Every finding on record at Muskingum Skilled Nursing & Rehabilitation

Based on record review, staff interview, and resident interview, the facility failed to ensure residents received the proper treatment to maintain vision and hearing abilities. This affected three residents (#3, #11, and #22) of three residents reviewed for vision and hearing. The facility census was 37. Findings include:1.Review of the record for Resident #22 revealed an admission date of 04/02/25 and diagnoses including chronic obstructive pulmonary disease, congestive heart failure, personality disorder, and morbid obesity. Review of a vision exam on 04/29/26 revealed the resident's chief complaint was dry eyes overall. Gets crusty and stuck in the mornings. No drops used and no current drops. Would like drops. Exam showed red flaky skin on lashes. The resident was noted to have squamous blepharitis (inflammation of the eyelids) of both eyes and both upper and lower eyelids. The eye physician recommended Erythromycin (antibiotic) ointment to both eyes twice daily for 10 days. Dry eye syndrome was also noted of both lacrimal glands and artificial tears to both eyes twice daily was recommended. There was no evidence the resident received either eye medication recommended by the eye physician. Review of a Minimum Data Set (MDS) assessment completed 07/01/26 revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Interview with the Director of Nursing on 07/29/26 at 8:20 A.M. confirmed there was no evidence the resident received either recommended eye drop. She stated the resident did want the eye drops as the fan she uses in her room makes her eyes dry. Interview with Resident #22 on 07/29/26 at 8:50 A.M. revealed she did want to use eye drops for her eyes. 2. Review of the record for Resident #11 revealed an admission date of 02/14/25 and diagnoses including paranoid schizophrenia, morbid obesity, diabetes, and chronic venous hypertension. Review of onsite audiology consults revealed on 11/06/25 and 02/04/26 otoscopy revealed completely occluding cerumen (wax) in both ears. Cerumen is too hard and impacted to remove safely. Will require an ear drop regimen with subsequent irrigation once daily for three days. This will either completely clear out the patients ears or soften the wax enough to allow for removal by me at the next visit. There was no evidence the resident ever received any ear drops or irrigation to remove the wax that was occluding his ears. Review of a MDS assessment completed 06/12/26 revealed a BIMS score of 13, indicating intact cognition. It further stated his hearing was adequate. Interview with the Director of Nursing on 07/28/26 at 3:45 P.M. confirmed there was no evidence Resident #11 ever received any ear drops or irrigations of his ears. 3. Review of the record for Resident #3 revealed an admission date of 12/23/21 and diagnoses including acute kidney failure, acute respiratory failure, diabetes, and morbid obesity. Review of an onsite vision exam on 04/29/26 revealed the resident reported his eyes feel dry. The note stated the resident had dry eye syndrome of both lacrimal glands. The note stated to continue Restasis drops (used to increase natural tear production) twice daily in both eyes and start artificial tears twice daily in both eyes. Review of the medication administration record revealed Resident #3 received Restasis drops in both eyes twice daily from 09/12/25 until 05/09/26, when they were discontinued. There was no documentation in the record to indicate why the drops were discontinued after it was recommended that they continue on 04/29/26. In addition, there was no evidence the resident received the artificial tears drops as recommended. Review of a MDS assessment completed 07/12/26 revealed a BIMS score of 15, indicating intact cognition. Interview with the Director of Nursing on 07/29/26 at 8:20 A.M. revealed there was no evidence the resident received the eye drops as recommended. She stated she did not know why the Restasis drops were discontinued. This deficiency represents non-compliance investigated under Complaint Number 3106020.

Based on record review, staff interview, and resident interview, the facility failed to assist a resident in making an appointment and arranging transportation to and from the dental service location to obtain dental care. This affected one resident (#22) of three residents reviewed for dental care. The facility census was 37. Findings include:Review of the record for Resident #22 revealed an admission date of 04/02/25 and diagnoses including chronic obstructive pulmonary disease, congestive heart failure, personality disorder, and morbid obesity. Review of an onsite dental consult on 10/16/25 revealed patient is bedbound and needs to be referred out for sedation and removal of remaining teeth. No pain or discomfort noted by patient. Review of nursing progress notes on 05/04/26 at 2:18 P.M. revealed an appointment had been set up with an outside dental service on 05/18/26. Review of nursing progress notes on 05/18/26 at 10:53 A.M. revealed the nurse was notified that the transportation office had canceled the transportation for the resident's dental appointment today. Contacted scheduler to reschedule appointment. There was no evidence that another outside dental appointment had been scheduled as of 07/29/26. Review of a Minimum Data Set assessment completed 07/01/26 revealed a brief interview for mental status score of 15, indicating intact cognition. Interview with the Director of Nursing on 07/29/26 at 8:20 A.M. confirmed there was no evidence of any attempts to reschedule an outside dental appointment for Resident #22 since 05/18/26. Interview with Resident #22 on 07/29/26 at 8:50 A.M. revealed that her teeth are bad and broken off. She stated that she did not have significant pain from her teeth. However, she stated she did want to see a dentist to have her teeth pulled. This deficiency represents non-compliance investigated under Complaint Number 3106020.

Based on observation, record review, interview, policy review, and review of hospital records, the facility failed to ensure a resident experiencing a decline in respiratory condition who requested to be sent to the hospital for evaluation and treatment for shortness of breath had the hospital transfer request approved. The resident continued to decline for 24 hours until she was subsequently sent to the hospital as originally requested. This affected one resident (Resident #19) of one resident reviewed for change in condition. Actual Harm occurred on 03/18/26 when Resident #19, an alert and oriented resident with conditions of chronic obstructive pulmonary disease (COPD) and respiratory failure, exhibited a change in condition beginning on 03/08/26 as evidenced by shortness of breath, coughing and sputum production, on 03/18/26 the resident requested to go to the hospital due to difficulty breathing but the medical provider stated she would be monitored in-house. There was no evidence that Resident #19 was made aware of the medical provider's order to monitor in house and no evidence Resident #19 was given the option to request to be sent to the hospital again. On 03/19/26, Resident #19's condition continued to decline and her oxygen saturation dropped to 89 percent with oxygen in place. Resident #19 was then sent to the hospital and admitted for treatment of acute hypoxic respiratory failure, sepsis, and pulmonary infiltrates. In addition, the facility failed to ensure the bowel protocol was initiated for a resident without a bowel movement for three or more days that affected one resident (Resident #36) of three residents reviewed for bowel protocol, failed to communicate effectively with hospice providers to ensure hospice services were coordinated that affected three residents (Residents #41,#47, and #48) of four residents reviewed for hospice services, and failed to complete accurate skin assessments and provide transportation to appointments that affected one resident (Resident #28) of one resident reviewed for skin concerns. The facility census was 38.Findings include:1.Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, atrial fibrillation, and peripheral vascular disease. Review of a care plan dated 02/26/19 revealed Resident #19 had an alteration in oxygen exchange or perfusion related to chronic respiratory failure and chronic obstructive pulmonary disease (COPD). The goals were for the lungs to be clear to auscultation and oxygen saturation to be above 90 percent, respirations to be unlabored, and for the resident to show adequate oxygen perfusion. Interventions included assess lung sounds per orders and nursing judgement report abnormal breath sounds to provider; bi-pap as ordered, see orders for settings, at times resident refuses; maintain head of bed elevated to prevent shortness of breath; evaluate shortness of breath for pain and discomfort when breathing and administer medications as ordered to relieve; monitor vital signs as ordered and report abnormalities to provider; nursing to monitor resident and assess for effectiveness of respiratory treatment, vital signs, lung sounds, mental status, skin color, and report abnormalities to provider and nursing to assure set up of all required equipment and clean up after; provide oxygen as ordered; and provide respiratory treatments as ordered. Review of a care plan dated 02/26/19 revealed Resident #19 had an alteration in respiratory function and was at risk for infections related to chronic respiratory failure and COPD. The goal was to keep oxygen levels at desired levels per physician. Interventions included but were not limited to administer oxygen as ordered; medications as ordered; monitor lung sounds as ordered; monitor oxygen as ordered; oxygen per nasal cannula at 3 liters (L) per nasal cannula at all times, and observe for signs and symptoms of dyspnea such as labored respiration, low oxygen saturation, use of accessory muscles, cyanosis, changes in mental status, and tachypnea. Review of an order dated 07/25/25 revealed Resident #19 had an order for albuterol sulfate HFA inhalation aerosol solution 108 micrograms/ACT two puffs inhale orally every four hours as needed for shortness of breath/congestion; an order dated 09/26/25 revealed Resident #19 was receiving humidified oxygen via nasal cannula continuously at three L per minutes and to check oxygen saturation each shift. Review of the Minimum Data Set (MDS) assessment, dated 02/19/26, revealed Resident #19's cognition remained intact, had no behaviors, and received oxygen therapy. Review of a nursing note dated 03/08/26 at 4:45 P.M. by Licensed Practical Nurse (LPN) #100 revealed staff alerted writer to Resident #19 due to shortness of breath and increased anxiety. Resident #19 was in bed with the head of bed at 90 degrees, oxygen was in place via nasal cannula at two L, oxygen was increased to four L and a rescue inhaler was given. Resident #19 had increased anxiety related to shortness of breath, color was flesh tone and had quick open-mouthed breathing. Review of an additional nursing note dated 03/08/26 at 6:20 P.M. by LPN #100 revealed the on-call physician service was made aware of Resident #19's condition, vital signs and increasing oxygen to four L to get oxygen saturation above 90 percent. A new order was received to give Mucinex 60 milligrams (mg) one tab by mouth three times a day and continue with as needed nebulizer treatment as previously ordered. Maintain oxygen at 4 L as needed to maintain oxygen saturation above 89 percent. Review of a nursing note dated 03/17/26 at 12:08 P.M. by LPN #100 revealed a new order was received from Nurse Practitioner (NP) #200 for Resident #19 to have a chest x-ray, two-view due to continuing to experience shortness of breath at times with aerosol treatments given per orders. There was no documentation in the medical record including vital signs, oxygen saturation level, a physical assessment, lung sounds, and condition of Resident #19 that precipitated LPN #100 notifying NP #200. Review of a nursing note dated 03/17/26 at 1:58 P.M. by LPN #100 revealed the chest x-ray results showed mild congestive heart failure. NP #200 was notified, dialysis would be notified, and no new orders at present. Review of a nursing note dated 03/18/26 at 3:22 A.M. by LPN #105 revealed Resident #19 requested to be sent to the hospital for shortness of breath. The on-call providers were notified and asked for the resident's oxygen level which was 99 percent. The on-call medical provider stated to continue to monitor resident and not send her out to the hospital. There was no additional information related to an assessment of Resident #19 including a physical assessment, additional vital signs, or lung sounds and there was no evidence Resident #19 was notified of the on-call's instructions or given the opportunity to request to be sent out to the hospital. Review of a nursing note dated 03/18/26 at 3:27 A.M. by LPN #105 revealed Resident #19's vital signs were: blood pressure, 142/58 mm/Hg (normal reading 120/80), temperature 97.5 degrees Fahrenheit (F) (normal reading 98.6), respirations 20 breaths per minute, heart rate of 80 beats per minute, and oxygen saturation of 99 percent on four L of oxygen. Review of a pre dialysis evaluation note dated 03/18/26 at 5:54 A.M. by LPN #105 revealed Resident #19 had no signs of difficulty breathing, she did have shortness of breath noted, a moist and loose productive cough, and a moderate amount of secretions. Review of a MAR dated March 2026 revealed Resident #19 received a nebulizer treatment on 03/19/26 at 8:45 P.M. which was ineffective. Review of a nursing note dated 03/19/26 at 9:20 P.M. by LPN #109 revealed Resident #19 was short of breath, oxygen level was at 89 percent, the on-call medical provider was notified, oxygen was turned up and oxygen saturation was still at 89 percent. A new order was given to send Resident #19 to the emergency room. Review of a nursing note dated 03/19/26 at 10:00 P.M. by LPN #109 revealed the squad had arrived, Resident #19 was transferred and on her way to the local hospital. Report was called to the emergency department. Review of a nursing note dated 03/20/26 at 4:37 A.M. by Registered Nurse (RN) #117 revealed Resident #19 was admitted to the hospital for hypoxic respiratory failure, sepsis, and pulmonary infiltrates. Review of a hospital note dated 03/20/26 at 2:28 P.M. revealed Resident #19 presented to the emergency department on 03/19/26 with complaints of shortness of breath. She stated shortness of breath began about a week ago in conjunction with more coughing and increased sputum production. A chest CT showed numerous nodules throughout the lungs, enlarged distal common bile duct calculus with associated intrahepatic and extrahepatic biliary ductal dilation. Resident #19 was admitted for further workup and management of sepsis secondary to pneumonia acute hypoxic respiratory failure. Resident #19 was started on empiric intravenous (IV) antibiotics for sepsis. Resident #19 had increased cough and sputum production and chest CT showed multifocal nodules procalcitonin elevated and was started on IV ceftriaxone and doxycycline. Resident #19 used two to three L of oxygen at baseline but stated she had not been using her oxygen for quite some time and required 4 L via nasal cannula on admission to maintain saturations and was suspected for COPD in the setting of acute pneumonia. DuoNeb breathing treatments were scheduled and IV methyl prednisone was started. During an interview on 05/11/26 at 3:45 P.M., LPN #100 stated Resident #19 recently had a change in condition and needed to have an as needed nebulizer treatment ordered related to thick sputum which made it hard for her to breathe. LPN #100 stated she was not aware if there was a delay in treatment for Resident #19 but if a resident had asked her to go to the hospital and the provider did not want to send them, she would inform the resident of the option to be treated in house and if they still wanted to go to the hospital, she would send them to the hospital. LPN #100 denied having knowledge that Resident #100 was having difficulty breathing on 03/19/26. During an interview on 05/12/26 at 7:32 P.M., LPN #105 stated Resident #19 had been coughing up and having a hard time breathing but would feel better after receiving a breathing treatment. Resident #19 always had a breathing treatment in place, despite seeing the order was for 03/08/26. Resident #19's baseline was to wear oxygen at 3 L per minute via nasal cannula. LPN #105 stated when assessing Resident #19, she listened to her lungs which were wheezing, but she wasn't using accessory muscles to breathe and a breathing treatment was given with no further concerns. LPN #105 stated resident had been coughing up a cream-colored sputum and the physician wanted to treat Resident #19 in house and the resident had been okay with that. LPN #105 confirmed there was no documentation of additional assessment completed or resident being informed of physician's orders to treat in-house. During an interview on 05/12/26 at 9:24 A.M., NP #200 stated Resident #19 was alert and oriented, doesn't always ask to go out to the hospital, and knows when she needs help. NP #200 stated if Resident #19 had asked her to go out to the hospital, she would have sent her. If she had been the on-call provider, she would have wanted to know more than just Resident #19's oxygen saturation related to shortness of breath and would like to have known about lung sounds, vital signs, if she was using accessory muscles. NP #200 stated timing matters when someone has sepsis because the longer you wait to treat, the harder and longer it takes to treat. NP #200 stated she felt this incident was a delay in care. NP #200 read the notes and stated there was no indication Resident #19 was made aware of what the provider had stated about being treated in-house, about having the option to still go to the hospital, and no documentation of physical assessment. NP #200 stated despite Resident #19 still attending dialysis, it was the facility's responsibility to ensure the resident received the care and services needed to prevent major illness. During an interview on 05/12/26 at 10:18 A.M., Behavioral Health Tech (BHT) #400 stated one day in March (2026), Resident #19 was really struggling to breathe. Certified Nursing Assistant (CNA) #139 had retrieved BHT #400 and asked for help because she had notified the nurse, LPN #100, at least three times of Resident #19 struggling to breathe and was dismissed each time. BHT #400 went to see Resident #19 who was using accessory muscles to breathe. BHT #400 stated she grabbed Registered Nurse (RN) #117 who assessed Resident #19 and administered a breathing treatment which helped the resident to feel better. BHT #400 stated she wouldn't have access to view documentation but she did make this observation. During an interview on 05/12/26 at 11:32 A.M., CNA #139 stated during her shift on either 03/16/26 or 03/17/26, Resident #19 had been short of breath and in distress. CNA #139 stated Resident #19's oxygen saturation kept dropping to 86 percent with oxygen in place via nasal cannula at 3 L per minute. CNA #139 stated she told the nurse (LPN #100) three times about her concerns with Resident #19's oxygen levels who stated it was an ongoing issue and she would check on her. CNA #139 stated LPN #100 did not ever go check on Resident #19 so she asked BHT #400 to intervene who then grabbed RN #117 and RN #117 gave Resident #19 a breathing treatment. CNA #139 stated Resident #19's eyes appeared sunken in and dark, her skin was pale, and her lips were blue. CNA #139 stated Resident #19 was clearly in distress and using her accessory muscles to breathe and stated she wanted to go to the hospital several times but no one would listen. During an interview on 05/12/26 at 11:48 A.M., RN #117 stated she could not recall if any staff had asked her to assess Resident #19 at any point in time for shortness of breath. RN #117 stated she was aware of new orders during the timeframe related to breathing treatments but could not recall additional information. Review of an undated policy titled Status Change in Resident Condition- Notification revealed the facility should promptly notify the resident, their attending physician, and the responsible party of changes in resident condition and/or status. Regardless of the resident's mental or physical condition, nursing will information residents of any changes in their medical care or nursing treatments. The licensed nurse will record in the resident's medical record any changes in the resident's medical condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted by the assessment coordinator. Review of online information obtained from the University of Pittsburg Medical Center website (https://www.upmc.com/services/divsion-infectious-diseases/conditions/sepsis) dated 2025 revealed the six main symptoms of sepsis were shortness of breath; fever, chills, feeling very cold; high heart rate or low blood pressure; extreme pain or discomfort; sweaty or clammy skin; and being confused or feeling a bit lost. Sepsis was an emergency blood infection that could lead to death within hours without proper treatment. Sepsis could progress quickly and cause death within 12 hours and the risk of death increases by 7.6 percent for every hour that passes without treatment and getting quick treatment can be the difference between life and death. Four types of infections that were more likely to lead to sepsis include pneumonia, a UTI, skin infections and gut infections. Those at a higher risk for sepsis include people 65 or older, weakened immune systems, having had a recent severe illness or hospital stay, or chronic illnesses such as lung disease or kidney disease. 2.Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including gastroesophageal reflux disease and hypertension. Review of an order dated 12/28/22 revealed Resident #36 had an as needed order for milk of magnesia suspension 400 mg/5ml give 30 ml by mouth every 24 hours as needed for constipation. Review of an order dated 09/26/25 revealed Resident #36 had an as needed order for Dulcolax suppository, insert one suppository rectally every 24 hours as needed for constipation; if no results from milk of magnesia on the subsequent shift still no bowel movement, may administer one suppository. Review of an order dated 09/26/25 revealed Resident #36 had an as needed order for fleet enema 7-19 gm/118 ml insert one application rectally every 24 hours as needed for constipation; may administer fleet enema if there is no bowel movement on the subsequent shift (after suppository) and may repeat one time. Review of an additional order dated 09/26/25 revealed if Resident #36 does not have a bowel movement after following steps one, two and three, notify physician of no bowel movement. Review of bowel movement documentation revealed Resident #36 did not have a bowel movement from 04/26/26 through 04/30/26, five days total. Review of the medication administration record (MAR) for April 2026 revealed Resident #36 did not receive any as needed intervention related to bowel movement protocol from 04/26/26 through 04/30/26. Interview on 05/12/26 at 11:46 A.M. with the Director of Nursing (DON) confirmed there was no bowel movement and no intervention for five days for Resident #36. Review of an undated policy titled Bowel Management and Treatment revealed for existing residents, upon initiation of the program, the licensed nurse or dietician will assess the resident's bowel pattern, history or potential for constipation, laxative use, intake of fluids and fiber, and daily exercise. If constipation is a concern, the licensed nurse will also access the resident for depression, dementia, medications, and physical constraints to toileting to identify possible contributing factors. The dietician will obtain a history of the resident's usual daily intake based on current likes/dislikes and adjust the diet as needed. The bowel program appropriate for resident's needed will be implemented. Resident will be encouraged to participate in routine exercise, and consume fluids and fibers as tolerated and as ordered. All of the above will be documented in the care plan. Residents who have not had a bowel movement for three consecutive days will have the following protocol initiated, unless, resident has individual orders specific to bowel management, or where the orders below would be contraindicated for the resident. 1. Initial nurse receiving the alert and identifying the lack of a bowel movement for three days will begin the following bowel protocol for the residents on the list:a. Assess bowel sounds.b. Administer 30 ml of milk of magnesia.c. If the resident refuses the milk of magnesia, the nurse will notify the attending physician and document such on the MAR and in the nurses' notes.d. Document on the MAR and in the nurses' notes when the resident has a bowel movement and then the resident will be placed on the modified promotional bowel regimen as is listed above.2. The medication nurse on the next shift will check the list upon beginning her shift and the following will be performed.a. Assess bowel sounds.b. If the resident does not have a bowel movement on the prior shift after receiving the milk of magnesia, the licensed nurse will administer a suppository per physician's order.c. If the resident refuses the suppository, the nurse will notify the attending physician and document such on the MAR and in the nurses' notes.d. Document on the MAR and in the nurses' notes when the resident has a bowel movement and then the resident will be placed on the modified promotional bowel regimen as is listed above.3. The medication nurse for the third consecutive shift will check the list at the start of her shift and the following will be performed: a. Assess bowel sounds.b. If the resident does not have a bowel movement on the prior shift after receiving the suppository, the licensed nurse will administer an enema per physician's order.c. If the resident refuses the enema, the nurse will notify the attending physician and document such on the MAR and in the nurses' notes.d. Document on the MAR and in the nurses' notes when the resident has a bowel movement and then the resident will be placed on the modified promotional bowel regimen as is listed above.e. If the resident does not have a bowel movement within one hour of receiving the enema, notify the attending physician for further instruction and document such in the MAR and in the nurses' notes.The promotional protocol includes residents with a history of difficult and infrequent passing of hard dry stools and fewer than three stools a week and those who voice a sensation of incomplete evacuation are placed on a promotional bowel regimen. Review medications, obtain physician's orders to hold all laxative and enema orders including stool softeners and bulk laxatives, daily administration of natural laxative of prune/fiber mixture with mediation pass, increase fluid intake for the resident, offer 1/2 cup of yogurt to the resident daily. Assess bowel sounds each shift and document. Each shift, the licensed nurse documents on the MAR/TAR when the resident has had a bowel movement. 3. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including candidiasis of skin and nails, eczema, anemia, and obesity. Review of Resident #28's impaired skin integrity plan of care related to immobility, incontinence, fungal areas, bed ridden, prefers to lay on right side, scratches and picks at wounds, and refuses appropriate hygiene care at times dated 10/29/26 revealed to educate resident on picking, encourage not to pick, inspect skin during routine daily rounds, medication as ordered, treatments as ordered, and gel overlay to bed. a. Review of Resident #28's skin observation note dated 10/03/25 and 10/10/25 revealed the resident continues to have red rash on right side, under skin folds and between breasts. Open area to abdomen with treatment in-place. Review of Resident #28's progress note dated 10/22/25 revealed the resident refused to go to a dermatology appointment and rescheduled for 11/26/25. The resident was in agreement to go to the dermatologist if she could have a Xanax (anti-anxiety) prior to the appointment. Review of Resident #28's progress note dated 11/26/25 revealed the transportation company was late, and the dermatology office could not accommodate the late arrival and would call back to reschedule. Review of Resident #28's progress note dated 12/04/25 revealed the wound Nurse Practitioner (NP) was at beside and the resident complained of itching related to skin issues. New orders received for hydroxyzine 10 milligrams every eight hours for itching. Review of Resident #28's progress note dated 12/15/25 revealed transport called and cancelled transport for today to go to the dermatologist. Appointment will be rescheduled as soon as transport is available. Review of Resident #28's progress note dated 02/19/26 revealed the wound NP reported the skin looks better this week, less redness and less complaints of itching. Interview with the Director of Nursing (DON) on 05/11/26 at 2:19 P.M., revealed not all of Resident #28's dermatology appointments were documented in the medical record, and she had to review emails to determine how many appointments have been scheduled with the dermatologist for Resident #28. The DON reported on 10/13/25 there was no transportation, on 10/22/25 the resident had refused, on 11/20/25 transportation cancelled, 11/26/25 transportation was late and the dermatologist office could not see her, 12/15/25 transportation cancelled, 12/22/25 there was no transportation, 01/06/26 no transportation, 01/16/26 no transportation, and 02/05/26 no transportation. The resident's next dermatology appointment is scheduled for 05/12/26 and she had called and verified transportation arrangements with the company. b. Review of Resident #28's physician note dated 04/29/26 revealed the resident had suspected psoriatic arthritis (arthritis that affect people who have psoriasis (skin condition that causes itchy, scaly patches on skin) and would benefit from immunosuppressive therapy to control the issue. The psoriasis on the head and back was severe. Awaiting referral to rheumatology. Review of Resident #28's nursing note dated 04/29/26 revealed the physician discontinued the Clobetasol (steroid cream) and ordered Clotrimazole cream 1 percent (antifungal cream) to skin fold rash daily and rheumatology appointment. Review of Resident #28's nursing note dated 04/30/26 revealed the wound care nurse wanted Clobetasol 0.05 percent twice daily ordered and to discontinue the Clotrimazole cream. Review of Resident #28's skin assessment dated [DATE] revealed the resident skin was intact and continue treatment to rash. Review of Resident #28's nursing note dated 05/05/26 revealed the facility NP stated to continue cream per the wound NP orders for Clobetasol 0.05 percent twice daily. Review of Resident #28's physician note dated 05/06/26 revealed the resident's skin condition doesn't appear to be fungal. Discontinue Clobetasol and trial pimecrolimus to prevent further skin atrophy. Review of Resident #28's skin assessment dated [DATE] revealed skin was intact. Continue treatment for redness to folds. No new areas noted. Review of Resident #28's orders and medication and treatment administration records dated 05/2026 revealed on 04/30/26 Clobetasol Propionate external cream (steroid) was re-ordered to apply to abdomen folds and rash area topically twice daily for a rash. On 05/05/26 the Clobetasol Propionate was discontinued and rewritten on 05/05/26 to apply twice daily to abdomen, breast, skin folds, and arm pit. The order was discontinued again on 05/06/26 and a new order was written for Pimecrolimus cream 1 percent apply to skin fold rash topically every eight hours as needed for rash. The Pimecrolimus cream was never applied. Interview on 04/28/26 at 10:32 A.M., with the Ombudsman revealed he had been working with the facility due to having issues with transporting Resident #28 to dermatology appointments and the resident doesn't feel the facility was addressing her skin issues appropriately and now she had an open area on her torso the facility was not applying a treatment to. Observation on 05/11/26 at 10:35 A.M. of Resident #28 with Registered Nurse (RN)/Wound Nurse #117 confirmed Resident #28 had an open area on her abdomen the size of a dime with a yellow center, a red rash on the torso of her body, and dry flaky skin on her head. Interview on 05/11/26 at 11:36 A.M., with Registered Nurse (RN)/Wound Nurse #117 confirmed the physician didn't agree with the wound NP order for steroid treatment and kept changing the treatment orders. The RN confirmed the physician had ordered pimecrolimus cream to the area, however staff never administered the medication, and the resident had a rash, and the medication should have been applied. The RN reported she was going to clarify orders on the pimecrolimus. Interview on 05/12/26 at 9:24 A.M., with Resident #28 confirmed the open area on the abdomen had been there for months and she had photos to confirm. The resident reported the area started out as a blister and then opened. She had asked staff for a band-aid due the area was draining and the staff would tell her no because she didn't have an order. The resident reported she had been working with the Ombudsman for help to find transportation to appointments and treatment to open area on her abdomen. Interview on 05/12/26 at 9:37 A.M., with Licensed Practical Nurse (LPN) #100 confirmed she had completed Resident #28's skin assessment on 05/08/26 and didn't include the open area on her assessment due to the area didn't appear new to her and it was not draining. 4. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including encephalopathy, osteomyelitis, chronic obstructive pulmonary disease, diabetes mellitus, asthma, dementia, major depression, urge incontinence, anxiety, long QT syndrome, insomnia, pain, peripheral vascular disease, Vitamin D Deficiency restless leg syndrome, gastritis, constipation, occlusion and stenosis of carotid artery, hyperglycemia, hyperlipidemia, nocturia, and hypomagnesemia. Review of Resident #41's admission minimum data set (MDS) accepted on 02/26/26 revealed the resident observation period ended on 02/17/26 for the assessment. Resident #41 was admitted to the facility on [DATE] under hospice services. Review of Resident #41's hospice plan of care dated 02/11/26 revealed to contact hospice for change in resident condition, administer medications as ordered, and hospice to collaborate care with facility staff. a. Review of Resident #41's hospice note dated 02/26/26 authored by Chaplin #201 revealed the Chaplin was visiting and the roommate reported that Resident #41 mistakenly received his mediation. The resident was confused as evidence by stating that this Chaplin was on TV and that he was as well. The resident could not remember the name of his phone. The Chaplin notified the hospice office via team thread. The Chaplin forgot to notify the facility at the time of his visit. The Chaplin called the facility and spoke to Licensed Practical Nurse (LPN) #100 who stated the facility was aware of the situation. Review of Resident #41's hospice note dated 02/26/26 authored by Hospice Registered Nurse (RN) #202 revealed the nurse spoke to the hospice physician about the medication error from the facility. New orders to monitor for four days. No change in medication at this time. Interview on 04/28/26 at 3:39 P.M., 3:45 P.M., and 04/29/26 at 7:10 A.M. and 8:21 A.M. with the Director of Nursing (DON) confirmed certified medication aide (CMA) #108, who was also the social service designee, admission coordinator, marketing director, certified nurse aide (CNA), and the facility's beautician, had administered Resident #49's medication to Resident #41 on 02/25/26. The DON confirmed the resident was admitted to hospice services on 02/10/26, however hospice was not notified of the medication error until 02/26/26. b. Review of Resident #41's electronic medical record and hospice binder revealed no evidence of hospice notes or hospice plan of care. Interview on 04/29/26 at 10:32 A.M., with the DON confirmed the hospice staff usually talk with her or floor staff when they enter the building, however they don't always follow up with staff prior to leaving. If there was a new order, hospice usually would email her the new order. The facility currently has three hospice providers providing services to the residents. Interview on 05/05/26 at 9:53 A.M., and 05/06/26 at 8:30 A.M., with the DON con

Based on record review, interview, review of infection control log, review of facility assessment, and policy review the facility failed to ensure adequate staffing was in place to meet the needs of the residents were met. This had the potential to affect all 38 residents residing in the facility. Findings include: Review of the infection control log dated May, 2026 revealed no evidence a log had been started. Review of the concern log dated April, 2025 to April, 2026 revealed the facility had no concerns reported each month. Interview on 04/28/26 at 10:32 A.M., with the Ombudsman revealed he had an open case that's been ongoing regarding call light response time and staff attitude. Residents had reported the staff attitudes had improved since the facility terminated a Certified Nurse's Aide employment, but it's not completely resolved. Interview on 04/28/26 at 2:44 P.M., with Scheduler/Dietary Manager/Human Resource #111 revealed the staffing level was determined by the census. On dayshift and nightshift, two nurses are scheduled. The Scheduler #111 indicated scheduled nursing was either a Registered Nurse (RN), Licensed Practical Nurse (LPN) or Medication Tech (MT). On dayshift she tries to schedule three Certified Nurses Aides (CNA) and nightshift two CNAs. Per Scheduler #111, Sunday through Tuesday there was usually an MT an LPN/RN and Wednesday to Saturday two LPN/RN. The facility currently only has three RN's (Director of Nursing (DON), Assistant Director of Nursing (ADON), and the facility shares a Minimum Data Set (MDS) Nurse). The ADON has been working the floor since 04/12/26 due to staff shortage. The ADON was also the Infection Preventionist and Wound Nurse. The MDS Nurse works three days a week, one week alternating with two days the following week. Interview on 05/04/26 at 9:23 A.M., with Resident #25 revealed the facility needs to upgrade staffing, doesn't want to say more when asked if there were needs that were not being met. Interview on 05/05/26 at 8:52 A.M., with Resident #8 revealed there was not adequate staffing on night shift. Sometimes she doesn't get her medication until 11:00 P.M. The resident reported she doesn't use her call light frequently; however, she can hear call lights on her hall go off over for extended periods of time. Interview on 05/05/26 at 9:23 A.M., with Resident #28 confirmed there was not adequate staffing to meet her needs. The call lights were not answered timely. Sometimes staff will answer the call lights but do not address her needs and say they will return and never come back. Medications were not administered timely and sometimes she doesn't receive the correct medications. The resident reported that sometimes she requests Motrin and sometimes she will get it and sometimes she won't. The facility doesn't pass ice timely as well. Interview on 05/05/26 at 10:26 A.M., with Resident #31 revealed the facility was not adequately staffed. The MT was not competent to provide care due to medications not being administered timely and sometimes he receives the wrong medications. Sometimes it takes up to three hours before staff will answer his call light. Interview on 05/06/26 at 7:22 A.M., with LPN #105 confirmed it was very stressful when she is the only nurse on midnight shift and she doesn't always have time to document care she had provided to residents. Interview on 05/06/26 at disclosed time, with anonymous Staff Member #500 confirmed the ADON had been working on the floor at least twice a week. The anonymous Staff Member #500 reported residents have voiced concerns that nurses don't follow up timely with care. Interview on 05/07/26 at disclosed time, with anonymous Staff Member #501 confirmed there isn't enough staff to meet the resident needs timely. Showers were not being done per the resident preferences and call lights were not being answered timely due to the staff were lazy. Nurses are not doing their job. The management staff have multiple rolls to fill. The Social Service Designee also works on the floor as a CNA and MT. She is also the facility's beautician, admission director and marketing director. The Dietary Manager was also the scheduler and human resources. The Medical records staff was also the activity director. The ADON was also the Infection Preventionist and Wound nurse. The ADON has been working the floor at least two days a week and occasionally the DON has been working the floor to cover spots. The Administrator doesn't engage with staff. Interview on 05/11/26 at 10:46 A.M., with RN #117 confirmed there had been five or six infections thus far in May, however she had not started the tracking or trending. The RN #117 confirmed due to the nursing shortage she had been working on the floor three 12 hours days a week and had been working on the Infection Control when she had some down time on those days. The RN confirmed documentation was an issue when MTs were working due to the MTs were not permitted to document in the medical records and it was the nurse's responsibility. Interview on 05/12/26 at 8:15 A.M. and 8:25 A.M., with Housekeeper Supervisor (HKS) #113 confirmed she could print the call light report, however Corporate told her she could not print the report or let the surveyor review the report and if there was a concern with call lights the facility would have addressed it internally. Interview on 05/12/26 at 8:55 A.M., with the Administrator and Director of Nursing (DON) confirmed Corporate had advised them not to release the call light reports due to the reports were not part of the medical record. The Administrator confirmed there was a general concern from the Ombudsman in February (2026) regarding call lights however she didn't complete a concern form, however moving forward she would start completing concern forms. The Administrator reported during the all staff meeting in February (2026) that the facility reviewed the call light response time. The Administrator reported staff complete call lights audits, however there was no documented evidence they were completed to provide to the surveyor. Interview on 05/12/26 at 9:43 A.M., with Nurse Practitioner (NP) #200 confirmed RN #117 had been working the floor, and she makes sure she gives orders to an LPN/RN. Interview on 05/12/26 at disclosed time with an anonymous contracted employee confirmed the facility doesn't have adequate staffing. The call lights were not answered timely, and the contracted employee has a difficult time finding staff to assist the residents. There currently is a lack of communication with staff. The contracted employees have reported changes in residents' conditions, and they are not followed up timely. Follow up interview on 05/13/26 at 8:17 A.M., with Scheduler #111 confirmed the information conducted during the interview on 04/28/26. Scheduler #11 confirmed RN #117 started working three 12-hour shifts on floor on 04/12/26. Prior to that she was working five eight-hour shifts. RN #117 was also the Assistant Director of Nursing (ADON), Infection Preventionist (IP), and wound nurse. The Scheduler reported she had no idea what the requirement hours were for the IP position. To ensure RN coverage the DON works Monday through Friday and every other weekend, the ADON and DON will alternate with occasionally the MDS Nurse helping to cover the eight-hour shifts. The MTs were overseen by the DON. The nurse who works with the MTs was also responsible for completing all the assessments, charting, and nursing care for residents in the building. The Scheduler reported she doesn't know what the facility assessment indicated the facility needed for staffing coverage. The nurses were not crazy about the MTs, and she relays the nursing concerns. Currently the facility has four full-time LPN's, two part-time LPNs, and two as needed LPNs. The facility has hired two LPN's and one RN; however, they have not started yet. The facility has no opening jobs for LPN's, one weekend opening for RN, and one part-time midnight opening for CNA. The Scheduler reported she determines the staffing by dividing the hours by the census. The DON reviews the schedules and will make changes if needed. Interview on 05/13/26 at disclosed time with anonymous Staff #506 revealed the staff members don't feel there was adequate staffing on both shifts. The showers, checking and changing residents for incontinence needs, and turning residents were not being done per the residents' plans of care. The nurses complain when they work with MT's because then they are responsible for all the residents in the building. The MTs were usually scheduled on one hall and the nurse on the other hall; however, the nurse was responsible for nursing care, assessments, and charting. The MTs can only administer medications. There had been some complaints on night shift staffing especially on the days residents go to dialysis. Two of three residents require extensive assistance to get ready early in the morning. Review of the facility's policy titled Antibiotic Stewardship dated 01/2020 revealed the IP would track, record, and analyze infections related to residents, staff, volunteers, and visitors. Review of the facility assessment dated 01/2026 revealed the staffing levels were based upon the acuity of the residents and resident population. The staffing patterns may fluctuate depending upon daily census and resident needs. The facility promotes continuity of care and resident-centered culture by providing consistent assignments for our direct care staff. The type of staff didn't include MTs, nor did the assessment include the number of staff required.

Based on observation, interview, and policy review.the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect 38 of 38 residents who received food from the kitchen. Findings include:Observations on 05/07/26 starting at 11:17 A.M. through 12:24 P.M. revealed the following:At 11:55 A.M., [NAME] #126 reached into a bag of bread without gloves and touched four pieces of the bread, she removed the third and fourth pieces of the bread from the bag to make a grilled cheese. Dietary Manager (DM) #111 asked [NAME] #126 to throw the bread away, wash her hands and get new bread out with gloves on but did not remove the other two pieces of bread from the bag which were touched.At 12:00 P.M. observations of the window sill revealed dust and debris, the ceiling above the food preparation area had large amounts of dust around the air vent and on sprinkler system waterlines, the walls in the food prep area had food splatters.At 12:13 P.M., [NAME] #126 was holding tongs over the bin of chicken, barehanded. She dropped the tongs into the chicken, removed them, and grabbed a new pair of tongs. The remaining chicken in the bin was still served. Interview on 05/07/26 at 12:24 P.M. with DM #111 confirmed all findings. Review of an undated policy titled Food Storage revealed storage facilities should keep food safe, wholesome and appetizing. Food should be stored in an area that is clean, dry, and free from contaminants.

Based on record review, observation, interview, policy review, review of fit testing, and review of the infection control log, the facility failed to properly store nebulizer masks and tubing and failed to maintain a comprehensive infection control log and ensure staff were fit tested. This affected two residents (Resident #19 and #48) but had the potential to affect 38 residents residing in the facility. Findings include:1.Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including end stage renal disease and atrial fibrillation. Review of a care plan dated 02/26/19 revealed Resident #19 had an alteration in oxygen exchange/perfusion related to chronic respiratory failure and chronic obstructive pulmonary disease. The goal was for lungs to be clean to auscultation and oxygen saturation above 90%, respirations to be unlabored, and show adequate oxygen perfusion. Interventions included but were not limited to evaluate shortness of breath for pain and discomfort when breathing and administer medications as ordered to relieve and provide oxygen per orders, and to provide respiratory treatment per orders. Review of orders revealed an order dated 03/08/26 for Resident #19 to have albuterol sulfate inhalation nebulization solution 0.63 mg/3ml one unit inhale orally via nebulizer every six hours as needed for shortness of breath/congestion. Observation on 05/05/26 at 7:52 A.M. revealed Resident #19 was resting in bed and her nebulizer mask and tubing were laying directly on her bedside table. Observation on 05/05/26 at 1:31 P.M. revealed Resident #19 was seated in her wheelchair and her nebulizer mask and tubing were laying directly on her bedside table. Interview on 05/06/26 at 6:45 A.M. with Maintenance Director (MD) #112 confirmed Resident #19's nebulizer mask and tubing were lying directly on the bedside table. Interview of 05/06/26 at 6:54 A.M. with Certified Nursing Assistant (CNA) #145 confirmed Resident #19's nebulizer mask and tubing were lying directly on the bedside table. Review of an undated policy titled Hand Held Nebulizer revealed when nebulizer treatment has been completed, rinse the med neb cup with tap water and store at bedside on a paper towel or in a plastic bag. 2. Review of the COVID, Flu A, and RSV infection control binder revealed there was an outbreak of COVID from 11/20/25 to 12/20/25, Flu A from 01/22/26 to 02/09/26, and respiratory syncytial virus (RSV) from 03/16/26 to 04/01/26. Review of the facility's policy titled Respiratory Protection Program dated 09/15/20 revealed N95 fit testing would be performed when an employee is initially required to wear a respirator, and thereafter on an annual basis. Interview on 05/13/26 at 11:40 A.M. with Infection Preventionist (IP) #117 revealed she had just taken over IP in October 2025, and she was not able to find evidence new hires or current employees have been fit tested for respirators in the past year. The IP confirmed the staff were required to wear respirators (N95) during recent outbreaks of COVID, Flu A, and RSV. The facility has quarterly education planned throughout the year and the next infection control was scheduled in September 2026, and she was planning on doing annual fit testing at that time. 3. Closed medical record review revealed R#48 was admitted to the facility on [DATE] with diagnosis of including urinary tract infection. Review of Resident #48's final urinalysis results dated 04/20/26 revealed Resident #48 grew greater than 100,000 CFU/ml of Escherichia Coli Extended-spectrum beta-lactamases (ESBL). Review of the infection control log dated 04/2026 revealed no evidence of Resident #48's infection. 4. Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnosis including acute kidney failure and retention of urine. Review of Resident #31 final urinalysis results dated 05/02/26 revealed the urine culture grew 25-30,000 proteus mirabilis and was resistant to Cipro. Review of Resident #31's medication administration record dated 05/2026 revealed the resident had received six doses of Cipro 500 milligrams for a urinary tract infection. Review of the infection control log dated 04/2026 and 05/2026 revealed no evidence of Resident #31 proteus mirabilis or Cipro. 5. Review of May 2026 infection control log revealed no evidence of any infection logged on the control log. Interview on 05/13/26 at 10:36 A.M., with Registered Nurse (RN)/Infection Preventionist (IP)/Wound Nurse (WN) confirmed she had been working three 12 hours shifts on the floor the last three weeks due to a nursing shortage. The RN/IP/WN reported there had been five or six infections in May 2026 however she had not started the May infection control log (trending and tracking) at this time and had been trying to work on the infection control log during her free time as she works on the floor. The IP confirmed Resident #31 and R#48 infections were not logged on the infection control log. Review of the facility's policy and procedure titled Infection Prevention and Control Program undated revealed the facility would perform surveillance activities to monitior and investigate causes of infection and manner of spread in order to prevent infection in the facility. Review of the facility policy and procedure titled Antibiotic Stewardship dated 01/2020 revealed each facility would designate an infection control preventionist. The person would be responsible track, record, and analyze infections related to resident, staff, volunteers, and visitors.

Based on review of infection and antibiotic control logs, review of the facility assessment, interviews, and policy review the facility failed to ensure the Infection Preventionist (IP) dedicated time to IP duties to maintain a comprehensive infection control program. This affected Resident #31 and #48 with urinary tract infections but had the potential to affect all residents in the facility. The census was 38. Findings include:1. Review of May 2026 infection control log revealed no evidence of any tracking or trending for May 2026 as of 05/13/26. Interview on 05/13/26 at 8:17 A.M., with Scheduler #111 confirmed Registered Nurse (RN) /Infection Preventionist (IP) #117 started working three 12-hour shifts on floor on 04/12/26. Prior to that RN/IP was working five eight-hour shifts. RN #117 was also the Assistant Director of Nursing (ADON) and Wound Nurse. The Scheduler confirmed she was not aware of the hours the IP was required to work. Interview on 05/13/26 at 10:36 A.M., with Registered Nurse (RN) #117confirmed she had been working three 12 hours shifts on the floor the last three weeks due to a nursing shortage. The RN reported there had been five or six infections in May 2026 however she had not started the May infection control log (trending and tracking) at this time and had been trying to work on the infection control log during her free time as she works on the floor. Review of the facility assessment dated 01/2026 revealed no evidence of who the infection preventionist was or the hours required to ensure the facility maintained a comprehensive infection control and antibiotic stewardship program. The Infection Prevention and Control Program and Antibiotic Stewardship policy and procedures didn't include the time designated for the IP to ensure the program was accurate and comprehensive. 2. Closed medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnosis of including urinary tract infection. Review of Resident #48's final urinalysis results dated 04/20/26 revealed Resident #48 grew greater than 100,000 Colony Forming Units/milliliter (CFU/ml) of Escherichia Coli Extended-spectrum beta-lactamases (ESBL). Review of the infection control log dated 04/2026 revealed no evidence of Resident #48's infection. 3. Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnosis including acute kidney failure and retention of urine. Review of Resident #31 final urinalysis results dated 05/02/26 revealed the urine culture grew 25-30,000 proteus mirabilis and was resistant to Cipro. Review of Resident #31's medication administration record dated 05/2026 revealed the resident had received six doses of Cipro 500 milligrams for a urinary tract infection. Review of the infection control log dated 04/2026 and 05/2026 revealed no evidence of Resident #31's potential infection was logged on the infection control log. Interview on 05/13/26 at 10:36 A.M., with Registered Nurse (RN) #117 confirmed Resident #31 and Resident #48's infections were not logged on the infection control log despite the infection control program being a responsibility of the IP, RN #117. Review of the facility's policy and procedure titled Infection Prevention and Control Program undated revealed the facility would perform surveillance activities to monitior and investigate causes of infection and manner of spread in order to prevent infection in the facility. Review of the facility policy and procedure titled Antibiotic Stewardship dated 01/2020 revealed each facility would designate an infection control preventionist. The person would be responsible track, record, and analyze infections related to resident, staff, volunteers, and visitors.

Based on record review, interviews, and policy review, the facility failed to ensure the resident's interdisciplinary team including the residents participated in the care planning process including care plan conferences. This affected four residents (#1, #4, #28, and #31) of five residents reviewed for care conferences. The facility census was 38.Findings include: 1.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and type II diabetes. Review of a care conference sign in sheet dated 02/03/26 revealed individuals present at the care conference were Resident #1's representative, Director of Nursing (DON), and Social Services (SS) #108. Review of a care conference sign in sheet dated 04/08/26 revealed individuals present at the care conference were Resident #1's representative and SS #108. Interview on 05/04/26 at 11:01 A.M. with Resident #1 revealed she had not been asked to participate in care conferences and this is something she would like to do. Interview on 05/07/26 at 12:53 P.M. with SS #108 confirmed Resident #1 was not asked to participate in their own care conference and not the entire disciplinary team attended Resident #1's care conferences. The staff knows the conferences are held on Thursday. 2. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Tourette's, heart failure, anemia, and depression. Review of Resident #4's quarterly minimum data set (MDS) assessment completed 04/04/26 revealed a brief interview for mental status (BIMS) score of 8 indicating moderate cognitive impairments, a total severity score of 8, the resident had no displayed behaviors. The resident had lower extremity impairment on both sides, was dependent for oral hygiene, toileting, showering and bathing, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The resident was dependent for mobility and transfers. The resident was frequently incontinent of bowel and bladder. The resident had a feeding tube. Review of Resident #4's care plan meeting completed on 01/02/26 revealed all parties present included Resident #4 and their representative, social service designee #108 , and the director of nursing. Review of the care plan meeting minutes revealed not all members of the interdisciplinary team were present. 3. Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, morbid obesity, congestive heart failure, personality disorder, depression, chronic obstructive pulmonary disease, hemoptysis, rheumatoid arthritis, drug-induced Cushing's, personality disorder, depression, generalized anxiety, post-traumatic stress disorder, personal history of suicidal behavior, gastro-esophageal reflux disease, poisoning by benzodiazepines, and sedative, hypnotic or anxiolytic dependence, in remission. Review of Resident #28's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's brief mental status score was 15 (cognition intact). Review of the electronic medical record revealed Resident #28 attended care conferences on 04/08/25, 07/07/25, 10/09/25. Others in attendance were registered nurses and social service designee (SSD). Review of a handwritten care plan meeting note dated 12/18/25 revealed the Director of Nursing (DON) and the resident were in attendance. Review of a handwritten care plan meeting note dated 03/27/26 revealed the Resident and SSD were the only two in attendance. A note indicated the resident refused weights and no dietary changes were noted. Resident will let SSD know if she has any complaints or concerns. Interview on 05/05/26 at 9:24 A.M. with Resident #28 revealed she had never been invited or attended a care conference in the two years she had been a resident at the facility. Resident #28 reported last week after the surveyor had spoken to her staff had brought in a bunch of papers for her to sign, however she doesn't know what she signed. Interview on 05/07/26 at 9:42 A.M. and 11:22 A.M. with Social Service Designee (SSD) #108 revealed on 12/18/25 she had attended the care conference, however forgot to sign the sign in sheet. The SSD confirmed the only staff in attendance for the care conference were the DON and herself. The SSD confirmed on 03/27/26 she was the only staff present for the care conference. SSD reported there is times she is the only staff in attendance if the DON is not available. The other interdisciplinary team (dietary, therapy, physician, or the direct care staff) did not attend the care conference, nor did they share information with her before the meetings. The IDT is aware the care conference is held every Thursday. The SSD confirmed she was not aware of who was required to attend the meetings. Interview on 05/13/26 at 7:09 A.M., with the Minimum Data Set (MDS) Registered Nurse (RN) #118 revealed she was new to the position and was not aware of the day care conferences were held. The MDS RN #118 confirmed she had never attended a care conference at the facility. The MDS RN #118 reported her work hours are split between two buildings. She works Monday, Wednesday, and Thursday then alternates Tuesday and Thursday the next week. 4. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including heart failure, kidney failure, chronic obstructive pulmonary disease, pneumonia, sepsis, atrial fibrillation, venous insufficiency, gastro-esophageal reflux disease, edema, laryngeal spasms, insomnia, opioid dependence, ventral hernia, pain, and anxiety. Review of handwritten care conference notes dated 03/06/25, 06/06/25, 08/13/25, and 11/11/25, revealed the resident, social service, and DON attended. On 02/11/26 the only persons in attendance were the resident and SSD. On 02/11/26 the resident had dietary changes, fluid restriction, and would like therapy services. Interview on 05/05/26 at 10:47 A.M., with Resident #31 revealed he had never attended nor had he been asked to attend a care conference. Interview on 05/07/16 at 12:53 P.M., with SSD #108 confirmed the only ones in attendance for the care conference on 03/06/25, 06/06/25, 08/13/25, and 11/11/25 was the resident, herself, and the DON. On 02/11/26 it was just herself and the resident. The IDT was aware that care conferences were held every Thursday. Review of the care conference policy and procedure undated revealed the physician, DON, Administrator, and Certified Nursing Assistant responsible for the individual patient, a member of the food or nutrition department, and Rehabilitation service will be invited to attend to discuss the medical condition, give input, and answer any question that may arise. Each member of the interdisciplinary team, including but not limited to MDS staff, social services, nursing, dietary, therapy, activities, as well as the primary care giver will review the medical record, visit the resident, seek out of any concerns, and assess the outcome of the last meetings recommendations prior to attending the care meeting.

Based on record review, and interview, the facility failed to ensure resident medical were complete, accurate, and readily accessible. This affected five residents (#3, #8, #41, #47, and #48) of 21 resident records reviewed. The census was 38. Findings include:1. Record review revealed Resident #03 admitted to the facility on [DATE] with diagnoses including type 2 diabetes, schizoaffective disorder, schizoaffective disorder, major depressive disorder, generalized anxiety disorder, seizures, sleep apnea, hypertension, gastro esophageal reflux disease, bipolar disorder, and mild intellectual disabilities. Review of Resident #03 assessment for PHQ 2-9 (brief depression screener) revealed an effective date of 01/08/26, and a created date of 05/01/26. Review of Resident #03 assessment for social determinants of health revealed an effective date of 01/08/26, and a created date of 05/01/26. Review of Resident #03 Brief Interview for Mental Status BIMS evaluation revealed an effective date of 01/08/26, and a created date of 05/01/26. Interview on 05/11/26 at 12:00 P.M. with facility social service designee revealed the assessments/ evaluations for BIMS, PHQ2-9, and social determinants of health should be completed in conjunction with the resident's minimum data set, or at least quarterly. Social service designee confirmed Resident #03 assessments for BIMS. PHQ 2-9, and social determinants of health are approximately four months late and were back dated. 2. Closed medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnosis including dementia. Review hospice progress note dated 04/20/26 revealed Licensed Practical Nurse (LPN) #105 called reporting Resident #48 had passed and requested hospice nurses to make a visit to pronounce. Review of Resident #48's progress notes dated 04/20/26 revealed no evidence when staff had found resident unresponsive or hospice or family was notified. Review of Resident #48's late entry progress note dated 04/21/26 revealed the resident was confirmed dead at 10:41 P.M., by the hospice nurse. Interview on 05/05/26 at 7:28 A.M., with LPN #105 revealed the night Resident #48 had expired a Medication Tech (MT) was working on Resident #48's hall and she was assigned to the other hall. The MT asked her to come and check on the resident around 9:00 P.M., because the resident had expired. The LPN reported she could not pronounce the resident's death by herself, so she called hospice and they arrived around 10:41 P.M. to confirm the resident had expired. The LPN confirmed herself or the MT documented when they had discovered the resident or they had notified hospice or the family. 3.Closed medical record review revealed Resident #47 was admitted to the facility on [DATE] with a diagnosis of protein-calorie malnutrition. Review of Resident #47's hospice note dated 02/23/26 revealed LPN #110 had called and wanted the nurse to give her a call back when she had a chance. Review of Resident #47's hospice note dated 02/23/26 revealed the resident was assessed today after the facility noted a decline. The resident appears pale, lethargic, and diaphoretic. Blood pressure hypotensive 83/42. No mottling observed. Review of Resident #47's progress notes dated 02/19/26 to 02/24/26 revealed no evidence of Resident #47 decline on 02/23/26. There were no progress notes from 02/19/26 until 02/24/26 at 5:25 A.M., when the resident was found unresponsive and pronounced dead. Interview on 05/05/26 at 7:28 A.M., with LPN #105 confirmed she had received in report that Resident #47 was passing, and his blood pressure was low. The LPN reported she had checked on the resident during the night but did not document findings. LPN #105 confirmed there was no documented evidence of the resident decline on 02/23/26 and the last documentation prior to his death on 02/24/26 was on 02/19/26. 4.Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including end stage renal disease and hyperlipidemia. Review of a care plan dated 07/29/25 revealed Resident #8 received pain medication. The goals included to be free from any adverse reactions from pain medication through review date and pain will remain within an acceptable range through review date. Interventions included but were not limited to administer medications per physician orders, monitor for effectiveness and potential side effects, notify physician of changes; consult physician to review medication if resident has persistent side effects from medication; monitor for potential fall risks; monitor for signs and symptoms of altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritis, respiratory distress, sedation, urinary retention, and notify physician of changes; monitor respiratory status after administration of pain medication as indicated; and review and assess whether pain medication is effective. Review of an order dated 02/08/26 revealed Resident #8 had oxycodone oral tablet 5 mg give one tablet by mouth every eight hours as needed for post surgery six tablets only in place. There were no parameters included in instructions for administration. Review of orders dated 02/21/24 revealed Resident #8 had oxycodone-acetaminophen 5-325 mg give one tablet by mouth every six hours as needed for pain. There were no parameters included in the instructions for administration. Review of a medication administration record (MAR) for February 2026 revealed Resident #8 received oxycodone 5 mg tablets on 02/08/26 at 1:57 P.M., 02/09/26 at 4:19 A.M. and 5:33 P.M., and on 02/18/26 at 9:09 P.M. Review of a MAR for March 2026 revealed Resident #8 received oxycodone 5 mg tablets on 03/09/26 at 4:57 P.M., 03/27/26 at 11:55 A.M., and on 03/29/26 at 5:21 P.M. Review of a MAR for May 2026 revealed Resident #8 received oxycodone 5 mg tablet on 05/01/26 at 12:04 P.M. Interview on 05/07/26 at 2:21 P.M. with DON confirmed the total tablets marked on Resident #8's MARs was eight, and she was not sure how that would be possible considering the order was for a total of six tablets only. Interview on 05/11/26 at 1:03 P.M. with DON revealed nurses were accidentally signing the MAR for oxycodone instead of oxycodone-acetaminophen 5-325 mg which was a current order. DON showed the times of administration versus the times medications were signed out on the narcotic logs lined up with Resident #8 receiving the oxycodone-acetaminophen but an error in documentation. 5. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including encephalopathy, osteomyelitis, chronic obstructive pulmonary disease, diabetes mellitus, asthma, dementia, major depression, urge incontinence, anxiety, long QT syndrome, insomnia, pain, peripheral vascular disease, Vitamin D Deficiency restless leg syndrome, gastritis, constipation, occlusion and stenosis of carotid artery, hyperglycemia, hyperlipidemia, nocturia, and hypomagnesemia. Review of the Medication Error Report Form dated 02/25/26 completed by the Director of Nursing (DON) revealed at 9:00 A.M., Resident #41 was administered the wrong medication. The Certified Medication Aide (CMA) was passing medication, and two other residents came to the medication cart wanting their morning medications. The CMA told them she would be there soon. The CMA went into the room and gave the medication to bed B instead of bed A. The incident was reported to the resident's physician, DON, and family. The corrective action taken was the five rights of medication pass was done one on one with CMA and house education was given to medication techs and nurses. How could the errors have been corrected included to practice five rights, decrease interruptions during medication pass, and facility admission staff to be cautious when resident names are close are placed in the same room. The report was signed off by the DON and Administrator on 02/25/26. Review of Resident #41 medical record dated 02/25/26 to 02/28/26 revealed no documented evidence of medication error incident that occurred on 02/25/26. Interview on 04/28/26 at 3:39 P.M., 3:45 P.M., and 04/29/26 at 7:10 A.M. and 8:21 A.M. with the Director of Nursing (DON) confirmed CMA #108 had administered Resident #49's medication to Resident #41 on 02/25/26. The DON confirmed the resident was admitted to hospice services on 02/10/26, however hospice was not notified of the medication error until 02/26/26. The DON also confirmed she notified the NP after the incident and received new orders to monitor the resident, obtain vital signs every two hours times one, then every four hours for 24 hours, and to hold sedative medication due to the resident would probably sleep all day after receiving Buprenorphine, however she never wrote the orders. Interview on 04/29/26 at 7:50 A.M., with CMA #108 confirmed she had administered Resident #49's medication to Resident #41 on 02/25/26. The CMA reported that CMAs were not permitted to notify doctors, families, representatives, assess residents, or document in the medical record. Review of the facility policy and procedure titled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection dated 01/2023 revealed medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and/or prescribers, the Pharmaceutical Service Committee, the pharmacy, and Food and Drug Administration MedWatch Program or USP/ISMP Medication Error Reporting Program. In the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to prevent the residents' safety and welfare. The prescriber is notified promptly of any significant error or adverse medication reactions. Any new prescriber's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. The incident is described on the shift change report to alert staff of the need to monitor the resident. The following information is documented in the resident's medical record and/or on the incident report: factual description of the error or adverse reaction, name of the prescriber and time notified, prescriber's subsequent orders, and residents' condition for 24 to 72 hours or as directed. Review of the facility's policy and procedure titled Status Change in Resident Condition-Notification undated revealed the facility would promptly notify the residents', his/her attending physician, and responsible party of changes in the resident's condition and/or status. The licensed nurse would notify the resident's attending physician for directive when the resident was involved in any accident/incident, a need to alter the resident's treatment significantly, or deemed necessary or appropriate in the best interest of the resident. Unless otherwise instructed by the resident, the licensed nurse would notify the resident responsible party. The licensed nurse will record in the resident's medical record any changes in the resident's medical condition or status.

Based on medical record review, review of hospice records, interviews, and policy review the facility failed to ensure a resident's hospice service and medical provider were notified of a medication error and failed to ensure a resident's physician and resident representative were notified of a new skin alteration. This affected one resident (#41) of one resident reviewed for medication errors and one resident (#40) of three residents reviewed for pressure ulcers. Findings include: 1.Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including encephalopathy, osteomyelitis, chronic obstructive pulmonary disease, diabetes mellitus, asthma, dementia, major depression, urge incontinence, anxiety, long QT syndrome, insomnia, pain, peripheral vascular disease, Vitamin D Deficiency restless leg syndrome, gastritis, constipation, occlusion and stenosis of carotid artery, hyperglycemia, hyperlipidemia, nocturia, and hypomagnesemia. The resident was a full code status, and allergies included Duloxetine, Morphine, and Betadine. Review of Resident #41's admission minimum data set (MDS) assessment dated [DATE] revealed the resident observation period ended on 02/17/26 for the assessment. Resident #41 was admitted to the facility on [DATE]. The resident's brief interview for mental status (BIMS) was noted to be 13 (cognition intact). The resident had no noted behaviors or rejection of care. Resident #41's diagnoses included hypertension, peripheral vascular disease, diabetes, hyperlipidemia, non-Alzheimer's dementia, malnutrition, anxiety, depression, pressure ulcer on foot, and pulmonary disease. Review of Resident #41's plan of care dated 02/11/25 revealed the resident received hospice services related to hypertension and heart disease. Interventions included contacting hospice for changes in the resident's condition and medication as ordered. Review of the facility's investigation for Resident #41's medication error on 02/25/26 revealed the investigation included: a list of the resident's blood pressure reading printed 04/28/26, a undated handwritten list of medication names (Thiamine (Vitamin), Carvedilol (Beta-Blocker) Propranolol (antidysrhythmic/beta blocker), Lisinopril (ace-inhibitors), Ascorbic Acid (Vitamin), Aspirin (antiplatelet), Amlodipine (calcium channel blocker), Pantoprazole (proton pump inhibitors), Venlafaxine (antidepressant), Folic Acid (vitamin), Buprenorphine (opioid analgesic), Baclofen (muscle relaxer), and sennoside (stool softener). Only one medication included the dose (Thiamine 100 mg), staff education dated 02/25/25, a written medication error report form dated 02/25/26, and electronic medication error report dated 02/25/26. There was no documented evidence the resident's hospice service provider or medical provider was notified of the medication error. Review of Resident #49's (Resident #41's roommate) orders and medication administration record (MAR) dated 02/2026 revealed Amlodipine 5 mg daily for hypertension, Ascorbic acid 500 mg daily for supplement, Aspirin 81 mg daily for anti-platelet, Baclofen 20 mg three times daily for muscle spasms, Buprenorphine 8 mg sublingual three times daily for detox, Carvedilol 6.25 mg twice daily for hypertension, Folic acid 1 mg daily for anemia, Lisinopril 40 mg daily for hypertension, Pantoprazole daily for gastric reflux disease, Propranolol 120 mg daily for hypertension, Thiamine 100 mg daily for supplement, Venlafaxine 50 mg daily for depression, and Sennosides 8.6 mg one twice daily. Resident #49's diagnoses on the orders included cirrhosis of the liver, anemia, emphysema, altered mental status, constipation, opioid dependence, metabolic and toxic encephalopathy, moderate protein-calorie malnutrition, paroxysmal atrial fibrillation, hypothyroidism, hypokalemia, and hypomagnesemia, Review of the Medication Error Report Form dated 02/25/26 completed by the Director of Nursing (DON) revealed at 9:00 A.M., Resident #41 was administered the wrong medication. The Certified Medication Aide (CMA) was passing medication, and two other residents came to the medication cart wanting their morning medications. The CMA told them she would be there soon. The CMA went into the room and gave the medication to bed B instead of bed A. The incident was reported to the resident's physician, DON, and family. The box was blank if it was reported to pharmacy. The corrective action taken was the five rights of medication pass was done one on one with CMA and house education was given to medication techs and nurses. How could the errors have been corrected included to practice five rights, decrease interruptions during medication pass, and facility admission staff to be cautious when resident names are close are placed in the same room. The report was signed off by the DON and Administrator on 02/25/26. There was no documented evidence hospice was notified of the medication error. Review of the electronic medication error report dated 02/25/26 at 9:00 A.M. and completed by the Assistant Director of Nursing (ADON)/Registered Nurse (RN) #117 revealed the Resident #41 had received roommate's medication with no adverse reactions noted at this time. Resident head to toe assessments completed within normal limits. The provider was notified and all medications reviewed to make sure no allergies were detected. Residents were made aware of the situation and every two hour vital signs times one, then every four hours for 24 hours initiated. Resident in agreement with plan of care. The level of consciousness, mobility, and mental status were blank. The resident was notified on 02/25/26 at 11:49 A.M., the provider at 11:28 A.M., and the DON at 11:28 A.M. There was no documented evidence hospice was notified of medication error. Review of Resident #41 medical record dated 02/25/26 to 02/28/26 revealed no documented evidence of medication error incident that occurred on 02/25/26 was documented in the medical record. In addition, there was no documented evidence hospice or the medical provider was notified of the medication error. Review of Resident #41's hospice note dated 02/26/26 authored by Chaplin #201 revealed the Chaplin was visiting and the roommate reported that Resident #41 mistakenly received his medication. The resident was confused. The Chaplin notified the hospice office via team thread. The Chaplin forgot to notify the facility at the time of his visit. The Chaplin called the facility and spoke to Licensed Practical Nurse (LPN) #100 who stated the facility was aware of the situation. Review of Resident #41's hospice note dated 02/26/26 authored by Hospice Registered Nurse (RN) #202 revealed the nurse spoke to the hospice physician about the medication error from the facility. New orders to monitor for four days. No change in medication at this time. Interview on 04/28/26 at 3:39 P.M., 3:45 P.M., and 04/29/26 at 7:10 A.M. and 8:21 A.M. with the Director of Nursing (DON) confirmed CMA #108, who was also the social service designee, admission coordinator, marketing director, CNA, and the facility's beautician, had administered Resident #49's medication to Resident #41 on 02/25/26. The DON confirmed the resident was admitted to hospice services on 02/10/26, however hospice was not notified of the medication error until 02/26/26. The DON also confirmed she notified the NP after the incident and received new orders to monitor the resident, obtain vital signs every two hours times one, then every four hours for 24 hours, and to hold sedative medication due to the resident would probably sleep all day after receiving Buprenorphine, however she never wrote the orders. Interview on 04/29/26 at 7:50 A.M., with CMA #108 confirmed she had administered Resident #49's medication to Resident #41 on 02/25/26. The CMA reported that CMAs were not permitted to notify doctors, families, representatives, assess residents, or document in the medical record. Interview on 04/29/26 at 9:00 A.M., with Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #117 confirmed she had spoken to Resident #41 the day of the medication error and he didn't want his wife called because she would think it was his fault. The resident was his own responsible party, but his cognition had really declined after the incident. The ADON confirmed there was no documented evidence hospice was notified of the medication error. Interview on 04/29/26 at 9:41 A.M., with NP #200 confirmed she had just taken over as the NP for the facility around the time of medication error involving Resident #41. The NP confirmed she had spoken to the DON and had given verbal order to monitor the resident, which would include orientation, if he was lethargic, not eating, behaviors changes, etc. The NP reported she was not notified he had slept all day, or his pulse had dropped below 60 beats per minute (normal 60-90 beats per minute). The NP confirmed the resident had received a beta-blocker and a pulse rate below 60 would be concerning. The NP confirmed her expectations would have been to be notified of the lethargy and pulse rate below 60 and she would have sent him to the hospital for evaluation. The NP reported that she doesn't recall telling the DON to hold sedative medications and confirmed the resident was not seen by a provider after the medication error and typically a resident would have been seen at the next visit, which would have been Friday 02/27/26, and she would have taken full ownership that he was not seen. The NP reported she was not aware of the resident's continued decline in mental status and he had not been seen by a provider since 02/20/26 and she had never seen the resident since she started in February. Review of the facility assessment dated 01/2026 revealed the staffing was based on resident population and acuity. Nursing services included: e.g. DON, RN, LPN, Certified Nursing Assistants (CNA), and Minimum Data Set (MDS) nurse. The assessment didn't indicate CMA. Staff competencies included medication administration in the fourth quarter (October, November, and December). Review of the facility policy and procedure titled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection dated 01/2023 revealed medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and/or prescribers, the Pharmaceutical Service Committee, the pharmacy, and Food and Drug Administration MedWatch Program or USP/ISMP Medication Error Reporting Program. In the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to prevent the residents' safety and welfare. The prescriber is notified promptly of any significant error or adverse medication reactions. Any new prescriber's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. The incident is described on the shift change report to alert staff of the need to monitor the resident. The following information is documented in the resident's medical record and/or on the incident report: factual description of the error or adverse reaction, name of the prescriber and time notified, prescriber's subsequent orders, and residents' condition for 24 to 72 hours or as directed. Review of the facility's policy and procedure titled Status Change in Resident Condition-Notification undated revealed the facility would promptly notify the residents', his/her attending physician, and responsible party of changes in the resident's condition and/or status. The licensed nurse would notify the resident's attending physician for directive when the resident was involved in any accident/incident, a need to alter the resident's treatment significantly, or deemed necessary or appropriate in the best interest of the resident. Unless otherwise instructed by the resident, the licensed nurse would notify the resident responsible party. The licensed nurse will record in the resident's medical record any changes in the resident's medical condition or status. 2. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including hypoglycemia, type 2 diabetes, dysphagia, benign prostatic hyperplasia, heart failure, major depressive disorder, insomnia, hallucinations, osteoarthritis, and mood disorder. Review of Resident #40's quarterly minimum data set (MDS) completed on 02/11/26 revealed a brief interview for mental status (BIMS) score of 06 indicating severe cognitive impairment and no displayed behaviors. The resident utilized a wheelchair for mobility, required supervision/ touching assistance for eating, toileting hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The resident required set up or clean up assistance for oral hygiene. The resident was occasionally incontinent of urine and frequently incontinent of bowel. The resident had a therapeutic diet ordered (low salt, low cholesterol, and diabetic). The resident had not had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. The resident was not at risk of developing pressure ulcers/injuries and had no active skin problems. Review of Resident #40's progress note for clinical admission dated 04/30/26 at 5:00 P.M. revealed the resident had a stage two pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) to the sacrum with a 5 centimeter (cm) circular non blanchable area with a small open area of 0.1 centimeters (cm) in length, 0.1cm in width, and 0.1 cm in depth. Review of Resident #40 progress note dated 04/30/26 at 5:00 P.M. revealed a note which stated the resident returned form the hospital via ambulance with two attendants on gurney. Resident transferred to bed with two assist. Daughter made aware of return to facility. Interview on 05/11/26 at 1:40 P.M. with the Assistant Director of Nursing confirmed there was no documentation in the resident's medical record of Resident #40's representative or physician being notified of the new alteration in the resident's skin integrity. Review of facility policy titled Wound Care Management (dated 02/2023) revealed if a new skin area is identified the physician and responsible party will be notified promptly of the newly identified skin area and a treatment. Review of the undated facility policy titled Status Change in Resident Condition revealed the licensed nurse will record in the resident's medical record any changes in the resident's medical condition or status. The facility will promptly notify the resident, his/her attending physician, and responsible party of changes in the resident's condition and/or status. This deficiency represents non-compliance investigated under Complaint Number 2800245.

Based on closed record review, interview, and policy review, the facility failed to provide the Notice of Medicare non coverage (NOMNC) to Medicare beneficiaries at least two days before the end of a Medicare covered part A stay. This had the potential to affect one (Resident #50) of three residents reviewed for Notice of Medicare non coverage. The census was 48.Findings Include: Closed record review revealed Resident #50 admitted to the facility on [DATE] with diagnoses including type two diabetes, chronic obstructive pulmonary disorder, nicotine dependence, major depressive disorder, generalized anxiety disorder, obstructive sleep apnea, atrial fibrillation, and hypertension.Review of Resident #50's Beneficiary protection notification revealed the residents last covered day of part A services was 11/11/25.Review of Resident #50 Beneficiary protection notification revealed the resident had been notified that coverage of services would end on the date on the notice [11/11/25] and that they could appeal this decision, the form was signed and dated by Resident #50 on 11/10/25.Interview on 05/12/26 at 12:36 P.M. with Social Service Designee #108 confirmed Resident #50's last covered day of part A services was 11/11/25 and the resident was provided the notice on 11/10/25.Review of the undated facility policy titled Form instructions for the in NOMNC revealed a Medicare health provider must give an advance, completed copy of the notice of Medicare non coverage to enrollees receiving skilled nursing, home health, or comprehensive outpatient rehabilitation facility services, no later than two days before the termination of services.

Based on observation and interview, the facility failed to ensure a shared resident bathroom was maintained in a sanitary manner. This affected one (Resident #31) of two resident's reviewed for environment. Findings Include: Interview on 04/28/26 at 2:52 P.M., 04/29/26 at 12:40 P.M., and 05/05/26 at 10:23 A.M., with Resident #31 revealed he had to share a bathroom with the room next door, and one of the male residents next door urinated and had bowl movements all over the bathroom and did not flush the toilet. Resident #31 shared photos from his phone of the unsanitary condition of the bathroom. The photos confirmed there was urine and bowel movements on the floors and toilet, and the toilet was not flushed. Interview on 05/13/26 at 9:21 A.M., with Housekeeping Supervisor (HKS) #113 confirmed Resident #31 had voiced concerns related to the male resident that shared a bathroom with him, missing the toilet when he urinated and he didn't flush. She stated the housekeeping staff cleaned all residents' bathrooms daily and upon request, which Resident #31 had requested additional cleanings of the bathroom in the past. Random tour of resident bathrooms on 05/13/26 at 9:28 A.M., with Maintenance Director revealed Resident #31's bathroom had urine on the floor, urine on the toilet rim, and the toilet had not been flushed. The Maintenance Director confirmed the findings during the observation. This deficiency represents non-compliance investigated under Complaint Number 2961731.

Based on medical record review, review of self-reported incident, review of concern log, observation, interview, and policy review, the facility failed to ensure an allegation of misappropriation was reported timely to the state agency. This affected one (Resident #41) of three reviewed for personal property. Findings Include: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including encephalopathy, osteomyelitis, chronic obstructive pulmonary disease, diabetes, obesity, depression, anemia, long QT syndrome, anxiety, pain, peripheral vascular disease, Vitamin D deficiency, restless legs syndrome, gastritis, constipation, occlusion and stenosis, hypomagnesemia, hyperglycemia, hyperlipidemia, and nocturia. Review of the concerns log dated 01/2026 to 05/2026 revealed there were no concerns that were reported in the last five months, including a missing wallet for Resident #41.Interview on 05/05/26 at 11:54 A.M., with Resident #41's wife revealed two or three weeks after Resident #41 was admitted his wallet came up missing. The wallet contained a credit card and a driver's license. Interview on 05/06/26 at 8:58 A.M., with the Administrator revealed she was not aware Resident #41 wallet was missing. The surveyor reported to the Administrator that Resident #41's wife had reported during a family interview her husband's wallet, containing a credit card and a driver's license, had been missing two or three weeks after he had been admitted . Observation on 05/06/26 at 8:58 A.M., of Resident #41's room with the Administrator confirmed there was no evidence of a wallet in the resident's room. The resident had noted cognition impairment and reported maybe his wife had his wallet. Interview on 05/06/26 at 9:00 A.M., with the Director of Nursing (DON) revealed she was not aware Resident #41's wallet was missing. Interview on 05/06/26 at 9:50 A.M., with Social Service Designee (SSD) #108 revealed she was unaware Resident #41's wallet was missing. The SSD reported Resident #41 had a roommate in February 2026, however he was discharged and went to New York. Interview on 05/06/26 at 9:55 A.M., with Resident #41's sister confirmed Resident #41's wife had reported to her back in February 2026 that Resident #41's wallet was missing and Resident #41's wife had reported the wallet missing to staff. Resident #41's sister confirmed the contents of the wallet. Follow-up interview on 05/06/26 at 10:11 A.M., with Resident #41's wife confirmed she has reported the missing wallet in February 2026 to Certified Nurses' Aide (CNA) #132 and a male staff member. The staff had looked for the wallet but were not able to locate it. Resident #41's wife confirmed she had a friend cancel the credit card, but the resident still didn't have a driver's license. Review of a typed statement authored by the Administrator dated 05/06/26 revealed the Administrator had spoken with Resident #41's wife asking if she knew of the missing wallet. The wife stated that he had a camo wallet that he was unable to find but was still looking for it. Interview on 05/11/26 at 1:21 P.M., with the Administrator revealed she did not initiate an SRI for Resident #41's missing wallet, credit card, and driver's license due to Resident's #41's wife didn't indicate the wallet was stolen and it was only missing. The Administrator reported she would offer to replace the wallet and take the resident to the Bureau of Motor Vehicle (BMV) to obtain a new driver's license. The Administrator confirmed she had spoken to Resident #41's sister last week to confirm the wallet was missing. An additional statement was obtained on 05/11/26 and authored by the Administrator with Resident #41's wife revealed the wallet contained one credit card, his driver's license and a picture of her. The statement indicated that management was not notified, however the statement did not include the two staff members names that the wallet was reported missing to, back in February when it was discovered missing. Review of undated statement authored by the Administrator revealed LPN #102 reported he had not seen the wallet; however, the wife had mentioned it. There was no additional details or information regarding what the wife had mentioned to LPN #102. Interview on 05/12/26 at 7:50 A.M., with the Administrator confirmed she still had not initiated an SRI because she had spoken to Resident #41's wife and didn't feel anyone had taken the wallet and she just wanted the facility to replace the wallet. The Administrator confirmed she had not completed an investigation except she had interviewed a few staff members. The surveyor had requested the interviews. The Administrator returned with the some typed and some written interviews dated 05/06/26, 05/11/26, 05/12/26, and some were not dated. The Administrator confirmed Resident #41's wife confirmed she had reported the missing wallet to CNA #132 and Licensed Practical Nurse (LPN) #102 however the Administrator confirmed she didn't include that information in her typed statement on 05/11/26. The Administrator reported the wife never reported the wallet missing to management. The Administrator reported she had not been able to interview CNA #132 at this time. Review of the self-reported incidents (SRI) dated 01/2026 to 05/2026 revealed no evidence the facility had initiated a self-reported incident for Resident #41's missing wallet that contained a credit card and driver's license in February 2026 when the wife reported she had reported the wallet missing nor on 05/06/26 when the State Surveyor had reported the missing wallet with a credit card and the residents driver's license to the Administrator, DON, and SSD. The facility initiated the SRI on 05/12/26 at 8:07 A.M. and indicated on 05/06/26 it was reported that Resident #41 had a missing wallet, that the surveyor notified the facility administrator, but the family did not. Review of the facility's undated policy and procedure titled Abuse Prohibition revealed residents would not be subjected to abuse, neglect, exploitation, mistreatment, misappropriation of property by anyone. Any reports or investigation will be reviewed by and conducted through the Quality Committee. A thorough investigation of all alleged violations will be conducted. Any alleged allegations are to be communicated immediately to the Administrator or designee. The investigation procedure begins immediately by the Administrator of facility designee. Reporting of all allegations not involving abuse or serious bodily injuries must not exceed 24hours. The results of a thorough investigation of the allegations will be reported to the department of health within five working days of the incident.

Based on medical record review, review of concern log, review of self-reported incident, observation, interview, and policy review, the facility failed to timely investigate an allegation of misappropriation of a resident's wallet. This affected one (Resident #41) of three reviewed for personal property. Findings Include: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including encephalopathy, osteomyelitis, chronic obstructive pulmonary disease, diabetes, obesity, depression, anemia, long QT syndrome, anxiety, pain, peripheral vascular disease, Vitamin D deficiency, restless legs syndrome, gastritis, constipation, occlusion and stenosis, hypomagnesemia, hyperglycemia, hyperlipidemia, and nocturia. Review of the concerns log dated 01/2026 to 05/2026 revealed there were no concerns that were reported in the last five months, including a missing wallet for Resident #41.Interview on 05/05/26 at 11:54 A.M., with Resident #41's wife revealed two or three weeks after Resident #41 was admitted his wallet came up missing. The wallet contained a credit card and a driver's license. Interview on 05/06/26 at 8:58 A.M., with the Administrator revealed she was not aware Resident #41 wallet was missing. The surveyor reported to the Administrator that Resident #41's wife had reported during a family interview her husband's wallet, containing a credit card and a driver's license, had been missing two or three weeks after he had been admitted . Observation on 05/06/26 at 8:58 A.M., of Resident #41's room with the Administrator confirmed there was no evidence of a wallet in the resident's room. The resident had noted cognition impairment and reported maybe his wife had his wallet. Interview on 05/06/26 at 9:00 A.M., with the Director of Nursing (DON) revealed she was not aware Resident #41's wallet was missing. Interview on 05/06/26 at 9:50 A.M., with Social Service Designee (SSD) #108 revealed she was unaware Resident #41's wallet was missing. The SSD reported Resident #41 had a roommate in February 2026, however he was discharged and went to New York. Interview on 05/06/26 at 9:55 A.M., with Resident #41's sister confirmed Resident #41's wife had reported to her back in February 2026 that Resident #41's wallet was missing and Resident #41's wife had reported the wallet missing to staff. Resident #41's sister confirmed the contents of the wallet. Follow-up interview on 05/06/26 at 10:11 A.M., with Resident #41's wife confirmed she has reported the missing wallet in February 2026 to Certified Nurses' Aide (CNA) #132 and a male staff member. The staff had looked for the wallet but were not able to locate it. Resident #41's wife confirmed she had a friend cancel the credit card, but the resident still didn't have a driver's license. Review of a typed statement authored by the Administrator dated 05/06/26 revealed the Administrator had spoken with Resident #41's wife asking if she knew of the missing wallet. The wife stated that he had a camo wallet that he was unable to find but was still looking for it. Interview on 05/11/26 at 1:21 P.M., with the Administrator revealed she did not initiate an SRI for Resident #41's missing wallet, credit card, and driver's license due to Resident's #41's wife didn't indicate the wallet was stolen and it was only missing. The Administrator reported she would offer to replace the wallet and take the resident to the Bureau of Motor Vehicle (BMV) to obtain a new driver's license. The Administrator confirmed she had spoken to Resident #41's sister last week to confirm the wallet was missing. An additional statement was obtained on 05/11/26 and authored by the Administrator with Resident #41's wife revealed the wallet contained one credit card, his driver's license and a picture of her. The statement indicated that management was not notified, however the statement did not include the two staff members names that the wallet was reported missing to, back in February when it was discovered missing. Review of undated statement authored by the Administrator revealed LPN #102 reported he had not seen the wallet; however, the wife had mentioned it. There was no additional details or information regarding what the wife had mentioned to LPN #102. Interview on 05/12/26 at 7:50 A.M., with the Administrator confirmed she still had not initiated an SRI because she had spoken to Resident #41's wife and didn't feel anyone had taken the wallet and she just wanted the facility to replace the wallet. The Administrator confirmed she had not completed an investigation except she had interviewed a few staff members. The surveyor had requested the interviews. The Administrator returned with the some typed and some written interviews dated 05/06/26, 05/11/26, 05/12/26, and some were not dated. The Administrator confirmed Resident #41's wife confirmed she had reported the missing wallet to CNA #132 and Licensed Practical Nurse (LPN) #102 however the Administrator confirmed she didn't include that information in her typed statement on 05/11/26. The Administrator reported the wife never reported the wallet missing to management. The Administrator reported she had not been able to interview CNA #132 at this time. Review of the self-reported incidents (SRI) dated 01/2026 to 05/2026 revealed no evidence the facility had initiated a self-reported incident for Resident #41's missing wallet that contained a credit card and driver's license in February 2026 when the wife reported she had reported the wallet missing nor on 05/06/26 when the State Surveyor had reported the missing wallet with a credit card and the residents driver's license to the Administrator, DON, and SSD. The facility initiated the SRI on 05/12/26 at 8:07 A.M. and indicated on 05/06/26 it was reported that Resident #41 had a missing wallet, that the surveyor notified the facility administrator, but the family did not. The investigation noted the facility immediately spoke with the residents family, and there were no immediate concerns for misappropriation though a comprehensive investigation was to follow. Review of the facility's undated policy and procedure titled Abuse Prohibition revealed residents would not be subjected to abuse, neglect, exploitation, mistreatment, misappropriation of property by anyone. Any reports or investigation will be reviewed by and conducted through the Quality Committee. A thorough investigation of all alleged violations will be conducted. Any alleged allegations are to be communicated immediately to the Administrator or designee. The investigation procedure begins immediately by the Administrator of facility designee. Reporting of all allegations not involving abuse or serious bodily injuries must not exceed 24hours. The results of a thorough investigation of the allegations will be reported to the department of health within five working days of the incident.

Based on medical record review and interview the facility failed to ensure a resident had an individualized trauma informed plan of care. This affected one resident (#28) of four residents reviewed for behaviors.FIndings include: Record review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including personality disorder, depression, generalized anxiety, post-traumatic stress disorder (PTSD), personal history of suicidal behavior, poisoning by benzodiazepines, and sedative, hypnotic or anxiolytic dependence, in remission. Review of Resident #28's psychiatric note dated [DATE] revealed the resident had PTSD and was stable on Zoloft (anti-depressant) and Xanax (anti-anxiety). The resident had PTSD from watching a friend wreck and die on motorcycle when she was younger and it plays back in her head. She had attempted suicide. There was no documented evidence of triggers or individualized intervention. Review of Resident #28's quarterly psychosocial/behavioral assessment dated [DATE] revealed the resident had PTSD. The assessment did not include triggers or individualized interventions. Review of Resident #28's risk for impaired social interaction related to history of trauma plan of care dated [DATE] revealed (triggers) the resident had a really good friend being killed, son not wanting anything to do with her, PTSD, and history of suicidal behavior. The intervention included to encourage positive communication with others, verbalizing feelings, medication per order, notify physician of decline, offer psych services, provide positive reinforcements, refer to counseling/psychiatry, social to provide education regarding outpatient community resources and support groups, set up as indicated. There was no evidence of triggers or individual interventions. Interview on [DATE] at 9:17 A.M., with Resident #28 revealed she had PTSD related to a combination of life events. She had watched a friend wreck a motorcycle in front of her and expired, a few months later her house burnt down with her pets inside and she lost everything and she had been in bad relationship. She had been having panic attacks and has not been sleeping well since she was taken off Xanax almost a year ago. She was seen by the in-house psychiatrist, but he yelled at her, so she fired him. The resident reported triggers for PTSD included the sound of motorcycles, loud noises, and certain words. Interview on [DATE] at 11:04 A.M. and 1:47 P.M., with Social Service Designee (SSD) #108 confirmed Resident #28 did not have a comprehensive PTSD assessment or comprehensive care plan for PTSD to include triggers or individualized interventions. The SSD reported she knew the resident prior to becoming a resident at the facility. The resident watched a close friend get killed on a motorcycle and another one got shot and killed five years later. She doesn't talk a lot about it and shuts down. She refused to see a psychologist and she would have to look to see if anyone had been following her psychological needs. The SSD didn't know what the resident triggers for the PTSD included.

Based on record review, observation, interview, and policy review, the facility failed to ensure residents who were dependent on staff were provided assistance with personal hygiene and bathing. This affected two residents (#19 and #25) of four residents reviewed for activities of daily living. The facility census was 38. Findings include:1.Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including end stage renal disease and atrial fibrillation. Review of a care plan dated 12/19/23 revealed Resident #19 required assistance with ADLs related to debility and weakness. The goals included to continue to participate in ADLs as able and have no decline in ADLs through review; remain clean, dry, odor free and appropriately dressed through the review; and remain well-groomed and free of odors at all times and will participate in ADL self-care. Interventions included but were not limited to staff to adjust care as needed to meet resident's needs; staff to encourage resident to participate in ADLs during care; and staff will assist as needed with daily hygiene and will assist with showering resident as per facility policy. Review of a minimum data set (MDS) dated [DATE] revealed Resident #19's cognition remained intact, had no behaviors, and was dependent on staff for personal hygiene. Observation on 05/05/26 at 7:53 A.M. revealed Resident #19 was resting in bed and her nails were long with a dark brown substance underneath. Observation on 05/05/26 at 1:31 P.M. revealed Resident #19 was seated in her wheelchair and had long, dark brown nails and long chin hairs. Interview on 05/06/26 at 6:54 A.M. with Certified Nursing Assistant (CNA) #145 confirmed Resident #19's fingernails were long and had a dark brown substance underneath. CNA #145 stated Resident #19 is often scratching her arms which may cause that. CNA #145 also confirmed Resident #19 had chin hair but stated she had an electric shaver she was able to use by herself. Resident #19 was awake at the time of the interview and stated her nails needed taken care of, but she would often do them herself. 2. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, malnutrition, amnesia, abdominal aortic aneurysm, depression, and gastro esophageal reflux disease. Review of Resident #25's Medicare 5 day minimum data set (MDS) completed on 04/16/26 revealed a brief interview for mental status (BIMS) score of 14. A total severity score of 05, no displayed behaviors. The resident required dependence on staff for oral hygiene, toileting, showering and bathing, upper and lower body dressing, putting on and taking off footwear, and dependence for transfers and mobility. The resident was always incontinent of bowel and bladder. Observation on 05/04/26 at 9:22 A.M. revealed the resident appeared unkempt wearing a white shirt with food and spilt items on it, long dirty finger nails, and no pants on. Review of Resident #25's record revealed no shower sheets, or documentation of the resident receiving and/or refusing to be showered/bathed for the month of May 2026. Interview on 05/14/26 at 2:17 P.M. with the director of nursing confirmed there was no evidence Resident #25 had received any showers for May 2026.

Based on record review, observations, interview, and policy review, the facility failed to ensure alternating air mattresses were on the correct setting to prevent pressure ulcers. This affected one resident (#19) of three residents reviewed for pressure ulcers and interventions. The facility census was 38. Findings include:Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including end stage renal disease and atrial fibrillation. Review of a care plan dated 10/24/21 revealed Resident #19 was at risk for impaired skin integrity related to decreased mobility, periods of bowel and bladder incontinence, bilateral lower extremity edema, oxygen per nasal cannula, history pressure ulcers, and prefers to lay on back. The goals were for excoriation will resolve without complication as occurrence arises and skin will be free of breakdown. Interventions included but were not limited to elevate heels off mattress, heel protectors as tolerated, inspect skin during daily care, lotion to skin as needed, low air loss mattress to bed, and pressure reduction devices if ordered. Review of orders revealed Resident #19 had an order in place dated 10/01/25 to ensure bed is on level four every shift and as needed. Observation on 05/05/26 at 7:51 A.M. revealed Resident #19's air mattress was set to level five. Observation on 05/05/26 at 1:31 P.M. revealed Resident #19's air mattress was set to level five. Interview on 05/06/26 at 6:45 A.M. with Maintenance Director (MD) #112 confirmed Resident #19's air mattress was set to level five. Interview on 05/06/26 at 6:54 A.M. with Certified Nursing Aide (CNA) #145 confirmed Resident #19's air mattress was set to level five. Review of an undated policy titled Pressure Ulcer Prevention Intervention revealed the policy of the facility is to implement preventative skin measures for all residents based on the levels and areas of risk to include moisture, nutrition, activity, mobility, mental status, psychosocial status, and general physical condition. When the interdisciplinary team is considering interventions, facility policy, standard of practice, and resident goals/preferences/advanced directives should be reviewed and considered prior to implementation.

Based on closed medical record review, review of infection control log, review contingency medication list, and interview the facility failed to ensure an urinalysis was collected timely and antibiotics were administered per order to treat urinary tract infection. This affected one resident (#48) of five residents reviewed for urinary tract infections.Findings include:Closed medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including dementia, anemia, scoliosis, and ulcerated proctitis. Review of Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was always incontinent of urine. Review of Resident #48's alteration in elimination related to incontinent of bowel and bladder dated [DATE] and cancelled [DATE] revealed to administer all treatments per order and monitor for signs and symptoms of urinary tract infections: foul smelling urine, cloudy urine, sediment, decreased output. Notify physician of changes. Review of Resident #48's urinary tract infection plan of care dated [DATE] and cancelled [DATE] revealed to administer antibiotics per physician orders, obtain and monitor labs per orders. a. Review of Resident #48's progress note dated [DATE] (Friday) revealed the hospice nurse was updated on foul smelling dark urine. New order for urinalysis, if unable to obtain Monday morning, attempt next morning. There was no evidence that the urinalysis was attempted to be collected or collected on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE] nor were there any assessments/signs or symptoms of the resident's urine/urinary tract infection. Review of a progress note dated [DATE] revealed urine was collected using aseptic technique via straight catheterization. The resident tolerated well and urine was labeled and placed in biohazard fridge with requisition paper inside the bag for pick up in the morning of [DATE]. Review of Resident #48's urinalysis and culture and sensitivity revealed the resident's urine was collected on [DATE], received on [DATE], and reported on [DATE]. The urine culture showed greater than 100,000 CFU/ml Escherichia Coli and Extended-spectrum beta-lactamases (ESBL) and was sensitive to Macrobid. Review of progress note dated [DATE] revealed hospice was notified of urinalysis results and requested to be faxed to them. Review of progress note dated [DATE] revealed the hospice nurse was notified of positive urinalysis culture and sensitivity. Nurse to review and return call to the facility. Review of a progress note dated [DATE] revealed new orders received from hospice physician for Macrobid (antibiotic) twice a day for seven days. Review of Resident #48's orders dated [DATE] revealed Macrobid 100 milligrams (mg) two times a day for seven days (14 doses) for urinary tract infection. Review of Resident #48's medication administration record (MAR) dated 03/2026 and 04/2026 revealed the resident only received 13 doses of Macrobid from [DATE] to [DATE]. The first dose on [DATE] was not administered and was coded 9 (see nurses note). Review of Resident #48's progress note dated [DATE] revealed no evidence of why the Macrobid was not administered on [DATE]. Review of a handwritten list of medications in the medication contingency box (undated) revealed Macrobid 100 mg was available. Review of Resident #48's McGeer Criteria for Infection Surveillance dated [DATE] revealed the resident had acute dysuria, suprapubic pain, new or marked increase of urgency and frequency, and greater than 100,000 cfu/ml of any organism and met criteria of a urinary tract infection. Review of Resident #48's antibiotic time-out form completed by the physician dated [DATE] revealed the resident was ordered Macrobid on [DATE] and McGeer's criteria for treatment. b. Review of Resident #48's orders dated [DATE] revealed orders for urinalysis. Review of Resident #48's progress notes dated [DATE] to [DATE] revealed no evidence the resident had signs or symptoms of urinary tract infection. Review of progress note dated [DATE] revealed straight catheterization for urine completed. Urine specimen in the refrigerator. Resident tolerated procedure well. Review of Resident #48's urinalysis and culture revealed the urine was collected on [DATE], received on [DATE], and reported on [DATE]. The urine culture showed greater than 100,000 CFU/ml Escherichia Coli and Extended-spectrum beta-lactamases (ESBL). Review of hospice note dated [DATE] revealed the resident continues to have dark, foul-smelling urine despite finishing a round of antibiotics. Review of progress note dated [DATE] revealed the resident was placed on last moments by hospice. Review of progress note dated [DATE] revealed hospice confirmed resident had expired at 10:41 P.M. Review of the infection control log dated 04/2026 revealed no evidence Resident #48 was documented on the log. Interview on [DATE] at 1:42 P.M., with Registered Nurse (RN)/ Infection Preventionist (IP) #117 confirmed Resident #48 urinalysis was ordered on [DATE] and not collected until [DATE], which was not timely. The RN/IP confirmed the lab was at the facility every day except Saturday and Sunday at that time. The RN/IP confirmed that the first dose of Macrobid was not administered on [DATE] as ordered nor was the order extended to ensure the resident received all 14 doses. RN/IP #117 confirmed Macrobid was available in the contingency box. The RN/IP confirmed that a Medication Technician (MT) had marked on the MAR on [DATE] to see documentation why the Macrobid was not administered, however there was nothing documented. RN/IP #117 also confirmed that the second urinalysis was ordered on [DATE] and not collected until [DATE], which was not timely collected as well. RN/IP confirmed the second urinalysis results were not documented on the infection control log nor was the resident treated due to the resident having expired on [DATE]. Interview on [DATE] at 2:09 P.M. with MT #133 confirmed she did not administer Resident #48's first dose of Macrobid on [DATE] due to the medication not being delivered via pharmacy. The MT reported the facility instructs the MT to chart 9 see nurses note, however MT's were not permitted to chart. The MT reported she was not sure if Macrobid was in the contingency box. The MT reported she told the nurse she didn't administer the Macrobid and it was the nurse's responsibility to document, modify order, and to follow up on the medication.

Based on interview, record review, laboratory test review, review of education material from the Cleveland Clinic, and policy review, the facility failed to ensure appropriate interventions were implemented for a resident with weight loss and compromised nutritional status. This affected one resident (#40) of three residents reviewed for nutrition. The census was 38.Findings include: Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including hypoglycemia, type 2 diabetes, dysphagia, benign prostatic hyperplasia, heart failure, major depressive disorder, insomnia, hallucinations, osteoarthritis, and mood disorder.Review of Resident #40's care plan initiated 08/09/25 revealed the resident was at risk for alteration in nutrition and hydration related to diabetes, and mechanically altered diet. Goals included the resident will be adequately nourished with no significant weight changes.Review of Resident #40's record revealed an order placed on 09/01/25 for monthly weights.Review of Resident #40's quarterly minimum data set (MDS) assessment completed on 02/11/26 revealed a brief interview for mental status (BIMS) score of 6, a total severity score of 2, and no displayed behaviors. The resident utilized a wheelchair for mobility, supervision/ touching assistance for eating toileting hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene, set up or clean up assistance for oral hygiene. The resident was occasionally incontinent of urinary and frequently incontinent of bowel. The resident had a therapeutic diet ordered (low salt, low cholesterol, and diabetic). The resident had not had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. The resident was not at risk of developing pressure ulcers/injuries and had no active skin problems. Review of the resident's Braden scale for predicting pressure ulcer evaluation completed 04/07/26 revealed a score of 17 indicating the resident was at risk for skin break down. Review of Resident #40's nutritional evaluation completed 04/09/26 revealed the resident had a weight loss of 5% or more in the last month or loss of 10% or more in 6 months with inadequate protein and oral intake, and altered nutrition related to labs. The resident was at nutritional risk related to type 2 diabetes mellitus, significant weight loss, and poor PO intake. Resident #40's estimated caloric intake needs included 2,455 calories, and 98 grams of protein.Review of Resident #40's weight record revealed on 01/07/26 the resident weighed 226.0 pounds (lbs). On 02/04/26 the resident weighed 229.6 lbs. On 03/04/26 the resident weighed 228.4 lbs. On 04/08/26 the resident weighed 216.0 lbs. On 04/15/26 the resident weighed 204.6 lb. On 04/22/26 the resident weighed 199.6 lbs. On 05/06/26 the resident weighed 195.0 lbs.Record review revealed Resident #40 had a 13.72% weight loss over five months.Review of Resident #40's laboratory work completed on 03/18/26 revealed an albumin level of 3.3 grams per deciliter (g/dl) [normal range 3.5-5.5 g/dl].Review of Resident #40's laboratory work completed on 04/02/26 revealed an albumin level of 2.5 g/dl [normal range 3.5-5.5 g/dl].Review of Resident #40's meal intake record revealed for 04/08/26 through 05/05/26 there was no documentation of 23 different meals. Of the 78 meals served to the resident , 55 meals had documented intakes. 26 meals served to Resident #40 had 0-25% consumed, 13 meals had 26-50% consumed, the resident refused seven meals.Record review revealed an order placed on 04/10/26 for house supplement juice drink 237 milliliters (ml) three times a day (TID) for supplement, 250 calories and nine grams of protein per 237 ml.Record review revealed an order placed on 04/10/26 for Remeron (appetite stimulant) oral tablet 15 milligrams (mg).Record review revealed an order placed on 04/22/26 for reduced carbohydrate diet, mechanical soft with fortified foods to all meals.Review of Resident #40's skin grid for pressure ulcers completed on 04/30/26 revealed the resident had a new pressure ulcer to the coccyx present upon readmission. Resident #40 had a Stage 2 pressure ulcer that measured 0.1cm in length, 0.1 cm in width, and 0.1 cm in depth. The wound had 100% granulation tissue with no drainage.Review of Resident #40's skin grid for pressure ulcer completed on 05/07/26 revealed the resident had a Stage 2 pressure ulcer to the coccyx with partial-thickness measuring 4.5 cm in length, 1.5 cm in width, and 0.1 cm in depth with 100% granulation tissue.Interview on 05/12/26 at 9:26 A.M. with the facility dietician revealed the facility holds a monthly nutritional risk meeting with different members of the interdisciplinary team. In these meetings they review weight loss, significant weight loss, new wounds, worsening wounds, tube feeds, and dialysis. The dietician stated Resident #40 has had significant weight loss and thought he was getting weekly weights. The dietician confirmed the order was for monthly weights. Facility dietician stated the last risk meeting for Resident #40 was on 04/06/26. Dietician stated they were not made aware Resident #40 had developed a new pressure ulcer.Review of education published from the Cleveland Clinic (https://my.clevelandclinic.org/health/diagnostics/22390-albumin-blood-test)updated 12/10/24 revealed albumin is protein in the blood plasma. Albumin levels can indicate underlying nutritional deficits, for example if someone is not getting enough protein. Lower than normal albumin levels in the blood may be a sign of poor nutrition.Review of undated facility policy title weight policy and procedure revealed any weight variance (increase or decrease) of three pounds in one week or three pounds in one month must be reweighed within 24 hours. All weights and reweights must be recorded on the resident weight sheet found in the weight book. All recorded weights must be initiated and dated by the person recording the weight.Review of undated facility policy titled pressure ulcer prevention intervention revealed hydration status needs monitored, consult the registered dietician as needed. If the resident who is well-nourished develops an inadequate dietary intake of protein and calories, a nutritional assessment should be completed by the registered/ licensed dietician.

Based on record review, observation, interviews, and policy review the facility failed to administer oxygen to residents as ordered and failed to ensure appropriate use of oxygen. This affected two residents (#19, #15) of five residents reviewed for respiratory care. The census was 38.Findings include: 1.Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including end stage renal disease and atrial fibrillation. Review of a care plan dated 02/26/19 revealed Resident #19 had an alteration in oxygen exchange/perfusion related to chronic respiratory failure and chronic obstructive pulmonary disease. The goal was for lungs to be clear to auscultation and oxygen saturation above 90%, respirations to be unlabored, and show adequate oxygen perfusion. Interventions included but were not limited to evaluate shortness of breath for pain and discomfort when breathing and administer medications as ordered to relieve and provide oxygen per orders. Review of orders revealed an order dated 04/30/26 for Resident #19 to have humidified oxygen via nasal cannula at three liters per minute continuously and check oxygen saturation each shift. Observation on 05/05/26 at 7:52 A.M. revealed Resident #19 was resting in bed and had oxygen in place via nasal cannula at four liters per minute. Observation on 05/05/26 at 1:31 P.M. revealed Resident #19 was seated in her wheelchair with oxygen in place via nasal cannula at four liters per minute. Interview on 05/06/26 at 6:45 A.M. with Maintenance Director (MD) #112 confirmed Resident #19 had oxygen in place via nasal cannula but was set to four liters per minute. Interview of 05/06/26 at 6:54 A.M. with Certified Nursing Assistant (CNA) #145 confirmed Resident #19's oxygen was set to four liters per minute. Review of an undated policy titled Nasal Cannula revealed the knob of the oxygen concentrator should be adjusted to the flow rate prescribed by the provider. 2, Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension, muscle weakness with difficulty walking, and type two diabetes. Review of Resident #15's order placed on 03/18/26 revealed the resident required oxygen continuously at three liters per minute for shortness of breath and COPD. Review of Resident #15's care plan dated 04/07/26 revealed the resident had an alteration in respiratory function and required oxygen at three liters per minute via nasal canula. Goals included their oxygen level will be kept at desired levels set per physician through review date. Interventions include administering oxygen as ordered, monitor oxygen saturation levels as ordered, and observe the resident for signs and symptoms of dyspnea such as labored respirations, low oxygen saturation, use of accessory muscles, cyanosis, changes in mental status, and tachypnea. Review of Resident #15's care plan dated 04/07/26 revealed the resident had an alteration in respiratory function related to COPD, and respiratory failure. Goals include the resident will be free from respiratory distress through the review date, the resident will show adequate oxygen perfusion through the review date, and oxygen saturation will be above 90% through the review date. Interventions include providing oxygen to the resident as ordered. Review of Resident #15's minimum data set (MDS) assessment completed 04/26/26 revealed a brief interview for mental status score of 9 indicating the resident had moderate cognitive impairment. Section O for special treatments revealed the resident required continuous oxygen therapy. Review of Resident #15 progress note dated 05/04/26 at 12:02 P.M. revealed the resident walked themself to the dining room without oxygen. Observation on 05/04/26 at 11:53 A.M. revealed Resident #15 in the dining room walking with walker towards door stating she needed air and could not breathe with pale lips, labored breathing, and delayed responses. Resident #15 then sat in a chair outside of the dining room and stated she was going to pass out, and she needed a nurse now. The surveyor remained with the resident, while an additional surveyor alerted a facility CNA of the resident and their status, trouble breathing, and requesting a nurse immediately. At 11:57 A.M. Registered Nurse (RN) #117 arrived to the resident, Resident #15 stated she needed air and couldn't breathe. Prior to placing oxygen on the resident or obtaining vital signs RN #117 guided resident to walk back into the dining room despite resident stating she felt like she was going to pass out. At 11:58 A.M. RN #117 placed the resident on oxygen via nasal cannula and obtained vital signs revealing an oxygen saturation of 67%.

Based on observation, record review, review of a facility self-reported incident (SRI), review of staff statements, review of the facility's abuse policy and procedure, and interviews, the facility failed to timely report and implement immediate and effective measures to protect residents following allegations of sexual abuse. This resulted in Immediate Jeopardy and the potential for actual harm including serious injury and psychosocial harm beginning on [DATE] at approximately 11:30 P.M. when Certified Nursing Assistant (CNA) #108 notified the supervisor, Licensed Practical Nurse (LPN) #115 she believed LPN #119 had assaulted Resident #22 and Resident #18 due to changes in the resident's behaviors, including yelling, screaming, crying, not complying with care, and shaking when LPN #119 was present with the resident(s). Upon notification, LPN #115 did not implement immediate safeguards to prevent further potential abuse including immediately assessing the residents, removing LPN #119 from resident care, and reporting the allegation to the Director of Nursing (DON) and/or Administrator. LPN #115 requested written statements from CNA staff to place in the DON's mailbox for review on [DATE]. As a result of LPN #115's inaction, CNA #108 called local police for assistance and to ensure resident safety. Upon police arrival, LPN #119 was removed from the facility. A police investigation remains ongoing at this time This affected two residents (#22 and #18) and had the potential to affect all 43 residents residing in the facility. On [DATE] at 5:28 P.M., the Regional Director of Operations, DON, and Administrator were notified Immediate Jeopardy began on [DATE] at approximately 11:30 P.M. when CNA staff reported allegations of staff to resident sexual abuse involving Resident #18 and Resident #22 to LPN #115. LPN #115 failed to immediately report the allegations to the Administrator and/or DON, failed to initiate a thorough and comprehensive investigation and failed to ensure LPN #119, the alleged perpetrator was removed from the facility to ensure resident safety, placing all 43 of 43 residents at risk for actual harm/abuse. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: On [DATE] at 7:00 A.M. the Administrator and DON initiated an investigation gathering statements from staff present at the time of the incident on [DATE]. Statements were gathered from LPN #115 and CNA #124 by 8:30 A.M. On [DATE] at 7:15 A.M. the DON completed skin assessments on Resident #22 and Resident #18. On [DATE] at 7:32 A.M. the detective notified Resident #22's family of the allegation. On [DATE] at 9:00 A.M. the Administrator notified the Medical Director of the sexual abuse allegation and investigation in progress and the DON, and LPNs #113 and #101 completed house wide skin assessments on 42 residents which were completed by 4:33 P.M. Resident interviews were conducted with 33 residents by Social Service Staff between 9:00 A.M. and 11:00 A.M. 10 residents were non-interviewable. On [DATE] at 10:05 A.M. the Quality Assurance nurse initiated an SRI regarding the sexual abuse allegation. On [DATE] at 11:04 A.M. the DON and Administrator notified Resident #18's family of the allegation. On [DATE] at 12:00 P.M. Human Resources (HR) and the Administrator initiated in person education regarding the abuse policy and procedure, reporting, and that if the nurse in charge was not addressing their issue or concerns to call the DON or Administrator. Six administrative staff, two housekeepers, one laundry aide, three CNAs, two dietary staff, two LPNs, one activity aide, and one medication technician received this in person training. In addition, at 3:40 P.M. the education was provided via phone to four LPNs, two registered Nurses (RNs), two housekeepers, one activity aide, eight CNAs, two medication technicians, one transport aide, and three dietary staff. On [DATE] at 6:00 P.M. a verbal statement was received by the DON and administrator from CNA #128. On [DATE] at 7:42 P.M. LPN #115 was suspended pending investigation for not following facility policy and procedure on abuse reporting. On [DATE] at 9:15 A.M. CNA #108's written statement was collected by Corporate Human Resource (HR) staff. On [DATE] at 5:53 P.M. re-education on the abuse policy and procedure, reporting, and that if the nurse in charge was not addressing their issue or concerns to call the DON or Administrator was completed for seven administrative staff, five CNAs, two dietary employees, four LPNs, two medication technicians, one activities employee, and one RN. The education was provided by HR and the Administrator. All staff not re-educated would receive reeducation prior to the start of their next shift by the Administrator, DON, or HR. On [DATE] between 6:52 P.M. and 8:00 P.M. 34 resident interviews related to abuse and safety were completed by Social Services #142. On [DATE] between 7:00 P.M. and 10:00 P.M. skin assessments for 43 residents were completed. On [DATE] between 7:15 P.M and 8:45 P.M. reeducation on the abuse policy and procedure, reporting, and that if the nurse in charge was not addressing their issue or concerns to call the DON or Administrator was reinitiated via phone by the Administrator for one administrative staff, four housekeepers, one laundry employee, seven CNAs, two dietary employees, four LPNs, two medication technicians, one activities aide, and one transport aide. On [DATE] at 7:30 P.M. a written statement was received from CNA #128 by the Administrator. On [DATE] at 1:46 A.M. re-education on abuse, reporting, and that if the nurse in charge was not addressing their issue or concerns to call the DON or Administrator was completed with one RN via phone by the Administrator. On [DATE] at 12:28 P.M. re-education on abuse, reporting, and that if the nurse in charge was not addressing their issue or concerns to call the DON or Administrator was completed via phone with one medication technician by HR. On [DATE] at 3:57 P.M. re-education on the abuse policy and procedure, reporting, and that if the nurse in charge was not addressing their issue or concerns to call the DON or Administrator was completed via phone with one CNA by HR. Any employee who had not received education would receive the education prior to the start of their next shift by the Administrator, DON, or HR. On [DATE] at 5:39 P.M. LPN #115 was terminated for not following facility policy and procedure on abuse reporting. Beginning on [DATE] the DON/Designee would interview three residents per day, five days a week for four weeks to rule out abuse. Beginning [DATE] the DON/ Designee would conduct three staff interviews per day, five days a week, for four weeks to ensure the abuse policy was being followed and allegations of abuse were reported timely. Beginning on [DATE] the DON/Designee would conduct three skin assessments per day of non-interviewable residents, five days a week for four weeks to ensure there were no signs of abuse beginning. An Ad-HOC Quality Assurance Performance Improvement (QAPI) was completed on [DATE] at 12:50 P.M. The topic was Abuse Policy and Procedure. The Abuse Policy, Abatement Plan and Root Cause Analysis related to late reporting and compromising the safety of the residents were reviewed. The Interdisciplinary Team (IDT) team met along with the Medical Director to review the Abuse Policy, Abatement plan and Root Cause Analysis related to late reporting and compromising the safety of the residents. The QAPI team was in agreement with the facility abatement plan and would continue to monitor those areas. Should any new concerns or issues arise, the QAPI team would reconvene at that time. Results of audits would be reviewed in monthly QAPI meetings with the Medical Director, Administrator, and DON. Results of audits would be reviewed in quarterly QAPI meetings with the IDT Team.Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance.1. Review of Resident #22's medical record revealed an admission date of [DATE] with diagnoses including respiratory failure with hypoxia, depression and dementia. Record review revealed Resident #22 was receiving Hospice (end of life) services. Review of the Minimum Data Set (MDS) assessment completed [DATE] revealed Resident #22 had moderately impaired cognition and no documented behaviors.Review of Resident #22's progress notes revealed no concerns/incidents were documented by LPN #119 or LPN #115 from [DATE] through [DATE]. Review of a skin check dated [DATE] (no time noted) completed by LPN #113 revealed Resident #22 had moisture-associated skin damage, and no other areas of concern noted.Review of a facility Self- Reported Incident (SRI) tracking number 263598 dated [DATE] revealed one staff member (CNA #108) alleged another staff member (LPN #119) had inappropriately touched two residents (#18 and #22). The SRI included the staff member (LPN #119) was immediately suspended. Review of a statement by CNA #124 dated [DATE] revealed she did not witness any assault to residents but had overheard CNAs #108 and #128 say residents were bleeding, someone touched them, and Resident #22's brief smelled of some man. CNA #124's statement indicated no resident had reported any concerns to her. CNA #124's statement also indicated the police were called instead of management because nothing ever got done when reported, and when they did report to management, they got yelled at by their nurses, AKA LPN #115 who would not call management because it was too much work. Attempts to reach CNA #124 for interview during the investigation were unsuccessful.Review of a statement by LPN #115 dated [DATE] revealed he did not witness assault toward a resident. In the statement LPN #115 mentioned how CNA #108 stated what she thought LPN #119 was doing to residents; no resident told LPN #115 they were being assaulted. LPN #115 asked CNA #108 and CNA #128 to write statements so there was a paper trail and then LPN #115 would notify the DON. LPN #115's statement revealed he thought the police were called because CNA #108 wanted a quick response, but he was not sure. Interview on [DATE] at 8:06 A.M. with the granddaughter of Resident #22 (Granddaughter #200) revealed between [DATE] and [DATE] there was an allegation Resident #22 experienced sexual assault which was still under investigation by the sheriff's department. Granddaughter #200 revealed the family had previously placed a camera in the resident's room, but the camera did not have recording capability because the facility had informed the family they were not allowed to have recording devices in resident rooms. Granddaughter #200 stated she was unsure what had happened but knew two aides had called the police, and she heard another resident (#18) had rectal bleeding due to abuse. Granddaughter #200 stated following the incident, the family chose not to send Resident #22 to the hospital for a rape kit because of the resident's (terminal) condition but stated she was aware LPN #119 had been interrogated by police for a couple hours, DNA evidence was collected, and LPN #119 agreed to take a polygraph. During the interview, Granddaughter #200 stated she was not informed of the allegations by the facility when the allegations were made the night before, but rather she had been notified by the sheriff's department on [DATE] at 7:13 A.M. Granddaughter #200 stated Resident #22 would be mortified (of the allegations/situation) because she was a very private person and after her husband passed away in 1982 she did not remarry. Interview on [DATE] at 9:20 A.M. with Lieutenant (LT) #144 revealed the police department had been called related to reports by a caregiver that LPN #119 had possibly sexually assaulted a couple residents. At the time of the interview, LT #144 revealed the incident was still under police investigation and items had been sent to the lab for testing. LT #144 was aware one resident (#18) was bleeding from her anus but staff had reported the resident did have hemorrhoids, and the other resident (#22) had yelled get off me, leave me alone but this resident had a history of behaviors.Interview on [DATE] at 9:28 A.M. with Resident #22's representative (Resident Representative [RR] #201) revealed he found out at 7:07 A.M. on [DATE] from the sheriff's department there was an allegation the night before that Resident #22, and another lady had been sexually assaulted. RR #201 stated no details were shared and when family spoke to the facility, they did not say anything about the allegation. There were two detectives present for a meeting with the facility who did all the talking. RR #201 felt there was no resolution to the situation, so he installed a recording device in the resident's room on [DATE]. RR #201 stated he installed the recording device because staff kept turning off the previous device ([NAME]) monitor (virtual assistant technology) that was in the room. RR #201 stated he was aware the nurse involved in the incident was supposed to be suspended. RR #201 did not know what other staff were working at the time of the incident or when the allegation was made. Interview on [DATE] at 10:28 A.M. with Hospice Nurse (HN) #146 revealed she was the on-call nurse over the weekend from [DATE] to [DATE] and had not been made aware on [DATE] of any allegation of sexual abuse involving Resident #22. HN #146 stated any time there was an allegation of sexual abuse, an assessment of the resident needed completed.Interview on [DATE] at 10:38 A.M. with HN #147 revealed she was made aware of an allegation of sexual abuse to Resident #22 and completed a head-to-toe assessment on [DATE]. However, the assessment was not specific to sexual abuse as HN #147 revealed she was not qualified to perform that type of assessment. HN #147 stated Resident #22 was minimally responsive (behavior wise) due to the resident being end of life, but she did have some moaning and groaning when staff assisted with turning. HN #147 stated the facility should let hospice know of abuse allegations within 24 hours.On [DATE] at 11:04 A.M. an attempt to interview CNA #124 was unsuccessful. A voice message was left with no return call received.Interview on [DATE] at 11:25 A.M. with LPN #115 revealed he had written a statement which he felt was complete, thorough, and accurate and that was all the information he could provide (content of statement noted above). During the interview, LPN #115 declined to answer any questions related to why he did not assess the resident, write a progress note, notify the DON or Administrator, and remove LPN #119 from resident care following the allegation of sexual abuse being made to him. Interview on [DATE] at 1:15 P.M. with [NAME] (SGT) #145 revealed there was a report two residents had been sexually assaulted, he did not personally see the residents, and his main objective was to interview the alleged perpetrator, LPN #119. SGT #145 stated evidence was being submitted to the lab, concurrent investigative techniques were on-going and additional information could not be released at this time since a criminal investigation was ongoing.During an interview on [DATE] at 1:56 P.M. CNA #108 voiced concerns the facility did not investigate things like they should. CNA #108 stated on [DATE] she and CNA #128 were in Resident #18's room when they heard LPN #119 calling for help. The CNA went into the hallway and LPN #119 was standing outside Resident #22's room, pushing his hair back, and stated she needs put back in bed and I don't think she is breathing. CNA #108 stated Resident #22 was sitting partly on the bed and partly off, and kept repeating, I didn't have my underwear on, while holding on to her incontinence brief. Resident #22's lips looked torn, and she looked like she was about to pass out with her eyes rolling back in her head. When LPN #119 attempted to enter the room Resident #22 went stiff and started shaking. CNA #108 stated she thought Resident #22 looked like she had been over-medicated and raped. CNA #108 stated when LPN #119 walked in the room, he passed by the [NAME] device, and she thought maybe he had turned the camera on at that time as the CNA stated the family had complained in the past about it being turned off. After Resident #22 began to panic, LPN #119 took off down the hallway. CNA #108 was unable to get Resident #22 to scoot up in the bed because she was scared to death. The CNA revealed the concerns were reported to LPN #115 who was the manager working. CNA #108 stated after reporting the concerns, LPN #115 wanted to talk to her, said she could not go around making allegations, and a witness statement needed to be filled out. CNA #108 went back to check on Resident #22 was who still in the same position and would not allow anyone to change her. Resident #22 was shaking and turning her head. CNA #108 stated she realized no one was going to do anything about the concerns the CNA staff had, so she called 911 (emergency services). CNA #108 stated LPN #119 had just come back to work after being suspended following a similar allegation (of sexual abuse from another resident). CNA #108 stated a female sheriff came to the facility with investigators to look at Resident #22, and when they entered the room and Resident #22 saw a female deputy her whole body relaxed, and she started crying. CNA #108 rolled Resident #22 over so her backside would face the female deputy and CNA #108 thought The resident's anus was protruding. CNA #108 also stated Resident #22's family requested that a nurse from outside the facility assess Resident #22, but the DON would not allow it. During the interview, CNA #108 was frantic and crying.Interview on [DATE] at 3:45 P.M. with Granddaughter #202 revealed she had been watching the [NAME] camera to check on Resident #22 at about 10:00 P.M. on [DATE] to make sure she received her medicine, which she did. Granddaughter #202 stated she then checked at about 11:00 P.M. and noticed Resident #22 was seated at the edge of the bed and she called the facility. LPN #119 answered, headed straight to the room, and helped Resident #22 lay back down. Granddaughter #202 stated she went to check the camera a little bit later and it indicated the service was out or connection could not be made, so she kept checking in. At about 12:00 -12:30 A.M. on [DATE], she checked the camera, and it was back on and there were three aides in Resident #22's room, one stated they were not going to touch her, and they needed to get LPN #115 in the room. Then LPN #115 and three aides were in the room; the view of Resident #22 was blocked, and they were all whispering but she did hear them say LPN #119's name. Granddaughter #202 called the facility and LPN #119 answered and stated nothing was wrong, and when asked why four people were in Resident #22's room he stated, Oh, LPN #115 is in there? She's ok. LPN #119 did not say anything else but she stated she did miss a call from him at about 2:30 A.M. The missed call indicated Resident #22 was agitated, they were going to give her medication, and someone would sit with her for a little bit. Granddaughter #202 stated that was all she knew until the family was contacted by the sheriff's department the following morning.Interview on [DATE] at 4:20 P.M. with LPN #119 revealed he had no clue what happened on [DATE]-[DATE], but the sheriff's department showed up and stated a complaint was called in. LPN #119 stated he called the Administrator regarding the sheriff's department being at the facility but was unable to tell her why they were at the facility since he stated he did not know. LPN #119 stated on [DATE] at about 5:00 A.M. - 5:30 A.M. a detective wanted to speak to him outside and he left the facility with the police. During the interview LPN #119 stated he was new to the unit Resident #22 was on because his assignment had been switched after an allegation of inappropriate touching had been made against him by a resident on a different unit. During the interview, the LPN denied knowledge of being suspended but indicated he had not worked in the facility since leaving with police on [DATE]. Interview on [DATE] at 6:27 P.M. with CNA #128 revealed she and CNA #108 had finished cleaning up Resident #18 but were still cleaning the room when CNA #108 exited to assist LPN #119. A couple minutes later, CNA #128 went in Resident #22's room and saw CNA #108 crouched next to Resident #22 at the resident's bedside. Resident #22 was screaming and not acting like herself. The CNA stated Resident #22 always got up on the side of the bed facing the window, but this time she was facing the door. Resident #22 was frantic, alarmed, and stated she had only been this way one time before, on the night of [DATE] which was LPN #119's first time working the hall. CNA #128 stated she was not sure what made Resident #22 act out, but the resident was flustered and in a panic. When LPN #119 entered the room from behind CNA #108, it got worse and Resident #22 began screaming, get away from me, stop touching me, but no one was actually touching her at that time. CNA #108 was crouching at the bedside to keep Resident #22 from falling, and when she noticed Resident #22's reactions, CNA #108 told LPN #119 to get out, and told CNA #128 to get LPN #115. When CNA #128 re-entered Resident #22's room with LPN #115, Resident #22 was no longer screaming and allowed CNA #108 to soothe her. CNA #128 stated CNA #108 then looked at LPN #115 and stated, he (LPN #119) did something to her. CNA #108 began to get worked up and left the room, so LPN #115 followed her. CNA #128 stated Resident #22's brief had been undone on the left side, but barely reattached and when she tried to fix it, Resident #22 began screaming so she told Resident #22 she would not change the incontinence brief and it would be okay. Resident #22 yelled stop touching me, it's my right. Once Resident #22 was calmed down, CNA #128 left the room to try to find out what was going on because she was no longer comfortable with LPN #119 working with the residents since there was a big change in resident behaviors since he started working on the unit. CNA #128 stated LPN #119 had kept his medication cart outside Resident #22's room the entire night and did not leave the area. LPN #115 was not helpful regarding the incident and just directed CNA #128 to write a witness statement. CNA #128 stated she had previously reported several concerns to LPN #115, including suspicion of LPN #119 being on drugs at work, and he did not do anything to address the concern. The CNA revealed LPN #115 stated if they did not want to write statements, everyone could sit in the break room together to come to a resolution and discuss their feelings. LPN #115 stated if the staff wrote statements he would put the witness statements in DON's mailbox to review the following morning. After 1:00 A.M. on [DATE], CNA #128 stated she encouraged CNA #108 to call the police since no one else was doing anything and they were both uncomfortable with LPN #119 being around the residents. CNA #128 stated LPN #115 should have called the Administrator as soon as concerns were brought to his attention. CNA #128 stated she was not sure what had occurred or been done to Resident #22, but she knew it was something traumatic or an action which caused the resident distress to be uncomfortable and act the way she did. CNA #128 stated the police arrived at the facility at about 3:00 A.M. and LPN #119 remained in the facility after the allegations were reported, until at least 5:15 A.M. Review of a nursing note dated [DATE] timed 8:44 A.M. authored by the DON revealed Resident #22 had expired. Resident #22's time of death was 8:39 A.M., hospice was notified, and family was at bedside.A follow up interview on [DATE] at 2:21 P.M. with CNA #108 revealed when Resident #22 began shivering and tensing up, the CNA looked at LPN #119 and asked, you did it again, didn't you? referring to previous allegation against LPN #119. CNA #108 stated when LPN #115 came in the room she stated specifically, he's [LPN #119] hurting them. What are you going to do about this? LPN #115 wanted statements written, but the residents needed help then.2. Review of Resident #18's medical record revealed an admission dated of [DATE] with diagnoses including unspecified fracture of lumbar vertebra, schizoaffective disorder, and mild cognitive impairment. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18's cognition was severely impaired, and she had verbal behaviors one to three days during the seven-day review period. Review of nursing notes dated [DATE] timed 7:30 A.M. and 8:52 A.M. authored by the DON revealed Resident #18's daughter was called with no success. Review of a nursing note dated [DATE] timed 11:04 A.M. revealed Resident #18's daughter was called and updated on her status.Review of a skin check dated [DATE] (no time noted) revealed Resident #18 had no new skin issues.Review of a facility Self- Reported Incident (SRI) tracking number 263598 dated [DATE] revealed one staff member (CNA #108) alleged another staff member (LPN #119) had inappropriately touched two residents (#18 and #22). The SRI included the staff member (LPN #119) was immediately suspended.Observation and attempted interview on [DATE] at 7:56 A.M. revealed Resident #18 was pleasantly confused, was smiling and appeared well-groomed.During an interview on [DATE] at 1:56 P.M. CNA #108 revealed on [DATE] she was assisting another aide (CNA #128) with providing care to Resident #18. During the care it was noted Resident #18's anus was bleeding, they could barely put cream on her anus, and the resident screamed men came in at night. CNA #108 stated Resident #18's anus looked like it had hairline rips or cuts and did not resemble hemorrhoids. CNA #108 also stated Resident #18's family had told her they had never seen Resident #18's anus bleed the way it had been for a couple weeks. Resident #18's family requested that a nurse from outside the facility assess Resident #18, but the DON would not allow it. CNA #108 described the blood at Resident #18's rectum as bloody with an almost jelly-like consistency. CNA #108 did not think the blood was from Resident #18 digging at the area. During the interview, CNA #108 was frantic and crying.Interview on [DATE] at 6:27 P.M. with CNA #128 revealed normally Resident #18 was very compliant with care, but she was not on the evening of [DATE]. Resident #18 required a lot of help that evening and CNA #108 was also in the room. They were in her room from about 8:30 P.M. to 9:00 P.M. CNA #128 stated Resident #18 screamed and screamed when cream was applied to her rectum, but it did not appear Resident #18 had hemorrhoids. Resident 18's rectum was red and sore, it was bleeding but not a lot and it looked like she had hairline cuts. CNA #128 stated the way Resident #18 was acting was not normal. CNA #128 stated the bleeding of Resident #18's rectum had been worse in the previous weeks. CNA #128 stated she did not believe Resident #18 was able to reach her own rectum to cause the bleeding. CNA #128 stated she had previously reported several concerns to LPN #115, including suspicion of LPN #119 being on drugs at work, and he did not do anything to address the concern. The CNA revealed LPN #115 stated if they did not want to write statements, everyone could sit in the break room together to come to a resolution and discuss their feelings. LPN #115 stated if the staff wrote statements he would put the witness statements in DON's mailbox to review the following morning. After 1:00 A.M. on [DATE], CNA #128 stated she encouraged CNA #108 to call the police since no one else was doing anything and they were both uncomfortable with LPN #119 being around the residents. CNA #128 stated LPN #115 should have called the Administrator as soon as concerns were brought to his attention. CNA #128 stated she was not sure what had occurred or been done to Resident #18, but she knew it was something traumatic or an action which caused the resident distress to be uncomfortable and act the way she was. CNA #128 stated the police arrived to the facility at about 3:00 A.M. and LPN #119 remained in the facility after the allegations were reported, until at least 5:15 A.M.Interview on [DATE] at 9:03 A.M. with the Administrator revealed she was not aware of any allegations of abuse/sexual abuse involving Resident #18 or Resident #22 until [DATE] at 7:30 A.M. when she first found out about the allegations. The Administrator reported the nurses did call her on [DATE] at about 4:00 A.M. to let her know the police were at the facility but they did not know why they were there. The Administrator confirmed LPN #115, who was the nursing supervisor, should have reported allegations (of abuse to her) as soon as they were made. The Administrator indicated when a supervisor did not address a concern, staff were to report directly to her or the DON. The Administrator stated no one had reported concerns to her from night shift previously and she would expect if concerns were reported to the nightshift supervisor they would be communicated to her or the DON.During an interview on [DATE] at 10:44 A.M. with the DON, the DON denied knowledge of concerns or reports being made to her about nightshift staff, including allegations of drug use or inappropriate behaviors. The DON stated abuse should be reported immediately to administration, then within two hours to the State agency. The DON said the alleged perpetrator should be removed from the facility as soon as allegations were made to ensure resident safety, the resident(s) should be assessed immediately, witness statements collected, family and physicians should be notified, and medical care should be obtained if needed. The DON stated she did not receive a call until about 4:00 A.M. on [DATE] when the first detective arrived at the facility, but during that call the nurses did not know what was happening. She was subsequently made aware the detectives took LPN #119 from the facility for questioning. The DON stated she arrived to the facility on [DATE] at about 4:35 A.M. and did not see LPN #119. The police informed the DON and Administrator of the allegations later that morning around shift change (shift change was at 6:00 A.M. for CNA staff and 7:00 A.M. for nurses). Interview on [DATE] at 2:01 P.M. to 2:34 P.M. with Resident #18's power of attorney (POA) (POA #203) revealed before the allegations, she was visiting Resident #18 and assisted in changing her incontinence brief when she noticed blood. The aide thought it could be vaginal bleeding but it went further back, so Resident #18 was rolled further and there was blood from her rectum. POA #203 stated Resident #18 had a history of irritable bowel syndrome, diverticulitis, constipation and hemorrhoids and had previously needed to manually remove stool from her rectum. A nurse checked over Resident #18 and POA #203 had no concerns at the time and reported seeing stool on her mom's fingers before so it made sense to her. POA #203 stated on the morning of [DATE], she received a phone call from the facility related to allegations of sexual abuse and was shocked because the allegations happened the night before but she had not been notified. She did not receive a phone call at the time but if she had she would have come to the facility to be with her mom and to make decisions related to the allegation. POA #203 revealed the Administrator was not aware until [DATE] because the police showed up to the facility. POA #203's initial reaction was nothing had happened, the aides were wrong and had jumped to conclusions. However, POA #203 stated she was informed of the allegations regarding the other resident (#22) as well. POA #203 stated she had spoken to SGT #145 and was aware they had collected evidence and would have additional information when the lab reported back. The police[TRUNCATED]

Based on medical records review, emergency room records review, interview, and facility policy review, the facility failed to develop and implement a comprehensive, individualized and adequate pain management program to provide effective and timely pain relief to residents after falls with injury/fractures. Actual harm occurred on 06/22/24 at 10:31 P.M. when Resident #35 was not provided effective pain management following a fall with hip fracture on 06/22/24 with complaints of significant verbal and non-verbal indicators of pain. The resident was subsequently sent out to the emergency room for the fracture and continued pain on 06/23/24 at 7:15 P.M. (approximately 20 hours after the fall occurred). Actual harm occurred on 03/17/24 at 6:45 A.M. when Resident #22 experienced a fall that resulted in pain and a non-displaced fracture of the greater tuberosity and minimally impacted humeral neck fracture component of the left shoulder fracture. Although the resident complained of pain, pain medication was not initially provided until 03/17/24 at 11:00 A.M. (over four hours after the fall). Actual harm occurred beginning on 01/04/24 at 10:38 P.M. when Resident #24 was not provided effective pain management after a fall with a left comminuted minimally displaced fracture of the proximal humerus. Following the fall, no pharmacological or effective non-pharmacological pain interventions were provided until the resident was transferred to the emergency room (ER) on 01/05/24 at 3:42 A.M. (over five hours later). Direct care staff reported the resident voiced complaints of pain to the area following the incident and before being transferred to the ER. Upon arrival to the ER the resident was assessed to have significant pain to the area. This affected three residents (#24, #22 and #35) of four residents reviewed for pain. The facility census was 46. Findings include: 1. Review of the medical record for Resident #35 revealed an admitted [DATE] with diagnoses including unspecified dementia, adult failure to thrive, difficulty in walking, muscle wasting and atrophy and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was assessed to require supervision or touching assistance with toilet hygiene and partial/moderate assistance with eating, bed mobility, and transfers. The resident was also assessed in the past 5 days to not receive any scheduled pain medication and received no non-pharmacological interventions for pain. Review of the progress note dated 06/22/24 10:31 P.M. revealed Resident #35 was found on the floor at the foot of the bed on the left side. The resident's head was bleeding, and the resident was wincing in pain when attempting to move him, and an order was obtained to send Resident #35 to the emergency department (ER). Review of Resident #35's progress note dated 06/23/24 2:10 A.M. revealed the resident returned to the facility from the ER at this time. Review of Resident #35's fall report dated 06/22/24 revealed the resident was confused, found at the foot of the bed on left side with abrasion to forehead, arm and hip pain and was sent to the ER. Record review revealed no evidence the facility developed a comprehensive and individualized plan of care to address the resident's pain or that the resident was monitored/assessed for pain upon return from the ER. Review of the progress note dated 06/23/24 at 12:20 P.M. (10 hours after he returned from ER) by Licensed Practical Nurse (LPN) #100 revealed Resident #35 was assessed for left leg/hip pain after staff reported resident screamed out in pain while changing and trying to get him up for lunch. When assessing, resident yelled when leg lifted and bent at the knee and place back in bed. The resident's left hip area noted to be discolored, area palpated, and resident screamed out in pain. Resident #35's wife was at bedside and said the hospital didn't x-ray the left hip during visit on 06/22/24. A STAT x-ray of the left hip was obtained at this time. Record review revealed no evidence the physician was notified of the pain the resident was displaying at this time to provide any type of pain management/pain relief. Review of the physician's order dated 06/23/24 at 12:20 P.M. reflected the order for Resident #35 to have a STAT x-ray of the left hip for pain. There was no indication the resident was provided any pharmacological or non-pharmacological pain interventions at this time. Review of the radiology report dated 06/23/24 at 5:40 P.M. for Resident #35 revealed a recent left hip fracture and a cat scan was suggested. Review of a progress note for Resident #35 revealed on 06/23/24 at 7:15 P.M. LPN #100 received the results from the x-ray. The note indicated hospice triage notified and would notify doctor for pain meds and will call back. At 7:40 P.M. the resident was sent out to the ER. Further review of Resident #35's record revealed no pharmacological, non-pharmacological pain interventions or follow-up/monitoring of the resident related to pain after the fall or after the resident's return from the ER. There was no evidence the facility developed a comprehensive and individualized plan of care to address the resident's pain upon return from the ER. Interview on 07/10/24 at 8:50 A.M. with STNA #555 revealed she was working the day of 06/23/24 and when staff would provide personal care/change Resident #35 every two hours, he would cry out in pain. STNA #555 stated she told the nurse, and they used a pillow to position him, but he would still cry out and grab at his left leg. Interview on 07/10/24 at 9:08 A.M. with LPN #100 revealed on 06/23/24, Resident #35 would cry out in pain when being changed every two hours the aides informed him of the resident being uncomfortable and crying out in pain, so a pillow was used to keep the resident propped up on his right side for comfort. The LPN verified no other non-pharmacological interventions, and no pharmacological interventions were implemented to address the resident's pain with being changed and stated the resident did receive Ativan for behaviors (previously ordered medication for anxiety) that were consistent with prior to the fall and that makes him sleepy. In addition, the LPN revealed staff did not get Resident #35 out of bed all day as a result of the pain he was experiencing status post fall. 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including bipolar disorder, major depressive disorder, schizoaffective disorder, anxiety disorder, and specified disorders of bone density and structure, unspecified site. Review of Resident #22's fall report revealed that a fall occurred on 03/17/24 at 6:45 A.M. when the resident was sitting on the side of the bed and reached for a paper on the floor and fell forward. Review of Resident #22's progress notes dated 03/17/24 at 6:45 A.M. by LPN #123 revealed the resident stated that her arms hurt. Review of the Medication Administration Reconciliation (MAR) dated 03/17/24 at 6:45 A.M. for Resident #22 revealed a pain level of seven on a scale of 0 to 10 documented per LPN #123. However, no pain medication was administered at that time. Review of the progress note dated 03/17/24 at 10:30 A.M. by LPN #100 revealed Resident #22 had complaints of left arm/shoulder pain and new order was received for Ibuprofen 400 milligrams (mg) oral every 8 hours as needed for one week and an x-ray of the left shoulder and elbow. Review of the physician order dated 03/17/24 at 10:51 A.M. for Resident #22 revealed a routine x-ray of the left shoulder and left elbow. Review of the MAR for Resident #22 revealed on 03/17/24 at 11:00 A.M. the resident had pain rated an eight on a scale of 0 to 10 and the Ibuprofen 400 mg was administered was administered at this time. Further review of Resident #22's record revealed no non-pharmacological pain interventions were initiated to address the resident's pain following the fall. Review of the radiology results dated 03/17/24 at 3:17 P.M. of the left shoulder and left elbow for Resident #22 revealed a non-displaced fracture of the greater tuberosity noted and minimally impacted humeral neck fracture component is present of the left shoulder. An appointment was made for the resident to see an orthopedic physician. Record review revealed no pain plan of care was developed for the resident with comprehensive and individualized interventions to address the resident's pain following this incident. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the resident was cognitively intact. The resident was assessed to require supervision or touching assistance for toilet hygiene and transfers and independent for bed mobility. The resident was assessed to be frequently incontinent and to have had pain in the past 5 days. Interview on 07/11/24 at 9:10 A.M. with Resident #22 revealed the resident recalled the fall on 03/17/24 and stated that it really hurt. The resident also stated she had asked for pain medicine because her left arm was hurting so bad. She denied having any non-pharmacological pain interventions after the fall and stated because of the fall/injury she needed assistance in the restroom when she had not before the fall. Interview on 07/11/24 at 9:17 A.M. with LPN #123 via telephone revealed when Resident #22 fell on [DATE] at 6:45 A.M. she reported the pain to her left arm was rated a seven on a pain scale of 0 to 10 as documented and put her back in bed and passed it along to LPN #100 in shift change that the resident had fallen and had some pain. The LPN verified no non-pharmacological or timely pharmacological interventions were provided for Resident #22. Interview on 07/11/24 at 10:50 A.M. with LPN #100 revealed he was the nurse that came on shift after Resident #22 had fallen on 03/17/24. LPN #100 indicated the resident did not ask for pain medication until 10:30 A.M. and he was not aware of the pain level of seven out of 10 documented by LPN #123 after the fall therefore, no follow-up assessment or evaluation was completed. The LPN verified no timely follow up was completed and stated the resident went to breakfast, so he didn't think she was in pain or needed anything for it. The LPN verified Resident #22's pain was rated an eight on a 0 to 10 scale when he received an order to medicate. The LPN also verified no non-pharmacological interventions were initiated for the resident after the fall to address her pain. Interview on 07/11/24 at 11:02 A.M. with STNA #555 revealed after Resident #22 had fallen on 03/17/24, she would need assistance to the restroom and was babying her left arm and stated that she never needed assistance before and would make faces if staff accidentally touched her left arm and would say it was hurting. The STNA verified the facility had not implemented any type of non-pharmacological interventions for Resident #22 following the fall/fracture. 3. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including generalized anxiety disorder, obsessive-compulsive personality disorder, dementia, Alzheimer's with late onset and unspecified osteoarthritis. Review of Resident #24's progress note dated 01/05/24 at 10:38 P.M. by Licensed Practical Nurse (LPN) #666 revealed the residents call light was on and the resident asked to be helped off the floor but was on the bed side. Upon assessment, this resident had left shoulder swelling and was painful to the touch, Resident #24 stated it hurt when moving it. LPN #666 obtained a STAT x-ray order for the left shoulder. Record review revealed no additional nursing progress notes were completed to indicate the resident was assessed/monitored for pain or evidence of any type of pain management being completed following the above note documented on 01/05/24 at 10:38 P.M. Review of Resident #24's fall report for 01/05/24 at 10:38 P.M. revealed the resident wanted help getting off the floor even though she wasn't on the floor. The report indicated Resident #24 had slipped on a wash rag on the floor per resident. Review of the radiology report dated 01/05/24 2:18 A.M. for Resident #24 revealed a left comminuted minimally displaced fracture of the proximal humerus. Further review of Resident #24's record revealed no pharmacological or non-pharmacological pain interventions were provided as follow up to the resident's pain after the fall. Review of the emergency room visit for Resident #24 revealed an arrival time of 3:42 A.M. with a pain level of six on a scale of zero to 10 scale with 10 being the most severe pain. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 out of 15 indicating the resident had cognitive impairment. The resident was assessed to be independent with toilet hygiene, bed mobility, and transfers. The resident was assessed to always be continent and in the last five days the resident received scheduled pain medications and non-pharmacological pain interventions with an interview with having pain in the past 5 days. Interview on 07/10/24 at 10:41 A.M. with State tested Nursing Assistant (STNA) #875 revealed after Resident #24 had fallen, she was the one who completed the vitals and stated Resident #24 would not let her do anything to her left arm and she was making faces when they tried to touch it. STNA #875 stated she had to help her until she went out and she was babying her left arm and said it was painful especially when helping to get her dressed to go to the emergency room . The STNA verified the resident had used the call light after the fall to indicate pain to the left arm which she stated was relayed to LPN #666 and only a pillow was utilized for a non-pharmacological intervention with no effectiveness. Attempts to reach LPN #666 during the survey were unsuccessful. In addition, attempts to interview Resident #24 related to the incident and/or pain were also unsuccessful due to the resident's cognitive impairment. Review of the facilities undated Pain Management policy revealed the facility will recognize the needto identify pain and its underlying cause, as able, that will allow for a prompt response to pain. The healthcare facility will assess, monitor, intervene, and re-evaluate the resident's pain, while updating the necessary documentation routinely. The resident will be encouraged to participate in pain relief and management, as able.

Based on record review, review of abuse policy training/acknowledgement documents, facility policy review and interview, the facility failed to ensure Residents #15 and #17 were free from abuse. This affected two residents (#15 and #17) of three residents reviewed for abuse. The facility census was 47. Actual psychosocial harm occurred, applying the reasonable person concept, on 10/31/23 to Resident #15, a resident with impaired cognition, when State tested Nurse Aide (STNA) #111 took humiliating pictures of the resident with the staff member's cell phone without consent of Resident #15. The pictures were of Resident #15 lying in bed wearing an incontinence (Depends) undergarment with urine and stool. STNA #111 then sent said pictures to the Administrator, who printed the pictures and presented them on 10/31/23 in a morning meeting to additional administrative staff, including staff who were not clinical. Actual psychosocial harm and the potential for actual physical harm, occurred on 11/29/23 to Resident #17, a resident with impaired cognition, when Resident #22 entered her room, grabbed her by the forearms and started yelling at her. Resident #17 was screaming, Help, she is beating me up. No physical assessment was documented as being completed for the resident following the incident. In addition, the resident reported being afraid and scared as a result of the incident. Findings included: 1. Review of Resident #15's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified psychosis not due to a substance or known physiological disorder, hypothyroidism, and essential hypertension. Review of Resident #15's Clinical Resident Profile revealed she had a guardian. Review of Resident #15's plan of care, dated 09/24/20, revealed she had an alteration in communication and was usually able to verbally or nonverbally express thoughts and ideas, and was sometimes able to understand others through verbal and non-verbal communication. Review of Resident #15's significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively impaired. Further review revealed she was sometimes able to express ideas and wants and was able to sometimes understand verbal content. Additionally, the assessment revealed she was always incontinent of her bladder and frequently incontinent of her bowel. Interview on 11/28/23 at 10:45 A.M. with STNA #144 revealed she heard that STNA #111 was told by administration (not sure who) to take pictures of Resident #15 regarding poor incontinence care. Telephone interview on 11/28/23 at 10:59 A.M. with STNA #111 revealed she came into work on 10/31/23 and discovered that Resident #15 had not received incontinence care. STNA #111 revealed it looked like Resident #15 had not had incontinence care all night as she was lying in urine and stool. STNA #111 revealed she was going to clean up Resident #15 and became so upset she went and got the current Administrator (who was then working as an administrative assistant). STNA #111 reported she and the Administrator went to Resident #15's room and once the Administrator saw the lack of incontinence care, the Administrator asked STNA #111 to take pictures of Resident #15 on her phone and send them to the Administrator. STNA #111 revealed she did take the pictures of Resident #15 without consent from the resident, her family or her guardian. She said the Administrator was in the room when she took the pictures. STNA #111 reported she sent the pictures to the Administrator by text and then about an hour later STNA #111 received a text back from the Administrator stating, I understand why you took these pictures, but you can't have pictures of residents on your phone. STNA #111 revealed she immediately deleted the pictures from her phone. STNA #111 reported she heard the Administrator printed the pictures out and showed them in the morning meeting. STNA #111 reported she heard that Regional Nurse #175 was present and asked who took the pictures and the Administrator responded, an aide. She reported she was not aware of any investigation regarding the pictures, and she had not received any discipline for taking the pictures. Review of Resident #15's progress notes, dated 10/31/23, revealed no documentation to support poor incontinence care or pictures being taken of the resident. Interview on 11/28/23 at 11:35 A.M. with the Administrator revealed the following staff attend morning meetings: Human Relations/Dietary Manger (HR/DM), Housekeeping/Laundry, Business Office Manager (BOM), Director of Nursing (DON), Maintenance Director (MD), Therapy Director (TD), Activities and the MDS Nurse. Interview on 11/28/23 at 11:38 A.M. with non-clinical anonymous Staff #140 revealed they were present at the 10/31/23 morning meeting. They reported the room was full and the staff present who were not clinical included the MD, the BOM, the Activities Director and the HR/DM. They reported the Administrator (who was then working as an administrative assistant) showed pictures of a resident, but they could not remember if the name of the resident was provided. They reported the resident was wearing a top, and what appeared to be an undergarment brief. Staff #140 reported the bed covers were pulled down exposing the Resident's undergarment brief and her legs. Staff #140 revealed the resident's feet were covered with bed linen. They did not remember seeing any of the resident's belly or chest. They reported the Administrator was showing the pictures and there were two or three pictures. Staff #140 revealed they were uncomfortable with the presentation and thought the Administrator should have known better. Staff #140 felt the resident's privacy and rights were violated by the pictures which were humiliating in nature. Staff #140 reported Regional Nurse #175 stopped the presentation and reported the facility and staff were not to take pictures of residents. Staff #140 revealed the facility policy on abuse (taking pictures of residents) was reviewed at the time. Interview on 11/28/23 at 12:08 P.M. with non-clinical anonymous Staff #176 revealed they were present at the morning meeting on 10/31/23. Staff #176 reported the Administrator (who was then working as an administrative assistant) was presenting pictures regarding poor resident incontinence care. They reported they did not look closely at the pictures because they were not clinical, and it was not part of her job. Staff #176 felt presenting pictures of the resident was not appropriate or acceptable. They reported it would emotionally upset them to have humiliating pictures of poor incontinence care taken without consent and presented to staff in a meeting. Staff #176 reported they did not think the resident was identified by the Administrator during the meeting. Interview on 11/28/23 at 2:38 P.M. with STNA #144 revealed Resident #15 was interviewable and could process to answer questions with yes and no responses. Interview on 11/28/23 at 2:40 P.M. with Resident #15 revealed she did not remember anyone taking pictures of her. This surveyor asked Resident #15 if someone took a picture of her from the waist down with only her depends on would she be emotionally upset and humiliated and Resident #15 responded, Yes, I would. Interview on 11/29/23 at 7:10 A.M. with STNA #137 revealed pictures were taken of Resident #15 by STNA #111. STNA #137 revealed she was told by STNA #111, that she was directed to take the pictures by the current Administrator who was in the role of Administrative Assistant at the time. STNA #137 reported STNA #111 told her the pictures were of Resident #15 with urine and stool from the waist down and Resident #15 was wearing a depend undergarment. STNA #137 reported taking the pictures and also printing them out and presenting then a meeting went against the facility abuse policy. STNA #137 revealed there were times Resident #15 had logical conversations and when asked questions can respond appropriately. Interview on 11/29/23 at 9:19 A.M. with STNA #111 revealed on 10/31/23 she went to get the current Administrator regarding the incontinence condition she found with morning care for Resident #15. STNA #111 reported she pulled the current Administrator into Resident #15's room about 8:45 A.M. STNA #111 reported the current Administrator directed STNA #111 to take the pictures. STNA #111 didn't ask why she wanted the pictures and the current Administrator was in the room when the pictures of Resident #15 were taken. STNA #111 reported the pictures of Resident #15 were from the waist down. STNA #111 reported as soon as she took the pictures, the current Administrator directed her to text the pictures to her. STNA #111 reported she did not have the current Administrator's phone number so the current Administrator provided it and STNA #111 text messaged the pictures of Resident #15 to her. STNA #111 revealed she was not questioned, and she did not know of any investigation regarding the taking of the pictures by the current Administrator, Regional Nurse #175 or the acting Administrator #178 at the time. She reported she did not receive any training following the incident regarding not taking pictures of residents. Interview on 11/29/23 at 1:45 P.M. with the current Administrator revealed on 10/31/23 she had just walked through the door in the morning and STNA #111 came to her with a concern regarding resident care. The Administrator revealed she went with the STNA #111 to Resident #15's room and discovered poor incontinence care. The Administrator revealed she did not direct STNA #111 to take pictures of Resident #15 as STNA #111 had already taken the pictures. The Administrator verified she did ask STNA #111 to send her the pictures of Resident #15 to her via a text message. The Administrator then verified she printed out the pictures she received from STNA #111 and presented them to the staff present at the morning meeting on 10/31/23. She reported she did not realize she was breaking any rules. The Administrator verified presenting the pictures was not acceptable behavior. She reported she had worked in other facilities when pictures of residents were presented in meetings, and stated she had an ick feeling about it. The Administrator revealed she screwed up but stated there was no malicious intent. Interview on 11/28/23 at 1:45 P.M. with Regional Nurse #175 revealed there was an incident where a photo of a resident in a brief was held up in a morning meeting on 10/31/23. She revealed no face was visible and she intervened and stopped the presentation of the picture. Regional Nurse #175 felt the purpose of the picture was for education and didn't view the issue as abuse. She reported there was immediate education for the staff in the morning meeting regarding the abuse policy and not taking pictures of residents. She reported then the entire facility received education on the abuse policy and not taking pictures of residents. Review of the form titled, Review Task Summary, undated, revealed STNA #111 had signed an acknowledgement of the Abuse Policy on 02/06/23. Review of the form titled, Review Task Summary, undated, revealed the Administrator had signed an acknowledgement of the Abuse Policy on 09/28/23. Review of the facility policy titled, Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property, dated 05/2018, revealed it was the goal of the facility that its residents will be protected from verbal, mental, sexual, or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation, and misappropriation of property through development of operationalized policies and procedures. Residents will not be subjected to abuse, neglect, mistreatment, or misappropriation of property by anyone. Further review revealed the definition of mental abuse included but was not limited to humiliation, harassment, or threats of punishment or deprivation. Under Section F: Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and/or Recordings revealed taking or using photographs, videos or recordings of a resident or his/her private space in any manner that would demean or humiliate a resident is strictly prohibited. At no time are any photographic or recording devices permitted in any resident room or common areas. Examples include, but are not limited to, taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), resident eating, or participating in an activity. This policy included employees, consultants, contractors, volunteers and other care givers. Staff must report to their supervisor any unauthorized (or suspected to be unauthorized) taking of photographs or videos as well the sharing of such recordings in any medium. Violations of this policy may result in disciplinary actions, including termination. Personal cell phones may only be used in designated employee break rooms. 2. Review of Resident #17's medical record revealed an initial admitted [DATE] and a readmitted [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, essential hypertension, and dysphagia. Review of Resident #17's plan of care, dated 02/14/23, revealed she had a behavioral problem related to biting, hitting, kicking, scratching, and yelling. Interventions included attempt 1:1 when behaviors start, intervene and redirect resident as needed, listen to resident concerns, monitor and assess behaviors, provide a calm and relaxing environment, refer to psych as needed, and administer medications as ordered. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/11/23, revealed the resident was cognitively impaired. Further review revealed she did not present physical behaviors towards others but did present verbal behaviors towards others daily. Review of Resident #17's progress notes for the month of November 2023 revealed four notes referring to behavioral concerns with staff only. Review of Resident #17's progress note, dated 11/23/23 at 4:26 A.M., revealed she yelled from her room and refused to use her call light. Resident #17 was repetitive and used derogatory names toward staff members. Staff continued to use therapeutic communication to provide a quiet environment for the resident. Review of Resident #17's progress note, dated 11/29/23 at 5:30 A.M., revealed STNA #102 was passing medications when another Resident (#22) was in Resident #17's room. Resident #22 was yelling and grabbing her (#17's) arms. Resident #22 was yelling, get out of my house. RN #183 was notified. Review of Resident #17's progress notes and evaluations revealed no head to toe physical assessment, psychosocial assessment, or pain assessment immediately following the incident. Review of Resident #22's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, unspecified anxiety disorder, and essential hypertension. Review of Resident#22's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed the resident was not cognitively intact. Further review revealed she did not exhibit physical or verbal behavioral symptoms towards others. Review of Resident #22's comprehensive plan of care revealed no care plan regarding aggressive verbal or physical behaviors toward other residents or staff. Review of Resident #22's progress notes for the month of November 2023 revealed 14 notes referring to behavioral concerns with residents and staff. Review of Resident #22's progress note, dated 11/15/23 at 9:52 A.M., revealed she became verbally aggressive towards her roommate and staff. Resident #22 took items from her roommate and began yelling at her roommate stating the roommate had stolen them from her. Resident #22 was not easily directed and insisted that her roommate did not sleep in her room or pay the bills. Resident #22 became agitated over her roommate using a nebulizer, as she thought it was hers. Resident #22 refused to leave the door open to accommodate heating issues for the room. Resident #22 was educated numerous times on both topics. Resident #22 was delusional and had auditory hallucinations of babies crying. The staff used therapeutic communication during the episode and distracted the resident with food and drink. Review of Resident #22's progress note, dated, 11/17/23 at 6:34 A.M., revealed that during the shift she had wandered through the hallways asking staff repetitive questions regarding children and babies crying. Resident #22 was delusional and not easily reoriented. Resident #22 would refuse care at times and was forgetful. Resident #22 accused staff of stealing her items and lying. She refused to keep the door open to her room to keep it heated. Resident #22 did not get along with her roommate and believed she was stealing her items. The staff continued to use distraction techniques and therapeutic communication. Review of Resident #22's progress note, dated 11/23/23 at 4:28 A.M., revealed she wandered throughout the halls yelling at staff members and telling them they didn't do their jobs. Resident #22 was delusional and believed there were kids outside crying. She attempted to wander into other residents' rooms and staff intervened. Resident #22 was unable to be reoriented and became aggressive. Staff provided a quiet environment for the resident, along with food/drink and therapeutic communication. Review of Resident #22's progress note, dated 11/24/23 at 2:37 A.M., revealed she was agitated with staff. Resident #22 was yelling and combative with staff for no known reason. Review of Resident #22's progress note, dated 11/29/23 at 5:30 A.M., revealed STNA #102 was passing medications when Resident #22 was in another Resident's (#17) room, grabbing the resident's arms and yelling, get out of my house. Registered Nurse (RN) #183 was notified. Review of Resident #22's progress notes and evaluations revealed no head to toe physical assessment, psychosocial assessment, or pain assessment immediately following the incident. Further review of Resident #22's progress notes revealed the last documented note regarding physician notification of her behaviors was 10/30/23. An order for Melatonin, a sleep aide, was ordered at the time. Interview on 11/29/23 at 7:30 A.M. with LPN #177 revealed he was passing medication at 5:30 A.M. when he was informed by STNA #102 that Resident #22 was in Resident #17's room and Resident #22 was holding onto Resident #17's arms. LPN #177 reported STNA #102 reported Resident #22 then attempted to get aggressive with STNA #102. LPN #177 reported that by the time he had walked down the hallway, Resident #22 had left Resident #17's room. He reported both Residents #17 and #22 appeared aggravated with each other. LPN #177 reported he assessed Resident #17's arms and didn't find any concerns. LPN #177 reported he immediately called RN #183 to let her know and she directed for LPN #177 and STNA #102 to complete witness statements. LPN #177 reported he did not receive any directives to separate the two residents, assess the two residents, or place Resident #22 on any type of observation. LPN #177 reported Resident #22 was able to walk the facility freely. Interview on 11/29/23 at 7:35 A.M. with STNA #137 revealed she had heard Resident #22 had entered Resident #17s room and was holding her arms and yelling at her this morning. Observation on 11/29/23 at 7:55 A.M. revealed Resident #22 and Resident #17 were sitting at the same table, side by side, in the dining room. Interview on 11/29/23 at 7:57 A.M. with Resident #17 revealed Resident #22 came into her room and attacked her. Resident #17 was able to point to Resident #22 as the resident who came into her room. Resident #17 reported she was afraid and scared when Resident #22 grabbed her arms. Telephone interview on 11/29/23 at 7:59 A.M. with STNA #102 revealed she was passing medications and heard screaming and yelling coming from Resident #17's room. STNA #102 reported she entered Resident #17's room and saw Resident #22 holding Resident #17's arms and trying to pull her up out of her wheelchair. Resident #22 was stating, It is my house, and you need to get out of here. Resident #17 was yelling, Help, she is beating me up. STNA #102 revealed Resident #22 then started walking aggressively toward her. STNA #102 reported Resident #22 didn't touch her but exited the room. STNA #102 reported Resident #22 did have a history of getting physical with staff. STNA #102 reported that on 11/26/23, Resident #22 grabbed her ponytail and almost pulled STNA #102 to the ground. STNA #102 reported that Resident #22 has a history of yelling at other residents and staff, but this past week she started putting hands on staff and today on another resident. STNA #102 revealed LPN #177 notified RN #183 and the directive she received regarding the incident was to complete a witness statement. STNA #102 reported she did not receive any directive to separate the two residents, or place Resident #22 on any type of observation. STNA #102 reported Resident #22 was able to walk the facility freely. Interview on 11/29/23 at 9:55 A.M. with STNA #137, who was working the hall of Residents #17 and Resident #22, revealed she had not received any directive regarding increased observation of Resident #22 either continuous or periodically for safety of other residents. Interview on 11/29/23 at 10:58 A.M. with STNA #111, who was working the hall of Residents #17 and Resident #22, revealed she had not received any directive regarding increased observation of Resident #22 either continuous or periodically for safety of other residents. Interview on 11/29/23 at 1:55 P.M. with the Administrator revealed she had contacted psychiatry in the A.M. regarding the behaviors of Resident #22 toward Resident #17. The Administrator revealed she received an order at 8:30 A.M. for 15 minute observations for Resident #22 and a stat urinalysis to be collected. She reported she received and reviewed the written statements from STNA #102 and LPN #177. Interview on 11/29/23 at 2:00 P.M. with RN #183 revealed she received a call earlier in the A.M. from both STNA #102 and LPN #177. She reported the directive she gave them was to make sure and document the occurrence in a progress note and complete witness statements. She reported she was not informed that Resident #22 had placed hands on Resident #17. Review of the Personal Witness Statement, dated 11/29/23 and timed 5:30 A.M. by LPN #177, revealed he was passing medications and heard Resident #17 and #22 yelling at each other. Upon walking up to the room Resident #22 came out of Resident #17's room and was trying to hit STNA #102. RN #183 was called regarding the incident. Review of the Personal Witness Statement, dated 11/29/23 and timed 5:30 A.M. by STNA #102, revealed she was passing medications when she heard yelling coming from Resident #17's room. When STNA #102 arrived to the room Resident #22 had hold of Resident #17's arms yelling at her to get out of her house. STNA #102 documented that when she entered the room, Resident #22 came at her swinging, then calmed down and walked away. Interview on 11/29/23 at 3:15 P.M. with LPN #181 revealed she received notice that 15 minutes checks were to be initiated for Resident #22 in the morning. LPN #181 reported she and RN #183 had discussed a plan for completing the 15 minute checks and LPN #181 thought the RN #183 was going to complete the 15 minute checks. LPN #181 had no documentation, either in the electronic health record or on paper, to support 15 minute checks had been completed on Resident #22. Observation on 11/29/23 at 3:17 P.M. revealed LPN #181 started 15 minute check documentation for Resident #22. Interview on 11/30/23 at 12:14 P.M. with anonymous Nurse #182 verified upon her review of Resident #17 and #22's medical records, there was no head to toe skin assessment for Resident #17 since 11/22/23 or for Resident #22 since 11/16/23. Anonymous Nurse #182 also verified no psychosocial or pain assessments for either resident since the resident to resident incident on 11/29/23 at 5:30 A.M. She verified there should have been a full body assessment (head to toe), a psychosocial assessment, and a pain assessment on both residents. Telephone interview on 12/01/23 at 1:46 P.M. with the Administrator verified Resident #22's physician had been contacted on 10/30/23 regarding trouble sleeping and then not again until 11/29/23 at 8:39 A.M. following the incident with Resident #17. Review of the facility policy titled, Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property, dated 05/2018, revealed it was the goal of the facility that its residents will be protected from verbal, mental, sexual, or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation, and misappropriation of property through development of operationalized policies and procedures. Residents will not be subjected to abuse, neglect, mistreatment, or misappropriation of property by anyone. Further review revealed the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This deficiency represents noncompliance investigated under Complaint Number OH00148026.

Based on medical record review, medication error log review, policy review, and interview, the facility failed to ensure Resident #17 received adequate monitoring following administration of a narcotic medication and a benzodiazepine medication simultaneously. In addition, the facility failed to ensure medications listed as an allergy were not administered to the resident. This affected one resident (#17) of three residents reviewed for change in condition. The facility census was 47. Actual harm occurred to Resident #17 on 10/01/23 when the resident was administered a narcotic medication (MS Contin) and a benzodiazepine medication (Ativan) simultaneously and failed to adequately monitor the resident for sedation as ordered by the prescriber resulting in the resident requiring administration of Narcan (opiate antagonist) and transfer to the hospital for evaluation. Findings include: Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, schizoaffective disorder and dementia. The resident was admitted to hospice services on 07/18/23. Review of the care plan: Alteration in Respiratory Function (revised 09/25/23) revealed nursing to monitor resident and assess for effectiveness of respiratory treatment, target oxygenation 88-92% and encourage use of oxygen. Review of the electronic Physician Orders (dated 09/30/23) revealed MS Contin 15 milligrams (mg) was ordered twice a day, once in the morning and once between 4:00 P.M. and 6:00 P.M Nursing staff was ordered to monitor for over sedation with new hospice medication orders and to report any signs of this to the hospice team immediately. Review of the Progress Notes revealed the following: -On 09/30/23 at 12:19 P.M., hospice called with updated medication orders. New orders placed and staff to monitor for over sedation. -On 10/01/23 at 11:15 P.M., resident had an altered level of consciousness, increased confusion, lethargic, shortness of breath with decreased oxygenation to 79% on four liters of oxygen. Medication changes in the past week included MSContin 15 mg and Ativan 0.5 mg twice a day. The resident's POA requested her to be sent to the emergency room for evaluation. -On 10/01/23 at 11:16 P.M., Resident #17 remained lethargic with an oxygen saturation of 74% on oxygen at 2L/min via nc and raise it to 4L/min bringing her oxygen saturation up to 79%. Message left with Hospice about concerns. -On 10/01/23 at 11:18 P.M., staff spoke with Hospice regarding concerns with medication. Hospice stated family should be called as resident may be actively dying and to call back with any concerns. -Late entry dated 10/02/23 at 12:31 A.M. revealed Nurse Practitioner #184 was made aware of resident status, power of attorney request, Hospice made aware and 911 was called. -On 10/02/23 at 1:14 A.M., Report received from emergency room (ER) stating that the squad had to administer Narcan to the resident in route to the ER, oxygen therapy was given at the hospital and that resident was back to base line and would be returning back to our facility. There was no evidence staff completed monitoring for over sedation of Resident #17 between 9:00 A.M. and 11:15 P.M. on 10/01/23 as ordered. Review of a the Treatment Administration Record (TAR) revealed a once a shift initial for 10/01/23. Review of the Medication Administration Record (MAR) and the Controlled Drug Receipt Record/Disposition Forms dated 10/01/23 revealed both MS Contin 15 mg ER and Ativan 0.5 mg were administered at 9:00 A.M. and 5:30 P.M Review of Resident #17's Hospital Discharge paperwork dated 10/02/23 revealed the resident was evaluated at the emergency room for respiratory arrest and opioid overdose. On 11/29/23 at 2:30 P.M., interview with Registered Nurse (RN) #182 verified there was no evidence of increased monitoring for over sedation of Resident #17 after the resident received Ativan and MS Contin routinely as ordered by hospice, the resident had a decrease in oxygenation, a significant change in condition requiring Narcan and evaluation at the hospital. In addition, review of Resident #17's Progress Notes revealed the resident was evaluated at the emergency room for respiratory arrest, opioid overdose and behavioral changes on 10/01/23. A medication allergy was noted on 10/02/23 for morphine sulfate and related medications. Review of the Physician Orders dated November 2023 revealed allergies included morphine (opioid) and related derivatives. Review of the Medication Administration Record dated November 2023 revealed Morphine (MSO4) 20 mg/milliliter (ml) administer 0.25 ml was administered on 11/04/23. On 11/30/23 at 10:53 A.M., interview with Registered Nurse #182 verified Resident #17 was administered MSO4 on 11/04/23 and MSO4 was listed as a severe allergy and the administration of this medication could cause a severe adverse reaction for the resident. This deficiency represents non-compliance investigated under Complaint Number OH00148026.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20, Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of the facility COVID-19 timeline, review of the county community COVID-19 transmission rate, review of staff time sheets, review of staff screening forms, review of resident and staff COVID-19 rapid point of care (POC) test results, review of the facility COVID-19 procedure policy and staff interview the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 as evidenced by the facility's failure to ensure staff did not provide direct resident care to residents while symptomatic of COVID-19, failure to ensure staff were properly screened for COVID-19 upon entrance into the facility and failed to ensure all staff utilized appropriate personal protective equipment (PPE) during a COVID-19 outbreak to help reduce the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy when State tested Nursing Assistant (STNA) #34 entered the facility on 06/07/22 with signs and symptoms of COVID-19, failed to wear appropriate PPE and provided direct care for residents including Residents #40 and #47 who were diagnosed with COVID-19 on 06/09/22. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. This affected Residents #31, #38, #1, #36, #11, #34, #47, #12, #40, #18, #45, #16, #32, #35, #13, #27, #20, #3, #98, #99, #33, #39, #7, #43, #2, #8, #17, #4, #28, #33, #37, #5, #10, #18, #19, #21, #24, #6, #23, #30, #9, #46 and #29. The facility census was 45. On 07/07/22 at 4:10 P.M. the Administrator and Director of Nursing (DON), Assistant Director of Nursing (ADON), the Administrator in Training, and the Regional Quality Assurance (RQA) (Registered Nurse (RN) #99) were notified that Immediate Jeopardy began on 06/07/22 when the facility failed to implement appropriate and recommended infection control practices after STNA #34 had signs and symptoms of COVID-19 and failed to wear proper PPE while providing care to 17 residents on Dodge Hall. The Immediate Jeopardy continued when the facility established outbreak status of COVID-19 and failed to implement policies to prevent exposure of non-infected (COVID-19 negative) residents from staff who were not donning and doffing appropriate PPE, sanitizing face shields, or changing N95 masks upon departure of resident rooms who were in isolation with confirmed COVID-19. The facility's continued failure for effective infection control practices continued the residents' risk for hospitalization , serious harm and/or death related to a COVID-19 outbreak in the facility. The Immediate Jeopardy was removed on 07/08/22 when the facility implemented the following corrective actions: · On 07/07/22 at 1:47P.M., a QAPI meeting was held with the Administrator, Regional Quality Assurance (RQA) Nurse/RN #99, Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator in Training (AIT), and the Medical Director via phone to review the policies for screening staff upon entry/ start of shift, not permitting staff to work if symptomatic for signs and symptoms of COVID-19, and proper PPE use via video with post-test. · On 07/07/22 at 2:30 P.M., the RQA Nurse/RN #99 educated the Administrator, AIT, DON, and ADON on policies for screening of staff and screeners not permitting staff to work with symptoms consistent with COVID- 19. Further education was provided on proper PPE use and isolation procedures for COVID-19 positive/ suspected residents and proper disinfection of face shields when leaving isolation rooms of those in droplet precautions. · On 07/07/22 at 4:30 P.M., the RQA Nurse/RN #99 or /Designee initiated an audit of all staff currently at the facility for screening of COVID-19 symptoms. No screenings or interviews revealed anyone working in house with symptoms. Staff included four nurses, five nurse aides, three dietary staff, one activity staff, one housekeeping/laundry, and eight management staff were included. · On 07/07/22 at 4:35 P.M., the DON/Designee initiated education to all staff on what symptoms of COVID-19 to report and when staff were not permitted to enter the building. They also received education regarding proper use of PPE including when and what type to wear, and proper procedure for disinfecting face shields between COVID-19 positive and COVID-19 negative residents, especially during outbreak. In addition, the staff were educated on staff screening procedures. Education included 14 nurses (seven RNs and seven LPNs), 18 nurse aides, eight dietary staff, three activities, three housekeeping/laundry, and five management staff were included in the training. · On 07/07/22 at 7:00 P.M., seven residents who have been free of COVID-19 were rapid tested for COVID-19 and no new positives were found. Testing was completed by the DON and/ or designee. All staff were tested for COVID-19 on this date and were negative. · On 07/08/22 at 5:00 A.M., re-education was initiated by the DON/designee of all staff on the screening process emphasizing no staff member was permitted to work if they had any symptoms of COVID-19, or if they checked having any symptoms on the screening log. Videos on proper PPE use to be watched by all staff with post-test on 7/08/22 or before returning from a leave of absence (LOA). Education included 13 nurses (six RNs and 7 LPNs), 16 nurse aides, eight dietary staff, three activities, three housekeeping/laundry, and six management staff were included in the training. · On 07/08/22 at 5:00 A.M., the DON/Designee had all staff perform competency testing on donning and doffing PPE, hand washing, COVID-19 testing, and COVID-19 screening. All other staff will be checked for competency before returning from a LOA. Education included 13 nurses (six RNs and seven LPNs), 16 nurse aides, eight dietary staff, three activities, three housekeeping/laundry, and six management staff were included in the training. · Beginning on 07/08/22 (time not identified), the DON/Designee will perform ongoing audits of screening logs three times per week for four weeks, then randomly thereafter to monitor for proper screening procedures ensuring symptomatic staff/visitors were not entering the facility. Audits will include ensuring the screening log was filled out in its entirety and that staff who were symptomatic or positive for COVID-19 were not permitted to work. Results of audits will be reviewed in QAPI for further recommendations. · Beginning 07/08/22 (time not identified), the LNHA/designee will audit five random employees three times per week for four weeks on their knowledge of the signs and symptoms of COVID-19, whom to report COVID-19 symptoms to, and if they know not to work with symptoms. Results of audits will be reviewed in QAPI for further recommendations. · Beginning 07/08/22 (time not identified), the LNHA/Designee will complete audits of five residents' rooms of those in isolation three times a week for four weeks, then randomly thereafter to monitor for proper PPE use including donning, doffing, mask use, face shield cleaning and disposal of supplies. Results of audits will be reviewed in QAPI for further recommendations. · On 07/08/22 at 1:00 P.M., the LNHA reviewed with the DON and Human Resource Director of new hires receiving education on infection control practices including isolation procedures, cleaning face shields, mask usage, Covid-19 symptoms, and the screening process. · On 07/11/22 from 10:18 A.M until 10:43 A.M., surveyor interview of STNA #15, RN #9, Laundry Staff #19, STNA #11, STNA #40, and LPN #73 was completed to determine if education was received and staff was knowledgeable about donning and doffing PPE, disinfecting the face shield, proper mask to wear, signs and symptoms of COVID-19, the screening process and when not to enter the facility or resident care areas. All staff had received the education and were knowledgeable. Although the Immediate Jeopardy was removed on 07/08/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure ongoing compliance. Findings Include: 1.Observation on 07/05/22 at 8:00 A.M. revealed the facility was in outbreak status via a sign posted on the front door. At the time of the observation, interview of Activities Director #48 (assigned as the facility infection control screener) revealed the facility currently had two residents positive for COVID-19. Interview on 07/06/22 at 10:30 A.M. with the Director of Nursing (DON) revealed the facility was providing COVID-19 testing two times a week, on Tuesday and Thursday with no set time, due to the county transmission rate was red or greater than ten percent. The DON stated night shift employees could test the morning after their shift on Tuesday and Thursday. The DON also stated when the county positivity rate was green or yellow the staff were required to wear only a surgical mask. When the positivity rate goes to red or the facility was in outbreak status, the staff were required to wear N95 mask and face shield. Review of the facility provided weekly transmission data calendars indicated the county transmission rate every week since 05/23/22 was high (red). Review of the CMS COVID-19 Nursing Home data website https://covid.cdc.gov/covid-data-tracker/#county-view of the county transmission rate for 06/02/22 through 06/09/22 revealed the facility's transmission rate was colored red, indicating high transmission rate. Review of the facility provided employee screening logs for COVID-19 dated 06/07/22 through 06/10/22 revealed STNA #34 was screened on 06/07/22 (no time indicated) by Licensed Practical Nurse (LPN) #78. STNA #34 responses included: · answered Yes to the following questions: Are you up to date with vaccination? Do you have congestion and/or runny nose? · answered No to the following questions: Do you have a cough? Do you have a sore throat? Do you have a new onset of shortness of breath or difficulty breathing? Do you have chills or repeated shaking with chills? Do you have fatigue? Do you have muscle pain? Do you have nausea, vomiting and or diarrhea? Do you have a headache? Do you have a new onset of loss of taste or smell? Have you been in contact with anyone Covid positive? Have you travelled within the last 14 days? If yes to previous question, were you wearing PPE? Have you had a recent Covid 19 test? If yes, date and results. Are you able to provide results of test? Review of the undated, untitled document (identified via interview with the RQA/RN#99 as the facility COVID-19 timeline) provided by the Regional Quality Nurse acting as the Infection Preventionist revealed the following information: The staff listed as follows, were asked three questions. a. Do you use PPE when at work-when needed or as ordered? b. Have you been around family/friends that's been positive with Covid-19? c. Have you been to large activities with large crowds? · On 06/07/22 STNA #34 said she went to a graduation for her grandkids and no family was positive with COVID-19. STNA #34 said she used her PPE and had no signs and symptoms when tested . There was no evidence contact tracing was completed. Surveyors requested evidence of contact tracing being completed and none was provided. Interview on 07/06/22 at 10:26 A.M. with Activity Director #48 revealed the front office staff screened staff and visitors as they entered the facility through the front door. Activity Director #48 stated the procedure was to write down the person's name, take (their) temperature, ask if they were vaccinated and then ask them about the symptoms listed on the log. If a staff member presented with any symptoms or sounded hoarse with cough for example, Activity Director #48 stated she would ask the staff to stay there in the front lobby as she called the nurse manager on duty. Interview on 07/06/22 at 2:42 P.M. with LPN #78 (responsible for screening STNA #34 on 06/07/22) revealed she must have marked yes to runny nose/congestion in error. LPN #78 stated she did not notice the STNA having a runny nose and denied the STNA reported she had a runny nose. LPN #78 stated if a staff member presented at screening with any signs and symptoms of COVID-19, the staff would be sent home. LPN #78 stated she did not feel STNA #34 needed to be sent home at that time. Interview on 07/06/22 at 2:46 P.M. with the DON revealed staff typically call off when they have any symptoms as they don't want to work. The DON stated the staff should report to the DON or charge nurse if they have any symptoms of COVID-19 prior to the start of their shift. The DON or Infection Preventionist was responsible to review the screening logs to ensure the screening logs were completed accurately and appropriate action was taken as appropriate/necessary. Interview on 07/06/22 at 6:52 P.M. with STNA #34 revealed she had a cough, vomiting, diarrhea, headache, and dizziness on 06/05/22 and 06/06/22 before coming back to work on Tuesday 06/07/22. STNA #34 stated when LPN #78 screened her in, she reported to the LPN she had a runny nose. LPN #78 asked if the STNA had allergies and she stated yes. STNA #34 denied any other symptoms at that time. STNA #34 stated the staff were wearing surgical masks the night she tested positive with no face shields. STNA #34 stated when she started her shift on 06/07/22 no nurse or staff member informed her the facility was in outbreak status. Further interview revealed LPN #13 asked STNA #34 if she wanted a COVID-19 test, not because she had symptoms or was told she had to be tested but was offered because they were in outbreak status and LPN #13 wanted to offer her a test. LPN #13 tested STNA #34 and the Point of Care (POC) test was positive, however, LPN #13 said nothing and went back to giving report. STNA #34 then asked LPN #71 to test her again and the second POC also showed positive results. LPN #71 instructed STNA #34 to go home. Further interview with STNA #34 revealed the DON completed COVID-19 testing on Tuesday and Thursday in her office from 9:00 A.M. through 3:00 P.M. and staff had to obtain special permission from their shift nurse to complete the test at a different time if night shift were unable to be tested during those hours. STNA #34 stated when she clocked in, she reported to her hall, Dodge. Residents #38, #1, #36, #11, #34, #47, #12, #40, #18, #16, #32, #35, #13, #27, #20, #3 and #29 resided on this hall and received care from STNA #34. STNA #34 did not divulge what time she tested positive on 06/07/22. A follow-up interview with STNA #34 on 06/07/22 at 6:52 P.M. revealed when she was screened in for her shift on 06/07/22, LPN #78 asked if her runny nose was due to allergies to which she told LPN #78 yes. During the interview, STNA #34 denied thinking her runny nose was a symptom of COVID-19 despite having a cough and other symptoms on 06/05/22 and 06/06/22. STNA #34 contributed her cough to smoking but confirmed she treated the cough with cough medicine so she could get some rest when she laid down those nights. STNA #34 denied reporting her other symptoms because those were resolved at the time of her screening, and she did not feel it was related to COVID-19 or her runny nose. Review of the employee timesheet verified STNA #34 did not clock in and out on 06/05/22 and 06/06/22 and had clocked in for work on 06/07/22 (the date she tested positive) at 5:51 P.M. and clocked out at 7:52 P.M. Review of the COVID-19 POC Test Log revealed on 06/07/22, no time indicated, STNA #34 tested positive for COVID- 19. On 06/09/22, resident testing was completed per outbreak testing protocol and three residents, Resident #40, #45 and #47, tested positive and were placed in airborne precautions. Review of the facility resident testing records revealed between 06/10/22 and 06/27/22, 35 additional residents tested COVID-19 positive (Residents #33, #39, #7, #36, #43, #2, #8, #13, #17, #27, #4, #12, #28, #33, #37, #38, #5, #10, #18, #19, #34, #98, #3, #21, #24, #6, #11, #20, #23, #30, #7, #9, #16, #46, and #31). There were no associated deaths. Physician #125, also the facility Medical Director, was contacted on 07/07/22 at 9:42 A.M., and again on 07/07/22 at 1:15 P.M,. with a message and return number left via voicemail. No return call was provided. Review of the un-dated facility policy titled Employee Screening revealed all staff will be screened upon entrance to the facility for their shift. They will complete the screening questions and have their temperature taken. Temperatures and answers to screening questions will be recorded on the Employee Screening Log. Employees with a temperature of 100.0 degrees Fahrenheit or greater, or who answer affirmatively to any screening question will not be permitted to enter facility and begin their shift. They will need to immediately speak to Infection Control regarding need for testing for COVID-19. If any employee begins to experience any of the symptoms during their shift the facility should have the employee leave the facility immediately and notify key management. Review of the facility policy titled COVID-19 Testing of Staff and Residents reviewed on 03/22 revealed at a minimum all residents and facility staff, including individuals providing services under arrangement and volunteers, the facility will conduct testing based on parameters set forth by the Centers for Medicare and Medicaid Services (CMS) and the Ohio Department of Health (ODH) and conduct testing in a manner that is consistent with current standards of practice for conduction COVID-19 tests. For each instance of testing: document that testing was completed and the results of each staff test and document in the residents record that testing was offered, completed and the results. Upon the identification of an individual specified in this paragraph with symptoms consistent with COVID-19 or who tests positive for COVID-19, take actions to prevent the transmission of COVID-19. The facility will conduct COVID-19 testing in accordance with the standards of practice as follows: staff with signs or symptoms of COVID-19 must be tested and should be restricted pending results. If confirmed, follow the CDC guidelines for return to work. Staff and residents will be tested in response to an identified outbreak, defined as the identification of a single new case. Routine testing for staff will be based on the County positivity rate from the previous week to determine needed testing frequency. Facility will monitor positivity rate and adjust according to guidance on frequency. Review of the facility COVID-19 testing cadence Up to Date facts sheet (not dated) stated any resident or staff member with even mild symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test as soon as possible. Review of the facility policy title COVID-19 Employee Reporting to Work and Return to Work reviewed 03/21 revealed the facility would actively encourage sick employees to stay home. Employees who have symptoms (fever, cough, or shortness of breath) should notify their supervisor and stay home. Employees who appear to have symptoms upon arrival to work or who become sick during the day should immediately be separated from others and sent home. 2. Observation on 07/05/22 at 10:45 A.M., noted Activities Assistant #18 enter the room of Resident #31. Resident #31 was in contact/droplet isolation precautions for being COVID-19 positive. Activities Assistant #18 entered the room only wearing a N95 mask and a face shield. Activities Assistant #18 did not don a gown or gloves before entering that room. She was then observed to exit that room without doffing her N95 mask and getting a new one or to disinfect her face shield as part of the doffing process before going to other areas of the facility. Resident #31's room was clearly marked as being in isolation with signs posted on the wall and a PPE cart outside the room. Interview on 07/05/22 at 10:47 A.M., with Activity Assistant #18 revealed she was not sure why Resident #31 was in isolation or if the sign posted outside his room was for him or the room next to him. Activity Assistant #18 acknowledged the signs posted were next to his entry way and not by the resident's entry way beside him. She confirmed where the signs were posted and the presence of a PPE cart outside Resident #31's room it was likely that he was the one in isolation, but she would have to check to see. Activities Assistant #18 stated they should don gloves and gowns in addition to their N95 mask and face shield when entering the room of residents in isolation for COVID-19. Activity Assistant #18 denied she had donned a gown or gloves before she entered Resident #31's room. She also denied she doffed her N95 mask when leaving his room nor did she disinfect her face shield after leaving that room before going to other non-COVID-19 areas of the facility. Activities Assistant #18 found disinfectant wipes in the PPE cart and acknowledged she should have disinfected her face shield. Observation on 07/05/22 at 11:51 A.M,. revealed Resident #98 was in droplet precautions for being COVID-19 positive. He was served his meal and STNA #77 was observed to don PPE before entering the room. STNA #77 already had a N95 mask and face shield on and was noted to don a gown, gloves, and a surgical mask over top of her N95 mask. When leaving the room, STNA #77 doffed her PPE by disposing of her gown, gloves and the surgical mask that was over top of her N95 mask. STNA #77 then disinfected her face shield using a disinfectant wipe in the PPE cart. STNA #77 was not observed to dispose of her N95 mask and don a new one before proceeding on to other areas of the facility. Interview on 07/05/22 at 12:01 P.M., with STNA #77 revealed they had not been instructed to don a new N95 mask when leaving a resident's room who was in isolation for COVID-19. STNA #77 stated they were told to put a paper mask over top of her N95 mask and to remove the paper mask when leaving the isolation room while keeping the same N95 mask on. STNA #77 stated she did not think they were supposed to do that but was following what she was told to do. STNA #77 denied the facility had a shortage of PPE. Observation on 07/05/22 at 11:53 A.M., noted STNA #5 to enter the room of Resident #99 to serve her meal tray (this resident was in an isolation room due to a 14-day quarantine period following a recent admission). STNA #5 was already wearing a N95 mask and face shield and donned a gown, gloves and a surgical mask over top of her N95 mask. STNA #5 was then observed to exit the room after serving the tray, doffing her gown, gloves and surgical mask. STNA #5 did not put a new N95 mask on when leaving the room nor did she disinfect her face shield after leaving the room. STNA #5 went down to the end of the hall and donned PPE before entering the room of Resident #31 at 11:56 A.M., (this resident was in droplet isolation precautions for being COVID-19 positive). STNA #5 again donned a gown, gloves, and surgical mask over her N95 mask that she was already wearing. STNA #5 continued to have a face shield on and entered the room to provide the resident with his meal tray. STNA #5 was observed to doff her PPE by removing gown, gloves and the surgical mask from over top of her N95 mask. STNA #5 did not remove her N95 mask and get a new one nor did she disinfect her face shield before leaving the area to other non-COVID-19 areas of the facility. Interview on 07/05/22 at 11:58 A.M,. with STNA #5 revealed she did don a surgical mask over top of her N95 mask when entering the rooms of Resident #99 and #31 to serve them their meal trays. She confirmed both residents were in isolation either for being COVID-19 positive or as part of a 14-day quarantine following a new admission. STNA #5 denied that she changed out her N95 mask after leaving those isolation rooms and did not disinfect her face shield either as part of her doffing process. STNA #5 stated they had been told to put a surgical mask over top of their N95 and she just forgot to disinfect her face shield both times when leaving the isolation rooms. Interview on 07/05/22 at 12:08 P.M. with LPN #78 revealed staff were instructed to don surgical mask over top of their N95 mask when entering the rooms of residents who were in isolation for COVID-19. LPN #78 denied they were instructed to get a new N95 mask when leaving those rooms and were only to remove the surgical mask as part of the doffing process. LPN #78 confirmed they were to disinfect their face shields with a disinfectant wipe when leaving an isolation room. LPN #78 denied any shortages of N95 masks and reported they had plenty available. Interview on 07/06/22 at 3:02 P.M. with the RQA/RN #99 (acting Infection Preventionist) revealed the DON, ADON and herself provided the staff education related to transmission-based precautions, donning and doffing PPE, hand washing, social distancing, and cough etiquette. RQA/RN #99 stated she was aware the staff were currently and during the outbreak wearing a surgical mask over the N95 mask and she did not discourage or encourage this practice as the staff felt it was an extra layer of protection. Further interview with RQA/RN #99 revealed the facility was not operating in crisis capacity for PPE and the expectation was for staff to change their N95 mask before exiting a COVID-19 positive room and to clean the face shield as well. RQA/RN #99 stated if staff did not enter a COVID-19 positive room during their shift, the N95 mask would be changed daily. An observation of the stock room with Supply Clerk #90 on 07/07/22 at 10:32 A.M. revealed the facility had three boxes of 100 each POC COVID-19 tests, seven boxes of 100 each disposable isolation gowns plus three packages of 10, 150 face shields, one case of 200 Niosh-N95 masks plus three boxes of 20, seven cases of various sizes of vinyl gloves, and 24 containers of bleach wipes. Observation on 07/07/22 at 10:32 A.M. revealed a facility posting (posted on the wall outside the isolation room doors) titled: Use of PPE When caring for Patients with Confirmed or Suspected Covid-19 revealed donning the proper PPE: 1. Identify and gather the proper PPE to don. 2. Perform hand hygiene using hand sanitizer. 3. Put on isolation gown, tie all the ties on the gown. 4. Put on NIOSH approved N95 filtering facepiece respirator or higher (may use a face mask if a respirator is not available). 5. Put on face shield or goggles. 6. Perform hand hygiene before putting on gloves. 7. May now enter the room Doffing PPE: 1. Remove gloves 2. Remove gown and dispose in trash receptacle. 3. May now exit the room. 4. Perform hand hygiene. 5. Remove face shield or goggles. 6. Remove and discard respirator or facemask. 7. Perform hand hygiene after removing the respirator.

Based on observations, medical record review, and staff interview the facility failed to ensure one resident (Resident #49) with a pressure ulcer received the necessary treatment to prevent infection and promote healing. This affected one of three residents reviewed for pressure ulcers (Resident #49). Actual Harm occurred when Resident #49's pressure ulcer dressing was not changed for 10 days with a resulting infection requiring the insertion of a peripherally inserted central catheter for the infusion of antibiotics. The facility census was 56. Findings include: Review of the medical record for Resident #49 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A pressure ulcer risk assessment completed 09/28/20 indicated the resident was at risk for the development of pressure ulcers. The plan of care stated the resident was at risk for impaired skin integrity. Interventions included inspect skin during routine daily care and skin assessments as ordered. Record review did not reveal an order for [REDACTED].#65 on 02/22/21 at 5:55 P.M. revealed weekly skin assessments are performed for residents. Review of a Minimum Data Set assessment completed 12/28/20 revealed the resident had a brief interview for mental status score of 9, indicating cognitive impairment. The resident required extensive assistance from two staff for bed mobility, dressing, and toileting and was totally dependent upon staff for transfers. The resident required extensive assistance from one staff for personal hygiene. Review of a weekly skin assessment dated [DATE] revealed the resident's skin was intact. Review of a weekly skin assessment dated [DATE] revealed Resident #49's skin was intact but also the assessment also indicated unable to complete full assessment. Resident complaining of pain to right foot and does not want to reposition. No abnormal skin issues in observable area. The assessment was then not locked or completed until 02/02/21. There was no evidence a complete skin assessment was completed after the weekly skin assessment could not be fully done on 01/24/21. A subsequent skin assessment was completed on 02/01/21. A nurses note on 02/01/21 at 11:00 A.M. stated a nursing assistant notified the nurse that Resident #49 had an old dressing dated 01/22/21 to his left posterior leg with green drainage and a foul odor. The nurse's note indicated the nurse went to the resident's room and noticed a foul smell in the room. The old dressing was removed with large amount of green drainage on old dressing dated 01/22/21. (10 days old). There was no documentation in the medical record to indicate who applied the dressing on 01/22/21 or why. There was no order for a dressing prior to 02/01/21. Review of a pressure ulcer skin grid dated 02/01/21 revealed Resident #49 had a stage two pressure ulcer of the left lower posterior leg first noted 02/01/21 with green drainage and odor measuring 6 by 2.5 by 0.3 centimeters. The physician was notified on 02/01/21 and a culture and sensitivity of the ulcer was ordered. A treatment was ordered to cleanse the left posterior leg with normal saline solution, apply hydrogel, cover with non-adherent dressing and secure with tape every shift (twice daily). Review of nurses notes on 02/04/21 at 12:12 P.M. revealed a note from the nurse practitioner which stated the resident had developed an ulcer of the left lower extremity measuring 6 centimeters (cm) by 0.5 cm. Edges of wound pink. Wound base white and moist. Culture pending. Antibiotics were ordered on [DATE] twice daily for 10 days. Review of the culture results revealed on 02/05/21 it was reported the wound had a moderate growth of [MEDICATION NAME] faecalis. Review of nurses notes on 02/08/21 at 6:08 P.M. revealed the note stated to make an appointment for peripherally inserted central catheter (PICC) placement for administration of IV antibiotics ([MEDICATION NAME]). On 02/09/21 at 11:07 P.M. a nurses note stated the PICC placement was scheduled for 02/10/21 due to left lower leg posterior wound. Nurses notes on 02/10/21 at 2:13 P.M. indicated the PICC line was in the left upper arm and the resident was receiving antibiotics ([MEDICATION NAME]) every 12 hours for wound infection. Review of a skin grid on 02/12/21 revealed the stage two pressure ulcer on the left lower posterior leg measured 4.3 by 0.5 by 0.1. centimeters. Review of nurses notes revealed the antibiotics were discontinued on 02/18/21 and the PICC line was removed on 02/19/21. A skin grid on 02/19/21 stated the stage two pressure ulcer on the left lower posterior leg measured 4.3 by 0.5 by 0.1. centimeters. Observation of the dressing change to the left lower posterior leg on 02/22/21 at 3:15 P.M. revealed LPN #65 removed the old dressing. The dressing was not dated to indicate when it had last been changed and was not initialed to indicate who changed the dressing last. This was confirmed by LPN #65 at that time. LPN #65 stated nurses are to date and initial a dressing when applied. The resident had a superficial open area approximately 4.5 cm long by 0.5 cm wide. No drainage or odor was noted. The skin around the open area was pink. Interview with the Director of Nursing on 02/25/21 at 9:20 A.M. confirmed that LPN #65 had reported that Resident #49 had a dressing dated 01/22/21 on his leg on 02/01/21. (10 days old). She stated she did not know who put the dressing on and confirmed there was no order for a dressing prior to 02/01/21. She confirmed there was no documentation of any issue with the resident's leg prior to 02/01/21 when a stage two pressure ulcer with green drainage and odor was noted. She confirmed the weekly skin assessment on 01/24/21 was unable to be completed fully and that someone should have went back and did a full skin assessment the next shift. She confirmed the resident required a PICC line with antibiotics due to infection of the leg ulcer. Interview with the Director of Nursing on 03/01/21 at 10:45 A.M. confirmed there was no evidence of any action taken on the wound culture results from 02/05/21 until 02/08/21 when it was noted to make an appointment for a PICC line for IV antibiotics. This deficiency substantiated Complaint Number OH 090.

Based on observation, record review, policy review, review of the operating instructions for use of a specialty mattress and staff interview, the facility failed to provide care and services to prevent the development of avoidable pressure ulcers, provide ongoing monitoring of pressure ulcers, properly stage pressure ulcers and utilize specialty mattresses in accordance with their operating instructions. This affected two (Resident #20 and #66) of three residents reviewed for pressure ulcers and resulted in harm for Resident #20 who developed multiple avoidable Stage 2 pressure ulcers after his admission to the facility. The facility identified six residents who had pressure ulcers at a Stage II or higher with two of the six occurring after admission. The census was 46. Findings include: 1. On 01/31/12 at 6:00 P.M., observation revealed Resident #66 was lying in bed in a supine position with his feet elevated on a cushion to elevate his heels off the bed. The sheets were pulled back making his feet visible. There was a necrotic (black) area to the right inner heel that was approximately the size of a golf ball. A reddened area with flaking skin was noted to the tip of the left great toe. The left outer foot just below the toes had an area that was light black in color with flaking skin around the wound area. A specialty mattress was in place with the blower pump secured to the foot of the bed. The blower pump included the settings for the mattress which was illustrated by the illumination of a series of eight lights. The eight lights ran horizontal with the left side marked as soft and the right side marked as firmer. The setting was set on the fifth light which was more on the firmer side than the soft side. A follow up observation on 02/02/12 at 3:10 P.M. noted the specialty mattress remained on the same setting with the fifth light illuminated. The blower pump was noted to have a piece of paper taped on the top of it that included the different settings that should be used based on the resident's body weight. The guidelines indicated the setting identified by the illumination of five lights was for a resident weighing between 285 to 395 pounds. Review of Resident #66's medical record revealed he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident was noted to have unstageable pressure ulcers to his sacrum and left ischium upon admission. An unstageable pressure ulcer, defined as a pressure ulcer that included eschar (black necrotic/dead or devitalized tissue that lost its usual physical properties and biological activity) covering the wound bed preventing adequate staging of the pressure ulcer. He also had the [DIAGNOSES REDACTED]. The resident's weight was 154 pounds on 12/31/11. The latest weight obtained was a weight of 153.4 pounds on 02/01/12. The resident was hospitalized multiple times during his stay at the facility with his last re-admission to the facility on [DATE]. A pressure ulcer risk assessment dated [DATE] completed upon readmission revealed the resident was at risk for pressure ulcers based on risk factors and the presence of existing pressure ulcers. A skin assessment completed upon readmission on 01/02/12 indicated the only pressure ulcers the resident had at the time of his readmission was a Stage IV pressure ulcer to the coccyx/ sacrum and a Stage IV pressure ulcer to the left ischium. ( A Stage IV pressure ulcer, defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present in some parts of the wound bed and often included undermining and tunneling). A weekly assessment of the pressure ulcers to the sacrum and the left ischium was completed on 01/11/12 and indicated an improvement in the pressure ulcers. There was no additional documentation of a weekly skin assessment being completed for these areas from 01/11/12 through 01/31/12. Skin grids for pressure ulcers dated 01/16/12 noted the development of new Stage I pressure ulcers to the resident's right heel, left heel and left outer foot. A Stage I pressure ulcer, defined as intact skin with non-blancheable redness of a localized area usually over a bony prominence. These areas were identified as not being present when the resident was readmitted to the facility on [DATE]. Additional pressure ulcers were documented as being first observed on 01/17/12. A Stage I pressure ulcer was noted to the left great toe. A Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer, with pink wound bed or slough, may also present as an intact or ruptured serum filled blister) was noted to the resident's left lower anterior leg. There was also a Stage II pressure ulcer to the right knee, right lower anterior leg, right outer ankle, right outer upper ankle and left great toe. There were two unstageable pressure ulcers noted to the third and fourth toes of the left foot. There were no additional wound assessments completed for the pressure ulcers from their initial assessment on 01/16/12 and 01/17/12 through 01/31/12. Review of the weekly skin assessments dated 02/01/12 revealed there had been additional assessments documented in the facility's computer software program of the resident's existing wounds. The assessment of the right heel described it as a Stage I pressure ulcer which was visualized as a suspected deep tissue injury (SDTI). A SDTI, defined 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. The assessment was completed by Licensed Practical Nurse #30. The DON and Registered Nurse #31( a Clinical Assistant RN) assessed the wound and both individuals indicated the pressure ulcers were not staged correctly. They both stated the pressure ulcer should have been staged as an unstageable area as there was eschar present. A skin grid pressure ulcer assessment form completed 02/02/12 staged the same right heel as an unstageable pressure ulcer. Review of the facility's policy on 'Skin: Pressure Ulcers, Staging Of' dated 10/18/01, and revised in 2007, revealed pressure ulcers would be assessed and staged according to the recommendations of the National Pressure Ulcer Advisory Panel. The Skin Pressure Ulcer policy also directed staff to document the site, grade, length, width, depth, drainage, color, odor and progress of the wound upon admission, re-admission, weekly or with complications or wound changes to document these assessments on a skin grid. Review of the operating instructions for the Power Turn Elite Lateral Rotation with Low Air Loss Therapy mattress revealed the blower pump included a micro-processor that allowed the caregiver to have total control of the the comfort and chosen therapy for the resident through use of user friendly controls. The instructions included weight recommendations based on the weight of the resident and guided the caregiver to the appropriate setting to be used. The weight recommendations were as follows: a) Light one was for a resident weighing 90-160 pounds. b) Light 2 was for a resident weighing 120-195 pounds c) Light 3 was for a resident weighing 160-225 pounds d) Light 4 was for a resident weighing 195-295 pounds e) Light 5 was for a resident weighing 285- 395 pounds f) Light 6 was for a resident weighing 375-475 pounds g) Light 7 was for a resident weighing 450-575 pounds h) Light 8 was for a resident weighing 550- 650 pounds Based on the resident's weight of about 153 pounds the setting that should have been used was light one or light two. On 02/02/12 at 3:15 P.M., interview with the DON revealed based on the operating instructions for the specialty mattress, the settings were not appropriately set based on the resident's weight. She acknowledged the resident's weight did not indicate the setting to be at light five. She pushed the button to the left of the light indicators which reduced the illuminated lights from five to two. The bed deflated as the setting was changed to the correct setting. She confirmed that the more lights illuminated the firmer the mattress was. She acknowledged there was a risk of new pressure ulcers developing or delayed wound healing of the existing pressure ulcers by having the mattress settings firmer than what was recommended. She stated the areas to the legs could be attributed to the resident's use of a [DEVICE] system and a clamp that was on the collection tubing. She stated the facility cut the clamp off after the pressure sores were noted and it was determined the clamp was the cause. She also stated the pressure ulcers to the heels were the result of the resident's tendency to slide down in bed. She again indicated once the pressure ulcers developed, the facility identified the cause and put interventions in place to correct the cause of the pressure ulcers. She acknowledged the concerns were not identified prior to the development of the pressure ulcers and the interventions were not implemented until after the pressure ulcers were present. She also acknowledged the pressure ulcers should have been monitored and assessed on a weekly basis. On 02/01/12 at 3:10 P.M., interview with Resident #66 revealed the adjustments made to the settings on the specialty mattress resulted in the mattress being softer and more comfortable. 2. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #20 was severely impaired for daily decision making, was dependent on staff for activities of daily living, and had a Stage IV pressure ulcer (Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures) that measured 1.7 centimeters (cm) in length (l) by 1.5 cm in width (w) by 0.5 cm in depth (d). Review of the Pressure Ulcer Risk assessment dated [DATE] revealed Resident #20 was at high risk for development of pressure ulcers. Review of the medical record revealed the last documented weight for Resident #20 was 176 pounds on 11/22/10. Review of the Skin Grid Pressure assessments revealed the following regarding Resident #20's Stage IV coccyx pressure ulcer: - On 01/04/12, the pressure ulcer measured 1.5 cm in (l) by 1.5 cm in (w) by 1.3 cm in (d) with a small amount of red drainage and no odor. -On 01/11/12, the pressure ulcer measured 2.0 cm in (l) by 2.0 cm in (w) by 1.3 cm in (d) with a small amount of dark brown drainage and no odor. -Review of the medical record revealed no documented evidence the resident's coccyx pressure ulcer was assessed between 01/11/12 and 02/01/12. -On 02/01/12, the pressure ulcer measured 1.5 cm in (l) by 1.5 cm in (w) by 0.5 cm in (d) no drainage was noted, the wound bed was pink with a small amount of bone noted deep in the wound bed. An odor was noted to the wound and the wound edges were hard and macerated. -On 02/02/12, the pressure ulcer measured 1.5 cm in (l) by 2.0 cm in (w) by 1.3 cm in (d). There was no documented evidence of the wound appearance, characteristics or presence of odor. Review of the medical record revealed no documented evidence the resident's physician and family were notified the resident's pressure ulcer had an odor on 02/01/12 or increased in size on 02/02/12. Review of the At Risk for Complications and Recurring Infection care plan (revised 06/16/11) revealed interventions included weekly wound assessments, an alternating air specialty mattress, to monitor for signs and symptoms of wound infection, and to update the family and physician of any changes in the wound. On 02/02/12 at 9:46 A.M., observation revealed Resident #20 was lying on an alternating air mattress set on setting number five. Resident #20's coccyx pressure ulcer measured 2 cm in (l) by 2 cm in (w) by 1.5 cm in (d). The wound bed was red with bone noted at the base of the wound with a foul odor. The wound edges and periwound were macerated. Licensed Practical Nurse (LPN) #22 was observed using the same four by four normal saline gauze to cleanse the Stage IV pressure ulcer wound bed, sides of the wound, wound edges and periwound in a blotting motion. On 02/02/12 at 10:10 A.M., interview with LPN #22 verified she used the same gauze when cleansing the Stage IV pressure ulcer wound and periwound. Review of the Skin Assessment-Monitoring of Healing Process policy (revised November 2006), revealed skin assessments were to be completed weekly including the wound location, staging, size, length, width, depth, exudate, odor, pain, and a description of the wound bed, wound edges and surrounding tissue. The nurse was to report signs and symptoms of infection, changes in the wound characteristics, failure of the wound to respond to the current treatment and any other symptom that may indicate complications or delayed wound healing. On 02/01/12 at 2:28 P.M., interview with the Director of Nursing (DON) verified the medical record revealed no documented evidence an assessment of Resident #20's Stage IV coccyx pressure ulcer was completed between 01/11/12 and 02/01/12. The DON verified pressure ulcer assessments were to be completed weekly, the resident's coccyx pressure ulcer was assessed to have declined on 01/11/12, and there was no evidence of an assessment or evaluation of the new treatment implemented on 01/12/12 until 02/01/12. The DON also verified the pressure ulcer assessment dated [DATE] indicated the wound had developed an odor, and the medical record revealed no documented evidence the physician or family was notified of the change in condition. Review of the Operating Instructions of the Alternating Air Floatation Mattress System (undated) revealed the following guidance to be used when determining the appropriate setting and the resident's weight: a) a weight of 85-140 pounds should have a setting of 1-2 b) a weight of 120-165 pounds should have a setting of 1-3 c) a weight of 150-195 pounds should have a setting of 1-4 d) a weight of 175-205 should have a setting of 2-4 e) a weight of 200-250 pounds should have a setting at 3-6 f) a weight of 245-300 pounds should have a setting of 4-6 g) a weight of 300-350 pounds should have a setting of 7-8 On 02/02/12 at 1:14 P.M., interview with Housekeeping Supervisor (HK) #23 verified the specialty mattress setting was determined by the residents weight and a setting number five indicated the resident's weight was between 200 and 300 pounds. (The Housekeeping Supervisor was responsible for the initial set up of the specialty mattresses). On 02/02/12 at 1:26 P.M., interview with Registered Nurse (RN) #1 verified the higher the specialty mattress setting, the firmer the mattress. On 02/02/12 at 3:15 P.M., interview with the DON verified the specialty mattress was set too high and acknowledged the higher setting resulted in the specialty mattress being to firm which could delay wound healing or result in additional pressure areas. On 02/03/12 at 7:40 A.M., interview with the DON verified Resident #20 was weighed this day and the weight was 171 pounds. The specialty mattress setting was then decreased to setting number four.