Every finding on record at Majestic Care of Whitehall

Based on medical record review, interviews, and observations, the facility failed to ensure appropriate infection control practices were followed during catheter care. This affected one Resident (#24) of the two residents reviewed for catheter care. The facility census was 124.Findings include: Review of the medical record for Resident #24 revealed an admission date of 02/06/26 with diagnoses of but not limited to sepsis, unspecified organism, quadriplegia C5-C7, incomplete, injury subsequent encounter, neuromuscular dysfunction of bladder, neurogenic bowel, fusion of spine, cervical region, hypotension, iron deficiency anemia, gastro-esophageal reflux disease, urinary tract infection, systemic inflammatory response syndrome of non-infectious origin with acute organ dysfunction, acute kidney failure, abnormal findings of blood chemistry, solitary pulmonary nodule, and constipation.Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #24 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. Additionally, the quarterly MDS dated [DATE] revealed Resident #24 had an indwelling catheter and was dependent on the staff for all care.Review of the care plan dated 02/11/26 revealed Resident #24 was at risk for infection/complications related to indwelling catheter, urinary retention, neuromuscular dysfunction of bladder and recurrent urinary tract infections with interventions to include catheter/peri care at least every shift and as needed.Review of an order dated 03/20/26 for Resident #24 revealed orders for Cefdinir (antibiotic) capsule 300 milligrams (mg) give one capsule by mouth two times a day for urinary tract infection for four days. Review of an order dated 03/20/26 for Resident #24 revealed foley catheter care every shift for infection control.Review of an order dated 05/18/26 for Resident #24 revealed Ciprofloxacin Hydrochloride (HCl) (antibiotic) oral tablet 500mg give one tablet by mouth two times a day for sepsis.Review of an order dated 06/17/26 for Resident #24 revealed Ciprofloxacin Hydrochloride (HCl) oral tablet 500mg give one tablet by mouth two times a day for possible infection (urinary tract infection) for three days.Review of an order dated 06/21/26 for Resident #24 revealed Ciprofloxacin Hydrochloride (HCl) oral tablet 250mg give one tablet by mouth every 12 hours for urinary tract infection for seven days.Review of an order dated 06/22/26 for Resident #24 revealed Bactrim (antibiotic) double strength (DS) tablet 800-160 mg (sulfamethoxazole-Trimethoprim) give one tablet by mouth two times a day for urinary tract infection for seven days.Review of an order dated 06/25/26 for Resident #24 revealed an order for contact isolation diagnosis Acinetobacter baumannii (CRAB) every shift for Acinetobacter baumannii (CRAB) in urine until 07/01/26.Observation on 07/09/26 from 10:24 A.M. to 10:39 A.M. with Certified Nursing Assistant (CNA) #246 revealed CNA #246 used hand sanitizer, put on a gown, and gloves, then filled two wash basins and carried them to Resident #24's bedside table. CNA #246 unplugged the wheelchair charger from the wheelchair and moved the wheelchair using the joystick. CNA #246 moved Resident #24's phone from the bedside table to the nightstand, then moved the body soap from the nightstand to the bedside table. CNA #246 opened the closet and removed an attend which she placed on the bed. CNA #246 picked up the bed remote from the bed rail and moved the bed up. Then CNA #246 performed peri care on Resident #24. Additionally, during peri care Licensed Practical Nurse (LPN) #216 had put on gown and gloves to assist CNA #246. LPN #216 pulled the privacy curtain and then touched the catheter securement device (adhesive or strap-based medical tools to anchor foley and indwelling catheters) to unlock it during catheter care.Interview on 07/08/26 at 10:46 A.M. with LPN #216 verified she had on gloves and touched the privacy curtain, then touched the catheter securement device without changing gloves or washing her hands.Interview on 07/08/26 at 10:47 A.M. with CNA #246 verified she had touched the wash basins, the wheelchair charger, the wheelchair joystick, Resident #24's phone, the body soap, the bedside table, the closet door, an attend, and the bed remote without changing gloves or washing her hands before completing peri care on Resident #24.Interview on 07/08/26 at 3:20 P.M. Director of Health Services (DHS) #88 verified Resident #24 had two urinary tract infections since being admitted to the facility.Review of the facility policy Handwashing-Hand Hygiene dated 03/05/25 revealed to prevent the spread of infections through proper hand hygiene. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60 to 90 percent (%) ethanol or isopropanol for all the following situations: before and after direct contact with Residents/Patients.This deficiency represents non-compliance investigated under Complaint Number 3056865.

Based on observation, review of food temperatures, and staff interview, the facility failed to ensure food was served at appetizing temperatures. This affected 19 residents (#100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118) of 19 residents residing on the 200 short hall. The census was 118. Findings include: Observation on 06/16/2026 at 8:00 A.M. revealed the food cart for the 200 short hall left the kitchen with the test tray. At 8:01 A.M. the food cart arrived to the unit (200 short hall). Trays were passed by facility staff and at 8:11 A.M. the test tray temperatures were obtained and revealed the following: scrambled eggs were 125 degrees Fahrenheit,biscuits and gravy 119 degrees Fahrenheit,cream of wheat 121 degrees Fahrenheit,milk was 46 degrees Fahrenheit; and orange juice was 51 degrees Fahrenheit. The eggs and biscuits and gravy were cold to taste. This was verified by the Dietary Manager #476 at the time of the observation. This deficiency represents non-compliance investigated under Complaint Number 3033233.

Based on interview, record review, and review of facility policy, the facility failed to ensure residents received beneficiary notices. This affected six (Resident #46, #146, #92, #147, #142, and #144) of eight residents reviewed for beneficiary notices. The facility census was 123 residents.Findings include:1) Review of Resident #144's medical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #144's census information from 10/21/25 to 10/31/25 revealed Resident #144's payer source was Medicare Part A. Resident #144 was discharged from Medicare Part A services on 10/31/25 with skilled days remaining. Resident #144 remained in the facility beginning 11/01/25.Review of Resident #144's progress notes from 10/21/25 to 10/31/25 revealed no documentation Resident #144 received a Notice of Medicare Non-Coverage (NOMNC) or Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) prior to Resident #144's discharge from Medicare Part A services on 10/31/25. Interview with Regional Business Office Manager #728 on 04/02/26 at 1:49 P.M. confirmed Resident #144 did not receive a NOMNC or SNF ABN upon discharge from Medicare Part A services on 10/31/25.2. Review of Resident #142's medical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #142's census information from 07/08/25 to 11/02/25 revealed Resident #142's payer source was Medicare Part A. Resident #144 was discharged from Medicare Part A services on 11/02/25 with skilled days remaining. Resident #142 remained in the facility beginning 11/03/25.Review of Resident #142's progress notes from 07/08/25 to 11/02/25 revealed no documentation that Resident #142 received a NOMNC or SNF ABN prior to Resident #142's discharge from Medicare Part A services on 11/02/25. Interview with Regional Business Office Manager #728 on 04/02/26 at 1:49 P.M. confirmed Resident #142 did not receive a NOMNC or SNF ABN upon discharge from Medicare Part A services on 10/31/25.3. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #46's census information from 07/30/25 to 11/06/25 revealed Resident #46's payer source was Medicare Part A. Resident #46 was discharged from Medicare Part A services on 11/06/25 with skilled days remaining. Resident #142 remained in the facility beginning 11/07/25.Review of Resident #46's progress notes from 07/30/25 to 11/06/25 revealed no documentation Resident #46 received a NOMNC or SNF ABN prior to Resident #46's discharge from Medicare Part A services on 11/06/25. Interview with Regional Business Office Manager #728 on 04/02/26 at 1:49 P.M. confirmed Resident #46 did not receive a NOMNC or SNF ABN upon discharge from Medicare Part A services on 11/06/25.4. Review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #92's census information from 02/13/26 to 03/23/26 revealed Resident #92's payer source was Medicare Part A. Resident #92 was discharged from Medicare Part A services on 03/23/26 with skilled days remaining. Resident #92 was discharged from the facility beginning 03/24/26.Review of Resident #92's progress notes from 02/13/26 to 03/23/26 revealed no documentation Resident #92 received a NOMNC prior to Resident #92's discharge from Medicare Part A services on 03/23/26. Interview with Regional Business Office Manager #728 on 04/02/26 at 1:49 P.M. confirmed Resident #92 did not receive a NOMNC upon discharge from Medicare Part A services on 11/06/25.5. Review of Resident #147's medical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #147's census information from 01/08/26 to 02/02/26 revealed Resident #147's payer source was Medicare Part A. Resident #147 was discharged from Medicare Part A services on 02/02/26 with skilled days remaining. Resident #147 was discharged from the facility beginning 02/03/26.Review of Resident #147's progress notes from 01/08/26 to 02/02/26 revealed no documentation that Resident #147 received a NOMNC prior to Resident #147's discharge from Medicare Part A services on 02/02/26. Interview with Regional Business Office Manager #728 on 04/02/26 at 1:49 P.M. confirmed Resident #147 did not receive a NOMNC upon discharge from Medicare Part A services on 11/06/25.6. Review of Resident #146's medical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #146's census information from 11/21/25 to 01/11/26 revealed Resident #146's payer source was Medicare Part A. Resident #146 was discharged from Medicare Part A services on 01/11/26 with skilled days remaining. Resident #146 was discharged from the facility beginning 01/12/26.Review of Resident #146's progress notes from 11/21/25 to 01/11/26 revealed no documentation that Resident #146 received a NOMNC prior to Resident #146's discharge from Medicare Part A services on 01/11/26. Interview with Regional Business Office Manager #728 on 04/02/26 at 1:49 P.M. confirmed Resident #146 did not receive a NOMNC upon discharge from Medicare Part A services on 11/06/25.Review of the policy 'Notice of Medicare Non-Coverage Procedure & Guide' effective 03/16/26 revealed the NOMNC must be issued when a Part A stay will end because the SNF determines the beneficiary no longer requires daily skilled services but has benefit days remaining. The NOMNC should be delivered at least 2 calendar days before services end or the second to last day of service if skilled services are not provided daily. This represent non-compliance investigated under Complaint Number 2641533.

Based on interview and record review, the facility failed to address pharmacy recommendations or initiate medication changes in a timely manner. This affected two (Residents #55 and #90) out of five residents reviewed for pharmacy recommendations. The facility census was 123. Findings include:1.Review of the medical record for Resident #90 revealed an admission date of 07/17/24 with diagnoses of insomnia, intellectual disabilities, muscle weakness, constipation, major depressive disorder, neuralgia, and neuritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #90 is cognitively intact and is receiving psychotropic drugs. Review of the care plan dated 10/16/24 revealed Resident #90 receives psychotropic medication and is at risk for adverse side effects related to the use of antidepressants, anti anxiety medications, and sleep aids. Interventions include administering medications as ordered by the physician and reviewing quarterly and as needed to maintain the lowest effective dose. Review of the monthly medication review (MMR) dated 06/24/25 revealed a recommendation for a gradual dose reduction (GDR) of trazodone 50 milligrams every night. The physician response recorded on 08/01/25 was disagree, stating past reduction attempts resulted in problematic behavior, staff inability to provide care, and psychiatric instability. Review of the physician order dated 08/01/25 revealed amitriptyline tablet 25 milligrams at bedtime for depression, with a discontinue date of 02/10/26. Review of the MMR dated 12/19/25 revealed a recommendation for a gradual dose reduction of amitriptyline to 10 milligrams every night, with the physician response agree on 02/06/26. Interview on 04/07/26 4:09 P.M. with the Director of Nursing (DON) and the Administrator confirmed Resident #90's pharmacy recommendations from 06/24/25 and 12/19/25 were not reviewed and acted upon timely. Review of the drug regimen review and reporting policy dated 01/27/25 revealed all identified irregularities and recommendations must be acted upon in a timely manner, and no later than 30 days. 2. Resident #55 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disease, peripheral vascular disease, chronic respiratory disease, type II diabetes, hereditary and idiopathic neuropathy, heart failure, hypertensive heart disease, morbid obesity, atherosclerotic heart disease, sensorineural hearing loss, muscle weakness, anemia, chronic kidney disease, major depressive disorder, atrial fibrillation, hyperlipidemia, and anxiety disorder. Review of his MDS assessment, dated 03/18/26, revealed he was cognitively intact. Review of Resident #55 pharmacy recommendation, dated 12/19/25, revealed a recommendation for a gradual dose reduction (GDR) for sertraline 50 milligrams (mg) to sertraline 25 mg. The provider did not address this recommendation until 02/06/26, in which they agreed with the recommendation to lower the dose. Interview with the DON on 04/01/26 at 3:42 P.M. confirmed this pharmacy recommendation was not addressed in a timely manner. She confirmed they address pharmacy recommendations within a month of them being issued by the pharmacist.

Based on observation, interview, record review, medication administration observation, and facility policy review, the facility failed to ensure staff administered medication following infection control procedures. This affected one (Resident #73) of four residents reviewed for infection control. The facility census was 123.Review of the medical record for Resident #73 revealed an admission date of 09/06/18 with diagnoses of end stage renal disease, hyperlipidemia, gastroesophageal reflux disease, polyneuropathy, hypertension, heart failure, and paroxysmal atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 is cognitively intact and requires set up or clean up assistance with eating. Observation of medication administration on 04/02/26 from 8:16 A.M. to 8:24 A.M. for Resident #73 revealed Licensed Practical Nurse (LPN) #511 began preparation of medications without practicing hand hygiene. Further observation revealed an Eliquis tablet 5 mg (Apixaban) was dropped on the cart, LPN #511 picked up the tablet with bare fingers and placed it into the medication cup. Two fludrocortisone acetate tablets 0.1 mg were popped directly from the pill package into the nurse's hand and then placed into the medication cup. After preparation, applesauce was added to the medications and the nurse entered the room. LPN #511 spoon fed the medications with applesauce to Resident #73, then exited the room and signed off the medications. Hand hygiene was not performed before preparation, during preparation, before resident contact, or after medication administration. Interview on 04/02/26 at 8:28 A.M. with LPN #511 confirmed hand hygiene was not conducted before medication preparation, before entering Resident #73's room, before touching pills or tablets, and after administering medications. Interview on 04/06/26 at 04:04 P.M. with the Director of Nursing (DON) and the Administrator revealed staff are required to perform hand hygiene before medication preparation and before touching pills or devices, and after resident contact or glove removal. Review of the medication administration policy dated 12/12/23 revealed staff are to perform hand hygiene prior to administering medication and after administration.

Based on observations, interviews, and medication records, the facility failed to appropriately manage pain for Resident #122. This affected one resident (#122) of the three residents reviewed for pain management. The facility census was 123.Findings include:Review of the medical record for Resident #122 revealed an admission date of 03/20/26 with diagnoses to include but not limited to disseminated malignant neoplasm, secondary malignant neoplasm of the bone and genital organs, ovary, right lung, intraabdominal lymph nodes, retention of urine, neoplasm related to pain, depression, anemia in neoplastic disease, muscle weakness, and unsteadiness on feet. Resident #122 spoke Spanish and had limited ability to speak English. Review of the admission Minimum Data Set (MDS) for Resident #122 revealed a Brief Interview for Mental Status of fourteen which indicated no cognitive impairment. Additionally, the MDS revealed no psychosis, no verbal or physical behaviors, and no rejections of care. Furthermore, the MDS revealed Resident #122 had a pain frequency rated as almost constantly which occasionally effected sleep and pain rated at eight. The MDS revealed Resident #122 received radiation.Review of the care plan revealed Resident #122 had chronic pain due to metastatic cancer which had spread to multiple other sites with interventions to notify physician of unrelieved or worsening pain and to provide resident and family with information about pain and options available for pain management to discuss and record preferences.Review of an order dated 03/20/26 revealed oxycodone hydrochloride (HCl) Oral Tablet ten milligrams (mg) give one tablet by mouth every four hours as needed for severe pain.Review of an order dated 03/21/26 revealed observe for signs or symptoms of pain every shift. If pain present, document level and location of pain, treat trying nonpharmacological interventions prior to medicating if appropriate. Document in the Progress Notes every shift.Review of an order dated 03/26/26 revealed Buprenorphine Transdermal Patch Weekly 20 microgram per hour (MCG/HR) apply one patch, transdermal, one time a day every Thursday for pain and remove per schedule.Observation on 03/30/26 at 8:45 A.M. of Resident #122 lying in bed on her left side with her right ankle which was red and puffy exposed lying on the bed. Resident #122 with tears in her eyes pointed to her right ankle and stated pain.Interview on 03/30/26 at 8:45 A.M. with Resident #122's daughter stated when Resident #122 is asleep, she misses her pain medication which is as needed every four hours. Resident #122's daughter stated Resident #122 has tumors in her ankle and lower back and should have scheduled pain medication. Resident #122's daughter stated they have spoken to staff regarding scheduling the pain medication, but it still isn't scheduled.Interview on 04/01/2026 at 8:05 A.M. with Certified Nursing Assistant (CNA) #705 stated Resident #122 asked for pain medications a lot. CNA #122 stated Resident #122 can say pain medicine in English. CNA #705 stated Resident #122 asked for pain medication sometimes every two to three hours and as soon as she woke up from sleeping. Interview on 04/01/26 at 8:13 A.M. with Licensed Practical Nurse (LPN) #315 stated Resident #122 came to the facility recently from an outside hospital with a right swollen ankle and Resident #122 was on pain medication and chemotherapy. LPN #315 verified that Resident #122 had foley catheter and lymphedema on her left shoulder. LPN #315 stated Resident #122 always asked for pain medication after three hours and the order was for every four hours. LPN #315 stated he thought there was an alarm on Resident #122's phone to remind her to call for pain meds at three hours. LPN #315 stated he did not talk to the doctor about Resident #122's pain. LPN #315 stated the lowest pain number Resident #122 said to him was five, but that Resident #122's pain was usually an eight or ten. LPN #315 stated Resident #122 never said her pain was at zero. LPN #315 stated yesterday Resident #122 was having pain in her left shoulder and Resident #122's daughter had taken Resident #122 back to the hospital on [DATE].Interview on 04/02/26 at 7:14 A.M. with LPN #312 stated she asked the residents if they are having pain, and have the resident rate pain, where, how often, severity, then give an as needed pain medication. LPN #312 stated if the resident does not have an as needed pain medication ordered, then she would get vital signs and call the physician. LPN #312 stated after giving pain medications, then she would monitor for effectiveness. LPN #312 stated when Resident #122 would ring her call light, she would go and give her pain medications because of Resident #122's diagnosis. LPN #312 stated Resident #122's pain medications were for every four hours, and that Resident #122 would ring on her call light every four hours for the pain medication. LPN #312 stated with Resident #122's diagnosis, she knew Resident #122 was in pain, so she would go right down with the pain medications. LPN #312 stated the highest pain rating Resident #122 gave was a seven and the lowest rating was a two or three. LPN #312 stated Resident #122 would show her fingers to indicate a number, but the lowest rating was only after the pain medications had been given to Resident #122. LPN #312 stated she did not think about Resident #122 needing pain medications scheduled since Resident #122 was getting them every four hours. LPN #312 stated she was not sure if the nurses were giving pain meds every four hours during the night. Interview on 04/02/2026 at 7:30 A.M. via phone with LPN #313 stated Resident #122 would ring her call light, and LPN #313 would ask Resident #122 on a scale of one to ten what her pain was and where the pain was located. LPN #313 stated Resident #122 could say, I'm in pain, and Resident #122's daughter would translate. LPN #313 stated if Resident #122's daughter was not there, then Resident #122 would say she was in pain and would hold up her fingers up to say the rating number. LPN #313 stated Resident #122's highest pain rating was six or seven and the lowest rating was zero after the pain meds. LPN #313 stated Resident #122 always requested pain medication, and the pain medications were ordered every four or six hours as needed. LPN #313 stated she never woke Resident #122 up to give Resident #122 pain medications, but Resident #122 would wake up herself and request pain medications. LPN #313 stated she did not think about scheduling Resident #122's pain medications or talking to anyone about scheduling Resident #122's pain medications. LPN #313 stated Resident #122 did not complain about anything except her pain. Interview on 04/02/26 at 8:26 A.M. with Unit Manager #407 who stated Resident #122 had a diagnosis of cancer which is scattered throughout her body. Unit Manager #407 stated the pain management care plan is implemented on admission to the facility. Unit Manager #407 stated the resident's pain regimen is reviewed when the nurse notices that something is not working, through a resident's body language or the frequency of when a resident is asking for pain medications. Unit Manager #407 stated there is a facility nurse practitioner who is in the facility on most days and night shift staff can contact the provider to communicate regarding the resident's pain. Unit Manager #407 stated the facility should have open communication with the provider regarding a resident's pain medications and if the facility provider cannot adjust or increase the pain medications, then possibly receive a pain management referral. Unit Manger #407 stated she was not aware that Resident #122 was requesting pain medications every three hours. Unit Manager #407 stated she was not aware that Resident #122's daughter wanted the pain medication scheduled and that none of the nurses had come to her to discuss Resident #122's pain medications. Unit Manager #407 stated if Resident #122 was requesting pain medications every three to four hours, then the provider should have been notified.Interview on 04/02/26 at 8:47 A.M. with the Director of Nursing (DON) stated she was not aware of Resident #122 asking for pain medications every three hours but did know that Resident #122 was receiving pain medications every four hours. The DON stated that instead of scheduling Resident #122's pain medications, the facility should have gotten something for in between to get Resident #122 to the four hours. The DON stated it would not have hurt to call the provider and let them know Resident #122 was requesting pain medication every four hours. The DON stated she was not aware of Resident #122's daughter talking to the staff about scheduling Resident #122's pain medications. The DON stated she was not aware Resident #122 was getting pain medication every three hours in the hospital. The DON stated they just go by the orders received from the hospital, but maybe if they had looked more into her paperwork, then they would have known. Review of discharge paperwork for Resident #122 dated 03/20/26 revealed Resident #122 was ordered oxycodone 10mgs one tablet by mouth every three hours as needed for moderate pain or severe pain. Review of the Continuity of Care for Resident #122 dated 03/20/26 revealed a prescription for oxycodone 10 mg take zero point five to one tablet by mouth every four hours as needed for moderate pain to severe pain, maximum 40 mg daily. The DON reviewed the Continuity of Care dated 03/20/26 and the discharge paperwork dated 03/20/26 and acknowledged there was a difference in the oxycodone prescription which needed to be clarified.Review of the facility policy Pain Management dated 01/02/24 revealed in order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the causes(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. new pain or an exacerbation of pain). Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain, consider evidence-based practice tools to assist in the assessment of the resident's pain, consider administering medication around the clock instead of as needed or combining longer acting medications wit as needed medications for breakthrough pain, utilize the most effective and least invasive route for analgesic administration (e.g. oral, rectal, topical, injection, infusion pump and/or transdermal), use lower doses of medication initially and titrate slowly upward until comfort is achieve.This deficiency represents non-compliance investigated under Complaint Numbers 2899477 and 2800477

Based on interview and record review, the facility failed to ensure weekly and daily weights were completed as ordered, failed to notify the physician of significant weight changes, failed to ensure contradictory weight orders were not in place, and failed to ensure reweights were completed timely and orders were transcribed correctly. This affected three residents (Resident #1, Resident #43, and Resident #90) out of seven residents reviewed for nutrition. The facility census was 123.Findings include:1.Review of the medical record for Resident #1 revealed an admission date of 2/27/26 with diagnoses of hemiplegia, metabolic encephalopathy, dysphagia, anoxic brain damage, gastrostomy status, and aphasia.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was dependent upon staff for activities of daily living, including eating, and received 51 percent or more of total calories and fluid intake via abdominal tube feeding.Review of the care plan initiated 03/08/26 and revised on 04/05/26 revealed Resident #1 was at nutritional risk with significant weight loss in one month. Interventions included registered dietitian evaluation, tube feed changes and recommendations as needed, weights as ordered or indicated, and notification of the physician for significant weight changes.Review of the hospital record dated 02/27/26 revealed Resident #1 weighed 135 pounds (lbs) during hospital admission.Review of the physician order dated 02/28/26 revealed weekly weights one time a day every seven day(s) for post admission weight monitoring for four weeks. Additionally, enteral feed was ordered every shift, continuous at 45 milliliters per hour (ml/hr).Review of the medication administration record (MAR) dated February 2026 revealed weekly weights one time a day every seven day(s) for post admission weight monitoring for four weeks, however on the assigned weigh day of 02/28/26 had no weight value documented.Review of the weight summary dated 03/07/26 revealed Resident #1 weighed 130.8 lbs.Review of the nutritional dietary enteral review dated 03/08/26 revealed Resident #1 received nutrition via percutaneous endoscopic gastrostomy (PEG) tube, with the most recent weight at 130.8 pounds and a basal metabolic rate of 22.4. Tube feeding was provided at 45 ml/hr, totaling approximately 1620 calories per day. The dietitian was to follow weekly for weights and tube feed tolerance.Review of emails titled, 'weights pending and reweights,' from Dietitian #727 to Unit Manager #507 dated 03/15/26 and 03/19/26 revealed Resident #1 required a weekly weight, with a request to enter weights into the electronic medical record as soon as possible.Review of the MAR dated March 2026 revealed weekly weights as ordered, with a weight completed on 03/07/26 at 130.8 lbs, however on assigned weigh days of 03/14/26 and 03/20/26 no weights were documented in the MAR. An additional weekly weight due 03/27/26 was also not obtained.Interview on 04/02/26 at 2:17 P.M. with Dietitian #727 confirmed weekly weights ordered on 02/28/26 were not completed on 03/14/26 and 03/20/26 as ordered. The dietitian stated the resident should have remained on weekly weights due to tube feeding status, however a current active order was not in place at that time. The dietitian confirmed nursing staff are required to obtain weekly weights according to the facility policy for residents receiving enteral nutrition. The dietitian reported sending emails to Unit Manager #507 as reminders, but did not receive a response or the weights.Interview on 04/02/26 at 2:46 P.M. with Unit Manager (UM) #507 confirmed Resident #1 was ordered weekly weights upon admission and should have remained on weekly weights due to tube feeding. UM #507 confirmed weights due on 03/14/26, 03/20/26, and 03/27/26 were not completed, and the medical record did not contain documentation explaining why, nor any refusals. UM #507 stated the scale required for Hoyer lift transfers was out of service.Interview on 04/02/26 at 05:10 P.M. with the Administrator and Regional Nurse #726 indicated they were not aware of any scale malfunction. There was no documentation in the medical record showing the scale was out of service during the period when weights were missed, and the dietitian did not report concerns regarding scale availability or equipment issues that would prevent weekly weight collection. Regional Nurse #726 confirmed residents receiving tube feed nutrition are required to receive a weekly weight.Review of the treatment administration record (TAR) dated April 2026 revealed monthly weights every day shift from the first through the fifth, with a reweigh if greater than a five pound change. On 04/04/26 a weight of 123.8 pounds was recorded.Review of the weight summary dated 04/04/26 revealed Resident #1 weighed 123.8 pounds, a 5.35 percent loss since 03/07/26.Review of the weight summary dated 04/05/26 revealed Resident #1 weighed 124.6 pounds.Review of the dietary progress note dated 04/05/26 revealed the resident weighed 123.8 pounds, showing a 5.3 percent weight loss in one month. Basal metabolic rate was 21.2. Weekly weights were to continue, and tube feed rate was increased to 55 ml/hr.Interview on 04/06/26 at 09:39 A.M. with the Administrator and Regional Nurse #726 revealed they denied the scale was not functioning and acknowledged the resident had significant weight loss. They reported bringing in a rental scale to verify the weight.Interview on 04/06/26 at 03:13 P.M. with Dietitian #727 confirmed Resident #1 exhibited a weight loss of 5.3 percent in one month. New intervention included an increase in tube feed formula to 55 ml/hr and continuation of weekly weights. The dietitian reported uncertainty about the initial 130.8 lb weight from 03/07/26 and stated weekly weights should continue to obtain an accurate weight trend. The dietitian reported the resident remained at a healthy basal metabolic rate.Review of weight monitoring policy dated 07/01/25 revealed weekly weights should be obtained and recorded in the electronic medical record for four weeks for new admission to the facility and residents determined to be at high nutritional risk.2. Review of the medical record for Resident #43 revealed an admission date of 12/30/25 with diagnoses of chronic respiratory failure, end stage renal disease (ESRD), chronic diastolic heart failure, complete atrioventricular block (AV block), pulmonary hypertension due to lung diseases, type 2 diabetes mellitus, essential hypertension, paroxysmal atrial fibrillation (PAF), and bradycardia.Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #43 is cognitively intact, does not reject care, and has not had a significant weight change in the past six months.Review of the care plan dated 12/31/25 revealed Resident #43 is at risk for fluid imbalance due to chronic kidney disease, poor intake, recent infection, congestive heart failure, pulmonary hypertension, and fluid restriction. Interventions include completing weights as ordered and notifying the physician of significant weight changes.Review of the physician order with a start date of 03/06/26 and discontinued 04/02/26 revealed daily weights every day shift for chronic heart failure.Review of the physician order dated 03/07/26 revealed weekly weights every week for four weeks for post admission weight monitoring.Review of the weight summary revealed that on 03/07/26 the resident weighed 159.3 pounds (lbs), on 03/10/26 the resident weighed 177.5 lbs which is an 18.2 pound and 11.42 percent gain from 03/07/26, on 03/12/26 the resident weighed 177.0 lbs, and on 03/14/26 the resident weighed 179.0 lbs.Review of the weight summary and Treatment Administration Record (TAR) revealed missing daily weights on 03/09/26, 03/11/26, 03/15/26, and 03/18/26.Review of progress notes from 03/08/26 through 04/01/26 revealed no weight refusals and no physician notification of the weight change.Review of the physician visit dated 03/13/26 revealed the physician was asked to see the resident for weakness and debility. The note documented general weakness that was moderate to severe and chronic and stable, chronic back and lower extremity pain, depression related to circumstances, stable chronic shortness of breath with activity also known as dyspnea on exertion (DOE), and fair oral intake. Skilled nursing facility (SNF) records and laboratory results were reviewed. The note did not document physician awareness of the resident's weight gains recorded on 03/10/26.Interview on 04/02/26 at 02:22 P.M. with Dietitian #727 revealed the resident had no active nutrition problems at that time but was at risk for fluid imbalance due to dialysis and chronic heart failure. The dietitian stated a significant weight change for this resident is two to three pounds in one day or five pounds in one week. The dietitian confirmed dialysis weights should flow into the vitals summary. The dietitian stated the facility has ongoing issues getting weights as ordered and did not find any documentation showing physician notification or resident refusals for the weight changes between 03/07/26 and 03/14/26.Interview on 04/02/26 at 02:52 P.M. with UM #507 revealed the medical record did not show the physician was notified of the weight change from 03/10/26 to 03/12/26 which was about 18 pounds and 11.42 percent difference. UM #507 stated this change was concerning because the weights stayed high on later days. UM #507 confirmed there were duplicate orders for daily weights and weekly weights that conflicted. UM #507 stated nurses are expected to document weight refusals in a progress note and to notify the physician of significant changes and could not provide any note showing refusals or physician notification for this period.Interview on 04/06/26 at 10:26 A.M. with Physician #999 revealed he could not recall being told about the approximately 18 pound change between 03/07/26 and 03/12/26. The physician stated a change this large in a resident with end stage renal disease (ESRD) and chronic heart failure is significant and the physician should be notified. The physician reported he would expect a progress note if he had been notified. 3. Review of the medical record for Resident #90 revealed an admission date of 07/17/24 with diagnoses of morbid obesity, type 2 diabetes mellitus (T2DM), lymphedema, and protein calorie malnutrition.Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #90 is cognitively intact, does not reject care, requires substantial or maximal assistance with bed mobility, is unable to ambulate, and has not had a significant weight change in the past six months.Review of the care plan dated 07/24/24 revealed Resident #90 has potential for nutritional risk related to a therapeutic diet, high body mass index (BMI) for height, obesity, depression, and extensive food dislikes. Interventions include obtaining weights as ordered and notifying the physician of significant weight changes.Review of the weight summary revealed on 01/04/26 the resident weighed 328.6 pounds (lbs). On 02/01/26 the resident weighed 315.0 lbs, which is a 13.6 lb and 4.14 percent loss.Review of the physician order placed by Unit Manager (UM) #508 with a start date of 02/01/26 and an end date of 01/30/26 revealed a daily weight every night shift for one day.Review of progress notes dated 02/01/26 through 02/08/26 revealed no documented refusals and no documented attempts to obtain a reweight.Review of the dietitian note dated 02/16/26 revealed Resident #90 refused a weight that week and no new weight was obtained. The note listed a recent weight of 315.0 lbs on 02/01/26 and a body mass index (BMI) of 55.8. The dietitian noted possible weight changes due to diuretic use and refusals, recommended weight loss, continuation of weekly weights, and follow up as needed.Interview on 04/02/26 at 4:30 P.M. with Unit Manager (UM) #507 confirmed a reweight was needed after a 13.6 lb loss and confirmed the order entered by UM #508 was not entered correctly.Interview on 04/02/26 at 4:49 P.M. with UM #508 confirmed Resident #90 had a 13.6 lb loss on 02/01/26. UM #508 stated a daily weight order was entered with a start date of 02/01/26 and an end date of 01/30/26, which made the order inactive due to the wrong dates. UM #508 stated the intent was to obtain a reweight, but the reweight was not completed.Interview on 04/06/26 at 4:09 P.M. with the Director of Nursing (DON) and the Administrator confirmed the physician order was not placed correctly and a reweight was not completed.Review of the weight monitoring policy dated 06/15/25 revealed residents who weigh over 100 pounds require a reweight if the weight changes more than 5 pounds.This deficiency represents non-compliance investigated under Complaint Number 1270133.

Based on observation, interview and record review the facility failed to ensure proper administration of oxygen and failed to ensure a valid physician order was in place for oxygen use. This affected two (Resident #90 and #87) out of three residents reviewed for oxygen administration. The facility census was 123. Findings include: 1.Review of the medical record for Resident #90 revealed an admission date of 07/17/24 with diagnoses of asthma, morbid obesity, edema, lymphedema, muscle weakness, and anxiety. Review of the care plan dated 10/16/24 revealed Resident #90 is at risk for respiratory distress related to asthma. Interventions include administering oxygen as ordered and monitoring oxygen saturation as ordered and as indicated. Review of active physician orders dated 04/01/26 revealed no current orders for oxygen administration. Observation on 03/31/26 at 2:48 P.M. and 4:27 P.M. revealed the resident was receiving oxygen by nasal cannula at five liters per minute. Interview on 03/31/26 at 4:29 P.M. with Licensed Practical Nurse (LPN) #512 confirmed Resident #90 was receiving oxygen by nasal cannula at five liters. Interview on 04/01/26 at 5:51 A.M. with LPN #216 confirmed Resident #90 was receiving oxygen by nasal cannula at five liters and did not have an active physician order for oxygen. Interview on 04/01/26 at 5:54 A.M. with the Director of Nursing (DON) confirmed Resident #90 was receiving oxygen by nasal cannula at five liters. Interview on 04/01/26 at 9:48 A.M. with the DON confirmed Resident #90 did not have an active physician order for oxygen. The DON stated the resident should receive continuous oxygen at two to three liters per minute and reported the resident has behaviors of turning up oxygen. The DON confirmed oxygen is a medication and nursing staff should verify the five rights of medication administration every shift, including right dosage, and confirm there is an active physician order. 2.Review of the medical record for Resident #87 revealed an admission date of 04/5/25 with diagnoses to include but not limited to metabolic encephalopathy, anorexia nervosa, myositis ossificans progressiva, right lower leg, polyneuropathies, dry beriberi, severe protein-calorie malnutrition, sequelae of unspecified nutritional deficiency, tachycardia, vitamin B12 deficiency anemia, other specified disorders of the liver, unspecified psychosis not due to a substance, mood disorder, major depressive disorder, thiamine deficiency, ascorbic acid deficiency, hypercalcemia, anxiety disorder, pericardial effusion, and hypotension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #87 revealed a Brief Interview for Mental Status (BIMS) score of thirteen which indicated no cognitive impairment. Additionally, the MDS revealed Resident #87 was dependent on staff for all care. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated for March 2026 revealed no order for oxygen noted. Review of the care plan for Resident #87 dated 03/19/26 revealed a focus of Resident #87 has a diagnosis of pneumonia with interventions to include administer oxygen as ordered. Review of a progress note dated 03/18/26 revealed two views of chest x-ray result indicates perihilar infiltrates, order received oxygen saturations at 97% with oxygen at two liters via nasal cannula. Review of progress note dated 03/19/26 revealed Resident #87 continues with antibiotic for upper respiratory infection, no signs or symptoms of adverse reaction noted. Resident #87 returned from family scheduled chest x-ray appointment per emergency medical services (EMS) personnel resident does not have any appointments today, the family did not show up. Oxygen saturations at 96% with oxygen at two liters via nasal cannula. Review of multiple progress notes dated 03/18/26 to 03/21/26 which stated Resident #87 was on two liters of oxygen via nasal cannula. Interview on 04/02/2026 at 5:04 P.M. with the Executive Director who stated there was no oxygen order for Resident #87. Review of the oxygen administration policy dated 08/01/25 revealed oxygen is administered under the orders of a physician.

Based on observation, interviews, and medical records, the facility failed to provide appropriate fall interventions, including placing the bed in a low position and use of a fall mat, for Resident #134. This affected one resident (#134) of the six residents reviewed for accidents. The facility census was 123.Findings include:Review of the medical record for Resident #134 revealed an admission date of 09/10/21 with diagnosis to include but not limited to unspecified sequelae of cerebral infarction, malignant neoplasm of unspecified kidney, vascular dementia, chronic obstructive pulmonary disease, arteriovenous malformation of cerebra vessels, dorsalgia, major depressive disorder, high risk heterosexual behavior, alcohol abuse, cerebral infarction, alcohol dependence, opioid dependence, restlessness, functional urinary incontinence, anxiety disorder, and psychotic disorder with delusions. Review of the quarterly minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. Review of the care plan for Resident #134 dated 09/22/25 revealed Resident #134 is at risk for falls and/or fall related injuries related to cognitive impairment, history of falling, wandering/agitation and/or confusion, incontinence, and generalized weakness with interventions to include, encourage resident to have bed in the lowest positions while sleeping and perimeter mattress. Review of an order dated 01/12/26 revealed an order for bed in lowest position every shift, which was discontinued on 03/30/26 at 3:44 P.M. Review of an order dated 04/29/25 revealed an order for perimeter floor mat as tolerated every shift for preventative care. Observation on 03/30/26 at 3:35 P.M. revealed Resident #134 lying in his bed, which was at normal height positioning and no perimeter floor mat on the floor by Resident #134's bed or in the room. Licensed Practical Nurse (LPN) #314 verified that Resident #134 was in bed with the bed in a normal and not low position and there was no perimeter floor mat around the bed or in the room at the time of the observation.

Based on record review and interview, the facility failed to ensure wound treatments were initiated timely for a resident with a skin alteration. This affected one (Resident #36) of three residents reviewed for pressure ulcers. The facility census was 123. Findings include:Review of the medical record for Resident #90 revealed an admission date of 07/17/24 with diagnoses of polyneuropathy, morbid obesity, type 2 diabetes mellitus (T2DM), and lymphedema.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #90 is cognitively intact, is dependent on staff for toileting hygiene, and is always incontinent of bowel and bladder.Review of the care plan dated 02/11/26 revealed Resident #90 has impaired skin integrity of the plantar aspect of the third toe. Interventions included assessing and documenting skin condition, completing wound treatment as ordered, and notifying the physician of any worsening wound.Review of the wound assessment report dated 02/11/26 revealed Resident #90 had a community acquired deep tissue injury (DTI) of the plantar aspect of the third toe, with 100 percent intact epithelium and evidence of deeper tissue injury, attached wound edges, and intact periwound. The wound measured 1.00 centimeters (cm) in length and 1.00 cm in width. Treatment orders included cleansing with wound cleanser twice per day, applying skin prep to surrounding tissue, and leaving the wound open to air.Review of the progress note dated 02/11/26 at 10:09 P.M. by the Director of Nursing (DON) revealed the resident was seen by the wound nurse practitioner, treatment orders were in place, and the wound nurse would continue to monitor.Review of progress notes from 02/12/26 through 02/15/26 revealed no documentation that treatment orders to cleanse with wound cleanser twice per day, apply skin prep to surrounding tissue, and leave open to air were initiated or completed.Review of the physician order dated 02/16/26 revealed treatment for the plantar aspect of the third toe pressure injury to cleanse with wound cleanser twice per day, apply skin prep to surrounding tissue, and leave open to air.Review of the Medication Administration Record (MAR) dated 03/01/26 through 03/31/26 revealed the plantar aspect of the third toe pressure injury treatment was initiated on 02/16/26 during night shift.Review of the wound assessment report dated 02/18/26 revealed the plantar aspect of the third toe had 100 percent intact epithelium with evidence of deeper tissue injury, attached wound edges, and intact periwound. The wound measured 1.00 centimeters (cm) in length and 1.00 cm in width. Treatment orders were to cleanse with wound cleanser twice per day, apply skin prep to surrounding tissue, and leave open to air.Interview on 04/06/26 at 1:54 P.M. with Regional Nurse #726 confirmed Resident #90's wound treatments were not initiated timely.Interview on 04/06/26 at 4:07 P.M. with the DON and the Administrator confirmed Resident #90's treatment was not initiated timely. Review of wound management policy dated 05/20/24 revealed the facility is to ensure residents with impaired skin integrity are recognized by the care team, treated timely and interventions are not exhausted until the skin is healed. This deficiency represents non-compliance investigated under Complaint Number 2800477 and Complaint Number 2724325.

Based on interview, medical record review, and facility policy review, the facility failed to conduct care planning meetings with the resident and/or their representative. This affected two residents (Resident #104 and #125) of thirty three records sampled. The facility census was 123 residents. Findings include: 1. Review of Resident #104's medical record revealed an original admission date of 12/28/22 and a readmission date of 03/26/26. Resident #104 had diagnoses that included metabolic encephalopathy, hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side, and unspecified sequelae of other nontraumatic intracranial hemorrhage. Review of Resident #104's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment and was dependent for toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #104 was always incontinent of bowel and bladder. Further review of Resident #104's medical record on 04/01/26 at 11:00 A.M. revealed the last documented care conference with the resident and/or the resident representative was conducted on 06/20/24. Interview with Regional Social Worker #727 on 04/01/26 4:14 P.M. confirmed there was no documentation of a care conference for Resident #104 since 2024. Interview with Regional Social Worker #727 on 04/02/26 at 7:51 A.M. revealed resident care conferences should follow the MDS schedule. 2. Resident #125 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, chronic obstructive pulmonary disease, paraplegia, pruritus, vascular dementia, chronic pain syndrome, anxiety disorder, heart failure, acute respiratory failure, dermatitis, major depressive disorder, anemia, dependence on supplemental oxygen, shortness of breath, and muscle weakness. Review of her MDS assessment, dated 02/10/26, revealed she was cognitively intact. Review of Resident #125's progress notes, dated September 2025 to April 2026, revealed no care conferences documented as being held in September 2025 and March 2026, which is when they were scheduled to occur. Interview with Regional Social Services #727 on 04/01/26 at 11:23 A.M. confirmed care conferences for Resident #125 had not been completed as scheduled in September 2025 and March 2026. She confirmed they will get them scheduled as soon as possible. Interview with the Administrator on 04/01/26 at 1:58 P.M. confirmed she completed a care conference with Resident #125 and her family on 03/02/26. She confirmed she had it recorded, but has not documented the information of the care conference on any document for review and/or implementation at this time. Review of policy, 'Care Conferences' effective 11/01/24 and revised 05/16/24 revealed care conferences will be scheduled as soon as possible after admission, routinely, and with a change in condition. This deficiency represents non-compliance investigated under Complaint Number 2599640.

Based on observations and interviews, the facility failed to maintain a safe, clean, and homelike environment. This affected one (Resident #113) of five residents reviewed for environment. The facility census was 123.Findings include:Observation on 03/30/26 at 8:37 A.M. of Resident #113's room revealed a hole in the wall about a foot long behind the bed. The dry wall had crumbled into several pieces. Interview at 03/30/26 at 8:37 A.M. with Resident #113 revealed the hole in the wall had been there since he moved to the room about two months ago.Interview on 03/31/26 at 7:25 A.M. with Unit Manager #407 verified the dry wall behind Resident #113's bed was crumbling in the wall and was about one foot long. Unit Manager #407 verified there was another area of the wall near the heating unit which looked like the plaster was coming off the walls and a black substance in the heating unit openings which did not come off when she attempted to remove it. Unit Manager #407 stated the black substance looked like mold in the heating unit. Review of the facility Admissions Packet undated revealed the rights of the residents of a home shall include, but are not limited to, the following: safe and clean-living environment. Review of the facility policy, Physical Environment, dated 01/01/26 revealed the purpose of the policy is to ensure our facilities are designed, constructed, equipped, and maintained in a manner that provides a safe, functional, sanitary, and comfortable environment for residents/patients, care team members, and the public. This deficiency represents non-compliance investigated under Complaint Numbers 2724325, 2718817, and 2599640.

Based on observations, interviews, and facility policy review, the facility failed to ensure staff could communicate with a Spanish speaking resident. This affected one (Resident #122) of one resident reviewed for communication. The facility census was 123.Findings include:Review of the medical record for Resident #122 revealed an admission date of 03/20/26 with diagnoses to include but not limited to disseminated malignant neoplasm, secondary malignant neoplasm of the bone and genital organs, ovary, right lung, intraabdominal lymph nodes, retention of urine, neoplasm related to pain, depression, anemia in neoplastic disease, muscle weakness, and unsteadiness on feet.Review of the admission Minimum Data Set (MDS) for Resident #122 revealed a Brief Interview for Mental Status (BIMS) of 14, indicating the resident was cognitively intact Additionally, the MDS for Resident #122 revealed her ethnicity as Mexican and her preferred language as Spanish.Review of the care plan for Resident #122 indicated no focus on Resident #122's primary language as Spanish or interventions for communication.Observation on 03/30/26 at 8:45 A.M. of Resident #122 lying in bed. Resident #122 called her daughter because she does not speak English.Interview on 03/30/26 at 8:45 A.M. with Resident #122's daughter stated Resident #122 calls her all throughout the day and night to translate for her. Resident #122's daughter stated in the beginning the facility mentioned a translator, but the facility has not provided one.Interview on 04/01/26 at 8:13 A.M. with Licensed Practical Nurse (LPN) #315 stated Resident #122 only understands English a little and calls her daughter when she needs something. LPN #315 stated Resident #122 can say pain medicine, but not much else in English. LPN #315 stated the facility had a website or interpreter services, but he didn't use them because Resident #122 was always on the phone with her daughter when Resident #122 needed something.Interview on 04/01/26 at 8:31 A.M. with Admissions Coordinator #207 stated if a resident doesn't speak English, then the admission Coordinator #207 meets with the family member who can speak English. admission Coordinator #207 stated he goes over the admission paperwork and packet with the family member who can translate and understand English. Admissions Coordinator #207 stated if there was no family member who could speak English, then he thought the facility had a translator service. Admissions Coordinator #207 stated Resident #122 was admitted to the facility and spoke very little English. Admissions Coordinator #207 stated Resident #122 called her daughter, and he went over the admission packet over the phone with Resident #122's daughter. Admissions Coordinator #207 stated Resident #122 signed the admission paperwork while her daughter was on the phone. Admissions Coordinator #207 stated he called Resident #122's daughter and told her he needed to get the paperwork signed and ask her to translate over the phone and then have Resident #122 sign which is what happened. Admissions Coordinator #207 stated Resident #122 can understand English if you talk a little slower with her. Admissions Coordinator #207 stated he used hand gestures to speak with Resident #122. Interview on 04/01/26 at 8:47 A.M. with MDS #208 stated there were a lot of staff members of different ethnicities who worked at the facility, so staff usually have someone who can interpret for staff and families/residents. Interview on 04/01/26 at 9:07 A.M. with Social Service #725 stated if someone doesn't speak English, then the resident will call their loved ones, or we do have an interpreter we can call. Social Service #725 stated she had completed the BIMS assessment through a Resident's loved one. Social Service #725 stated Resident #122 called her daughter to complete the BIMS via the phone, but Resident #122's daughter wanted to be in the building because it would be easier. Social Service #725 stated Resident #122's daughter did come into building and the BIMS and Patient health Questionnaire-nine (PHQ-9) (a tool used by clinician to screen for and measure the severity of adult depression based on symptoms over the past two weeks) was completed through Resident #122's daughter. Social Service #725 stated she did explain to Resident #122's daughter to not add anything to Resident #122's answer. Social Service #725 stated there was no reason that she did not call an interpreter service. Social Service #725 stated she would call the interpreter service if the resident could not reach a loved one. Social Service #725 stated Resident #122 did not understand any English and only understood the BIMS and PHQ-9 questions through Resident #122's daughter translating. Social Service #725 stated she does not call an interpreter service if a resident has reached out to a loved one. Social Service #725 stated she used an interpreter in a past facility but not at this facility. Social Service #725 stated she felt the interpreter service conveyed what she said and did not add anything to it. Social Service #725 stated it would be better to use an interpreter service instead of a loved one because it is non-bias and they aren't going to add anything to what the residents are saying. Social Service #725 stated she had not observed anyone using interpreter services in this facility. Social Service #725 stated she does not know where the interpreter service number is located and does not know the number to call an interpreter.Interview on 04/01/2026 at 9:52 A.M. with Regional Social Worker #727 stated the facility has an account for an interpreter service. Regional Social Worker #727 stated the staff can call the number to access an interpreter and it will direct them to the language which they need. Regional Social Worker #727 stated the facility does have an account for interpreting, and the staff should be calling to use it. Regional Social Worker #727 stated the nurses will talk to the family member to interpret; social services should definitely use the interpreter service to do the MDS assessments for non-English speaking persons. Interview on 04/02/26 at 7:14 A.M. with LPN #312 stated she would ask on the other units to see if there was a Spanish speaking staff member to be able to interpret. LPN #312 did not use an outside interpreter service and was not sure if the facility had an interpreter service. Interview on 04/02/26 at 8:26 A.M. with Unit Manager #407 stated Resident #122's primary language is Spanish. Unit Manger #407 stated when she would go into Resident #122's room, then Resident #122 would call her daughter to interpret for her. Unit Manger #407 stated the facility had an interpreter service which was in place when she started so the staff should know about it. Interview on 04/02/26 at 8:47 A.M. with the Director of Nursing (DON) stated Resident #122 communicated more common things like if she needed something, but for more in-depth things, we do have an interpreter service and an app on the phone if the staff needed an interpreter. The DON stated she did not know the policy at this facility, but staff always need to be careful using family as an interpreter because the family could change the question or meaning because staff do not know the language. The DON stated the staff are aware there is an interpreter service for the facility and the papers should be in the nurses' stations. Review of the facility policy Culturally Competent Care dated 08/05/25 revealed the purpose of the policy is to ensure that all residents/patients receive care that respects and responds to their cultural linguistic, spiritual, and individual preferences, thereby enhancing quality of life, dignity, and health outcomes. This violation represents non-compliance investigated under Complaint Number 2641533.

Based on medical record review and interview, the facility failed to ensure physician appointments were arranged as ordered. This affected one (Resident #16) of four sampled residents. The census was 118. Findings include: Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease, morbid obesity, cirrhosis of the liver, congestive heart failure, anxiety and hypertension. Review of the Annual minimum data set assessment dated [DATE] revealed his cognition was intact. He is continent of his bowel and bladder. Uses a wheelchair for mobility. Requires supervision or touching assistance with oral hygiene, toileting, bathing, dressing and personal hygiene. Review of the physicians orders revealed an order on 11/27/24 for a consult with Central Ohio Urology regarding a staghorn calculus (type of kidney stone with branches that can block urine flow and cause kidney failure) evaluation and treatment and consult Ohio Gastroenterology regarding gastric/esophageal thickening. Further review of the progress notes dated 12/17/24 revealed the facility contacted Gastroenterology and urology and they did not accept Resident #16's payment source (two different payment sources documented). There was no other documentation in attempting to get Resident #16 an appoint with Urology or Gastroenterology. Interview with the Director of Nursing on 01/02/25 at 3:50 P.M. verified they had not followed up and made the appointments for urology and Gastroenterology for Resident #16 since 12/17/24. This was an incidental finding discovered during Master Complaint Number OH00161075, Complaint Number OH00160843, OH00160779 and OH00160525.

Based on observation and staff interview, the facility failed to maintain a safe and functional environment when the transition strips (slim strips fitted at the base of doorways to bridge the gap between different floor surfaces or levels) were not in place to level the resident room floor and the hallway floor. This had the potential to affect eight residents (#14, #35, #41, #64 #65, #70, #105, and #115) of 22 residents residing on the [NAME] hallway. The facility census was 118. Findings Include: On 11/04/24 at 9:27 A.M., observations of Resident #14, #35, #41, #64 #65, #70, #105, and #115 rooms revealed the transition strips were missing in the doorway causing an unleveled surface entering and exiting the resident rooms. On 11/06/24 at 12:05 P.M., interview with the Director of Nursing (DON) revealed the facility had removed carpet and replaced with different floor. The facility provided no additional information as to why the transition strips were not replaced.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure Resident #59 was treated with respect and dignity. This affected one resident (#59) of nine sampled residents. The facility census was 118. Findings include: Review of the medical record for Resident #59 revealed an initial admitted [DATE] with the diagnoses including but not limited to early onset Alzheimer's disease, chronic obstructive pulmonary disease, severe dementia with mood disturbance, psychotic disorder with delusions, major depressive disorder, hypertension, hyperlipidemia, osteoarthritis, mood disorder, sleep disorders, atrial fibrillation, anxiety disorder, insomnia, wandering in diseases, hypothyroidism, constipation, sleep apnea and drug induced secondary Parkinsonism. Review of the plan of care dated 10/28/22 revealed the resident needed assistance with activities of daily living due to impaired mobility, weakness, debility, secondary Parkinsonism, dementia, osteoarthritis, anxiety, depression and psychotic mood disorder. Interventions included resident required staff assistance with dressing. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the resident's monthly physician orders for November 2024 identified orders dated 10/28/22 for non-skid footwear. On 11/04/24 at 10:48 A.M., observation of Resident #59 revealed he was wandering behind the memory care unit nurse's station with one yellow non-skid sock on the right foot and a white low cut sock on the left foot. Licensed Practical Nurse (LPN) #235 was notified the resident's socks were not matching and of the same type. LPN #235 took Resident #59 to his room to change his socks. On 11/04/24 at 10:50 A.M., observation of Resident #59 revealed the resident had a yellow non-skid sock on his right foot and a navy blue non-skid sock on his left foot. LPN #235 verified the resident was not being treated in a dignified manner by having mismatched non-skid socks on. Review of the facility policy titled, Dignity, dated 01/02/24 revealed it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances each resident's quality of life by recognizing each resident's individuality. This deficiency represents non-compliance investigated under Complaint Number OH00159215.

Based on medical record review, staff interview, and policy review, the facility failed to ensure Resident #133's physician was notified of a blood pressure outside of the physician ordered parameters. This affected one (Resident #133) of nine sampled residents. The facility census was 118. Findings include: Review of the medical record for Resident #133 revealed an initial admitted [DATE] with the latest readmission of 08/21/24 with the diagnoses including but not limited to end stage renal disease (ESRD), puncture wound with foreign body of thorax, osteonecrosis of multiple sites, chronic obstructive pulmonary disease (COPD), stenosis of vascular prosthetic devices, implants and grafts, dependence on hemodialysis, renal osteodystrophy, chronic kidney disease (CKD), endocarditis, atrial fibrillation, seasonal allergic rhinitis, bipolar disorder, hypertension, hyperlipidemia, constipation, anemia and nicotine dependence. Review of the plan of care dated 06/07/24 revealed the resident was at risk for impaired cardiac output related to diagnoses anemia, hyperlipidemia, hypertension and hyperlipemia. Interventions included notify physician or Certified Nurse Practitioner (CNP) of blood pressures greater than 150/90, complete progress note, vital signs as ordered and indicated, notify physician of abnormalities, observe for signs/symptoms of cardiac dysfunction, administer medication as ordered, diet as ordered and follow up with cardiologist as needed/indicated. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the resident's monthly physician orders for November 2024 identified orders dated 10/03/24 to notify physician/Certified Nurse Practitioner (CNP) of blood pressure greater than 150/90, and complete a follow up progress note. Review of the resident's blood pressure revealed on 10/27/24 the resident's blood pressure was 161/93, on 10/28/24 the resident's blood pressure was 154/84, on 10/29/24 the resident's blood pressure was 153/92 and on 11/03/24 the resident's blood pressure was 159/87. Further review revealed no notification to the physician of the blood pressures outside of the physician ordered parameters or a follow up progress note. On 11/05/24 at 2:10 P.M., interview with the Director of Nursing (DON) verified the resident's physician was not notified of the blood pressures outside of the physician ordered parameters and a follow up progress note was not documented in the resident's medical record. It is the policy of this facility to promptly identify, respond to, and report changes in resident condition to the resident's physician/Certified Nurse Practitioner (CNP)/Physician Assistant (PA) and resident/resident representative. A significant change is a major decline or improvement of the resident's status. The nurse would notify the physician/NP/PA and the resident/resident representative when abnormal labs, weights, or vital signs.

Based on medical record review and staff interview, the facility failed to ensure sutures were removed as physician ordered for Resident #133. This affected one resident (#133) of nine sampled residents. The facility census was 118. Findings Include: Review of the medical record for Resident #133 revealed an initial admitted [DATE] with the latest readmission of 08/21/24 with the diagnoses including but not limited to end stage renal disease (ESRD), puncture wound with foreign body of thorax, osteonecrosis of multiple sites, chronic obstructive pulmonary disease (COPD), stenosis of vascular prosthetic devices, implants and grafts, dependence on hemodialysis, renal osteodystrophy, chronic kidney disease (CKD), endocarditis, atrial fibrillation, seasonal allergic rhinitis, bipolar disorder, hypertension, hyperlipidemia, constipation, anemia and nicotine dependence. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the resident's plan of care dated 10/25/24 revealed the resident has a laceration above his left eye with sutures in place and the sutures were to be removed in five to seven days. Interventions included observe for increase in size of bruise or development of new bruising, observe for signs of pain, provide pain medication as needed, observe resident environment for potential to cause skin trauma, document abnormal findings and notify physician, keep area clean and dry, observe for symptoms of infections (redness, drainage, warmth, increased pain), and treatment as ordered. Review of the medical record revealed the resident's sutures were removed at day 10 instead of the physician ordered five to seven days. On 11/05/24 at 2:10 P.M., interview with the Director of Nursing (DON) verified the sutures were removed at day 10 instead of the physician ordered five to seven days.

Based on observation, staff interview and facility policy review, the facility failed to maintain appropriate infection control practices during the administration of eye drops to prevent potential infection. This affected one resident (#70) of two residents observed for eye drop administration. The facility census was 118. Findings Include: On 11/04/24 at 9:33 A.M., observation of medication administration revealed Licensed Practical Nurse (LPN) #210 applied (donned) a pair of gloves at the medication administration cart, gathered Resident #70's medications which included a nasal spray and eye drops and entered the resident's room. The LPN assisted Resident #70 to take her oral medications. The LPN then used a tissue and wiped the tip of the Fluticasone 50 micrograms (mcg) nasal spray applicator. The LPN then administered two sprays of the Fluticasone 50 mcg in each nostril. The LPN using the same gloves administered one eye drop in each of the resident's eyes. LPN #210 verified the lack of infection control practices by not washing hands and changing gloves between the Fluticasone 50 mcg nasal spray administration and the artificial tears administration. Review of the facility policy titled, Hand Hygiene, dated 01/02/24 revealed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents or visitors. This applies to all staff working in all locations of the facility.

Based on observation, resident interview, and staff interview, the facility failed to maintain a safe, clean and comfortable environment. This affected two rooms on the 400 unit (room [ROOM NUMBER] and 408). The census was 137. Findings include: 1. On 09/19/24 at 2:35 P.M. observation of room [ROOM NUMBER] revealed a night stand with a drawer missing and finish coming off of it, food debris on floor, the wall had patches of drywall showing and the privacy curtain had dark stains. On 09/23/24 at 8:57 A.M. and 12:00 P.M. observations of room [ROOM NUMBER] revealed a mat to the floor with dark stains, a night stand with a drawer missing and finish coming off of it, there was food debris on floor, the wall had patches of drywall showing and the privacy curtain had dark stains. On 09/25/24 at 3:55 P.M. observations of room [ROOM NUMBER] revealed a mat to the floor with dark stains, a night stand with a drawer missing and finish coming off of it, there was food debris on floor, wall with patches of drywall showing and the privacy curtain had dark stains. This was verified on 09/25/24 at 3:55 P.M. during interview with the Director of Nursing. 07316 2. Observations on 09/17/24 at 11:55 A.M. revealed the sink in the bathroom in room [ROOM NUMBER] was clogged with standing, dirty water in the sink. Interview with the resident who resided in the room, revealed the sink gets clogged everyday. He stated the maintenance staff just unclogged it the day before and it just gets clogged again. Observations on 09/19/24 at 9:28 A.M. revealed the sink in the bathroom in room [ROOM NUMBER] was clogged with standing, dirty water up to the rim of the basin (ready to overflow). Interview with Maintenance Director #200 on 09/19/24 at 10:17 A.M. confirmed the sink in room [ROOM NUMBER] was clogged. He stated that a resident in room [ROOM NUMBER] puts food down the sink causing it to clog, although he did not know which resident (two residents residing in the room). He confirmed the sink had been clogged on previous occasions also. He stated he was not aware that the sink was clogged on 09/17/24 or 09/19/24, until the surveyor brought it to his attention. He stated he did not know if a work order had been put in for the clogged sink or not. Interview with Licensed Practical Nurse #168 (director of the memory care unit) on 09/19/24 at 10:30 A.M. confirmed the sink does get clogged frequently. She stated maintenance comes and unclogs the sink but then it just gets clogged again. She stated the residents in room [ROOM NUMBER] do not put food down the sink. She confirmed the residents would not be able to wash their hands with the sink basin completely full of dirty water. She stated she did not know why maintenance could not put something in the sink basin to strain/prevent particles from going down the sink if that is why they felt it was continually getting clogged. This deficiency represents non-compliance investigated under Master Complaint Number OH00157991 and Complaint Number OH00157451. This deficiency is evidence of continued non-compliance from the survey completed 06/18/24.

Based on medical record review, resident and staff interviews, review of a Self-Reported Incident (SRI), review of the activity log, and facility policy review, the facility failed to ensure residents were free from verbal abuse by another resident. This resulted in actual Psychosocial Harm when Resident #63 was cursed at, physically intimidated, and called inappropriate names by Resident #128 resulting in Resident #63 becoming afraid of Resident #128 and not attending activities or leaving her room for two days following the incident. This affected one (Resident #63) of five residents reviewed for abuse. The facility census was 128. Findings include: Review of Resident #63's medical record revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/22, revealed Resident #63 had moderately impaired cognition. Resident #63 required extensive assistance from two staff for bed mobility and transfers, and supervision for locomotion via wheelchair. Resident #63 did not have any behaviors indicated in the assessment. Review of Resident #63's care plan, revised 11/30/20, revealed Resident #63 preferred to structure her own day of activities including attending activities such as bingo, arts and crafts, and socializing with friends and peers. Resident #63 had a self-care deficit due to stroke with [CONDITION(S)] and [CONDITION(S)]. Interventions included bed mobility/transfers per staff assistance as needed and eating with staff set up help. Resident #63 propelled herself in a wheelchair and wore a vinyl glove on the hand she propelled herself with. Resident #63 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included one on one meetings as needed, ensure Resident #63's physiological needs are met, and provide a calm, reassuring and nonthreatening environment. Review of Resident #63's nurse's notes revealed on 09/23/22 at 6:07 P.M., the Nursing Home Administrator (NHA) called Resident #63's son to inform him Resident #63 was involved in a negative verbal conversation from a male resident (later identified as Resident #128). An SRI was submitted and further investigation would be completed. There were no additional notes related to the incident. On 09/28/22 at 6:30 P.M., MDS Nurse #222 completed an interview with Resident #63. Resident #63 stated she preferred to keep to herself as to not have any issues or incidents where she is involved. Resident #63 stated she felt mostly safe. Resident #63 stated she continued to be [NAME] or apprehensive about engaging with others at that time. Review of the psychiatric note, dated 09/30/22 at 1:00 A.M., revealed Resident #63 was seen from 12:02 P.M. to 12:18 P.M. by Psych Physician (PP) #529. During the session, Resident #63 presented as anxious, tearful/crying, cooperative, and engaged. There was no indication of any follow up with Resident #63 related to the verbal altercation that occurred with Resident #128 on 09/23/22. Review of the activity logs, dated 08/2022 and 09/2022, revealed Resident #63 engaged in group activities on 08/05/22, 08/18/22, 08/19/22, 08/25/22, 08/29/22, 09/05/22, and 09/12/22. Resident #63 did not attend any activities on 09/23/22, 09/24/22, or 09/25/22. Review of the closed medical record for Resident #128 revealed an admitted on 08/27/21 and a discharge date on 09/26/22. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #128's Annual MDS assessment, dated 08/11/22, revealed Resident #128 had intact cognition. No signs or symptoms of [CONDITION(S)] were indicated. No behavioral symptoms were indicated on the assessment. Review of Resident #128's nurse's notes revealed on 09/23/22 at 6:16 P.M., the NHA called Resident #128's wife to inform her Resident #128 was involved in a negative verbal conversation toward two female residents. Resident #128 was the verbal aggressor in the situation. On 09/24/22 at 12:29 A.M., Licensed Practical Nurse (LPN) #333 noted Resident #128 was both physically and verbally aggressive towards staff and other residents. Resident #128 had called Resident #63, who was on another hall, a (expletive). Review of Resident #128's care plan, dated 08/30/21, revealed Resident #128 exhibited behaviors of keeping alcoholic beverages in his room, drinking in the facility and being intoxicated, refusing medications at times, using inappropriate language/profanity as regular communication with staff and residents, making unwanted advances towards female residents at times, yelling and cursing at staff and other residents. Interventions included document behaviors per behavior management program, educate resident on facility policy of alcoholic beverages and risks of intoxication, social services to offer addiction intervention services and evaluation as needed, every 15 minute checks on resident's activity and location (09/23/22), maintain a safe environment, remove resident from situation, and notify physician and psych services for increases in behavioral symptoms. Review of the SRI, dated 09/23/22, revealed Resident #63's written statement stated she was sitting in the facility community room on 09/22/22, speaking with Resident #70, when Resident #128 approached her. Resident #63 felt like he may have wanted to harm me by the way he was looking at her and then Resident #128 got close to her by standing over her. Resident #128 called Resident #63 out of my name several times and was still looking down on her. Resident #63 wrote I got very scared because I thought he would do harm to me. He scared me and indicated she was elderly and paralyzed on the left side. Resident #63 continued, He kept calling me nasty names and standing over me, looking mean at me and cursing at me. Now I am nervous to come out of my room to be able to go to speak to my friends. I enjoy speaking with people but I am in fear of Resident #128. Review of the written witness statement from Resident #70, dated 09/23/22, revealed on 09/22/22, Resident #128 entered the community room from the smoking area and went toward her friend (Resident #63) looking for trouble. Resident #70 got up to protect Resident #63 from Resident #128. Resident #128 came nose to nose with me and said do not test me. Resident #128 backed off for only a few seconds and then turned around and came back to the community room and went towards Resident #63 again. Resident #128 called Resident #63 a (expletive), (expletive) and stupid. Resident #70 stood up again to intervene between Resident #128 and Resident #63. Review of the written witness statement from Resident #283, dated 09/23/22, revealed he saw a man (later identified as Resident #128) cussing at two ladies (later identified as Residents #63 and #70). Resident #128 said he would slap the (expletive) out of them and was calling them (expletive) and other words. Interview on 09/28/22 at 1:55 P.M. with the Director of Nursing (DON) revealed she had not witnessed Resident #128 be physically aggressive with any staff or residents, but Resident #128 was verbally aggressive. Resident #128 drank alcohol usually after hours and gave other residents money to get the alcohol for him. On 09/23/22, Resident #128 had a verbal altercation with two female residents (later identified as Resident #63 and #70) during which Resident #128 called the female residents names and was threatening toward them. Resident #128 was placed on 15 minute checks, was being seen by psych services, and was on medication for alcohol abuse. Interview on 09/28/22 at 2:13 P.M. with Medical Records (MR) #203 revealed she was not clinical but was familiar with Resident #128. MR #203 stated Resident #128 was easily agitated and became verbally aggressive toward staff and other residents, especially when he was drinking alcohol. MR #203 stated she had witnessed Resident #128 engage in verbal altercations during the day and had heard from staff that altercations also occurred at night. Interview on 09/28/22 at 3:25 P.M. with Resident #70 confirmed she was involved in a verbal altercation with Resident #128 on the evening of 09/22/22. Resident #70 stated she was talking with Resident #63 when Resident #128 entered the same area and started yelling and cursing at Resident #63. Resident #128 called Resident #63 (expletive) and (expletive). Resident #128 went directly to Resident #63 and got in her face and was nose to nose with her, standing over top of her, and pointing his finger in her face. Resident #70 stated she was scared for Resident #63. Resident #70 stated, I'm sure he was on something or was intoxicated. No facility staff were present to intervene when the incident occurred but she intervened to defend Resident #63. Resident #70 stated Resident #128 was completely unprovoked. Resident #70 stated she carried on with her normal routine following the incident but Resident #63 was scared to come out of her room for a couple of days. Interview on 09/28/22 at 3:45 P.M. with Resident #63 confirmed Resident #128 walked up to her and started yelling and cursing at her and calling her foul names, (expletive) and (expletive). Resident #63 stated Resident #128 was standing over top of her and she thought he was going to hit me. Resident #63 stated Resident #70 helped her. Resident #63 stated she was scared and intimidated by Resident #128. Resident #63 stated she stayed close to her room for a couple of days because she did not want to run into him again. Resident #63 stated she talked with Resident #70 but that was all she engaged in for the weekend following the incident. Interview on 09/29/22 at 8:47 A.M. with Unit Manager (UM) #318 confirmed a verbal altercation between Resident #128, Resident #63, and Resident #70 occurred on 09/22/22 around 8:00 P.M. Resident #70 reported the incident to her. UM #318 stated Resident #70 informed her that she and Resident #63 were approached by Resident #128 who was clearly on something or intoxicated and went after Resident #63. Resident #283 witnessed Resident #128 calling Resident #63 foul names including, (expletive), (expletive), (expletive). UM #318 stated both Resident #63 and Resident #70 reported being scared and intimidated by Resident #128. UM #318 confirmed Resident #63 did not leave her room as much as usual following the incident. Interview on 09/29/22 at 1:40 P.M. with Activities Director (AD) #206 confirmed Resident #63 liked to engage in group activities and regularly left her room prior to the incident on 09/22/22. Review of the facility policy, Abuse Prevention Program, revised 03/2021, revealed the policy stated, our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.

Based on observation, record review, facility policy and procedure review and interview the facility failed to implement adequate and individualized interventions to prevent the development of a deep tissue injury (DTI) (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) pressure ulcer to Resident #103's left heel. Actual harm occurred on 03/10/22 when Resident #103, who was severely cognitively impaired, required extensive assistance from two staff for bed mobility and had increased pain and decreased mobility of the left leg was found to have a DTI to the left outer heel. There was no evidence the facility had adequate interventions in place to prevent the development of the DTI and failed to ensure adequate interventions were implemented timely to promote the healing of the DTI following the development of the area. This affected one resident (#103) of one resident reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #103 revealed an initial admitted [DATE] with the latest re-admission of 04/14/22. Resident #103 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a plan of care, dated 10/30/21 revealed Resident #103 was at risk for skin breakdown. Interventions included assist with bed mobility to turn and reposition routinely as needed, assist with routine toileting as needed, check for incontinence care and provide incontinence care as needed, notify nurse of any redness or irritation, preventative skin care as ordered/indicated and skin inspection weekly and as needed, document and notify physician of any abnormal findings. The care plan did not include any pressure reduction/reducing interventions for the resident's heels. Review of an interdisciplinary team care plan conference summary, dated 02/08/22 at 1:30 P.M. revealed Resident #103 complained of increased pain in his leg/knee and expressed a desire to have as needed pain medication. The note indicated nursing would follow up. Record review revealed no changes to the resident's skin risk or mobility plan of care to implement pressure ulcer preventative measures for the resident's heels at that time. Review of a nurse's note, dated 02/10/22 at 6:35 P.M. revealed the resident reported pain rated a ten out of ten (most severe pain) on a standard pain scale with frequent pain to his left leg and upper extremity. The note also documented weakness to the area. The resident reported he fell on [DATE]. Record review revealed no changes to the resident's skin risk or mobility plan of care to implement pressure ulcer preventative measures for the resident's heels at that time. Record review revealed the resident was hospitalized from 02/10/22 to 02/20/22 due to a change in respiratory status. The resident was admitted and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a re-admission nursing assessment, dated 02/21/22 revealed the resident's heels were intact. Review of a nurse's note, dated 02/28/22 at 11:12 A.M. revealed the resident was complaining of pain when repositioning and changing resident. The resident's daughter voiced concerns related to the resident's pain to the physician and a new order was obtained for [MEDICATION(S)] 50 milligrams (mg) by mouth twice a day as needed (PRN) for 30 days. Review of a nurse practitioner (NP) progress note, dated 03/04/22 at 12:00 A.M. revealed the resident's [MEDICATION(S)] 50 mg was scheduled three times daily due to the resident not remembering to ask for the medication. The NP also ordered a left knee x-ray and to consider an orthopedic consult (due to continued complaints of pain to the left knee). Record review revealed no evidence the resident's skin risk or mobility of the left leg was re-assessed or interventions initiated to prevent skin breakdown. A NP progress note, dated 03/05/22 at 12:00 A.M. revealed the left knee x-ray results were reviewed, pain management was to continue with the addition of Advil (non-steroidal anti-[CONDITION(S)]) for five days and [MEDICATION(S)] gel. The note indicated, if pain persists will make orthopedic appointment. Record review revealed no evidence the resident's skin risk or mobility of the left leg was re-assessed or interventions initiated to prevent skin breakdown. Record review revealed no written evidence of skin breakdown to the resident's left heel or of documented pressure reducing/relieving interventions being implemented for the resident's heels between the 02/21/22 re-admission assessment and 03/10/22. Review of a pressure ulcer risk assessment, dated 03/10/22 revealed a score of 15 indicating the resident was at high risk for the development of pressure ulcers. There were no changes/updates to the 10/30/21 risk for skin breakdown plan of care following the completion of this assessment. Review of a nursing progress note, dated 03/10/22 at 4:22 P.M. and authored by Registered Nurse (RN) #246 revealed resident complained of left leg pain, on assessment this nurse notified stage one pressure ulcer on left heel, wound nurse notified. The note failed to provide any description or measurements of the left heel or evidence of interventions in place prior to or at the time this nursing progress note entry. The next nursing progress note, dated 03/10/22 at 5:00 P.M. (documented 38 minutes later) by the same RN, RN #246, revealed Resident #103 complained of left leg pain during activity of daily living care and upon assessment dark skin to the left heel was noted with the surrounding skin intact. The resident complained of pain rated an eight on a scale of one to 10 (with 10 being the most severe pain). The resident was medicated with [MEDICATION(S)] for pain and a bordered foam to the left heel was applied. The note indicated to change daily, elevate heels and pillows under both heels. The note also documented the nurse practitioner, family and physician were notified at that time. The nursing progress note failed to contain measurements or staging of the left heel ulcer at that time. Record review revealed no written evidence staff were elevating the resident's heels or ongoing use of pillows under both heels. Review of a nursing progress note, dated 03/11/22 at 9:24 A.M. and authored by Licensed Practical Nurse (LPN) #210 revealed this certified wound eval resident left heel for new reported area, phoned Healing Partners NP [nurse practitioner] after eval and uploading photo to tablet with concerns of arterial versus DTI. Review of a wound evaluation note, dated 03/14/22 (five days after the pressure ulcer was first identified) and completed by Wound Nurse Practitioner (NP) #275 revealed Resident #103 was being monitored for a DTI to left heel and noted to have a DTI to the left outer heel. The wound measured 3.07 centimeters (cm) in length by 2.32 cm width with an inability to measure the depth. The wound bed was black in color with the surrounding tissue reddish-pink. A new order was obtained to cleanse the heel with normal saline (NS) and apply skin prep twice a day. The note revealed to implement pressure reduction/offloading interventions to float heels, ensure compliance with turning protocol, elevate legs regularly and specialty bed (air mattress). However, record review revealed do written evidence staff were elevating the resident's heels or of the use of pillows under both heels. Review of a weekly wound evaluation note, dated 03/21/22 revealed the DTI present on the left outer heel measured 2.79 cm by 2.21 cm with an inability to measure the depth. The wound bed was black in color with the surrounding tissue being red. No changes to the treatment were made at that time. Review of a weekly wound evaluation note, dated 03/28/22 revealed the DTI present on the left outer heel measured 3.27 cm by 2.10 cm with an inability to measure the depth. The wound bed was black in color with the surrounding tissue being red. No changes to the treatment were made at that time. Review of a weekly wound evaluation note, dated 04/04/22 revealed the DTI present on the left outer heel measured 1.36 cm by 1.04 cm with the inability to measure the depth. The wound bed was black in color with yellow slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). The surrounding tissue was red. No changes to the treatment were made at that time. Review of an orthopedic consultation progress note, dated 04/08/22 revealed Resident #103 presented with left knee pain. The resident had been complaining of left knee pain following a fall occurring three weeks ago and had been unable to ambulate since the fall. The progress note documented the resident was unable to actively extend his left knee with a palpable defect present at the superior pole of the patella. The plan of treatment was for a quad repair on Monday, 04/11/22. The family was agreeable to the surgery to give him the best chance to be able to ambulate again. On 04/12/22 hospital records revealed the resident's left heel had a deep tissue injury pressure ulcer measuring two cm in length by two cm width that was present on hospital admission. The ulcer was described as dark purple in color. Recommendations to elevate the resident's heels were made at that time. Review of the resident's hospital discharge packet, dated 04/14/22 revealed the resident was taken to the operating room on 04/11/22 for a planned repair of a left quadricep tendon rupture. During the surgery the quad tendon was found to be intact but there was an effusion resulting in a 2.0 centimeter (cm) arthrotomy latterly through the quad tendon to explore the joint. The left knee joint was full of purulent fluid expressed at that time and a culture swab of the left knee joint was obtained. The area was irrigated with copious amounts of sterile water and a deep drain was placed. The culture of left knee was positive for an infection. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a plan of care, dated 04/15/22 revealed Resident #103 had impaired skin integrity related to a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) pressure ulcer to left outer heel. The care plan noted interventions included air mattress to bed, assess and document skin conditions, notify physician of any signs of infection, assess for pain and treat as indicated, assist with bed mobility to turn and reposition routinely, check for incontinence care and provide incontinent care as needed, notify nurse of any redness or irritation, ensure plus, float heels while in bed as tolerated, multivitamin as ordered, notify physician of worsening or not improving in wound, pressure reducing/redistributing cushion in chair and wound treatment as ordered. Record review revealed no indication to support a Stage II pressure ulcer at that time. Review of a weekly wound evaluation note, dated 04/18/22 revealed a DTI present on the left outer heel measured 2.17 cm by 1.34 cm with the inability to measure the depth. The wound bed was black in color. No changes were made to the treatment at that time. Review of the five-day Medicare Minimum Data Set (MDS) 3.0 assessment, dated 04/20/22, revealed the resident had clear speech, understood others, made himself understood and had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of four. The resident required extensive assistance of two staff members for bed mobility, transfers and ambulation had not occurred. The resident was frequently incontinent of bladder and always incontinent of bowel. The resident was assessed as being at risk for skin breakdown and had one Stage I pressure ulcer on admission to the facility and a DTI that was not present on admission. The facility implemented pressure reducing devices to bed and chair, turning/repositioning program, application of nonsurgical dressing, application of ointments/medication other than to feet and application of dressing to feet. Review of a weekly wound evaluation note, dated 04/25/22 revealed the DTI present on the left outer heel measured 2.17 cm by 1.91 cm with the inability to measure the depth. The wound bed was black in color. No changes to treatment were made at that time. On 04/29/22 the resident was provided an air mattress. Review of a weekly wound evaluation note, dated 05/02/22 revealed the DTI present on the left outer heel had evolved had evolved into a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer. The wound measured 1.91 cm by 1.41 cm by 0.1 cm. However, the wound was described to have slough tissue present and areas of black in color. The surrounding tissue was red in color. At this time the treatment was changed to cleanse the wound with NS, apply medical grade honey and cover with bordered foam gauze. Based on record review, it could not be determined how the facility identified the area to now be a Stage II with slough tissue present and the wound being black in color at this time. Review of a weekly wound evaluation note, dated 05/12/22 revealed the facility documented the pressure ulcer as a Stage II. The ulcer measured 2.15 cm by 1.90 cm by 0.1 cm with the wound bed covered with slough and areas of black in color. The surrounding tissue was reddish-pink in color. No changes to the treatment were noted at that time. Review of a weekly wound evaluation note, dated 05/16/22 revealed the facility documented the pressure ulcer as a Stage II to the left outer heel measuring 0.84 cm by 0.70 cm by 0.1 cm. The wound bed was described as reddish-pink in color with some slough tissue present. No changes were made to the treatment at that time. Review of a weekly wound evaluation note, dated 05/23/22 revealed the facility documented the pressure ulcer as a Stage II measuring 0.59 cm by 0.74 cm by 0.1 cm. The treatment order was changed at that time to cleanse with NS, apply hydrogel and cover with foam bordered gauze. On 05/24/22 a new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a weekly wound evaluation note, dated 05/31/22 revealed the facility documented the resident had a Stage II pressure ulcer to the left outer heel measuring 0.65 cm by 0.66 cm by 0.1 cm. On 05/31/22 at 9:55 A.M. Resident #103 was observed sitting in a specialized Broad chair with his feet/heels directly on the floor. The resident did not have any type of pressure reducing/reduction off-loading interventions in place to his heels at that time. On 06/01/22 an order was obtained for bilateral heel boots while in bed with special instructions the boots may be removed for care and to be laundered. This was the first evidence, prior to and following the development of the DTI to the left heel of heel boots being provided. On 06/02/22 at 11:25 A.M. Licensed Practical Nurse (LPN) #210 was observed providing the pressure ulcer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempts to straighten the resident's leg by the LPN were met with resistance. The physician ordered heel boots were not in place and were observed laying on the floor at the bottom of the bed. The resident was observed to have an air mattress in place at the time of the observation. The LPN placed a barrier on the bedside table and set-up the required supplies. She then washed her hands and applied a pair of disposable gloves. She positioned the resident's left foot on top of his right leg. She removed the soiled dressing, washed her hands and applied a clean pair of disposable gloves. She cleansed the wound with normal saline (NS) using a four by four gauze, applied hydrogel soaked gauze and covered the ulcer with a foam bordered dressing. The wound measured 0.65 cm by 0.66 cm by 0.1 cm and the wound bed was noted to be reddish-pink in color. On 06/02/22 at 9:29 A.M. interview with the resident's daughter revealed she lived out of state and visited the resident every couple of months. The daughter revealed when she visited the resident in December 2021 he was independent with activities of daily living (ADL) and she would take him out of the facility all day. She said when she flew back to visit in February 2022, the resident was balled up in bed and wouldn't let her touch his leg. She said the nurse said the physician was aware and the resident was being given Tylenol and Advil for pain. The daughter indicated obviously the medication was not helping his leg. She said she demanded something stronger for pain from the physician and that was when he ordered the [MEDICATION(S)]. The resident's daughter revealed the resident was now dependent on staff for all care and felt her father's decline was from neglect on the facility's part. She said the resident had numerous falls and started complaining of pain to his left leg which went untreated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/02/22 at 1:10 P.M. interview with the Director of Nursing (DON) revealed staff assisted the resident with turning and repositioning (although there was no documentation of turning and repositioning) prior to the development of the pressure ulcer and provided an air mattress to the resident on 04/29/22 (after the development of the DTI on 03/10/22). The DON was unable to provide evidence the resident's risk for pressure ulcer development to his heels had been comprehensively assessed prior to the identification of the DTI to the heel found on 03/10/22 or that effective interventions were in place prior to the development after the resident was noted to have decreased mobility and increased pain to his left leg. Review of facility policy titled Skin Management, dated 10/2019 revealed residents identified at risk for skin breakdown would have appropriate prevention interventions in place. This deficiency substantiates Complaint Number OH 676. This deficiency is an example of continued non-compliance from the survey dated 04/12/22.

Based on record review and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #5) out of three residents reviewed for monitoring of medication levels. Harm occurred to Resident #5 when orders for [MEDICATION(S)] (mood stabilizer) levels were not completed as ordered 15 days prior to the resident being sent to the hospital. Resident #5 developed symptoms of [MEDICATION(S)] toxicity seven days prior to being admitted to the hospital on 04/29/21. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE]. Resident #5 was discharged to the hospital on 04/29/21 and returned to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 10/16/20 revealed Resident #5 was at risk for complications related to medical conditions, medications, and treatments. Interventions included to document and notify the physician of abnormal findings. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of psychiatry progress note dated 04/14/21 revealed Resident #5 was admitted on [MEDICATION(S)] 450 milligrams (mg) twice a day. The psychiatry progress note revealed on 12/14/20 and 01/18/21 Resident #5's [MEDICATION(S)] level was within normal range. The therapeutic range for [MEDICATION(S)] was 0.6 to 1.2 mmol/L. A basic metabolic panel (BMP) and [MEDICATION(S)] level were ordered for drug therapy. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed Resident #5 was ordered a BMP and [MEDICATION(S)] level. Review of progress note dated 04/23/21 at 4:51 P.M. revealed Resident #5 was lethargic. The resident stated she felt tired. Resident #5 bilateral arms and upper torso was shaking. Resident #5 stated the shaking/tremors had been going on for a couple days. The nurse paged the physician. Review of alert note dated 04/26/21 at 5:40 P.M. revealed new orders were received for Resident #5 to have complete blood count (CBC), comprehensive metabolic panel (CMP), [CONDITION(S)]-stimulating hormone (TSH) test, hemoglobin A1c (HgbA1c), and urinalysis with culture and sensitivity (UA C&S) due to mental status change and lethargy. Review of the orders did not reveal a [MEDICATION(S)] level was reordered. Review of health status note dated 04/28/21 at 3:19 P.M. revealed Resident #5 had muscle twitches. The physician was notified, and a new order was received to refer the resident to a neurologist. Review of alert note dated 04/29/21 at 2:05 P.M. revealed Resident #5 was very confused in the morning but more alert in the afternoon. Review of Situation, Background, Assessment, Recommendation (SBAR) summary dated 04/29/21 at 4:53 P.M. revealed Resident #5 had altered mental status and required more assistance. An order was received to send Resident #5 to the emergency department for evaluation. Review of hospital records revealed Resident #5 was admitted to the hospital on 04/29/21 at 9:15 P.M. Review of the history and physical from the hospital dated 04/29/21 at 9:45 P.M. revealed Resident #5 reported she had been experiencing increased weakness and had been sleepier over the past couple of days. The resident also reported she had been shaky. Resident #5 had [CONDITION(S)] exacerbation, shakiness, generalized weakness and was tremulousness. Resident #5 had slight tachycardia with a heartbeat of 111 beats per minute and elevated blood pressure of 162/85 millimeters of mercury (mmHg). A chest x-ray revealed Resident #5 had cardiomegaly and mild vascular congestion suspected for [CONDITION(S)]. Resident #5 had acute [CONDITION(S)], [CONDITION(S)] exacerbation, shakiness weakness and tremulousness, and [CONDITION(S)]. The resident had an abnormal chest x-ray with cardiomegaly and vascular congestion with no prior history of [CONDITION(S)] or ischemic heart disease. Resident #5 had an elevated [MEDICATION(S)] level of 2.2 mmol/L. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital clinical summary dated 05/07/21 at 11:56 A.M. revealed Resident #5's [MEDICATION(S)] 450 milligram (mg) twice a day was to be discontinued. Interview on 05/14/21 at 10:57 A.M. Resident #5 stated she was admitted to the hospital for an adverse reaction to [MEDICATION(S)]. Resident #5 stated she was allergic to [MEDICATION(S)]. Interview on 05/14/21 at 1:05 P.M. Licensed Practical Nurse (LPN) #203 stated she was the nurse that sent Resident #5 to the hospital. LPN #203 verified Resident #5 had been having tremors and shortness of breath. Interview on 05/14/21 at 1:50 P.M. Director of Nursing (DON) verified the [MEDICATION(S)] level and BMP was not completed as ordered on 04/14/21. Review of Medscape website on 05/17/21 revealed [MEDICATION(S)] toxicity was anything over 2.0 mmol/L. Review of the National Center for Biotechnology Information website on 05/17/21 revealed the severity of [MEDICATION(S)] toxicity was often divided into three grades. Mild symptoms included lethargy, tremor, and fatigue. All patients with toxicity signs and symptoms should be admitted for monitoring in the hospital. This deficiency substantiates Complaint Number OH 067.

Based on observation, closed record review, staff interview and facility policy and procedure review the facility failed to implement individualized, comprehensive and effective interventions to prevent the worsening of a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer, failed to ensure timely assessments were completed, failed to modify treatment when the ulcer deteriorated and failed to prevent the development of three new pressure ulcers for Resident #115. This affected one resident (#115) of three residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. Actual harm occurred when Resident #115, who was assessed to be at high risk for pressure ulcer development and required staff assistance for bed mobility, ambulation and transfers developed two deep tissue injuries (DTI) (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) pressure ulcers and a new Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) pressure ulcer. There was no evidence comprehensive, individualized or effective interventions were in place to prevent the development of these pressure ulcers. Findings include: Review of Resident #115's closed medical record revealed an admitted [DATE]. The resident was discharged on [DATE] to an acute care hospital. At the time of the complaint survey, completed on 04/12/21 and 04/13/21 the resident remained out of the facility and therefore could not be observed. Resident #115 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's hospital discharge continuity of care, dated 12/09/20 revealed the resident had a DTI to the left knee with the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE] identified Resident #115 was admitted to the facility with a dark scab measuring 1.5 centimeters (cm) by 1.0 cm to her left front knee. The wound had no description or classification reflecting a pressure injury. Review of the pressure ulcer risk assessment, dated 12/09/20 revealed a score of 12 indicating the resident was at high risk for the development of pressure ulcers. Review of the plan of care, dated 12/10/20 revealed Resident #115 was at risk for skin breakdown. Interventions included to assist with bed mobility to turn and reposition routinely, assist with toileting, check for incontinence and provide incontinent care as needed, pressure reducing/redistributing cushion in chair, pressure reducing/redistributing mattress on bed and preventative skin care as ordered/indicated. Review of the plan of care, dated 12/11/20 revealed the resident had impaired skin integrity with a left knee wound. Interventions included to assess and document skin condition, notify physician of signs of infection, assist with toileting, check for incontinence and provide incontinent care as needed, wound treatment as ordered. A second plan of care, dated 12/24/20 revealed Resident #115 had skin trauma/wound/infection to the left knee. Interventions included to assess and document skin condition weekly and as needed, observe for sings of pain and provide pain medication as needed, observe for symptoms of infection and treatment as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/16/21 revealed Resident #115 had unclear speech, understood others, made herself understood and had no cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 13. The resident required one staff for bed mobility, extensive assistance of two staff for transfers and ambulation only occurred once or twice with the assistance of one staff. The assessment indicated the resident had a Stage IV pressure ulcer that was present upon admission. a. Review of the medical record revealed no weekly pressure ulcer evaluations were completed from 12/09/20 through 02/17/21 for the DTI to the resident's left knee. Review of the weekly pressure ulcer evaluation, dated 02/17/21 revealed the DTI declined to a Stage IV pressure ulcer measuring 6.2 centimeters (cm) in length by 9.2 cm width with 0.3 cm depth. The wound was described as 40% slough, 40% granulation and 20% muscle with a large amount of serous foul smelling drainage. The treatment at that time was to cleanse the wound with normal saline (NS), pat dry, apply Santyl ointment, apply calcium alginate and cover with a dry dressing daily for 30 days. Review of a nursing assessment, dated 02/19/21 revealed the resident was readmitted to the facility with an abrasion covered with a foam dressing to her left front knee. The assessment failed to contain a description, measurements or classification reflecting a pressure injury. Review of the weekly pressure ulcer evaluation dated 02/24/21 revealed a Stage IV pressure ulcer measuring 6.2 cm by 9.2 cm by 0.3 cm. The wound was described as 30% necrotic tissue, 20% slough, 20% granulation and 20% bone with a large amount of serous foul smelling drainage. There was no change in treatment to the wound. Review of the weekly pressure ulcer evaluation, dated 03/03/21 revealed a Stage IV pressure ulcer measuring 9.2 cm by 9.2 cm by 0.3 cm. The wound was described as 55% necrotic tissue, 20% slough, 10% granulation and 40% tendon with a large amount of serous foul smelling drainage. The assessment indicated the wound had worsened, however, there was no change in treatment to the wound at that time. Review of the weekly pressure ulcer evaluation, dated 03/10/21 revealed a Stage IV pressure ulcer measuring 9.8 cm by 8.9 cm by 0.3 cm. The wound was described as 55% necrotic tissue, 20% slough, 10% granulation and 15% tendon with a large amount of serous foul smelling drainage. The assessment indicated the wound had worsened, however, there was no change in treatment to the wound at that time. Review of the medical record revealed no documented evidence a weekly pressure ulcer evaluation was completed for the week of 03/17/21. Review of the weekly pressure ulcer evaluation, dated 03/24/21 revealed a Stage IV pressure ulcer measuring 16.2 cm by 15.8 cm by 0.3 cm. The wound was described as 60% necrotic tissue, 20% slough, 10% granulation and 15% tendon with a large amount of serous foul smelling drainage. The treatment was changed at this time due to worsening of the wound. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Review of the weekly pressure ulcer evaluation, dated 03/25/21 revealed the resident had developed a Suspected Deep Tissue Injury (SDTI) to her right hip measuring 7.0 cm by 7.0 cm with 100% dermis. The facility implemented a treatment to monitor the right hip and encourage the resident to turn and reposition every two hours as tolerated. Review of the weekly pressure ulcer evaluation, dated 03/25/21 revealed the resident had developed a SDTI to her left hip measuring 6.0 cm by 6.0 cm with 100% epidermis. The facility implemented a treatment to monitor the left hip and encourage the resident to turn and reposition every two hours as tolerated. Review of the weekly pressure ulcer evaluation dated 03/25/21 revealed the resident had developed a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) pressure ulcer to the left ankle measuring 2.5 cm by 2.0 cm by 0.1 cm with 25% slough and 75% skin with no drainage. The facility implemented an order to apply border gauze three times a week and also added an alternating air mattress at this time. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's notes from 12/09/21 through 03/30/21 revealed no documented evidence to support when each area was first identified, evidence the resident's family was notified of the new areas or changes in condition or what interventions were in place at the time of development or implemented to prevent additional development of skin breakdown. On 04/13/21 at 11:10 A.M. interview with the Director of Nursing (DON) verified the facility failed to implement interventions to prevent the worsening and development of new pressure ulcers for Resident #115. The DON also verified the facility failed to completed weekly pressure ulcer assessments as noted above. Review of facility policy titled Skin Management,dated 10/19 revealed was the policy of the facility to assess each resident to determine the risk of potential skin integrity impairment. Residents would have a skin assessment completed upon admission and no less than weekly by a licensed nurse in an effort to assess overall skin condition, skin integrity and skin impairment. All alterations in skin integrity would be documented in the medical record. All newly identified areas after admission would be documented on the weekly pressure/non-pressure evaluation. This deficiency substantiates Complaint Number OH 453.

Based on review of a facility self reported abuse investigation, medical record review, personnel file review, resident interview and staff interview the facility failed to ensure Resident #52 was free from sexual abuse by an employee. Actual Harm occurred on 02/05/20 when Housekeeper #150 engaged in sexual activity with the resident, who was dependent on staff for personal care and in bed, which was observed by Physical Therapy Assistant (PTA) #151, Resident #14 and the Director of Nursing (DON). This affected one resident (#52) of one resident reviewed for allegations of sexual abuse. Findings include: Review of the medical record for Resident #52 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) 3.0 assessment completed on [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, indicating the resident had intact cognition. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was totally dependent upon two staff for transfers. Review of a facility self reported incident form revealed on 02/05/20 at 3:15 P.M. an allegation of sexual abuse was reported to the Administrator. The report revealed an employee (Housekeeper #150) was in Resident #52's room and was receiving sexual favors. A statement from Physical Therapy Assistant (PTA) #151 stated she was returning Resident #14 to her room (Resident #52's room mate) when she saw Resident #52 laying in bed, bent over to the right side with her hand and head moving. She saw a man turn quickly towards the wall. PTA #151 did not feel comfortable leaving Resident #14 in the room so they turned around and left the room. As they were leaving the room, Resident #14 said Resident #52 was performing oral sex on Housekeeper #150. Resident #14 was later interviewed and repeated the statement of what she saw. The Director of Nursing (DON) was immediately notified. The DON then went to Resident #52's room. She observed Resident #52 rubbing Housekeeper #150's penis. A statement from the DON stated the Rehab Manager and one of the therapists came to her and stated PTA #151 and Resident #14 just saw a male housekeeper in Resident #52's room and it looked like the female was leaning off the bed with her head in the male staff members crotch. The DON documented she then went to Resident #52's room and when she walked in she saw the female resident rubbing the male staff member's penis. He was clothed at that time. She then instructed Housekeeper #150 to come to her office. She asked him what he was doing and Housekeeper #150 said nothing. He then said the resident was rubbing his stomach. The DON stated to Housekeeper #150 that was not what she saw and he needed to be honest and not lie. Housekeeper #150 then said the resident wanted to rub it. He confirmed this meant his private parts. Resident #52 was then interviewed by the Administrator and DON. The resident denied anything happened at all. She stated she did not touch Housekeeper #150 at all and was very defensive. Resident #52 had a white substance on her lips and around her mouth. The police were notified and Resident #52 continued to deny the incident but did ask when the employee would be back to work. A statement from Maintenance Director #152 (Housekeeper #150's supervisor) revealed Housekeeper #150 told him Resident #52 was rubbing his belly and her hand slipped to his junk. A statement from Employee #153 revealed she overheard Housekeeper #150 say he thought he got himself in trouble for a resident touching him inappropriately. Housekeeper #150 was immediately suspended and then terminated from employment at the facility. Interview with Resident #52 on [DATE] at 9:20 A.M. revealed she denied any type of abuse had occurred in the facility. She stated the facility fired a guy that worked there because they said she did something with his penis. She stated they called the police. She said nothing happened and what they were insinuating, she does not like. She stated this employee visited with her and they talked about her son and the employee was uplifting to her. She stated he never asked her to do anything sexually and she thought the facility went overboard. Interview with the Administrator and DON on [DATE] at 2:50 P.M. confirmed the sexual abuse allegation against Housekeeper #150 involving Resident #52 on 02/05/20. The DON stated after the therapist reported the allegation to her, she went to Resident #52's room and the resident was touching Housekeeper #150 over top of his pants in the private parts area. They confirmed the resident denied anything sexual happened. They confirmed Housekeeper #150 was terminated due to the allegation. The Administrator stated the allegation of sexual abuse was unsubstantiated by the facility due to the fact that the resident said it did not happen. Interview on 02/26/20 at 1:05 P.M. with PTA #151 revealed she had been employed with the facility as a PTA for the past two and a half years. She said she was treating Resident #52's roommate, Resident #14 and on 02/05/20 when she was returning Resident #14 to the room, Resident #52 was in bed and her bed was positioned so she had to push Resident #14 past the foot of the bed. She said the privacy curtain was not pulled and she saw the resident leaning out of the bed with her head and hands in motion mimicking someone providing oral sex. She said she could see a male turning to face the wall and adjusting his penis into his pants. She said she backed Resident #14 in next to her bed and realized the person in the room was an employee. She said she was in shock and told Resident #14 she had forgotten her blanket in the therapy room and would be right back. She said she ran to the therapy room and retrieved her blanket and went straight back to the room. She said Housekeeper #150 was still in the room. She said she didn't want to leave Resident #14 in the room, so she told her she was going to take her and adjust her wheelchair leg rest. She said she was pushing Resident #14 out the door and Resident #14 said, she was sucking (explicative). She said she asked Resident #14 if this went on all the time and she said yes but that was the first time she had seen it. PTA #151 revealed she went straight to her supervisor and reported what she had seen. She said they went back to the room and Housekeeper #150 was still in the room and that was the end of her story with the incident. She said she was the only PTA right now in the building, so she was the one who provided the care for Resident #14 daily. She said she did notice Housekeeper #150 spent a lot of time in the resident's room but didn't feel like anything was going on. She said there was a Friday she did think something was off and thought maybe he was being inappropriate with Resident #14, so she did take her to a private area and asked her if the housekeeper had ever touched her in any way or been inappropriate with her. She said Resident #14 denied any inappropriate interactions involving the housekeeper. Review of Housekeeper #150's employee file revealed the employee had been hired by the facility on 07/24/19. A letter of termination dated 02/07/20. The letter served as a formal notice of involuntary separation for violation of the company's code of conduct. The letter indicated as a team member, we had a responsibility to uphold and abide by our core values and code of conduct. Your actions and own admittance on Wednesday 02/05/20 clearly violated the facility's code of conduct. Your actions were a clear failure to act morally and ethically. Therefore, as a result of your actions we will be immediately separating your employment. In addition, review of the Review of the Housekeeper #150's personnel file revealed no evidence the facility had requested a criminal records check with the BCII at any time during Housekeeper #150's employment with the facility. Review of the facility policy titled Abuse Prevention Program, dated 02/22/18 revealed a policy statement which indicated our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptom. Policy interpretation and implementation revealed the facility was committed to protecting residents from abuse by anyone including, but not limited to facility staff. The program policy defined sexual abuse as non-consensual sexual contact of any type with a resident. The facility policy failed to include language which prohibited employees from engaging in any type of sexual activity with residents. This deficiency substantiates Self-Reported Incident Control Number OH 199.

Based on observation, measurement of hot water temperatures, observation of the facility's hot water supply tanks, staff interview, review of the facility's hot water temperature log, review of the facility water tempter explanation and instruction guide and review of information provided from the American Burn Association and Centers for Disease Control, the facility failed to ensure hot water in the 100 hallway central shower room, central bathroom and resident rooms was maintained at safe temperatures to prevent injury. This resulted in the potential for serious harm which could result from burns from hot water. Immediate Jeopardy occurred when the facility failed to adequately monitor water temperatures resulting in water temperatures between 123 and 143 degrees Fahrenheit (F). This affected Residents #1, #7, #14, #28, #35, #36, #40, #43, #44, #47, #48, #50, #57, #58, #69, #70, #74, #77, #78, #81, #84, #89, #91, #92, #97, #103, #116, #121, #124, #130, #136, #138, #139, #171, #186 and #199, who resided in rooms where the water temperatures were above 120 degrees F. Of the 36 residents noted above residing in the rooms affected, the facility identified eight residents (Residents #28, #43, #44, #47, #69, #97, #139 and #171) who were assessed to have moderate to severe cognitive impairment and were independently mobile. Forty-six residents resided on the 100 unit. The facility census was 140. On 05/03/16 at 3:18 P.M., the Administrator was notified Immediate Jeopardy began on 04/18/16 at approximately 9:30 A.M. when review of the facility ' s water temperature log revealed the hot water in Resident #28 and Resident #92 ' s bathroom measured 127 degrees F. The lack of corrective action at that time resulted in hot water temperatures, obtained by the survey team on 05/03/16, ranging from 123 degrees F to 143 degrees F in resident rooms identified above, the central shower and central bathroom on the 100 hallway which posed a significant safety risk and risk for serious burns to the residents residing on the unit. The Immediate Jeopardy was removed on 05/04/16 when the facility implemented the following corrective actions: · On 05/03/16 at 3:40 P.M. the Administrator provided education to Maintenance Supervisor #12 and Maintenance Staff #10 and #11 related to immediate response to hot water temperatures above 120 degrees F. · On 05/03/16 at 4:20 P.M. the Administrator provided education to unit manager staff, Registered Nurse (RN) #193 and Licensed Practical Nurses (LPN) #191 and #192 regarding reporting elevated temperatures and concerns related to hot water temperatures. · On 05/03/16 at 4:25 P.M. RN #193 and LPNs #191 and #192 began educating the current direct care staff working on the day shift regarding elevated water temperatures and reporting concerns. · On 05/03/16 at 5:00 P.M., the facility implemented a water temperature monitoring schedule. Hot water temperatures were to be checked maintenance or designee every two hours for 48 hours, then twice a day for one week, then daily for one week and then weekly thereafter. · On 05/03/16 at 4:38 P.M. an external vendor evaluated the heating system. A regulator was recommended. The Administrator approved the purchase and the regulators were ordered. On 05/03/16 at 7:30 P.M. RN #193 and LPNs #191 and #192 began educating the current staff working on the afternoon shift regarding elevated water temperatures and reporting concerns. · 05/04/16 hot water temperatures were checked every two hours by Maintenance Supervisor #12 or designee in the bathrooms of the following rooms, 102, 105, 108, 110, 113, 115, 117, 120, 124, 127, 201, 206, 207, 210, 213, 216, 217, 220, 223, 228, 303, 304, 305, 306, 307, 308, 309, 310, 311, 312, 402, 403, 04, 405, 406, 407, 408, 409, 410 and 412 and revealed they were between 105 and 120 degrees F. · On 05/04/16 at 6:57 P.M., RN #193 and LPNs #191 and #192 provided evidence that education had been provided to all 302 facility staff regarding elevated water temperatures and reporting concerns. · On 05/09/16 between 5:10 P.M. and 5:23 P.M., interviews regarding the facility provided education on hot water temperatures were conducted with four LPNs #20, #35, #38 and #100 and four State tested Nursing Assistants (STNA) #126, #169, #170 and #187. All staff interviewed were knowledgeable of the facility ' s hot water policy and who to report elevated hot water temperatures to. Although the Immediate Jeopardy was removed on 05/04/16, the facility remained out of compliance at Severity Level 2 (potential for more than minimal harm that is not Immediate Jeopardy) as the water regulator device had not been received or installed and the facility was continuing with hot water audits. The facility also failed to ensure adequate supervision and/or assistive devices were in place for Resident #193 related to turning in bed, Resident #155 related to fall risk, Resident ##34 related transfers and Resident #230 related to smoking. This affected four additional residents (Resident #193, #155, #34 and #223) reviewed related to abuse, falls and smoking. Findings Include: 1. On 05/03/16 beginning at 8:30 A.M. hot water temperatures were obtained on the 100 unit hallway, using a bayonet thermometer which included temperatures obtained in resident rooms, the central shower room and central bathroom. The following temperatures were noted: On 05/03/16 at 10:34 A.M., the hot water temperature in Resident #69 and #186 ' s room was 126 degrees F. This water temperature was verified by Maintenance Staff #10 at the time it was obtained. At 10:35 A.M., the hot water temperature in Resident #1 and Resident #36 ' s room was 127 degrees F. This water temperature was verified by Maintenance Staff #10 at the time it was obtained. At 10:36 A.M., the hot water temperature in Resident #7 and Resident #121 ' s room was 127 degrees F. The water temperature was verified by Maintenance Staff #10 at the time it was obtained. On 05/03/16 at 10:36 A.M. observation of the mechanical room with Maintenance Staff #10 revealed two hot water tanks which served the 100 and 300 halls. Maintenance Staff #10 reported the water from the two tanks circulated throughout the 100 and 300 halls and the tanks had a mixing valve to help regulate the temperature. Maintenance Staff #10 stated the temperature gauge in the maintenance room reflected the temperature the water would be when going to the residents ' rooms. Maintenance Staff #10 confirmed at the time of the observation the temperature on the gauge located in the mechanical room was 122 degrees (F). On 05/03/16 beginning at 11:23 A.M. the following temperatures were obtained: Resident #78 and #139 ' s room: 123 degrees F Resident #84 and #136 ' s room: 134 degrees F Resident #14 and 50 ' s room: 134 degrees F Resident #199 ' s room: 134 degrees F Resident #48 and #89 ' s room: 134 degrees F Resident #43 and #58 ' s room: 136 degrees F Resident #47 and #124 ' s room: 136 degrees F Resident #103 ' s room: 132 degrees F Resident #57 and #97 ' s room: 122 degrees F Resident #40 and #77 ' s room: 126 degrees F Resident #70 and #116 ' s room: 126 degrees F Resident #81 and #171 ' s room: 143 degrees F Resident #69 and #186 ' s room: 142 degrees F Resident #28 and #92 ' s room: 141 degrees F Resident #7 and #121 ' s room: was 142 degrees F. Resident #91 and #130 ' s room: 135 degrees F Resident #35 and #183 ' s room: 135 degrees F Resident #44 and #74 ' s room: 130 degrees F Resident #1 and #36 ' s room: 138 degrees F The 100 hallway central bath sink: 142 degrees F. On 05/03/16 at 11:38 A.M. observation of the hot water tanks serving the 100 and 300 halls revealed the 75 gallon hot water tanks were set on 130 degrees F and the 130 gallon tank thermostat was set on A . Maintenance Director #12 reported the A setting was for water temperatures of 130 degrees F. Maintenance Director #12 verified on 05/03/16 at 11:40 A.M. the temperature gauge past the mixing point from the two hot water tanks indicated the water temperature was 134 degrees F. Maintenance Director #12 reported the facility set the temperature of the hot water tanks at 130 degrees (F), because when the temperature was set at a lower setting, the facility experienced problems maintaining an acceptable hot water temperature on the 300 hall. On 05/03/16 at 11:43 A.M., the hot water temperature in the central bathroom sink was obtained with Maintenance Director #12. Maintenance Director #12 was observed placing the stem of the bayonet thermometer through the water flow with the tip of the thermometer not in contact with the water. Maintenance Director #12 obtained a reading of 111 degrees F, however steam was observed to be rising from the water flow. When the temperature was obtained by the surveyor by immersing the thermometer into the water flow with the tip of the thermometer and the shaft of the thermometer coming in contact with the water, the temperature was 142 degrees F. This was confirmed by the Maintenance Director #12 who then placed his thermometer into the water flow with the tip of the thermometer and the shaft of the thermometer immersed and found the temperature was 142 F. On 05/03/16 at 11:50 A.M., Maintenance Director #12 obtained the temperature of the hot water in the common shower and it was 139 degrees F. Maintenance Director #12 also confirmed the temperature of the water in Residents #69 and #186 ' s room was 142 degrees F at that time and said he did not need to obtain or confirm any other of the hot water temperatures noted above because he felt they were all correct and verified they were too hot. On 05/03/16 at 11:52 A.M., Maintenance Director #12 reported he had not been trained in the use of the bayonet thermometer. However, he had just ordered a new thermometer which may have directions on the package. Review of the directions for the use of a digital pocket thermometer, revealed the thermometer stem was to be immersed at least 1.2 centimeters (cm) for accurate readings. The directions on the back of the package demonstrated using the pocket case holder to hold the thermometer while placing the stem into the product to be tested . Interview with Maintenance Staff #10 on 05/03/16 at 12:10 P.M. revealed on 04/18/16 he obtained a temperature of 127 degrees (F) in Resident #28 and Resident #92 ' s room. Maintenance Staff #10 revealed he checked to make sure the temperature on the hot water tank was set at 122 degrees (F) at the mixing valve (this is a mechanical device that mixes cold water with hot to maintain a constant temperature) at that time. Maintenance Staff #10 verified he adjusted the hot water temperature but did not recheck the water temperature after the adjustment. Maintenance Staff #10 verified he did not recheck the hot water temperature of Resident #28 and Resident #92 ' s room or a room close to the hot water supply tanks the following week. Maintenance Staff #10 revealed the hot water in the resident rooms was hotter in the rooms closest to the hot water tank, which would be Rooms 121 to 128. On 05/03/16 at 12:12 P.M., review of the hot water temperature log for 2016 revealed between 01/04/16 and 04/25/16, the hot water in rooms closest to the hot water tank (Rooms 121-128) were only checked once, on 04/18/16. This finding was verified by Maintenance Staff #10 On 05/03/16 at 2:00 P.M., interview with the Administrator revealed she had been notified earlier in the day of the hot water temperatures being too high in resident rooms, the central shower and central bathroom. The Administrator revealed following the notification to her, all residents who were identified as having impaired cognition who were independently mobile were assessed for impaired skin integrity and burns. The Administrator indicated no injuries were noted. The Administrator also stated she had contacted an outside vendor to come and check the hot water supply. On 05/03/16 at 6:05 P.M., interview with the outside vendor technician revealed the hot water tank was previously set at 130 degrees F and the technician adjusted the tank to 115 degrees F. The technician reported the facility needed to install a safety device to ensure the water temperature would not elevate above 120 degrees F. The technician said he submitted a proposal on the cost of installing the device on both water heating supply systems the facility currently used. Observations on 05/06/16 between 1:36 P.M. and 3:35 P.M. revealed Residents #28, #69, #139 and #47 were able to independently propel themselves throughout the unit in their wheelchairs. Interview with STNA #170 on 05/06/16 at 3:45 P.M., revealed Resident #44, #171 and #139 ambulated and toileted independently and Resident #28 propelled herself to the bathroom to toilet independently. Review of the facility ' s undated, water tempter explanation and instructions revealed the maintenance manager and or staff were required to keep a weekly log for hot water temperatures throughout the building. The instructions revealed the Maintenance Supervisor could select various locations each week. According to the American Burn Association, the severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees F. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140 degrees F, it takes five seconds or less for a serious burn to occur. Since immediate removal of the hot liquid from the skin may lessen severity, splash and spill burns may not be as deep as burns suffered in a bathtub. According to the Center for Disease Control (MMWR Weekly, 09/18/09), adults over age 65 have a worse prognosis than younger patients after scald burns because of age-related factors and comorbid medical conditions, and are subject to more extensive medical treatment. Compared with younger adults, older adults with scald-related burns are more frequently admitted to hospitals, experience longer intensive-care unit and hospital stays, and have increased hospital mortality. 2. Review of Resident #193's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #193's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/16/15 revealed the resident was severely cognitively impaired. The MDS revealed the resident was dependent on two or more staff for bed mobility and to transfer. Review of Resident #193's medication administration record revealed on 02/20/16 the resident complained of pain and received a pain medication (Tylenol). On 02/21/16 a right shoulder x-ray was obtained and revealing degenerative joint disease of the right shoulder, no fracture or dislocation was seen. Review of a facility self reported incident form (SRI), dated 02/20/16 revealed Resident #193 alleged she was physically abused by State tested nursing assistant (STNA) #163. The resident alleged STNA #163 was rough with her when providing care. Review of the witness statements revealed on 02/20/16 Resident #193's granddaughter came to visit her at 2:25 P.M. The granddaughter stated Resident #193 was crying so hard she was red and barely breathing. Resident #193 reported to her granddaughter a nurse slammed her against the wall while she was in bed. The granddaughter reported the nurse was trying to get Resident #193 to turn on her side and the resident was not able to do this. Resident #193 reported the nurse put her weight on her shoulder and pushed her into the wall. The resident revealed to her family member she was barely able to move her right arm and when she did she had pain. Review of STNA #163's statement revealed she went to check and change Resident #193. STNA #163 stated while she was providing care and when she turned the resident, the resident's bed moved causing the resident to think the STNA threw her against the wall. The statement indicated the next time she would make sure the bed was locked securely before performing care. On 05/06/16 at 10:25 A.M. interview with STNA #163 verified she was providing care for Resident #193 on 02/20/16. The STNA indicated no other staff were assisting her with providing care. The STNA indicated when she went to turn the resident the bed moved causing the resident to fall into the wall. The STNA revealed she should have checked the bed to make sure it was locked before attempting to provide care. The STNA also indicated she frequently provided care to Resident #193 by herself and was unaware the most current MDS assessment reflected two staff were required for bed mobility/turning. 3. Review of Resident #155's medical record revealed the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #155's annual MDS 3.0 assessment, dated 04/10/16 revealed the resident was severely cognitively impaired. The resident required extensive assistance of two or more staff to walk in her room and the resident was dependent on one staff for locomotion on and off the unit. The MDS revealed the resident had sustained two or more falls with no injury during the referenced time period. Review of Resident #155's May 2016 monthly physician orders [REDACTED]. Review of the fall investigations revealed on 03/01/16 at 9:38 P.M. Resident #155 slid to the floor from the side of her bed. On 03/02/16 the intervention to prevent further falls included encouraging the resident to be in in common areas when she was out of bed, have therapy evaluate for wheelchair positioning, and resident to have a pommel cushion in wheel chair. Record review revealed no therapy evaluation was conducted after the fall on 03/01/16. On 04/07/16 at 11:49 P.M. Resident #155 was found on floor in the doorway sitting on her buttocks she was agitated and the pommel cushion was noted to be in the hallway. The resident was checked on by staff every 15 minutes On 04/28/16 at 4:00 P.M. Resident #155 was found laying on the floor in front of her wheelchair. The resident's pommel cushion was found by the resident's closet A new intervention was to add a slip resistant material below and above the resident's pommel cushion. Observations of Resident #155 on 05/02/16 at 11:21 A.M. and on 05/03/16 at 8:05 A.M. revealed she did not have a defined parameter mattress on her bed. Observation on 05/05/16 at 9:15 A.M. revealed the resident was her room in a wheelchair with no pommel cushion in the wheelchair and no anti-roll back brakes on the wheelchair. The resident was again observed at 6:15 P.M. sitting in the hall in a wheelchair with no pommel cushion On 05/07/16 at 10:02 A.M. the resident was observed laying in bed with no defined parameter mattress. Interview of LPN #191 on 05/07/16 at 10:30 A.M. confirmed Resident #155 was to have a pommel cushion in her wheelchair, anti roll back brakes on the wheelchair and a defined parameter mattress on her bed. The LPN verified these interventions were not in place at this time. This LPN also confirmed no therapy evaluation was completed after the resident fell on [DATE]. 4. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #34's annual Minimum Data Set (MDS) 3.0 assessment, dated 03/09/16 revealed this resident had short and long term memory problems, recalled location of room, and staff names and faces and had moderately impaired decision making. This resident rejected care one to three times a week, and was dependent on two or more staff for bed mobility, and transfers. Review of Resident #34's May 2016 monthly physician orders [REDACTED]. Review of Resident #34's plan of care for activities of daily living revealed the use of a mechanical lift was an intervention for transferring the resident. Interview of STNA #148 on 05/05/16 at 10:00 A.M. revealed the resident transferred from the bed to to the chair and from the chair to the bed with staff assistance. The STNA stated Resident #34 stands up and two STNA's using a gait belt transfer the resident. Interview of LPN #42 on 05/05/16 at 10:10 A.M. revealed the resident stands for transfers. The STNAs use a gait belt and two STNA transfer him. This LPN stated the resident could stand and pivot. Interview of Registered Nurse (RN) #93 on 05/06/16 at 11:13 A.M. revealed Resident #34 was assessed to require a mechanical lift for transfers and the STNA staff should not transfer him without the lift. 5. Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #230 was assessed on 04/13/16 to be independent with all activities of daily living and no behaviors were identified. Review of the physician orders [REDACTED].M. dose of medications. The smoking assessment completed on 04/13/16, upon admission indicated Resident #230 chose not to smoke. The MDS 3.0 assessment completed on 04/20/16 revealed Resident #230 was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15 Review of the medical record revealed a smoking assessment completed on 05/02/16 indicated there was a significant change in Resident #230's condition and Resident #230 choose to smoke. The Smoking Assessment on 05/02/16 indicated Resident #230 had no cognitive, communication, physical ability delays and was observed to smoke safely. Summary of evaluation completed on 05/02/16 indicated Resident #230 must be supervised by staff, volunteer, or family member at all times when smoking. Review of the plan of care for Resident #230 identified that Resident #230 was allowed to have unsupervised leave of absence. On 05/03/16 at 08:49 A.M. Resident #230 was observed smoking in an undesignated smoking area at the front of the facility. During an interview with Resident #230, he stated he was informed the designated smoking area was across the street at the park, however he did not want to walk that far. Resident #230 stated he had smoked at the undesignated smoking area location yesterday after they had changed the smoking rules. Resident #230 reported that previously he had been able to go to the designated area in the court yard, however now this area was only used at designated times and he would exit the facility through the front door to smoke. Resident #230 stated he was allowed to possess his own cigarette and lighter. Resident #230 also shared he had an electronic cigarette in his pocket and showed it to the surveyor. On 05/03/16 at 8:55 A.M. during an interview with the Director of Nursing (DON), she stated residents identified as 'independent smokers' could sign out of the facility on a leave of absence (LOA) and go outside of the facility and smoke whenever they would like. The DON reported residents were supposed to go to the park area to smoke. The DON confirmed Resident #230 did possess his own cigarettes and lighter. The DON stated she was aware that residents were smoking on the facility in undesignated smoking areas. On 05/09/16 at 5:13 P.M. during an interview with State tested Nursing Assistant (STNA) #187, the STNA reported he had been working at the facility for three weeks. STNA #187 reported Resident #230 had been smoking independently since he had started working at the facility. On 05/09/16 at 5:14 P.M. Licensed Social Worker (LSW) #61 reported nursing was responsible for completion of the smoking assessments. LSW #61 stated she had observed Resident #230 smoking independently since he was admitted to the facility. On 05/10/16 at 8:24 A.M. during an interview with the Administrator, she confirmed Resident #230 had not signed a Smoking Contract which governed the regulations for the use and possession of tobacco at the facility. The Administrator stated this contract and Smoking Policy was applicable for e cigarettes also. Review of the Smoking Policy dated January, 2014 indicated that B) Residents may only smoke in designated locations and at specified times and C) Smoking materials will be retained and distributed by the facility staff to the residents during the designated smoking times: No resident is permitted to maintain or store smoking materials on their person or in their room.

Based on observation, staff interview, review of the facility's Abuse policy, review of a facility self-reported incident (SRI), review of discipline documentation, review of Managing Employee Burnout Protocol, and review of the facility abuse investigation, the facility failed to identify staff burnout and encouraged staff expressing frustration and burnout to continue to provide care to residents resulting in staff to resident physical and verbal abuse. This resulted in Immediate Jeopardy for one resident (Resident #233) when State tested Nurse Aide (STNA) #207 was physically and verbally abusive to Resident #233. Resident #233 sustained actual harm when he was thrown into a chair and cursed at. This affected one of two residents reviewed for abuse (Resident #233) and had the potential to affect all 141 residents. The facility census was 141. On 05/05/16 at 4:03 P.M., the Administrator was notified Immediate Jeopardy began on 04/26/16 at 10:30 P.M. when STNA #207 reported to RN #193 she was frustrated and did not want to work at the facility. RN #193 persuaded STNA #207, who had already exhibited signs of burn out on 04/22/16 at 1:00 P.M. when she was in the hallway yelling profanity at the nurse as observed by Activity Director #54, to continue to work and provide care to residents. There was no evidence RN #193 reported STNA #207 ' s sign of burnout to the Administrator. At 5:55 A.M. Resident #233 reported to RN #109 that STNA #207 threw him into his chair and told him he was not her expletive patient. At 6:15 A.M. STNA #207 was laughing and giggling as she told RN #193 she was leaving the facility because she went off on Resident #233 and threw him into his chair. The Immediate Jeopardy was removed on 05/05/16 at 7:15 P.M. when the facility implemented the following corrective action: · On 04/26/16 at 6:30 A.M. STNA #207 resigned and was no longer employed by the facility. · On 05/05/16 at 4:45 P.M. the Regional Director of Clinical Service educated the Administrator and DON regarding abuse investigations, conducting a thorough investigation and identification of signs and symptoms of employee burnout. · On 05/05/16 at 4:50 P.M. fourteen (14) department managers across all disciplines were educated by the Regional Director of Clinical Services regarding identification of signs and symptoms of employee burnout and abuse. · On 05/05/16 at 5:00 P.M. the DON, LPN #122, #191, #192, RN #105, #193, and Admission Staff #66 initiated interviews with 111 interviewable residents regarding abuse. · On 05/05/16 at 7:15 P.M fourteen (14) department managers provided one on one education with 56 in house employees on the facility Abuse policy and procedure dated January, 2016 and the undated Burn Out Protocol. Staff not working on 05/05/16 were contacted by six department managers via telephone on 05/05/16 at 7:15 P.M. regarding abuse and burnout. Any employees not reached by telephone on this date will not be permitted to work until training is received. · On 05/05/16 between 2:47 P.M. and 3:20 P.M. interviews with LPN # 26, LPN #191, Physical Therapy Assistant #207, STNA #169, and STNA #147 revealed the staff were knowledgeable regarding the facility's Resident Abuse and Employee Burnout policies and procedures. · On 05/06/16 the Regional Director of Clinical Services or designee began auditing previous resident allegations of abuse to ensure an appropriate and thorough investigation was conducted on each incident. Future auditing was scheduled to be completed for 30 days, once weekly for four weeks, and monthly for two months. · On 5/06/16 at 10:00 A.M., RN #105 interviewed six residents, who had not yet been interviewed, regarding resident abuse. · On 05/06/16 at 10:00 A.M. the facility completed an updated Resident Abuse policy and procedure. · On 5/06/16 at 11:15 A.M. the Regional Director of Clinical Services educated the DON and Administrator on the revised Resident Abuse policy dated May, 2016. The changes included notification of the Regional Director of Clinical Services and reaching a conclusion. · On 05/06/16 at 12:00 P.M. the facility submitted an addendum to the SRI regarding Resident #233 substantiating the allegation of physical abuse on 04/26/16 to the State Survey Agency · On 05/06/16 at 4:45 P.M. the facility implemented random post testing with 11 facility staff to facilitate retention of education provided. Social Services or designee will conduct the random testing three times weekly for one month, then weekly for four months. · On 05/06/16 at 4:45 P.M. the facility conducted an Abuse/Burn Out post- test for 10 employees. · On 05/07/16 at 4:15 P.M. the facility placed posters in the employee break room and above the time clock which addressed/provided key facts regarding Abuse reporting and employee burn out to facilitate retention of education provided. · By 05/13/16 the Corporate Social Services Director or designee will conduct facility wide training on sensitivity, stress management, and dealing with difficult residents. Although the Immediate Jeopardy was removed, 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 had not completed all staff in-service education on the Abuse policy and had not conducted facility wide training on sensitivity, stress management, and dealing with difficult residents. Findings Include: Review of the medical record for Resident #233 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment completed on 04/28/16 indicated Resident #233 was alert and oriented with mood described as feeling down, depressed or hopeless, feeling tired or having little energy, and difficulty concentrating on things. No behaviors were identified. Resident #233 needed extensive assistance with activities of daily living including bed mobility, transferring, walking in room and corridor, and locomotion on the unit. Resident #233 was identified as high risk for falls and was assessed as being able to smoke independently. Review of the plan of care (POC) for Resident #233 indicated the resident was non-compliant with care. Review of an SRI dated 04/26/16 indicated a physical abuse allegation was made by the resident. The report indicated Resident #233 complained that STNA #207 was rough with him on 04/26/16 at 5:50 A.M. when she assisted him with transferring into the wheelchair. Resident #233 also alleged STNA #207 used unprofessional language while she was assisting him. According to the SRI, STNA #207 was immediately suspended during the investigation. A statement from RN #109 completed on 04/26/16 at 5:55 A.M. revealed she had asked STNA #207 to help Resident #233 to his wheelchair. RN #109 reported she heard some noise from the resident ' s room. RN #109 stated Resident #233 came out of his room as STNA #207 was walking down the hall and stated nurse, she almost made me fall; she threw me into the chair and said she didn ' t ' t give a damn, I ' m not her patient anyway . RN #109 reported she then requested STNA #207 write a report regarding what transpired between her and Resident #233. RN #109 stated STNA #207 replied I don ' t care, I ' m quitting this morning. RN#109 requested STNA #207 leave the floor and STNA #207 said Bye. A statement from Admission Staff #58 dated 04/26/16 at 6:00 A.M. indicated Resident #233 stopped her as she was walking on the 300 Hall just as STNA #207 was walking by. Resident #233 told her that STNA #207 should be fired because she threw him in his wheelchair and said I don ' t give a expletive if you fall, you ' re not my patient anyway. Admission Staff #58 reported she told STNA #207 to go punch out and leave the facility immediately. Review of facility investigation revealed the Administrator obtained a statement from Resident #233 on 04/26/16 at 6:30 A.M. when the resident reported STNA #207 said you are not my (expletive) patient. Resident #233 stated STNA #207 threw me. The resident stated he told her you don ' t have any right to do that. You need your job changed. Resident #233 stated STNA #207 responded that she didn ' t give a (expletive). A signed statement from STNA #207 dated 04/26/16 was located in the investigative folder. STNA #207 ' s statement identified she gave notice effective immediately that she would no longer be working at the facility. Review of the written statement by STNA #207 did not address the incident regarding Resident #233. The SRI summary documented the facility conclusion/disposition section identified the abuse was unsubstantiated. State tested nurse aides were in- serviced on transfer techniques and professionalism. Review of the in-service record indicated 16 STNAs were in serviced. There was no date indicating when the in-service was provided. On 05/05/16 at 8:04 A.M during an interview with the Administrator she reported Resident #233 yelled out frequently, was inappropriate at times, and talked nasty to staff with inappropriate comments. The Administrator stated Resident #233 was standing in his room yelling and screaming at STNA #207 when she offered to help transfer him to the chair. The Administrator confirmed that she did not have a written statement from STNA #207 describing the incident with Resident #233. The Administrator stated that she was given a written report from RN #109 and Admission Staff #58. The Administrator stated she interviewed like residents throughout the facility to see if they had concerns. No concerns were identified and she determined the allegation (and the SRI) was unsubstantiated. On 05/05/16 at 10:32 A.M., during an interview with the Administrator she confirmed that STNA #207 had received two written disciplinary referrals on 04/22/16. The Administrator confirmed there was no documentation of education in the discipline file or evidence that burnout had been addressed. The Administrator stated if an employee had two written discipline referrals in the same day, they would not be allowed to finish their shift. The Administrator stated she believed that STNA #207 was sent home. Review of STNA #207 ' s time sheet on 04/22/16 revealed STNA #207 finished her shift working 11.5 hours. On 05/05/16 at 10:52 A.M. during an interview with Activity Director #54 she confirmed on 04/22/16 she had completed a written disciplinary action for STNA #207 after she had heard her talking loudly and using profanity towards a nurse. Activity Director #54 reported that STNA #207 stated she was having a bad day and confirmed she had addressed the nurse inappropriately and signed the disciplinary referral. Activity Director #54 stated the policy for the facility was that if you were having a bad day, you were to explain to your supervisor that you needed a minute to take a walk, go outside, talk or whatever you needed to do to calm down and get yourself together. Activity Director #54 reported this was the first incident where she had witnessed someone lose it . Activity Director #54 stated after STNA #207 signed the discipline referral she returned to work until her shift was over at 7:00 P.M. On 05/05/16 at 11:04 A.M., interview with RN #193 revealed she was working the 200 Long hall on 04/26/16, the night STNA #207 had thrown Resident #233 into his chair. RN #193 reported on 04/26/16 at 10:30 P.M. STNA #207 told RN #193 she was frustrated and did not want to work at the facility. RN #193 persuaded STNA #207 to continue to work and provide care to residents. At 6:15 A.M. STNA #207 was laughing and giggling as she told RN #193 she was leaving the facility because she went off on Resident #233 and threw him into his chair. RN #193 reported she told STNA #207 to write a statement that she was leaving and to exit the building immediately. RN #193 stated she wrote a statement regarding the incident on 04/26/16 and left it under the Administrator ' s door before she went home at 7:00 A.M. RN #193 confirmed that leaving documentation under the Administrator ' s door was normal procedure and she did not ask STNA #207 to write a statement regarding the incident. On 05/05/16 at 11:18 A.M. interview with the Administrator reported she was unaware that RN #193 was working when the alleged incident between STNA #207 and Resident #233 occurred. The Administrator stated that she did not receive a report from RN #193. The Administrator confirmed that employees did leave confidential information for her to receive under the door. The Administrator stated she would look and bring the information to the surveyor if she was able to locate anything. The Administrator confirmed that when doing the investigation she did not check the employee schedule to verify staff working at the time of the alleged abuse. On 05/05/16 at 2:08 P.M. during an interview, Resident #233 stated staff had been mean to him and this occurred with people working second shift. He stated he was thrown into his chair by STNA #207 a few weeks ago. STNA #207 stated that he was not her patient and she didn ' t have to do anything he asked her to do. Resident #233 stated that STNA #207 no longer worked at the facility and she should not be taking care of anyone. On 05/05/16 at 2:30 P.M. the Administrator provided written documentation that she spoke with STNA #207 on the telephone on 05/05/16 at 11:35 A.M. STNA #207 stated that she recalled the events that occurred the last night she worked at the facility. She stated she was going to quit in the middle of the night because she was stressed but did not want it to be considered neglect so she did not leave. STNA #207 reported that at 6:30 A.M. one resident was yelling from his room and being rude and she yelled back at the resident. STNA #207 reported that she did not enter the resident ' s room. STNA #207 stated that she told RN #193 she was quitting and RN #193 told her to just leave now. Review of STNA #207 ' s discipline documentation revealed two written discipline referrals were dated 04/22/16. The first discipline referral addressed STNA #207 did not provide morning care to a resident nor did she assist with the meal. STNA #207 refused to sign the discipline referral and indicated in a written statement the resident was lying to the Administrator and she had offered morning care. She also stated she had witnessed the resident feeding himself and the resident did not need to be fed. The second discipline was dated 04/22/16 at 1:00 PM and was completed by Activity Director #54 after STNA #207 became upset and loud in the hall stating (expletive) you! You think I am going to steal your (expletive) and walked away. On 05/05/16 at 2:40 PM during an interview with the Administrator she reported she completed a second interview with Resident #233 on 05/05/16 at 12:45 P.M. when he continued to state that STNA #207 threw him into his chair. The Administrator stated the alleged perpetrator no longer worked at the facility and there was nothing further she was going to do. On 05/05/16 at 7:09 P.M. during an interview with the Administrator and the Regional Director of Clinical Services, the Administrator stated STNA #207 should not have returned to work after the second discipline referral on 04/22/16. The Regional Director of Clinical Services stated after STNA #207 was visibly upset and talked to RN #193 on 04/26/16, she should have been sent home and not returned to work with residents. The Regional Director of Clinical Services stated it was not the policy of the facility to allow employees exhibiting signs of burnout to continue to work with residents. Review of the facility document titled Managing Employee Burnout Protocol (not dated) revealed under the category of Recognize Signs of Employee Burnout: irritability, arguing with co-workers or supervisors, lack of patience with care of residents, changes in behavior and demeanor (not all inclusive). Under the category of Actions to Address Burnout: Employees are to report to their supervisors when they note signs of employee burnout in their co-workers; Employees are encouraged to report to their supervisors whenever they recognize signs of burnout within themselves and without fear of recrimination; Any Employee noted to exhibit signs of burnout to the degree that residents/patients, other employees, visitors, etc. may be affected by such behavior will immediately be removed from the patient care area. Administrator or designee will be notified and an investigation conducted to determine further actions (e.g. employee sent home, advised to seek medical/psychosocial assistance, diagnostic evaluation, additional training, coping strategies, change in work assignment, etc.). Review of the facility Resident Abuse policy dated May, 2016, originally dated June, 2015, indicated the facility will not tolerate mistreatment, abuse, involuntary seclusion or neglect of its residents. Review of the Abuse, Neglect, Misappropriation of Property Policy dated 01/26/16 indicated the facility would protect the residents from abuse, neglect misappropriation of property, corporal punishment and involuntary seclusion. The facility protocol for managing employee burnout identified that employee burnout may have a negative impact on resident/patient care and the facility would strive to prevent employee burnout and the

Based on observation, record review and interview the facility failed to implement restorative range of motion and splinting to prevent a reduction in active range of motion and the development of contractures for Resident #81 and #116. Harm occurred when Resident #81, who was admitted to the facility with no evidence of a contracture to the left hand developed a contracture. The resident had been previously discharged from therapy with a recommendation for restorative splinting and ROM program which were not implemented. This affected two residents (Resident #81 and #116) of four residents reviewed for range of motion. Findings Include: 1. Review of Resident #81's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the resident's restorative functional data collection and decision form dated 08/08/15 indicated the resident had no joint limitations. Review of an occupational therapy (OT) evaluation and plan of treatment dated 08/10/15 indicated the resident did not have a contracture to his left hand. Review of the OT discharge summary dated 09/28/15 recommended a restorative program for ROM and splinting to the resident's left hand for five hours per day to maintain the current level of performance and to prevent a decline. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had clear speech, understands others, makes himself understood has both long and short term memory problems and has a severe cognitive impairment. The MDS indicated the resident had functional limitations in ROM on one side of both the upper and lower extremities. The MDS indicated the resident did not receive restorative nursing services. Review of the resident's monthly physician's orders [REDACTED]. Further review revealed no orders for any type of occupational therapy (OT) evaluation or restorative nursing program. Review of the OT evaluation and plan of treatment dated 05/05/16 indicated the resident had contractures to the first through fifth fingers on the left hand. On 05/03/16 at 4:01 P.M. observation made of Resident #81 revealed the first through the fourth fingers on the left hand were curled under and no splint device was observed in place. On 05/04/16 at 11:00 A.M. interview with Occupational Therapist (OT) #198 revealed, OT was working on wheelchair positioning and ROM with the resident's upper extremities. OT #198 said during the treatment time of 08/07/15 through 09/28/15 the recommendation was made for the resident to have a resting left hand splint for five hours a day and restorative program was written for the program. OT #198 verified the resident did not have a contracture to the left hand upon discharge from OT treatment on 09/28/15 but the interventions were implemented to prevent such from occurring. On 05/05/16 at 8:42 A.M. interview with State tested Nurse Aide (STNA) #104 revealed she functioned as the facility Restorative Manager. STNA #104 revealed Resident #81 received range of motion exercises by the direct care STNA during their activities of daily living care. STNA #104 verified Resident #81 was not on a formal restorative splinting program. On 05/06/16 at 8:50 A.M. interview with Therapy Program Manager #210 revealed when Resident #81's initial OT evaluation was completed on 08/10/15 the resident did not have a contracture present as indicated on the OT evaluation & plan of treatment. The manager verified the resident had subsequently developed a contracture without evidence nursing staff had implemented a comprehensive restorative range of motion and splinting program following the resident's discharge from OT in September, 2015. 2. Review of Resident #116's medical record revealed an admission date of [DATE] with the latest re-admission on 05/27/15 with the admitting [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS 3.0 assessment dated [DATE] indicated the resident had both short and long term memory loss and had severe cognitive impairment. The MDS indicated the resident was dependent on staff for bathing and personal hygiene. Review of Resident #116's admission evaluation and interim care plan dated 12/03/14 indicated the resident had no documented evidence of contractures. Review of the resident's OT evaluation and plan of treatment dated 12/06/14 revealed the resident received therapy services for wheelchair positioning and splint application. The evaluation documented the resident's right upper extremity ROM was impaired and the left upper extremity ROM was within functional limits. Review of the OT discharge summary dated 12/31/14 revealed the resident was discharged tolerating splint application for two hours on and two hours off. Review of the resident's restorative functional data collection and decision form dated 04/15/16 indicated the resident had no joint limitations. On 05/02/16 at 3:45 P.M. observation of Resident #116 revealed the resident had contractures to both her elbows, wrist and fingers. Further observation revealed no splints were in place. On 05/02/16 at 4:20 P.M. interview with STNA #187 revealed the STNA was unaware of ROM being part of the resident's activities of daily or any type of restorative splinting program. On 05/02/16 at 4:25 P.M., interview with the DON verified the resident's had no current splinting program to address the identified contractures of the elbows, wrist or fingers. The DON verified OT had previously recommended range of motion and splinting for the resident. On 05/04/16 at 11:00 AM interview with OT #198 revealed, upon discharge from OT services a splinting program had been developed and communicated to Restorative nursing for implementation. OT #198 said once the program was communicated to the nursing department it was their responsibility to implement the program. On 05/05/16 at 8:42 A.M. interview with STNA #107 revealed this STNA functioned as the facility Restorative Manager. The STNA indicated the the therapy department developed the programs and communicated the programs to her. Once she received the program she implemented the program and gives a copy to the DON. The STNA said she delivered all restorative programs except, activities of daily living, eating, ROM, bed mobility and transfers. STNA #107 said the STNA assigned to the resident(s) for personal care were responsible for programs and documentation the programs had been completed. STNA #107 said the DON as the nurse who actually approved and monitored the program. On 05/09/16 at 1:30 P.M., interview with Therapy Program Director #210 revealed, the therapist developed the restorative program and the program was communicated with the nursing department for implementation. She said each resident in the building was screened quarterly and if a decline was found the therapy department evaluated the resident and determined if the resident required therapy services. On 05/02/16 at 4:25 P.M., interview with the DON revealed she was unsure what facility employee was responsible for the implementation and monitoring of the restorative programs. On 05/11/6 at 3:20 P.M., interview with the DON verified the facility had not implemented all recommended programs or monitored the current restorative programs for a decline. The facility did not have a policy for range of motion.

Based on record review, observation, interview and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement interventions to prevent the development of an avoidable pressure ulcer. This resulted in harm for one resident (Resident #114) who developed an avoidable Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer), to the right heel which progressed to an unstageable pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). The deficient practice affected one of four residents reviewed for pressure ulcers. The facility census was 129. Findings Include: According to the NPUAP, an unstageable pressure ulcer is a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown dead tissue) and /or eschar (tan, brown or black dead tissue) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III or IV). Review of the medical record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #114 had severe cognitive impairment and required extensive assistance of one staff for bed mobility and transfer. Resident #114 did not have any pressure ulcers. Review of the MDS significant change assessment dated [DATE] revealed the resident was totally dependent of staff for bed mobility, transfers and all hygiene care, was at risk for skin break down and Hospice care was initiated. Review of a nurse note dated 12/20/14 revealed a blister was noted to Resident #114 ' s right heel and staff was to pad and protect the bilateral heels per the Hospice Nurse #222. Review of the nurse note dated 12/21/14 documented a round fluid filled blister to the right inner heel measured 7 centimeter (cm) by 7.5 cm. Review of the physician's order [REDACTED]. Review of the Treatment Administration Record (TAR) dated December 2014 revealed no documentation to reflect the order for padding and protecting the heels. Review of the acute plan of care dated 12/21/14 documented the skin was impaired as a fluid filled blister to right inner heel and the goal was for the area to heal without complication. Interventions included to turn and reposition the resident at least every two hours and as needed. The care plan did not address the elevation of the heels. Review of the facility incident report dated 12/22/14 documented an 8 cm by 8 cm fluid filled blister to the Resident #114 ' s inner right heel. Review of the physician's order [REDACTED]. Use skin prep to the right inner heel and cover, and to encourage and assist to elevate bilateral heels in bed. physician progress notes [REDACTED]. Review of the weekly wound assessments (WWA) revealed the following: *On 12/29/14: 7 cm by 7 cm Stage II pressure ulcer without fluid which is purple in color and intact. Encourage and assist to elevate heel in bed. *On 01/06/15: 7 cm by 7 cm by 0.1 cm deep Stage II pressure ulcer to the right heel and was deteriorating. *On 01/13/15: 8.0 cm by 7.0 cm by 0.1 cm and now " unstageable " with a necrotic wound bed appearance and a wound status of deteriorating. *On 01/20/15: 3.0 cm by 3.0 cm by 0.1 cm unstageable pressure ulcer with a yellow and necrotic wound bed appearance. The note indicated Resident #114 was in a padded Broda (reclining wheelchair) and was to elevate the heels. *On 01/27/15: the right heel remained unstageable and measured 2.2 cm by 2.4 cm by 0.1 cm. The wound bed was yellow, slough and red. A small area with slough remains surrounded by beefy red granulation tissue. *On 02/03/15: Resident #114 ' s right heel unstageable pressure ulcer measured 2.2 cm by 3.0 cm by 0.1 cm with a faint odor. *On 02/10/15: The heel wound was a 3.0 cm by 2.3 cm by 0.1 cm unstageable pressure area to the right heel with moderate drainage, an odor and deteriorating. Review of the Plan of Care (POC) dated 01/02/15 revealed Resident #114 had an alteration in skin integrity related to the blister on right heel and the goal was to show signs of healing and remain free from infection. Interventions included to encourage and assist to elevate heels while in bed and encourage to turn and reposition while in bed. Review of the physician's order [REDACTED]. Review of the Certified Nurse Practitioner (CNP) #224 ' s note dated 02/09/15 documented the resident had pain when the right heel was touched, the heel was soft, "mushy" some thick callous tissue surround the wound and does not show much improvement. On 02/09/15 at 1:20 P.M., Resident #114 was observed in his room lying on his left side facing the wall with his right inner heel lying directly on the mattress. Pillows were observed under the resident ' s legs but they were not preventing the heel from touching the surface. On 02/10/15 at 10:00 A.M., Resident #114 was observed in his room lying on his back slightly turned towards the wall with his right inner heel directly touching the surface of the mattress and the left outer heel directly touching the surface of the mattress. On 02/10/15 at 4:29 P.M., Resident #114 was observed lying on the left side facing the wall and his right inner heel was directly touching the surface of the bed. On 02/10/15 at 4:55 P.M., Resident #114 was observed up in the Broda chair feet and heels resting against the firm plastic of the chair and no cushion or padding was noted on the chair. On 02/11/15 at 8:00 A.M., Resident #114 was brought out of his room in the Broda chair to the dining room by STNA #182. There was a pillow located on the bottom of the leg rest of the chair but no observed padding or protection from the back of the leg rest where the back and inner right heel was resting on the surface. On 02/11/15 at 8:11 A.M., a family of Resident #114 had STNA #182 and Licensed Practical Nurse (LPN) #86 and was asking if the resident should have his heels resting on the back of the Broda chair. At this time, LPN #86 verified the heels were resting on the chair and began to off load the heels from the chair surface. On 02/11/15 at 10:28 A.M., Resident #114 was observed sitting in the Broda chair with his heels resting against the leg rest of the chair. On 02/11/15 at 1:56 P.M., Resident #114's right heel treatment was observed with CNP #224 and RN #200. The old dressing was removed and yellow slough and drainage was noted. After the area was cleansed, the right heel was about 20 percent covered in yellow slough and about 80 percent granulation (pink) tissue. This was confirmed by CNP #224 at the time of the observation. On 02/11/15 at 1:34 P.M., CNP #224 revealed if the pressure was not relieved the wound would continue to deteriorate. She further reported the heels touching the surface of the bed or the Broda chair could have been a point of pressure. This deficiency substantiates allegations in complaint OH 695.

Based on observations, medical record review and staff interviews, the facility failed to provide pain medications to a resident. This resulted in actual harm for Resident #230 who complained of severe pain to his right leg after a recent surgery. In addition, the facility failed to provide wound treatments for Resident #185 and failed to address the behaviors of Resident #51. This deficient practice affected two (Resident #230 and #185) of three residents reviewed for physician's orders [REDACTED]. The facility census was 132. Findings include: 1. Review of the clinical record for Resident #230 revealed an admission date of [DATE] at 4:00 P.M. with [DIAGNOSES REDACTED]. Review of the resident's admission orders [REDACTED]. There also was a prescription for [MEDICATION NAME] 5 mg,1-2 tablets every four hours as needed for severe pain. Review of the Medication Administration Record (MAR) for November 2013 revealed the [MEDICATION NAME] ER 60 milligrams (mg.) was scheduled to be given at 9:00 A.M., 5:00 P.M. and 1:00 A.M. There was no evidence the resident ever received this medication. There was an order for [REDACTED].M. Review of the nurse's progress note dated 11/01/13 4:00 P.M., revealed the resident was admitted at 4:00 P.M. from the hospital with previous history of infections in right leg, recovering from her 11th surgery to right leg. Resident #230 complained of pain in her bilateral legs, rating the pain as 10/10 on the pain scale, (10 being the worst pain) and the pain was continuous. There was no evidence the resident was medicated for pain even after being assessed with [REDACTED]. Review of the next nurse's note entry dated 11/01/13 at 7:00 P.M.-7:00 A.M., (no specific time entry was written), revealed Resident #230 was very agitated and upset. Pain medications have not yet arrived from pharmacy. Orders sent per prior nurse. Pharmacy notified/contacted to check on orders. Pharmacy said to please send again, they were not faxed. Medications faxed times two. Resident began to curse and scream and threaten staff with violence. Other residents on hall afraid of resident. All residents moved to a safe area and doors closed. Columbus police was dispatched and attempted to calm resident. Resident refused to calm down. Resident came to nurses station and pulled out her PICC (Peripherally Inserted Central Catheter) line. Resident was offered Tylenol and/or [MEDICATION NAME] and refused. Ambulance arrived and resident went to emergency department and had PICC line reinserted and was given [MEDICATION NAME] pain medication IV push. Pharmacy contacted multiple times, discussed orders with them. They then told this nurse that the prescription was invalid. Physician called and message left, nurse practitioner called and message left. Resident returned to the building around 2:30 A.M., came in and while on stretcher began yelling about pain medication. There were no further entries in the nurses notes until 8:50 A.M. There was no evidence the resident was given any pain medication in the facility since the [MEDICATION NAME] administered at 1:00 A.M, at the hospital. Review of the Narcotics record revealed the first narcotic medication was administered to Resident #230 at 4:40 A.M. on 11/12/13, 12 hours and 40 minutes after his admission. This was not documented on the Medication Administration Record or the nurses notes. This was documented only on the narcotic log and revealed the resident received [MEDICATION NAME] IR 5 mg, two tablets. There was no evidence if the nurse reassessed the resident after the medication was given to determine if the medication was effective. Review of the medical record revealed at 8:00 A.M. Resident #230 was given [MEDICATION NAME] IR 5 mg, 10 tablets to equal the 50 mg that was ordered at 8:00 A.M. to be given one time. Again there was no assessment to determine if the medication was effective. Review of a telephone order revealed [MEDICATION NAME] 5 mg/325 mg., two tablets was to be given now (12:30 P.M.) There was no assessment to determine if this medication was effective. Review of the narcotic contingency box records revealed the facility had the [MEDICATION NAME] 5 mg tablet available in house. (Contingency box is a stock of medications available in the facility to use until a medication is able to be delivered by the pharmacy for an individual resident). Interview on 11/06/13 at 9:35 A.M. with RN #22, the unit manager, confirmed the resident was admitted on [DATE] at 4:00 P.M. and was not given pain medication until the next morning after admission. Interview with the Director of Nursing (DON) on 11/06/13 at 10:00 A.M., revealed the pain medications did not have a valid prescription due to there was no quantity on the prescription. The nurse called the surgeon and he wouldn't validate it. When this prescription was reviewed it did have quantity on it for #50 [MEDICATION NAME]. The DON confirmed the documentation in the nurses notes was not time specific as to when the nurses called the pharmacy and physician regarding the nurses attempt to get the pain medication for the resident. She was asked why the [MEDICATION NAME] 5 mg tablets from the contingency box was not used and she stated she would get back with the surveyor with an answer, she was going to call the nurse who worked. The DON did not provide any further information to the surveyor. Interview with the Certified Nurse Practitioner (CNP) #206 at 10:50 A.M. revealed the resident was "on the ceiling" with her pain. She was also acting out and stated she was given some pain medication at the hospital via IV (intravenous) while there at about 1:30 A.M. on 11/02/13. 2. Review of the clinical record for Resident #185 revealed an admittion of 11/02/13 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the non pressure skin condition report revealed the resident had five incision areas: 1. above right knee, anterior, with three staples. 2. right thigh, inferior, three staples, 3. right thigh, superior, four staples, 4. right hip, eight staples and 5. right groin, four staples. Review of the treatment administration record revealed there were no instructions or orders for the care of the post operative incisions and no evidence the dressings that were on the incision areas had been changed since admission. Review of the nurses progress notes revealed there was no evidence there was any care to the post operative incisions on the right hip areas. Observation on 11/05/13 at 8:00 A.M. revealed the resident was lying in bed with the head of the bed up. The resident was dressed in an undershirt and covered with a sheet. She was given medication by the nurse. Observation on 11/05/13 at 2:00 P.M. with Licensed Practical Nurse (LPN) #28 revealed the resident was lying in bed with the head of the bed up, wearing only an undershirt and adult brief. The covers were bunched up and being held by the resident in her lap. The nurse revealed the resident had three dressings, one to lower anterior right thigh area that was partially off, undated, one to right lower trochanter area partially loosened, and one to upper right hip area that was in place and just under where adult brief was taped. The nurse removed all three of the dressings and all three had a small amount of drainage yellowish/brown in color. There were staples present at all three areas. The resident was confused and was touching the incisions sites after the dressings were removed. LPN #28 stated she didn't know if the dressings were there yesterday. She stated she was unaware the resident even had dressings on the incisions. Interview with Registered Nurse #15, Unit manager at 2:30 P.M. confirmed there was no evidence the dressings were changed since admission and stated she called the physician for orders after questioned by the surveyor. 3. Review of Resident #51' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set version 3.0 assessment ((MDS) dated [DATE] revealed the resident displayed behaviors one to three days that did not affect others (disruptive sounds, disrobing, etc). The care area assessment revealed the behaviors were triggered and a plan of care was indicated. Review of the behavior monitoring records dated 10/20/13 through 11/06/13 revealed Resident #51 displayed behaviors of yelling out 15 out of 17 days monitored. Interventions to be utilized included redirection, return the resident to their room, offer food, encourage to rest, one on one, activities and offer fluids. The outcome for each intervention was documented to indicate the behavior was unchanged. Review of Resident #51 ' s care plans revealed there was no care plan initiated for behaviors. Interview with licensed practical nurse (LPN) #54 on 11/06/13 at 8:10 AM revealed the resident yelled out daily. Interview with Social Services #108 on 11/06/13 at 1:35 PM confirmed the resident yelled out daily. Social Services #108 revealed she talked with Resident #51 when behaviors were present in an attempt to calm the Resident. Interview with the Director of Nursing (DON)on 11/06/13 at 2:00 PM confirmed the resident yelled out daily. The facility began behavior monitoring on 10/20/13. The DON verified there was no behavior care plan for Resident #51.

Based on medical record review, staff interviews and review of facility policy, the facility failed to ensure ordered tube feeding was provided to a resident who ate nothing by mouth. This resulted in actual harm for Resident #183 who incurred a significant weight loss that was never regained. This deficient practice affected one (Resident #183) of two residents reviewed for nutrition. The total facility census was 132. Findings include: Resident #183 was admitted to facility on 03/23/13 with [DIAGNOSES REDACTED]. She had a percutaneous endoscopic gastric (PEG) present upon admission due to swallowing difficulty. Diet orders for Resident #183 indicated "nothing by mouth." Tube feed orders written and included tube feed formula ([MEDICATION NAME] 1.5) at 30 milliliters around the clock. Registered Dietitian (RD) #14 completed an initial nutrition therapy assessment on 03/26/13 and identified Resident #183 had a weight of 91# and a body mass index (BMI) of 17.7 (19-25 within normal range). RD #14 calculated estimated energy needs and recommended to increase the tube feed goal rate to 37 milliliter per hour to provide 1332 kilocalories, 60 grams protein, and 690 milliliters of fluids. Review of the physician orders [REDACTED]. Nutrition plan of care for Resident #183 was initiated on 04/01/13 and indicated she was at nutrition risk related to gastric tube, a low BMI, and history of weight loss. Goals included will be free of significant weight changes each month. Interventions included to provide tube feed per order and to report 5% significant weight loss to physician and registered dietitian. On 11/05/13, the plan of care was revised to include the goal for Resident #183 that estimated needs will be met with combination of oral intake and tube feed. Resident #183 was weighed on 05/05/13 at 84 pounds, which resulted in a nine pound weight loss in fifteen days (9.7% significant weight loss). RD #14 wrote on a progress note on 05/10/13 that indicated "nursing reported therapy services turned off tube feed pump and disconnecting for therapy. Also, when Resident (#183) brought back to room, nursing stated they weren't always notified of resident return to immediately resume continuous tube feed." The intervention put in place 05/10/13 indicated the resident was to stay on the tube feed continuous and no disconnecting the tube feed pump. Interview with Registered Dietitian #14 on 11/05/13 at 2:00 P.M. verified the intervention after Resident #183's lost weight was identified on 05/10/13 was for therapy to not disconnect the tube feed. RD #14 further stated Resident #183 never regained the weight back. Interview with Therapy Director #46 on 11/06/13 at 3:00 P.M. revealed therapy never disconnected the tube feed. He said the therapists ask the nurses to disconnect the tube feed so to take the resident down to therapy. Therapy relied on nursing to know if the tube feed was continuous or not. He also stated Resident #183 was disconnected from the tube feed for therapy for two to three total weeks. Review of the Enteral nutritional therapy policy dated November 2011 revealed the facility will ensure the resident who requires nutritional intake via enteral feeding will receive the appropriate amount of caloric intake and in conjunction with the dietician and the physician the resident will not encounter any adverse effects of the enteral nutritional therapy.

Based on medical record review, fall investigation , family and staff interviews, the facility failed to ensure adequate assistance was provided to prevent falls. This resulted in actual harm for Resident #64 who suffered a right humerous fracture and contusion to the right arm after she was transferred improperly and fell . This deficient practice affected one (Resident #64) of three residents reviewed for accidents. The total facility census was 132. Findings include: Review of Resident #64's medical record revealed the resident was initially admitted to the facility on [DATE] with a history of falls, aphasia due to cerebrovascular disease, malaise and fatigue, muscle weakness, difficulty walking and late effects of cerebrovascular disease. Review of a fall risk evaluation dated 07/08/13 revealed the resident was high risk for falls. Review of a re-evaluation for falls dated 10/06/13 and 10/17/13 revealed Resident #64 had a fall risk score of 18 (high risk for falls). Review of the admission physical function dated 07/08/13 revealed Resident #64 was dependent on staff for bed mobility, transfer, walking/locomotion, dressing, toileting, personal hygiene and bathing. Review of the admission Minimum Data Set assessment ((MDS) dated [DATE] revealed the resident required extensive assist of two plus persons for transfers. The quarterly MDS dated [DATE] revealed the resident was totally dependent of two plus person assist with transfers. Review of a care plan for falls included interventions to transfer the resident with the assistance of one to two. Review of resident care card (undated) revealed the resident was an extensive assist of two for transfers. Review of the nurses's notes revealed Resident #64 sustained a fall on 10/06/13 at 8:20 P.M., when the resident slid out of a wheelchair in the bathroom. The note indicated the resident complained of knee pain. The nurse performed a range of motion assessment and noted no injuries. The resident's daughter was in facility at time of incident. A new order was written to wear gripper socks at all times. Review of the nurses notes dated 10/17/13 revealed Resident #64 sustained a second fall at 3:30 P.M., when a nursing assistant (STNA) was transferring the resident in the bathroom. The note indicated the resident fell in bathroom when transferred from the toilet to the wheelchair. The nurse assessed the resident and noted right arm pain with range of motion. The doctor was notified and orders were obtained for x-rays. Review of nurses notes dated 10/17/13 at 5:15 P.M.revealed an acute fracture was noted to Resident #64's right forearm and wrist. After notifying the doctor of the x-ray results, the resident was transferred to emergency room for evaluation. The medical record revealed Resident #64 returned to the facility on [DATE] at 10:15 P.M., with a wrist splint with ace wrap on the right arm. Discharge orders for the resident indicated to follow up with an orthopedic in one to two days for right wrist fracture. Review of the nurses notes from admission to present revealed the resident was a two person assist with transfers. Review of an incident report for the fall that occurred on 10/06/13 revealed only one STNA was present at the time of the fall. The investigations concluded the resident slid off the wheelchair after a transfer by only one STNA. The resident complaining for bilateral knee pain and was noted not wearing non-skid shoes. Review of an incident report for the fall that occurred on 10/17/13 revealed only one STNA was present at the time of incident. The investigation concluded that the resident fell when she was transferred from the toilet onto the wheelchair. The resident complained of pain in right arm. Review of an orthopedic note dated 10/22/13 revealed the injury did not appear to be a chronic issue. The lines were well marginated and was an acute injury. The Impression/Plan concluded a surgical neck humerous fracture, ecchymosis and contusion to right upper extremity. Family and orthopedic elected to treat with a sling for comfort. When resident has to be transferred, staff needs to use belt and try not to grab resident under the axilla to try to prevent some pain. Resident will return in a period of three weeks for x-ray recheck or sooner if any problems arises. Interview on 11/07/13 at 9:02 A.M. with family member #20 revealed only one staff member transferred Resident #64 during the fall on 10/06/13 and 10/17/13. The family member also affirmed that on 10/06/13 she offered STNA #172 help transferring the resident and was told "no thank you I can do it myself I don't need help." Interview on 11/06/13 at 9:20 A.M. with LPN #162 revealed Resident #64 required two assist since admission. Interview on 11/07/13 at 11:14 A.M. with the Director of Nursing (DON) verified there was only one staff member with Resident #64 when she fell on [DATE] and 10/17/13. She confirmed the fall with the surgical neck humerous fracture ccurred with Resident #64 as a result of STNA #300 providing unsafe care.

Based on medical record review, policy review and staff interview, the facility failed to ensure a resident's pain management was provided when exhibiting signs and symptoms of pain. This affected one of three residents reviewed for pain management (Resident #41). The facility identified 80 residents on pain management programs; however, Resident #41 was not included on a pain management program. Findings include: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment (dated 08/15/11) revealed the resident was severely impaired for daily decision making and was dependent on staff for transfers, bed mobility, bathing and toileting. The resident was rarely/never understood and rarely/never understood verbal content. Resident #41 received no scheduled or as needed pain medication, and did not receive non-medication interventions for pain. The resident expressed pain with non-verbal sounds and facial expressions, and the resident was observed to be in pain three to four days during the seven day assessment period. The resident also received 315 minutes of occupational therapy and 220 minutes of physical therapy. Review of the initial pain assessment tool (dated 08/08/11) revealed Resident #41's manner of expressing pain was with grimacing and facial expressions. The assessment revealed no documented evidence of what relieved the resident's pain, what caused or increased the pain, or what medications/treatment was to be implemented if pain was present. Review of the interim pain care plan dated (08/08/11) revealed the resident was to be monitored for signs and symptoms of pain. Review of Resident #41's head-to-toe assessment dated [DATE], 08/12/11, 08/14/11, 08/15/11, 08/17/11, 08/20/11 and 08/21/11 revealed no assessment regarding pain. On 08/15/11, the head-to-toe assessment indicated the resident was yelling out but this was documented as a behavior. Review of the initial occupational therapy (OT) evaluation (dated 08/09/11) revealed Resident #41 had severe pain with passive range of motion of the right shoulder. Review of the OT progress notes (dated 08/17/11) revealed Resident #41 had contracture's of the right upper extremity, and presented with increased sadness with tears in his eyes. Review of the initial physical therapy (PT) evaluation (dated 08/09/11) revealed Resident #41 expressed pain with cries and yelling (with range of motion) of the right shoulder. Review of the PT daily progress notes revealed the following: -On 08/17/11 and 08/18/11, the resident cried easily during therapy. -On 08/20/11, during passive range of motion of bilateral lower extremities, the resident verbalized discomfort with any movement of the right lower extremity. -Functional progress note (undated) revealed the resident displayed discomfort with range of motion of the right lower extremity. Review of the medical record revealed no documented evidence of pain management for Resident #41 on 08/09/11, 08/17/11, 08/18/11 or 08/20/11. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Pain Management procedure (revised November 1997) revealed pain was to be assessed, medications and alternative interventions were to be implemented to enhance the residents comfort. If pain was observed, an assessment including the pain level and location was to be documented on the pain flow sheet. Non-pharmacological interventions to attempt included positioning, back rub, and distraction. The physician was to be notified if the residents pain management was ineffective. On 08/22/11 at 4:30 P.M., interview with Certified Nurse Practioner (CNP) #5 verified the physician was not notified Resident #41 was having pain. On 08/22/11 at 4:40 P.M., interview with the Director of Nursing (DON) revealed resident's were to be assessed every shift for signs and symptoms of pain. The DON verified the medical record revealed no documented evidence Resident #41 was assessed for pain or interventions implemented for symptoms of pain on 08/09/11, 08/17/11, 08/18/11 or 08/20/11. On 08/22/11 at 4:55 P.M., interview with CNP #5 revealed after assessing the resident, she was able to verify that Resident #41's shoulders were in a fixed position, the resident was cognitively impaired and denied pain verbally but when touched would grimace and yell out with any movement. CNP #5 verified the resident would experience pain with movement especially therapy. On 08/22/11 at 5:00 P.M., interview with the DON verified the physician was not notified that Resident #41 was experiencing pain. On 08/22/11 at 5:55 P.M., interview with the DON verified the admission MDS (dated 08/15/11) indicated the resident had pain three to four days during the assessment period and received no pain medications or interventions. This deficiency substantiates Complaint Number OH 930.