors prior to using them to cut the gauze. Infection Control LPN #146 stated LPN #169 should have performed hand hygiene between glove changes and should have cleansed the scissors from her pocket prior to cutting the gauze that was placed in Resident #22's sacral wound. Review of facility policy dated 05/30/24 and titled Wound Management revealed the resident care team would act to prevent infection while managing resident wounds. 2. Review of the medical record for Resident #03 revealed an admission date of 06/02/17 with a readmission date of 11/04/22, diagnoses included pneumonia, protein-calorie malnutrition, chronic obstructive pulmonary disease, Alzheimer's disease, anxiety, dysphagia, and depression. Review of the 5-day MDS assessment, dated 12/10/25, revealed Resident #03 had severely impaired cognition, required substantial/maximal assistance for rolling from left to right and for toileting hygiene, was always incontinent of bowel and bladder, and had a feeding tube. Review of a physician order for Resident #03, dated 12/11/25, revealed staff should practice Enhanced Barrier Precautions (EBP) when engaging in high contact resident care activities. EBP includes the practice of wearing personal protective equipment (gown and gloves) when providing care. Observation on 12/17/25 at approximately 12:18 P.M. revealed an EBP sign posted on Resident #03's door stating personal protective equipment (PPE), including disposable gowns and gloves must be worn when providing high contact resident care. Observation on 12/17/25 at 12:20 P.M. of incontinence care provided by Certified Nurse Assistant (CNA) #123 for Resident #03 revealed CNA #123 performed hand hygiene, put on gloves, and used a cloth washcloth to cleanse and rinse Resident #03 who had been incontinent of urine. After CNA #123 completed incontinence care, CNA #123 used the same gloves to apply barrier cream to Resident #03's sacrum and placed a clean brief on Resident #03. Continued observation revealed CNA #123 removed her gloves, proceeded to move Resident #03's pillows and reposition Resident #03. CNA #123 then determined she needed an additional pillow and left the room, obtained another pillow, returned to the room, and continued to reposition Resident #03. Interview on 12/17/25 at 12:35 P.M. with CNA #123 revealed she should have worn a disposable gown while providing incontinence care to Resident #03. CNA #123 further confirmed she did not wash her hands after removing the gloves after providing incontinence care and before repositioning Resident #03, and confirmed she should have. CNA #123 further confirmed she should have washed her hands prior to leaving Resident #03's room to obtain another pillow. Review of the policy, Handwashing-Hand Hygiene, dated 03/01/25, revealed care team members must wash their hands for twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents; after removing gloves; and after handling items potentially contaminated with blood, body fluids, or secretions. 3. Review of the medical record for Resident #71 revealed an admission date of 10/30/25 with diagnoses of Huntington's disease, dysphagia, and gastrostomy status. Review of the comprehensive admission MDS assessment, dated 11/06/25, revealed Resident #71 was rarely/never understood, and had a feeding tube. Review of the current care plan, revised 11/13/25, revealed Resident #71 was at risk for complications due to tube feeding related to dysphagia. Interventions included EBP. Review of the physician order dated 10/30/25 revealed staff were required to wear enhanced barrier precautions when engaging in high contact resident care activities. Observation on 12/17/25 at 4:21 P.M. revealed Resident #71 had an EBP sign on her door and PPE, including disposable gowns and gloves, available outside the room. Observation on 12/17/25 at 4:26 P.M. revealed Registered Nurse (RN) #133 washing her hands and preparing a syringe and plastic water beaker to provide water flushes to Resident #71. RN #133 donned disposable gloves and accessed Resident #71's g-tube medication port to administer medications and water flushes. Interview on 12/17/25 at 4:34 P.M. with RN #133 confirmed she did not wear a disposable gown while accessing Resident #71's g-tube. RN #133 confirmed Resident #71 had an EBP sign posted on her door. RN #133 stated she was unclear whether EBP PPE was required when accessing Resident #71's g-tube. Interview on 12/18/25 at 11:05 A.M. Infection Preventionist #146, confirmed staff should wear EBP, including a gown and gloves, when administering medications through a g-tube for Resident #71. Review of the undated policy Enhanced Barrier Precautions, revealed the facility would implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Review of the Enhanced Barrier Precaution sign revealed staff should wear gloves and a gown when providing high-contact resident care activities. This deficiency identified non-compliance investigated under Complaint Number 2680650.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure appropriate incontinence care. This affected one (#03) of three residents reviewed for incontinence. The facility census was 63. Review of the medical record for Resident #03 revealed an admission date of 06/02/17 with a readmission date of 11/04/22, diagnoses included pneumonia, protein-calorie malnutrition, chronic obstructive pulmonary disease, Alzheimer's disease, anxiety, dysphagia, and depression.Review of the 5-day Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #03 had severely impaired cognition, required substantial/maximal assistance for rolling from left to right and for toileting hygiene, was always incontinent of bowel and bladder, and had a feeding tube.Observation on 12/17/25 at 12:20 P.M. of incontinence care provided by Certified Nurse Assistant (CNA) #123 for Resident #03 revealed CNA #123 performed hand hygiene, put on gloves, and used a cloth washcloth to cleanse and rinse Resident #03 who had been incontinent of urine. CNA #123 cleansed Resident #03's perineal area from back to front (the anus toward her pubic area), then used a clean cloth to rinse Resident #03's perineal area, again wiping from back to front. CNA #123 then applied barrier cream to Resident #03's sacrum and placed a clean brief on Resident #03. Interview on 12/17/25 at 12:35 P.M. with CNA #123 confirmed she cleaned Resident #03 from back to front. CNA #123 confirmed she should have cleansed and rinsed Resident #03 from front to back (the pubic area toward the anus). Review of the policy, Perineal Care, dated 12/12/23, revealed perineal care should be provided to all incontinent residents in order to promote cleanliness and prevent infection to the extent possible. Further review revealed female residents should be cleansed from front to back (from pubic area toward anus). This deficiency identified non-compliance investigated under Complaint Number 2680650 and Complaint Number 2668243.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of a self -reported incident, review of facility investigation, review of in-service records, and policy review, the facility failed to ensure supervision and a safe environment was provided to prevent the elopement of a resident.Actual harm occurred on 07/29/25, when Resident #47 eloped from the facility through an unalarmed and unlocked exit door in the dining room. Resident #47 fell, sustaining an acute mildly displaced fracture of the right distal fibula at the ankle. This affected one (Resident #47) of three residents reviewed for elopement. The facility census was 65. Findings include:Review of the medical record for Resident #47 revealed an admission date of 10/13/22, with diagnoses including Alzheimer's disease, dementia, and depression. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 07/07/25, revealed Resident #47 had severely impaired cognition and required assistance for all functional abilities. Review of the elopement risk assessments dated 02/21/25, 02/27/25, 04/02/25, 06/04/25, 06/30/25, 07/03/25, and 07/29/25 revealed Resident #47 was at risk for elopement. Review of the Morse fall assessment risk, dated 02/21/25, 03/18/25, and 04/02/25, revealed Resident #47 was at high risk for falling. Review of the care plan date 05/09/25 revealed Resident #47 was an elopement risk due to diagnoses of dementia. Interventions included assess for unmet needs when wandering/exit seeking, elopement risk assessment quarterly and as needed, place resident profile in elopement book, redirect resident when wandering or exit seeking - engage in conversation, Secure Care (alarming bracelet device to prevent elopement) to left ankle, check placement every shift and function daily, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book. Review of the care plan dated 06/08/25 revealed Resident #47 is at risk for falls or fall related injury related to dementia and depression. Interventions included encourage and assist to wear appropriate nonskid footwear when up and when in bed, ensure wheelchair is close to bed - Resident #47 frequently transfers herself, follow facility fall protocol, keep call light and frequently used personal items within reach, keep pathways clear and well lit, therapy to screen quarterly and as needed, notify therapy of changes in gait or balance and therapy to treat as ordered, assist with toileting, and assist with transfers. Review of the facility's Self-Reported Incident (SRI) number 236677 revealed Resident #47 was not in her room when facility staff performed their rounds on 07/29/25 at 3:00 A.M. At this time the nurse was notified, and a search began for Resident #47. Resident #47 was located at 3:15 A.M. laying in the grass on facility property to the rear of the facility. Facility staff assisted Resident #47 back into the facility, where she was assessed and neuro-checks (frequent assessment of neurological function) were initiated. At this time, Resident #47 verbalized her right ankle and knee was painful. The facility notified the physician and an order for X-rays were obtained. The facility also notified Resident #47's emergency contact. Resident #47 had a Secure Care Bracelet (an alarming device when exiting the facility) in place prior to the elopement, and its functionality was tested, and it was determined to be functional. X-rays were obtained and it was discovered Resident #47 had a mildly displaced fracture of the distal fibula of her right leg. At this time, Resident #47 was transported to the hospital emergency room (ER) for evaluation. Review of the SRI revealed Resident #47 was last seen in her room by staff on 07/29/25 at approximately 2:00 A.M. by Certified Nursing Assistant (CNA) #175. It was determined Resident #47 exited the facility through a door that was not locked due to no power supply. An investigation conducted by Maintenance Director #137 on 07/29/25 determined that the main power supply to the door had failed. Maintenance Director #137 was able to replace the rechargeable battery in the door and return it to functionality until it was able to be repaired by the vendor. Review of the SRI revealed the door vendor was at the facility on 07/30/25 and determined the cause of the power failure to this door was due to the power supply to the door, located in the facility attic, was beginning to be dislodged. During an interview on 09/04/25 at 10:43 A.M., Maintenance Director #143 revealed all exit doors are locked with electronic locks, and each has a backup battery. The backup batteries are rechargeable and recharge with there is a power supply to the door. When the batteries are fully charged, they can provide power to the door for up to 24 hours. During the thunderstorm on 07/26/25, the facility lost power from 1:50 P.M. until 9:15 P.M., and when the power returned to the facility, he checked all doors to make sure they were properly functioning and had returned to electrical power from backup battery power. He stated that when doors are on backup battery power, the door will beep approximately every 30 seconds and there were no doors beeping. When Maintenance Director #143 returned to the facility on [DATE] at approximately 7:30 A.M., he noted the panel for the exit door located in the left rear corner of the main dining room was not lit up. At this time, he replaced the backup battery and the panel illuminated properly and he contacted the vendor who services the door and scheduled a service appointment on 07/30/25. He stated that when the vendor who services the door was at the facility on 07/30/25, it was determined the power supply had become interrupted and was supplying intermittent power to this door from the storms earlier in the week and drained the back up battery. Review of the Facility Investigation, dated 07/29/25, revealed Resident #47 exited the facility through the door located in the left rear corner of the facility's main dining room. The door alarm failed due to unknown storm damage. Resident #47 was propelling herself in her manual wheelchair through the grass, when she attempted to walk, her foot became stuck, and she fell to the ground. During an interview on 09/04/25 at 1:20 P.M., the Administrator stated Maintenance Director #143 would continue to check all exit doors weekly to ensure they are locked appropriately. Review of the facility policy titled, Wandering and Elopement, dated 01/02/24, revealed the facility ensures residents who exhibit wander behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Under the category of procedure for locating a missing resident, the policy indicated: any staff member becoming aware of a missing resident will alert personnel using approved protocol. The designated facility staff will look for the resident. Appropriate reporting requirements for the state survey agency should be conducted. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 07/30/25: On 07/29/25 at 3:00 A.M., Resident #47 was observed missing, and the facility missing resident protocol was implemented. Upon observation that Resident #47 was not in her room, CNA #175 notified LPN #208 that Resident #47 was not in her room and staff began searching for Resident #47. On 07/29/25 at 3:15 A.M., Resident #47 was found, by Licensed Practical Nurse (LPN) #208 and returned to the inside of the facility. On 07/29/25 at 3:20 A.M., a head-to-toe assessment was performed by LPN #208 and which revealed Resident #47's right ankle and right knee were swollen and painful and she had a bruise on her right palm. On 07/29/25 at 3:25 A.M., a headcount was performed, and all residents were accounted for. On 07/29/25 at 3:30 A.M., Resident #47's physician was notified, and an x-ray was ordered. On 07/29/25 at 3:30 A.M., Resident #47 was placed on every 15-minute checks. On 07/29/25 at 3:33 A.M., the on-call nurse manager, LPN #138, was notified. On 07/29/25 at 3:35 A.M., Resident #47's emergency contact was notified. On 07/29/25 at approximately 7:30 A.M., Maintenance Director #143 replaced the battery in the door Resident #47 exited through, returning it to full functionality. On 07/29/25, the inter-disciplinary team members met to review residents' current care plan and update as needed, interventions, and elopement assessment also completed. On 07/29/25, x-ray was completed, and results were received revealing a mildly displaced fracture of the distal fibula on Resident #47's right leg. Resident #47's emergency contact and Nurse Practitioner (NP) #301 were notified and Resident #47 was taken to the emergency room for treatment. On 07/29/25 at 5:15 P.M., Resident #47 was transported to the ER. Resident #47 revealed she returned to the facility with a soft cast and orders to follow up with an orthopedic surgeon. On 07/29/25, Director of Nursing Services (DNS) completed new Elopement Evaluations for all current residents and elopement evaluation scores have been reviewed to identify any residents at risk for elopement. On 07/29/25, all at risk for elopement residents care plans were reviewed and interventions reviewed for accuracy. All resident elopement binders, located at the front desk and nursing stations, were reviewed to ensure accuracy. All residents with Secure Care bands in place had placement and expiration date verified. On 07/29/25, all doors with Secure Care system tested by Maintenance Director #143, to ensure all exit doors were locked appropriately. On 07/29/25, Director of Nursing Services (DNS) or designee educated all staff on the elopement policy, and any employees unable to be educated on this date will receive education prior to their next worked shift. On 07/30/25, ICU Security Solutions was at facility and checked all security doors and alarms and made repairs from storm earlier in the week. On 07/30/25, an elopement drill was conducted on all three shifts. On 07/29/25, Director of Nursing Services (DNS) or designee educated all staff on the elopement policy, and any employees unable to be educated on this date will receive education prior to their next worked shift. Review of the staff in-service dated 07/29/25 revealed staff members were educated on exit-seeking behaviors, staff responsibilities, and what to do if an elopement occurs while you're working, review of staff sign-in sheets revealed all staff were provided education on elopements on 07/29/25 or prior to their next worked shift. Interviews on 09/04/25 and 09/08/25 with CNA #141, CNA #143, CNA #155, Director of Housekeeping #188, LPN #132, LPN #300, Registered Nurse (RN) #103, RN #113, RN #124, and RN #195 revealed they were educated on the facilities elopement policies and procedures and possessed appropriate knowledge in what do to in the event of an elopement. Review of two additional residents (#12 and #33) revealed no concerns with supervision and elopements. This deficiency represents non-compliance investigated under Complaint Number 2601843.

Based on medical record review, staff interview, review of the facility Self-Reported Incident (SRI) and review of the facility policy, the facility failed to ensure comprehensive person center care plans were updated to include identified resident needs and appropriate interventions. This affected two (#48 and #60) of three residents reviewed for comprehensive care plans. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #48 was admitted on [DATE]. Diagnoses included unspecified dementia, major depressive disorder, atherosclerotic heart disease of native coronary artery without angina pectoris, cerebrovascular disease, essential hypertension, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 05/02/25, revealed the resident was severely cognitively impaired. Review of a facility SRI, completed on 06/05/25, revealed on 05/30/25 at 6:15 P.M. a Certified Nursing Assistant (CNA) was picking up dinner trays and entered Resident #60's room and found Resident #48 and Resident #60 in bed together, naked. The facility initiated an investigation for resident to resident sexual abuse. At the end of the investigation, the facility unsubstantiated sexual abuse. All staff were re-educated on the facility's sexual expression policy and Resident #48's care plan was reviewed and updated. Review of the care plan, revised on 06/11/25, revealed Resident #48 had impaired cognitive function or impaired thought processes due to dementia. Interventions included the resident would reach out to people to hold and kiss hands and faces. Further review revealed no additional interventions or information to address Resident #48's reaching out to people to hold and kiss hands and faces, including any needs related to sexual behavior/expression. Interview on 06/12/25 at 2:15 P.M. with the Administrator verified the investigation stated Resident #48's care plan was updated and further confirmed the resident's care plan did not include any information specific to the resident's sexual behavior/expression or interventions related to behavior identified in the SRI. 2. Review of the medical record revealed Resident #60 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with diabetic polyneuropathy, essential primary hypertension, chronic diastolic congestive heart failure (CHF), major depressive disorder, neoplasm of prostate, and hyperlipidemia. Review of the MDS assessment, dated 03/18/25, revealed Resident #60 was cognitively intact. Review of a facility SRI, completed on 06/05/25, revealed on 05/30/25 at 6:15 P.M. a CNA was picking up dinner trays and entered Resident #60's room and found Resident #48 and Resident #60 in bed together, naked. The facility initiated an investigation for resident to resident sexual abuse. At the end of the investigation, the facility unsubstantiated sexual abuse. All staff were re-educated on the facility's sexual expression policy and Resident #60's care plan was reviewed and updated. Review of the care plan, revised on 06/02/25, revealed Resident #60 subjected behavior symptoms of verbal aggression, refusing medication, argumentative behaviors, inappropriate sexual comments related to inadequate coping skills. Interventions included to redirect the resident when he made inappropriate sexual comments. Further review revealed no additional information or interventions related to the resident's behaviors, including sexual behavior/expression. Interview on 06/12/25 at 2:15 P.M. with the Administrator verified the investigation stated Resident #60's care plan of care was updated following the facility investigation and further confirmed the resident's care plan did not include any information specific to the resident's sexual behaviors or interventions related to the incident identified in the SRI. Review of the policy, Comprehensive Care Plan, dated 11/01/24, verified the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, including measurable objectives and timeframes. The care planning process would include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. This deficiency was an incidental finding identified during the complaint investigation.

Based on medical record review, hospital medical record reviews, review of the facility ' s daily staffing review, interviews with facility staff, the physician, the nurse practitioner, the physician, review of the emergency squad run sheet, review of facility self-imposed action plan, review of the Enhanced Information Dissemination and Collection (EIDC) electronic reporting system, review of the facility's policies for Enteral Nutrition Therapy ,Admission Assessment and Follow Up: The Role of the Nurse, and Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, the facility failed to ensure Resident #70 was free from neglect, when the facility staff failed to provide appropriate services to ensure the resident received sufficient nutrition and hydration via enteral tube feeding. Resident #70 was not assessed by a dietitian for nutritional and hydration needs, no physician orders were obtained for nutrition, and no interventions were implemented for the care and treatment of the gastrostomy tube. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or negative health outcomes for one (#70) resident who was newly admitted to the facility on [DATE] and whose only means of nutritional intake was via gastrostomy tube (g-tube), when physician orders were not obtained for nutrition and this resident was not provided sufficient enteral nutrition and fluids for five days, from 01/05/23 to 01/10/23. Consequently, Resident #70 suffered an acute change in condition and was sent by emergency squad to the hospital. The resident was admitted to the hospital in critical care for acute hypernatremia (elevated sodium) with dehydration, acute hypoxic (low oxygen levels) respiratory failure and acute metabolic encephalopathy multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia (loss of body weight, muscle mass and weakness), and acute mucositis (inflammation of the mouth). This affected one (#70) of six residents reviewed for potential neglect. The facility identified a total of five (#07, #09, #21, #23 and #37) residents currently receiving enteral nutrition. The facility census was 64. On 02/09/23 at 3:19 P.M., Corporate Administrator #903, the facility Administrator, Director of Nursing (DON), Regional Director of Clinicals (RDC) #701, and Chief Nursing Officer (CNO) of Clinical Services #802, were notified Immediate Jeopardy began on 01/05/23 when staff failed to assess a newly admitted resident (#70) for nutrition and hydration, who required enteral tube feeding for nutrition, failed to obtain dietary orders, failed to provide sufficient enteral nutrition for five days, failed to provide sufficient fluids to prevent dehydration, failed to facilitate interdisciplinary communication between the Doctor, RD #106, and direct care staff regarding Resident #70's nutritional needs and failed to initiate an acute care plan with interventions to address nutritional requirements. Resident #70 was transferred to the hospital per family request on 01/10/23. Review of emergency department assessment dated [DATE], did not reference tube feeding and the preadmission medication list had no reference of a feeding tube or nutrition in the physical assessment. Review of the emergency department attending physician assessment dated [DATE], revealed Resident #70 was assessed as appearing chronically ill, cachectic (loss of body weight and muscle mass and weakness) with multiple issues that included tachycardia, hypoxia, and hyperglycemia. Resident #70 was admitted to critical care for altered mental status, hypernatremia (elevated sodium level), and hyperammonemia (elevated ammonia level). Review of the hospital admission assessment dated [DATE], referenced a gastrostomy tube and remained silent for tube feeding. Review of the hospital admitting diagnoses included: acute hypernatremia with dehydration, acute hypoxic respiratory failure and acute metabolic encephalopathy, multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia, and acute mucositis (inflammation of the mouth). The Immediate Jeopardy was removed on 02/14/23 when the facility implemented the following corrective actions: On 01/10/23, Resident #70 was transferred out of the facility to the hospital. On 01/12/23, a facility-wide audit was completed to ensure accuracy of residents receiving tube feed orders were documented in the residents ' medical records. On 01/12/2023, the CNO #802 and RDC #701 reviewed the policies and procedures related to enteral nutrition and documentation. There was no revision to the policy made. Beginning on 01/12/23, the DON began weekly audits of medical records for accuracy of diet orders and will continue until 03/09/23 and randomly after. On 02/09/23, the consulting Nurse Practitioner (NP)#105 was made aware by the RDC #701 verbally, the Immediate Jeopardy citations and the systemic actions that were starting to be implemented. On 02/09/23, the DON added Intake and Output orders on resident ' s medical records who receive enteral nutritional orders. On 02/10/23, the interdisciplinary team (IDT) with Registered Dietitian (RD) #106 reviewed all residents for nutritional and hydration (at risk) status. All care plans were validated as being current and correct. On 02/10/23, the IDT, the DON and the RD #106 reviewed all residents ' diets to validate all residents have current diet orders and are correctly listed on the medical record. On 02/10/23, the Administrator and DON provided the agency nurse who admitted and took care of Resident#70 with a do not return to clip board agency human resource (HR) director. On 02/10/23, a Root Cause Analysis using a Fishbone diagram was completed to review the alleged deficiency. This was completed by the CNO #802 and RDC #701 with other members of the Quality Assurance Performance Improvement (QAPI) Team. Beginning on 02/10/23, all staff will be in-serviced on the policies and procedures related to Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. This was provided by the DON. Beginning on 02/14/23, an agency binder for all licensed nursing placed on both units all education for current survey(s). The daily schedule will have a notice for agency staff to see Agency Binder. The binder will be reviewed daily at staffing meeting per Administrator, the DON and HR director for completion. Beginning on 02/10/23, the DON will discuss and review all changes in condition of the resident with RD #106 during weekly Quality of Life meeting, that is an IDT meeting currently taking place. Beginning on 02/10/23, the facility will discuss results of the audits during a weekly Ad-Hoc QAPI meeting for the next four (4) weeks to ensure compliance. On 02/13/23 and 02/14/23, random staff interviews with Registered Nurse (RN) #107, Licensed Practical Nurse (LPNs) #114, #115, #116 and #117, Housekeeper #113 and State tested Nurse Aides (STNA) #112 were completed to verify in-service on Abuse and Neglect and was able to verbalize the education. Beginning on 02/14/23, an agency binder for all licensed nursing staff was placed on both units all education for current survey(s). The daily schedule will have a notice for agency staff to see Agency Binder. The binder will be reviewed daily at staffing meeting per Administrator, the DON and HR director for completion. On 02/14/23, review of the daily schedule revealed a statement for agency staff to review the agency staff binder for the education on the facility ' s policy on abuse and neglect before the beginning of their shift. On 02/14/23, random interviews with agency STNAs (#118, #120 and #121) revealed they had reviewed the agency binder and was able to verbalize the facility ' s education. On 02/14/23, review of the agency binder sign in sheet revealed agency staff had been reviewing the binder and they were acknowledging the facility corrective action. Although the Immediate Jeopardy was removed on 02/14/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #70 revealed an admitted [DATE]. Admitting diagnoses for Resident #70 included: hemiplegia, hemiparesis and aphasia following a cerebral infarct (stroke) April 2022, severe protein calorie malnutrition, vascular dementia, chronic obstructive pulmonary disease, traumatic brain injury, epilepsy, hypertension, hypothyroidism, and osteoarthritis. Resident #70 had three wounds: one Stage II to the right hip and two unstageable wounds, to the left hip and left heel. Resident #70 was discharged on [DATE] to the hospital. Review of the hospital inpatient record dated 12/28/22 revealed Resident #70 had a diagnoses of severe protein calorie malnutrition and had received enteral nutrition for a continuous feed for 23 hours a day with 150 milliliters (ml) water flushes every 4 hours, with intake of 2100 (ml) the previous 24 hours. Review of the hospital discharge summary with a print date of 01/04/23 at 3:16 P.M., from the acute hospital revealed there was no orders for enteral feedings. Review of the admission physician orders dated 01/05/23, revealed the resident was ordered to admit to SNF (skilled nursing facility and for long-term care and skilled care) and DNRCC-A (Do Not Resuscitate Comfort Care -Arrest) code status. There were no orders to address the resident ' s nutritional status. Review of diet order changes and communication form dated 01/05/23 revealed Resident #70 was a new admit with a diet order of NPO (nothing by mouth) and did not state how Resident #70 was to receive nutrition. Review of physician orders from 01/06/23 to 01/10/23 revealed no physician orders to address the nutritional status. On 01/08/23, an order to flush enteral tube with 150 ml of water every four hours providing 900 ml per day. Review of the history and physical dated 01/07/23, revealed there was no documentation to address the g-tube or nutritional needs of the resident. This was completed by Nurse Practitioner (NP) #105. Review of the January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #70 revealed medications administered via g-tube were documented as given per orders. Water flushes of the g-tube tube for 150 ml were documented as being completed beginning on 01/08/23 at 12:00 P.M., 4:00 P.M. and 8:00 P.M., on 01/09/23 at 12:00 A.M., 4:00 A.M., 8:00 A. M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. and on 01/10/23 at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M. and 4:00 P.M. There was no documentation of any tube feeding being administered. Review of the speech therapy evaluation dated 01/09/23, revealed the referral was made due to feeding tube placement due to dysphagia and malnutrition. The evaluation listed the resident as NPO and with significant weight loss. Review of the progress note dated 01/09/23 at 4:55 A.M., documented this nurse was called to the resident ' s room, State tested Nurse Aide (STNA) stated heard something from his room and found him on the floor, with his head under the bed lying on his left side. This nurse assessed resident ' s vital signs, with in normal limits for resident. Blood pressure 114/80, oxygen not on, replaced oxygen, respirations 20, temperature 97.6 degrees Fahrenheit. Oxygen levels went up to 95% after 15 minutes. Assessed for injuries, with bruise noted to left scapula of red/purple color, redness starting to form over left hip, small skin tear 0.5 by 0.5 centimeters to back of right hand, with treatment initiated. Family notified and voice mail left for nurse practitioner. Review of the medical record revealed no return call received from the nurse practitioner. Review of the neurological assessment form post fall, dated and timed from 01/09/23 at 4:55 A.M. to 01/10/23 at 11:40 A.M., revealed vitals and neurological checks were completed every fifteen minutes times four, then every 30 minutes for two hours, every one hour for four hours and then every eight hours. Neurological assessment stated the resident was alert with pupil response, equal hand grasps and moved all extremities and had an appropriate response to pain. Blood pressure ranged from 114/80 on 01/09/23 at 4:55 A.M. to 149/86 on 01/09/23 at 10:40 A.M. Heart rate ranged from 97 beats per minute on 01/09/23 at 7:10 A.M. to 117 beats per minute on 01/10/23 at 11:40 A.M. Respirations ranged from 18-20 breaths per minute and the resident remained afebrile (without temperature). Review of Resident #70's weights in the electronic health record (EHR) and paper medical record revealed there were no weights documented as being obtained by the facility. Review of the progress notes throughout the admission for Resident #70, lacked any documented evidence for nutrition or for the resident eating. Review of the progress note dated 01/10/23 at 6:07 P.M., documented the writer noted resident with increased respirations of 42 breaths a minute. Resident not responding to brother as usual, noted lethargic, pulse oximetry 90% with oxygen via nasal cannula at 3 liters, temperature 97.8 degrees Fahrenheit, and blood pressure 100/62. Writer notified on call (physician); orders were given to send resident to emergency room . Emergency 911 was called and arrived about 5:50 P.M. Resident #70 noted with elevated blood sugar of 432. Resident #70 transferred out of facility at 6:07 P.M. Family at bedside aware of it all. Writer called hospital to give report. Review of the complete medical record from admission to discharge revealed no evidence of the physician being contacted for physician orders to address the nutritional need. There was no assessments and treatment plan to address Resident #70 ' s nutritional needs addressed by the Registered Dietitian #106. Review of the emergency squad run sheet dated 01/10/23, reveals no documentation of the resident having any enteral tube feeding being administered. The report documented the chief complaint was for respiratory distress lasting for three days. The level of distress was listed as severe acute respiratory distress. The injury listed was from a fall from the bed at the nursing home on 01/09/23. Review of the hospital record dated 01/10/23 revealed Resident #70 arrived at the emergency department at 6:23 P.M., upon arrival the resident had tachycardia (elevated heart rate) was hyperglycemic (elevated blood sugar) and hypoxic (low oxygen levels) with oxygen saturation in the 80 ' s. Review of the emergency department laboratory test results dated 01/10/23, revealed a blood sugar of 294 (normal range 70 to 99), blood urea nitrogen was elevated at 95 (normal range 8 to 23), creatinine level was 1.19 (normal range 0.7 to 1.2) and the ammonia level was 75 (normal range 11 to 32). Review of the emergency department assessment dated [DATE], did not reference tube feeding and the preadmission medication list had no reference of a feeding tube or nutrition in the physical assessment. Review of the emergency department attending physician assessment dated [DATE], revealed Resident #70 was assessed as appearing chronically ill, cachectic (loss of body weight and muscle mass and weakness) with multiple issues that included tachycardia, hypoxia, and hyperglycemia. Resident #70 was admitted to critical care for altered mental status, hypernatremia (elevated sodium level), and hyperammonemia (elevated ammonia level) Review of the hospital admission assessment dated [DATE], referenced a gastrostomy tube and remained silent for tube feeding. Review of the hospital admitting diagnoses included: acute hypernatremia with dehydration, acute hypoxic respiratory failure and acute metabolic encephalopathy, multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia, and acute mucositis (inflammation of the mouth). Review of the daily staffing for nurses assigned to care for Resident #70 revealed: on 01/05/23 and 01/06/23, for the 6:45 A.M. to 7:15 P.M. shift and the 6:45 P.M. to 7:15 A.M. shift, revealed agency nurses were assigned; on 01/07/23 and 01/08/23, for the 6:45 A.M. to 7:15 P.M. shift, Registered Nurse (RN) #107 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned; on 01/09/23, for the 6:45 A.M. to 7:15 P.M. shift, LPN #109 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned; on 01/10/23, for the 6:45 A.M. to 7:15 P.M. shift, LPN #110 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned to the care. Review of the facility ' s self- imposed action plan dated 01/12/23, revealed under the area of identified practice there was no area of concern listed. The next category was addressing how corrective action will be accomplished for the residents found to be affected by the identified practice: What did you do for the Resident affected? Resident #70 was transferred to the emergency department on 01/10/23. Review of the Enhanced Information Dissemination and Collection (EIDC) electronic reporting system for the potential neglect being reported to the state agency revealed there was no incidents of potential neglect reported by the facility from January 2023 to February 13, 2023. Interview on 02/07/23 at 7:30 A.M., with LPN #110 verified she had cared for Resident #70. LPN #110 was unable to state if the resident had a feeding tube and was unsure about tube feeding. Interview on 02/07/23 at 10:17 A.M., with the Registered Dietitian (RD) #106 revealed RD #106 did not receive a call when Resident #70 was admitted to the facility and had not seen the resident. RD #106 verified she had not completed a nutritional assessment and did not order tube feeding. When asked about the process for a new admission with a feeding tube, RD #106 stated I am to be notified to ensure a timely assessment and recommendations for those residents at high nutritional risk are made. RD #106 stated I am clueless on what happened and again stated she had not seen the resident. Interview on 02/07/23 at 11:42 A.M., with the Director of Nursing (DON) verified Resident #70 did not have enteral feeding ordered, verified documentation did not exist for any type of feeding in the medical record for Resident #70 and further verified no proof existed for enteral feeding was provided. Interview on 02/07/23 at 3:19 P.M., with LPN #109 verified Resident #70 was transferred to the hospital per family request on 01/10/23. LPN #109 had only provided care to the resident on 01/10/23 and remembered providing water flushes through the g- tube, however, was unable to verify Resident #70 received tube feedings. Interview on 02/08/23 at approximately 10:20 A.M., with Resident #70's NP #105, revealed NP #105 stated she was unfamiliar with the resident and had only seen the resident once after the fall on 01/09/23. NP #105 verified no feeding was ordered for Resident #70 and further verified the history and physical review completed by herself on 01/07/23, did not address the diet or nutritional status of Resident #70. Interview on 02/08/23 at approximately 11:00 A.M., with Registered Nurse (RN) #107 verified Resident #70 had a g-tube; however, RN #107 could not recall if the resident received an enteral feeding and stated, I will have to check the orders. Review of the physician orders by RN #107 verified no enteral feeding formula had been ordered for Resident #70. Interview on 02/08/23 at 4:05 P.M., with RN #108 verified she completed the nutritional section of the admission assessment. RN #108 stated she does not remember if Resident #70 had tube feeding. Interview on 02/08/23 at 5:00 P.M., with the Administrator, the DON, and the RDC #701, verified the electronic medical record for Resident #70 contained no orders for enteral tube feeding and further verified the medical record provided no evidence Resident #70 received feeding while at the facility from 01/05/23 to 01/10/23. Interview on 02/13/23 at 2:32 P.M., with Physician #01 revealed he was unfamiliar with Resident #70 and had only seen him once. Physician #01 stated he knew the resident had a feeding tube. Physician #01 verified the resident did not have an enteral tube feeding order in the record. Interview on 02/13/23 at 3:00 P.M., with the Administrator and the RDC #701 revealed their concern related to the care of residents due to the number of agency staff used by the facility, both nurses and aides. The Administrator stated their hands are tied due to the facility staff being a union as they cannot get staff hired based on the wage offered. The RDC #701 stated the agency staff just do not care and are not vested in the facility, and added it is hard to get consistent care. Review of the policy and procedure titled, Enteral Nutrition Therapy dated April 2018 and revised March 2022, revealed the purpose of the policy was to provide liquid nourishment through a tube inserted into the stomach and to provide hydration through a tube inserted into the stomach. Review of the policy titled, Admission Assessment and Follow Up: The Role of the Nurse, dated April 2018, revealed the policy indicated the nurse is to gather information about the resident ' s physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. The nurse is required to reconcile the list of medications from the medication history, admitting orders, the previous medication administration record (if available), and the discharge summary from the previous institution, contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings and notify other disciplines and departments of the resident ' s admission. The nurse is also responsible to for reporting immediate needs of the resident to the supervisor and the attending physician. Review of the policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated October 2022, indicated residents have the right to be free from neglect and further revealed neglect is the failure of the facility, its employees or facility services providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency demonstrates non-compliance related to the allegations in Master Complaint OH00139917, and Complaint Numbers OH00139754 and OH00139691.

Based on medical record review, hospital medical records review, review of the facility's daily staffing, interviews with facility staff, the physician, the nurse practitioner, and the fire captain, review of the emergency squad run sheet, review of the facility's policies for Enteral Nutrition Therapy, Admission Assessment and Follow Up: The Role of the Nurse, Weight Policy, Care Plan Policy, Dietary Communication Pathway and review of the job description of the Registered Dietitian, the facility failed to assess a newly admitted resident for nutrition and hydration who required enteral tube feeding for nutrition, failed to obtain dietary orders, failed to provide sufficient fluids to prevent dehydration, failed to facilitate interdisciplinary communication between the Doctor, Registered Dietitian (RD) #106 and direct care staff regarding Resident #70's nutritional needs and failed to initiate an acute care plan with interventions to address the resident's nutritional requirements. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or negative health outcomes for one (#70) resident who was newly admitted to the facility on [DATE] and whose only means of nutritional and hydration intake was via gastrostomy tube (g-tube), when physician orders were not obtained for enteral nutrition needs, no assessment was completed for nutritional requirements and no documented evidence of this resident being provided sufficient enteral nutrition for five days, from 01/05/23 to 01/10/23. Consequently, Resident #70 suffered an acute change in condition and was sent by emergency squad to the hospital. The resident was admitted to the hospital in critical care for acute hypernatremia (elevated sodium) with dehydration, acute hypoxic (low oxygen levels) respiratory failure and acute metabolic encephalopathy multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia (loss of body weight, muscle mass and weakness), and acute mucositis (inflammation of the mouth). This affected one (#70) of six residents reviewed for nutrition and hydration needs. Additionally, the facility failed to ensure two (#21 and #23) of six residents reviewed were receiving the care and treatment to meet their hydration and nutritional needs that placed the residents at risk for potential for more than minimal harm that is not Immediate Jeopardy. The facility identified a total of five (#07, #09, #21, #23 and #37) residents currently receiving enteral nutrition. The facility census was 64. On 02/09/23 at 3:19 P.M., Corporate Administrator #903, the facility Administrator, Director of Nursing (DON), Regional Director of Clinicals (RDC) #701, and Chief Nursing Officer (CNO) of Clinical Services #802, were notified Immediate Jeopardy began on 01/05/23 when staff failed to assess a newly admitted resident (#70) for nutrition and hydration, who required enteral tube feeding for nutrition, failed to obtain dietary orders, failed to provide sufficient enteral nutrition for five days, failed to provide sufficient fluids to prevent dehydration, failed to facilitate interdisciplinary communication between the Doctor, RD #106, and direct care staff regarding Resident #70's nutritional needs and failed to initiate an acute care plan with interventions to address nutritional requirements. Resident #70 was transferred to the hospital per family request on 01/10/23. Review of emergency department assessment dated [DATE], did not reference tube feeding and the preadmission medication list had no reference of a feeding tube or nutrition in the physical assessment. Review of the emergency department attending physician assessment dated [DATE], revealed Resident #70 was assessed as appearing chronically ill, cachectic (loss of body weight and muscle mass and weakness) with multiple issues that included tachycardia, hypoxia, and hyperglycemia. Resident #70 was admitted to critical care for altered mental status, hypernatremia (elevated sodium level), and hyperammonemia (elevated ammonia level). Review of the hospital admission assessment dated [DATE], referenced a gastrostomy tube and remained silent for tube feeding. Review of the hospital admitting diagnoses included: acute hypernatremia with dehydration, acute hypoxic respiratory failure and acute metabolic encephalopathy, multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia, and acute mucositis (inflammation of the mouth). The Immediate Jeopardy was removed on 02/14/22 when the facility implemented the following corrective actions: On 01/10/23, Resident #70 was transferred out of the facility to the hospital. On 01/12/23, a facility-wide audit was completed to ensure accuracy of residents receiving tube feed orders were documented in the residents ' medical records. On 01/12/23, CNO #802 of Clinical Services and RDC #701 reviewed the policies and procedures related to enteral nutrition and documentation. There were no revisions made to the policy and procedures. Beginning on 01/12/23, the DON began weekly audits of medical record of physician orders for diet orders and will continue until 03/09/23 and randomly after. On 02/09/23, the consulting Nurse Practitioner (NP) #105 was made aware by RDC #701 verbally, of the Immediate Jeopardy citations and the systemic actions that were starting to be implemented. On 02/09/23, the DON added Intake and Output orders on resident's medical records who receive enteral nutritional orders. On 02/10/23, the interdisciplinary team (IDT) with the Registered Dietitian (RD) #106 reviewed all residents for nutritional and hydration (at risk) status. All care plans were validated as being current and correct. On 02/10/23, the IDT, the DON and the RD #106 reviewed all residents ' diets to validate all residents have current diet orders and are correctly listed on the medical record. On 02/10/23, the Administrator and DON provided the agency nurse who admitted and took care of Resident#70 with a do not return to the clip board agency human resource (HR) director. On 02/10/23, a Root Cause Analysis using a Fishbone diagram was completed to review the alleged deficiency. This was completed by CNO #802 of Clinical Services and RDC #701 with other members of the Quality Assurance Performance Improvement (QAPI) Team. Beginning on 02/10/23, all licensed nursing staff will be in-serviced on the policies and procedures related to enteral nutrition and documentation. In addition, the policies for notice for change in condition to the physician and implementing admission orders upon admit was also addressed. This was provided by the DON. Beginning on 02/10/23, the DON will discuss and review all changes in condition of residents with the RD #106 during weekly Quality of Life meeting, that is an IDT meeting currently taking place. Beginning on 02/10/23, the facility will discuss results of the audits during a weekly Ad-Hoc QAPI meeting for the next four (4) weeks to ensure compliance. On 02/13/23 and 02/14/23, random staff interviews with Registered Nurse (RN) #107, Licensed Practical Nurses (LPNs) #114, #115, #116 and #117, and State tested Nurse Aide (STNA) #112 were completed to verify in-service on enteral nutrition, documentation and change in condition had been completed and staff were able to verbalize the education. On 02/14/23, review of in-service records revealed all facility staff had received education on the on enteral nutrition, documentation and change in condition. Beginning on 02/14/23, an agency binder for all licensed nursing staff was placed on both units with phone numbers to call for admission orders and change in condition and all education for current survey(s). The daily schedule will have a notice for agency staff to see Agency Binder. The binder will be reviewed daily at staffing meeting per Administrator, the DON and HR director for completion. On 02/14/23, review of the daily schedule revealed a statement for the agency staff to review the agency education binder on the enteral nutrition and documentation, and change in condition. On 02/14/23, random interviews with agency STNAs (#118, #120 and #121) revealed they had reviewed the agency binder and they were able to verbalize the facility's education. On 02/14/23, review of the agency binder sign in sheet revealed agency staff had been reviewing the binder and acknowledging the facility corrective action. Although the Immediate Jeopardy was removed on 02/14/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the closed medical record for Resident #70 revealed an admitted [DATE]. Admitting diagnoses for Resident #70 included hemiplegia, hemiparesis and aphasia following a cerebral infarct (stroke) April 2022, severe protein calorie malnutrition, vascular dementia, chronic obstructive pulmonary disease, traumatic brain injury, epilepsy, hypertension, hypothyroidism, and osteoarthritis. Resident #70 had three wounds: one Stage II to the right hip and two unstageable wounds to the left hip and left heel. Resident #70 was discharged on [DATE] to the hospital. Review of the hospital inpatient record dated 12/28/22 revealed Resident #70 had a diagnoses of severe protein calorie malnutrition and had received enteral nutrition for a continuous feed for 23 hours a day with 150 milliliters (ml) water flushes every 4 hours, with intake of 2100 (ml) the previous 24 hours. Review of the hospital discharge summary with a print date of 01/04/23 at 3:16 P.M., from the acute hospital, revealed under the area Nursing/Mobility and Activities of Daily Living revealed a subcategory of feeding: medication delivery g-tube. Under the area of Nutrition Therapy revealed a subcategory of Current Nutrition Therapy: oral diet: general; subcategory of Routes of Feeding: g-tube and subcategory of Liquids: no restrictions. The last weight documented as obtained on 01/02/23, was 116 pounds 13.5 ounces (53 kilograms), with a height of five foot ten inches and a body mass index of 16.77. Resident #70's prognosis at discharge was listed as fair; condition at discharge was listed as stable and rehabilitation potential as fair. Review of the admission physician orders dated 01/05/23, revealed the resident was ordered to admit to SNF (skilled nursing facility and for long-term care and skilled care), DNRCC-A (Do Not Resuscitate Comfort Care -Arrest) code status, verbal order for I approve the plan of care and discharge, may crush meds (medications) as appropriate, may crush meds or open capsules and mix with food if not contraindicated, may have annual flu vaccine, may substitute generics unless otherwise indicated, may use OTC (over the counter) meds from house supply, may use liberal medication administration times, Tiotropium Bromide Monohydrate capsule 18 micrograms (mcg), one inhalant each morning and at bedtime, pain evaluation every shift for monitoring of patient's pain level, POC (point of care) testing PRN (as needed) per regulation until further notice, physical therapy two to five times a week and prescriber written order for overall plan of care approved. There were no orders to address the nutritional status. Review of diet order changes and communication form dated 01/05/23 revealed Resident #70 was a new admit with a diet order of NPO (nothing by mouth). Review of the admission assessment dated [DATE], and started 01/06/23, revealed the nutrition section listed the resident as NPO or un supplemented clear liquid (without enteral total parental nutrition support) for greater than forty-eight hours. Further review of the medical record revealed there was no evidence of a nutrition assessment, or the resident being evaluated by the dietitian. Review of the care plan initiated on 01/05/23, revealed no interventions to address the type or method of enteral nutrition provided. The facility revised the resident's care plan on 01/10/23 (date of discharge) to include encouraged good nutrition and hydration to promote healthy skin due to Resident #70 identified with the potential and actual skin impairments and due to the risk for pain staff were to monitor, record and report to the nurse loss of appetite, refusal to eat and weight loss. Review of additional physician orders dated 01/06/23, revealed Resident #70 was ordered occupational therapy two to five times a week for 30 days. There were no orders to address the nutritional status. Review of physician orders dated 01/07/23, revealed the resident was ordered oxygen at two liters minute to keep oxygen saturation above 90 percent, Aspirin 81 milligrams (mg) once daily administered per gastrostomy tube (g-tube), Carbidopa-Levodopa 25-100 mg tablet twice a day administered per g-tube, Clopidogrel Bisulfate 75 mg twice daily administered per g-tube, Ferrous Sulfate Liquid 5.4 milliliters (ml) via g-tube once a day, Pantoprazole Sodium, delayed release 40 mg once daily via g-tube, Quetiapine Fumarate 25 mg once daily via g-tube, Lacosamide Solution (10 mg per ml) with 20 ml administered per g-tube once daily. There were no orders to address the nutritional status for Resident #70. Review of the history and physical dated 01/07/23, revealed Resident #70 was admitted from the hospital after being found down and suffering a laceration to the left side of head and was diagnosed with a heart attack. Past medical history of chronic obstructive pulmonary disease, dementia, cardiovascular accident, falls, hypothyroid, hyperlipidemia, osteoarthritis seizure disorder and trans ischemic attack, and a developmental delay related to traumatic brain injury. Surgical history revealed a right carotid stent and a left aneurysm clipping. Social history stated resident was single, had a history of smoking, alcohol, and marijuana use. Advance directive was reviewed and indicated, do not resuscitate, if arrest. Allergies to codeine and Keppra. There was no documentation to address the g-tube or nutritional needs of the resident. This was completed by Nurse Practitioner (NP) #105. Additional review of physician orders dated 01/08/23, included Midodrine Hydrochloride 5 mg, three times a day administered via g-tube and an order to flush enteral tube with 150 ml of water every four hours. There were no orders to address the nutritional status. Review of physician orders dated 01/09/23, included a diet order for nothing by mouth (NPO), speech therapy evaluation and treatment one to three times a week for thirty days. Review of the January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #70 revealed medications administered via g-tube were documented as given per orders. Water flushes of the g-tube tube for 150 ml were documented as being completed beginning on 01/08/23 at 12:00 P.M., 4:00 P.M. and 8:00 P.M., on 01/09/23 at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. and on 01/10/23 at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M. and 4:00 P.M. There was no documentation of any tube feeding being administered. Review of the speech therapy evaluation dated 01/09/23, revealed the referral was made due to feeding tube placement due to dysphagia and malnutrition. The evaluation listed the resident as NPO and with significant weight loss. Review of the progress note dated 01/09/23 at 4:55 A.M., documented this nurse was called to the resident's room, State tested Nurse Aide (STNA) stated heard something from his room and found him on the floor, with his head under the bed lying on his left side. This nurse assessed resident's vital signs, with in normal limits for resident. Blood pressure 114/80, oxygen not on, replaced oxygen, respirations 20, temperature 97.6 degrees Fahrenheit. Oxygen levels went up to 95% after 15 minutes. Assessed for injuries, with bruise noted to left scapula of red/purple color, redness starting to form over left hip, small skin tear 0.5 by 0.5 centimeters to back of right hand, with treatment initiated. Family notified and voice mail left for nurse practitioner. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had total dependence for feeding and had a feeding tube. Review of Resident #70's weights in the electronic health record (EHR) and paper medical record revealed there were no weights documented as being obtained by the facility. Review of the progress notes throughout the admission for Resident #70, lacked any documented evidence for nutrition or for the resident eating. Review of the progress note dated 01/10/23 at 6:07 P.M., documented the writer noted resident with increased respirations of 42 breaths a minute. Resident not responding to brother as usual, noted lethargic, pulse oximetry 90% with oxygen via nasal cannula at 3 liters, temperature 97.8 degrees Fahrenheit, and blood pressure 100/62. Writer notified on call (physician); orders were given to send resident to emergency room . Emergency 911 was called and arrived about 5:50 P.M. Resident #70 noted with elevated blood sugar of 432. Resident #70 transferred out of facility at 6:07 P.M. Family at bedside aware of it all. Writer called hospital to give report. Review of the emergency squad run sheet dated 01/10/23, reveals no documentation of the resident having any enteral tube feeding being administered. The report documented the chief complaint was for respiratory distress lasting for three days. The level of distress was listed as severe acute respiratory distress. The injury listed was from a fall from the bed at the nursing home on 01/09/23. Review of the hospital record dated 01/10/23 revealed Resident #70 arrived at the emergency department at 6:23 P.M. Upon arrival, the resident had tachycardia (elevated heart rate) was hyperglycemic (elevated blood sugar) and hypoxic (low oxygen levels) with oxygen saturation in the 80's. Review of the emergency department laboratory test results dated 01/10/23, revealed a blood sugar of 294 (normal range 70 to 99), blood urea nitrogen was elevated at 95 (normal range 8 to 23), creatinine level was 1.19 (normal range 0.7 to 1.2) and the ammonia level was 75 (normal range 11 to 32). Review of emergency department assessment dated [DATE], did not reference tube feeding and the preadmission medication list had no reference of a feeding tube or nutrition in the physical assessment. Review of the emergency department attending physician assessment dated [DATE], revealed Resident #70 was assessed as appearing chronically ill, cachectic (loss of body weight and muscle mass and weakness) with multiple issues that included tachycardia, hypoxia, and hyperglycemia. Resident #70 was admitted to critical care for altered mental status, hypernatremia (elevated sodium level), and hyperammonemia (elevated ammonia level). Review of the hospital admission assessment dated [DATE], referenced a gastrostomy tube and remained silent for tube feeding. Review of the hospital admitting diagnoses included: acute hypernatremia with dehydration, acute hypoxic respiratory failure and acute metabolic encephalopathy, multi-factorial due to vascular dementia, severe protein-calorie malnutrition with anorexia and cachexia, and acute mucositis (inflammation of the mouth). Review of the daily staffing for nurses assigned to care for Resident #70 revealed on 01/05/23 and 01/06/23, for the 6:45 A.M. to 7:15 P.M. shift and the 6:45 P.M. to 7:15 A.M. shift, revealed agency nurses were assigned; on 01/07/23 and 01/08/23, for the 6:45 A.M. to 7:15 P.M. shift, Registered Nurse (RN) #107 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned; on 01/09/23, for the 6:45 A.M. to 7:15 P.M. shift, LPN #109 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned; on 01/10/23, for the 6:45 A.M. to 7:15 P.M. shift, LPN #110 was assigned and for the 6:45 P.M. to 7:15 A.M. shift, an agency nurse was assigned to the care. Interview on 02/07/23 at 7:30 A.M. with LPN #110 verified she had cared for Resident #70. LPN #110 was unable to state if the resident had a feeding tube and was unsure about tube feeding. Interview on 02/07/23 at 10:17 A.M. with Registered Dietitian (RD) #106 revealed RD #106 did not receive a call when Resident #70 was admitted to the facility and had not seen the resident. RD #106 verified she had not completed a nutritional assessment and did not order a tube feeding. When asked about the process for a new admission with a feeding tube, RD #106 stated I am to be notified to ensure a timely assessment and recommendations for those residents at high nutritional risk are made. RD #106 stated I am clueless on what happened and again stated she had not seen the resident. Interview on 02/07/23 at 11:42 A.M., with the DON verified Resident #70 did not have enteral feeding ordered, verified documentation did not exist for any type of feeding in the medical record for Resident #70, and further verified no proof existed for enteral feeding was provided. Interview on 02/07/23 at 3:19 P.M., with LPN #109 verified Resident #70 was transferred to the hospital per family request on 01/10/23. LPN #109 had only provided care to the resident on 01/10/23 and remembered providing water flushes through the g- tube; however, was unable to verify Resident #70 received tube feedings. Interview on 02/08/23 at approximately 10:20 A.M., with Resident #70's NP #105, revealed NP #105 stated she was unfamiliar with the resident and had only seen the resident once after the fall on 01/09/23. NP #105 verified no feeding was ordered for Resident #70 and further verified the history and physical review completed by herself on 01/07/23, did not address the diet or nutritional status of Resident #70. Interview on 02/08/23 at approximately 11:00 A.M., with RN #107 verified Resident #70 had a g-tube; however, RN #107 could not recall if the resident received an enteral feeding and stated, I will have to check the orders. Review of the physician orders by RN #107 verified no enteral feeding formula had been ordered for Resident #70. Interview on 02/08/23 at 4:05 P.M., with RN #108 verified she completed the nutritional section of the admission assessment. RN #108 stated she does not remember if Resident #70 had a tube feeding. Interview on 02/08/23 at 5:00 P.M., with the Administrator, the DON, and RDC #701, verified the electronic medical record for Resident #70 contained no orders for enteral tube feeding and further verified the medical record provided no evidence Resident #70 received feeding while at the facility from 01/05/23 to 01/10/23. Interview on 02/13/23 at 11:47 A.M., with Fire Captain #111 revealed the run sheet for 01/10/23 for Resident #70 contained no information regarding the resident having a tube feeding and would be on there if the resident had one. Interview on 02/13/23 at 2:32 P.M., with Physician #01 revealed he was unfamiliar with Resident #70 and had only seen him once. Physician #01 stated he knew the resident had a feeding tube. Physician #01 verified the resident did not have an enteral tube feeding order in the record. Interview on 02/13/23 at 3:00 P.M., with the Administrator and RDC #701, revealed their concern related to the care of residents due to the number of agency staff used by the facility, both nurses and aides. The Administrator stated their hands are tied due to the facility staff being a union as they cannot get staff hired based on the wage offered. RDC #701 stated the agency staff just do not care and are not vested in the facility, and added it is hard to get consistent care. 2) Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including pericardial effusion, type II diabetes mellitus, severe protein-calorie malnutrition, acute respiratory failure, emphysema, hypertension, atrial fibrillation, and epilepsy. Review of the hospital continuation of care instructions printed on 12/30/22 at 3:39 P.M. revealed Resident #21 had a gastrostomy tube, was to have nothing by mouth, and received tube feedings at 45 ml per hour continuously for 20 hours and received a water flush of 200 ml every six hours. Review of the comprehensive MDS assessment dated [DATE], revealed Resident #21 had moderate cognitive impairment, required total dependence for eating and had a gastrostomy tube and received more than 51% of total calories through the feeding tube with an average fluid intake of 501 milliliters (ml) or more per day via the feeding tube. Review of the admission physician orders written on 12/31/22 revealed a nothing by mouth diet, tube feeding administered via pump at 45 ml per hour 24 hours a day. Review of the nutrition assessment completed on 01/02/23, revealed Resident #21 was severely underweight and it was recommended for the tube feeding to be increased to 75 ml per hour at 10 ml increments as tolerated and 100 ml water flushes to be administered every four hours. Review of the physician orders dated 01/02/23 revealed Resident #21 was not to receive anything by mouth, tube feeding at 45 ml per hour and advanced by 10 ml per hour as tolerated to a goal rate of 75 ml per hour, six times a day flush the feeding tube with 100 ml water. Review of the medication administration record for January 2023 revealed the first bolus of water was received by Resident #21 via the feeding tube at 5:00 P.M. on 01/02/23. Interview on 02/14/23 at 11:25 A.M. with the DON verified the recommended continuation of care order for water flushes were not followed and the DON further verified Resident #21 admitted to the facility on [DATE] and had not received the recommended water flushes per feeding tube until 01/02/23. 3) Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, dysphagia, acute respiratory failure, moderate protein-calorie malnutrition, seizures, hypertension, bipolar disorder, pulmonary hypertension, substance abuse, alcohol dependence, heart failure, Vitamin D deficiency, and depression. Review of the comprehensive MDS assessment dated [DATE], revealed resident had a feeding tube and received 51% or more of total calories from enteral nutrition and 501 ml or more of fluid intake per day via the feeding tube. Review of the current physician orders for February 2023 revealed Resident #23 had an order written on 02/09/23 for enteral tube nutrition at 90 ml hour for twenty hours a day from 1:00 P.M. to 9:00 A.M. per pump and record every shift the amount of enteral intake. An order dated 02/11/23 revealed the enteral feeding tube to be flushed with 65 ml of water every hour while the continuous enteral nutrition formula was running for twenty hours. Observation on 02/13/23 at 7:49 A.M. of the feeding pump for Resident #23 revealed enteral nutrition infusing at 90 ml per hour with 65 ml of water programmed to be infused every zero hours. The water flush bag was dated 02/12/23 and timed 5:50 A.M. and contained approximately 400 ml. Review of the intake for the 65 ml an hour water flush, every hour for 20 hours while the tube feeding was running, revealed an intake on 02/12/23 from 7:00 A.M. to 7:00 P.M. of 130 ml and from 7:00 P.M. to 7:00 A.M. of zero ml. Observation on 02/13/23 at 9:59 A.M. of the feeding pump for Resident #23 revealed the enteral feeding infusing at 90 ml per hour with the total volume infused at 347 ml and the water flush programmed at 65 ml every zero hours with zero volume infused. The water flush bag was observed with approximately 400 ml of fluid and was dated 02/12/23 timed 5:50 A.M. Interview on 02/13/23 at 9:59 A.M. with the DON revealed the water flush was programmed incorrectly for Resident #23 on the pump and verified the total volume for the water infused read zero. The DON further verified Resident #23 had not received water flushes as ordered for an unknown amount of time. Review of the policy and procedure titled Enteral Nutrition Therapy dated April 2018 and revised March 2022, revealed the purpose of the policy was to provide liquid nourishment through a tube inserted into the stomach and to provide hydration through a tube inserted into the stomach. Review of the policy titled, Admission Assessment and Follow Up: The Role of the Nurse, dated April 2018, revealed the policy indicated the nurse is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. The nurse is required to reconcile the list of medications from the medication history, admitting orders, the previous medication administration record (if available), and the discharge summary from the previous institution, contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings and notify other disciplines and departments of the resident's admission. The nurse is also responsible to for reporting immediate needs of the resident to the supervisor and the attending physician. Review of the policy titled, Weight Policy, revised May 2021, revealed weights will be obtained within 72 hours of admission then weekly for four weeks. If a resident experiences a significant change in weight, nursing staff will complete a re-weigh within four days. In addition, this policy denoted if a significant weight change is verified, the resident may be weighed on a weekly basis until the weight is stabilized. Review of the policy titled, Care Plan Policy, dated October 2022, revealed a baseline care plan to identify key areas such as diagnoses, medications, care needs, treatments, risks, and other areas of immediate concern will be developed with input from the resident and/or the identified resident representative and implemented within 48 hours of admission. Review of the policy titled Dietary Communication Pathway, dated February 2021 revealed in a healthcare setting such as long-term care, it is very important for the clinical team to have a clear means of communication with the Registered Dietitian. The attending can address any nutritional concerns until the registered dietitian can be present to access. Review of the undated job description for the Registered Dietitian (RD) stated the RD is responsible for the clinical nutrition documentation and medical nutrition therapy using the nutrition care process to assess each individual's nutrition status, diagnose nutrition conditions, assist in the selection of appropriate nutrition intervention, monitor and evaluate progress an provide nutrition education as needed. This deficiency demonstrates non-compliance related to the allegations in Master Complaint OH00139917, and Complaint Numbers OH00139754 and OH00139691.

Based on record review, staff interview, resident interview, review of hospital records, and review of facility policies, the facility failed to provide ongoing monitoring and assessment for a resident with a change of condition. This resulted in actual harm when Former Resident #73 experienced low blood pressure, with the Certified Nurse Practitioner (CNP) being contacted and providing orders for intravenous (IV) hydration and laboratory tests. There was no evidence of any ongoing monitoring or assessment of Former Resident #73's condition throughout the night until the day shift staff discovered the resident remained hypotensive with lethargy, was transferred to the hospital, and was admitted with a diagnosis of hypotension. This affected one (FR #73) of three residents reviewed for change of condition. Additionally, the facility failed to maintain the bed linens of a resident in a manner to prevent the attraction of ants which led to the presence of insects on the resident's body, which was not actual harm. This affected one resident (#57) reviewed for ant infestation. The facility also failed to complete non-pressure wound treatments per physician orders for two (#71 and #25) of three residents reviewed for non-pressure wound treatments, which was not actual harm. The facility census was 59. Findings include: 1. Review of Former Resident (FR) #73's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, intracardiac thrombosis, lupus, chronic kidney disease, and congestive heart failure. Review of FR #73's medical record revealed a progress note dated 12/31/22 at 9:59 A.M. which revealed the nurse went in to administer medications and found the resident's blood pressure to be 66/45 and the heart rate was 116. When the nurse notified the CNP of the findings, the CNP inquired about the orders for IV fluids and immediate laboratory tests that were given to the night nurse. The day nurse did not note any orders in the electronic medical system and was not informed of these orders by night nurse in report. The day nurse followed through with the orders given on the previous shift and pulled the fluids. The CNP ordered midodrine to be given one time which the nurse administered. FR #73 was stating repeatedly that she did not feel good. The nurse asked her if she would like to go to the hospital, or receive fluids here and let the facility treat her low blood pressure. FR #73 stated Yes, hospital. The resident was transferred to the local hospital and did not return to the facility. Review of the medical record revealed no assessment or monitoring of the resident's change in condition which occurred the evening of 12/30/22. Review of the hospital record revealed FR #73 was admitted with the diagnosis of hypotension. Interview with Licensed Practical Nurse (LPN) #127 on 02/01/23 at 12:35 P.M. revealed on the morning of 12/31/22 she found FR #73 lethargic and hypotensive. The LPN contacted CNP #190 to inform her of the situation and the CNP was upset because the orders she gave to the night nurse were not carried out. It was decided to send FR #73 to a local hospital due to her condition. In addition, LPN #127 verified the night nurse failed to complete any documentation regarding the resident's condition throughout the night nor put orders into the electronic medical records. Telephone interview with CNP #190 on 02/01/23 at 12:51 P.M. revealed on 12/30/22 at approximately 10:30 P.M. she was alerted that FR #73 was hypotensive by the night staff. The CNP ordered immediate blood work which included a complete metabolic panel (CMP), a complete blood count (CBC), and a urinalysis. She also ordered 0.45% normal saline via IV for hydration. The CNP stated the following morning she received a call from LPN #127 who informed her the previous orders were never followed, and FR #73 continued to be hypotensive and lethargic. The CNP decided to send the resident out to be evaluated at the local hospital. CNP #190 revealed it was possible, but hard to say if the hospitalization was a result from FR #73 failing to received the ordered IV fluids. Interview with the Director of Nursing on 01/18/23 at 10:33 A.M. verified the night nurse on 12/31/22 failed to implement the orders provided from CNP #190. The DON stated The night nurse obviously did nothing. 2. Review of Resident #57's medical record revealed an admitted [DATE]. Diagnoses included multiple sclerosis, acute kidney failure, pressure ulcer stage three to the buttock, crohns disease with a colostomy, and peripheral vascular disease. Review of Resident #57's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a high cognitive function. The resident was dependent on staff for bathing and toilet use. An extensive two person assist was used for bed mobility. Review of Resident #57's Social Service note dated 12/23/22 revealed the social worker had spoke with the resident's sister who reported the resident having ants in her bed. The sister required the resident receive a bath and have the linens changed. The Director of Nursing and Unit Manager completed a bed bath and changed her gown and her linens. The resident was educated on not eating in her bed and asked if she would like to move to another room. Resident #57 refused either option choosing to stay in her current room and bed. Review of Resident #57's medical record revealed a nurses note dated 12/25/22 which stated the resident was difficult to arouse, not responding to questions, and only making moaning sounds. Vitals were assessed, the physician was notified and the resident was transported to a local hospital. Review of Resident #57's hospital emergency room note, dated 12/25/22, revealed the resident presented to the emergency room due to complaints of altered mental status. On examination the patient did have several dozen ants crawling on her abdomen and extremities. Review of the hospital Licensed Social Worker's note dated 12/25/22 revealed she was notified by the medical staff that Resident #57 returned to the hospital for altered mental status and sores/wounds to her body. Emergency Medical Services (EMS) staff reported they found the patient at the nursing facility with ants crawling on her. Adult Protective Services were notified and referred the case to the Ombudsman who was notified. Interview with the Ombudsman on 01/18/23 at 12:01 P.M. revealed she had been working with Resident #57 and the family regarding a lack of peri care and ants in the resident's bed. Interview with the Administrator and DON on 01/18/23 at 12:25 P.M. revealed Resident #57 was hospitalized and ants were found in her peri-area in the emergency room . The Administrator revealed the ants were due to the resident eating in bed and dropping crumbs. The room had since been treated by an extermination company and the problem was resolved. Interview with Resident #57 on 01/18/23 at 1:07 P.M. revealed the ants she recently had ants in her room. She reported she had only seen one ant recently. Review of the facility policy titled Pest Control dated 2018 revealed it was the policy of the center to maintain a routine pest control program that consisted of monthly visits from the pest control company and monthly visits would include the resident's rooms. 3. Review of Resident #71's medical record revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, diabetes mellitus, chronic kidney disease, peripheral vascular disease, and congestive heart failure. Review of Resident #71's physician's order dated 12/13/22 revealed an order to treat the left gluteal fold by cleansing with soap and water, pat dry, and apply Triad wound paste every shift and as needed. Review of Resident #71's Treatment Administration Record (TAR) for December 2022 revealed there was no documentation showing completion of the treatment to the gluteal fold on 12/18/22, 12/21/22, 12/23/22, and 12/27/22 on the day shift and on 12/16/22, 12/23/22, 12/24/22 on the night shift. On 12/20/22 on the day shift, the TAR read 9 which indicated other/see progress note. Review of Resident #71's progress notes for 12/20/22 revealed no documentation regarding the missed dressing change for that day. Review of Resident #71's physician's orders revealed an order dated 11/08/22 to treat the right lower extremity by scrubbing the leg with dandruff shampoo, allow to sit for 10-20 minutes, rinse well, pat dry, apply thick layer of ammonium lactate lotion, apply Medi honey, cover with abdominal dressing, and wrap with kerlix from the base of the toes to below the knee every other night shift and as needed. Review of Resident #71's TAR dated December 2022 revealed the treatment to the right lower extremity was not documented as completed on 12/06/22, 12/12/22, 12/16/22, 12/24/22, and 12/26/22. Review of Resident #71's January 2023 TAR revealed staff were to apply Medi honey to the right lower extremity wound bed twice daily and as needed. The staff failed to complete the treatment on 01/02/23, 01/05/23, 01/09/23, and 01/12/23 in the morning and on 01/02/23 on the evening shift. Further review of Resident #71's physician's order revealed an order to apply Aquaphor ointment to open sores every shift for sores to the arms and legs. Review of Resident #71's TAR for December 2022 revealed staff failed to complete the Aquaphor ointment application on 12/02/22, 12/07/22, 12/08/22, 12/18/22, 12/121/22, 12/24/22, 12/27/22, and 12/31/22 on the day shift. The night shift failed to be completed on 12/06/22 and 12/28/22. Review of Resident #71's TAR dated January 2022 revealed the resident failed to have the Aquaphor treatment on 01/02/23, 01/05/23, and 01/09/23 on the day shift. It was also not completed on 01/02/23 on the night shift. Review of Resident #71's physician's orders revealed an order dated 10/25/22 for the left heel to be cleansed with wound wash, pat dry, filled with calcium alginate, cover with an abdominal pad and wrapped with kerlix every night shift every other day and as needed. Review of Resident #71's December 2022 TAR revealed staff failed to cleanse the left heel wound on 12/06/22, 12/12/22, 12/16,22, 12/24/22, and 12/26/22. Review of Resident #71's physician's orders revealed an order dated 12/30/22 to treat the left lower extremity by applying Dakin's 1/4 strength, apply a moist-to-moist dressing to wound bed, cover with an abdominal pad, and wrap with Kerlix, change twice daily every shift for wound care. Review of Resident #71's January 2023 TAR revealed staff failed to complete the treatment to the left lower extremity wound on 01/02/23 and 01/05/23 on the day shift and on 01/02/23 on the night shift. Additionally, Resident #71 had an order to cleanse the left lower extremity with dandruff shampoo and review of the TAR revealed this did not get completed on 12/06/22, 12/12/22, 12/16,22, 12/24/22, and 12/26/22. Review of Resident #71's physician's orders revealed an order dated 12/30/22 to apply Ace wraps in the morning and off at night one time a day for wound care. Further review of Resident #71's medical record and progress notes from November 2022 to January 2023 revealed no documentation as to why wound treatments were not completed as ordered. Observations of Resident #71 on 01/17/23 at 7:20 A.M. and 10:22 A.M. revealed the resident failed to have the ace wraps applied to his bilateral lower extremities. Interview with Resident #71 on 01/17/23 at 10:22 A.M. revealed the ace wraps had not been applied in over two weeks. Interview with Registered Nurse (RN) #173 on 01/17/22 at 10:25 A.M. revealed the night shift were to place the ace wraps on Resident #71 at 6:00 A.M. and it was not her responsibility. RN #173 verified the ace wraps were not applied regularly and she would place them on the resident after her medication pass. 4. Review of Resident #25's medical record revealed an admitted [DATE]. Diagnoses included congestive heart failure, epilepsy, acute kidney failure, pulmonary embolism, and myocardial infarction. Resident #25 was under the care of Hospice. Review of Resident #25's quarterly MDS assessment dated [DATE] revealed the resident had high cognition level. She required extensive two-person assistance for transfers and extensive one-person assistance for bed mobility, dressing, toilet use, and personal hygiene. Resident #25 was at risk for developing pressure ulcers but had none at the time of the assessment. It was noted Resident #25 had an open lesion. Review of Resident #25's most recent care plan revealed she had a cancerous lesion to the left scalp and was refusing a dermatology consult. Interventions were to consult with the physician, provide education to the resident of the need to not disturb the site, observe the skin daily, and to give showers/shampoo twice weekly. Other skin interventions were to document all refusals. Review of Resident #25's Wound Assessment and Plan dated 12/13/22 revealed the wound to the top of the head was a recurrent dermal lesion which began on 02/08/20. The wound was stable and measured 0.2 cm x 0.2 cm x less than 1 cm. Review of Resident #25's Wound Assessment and Plan dated 01/10/23 revealed the wound was healing. It measured 0.7 cm x 0.5 cm x less than 0.1 cm with a moderate amount of exudate. Review of Resident #25's physician's orders revealed an order dated 11/08/22 to treat the scalp lesion by cleansing with Dakin's, lightly scrub scabbed areas to loosen, pat dry, and cover with Vaseline (petroleum gauze) every shift. Review of Resident #25's December 2022 TAR revealed the treatments failed to be completed on 12/20/22, 12/29/22, 12/30/22, and 12/31/22 on the day shift and 12/04/22 and 12/23/22 on the night shift. Review of Resident #25's January 2022 TAR revealed the treatments failed to be completed on 01/03/23 and 01/04/23 on the day shift and 01/02/23 on the night shift. Further review of Resident #25's medical record and progress notes from November 2022 to January 2023 revealed no documentation explaining why the treatments were not completed as ordered. This is an example of non-compliance found during the investigation of Master Complaint Number OH00139199, and Complaint Number OH00139604.

Based on record review, staff interview, review of hospital records, and policy review the facility failed to follow a health practitioner order to administer intravenous (IV) fluids to a resident with a change of condition. This resulted in actual harm for one resident (#73) who was ordered IV hydration after being found hypotensive. The IV fluid orders were never written by the facility staff and were not administered. The following morning the resident remained hypotensive and was lethargic requiring transfer and admission to the hospital for hypotension. This affected one (#73) of three residents reviewed for IV therapy. The facility census was 59. Findings include: Review of Former Resident (FR) #73 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, intracardiac thrombosis, lupus, chronic kidney disease, and congestive heart failure. Review of FR #73's medical record revealed a progress note dated 12/31/22 at 9:59 A.M. which revealed the nurse went in to administer medications and found the resident's blood pressure to be 66/45 and the heart rate was 116. When the nurse notified the Certified Nurse Practitioner (CNP) of the findings, the CNP inquired about the orders for fluids that were given to the night nurse. The day nurse did not note any orders in the electronic medical system and was not informed of these orders by night nurse in report. The day nurse followed through with the orders given on the previous shift and pulled the fluids. FR #73 was stating repeatedly that she did not feel good. The nurse asked her if she would like to go to the hospital, or receive fluids here and let the facility treat her low blood pressure. FR #73 stated Yes, hospital. The resident was transferred to the local hospital and did not return to the facility. Review of the hospital record revealed FR #73 was admitted to the hospital for hypotension. The resident was transferred to a hospice facility from the hospital. Interview with the Director of Nursing on 01/18/23 at 10:33 A.M. verified the night nurse on 12/31/22 failed to follow the NP's order to administer IV fluids for FR #73. He stated The night nurse obviously did nothing. Interview with Licensed Practical Nurse (LPN) #127 on 02/01/23 at 12:35 P.M. revealed 0.45% normal saline was ordered for FR # about 11:00 P.M. on 12/30/22 by the CNP. LPN #127 revealed on the morning of 12/31/22 she found FR #73 lethargic and hypotensive. The LPN contacted CNP #190 to inform her of the situation and the CNP was upset because the orders she gave to the night nurse were not carried out. It was decided to send FR #73 to a local hospital due to her condition. Telephone interview with CNP #190 on 02/01/23 at 12:51 P.M. revealed on 12/30/22 at approximately 10:30 P.M. she was alerted that FR #73 was hypotensive by the night staff. Medications ordered included IV fluids of 0.45% normal saline for hydration. The following morning the CNP stated she received a call from LPN #127 who informed her that the previous orders were never followed and FR #73 continued to be hypotensive and lethargic. The CNP decided to send the resident out to be evaluated at the local hospital. CNP #190 revealed it was possible, but hard to say if the hospitalization was a result from FR #73 failing to received the ordered IV fluids. Review of the facility policy titled Infusion Therapy Responsibilities and Scope of Practice, undated, revealed the nurses' responsibilities included administering medications within specified times, starting treatments within a responsible time after order is written, and administering medications in a safe, responsible manner. This was non-compliance discovered during the investigation of Master Complaint Number OH00139199.

THIS DEFICIENCY REPRESENTS AN EXAMPLE OF PAST NON-COMPLIANCE. Based on observations, medical record review, staff interviews, review of facility investigation, and review of facility in-services, the facility failed to ensure a resident was transported safely in wheelchair equipped with footrest. Actual harm occurred when Resident #01 was transported by staff, by pushing the resident in a wheelchair without footrest. Resident #01 placed her foot to the floor without notice, resulting in extreme pain and a left distal femur fracture. This deficient practice affected one (#01) of three residents reviewed for the use of wheelchairs for mobility. The facility census was 60. Findings include: Review of the closed medical record for Resident #01 revealed an admission date of [DATE], with the [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE], revealed the resident was identified as a [AGE] year old and is usually understood, sometimes understands others, with severe cognitive impairment, and required extensive assistance of one person for activities of daily living including: bed mobility, transfer, and locomotion using a wheelchair. On 01/03/21, a fall risk assessment scored the resident at high risk for falls. Review of the nurse's notes dated 01/04/21 at 10:30 A.M., revealed a Change of Condition Note documenting therapy staff brought the resident back to nurse's station after a session. Resident #01 was alert, crying and complaining of pain at her left knee. The Nurse Practitioner (NP) and the nurse assessed Resident #01 and noted the resident's left knee to be swollen, painful with decreased range of motion. An order was received to obtain an X-Ray of the left lower extremity, knee to ankle. The resident was given as needed (prn) Tylenol at this time for pain. She was then returned to her room, assisted into bed and a ice bag applied to her left knee. At 10:30 A.M., a late entry, indicated the nurse spoke with therapist who assisted the resident back to her room after the therapy session. Per the therapist, during the wheelchair transport, the resident did not have her footrests on and set her left foot down on the ground, causing the wheelchair to abruptly stop. Resident #01 immediately had left knee/left lower extremity pain. Resident #01 was assessed by the NP. Wheelchair rests (footrest) were immediately obtained and placed in room, due to the resident being transferred to bed. Interventions will be to ensure wheelchair rests are being used when resident is not self-propelling in wheelchair. Review of the X-Ray results of the left lower extremity dated 01/04/21, reported at 4:21 P.M., revealed the resident was diagnosed with [REDACTED]. Review of the nurse's notes dated 01/04/21 at 4:30 P.M., revealed the nurse received the results of the resident's X-Ray, which indicated a fracture, and the results were forwarded to the NP. A physician order [REDACTED]. The resident's son was notified of the resident's status and agreed to transfer the resident to the hospital. The resident did not return to the facility. Review of a written statement dated 01/04/21 at 10:20 A.M., by the Certified Occupational Therapy Assistant (COTA) #200 revealed the therapist was transporting Resident #01 in her wheelchair after an occupational therapy (OT) treatment. Resident #01 did not have footrest on her wheelchair. Upon exiting the therapy room, Resident #01 put her left foot down on the floor, which resulted in extreme pain in her left leg. COTA#200 immediately went to the resident's nurse and Nurse Practitioner after placing the footrest under the resident's foot to transport. Review of a verbal discussion report dated 01/08/21, no time, documented COTA #200 was transporting a resident from therapy in a wheelchair without leg/foot rests. Resident #01 was holding up her legs when COTA #200 was pushing the wheelchair when suddenly, the resident put her feet down to the floor without telling COTA #200, which resulted in injury of the left knee/leg. Requested action noted: when transporting a resident in a wheelchair, bilateral leg/foot rests must be used. The Director of Rehabilitation (DOR) provided education to COTA #200 on 01/06/21 and will monitor compliance. DOR will have follow-up discussion on 02/08/21. Interview on 02/08/21 at 12:15 P.M., with the DOR and COTA #200 verified the staff was pushing the resident in the wheelchair from behind, when the resident abruptly placed her foot to the floor without warning. The wheelchair was not equipped with footrest. The DOR and COTA #200 stated prior to the incident therapy staff would frequently transport residents in wheelchairs without footrest. Interview on 02/08/21 at 12:45 P.M., with the DOR revealed no evidence indicating the wheelchair Resident #01 was using at the time of the incident was evaluated for appropriate use. As a result of the deficient practice the facility has implemented corrective action as of 02/03/21 as follows: · On 01/06/21, COTA#200 was given training on the appropriate use of wheelchair footrest when transporting residents by the DOR. · Between 01/05/21-01/08/21, all staff was in-serviced on the use of foot pedals/transfers/assistance with wheelchairs by the Director of Nursing (DON). · On 01/06/21, an audit of all residents who utilize wheelchairs was completed to ensure wheelchair leg/foot rests were available in their room for use when not self -propelling by the DON. · Audits and observations by the DON were completed on 01/13/21, 01/20/21, 01/27/21, 02/03/21 to ensure footrest were being applied to resident wheelchairs as required. · On 02/08/21, observation was made of staff transporting residents in wheelchairs equipped with footrest. · On 02/09/21, interviews with State tested Nurse Aide (STNA) #600, STNA #601, and Certified Occupational Therapy Assistant (COTA) #201 verified they received training related to the transport of residents in wheelchairs and the use of footrest. All staff was able to verbalize the procedure. This deficiency substantiates Complaint Number OH 790.