Every finding on record at Momentous Health at Franklin

Based on record review, observations, resident and staff interviews, review of dietary spreadsheets, review of guidelines for pureeing food, and policy review, the facility failed to ensure residents received enough food to meet their needs and preferences, serve portions sizes as planned on the menu, ensure pureed food was prepared in a manner to maintain the nutritive value of the food, and ensure posted menus were updated for the residents to view what meals they were having for the day. This affected Resident #3 and had the potential to affect 65 of 66 residents. The facility identified one resident (#9) who did not receive food from the kitchen. The facility census was 66. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 05/21/25. Diagnoses included type II diabetes mellitus, end-stage renal disease (ESRD) with dependence on renal dialysis, and gastroesophageal reflux disease. Review of the nutrition care plan dated 05/23/25 revealed Resident #3 was on a restricted diet due to ESRD with interventions of provide diet as ordered and communicate with the renal registered dietician (RD) as needed. There was no interventions listed to address Resident #3 not receiving enough food and addressing Resident #3's behavior to eat off other resident's used food trays. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderately impaired cognition. Interview on 09/08/25 at 12:05 P.M., Resident #3 stated he was supposed to receive a renal diet and sometimes he does not get enough food to eat. Resident #3 stated he was supposed to get double portions. Observation on 09/10/25 at 8:22 A.M. revealed Resident #3 was pulling food off of used food trays on the food services cart. Resident #3 was eating the food items pulled off the cart. Interview on 09/09/25 at 8:24 A.M. with Licensed Practical Nurse (LPN) #151 confirmed Resident #3 was pulling and eating food off the used breakfast trays located on the food services cart. LPN #151 stated Resident #3 pulls food off the dirty food trays on the food services cart all the time and eats it. LPN #151 confirmed the facility hasn't stopped Resident #03 from eating food off the dirty trays stating you can't stop him we just let him do it. Review of the Meal Delivery policy dated 05/01/22 revealed nursing staff collects all the trays from the resident's rooms and places them back into the mobile trucks after mealtime, then the cart is returned to the Dietary Department. 2. Review of the dietary spreadsheet, dated 09/09/25 revealed two beef tacos, each containing a #16 (2 ounce) scoop of meat in each, were to be served. Observation on 09/09/25 from 11:53 A.M. to 12:29 P.M. of tray line for the lunch meal revealed [NAME] #166 placed one taco (one flour tortilla containing 2 ounces of taco meat) on each plate. Continued observation revealed [NAME] #166 provided two tacos for residents who were supposed to receive double portions. At 12:03 P.M., a cart containing trays for the dining room left the kitchen. At 12:14 P.M., a cart containing trays for the 100 hall left the kitchen. At 12:28 P.M., a cart containing trays for the 300 hall left the kitchen. Interview on 09/09/25 at 11:53 A.M., [NAME] #166 stated residents who received the standard menu were served one taco and residents on double portions were served two tacos. Interview on 09/09/25 at 12:29 P.M. Dietary Supervisor #168 verified the portion size for the tacos was supposed to be two tacos and residents on double portions should have received four tacos. Review of the facility policy titled Portion Control dated 2010 revealed residents would receive the appropriate portions of food as planned on the menu. 3. Observation on 09/09/25 at 10:43 A.M., [NAME] #166 stated there were five residents on pureed diets. [NAME] #166 added five scoops of taco meat to the food processor, then added approximately 6 ounces of beef broth. [NAME] #166 then started the food processor and added approximately half cup of bread crumbs and continued pulsing. [NAME] #166 turned the food processor off and checked the consistency of the mixture, and stated it was more runny than he preferred, added more bread crumbs, and started the food processor again. Interview on 09/09/25 at 10:58 A.M., [NAME] #166 verified he added liquid to the processor before assessing the need to add liquid. When queried regarding the use of a recipe for making pureed food, [NAME] #166 stated, that's how I make it. That's my recipe. Interview on 09/09/25 at 1:18 P.M., DS #168 verified the guidelines for making pureed food indicated the appropriate procedure was to place the food in the food processor, puree, and then assess the need to add more water or thickening agent. Review of the facility policy titled Pureed Food Preparation dated 2009 revealed food should be placed in the processor bowl, drained of liquid, and pureed well. The addition of fluid may not be necessary, depending on product composition. 4. Observation on 09/08/25 at 9:09 A.M. revealed the menu posted in the 200 hall was for Friday, 09/05/25. Observation on 09/08/25 at 9:10 A.M., Resident #39 looked at the posted menu on the 200 hall and stated, that doesn't do me any good. That's from several days ago. Interview on 09/08/25 at 9:10 A.M., Certified Nursing Assistant (CNA) #116 verified the menu posted on the 200 hall was from 09/05/25, three days prior. Interview on 09/11/25 at approximately 8:00 A.M., Dietary Supervisor (DS) #168 stated she or the cook is responsible for posting the daily menus. DS #168 stated she was unable to get menus printed over the weekend and was not able to update the posted menu until Monday morning. The facility identified Resident #9 did not receive food from the kitchen.

Based on observation, resident and resident representative interviews, and staff interview, the facility failed to ensure residents received foods that were palatable. This had the potential to affect 65 of 66 residents. The facility identified one resident (#9) who did not receive food from the kitchen. The facility census was 66. Findings include: Review of a test tray on 09/09/25 at 12:52 P.M. with Dietary Supervisor (DS) #168, revealed the taco, refried beans, and rice and beans were luke warm and not palatable. DS #168 verified the taco, refried beans, and rice and beans were not served at a suitable temperature and were not palatable. Interview on 09/09/25 at 1:07 P.M., Resident #39 stated the food he was served for lunch was cold. Interview on 09/09/25 at 1:11 P.M., Resident #20 stated the food she was served for lunch was cold, like it always is. The resident described the food as hog slop. Interview on 09/08/25 at 9:10 A.M., Resident #77 complained of the food being cold. Interview on 09/08/25 at 10:03 A.M., Resident #24's responsible party stated Resident #24 often complained about the food being cold. The facility identified Resident #9 did not receive food from the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00165869 (1260837).

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to protect against the potential spread of foodborne illness. The facility also failed to ensure staff wore hair restraints in the kitchen. The facility also failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 65 of 66 residents in the facility. The facility identified one resident (#09) who did not receive food from the kitchen. The facility census was 66. Findings include: Observation and interview on 09/08/25 at 7:50 A.M. of the kitchen's reach-in refrigerators with Dietary Supervisor (DS) #168 revealed a reusable plastic bag of cheese slices that was unsealed, and a package of bologna slices not dated or sealed. There was also a box containing two bags of sausage and one of the bags was not sealed and did not have a date. DS #168 verified the cheese was not sealed and the bologna and sausage were not sealed or dated. DS #168 verified all food should be sealed and dated. Observation and interview on 09/08/25 at 8:00 A.M. with DS #168 revealed a bag of cookie dough which was not sealed and two plastic disposable cups containing an unidentified food, which were not sealed, labeled, nor dated. DS #168 verified the cookie dough was not sealed and the two plastic cups were not sealed, labeled, or dated. Observation and interview on 09/09/25 at 10:43 A.M. revealed [NAME] #166 preparing pureed taco meat. [NAME] #166 had facial hair, measuring approximately one-fourth inch, and was not wearing any type of restraint for his facial hair. At 11:09 A.M., [NAME] #166 verified he was not wearing a hair restraint for his facial hair. Observation and interview on 09/09/25 at 11:03 A.M. with DS #168 revealed there was a round vent on the ceiling above the steam table. The vent was coated in light brown debris and there were black specs on the ceiling in the surrounding four foot area which were flapping in the breeze from the vent. The support beam for the steam table, which extended to the ceiling of the kitchen revealed the top-most portion, measuring approximately two feet, was coated in a brown and grey fuzzy substance. DS #168 verified the vent was coated in light brown debris and black specs surrounded the four foot area around the vent. DS #168 verified the support beam was coated in a brown and grey fuzzy substance. DS #168 verified the areas needed to be cleaned and stated she was unable to reach the areas. DS #168 was standing next to [NAME] #166 while [NAME] #166 was preparing food for the lunch meal. DS #168 was wearing a hair net, however her hair was not fully covered, and approximately three inches of hair was sticking out from under the hair net around the head. DS #168 verified her hair was not fully contained by the hairnet. Review of the facility's undated policy titled Food Safety and Sanitation revealed hair restraints are required and should cover all hair on the head and beard nets are required when facial hair is visible. Food should be protected from contamination (including dust). All time and temperature control for safety (TCS) foods should be labeled, covered, and dated when stored. When a food package is opened, the food item should be marked to indicate the open date, which is used to determine when to discard the food.

Based on review of the facility's quality assurance performance improvement (QAPI) meeting sign-in sheets, review of the facility's QAPI meetings policy, and staff interview, the facility failed to ensure required QAPI team member were present at meetings. The had the ability to affect all 66 residents residing in the facility. Findings include: Review of the facilities' QAPI/Quality Assessment and Assurance (QAA) meeting sign in sheets revealed the following: The Director of Nursing (DON) and Medical Director (MD) were not present at a meeting 10/23/24. No designees for the DON or MD were listed.The DON and MD were not present at a meeting dated 02/10/25. No designees for the DON or MD were listed. No staff identified as the infection preventionist (IP) or designee was present. No designee for the IP listed.The DON was not present at a meeting dated 04/22/25. No designee for the DON was listed.The IP was not present at a meeting dated 08/26/25. No designee for the IP listed. Review of the facility's QAPI meetings policy dated 08/01/23 revealed the facility Quality Assurance and Quality Improvement (QA/QI) Committee members include but are not limited to the DON, MD or physician, Administrator, Director of Housekeeping/Laundry, Director of Therapeutic Recreation, Director of Social Work, Director of Food Services, Director of Rehabilitation, QA Nurse, Director of Maintenance, and other designated facility staff. The QA/QI Committee will meet at least quarterly to identify QA/QI issues and to develop appropriate plans of action needed to correct the issues. The Committee monitors the effect of the implemented changes and makes any revisions necessary to the plan of action. Further review revealed the IP was not listed as a required team member. Interview with the Administrator on 09/10/25 at 3:09 P.M. confirmed QAPI meetings dated 10/23/24, 02/10/25, 04/22/25, and 08/26/25 did not have the required members attending. The Administrator confirmed the IP was not listed as a required member in the facility's policy. Interview with Chief Operating Officer #210 on 09/10/25 at 3:17 P.M. confirmed QAPI meetings dated 10/23/24, 02/10/25, 04/22/25, and 08/26/25 did not have the required members attending. The Administrator confirmed the IP was not listed as a required member in the facility's policy.

Based on observation, policy review, resident interview, and staff interview, the facility failed to maintain a clean, sanitary, and safe environment for all residents. This affected Residents #4 and #31 and had the potential to affect all 66 residents residing in the facility.Findings include: 1. Observations on 09/08/25 between 9:00 A.M. and 10:00 A.M. revealed the floors of the 200 and 300 halls contained numerous areas of dark grey and black shoe (foot) prints, dark grey and black wheelchair trail marks, and dark grey and black marks suggestive of dried liquid drips. There was dirt, grime, and dust throughout both halls. Interview on 09/08/25 at 10:02 A.M., Resident #31 described the facility cleanliness as “nasty” and stated all of the housekeepers but one were recently fired. Interview on 09/08/25 at 11:21 A.M., Resident #4 complained the floors in the common area were not very clean and further stated he thought the floors were dirty because there was only one person in housekeeping for the entire building. Interview on 09/08/25 at 10:12 A.M., Housekeeper #109 verified the 200 and 300 halls contained numerous areas of foot prints, wheelchair marks, dried liquid, dirt, grime, and dust. Housekeeper #109 stated she was upset at the condition of the hallways when she arrived to begin her shift that morning and further stated the halls had not been cleaned over the weekend because the majority of the housekeeping staff had recently been fired. 2. Observations on 09/11/25 at 1:22 P.M. revealed a build up in the lint trap of all three dryers in the laundry room. Interview on 09/11/25 at 1:25 P.M. with Housekeeper #126 verified that the amount of lint in the trap would be from a couple loads. Housekeeper #126 stated she arrived to work at 1:00 P.M. and was doing her first load of laundry for the day. Housekeeper #126 verified the lint traps should be cleaned regularly to prevent a build up of lint. Review of the facility policy titled “Infection Control – Housekeeping”, dated 10/27/21 revealed the facility procedure is to provide a safe and septic handling, washing, and storage of linens. This deficiency represents non-compliance investigated under Complaint Number 2605044, Complaint Number 2574888, Complaint Number OH00164929 (1260835), Complaint Number OH00164419 (1260832), and Complaint Number OH00166722 (1260778).

Based on record review, observation, staff interview, policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow physician orders for contact isolation precautions for Residents #57 and #13. This affected Residents #57 and #13 and had the potential to affect the residents residing on their units, 100 and 200 halls. The facility census was 66. Findings include: 1. Review of the medical record for Resident #13 revealed an admission dated of 12/14/11. Diagnoses included cerebrovascular disease, obsessive-compulsive disorder, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Review of the physician orders dated 09/09/25 revealed an order for contact isolation precautions every shift for shingles until resolved. Observation on 09/09/25 at 11:16 A.M. revealed Resident #13 sitting in the dining room, leaning on a dining room table, with ten other residents and one Certified Nursing Assistant (CNA) present. Interview on 09/09/25 11:20 A.M. with Licensed Practical Nurse (LPN) #114 confirmed Resident #13 was positive for shingles infection as of 09/09/25, Resident #13 had open and moist blisters, and should be in contact isolation. LPN #114 confirmed Resident #13 should not be in the dining room with other residents due to a diagnosis of active shingles. Interview on 09/09/25 at 11:23 A.M. with Activities Personnel #130 stated she was not aware of Resident #13 was required to be in contact isolation, and that was not communicated to her. Review of the Transmission Based Precautions policy dated 05/01/22 revealed contact precautions are required for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the resident. If the resident is transported to another area in the facility, the facility will notify the unit of the type of precautions the resident needs. Review of CDC guidance titled Preventing FZV (Varicella-Zoster Virus) Transmission in Healthcare Settings dated 04/19/24 and found at https://www.cdc.gov/shingles/hcp/infection-control/index.html revealed facilities should use the table [Found at website] to determine if any additional infection control precautions are required. Infection control precautions are based on the patient's immune status and rash localization. 2. Record review for Resident #57 revealed an admissions date of 04/18/22 with diagnoses including cerebral infraction and dementia. Review of the physician orders dated 08/21/25 revealed Resident #57 had an order for contact isolation precautions due to wounds from the herpes simplex virus. Observation on 09/08/25 at 9:19 A.M. revealed Resident #57's room did not have a sign stating to use contact precautions prior to entering or a personal protective equipment (PPE) supply cart outside the room. Interview on 09/08/25 at 9:31 A.M. with Licensed Practical Nurse (LPN) #148 verified Resident #57 did not have contact isolation precaution signage or PPE stored outside the room. Interview on 09/08/25 at 9:36 A.M. with Certified Nursing Assistant (CNA) #129 verified she was recently alerted of Resident #57's contact isolation precautions order. CNA #129 stated that while she was performing care for Resident #57 that morning, the only PPE she used was gloves. Review of the facility policy titled Transmission Based Precautions dated 05/01/22, revealed when a resident has orders for contact precautions, a gown should be worn when entering the room and the facility will implement a system to alert staff to the type of precautions for the resident.

Based on record review, observation, resident and staff interviews, and policy review, the facility failed to ensure activities met the needs and preferences of the residents. This affected one (Resident #77) of two residents reviewed for activities. The facility census was 66.Findings included: Review of the medical record for Resident #77 revealed an admission date of 09/02/25 with diagnoses of paraplegia, schizophrenia, anxiety disorder, and bipolar disorder. There was no Minimum Data Set (MDS) assessment available to review due to recent admission. Interview on 09/08/25 at 12:04 P.M. with Resident #77 revealed there were no activities. Observation on 09/11/25 at 8:26 A.M. revealed the schedule of activities for September 2025 had no activities scheduled for the residents after the 2:00 P.M. everyday of the month, except for every other Tuesday when church services were scheduled at 6:00 P.M. Interview on 09/11/25 at 8:38 A.M. with Activities Director #104 confirmed there were no activities scheduled for the residents after the 2:00 P.M. scheduled activity is completed, except for every other Tuesday when church services were held at 6:00 P.M. Activities Director #104 stated there was not enough help in the activities department and she was trying to find help. Review of the activities policy dated 05/01/22 revealed activities will be scheduled periodically during the day, as well as during the evenings, weekends, and holidays.

Based on record review, staff interview, and policy review, the facility failed to ensure medical records were complete and accurate. This affected one (#3) of 23 residents reviewed medical record accuracy. The facility census was 66.Findings include: Review of the medical record of Resident #3 revealed an admission date of 05/21/25. Diagnoses included end-stage renal disease (ESRD) with dependence on renal dialysis, and heart failure. Review of Resident #3's physician orders revealed orders dated 05/22/25 and 05/24/25 for Resident #3 to attend dialysis on Tuesday, Thursday, and Saturday with pickup at 5:30 A.M. On 05/27/25, there was an order to send Resident #3 to the emergency room for evaluation. Review of a progress note dated 05/27/25 at 7:23 A.M. revealed Registered Nurse (RN) #128 was notified Resident #3 was not picked up for transport for dialysis that morning (05/27/25) and may have missed dialysis on Saturday (05/24/25) due to transport. NP #301 was notified and an order was received to send the resident to the hospital for evaluation and treatment due to missing dialysis treatments. There was no evidence in the medical record of the physician being notified of Resident #3 missing dialysis treatments on 05/22/25 nor 05/24/25. There was no documentation the physician recommended Resident #3 going to the hospital on [DATE] and 05/24/25 and Resident #3 refusing to go to the hospital. Interview on 09/15/25 at 3:42 P.M., Physician #502 stated he was notified of Resident #3 missing dialysis treatments on 05/22/25 and 05/24/25. Physician #502 stated he suggested Resident #3 go to the hospital, however the resident refused to go to the hospital. Interview on 09/11/25 at 9:38 A.M., the Director of Nursing (DON) verified there was no documentation acknowledging Resident #3 had missed dialysis until 05/27/25. The DON verified any missed dialysis treatments and physician notification should be documented. Interview on 09/15/25 at 3:15 P.M., Chief Operating Officer (COO) #210 verified Resident #3's medical record was silent for physician notification of missing dialysis treatments on 05/22/25 and 05/24/25. Review of the facility policy titled Change in Condition Monitoring dated 05/01/22 revealed the nurse will record in the resident's medical record information relative to changes in the residents' medical condition or status.

Based on record review, policy review, observations, and resident and staff interviews, the facility failed to ensure all residents were provided with a safe, clean and homelike environment. This affected two (#13 and #25) of two residents reviewed for homelike environment. The facility census was 66.Findings included: 1. Observation on 09/08/25 at 8:47 A.M. revealed Resident #25's bathroom smelled of urine. There was a yellow substance surrounding the base of the toilet, and an area measuring approximately eight inches (in) by 8 in of a similarly appearing yellow substance. There were several brown marks throughout the floor of the bathroom. Interview on 09/08/25 at 8:47 A.M., Resident #25 stated his bathroom floor was dirty, and the bathroom smelled like urine. Resident #25 stated his bathroom did not get cleaned very often. Interview on 09/08/25 at 9:00 A.M., Certified Nursing Assistant (CNA) #129 verified Resident #25's bathroom had yellow stains around the base of the toilet, brown marks throughout the floor, and a strong urine odor. CNA #129 stated there hadn't been a housekeeper assigned to the 100 hall in over a month. 2. Review of the medical record of Resident #13 revealed an admission dated of 12/14/11. Diagnoses included cerebrovascular disease and obsessive-compulsive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact and dependent on staff with ambulating. Observation on 09/08/25 at 8:54 A.M. revealed the floor tile, in Resident #13's room, had multiple pieces of tile missing. The floor tile with missing pieces was in front of Resident #13's table and was located in middle of the floor. Interview on 09/08/25 at 10:22 A.M. with Licensed Practical Nurse (LPN) #114 confirmed Resident #13's room had one floor tile in his room that has multiple pieces of tile missing. LPN #114 confirmed the floor tile was located in the walkway to the door. LPN #114 confirmed Resident #13 has two other floor tiles in his room that has one small piece missing. LPN #114 stated Resident #13 utilized a walker at times to ambulate. Review of the facilities Homelike Environment policy dated 10/27/21 revealed residents are provided with a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Complaint Number 2605044, Complaint Number 1260835, Complaint Number OH00164419 (1260832), Complaint Number OH00164929 (1260832), and Complaint Number OH00166722 (1260778).

Based on record review, staff interview, review of Self-Reported Incidents (SRI), and facility policy review, the facility failed to ensure all alleged violations of staff-to-resident physical abuse were reported timely to administration and the State Survey Agency. This affected one (#40) of five residents reviewed abuse. The facility census was 66.Findings include: Review of the medical record for Resident #40 revealed an admission date of 06/09/25. Diagnoses included cerebral infarction with left-sided hemiplegia, chronic obstructive pulmonary disease, hypertension, anxiety, and chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had moderately impaired cognition. Review of the progress notes dated 07/01/25 at 6:05 A.M. revealed Licensed Practical Nurse (LPN) #160 entered Resident #40's room and heard Resident #40 yelling profanities and get off of me directed at an unknown certified nurse aide (CNA). The progress note revealed the unknown CNA was providing personal care for Resident #40. LPN #160 documented Resident #40 hit the unknown CNA twice. LPN #160 asked Resident #40 what happened, but Resident #40 would not provide an answer. According to the progress notes, approximately 20 minutes after the incident, Resident #40 apologized for her actions stating she was in her sleep. Review of the facility's SRI dated 07/01/25 to 09/10/25 revealed there were no allegations of physical abuse involving Resident #40 reported to the State Survey Agency. Interview with the Administrator on 09/09/25 at 8:49 A.M. confirmed she was not aware of the allegation of physical abuse by Resident #40 and did not report this to the State Survey Agency. Interview on 09/11/25 at 8:00 AM with LPN #160 revealed she could not remember who the CNA was during the incident that occurred on 07/01/25 but recalls that she asked the CNA to leave Resident #40's room. LPN #160 confirmed she did not report the incident on 07/01/25 to a member of administration. Review of the facility policy titled Abuse Prevention dated 08/20/21 revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Staff should report all incident/allegations immediately to the administrator or designee. This deficiency represents non-compliance investigated under Complaint Number 2574888.

Based on medical record review and staff interview, the facility failed to ensure admission comprehensive Minimum Data Set (MDS) assessments were completed within the required timeframes. This affected three (#3, #25, and #39) of three residents reviewed for resident assessment. The facility census was 66.Findings include: 1. Review of the medical record of Resident #39 revealed an admission date of 07/14/25. Diagnoses included major depressive disorder, anxiety disorder, suicidal ideations, hypertension, and morbid obesity. Review of the admission comprehensive MDS assessment dated [DATE] revealed the resident had a severe cognitive impairment. The assessment was not locked as completed until 08/18/25. Interview on 09/09/25 at 4:26 P.M., MDS Nurse #172 verified Resident #39's admission comprehensive MDS assessment was not locked as completed until 08/18/25. MDS Nurse #172 verified Resident #39's admission comprehensive MDS assessment should have been completed within 14 days of admission by 07/27/25. 2. Review of the medical record of Resident #25 revealed an admission date of 06/19/25. Diagnoses included dementia, anxiety, and depression. Review of the admission comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The assessment was not locked as completed until 07/08/25. Interview on 09/09/25 at 4:26 P.M., MDS Nurse #172 verified Resident #25's admission comprehensive MDS assessment was not locked as completed until 07/08/25. MDS Nurse #172 verified Resident #25's admission comprehensive MDS assessment should have been completed by 07/02/25. 3. Review of the medical record of Resident #3 revealed an admission date of 05/21/25. Diagnoses included cellulitis, depression, viral hepatitis C, end-stage renal disease with dependence on renal dialysis, anxiety, gastroesophageal reflux disease, and heart failure. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident #3's admission comprehensive MDS assessment dated [DATE] revealed the assessment was not completed until 06/16/25. Interview on 09/09/25 at 4:26 P.M., MDS Nurse #172 verified Resident #3's admission comprehensive MDS assessment was not completed within 14 days of Resident #3's admission. MDS LPN #172 verified Resident #3's admission comprehensive MDS assessment should have been completed by 06/15/25.

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident care plans were complete and specific to each resident. This affected two (#3 and #55) of six residents reviewed for care planning. The facility census was 66. Findings included: 1. Review of the medical record of Resident #3 revealed an admission date of 05/21/25. Diagnoses included cellulitis, depression, type II diabetes mellitus, history of nontraumatic intracerebral hemorrhage, end-stage renal disease with dependence on renal dialysis, anxiety, gastroesophageal reflux disease, and heart failure. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the plan of care dated 05/29/25 revealed there was no care plan to address Resident #3's ability to carry out his activities of daily living (ADLs). There was no dental care plan to address Resident #3's edentulism. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. Resident #3 was independent or required supervision for all ADLs. Resident #3 required supervision and touching assistance with walking up to 50 feet. Interview on 09/09/25 at 4:26 P.M., MDS Nurse #178 verified Resident #3's care plan was incomplete. MDS Nurse #178 verified Resident #3's care plan did not address ADLS or Resident #3's edentulism. 2. Review of the medical record for Resident #55 revealed an admission date of 06/13/24. Diagnoses included traumatic subdural hemorrhage without loss of consciousness and major depressive disorder. Review of the physician orders revealed an order dated 11/12/24 for Mirtazapine (psychotropic) oral tablet 7.5 milligrams (mg) give one tablet by mouth at bedtime related to major depressive disorder; an order dated 11/19/25 for Celexa (psychotropic) oral tablet 10 mg give one tablet by mouth at bedtime related to major depressive disorder; and an order dated 12/15/24 for Eliquis (anticoagulant) oral tablet five mg give one tablet by mouth two times a day related to acute embolism and thrombosis of deep vein of left lower extremity. Review of Resident #55's care plans revealed there were not a care plans for the medication use of anticoagulants or psychotropic medications. Interview on 09/15/25 at 8:43 A.M. with Minimum Data Set (MDS) Nurse #172 confirmed Resident #55 did not have a care plan for anticoagulants or psychotropic medications. Review of the facility policy titled Resident Care Plans dated 05/01/22 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on medical record review, staff interview, and policy review, the facility failed to ensure care plans were updated timely to reflect new diagnoses, new sexual behaviors, and medications to treat the new diagnoses and behaviors. This affected two (#45 and #57) of six residents reviewed for care planning. The facility census was 66. Findings include: 1. Record review for Resident #57 revealed an admissions date of 04/18/22 with diagnoses including cerebral infraction, dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired. Review of the medical laboratory records dated 08/19/25 revealed Resident #57 was positive for Herpes Simplex 1. Review of the physician's orders dated 08/24/25 revealed Resident #57 had a new order of Valtrex (treats Herpes) 500 milligrams (mg). Review of Resident #57's care plan on 09/10/25 revealed that the new diagnoses and medication was not included in the care plan. Interview on 09/10/25 at 3:40 P.M. with Director of Nursing verified Resident #57's care plan was not updated timely and it should include the new diagnosis of Herpes Simplex 1 and the new medication to treat it. 2. Record review for Resident #45 revealed an admissions date of 01/28/25 with diagnoses including alcohol dependence with alcohol induced persisting dementia. Review of the nursing progress notes revealed Resident #45 had increased sexual behaviors on 08/31/25 and 09/07/25. Review of the physician orders revealed Resident #45 was ordered medroxyprogesterone acetate five milligrams (mg) on 09/02/25 for increased sexual behaviors. Review of Resident #45's care plan revealed the care plan was not updated timely and it did not include Resident #45's sexual behaviors and the new medication to treat the behavior. Interview on 09/10/25 at 3:40 P.M. with Director of Nursing verified Resident #45's care plan was not timely updated and it should have been to include new behaviors and medications used to treat behaviors. Review of the facility policy titled Resident Care Plans dated 05/01/22 revealed assessments are ongoing and care plans are revised as information about the resident and residents' conditions change.

Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents who required assistance with activities of daily living received adequate assistance with nail care. This affected one (#22) of two residents reviewed for ADLs. The facility census was 66. Findings include: Review of the medical record for Resident #22 revealed an admission date of 01/25/24. Diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, major depressive disorder, dementia, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. The resident was independent with personal hygiene, required setup/cleanup assistance with dressing, and required supervision or touching assistance with bathing. Review of the plan of care dated 08/06/24 revealed Resident #22 was independent/supervision for ADLs except for bathing. Interventions included to monitor for any decline and report immediately, and to setup supplies for the resident as needed. Review of task documentation dated 08/12/25 through 09/10/25 revealed Resident #22 required setup, supervision or limited assistance of one person with personal hygiene tasks and supervision and setup for bathing. Review of shower sheets dated 07/02/25 through 09/10/25 revealed Resident #22's nails were last cleaned and clipped on 08/16/25. Observation and interview on 09/08/25 at 9:51 A.M. revealed Resident #22 had several fingernails which were long, extending approximately one inch or more beyond the finger tip. Resident #22's fingernails had chipped fingernail polish and were curling and jagged around the edges. Resident #22 stated, despite her requests, staff had not assisted her with cutting her fingernails in a long time. Resident #22 stated she had carpal tunnel syndrome and was unable to cut her fingernails on her own. Resident #22 stated her fingernails were splitting and getting caught on clothing and bedding and stated she wished staff would help her cut them. Interview on 09/08/25 at 10:00 A.M., Admissions #162 verified Resident #22's fingernails were long, jagged, and curling around the edges and the resident was in need of nail care. Review of the facility policy titled Resident ADL Care, dated 07/01/23, revealed when autonomy and independence are no longer possible or feasible, facility staff will provide the necessary support in all ADL functioning. Resident nails are expected to be trimmed and kept neat to prevent skin tears, scratches, or injuries. Nail care will be provided as needed to the resident. This deficiency represents non-compliance investigated under Complaint Number 2605044, Complaint Number 2574888, Complaint Number OH00166722 (1260778), Complaint Number OH00165869 (126837), Complaint Number OH00164929 (1260835), Complaint Number OH00164419 (1260832), and Complaint Number OH00163480 (1260830).

Based on record review, observation, resident and staff interviews, review of U.S. Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure residents vaped in the facility's designated smoking area. This affected one (Resident #11) of two residents reviewed for supervision. The facility census was 66.Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/29/24 with diagnoses including centrilobular emphysema and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had moderate cognitive impairment, rejected care at times and was independent with ambulation. Review of the Smoking assessment dated [DATE] revealed Resident #11 required supervision while smoking. There was no documentation that Resident #11 was non-compliant with the facility's smoking policy. Observation and interview on 09/08/25 at 10:15 A.M. revealed Resident #11 with a cloud of smoke above her knees and a vape machine in her left hand while lying in the bed. Resident #11 reported it was nothing. Licensed Practical Nurse (LPN) #114 confirmed at time of observation that Resident #11 had the vape in her room and was not allowed to have a vape in her room. The Director of Nursing (DON) went to the resident's room and spoke with the resident and removed the vape. Interview on 09/08/25 at 10:21 A.M. with Certified Nursing Assistant (CNA) #116 stated Resident #11 was always vaping in her room. Review of the facilities smoking policy dated 08/01/23 revealed the facility shall establish and maintain safe resident smoking practices, allowing residents who wish to the ability to smoke, while also doing in safe manner. Designated smoking area signs shall be prominently displayed where smoking is allowed. Smoking restrictions shall be strictly enforced in all nonsmoking areas. The facility may check periodically to determine if residents have any smoking articles in violation of their smoking policies. Review of the FDA's guidance titled E-Cigarettes, Vapes, and other Electronic Nicotine Delivery Systems (ENDS) dated 07/17/25 and found at https://www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends#Are%20You%20Looking%20for%20General%20Health%20Information%20about%20ENDS%20Products? revealed there are no safe tobacco products, including ENDS. FDA has received reports from the public about safety problems associated with vaping products including overheating, fires, and explosions. These problems can seriously hurt the person using the ENDS product and others around them.

Based on observation, staff interviews, and policy review the facility failed to ensure the medication error rate did not exceed five percent (%). There were two observed errors out of 34 opportunities that resulted in a medication error rate of 5.88%. This affected one (Resident #42) out of four residents reviewed for medication administration. The facility census was 66. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/20/21. Review of the physician orders revealed an order dated 01/09/24 for Calcium plus Vitamin D3 Oral Tablet 500-5 milligrams (mg)- microgram (mcg) give one tablet by mouth one time a day for supplement. There was an order dated 07/17/25 for Duloxetine HCl oral capsule delayed release sprinkle 30 mg give one capsule by mouth one time a day for schizophrenia. Observations on 09/10/25 from 8:00 A.M. through 8:30 A.M. with Licensed Practical Nurse (LPN) #151 revealed LPN #155 administered 33 medications to three residents. Resident #42 was administered the following medications in error, Calcium + Vitamin D3 Oral Tablet 600-10 mg-mcg one tablet by mouth and Duloxetine HCl Oral Capsule Delayed Release Sprinkle 20 mg one capsule by mouth. Interview on 09/10/25 at 11:17 A.M. with LPN #151 confirmed she administered the wrong doses of medications to Resident #42. LPN #151 confirmed she Calcium + Vitamin D3 Oral Tablet 600-10 mg-mcg one tablet by mouth and confirmed the physician order was for Calcium + Vitamin D3 Oral Tablet 500-5 mg-mcg give one tablet by mouth. LPN #151 confirmed she administered Duloxetine HCl oral capsule delayed release sprinkle 20 mg one capsule by mouth to Resident #42 and confirmed the physician order was for Duloxetine HCl oral capsule delayed release sprinkle 30 mg give one capsule by mouth. LPN #151 stated she administered the wrong dose because that was what was available in the medication cart and she did not know what to do to get the correct dosage. Review of the medication administration policy dated 05/01/22 revealed medications will be administered as prescribed with the correct dosage. This deficiency represents non-compliance investigated under Complaint Number OH00164691 (1260834).

Based on observation, staff interview, record review, the facility failed to ensure food items were stored in a sanitary manner. This had the potential to affect 59 of 59 residents who receive their meals from the kitchen, the facility identified two residents (#25 and #31) that received no food by mouth. The facility census was 61. Findings include: Observation of the kitchen on 07/03/24 at 7:45 A.M. revealed the reach in refrigerator in the kitchen was 60 degrees Fahrenheit. A package of ham, a package of hamburgers and a package of hotdog's were located in the refrigerator. There was also a gray fuzzy substance on the line that went from the ceiling to the steam table and there was a gray fuzzy on the ceiling vent located directly above the onions in the dry storage room. There were also three flies sitting on the line that went from the ceiling to the steam table in the kitchen. Interview with Dietary Supervisor (DS) #110 on 07/03/24 at 7:45 A.M. verified the reach in refrigerator was 60 degrees Fahrenheit and there was a package of ham, a package of hamburgers and a package of hotdog's located in the refrigerator. DS #110 stated the refrigerator had been broken approximately one week. DS #110 also verified there was a gray fuzzy substance on the line that went from the ceiling to the steam table and there was a gray fuzzy on the ceiling vent located directly above the onions in the dry storage room. DS #110 confirmed there were three flies sitting on the line that went from the ceiling to the steam table in the kitchen. Review of the facility's preventing foodborne illness policy dated 05/01/22 revealed food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The policy stated federal standards require that refrigerated food be stored below 41 degrees Fahrenheit. This deficiency represents non-compliance investigated under Complaint Number OH00155177.

Based on observation, staff interview, review of the facility menu and spreadsheet and policy review, the facility failed to ensure menus were followed. This had the potential to affect 59 of 59 residents who receive their meals from the kitchen, the facility identified two residents (#25 and #31) that received no food by mouth. The facility census was 61. Findings include: Review of the menu dated 07/03/24 revealed oatmeal or cold cereal, cheesy scrambled eggs, a sausage patty, assorted toast, whole milk or two percent milk and coffee or tea were to be served for breakfast. Review of the undated menu spreadsheet revealed regular diets were to receive six ounces of oatmeal, two ounces of cheesy scrambled eggs, and one slice of toast for breakfast, mechanical soft diets were to receive six ounces of oatmeal, two ounces of cheesy scrambled eggs, and one slice of toast for breakfast and pureed diets were to receive six ounces of pureed oatmeal, two ounces of pureed cheesy scrambled eggs, and two ounces of pureed toast for breakfast. Observation of the kitchen on 07/03/24 at 7:38 A.M. revealed [NAME] #65 took the temperature of the food on the tray line. The oatmeal was 160 degrees Fahrenheit, the ham was 145 degrees Fahrenheit, the mechanical ham was 180 degrees Fahrenheit, the pureed sausage was 160 degrees Fahrenheit, and the scrambled eggs were 140 degrees Fahrenheit. [NAME] #65 was observed to serve regular diets six ounces of oatmeal, one slice of ham and one slice of toast, mechanical soft diets six ounces of oatmeal, two ounces of mechanical ham and one slice of toast and pureed diets six ounces of oatmeal, four ounces of pureed scrambled eggs and four ounces of pureed sausage. Interview with [NAME] #65 on 07/03/24 at 7:38 A.M. verified regular diets were served six ounces of oatmeal, one slice of ham and one slice of toast, and mechanical soft diets were served six ounces of oatmeal, two ounces of mechanical ham and one slice of toast. [NAME] #65 verified regular and mechanical soft diets did not receive cheesy scrambled eggs per the menu spreadsheet and the facility did not provide regular or mechanical soft diets a substitution for the cheesy scrambled eggs. [NAME] #65 also verified pureed diets received six ounces of oatmeal, four ounces of pureed scrambled eggs and four ounces of pureed sausage and pureed diets did not receive pureed bread per the menu spreadsheet. [NAME] #65 stated that ham was provided to residents that received regular and mechanical soft diets as a substitution for sausage because the facility was out of sausage. Review of the nutritional services policy dated 05/01/22 revealed food portion sizes will be reviewed by the dietician on an as needed basis to ensure nutritional needs are met. This deficiency represents non-compliance investigated under Complaint Number OH00155177.

Based on medical record review, observations, staff and resident interviews and policy review, the facility failed to ensure medications were stored securely. This affected five (#18, #29, #32, #55 and #56) out of five residents reviewed for medication storage. This had the potential to affect four (#29, #48, #10 and #57) residents that the facility identified as cognitively impaired and independently mobile. The facility census was 61. Findings include: 1. Medical record review for Resident #18 revealed an admission on [DATE] with diagnoses including but not limited to schizophrenia, left female breast cancer, anxiety disorder, impaired cognition and bipolar disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed an intact cognition. Resident #18 was independent for eating and supervised toileting, bed mobility, and transfers. Resident #18 was incontinent of bowel and bladder. Resident #18 was receiving hospice services. Review of the plan of care for Resident #18 revealed resident remains at risk for skin breakdown due to medical conditions. Previously closed area on coccyx has reopened and nurse practitioner will follow and as needed. Interventions include body audits as scheduled, monitor labs, monitor pain symptoms, reposition every two hours, and wound nurse weekly. Review of the active physician orders for [DATE] for Resident #18 revealed an order dated [DATE] for a low air loss mattress to bed, an order dated [DATE] to cleanse coccyx with normal saline. Pat dry. Apply triad cream three times a week and as needed. Hospice to perform two times a week and facility staff to perform one time a week and as needed. Hospice to perform care on Monday and Wednesday. Review of the discontinued physician orders for Resident #18 revealed an order dated [DATE] and discontinued on [DATE] for cleanse open area to coccyx with normal saline, pat day, pack with calcium alginate and cover with silicone sterile adhesive dressing. Observation on [DATE] at 4:13 P.M. of Resident #18 bedside stand revealed one spray bottle of Integrity wound cleaner with a warning on the label if swallowed seek medical attention, a second wound cleanser bottle, a box of comfort foam dressings, an open package of calcium alginate wound dressing and a hydrophilic wound dressing unsupervised. Interview on [DATE] at 4:19 P.M. with Assistant Director of Nursing (ADON) #69 verified the observation and stated the wound cleansing products should not be in the room. 2. Medical record review for Resident #29 revealed an admission on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following a stroke, peripheral vascular disease, dementia, convulsions, major depression disorder, hypothyroidism, vascular dementia, and hypertension. Review of the quarterly MDS assessment dated [DATE] for Resident #29 revealed was unable to complete the brief interview for mental status with staff interview revealing modified independence. Resident #29 was coded as independent with eating. Resident #29 required maximum assistance for toileting, bed mobility and transfers. Review of the active physician orders for Resident #29 revealed an order dated [DATE] for Norco oral tablet ,d+[DATE] mg one tablet every 12 hours for pain related to headache and an order dated [DATE] for Senna 8.8 mg two tablets every 12 hours for constipation. Observation on [DATE] at 8:42 A.M. of Resident #29 revealed a bottle of nystatin powder on bedside in resident's room. Further observation of the pharmacy label revealed it was ordered for Resident #30. Interview on [DATE] at the time of observation with LPN #36 verified that the bottle of nystatin powder was for Resident #30 and should not be in the room. 3. Medical record review for Resident #32 revealed an admitted d on [DATE] with diagnoses including but not limited to encephalopathy, epilepsy atherosclerotic heart disease of native coronary artery, hemiplegia and hemiparesis following a stroke affecting the left non dominant side, major depressive disorder, retention, hypertension and pain. Review of the Admission MDS assessment dated [DATE] revealed resident #32 had intact cognition. Resident #32 was coded as independent with eating, maximal assistance with toileting, supervision for bed mobility and moderate assistance with transfers. Observation on [DATE] at 9:06 A.M. revealed LPN #36 prepared the oral medication for Resident #32. Medication including Baclofen 20 mg one tablet, Eliquis tab 5 mg one tablet, Aspirin 81 chewable one tablet, Atenolol 25 mg one tablet, Famotidine 20 mg one tablet, Folic acid 1 mg one tablet, Gabapentin 300 mg one tablet, Levetiracetam 1000 mg one tablet, Omeprazole 40 mg tab one tablet and Vitamin B12 100 mg one tablet. LPN #36 carried the medication into the room and set it on the bedside table in front of Resident #32. LPN #36 then left the room to ensure there was not any blood pressure parameters related to scheduled medication. Additional observation on [DATE] at 9:16 A.M. of Resident #32's bedside table revealed two large tubes of Voltaren topical ointment. Further observation revealed one tube did not have a label and the other tube had a label from the hospital prior to admission. Interview on [DATE] at 9:16 A.M. with Resident #32 stated the hospital gave one tube to him and he brought it with him when he transferred and has been on that table since arrival. Interview on [DATE] at 9:25 A.M. with LPN #36 verified she left the prepared medication in the residents 'room unsupervised and should not have. LPN #36 verified that Resident #32 did not have orders for the Voltaren topical ointment and stated it should not have been in his room. 4. Medical record review for Resident #55 revealed an admission on [DATE] with diagnoses including but not limited to heart disease, ventricular tachycardia, extended spectrum Beta Lactamase resistance, chronic kidney disease stage three, hypertension, chest pain, chronic embolism and thrombosis, spinal stenosis. Review of the quarterly MDS assessment dated [DATE] for Resident #55 revealed an intact cognition. Resident #55 is independent for eating and bed mobility. Resident #55 requires supervision for transfers and toileting. Observation on [DATE] at 9:40 A.M. of Resident #55 bedside table revealed two bottles of Nasal spray oxymetazoline hydrochloride 0.05% with expired dates of ,d+[DATE] and ,d+[DATE]. Interview on [DATE] at 9:48 A.M. with LPN #55 verified Resident #55 did not have orders for the medications and stated they should not be in his room unsupervised. 5. Medical record review for Resident #56 revealed an admission on [DATE] with diagnoses including but not limited to heart disease, chronic kidney disease, hypertension and major depressive disorder. Review of the comprehensive MDS assessment dated [DATE] for Resident #56 revealed an intact cognition. Resident #56 was coded as independent for eating, bed mobility, transfers. Resident #56 required moderate assistance with toileting. Observation on [DATE] at 10:00 A.M. from the hallway into Resident #56's room revealed a bookshelf with three bottles on it. Further observation with LPN #55 revealed one opened bottle of hydrogen peroxide, a nasal spray bottle (oxymetazoline hydrochloride 0.05%) and an opened bottle of acetone fingernail polish removed. The bottles of hydrogen peroxide and the acetone both had warning labels to contact medical services if ingested. Interview on [DATE] at the time of the observation with LPN #55 verified the items noted should not be in the residents' room and removed them. 6. Observation on [DATE] at 10:35 A.M. of the four-drawer treatment cart located on the 300 hundred hall was unlocked and unsupervised. Observation on [DATE] at 10:35 A.M. with LPN #55 and the Administrator verified the cart contained treatment supplies, topical creams and ointments and bottles of hydrogen peroxide and dyna hex with label to contact poison control if ingested. Interview on [DATE] at 10:35 A.M. with LPN #55 and the Administrator verified the treatment cart contained medical supplies with warning labels to contact the poison control center if ingested and should have not been unlocked and unsupervised. The facility confirmed there were four (#29, #48, #10 and #57) residents that are cognitive impaired and independently mobile that could access unsecured medications. Review of the facility policy titled Medication Storage dated [DATE] states the facility shall store all drugs and biological's in a safe, secure and orderly manner. Number 7 states compartments including but not limited to drawers, cabinets, room, carts containing drugs ad biological shall be locked when not in use and shall not be left unattended. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review and staff interviews, the facility failed to ensure a resident's admission assessments were timely completed in the electronic health record. This affected one (#300) out of three residents reviewed for medical record accuracy and completeness. The facility census was 61. Findings include: Medical record review for Resident #300's chart revealed resident admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, emphysema, congestive heart failure, chronic kidney disease and hypertension. Resident #300 discharged from the facility on 05/23/24 at approximately 9:49 A.M. Review of Resident #300's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #300 was independent with eating. Resident #300 required maximal assistance with toileting, showering, lower body dressing, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, tub transfers, and walking ten feet. Resident #300 required moderate assistance with upper body dressing, personal hygiene, rolling left and right. Resident #300 was coded as always incontinent of bladder and occasionally incontinent of bowel. Resident #300 had two stage two pressure ulcers that were present on admission. Review of the plan of care for Resident #300 revealed the document was not completed. Review of the Nursing Admission Assessment with Care Plan for Resident #300 revealed the assessment was opened in the electronic health record on 05/16/24 but wasn't marked as completed until 05/23/24 at 11:59 A.M. which was after the resident was discharged . The assessment was completed by the Administrator/Licensed Practical Nurse (LPN) #100. Further review of the assessment revealed the two pressure ulcers were not documented on the skin assessment only bruising on both right and left hands. Review of the Bowel and Bladder Assessment for Resident #300 revealed the assessment was opened on 05/17/24 and completed on 05/23/24 at 10:55 A.M. after the resident was discharged by Registered Nurse (RN) #804. Review of the Braden scale for Resident #300 revealed the assessment was opened on 05/17/24 at 10:56 A.M. and completed on 05/23/24 at 10:57 A.M. after the resident was discharged by RN #804. Review of the dental oral evaluation for Resident #300 revealed the assessment was opened on 05/17/24 at 10:58 P.M. and completed on 05/23/24 at 10:59 A.M. after the resident was discharged by RN #804. Review of the pain tool for Resident #300 revealed the assessment was opened on 05/17/24 at 11:02 A.M. and closed on 05/23/24 at 11:09 A.M. after the resident was discharged by RN #804. Review of the weekly Head to Toe assessment for Resident #300 revealed the assessment was opened on 05/16/24 at 12:00 P.M. and completed on 05/23/24 at 11:25 A.M. after the resident was discharged . Review of the falls assessment for Resident #300 revealed the assessment was opened on 05/17/24 and completed on 05/23/24 by RN #804. Interview on 07/10/24 at 12:59 P.M. with RN #804 verified she was the Director of Nursing (DON) for a sister facility and helping at this facility due to having an Intern DON at the facility. RN #804 verified the assessments were not documented as completed until after Resident #300 had left the facility. Interview on 07/10/24 at 3:05 P.M. with the Corporate RN #800 stated the facility did not have a policy regarding the documentation or completion of the admission assessments. Interview on 07/11/24 at 11:37 P.M. with the Administrator verified the admission assessments were completed/locked after Resident #300 was discharge and further verified that it was the expectation of the facility to have the admission assessments (bowel and bladder assessment, Braden assessment, fall assessment, pain assessment, dental assessment and elopement assessment) completed on the day of admission. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and review of facility policy, the facility failed to respond to an acute change in condition, including an elevated temperature for Resident #49 in a timely manner. Actual harm occurred on 01/27/23 when Resident #49, who was in a persistent vegetative state and dependent on staff for all activity of daily living care, was transferred to hospital and admitted for treatment of pneumonia requiring intravenous (IV) antibiotics. The resident had been initially assessed to have an elevated temperature on 01/25/23 of 101.3 with no evidence of physician notification, comprehensive assessment or treatment. The resident was hospitalized until 02/02/23. The facility's census was 51. Findings include: Review of Resident #49's medical record revealed the resident was readmitted to the facility on [DATE]. Diagnoses included, diffuse traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state. Review of Resident #49's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition related to his persistent vegetive state. Further review revealed Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs). Review of Resident #49's progress note dated 01/14/23 revealed the resident was discharged to the hospital from the nursing facility related to a fever. On 01/14/23 the progress notes confirmed Resident #49 was admitted to the hospital with the diagnosis of systemic inflammatory response syndrome (SIMS). Resident #49 returned to the facility on [DATE]. Review of Resident #49's vital signs history revealed on 01/25/23 at 5:38 P.M., Resident #49's body temperature was elevated at 101.3 degrees Fahrenheit (F). On 01/26/23 at 2:37 P.M., Resident #49's body temperature was elevated at 101.9 F. On 01/27/23 at 7:45 A.M., Resident #49's body temperature was elevated at 101.3 F. On 01/27/23 at 9:54 A.M. Resident #49's body temperature was elevated at 99.8 F. On 01/27/23 at 2:45 P.M., Resident #49's body temperature was elevated at 104.0 degrees F. (Normal body temperature 97 to 99 degrees F) Further review of the nursing progress notes from 01/25/23 to 01/27/23 revealed no documentation the physician was notified of elevated temperatures on 01/25/23 or 01/26/23. The physician was not notified until 01/27/23 when abnormal labs were received. Further review of Resident #49's progress notes revealed on 01/27/23 at 2:45 P.M. the facility obtained an order for 325 milligrams (mg) of Acetaminophen, give two tablets via percutaneous endoscopic gastrostomy (PEG) tube every six hours as needed for temperature. At 3:18 P.M., the physician was notified of lab work indicating Resident #49 had an elevated white blood cell (WBC) count and Resident #49 also had a temperature of 104 degrees. On 01/27/23 at 11:11 P.M. the hospital was contacted and notified the facility Resident #49 was admitted to the hospital with a diagnosis of pneumonia. Review of the Medication Administration Record (MAR) for Resident #49 revealed on 01/27/23 at 2:45 P.M. the resident was administered Acetaminophen via PEG tube for a body temperature of 104. Review of the hospital documentation revealed Resident #49 was admitted to the hospital on 01/27/23 with health-care associated pneumonia. Resident #49 required intravenous (IV) antibiotics. Review of Resident #49's progress notes revealed the resident returned to the facility from the hospital on 02/02/23. Interview on 02/07/23 at 3:03 P.M. with the Director of Nursing (DON) confirmed Resident #49 experienced a change of condition of an elevated temperature on 01/25/23 and 01/26/23. The DON verified the facility failed to notify the physician of this change of condition and fever on 01/25/23 and 01/26/23. The physician was not notified until later in the day on 01/27/23 after Resident #49's temperature reached 104.0. The DON further verified Resident #49 required hospitalization . Review of the facility policy titled, Change in Condition, dated 05/30/22 revealed the Charge Nurse will notify the resident's Attending Physician or On-Call Physician where there has been a significant change in the resident's physical/mental/or emotional condition.

Based on medical record review, interviews with the resident, facility staff, pharmacy staff and physician office staff, and review of information from Medscape, the facility failed to ensure a resident's pain was adequately managed. This resulted in Actual Harm when the facility failed to administer an as needed (prn) pain medication and/or adequately manage Resident #315's pain resulting in the resident reporting unrelieved severe pain. This affected one (#315) out of three residents reviewed for pain management. The facility identified 38 residents on pain management programs. The facility census was 65. Findings include: Review of Resident #315's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An initial Minimum Data Set (MDS) assessment was not yet available but review of the Initial Care Plan revealed Resident #315 was alert, oriented, without cognitive deficit and required minimal assist of one staff for activities of daily living. Review of Resident #315's physician orders [REDACTED].#3, 300/30 milligrams (mg), one orally every four hours as needed for moderate pain. Interview on 10/15/18 at 10:48 A.M. with Resident #315 revealed he suffered generalized arthritis and [MEDICAL CONDITION] pain of all extremities that never got below a pain level of three. He stated the pain gets to a level of eight or nine on a severity of zero to 10 scale with 10 being the worse pain ever experienced. He stated the facility nurse had his family retrieve his pain medication from home on admission since they did not have it from the pharmacy. Resident #315 reported his medication is Tylenol #3, one tablet every four hours as needed. Interview on 10/16/18 at 11:10 A.M. with Resident #315 revealed his day was horrible. He stated he had asked for a pain pill on awakening at approximately 6:00 A.M. and was told the medication had not been delivered from the pharmacy and he had taken the last one at the prior bedtime. Interview on 10/16/18 at 11:16 A.M. with Licensed Practical Nurse (LPN) #14 revealed Resident #315 had an order for [REDACTED].#315 received his last pain medication on 10/15/18 at 9:00 P.M. and she would like to take the medication from the in-facility emergency stock but could not since she could not fax the pharmacy for permission. LPN #14 reported the fax machine was inoperable due to current electricity outage. Observation of Resident # 315 on 10/16/18 at 11:58 A.M. revealed him in the therapy room sitting in a wheelchair, moving feet with poor effort and facial grimacing present. A telephone interview on 10/16/18 at 12:25 P.M. with pharmacy staff #90 revealed no request had been made for Resident #315's Tylenol #3 and his profile did not contain an order for [REDACTED].#90 reported facility staff key in medication orders through a computer program and if the medication was a controlled substance then a second step was to fax the order to the pharmacy. Interview on 10/16/18 at 1:32 P.M. with Physical Therapy Assistant (PTA) #91 reported Resident #315 did his exercises that day and a couple of steps but did not walk as far due to pain. PTA #91 reported Resident #315 had complained he did not receive any pain medications that day. Interview with Resident #315 on 10/16/18 at 1:37 P.M. reported his had increased to a nine and he wasn't able to do as much therapy earlier due to pain. Resident #315 stated he hurt head to toe and his ankles had never hurt so bad. Interview on 10/16/18 at 1:47 P.M. with the Director of Nursing (DON) denied knowing of Resident #315 not receiving pain medication. The DON states the pharmacy is unpleasant to get new resident medications from, but the floor nurse should have called the pharmacy the day after admission to question why the medication had not been received on the next delivery. Interview on 10/16/18 at 4:02 P.M. with LPN #24 reported at shift change on 10/15/18 she received report that Resident #315's physician had sent prescriptions for pain and antianxiety medications to the pharmacy and to expect a delivery that night. LPN #24 reported she administered the last pain medication to Resident #315 at 9:00 P.M. on 10/15/18 and he requested pain medication at 6:20 A.M. on 10/16/18 with a reported pain level of eight. LPN #24 states she asked Resident #315 if he wanted anything else and then reported to the dayshift nurse at 7:00 A.M. that Resident #315 was already requesting pain medication. Interview on 10/16/18 at 5:20 P.M. with LPN #14 reported she had not received any return from the fax to pharmacy and has not spoken to physician. Interview on 10/16/18 at 5:44 P.M., the DON reported she had called the physician's office to obtain pain medications for Resident #315. A telephone interview on 10/16/18 at 6:04 P.M. with Resident #315's physicians office staff #92 reported the answering service has no record of facility calls regarding pain medication prescription needed for Resident #315. She stated a fax was received on 10/13/18 for insulin and a fax on 10/16/18 at 2:32 P.M. requesting a prescription for pain and antianxiety medications. Further review of the controlled substances record for Resident #315 revealed a last dose of Tylenol #3 was given on 10/15/18 at 9:00 P.M. Review of Resident #315's medical record revealed a progress note dated 10/16/18 at 6:21 A.M. indicated the resident reported he was experiencing pain level of eight and an entry at 6:22 A.M. indicated a pain level of two. Further review of Resident #315's progress note for 10/16/18 at 6:34 P.M. documented nonpharmacological interventions were ineffective for residents' pain at a level 10 for back, bilateral hip, and lower extremity pain. A subsequent note at 7:17 P.M. indicated Resident #315 finally received an [MEDICATION NAME]-[MEDICATION NAME] 300-30 mg tablet. Review of information from Medscape revealed Tylenol #3 is an opioid [MEDICATION NAME] that is indicated to treat pain. Further review revealed precise and systematic pain assessment is required to make the correct [DIAGNOSES REDACTED]. During a Pain Assessment the residents pain is assessed on a zero to 10 scale with zero being no pain and 10 being the most severe pain. It was also indicated that pain medications work best if used at first signs of pain, if delay the medication may not work as well.

Based on medical record review, review of the incident log, review of the facility's internal investigation, review of hospital documentation, staff, family, and physician interviews, review of personnel files, observation of the facility transport bus, and review of the manufacturer's guidelines for the facility's transport bus, the facility failed to ensure a resident received adequate supervision and assistive safety devices to prevent a fall during transport. This resulted in Immediate Jeopardy for one (#10) of six residents reviewed for the use of assistive devices during transport in the facility's bus. Resident #10 was not safely secured in the wheelchair with a seatbelt during transport and sustained serious harm and injuries resulting in multiple fractures to the left and right femur, left and right tibia and left and right fibula. The facility identified 19 residents who utilize the facility transportation service and remain in a wheelchair during transportation. The facility census was 82. On 06/14/17 at 3:04 P.M., the Administrator was informed that Immediate Jeopardy began on 06/08/17 at approximately 11:30 A.M. when Bus Driver #250 and Resident Care Associate (RCA) #150 failed to properly secure Resident #10 with a shoulder and lap safety belt during a facility bus transport. Resident #10's wheelchair was secured to the floor of the bus but the resident was not seat belted into the wheelchair. During transport, the bus ride became very bumpy, possibly striking a curb, causing Resident #10 to fall out of the wheelchair onto the floor of the bus. Resident #10 required Emergency Medical Services (EMS) and was transferred to the local hospital for evaluation and treatment and subsequently hospitalized with multiple fractures requiring orthopedic surgical intervention and intubation for stabilization. The Immediate Jeopardy was removed on 06/09/17 when the facility implemented the following corrective actions: · On 06/08/17 at approximately 11:30 A.M., Resident #10 was assessed by facility nursing staff and EMS was notified and transported the resident to the local hospital for evaluation and treatment. · On 06/08/17, Bus Driver #250 was immediately suspended pending further investigation by the Administrator. Bus Driver #250 did not perform any further transportation and resigned on 06/13/17. · On 06/08/17 and 06/09/17, the Administrator removed the facility bus from service. · On 06/08/17, the Administrator implemented a bus transport checklist to be completed by the bus driver for all resident transports to ensure resident safety. The resident transport checklist will be completed by the bus driver for all residents being transported by the facility bus with each transport. The resident transport checklist will be on-going and monitored monthly by the Director of Maintenance. · On 06/09/17, the Administrator developed a new policy for bus transportation to ensure residents are safely secured during transportation. · On 06/09/17, all bus drivers were provided education on the new bus transportation policy by the Administrator and the Director of Maintenance. All drivers were instructed that safety securement of the residents is the responsibility of the bus driver including that if a resident could not be appropriately and safely secured in the bus, the driver must remove the resident from the bus and return the resident to the facility, notifying the Administrator or Director of Nursing (DON) the transport could not be safely completed. Alternate transportation arrangements will then be made by the appointment scheduler. · On 06/09/17, the Director of Maintenance implemented a monthly bus inspection to ensure appropriate safety of the bus including working lights, brake function, emergency break function, seatbelt placement and proper function with no frays, wheelchair straps and buckles in place and functioning properly, and wheelchair shoulder straps and buckles in place and functioning properly with no frays. · On 06/09/17, the Administrator and Director of Maintenance completed a bus competency for all bus drivers with return demonstration of competency of lights, turn signals, proper positioning of wheelchair on the bus lift, open/close of the bus door, securing wheelchair in bus with turn buckles, securing resident with shoulder strap, position of mirrors, and backing up the bus and driving. The competency was completed on 06/09/17. · On 06/14/17 and 06/15/17 a review of five (#15, #20, #25, #30 and #35) additional medical records revealed there were no other incidents/accidents involving the facility bus. · On 06/15/17, the Administrator purchased a seatbelt extender for the facility bus. · On 06/15/17, a bus audit and assessment was implemented and completed by the Director of Maintenance for all 19 residents who are transported by the facility bus regarding wheelchair safety and to ensure the facility seatbelts appropriately and safely secure the resident during transportation. · On 06/15/17 between 2:29 P.M. and 2:40 P.M., interviews with staff assigned to drive the bus, which included Bus Driver #300, the Director of Maintenance and the Administrator, revealed they were knowledgeable regarding bus safety and ensuring residents were appropriately secured and seat belted in during transportation. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility has not fully implemented monitoring and auditing of the proper use of assistive safety devices. Findings include: Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10's Brief Interview for Mental Status (BIMS) was 15 which indicated the resident was cognitively intact. Further review of the MDS revealed the resident was totally dependent for transfers and required the physical assistance of two facility staff. The assessment of functional limitations in range of motion for the upper and lower extremities was documented as impairment on both sides. The MDS documented Resident #10 utilized a wheelchair. Resident #10 was independent with eating and required limited assistance of one staff member for personal hygiene. Review of Resident #10's comprehensive care plan dated 06/06/17 documented the resident utilized a battery-operated wheelchair. The care plan revealed therapy attempted evaluation of safety awareness and ability to operate the motorized wheelchair on many occasions, which Resident #10 refused. Review of the care plan revealed non-compliance with motorized wheelchair safety and operational abilities of the resident. Review of the nursing progress notes dated 06/08/17 at 11:25 A.M. documented the Director of Nursing (DON) was called outside of the facility to assist with Resident #10 who had fallen out of the wheelchair onto the bus floor. Resident #10 was documented as on the floor of the facility bus in the main aisle between the rows of seats. The DON immediately entered the bus and assessed Resident #10. Resident #10 had oxygen in place and was alert and talking with staff. Lacerations were noted to bilateral lower extremities. Resident #10's right leg was bent at the knee; left leg was out straight. Resident #10's color to her bilateral extremities was natural and warm to touch. An attempt was made by the DON to palpate pedal pulses but was unable to obtain due to thick non-skid socks. Resident #10's left leg was cleaned and a sterile pad was applied, wrapped with Kerlix and secured with tape. The DON attempted to dress Resident #10's right leg, applied two sterile pads and started to wrap with Kerlix when EMS arrived and took over care. Resident #10's airway was maintained/patent throughout. Resident #10 was alert and answering questions appropriately. Review of the incident/accident tracking log dated 06/08/17 revealed Resident #10 experienced a fall from a chair. Per the log, Resident #10 was sent to the emergency room . Review of the facility's incident/accident investigation dated 06/08/17 revealed two facility staff members, which included Bus Driver #250 and RCA #150, were on the transport bus at the time of the occurrence. Review of RCA #150's witness statement dated 06/08/17 revealed the safety belt located on the facility bus was not in place due to the fact the safety belt would not fit around Resident #10 and the resident's wheelchair. The witness statement revealed as the bus turned onto another street, Resident #10 yelled for help, and as RCA #150 was turning around to check on the resident, Resident #10 was observed falling towards RCA #150 and landing on the floor of the facility bus. Review of the witness statement provided by Bus Driver #250 dated 06/08/17, revealed Resident #10's wheelchair was buckled in with hooks and belt. There is no documentation of the shoulder strap or lap belt being applied for the resident. The witness statement revealed Resident #10 fell out of the wheelchair and onto the bus floor as the bus was turning the corner. Review of Hospital #1's documentation dated 06/08/17, revealed vital signs obtained by the hospital at 2:00 P.M. were blood pressure 77/44 millimeters of Mercury (mmHg), pulse 81 beats per minute, respirations 18 per minute and oxygen saturation 98 percent (%). A three-view x-ray of Resident #10's left knee and a two-view x-ray of bilateral femurs was obtained. Findings included comminuted mildly displaced fracture of the distal right femoral shaft, acute distal left femur fracture with overlap, angulation, and displacement of fracture fragments. There is left knee lipohemarthrosis from intra-articular extension of the femur fracture. Review of two-view x-ray results of the resident's bilateral tibia and fibula revealed acute fractures are present involving the right tibial plateau and fibular head. Compound fractures were present involving the distal shaft of the left tibia and fibula. On 06/09/17, Resident #10 was taken to the operating room at Hospital #1; however, the orthopedic team was concerned Resident #10 required a higher level of care to repair the right lower extremity injuries. On 06/09/17, Resident #10 was transferred to Hospital #2. Upon discharge from Hospital #1, Resident #10's discharge condition was documented as critical. Review of Hospital #2's History and Physical (H&P) revealed Resident #10 was in traumatic shock and acute hypoxic respiratory failure as the resident's orthopedic injuries were repaired on 06/09/17; however, Resident #10 became hypotensive during surgery and post-operatively. Resident #10 was started on Vasopressor, continued with intubation and was admitted to the Intensive Care Unit (ICU) at Hospital #2. Telephone interview on 06/14/17 at 8:47 A.M. with Resident #10's family member revealed the resident was recently involved in an incident while riding on the facility bus. Resident #10's family member stated the resident was returning to the facility from an appointment and fell out of the wheelchair while on the bus. Resident #10's family member stated the resident was admitted to the hospital intensive care unit related to the severity of the injuries sustained, and the resident continues to be in the hospital in critical condition. Interview on 06/14/17 at 9:27 A.M. with the Director of Maintenance revealed the cargo area located at the back of the facility bus was equipped with shoulder/lap safety belts for resident use. The Director of Maintenance reported the safety belts have always been on the bus for passenger use since purchase of the vehicle. During the interview and observation of the facility bus revealed a cargo area located at the back of the bus where residents/riders with wheelchairs can be secured. The area was equipped with shoulder/lap safety belts for use. The shoulder/lap safety belts were attached to the bus and in working condition. There was no observation of a seat belt extender at the time of the observation. Interview on 06/14/17 at 11:00 A.M. with the DON revealed she was called to the facility bus to assess Resident #10 on 06/08/17. The DON stated Resident #10 sustained lacerations to bilateral lower extremities after falling out of her wheelchair onto the bus floor during transportation. There were no obvious signs of broken bones at that time. The DON stated Resident #10 was resting on the bus floor on her right side in a natural position upon her arrival. The DON stated EMS was immediately called to the scene. The DON was not aware the shoulder/lap safety belt did not fit around Resident #10 and the wheelchair prior to the 06/08/17 incident. Interview on 06/14/17 at 11:33 A.M. with RCA #150 verified the shoulder/lap safety belt system located on the bus was not placed around Resident #10. RCA #150 revealed Resident #10's wheelchair was strapped to the bus but the safety belt would not fit around the resident and the resident's wheelchair. Neither RCA #150 nor Bus Driver #250 attempted to secure Resident #10 to the wheelchair because it was known from past-experience that the safety belt would not fit. RCA #150 revealed upon return to the facility, the bus turned a corner and became very bouncy as if the bus had struck the curb. Resident #10 then yelled for help and fell from the wheelchair to the floor of the bus. Resident #10 came to rest on the floor in the aisle way between the rows of seats. Resident #10 was on the floor in a tangled, unnatural looking position. Interview on 06/14/17 at 11:36 A.M. with the Administrator verified Resident #10 fell while on a bus transport on 06/08/17. The Administrator stated Resident #10 fell out of her electric wheelchair to the floor of the bus and the resident was not wearing the shoulder/lap safety belt that is equipped on the bus. The Administrator was not aware of the shoulder/lap safety belt not properly fitting Resident #10 until after the occurrence. The Administrator was not able to identify what brand of electric wheelchair Resident #10 utilized as the resident's family had removed all of the resident's belongings including the wheelchair from the facility after the incident. The Administrator stated it was the bus driver's responsibility to ensure all resident/riders on the bus are properly secured in the bus prior to transportation. Telephone interview on 06/14/17 at 1:07 P.M. with Bus Driver #250 verified Resident #10 was not wearing a safety belt at the time of the bus incident on 06/08/17. Bus Driver #250 revealed after assisting Resident #10 on the bus, straps were placed on the resident's wheelchair to secure the wheelchair to the bus. The shoulder/lap safety belt was not placed around the resident as the safety belt would not fit around Resident #10 and the resident's wheelchair. Interview on 06/15/17 at 11:42 A.M. with Physician #400 revealed Resident #10 had severe osteopenia. Physician #400 reported Resident #10 was morbidly obese with many co-morbidities. The physician stated the facility notified the physician on 06/08/17 following the bus incident to obtain orders for hospital evaluation and treatment. Physician #400 was not at the facility during the incident and has not been involved with Resident #10 since being transferred to the hospital. Review of the employee file for Bus Driver #250 revealed the employee was hired on 08/16/11. Review of the disciplinary action form dated 06/12/17 revealed the employee was disciplined for unsatisfactory job performance related to resident transport. Further review of the disciplinary action revealed the transport bus driver was given a written warning with one day of suspension. Bus Driver #250 voluntarily resigned from the facility on 06/13/17. Review of the facility bus operation manual/manufacturer's guidelines for the facility's 2008 bus revealed all occupants of the vehicle should always properly wear their safety belts. It is extremely dangerous to ride in the cargo area of a vehicle. In a collision, people riding in these cargo areas are more likely to be seriously injured or killed. Do not allow people to ride in any area of the vehicle that is not equipped with safety belts. Be sure everyone in your vehicle is in a seat, and using a safety belt properly. This deficiency substantiates Complaint Number OH 736.

Based on medical record review, observation, staff interview, facility policy review and review of documentation from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement interventions to prevent avoidable in-house acquired pressure ulcers. This resulted in actual harm to two (Residents #63 and #85) of four residents reviewed for pressure ulcers. The facility identified three residents with in-house acquired pressure ulcers. This had the potential to affect all residents in the facility. The facility census was 87. Findings Include: 1. Review of Resident #85's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #85's care plan dated 07/31/13 revealed Resident #85 had a progressive deficit in intellectual functioning characterized by deficit in memory, judgment, decision making, and though process related to short and long term memory loss related to [MEDICAL CONDITION]. Review of Resident #85 care plan dated 07/31/13 revealed the resident was at risk for skin breakdown due to medical condition or other risk factors due to [MEDICAL CONDITION], behavioral issues, and cognitive disorder, interventions included weekly body audits and as needed. The plan of care was updated on 01/14/14 and documented actual pressure ulcer unstageable area noted on coccyx, interventions included being monitored as need by Wound Nurse Practitioner. On 01/23/14 the intervention of a protein supplement and vitamins to promote wound healing was added and on 02/07/14, a low air loss mattress was added. Review of the Kardex dated 08/19/13 did not indicate the resident's updated activities of daily living needs or that the resident needed to be turned and repositioned, and that she was getting pressure ulcer care. Review of Hospital Discharge paperwork dated 01/01/14 revealed the resident had a stage II ulcer to the coccyx which appeared to be healing, and had a heart shaped dressing in place. Review of the comprehensive assessment dated [DATE] from readmission on 01/01/14 revealed there were no pressure ulcers noted. Resident #85 was noted to be severely cognitively impaired and was dependent for locomotion on and off of the unit, needed extensive assistance for bed mobility and dressing, and limited assistance for eating and hygiene. Review of Admission Nursing assessment dated [DATE] at 7:00 P.M. revealed "discoloration " was noted to the coccyx. No other description of the wound was noted on this form or in the medical record. Review of nursing notes dated 01/02/14 7:05 P.M. revealed the resident was admitted to the facility; the note did not include any indication of any skin breakdown to the coccyx, but did note a weekly skin assessment should be completed on Wednesdays on the 7:00 P.M. to 7:00 A.M. shift. From this date and time the nursing notes do not indicate any areas of skin breakdown until 01/13/14. Nursing notes on 01/13/14 at 2:00 A.M. revealed while doing care, staff observed a small red area to the upper buttocks. There was no further description regarding size or appearance. A physician order was received to cleanse the area to the upper buttocks with Sea Clens (normal saline), pat dry, apply Calcium Alginate, cover with ABD pad and change daily and as needed. Review of the medical record revealed no skin sheets from 01/02/14 until 01/15/14. On the skin sheet dated 01/15/14 it was noted the resident had skin issues but a treatment was in place. The significant change assessment dated [DATE] revealed the resident had an unstageable pressure ulcer measuring 4 centimeters (cm) (length) by 3 cm (width) and 0.1 cm (depth) and slough was present. Review of Nurse Practitioner (NP) #200's progress notes dated 01/23/14 revealed Resident #85 had a recent hospitalization for [MEDICAL CONDITION] hip and has a leg brace that was to stay in place. Staff noted the brace made it difficult for the patient to reposition frequently due to comfort issues. The resident was incontinent of bowel and bladder and was bed and wheelchair bound. The wound was documented as being on the resident's buttocks and unstageable. It measured 4 cm by width of 3 cm and the depth was 0.10 cm. The status of the wound was new. Review of skilled documentation wound notes starting 02/15/14 revealed there was a foul odor and yellow drainage was noted on 02/16/14, and 02/19/14. Review of Nurse Practitioner #200 notes dated 02/20/14 revealed the wound with all slough to the wound bed, debrided of subcutaneous slough the patient verbalizes area to edge was tender when touched; no verbalization of pain with debridement of center of wound noted. Not able to obtain tissue sample for culture and sensitivity due to amount of slough and no clean tissue visible. Wound measurements were length 6.0 width 5.0 depth 2.0 and undermining/tunneling at 12 o'clock, 3 cm; 3 o'clock, 3 cm; 6 o'clock 3.5 cm and 9 o' clock, 1.2 cm. Status of the wound was deteriorating. Review of NP #200's notes dated 02/24/14 revealed a telephone call was received from staff on 02/23/14 reporting odor to wound bed and pain. A culture and sensitivity was ordered. Visit on 02/24/14 staff report continued drainage and increased depth to wound, final culture and sensitivity revealed positive for pseudomonas infection. Wound measures 5.50 length and 4.0 cm width and depth 5.0 and undermining/tunneling at 12 o' clock, 0.5 cm; 3 o' clock, 1 cm; 6 o' clock, 4 cm; 9 o'clock 1 cm. Status of the wound was deteriorating. Review of most recent notes from NP #200 notes dated 04/10/14 revealed the wound continues to be on the coccyx and staged as unstageable. The wound length was 3.5 cm by 2.9 cm and wound depth was 2.9 with undermining/tunneling at 12 o'clock was 1.5 cm; 3 o'clock, 2.7 cm; and 6 o'clock, 1.2 cm. Licensed Practical Nurse (LPN) #90, with the assistance of Registered Nurse (RN) #63, was observed performing the treatment to the resident's coccyx on 04/13/14 at 7:30 A.M. LPN #90 stated Resident #85's dressing had come off during incontinence care and it had stool on it. LPN #90 cleansed the wound with normal saline. Without changing gloves or washing her hands, she proceeded to pack the wound as ordered and covered it with an ABD pad. LPN #90 and RN#63 both confirmed at the time of the observation that LPN #90 did not wash her hands or remove her gloves after cleaning the wound. During interview on 04/14/14 at 11:16 A.M., RN #58 was unable to explain how the facility was monitoring or caring for the resident's skin break down form 01/01/14 until 01/13/14 when the unstageable pressure ulcer was found. She confirmed the policy was not followed regarding documenting each shift. Review of the facility policy titled "Dressing", revised June 2005, documented the following information should be recorded in the resident's medical record: date and time dressing changed, wound appearance to include wound bed, edges and drainage, the type of treatment and how the resident tolerated it. Review of the facility policy titled "Wound Care Initial Wound Treatment Protocol", dated February 2013, revealed if a wound is found with moderate to heavy drainage with or without slough then the order is to clean with normal saline use alginate and abdominal pad. 2. Record review revealed Resident #63 was admitted to the facility 07/11/13 with [DIAGNOSES REDACTED]. Review of the Kardex, updated 09/20/13 and which documented the care provided to Resident #63, revealed the only area marked "intervention" was incontinence care and to provide a moisture barrier with each incontinence episode. Review of Resident #63's nursing readmission assessment, dated 10/09/13 after a three day hospitalization , documented there was no skin break down related to pressure ulcers. The Braden scale for predicting pressure sore risk, dated 10/09/13, revealed the resident was at mild risk for developing pressure ulcers. Review of the comprehensive quarterly assessment dated [DATE] revealed the resident had severe cognitive impairment, was totally dependent on two staff for bed mobility, transfers and toileting. The resident did not walk. There were no pressure ulcers documented at this time but revealed the resident was at risk for skin breakdown and a care plan was put into place. The care plan, initiated 07/13/13 with a target date of 07/15/14, documented the resident was at risk for skin breakdown and the goal was to be free of skin breakdown with interventions including float heels off the bed with a pillow when the resident will allow, incontinence care, weekly body audits and pressure reduction pad in chair. Review of the Treatment Administration Record (TAR) dated October 2013 documented no weekly skin checks were completed for the month. The November 2013 TAR contained no documented weekly skin checks, but were documented on a nurse's "weekly skin audit check" sheet; however they had missed the last week of the month. The December 2013 "weekly skin audit check" sheet documented discoloration to both lower legs with no open areas. An undated weekly skin audit in December 2013 documented redness to the buttocks. The January 2014 weekly skin audits revealed not all weekly audits were completed. Review of the December 2013 TAR documented a treatment was started on 12/22/13 to the coccyx. The treatment was to cleanse the area with Sea Clens (normal saline) and pat dry, apply an [MEDICATION NAME] dressing and cover with gauze; apply skin prep to intact surrounding skin every shift. Skin prep to both heels began on the same day. The TAR dated 01/03/14 documented the heels were discolored with no other descriptive words to describe the areas to the heels. The right heel discoloration measured 1.6 cm by 0.8 cm; the left heel discoloration measured 2 cm by 0.5 cm. The facility documented both heels as wound #1. Wound #2 documented an area to the coccyx measured 2.3 cm by 1.2 cm by 0.2 cm with no other descriptive words documented. The treatment was unchanged. The TAR dated 01/18/14 documented Wound #1 was the right heel was a dark area that measured 1.6 cm by 0.8 cm . The next entry documented wound #2 as 2.3 cm by 1.2 cm by 0.2 cm open area on the heel. This documentation did not describe the wound although wound #2 was previously identified as the coccyx, it was now documented that wound #2 was the heel. On 01/18/14 only two wounds (heels/coccyx) were measured and documented; the treatment remained unchanged. The TAR dated 01/25/14 documented wound #1, right heel, was a dark area under the skin and measured 1.6 cm by 0.8 cm; the left heel had a dark area to the other side and measured 0.6 cm by 0.5 cm. Wound #2, coccyx, measured 2 cm by 1.5 cm with a yellow wound bed. The treatment remained unchanged. The TAR dated 02/03/14 changed the wound numbers to wound #1 as the coccyx and measured 3 cm by 1.4 cm open area with yellow wound bed with foul odor. Wound #2 was the left heel with two small black areas measured at 0.2 diameter and 0.3 diameter and a small amount of drainage from both areas. Wound #3 was the right heel with red skin. On 02/03/14, the treatment was changed to cleanse the coccyx and left heel with full strength Dakin's solution, an antiseptic solution, rinse with wound cleaner, then apply calcium alginate inside the wound bed and cover with a dressing. There was no supporting documentation after the treatment was changed on 02/03/14 to show the treatment had been completed until 03/01/14. The TAR dated 02/08/14 documented wound #1 as the coccyx and measuring 2.9 cm by 1.6 cm yellow wound base. Wound #2, the left heel, had two small open black areas measuring 0.3 and 0.2 cm in diameter with purulent drainage. Wound #3, right heel, had new pink skin. The TAR dated 02/17/14 documented wound #1, coccyx, had increased in size and now measured 3.4 cm by 2 cm by 0.1 cm with a yellow wound bed. Wound #2, left heel, had two small areas measuring 2.5 cm by 0.5 cm by 0.1 cm with no further description; and wound #3, right heel, was pink with new skin. The Culture and Sensitivity lab report dated 02/21/14 showed left heel drainage was positive for Staph aureus (an bacterial infection). There were new orders to treat topically. The initial wound management, completed by a Certified Nurse Practitioner consultant, revealed notes dated 02/27/14 which documented the open area to left heel appears related to the resident rubbing on the mattress, creating friction/tear of skin. The etiology of the left heel was pressure and described as a Payne-Martin 3 (an area due to friction and pressure) measured 0.7 cm by 0.7 cm by 0.3 cm with undermining of 0.2 at 12 o'clock, 3 o 'clock and 9 o'clock and 0.3 cm at 6 o clock. The wound was 75 percent granulation tissue and 25 percent [MEDICATION NAME] and was not present on admission. The coccyx wound etiology was pressure area and staged at a three (which is a full thickness of skin is lost, exposing the subcutaneous tissues- presents as a deep crater with or without undermining adjacent tissue), measured 2.8 cm by 1.8 cm by 0.1 cm the wound bed was with yellow slough or necrotic tissue was 50% of wound bed and this wound was not present on admission. Interventions included a pressure reducing mattress, pressure reducing cushion to wheelchair and chair when used, and offload heels when in bed. On 04/11/14 at 10:30 A.M., an observation was made of Resident #63 sitting in a geri-chair with both heels touching the surface of the chair. On 04/11/13 at 11:30 A.M., Resident #63 was observed sitting in the dining room in the geri-chair with both heels touching the surface of the chair. On 04/11/14 at 12:40 P.M., Resident #63 was observed sitting up in the geri-chair with the right heel resting on the surface of the chair and the left heel the resident is rubbing the left foot up and down against the surface of the chair. Staff were observed walking by the resident with no interaction. At 3:30 P.M., Resident #63 was observed sitting up in the geri-chair with both heels resting on the surface of the chair. At 4:52 P.M., the resident was observed sliding down in the geri-chair with both heels rubbing and resting on the foot rest of the positioning chair. At 5:00 P.M., the resident was observed sitting up in the geri-chair with both heels resting on the surface of the chair while in the dining room getting ready for dinner. On 04/12/14 at 7:30 A.M., Resident #63 was observed lying in bed on her back while both heels were touching the surface of the bed. No pillows were observed on the bed or lying on the floor or sitting in the chair in the room. The bed did not have a low air loss mattress. At 10:11 A.M., Resident #63 was observed lying on her back. State tested Nursing Assistant (STNA) #23 was in the room. The resident's heels were observed and they were lying directly against the surface of the mattress; there were no pillows in place to relieve pressure on the heels. The resident's brief was soiled at this time. When STNA #23 went to remove the brief, she pulled it out from under the resident, instead of rolling the brief up and rolling the resident to the side. The coccyx area was observed with a dressing intact. STNA #23 performed care and applied a clean incontinent brief. No A & D ointment was applied as ordered. After care, STNA #23 repositioned the resident in bed, but did not float her heels off the mattress. On 04/12/14 at 3:00 P.M., Resident #63 was observed with her heels lying directly on the mattress without being floated with a pillow. On 04/13/14 at 6:30 A.M., the resident was observed lying in bed asleep with her heels lying directly on the mattress. At 6:40 A.M., Resident #63 during wound care treatment being completed by RN #46 and LPN #90. When the nurses removed the blanket, the resident's legs were resting on each other and there was a quarter sized red spot on the bony prominence where the legs had been touching. There was not a pillow in between the legs at this time. The heels were touching the mattress and no pillows were noted around the resident. The incontinent brief was removed and was soiled with urine. The coccyx area was red and there was no dressing in place. LPN #90 said she got report a while ago it had come off during a check and change. RN #46 cleaned the coccyx wound. The area was pink in color and had granulation tissue. RN #46 then removed the old dressing to the left heel. There was a scant amount of sanguineous drainage with no odor. The outer edges of the wound were white with red around the heel; the wound bed was pink and undermining was observed. Without changing her gloves or washing her hands, RN #46 applied the new dressing. After the treatment was completed the resident was positioned in the bed with both heels touching the mattress and no pillows in place for positioning. During the wound treatment ants were confirmed crawling on the bedside table. On 04/13/14 from 9:44 A.M. to 12:15 P.M., a continuous observation of Resident #63 revealed she was sitting up in the geri-chair with both heels resting on the foot rest of her reclining chair with no pressure relief. On 04/12/14 at 10:30 A.M., interview with STNA #23 and STNA #43 confirmed they did not float the heels off the bed and it was not listed on their Kardex. They then showed the STNA Kardex for Resident #63 and it did not have any preventative interventions documented for the resident's heels. On 04/13/14 at 7:10 A.M., LPN #70 said she does the treatment when she is at the facility and she never documents what the wound looks like in the nursing notes. She just initials the TAR that the wound treatment was completed. She did not know what the facility's policy was for documentation of wounds. On 04/13/14 at 7:30 A.M., interview with RN #46 said she did not document any wound stage, nor did she document what the wound looked like every week when she performed the treatments and measurements. On 04/14/14 at 4:09 P.M., interview with the Administrator said she had identified there was a problem with pressure sores in the facility, she was aware of this about one week ago. Review of the Dressing policy revised June 2005 under documentation the following information should be recorded in the resident's medical record: date and time dressing changed, wound appearance to include wound bed, edges and drainage, the type of treatment and how the resident tolerated it. Information from the National Pressure Ulcer Advisory Panel (NPUAP) defined a pressure ulcer as a 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; a number of contributing or confounding factors are also associated with pressure ulcers. An unstageable pressure ulcer was defined as a pressure ulcer where the depth of the wound is unknown, however, the patient has suffered full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined and the eschar will develop in days over a Stage II blister or a deep tissue injury if pressure is not removed. The NPUAP defined a suspected deep tissue injury (sDTI) as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Evolution of an sDTI may include a thick blister over a dark wound bed, the wound may further evolve and become covered by eschar and evolution may also include rapid exposing of additional layers of tissue. The NPUAP indicated that early assessment of risk factors and the implementation of preventative measures were key. The NPUAP offered various preventative points which included various approaches such as: frequent repositioning of bed/chair-bound resident and the use of devices that eliminate pressure on the heels should be used; for short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed and to utilize heel suspension boots for long-term use.

Based on observation, record review and interview, the facility failed to ensure a resident with a history of a fall from the toilet was provided adequate supervision as directed by her plan of care to prevent a second avoidable fall from the toilet. This fall resulted in a fractured shoulder and harm to the resident. This affected one (#40) of three residents reviewed for accidents. The facility identified 15 residents who had falls within the past 30 days. Findings include: Review of Resident #40's medical record indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's comprehensive assessment dated [DATE] indicated the resident was cognitively intact and required extensive assistance with activities of daily living (ADL) including bed mobility, transfers, ambulation, and toileting. The resident was assessed to be at risk for falls and had care plan interventions in place to prevent falls. Review of the nursing notes documented on 09/08/13 the resident was found on the floor next to the toilet. The resident sustained [REDACTED]. The facility's investigation of the incident indicated the staff assisted the resident to the bathroom and per the resident request left the resident on the toilet. The resident told the staff she would pull the call light when she was finished. After the resident was found on the floor, the resident told the staff she was unable to use the call light because she fainted. The resident's plan of care for falls was updated and staff's kardex (the staff's care card) was updated. To prevent future falls from the toilet the facility initiated a the new intervention of not leaving the resident alone in the bathroom. Nursing notes dated 03/30/14 the resident was again found on the floor beside the toilet. The resident stated she blacked out while trying to have a bowel movement. No injuries were noted at time. Later the resident complained of knee and shoulder pain. X-rays were taken and the resident was found to have a right humeral neck fracture (shoulder) and an interior displacement of the right humeral head. On 04/12/14 at 8:50 A.M. and again at 9:54 A.M. Resident #40 was observed in her bed with a sling on her right shoulder. During interview at 9:54 A.M., Resident #40 stated she does not remember falling off the toilet and breaking her shoulder. She stated the staff told her she fell in the bathroom. She stated the that staff was supposed to be with her while she was in the bathroom on the toilet. Resident #40 further stated she her arm is very painful and it hurts whenever she moves. During interview on 04/12/14 at 10:05 A.M. State tested Nursing Assistant (STNA) #72 stated he took her to the bathroom and left her because she has always been good about pulling the cord when she is finished. He stated he heard her yelling so he went in and she was on the floor between the toilet and wall. STNA #72 stated he did not realize the resident had the fall intervention not to be left alone in the bathroom. STNA # 72 stated he did not think he had to stay with her because she was alert and oriented and did not have a alarm,. STNA #72 stated his routine with her was to let her sit by herself. STNA #72 further stated if he did not know how to care for a resident, the Kardex would tell him, but he had not looked at the Kardex for Resident #40. During interview on 04/13/14 at 1:18 P.M. Licensed Practical Nurse (LPN) #14 stated she was called to room when the resident was found on the floor in the bathroom. LPN #14 stated the resident said she was trying to have a bowel movement, felt dizzy and fell . LPN # 14 further stated the resident complained of pain all over, not just her shoulder, and she gave her Tylenol. During interview on 04/12/14 at 11:13 A.M. the Director of Nursing (DON) verified the resident's plan of care and Kardex dated 03/30/14 indicated the resident should have not been left alone in the bathroom.