Every finding on record at Marion Valley Post Acute

Based on observation, dishwasher temp logs, manufacturer recommendations, interview, and policy review the facility failed to ensure the dishwasher temp was high enough for sanitation. This had the potential to affect all residents who reside in the facility. The facility census was 113.Findings include:Observation on 04/20/26 at 9:31 A.M. of the dishwasher revealed the tag on front of dishwasher minimum temperature of wash cycle was 159 degrees Fahrenheit (F), pump rinse of 160 degrees F, and final rinse of 180 degrees F with 20 psi pressure. Observation of the dishwasher not running revealed a wash temp of 160 degrees, rinse pump 170 degrees F, and final rinse of 178 degrees F. Observation of the dishwasher running revealed the was temp gauge moved to 162 degrees F, the rinse pump gauge did not move at all, and the final rinse gauge did not move at all. The dishwasher did not kick on for the pump rinse or the final rinse and pushed the tray out the end of the conveyor belt. Observation times two trays coming through the dishwasher where the rinses did not kick on for each observation.Interview on 04/20/26 at 9:41 A.M. with Dietary Manager (DM #272) revealed the dishwasher was spraying water continuously in the machine but verified the machine did not kick on for the rinse cycles. DM #272 stated that when the dishes were pushed into the machine the wash cycle gauge moved and the rinse cycles did not kick on for the third observation. DM #272 instructed the staff to shut the machine off and reset to make sure the rinse cycle would turn on. Observation of the rinse cycle after the machine was reset revealed the rinse cycles still did not kick on after the wash cycle. DM #272 verified the dishwasher was a high temp machine. DM #272 stated the facility would serve on Styrofoam plates and handwash until the Maintenance Director (MD #342) looked at the dishwasher.Follow up observation and interviews on 04/21/26 at 9:05 A.M. of the dishwasher revealed that while the dishwasher was not running the temperatures on the wash gauge was 164 degrees F, pump rinse 162 degrees F, and final rinse 120 degrees F. Observation of the dishwasher running was wash gauge 150 degrees F, pump rinse 160 degrees F, and final rinse 170 degrees F times five cycles of the dishwasher. DM #272 and MD #342 were observing the dishwasher at the same time. DM #272 turned off the breaker and turned back on and ran the dishwasher for five more cycles with the same results. MD #342 and DM #272 verified the dishwasher was not washing or rinsing the dishes per the manufacturer recommendations. DM #272 stated that the dishes would be washed by hand and they would use Styrofoam until the technician came in the afternoon.Interview on 04/21/26 at 9:34 A.M. with MD #342 revealed that he reset the boiler yesterday and ran the dishwasher last evening and it was working correctly at that time. MD #342 verified the dishwasher temp logs for the past four months had multiple days that the temperatures of the final rinse were not at the recommended minimums.Review of high temperature dish machine log for April 2026 revealed the following rinse temperatures 04/07 supper 178 F, 04/08 177 F, 04/09 177 F, 04/12 supper 179 F, and 04/16 supper wash temp 150 F.Review of American dish service manufacturer manual revealed hot water sanitizing final sanitizing rinse minimum temperature: 180 F, pumped rinse tank minimum temperature of 160 F, wash tank minimum temperature of 150 F final rinse minimum pressure 20 psi, and maximum conveyor speed 6.8 feet per minute.Review of the facilities infection control log for the past four months revealed no food borne illnesses.Review of policy titled, Kitchen Infection Control Policy, not dated revealed dishwashing must meet temperature and sanitation standards.Review of policy titled, Sanitation, revised November 2022 revealed dishwashing machines are operated according to manufacture's instructions. General recommendations for heat and chemical sanitization are: high temperature dishwasher: wash temperature (150-165 F) and rinse temperature (180 F)- (160 F at the rack level/dish surface reflects 180 F at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured); or 165 F for a stationary rack, single temperature machine.This deficiency represents non compliance investigated under Complaint Number 2970467.

Based on record review, interview, and policy review, the facility failed to ensure the comprehensive care plan included all skin issues. This affected one (#68) of four residents reviewed for wounds. The facility census was 113.Findings include:Review of medical record for Resident #68 revealed an admission date of 03/14/26 with diagnoses including but not limited to pressure ulcer of left heel stage two (partial thickness skin loss involving the epidermis and dermis) and pressure ulcer of right heel stage three (full thickness skin injury characterized by a deep crater like wound that exposes fatty tissue).Review of current physician orders revealed wound care for pressure to right heel: cleanse with normal saline (NS), pat dry, apply betadine wet to dry sterile dressing, cover with ABD and wrap with kerlix (apply betadine only to wound area) daily and as needed. Apply antibiotic cream and Band-Aid to left heel daily, offload right foot at all times while in bed, and wear heelless shoe to right foot while ambulating.Review of care plan dated 03/14/26 revealed the resident was at risk for pressure ulcers and other skin problems such as skin tears, bruising, bleeding, abrasions, rashes, excoriation related to decreased mobility with diabetes. Wound to left heel. Interventions included monitor hydration every shift, monitor skin daily with routine care, pressure redistribution cushion to wheelchair, pressure redistribution mattress to bed, and weekly skin assessment per nurse.Interview on 04/22/26 at 2:00 P.M. with Director of Nursing (DON) verified there was no care plan for the pressure ulcer to the right heel or the interventions for the heelless shoe or offloading.Review of policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022 revealed the comprehensive, person-centered care plan includes measurable objectives and times, describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being, includes the resident's stated goals upon admission and desired outcomes, builds on the resident's strengths, and reflects currently recognized standards of practice for problem areas and conditions.This was an incidental finding discovered over the course of the complaint investigation.

Based on record review, interview, and policy review, the facility failed to ensure code status forms were in the medical record. This affected one (#116) of three residents reviewed for code status. The facility census was 113.Findings include:Review of the medical record for Former Resident (FR #116) revealed an admission date of 11/12/26 and discharge date of 01/09/25 with diagnoses including but not limited to sepsis due to enterococcus, acute and subacute infective endocarditis, bacteremia, urinary tract infection, and acute pulmonary edema.Review of the care plan dated 11/12/25 revealed FR #116 had an advanced directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA). Interventions included but not limited to code status will be in the medical record at all times.Review of physician order revealed code status DNRCCA from 11/12/25 through 01/09/26.Review of scanned documents in the electronic record (PCC) revealed no advanced directive DNRCCA was scanned into PCC upon admission through discharge.Review of eInteract hospital transfer form dated 01/09/26 revealed code status DNRCCA with no signed code status paper on file.Interview on 04/22/26 at 8:15 A.M. with the Director of Nursing (DON) revealed the DNRCCA paperwork for FR #116 was in medical records. DON denied knowing why the form was not scanned into PCC. DON verified the DNRCCA was not scanned into PCC for the nurses to have access to it.Interview on 04/23/26 at 8:23 A.M. via phone with Licensed Practical Nurse (LPN #302) revealed that they could not locate the DNRCCA paperwork for FR #116 to send with the resident to the Emergency Department.Review of policy titled, Advanced Directives, dated 2001 revealed if the resident or the residents representative has executed one or more advance directive, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.This deficiency represents noncompliance investigated under Complaint Number 2717941.

Based on medical record review, staff interview, and policy review, the facility failed to report an injury of unknown origin to the State Agency as required. This affected one (#84) resident out of three residents reviewed for incidents/accidents. The facility census was 113. Findings include:Review of the medical record for Resident #84 revealed an admission date of 11/22/24 with medical diagnoses of chronic obstructive pulmonary disease, anxiety, diabetes mellitus, hypertension, and unspecified hemiplegia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/27/26, revealed Resident #84 had moderate cognitive impairment and was dependent upon staff for toilet hygiene, bed mobility, transfers, and bathing. Review of nurse's notes for Resident #84 revealed a note dated 08/04/25 at 11:49 A.M. which stated the nurse went into Resident #84's room due to resident being on the floor. The note stated Resident #84 was observed lying on her bedroom floor with her back to the floor and head against the bedside stand. The note indicated Resident #84's family, Certified Nurse Practitioner (CNP), and Director of Nursing (DON) were notified. The note stated orders received for x-rays.Review of nurse's note dated 08/05/25 at 11:53pm stated the x-rays of Resident #84's right arm and leg were negative for fractures.Review of Resident #84's nurses' note, dated 09/07/25 at 6:54pm, stated an x-ray reviewed at this time by CNP and an order for computed tomography (CT) scan without contrast was to be completed.Further review of Resident #84's nurses notes revealed a note dated 10/23/25 at 6:06 A.M. which stated CNP was notified of Resident #84's right hip fracture.Review of the x-ray results dated 08/05/25 for Resident #84's right humerus and right femur revealed no evidence of fracture of dislocation and diffuse osteopenia. Review of x-ray results of Resident #84's right hip, dated 08/23/25, revealed no evidence of a fracture. Review of x-ray results dated 09/06/25 of Resident #84's right hip with unilateral pelvis revealed a cortical breach with a small step deformity on the medial aspect of the femoral neck which is only seen on the oblique projection and diffuse osteopenia. No evidence of dislocation was noted. A CT was recommended for further evaluation of the hip joint. Review of Resident #84's CT scan of right hip, dated 10/16/25, revealed nondisplaced right intertrochanteric femur fracture. Interview on 04/22/26 at 8:19 A.M. with DON stated Resident #84 had multiple x-rays done to her right hip and leg after the fall on 08/04/25 because of continued complaints of pain and all were negative for fractures until 09/06/25. DON stated Resident #84 refused to have a CT scan done on 09/17/25 and it was rescheduled for 10/13/25. DON confirmed the CT scan on 10/13/25 showed a nondisplaced right intertrochanteric femur fracture. DON stated the facility did not believe the fracture occurred from the fall on 08/04/25 but could not say what caused the fracture found on the CT scan on 10/13/25. DON stated Resident #84 was dependent upon staff for all transfers, toileting, and bed mobility and could not say if the fracture was caused during routine care. DON stated the facility Medical Director documented in a progress note dated 10/13/25 that the fracture was pathological due to her disease processes. DON confirmed the facility had not completed a Facility-Reported Incident (FRI) report, completed an investigation into the injury of unknown origin, or reported the injury of unknown origin to the State Agency when identified on 10/13/25. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021 stated residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The policy stated to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and to investigate and report any allegations within timeframes required by federal requirements.This was an incidental finding discovered over the course of the complaint investigation.

Based on medical record review, staff interview, and policy review, the facility failed to investigate an injury of unknown origin. This affected one (#84) resident of the three residents reviewed for incidents/accidents. The facility census was 113. Findings include:Review of the medical record for Resident #84 revealed an admission date of 11/22/24 with medical diagnoses of chronic obstructive pulmonary disease, anxiety, diabetes mellitus, hypertension, and unspecified hemiplegia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/27/26, revealed Resident #84 had moderate cognitive impairment and was dependent upon staff for toilet hygiene, bed mobility, transfers, and bathing. Review of nurse's notes for Resident #84 revealed a note dated 08/04/25 at 11:49 A.M. which stated the nurse went into Resident #84's room due to resident being on the floor. The note stated Resident #84 was observed lying on her bedroom floor with her back to the floor and head against the bedside stand. The note indicated Resident #84's family, Certified Nurse Practitioner (CNP), and Director of Nursing (DON) were notified. The note stated orders received for x-rays.Review of nurse's note dated 08/05/25 at 11:53pm stated the x-rays of Resident #84's right arm and leg were negative for fractures.Review of Resident #84's nurses' note, dated 09/07/25 at 6:54pm, stated an x-ray reviewed at this time by CNP and an order for computed tomography (CT) scan without contrast was to be completed.Further review of Resident #84's nurses notes revealed a note dated 10/23/25 at 6:06 A.M. which stated CNP was notified of Resident #84's right hip fracture.Review of the x-ray results dated 08/05/25 for Resident #84's right humerus and right femur revealed no evidence of fracture of dislocation and diffuse osteopenia. Review of x-ray results of Resident #84's right hip, dated 08/23/25, revealed no evidence of a fracture. Review of x-ray results dated 09/06/25 of Resident #84's right hip with unilateral pelvis revealed a cortical breach with a small step deformity on the medial aspect of the femoral neck which is only seen on the oblique projection and diffuse osteopenia. No evidence of dislocation was noted. A CT was recommended for further evaluation of the hip joint. Review of Resident #84's CT scan of right hip, dated 10/16/25, revealed nondisplaced right intertrochanteric femur fracture. Interview on 04/22/26 at 8:19 A.M. with DON stated Resident #84 had multiple x-rays done to her right hip and leg after the fall on 08/04/25 because of continued complaints of pain and all were negative for fractures until 09/06/25. DON stated Resident #84 refused to have a CT scan done on 09/17/25 and it was rescheduled for 10/13/25. DON confirmed the CT scan on 10/13/25 showed a nondisplaced right intertrochanteric femur fracture. DON stated the facility did not believe the fracture occurred from the fall on 08/04/25 but could not say what caused the fracture found on the CT scan on 10/13/25. DON stated Resident #84 was dependent upon staff for all transfers, toileting, and bed mobility and could not say if the fracture was caused during routine care. DON stated the facility Medical Director documented in a progress note dated 10/13/25 that the fracture was pathological due to her disease processes. DON confirmed the facility had not completed a Facility-Reported Incident (FRI) report, completed an investigation into the injury of unknown origin, or reported the injury of unknown origin to the State Agency when identified on 10/13/25. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021 stated residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The policy stated to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and to investigate and report any allegations within timeframes required by federal requirements.This was an incidental finding discovered over the course of the complaint investigation.

Based on medical record reviews, staff interviews, and policy reviews, the facility failed to ensure comprehensive skin evaluations were completed upon admission for Resident #35 and failed to ensure wound care was completed as per physician orders for Resident #117. This affected two (#35 and #117) residents out of the three residents reviewed for skin breakdown. The facility census was 113.Findings include:1.Review of the medical record for Resident #35 revealed an admission date of 03/13/26 with diagnoses of end stage renal disease, chronic obstructive pulmonary disease, anemia, and peripheral vascular disease. Review of the medical record revealed Resident #35 discharged to the hospital on [DATE] and readmitted to the facility on [DATE].Review of Resident #35's admission Minimum Data Set (MDS) assessment, dated 03/15/26, indicated Resident #35 was cognitively intact and was dependent upon staff for toilet hygiene and transfers, required partial/moderate staff assistance with eating, and supervision with bed mobility. The MDS indicated Resident #35 admitted with surgical wounds. Review of the medical record for Resident #35 revealed a Nursing admission evaluation, dated 03/13/26, which stated Resident #35 was admitted for wound care/wound vac (Vacuum-Assisted closure- a medical device that uses continuous or intermittent suction to accelerate healing in acute or chronic wounds by removing excess fluid, decreasing bacteria, and increasing blood flow) and had multiple skin issues. Review of the evaluation revealed no documentation to support the location, description or measurements of the wounds. Review of a skin issue evaluation, dated 03/17/26, indicated Resident #35 had a surgical wound to front right trochanter (large bony prominence on the upper, outer side of the femur that serves as a crucial attachment point for hip muscles) which measured 10.34 centimeter (cm) by 6.44 cm by 3.2 cm.Review of the Nursing admission evaluation, dated 03/25/26, indicated Resident #35 had no skin issues.Review of the skin issue evaluation, dated 03/31/26, indicated Resident #35 admitted with a surgical site to front right trochanter which measured 7.5 cm by 5.75 cm by 3 cm and was present upon admission.Interview on 04/23/26 at 11:15 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #35 did not have documentation to support the facility completed comprehensive skin evaluations upon admission on [DATE] and 03/25/26 to include the location, description, or measurements of the surgical wound. DON stated the expectation was for staff to complete comprehensive wound assessments upon admission that would include the location, description, and measurements of the wounds.2. Review of the medical record for Resident #117 revealed an admission date of 01/27/26 with medical diagnoses of atherosclerosis of native arteries of left leg with gangrene, left above the knee amputation (AKA), peripheral vascular disease, diabetes mellitus, and congestive heart failure. Review of the medical record revealed Resident #117 discharged to the hospital on [DATE], readmitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE], and discharged to the hospital on [DATE] and had not returned. Review of Resident #117's admission MDS assessment, dated 02/03/26, revealed Resident #117 was cognitively intact and required substantial/maximum staff assistance for toilet hygiene, bathing, and bed mobility and was dependent upon staff for transfers. The MDS indicated Resident #117 had a surgical site. Review of Resident #117's medical record revealed a wound assessment dated [DATE] which indicated Resident #117 had a surgical site to right foot fifth toe which measured 0.37 cm by 0.32 cm by 0.1 cm, a deep tissue injury pressure ulcer to right heel which measured 3.26 cm by 2.64 cm by 0.2cm, and surgical site to left lateral thigh which measured 4.07 cm by 11.93cm by 0.9cm. The assessment indicated all wounds were present upon readmission on [DATE].Review of the physician orders for Resident #117 revealed orders dated 02/26/26 to surgical amputation site to right foot fifth toe to cleanse with normal saline, pat dry, apply betadine, cover with abdominal pad (ABD) and wrap with kerlix every night shift and for right heel wound to cleanse with normal saline, pat dry, apply betadine, cover with ABD, and wrap with kerlix every night shift. Further review of Resident #117's physician orders revealed an order dated 02/26/26 to change dressing to wound vac every Tuesday, Thursday, and Saturday and an order dated 03/03/26 for wound vac therapy to left AKA bridged to left lateral thigh to ensure wound vac dressing was sealed/intact and setting at 125 millimeters of mercury (mmHG) continuous therapy. Review of the Resident #117's March 2026 Treatment Administration Record (TAR) revealed no documentation to support wound care was completed to right foot fifth toe surgical site or right heel wound on 03/09/26, 03/10/26, and 03/13/26. Further review revealed no documentation to support wound vac dressing was changed on 03/05/26 or documentation to support the wound vac was properly functioning on 03/05/26, 03/11/26, and 03/13/26.Interview on 04/22/26 at 1:57 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #117 did not have documentation to support wound care was completed as ordered to the left lateral thigh or right foot fifth toe surgical sites or pressure ulcer to right heel on 03/05/26, 03/09/26, 03/10/26, 03/11/26, and 03/13/26. Review of the facility policy titled, Pressure Injury Risk Assessment, revised March 2020 stated purpose was to provide guidelines for the structured assessments and identification of residents at risk of developing new pressure injures or worsening of exiting pressure injuries. The policy stated the following should be recorded in the resident's medical record utilizing facility forms: 1) type of assessment conducted, 2) dates, time, and type of skin care provided, if appropriate, 3) the name and initials of the individual who conducted the assessment, 4) any change in the resident's condition, 5) the condition of the resident's skin (i.e., size and location of any red or tender areas) if identified, 6) how the resident tolerated the procedure or his/her ability to participate in the procedure, 7) any problems or complaints made by the resident related to the procedure, 8) if the resident refused the treatment and reason why, document family and physician notification of refusal, 9) observations of anything unusual exhibited by the resident, 10) initiation of (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted, 12) documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated, 13) documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care, if indicated.Review of the facility policy titled, Prevention of Pressure Injuries, revised April 2020 stated staff are to conduct a comprehensive skin assessment upon admission (or soon after) admission, with each risk assessment, as indicated according to resident's risk factors, and prior to discharge.This deficiency represents non-compliance investigated under Complaint Number 2979521.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to provide care/services to prevent a fall. This affected one (#84) resident out of three residents reviewed for falls. The facility census was 113.Findings include:Review of the medical record for Resident #84 revealed an admission date of 11/22/24 with medical diagnoses of chronic obstructive pulmonary disease, anxiety, diabetes mellitus, hypertension, and unspecified hemiplegia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/27/26, revealed Resident #84 had moderate cognitive impairment and was dependent upon staff for toilet hygiene, bed mobility, transfers, and bathing. Review of the physician orders for Resident #84 revealed an order dated 01/14/25 for pressure reduction mattress to bed.Review of nurse's notes for Resident #84 revealed a note dated 08/04/25 at 11:49 A.M. which stated the nurse went into Resident #84's room due to resident being on the floor. The note stated Resident #84 was observed lying on her bedroom floor with her back to the floor and head against the bedside stand. The note stated Resident #84 stated the Certified Nursing Assistant (CNA) left her alone in the room to obtain more linen and she fell out of bed onto the floor. Resident #84 expressed pain in her right leg and right arm. The note indicated Resident #84's family, the Certified Nurse Practitioner (CNP), and the Director of Nursing (DON) were notified. The note stated orders received for x-rays. Review of nurse's note dated 08/05/25 at 11:53pm stated the x-rays of Resident #84's right arm and leg were negative for fractures. Interview on 04/20/26 at 10:27 A.M. with Resident #84 stated she fell out of bed several months ago after an aide left her on her side while performing incontinence care to go get more linen from the linen closet. Resident #84 stated she was on low air loss mattress and the mattress inflated and pushed her out of the bed. Interview on 04/21/26 at 10:32 A.M. with CNA #130 confirmed she was providing incontinence care for Resident #84 when she left Resident #84 on her side in her bed to go get more linen. CNA #130 stated when she returned to the room Resident #84 had fallen out of bed and was lying on the floor. CNA #130 stated she did not lower Resident #84's bed to the lowest position when she left the room to get linens but instead stated the bed was at waist level height. CNA #130 confirmed she was the only staff member providing care for Resident #84 at that time and that Resident #84 required two-person assist for incontinence cares and bed mobility. Interview on 04/22/26 at 8:19 A.M. with DON confirmed Resident #84 required two-person assistance for bed mobility, transfers, and incontinence cares. DON confirmed that on 08/04/25 CNA #130 left Resident #84 alone on her side on a low air loss mattress and left the room to get more linen which resulted in Resident #84 falling out of bed. Review of the facility policy titled, Falls-Clinical Protocol, revised March 2018 stated would evaluate and document falls that occur while the individual was in the facility and should be identified as witnessed or unwitnessed events. The staff, with the physician's guidance, would follow up on any fall associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved.This deficiency represents non-compliance investigated under Complaint Number 2714112.

Based on review of Quality Assurance and Performance Improvement (QAPI) sign in sheets, staff interview and policy review, the facility failed to ensure the Medical Director attended QAPI meetings quarterly, as required. This had the potential to affect all 80 residents residing in the facility. The facility census was 80. Findings include: Review of the facility QAPI sign in sheets revealed the facility held monthly meetings on 02/11/25, 03/31/25, 04/24/25, 05/30/25, and 06/26/25. Further review revealed the facility's Medical Director was not present for any of the QAPI meetings during this time. Interview on 07/01/25 at 2:19 P.M. with the Director of Nursing (DON) verified the Medical Director did not attend QAPI meetings quarterly. Review of the facility policy titled, Quality Assurance and Performance Improvement Committee, undated, revealed the following individuals would serve on the committee: Administrator, DON, Medical Director, dietary representative, pharmacy representative, social services representative, activities representative, environmental representative, infection control representative, rehabilitative/restorative services representative, staff development representative, safety representative, and medical records representative. The committee would meet monthly at an appointed time.

Based on medical record review, review of Binding Arbitration Agreements, resident interview, staff interview and policy review, the facility failed to ensure residents were able to understand and comprehend the terms of a Binding Arbitration Agreement before entering into one. This affected five (#27, #31, #60, #64, and #84) of six residents reviewed for arbitration agreements. The facility census was 80. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 05/14/25 with diagnoses including, but not limited to, dementia. Review of the Minimum Data Set (MDS) assessment, dated 05/21/25, revealed Resident #27 was moderately cognitively impaired. Review of the Binding Arbitration Agreement, signed 05/14/25, revealed Resident #27 signed the document herself. Interview on 06/30/25 at 8:01 A.M. with Resident #27 revealed the resident stated that an arbitration agreement was when two people got together and argued a point and come to a solution. Resident #27 stated she did not think she would sign an arbitration agreement with the facility. 2. Review of the medical record for Resident #31 revealed an admission date of 04/22/25 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of the MDS assessment, dated 04/29/25, revealed Resident #31 was moderately cognitively impaired. Review of the Binding Arbitration Agreement, signed 04/25/25, revealed Resident #31 signed the document himself. Interview and observation on 06/30/25 at 7:56 A.M. with Resident #31 revealed the resident stated an arbitration agreement was when you discuss stuff. Resident #31 stated he would sign one if he did not have any issues. Observation at the time of the interview revealed the resident appeared to be confused and would change the subject to unrelated topics while being interviewed. 3. Review of the medical record for Resident #60 revealed an admission date of 06/13/25 with diagnoses including cognitive communication deficit. Review of the MDS assessment, dated 06/20/25, revealed Resident #60 was moderately cognitively impaired. Review of the Binding Arbitration Agreement, signed 04/07/25, revealed Resident #60 signed her own document. Interview on 06/30/25 at 8:03 A.M. with Resident #60 revealed the resident did not respond when asked if she understood what an arbitration agreement was. Resident #60 stated she was uncertain if she would sign one or not and was unaware if she had already signed one with the facility. 4. Review of the medical record for Resident #64 revealed an admission date of 05/30/25 with diagnoses including, but not limited to, bipolar disorder. Review of the MDS assessment, dated 06/06/25, revealed Resident #64 was moderately cognitively impaired. Review of the Binding Arbitration Agreement, signed 06/02/25, revealed Resident #64 signed the document himself. Interview on 06/30/25 at 8:05 A.M. with Resident #64 revealed the resident stated he did not know what an arbitration agreement was and further stated he would not sign one. 5. Review of the medical record for Resident #84 revealed an admission date of 04/01/25 with diagnoses including, but not limited to, Alzheimer's disease, dementia, and cognitive communication deficit. Review of the MDS assessment, dated 04/02/25, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of zero, indicating the resident was severely cognitively impaired. Review of the Binding Arbitration Agreement, signed 04/01/25, revealed Resident #84 signed the document herself. Observation on 06/30/25 at 8:11 A.M. revealed Resident #84 resided on the memory care unit. An attempt to interview the resident revealed the resident was unable to understand questions asked or provide any relevant information. Interview on 06/30/25 at 8:14 A.M. with admission Coordinator (AC) #447 revealed that when she explained arbitration agreements to residents, she told them it was voluntary and the facility would follow up with the resident if they had a complaint to try and rectify the situation to make them happy before they would have to get an attorney involved. AC #447 stated that she used her laptop for admission paperwork and the residents used the mouse to electronically sign the documents. AC #447 stated that she used the cognitive tests that nursing performed to determine if a resident had the capability to sign their own paperwork. AC #447 verified that Resident #84 had a BIMS score of zero, indicating severe cognitive impairment, and resided on the memory care unit. Review of the facility policy titled, Binding Arbitration Agreements, dated November 2023, revealed the terms and conditions of a binding arbitration agreement were explained to the resident or representative in a form and manner that he or she understood, taking in to consideration the resident's or representative's language, literacy, and stated preference for learning. The terms and conditions of a binding arbitration agreement were explained to the resident or representative in a way that ensured his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding. If arbitration agreements were embedded within other contracts or agreements (for example the admission agreement) the facility would ensure that the arbitration agreement was distinguished from the other agreement and explain to the resident or representative that he or she may accept or decline each agreement separately.

Based on medical record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered or provided the COVID-19 vaccination. This affected four residents (#28, #33, #47, #50) of five residents reviewed for immunizations. The facility census was 80. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 02/06/19, with diagnoses including chronic heart failure, anxiety disorder, dementia, depression, cardiac arrhythmia, and adult failure to thrive. Review of Resident #47's medical record revealed no evidence she had been offered a COVID-19 booster since 2023. Interview on 07/01/25 at 10:48 A.M. with Licensed Practical Nurse (LPN) #506 verified that there was no evidence the COVID-19 vaccine had been offered to Resident #47 since 2023. 2. Review of Resident #50's medical record revealed an admission date of 03/11/20, with diagnoses including type two diabetes mellitus, chronic respiratory failure, depression, heart failure, and major depressive disorder. Review of Resident #50's medical record revealed no evidence she had been offered a COVID-19 booster since 2023. Interview on 07/01/25 at 10:48 A.M. with LPN #506 verified that there was no evidence the COVID-19 vaccine had been offered to Resident #50 since 2023. 3. Review of Resident #28's medical record revealed an admission date of 09/02/15, with diagnoses including multiple sclerosis, major depressive disorder, peripheral vascular disease, chronic heart disease, and obstructive sleep apnea. Review of Resident #28's medical record revealed no evidence she had been offered a COVID-19 booster since 2023. Interview on 07/01/25 at 10:48 A.M. with LPN #506 verified that there was no evidence the COVID-19 vaccine had been offered to Resident #28 since 2023. 4. Review of Resident #33's medical record revealed an admission date of 07/12/17, with diagnoses including dysphagia, type two diabetes mellitus, chronic heart failure, and anxiety disorder. Review of Resident #33's COVID-19 vaccine consent form revealed the resident consented to receive the vaccine on 10/19/24. Further review of Resident #33's medical record revealed no evidence the resident received the COVID-19 vaccination. Interview on 07/01/25 at 10:48 A.M. with LPN #506 verified Resident #33 did not receive the vaccine he had consented to. Review of the CDC guidance titled, Staying Up to Date with COVID-19 Vaccines, dated 06/06/25 and located at https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, revealed getting the COVID-19 vaccine was especially important for those over the age of 65, were at high risk for severe COVID-19, or resided in a long-term care facility.

Based on medical record review, staff interview and review of the Medscapes (online resource for healthcare professionals) indications for medication use, the facility failed to ensure residents were not ordered psychotropic medications without an appropriate indication for use and further failed to ensure residents were monitored for the use of psychotropic medications. This affected three (#43, #71, and #76) of six residents reviewed for unnecessary medications. The facility census was 80. Findings include: 1. Review of Resident #43's medical record revealed an admission date of 04/16/24 with diagnoses including dementia, anxiety disorder, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), major depressive disorder, and insomnia. Review of Resident #43's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of the plan of care dated 04/17/24 revealed Resident #43 required use of psychotropic medications with the potential for adverse reactions related to ADHD, anxiety, depression, PTSD, and history of substance abuse. Interventions included administering medications as ordered, evaluating effectiveness, monitoring the resident's interactions with others, monitoring mood and behavior, monitoring mental status, monitoring for side effects, and monitoring for signs of depression. Review of the physician orders revealed from 04/07/25 to 06/19/25, Resident #43 was ordered Depakote Sprinkles 125 milligrams (mg), one capsule by mouth two times a day for mood. Further review revealed from 06/19/25 to 06/27/25, Resident #43 was ordered Depakote Delayed Release 250 mg, one tablet by mouth twice a day for mood stability. Lastly, on 06/28/25, Resident #43 was ordered revealed an order for Depakote Delayed Release Sprinkles 125 mg, two capsules (250 mg total) by mouth twice a day for mood. Review of Resident #43's Medication Administration Record (MAR) and progress notes for June 2025 revealed no documented behaviors between 06/01/25 and 06/28/25. Interview on 06/30/25 at 3:39 P.M. with the Director of Nursing (DON) verified Resident #43's medical record contained no evidence of increased behaviors or concerns prior to the initiation of the higher dosage of Depakote (from 125 mg two times daily to 250 mg two times daily) on 06/19/25. Further interview with the DON confirmed the resident did not have a diagnosis to support the use of Depakote. 2. Review of Resident #76's medical record revealed an admission date of 04/20/24 with diagnoses including metabolic encephalopathy, dementia without psychosis, chronic kidney disease stage four, peripheral vascular disease, anxiety, depression, and dysphagia. Review of Resident #76's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #76's plan of care dated 04/22/24 revealed the resident required the use of psychotropic medications with potential adverse reactions related to anxiety, depression, and dementia with psychosis. Review of Resident #76' physician orders revealed from 05/20/25 to 06/19/25, the resident was ordered Depakote 250 mg twice a day for mood. Further review revealed from 06/19/25 to 06/27/25, the resident was ordered Depakote Delayed Release 375 mg by mouth two times a day for mood stabilizer. From 06/19/25 to 07/03/25, Resident #76 was ordered Xanax (antianxiety medication) 0.25 mg one tablet by mouth every 12 hours as needed. On 06/27/25, Resident #76 was ordered Depakote Delayed release 125 mg, three tablets (375 mg total) by mouth two times a day for mood. Additionally, on 06/27/25, Resident #76 was ordered Depakote Sprinkles 125 mg three tablets (375 mg total) by mouth two times a day for mood. Review of Resident #76's Medication Administration Record (MAR) and progress notes for June 2025 revealed no evidence of increased behaviors or concerns. Further review of the MAR revealed Resident #76 received Xanax on 06/19/25, 06/22/25, 06/23/25, 06/24/25, and 06/26/25. Interview on 06/30/25 at 3:39 P.M. with the DON verified the facility had no evidence to support the increase in Resident #76's Depakote or the use of Xanax. The DON confirmed the medical record should contain documentation related to the use of psychotropic medications, including as needed medications. 3. Review of the medical record for Resident #71 revealed that she was admitted on [DATE] with diagnoses that included unspecified dementia without agitation and depressive disorder. Review of Resident #71's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision making. She did not have disorganized thinking, rejection of care or physical or verbal behaviors. Review of Resident #71's physician orders revealed that she was prescribed Depakote Sprinkles Delayed Release oral capsule 125 mg, three capsules twice a day for mood. Interview with the DON on 06/30/25 at 3:38 P.M. confirmed that Resident #71 did not have the appropriate medical diagnosis to justify the use of Depakote. Review of the Medscapes website revealed the indications for the use of Depakote included mania (such as associated with bipolar disorder), epilepsy, or migraine prophylaxis.

Based on observations, staff interviews and review of facility policy, the facility failed to ensure foods were labeled, dated, and stored in a manner to ensure food safety. This had the potential to affect all residents residing in the facility, except for one (#9) resident identified as receiving no food from the kitchen. The facility census was 80. Findings include: Observation of the kitchen walk-in refrigerator on 06/29/25 at 8:15 A.M. revealed a package of waffles that were open and undated, a container of Danishes that were opened, undated and unsealed, an undated 32 ounce (oz) jug of opened salsa, twenty-two open-to-air uncovered dishes of peaches and cobbler desserts in tulip bowls, two uncovered thickened yellow liquid in 8 ounce cups, an opened and undated 4.5 pound cheesecake delight tub, three 16 oz chicken bases that were opened and undated, a half of a cake that was unlabeled and undated in a gallon sized plastic bag, an unlabeled and undated pitcher of dark purple liquid, a 64 oz half-full opened garlic parmesan sauce with no use-by date, a 160 oz barbecue sauce that was opened and had no use-by date, and a half-full box of thawed (previously frozen) strawberry nutrition milkshakes with a pull-date of 04/17/25. Observation of the kitchen walk-in freezer on 06/29/25 at 8:26 A.M. revealed an opened package of cinnamon French toast that was open-to-air and stored directly on the freezer floor, and five additional boxes of food product stored on the floor containing frozen vegetables, mini galettes, and cream pies. Interview with [NAME] #549 on 06/29/25 at 8:29 A.M. verified the above findings in the walk-in refrigerator and walk-in freezer. A follow up observation on 06/30/25 at 11:05 A.M. revealed that the half-full box of thawed (previously frozen) strawberry nutrition milkshakes with a pull-date of 04/17/25 was still present in the walk in refrigerator. Interview with Dietary Director (DD) #455 on 06/30/25 at 11:05 A.M. confirmed that the strawberry nutrition milkshakes could only be thawed and stored for twenty days and that the pull date on the box of milkshakes read 04/17/25. DD #455 removed the strawberry nutrition milkshakes from the refrigerator and stated that she would discard them. Review of the facility policy titled, Food Receiving and Storage, dated 2001, revealed that all foods stored in the refrigerator or freezer should be covered, labeled and dated with a use by date. The food in the walk-ins would be stored off of the floor.

Based on resident and staff interview, medical record review, and review of activities documentation, the facility failed to ensure activities were offered to all residents. This affected one (#342) of one resident reviewed for activities. The facility census was 80. Findings include: Review of the medical record revealed Resident #342 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/29/25, revealed Resident #342 had intact cognitive status. The MDS indicated the resident identified that it was somewhat important for her to listen to music that she liked, keeping up with the news, being around pets, going outside when the weather was good and participating in religious practices. Review of Resident #342's activity assessment, dated 06/27/25, revealed that she preferred in-room activities. Interview with Resident #342 on 06/29/25 at 9:45 A.M. revealed that she was not included in activities, but she would like to attend activities. Review of the one-on-one activities and in-room activities tasks since admission on [DATE] revealed Resident #342 had not been offered any activities to participate in. Interview with Activity Assistant (AA) #456 on 06/30/25 at 2:36 P.M. revealed she was not familiar with Resident #342 and was uncertain if she had ever been invited to attend activities. AA #456 verified there was no documented evidence that Resident #342 had been offered any in-room or one-on-one activities since admission on [DATE].

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to maintain resident dignity by ensuring catheter collection bags were covered in common areas. This affected two (#45 and #70) of three residents reviewed for catheter care. The facility census was 80. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 09/04/22 with diagnoses including muscle wasting, obstructive and reflux uropathy, benign prostatic hyperplasia without lower urinary tract symptoms and retention of urine. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/08/25, revealed Resident #70 was cognitively intact, had an indwelling catheter and was always incontinent of bowel. Review of the care plan, dated 11/07/23, revealed Resident #70 was at risk for infection and/or trauma related to the use of a supra-pubic catheter for obstructive uropathy. Interventions include administer medications per physician order, catheter care every shift, change suprapubic catheter on the 19th of the month, check catheter for patency, kinks in tubing every shift, and provide catheter care per facility policy. Review of a physician order dated 01/03/25 revealed to maintain indwelling catheter every shift, 16 french (Fr) and 10 milliliter (ml) balloon for diagnosis of obstructive and reflux uropathy. Observation on 06/29/25 at 9:52 A.M. of Resident #70 revealed the resident's catheter collection bag was uncovered, exposing the contents of the bag. Observation on 07/01/25 at 10:08 A.M. of Resident #70 revealed the resident was sitting in the facility's main lobby, near the door. The resident's catheter collection bag was not covered, exposing the contents of the collection bag. Interview with Licensed Practical Nurse (LPN) Manager #506 on 07/01/25 at 10:09 A.M. confirmed that Resident #70 was sitting in a common area without a dignity covering on his catheter collection bag. 2. Review of Resident #45's medical record revealed an admission date of 12/04/24. Diagnoses included included obstructive and reflux uropathy. Review of Resident #45's MDS 3.0 assessment, dated 06/24/25, revealed that the resident had moderately impaired cognition. The resident had an indwelling catheter. Review of Resident #45's care plan, dated 06/18/25, revealed the resident used a 16 Fr Foley catheter for obstructive uropathy. Interventions included to clean and empty every shift and as needed, the physician would be notified of signs and symptoms of a urinary tract infection (UTI), and the resident would be observed for signs of urinary retention. Observation on 06/29/25 at 9:30 A.M. revealed Resident #45 was sitting in the hallway, across from the nurses' station. Further observation revealed the resident's catheter collection bag was not covered, exposing the contents of the collection bag. Interview with LPN #537 on 06/29/25 at 9:46 A.M. confirmed that Resident #45 did not have a dignity privacy covering on his catheter collection bag. LPN #537 confirmed that a dignity covering should be in place on catheter collection bags when residents were in common areas. Observation on 06/30/25 at 11:57 A.M. revealed Resident #45 was sitting in the hallway, across from the nurses' station. The resident's catheter collection bag remained uncovered, exposing the contents of the collection bag. Interview with LPN #563 on 06/30/25 at 11:57 A.M. confirmed that Resident #45 did not have a dignity privacy covering on his catheter collection bag. Review of the facility policy titled, Dignity, dated 2001, revealed that staff would promote, maintain and protect resident privacy. Demeaning practices and standards of care that compromised dignity were prohibited. Staff were expected to promote dignity and assist residents, including helping to cover urinary catheter bags.

Based on observation, resident and staff interview, medical record review, review of bathing documentation and review of facility policy, the facility failed to ensure dependent residents received timely and adequate staff assistance with personal hygiene. This affected one (#32) of two residents reviewed for activities of daily living (ADLs). The facility census was 80. Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE] with diagnoses including hemiplegia, muscle weakness, major depressive disorder, abnormalities of gait and mobility, dysphagia, and overactive bladder. Review of the care plan, dated 11/20/23, revealed Resident #32 had an ADL self-care and mobility performance deficit related to generalized weakness, dizziness, post-cerebrovascular accident (stroke), diabetes, and obesity. Interventions included the use of a Hoyer lift, two-person (staff) assistance with toileting and bed mobility, and staff assistance with daily hygiene, grooming, and oral care. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/08/25, revealed Resident #32 was cognitively intact and was totally dependent on staff for bathing and personal hygiene, including shaving. Review of the facility's bathing documentation from 06/02/25 through 07/01/25 revealed Resident #32 received a bath on 06/26/25 at 6:43 P.M. and on 07/01/25 at 6:32 A.M. However, further review of the shower/bed bath records showed no documentation shaving was offered or completed on those dates. Observation on 06/29/25 at 10:07 A.M. revealed Resident #32 had visible chin hairs approximately half an inch in length. Subsequent observations on 06/30/25 at 12:16 P.M. and on 07/01/25 at 8:15 A.M. confirmed the facial hair remained present. Interview on 07/01/25 at 8:15 A.M. with Resident #32 revealed she received a bath on the evening of 06/30/25 but staff did not offer to assist with shaving, despite her expressing a desire for hair removal. Interview with Licensed Practical Nurse (LPN) #518 on 07/01/25 at 8:19 A.M. confirmed the presence of facial hair on Resident #32's chin and stated that Certified Nursing Assistants (CNAs) were expected to offer shaving during bathing. LPN #518 stated she would remind the aides that shaving needed to be completed for Resident #32. Interview with CNA #520 on 07/01/25 at 9:33 A.M. revealed residents were offered shaving during bath routines or as needed. She acknowledged shaving should have been provided for Resident #32 and stated it would be completed later that day. Interview with the Director of Nursing (DON) on 07/01/25 at 9:57 A.M. confirmed shaving should be offered to residents during scheduled bath times and as needed. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated April 2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, including bathing, dressing, grooming and oral care.

2. Review of medical record for Resident #53 revealed an admission date of 07/31/24 with diagnosis including, but not limited to, obstructive sleep apnea (difficulty breathing when sleeping). Review of current physician orders revealed an order dated 02/19/25 to schedule a sleep study for Resident #53. Further review of Resident #53's medical record revealed no evidence a sleep study was scheduled or completed. Review of a nursing progress note dated 06/09/25 revealed the Certified Nurse Practitioner (CNP) called into the facility to give a new order for a sleep study. Per the resident, they used a continuous positive airway pressure (CPAP) at home and did not bring it to the facility due to it being broken. Interview on 06/29/25 at 10:22 A.M. with Resident #53 revealed that he was supposed to have a sleep study done but it had not happened. Interview on 06/30/25 at 11:04 A.M. with the Director of Nursing (DON) revealed she would look into the status of the sleep study for Resident #53. A follow-up interview on 07/01/25 at 1:49 A.M. with the DON verified a sleep study was ordered for Resident #53 on 02/19/25 and again on 06/09/25. The DON verified the order did not get sent over to the hospital until 06/30/25 to schedule the sleep study. The DON explained the order had to be entered into EPIC (hospital electronic charting system) for the hospital to schedule a sleep study. The DON verified the order for Resident #53's sleep study had not been arranged timely. 3. Review of the medical record for Resident #32 revealed an admission date of 01/25/19, with diagnoses including type II diabetes mellitus, hemiplegia, obesity, and difficulty walking. Review of the care plan, dated 11/20/23, revealed Resident #32 was at risk for pressure ulcers and alterations in skin integrity related to generalized weakness and impaired mobility. Interventions included administering treatments as ordered, monitoring for effectiveness, and performing weekly skin assessments. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/08/25, revealed Resident #32 was cognitively intact and had no current skin concerns. Review of the physician order dated 06/13/25 revealed Resident #32 had an order to cleanse the right toes with normal saline, pat dry, apply triple antibiotic ointment, and cover with a bordered foam dressing, to be completed every day shift for wound care. Review of the Treatment Administration Record (TAR) from 06/13/25 through 06/30/25 revealed the physician's order for the right toes was documented as completed daily. Observation on 06/29/25 at 10:07 A.M. revealed Resident #32's right foot dressing was dated 06/26/25. Subsequent observations on 06/29/25 at 12:16 P.M. and 1:51 P.M. revealed the dressing on Resident #32's right toes remained unchanged from 06/26/25. Interview on 06/29/2025 at 2:03 P.M. with Licensed Practical Nurse (LPN) #546 verified the dressing in place on Resident #32's right toes was dated 06/26/25 and further confirmed the physician order was for daily dressing changes. Interview on 06/30/25 at 1:19 P.M. with Assistant Director of Nursing (ADON) #571 confirmed the dressing on Resident #32's right toes was to be changed daily. She further stated that if nursing staff did not complete the dressing changes as ordered, they should not document them as completed in the medication administration record. Based on medical record review, observation, staff interview and review of facility policies, the facility failed to ensure compression stockings were applied per physician order. This affected one (#81) of one residents reviewed for edema. In addition, the facility failed to ensure timely follow-up on physician ordered testing. This affected one (#53) of one resident reviewed for physician orders. Lastly, the facility failed to ensure non-pressure ulcer dressings were changed as ordered. This affected one (#32) of two residents reviewed for non-pressure ulcer skin conditions. The facility census was 80. Findings include: 1. Review of the medical record revealed Resident #81 was admitted on [DATE] with a diagnosis of hypertension. Review of the Minimum Data Set (MDS) assessment, dated 05/05/25, revealed Resident #81 had intact cognition. Further review revealed Resident #81 required set up assistance for lower body dressing. Review of a physician order dated 06/18/25 revealed Resident #81 had an order for tubi grips (provides support and compression) or ace wraps on her bilateral lower extremities (BLE) every day for edema starting at 7:00 A.M. Review of Resident #81's nursing progress notes revealed that on 06/20/25, Resident #81 had a cough and was discharged to the emergency room at the request of her family. Review of hospital discharge paperwork dated 06/20/25 revealed Resident #81 had a new diagnosis of edema. The discharge care instructions recommended for Resident #81 to wear support stockings and to wear them in the morning to prevent the swelling from getting worse. Review of nursing progress notes dated 06/21/25 revealed that Resident #81 was able to return back to the facility with new orders for a diuretic, Lasix, and she had BLE edema. Observations on 06/29/25 at 10:00 A.M., 12:00 P.M. and 4:34 P.M. revealed that Resident #81 was not wearing tubi grips or ace wrappings on her BLE extremities and edema present. Interview with Medication Aide (MA) #439 on 06/29/25 at 4:34 P.M. confirmed that Resident #81 was not wearing tubi grips or ace wrappings on her BLE. MA #439 confirmed that nursing was responsible for wrapping Resident #81's BLE on a daily basis to prevent edema.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure oxygen tubing was changed routinely. This affected two (#50 and #78) of three residents reviewed for oxygen. In addition, the failed to monitor and document as needed oxygen use. This affected one (#32) of three residents reviewed for oxygen. The facility census was 80. Findings include: 1. Review of medical record for Resident #50 revealed an admission date of 03/11/20 with diagnoses including, but not limited to, chronic respiratory failure with hypercapnia and hypoxia (trouble breathing), obstructive sleep apnea (difficulty breathing while sleeping), and morbid obesity with alveolar hypoventilation (weight obstructs breathing deeply). Review of the current physician orders revealed Resident #50 received oxygen at two liters per minute (lpm) via nasal cannula (NC) continuously. Observation on 06/29/25 at 10:17 A.M. of Resident #50's oxygen tubing revealed the tubing was dated 03/02/25. Interview on 06/29/25 at 10:18 A.M. with Certified Nursing Assistant (CNA) #554 verified Resident #50's oxygen tubing was dated 03/02/25. 2. Review of medical record for Resident #78 revealed an admission date of 07/10/24 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and hypercapnia, and congestive heart failure (CHF). Review of the current physician orders revealed Resident #78 received oxygen at six lpm via NC with oxygen ears or posey strap. Observation 06/29/25 at 9:50 A.M. revealed Resident #78's oxygen tubing was dated 01/27/25. Interview on 06/29/25 at 09:58 A.M. with CNA #575 verified Resident #78's oxygen tubing was dated 01/27/25. Interview on 06/30/25 at 10:12 A.M. with the Director of Nursing (DON) revealed the facility did not enter physician orders to change oxygen tubing as it was the facility's policy to change oxygen tubing weekly and nursing staff were aware of the policy. Review of the facility policy titled, Equipment Change and Cleansing, undated, revealed nasal cannula's would be changed weekly, and as needed, and discarded in a regular waste container. 3. Review of the medical record for Resident #32 revealed an admission date of 01/25/19, with diagnoses including morbid obesity, type two diabetes mellitus, chest pain, dysphagia, and cerebral infarction. Review of a physician order dated 01/14/25 revealed Resident #32 received oxygen at two lpm via nasal cannula as needed. Review of the care plan dated 01/15/25 revealed Resident #32 required oxygen, with interventions including monitoring and reporting signs of hypoxia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was cognitively intact and received no oxygen therapy at that time. Review of the oxygen saturation summaries revealed on 04/25/25, Resident #32's oxygen saturation was 94% at two liters via NC; on 05/06/25 at 8:49 A.M., saturation was 94% on room air; on 05/27/25 at 1:11 P.M., saturation was 94% on room air; and on 06/28/25 at 12:03 P.M., saturation was 96% on room air. Review of the Treatment Administration Record (TAR) from 06/01/25 through 06/30/25 revealed Resident #32's oxygen administration was not documented as given at any time during the month. Observation on 06/29/25 at 10:07 A.M. revealed Resident #32 had a NC in place, receiving oxygen at two lpm. Subsequent observations on 06/29/25 at 1:51 P.M., 06/30/25 at 12:16 P.M., and 07/01/25 at 8:15 A.M. revealed oxygen administration via NC remained in place. Interview on 07/01/2025 at 9:28 A.M. with Licensed Practical Nurse (LPN) #518 revealed Resident #32 had orders to receive two liters of oxygen via NC as needed. LPN #518 stated the resident applied the oxygen herself for comfort and that vital signs were not taken when the oxygen was applied. She also stated that vital signs would be documented on the TAR if ordered with oxygen administration. The nurse was unaware of the resident's baseline oxygen saturation. Interview on 07/01/2025 at 9:51 A.M. with the DON revealed oxygen administration should be documented on the TAR when it was administered. She confirmed Resident #32's record did not contain evidence that oxygen administration was being properly documented. Additionally, the DON stated there was no documentation of baseline vital signs taken prior to oxygen administration. Review of the facility's oxygen administration policy, dated October 2010, revealed before administering oxygen, and while the resident was receiving oxygen therapy, staff were to assess for cyanosis (skin turns bluish in color), hypoxia, oxygen toxicity, vital signs and lung sounds. Additionally, after completing the oxygen set up or adjustment, the reason for as needed administration, the frequency, and the duration of the treatment should be documented in the record.

Based on interview, medical record review, and policy review the facility failed to ensure parameters were in place for pain medication administration and ensure non-pharmacological interventions were implemented and descriptions of pain were documented with administration of pain medication. This affected one resident (#48) of two residents reviewed for pain. The facility census was 80. Findings include: Review of Resident #48's medical record revealed an admission date of 03/28/24 with diagnoses including chronic respiratory failure, type two diabetes mellitus, major depressive disorder, generalized anxiety disorder, cognitive communication deficit, unspecified dementia, and metabolic encephalopathy Review of Resident #48's plan of care dated 09/09/24 revealed the resident was at risk for pain related to decreased mobility with neuropathy, restless leg syndrome, and history of migraine headaches. Interventions included acknowledging the presence of pain and discomfort, administering pain medication as ordered, assessing for pain, encouraging non-medicinal interventions, evaluating effectiveness of pain interventions, and referring to therapy for evaluation and treatment. Review of Resident #48's physician order dated 03/28/24 revealed an order for Tylenol 325 milligrams (mg), two tablets to be given by mouth every six hours as needed for pain. Further review revealed an order dated 04/15/25 for tramadol (opioid pain medication) oral tablet 25 mg, one tablet by mouth every 12 hours as needed for pain. Neither physician order provided parameters for the administration of either pain medication. Review of Resident #48's Medication Administration Record (MAR) for June 2025 revealed tramadol was given on 06/05/25 for a pain of level of six (on a scale of zero to 10, with 10 being the worst), on 06/07/25 for a pain level of five, on 06/13/25 for a pain level of five, on 06/15/25 for a pain level of four, and on 06/16/25 for a pain level of two. Tylenol was administered on 06/05/25 for a pain level of four, on 06/16/25 for a pain level of three, on 06/19/25 for a pain level of three, on 06/21/25 for a pain level of three and zero, on 06/22/25 for a pain level of three, on 06/24/25 for a pain level of three, on 06/26/25 for a pain level of four, and on 06/29/25 for a pain level of five. Review of Resident #48's progress notes revealed there was no description of the resident's pain or nonpharmacological interventions implemented for administration of tramadol on 06/05/25 and 06/16/25 and no nonpharmacological interventions on 06/07/25, 06/13/25, and 06/15/25. There was no description of pain or nonpharmacological interventions implemented for administration of Tylenol on 06/05/25, 06/16/25, and 06/24/25 and no pharmacological interventions on 06/19/25, one administration on 06/21/25, and 06/22/25. Interview on 07/01/25 at 9:57 A.M. with the Director of Nursing (DON) revealed nursing staff should be documenting nonpharmacological interventions and descriptions of pain with administration of as needed medications. She reported without physician parameters for pain medication, nursing staff administered per nursing judgement or by resident request. Review of the facility policy titled, Pain Clinical Protocol, dated April 2025, revealed pain medications should be utilized with the lowest risk medication before using more problematic or higher risk approaches.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure pre and post dialysis evaluations were completed. This affected one (#15) of one resident identified as receiving dialysis. The facility census was 80. Findings include: Review of medical record for Resident #15 revealed an admission date of 08/11/17 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Review of Resident #15's current physician orders revealed to complete a post-dialysis evaluation, complete a pre-dialysis evaluation and send with the resident, and dialysis every Monday, Wednesday, and Friday. Review of Resident #15's dialysis evaluations for May 2025 and June 2025 revealed no pre or post dialysis evaluations were completed on 05/23/25, 05/30/25, 06/02/25, 06/04/25, 06/13/25, and 06/16/25. Further review of the dialysis communication revealed no post-dialysis evaluations were completed on 06/09/25 and 06/27/25. Interview on 06/30/25 at 11:54 A.M. with the Director of Nursing (DON) verified the facility had no evidence the pre and post dialysis evaluations were completed for Resident #15 on the above dates, as ordered. Review of the facility policy titled, PACS Dialysis Communication: PACS Best Practice Workflow, revised November 2024, pre-dialysis communication was to be completed by the nurse before the resident left for a dialysis appointment. The post-dialysis communication was to be completed by the nurse after the dialysis treatment.

Based on medical record review, staff interview, and policy review the facility failed to ensure comprehensive care plans were developed to address resident care needs. This affected one (#53) of six residents reviewed for care plans. The facility census was 80. Findings include: Review of medical record for Resident #53 revealed an admission date of 07/31/24 with diagnoses including, but not limited to, infection and inflammatory reaction to internal right knee prosthesis. Review of the current physician orders revealed Resident #53 was ordered doxycycline (antibiotic) 100 milligrams (mg) twice daily for prophylactic related to total right knee infection per orthopedic surgeon. Review of current care plan revealed no care plan for antibiotic use or infection. Interview on 06/30/25 at 11:04 A.M. with the Director of Nursing (DON) verified Resident #53 did not have a care plan for antibiotic use or infection. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident.

Based on medical record review, review of a fall investigation, review of an electronic mail (email) communication, staff interview, review of personnel files and policy review, the facility failed to ensure a resident was provided appropriate/adequate assistance during bed mobility and while utilizing a standing lift resulting in two separate avoidable incidents involving the resident being lowered to the floor. This resulted in actual harm when a staff member assisted Resident #20 with a standing lift without utilizing a second staff member for assistance, the resident was not positioned in the standing lift appropriately, the resident was subsequently lowered to the floor and a [MEDICAL CONDITION] trochanter of the left hip was discovered. This affected one (#20) of three residents reviewed for falls. Facility census was 89. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of fall assessments revealed Resident #20 had a fall assessment completed on 10/29/19 which revealed the resident has weakness, joint pain arthritis, uses narcotic [MEDICATION NAME] and has a difficult time maintaining standing position with musculoskeletal problems. Review of Resident #20's care plan revealed the resident had a fall care plan in place indicating the resident was to be a two person stand lift transfer with an initiation date of 04/14/20. Resident #20's care plan indicated the resident required two persons assist with bathing, dressing and transfers, but the care plan did not address the amount of assistance needed with bed mobility. Review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15, had no behaviors, delusions or hallucinations coded. Resident #20 was coded as requiring extensive assist from two staff for bed mobility, transfers, dressing, toileting and personal hygiene. Review of Resident #20's Kardex from 07/10/20 revealed the resident was two-person staff assist with daily hygiene, grooming and dressing. One assist with oral hygiene set up assist with meals. Resident #20 utilized a sit-to-stand lift with transfers and uses walker/wheelchair under safety the resident was to have the bed in the low position, common articles within reach, perimeter mattress, self-releasing seatbelt per physician orders. The Kardex indicated to see the Activity of Daily Living (ADL) care plan, sit-to-stand for transfers for further details. For bowel and bladder, the resident used bariatric briefs was on prompted toileting, provide assistance with toileting (no number of staff noted) and provide incontinent care as needed. Review of Resident #20's progress note dated 07/14/20 at 3:45 A.M. revealed the resident was lowered to the floor after the resident's legs slid off the bed during a check and change. Resident #20 had no complaints of injury or pain at this time, full range of motion was noted and all notifications to be made later in the day. Review of Resident #20's progress note dated 07/14/20 at 4:20 P.M. indicated the Interdisciplinary team (IDT) team reviewed the resident fall and determined the resident should have two staff assist with ADL care that require rolling in bed. Resident #20 apparently was able to move his/her legs to help staff and swung them over the edge during the fall. Review of progress note dated 07/15/20 at 6:25 P.M. revealed Resident #20 complained of pain in left hip. The physician was in the facility for a professional visit and gave a new order for X-[MEDICAL CONDITION] (x-ray) of the left hip. Resident #20's daughter was updated regarding the resident condition and the new order. Review of progress note dated 07/16/20 at 1:01 P.M. revealed the daughter was updated on x-ray results of left hip and about excoriation findings under the resident breast. Daughter stated the resident complained to her last night on the phone that the left side ribs were hurting. The physician was paged and awaiting return phone call. Review of progress note dated 07/16/20 at 5:18 P.M. revealed the nurse spoke with the physician and new orders for x-ray of left side of ribs due resident complaints of pain from fall 07/14/20. Message left for daughter requesting call back to update on new orders. Review of progress note dated 07/17/20 at 10:20 A.M. revealed Resident #20 continues to have complaints of pain from incident of lowering out of bed to floor on 07/14/20. Pain is noted to be in left rib, hip and knee. Physician in to visit with the resident and resident x-ray of the left hip and ribs were completed and were negative. Physician gave a new order for x-ray of left knee. Daughter aware of new order. Nurse indicated the resident will continue to be monitored and has call light in reach. Review of Resident #20's progress note dated 07/17/20 at 6:03 P.M. indicated the physician was notified of x-ray results of acute/recent [MEDICATION NAME] supracondylar distal femur fracture. Review of Resident #20's x-ray completed on 07/17/20 revealed the x-ray of the left knee, two views result revealed a long stem left total knee arthroplasty remains unchanged, without visualized hardware complications, though it should be noted that the proximal tip of the left femoral component and the distal tip of the tibial component are not included on the images; diffuse osteopenia is noted, with a new acute periprosthetic [MEDICAL CONDITION] proximal tibia with a 3.2 centimeter (cm) by 1.0 cm fracture fragment which is anteriorly displaced by 0.9 cm, as seen on the lateral view; and chronic mildly peripherally displaced well corticated periprosthetic fracture fragments remain unchanged arising from the distal metaphysis of the left femur. Review of Resident #20's x-ray completed on 07/17/20 revealed bilateral hips with pelvis result revealed moderate to severe generalized osteopenia and multifocal stable arthritic changes about both sacroiliac joints and hips. The arthritic changes are most apparent about the right hip. No convincing evidence of acute fracture or dislocation. Review of Resident #20's progress note dated 07/18/20 at 12:30 A.M. revealed the resident returned from the emergency room (ER) on 07/17/20 at 11:50 P.M Resident #20 was awake with a knee immobilizer to left knee. Review of Resident #20's progress note dated 07/18/20 at 10:36 A.M. revealed ER discharge paperwork indicated the resident is to a have two-person extensive assist for care due to condition and pain. Resident #20 stated her pain is ok at this time. Review of Resident #20's progress note from orthopedic physician written on 07/22/20 revealed there was no acute fracture, the resident can return to normal activities and as needed follow up visits. Review of Resident #20's progress note from 07/22/20 at 11:05 A.M. revealed the resident returned to the facility from orthopedic appointment. No new orders were received and there was no new fracture. Resident #20 can resume all activities resting in bed at this time knee immobilizer in place. Further review of investigation for Resident #20's fall on 07/15/20 revealed the witness statement from State tested Nursing Assistant (STNA) #341 revealed Resident #20 was incontinent and needed changed. Resident #20 normally does fine rolling for the STNA and the STNA had never had a problem providing care to this resident in the past. STNA #341 indicated the resident was positioned on the right side of bed between the roommates, and Resident #20 was rolled away from the STNA facing towards the window. STNA #341 indicated Resident #20's bottom sheet was wet so the STNA turned and got another sheet and had just tucked it underneath the resident when the STNA looked up, and noted Resident #20's legs were off the bed and the resident was holding onto the closet door. Resident #20 was about three-fourths (¾) of the way out of the bed. STNA #341 stated I stopped what I was doing, and went to the other side of the bed and lowered the resident the rest of the way to the floor, then I went and got the nurse and we Hoyered back into the bed. Review of Resident #20's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact with a BIMS score of 13 out of 15, had no behaviors, delusions or hallucinations coded. Resident #20 was coded as requiring extensive assist from two staff for bed mobility, transfers, dressing, toileting and personal hygiene. Resident #20 only requires supervision for eating. Resident #20 utilized a wheelchair for mobility. Review of Resident #20's fall assessment completed on 08/05/20 revealed the resident uses cardiovascular medications, diuretics, and narcotic [MEDICATION NAME] medications, has weakness, joint pain arthritis, and fatigue, and has difficulty maintaining standing position. Further review of the Kardex dated 08/28/20 revealed Resident #20 had change to the Hoyer lift for a means of transfer, and is non-weight bearing on the left leg. Resident #20 also has a change added under safety tab for two-person staff assist with ADL's that require rolling in bed, two person assist with ADL's that require log rolling in the bed. The Kardex from 09/17/20 was reviewed and revealed one-person staff assist with daily hygiene, grooming, dressing, oral care and eating as needed. Under the section for ADL assist the resident is to transfer with the Hoyer lift. Two-person staff assist for care that requires rolling side to side in bed, low bed room close to nurses station. Review of Resident #20's progress note dated 08/05/20 at 3:15 P.M. revealed the nurse was alerted by aide that resident was lowered onto floor. Resident #20 found sitting on bottom on floor back against wheelchair with right knee bent back and to right side to her. Resident #20 stated his/her knee gave out because it was taking too long. Range of motion active times four extremities, no injuries noted at this time. Resident #20 denies any pain. Resident #20 assisted via mechanical lift (Hoyer) from floor to bed. Physician in the facility made aware of Resident #20 being placed on the floor and new order for x-ray of right knee. Daughter notified no further questions at this time. Review of Resident #20's progress note dated 08/05/20 at 6:42 P.M. revealed the physician was in for a professional visit. New order to x-ray the residents left knee and hip. Review of Resident #20's progress note 08/06/20 at 3:35 P.M. revealed physician was paged in regard to x-ray results. Physician called and gave orders for patient to be sent to acute care hospital. Daughter notified at this time and Resident #20 transferred to the hospital. Review of hospital ER physician notes dated 08/06/20 at 7:27 P.M. revealed Resident #20 was seen for a fall and found to have a closed [MEDICAL CONDITION] hip. Further review of the results of a Computerized Tomography (CT) scan of the left hip revealed Resident #20 was found to have a nondisplaced [MEDICAL CONDITION] trochanter of the left hip. This may be a subacute injury as the resident did have a fall with imaging performed last month. Review of Resident #20's progress note dated 08/06/20 at 9:30 P.M. revealed the resident arrived via squad expressed pain with transfer from gurney to bed then pain subsided quickly. Resident #20 was given pain medication as scheduled. Call light in reach, needs met at this time. Resident #20 to follow up with orthopedic surgeon within one week from today. Scheduling to be updated tomorrow. Review of Resident #20's progress note dated 08/07/20 at 8:26 A.M. revealed the IDT met to discuss the resident's fall that occurred on 08/05/20. Resident #20 was being transferred by STNA #337 via sit to stand lift when legs began to give out and resident was lowered to the floor. Resident #20 was assisted back to bed via Hoyer by nurse and STNA's once positioned in bed complained of leg pain. Nurse assessed left leg and noticed swelling to lower leg with pain in hip and knee on left side. X-ray was obtained and noted to have greater trochanter [MEDICAL CONDITION] hip. Physician gave order to send to ER for evaluation on 08/06/20. Patient returned to facility on 08/06/20 with [DIAGNOSES REDACTED]. No surgical intervention at this time and to follow up with orthopedic next week. Resident #20 has scheduled pain medications in place and as needed medications for pain. Neurological (neuro) checks were not initiated due to staff witnessed fall and did not hit head. Physician and family updated and involved in plan of care. STNA #337 was educated on proper lift techniques and fall protocols. Care plan was updated. Even with interventions in place resident remains at risk for falls. Review of Resident #20's orthopedist consult note dated 08/14/20 revealed the resident has an isolated greater trochanter of the left hip, non-displaced. At this time will continue non weight bearing status. Resident #20 states she has not walked in over a year. Resident #20 states pain has been well controlled. Would like to recheck an x-ray of the left hip and pelvis in one month. Would be easiest for Resident #20 to have mobile x-ray at the nursing facility and send report and disc to our office. Review of Resident #20's progress note dated 08/15/20 at 3:06 P.M. revealed the resident saw the orthopedic physician on 08/14/20 and continues to be non-weight bearing on the left extremity. Swelling continues to the left lower extremity. Resident #20 denies much pain at this time, stated pain is about a four out of 10 (with 10 being the worst pain). Well controlled by current pain medication. Swelling to left leg continues pedal pulses palpable but weak. Lungs clear, denies cough this time. Orthopedist would like a repeat x-ray in one month around 09/14/20, order placed via mobile x-ray group. No needs voiced, call light in reach. Review of an email communication from the DON on 09/16/20 at 4:15 P.M. confirmed STNA #337, reported that he/she knew they were wrong with proceeding by himself/herself but chose to attempt the transfer anyway on 08/05/20 resulting in Resident #20 being lowered out of the sit-to-stand lift. The DON further confirmed on 07/14/20 a staff member, STNA #341, was providing check and change assistance to the Resident #20 alone. The DON indicated STNA #341 rolled Resident #20 away from the staff member's body. The intervention for this incident was to make the Resident #20 a two-person staff assist with incontinence care. During an interview with the DON on 09/28/20 at 1:18 P.M. confirmed Resident #20 sustained a fracture to the femur when the resident was not transferred correctly with the sit-to-stand lift on 08/05/20. The DON stated Resident #20 did not have a surgical intervention as the hospital determined the resident was not a surgical candidate and the surgeon agreed. The DON stated Resident #20 was seen by the orthopedist and had a follow up appointment scheduled however the resident was in the hospital at the time of the appointment and was unable to go to the appointment. Interview with STNA #310 on 09/08/20 at approximately 4:30 P.M. verified the stand lift should always be used with two staff members. Review of STNA #341's personnel file revealed a hire date of 05/01/19. Further review of the personnel file revealed STNA #341 received a counseling education regarding turning residents toward yourself and not away from one's self, with the STNA signing the education on 07/23/20. Review of STNA #337's personnel file revealed a hire date of 01/15/20 and received training on this date for sit to stand lift transfers. The training included to the lift resident's feet on the platform of the lift, fasten the leg straps, and place safety belt around waist with clips fasten of the sling. STNA #337's file indicated the employee was in good standing with the nurse aide registry. STNA #337's received disciplinary action for not operating the sit to stand lift correctly as per facility standard with Resident #20 and STNA #337's employment was terminated. Review of the facility policy titled Mechanical Lift dated 03/2001 with last revision on 04/2019 revealed staff are to inspect slings for wear and tear prior to use. Remove any slings from service that does not meet manufacturers specifications. Disposable slings are not used. Staff are to verify transfer assistance needed per Kardex. Obtain additional assistance and needed equipment as indicated. Use of a mechanical lift requires a second care giver. This deficiency substantiates Complaint Number OH 580, Complaint Number OH 912, Complaint Number OH 582 and Complaint Number OH 553.

Based on medical record review, review of hospital records, staff and resident interview, the facility failed to ensure a safe transfer for a resident. This resulted in actual harm when the resident sustained [REDACTED]. This affected one Resident (#10) of three reviewed for accidents. The facility census was 107. Findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Kardex Report for Resident #10 dated 12/04/19 revealed the resident required transfer with Sit to Stand lift (a machine that assists a resident with transfers, similar to a lift chair). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition and required extensive assistance with two-person assistance for Activities of Daily Living (ADLs). Review of Resident #10's progress note dated 12/06/19 at 6:46 [NAME]M., revealed a State tested Nursing Assistant (STNA) notified the nurse Resident #10 had reported to her she was in pain and needed repositioned. The resident also reported to her she had fallen on 12/05/19 in the bathroom during a transfer. The nurse completed an assessment and documented range of motion was intact to all extremities except the resident's left knee. The resident reported increased pain and was not able to move it. The nurse informed the physician and obtained an order for [REDACTED]. Review of Resident #10's progress note dated 12/06/19 at 12:17 P.M., revealed after review of the x-ray results, the physician gave an order to send the resident to the emergency room (ER) for treatment of [REDACTED]. Review of the ER note dated 12/06/19 at 1:45 P.M., revealed Resident #10 had sustained a left proximal and distal fibular fractures, with the distal fracture being slightly displaced. [MEDICATION NAME] (narcotic pain medication) was administered for pain control. Resident #10 reported to the ER she fell in the bathroom and her left lower extremity was bent underneath of her. The resident reported pain with any attempted touch of the lateral aspect of the left leg. The resident was admitted for pain control and scheduled for an orthopedic consult. Review of the Orthopedics Consult note dated 12/06/19 at 6:55 P.M., revealed Resident #10 reported she was half way off the wheelchair when she slipped out and fell on the floor. The physician recommended non-weight bearing on the left leg. A short leg boot was ordered and until the boot arrived the resident would wear a splint. Ice, elevation, and pain control were also recommended. Interview with STNA #120 on 12/23/19 at 1:04 P.M. revealed she transferred Resident #10 out of bed on 12/05/19 by herself and into her wheelchair. Then later the STNA revealed the resident requested to be transferred to the commode. STNA #120 revealed she, STNA #121, and four STNAs in training, used a gait belt to transfer the resident out of the wheelchair and onto the commode. The STNAs left the room to provide privacy for the resident. STNA #120 stated the next shift was informed to use the Sit to Stand lift to transfer the resident from the commode back to the resident's wheelchair when the resident was ready. STNA #120 revealed when she and STNA #121 were leaving for the day and passed Resident #10's room, they saw the resident on the floor of the bathroom with STNA #122 and STNA #123 in the room. The resident was on the floor in front of the toilet with her right leg extended straight out in front of her and her left leg was bent at the knee against the floor in a V shape. The STNA revealed she straightened the resident's left leg out and bent both resident's legs at the knees, so her feet were flat on the floor. The STNA revealed then she and STNA #121 then used the gait belt to lift the resident off the floor and transferred her back into her wheelchair. Interview with Resident #10 on 12/23/19 at 2:34 P.M., revealed the resident was alert and oriented. Resident #10 revealed on the day of the fall two STNAs had helped her to the bathroom and when she was finished, the staff transferred her back into her wheelchair but did not push her all the way back in the chair and she went to the floor. The resident stated she started sliding and the STNAs could not hold her up and her legs folded underneath of her. Resident #10 revealed one of the STNAs said she was leaving and left her with the other STN[NAME] The STNA attempted to assist her to her wheelchair, however was not able to hold her up and she fell on the floor. Resident #10 revealed she yelled out in pain immediately and stated the pain was in her left leg. Several other STNAs then arrived at her bathroom to help her off the floor and back in her wheelchair. She revealed she always had two staff members to help her with transfers and would never attempt to transfer by herself due to weakness. The resident confirmed she had a fracture in her lower left leg and remained non-weight bearing at this time. Interview with STNA #121 on 12/23/19 at 2:51 P.M., revealed when Resident #10 requested to be transferred to the commode, STNA #120, herself, and four STNAs in training assisted Resident #10 to the commode using a gait belt, and they all left the bathroom to provide privacy. STNA #121 revealed she reported to the oncoming STNAs to use the Sit to Stand lift to transfer Resident #10 off the commode and back into her wheelchair due to the resident's weakness. STNA #121 revealed she and STNA #120 were on their way out of the facility when they saw Resident #10 on the floor in her bathroom. STNA #121 stated STNA #122 and STNA #123 were in the bathroom with the resident. STNA #123 reported Resident #10 had self-transferred off the commode and was standing up holding on to the grab bar when she arrived in the resident's room. STNA #122 and STNA #123 lowered the resident to the floor and reported the incident to a nurse. STNA #121 revealed her and STNA #120 assisted the resident back into her wheelchair using a gait belt while the nurse, Licensed Practical Nurse (LPN) #124 held the resident's wheelchair in place. Interview with STNA #123 on 12/23/19 at 3:07 P.M. revealed when she went to Resident #10's room she observed Resident #10 in the bathroom, standing in front of the commode, holding on to the grab bar with a gait belt on. STNA #123 stated when she saw the gait belt, she knew the resident was not supposed to be standing without assistance and immediately grabbed the resident's gait belt to hold her up. She revealed the gait belt slipped when she grabbed it and she then wrapped her arms around the resident's arms to keep the resident from falling. The resident's feet started sliding out in front of her. STNA #123 revealed she asked STNA #122 for help and lowered the resident to the floor. STNA #120 and STNA #121 then arrived to assist and she left the room to retrieve a Hoyer lift to assist the resident off the floor. However, STNA #120 and STNA #121 did not use the Hoyer lift and lifted the resident off the floor by grabbing the resident's gait belt. STNA #123 stated STNA #120 and STNA #121 bent both of the resident's legs first so the resident could stand up easier, however the first attempt was unsuccessful, and the resident needed to be set back down on the floor. The second attempt they were able to get the resident back in her wheelchair. Interview with STNA #122 on 12/23/19 at 4:20 P.M. revealed when he arrived to Resident #10's room he observed STNA #123 in the bathroom with Resident #10 standing up holding the grab bar and the STNA was holding the resident's gait belt. He revealed he was not familiar with how the resident should have been transferred. He revealed he and STNA #123 lowered the resident to the floor instead of attempting to transfer her back to her wheelchair. Once the resident was lowered to the floor, STNA #122 observed the resident's left leg was crossed underneath her right leg. STNA #120 and STNA #121 then arrived in the resident's bathroom and took over. STNA #120 and STNA #121 lifted Resident #10 off the floor by bending the resident's legs toward the ceiling and grabbing the resident's gait belt, assisting the resident to her feet and into the wheelchair. STNA #122 revealed the resident was complaining of pain, and revealed following the incident, he was informed Resident #10 should have been transferred with a stand to lift machine. Interview with the Director of Nursing (DON) on 12/23/19 at 5:13 P.M. confirmed Resident #10 should have been transferred with a Sit to Stand lift. She revealed STNA #120 and STNA #121 failed to follow the Kardex instructions for transfers for the resident. The DON further revealed there was a delay in reporting the incident because LPN #124 failed to complete an incident report regarding the fall. She revealed STNA #120 and STNA #121 were given written disciplinary action for not using the proper assistance to transfer Resident #10. LPN #124 also received disciplinary action for not following the facility policy for reporting an incident. This deficiency substantiated Control Number OH 899.

Based on medical record reviews, observations, staff interviews, and review of the National Pressure Ulcer Advisory Panel/NPUAP (www.npuap.org), the facility failed to timely identify a resident's wound. This resulted in harm when Resident #77 developed a facility acquired unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could not be confirmed because it was obscured by slough or eschar) pressure ulcer. The facility further failed to ensure ordered interventions were timely implemented for the resident's unstageable pressure ulcer. Additionally, the facility failed to accurately assess two additional pressure ulcers for two (#20 and #24) of five residents reviewed for pressure ulcers. The facility census was 112. Findings include: 1. Review of Resident #77's medical record revealed an admitted date of 03/17/18, with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had moderate cognitive impairment. The assessment further revealed Resident #77 required an extensive two person assist with bed mobility. Review of Resident #77's care plan revealed the resident was at risk for skin integrity related to impaired mobility. Interventions included to encourage to reposition as needed, float heels as able, and observe skin condition with activity of daily living care daily and report abnormalities. Review of Resident #77's physician's orders [REDACTED]. The MAR indicated [REDACTED]. There was no evidence the resident had any skin impairments to her left heel, or ankle. The (MONTH) (YEAR) MAR further revealed the resident had an order to cleanse the left heel with [MEDICATION NAME], allow to dry, apply a non-adherent pad, and wrap with Kerlix (gauze bandage roll) for protection, every night. The MAR indicated [REDACTED]. Review of Resident #77's skin progress notes dated 06/20/18 at 3:48 P.M., revealed the resident was noted to have a facility acquired unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could not be confirmed because it was obscured by slough or eschar) pressure ulcer on her left heel, and left outer ankle. The pressure ulcer measured 0.7 centimeters (cm) by 0.5 cm. The wound bed was noted 100% green slough (thin nonviable tissue that is yellow or white in appearance, adherent to the wound base, usually moist, can be soft and stringy). The pressure area on the left outer ankle was noted to be an unstageable pressure ulcer, measuring 0.4 cm by 0.3 cm. The wound bed was 100% slough. The treatment was [MEDICATION NAME], cover with a four by four dressing, and wrap with Kerlix. Review of the dietician recommendation dated 06/21/18, revealed a recommendation for ProSource (liquid protein supplement) 30 milliliters (ml) two times a day, and Zinc Sulfate 220 mg two times a day, for 14 days, to promote wound healing. The physician agreed with the recommendation and signed the order on 06/22/18. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the skin progress note dated 07/17/18 at 2:34 P.M., revealed the resident still had an unstageable wound to her left heel measuring 0.3 cm by 0.2 cm, with a dry light yellow scab noted, with a dark center. The surrounding tissue was dry, flaky, and without odor or drainage. Additionally, the resident still currently had an unstageable wound to her left outer ankle measuring 0.6 cm by 0.5 cm, with a dark dry scan noted on the ankle, it was firmly attached at the edges. Observation of Resident #77's pressure ulcers on 07/18/18 at 6:23 A.M., with Licensed Practical Nurse (LPN) #51 and LPN #133 revealed the resident had an unstageable pressure ulcer to her left heel with a yellow colored scab. Resident #77's left outer ankle had an unstageable pressure ulcer with a dark colored scab. The LPN's did not measure the areas. LPN #51 completed the treatment, and the resident denied pain. Interview with the Director of Nursing (DON) on 07/19/18 at 11:01 A.M., confirmed the facility acquired unstageable pressure areas to Resident #77's left heel and left ankle, should have been found prior to being found at as unstageable pressure ulcers, containing slough. Interview with Unit Manager (UM) #113 and DON on 07/19/18 at 1:19 P.M., revealed the UM #113 confirmed the ProSource 30, and Zinc Sulfate ordered on [DATE] was not started until 06/25/18. The DON confirmed both the ProSource and the Zinc Sulfate should have been started prior to 06/25/18. Review of information from the www.npuap.org, revealed an unstageable pressure ulcer was a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could be confirmed because it was obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The NPUAP further revealed staff should assess pressure points, such as the heels, and beneath medical devices. Ensure the heels are free from the bed, and use heel offloading devices, or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], revealed the resident had severely impaired cognition. Further review revealed the resident required extensive staff assist with bed mobility. The assessment revealed the resident had no pressure ulcers, and was receiving hospice services. Review of the Braden assessment for predicting pressure sore risk, dated 05/07/18, revealed Resident #20 was at moderate risk for developing pressure ulcers. Review of the skin alteration record, initiated 07/11/18, revealed Resident #20 had an open area on her left inner buttocks measuring 2.3 cm in length, by 1.8 cm in width, by 0.1 cm depth. The area had a dark pink/red tissue with a scant amount of serous (clear) drainage. The area was not identified as a pressure ulcer. Observation on 07/18/18 at 2:16 P.M., revealed Registered Nurse (RN) #121 changed the dressing to Resident #20's open area on the left buttocks. Observation of the wound revealed a pink wound bed with 50% [MEDICATION NAME] tissue and 50% granulation tissue. The open area measured 1.3 cm length, by 1.7 cm width, by less than 0.1 cm depth. Interview immediately following the observation with RN #121 revealed the open area was an abrasion that opened up from moisture. Review of progress notes, dated 07/18/18 at 3:33 P.M., revealed the open area was re-assessed after the observation, and identified as a facility acquired pressure ulcer presenting as a stage 2 pressure ulcer. Interview on 07/18/18 at 4:45 P.M. with RN #121 revealed Resident #20's physician assessed the wound to her left inner buttocks, and identified the open area as a stage 2 pressure ulcer. The RN confirmed the area had not been assessed, or treated as a pressure ulcer. 3. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment revealed the resident was cognitively impaired, and required extensive assistance with toileting. Review of Resident #24's physician order [REDACTED].#24 had an abrasion to the left buttock, due to shearing. The treatment was to cleanse the wound with an antimicrobial cleanser, apply z-guard cream, every shift, and as needed, until healed. Observation on 07/18/18 at 9:33 A.M., of wound care for Resident #24 with LPN #304 and Nurse Supervisor LPN #309, confirmed the wound on the resident's left buttock was open. Unit Manager #46 then came into the room and revealed the area on the resident's left buttock was not over a bony prominence, and the wound was due to shearing, and not a pressure ulcer. Review of Resident #24's progress note dated 07/19/2018, revealed the wound to the resident's left inner buttock was reassessed. The area was now deemed a facility acquired pressure ulcer. The treatment was changed to comfort foam.

Based on review of documentation including a Self Reported Incident (SRI), clinical record and police reports, interviews with staff, resident, family and police, observation, and abuse policy review, the facility failed to prevent harm of physical abuse resulting in a dark purple black eye for one (#38) resident of three reviewed for abuse. The census was 130. Findings include: Review of Resident #38's clinical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's medications included baby aspirin and [MEDICATION NAME] (both with anticoagulation properties and contribute to bruising) and two anti-depressants. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact and he required extensive assistance with transfers and toilet use. Review of the physician's assessment dated [DATE] around 10:00 A.M. revealed the resident had a ecchymotic area on the left periorbital area laterally with a small abrasion with no bleeding noted. The nursing notes revealed the resident complained of mild pain and extra strength Tylenol was administered twice on 03/19/16. Review of a facility Self Reported Incident (SRI) dated 03/19/16 revealed abuse was substantiated and State tested Nursing Assistant (STNA) #5 terminated after Resident #38 alleged the STNA hit him. The nursing assessment completed by Registered Nurse (RN) #3 revealed the resident had a superficial laceration on the left eyebrow and two small blood blisters on the left eye lid which later appeared black. STNA #5 stated the resident hit her. STNA's #5's time record showed she clocked out at 6:25 A.M. on 03/19/16 immediately after this incident. The police were notified. Review of the documentation from the police department which included witness statements revealed Policeman #2 arrived to the facility on [DATE] at 7:01 A.M. after a report of assault to Resident #38 by STNA #5. Interview with the night shift RN #3 revealed she heard banging coming from the resident's room and STNA #5 came out of the room upset and told the other STNAs she was assaulted by the resident. RN #3 reported STNA #5 had a red mark on her forehead and her shirt was wet and stated the resident was mad after an episode of incontinence because he had to wait. STNA #5 told RN#3 she stepped out of the room to obtain clean linens and the resident started yelling, slammed the cabinet door on her head, and threw pop on her. In turn she put her hands up to defend herself from Resident #38 hitting out at her and accidentally hit his eye. RN #3 stated when she entered Resident #38's room he stated that fu----- bi--- punched me in my eye and was crying. The resident told Policeman #2 the STNA was angry and punched him in the eye. STNA #4 also heard banging in the room and heard the resident say the STNA punched him in the eye and he was emotional and crying. On 03/20/16 at 10:30 A.M. Policeman #2 went to STNA #5's home and she reported the resident slammed the cabinet door on her head and threw pop on her; when she put her hands up to defend herself and swat his hands away she must have accidentally scratched his eye. Interview with Resident #38 on 03/24/16 at 8:15 A.M. revealed a small white STNA came into my room last weekend after I had my call light on twice around 4:00 A.M. and 6:00 A.M. because I needed help to use the toilet. The STNA asked why I pushed the call light and I told her I needed help to use the toilet and then she hit me with her fist in the face. It hurt then and it still hurts! Resident #38 denied throwing pop and hitting STNA #5 in the face. Observation with the RN #6 at that time revealed the Resident #38's left eye lid and under the eye was a dark purple circle that measured 5.5 centimeters by 5.5 centimeters. RN #6 verified the measurements and dark purple circle around the left eye. Interview with the DON and Administrator on 03/24/16 at 9:30 A.M. revealed they were unable to interview STNA #5 after several attempts to reach her and she ran out of the building after the incident stating I don't have to put up with this. Interview on 03/24/16 at noon with Policeman #1 who was visiting the facility revealed both the resident's and STNA #5's stories were possible; however, the resident's bruising on the left eye appeared like he was hit during an altercation. He provided the surveyor with witness statements from the staff and pictures of the resident and STNA #5 obtained on 03/19/16. On 03/24/16 at 12:50 P.M., interview with the resident's wife who was visiting revealed she was happy with the care except for the incident with STNA #5 because she felt her husband was defenseless and weak after a stroke. On 03/24/16 at 1:15 P.M., a phone interview with STNA #5 revealed the resident had a cut on his left eye which could have been from her fingernail when she was blocking him from hitting her multiple times in the head. The STNA denied hitting the resident and stated she was trying to clean the resident who had soiled himself and change his bed linens when he became combative and threw pop on her shirt then hit her with the cabinet door on the head. On 03/24/16 at 3:30 P.M., a phone interview with the RN #3 revealed she observed STNA #5 come out of Resident #38's room the morning of 03/19/16 after she heard banging noises. STNA #5 stated she was hit by the resident and scratched his eye when she put her hands up to defend herself. The resident said STNA #5 hit him in the eye. Review of the abuse policy with no date revealed the policy contained the seven required elements to prevent abuse to residents. The policy revealed physical abuse to residents was not tolerated. This deficiency substantiates Complaint Control Number OH 184.