Every finding on record at Meadowbrook Care Center

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent foodborne illness. This had the potential to affect all of the residents residing in the facility with the exception of for eight facility-identified (Residents#1, #8, #15, #20, #43, #67, #91, and #124) with orders for nothing by mouth. The facility census was 107 residents. Findings include: 1. Observation n 06/01/26 at 8:13 A.M. of the freezer next to the grill line revealed it included the following items which had ice crystals on them: two bags of chopped carrots, one bag of fish, two bags of raw chicken, one bag of raw pork, three bags of hot dogs, one bag of sausages, one bag of beef. Interview on 06/01/26 at 8:20 A.M. with [NAME] #392 verified the items in the freezer had ice crystals and appeared to have freezer burn. Interview on 06/01/26 at 8:24 A.M. with Dietary Manager (DM) #384 verified the food in the freezer had ice crystals and appeared to have freezer burn and food with ice crystals should be discarded. 2. Observation on 06/01/26 at 8:28 A.M. revealed the can opener blade was dirty with food debris. Interview on 06/01/26 at 8:28 A.M. with DM #384 verified the can opener blade was dirty and should have been cleaned. 3. Observation on 06/01/26 at 8:30 A.M. revealed the freezer contained a supply of nutritional supplements that were not properly frozen. Interview on 06/01/26 at 8:30 A.M. with DM #384 confirmed staff notified her last night that the breaker to the freezer had stopped working and the supplements had melted. DM #384 verified the supplements should have been discarded. 4. Observation on 06/01/26 at 8:38 A.M. revealed the floors throughout the kitchen were dirty with debris and grime on the grout and floor tiles and missing grout on the floors in the dish machine area. Interview on 06/01/26 at 8:39 A.M. with [NAME] #392 verified the facility had a few businesses come in to professionally clean the floors, but it never really worked. [NAME] #392 stated it was difficult to keep the floors clean due to the condition of the floor. Interview on 06/01/26 at 8:52 A.M. with DM #384 confirmed she felt the floors were impossible to clean and always looked dirty. 5. Observation on 06/01/26 at 8:52 A.M. revealed the air vents by the dish washing and food prep areas were dirty with a build up of dust. Interview on 06/01/26 at 8:52 A.M. with DM #384 verified the air vents were dirty. 6. Observation on 06/01/26 at 8:54 A.M. revealed an air conditioning unit installed on the wall above the preparation sink was leaking water into a bucket stored on the preparation sink. The bucket was more than half way full and each time water dripped, it splashed into the sink and onto clean utensils in the area. Interview on 06/01/26 at 8:54 A.M. with DM #384 verified that the air conditioning unit was leaking and contaminating the food preparation area. 7. Observation on 06/01/26 at 8:56 A.M. revealed four knives that had missing chips on the blade were stored in the clean knife storage rack. Interview on 06/01/26 at 8:56 A.M. with DM #384 verified that the knives had missing chips of metal from the blade and should have been replaced. 8. Observation on 06/01/26 at 8:57 A.M revealed there were two rubber spatulas with chunks of rubber missing. Interview on 06/01/26 at 8:57 A.M. with DM #384 verified that the spatulas had chunks of rubber missing and should have been replaced. 9. Observation on 06/01/26 at 9:01 A.M. revealed the following items in the walk-in cooler: an opened undated package of bologna, a diced ham dated 05/01/26, an open and undated bag of shredded lettuce. Interview on 06/01/26 at 9:01 A.M. with DM #384 verified the bologna and lettuce should have been dated when they were opened and the ham should have been discarded within seven days. 10. Observation on 06/01/26 at 9:04 A.M. revealed there was an unopened bag of shredded lettuce that looked mushy and translucent in the walk in cooler. Interview on 06/01/26 at 9:04 A.M with DM #384 confirmed the bag of lettuce was new but it should have been discarded due to its spoiled appearance. 11. Observation on 06/01/26 at 9:06 A.M. revealed the reach in cooler contained the following items: undated sliced bologna, sliced ham and turkey dated 5/22/26. Interview on 06/01/26 at 9:06 A.M. with DM #384 verified that the bologna was undated and the ham and turkey should have been discarded within seven days. 12. Observation on 06/03/26 at 12:04 P.M. revealed the metal rack behind the steam table where clean plate insulated lids and bases were stored was dirty, rusted, and had paint chipping off. Interview 06/03/26 at 12:04 P.M. with DM #384 verified the metal rack was dirty, rusted, and the paint was chipping off. Interview on 06/04/26 at 1:52 P.M. with Dietician #511 confirmed she completed monthly audits in the kitchen and she sent the results to the Administrator and DM #384. Dietitian #511 verified her last audit was completed in April 2026 and she shared concerns regarding the cleanliness and condition of the flooring suggesting the floors might need to be replaced and also of concerns the freezer door was not sealing properly or staying shut. Review of the facility policy titled Food Preparation and Services dated October 2017 revealed food and nutrition service employees shall prepare and serve food in a manner that complies with safe food handling practices. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed foods shall be received and stored in a manner that complies with safe handling practices. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. All foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use by date. All perishable foods must be used within seven days. Review of the facility policy titled Sanitization dated October 2008 revealed food service areas shall be maintained in a clean and sanitary manner. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.

Based on review of the facility diet listing, review of the facility menu, review of the facility spreadsheet, observation, staff interview, and policy review, the facility failed to ensure residents with an order altered textured diets were served foods in a form that was safe and appropriate. This affected 35 facility-identified with orders for diets with altered textures. The facility census was 107 residents. Findings include: Review of the diet listing revealed the following residents had orders for a mechanical soft textured diet: Residents #3, #16, #17, #21, #25, #35, #38, #39, #46, #49, #51, #59, #65, #71, #73, #75, #77, #80, #83, #89, #90, #101, #102, #104, #106 The following residents had orders for a pureed diet: Residents #9, #17, #20, #26, #11, #45, #60, #66, #112, #122. Review of the facility menu for 06/03/26 revealed lunch included chicken noodle casserole, carrot coins, assorted bread, and ambrosia salad. Review of the dietary spread sheet revealed residents with an order for mechanical soft diets should receive extra gravy on the chicken noodle casserole and chopped carrots. Residents with an order for a pureed diet should receive pureed chicken noodle casserole with gravy. Observation 06/03/26 at 11:48 A.M. revealed residents with a mechanical soft diet were being served chicken noodle casserole without extra gravy and carrot coins instead of chopped carrots. Residents with a pureed diet were being served pureed chicken noodle casserole without gravy. Interview on 06/03/26 at 11:48 A.M. with [NAME] #392 verified that he did not have gravy made to serve residents with a mechanical soft or pureed diet. [NAME] #392 also verified that he was serving carrot coins instead of chopped carrots to residents with a mechanical soft diet. Interview on 06/03/26 at 11:58 A.M. with Dietary Manager (DM) #384 verified residents with a pureed and mechanical soft diet were not receiving gravy on top of the chicken noodle casserole and residents with an order for mechanical soft were being served carrot coins instead of chopped carrots. DM #384 verified that she did have chopped carrots in the facility but decided to serve carrot coins because she thought that it would be soft enough for the residents to eat. Interview on 06/04/26 at 1:52 P.M. with Dietician #511 verified that residents with mechanical soft and pureed diets should have received gravy on the chicken noodle casserole. Dietician #384 also verified residents with a mechanical soft diet should have been served chopped carrots per the dietary spreadsheet. Review of the facility policy titled Therapeutic Diets dated October 2017 revealed therapeutic diets will be followed by the facility to support a resident's treatment and plan of care in accordance with his or her goals and preferences.

Based on medical record review, observation, staff interview, and policy review, the facility failed to provide residents with a dignified dining experience. This affected 13 (Residents #39, #79, #55, #20, #45, #31, #49, #17, #42, #32, #48, #71, and #102) with the potential to affect all of the residents except eight residents with orders for nothing by mouth (NPO). The facility census was 107 residents.Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 09/23/10 with diagnoses including type one diabetes mellitus and anorexia. Review of the Minimum Data Set (MDS) assessment for Resident #71 dated 04/08/26 revealed the resident was cognitively impaired and required set up or clean up assistance with eating. Review of the medical record for Resident #105 revealed an admission date of 08/10/18 with a diagnosis of Alzheimer's disease. Review of the MDS assessment for Resident #105 dated 03/30/26 revealed the resident was cognitively impaired and required set up or clean up assistance with eating. Review of the medical record for Resident #48 revealed an admission date of 05/20/26 with a diagnosis of hemiplegia and hemiparesis following cerebral infraction affecting the right side. Review of the MDS assessment for Resident #48 dated 06/02/26 revealed the resident was cognitively intact and required set up or clean up assistance with eating. Observation on 06/01/26 at 11:50 A.M. revealed Resident #71 was seated at a table with Resident #13. Staff delivered a meal to Resident #13 but staff did not deliver food to Resident #71. Residents #25 and #48 were seated at a table together at this time, but staff did not deliver food to their table. Interviews on 06/01/26 at 12:06 P.M. with Certified Nursing Assistant (CNA) #284 and #364 confirmed Residents #25, #38, and #71 were waiting for their trays to be delivered while other residents in the dining room were eating. Observation on 06/01/26 at 12:22 P.M. revealed staff delivered meals to Residents #71, #25, and #48. Interview on 06/01/2026 at 12:24 P.M. with Regional Clinical Director (RCD) #510 verified Residents #71, #25, and #48 had to wait for their meal trays to be delivered until 12:22 P.M. while watching other residents consume the lunch meal in front of them while the residents waited. 2. Observation on 06/01/26 at 12:40 P.M. revealed ten (Residents #39, #79, #55, #20, #45, #31, #49, #17, #42, #32) dining in the B Unit back hallway dining room were served their meal on a cafeteria style tray. Staff did not remove plates, cups, and flatware to provide a homelike dining experience. Residents consumed their meals from the cafeteria style trays. Interview on 06/01/26 at 12:49 P.M. with CNA #256 confirmed the ten residents dining in the B Unit back hallway dining room were served their meals on trays. CNA #256 stated staff should not serve resident meals on trays, and plates, cups, and flatware should be placed directly on the table for residents at meal service. Interview on 06/01/26 at 12:50 P.M with RCD #510 confirmed staff should not serve resident meals on trays and when a meal is served, the plates should be placed on the table in front of the resident and the trays should be removed. Review of the facility policy titled Dignity dated 03/28/23 revealed each resident would be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. This deficiency represents noncompliance investigated under Complaint Number 3012702 and Complaint Number 2621572.

Based on review of the facility menu, review of the dietary spreadsheet, observation, staff interview, and policy review, the facility failed to ensure staff followed the menu for residents with orders for a pureed diet. This affected ten facility-identified (Residents (#9, #11, #17, #20, #26, #45, #60, #66, #112 and #122) with order for a pureed diet. The facility census was 107 residents. Findings include: Review of the facility menu dated 06/03/26 revealed lunch included chicken noodle casserole, carrot coins, assorted bread, and ambrosia salad.Review of the dietary spreadsheet revealed residents on a pureed diet should receive pureed bread when it was on the menu. Observation of the lunch service on 06/03/26 revealed residents with pureed diets were not being served bread. Interview on 06/03/26 at 11:58 A.M. with Dietary Manager (DM) #384 verified residents with a pureed diet were not being served bread. DM #384 stated the pureed bread didn't taste good, and she thought that the residents were getting enough carbohydrates from the noodles in the casserole. DM #384 verified the residents on a regular or mechanical soft diet were being served both the chicken noodle casserole and bread. Interview on 06/04/26 at 1:52 P.M. with Dietician #511 verified that residents with a pureed diet should have been served pureed bread at lunch on 06/03/26. Review of the facility policy titled Menus dated October 2017 revealed menus were made to meet the nutritional needs of each resident following established national guidelines for nutritional adequacy.

Based on medical record review, observation, staff interview and facility policy review, the facility failed to provide a sanitary environment for residents. This affected one (Resident #97) of five residents reviewed for physical environment. The facility census was 107 residents.Findings include: Review of the medical record for Resident #97 revealed an admission date of 12/26/22 with diagnoses including Parkinson's disease and Alzheimer's disease. Review of the Minimum Data Set assessment for Resident #97 dated 03/06/26 revealed the resident was and required substantial staff assistance with toileting hygiene. Observation on 06/03/26 at 10:34 A.M. of Resident #97's room revealed there was a pair of balled up clinical gloves on floor near the bedroom door. Interview on 06/03/26 at 10:55 A.M. with Certified Nurse Assistant (CNA) #282 confirmed there was a pair of balled up clinical gloves on Resident #97's bedroom floor . Observation on 06/03/26 at 10:58 A.M. of Resident #97's room revealed there was a personal fan covered with dust build-up in the bedroom and there were two bedpans with stains of a dried dark amber fluid on the bathroom floor. Interview on 06/03/26 at 10:58 A.M. with Registered Nurse (RN) Supervisor #350 confirmed the dust build up on Resident #97's personal fan and the soiled bed pans on the bathroom floor. RN Supervisor #350 stated soiled bed pans should not be left on resident bathroom floors.Review of facility policy titled Quality of Life-Homelike Environment revised 2017 revealed the facility staff and management shall maximize to the extent possible characteristics that include a clean, sanitary, and orderly environment. This deficiency represents noncompliance investigated under Complaint Number 3005760 and Complaint Number 2566801.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #116) of three closed resident records sampled. The facility census was 107 residents. Findings include: Review of the medical record for Resident #116 revealed admission date of 03/10/25 with diagnoses including fibromyalgia, chronic kidney disease, diabetes mellitus type two. Review of physician's orders for Resident #116 revealed order dated 03/11/25 for morphine sulfate 15 milligrams (mg) by mouth one time a day for five days with a start date on 03/11/25 and an end date of 03/16/25. Review of narcotic sign out sheet for Resident #116's morphine sulfate revealed Licensed Practical Nurse (LPN) #294 signed out administration of two doses of morphine sulfate on 03/17/25 and 03/19/25. Review of the Medication Administration Record (MAR) for Resident #116 dated March 2025 revealed it did not include documentation of morphine sulfate administration for the resident on 03/17/25 or on 03/19/25. Review of the progress notes for Resident #116 dated 03/17/25 and 03/19/25 revealed there was no documentation regarding administration of morphine sulfate to the resident. Interview on 06/04/26 at 11:04 A.M. with LPN #294 confirmed his initials on Resident #116's narcotic sign out sheet for morphine sulfate 15mg on 03/17/25 and on 03/19/25. LPN #294 verified he did not check Resident #116's active medication orders before pulling the morphine sulfate 15mg on 03/17/25 and on 03/19/25. LPN #294 confirmed he administered the doses on 03/17/25 and on 03/19/25 to Resident #116 and did not document that he had done so in the residents chart. LPN #294 reported he pulled and gave the morphine sulfate 15mg because the medication was still in the cart. Review of facility policy titled Administering Pain Medications revised 2010 revealed pain medications were to be administered as ordered by the physician. This deficiency represents noncompliance investigated under Complaint Number 2611764 and 2621572.

Based on medical record review, observation, and staff interview, the facility failed to ensure residents received appropriate incontinence care. This affected one (Resident #97) of three residents reviewed for incontinence care. The facility census was 107 residents.Findings include: Review of the medical record for Resident #97 revealed admission date of 12/26/22 with diagnoses including Parkinson's disease with dyskinesia, Alzheimer's disease, and mixed incontinence. Review of the physician's orders for Resident #97 revealed an order dated 12/26/22 for moisture barrier apply topically to the peri area after each incontinent episode and as needed. Certified Nursing Assistant may apply.Review of the care plan for Resident #97 dated 01/05/23 revealed the resident was at increased risk for skin breakdown related to moisture exposure with interventions including following facility policies/protocols for prevention/treatment of skin break down. Review of the Minimum Data Set (MDS) assessment for Resident #97 dated 03/06/26 for revealed the resident required substantial/maximal assistance with toileting hygiene. Observation on 06/03/26 at 10:33 A.M. of incontinence care for Resident #97 per CNA #282 revealed the aide provided care for the resident cleansing the resident's peri area with soap and water and assisting the resident with getting dressed and transferred to the the motorized wheelchair. CNA #282 did not apply moisture barrier as ordered and per the resident's care plan. Interview on 06/03/26 at 10:42 A.M. with CNA #282 confirmed the aide did not apply ordered topical moisture barrier to Resident #97 after the episode of incontinence. This deficiency represents noncompliance investigated under Complaint Number 3005760 and Complaint Number 2625173 and Complaint Number 2623943

Based on observation, staff interview, and review of the facility policy, the facility to properly store, label and date food, failed to monitor refrigerator temperatures, failed to dry dishes in sanitary manner, failed to ensure staff prepared food in a clean and sanitary manner, and failed to ensure staff wore beard restraints during food preparation. This had the potential to affect all of the residents residing in the facility. The facility census was 89 residents. Findings include: 1. Observation 05/05/25 at 8:50 A.M. of the free-standing refrigerator revealed the following contents: an open undated jar of grape jelly, unlabeled and undated pitchers of orange drink, lemonade and red punch. Interview on 05/05/25 at 8:50 A.M. with the Dietary Manager (DM) confirmed the jar of jelly and the pitchers of drinks were unlabeled and undated. 2. Observation on 05/05/25 at 8:54 A.M of the walk-in refrigerator revealed temperature logs posted on the front of the refrigerator had not been completed. The refrigerator contained the following: an open and undated carton of a thickened beverage, open and dated containers of barbeque sauce, mayonnaise, sweet and sour sauce, Italian dressing, mustard, and pickle relish. Interview on 05/05/25 at 8:54 A.M. with the DM confirmed the temperature log on the outside of the walk-in refrigerator was not complete and there were open and undated food items in the refrigerator. Dietary manager #180 confirmed all containers to be opened and undated. 3. Observation of the dry storage area on 05/05/25 at 9:07 A.M. revealed the following: an open and undated box of cornstarch, an open, undated, and unlabeled box of cereal, 12 unlabeled and undated individual bowls of cereal. Interview on 05/05/25 at 9:07 A.M. with the DM confirmed there open, unlabeled and undated items in the dry storage area. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed all food stored in the refrigerator or the freezer would be covered, labeled and dated. The functioning of refrigeration and food temperatures would be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state specified requirements. 4. Observation on 05/05/25 at 9:10 A.M. revealed the insulated lids being used to cover breakfast plates were stored in a manner that allowed for pooling of water after being washed. Interview on 05/05/25 at 9:10 A.M. with the DM confirmed the lids had excess water pooling inside and should have been stored upside down so the water would have run off and allowed the plates to dry properly. 5. Observation on 05/07/25 at 11:27 A.M. revealed [NAME] #189 was wearing gloves as he began plating foods. [NAME] #189 used a set of tongs to remove buns from the pan, but he opened and closed buns using his gloved hand. [NAME] #189 touched utensils, the counter, plates, and rubbed his head while plating the food and wore the same pair of gloves the entire time. Interview on 05/07/25 at 11:37 A.M. with the DM confirmed [NAME] #189 did not change gloves and wash his hands while plating food as per the facility policy. 6. Observation on 05/07/25 at 12:03 P.M. revealed [NAME] #189 was observed put oven mitts over his gloves to remove a pan of from the oven. After placing pan in the steam table, [NAME] #189 removed the oven mitts and then continued to plate food with gloved hands and touching sandwich buns with his gloved hands. Interview on 05/07/25 at 12:08 P.M. with the DM confirmed [NAME] #189 placed oven mitts over his gloves to take a plan from the oven and place it in the steam table and then removed the oven mitt and continued to wear the same gloves to plate food with gloved hands and touching sandwich buns with gloved hands. The DM confirmed [NAME] #189 was not changing gloves and washing hands during food preparation as required. Review of facility policy titled Food Preparation and Service dated October 2017 revealed staff would adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. 7. Observation on 05/07/25 at 12:10 P.M. revealed [NAME] #184, [NAME] #189 and Dietary Aide (AD) #185 all had facial hair and were not wearing beard restraints while preparing lunch. Interview on 05/07/25 at 12:15 P.M. with the DM confirmed [NAME] #184, [NAME] #189, and AD #185 were not wearing beard restraints while preparing food and they should have been wearing beard restraints. Review of facility policy titled Food Preparation and Service dated October 2017 revealed food and nutrition staff shall wear hair restraints and beard restraints while preparing food to prevent hair from coming in contact with the food.

Based on observation and staff interview, the facility failed to the washers were maintained in a clean manner and free of leaks. This had the potential to affect all of the residents residing at the facility. The facility census was 89 residents. Findings include: Observation on 05/08/25 at 9:21 A.M. of the facility's laundry room revealed there were four washers that had brown, blue and white build-up on the top and along the sides of the washers. Further observation of the laundry room revealed water was coming out of the water reserve tank behind the washers which had run onto the floor in front of the washers. Interview on 05/08/25 at 9:21 A.M. with Housekeeping Supervisor (HS) #900 confirmed there a brown, blue and white build- up on the top and along the sides of the washers. HS #900 confirmed water was coming out of the water reserve tank behind the washers and the water had run on the floor in front of the washers. HS #900 stated that the water on the floor was from the water reserve tank overflowing, and the water reserve tank had been overflowing for over a week onto the laundry room floor.

Based on medical record review and staff interview, the facility failed to issue appropriate bed hold notices and/or Ombudsman notification when residents were discharged or transferred to the hospital. This affected four (Residents #06, #10, #197, #200) of five residents reviewed for discharge and hospitalization . The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #200 revealed an admitted [DATE] with a diagnosis of acute on chronic diastolic heart failure. The resident discharged to the hospital on 02/04/25 and did not return to the facility. Review of the Minimum Data Set (MDS) assessment for Resident #200 dated 01/23/25 revealed the resident had intact cognition. Review of the medical record for Resident #200 revealed the record did not include documentation of Ombudsman notification of the resident's transfer to the hospital on 02/04/25. Interview on 05/06/25 at 2:02 P.M. with the Administrator confirmed the facility failed to the notify the Ombudsman of Resident #200's discharge to the hospital on 02/04/25. 2. Review of the medical record for Resident #197 revealed an admitted [DATE] with diagnoses including right hip fracture and osteomyelitis. Resident #197 transferred to the hospital on 02/19/25 and returned to the facility on [DATE]. The resident transferred to the hospital again on 03/20/25 and did not return. Review of the MDS assessment for Resident #197 dated 03/11/25 revealed the resident had severely impaired cognition. Review of the medical record for Resident #197 revealed the record did not include documentation of Ombudsman notification of the resident's transfers to the hospital on 02/19/25 and 03/20/25. Interview on 05/06/25 at 2:02 P.M. with the Administrator confirmed the facility failed to the notify the Ombudsman of Resident #197's transfers to the hospital on 02/19/25 and 03/20/25. 43062 3. Review of the medical record for Resident #06 revealed an admitted [DATE] with diagnoses including hypothyroidism, cardiomegaly, and atrial fibrillation. Resident #06 was discharged to the hospital on 02/15/25 and readmitted to the facility on [DATE]. Review of the MDS assessment for Resident #06 dated 03/21/25, revealed the resident had mild cognitive impairment and required staff assistance with activities of daily living (ADLs) Interview on 05/06/25 at 1:46 P.M. with Business Office Manager (BOM) #104 confirmed the facility failed to provide a bed hold notice to Resident #06 for the hospitalization from [DATE] and 02/20/25. Interview on 05/06/25 at 2:02 P.M. with the Administrator confirmed the facility failed to the notify the Ombudsman of Resident #06's transfer to the hospital on 02/20/25. 44083 4. Review of the medical record for Resident #10 revealed and admitted [DATE] with diagnoses including diabetes, schizoaffective disorder and chronic kidney disease. Resident #10 was hospitalized from 11/14/24 to 12/13/24 and returned to the facility. Review of the MDS assessment for Resident #10 dated 04/01/25 revealed the resident had severely impaired cognition and was dependent on staff for ADLs. Interview on 05/06/25 at 2:25 P.M. with Regional Operations Manager (ROM) #501 confirmed the facility failed to provide a bed hold notice to Resident #10's representative for the resident's hospitalization from [DATE] to 12/13/24.

Based on record review, resident interview, staff interview, and review of the facility policy, the facility failed to document and follow up on resident concerns brought up in the Resident Council meetings. This affected 10 (Residents #12, #15, #33, #36, #40, #46, #51, #63, #72, #78) of 10 residents who regularly attended the Resident Council meetings. The facility census was 89 residents. Findings include: Review of the monthly Resident Council meeting minutes dated May 2024 to April 2025 revealed the facility did not follow up on concerns raised in Resident Council meetings. The section of the minutes titled Old Business was left blank and did not include follow up on previous concerns brought by residents which include agency staffing, call lights, medications, laundry, and menus. Interview on 05/07/25 at 10:06 AM with Resident #200 confirmed she was the president of the Resident Council, and the facility had not provided follow up to the group on concerns brought up during the meetings. Interview on 05/07/25 at 10:07 A.M. with Resident #51 confirmed the facility had not provided follow up to resident concerns raised in the Resident Council meetings. Interview on 05/07/25 at 10:08 AM with Activities Director (AD) #200 confirmed the facility had no documentation of follow-up to the concerns brought up by the Resident Council members for the monthly meetings dated May 2024 to April 2025. Review of the facility policy titled Resident Council dated 01/12/22 revealed the facility would track and document response and resolution to concerns raised by the Resident Council members.

Based on observation and staff interview, the facility failed to ensure adequate lighting in resident rooms. This affected one (Resident #21) of 16 residents reviewed for adequate lighting. The facility also failed to ensure a clean environment. This affected the 48 residents residing on the C Unit who used the shower room (Residents #01, #03, #04, #06, #09, #11, #13, #14, #15, #16, #17, #18, #19, #21, #22, #25, #26, #27, #29, #32, #33, #34, #36, #39, #40, #41, #45, #46, #48, #49, #50, #51, #52, #59, #61, #64, #67, #75, #76, #77, #78, #80, #85, #89, #146, #147, #196, and #196). The facility census was 89 residents. Findings include: 1.Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including heart failure, vascular dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 02/18/25 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs.) Observation of wound care for Resident #21 on 05/07/25 at 1:32 PM per Licensed Practical Nurse (LPN) #146 revealed the resident's room did not have adequate overhead lighting when the curtain was closed. Light sources in Resident #21's room included a sink light, a bathroom light, and an over the bed light. Interview on 05/07/25 at 1:35 PM with LPN #146 confirmed Resident #21's room did not have adequate light for performing wound care and staff sometimes had to use a flashlight when providing care for Resident #21 due to inadequate overhead lighting when the curtain was closed. 42731 2. Observation on 05/07/25 at 10:11 A.M. of the C Hall shower room with LPN #146 revealed there was an area measuring approximately two inches by three inches of brown skid marks of an unidentified substance on the wall by the toilet. Further observation revealed the walls surrounding the entire shower area contained a layer of a brown unidentifiable material where the wall met the floor, measuring approximately two inches up the wall. Interview on 05/07/25 with LPN #146 confirmed the brown skid marks on the wall by the toilet and the brown substance on the walls surrounding the shower and all of the C Hall residents had access to the shower room. This violation represents noncompliance investigated under Master Complaint Number OH00165072 and Complaint Number OH00164179 and Complaint Number OH00161596 and Complaint Number OH00161253

Based on review of medical records, observation, staff interview and review of the facility policy, the facility failed to serve food portions as planned by the Registered Dietitian (RD). This affected six (Residents #9, #13, #21, #30, #38, #65) of six residents with orders for a pureed diet. The facility census was 89 residents. Findings include: Review of the medical records for Residents #9, #13, #21, #30, #38 and #65 revealed the residents had physician's orders to receive a pureed diet. Observation of lunch being served on 05/07/25 at 11:27 A.M. revealed [NAME] #188 served pureed portions of barbeque ham sandwiches and pureed potatoes for Residents #9, #13, #21, #30, #38, and #65. [NAME] #18 used a four-ounce scoop to plate the pureed barbeque ham sandwiches and a three-ounce scoop for the potatoes. Further observation revealed there was a poster in the kitchen which explained coded measurement indicators on utensils for reference when portioning food. Review of the dietary spreadsheet for lunch on 05/07/25 revealed the barbeque ham sandwich portion should be five and one-half ounces and the potato portion should be four ounces. Dietary manager confirmed that inappropriate scoop sizes were being used for the pureed barbeque ham and pureed potatoes servings. Interview on 05/07/25 at 11:45 A.M with the Dietary Manager (DM) confirmed [NAME] #18 had used the wrong scoop sizes to plate the pureed barbeque ham sandwiches and potatoes for Residents #9, #13, #21, #30, #38, and #65. The DM confirmed [NAME] #18 had not followed the spreadsheet which had been planned and approved by the RD. Review of facility policy titled Kitchen Weights and Measures dated April 2007 revealed staff were to be trained in appropriate measurement and type of serving utensil to use for each food. This deficiency represents noncompliance investigated under Complaint Number OH00161596 and Complaint Number OH00164317.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to develop comprehensive resident care plans. This affected two (Residents #19 and #75) of 21 residents reviewed for care planning. The facility census was 89. Findings include: 1.Review of the medical record for Resident #75 revealed an admitted [DATE] with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction. Review of the physician's orders for Resident #75 revealed an order dated 01/08/25 for Ambien five milligrams (mg) one table per mouth at bedtime for sleep assistance. Review of the Minimum Data Set (MDS) assessment for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs) and received a hypnotic medication during the review period. Review of the care plan for Resident #75 last updated on 02/19/25 revealed the care plan did not address the use of Ambien, a hypnotic medication. Review of the diagnosis list for Resident #75 dated 05/07/25 revealed the resident had no diagnosis of a sleep disorder or related diagnosis. Interview on 05/08/25 at 8:31 A.M with the Director of Nursing (DON) confirmed the facility had not initiated a care plan for Resident #75's use of Ambien, a hypnotic medication. 2. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including benign prostatic hyperplasia, chronic kidney disease, and unspecified intellectual disabilities. Review of the admission MDS assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired and was not coded as edentulous (having no natural teeth.) Review of the dental care plan for Resident #19 dated 04/03/25 revealed Resident #19 had the potential for oral or dental health issues related to the disease process and an ADL self-care deficit. Interventions included the following: coordinate and arrange for dental care and transportation as needed, provide mouth care, occupational therapy screen for adaptive equipment as needed, diet as ordered and monitor, document and report as needed signs and symptoms of dental problems. The care plan did not address Resident #19's status as edentulous status. Observation on 05/05/25 at 11:35 A.M. of Resident #19 revealed the resident was edentulous. Interview on 05/05/25 at 11:36 A.M with Resident #19 confirmed he was edentulous and had been so upon admission to the facility. Interview on 05/06/25 at 4:20 P.M with MDS Registered Nurse (MDS RN) #175 confirmed Resident #19 was edentulous upon admission, and the facility had not correctly coded the resident's dental status on the resident's admission MDS dated [DATE]. MDS RN #175 also verified Resident #19's dental care plan did not address that Resident #19 was edentulous. Review of the facility policy titled Comprehensive Person-Centered Care Plans dated 10/10/22 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.

Based on medical record review and staff interview facility failed to revise Preadmission Screening and Resident Review (PASARR) assessments after a change in resident condition. This affected one (Resident #58) of four residents reviewed for PASARR completion. The facility census was 89 residents. Findings include: Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including cerebrovascular disease, chronic obstructive pulmonary disease, neurocognitive disorder, and diabetes. Review of the physician's orders for Resident #58 revealed an order dated on 09/11/24 for the resident to begin receiving hospice services. Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 02/28/25 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Interview on 05/08/25 at 9:20 A.M. with Social Worker (SW) #205 on 05/08/25 confirmed the facility should have completed an updated PASARR for Resident #58 when the resident was enrolled in hospice on 09/11/24, but the facility had not done so.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident Preadmission Screening and Resident Review (PASARR) was completed within 30 days of being admitted to the facility with a hospital exemption. This affected one (Resident #19) of four residents reviewed for PASARR completion. The facility census was 89 residents. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including osteoarthritis, benign prostatic hyperplasia, chronic kidney disease stage three, and unspecified intellectual disabilities. Review of the admission Minimum Data Set (MDS) assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the hospital exemption from preadmission screening notification for Resident #19 dated 03/22/25 revealed the resident had a mental disability that was not solely caused by mental illness and was manifested prior to age 22. Resident #19's intellectual disability was listed on the hospital exemption. Further review of the hospital exemption revealed the nursing facility accepted responsibility for electronically initiating a PASARR prior to the 30th day following the resident's the admission from the hospital. Review of the medical record for Resident #19 revealed it did not include a completed PASARR. Review of the hospital record for Resident #19 dated 03/18/25 revealed the resident had a history of intellectual disabilities and presented to the emergency department on 03/18/25 from a group home after having progressively increased lower extremity swelling prior to admission to the facility. Review of the diagnosis list for Resident #19 revealed the resident's diagnosis of unspecified intellectual disabilities was added to the diagnosis list on 03/22/25, the date of the resident's admission to the facility. Interview on 05/07/25 at 2:12 P.M with Licensed Social Worker (LSW) #205 confirmed Resident #19 was admitted to the facility on [DATE] with a diagnosis of an intellectual disability which had manifested prior to the resident's 22nd birthday, and the facility had not completed a PASARR for the resident. Review of the facility policy titled Admissions dated March 2017 revealed the PASARR will be provided to the facility prior to or upon the resident's admission.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure the accuracy of resident Minimum Data Set (MDS) assessments regarding resident dental status and range of motion and mobility. This affected three (Residents #19, #75 and #80) of 21 residents reviewed for MDS accuracy. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including benign prostatic hyperplasia, chronic kidney disease, and unspecified intellectual disabilities. Review of the admission Minimum Data Set (MDS) assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired and was not coded as edentulous (having no natural teeth.) Observation on 05/05/25 at 11:35 A.M. of Resident #19 revealed the resident was edentulous. Interview on 05/05/25 at 11:36 A.M with Resident #19 confirmed he was edentulous and had been so upon admission to the facility. Interview on 05/06/25 at 4:20 P.M with MDS Registered Nurse (MDS RN) #175 confirmed Resident #19 was edentulous upon admission, and the facility had not correctly coded the resident's dental status on the resident's admission MDS dated [DATE]. 2. Review of the medical record for Resident #75 revealed an admitted [DATE] with diagnoses including cerebral infarction, asthma, and anxiety disorder. Review of the occupational therapy evaluation and plan of treatment for Resident #75 dated 12/10/24 revealed the resident had a contracture of the left hand. Review of the quarterly MDS for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and had no functional impairment to the upper extremities. Review of the occupational therapy discharge summary for Resident #75 dated 03/27/25 revealed the resident was discharged from therapy with recommendations to wear a left carrot splint as tolerated and for staff to provide passive range of motion (PROM) to left upper extremity as tolerated. Observation on 05/05/25 at 11:46 A.M of Resident #75 revealed the resident had a contracture of his left hand and was unable to open his left hand. Interview on 05/05/25 at 11:46 A.M. with Resident #75 confirmed he had a contracture of the left hand which required the use of a carrot. Resident #75 reported he was unable to open his left hand. Interview with on 05/06/25 at 4:20 P.M. with MDS RN #175 confirmed Resident #75 had a left-hand contracture which the facility had not accurately coded on the quarterly MDS dated [DATE]. 3. Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, peripheral vascular disease, and cerebral infarction. Review of the admission MDS assessment for Resident #80 dated 03/20/25 revealed the resident was cognitively intact and the MDS was not coded for the presence of broken natural teeth. Interview on 05/05/25 at 3:58 P.M with Resident #80 confirmed he had a broken teeth which had broken prior to his admission to the facility. Observation on 05/05/25 at 4:20 P.M. of Resident #80 revealed the resident had a broken tooth on the rear left side of his mouth and had black spots on his back teeth. Interview on 05/06/25 at 4:20 P.M with MDS RN #175 confirmed the resident had a broken tooth on the rear left side of his mouth and had black spots on his back teeth which possibly could have been cavities. MDS RN #175 confirmed the facility had not accurately coded Resident #80's dental status on the admission MDS dated [DATE].

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure hypnotic medications were used with adequate indications for administration and with adequate monitoring. This affected one (Resident #75) of five residents reviewed for unnecessary medications. The facility census was 89 residents. Findings include: Review of the medical record for Resident #75 revealed an admitted [DATE] with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction. Review of the physician's orders for Resident #75 revealed an order dated 01/08/25 for Ambien five milligrams (mg) one table per mouth at bedtime for sleep assistance. Review of the Minimum Data Set (MDS) assessment for Resident #75 dated 02/04/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs) and received a hypnotic medication during the review period. Review of the care plan for Resident #75 last updated on 02/19/25 revealed the care plan did not address the use of Ambien, a hypnotic medication. Review of the diagnosis list for Resident #75 dated 05/07/25 revealed the resident had no diagnosis of a sleep disorder or related diagnosis. Interview on 05/08/25 at 8:05 A.M. with the Director of Nursing (DON) confirmed Resident #75 had an order for Ambien at bedtime for sleep assistance but the resident's record did not include an appropriate diagnosis or medical indication for hypnotic use. Interview with the DON on 05/08/25 at 8:31 A.M. confirmed the facility had not developed a care plan for Ambien use for Resident #75 to outline how the facility would monitor the resident for use of the hypnotic medication. Review of the facility policy titled Psychotropic Medication Use dated 01/19/24 revealed residents would not receive medications that were not clinically indicated to treat a specific condition. Residents receiving psychiatric medications would be monitored and assessed for adverse consequences. This deficiency represents noncompliance investigated under Complaint Number OH00161596.

Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure resident personal privacy was maintained . This affected three (Residents#10, #21, and #43) of three residents reviewed for personal privacy. The facility census was 89 residents. Findings include: 1. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including diabetes, schizoaffective disorder, bipolar disorder, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/01/25 revealed the resident had severely impaired cognition and was dependent on staff for activities of daily living (ADLs.) Review of the nurse progress note for Resident #10 dated 04/03/25 revealed the resident's representative informed Registered Nurse Unit Manger (RNUM) #160 she did not want the resident's picture posted on social media. Interview on 05/06/25 at 3:16 P.M. of Activity Director (AD) #200 confirmed the facility had posted a picture of Resident #10 on social media a couple months ago and the picture remained online for a few weeks. Resident #10's representative reported her concerns to RNUM #160. AD #200 confirmed the facility had not obtained prior consent from the resident and/or the resident's representative before posting the resident's picture on social media. Interview on 05/06/25 at 3:44 P.M. with Medical Records Clerk (MRC) #179 confirmed Resident #10's record did not include consent to post the resident's picture on social media. Interview on 05/06/25 at 4:25 P.M. with RNUM #160 confirmed Resident #10's representative contacted her when she saw a picture of the resident posted on social media by the facility and asked for the picture to be removed. RNUM #160 confirmed Resident #10's representative had not consented for the facility to post the resident's picture on social media. Review of facility policy titled Videotaping, Photographing and Other Imaging of Residents dated April 2017 revealed the staff could not release images of any resident without explicit written consent from the representative prior to obtaining images. Transmitting unauthorized images of any resident through social media was considered a violation of resident rights. 51520 2. Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including heart failure, vascular dementia, and major depressive disorder. Review of the MDS assessment for Resident #21 dated 02/18/25 revealed the resident had severely impaired cognition and was dependent on staff assistance with ADLs. Observation of incontinence care for Resident #21 on 05/07/2025 at 1:30.PM. per Certified Nursing Assistant (CNA) #133 and Licensed Practical Nurse (LPN) #146 revealed the curtain to the outside window which opened to the staff parking lot was not closed during provision of care. Interview on 05/07/25 at 1:35 PM with CNA #133 confirmed she had not closed the curtain to the window of the resident's room during incontinence care for Resident #21. Interview on 05/07/25 at 1:36 P.M. with LPN #146 confirmed staff members could potentially see inside Resident #21's window during incontinence care because the curtain was not drawn. LPN #146 further confirmed the curtain to the outside window should be drawn to provide visual privacy for the resident. Review of the facility policy titled Resident Rights undated revealed residents have the right to privacy. 51523 3. Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses including diabetes mellitus, bipolar disorder, and Alzheimer's Disease. Review of the MDS assessment for Resident #43 dated 3/12/25 revealed the resident had severely impaired cognition and received insulin. Observation on 05/05/25 at 11:27 A.M. revealed Resident #43 was seated in the dining room with multiple residents who were waiting for lunch to be served. Registered Nurse (RN) #152 approached Resident #43 and told her she was going to check her blood sugar. RN #152 did not obtain consent from the resident. RN #152 then cleansed Resident #43's finger and pierced it with a lancet to obtain a blood sample to perform a blood sugar check. Interview on 05/05/25 at 11:35 A.M. with RN #152 confirmed she checked Resident #43's blood sugar in the dining room in the presence of other residents and did not provide visual privacy during treatment for the resident. This deficiency represents noncompliance investigated under Complaint Number OH00162453.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify resident physicians/medical providers of significant weight loss. This affected one (Resident #45) of eight residents reviewed for weight changes. The facility census was 89 residents. Findings include: Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), panic disorder, and pulmonary hypertension. Review of the physician's orders for Resident #45 revealed an order dated 10/07/24 for daily weights. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 03/05/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the weight record for Resident #45 revealed the following weights: 187 pounds on 12/04/24, 169 pounds on 12/05/24, 169.5 pounds on 12/06/24. Interview on 05/08/35 at 2:17 PM with Dietician #504 confirmed staff did not notify Nurse Practitioner (NP) #510 of Resident #45's significant weight loss from 12/04/24 to 12/06/24. Interview on 05/08/25 at 2:34 PM with NP #510 confirmed staff had not notified her of the weight change for Resident #45 from 12/04/24 to 12/06/24. NP #510 confirmed this was significant weight loss of 9.3 percent (%) and she should have been notified by staff members. NP #510 confirmed if the facility had notified her, she would have ordered lab work for the resident. Review of facility policy titled Impaired Nutrition/Unplanned Weight Loss dated September 2012 revealed staff members should observe and report significant weight gain or loss to the physician/provider. The policy defined significant weight loss as a 5 % loss and severe weight loss as greater than 5 %.

Based on medical record review, interviews with facility staff and Nurse Practitioner (NP) #350, and review of the facility policy, the facility failed to monitor a residents bowel function. This resulted in Actual Harm for Resident #105 when the resident went multiple days with no recorded bowel movements and was subsequently treated at the hospital for severe fecal impaction. This affected one (Resident #105) of three residents reviewed for constipation. The census was 97. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE]. Diagnoses include multiple sclerosis, hemiplegia and hemiparesis following cerebral infarction, quadriplegia, and neuromuscular dysfunction of bladder. Resident #105 discharged from the facility on 01/14/23. Review of the Minimum Data Set (MDS) assessment for Resident #105 dated 10/20/22 revealed the resident was cognitively intact and required extensive assistance of one staff to total dependence of two staff with activities of daily living (ADL's). Resident #105 was always incontinent of bowel. Review of the care plan for Resident #105 dated 07/18/22 revealed the resident was at risk for constipation due to decreased mobility, and wheelchair was primary form of locomotion. Goal of care was for Resident #105 to pass a soft, formed stool at the preferred frequency of at least every three days. Interventions included the following: encourage exercise and movement with activities, monitor and record bowel movement pattern each day, monitor medications for side effects of constipation, keep physician informed of any problems, monitor/document/report to physician as needed any signs and symptoms of complications related to constipation: change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, bradycardia (slow, low pulse), abdominal distension, vomiting, small loose or stools, fecal smearing, bowel sounds, diaphoresis, abdomen: tenderness, guarding and rigidity. Review of January 2023 physician orders for Resident #105 revealed an order dated 01/05/23 for Miralax 17 grams by mouth daily for treatment of constipation. Further review of Resident #105's physician orders revealed the resident had no other orders for routine or as needed laxatives, stool softeners, fiber products, etc. Review of the January 2023 Medication Administration Record (MAR) for Resident #105 revealed the resident received Miralax 17 grams by mouth daily. Further review of Resident #105's MAR revealed the resident had no other routine or as needed laxatives, stool softeners, fiber products, etc. Review of the bowel records for Resident #105 dated 12/14/22 to 01/14/23 revealed the resident had no bowel movements on the following dates: 12/14/22, 12/15/22, 12/16/22, 12/18/22, 12/19/22, 12/20/22, 12/21/22, 12/22/22, 12/23/22, 12/24/22, 12/26/22, 12/28/22, 12/29/22, 12/30/22, 12/31/22, 01/01/23, 01/03/23, 01/04/23, 01/05/23, 01/06/23, 01/07/23, 01/08/23, 01/09/23, 01/10/23, 01/12/23 and 01/14/23. Review of bowel record for Resident #105 revealed the resident had a small bowel movement on the following dates: 12/17/22, 12/25/22, 12/27/22, 01/06/23, 01/11/23 and 01/13/23. Review of bowel record revealed Resident #105 had a medium bowel movement on 01/02/23. The bowel record included no further description of the bowel movements. Review of the nurses progress notes for Resident #105 dated 12/14/22 to 01/14/23 revealed the notes did not include an assessment of the resident's condition, including an abdominal assessment of resident for signs of constipation per the resident's care plan. Review of the progress notes revealed the documentation did not include physician notification of absence of bowel movements for multiple consecutive dates in December 2022 and January 2023. Review of the progress note for NP #350 dated 01/10/23 revealed Resident #105's abdomen was described as soft, non-tender, no masses/distention, and bowel sounds active times four. There was no other documentation in NP #350's progress note regarding Resident #105's bowel function/status. Review of the nurse's progress note for Resident #105 dated 01/14/23 revealed the resident had decreased responsiveness and was unable to swallow fluids or medication. The facility had obtained labs and a chest-x-ray and were awaiting results. The provider on call for Resident #105's attending physician was notified and gave an order to send the resident to the hospital for an evaluation. Review of the nurse's progress note for Resident #105 dated 01/15/23 revealed the resident was admitted to the hospital with septicemia, kidney infection, and pneumonia. Review of hospital records for Resident #105 dated 01/15/23 revealed a fecal impaction was listed as one of the resident's admission diagnoses. Review of the hospital notes revealed there was a massive manual disimpaction of stool which was performed in the emergency department. Further review of the notes revealed Resident #105 was noted to have a distended and firm abdomen and a fecal impaction which was disimpacted with improvement of her abdomen. Resident #105 was also was noted to have what appeared to be stool coming from her suprapubic catheter. Review of the Computed Tomography (CT) scan of the abdomen and pelvis results revealed Resident #105 had a massive fecal impaction. There were new findings of hydronephrosis and hydroureter of the right kidney with multiple stones in the renal pelvis and mid and upper kidney. There was wall thickening throughout the renal pelvis and ureter which may relate to infection of the kidney as well. The ureter could not be traced entirely to the pelvis because of massive rectal fecal impaction. Interview on 02/01/23 at 11:30 A.M. with Licensed Practical Nurse (LPN) #325 confirmed the aides recorded resident bowel movements (BM) in the electronic medical record. LPN #325 confirmed if a resident went three or more days without a bowel movement the nurse should physically assess the resident and the physician should be notified to determine treatment for resident's constipation. Interview on 02/01/23 at 5:17 P.M. with NP #350 confirmed she examined Resident #105 on 01/10/23 and she listened to the resident's bowel sounds on that date. NP #350 confirmed she did not review Resident #105's BM records and she relied on the nursing staff to notify her and/or the attending physician if a resident has had a string of days without a BM. NP #350 confirmed she was not notified of multiple consecutive days in December 2022 and January 2023 where Resident #105 had no BM. NP #350 confirmed she was aware that Resident #105 presented with a fecal impaction at the hospital on 01/14/23. Interview on 02/01/23 at 5:42 P.M. with the Administrator confirmed Resident #105's bowel records showed she had no BM's for multiple consecutive dates in December 2022 and January 2023. The Administrator confirmed Resident #105's nurses progress notes did not include an assessment of the resident for constipation or notification of the physician of resident's absent bowel movements. Administrator confirmed Resident #105 was admitted to the hospital on 01/14/23 with fecal impaction as one of her admitting diagnoses. Review of the facility policy titled Bowel (Lower Gastrointestinal GI Tract) Disorders - Clinical Protocol dated September 2012 revealed staff should identify residents with lower GI conditions including an alteration in bowel movements. The nurse's assessment should include the following: quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount, consistency, etc.), change in mental status or level of consciousness, presence of fecal impaction, signs of dehydration (altered level of consciousness, lethargy, dizziness, recent change in mental status), an abdominal assessment, digital rectal examination, presence of cramps and bloating, onset duration and frequency of symptoms. Findings should be reported to the attending physician. This deficiency represents non-compliance investigated under Complaint Number OH00139585.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's diabetes was monitored. This resulted in Actual Harm when Resident #40 was found with extreme lethargy and subsequently hospitalized with a blood sugar level of 1,211 milligrams per deciliter (mg/dL). This affected one resident (#40) out of three residents reviewed for diabetes. The facility census was 107. Findings Included: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive minimum data set (MDS) assessment revealed Resident #40 was cognitively intact. Resident #40 required supervision only for eating. Review of the plan of care revealed Resident #40 was at risk for [CONDITION(S)] or [CONDITION(S)] for complications associated with diabetes mellitus and stage three [CONDITION(S)]. Interventions included avoid exposure to extreme heat and cold, check all of body for breaks in skin, treat promptly as ordered, take diabetes medication as ordered, monitor, document, and report signs and symptom of increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, and muscle cramps. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The diet was updated to a carb-controlled diet after readmission from the hospital on 02/15/22. Review of the nursing admission assessment dated [DATE] revealed Resident #40 had an abdominal surgical wound. Review of the laboratory report dated 06/04/21 revealed the hemoglobin A1C (a test that measures the average blood sugar levels over the past three months) was 6.6 percent with a mean blood sugar level of 143 mg/dL. A normal hemoglobin A1C is less than 5.7 percent. Review of the wound assessment dated [DATE] revealed Resident #40 had an abdomen surgical, non-healing wound, that was healing. Wound onset date was 06/01/21. Wound measurement 0.8 centimeter (cm) by 0.3 cm by 0.3 cm. The wound was 100 percent granulation tissue with a moderate amount exudate. Review of a Progress Note dated on 02/07/22 at 5:48 P.M. documented by Licensed Practical Nurse (LPN) #245 revealed resident was sent to the hospital due to a change in the resident's mental status as well as the patient being extremely lethargic. Resident's vitals were as follows: blood pressure 179/96 millimeters of mercury (mm/Hg), heart rate 109 beats per minute, respirations 24 breaths per minute, and oxygen saturation 93 percent. The Nurse Practitioner (NP) #206 was notified. The resident was sent to the hospital. Review of the local hospital admission documentation dated 02/07/22 revealed Resident #40 was evaluated in the emergency department with lethargy. A computerized tomography (CT) scan of the resident's head was negative for an acute [CONDITION(S)]. Resident #40 was found with a blood glucose of 1,211 mg/dL, an anion gap (the level of metabolic acidosis) of 29 milliequivalents per liter (mEq/L). Resident #40 was started on a fluid resuscitation of one liter of normal saline and given 10 units of insulin for diabetic ketoacidosis (DKA). Resident #40 was [CONDITION(S)], hypertensive, tachypneic, but saturating well on room air. The resident was started on the DKA protocol and transferred to the Progressive Care Unit (PCU) for further evaluation and treatment. Review of the local hospital discharge document dated 02/15/22 revealed Resident #40 had returned to the facility with MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40 had a Hemoglobin A1C level of 14.7 on 02/08/22 which was an estimated average blood sugar during the three months prior was a glucose of 375 mg/dL. Review of the wound assessment dated [DATE] revealed Resident #40's surgical abdominal wound was completely healed, and the resident was discharged from wound services. Interview on 06/25/22 at 12:34 P.M., with NP #206 stated Resident #40 was not on the radar about his blood glucose control. Resident was admitted to the facility for abdominal wound and had diabetes mellitus Type II. NP #206 verified she would check the resident's Hemoglobin A1C once or twice a year. NP #206 said Resident #40 had no routine/daily blood glucose monitoring. NP #206 verified Resident #40 should have been checked every six to 12 months, since his HgbA1C was below 7. Since the resident had been hospitalized for DKA the next time they would check Resident #40's Hemoglobin A1C would be no more than in four months, like June 2022. NP #206 stated they should have checked the residents blood glucose levels since the resident had a diabetic diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NP #206 stated the Hemoglobin A1C showed the last 90-120 days of the blood glucose history. Interview on 07/06/22 at 3:20 P.M., with the Director of Nursing (DON) who stated Resident #40 had refused no medication, or blood glucose monitoring since he returned to the facility on [DATE]. The DON verified the blood glucose level was not checked when he was found lethargic. The DON was also working on ensuring this had not or would not happen to other diabetic residents. Review of policy titled Diabetes Clinical Protocol, revised December 2015, revealed criteria for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Protocol stated as part of the initial assessment, the physician will help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes, as well as factors that may influence glucose intolerance, for example, medications including [MEDICATION(S)], thiazide diuretics or some antipsychotic medications. For residents who meet the criteria for diabetes testing, the physician will order pertinent screening, for example A1C, fasting plasma glucose, or 2-hour plasma glucose with oral glucose load. For residents with confirmed diabetes, the nurse shall assess and document and report the following during the initial assessment: A. Resident's age and sex B. Level of consciousness, change in orientation C. Dose and time of most recent anti-hyperglycemic given D. All other current medications E. Illnesses, Any signs or symptoms of infections (urine, skin/wound, upper respiratory, etc.) or other acute F. Usual patterns of eating and drinking G. Approximate intake over last 24 hours H. Recent change in intake and thirst I. Resident's blood sugar history over 48 hours J. Usual patterns (fluctuation, trends) of blood sugar over recent months K. Onset, duration or any change, and L. Recent labs This deficiency substantiates Complaint Number OH 331.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the coroner ' s report, review of the Hospice record and staff interview, the facility failed to ensure a resident received the assistance of two staff during incontinence care. This resulted in Immediate Jeopardy when Resident #63 was rolled out of bed onto the floor during care by State tested Nursing Assistant (STNA) #113. The resident sustained serious life-threatening injuries of bilateral femur fractures and subsequently expired at a Hospice facility. The coroner ruled the resident ' s death an accident due to complications of bilateral femur fractures and a fall. This affected one (Resident #63) of three residents reviewed for falls. The facility identified 10 residents requiring a two person assist for bed mobility. The facility census was 105. On [DATE] at 2:08 P.M., the Director of Nursing (DON), Regional Director of Operations #119 and Regional Clinical Director #12, with the Administrator and Vice President of Operations #121 participating in the notification by phone on speaker, were notified Immediate Jeopardy began on [DATE] at 10:45 P.M. when STNA #113, providing care alone, rolled Resident #63 over during routine care. STNA #113 lost control, resulting in the resident falling from the bed onto the floor. Resident #63 landed on her hands and knees. She was sent to the hospital on [DATE] at 11:10 A.M., per family request, where she was then admitted for bilateral knee fractures and remained there from [DATE] to [DATE]. She was then transferred to Hospice care on [DATE] and expired on [DATE]. The coroner ' s report indicated her immediate cause of death was due to A) Complications of bilateral femur fractures with significant contusions and [CONDITION(S)]; B) Falling out of bed; and C) Generalized weakness, [CONDITION(S)], and [CONDITION(S)]. The manner of death was identified as accidental. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE], when the facility implemented the following corrective actions: · On [DATE], the intervention of assistance of two staff for bed mobility and a larger bariatric bed was added to Resident #63 ' s care plan by the Minimum Data Set (MDS) Coordinator. (The intervention was not implemented as the resident did not return to the facility.) · On [DATE] at 5:30 P.M., the DON/Designee completed fall risk assessments on all residents. · On [DATE] at 5:30 P.M., the DON/Designee conducted a full house audit of all falls with bed mobility deficits during the past 90 days to ensure new intervention(s) were implemented and placed on the care plan to ensure resident safety. · On [DATE] by 5:30 P.M., the DON/Designee educated Unit Managers, Licensed Practical Nurse (LPN)/Treatment Nurse #08, and the MDS Coordinator on implementation of new fall interventions, including ensuring a safe environment and moving the residents with proper assistance. · On [DATE] by 5:30 P.M., the DON/Designee educated nurses and STNA's on fall prevention, implementation of post fall interventions and updating care plans to ensure resident safety. · On [DATE], the DON/Designee initiated random audits of residents weekly for four weeks who had a fall related to bed mobility to ensure new intervention(s) were implemented and noted on the care plan. The findings were submitted to the Quality Assurance and Performance Improvement (QAPI) team. · Review of staff education sign-in-sheets dated [DATE] through [DATE] revealed all nurses and STNA's were educated regarding fall prevention, implementation of new and post fall interventions and updating care plans. · Review of the random audits, dated [DATE] through [DATE], revealed any resident who had a fall related to bed mobility had new interventions implemented. · On [DATE], interviews with LPN #16, LPN Unit Manager #69, and LPN/Treatment Nurse #08 revealed all had attended an in-service in May about proper transfers, using the appropriate number of staff with resident care, fall prevention, how to put interventions in place, and updating the care plan. Findings include: Review of Resident #63 ' s medical record revealed she was originally admitted to the facility on [DATE] and was readmitted on [DATE]. She was discharged on [DATE]. Her diagnoses included chronic diastolic (congestive) heart failure and need for assistance with personal care. Review of Resident #63 ' s quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed she was cognitively intact. She needed extensive assistance of two staff for bed mobility, dressing, and personal hygiene. She was totally dependent on two staff for transfer, toilet use, and bathing. She did not walk. She needed supervision and set up help for eating. She was always incontinent of urine and frequently incontinent of bowel. Review of Resident #63 ' s quarterly MDS assessment, completed on [DATE], revealed she had moderate cognitive impairment. She needed limited assistance of two staff for bed mobility and personal hygiene. She needed extensive assistance of two staff for transfer and dressing. She did not walk. She needed supervision and setup help for eating. She was totally dependent on two staff for toilet use and bathing. She was always incontinent of bowel and bladder. Review of the most recent plan of care dated [DATE] revealed Resident #63 was at risk for falls related to her need for extensive assistance with bed mobility, Hoyer lift use to/from recliner, and transfers due to unsteady balance and poor coordination. She was easily fatigued, did not ambulate, used a wheelchair as a primary form of locomotion, required extensive assistance for dressing and personal hygiene, receiving therapy services, and diagnoses of diabetes mellitus, acute renal failure, and [CONDITION(S)]. Review of Resident #63 ' s Fall Risk Assessments dated [DATE], [DATE] and [DATE] revealed she scored a 10, indicating she was at high risk for falls. Review of Resident #63 ' s nursing notes, dated [DATE] at 5:44 P.M., revealed STNA #107 notified the nurse that Resident #63 was on the floor. STNA #107 stated the resident fell over the side of bed while she was changing her incontinent brief. LPN #60, another nurse and STNA #107 went to the resident's room. The resident was laying on the floor on her back with a pillow under her head. LPN #60 assessed her for injuries, and she had a large skin tear to the back of right hand. Resident #63 and STNA #107 stated she did not hit her head, and there were no injuries on her head. Staff placed the Hoyer pad under the resident and then assisted her off the floor and into bed. A dressing was applied to the skin tear. Resident #63 was referred for Physical Therapy on [DATE] due to a recent fall out of bed. The reason for skilled services was that the resident presented with declined independence and safety awareness with functional mobility, impaired tolerance upright, poor postural awareness and control, and declined lower extremity strength and endurance. Due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the resident was at risk for falls, increased dependency upon caregivers and limited out-of-bed activity. The intervention of a two person assist for bed mobility was not added to the care plan at that time, although she was assessed in the most current MDS as needing assist of two staff. The Physical Therapy Discharge Summary dated [DATE] indicated she required moderate to maximum assist with handrails when rolling to decrease the burden of care and prepare for a Hoyer lift transfer. Her functional skills assessment indicated she needed substantial/maximal assist when rolling from left to right. Although she did have some improvements, her mobility score was Zero on a scale of Zero to 12 with 12 being the highest. She was discharged due to exhausting her benefits and the resident/responsible party declined continuing treatment. Review of Resident #63 ' s nursing notes, dated [DATE] at 1:56 A.M. revealed on [DATE] at 10:45 P.M., STNA #113 called LPN #33 to come to Resident #63 ' s room. The resident was on the floor in a kneeling position. STNA #113 was holding Resident #63 around the shoulders. STNA #113 said she rolled Resident #63 over during routine care, she lost control and the resident went kneeling on the floor. There were three other nurses called to assist to reposition the resident on the floor with her head on a pillow. She was assessed, and a skin tear was noted from a previous bruised area on her elbow and right hand. Her vital signs were as follows: Blood Pressure ,d+[DATE], Pulse 45 beats per minute, Oxygen Saturation 97%, and Respirations 16. Resident #63 was assisted to bed with assist of four staff and a Hoyer lift. The resident was lifted back to bed and her skin tear was cleaned with normal saline, covered with gauze, and secured with tape. She was exhibiting no distress or discomfort. The on-call physician was notified and said since all vitals were within normal limits (although her pulse was 45), she should not go to hospital, but be monitored closely. The resident ' s family was informed and requested staff update them of Resident #63 ' s health status in the morning. A nursing note dated [DATE] at 4:25 A.M. documented the resident had a skin tear on her left elbow and right hand, which was cleaned with normal saline, pat dry, and gauze and tape. Her vitals were assessed on [DATE] at 9:00 A.M. On [DATE] at 11:10 A.M., Resident #63 ' s family member came into the building and called 911 for the resident to be sent out to the hospital for further evaluation. There was an order in place for STAT bilateral x-rays, but the resident ' s family member thought it would be best for Resident #63 to be seen at the hospital for further evaluation. Review of the facility ' s investigation, dated [DATE], revealed on [DATE] at approximately 10:45 P.M., STNA #113 called the nurse (LPN #33) to Resident #63 ' s room. Upon entering, the nurse noted the resident kneeling on the floor by her bed with STNA #113 supporting her to remain in the upright position. The nurse called other staff to the room to assist. Staff assisted the resident into a comfortable lying position on the floor. Per nurse assessment, her vitals were as follows: Blood Pressure ,d+[DATE], Pulse 45 beats per minute, Respirations 16 Breaths Per Minute, and Oxygen Saturation 97%. Skin tears were noted to her left elbow (previously bruised area) and right hand. Resident #63 was documented as being without complaint of pain or discomfort. Four staff members assisted the resident back to bed using a Hoyer lift. Her skin tears were treated/dressed. The Medical Doctor (MD) was notified and stated since the vital signs were stable and there was no complaint of pain, there was no need to send her to the hospital at that time and to monitor her closely. Family was notified of the incident and requested an update the next morning. STNA #113 ' s statement was she was providing care to the resident and when the resident was assisted to roll over, she slid out of bed onto her knees. On [DATE] at 8:00 A.M., the MD ordered STAT x-rays to her bilateral knees to rule out fractures. Shortly after receiving the order, the resident ' s family member arrived at the facility and requested the resident be sent to the hospital for an evaluation versus waiting for STAT x-ray results at the facility. The resident was sent to the hospital and the MD was notified of the transfer. Resident #63 was admitted to the hospital with bilateral knee fractures. The contributing factors were identified as generalized muscle weakness, incontinence, need for assist with personal care, and [CONDITION(S)]. Statements from STNA #113 and LPN #33 were requested from the facility on [DATE] and [DATE] at approximately 5:30 P.M. They indicated they could not find the statement from STNA #113 and that the statement from LPN #33 was documented in the nursing notes. Review of Resident #63 ' s Hospice notes revealed she was eligible for services with a terminal diagnosis of acute kidney injury on chronic kidney disease. The reason for the Hospice referral was that the resident was admitted to the hospital on [DATE] after falling out of bed. It indicated at baseline the resident was non-ambulatory and spent most of her time bed bound. She had imaging upon admission and was found to have bilateral femur fractures. Surgery was consulted, but the family opted for comfort measures. On admission to the hospital, she was found to have acute kidney failure on chronic kidney disease. Resident #63 was started on intravenous fluids. During the hospital admission, the resident developed chest pain. The resident was found to have A non-ST segment elevation [CONDITION(S)] (NSTEMI) and was started on a [MEDICATION(S)] drip. Nephrology was consulted and there were recommendations for hemodialysis. The family wanted to focus on comfort care, and not proceed with [CONDITION(S)]. Palliative care was consulted. Upon discussion between the family and medical team the resident was made a Do Not Resuscitate with Comfort Care upon Arrest (DNR CCA). Hospice was consulted. Resident #63 passed away on [DATE] at 10:06 P.M. Review of the coroner ' s report, dated [DATE], revealed the cause of death was complications of bilateral femoral fractures with significant contusions and [CONDITION(S)] due to falling out of bed, and due to generalized weakness, [CONDITION(S)], and [CONDITION(S)]. Contributory causes of death were [CONDITION(S)] and hypertensive cardiovascular disease; and Type II diabetes mellitus. The manner of death was identified as accidental. During an interview on [DATE] at 4:14 P.M., STNA #113 stated the night Resident #63 fell , she had help from STNA #56 getting her into bed. She stated STNA #56 had to go out on the floor to answer a couple of call lights. She was changing the resident when STNA #56 left the room. She turned her head to get the butt paste and the next thing Resident #63 said was I am falling. The resident was falling away from her toward the window. She said she grabbed her leg, but half of her body was already down. She eased her down onto the floor and screamed for help. She said Registered Nurse (RN) #88, LPN #33 and LPN #67 came in and had to lay her down since she was on her knees. They got a Hoyer lift to pick her up. She indicated they were all freaking out and STNA #113 told them they needed to call her family and send her out [to the hospital]. STNA #113 stated she knew the resident ' s family well and called them to let her know what happened. STNA #113 stated Resident #63 was a two-person assist and there were only two aides for the whole A wing. She stated Resident #63 was complaining of pain. When the staff went in to do care on the resident approximately an hour later (approximately 1:00 A.M.), they turned on the light and she was scared. She said when they removed the bed covers, they immediately saw how bruised and swollen her knees were. She stated LPN #33 was made aware and he was aware that she was in pain. The resident did not want to be left alone. She said that her and STNA #56 took turns sitting with her when they could. She stated LPN #33 did not give the resident any pain medication. She stated LPN #33 was made aware that her knees were swollen. She said they just touched the resident and she screamed. During an interview on [DATE] at 4:48 P.M., LPN #33 stated when Resident #63 fell , he was attending to another patient that had just fallen. He said an aide told him that Resident #63 had fallen. He came in with another nurse to see what had happened. He revealed STNA #113 was changing the resident and while she was turning her, she fell . He indicated he called five nurses to come and assist him getting her off the floor due to her being in a dangerous position. He said he checked her vitals before she was moved. LPN #33 said Resident #63 required two staff assist and that there were only two staff on the hall. He said STNA #113 was the only aide in the room. He revealed he informed the supervisor and DON that she needed to be sent to the hospital. He indicated she declined going, and the supervisor was trying to communicate with the DON. The aide informed the family and they called him to see what was going on. The aide had told the family that they were sending her to the hospital. He said he asked the family if he could send her to the hospital and they asked what she wanted to do. He let them know she did not want to go. He indicated about 40 minutes after the fall she was having a funny feeling in her legs. She had a skin tear and bruise that he was taking care of. He indicated he wanted to send her to the hospital, but the company that had taken over the facility indicated the DON would have to make the call for her to go to the hospital unless there was an obvious injury. He said the next morning he talked to her family and she asked if the family could come for her and take her to the hospital. He felt she did not show any signs of danger and did not notice any swelling on the knee. He indicated she did not complain of pain, but he gave her Tylenol. He said he did not check range of motion in her legs before she was moved after the fall due to her not using her legs. He said she complained of spasms in her knee and he then checked her range of motion. He indicated it was not pain. During an interview on [DATE] at 6:26 P.M., STNA #56 stated when Resident #63 fell she was in another room. She had helped transfer her by Hoyer lift to the bed prior to the fall. She said generally it took three staff to transfer her with the Hoyer lift. She revealed Resident #63 was in so much pain and swollen after the fall. She said the resident started vomiting when they tried to roll her. She stated LPN #33 was aware that Resident #63 was in pain, because she told him. She said the resident refused to go to the hospital at first, but she changed her mind. STNA #56 stated LPN #33 was made aware the resident wanted to go to the hospital, but he told them she wasn ' t going to the hospital. She was in pain and her thighs and knees were swelling fast. She said the resident was so scared and didn ' t want them to leave her. She stated they turned her bed so she could see into the hall and took turns sitting with her when they could. A review of the facility policy titled Assessing Falls and Their Causes, revised [DATE], revealed under the section Steps in the Procedure, After a Fall: it states 1) If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. 2) If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. 3) Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 4) Nursing staff will notify the resident ' s Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone. 5) Nursing staff will observe for delayed complications of a fall for approximately forty-eight hours after an observed or suspected fall and will document findings in the medical record. 6) Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. This deficiency substantiates Complaint Number OH 951.

Based on observation, staff interview, record review, National Pressure Injury Advisory Panel (NPIAP) recommendations and facility policy review, the facility failed to ensure a resident was provided proper positioning in bed with pressure relief to the feet to prevent the development of an avoidable pressure ulcer. This resulted in actual harm when Resident #79 developed an avoidable pressure ulcer to her left fourth toe that progressed from a Stage II to a Stage IV pressure ulcer. This affected one Resident (#79) of four residents reviewed for positioning. The facility identified four additional residents (#06, #37, #87 and #89) with facility acquired pressure ulcers. The total facility census was 116. Findings include: Review of medical record for Resident #79 revealed and admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of most recent Minimum Data Set (MDS) assessment, dated 03/16/21, revealed Resident #79 had severely impaired cognition, had no behaviors, did not reject care, did not wander, was dependent for toileting, bathing, locomotion, required extensive assistance for bed mobility, transfers, dressing, and personal hygiene, was always incontinent of bowel and bladder. Section M for skin conditions revealed the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Review of plan of care for Resident #79 revealed resident had an activities of daily living (ADL) self-care performance deficit related to Alzheimer's disease, dementia, and muscle weakness. Interventions included resident was bedfast most of time and staff to assist with ADL's; resident was totally dependent on staff for repositioning and turning in bed; and resident was totally dependent on staff for bathing. The plan of care also stated the resident was at increased risk for developing pressure ulcers related to immobility, incontinence, and diabetes. Interventions included follow facility protocols for prevention / treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Braden Scale for predicting pressure sore risk assessment for Resident #79. dated 12/10/20 revealed resident was scored at 12, high risk, due to very limited sensory perception, very limited activity, and potential problems related to friction and shear. Review of the health status note (nursing progress notes) dated 01/01/21 through 04/14/21 revealed no documented evidence resident refused to be turned and repositioned. Review of infection control logs from 02/01/21 through 04/12/21 revealed Resident #79 was absent from the log. Review of incident/accident report from 02/01/21 through 04/12/21 revealed Resident #79 was absent from the log. Review of infection logs dated 02/01/21 through 04/30/21 revealed Resident #79 was on [MEDICATION(S)] 100 mg twice daily on 02/25/21, 03/18/21 and 04/07/21. Review of weekly skin assessments for Resident #79 dated 02/11/21 revealed resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the wound notes for Resident #79, dated 02/16/21 by the dedicated wound nurse, Licensed Practical Nurse (LPN) #30, indicated the nurse was notified by a State tested Nursing Assistant (STNA) that resident had an open area to the left toe. The wound measured 1.5 centimeters (cm) by 1.8 cm by 0.1 cm (depth). The resident was ordered to receive Calcium Alginate and Santyl and cover with clear dry dressing. The resident's wound was determined to be from the support beams of the foot board on the bed. Pressure redistribution boots were in place and a new order was received for a bed extender to the foot of bed. Review of wound evaluation sheet for Resident #79, dated 02/16/21, revealed the wound was acquired in house on 02/16/21. The notes stated the resident had a wound on the left toe that measured 1.5 cm by 1.8 cm by 0.8 cm (depth). The wound bed was red, with no exudate and no odor. The treatment included Santyl and Calcium Alginate cream, and resident had pressure redistribution boots in place. The weekly skin assessment dated [DATE] revealed the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The weekly skin assessment grid and evaluation revealed no documented evidence of wound assessment such as location, type, size, staging or description. Review of wound notes dated 02/22/21 revealed the wound was a stage II pressure ulcer. Review of the physician note for Resident #79, dated 02/23/21, revealed the resident's pressure ulcer was not documented as being assessed. There was no documentation concerning a skin condition or pressure ulcer assessment. Review of the facility work order notes dated 02/23/21 indicated Resident #79 needed a bed that had or could have a bed extender. The resident's bed needed a bed extender and was in a bed that did not allow for one to be installed. Notes indicated the work order was marked completed on 02/24/21. Review of physician orders for Resident #79 dated 02/24/21 revealed resident was ordered [MEDICATION(S)] 100 milligrams (mg) twice daily for 10 days due to a wound infection. Review of Nurse Practitioner (NP) #10's progress notes, dated 02/24/21, revealed staff reported the resident's left foot rested on the foot board of bed and a new area was discovered on the resident's left fourth toe on 02/16/21. The wound had the etiology of a pressure ulcer located on left fourth toe. The wound measured 0.8. cm by 0.7 cm by 0.3 (deep) with bone exposed. There was a small amount of necrotic tissue and the resident was diagnosed with a stage IV pressure ulcer and [CONDITION(S)] of lower left limb. Notes indicated the resident was ordered off-loading boots, a X-ray of left foot to rule out [CONDITION(S)], [MEDICATION(S)] 100 mg twice daily for ten days for [CONDITION(S)], to have the pressure ulcer cleansed with normal saline, Santyl applied, and covered with gauze daily. NP #10's progress notes dated 03/03/21 revealed the [CONDITION(S)] had improved. The wound continued to be open with bone exposure but showed some improvement, measuring 0.8 cm by 0.9 cm by 0.3 cm (deep), and there was no necrotic tissues within the wound bed. Notes indicated resident was ordered to continue with off-loading boots and the pressure ulcer was ordered to be cleansed with normal saline, Santyl applied, and covered with gauze daily. Review of podiatry notes for Resident #79, dated 03/08/21, revealed the resident presented to their office and the resident had an ulceration on her left fourth toe and unknown how long it had been present. The physical exam revealed the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was to follow up in one week at the wound care center. The assessment and plan included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's responsible party, who was present, was informed that exposed bone means a likelihood of [CONDITION(S)] and could necessitated amputation if worsened. The resident was to be seen within one week at the wound care center. Review of the wound note dated 03/03/21 revealed an X-ray showed the resident had bone spurs along with a pressure ulcer and NP #10 made a new referral for the resident to see a podiatrist. NP #10's progress notes, dated 03/10/21, revealed the resident's stage IV pressure ulcer continued to be open, measured 0.5 cm by 1 cm by 0.1 cm deep, bone was exposed, no granulation within the wound and 57 to 100 percent of necrotic tissue. The [CONDITION(S)] had resolved, antibiotics were completed and resident was ordered to receive the same wound care/dressing changes. NP #10's notes dated 03/17/21 revealed resident was was seen by podiatry on 03/08/21 and referred to a wound clinic where the podiatrist also practiced. The pressure ulcer on the left fourth toe measured 0.5 cm by 0.9 cm by 0.1 cm deep, with bone exposed, medium amount of necrotic tissue within the wound bed. The resident was ordered to have wound cleansed with normal saline, calcium alginate with silver cream applied to wound, and covered with gauze daily. Physician orders dated 03/18/21 revealed resident was ordered [MEDICATION(S)] 100 mg twice daily for 10 days due to wound infection. Review of wound care center notes for Resident #79, dated 03/23/21, revealed the resident was seen at the wound care center by the same podiatrist from the 03/08/21 podiatry office visit. The resident was referred to wound care center due to exposed bone. The resident had an open wound as a result of a pressure injury and wound was classified as Stage III with etiology of pressure ulcer and was located on left fourth toe. The wound measured 0.5 cm in length by 0.9 cm in width by 0.2 cm deep with subcutaneous (fat layer) exposed, large necrotic tissue present and adherent slough. An excisional skin, subcutaneous tissue, muscle and bone debridement was completed. Post debridement, the wound measured 0.6 cm length by 1.0 cm width by 0.2 cm depth and the post debridement stage was stage III. The resident was discharged from the wound care center and instructed to follow up with NP #10 at the facility. Review of the wound note dated 03/31/21 revealed resident was seen by NP #10 and the wound measured 1.0 cm by 1.0 cm by 0.2 cm (depth) with slight bone exposure. The resident would continue being seen daily by the wound care nurse and weekly by NP #10. NP #10's notes dated 03/31/21 revealed the resident's stage IV pressure ulcer continued to be open, measuring 1.0 cm by 1.0 cm by 0.2 cm (depth), bone was exposed, large granulation tissues within wound bed and no necrotic tissue within wound bed. The resident was ordered to receive wound cleansing with normal saline and collagen applied every other day per wound center orders. Physician orders dated 04/07/21 revealed resident was ordered [MEDICATION(S)] 100 mg twice daily for 10 days due to wound infection. NP #10's progress notes dated 04/07/21 revealed the resident's stage IV pressure ulcer continued to be open, measured 0.6 cm by 0.7 cm by 0.2 cm (depth), bone was exposed, large granulation tissues within wound bed and no necrotic tissue within wound bed. The resident was ordered same wound care. The Wound Evaluation Flowsheet, dated 04/07/2, revealed the wound was acquired in house on 02/16/21 on the fourth left toe. The pressure ulcer measured 0.6 cm in length by 0.7 cm in width and 0.2 cm deep. The resident was ordered collagen and dry dressing and be changed every other day. Preventative measures in place included a bed extender and pressure redistribution boots. Interview with LPN #31 on 04/13/21 at 11: 44 A.M. stated she was alerted by a STNA on 02/1/6/21 that Resident #79 had a new wound on her toe. LPN #31 stated she assessed resident to find an open area on her left toe which measured 1.5 cm by 1.8 cm by 0.1 cm (depth). LPN #31 stated she called the facility physician and received orders for the resident to receive Calcium Alginate and Santyl cream to be applied and wound to be covered with clear, dry dressing. LPN #31 stated the facility determined the resident's wound was caused from resident's left foot being positioned on the metal support beams which hold the foot board on the bed. LPN #31 stated the way resident positioned herself in bed, her feet rested against the footboard metal supports located on the edges of footboard and stated staff were required to reposition resident in bed. LPN #31 stated resident had pressure redistribution boots in place but she somehow got her foot out of the boot and rested it on the footboard. LPN #31 stated the facility ordered a bed an extender for the resident's bed. LPN #31 stated resident was assessed by wound specialist NP #10 on 02/24/21 and diagnosed Stage IV pressure ulcer. She assessed the wound on 02/16/21 but could not recall if resident's bone was exposed. Observation of the dressing change to the toe for Resident #79 on 04/14/21 at 10:12 A.M. with LPN #31 and NP #10 revealed the resident had an open wound on left fourth toe. During interview with NP #10 at the time of the observation, she stated the wound had improved. It measured 0.5 cm by 0.6 cm by 0.2 (depth) with no bone being exposed. NP #10 stated resident continued to receive daily wound treatments and assessments weekly. During interview on 04/14/21 at 12:20 P.M., NP #10 stated she initially saw Resident #79 on 02/24/21 and diagnosed the resident with [CONDITION(S)] and stage IV pressure ulcer on left fourth toe with bone exposure. NP #10 stated she was informed by LPN #31 that resident's toes had rested against the metal supports of footboard which caused the pressure ulcer and [CONDITION(S)]. NP #10 stated the resident would slide down in bed numerous times a day and required repositioning by staff. NP#10 stated when she assessed resident on 02/24/21, resident had no tissue in the wound and bone was the only thing visualized in the wound. NP #10 stated she assessed Resident #79 on the next scheduled wound rounds after the wound was discovered. NP #10 stated she ordered Santyl cream to be applied to keep bone moist, ordered [MEDICATION(S)] (antibiotic) twice daily for [CONDITION(S)] and ordered an X-ray to rule out [CONDITION(S)] (bone infection). NP #10 stated the X-ray results showed the resident had a chronic bone spur, so she recommended resident be seen by a podiatry for assessment of the bone spur, not the wound. NP #10 stated the resident was seen by a podiatrist on 03/08/21 and he wanted to see her in the wound clinic for debridement, where he also practiced. NP #10 stated after the podiatrist saw resident in the wound clinic on 03/23/21, he messaged her to inform her he had trimmed off bone, and the resident was discharged from wound clinic. There was no follow-up required unless the wound did not improve and if that happened, there was a the possibility of the resident's toe being amputated. NP #10 stated podiatrist recommended for her wound group to follow-up with the resident in the facility and notify wound clinic if resident had any changes. NP #10 stated she was not sure who ordered the bed extender or when it was installed. NP #10 further stated she could not comment on whether the wound was avoidable or not. During interview on 04/14/21 at 3:00 P.M., the Administrator stated the facility ordered a bed extender for resident's bed on 02/23/21 and it was installed on 02/24/21. Review of the facility policy titled Repositioning, dated 05/01/13, revealed the facility would reposition residents to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning was critical for a resident who is immobile or dependent on staff for repositioning and resident who are in bed should be repositioned on a schedule of at least every two hours and if repositioning was ineffective, then turning and repositioning frequently should be increased. Review of NPIAP website (https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf) revealed pressure ulcers have been defined by the National Pressure Ulcer Advisory Panel (NPUAP) as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. References indicated a stage four pressure injury was a full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon ligament, cartilage or bone in the ulcer, slough and/or eschar may be visible, and depth varies by anatomical location. References also indicated to choose the correct size of medical devices to fit the individual. This deficiency substantiates Complaint Number OH 518.