Every finding on record at New Dawn Rehabilitation and Healthcare Center

Based on interview and closed record review the facility failed to correctly transcribe a resident's pain medication orders resulting in missed doses and pain. This affected one (Resident #81) of three residents reviewed for pain. The facility census was 72. Findings include: Review of Resident #81's closed medical record revealed an admission date of 07/10/26 at 1:51 P.M. and a discharge date of 07/15/26. Diagnoses included but were not limited to heart failure, chronic kidney disease stage four, anxiety disorder, and unspecified fracture of the fourth thoracic vertebra.Review of Resident #81's Hospice Medication List and orders provided to the facility, dated 07/09/26, revealed an order for Oxycodone 5 milligrams (mg) by mouth every four hours for pain and Oxycodone 5 mg by mouth every four hours as needed for pain.Review of Resident #81's admission orders from the facility dated 07/10/26 revealed an order for Oxycodone 5 mg by mouth every four hours as needed for pain. The facility did not transcribe the scheduled Oxycodone 5 mg every four hours Review of Resident #81's Medication Administration Record and narcotic sign off sheets revealed the resident received Oxycodone 5 mg on 07/10/26 at 3:31 P.M. and not again until 07/11/26 at 7:45 A.M.Review of Resident #81's pain assessments revealed the following pain levels07/10/26 at 1:47 P.M. a pain level of 9 out of a possible 10 pain rating (on a pain scale of 1-10 with 1 being minimal pain and 10 being the worst pain the resident has felt). On 07/10/26 at 3:31 P.M. a pain level of 10. On 07/10/26 at 6:09 P.M. a pain level of 2. On 07/11/26 at 5:59 P.M. a pain level of 6. There was no documented pain assessment completed from 07/10/26 after 6:09 P.M until 07/11/26 at 5:59 P.M.Review of Resident #81's nursing progress notes revealed on 07/11/2026 at 7:45 A.M. revealed the resident (was) crying (and) states she is having back pain of 10. Pain medication (was) given at this time. On 07/11/26 at 8:15 A.M. revealed Hospice called to review orders. They said that the hospice nurse would be coming in to the facility to review medications and give corrections if needed. The resident (is) resting quietly in bed at this time. On 07/11/26 at 9:09 A.M. revealed the hospice nurse here to review medications. The resident continues to rest quietly in bed. no signs or symptoms of pain except when gotten up to the bathroom. On 07/11/26 at 11:45 A.M. revealed pain medication was given as ordered. Medication is scheduled every four hours.Review of Resident #81's care plan dated 07/15/26 revealed the resident has pain. Interventions included anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Evaluate the effectiveness of pain interventions every shift and as needed. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; and Monitor/record pain characteristics every shift and as needed.During an interview on 07/23/26 at 11:23 A.M. LPN #123 reported she was the nurse who admitted Resident #81. She stated hospice had provided her a list of medication orders which she transcribed. LPN #123 reported she believed the Oxycodone 5mg was to be as needed and she did not see that it was ordered on a scheduled basis. She continued that the resident's family had medicated her pain prior to bringing her in and she also administered medication during her shift. LPN #123 stated when she left around 7:00 P.M., the resident was not in pain.During a phone interview on 07/23/26 at 12:10 P.M. Family Member #111 reported she received a phone call from Resident #81 on 07/11/26 around 8:00 A.M. Family Member #111 stated the resident reported she had not received her scheduled medication all night and was experiencing pain.During a phone interview on 07/23/36 at 1:54 P.M. Hospice Registered Nurse (RN) #110 reported at the time of Resident #81's admission to the facility, she was supposed to be ordered Oxycodone 5 mg every four hours and then Oxycodone 5 mg as needed for breakthrough pain every four hours.During an interview on 07/23/26 at 11:43 A.M. Clinical Manager #112 verified, upon review of Resident #81's record, Resident #81's Oxycodone 5 mg was transcribed incorrectly resulting in missed doses during the night. She stated Hospice arrived the next morning and adjusted her medication.This deficiency represents non-compliance investigation under Complaint Number 3092718.

Based on medical record review, review of hospital records, review of the facility's investigation, facility policy review and interviews, the facility failed to provide necessary and timely treatment for Resident #10 following a reported injury by the resident. This affected one resident (#10) of three residents reviewed for accident hazards. Actual harm occurred on 04/18/26, when Resident #10 reported to staff that someone dropped her last night while getting changed and she had left knee pain. The resident's left knee was noted to be swollen, and she could only slightly lift her knee. Licensed Practical Nurse (LPN) #15 administered as needed Tylenol for pain. LPN #15 failed to notify the resident's medical provider of the reported fall and change in condition of Resident #10 resulting in delaying necessary treatment including x-rays and orthopedic consult. On 04/20/26, two days after the reported incident, the resident continued to have pain and swelling. The medical provider was notified and ordered an x-ray on 04/20/26 that confirmed the resident had a comminuted fracture (caused by trauma) of the distal femur. The resident was transported to the emergency room for a trauma consult on 04/21/26. Orthopedics deemed the resident a non-surgical candidate and recommended palliative approach with pain management and knee immobilizer due to the resident was non-ambulatory. The resident was admitted to hospice services on 04/27/26 and ordered Oxycodone 2.5 milligrams (mg) every two hours for pain. Findings include: Medical record review revealed Resident #10's most current admission to the facility was 06/05/22 with diagnoses including dementia, insomnia, unsteadiness on feet, difficulty walking, abnormal posture, unspecified fall, reduced mobility, muscle weakness, history of transient ischemic attack (TIA), anemia, depression, anxiety, bipolar, and paranoid personality disorder. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate hearing and vision, spoke clearly, and understood others and self. The resident's brief interview for mental status (BIMS) score was 11 (moderate cognition impairment) out of 15. The residents' inattention, disorganized thinking and altered level of consciousness was noted to fluctuate. The residents had no limitation in range of motion, behaviors or rejection of care. The resident was dependent on staff for hygiene, lower body dressing, and transfers. Resident #10 used a manual wheelchair for mobility. The resident had no pain during the assessment period and was not receiving scheduled pain medication. Review of Resident #10's behavior plan of care initiated on 04/09/26 and revised 04/22/26 (a day after fracture was confirmed) revealed the resident displayed behaviors of making false allegations regarding her husband cheating on her, staff not treating her right, and falsehood about care. Resident #10 was resistive to care at times and refused medications, showers, changing clothing and declined to use leg rests on her wheelchair. Review of Resident #10's medication administration and nursing progress notes dated 04/17/26 revealed no evidence the resident had an accident or injury or received as needed pain medication. Review of Resident #10's medication administration progress note dated 04/18/26 at 9:30 A.M., revealed LPN #15 administered Acetaminophen 325 mg two tablets by mouth for pain. There was no documented evidence of where the pain was located. Review of Resident #10's nursing progress note authored by LPN #15 dated 04/18/26 at 12:01 P.M., revealed the resident was complaining of left knee pain. The resident stated to aides they dropped me last night while I was getting changed. Midnight nurse or aide did not report any incident. Resident #10's left knee was swollen, with no redness and skin intact. Resident was able to move toes and ankles of the left leg and could slightly lift the knee. Resident was given as needed medication; resident was resting in bed. Review of Resident #10's medication administration note dated 04/18/26 at 12:32 P.M., revealed the Acetaminophen was effective and the resident's follow up pain scale was zero out of 10. Review of Resident #10's shower sheet dated 04/19/26 authored by Certified Nurse's Aide (CNA) #35 and signed off by LPN #71 revealed CNA #35 documented she gave Resident #10 a bed bath because of her knee. The resident said night shift had dropped her while changing her on 04/18/26, so since she was still yelling in agony with the slightest movement, we just gave her a bed bath and changed her sheet. Review of Resident #10's medication administration record (MAR) dated 04/20/26 at 9:30 A.M., revealed the resident received Acetaminophen 325 mg two tablets by mouth for pain rated five out of 10 (1-10 pain scale). There was no indication where the pain was located. There was no evidence that the resident's medical provider was notified of the resident's reported fall, pain, and limitation in range of motion. Further review of Resident #10's nursing notes revealed no further documentation regarding the resident's knee, pain, or incident until 04/20/26 when LPN #4 documented a late entry at 10:29 A.M., that indicated new orders were obtained per the resident's physician for an x-ray of the left knee. Floor nurse was updated. Review of the facility provider communication binder (not part of the resident's medical record) revealed on 04/20/26 an unknown staff at unknown time had written a note that the resident in room [ROOM NUMBER], bed 2 (Resident #10), had complaints of a fall on Friday and had complaints of left leg pain, swelling, and crying when leg was moved. X-ray??? Review of Resident #10's visiting physician note authored by Medical Doctor (MD) #101 dated 04/20/26 revealed the resident was seen today to follow up on a fall which occurred on 04/17/26. The resident was now complaining of left leg pain, and she was crying when it was moved. Staff reported that there was swelling. Per the documentation in the medical record on 04/18/26 the resident had reported to aides that she was dropped last night while she was getting changed. The resident's medication included Acetaminophen 325 mg two tablets every six hours as needed and Acetaminophen PM 500-25 mg at bedtime for insomnia. The provider's assessment and plan included getting an x-ray of the left knee, hopefully today, as it was swollen and resident stated it was painful. Review of Resident #10's order dated 04/20/26 revealed left knee x-ray STAT for increased pain and swelling. Review of Resident #10's left knee radiology report dated 04/20/26 at 6:10 P.M. revealed the resident had a comminuted impacted fracture of the distal femur that was identified. The fracture did involve the articular surface laterally. Anterior lateral displacement of the distal fracture fragments was noted. A large joint effusion was identified. Soft tissue swelling was noted. Moderate degenerative changes were noted. Review of Resident #10's medical record revealed no evidence MD #101 or a nurse practitioner (NP) were notified of the x-ray results on 04/20/26. The next progress entry was a late entry dated 04/21/26 at 10:31 A.M. authored by LPN #4 that revealed the results were obtained and NP updated. The noted indicated to send the resident to the emergency room for further evaluation per daughter and NP. Review of a visiting Nurse Practitioner (NP) note authored NP #102 dated 04/21/26 revealed yesterday the resident had reported knee pain to the MD and an x-ray was obtained. The resident continued to complain of pain. The x-ray results were reviewed today (per x-ray report the results were completed on 04/20/26 at 6:10 P.M.) and there was a comminuted impacted fracture of the distal femur. Fracture fragments were noted and there was a large joint effusion identified as well as soft tissue swelling. The resident at this point of time will be sent to the emergency department for evaluation of the fracture and need for surgical intervention moving forward. Review of Resident #10's hospital emergency notes authored by MD #103 dated 04/21/26 revealed the resident's daughter was at the bedside and endorses that the resident had an unwitnessed fall at the nursing home and was not able to confirm the mechanism of injury. The resident appears to be alert and oriented times three at bedside, however unable to provide any significant history in regard to the fall or incident leading up to it. The resident had noted pain and tenderness in the distal thigh region. The resident had a computed tomography (CT) scan of the femur that indicated a comminuted distal femoral fracture with displaced fragments and impaction. Diffuse osteopenia (indicates early bone loss that is less severe than osteoporosis). There was a large knee joint effusion with fat/fluid levels. After a long discussion with the resident's daughter given that the resident was non-ambulatory and relatively non-painful she was okay with proceeding with conservative treatment of her distal femur fracture and knee immobilizer. The resident was to maintain non-weight bearing restrictions in the knee immobilizer and to follow up as outpatient with orthopedics. Review of Resident #10's April 2026 MAR revealed the resident had only received the one dose of Acetaminophen. On 04/28/26 Oxycodone 2.5 mg was ordered every two hours for pain. The resident received a dose of the Oxycodone on 04/28/26, 04/29/26, 04/30/26. Review of the facility's fall investigation dated 04/20/26 revealed the fall/incident occurred on 04/18/26. The collaborative team meeting was held to review the incident dated 04/18/26. Nurse was called to the resident's room due to left knee pain. Nurse assessed the resident's knee with swelling noted without redness, skin intact, bilateral knees equal in temperature. Range of motion within normal limits to left ankle and toes. Resident would not bend left knee due to increased pain stating, they dropped me while I was getting changed. Resident unable to explain what happened at time of fall, who was with her, so resident repeated, I was dropped when I was getting changed. Nurse offered as need pain medication and the resident accepted. Further investigation of all staff conducted; staff deny recent falls however, staff reported that during wheelchair transport to shower, resident left leg/heel touched down to floor and was jarred. MD and resident representative aware, new order for x-ray. Resident was currently in bed resting. Leg rests to be on at all times when resident in wheelchair, staff education provided. Care plan reviewed and updated as necessary.The following staff statements were obtained as part of the facility's investigation:Review of staff statements revealed no evidence Agency LPN #104, who worked on 04/17/26 was interviewed. Review of CNA #98's written statement dated 04/21/26 and witnessed by LPN #4 revealed she was transporting Resident #10 to her room in wheelchair before dinner when the resident stated, my foot keeps falling. The CNA told the resident to try and keep her feet up. After stopping the wheelchair immediately and checking over the resident's foot. Review of CNA #70's statement dated 04/21/26 revealed on Friday (04/17/26) the resident reported someone had dropped her and said her left leg hurt and the CNA had told next shift about it. On Saturday (04/18/26) the CNA was told that the resident had someone coming to do an x-ray. When it came to be Sunday (04/19/26), CNA #70 told two of the nurses on night shift to come to Resident #10's room to look at her leg. Resident #10 then said when she was in the wheelchair someone was going fast and her leg got caught. Review of LPN #7's written statement dated 04/21/26 and witnessed by LPN #4 revealed LPN #17 had reported the resident had some pain during the night, and the doctor was updated with new orders for x-ray. Review of LPN #15's written statement dated 04/22/26 revealed she was called to Resident #10's room due to the resident complaining of left knee pain. The LPN evaluated the resident's left knee; resident was able to move toes, hip, and ankle with no pain or issues. Resident's knee was swollen, no redness, equal in temperature with right knee and skin was intact. Resident stated to this nurse they dropped me last night when I was getting changed. The nurse asked day shift aides if they had got in report that the resident had fallen. All day shift aides stated they had not heard of her falling. Resident was given as needed Tylenol at 9:30 A.M., and it was effective. This nurse passed on to oncoming nurse to monitor for increased pain or discomfort. Interview on 06/11/26 at 12:45 P.M., with the Director of Nursing and LPN #4 revealed at the time of the incident the DON was off and LPN #4, who was the Unit Manager, completed the investigation. The DON reported she had reviewed the fall/incident report and confirmed the date the incident report was completed was inaccurate due to the facility believed the incident occurred on 04/17/26. The DON reported the injury was of unknown origin and was not reported to the State Agency. The DON and LPN #4 confirmed there was a delay in medical provider notification and treatment for Resident #10 beginning on 04/17/26 when CNA #70, who worked night shift on the Friday (04/17/26), had documented the resident had reported someone had dropped her and her left leg was hurt and the CNA did not report the incident until the next shift on Saturday (04/18/26). The DON confirmed the delay in treatment continued when LPN #15 assessed the resident on 04/18/26, however never reported the incident or injury to the resident's medical provider. The DON confirmed that LPN #15 was given a disciplinary action form as a result of not reporting the incident. LPN #4 confirmed she did not obtain a statement from the Agency Nurse (LPN #104) who worked the night on 04/17/26 and provided care to Resident #10. Per the DON, on 04/19/26 CNA #35 completed the shower sheet that was signed by LPN #71 that indicated the resident was not given a shower because she was yelling in agony with the slightest movement and reported staff had dropped her, however staff still never documented or reported the change in condition or the incident to the resident's medical provider. LPN #4 stated that on Monday 04/20/26 the Administrator had notified her of the incident, and she notified the medical provider. The provider visited the same day and ordered an x-ray. The x-ray results were received on 04/20/26, however the results were not reviewed until 04/21/26 by the NP. The DON verified the x-ray results identified Resident #10 had a comminuted fracture, and the family had requested she be sent to the emergency room. The family elected palliative care (hospice) and declined surgery and orthopedic consult. The DON and LPN #4 reported the only explanation they could determine was that CNA #98 verbally reported she was transporting Resident #10 in the wheelchair without the footrest and jarred her leg and the resident said ouch, however there was no statement or supporting evidence to support the theory. CNA #98 was disciplined for not using footrest. The DON confirmed there was no documentation on 04/17/26 regarding the incident reported to CNA #70, no evidence of documentation on 04/19/26 regarding the resident's pain or assessment of the resident's leg. Interview on 06/11/26 at 1:02 P.M., with CNA #98 confirmed she had worked on 04/17/26 and provided care to Resident #10. The CNA confirmed she had given the resident a shower and left her up in the wheelchair to have dinner in the dining room. While she was pushing the resident back to her room after dinner the resident kept reporting her foot was falling. The CNA confirmed the wheelchair did not have footrest on it and she had the resident hold her legs out straight and she pushed her down the hallway. The CNA reported she doesn't recall the resident feet touching the floor, feeling any resistance, running over the resident's foot, jarring the resident feet/leg, or the resident saying ouch during the transport. The CNA reported that the resident reported to her on Saturday (04/18/26) that night shift had dropped her out of bed. Interview on 06/11/26 at 2:00 P.M., with MD #106 (who was covering for MD #101) and the DON revealed due to the resident's age and osteoporosis it would not take much to cause a traumatic fracture. The MD reported if staff had dropped the resident he would have expected more trauma. The MD confirmed the fracture was of unknown origin. The DON and MD #106 confirmed there was no documentation or evidence the provider was notified of the change of Resident #10's condition (leg pain and swelling) and allegation she was dropped until three days later on 04/20/26. Interview on 06/11/26 at 2:27 P.M., with CNA #35 confirmed she had provided care to Resident #10 on 04/19/26 and the resident was screaming out in pain, and her left leg was more swollen than usual. The CNA confirmed she had reported the finding to LPN #71. Attempts to interview Resident #10 throughout the survey were unsuccessful. The resident was not able to answer questions appropriately.Review of the facility's policy titled Charting and Documentation dated 2021 revealed all services provided to the resident, or any change in the resident's medical or mental condition, shall be documented in the resident's medical record. Incidents, accidents, or changes in resident's condition must be recorded.

Based on observation and interview, the facility failed to provide a safe environment when facility dryers were not maintained. This had the potential to affect all residents residing in the facility. The census was 68. Findings include: Observation of the facility laundry room on 06/15/26 at 10:18 A.M. revealed two dryers. Upon opening the lint trap of each dyer an excessive amount of lint in each trap was revealed. Each lint trap was entirely covered in a layer of thick white lint. Build up of the lint in each dryer was excessive to the point lint was also built up on the bottom of the floor of the dryer. Interview on 06/15/26 at 10:18 A.M. with Laundry Attendant #105 confirmed there was an excessive amount of lint built up in the lint trap of each dryer. Laundry Attendant #105 stated it appeared that the amount of lint build up was from more than one day.

Based on observation, interview, and policy review the facility failed to ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and considering the number, acuity, and diagnoses of the facility's resident population. This affected 68 of 68 residents residing in the facility. The facility census was 68. Findings include: Interview on 06/08/26 at 9:39 A.M. with Resident #2 revealed there was not enough staff in the facility. It seemed like there were just less and less people to help.Interview on 06/08/26 at 9:41 A.M. with Resident #7 revealed there was not enough staff in the building. There was no specific time staffing is short, its all shifts and all days of the week. When she [Resident #7] calls for assistance, it takes a long time.Interview on 06/08/26 at 11:01 A.M. with Resident #39's representative revealed call lights are always going off, they aren't answered timely, you have to wait a long time for incontinence care or to receive your showers.Interview on 06/08/26 at 1:32 P.M. with Resident #4 revealed the staff is overworked, they are not able to give the time they would like to give, affecting the quality of care as well. The call light response is slow.Interview on 06/08/26 at 1:53 P.M. with Resident #54's representative revealed the staff is not very attentive to the residents. There have been several occasions they [Resident #54's representative] have had to wander down the halls to track someone down to get Resident #54 assistance. If you need assistance no one is there, they [facility staff] are not very attentive to the residents. Interview on 06/08/26 at 3:02 P.M. with Resident #53 revealed there is not enough staff in the facility to meet the needs of the residents, you have to wait a long time for staff to answer your call light.Observation on 06/10/26 revealed Resident #34 initiated their call light at approximately 8:58 A.M. and their call light was responded to by staff at 9:20 A.M.Interview on 06/10/26 at 11:13 A.M .with Resident #34 revealed they had pressed their call button earlier that morning because they needed to use the bathroom. Resident #34 stated it took awhile for someone to respond to their call light. Resident #34 stated there have been times where she waits for the call light to be answered to use the bathroom but she can't hold it, and it causes her to be incontinent. Resident #34 stated she wears a brief, if she has waited awhile and can feel she is about to be incontinent she will hold her brief as close as possible to her to not make a mess, but it never fully catches all of the urine. This causes the bed, and her clothes needing to be changed, it causes more work for the staff, and they are already so busy, so they get more behind, and more people have to wait. Resident #34 stated she knows the staff are busy, and there are other people who need help, and need showers, she understands but she feels like there needs to be more staff. Resident #34 stated all the staff is very nice but there are not enough of them.Interview on 06/16/26 at 10:30 A.M. with Certified Nurses Assistant (CNA) #151 confirmed the facility utilized agency staff (CNA and nurses) to staff the facility. Review of undated facility policy titled Answering the Call Light revealed the purpose of the procedure is to respond to the residents' requests and needs. Answer the residents' call as soon as possible and be courteous in answering the residents' call.This deficiency represents non-compliance investigated under Complaint Number 3030059.

Review of review of the facility infection control log, interview, and policy review the facility failed to have a comprehensive infection control program and failed to ensure staff were knowledgeable on the laundry process for infectious linens. This affected all 68 residents residing in the facility. The facility census was 68. Findings include: 1.Review of the infection control log dated 06/2025 to 06/2026 revealed no evidence the log included trending of infections. In addition there was not an infection control log for 06/2026. Further review of the April 2026 infection control log revealed the log was not comprehensive to include infection types and microorganisms. On 04/09/26 the log indicated Resident #4's infection type was labs and microorganism was elevated white blood cells. There were five residents listed as having urinary infections and the microorganism was listed as UTI. The log indicated there were 24 residents on isolation, however, didn't indicate the type of isolation or the organism/type of infection that required isolation. There were 39 infections listed on the log for April 2026. Review of the May 2026 infection control log revealed there were two urinary tract infections, however the microorganism indicated UTI. On 05/14/26 the log indicated Resident #4's infection type was labs and microorganism was elevated white blood cells. The log indicated there were nine residents on isolation, however, didn't indicate the type of isolation or the organism/type of infection that required isolation. There were seven residents treated for a vaginal infection. There was 24 infections listed on the log for May 2026. Interview on 06/15/26 at 11:15 A.M., with Licensed Practical Nurse (LPN)/Infection Preventionist (IP) #4 confirmed there was no evidence the facility had been trending infections from 06/2025 to 06/2026. The LPN/IP #4 confirmed there were new infections in June 2026, however she had not started the log timely. The LPN/IP #4 reported she just took over the infection control program about three months ago and she was still learning. The LPN/IP #4 confirmed she could not review the logs for the last year to identify if there was a trend in infections. The LPN/IP #4 confirmed April and May 2026 logs did not include the type of infection on all the residents nor the correct microorganism for urinary tract infections. LPN/IP #4 confirmed the April 2026 infection log indicated there were 24 residents on isolation and nine in May 2026, however there was no indication/organisms why or type of isolation. The LPN/IP #4 reported some were just enhanced barrier precautions. The LPN/IP #4 confirmed there was a trend of vaginal infections in May 2026, but she had not investigated to determine the cause. Review of the facility's policy titled Surveillance for Infection dated 2001 revealed the purpose of the surveillance of infections was to identify both individual cases and trends of epidemiologically significant organisms and Health care -associated infection to guide appropriate interventions and to prevent future infections. Nursing staff will monitor residents for signs and symptoms that may suggest infections, according to current criteria and definition of infections, and will document and report suspected infections to the charge nurse as soon as possible. Daily record detail information about the resident and infection on an individual infection report form. 2. Interview on 06/15/26 at 10:15 A.M. with Laundry Attendant #105 revealed the certified nurses' aides (CNA) collect dirty linen. All dirty linen is placed in the dirty/ soiled room. Isolation linen is placed in red bags and then into the dirty/ soiled room. Laundry Attendant #105 stated housekeeping/ laundry will then collect the linen from the dirty/ soiled room and bring it into the laundry room. Isolation linen is kept separate by placing it in red bags. Laundry Attendant #105 stated they do not know what type of isolation or what (infection) the resident is on isolation for, they just keep any isolation in the red biohazard bag. When washing linen, whether in the red biohazard bag for isolation or regular linen they utilize the chart on the wall for settings to wash the linen on [laundry formula chart]. Laundry Attendant #105 stated it depends on how soiled items in the red bags are, if they keep them separate from regular linen while washing. Review of the Laundry formula chart revealed Heavy soiled linen is washed on setting #1. Personal items with no bleach is washed on setting #5. Rags and mops are washed on setting #7. Bibs or a short wash is washed on setting #6. Review of undated facility policy titled Laundry and Bedding, Soiled revealed soiled laundry and bedding shall be handled, transported and processed according to best practices for infection prevention and control. Review of undated facility policy titled Medical Waste Handling revealed medical waste will be handled safely in accordance with regulatory requirements. Contaminated linens and personal items will be laundered separately and stored in biohazard begs and/ or designated area prior to laundering.

Based on medical record review, interview, and policy review the facility failed to maintain an effective antibiotic stewardship program. This affected all 68 residents residing in the facility. The facility census was 68. Findings include: 1.Review of infection control program dated 06/2025 to 06/2026 revealed no evidence of an antibiotic stewardship program that included documentation of the indication, dose, and duration of the antibiotic, review of laboratory reports to determine if the antibiotic was indicated or needed to be adjusted. There was no evidence of an infection assessment tool or management algorithm being used when prescribing and a system to monitor antibiotic use. There was no system to monitor antibiotic use. Interview on 06/15/26 at 11:15 A.M., with Licensed Practical Nurse (LPN)/Infection Preventionist (IP) #4 revealed she recently took over the infection control program three months ago and was still learning. The LPN/IP #4 reported there was no documented evidence from 06/2025 to 06/2026 to determine if residents met criteria for treatment or not. LPN/IP #4 confirmed the facility was utilizing the McGeer's criteria however she doesn't complete the McGeer's criteria form or document if the resident met or didn't meet criteria anywhere. The LPN/IP #4 reported she doesn't attend the morning meetings and she doesn't always know when a resident was ordered an antibiotic until it was too late. LPN/IP #4 confirmed the facility did not have a system in-place to effectively monitor antibiotic use. Interview on 06/15/26 at 11:22 A.M., with the Director of Nursing (DON) revealed she took over the DON position in January 2025, and she had not provided education to the nursing staff regarding the McGeer's criteria. 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnosis including diabetes, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the infection control log dated 04/2026 revealed Resident #12 was treated with Doxycycline (antibiotic) for an upper respiratory infection. The chest x-ray was negative. There was no evidence that the resident met criteria for antibiotic treatment, the dosage or strength of the antibiotic, or justification for antibiotic use. Review of Resident #12's order dated 04/23/26 revealed an order for a chest x-ray for a harsh cough and rhonchi. Review of Resident #12's chest x-ray dated 04/23/26 revealed no acute disease process. Review of Resident #12's medication administration record dated 04/2026 revealed the resident was ordered and received Doxycycline 100 milligrams (mg) one twice daily from 04/25/26 to 05/01/26. Interview on 06/15/26 at 2:14 P.M., with LPN/IP #4 revealed after reviewing the resident's medical record the resident did not meet criteria per McGeer's for antibiotic treatment. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, hypothyroidism, diabetes mellitus, hypercholesterolemia, hypertension, bilateral osteoarthritis of knee, benign prostatic hyperplasia with lower urinary tract symptoms, and history of venous thrombosis and embolism. Review of Resident #6's bladder incontinence plan of care dated 02/03/26 revealed to monitor/document for signs and symptoms of urinary tract infection (UTI): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of Resident #6's quarterly MDS dated [DATE] revealed the resident was always incontinent of bladder and bowel. He was not on a toileting program. Review of Resident #6's progress notes dated 05/2026 to 06/10/26 revealed no evidence Resident #6 had signs or symptoms of a urinary tract infection. Review of urology fax dated 05/26/26 revealed orders for urinalysis for hydronephrosis of right kidney. Review of Resident #6's urine culture dated 05/30/26 revealed the resident had greater than 100,000 cfu of Escherichia coli and Klebsiella pneumonia in the urine. Ceftriaxone was sensitive to both organisms. The urine was collected on 05/26/26, received on 05/27/26, and verified on 05/30/26. Review of Resident #6's nursing progress note dated 06/01/26 revealed the urine results were faxed to urology. Review of Resident #6's nursing note dated 06/03/26 revealed no new orders were given from urology. Review of Resident #6's nursing progress note dated 06/04/26 revealed the facility's Nurse Practitioner reviewed the urine culture and sensitivity from urology and new orders obtained for a urinary tract infection (UTI) Review of Resident #6's orders dated 06/04/26 revealed Ceftriaxone one gram intramuscular (IM) one time a day for seven days for UTI. Review of Resident #6 medication administration record (MAR) dated 06/2025 revealed the resident started Ceftriaxone (antibiotic) one gram IM for a UTI on 06/05/26. Review of Resident #6 antibiotic therapy plan of care related to UTI dated 06/05/26 revealed to administer medications as ordered, monitor for adverse reaction and secondary infections such as thrush, colitis, and vaginitis. Review of the infection control log dated 06/2025 to 06/2026 revealed there was no infection control log for 06/2026. Interview on 06/10/26 at 9:28 A.M., with Licensed Practical Nurse (LPN)/Infection Preventionist (IP) #4 revealed she doesn't have a log or map (trending) for June (2026) infections. The LPN/IP #4 reported she was not sure if the resident had met criteria for treatment. The LPN/IP #4 reported she just took over IP role three months ago and was still learning. The LPN/IP #4 reported that she uses the McGeer criteria; however, she doesn't complete the forms or documents on the infection control log to ensure residents meet criteria. Interview on 06/10/26 at 11:11 A.M. with LPN #87 revealed the urologist didn't want Resident #6's urine treated, however a few days later the facility's NP had written orders to treat the urine, however there was no documented rational why he wanted the urine treated. Interview on 06/10/26 at 11:30 A.M., with Resident #6 revealed he didn't have pain or any new urinary symptoms prior to starting the antibiotic. The resident reported the only urinary symptom he has had, which he has had for three years now, was dibbling when he urinates. Interview on 06/10/26 at 12:19 P.M. with LPN/IP #4 revealed she had reviewed Resident #6's medical record again and there was no documented evidence the resident had any signs or symptoms of urinary tract infection and he did not meet the McGeer's criteria for antibiotic treatment. Review of the facility's policy titled Antibiotic Stewardship Program dated 2001 revealed the IP or designee would review all antibiotics starts within 48 hours to determine if continued therapy was justified, justified with needed interventions, or not justified. All resident antibiotics regimens would be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include the resident name and medical record number, unit and room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome and adverse events. Review of the facility's policy titled Surveillance for Infection dated 2001 revealed the purpose of the surveillance of infections was to identify both individual cases and trends of epidemiologically significant organisms and Health care -associated infection to guide appropriate interventions and to prevent future infections. Nursing staff will monitor residents for signs and symptoms that may suggest infections, according to current criteria and definition of infections, and will document and report suspected infections to the charge nurse as soon as possible. Daily record detail information about the resident and infection on an individual infection report form.

Based on record review, interview, and policy review, the facility failed to ensure residents receiving psychotropic medications were provided education on the risks/ benefits of those psychotropic medications for them or their resident representative to be able to give an informed consent for the use of those medications. This affected five residents (#3, #8, #9, #53, and #76) of five residents reviewed for unnecessary medications. Findings include:1.Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included depression and anhedonia (inability to experience pleasure or a diminished interest in activities that were once enjoyable). Review of Resident #3's physician's orders revealed he had an order to receive Zoloft (an antidepressant) 75 milligrams (mg) by mouth (po) once daily for depression. He also had an order to receive Remeron (an antidepressant) 15 mg po once daily for an appetite stimulant. Review of Resident #3's electronic medical record revealed there was no documented evidence of the resident and/ or his representative to have been provided education on the risks/ benefits of his psychotropic medication (Zoloft and Remeron) to be able to provide an informed consent. On 06/09/26 at 3:20 P.M., an interview with the director of nursing (DON) confirmed there was no evidence of the resident having been provided education on the risks/ benefits on the use of the two psychotropic medications the resident was receiving. She provided a copy of a consent form to receive psychiatric services, but denied they had an informed consent obtained from the resident regarding his use of Zoloft and Remeron. She acknowledged the facility should be obtaining informed consents from any resident and/ or their family, who were receiving psychotropic medications. She denied that they had been doing that, since it was added as a requirement, but would start doing so from that point on. 2. Review of Resident #53's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, major depressive disorder, and generalized anxiety disorder. Review of Resident #53's physician's orders revealed she had an order to receive Zoloft 25 mg po once daily for depression. The order originated on 06/20/25. Further review of Resident #53's medical record revealed it was absent for any evidence of the resident having been provided with education on the risks/ benefits of taking Zoloft for her to be able to give an informed consent. On 06/09/26 at 3:20 P.M., an interview with the DON revealed they had a consent to treatment form for the Resident #53 receiving psychiatric services, but she could not find evidence of an informed consent being obtained from the resident or her representative pertaining to the use of her Zoloft. She acknowledged they were required to obtain informed consents for the use of any psychotropic medications for a resident by educating them on the risks and benefits of treatment with that medication before it was initiated. She denied they had been doing so, but would start ensuring that was being provided when psychotropic medications were used for a resident. 3. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including mood disorder, dementia, schizoaffective disorder, post-traumatic stress disorder, visual hallucinations, delusions, mild cognitive impairment, anxiety, major depressive disorder, hemiplegia, hypertension, transient ischemic attack, cerebral infarction, and osteoarthritis. Review of Resident #9's orders revealed an order for Ativan oral tablet 0.5 milligram (mg) (lorazepam). Give 0.5mg by mouth two times a day related to delusional disorders. Review of Resident #9's orders revealed an order for risperidone tablet 0.5 mg. give one tablet by mouth one time a day for schizoaffective disorder and give two tablets by mouth at bedtime for schizoaffective disorder. Review of Resident #9's medical record revealed no documented evidence of the resident and/ or their representative to have been provided education on the risks/ benefits of their psychotropic medication (Ativan and Risperidone) to be able to provide an informed consent. Interview on 06/09/26 at 4:00 P.M. with the DON confirmed the facility had no evidence of the resident and/ or their representative being provided education on the risks/ benefits or informed consent of the psychotropic medications the resident was taking (Ativan and Risperidone). 4. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, urinary incontinence, xerosis cutis dementia, depressive episode, osteoarthritis, femur fracture, hypertension, anxiety, major depressive disorder, and myocardial infarction. Review of Resident #8's orders revealed an order for Clonazepam Tablet 0.5 MG. give 0.5 mg by mouth two times a day related to general anxiety disorder. Review of Resident #8's medical record revealed no documented evidence of the resident and/ or their representative to have been provided education on the risks/ benefits of their psychotropic medication (Clonazepam) to be able to provide an informed consent. Interview on 06/09/26 at 4:00 P.M. with the DON confirmed the facility had no evidence of the resident and/ or their representative being provided education on the risks/ benefits or informed consent of the psychotropic medications the resident was taking (Clonazepam). 5. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses of depression, anxiety, and insomnia. Review of Resident #76's orders and medication administration records dated June, 2026 revealed the resident was ordered and received the following psychotropic medications: alprazolam 0.25 milligrams (mg) twice daily for anxiety, Remeron 7.5 mg at bedtime for depression, and Quetiapine 50 mg twice daily for depression. Review of Resident #76's medical record revealed no evidence the resident or resident's representative was educated on the risk/benefits of psychotropic medications. Interview on 06/11/26 at 11:55 A.M., with the DON confirmed there was no documented evidence Resident #76 or Resident #76's resident representative were provided education on the risk /benefits of psychotropic medications. The DON reported the facility was going to start today obtaining signed consent to ensure resident and representatives were informed on risk/benefits. Review of the facility's policy on Psychotropic Medication Use (revised February 2025) revealed, prior to the initiating the use of psychotropic medications, increasing a dose, or switching to a different psychotropic medication, the staff and physician would review the following with the resident or their representative: non-pharmacological alternatives, the indications and rationale for the recommendation, the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings), and the resident's and/ or representative's right to accept or decline the treatment.

Based on paper and electronic medical record review, review of emergency binder, interview, and policy review the facility failed to ensure resident advance directives were accurate in all records. This affected four residents (#2, #6, #10, #76) of four residents reviewed for advance directives. Findings include: 1. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertension, anemia, type two diabetes, depression, anxiety, end stage renal disease, and dependence of renal dialysis. Review of resident orders, plan of care, and medical record revealed no evidence of the resident's advance directive. Review of the emergency binder revealed no evidence of Resident #76's advance directive. Interview on 06/09/26 at 9:50 A.M., with Licensed Practical Nurse (LPN) #71 and #87 confirmed there was no documented evidence in the resident's medical record or emergency binder regarding the resident's advance directive (code status). The LPN's reported the first place to look was the emergency binder, then paper chart, then the electronic medical record. 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including dementia, fracture of femur, insomnia, depression, anxiety, anemia, hypothyroidism, diabetes. Review of the emergency binder revealed no evidence of Resident #10's advance directives. Review of Resident #10's signed advance directive dated 04/27/26 revealed the resident code status was changed to do not resuscitate comfort care. Review of Resident #10's orders dated 04/28/26 revealed the resident's advance directives was do not resuscitate comfort care. Review of Resident #10's care plan revised on 04/28/26 revealed the resident's code status was do not resuscitate comfort care. Interview on 06/09/26 at 9:50 A.M., with LPN #71 and #87 confirmed the emergency binder did not include Resident #10's advance directive. The LPN's confirmed the nurses should refer to the emergency binder first during a code situation. 3.Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, hypothyroidism, diabetes mellitus, hypercholesterolemia, hypertension, bilateral osteoarthritis of knee, benign prostatic hyperplasia with lower urinary tract symptoms, and history of venous thrombosis and embolism. Review of Resident #6's advance directives care plan dated 01/30/26 revealed the resident was a full code. Review of Resident #6's current orders dated 06/2026 revealed the resident was a full code. Review of Resident #6's paper medical record revealed the resident was full code. Review of the emergency binder revealed no evidence of Resident #6's code status. Interview on 06/09/26 at 1:18 P.M., with Licensed Practical Nurse (LPN) #87 confirmed staff were to refer to the emergency binder to verify a resident code status. Review of the facility's policy titled Advance Directives (dated 2001) revealed prior to or upon admission of a resident to the facility, the social services director or designee would provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. The Nurse Supervisor and/or designee would be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. 4. Record review revealed Resident #2 admitted to the facility on [DATE] with diagnoses including atrial fibrillation, peripheral vascular disease, chronic kidney disease, anemia, hypertension, gout, and osteoarthritis. Review of Resident #2's electronic medical record orders revealed an order placed on 05/12/26 for full code status. Review of Resident #2's paper medical record revealed a signed advanced directive dated 01/31/25 for do not resuscitate comfort care (DNRCC) Review of Resident #2's care plan dated 02/08/25 revealed the resident was a DNRCC. Goals included resident advance directives would be reviewed/ revised as needed through the review date and the resident advanced directives will be regarded and respected through the review date. Interventions included properly labeling medical records and following advanced directives labelling protocol. Revise and review advanced directives as needed. And send copies of advance directives during transfers to the hospital/ clinicals. Interview on 06/09/26 at 3:45 P.M. with Licensed Practical Nurse (LPN) #87 confirmed the advanced directives in Resident #2 medical record including electronic and paper do not match including signed consents, orders, and care plans. LPN #87 confirmed they were unsure what Resident #2's current code status was but they would investigate it.

Based on medical record review, observation, review of pictures, review of concern log, and interview the facility failed to ensure a safe and sanitary environment for the residents. This affected three residents (#2, #7 and #39) of 28 residents reviewed during the initial pool. Findings include: 1.Medical record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, Alzheimer's disease, and dementia. Review of Resident #39's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was not on a toileting program and was frequently incontinent of urine and was continent of bowel. Observation on 06/08/26 at 12:30 P.M. and 1:18 P.M. of 400 hallway revealed the hallway smelled of urine. Observation on 06/09/26 at 2:21 P.M., of Resident #39's room with Resident #39's daughter revealed the resident's bed sheet had a yellow ring. Resident #39's daughter smelled the area and reported the area smelled of urine. There was urine dried on the floor around the toilet. The resident's daughter cleaned one area around the toilet during observation. The resident's daughter reported the dirty sheets, urine odors, and bowel movements smeared in the bathroom by the roommate has been an ongoing concern and she had voiced concerns with staff and management. The daughter provided photo (dated and timed) evidence of bowel movements smeared on walls and toilet, urine on the floor, and dirty sheets in her mom's room that was not cleaned for 3-10 days for the last five months. The resident's daughter reported her mom had a visitor that could not stay and visit due to the odors in the room. Observation and interview on 06/10/26 at 11:38 A.M., of Resident #39's room with Certified Nurse's Aide (CNA) #74 revealed the yellow ring on the bedsheets was still there from the observation on 06/09/26 at 2:21 P.M., and there was bowel movement on the toilet seat and rails and urine on the floor. The resident's room had just been mopped due to the floor was still wet. CNA #74 confirmed the room had just been cleaned and mopped. The CNA #74 confirmed findings and reported she would have housekeeping re-clean room and she would change the bed sheet. Review of concern log revealed on 05/28/26 the ombudsman had voiced concerns to the facility regarding odors. Review of the concern form dated 05/28/26 revealed Licensed Practical Nurse (LPN) #87 received a concern from the ombudsman that reported the daughter of Resident #39 had concerns regarding urine smell in the room. The action taken was housekeeping to audit the room/linens, wheelchair cushion switched out and spoke to residents and no complaints and denies incontinence. The facility spoke to the daughter that was the power of attorney (POA) and not the daughter that voiced concerns and the POA had no concerns with care or the room. Interview on 06/09/26 at 1:46 PM with LPN #71 confirmed there were odors on 400 hall, and some days were worse than others. Interview on 06/10/26 at 1:56 P.M., with LPN #87 confirmed he was aware of Resident #39's daughters concerns with the bathroom and linens. The surveyor shared pictures of the bowel movements on the toilet and dirty linens with the LPN. The LPN verified pictures on bowel movements on the toilet and walls because he was the staff member the daughter reported the concern to. The LPN reported the resident roommate sometimes toilets herself and was the reason there was urine and bowel movement on the toilet, rails, and walls. The LPN reported he usually checks the resident's linens every morning, but he didn't this morning. 2. Observation and interview on 06/08/26 at 9:44 A.M., with Resident #7 revealed the bathroom was noted to have a strong urine odor. Resident denied using the bathroom and it was a private bathroom for her use only. Noted to have a bed pan that was sitting over the toilet resting on the toilet seat that was not in a bag when not in use. The resident confirmed she does use the bedpan. The wall by the door was noted to be scuffed, gouged and in the need to be repaired. Resident reported she would like to have it fixed but she could not say anything. 3. Observation on 06/10/26 at 2:00 P.M. of Resident #2's bathroom revealed several soiled briefs in a small trash can with no liner and a strong urine odor. Interview on 06/10/26 at 2:10 P.M. with anonymous staff member #58 confirmed there was an odor issue, urine odor. The staff member was unsure what was causing it, possibly the resident's soiled briefs being left in trash cans in their rooms after incontinence care or toileting. Per the anonymous staff member, some staff throw the briefs into the trash can even if there is not a liner inside. This deficiency represents non-compliance investigated under Complaint Number 3030059 .

Based on menu review, observation, interview, and policy review, the facility failed to ensure food was prepared in a form designed to meet individual needs when the prepared pureed food items were not the proper consistency. This affected five residents (#13, #5, #37, #54, #58) of five residents reviewed for ordered pureed diets. The census was 68. Findings include: Review of facility menu revealed on 06/10/26 lunch included chicken and dumplings, green peas, dinner roll, and chocolate chip bar. Observation on 06/10/26 at 11:30 A.M. revealed Dietary Staff #48 placed chicken and a dumpling/ noodle item into the facility robot coupe. Dietary Staff #48 proceeded to blend the food items. Dietary Staff #48 checked the consistency, scraped the sides, and blended the items again while adding 4 ounces of chicken gravy. Dietary Staff #48 then placed the food into a serving bowl. Surveyor #51519 tasted the pureed item at 11:31 A.M. which revealed gritty pieces of chicken and larger pieces of noodle/ dumpling item. Dietary Staff #48 did not orally check the consistency of the pureed meal. Dietary Staff #48 proceeded to place a lid on the serving bowl and placed it in the warmer to prepare for tray line. Interview on 06/10/26 at 11:33 A.M. with Dietary Manager #62 revealed pureed items should be smooth, with no chunks, no skin, nothing left over. Observation and interview on 06/10/26 at 11:47 A.M. with Dietary Manager #62 confirmed the pureed chicken and dumplings could have been pureed a little longer to ensure proper consistency. Dietary Manager #62 proceeded to take the chicken and dumplings back to the robot coupe to change the consistency. Review of the undated facility policy titled Therapeutic Diets revealed mechanically altered diets as well as all diets modified for medical or nutritional needs will be considered therapeutic diets. The food services manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered.

Based on record review and staff interview, the facility failed to ensure a resident's quarterly Minimum Data Set (MDS) assessment was completed accurately to reflect all known active medical diagnoses. This affected one resident (#3) of 20 residents reviewed for assessments. Findings include:Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, adult-onset diabetes mellitus, hypertension, muscle weakness, and difficulty walking. Review of Resident #3's physician's orders revealed he had orders in place to receive Remeron (an antidepressant medication used in the treatment of depression and also as an appetite stimulant) 15 milligrams (mg) by mouth (po) once daily for an appetite stimulant. That order had been in place since 01/11/26. He also had an order for Zoloft (an antidepressant) 75 mg po once daily for depression and anhedonia (the inability to experience pleasure or a profound loss of interest in activities that were once enjoyed). He had been on Zoloft since 02/09/26, with an increase in dose at the current order being given on 05/05/26. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's active diagnoses were coded under Section I. (Active Diagnoses). Section (I.) included a place to code psychiatric/ mood disorders the resident was known to have with depression being one of the diagnoses listed. The MDS assessment was not marked to reflect the resident had an active diagnosis of depression, despite the resident receiving antidepressants for such at the time the MDS assessment was completed. Section (N.) of the MDS assessment included a place to check high-risk drug classes received by the resident during the seven day assessment period (04/01/26- 04/07/26). He was marked as having received an antidepressant during that assessment reference period. Review of Resident #3's medication administration record (MAR) for April 2026 confirmed the resident was receiving antidepressants (Remeron and Zoloft) between 04/01/26 and 04/07/26. The medical conditions listed on the MAR did not include depression and one of his medical conditions despite the MAR showing Zoloft was being used for depression. On 06/09/26 at 4:15 P.M., an interview with the director of nursing (DON) confirmed Resident #3's quarterly MDS assessment dated [DATE] was not coded accurately, as it did not include depression as one of the resident's active diagnoses. She acknowledged the MAR for April 2026 showed the resident was receiving Zoloft and Remeron during that time and depression should have been coded as one of his active diagnoses.

Based on medical record review, review of facility investigation, policy review, and interview the facility failed to report an injury of unknown origin to the state survey agency. This affected one resident (#10) of three residents reviewed for accidents. Findings include:Medical record review revealed Resident #10 most current admission to the facility was 06/05/2022 with diagnosis including dementia, insomnia, unsteadiness on feet, difficulty walking, abnormal posture, unspecified fall, reduced mobility, muscle weakness, history of transient ischemic attack (TIA), anemia, depression, anxiety, bipolar, and paranoid personality disorder. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had adequate hearing and vision, spoke clear, and understood others and self. The resident's brief interview for mental status (BIMS) score was 11 (moderate cognition impairment) out of 15. Review of Resident #10's nursing progress note authored by LPN #15 at 12:01 P.M., revealed the resident was complaining of left knee pain. The resident stated to aides they dropped me last night while I was getting changed. Midnight nurse or aide did not report any incident. Left knee was swollen, with no redness and skin intact. Resident was able to move toes and ankles of left leg and can slightly lift knee. Resident was given as needed medication; resident was resting in bed. Review of Resident #10's shower sheet dated 04/19/26 authored by Certified Nurse's Aide (CNA) #35 and signed off by LPN #71 revealed CNA #35 documented she gave Resident #10 a bed bath because of her knee. The resident said night shift had dropped her while changing her on 04/18/26, so since she was still yelling in agony with the slightest movement, we just gave her a bed bath and changed the sheet. Further review of Resident #10's nursing notes revealed no further documentation regarding the resident's knee, pain, or incident until 04/20/26 when there was a late entry by LPN #4 at 10:29 A.M., that indicated new orders were obtained per MD for x-ray of left knee. Review of the facility provider communication binder (not part of the medical record) revealed on 04/20/26 an entry from an unknown author and time that room [ROOM NUMBER] bed 2 (Resident #10) had complaints of a fall on Friday and had complaints of left leg pain, swelled, and crying when leg was moved. X-ray??? Review of Resident #10's visiting physician note authored by Medical Doctor (MD) #101 dated 04/20/26 revealed the resident was seen today to follow up on a fall which occurred on 04/17/26. The resident was now complaining of left leg pain, and she was crying when it was moved. Staff reported that there was swelling. Per the documentation in the medical record on 04/18/26 the resident had reported to aides that she was dropped last night while she was getting changed. Review of Resident #10's order dated 04/20/26 revealed left knee x-ray STAT (immediately) for increased pain and swelling. Review of Resident #10's left knee radiology report dated 04/20/26 at 6:10 P.M. revealed the resident had a comminuted impacted fracture of the distal femur. The fracture did involve the articular surface laterally. Anterior lateral displacement of the distal fracture fragments was noted. A large joint effusion was identified. Soft tissue swelling was noted. Moderate degenerative changes were noted. Review of Resident #10's hospital emergency notes authored by MD #103 dated 04/21/26 revealed the resident's daughter was at the bedside and endorsed that the resident had an unwitnessed fall at the nursing home and was not able to confirm the mechanism of injury. The resident appeared to be alert and oriented times three at bedside, however unable to provide any significant history in regard to the fall or incident leading up to it. The resident had noted pain and tenderness in the distal thigh region. The resident had a computed tomography (CT) scan of the femur that indicated a comminuted distal femoral fracture with displaced fragments and impaction. Diffuse osteopenia (indicates early bone loss that is less severe than osteoporosis). There was a large knee joint effusion with fat/fluid levels. Review of the facility's fall investigation dated 04/20/26 revealed the fall/incident occurred on 04/18/26. The collaborative team meeting was held to review the incident dated 04/18/26. Nurse called to the resident's room due to left knee pain. Nurse assessed knee; swelling noted without redness, skin intact, bilateral knees equal in temperature. Range of motion within normal limits to left ankle and toes. Resident would not bend left knee due to increased pain stating, they dropped me while I was getting changed. Resident unable to explain what happened at time of fall, who was with her, so resident repeated, I was dropped when I was getting changed. Nurse offered as need pain medication and resident accepted. Further investigation of all staff conducted; staff deny recent falls however, staff reported that during wheelchair transport to shower, resident left leg/heel touched down to floor and was jarred. MD and resident representative aware, new order for x-ray. Resident was currently in bed resting. Leg rests to be on at all times when resident in wheelchair, staff education provided. Care plan reviewed and updated as necessary. Review of CNA #98's written statement dated 04/21/26 and witnessed by LPN #4 revealed she was transporting Resident #10 to her room in wheelchair before dinner when the resident stated, my foot keeps falling. The CNA told the resident to try and keep her feet up. After stopping the wheelchair immediately and checking over the resident's foot. Interview on 06/11/26 at 12:45 P.M., with the Director of Nursing and LPN #4 revealed the injury was of unknown origin due to the facility could not confirm what actually caused the fracture, however the only explanation they could determine was that CNA #98 verbally reported she was transporting Resident #10 in the wheelchair without the footrest and jarred her leg and said ouch, however there was no statement or supporting evidence to support the theory. Interview on 06/15/26 at 10:35 A.M., with the Administrator confirmed she did not report the injury to the State Survey Agency. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property undated revealed an injury of unknown source was an injury is classified as an Injury of Unknown Source when both of the following conditions were met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury was suspicious because the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incident of injuries over time. All unexplained injuries would be investigated by the DON or designee, to ensure that the health and safety of the residents had not been jeopardized. Should a resident be observed with unexplained injuries, the nursing supervisor on duty must complete an investigation. Written statements would be obtained by the supervising nurse on duty. Statements would be from all personnel including consultants, contract employees, volunteers, visitors, family, etc., who may have had contact with the residents during the past 48 hours. The facility staff should immediately report all such allegations to the Administrator and to the State Agency in accordance with the procedures in this policy.

Based on record review, interview, and policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR) were complete and failed to ensure PASARR recommendations were implemented. This affected two residents (#9, #10) of two residents reviewed for accuracy of PASARR. The census was 68. Findings include: 1.Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including mood disorder, dementia, schizoaffective disorder, post-traumatic stress disorder, visual hallucinations, delusions, mild cognitive impairment, anxiety, major depressive disorder, hemiplegia, hypertension, transient ischemic attack, cerebral infarction, and osteoarthritis. Review of Resident #9's orders revealed an order for Ativan oral tablet 0.5 milligram (mg) (lorazepam). Give 0.5mg by mouth two times a day related to delusional disorders. Review of Resident #9's care plan dated 09/07/23 revealed the resident used psychotropic medications related to dementia, anxiety, delusional disorder, and schizoaffective disorder. Review of Resident #9's PASARR dated 02/29/24 had no documentation of the residents diagnosis of delusional disorder. Review of Resident #9's psych service visit dated 03/18/26 revealed the resident had diagnoses of schizoaffective disorder and delusions, hallucinations, dementia with behaviors, depression, anxiety and no medication changes indicated at that time. Interview on 06/11/26 at 9:51 A.M. with Social Service Designee (SSD) #73 confirmed Resident #9's most recent PASARR dated 02/29/24 did not reflect the resident's diagnosis of delusional disorder. 2. Medical record review of Resident #10's PASARR dated 03/30/21 revealed no evidence of delusions, anxiety or paranoid personality disorder. Medical record review revealed Resident #10 was admitted on [DATE] with diagnoses of schizoaffective disorder bipolar type, delusional disorders, dipolar, major depression, anxiety and paranoid personality disorder. Review of Resident #10's annual MDS dated [DATE] revealed the resident was not considered by the State Level II PASARR process to have a serious mental illness and/or intellectual disability or related concern. Further review revealed the resident triggered for Level II evaluation due to schizoaffective disorder, bipolar, dementia with behavioral disturbance and delusional disorder. It was recommended that the nursing facility have a psychiatrist or other mental health provider provide ongoing review of the resident's mental health medication, to be sure they were working correctly. The facility's doctor monitors the medication to be sure it is meeting the resident's health care needs. Neurological exams to assess the progression of the resident's neurocognitive disorder. Mental health counseling for the symptoms and behaviors the resident was having. It was recommended that the nursing facility construct a safety plan to help prevent the resident from harming others. The nursing facility should develop a behavioral based treatment plan to offer strategies and tips for staff to deescalate, resident negative behaviors and symptoms. Therapy, encourage activities, and take medication as ordered. Review of Resident #10's current plan of care revealed no evidence of a plan of care for PASARR or a safety plan. Interview on 06/11/26 at 7:51 A.M. with SSD #73 confirmed the PASARR did not reflect the residents' delusions, anxiety and paranoid personality disorder. SSD #73 reported the PASARR was completed prior to admission and was not updated. Interview on 06/11/26 at 8:53 A.M. with MDS Nurse confirmed the annual MDS was inaccurate and didn't reflect serious mental disorder, the resident did not have a safety plan of care, or a PASARR plan of care.

Based on record review and staff interview, the facility failed to ensure a comprehensive care plan was developed to address constipation for a resident receiving a stool softener on a scheduled basis. This affected one resident (#3) of 20 residents reviewed for care plans. Findings include: Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, adult-onset diabetes mellitus, muscle weakness, and difficulty walking. Review of Resident #3's physician's orders revealed the resident had an order to receive Colace ( a stool softener) 100 milligrams (mg) two capsules by mouth (po) twice a day for constipation. The order had been in place since 01/11/26. Review of Resident #3's active care plans revealed the resident did not have a care plan in place to address constipation. On 06/09/26 at 4:15 P.M., an interview with the director of nursing (DON) confirmed Resident #3's comprehensive care plans did not include a care plan to address constipation. She acknowledged the resident was receiving Colace twice a day on a scheduled basis for constipation and should have had a care plan to address that. She stated that was one of the care plans that she had trouble remembering to initiate, when developing the comprehensive care plans.

Based on record review, interview, and policy review, the facility failed to ensure a resident's quarterly care planning conference was scheduled and the resident and/ or their family was afforded the opportunity to participate in their care planning process. This affected one resident (#7) of one resident reviewed for care planning conferences. Findings include: Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included chronic respiratory failure, dependence on a respiratory ventilator, hypertension, lymphedema, peripheral vascular disease, depression, anxiety disorder, muscle weakness, and abnormalities of gait and mobility. Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was known to have a functional limitation in her range of motion of one side of her lower extremities. She used a wheelchair for a mobility device. Further review of Resident #7's medical record revealed an initial care conference was held for the resident on 02/18/26. Her medical record was absent for any evidence of the resident having a quarterly care planning conference held on her behalf since her admission. On 06/08/26 at 9:43 A.M., an interview with Resident #7 revealed she had not been invited to attend any quarterly care planning conferences since being admitted to the facility on [DATE]. She did not recall having any meetings held that included herself, her husband, and different disciplines within the facility for the purpose of reviewing her care, orders, or goals while in the facility. On 06/10/26 at 9:38 A.M., an interview with Licensed Social Worker (LSW) #73 revealed care conferences were to be held every three months (quarterly) for residents. She confirmed they did not have evidence of a quarterly care conference having been completed for Resident #7, since her admission. She calculated how long the resident had been there and confirmed a care conference should have been held in May 2026. She reported the facility's activity director was responsible for scheduling the care conferences when they were due. The activity director had a calendar that she went by and also ran an admission report to see when a resident was due for their first quarterly. On 06/10/26 at 9:51 A.M., an interview with Activity Director #83 revealed it was her responsibility to schedule care planning conferences for the residents, when they were due. She would then send out letters to the families and email all the management team to let them know when a care conference meeting was scheduled. She completed the care conference forms when they were held and had the residents sign to show they attended and received a copy. With the new admissions, she would have to talk with the LSW, after the initial care conference was held, to see if the resident would be there for three months or longer, so a quarterly care conference could be scheduled. She stated she did not feel she was the best person to track when care planning conferences were needing to be scheduled, as she did not know which residents were remaining in the facility long enough to require one. She felt she was kind of the middle person in all that and likely not the best person to schedule them. She relied on information from the social worker on who was going to be there longer than a few months that would require a care planning conference. Review of the facility's policy on Resident/ Family Participation- Assessments/ Care Plans revised April 2016 revealed each resident and his/ her family members were encouraged to participate in the development of the resident's comprehensive assessment and care plan. The resident and his/ her family, and/ or legal representative were invited to attend and participate in the resident's assessment and care planning conference. Care conferences were to be held upon admission, quarterly, and as needed/ upon request.

Based on record review and interview, the facility failed to ensure a resident, who was dependent on staff for personal care, received the assistance needed with receiving showers as scheduled. This affected one resident (#78) of four residents reviewed for activities of daily living. Findings include:Review of Resident #78's medical record revealed she was admitted to the facility on [DATE]. She was hospitalized between 04/30/26 and 05/31/26, before returning to the facility as a re-admission. Her diagnoses included reduced mobility, muscle weakness, major depressive disorder, paranoid schizophrenia, Bipolar disorder, anxiety disorder, stroke, muscle spasms, difficulty walking, dependence on a wheelchair, and repeated falls. Review of Resident #78's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not indicated to have displayed any behaviors or reject care during the seven days of the seven day assessment period. She required a substantial/ maximum assist with showers/ bathing. Review of Resident #78's active care plans revealed she had a care plan in place for an activities of daily living (ADL) self-care performance deficit related to her diagnoses of a stroke, weakness, unsteady gait, and anxiety. The interventions indicated the resident was dependent on staff for showers/ bathing. A Hoyer lift (mechanical lift used for transferring a resident from bed to chair) and staff assist were needed for transfers. Review of the shower schedule for Resident #78's hall revealed the resident was to be showered as requested. Her name was listed on the shower schedule under the day shift section but did not indicate specific days she was scheduled. She was added in each column under every day of the week as being as requested. The shower schedule indicated shower sheets were to be filled out even if the shower was refused. If they (facility staff member tracking showers) did not receive a shower sheet, they were going to assume that it was not done. Any showers that were not completed would result in a write up. Bed baths did not take the place of a shower. If a resident requests a bed bath, the aide was to notify their nurse. Review of Resident #78's bathing sheets, since her return from the hospital on [DATE] through 06/10/26, revealed she was documented as having received showers on 06/01/26 through 06/03/26. There was no documentation of a shower having been provided or offered on 06/04/26, 06/05/26, 06/06/26, 06/08/26, or on 06/09/26. Bathing sheets for 06/07/26 and 06/10/26 revealed the resident had been offered a shower on those days, but the showers were refused. Review of Resident #78's progress notes from 06/04/26 through 06/10/26 revealed no documented evidence of a shower having been offered and refused on the dates not documented showers were noted, as above. On 06/09/26 at 3:45 P.M., an interview with Resident #78 revealed she had not been showered on six different days, since she returned to the facility from the hospital. She indicated she was supposed to be getting showers daily, but was not getting them. She claimed she was not getting her showers, due to being a Hoyer lift, and it taking two people to use that. She had been told by the staff that they did not have the time to do it. On 06/10/26 at 4:21 P.M., an interview with Licensed Practical Nurse (LPN) #44 revealed Resident #78 required an extensive assist by staff for her care. She could do some things on her own, such as washing her face. She indicated the resident took showers and liked to have one every day. The other day (06/10/26) was the first time she had known the resident to refuse a shower when offered. The resident indicated on that day that she might take one later in the day, but she did not know if she ended up taking one or not. She reported the resident was to be offered a shower daily. She denied she had known the resident to refuse her showers when offered, prior to yesterday. She denied she was the nurse that worked between 06/04/26 and 06/09/26 when the resident was not documented as having received or refused a shower. On 06/10/26 at 4:28 P.M., an interview with Certified Nurse Aide (CNA) #102 revealed Resident #78 was a total assist with her care. She could only eat and drink on her own and needed help with everything else. The resident would do showers or bed baths depending on the day. Before going down hill, the resident took showers every day and was scheduled to receive them every day. The staff would ask her daily if she wanted a shower. The resident would take her showers, when offered, and she liked taking them. She did not have any knowledge as to why the resident was not documented as having been provided a shower between 06/04/26 and 06/09/26. She did recall on 06/07/26 the resident was yelling out that she wanted a bed bath and she believed her co-worker had completed the bed bath as requested. She indicated some staff may look at the shower schedule and see that the resident was to receive a shower as requested and may leave it up to the resident to request without offering one to her. With how the resident was upon her return to the facility on [DATE], you would have to ask the resident if she wanted a shower and not leave it up to the resident to request it. On 06/10/26 at 4:50 P.M., an interview with the Director of Nursing (DON) revealed shower documentation was done on the paper bathing sheets. She acknowledged Resident #78 reported she went without a shower for six days, after she returned to the facility from the hospital on [DATE], and the shower documentation provided confirmed that. She talked to the unit manager and he did not feel that was accurate. She was asked to provide any additional shower documentation they had to show showers were provided or offered to the resident between 06/04/26 and 06/09/26. She was only able to find one additional bathing sheet that showed the resident was offered a shower on 06/07/26 and refused. It was consistent with what the aide interview said about the resident yelling out that she wanted a bed bath, but did not match up with her coworker documenting that it had been offered and refused. There was still no documentation for any showers being completed or offered and refused on 06/04/26, 06/05/26, 06/06/26, 06/08/26, or 06/09/26. This deficiency represents non-compliance investigated under Complaint Number 3030059.

Based on medical record review, observation, interview, and policy review the facility failed to timely and comprehensively assess a pressure ulcer. This affected one resident (#76) of two residents reviewed for pressure ulcers. Findings include: Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses of chronic pulmonary disease, adult failure to thrive, anemia, type two diabetes, heart disease, fibromyalgia, rheumatoid arthritis, history of transient ischemic attack, end stage renal disease, dependence on renal dialysis, and wedge compression fracture of the first lumbar vertebra. Review of Resident #76's baseline plan of care dated 06/08/26 revealed the resident was at risk for skin breakdown and to monitor and document location, size, and treatment of skin injury. Review of Resident #76's orders dated 06/08/26 revealed to cleanse mid- spine with normal saline, apply skin prep then cover with a border foam dressing three times a week and as needed. Review of Resident #76's medical record revealed no evidence of a comprehensive skin assessment was completed on admission or on the area on the mid spine that required treatment. Review of Resident #76's wound progress note dated 06/08/26 revealed the resident was not evaluated by the wound team today. Resident was very anxious and had behavior during visit. Will re-attempt next visit for skin sweep. Interview and observation of Resident #76 on 06/09/26 at 2:08 P.M., with Licensed Practical Nurse (LPN) #71 confirmed there was no skin assessments in the medical record nor an assessment on the mid- spine. The LPN reported she was not sure if the area on the spine was pressure or non-pressure due to she had not observed the area. The LPN spoke to the unit managers and returned and reported the unit managers told her it was a scratch. At this time, observation of the area revealed the resident had two by two-inch undated dressing on the mid spine. The resident had a red area above and below the dressing approximately four inches above and below the dressing. The LPN removed the dressing and there was a scant amount of serosanguinous drainage noted on the old dressing and an open area on the mid spine the size of pea. The resident reported she has had a bedsore for some time and was told it was caused from lying in bed. The LPN confirmed these findings during the observation. Interview on 06/10/26 at 8:27 A.M. with the Director of Nursing (DON) confirmed there was no skin assessment completed on Resident #76 on admission or on 06/08/26 when a skin alteration was noted and new treatment implemented. Review of Resident #76's skin assessment dated [DATE] revealed the resident had an open area on the mid- spine measuring 0.4 centimeters (cm) by 0.3 cm by 0.0 cm with scant bloody drainage. The type of skin alteration was pending. Interview on 06/11/26 at 11:11 A.M., with LPN #4, who was also the wound nurse, confirmed there was no skin assessment completed on admission or after a skin alteration was noted on 06/08/26. The LPN confirmed the facility still hadn't completed a comprehensive assessment of the mid-spine due to the Wound Nurse Practitioner (NP) only comes on Monday and Thursday and as a LPN she can't stage a wound. The LPN confirmed the Wound NP did not see the resident on 06/08/26 due to the resident was at dialysis and then was sent to the hospital and didn't return until later in the day. Review of the Pressure Ulcer policy (dated 2013) revealed the facility should have a system in place to assure assessments are timely and appropriate changes in condition are recognized, evaluated, and reported to the practitioner, physician, and family and addressed.

Based on record review, interview, and policy review the facility failed to ensure a comprehensive assessment was completed to determine the type of urinary incontinence and failed to implement an effective treatment plan to address the resident's incontinence. This affected one resident (#54) of two residents reviewed for bowel and bladder incontinence. The census was 68. Findings include:Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including left rib fracture, urinary tract infections, subarachnoid hemorrhage, metabolic encephalopathy, dementia, chronic kidney disease, and obstructive and reflux uropathy. Review of Resident #54's admission minimum data set (MDS) assessment completed on 05/07/26 revealed a brief interview for mental status score was unable to obtain. The resident had no displayed behaviors. The resident utilized a walker for mobility. The resident required set up or clean-up assistance for eating, supervision or touching assistance for upper body dressing, oral hygiene, moderate assistance for lower body dressing, personal hygiene, toileting hygiene, showering and bathing, and for mobility and transfers. The resident was frequently incontinent of bowel and urine.Review of Resident #54's care plan initiated on 05/11/26 revealed the resident had incontinence related to weakness, age related changes, and obstructive/ reflux uropathy.Review of Resident #54's medical record revealed no documented evidence of incontinence care being completed on 05/12/26, 05/13/26, 05/15/26, 06/02/26.Review of Resident #54's medical record revealed Resident #54 had incontinence care provided only once a day on 05/14/26, 05/16/26, 05/18/26, 05/19/26, 05/20/26, 05/23/26, 05/25/26, 05/26/26, 05/28/26, 05/30/26, 06/03/26, 06/04/26, 06/05/26, 06/06/26, 06/07/26, and 06/08/26.Interview on 06/08/26 at 1:48 P.M. with Resident #54's representative revealed they have had some issues with the resident being provided timely, adequate incontinence care. When they come in to visit, they can smell urine and see her (incontinence) brief was soaked, sometimes including her pants.Interview on 06/15/26 at 2:00 P.M. with the Director of Nursing (DON) confirmed there was a lack of evidence regarding incontinence care being completed for Resident #54. The DON stated the resident was not on a urinary toileting trial/ program and they did not know the type of urinary incontinence the resident had.Review of undated facility policy titled Urinary Continence and Incontinence - Assessment and Management revealed the staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. Management of incontinence will follow relevant clinical guidelines. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. Relevant information related to urinary continence includes history of urinary incontinence, factors precipitating incontinence, and associated symptoms; previous treatment and management attempts and response to interventions; observations including wet bed or clothing; functional and cognitive capabilities or limitations that could affect continence; additional information such as the type and frequency of physical assistance necessary for the resident to access the toilet, commode and the scope of prompting needed to encourage urination; and environmental factors and assistive devices that may restrict or facilitate a resident's ability to access the toilet. Minimum data set criteria for frequent incontinent means the resident has had at least seven (7) episodes of bladder incontinence in the previous seven days. A check and change strategy involves checking the resident continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin.Review of undated facility policy titled Charting and Documentation revealed all services provided to the resident or any changes in the resident's medical or mental condition shall be documented in the resident's medical record. Observations, services performed, procedures, treatments, etc. must be documented in the resident's clinical records. Incidents, accidents, or changes in the residence condition must be recorded. This deficiency represents non-compliance investigated under Master Complaint Number 3045760 and Complaint Number 3030059.

Based on observation, interview, record review, and policy review the facility failed to ensure a resident's meal intakes were monitored and the resident was comprehensively assessed regarding weight loss. This affected one resident (#54) of four residents reviewed for nutrition. The census was 68. Findings include: Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including left rib fracture, urinary tract infections, subarachnoid hemorrhage, metabolic encephalopathy, dementia, chronic kidney disease, and obstructive and reflux uropathy. Review of Resident #54's care plan initiated on 05/06/26 revealed the resident had a nutrition risk related to left sided rib fracture, dementia, chronic kidney disease, metabolic encephalopathy, weakness, altered mental status and subarachnoid hemorrhage. Goals included the resident would maintain nutritional status through next review period. Interventions included monitoring the resident's meal intakes. Review of Resident #54's admission minimum data set (MDS) assessment completed on 05/07/26 revealed a brief interview for mental status score was unable to be obtained. The resident had no displayed behaviors. The resident utilized a walker for mobility. The resident required set up or clean up assistance for eating, supervision or touching assistance for upper body dressing, oral hygiene, moderate assistance for lower body dressing, personal hygiene, toileting hygiene, showering and bathing, and for mobility and transfers. The resident is frequently incontinent of bowel and urine. The resident had an ordered therapeutic diet. Review of Resident #54's orders revealed an order dated 05/22/26 for no added salt diet, pureed texture, thin liquids. Review of Resident #54's weights revealed the following:a weight of 127.2 pounds (lbs) on 05/06/26a weight of 115.8 lbs. on 06/03/26; a weight loss of 10.43% in 29 days. There was no evidence nutritional interventions were developed and implemented for Resident #54's weight loss. Review of Resident #54's mini-nutritional assessment completed 05/07/26 revealed a score of 8 indicating the resident was at risk of malnutrition. Review of Resident #54's medical record revealed no evidence of any meal intakes including breakfast, lunch, and dinner on 06/04/26, 05/25/26, 05/18/26, 05/15/26, and 05/11/26. Review of Resident #54's medical record revealed no evidence of meal intake for lunch and dinner on 05/13/26, no evidence of dinner intake on 05/14/26 and 05/19/26, and no evidence of meal intake for breakfast or dinner on 06/02/26. Interview on 06/08/26 at 1:48 P.M. with Resident #54's representative revealed they believe the resident had lost weight but had been at the facility for only a month. Resident #54's representative revealed the resident cannot physically feed themselves and they are unsure if the staff of the facility is consistently helping her [Resident #54] eat during every meal. Observation on 06/10/26 at 8:03 A.M. revealed four staff members passing breakfast trays to residents on Hall 200. At the time of the observation, Certified Nurse Assistant (CNA) #75 stated I absolutely will not feed her. Interview on 06/15/26 at 2:00 P.M. with the Director of Nursing (DON) confirmed there was a lack of evidence for Resident #54's meal intakes and the resident was dependent on staff for dining/eating. Review of undated facility policy titled Weight Assessment and Intervention revealed the multidisciplinary team will stive to prevent, monitor, and intervene for undesirable weight loss of the residents. Interventions for undesirable weight loss shall be based on careful consideration of the residents choices, nutritional and hydration needs of the resident, functional factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities, need for diet modifications, medications that may interfere with appetite, chewing, swallowing, or digestion, and the use of supplementation. The threshold for significant unplanned and undesired weigh loss includes a weight loss of at least 5% in one month. Review of undated facility policy titled Charting and Documentation revealed all services provided to the resident or any changes in the residents medical or mental condition shall be documented in the resident's medical record. Observations, services performed, procedures, treatments, etcetera must be documented in the resident's clinical records. Incidents, accidents, or changes in the residence condition must be recorded.This deficiency represents non-compliance investigated under Complaint Number 3045760

Based on medical record review, observation, and interview the facility failed to ensure a resident's dialysis port was assessed and monitored. This affected one resident (#76) of one resident reviewed for dialysis. Findings include: Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses of anemia, type two diabetes, end stage renal failure, and dependence on renal dialysis. Review of Resident #76's hospital records dated 06/02/26 revealed the resident had an Arteriovenous (AV) fistula (dialysis port). Review of Resident #76's nursing note dated 06/05/26 at 5:46 P.M., revealed the emergency nurse called report and reported the resident had a fistula in the left arm and had 500 milliliters (ml) removed from dialysis today. Review of Resident #76's baseline plan of care dated 06/2026 revealed no evidence of a dialysis plan of care. Review of Resident #76's admission assessment dated [DATE] and 06/06/26 revealed no evidence the resident had an AV fistula. Review of Resident #76's orders dated 06/2026 revealed the resident was ordered dialysis Monday, Wednesday, and Friday. Further review of Resident #76's orders revealed no evidence of orders for staff to assess or monitor Resident #76's AV fistula. Review of Resident #76's medical record revealed no evidence staff were assessing or monitoring Resident #76's AV fistula. Interview on 06/09/26 at 1:38 P.M., with Licensed Practical Nurse (LPN) #71 confirmed there were no orders or evidence Resident #76 AV fistula was being assessed or monitored. The LPN reported she had not assessed the AV fistula yet, but she thought it was in the resident's right arm. Observation on 06/09/26 at 1:38 P.M., of Resident #76 with LPN #71 revealed the resident had a dressing on her right arm. The resident reported she had been receiving dialysis for over a year and had an AV fistula in her right arm. The resident confirmed she had gone to dialysis yesterday and the dialysis nurse had placed the dressing on her fistula. The resident reported usually dialysis has her remove the dressing the next day, however she was too weak to remove it herself. The resident reported she doesn't know how to check the AV fistula to ensure it was functioning. The LPN confirmed there were no orders to remove the dressing, and she would call the dialysis center to obtain orders for the dressing and monitoring of the AV fistula. Interview on 06/10/26 at 8:27 A.M., with the Director of Nursing (DON) confirmed Resident #76 did not have a baseline plan of care for dialysis, no orders to assess and monitor AV fistula, and no orders to remove the dressing.

Based on observation, closed medical record review, review of a facility investigation, police report, Elopement policy and interviews with facility and agency staff, Physician Office Staff #201 and Resident #53's family the facility failed to provide appropriate and adequate supervision and implement effective interventions to prevent one cognitively impaired resident (#53), who was identified to be an elopement risk/wanderer and exhibited exit seeking behaviors, from leaving the facility without staff knowledge on 06/20/20. The facility failed to ensure the circumstances of the elopement incident involving Resident #53 were accurately and timely documented in the resident's medical record. This resulted in Immediate Jeopardy on 06/20/20 at approximately 6:00 A.M. when Resident #53 was last seen by staff in the facility. Once determined by staff to be missing, initial searches both inside and outside the facility were unsuccessful in locating the resident. Resident #53's family was notified of the elopement and suggested the facility check to see if the resident had returned to his home in the community. The resident was subsequently found (on 06/20/20 at 8:45 A.M.) at this location. The potential for actual harm, serious injury or death was identified as the resident traveled approximately one mile from the facility to his home with the route identified to be a major highway with four lanes of traffic and no sidewalks. This affected one resident (#53) of three sampled residents reviewed for elopement. The facility census was 54. On 06/30/20 at 10:10 A.M. the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #120 and facility legal counsel were notified Immediate Jeopardy began on 06/20/2020 at approximately 6:00 A.M. when Resident #53, who was ambulatory, cognitively impaired, exhibited exit seeking behaviors and had a wander guard in place was last seen by staff in the facility. A facility investigation determined the resident had left the facility without staff knowledge via the window from his room to the outside. The resident was located by staff after discussion with his family on 06/20/20 at approximately 8:45 A.M. at his previous home in the community. The Immediate Jeopardy was removed on 07/01/2020 when the facility implemented the following measures: · On 06/20/20 at approximately 9:30 A.M. Resident #53 returned to the facility with family and was provided one on one supervision until he was transferred to an inpatient psychiatric hospital on [DATE] at 5:20 P.M. The resident had not returned to the facility as of 06/29/20 the date of the onsite survey. · On 06/20/20 the DON reviewed the medical records for Resident #20, #22, #27, #28, #32, #41 and #56, who had orders for wander guards to ensure elopement risk assessments were current and accurate. These residents with wander guards were placed on every 15-minute checks until the windows in the resident's rooms were adjusted to not open more than six inches. · On 06/20/20 every facility window was checked by Maintenance #114. The windows were modified by placing a screw mechanism to prevent all windows from opening beyond six inches if the window bar was removed. This was completed on 06/20/20 at 2:45 P.M. · On 06/20/20 the facility Quality Assessment Performance Improvement (QAPI) team (which included the Administrator, DON, ADON, Clinical Care Manager, Maintenance Director, Director of Admissions and Social Service) discussed and determined the root cause of the resident's elopement was the window lock ability being removed. · On 06/20/20 all facility staff were sent a text message of the facility Elopement policy and Call Off Policy. · On 06/22/20 a plan for housekeeping staff to monitor for signs of damage to windows as part of their daily cleaning routine and notify the Maintenance Director to address any issues was implemented. · On 06/23/20 a plan for the Director of Maintenance or designee to audit weekly for 4 weeks all resident windows for effectiveness of new devices to stop window from opening at six inches was implemented. The audits would be discussed at monthly quality assessment performance improvement (QAPI) meetings and if no further concerns were identified would be deemed effective. · On 06/25/20 the DON provided education to six agency staff nurses regarding the facility call off procedures. Agency staff were also educated related to documentation including ensuring the nursing progress notes included change in condition, incidents and skilled notes which encompassed resident cognition and safety interventions such as wander guard bracelets. A plan for any new agency staff to be given this education as part of their orientation to the facility was implemented. · On 06/26/20 Consultant Registered Nurse (RN) #118 completed an audit for Resident #20, #22, #27, #28, #32, #41, #56 and #1 who had orders for a wander guard device to ensure care plans and assessments were appropriate and accurate. · On 07/01/20 a plan for the DON to monitor staff schedules daily for the next day for adequate staffing levels was provided as part of the facility corrective action plan. The plan revealed that if at any point the staffing would fall below facility minimum requirements, the DON would activate the emergency staffing plan utilizing agency staff, employee mandated staff and/or management nurses assigned to the floor. · On 07/01/20 a plan for the DON, ADON and Clinical Manager to provide all staff including any agency staff working in the facility education (prior to their next scheduled shift) related to resident behaviors of exit seeking and prevention of elopement was implemented. · On 07/01/20 a plan for the DON, ADON and Clinical Care Manager to review the 24 hour report for documentation related to exit seeking behaviors and appropriate interventions daily during the clinical review meeting was implemented. · On 07/02/20 a plan for the DON/designee to complete random audits at a minimum of five staff per week for four weeks for staff retention of education regarding response to behaviors of exit seeking and wandering was implemented. The results of the audits will be discussed during QAPI meetings. Although the Immediate Jeopardy was removed on 07/01/20 the facility remains 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 continued to provide staff education and monitoring of corrective actions. Findings include: Review of Resident #53's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. The order indicated to check placement, function and skin integrity every shift. An admission assessment, dated 06/04/20 revealed Resident #53 was only oriented to person and required extensive assistance from staff for bed mobility, transfers, dressing and toilet use. The assessment revealed the resident required limited assistance with personal hygiene and independence with eating. An elopement screen, dated 06/05/20 revealed the resident was not at risk for elopement as he scored an eight on the screening tool. A resident was considered at risk for elopement with a score of nine or higher. Review of undated State tested Nursing Assistant (STNA) Kardex information revealed Resident #53 had a wander guard and staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. Review of Resident #53's nursing progress note revealed a note authored by Registered Nurse (RN) #130, dated 06/06/20 at 9:51 P.M. which documented the resident was exit seeking. Record review revealed there was no elopement screen completed following this incident, no plan of care developed at this time and no written evidence of interventions being in place to address the exit seeking behavior. In addition, the progress note failed to elaborate on specific circumstances surrounding the residents exit seeking behaviors (i.e. was the resident talking about going home, trying to exit or successful at exiting a particular door and/or whether this a repeated behavior that was occurring or isolated behavior). Review of the five-day admission Minimum Data Set (MDS) 3.0 assessment, dated 06/10/20 revealed Resident #53 had severely impaired cognition, required supervision for all activities of daily living, exhibited wandering behavior one to three days in the assessment period and used a wander/elopement alarm daily. Record review revealed a plan of care was initiated on 06/17/20. However, documentation included on the care plan noted a created dated of 06/22/20 and a revision date of 06/22/20 indicating Resident #53 was an elopement risk/wanderer as evidenced by impaired safety awareness, impaired cognition, behaviors of wandering and exit seeking related to dementia. Interventions included to assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, monitor for fatigue and weight loss and a wander guard. Review of Resident #53's nursing progress notes revealed a note dated 06/17/20 at 7:27 A.M. and authored by Agency LPN #115 indicating Resident #53 was exit seeking last night and was redirected by the nurse which was effective. The nursing note documented the resident was being monitored closely and was in his room resting at that time. Record review revealed there was no elopement screen completed following this incident. In addition, the progress note did not elaborate on the type of re-direction that was provided to the resident, evidence of interventions included on the plan of care being attempted and whether these interventions were successful or not. A nursing progress note, dated 06/19/20 at 10:03 P.M. and authored by Agency LPN #115 revealed Resident #53 was exit seeking around 9:55 P.M., redirection was given and was not effective. The resident continued to stand by the door (which door was not specified). The nurse asked the resident to go get ready for bed and the resident had become combative grabbing the nurse's arm and using swear words. The nursing progress note revealed the resident entered his room and slammed the bedroom door. There was no evidence the physician or resident's family were notified of this incident. The note failed to contain evidence any identified interventions from the plan of care were attempted and did not contain any type of follow up assessment or note on 06/20/20 to ensure the resident was safe in his room after entering the room and slamming the door. Review of a police report, dated 06/20/20 at 8:35 A.M. revealed the facility reported an [AGE] year-old missing resident, Resident #53. The police report documented the subject had exited through his bedroom window. It was unknown when he left or his last clothing description. He has dementia. The report continued and indicated the subject had been located at his previous residence and was being returned to the facility. The police arrived at the facility at 8:47 A.M. and the case was cleared at 9:03 A.M. Review on the STNA flow sheets for 06/20/20 revealed there was no documentation of care provided to Resident #53 from 12:00 A.M. to 7:00 A.M. The care documented on the STNA Flow sheets should have included ambulation in the corridor, ambulation in the room, bathing/showers, mobility, bladder continence, bowel movements, dressing, locomotion on and off the unit, personal hygiene, toileting, transferring and the amount eaten for each shift and should have been initialed by the nursing staff providing the care. The next nursing progress note (after the 06/19/20 note at 10:03 P.M.), dated 06/23/20 at 12:27 A.M. as a late entry note for 06/20/20 at 6:55 A.M. revealed the nurse (Agency LPN #115) had done rounds every two hours and the last round was at 5:15 A.M. The note indicated Resident #53 was resting in bed with the call light within reach. A nursing progress note, dated 06/23/20 at 8:28 P.M. as a late entry for 06/20/20 at 9:56 A.M. and authored by the DON revealed Resident #53 had left the facility and went home. The note documented the family brought the resident back to the facility and a head to toe assessment and skin check were completed with no issues identified. The DON also documented in the progress note that the family, physician, DON and Administrator were updated. A nursing progress note, dated 06/29/20 at 7:04 P.M. as a late entry note for 06/20/20 at 8:52 P.M. and authored by LPN #119 revealed the DON was notified by the nursing management (no specific staff identified) Resident #53 was not inside the facility building and that staff (no specific staff identified) were walking inside and outside looking for resident. LPN #120 had been notified and was on her way to the facility. The resident's family and 911 were called. The resident's daughter stated the resident had done this once before and he had gone to his house in New Philadelphia. Review of the facility staffing schedules and unit assignments for 06/19/20 and 06/20/20 revealed Agency LPN #115 was scheduled to work the rehabilitation unit from 06/19/20 at 8:00 P.M. until 06/20/20 at 7:00 A.M. Agency STNA #116 was scheduled to work on 06/19/20 from 11:00 P.M. to 06/20/20 at 7:00 A.M. to care for 40 residents residing on the rehabilitation unit (which was the 200 unit), the 300 unit and 400 unit. On 06/20/20 at 2:00 A.M. a personal care assistant from the attached assisted living (PCA #110) was pulled from the assisted living to work in the nursing home and was noted to work on the rehabilitation unit. Additional record review revealed PCA #110 was not State tested . Record review revealed the facility initiated an investigation related to the incident of Resident #53 eloping on 06/20/20. Statements obtained from the three staff members assigned to the unit where Resident #53 resided revealed: A witness statement obtained from Agency STNA #116 dated 06/20/20 revealed she only went over to the 200 (rehabilitation) hallway to help a few times and she never saw the resident (Resident #53). A witness statement from PCA #110 dated 06/20/20 revealed she saw Resident #53 between 5:30 A.M. and 6:00 A.M. when he came out of his room and then went back into his room shutting the door. A witness statement from Agency LPN #115 revealed the last time she saw Resident #53 on 06/20/20 was around 5:15 A.M. when she was passing medications and last rounds had started. In addition, a witness statement from agency LPN #121, dated 06/20/20 revealed she had seen Resident #53 between 12:00 A.M. and 1:00 A.M. She indicated he had been up walking the halls and looking out the doors. This agency LPN was working on the facility 400 unit on this night. A witness statement obtained from LPN #113, dated 06/20/20 (no time documented) revealed she had come in to work (on 06/20/20 for day shift), gotten report, counted narcotics, cleaned and set up her medication cart and went to the bathroom. When she came out of the bathroom STNA #112 had informed her Resident #53 was not in his room and the elopement process was started. A witness statement from STNA #112, dated 06/20/20 revealed the STNA had walked onto the unit (rehabilitation unit) at 7:00 A.M. on 06/20/20. She did not get report from the midnight aide because this aide had already left the floor. She went and got a resident up and dressed for the day. Around 7:30 A.M. the breakfast cart arrived and the nursing assistant she was working with went into the room of Resident #53 and he was not in his room. She indicated they noticed the window had been cracked open after they searched his room. She indicated she never saw the resident on her shift until he came back to the facility. The investigation also contained a statement from LPN #120 who was the staff member who first encountered Resident #53 at his home. The LPN's statement revealed she drove to the resident's home (which was close to facility) and found him sitting in his back yard at the picnic table at 8:45 A.M. She then notified the DON the resident had been found. The resident was wearing a T-shirt, flannel button up shirt and jeans. His flannel was warm and damp. The statement did not indicate if the resident was wearing shoes or what type of shoes he was wearing. The resident refused to return to the facility with the nurse. His daughter and her husband arrived and gave the resident a bottle of water. The LPN's statement revealed when questioned what time he left the facility he stated 8:00 A.M. and stated he went out through the window. The resident was pleasant with general conversation, but when questioned if he would like to go for a ride in the LPN's car, he became agitated and refused. The witness statement revealed the resident was returned to the facility by his family and placed with one on one supervision upon returning to the facility. During the complaint investigation the following staff interviews were obtained related to Resident #53, the elopement incident on 06/20/20 and staff knowledge of the resident's exit seeking behaviors: On 06/29/20 at 11:35 A.M. interview with STNA #107 revealed Resident #53 was very agitated and tried to get out of the building numerous times while he resided in the facility. During the interview the STNA revealed the windows in the resident rooms had been easy to open but since the incident with Resident #53 eloping, the facility had placed something on them so they would no longer open. On 06/29/20 at 11:40 A.M. interview with the Administrator revealed Resident #53's window did not have a screen and it was open about three inches at the time it was determined the resident was missing from the facility (on 06/20/20). The Administrator revealed she believed the resident had exited the facility via this window. The Administrator revealed Resident #53 did have a wander guard bracelet on at the time he eloped. However, the Administrator revealed she did not believe Resident #53 left the facility through an exit door. On 06/29/20 at 11:40 A.M. observation of Resident #53's window revealed a sliding glass window without a screen on the window with a screw in the window frame preventing it from opening more than six inches. On 06/29/20 at 1:32 P.M. interview with Resident #53's family, Family Member #122 revealed she had brought the resident to the facility on [DATE] because of his confusion. She indicated he had exit seeking behaviors since he had been admitted to the facility. She indicated the facility had to change the codes on the doors because the resident knew the codes from when he would visit his wife at the facility prior to his admission and because he had watched the staff put the codes in the door key pad. Family Member #122 revealed she was told by staff that on 06/20/20 at 5:15 A.M. the resident was in bed and staff had not noticed he was missing until around 8:00 A.M. LPN #120 had went to his house to look and see if he was there and he was found sitting on the picnic table because he could not get into the house. Her sister had to bring him back to the facility. He had an ankle bracelet on. She indicated her father did not know how he got out of the building. She stated his house was about one to one and a half miles from the facility. Review of the route from the facility to the resident's location revealed the route was a major four lane busy highway with no sidewalks available. The area contained multiple businesses. On 06/29/20 at 3:36 P.M. interview with LPN #113 revealed on 06/20/20 she had gotten report from the off going nurse (Agency LPN #115 and the nurse stated she had last seen Resident #53 at bedtime. She stated the off going Agency LPN indicated the resident had become angry with her, so he went into his room. She indicated they had done report and counted medications. They finished up around 7:30 A.M. LPN #113 revealed shortly after this she received a call on her cell phone from the 400 hall nurse telling her one of her residents (Resident #53) was missing. She indicated there were staff inside and outside looking for him. She indicated the other nurse told her to call the family and 911 and she would call the administrator. When she was talking to the daughter, she told her the resident had done this before when he lived with them and they found him at his house. The police showed up and she was giving them his address and at the same time a staff member called her and stated they had found him at his house but he would not get into the car with him and so the family was bringing him back to the facility. On 06/29/20 at 5:00 P.M. interview with Agency LPN #115 revealed on 06/20/20 she saw Resident #53 during her medication pass around 5:00 A.M. and he was in his room in bed. She stated she did not give him any medications at that time. The Agency LPN revealed at the time she left the facility (at the end of her shift) she was unaware Resident #53 was missing and was not aware until she received a call from the a day shift nurse around 8:30 A.M. that morning. During the interview, the Agency LPN denied hearing any door alarm sound during the morning. During a follow up interview with agency LPN #115 on 06/29/20 at 5:56 P.M., Agency LPN #115 revealed she had worked from 8:00 P.M. on 06/19/20 until 7:00 A.M. on 06/20/20 and had not charted on Resident #53 because she had run out of time. When the DON called her to question her about that night, she had told her she would chart the next day she came in to work (which was on 06/23/20). She stated she had been coming to the facility to work (through the agency) for about two weeks now and voiced concerns there were never enough staff working. She stated on 06/20/20 her one nursing assistant scheduled to work left at the beginning of the shift and she was the only one working the unit until a nursing assistant came in at 2:00 A.M. She indicated Resident #53 had been trying to get out of the building all night. She stated he was trying to exit the facility via the door at the end of the rehabilitation unit. She stated she was in a resident room trying to hang an intravenous medication and the door alarm kept going off and she would have to stop what she was doing, run down to get him away from the door and shut the alarm off. Agency LPN #115 revealed she did not feel Resident #53 was appropriately placed on the rehabilitation unit and indicated he required more supervision. On 06/29/20 at 5:06 P.M. interview with Agency STNA #116 revealed she was the only STNA working the night of 06/19/20 from 11:00 P.M. to 7:00 A.M. shift and was assigned for the 200/rehabilitation unit, 300 and 400 units (40 residents). She indicated one nursing assistant was a no call/no show and the other one supposedly came in and went home but she never saw him. She stated around midnight she asked the nurse if there were any additional staff coming to help. At 2:00 A.M. she stated she asked the aide from the assisted living to help her do rounds on the rehabilitation unit. She indicated she had not been on the rehabilitation unit at all that night up to that point. She indicated PCA #110 came over from the assisted living and ended up staying on the rehabilitation unit the rest of the shift and she stayed on the 300/400 unit. She indicated she had gone over a few times to help but had not seen Resident #53 at all. On 06/29/20 at 5:21 P.M. interview with STNA #108 revealed the STNA was aware that Resident #53 was always trying to get out the doors and he had been caught (she did not say by who) putting the door code in and it had to be changed. Upon further interview, the STNA was unable to provide any dates as to when this had occurred. On 06/30/20 at 7:20 A.M. interview with STNA #112 revealed on 06/20/20 when she came on shift (day shift) she had gone to get supplies to start getting residents up around 7:30 A.M. She stated the other nursing assistant (STNA #131) she was working with said Resident #53 was not in his room when she took his breakfast tray into the room. She stated they searched his room and that was when she noticed the window was open about an inch to an inch and half. She told the nurse (LPN #113) on duty and they started to search the building and outside for him. She stated he was always talking about going home and was always trying to get out. She indicated his wife had been a resident at the facility for awhile and he would walk to the facility (from home) to see her after his family took his car away from him, so she thought he would know his way home. She indicated she did not remember seeing a bar in the window of the resident's room at the time he was identified to be missing. On 06/29/20, 06/30/20, 07/01/20 and 07/02/20 attempts to reach PCA #110 via telephone were unsuccessful. In addition, requests were made to the DON to facilitate communication with PCA #110 which were also unsuccessful. On 06/30/20 at 10:27 A.M. telephone interview with the Administrator revealed there was no bar located in Resident #53's window on 06/20/20. On 07/01/20 at 9:53 A.M. an additional interview with Agency LPN #115 revealed following the incident involving Resident #53 she was not provided any facility education related to elopement, residents with exit seeking behaviors and/or the timely implementation of interventions related to exit seeking behaviors for residents. In addition, she was not aware she could document incident details on a piece of paper at the time of an incident to later be uploaded into the computer during an emergency. On 07/01/20 at 3:00 P.M. interview with Physician's Office Staff #201 revealed the physician was unable to speak to with the surveyor personally, however he indicated he had been notified Resident #53 had left the building without staff knowledge and indicated the resident was not safe to leave the building without supervision. On 07/01/20 at 3:47 P.M. interview with the DON verified the unit assignments for 06/19/20 and 06/20/20 revealed Agency LPN #115 was working the rehabilitation unit from 06/19/20 at 8:00 P.M. until 06/20/20 at 7:00 A.M. Agency STNA #116 was working on 06/19/20 from 11:00 P.M. to 06/20/20 at 7:00 A.M. to care for 40 residents residing on the rehabilitation unit (which was the 200 unit), the 300 unit and 400 unit. During the interview, the DON verified PCA #110, who was a patient care assistant (non State tested ) from the assisted living did work in the nursing home on the rehabilitation unit on 06/20/20, but the DON was unable to provide the exact time PCA #110 came over to help. The DON revealed PCA #110 would have only answered call lights and passed ice to help the nurse, she would not have provided hands on care to the residents. On 07/02/20 at 9:49 A.M. interview with the DON revealed the midnight shift staff would be responsible to document on the STNA flowsheets for any care provided to the resident during their shift. On 07/20/20 at 12:16 P.M. interview with the DON verified there was no care documented for the resident on the flowsheets and the only documentation of provided on 06/20/20 was what was in the nursing progress notes as noted above. The DON indicated only the nurse (Agency LPN #115) would have provided any care to the resident. Review of the undated facility policy titled Elopements revealed staff would investigate and report all cases of missing residents. An elopement was defined as a resident who had left the facility and his or her location was unknown by the staff. This deficiency substantiates Master Complaint Number OH 757 and Complaint Number OH 669.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to securely maintain the covering over the baseboard heat registers. This resulted in Actual Harm for one resident when Resident #70 was found in her room with direct skin contact to the baseboard heater after the faceplate/cover had fallen off. This resulted in second [MEDICAL CONDITION](defined as a burn marked by pain, blistering, and superficial destruction of dermis with [MEDICAL CONDITION] and hyperemia of the tissues beneath the burn) to Resident #70's vaginal area, bilateral buttocks, thighs, and feet. This affected one (Resident #70) of three residents reviewed for a safe environment. Facility census was 61. Findings include: Review of the closed medical record revealed Resident #70 was admitted on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 02/08/19 revealed Resident #70 was at risk for falls due to an unsteady gait pattern. Interventions included the bed in low position and to keep the resident in a safe environment. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/11/19, revealed Resident #70 had impaired cognition. The resident required extensive assistance of two for bed mobility and transfers. Review of the fall risk assessment dated [DATE] revealed Resident #70 was at high risk for falls. Review of the facility fall investigation revealed on 01/07/20 at 11:20 P.M. the night shift State tested Nursing Assistant (STNA) found Resident #70 sitting on the baseboard heater in the resident's room. The resident was leaning forward with her knees on the floor and her head and arms on the bed. The report indicated the resident had broken the shield/cover off the heater and the heating coils were exposed. Review of the nurse's note dated 01/08/20 at 2:09 [NAME]M. revealed on 01/07/20 at 11:25 P.M. Resident #70 was noted sitting on the heating register in the resident's room. The resident had a 25.4 centimeter (cm) long and 25.4 cm wide reddened area with three fluid filled blisters and three strips of loose tissue on the right gluteal fold and right posterior thigh. The left gluteal crease and posterior thigh had a 5.08 cm long and 25.4 cm wide reddened area with a strip of loose tissue noted. At 12:30 [NAME]M. the local hospital called and stated Resident #70 had been admitted to the burn unit with second degree burns. A written statement by assistant director of nursing (no date) revealed Resident #70's bed was parallel with the wall that had a base board heater. Housekeeping had attempted to turn the resident's bed perpendicular to the wall, but the resident's heart monitor needed to be plugged in and there were no outlets on the exterior wall so the resident's bed remained parallel to the wall. Review of the hospital history and physical dated 01/08/20 revealed Resident #70 had [MEDICAL CONDITION] sitting on a heater for an unknown amount of time. Resident #70 had second [MEDICAL CONDITION] the buttocks, vaginal area, bilateral upper legs and the bottom of bilateral feet. The resident had a total body surface area (TBSA) burn of 5.05 percent. The physical exam revealed [MEDICAL CONDITION] to be a mix of second and possible third-degree burns. There were areas with intact blisters. Some areas had a moist, pink/white and mottled appearance. Other areas were completely white and dry. Petechiae (tiny round brown-purple spots due to bleeding under the skin) were noted to the burned areas and surrounding skin.[MEDICAL CONDITION] the vaginal area appeared to be second-degree and were pink/white mottled and moist.[MEDICAL CONDITION] left and right foot were second-degree with intact blisters. A palliative care inpatient consult dated 01/16/20 revealed Resident #70 had full [MEDICAL CONDITION] would require surgery to close. The family agreed to no surgeries due the resident's age. The hospital discharge summary dated 01/17/20 revealed Resident #70 [MEDICAL CONDITION] urinary tract infection upon admission. The resident's intake was poor and an enteral feeding tube was placed at the hospital. There was no improvement in the healing of the resident's wounds. The wounds appeared to be converting to full thickness with thick yellow/brown eschar (dead tissue). The resident also had early [MEDICAL CONDITION] (bacterial skin infection) to the wound on the right buttock. There was no evidence of wound healing and Resident #70 had an increased risk of infection [MEDICAL CONDITION]. The family ultimately choose Hospice care and Resident #70's intravenous antibiotics were discontinued and the enteral feeding tube was removed. Interview on 01/27/20 at 11:14 [NAME]M. Director of Maintenance #101 verified the cover had come off the baseboard heater, the heating coils were exposed, and Resident #70 had been burned. Director of Maintenance #101 stated the cover must have come off the heater when Resident #70 fell or hit the heater. An additional interview on 01/27/20 at 1:12 P.M. with Director of Maintenance #101 revealed the baseboard heaters often got hit with the beds and caused damage to the top of the heaters. Director of Maintenance #101 stated the front cover on the baseboard heaters was held in place by clips/hangers. Director of Maintenance #101 verified there was no documentation of routine checks being done to ensure the baseboard heaters were operating safely and the front cover was appropriately clipped in place. Interview on 01/27/20 at 2:59 P.M. with the Administrator revealed Resident #70 sat on the baseboard heater and busted off the front cover. The resident did not have an incontinence brief on, [MEDICAL CONDITION] to the residents buttocks and vaginal area. The Administrator stated the baseboard heater had not been damaged before the resident sat on it. The Administrator verified she was unsure if there was documentation of baseboard heaters being regularly checked, prior to Resident #70 being burned. Interview on 01/27/20 at 5:09 P.M. with Head of Housekeeping #220 revealed the housekeepers had to remind the nursing staff to keep resident beds from the baseboard heaters. The deficient practice was corrected on 01/22/20 when the facility implemented the following corrective action: · Resident #70 was discharged to the hospital on [DATE]. · On 01/08/20 the facility nurse managers reviewed all residents who were at risk for falls and in beds near the heaters. No other high risk for fall resident beds were identified to have their bed parallel to the baseboard heater. · On 01/08/20 Maintenance Director audited all the facility baseboard heaters for proper functioning of the front plate connectors. All the heaters had faceplates that were secure per the manufacture guidelines. · On 01/08/20 through 01/22/20 all staff were educated about keeping the beds of residents, who were at risk for falls, perpendicular from the baseboard heaters and to report any issues with the baseboard heaters. · On 01/08/20 housekeeping staff were educated to monitor for signs of damage to baseboard heaters as part of their daily cleaning routine and notify maintenance to address any issues. · On 01/09/20 Maintenance Director installed a new baseboard heater in the room Resident #70 had been in. · On 01/09/20 six new baseboard heaters were purchased. The new heaters had covers that were screwed on. The new baseboard heaters were installed. · Beginning on 01/08/20 the Maintenance Director would do audits weekly for four weeks to all resident room baseboard heaters for signs of damage and replace heaters as needed. · The audits would be discussed at the monthly quality assurance performance improvement (QAPI) meeting. · The nurse management team would continue to review falls and appropriate interventions. This deficiency substantiates Complaint Number OH 545.

Based on observation, record review and staff interview, the facility failed to ensure appropriate supervison for one resident (Resident #3), assessed to be a fall risk, while in the shower. Actual harm occurred when Resident #3 fell out of the shower chair while unattended and sustained a nasal fracture requiring an emergent hospital transfer. This affected one of three residents reviewed for falls. The facility census was 65. Findings include: Review of Resident #3's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a plan of care dated 04/16/19 indicating the resident was at risk for falls related to an unsteady gait, possible side effects of medication and weakness. Interventions included a low bed, floor mat, body pillow and an audio call device. Review of a 06/26/19 fall risk assessment included intermittent confusion, chair bound, and problems with gait and balance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was moderately impaired for daily decision making, required extensive assist of two for bed mobility and transfers, did not ambulate, was a total assist for locomotion on or off the unit, required physical help for part of bathing and was not steady and only able to stabilize with human assistance for surface to surface movement. Review of the nurse notes revealed Resident #3 fell on [DATE] at 7:15 [NAME]M. in the central shower room. The resident was laying in the back shower stall on the floor on her left side with the left side of her face on the floor, head against the wall and feet touching the other side of the shower. Bright red drainage was coming from her forehead. When asked what happened, the resident stated she was reaching for something and fell . There was a skin tear to center of her forehead and abrasion on brim of nose. The resident was alert and oriented times two. The resident was sent to the emergency room (ER) and returned with mildly displaced bilateral nasal bone fractures angled and displaced to the left slightly. The resident received sutures in her forehead. Review of a witness statement indicated State tested Nurse Aide (STNA) #22 showered the resident and in doing so noticed an area on her head. STNA #21 came into the shower room. STNA #22 handed the resident a towel and told STNA #21 she was going to go get the nurse, (leaving Resident #3 unattended). When she returned she heard a thump. She saw STNA #21 washing her hands at the sink. They rushed to find the resident on the floor in the shower. STNA #22 revealed she could have asked STNA #21 to get the nurse, finish with Resident #3 and got her in her wheelchair before going for the nurse or ask STNA #21 to stay by the resident until she returned. STNA #22 indicated she let her guard down and you can't be certain that accidents won't happen. Witness statements included STNA #21 was standing at the sink washing her hands to get ready to help STNA #22 dress Resident #3 for breakfast. STNA #22 had gone out to get the nurse so she could see a mark on the resident's head. In that time, the resident went to reach for something and fell off the shower chair. STNA #21 revealed she should of made sure she stood by her and not left her side at all until her coworker returned. A 07/16/19 change of status MDS was completed related to a fall resulting in a fracture to her nose and a decline in activities of daily living. The MDS changes from the previous 06/26/19 assessment revealed the resident was severely impaired for daily decision making, totally dependent of two staff for bed mobility, totally dependent of one staff for personal hygiene and bathing, required as needed opioid pain medication and had one fall with major injury since the last assessment. Interview with the Director of Nursing (DON) 09/19/19 at 12:38 P.M. verified the resident was getting a shower, fell and fractured her nose when staff left her out of their reach while on a shower chair. One aide stepped out of the shower room, and the other walked away from the resident when she went to the sink. Education was provided to the staff related to staying by the resident since she was a fall risk. The DON verified there were no audits/spot checks of showers to ensure staff was attentive to residents and identification of like individuals to plan their care accordingly. Observation of the shower room took place 09/19/19 at 1:10 P.M. with Registered Nurse (RN) #20. Observation revealed the sink was approximately eight feet from the shower edge and approximately 10 to 11 feet from the center of the shower head. A shower chair was placed in front of the shower head. When standing at the sink and turning around to look in the shower; no portion of the shower chair was visible. The resident would of been out of sight if the shower chair was centered with the shower head, and the STNA was in front of the sink washing her hands. Interview 09/19/19 at 3:06 P.M. with the DON verified the STNA should of stayed with the resident. The DON revealed she got careless because the resident never moved. This deficiency substantiates Complaint Number OH 914.

Based on observation, interview and record review, the facility failed to provide pain control during a dressing change to a wound. This resulted in actual harm for Resident #125 who continued to yell out "Stop, it hurts" and strike out at the staff during the dressing change. This affected one (Resident #125) of one resident observed for a dressing change. The facility census was 92. Findings include: 1. Review of Resident #125's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was difficult to assess, was oriented to name only and not oriented to place, date or year. Review of Resident #125 physician orders [REDACTED]. an order for [REDACTED]. Review of a physician order [REDACTED]. A new order reflected to clean and irrigate the wound with normal saline and pat dry. The wound was then to be packed with [MEDICATION NAME] (a topical antibiotic ointment) buttered gauze and to try to pack all undermining areas. A review of nurses' notes from 10/01/14 through 10/16/14 revealed one assessment of pain documented on 10/14/14 after Resident #125 was medicated with [MEDICATION NAME] for hip pain. The note was not specific to wound pain. On 10/15/14 at 2:35 P.M. an observation of a Stage IV pressure ulcer (a full thickness tissue loss with exposed bone, tendon or muscle) dressing change by Licensed Practical Nurse (LPN) #57 revealed Resident #125 was turned onto the side and LPN #57 removed the outer covering of the dressing from the left ishium. Resident #125 yelled in a high pitched voice "That hurt." LPN #57 removed the packing from inside the pressure ulcer. Resident #125 was yelling repeatedly "Ouch, stop, that hurts." LPN #57 performed measurements of the wound. The wound measured 1.6 centimeters (CM) deep by 0.5 cm by 0.4 cm. The pressure ulcer also was measured for the amount of tunneling that was present. With each measurement taken, Resident #125 was yelling loudly "That hurts, Stop it" and was swatting at LPN #57's hands. Resident #125's leg muscle was tightened up at this point in the dressing change. The wound was then packed by LPN #57 and covered with the [MEDICATION NAME] covered gauze. Resident #125 was continuously yelling "Stop it" and "That hurts" and was trying to grab the LPN's hand during packing process. LPN #57 continued to pack wound despite Resident #125 yelling to stop. Resident #125 was observed to stop yelling and was calm during a break in the dressing change process. An interview on 10/15/2014 at 3:07 P.M. with LPN #57 revealed Resident #125 was medicated with scheduled Tylenol on 10/15/14 at 1:00 P.M. LPN #57 verified Resident #125 had an order for [REDACTED].#57 verified Resident #125 was yelling "Stop it" and "that hurts" during the dressing change and no effort was made to further medicate or stop the dressing change all together. Review of the pain management policy (undated) revealed it was the policy of the facility to provide [MEDICATION NAME], appropriate assessment and intervention to control a residents pain.

Based on observation, medical record review, staff interview, and review of the facility policy and procedure for pressure ulcers, the facility failed to provide treatment and interventions to promote healing and prevent new pressure sores from developing for two of three Stage 2 sampled residents with pressure ulcers (Residents #48 and #151). The facility identified four residents with pressure ulcers. The census was 91. Harm occurred when Resident #48, who was readmitted from the hospital on [DATE], was assessed as moderate risk for the development of pressure ulcers, and did not receive the care and treatment to prevent new pressure ulcers. The resident was readmitted to the facility with two pressure areas. Observation during the survey revealed four additional facility acquired pressure ulcers on the right foot that had not been assessed or treated by the facility. Findings include: 1. Review of minimum data set (MDS) assessment dated [DATE] revealed Resident #48 was re-admitted to the facility on [DATE] from the hospital. Resident #48 displayed cognitive impairment. Functional capabilities included extensive assistance required in the areas of bed mobility and transfers. Resident #48 was non-ambulatory and required total dependence on staff for locomotion via wheelchair. Review of Skin Conditions section revealed Resident #48 did not have any pressure ulcers at time of MDS assessment. Review of problem list dated 06/27/07-06/24/10 included [DIAGNOSES REDACTED]. Review of the nurses' notes dated 02/28/11 at 3:14 P.M., revealed Resident #48 was admitted to the hospital. Review of the hospital history and physical dated 02/28/11 revealed Resident #48 was admitted with [DIAGNOSES REDACTED]. Resident #48 returned to the facility on [DATE] with a feding tube. Nurses' notes dated 03/05/11 at 2:19 P.M., revealed soft heels bilaterally with heel cuffs in place. Right great toe was red and fragile on outer aspect. [MEDICATION NAME] and dressing was applied. [MEDICATION NAME] to sacral area was removed and replaced. Sacral area had an open area that measured 2.8 cm x 5cm x 0.1 cm, was black in color and surrounding skin was red and blanchable. There was no evidence the facility staged the area. Review of the care plan for Resident #48 dated 07/01/10-04/25/11 revealed problem/need related to at risk for pressure area. On 03/05/11, the problem was added that Resident #48 was readmitted from hospital with large sacral area and right great toe was red and fragile. The goal was for Resident #48's open area to heal without complications. Interventions included: turn every two hours, eggcrate mattress to bed, cradle to bed to protect foot, follow Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Braden Risk Assessment Scale dated 12/21/10 indicated total score of 13 which was moderate risk. Review of physician's orders dated March 2011 revealed orders for [MEDICATION NAME] dressing to sacral area every three days, cleanse with soap and water or normal saline, and apply [MEDICATION NAME] ointment twice daily and as needed for fourteen days. There were physician orders for right great toe to cleanse with normal saline and apply [MEDICATION NAME] ointment. There were no other areas identified on the physician orders for treatment. On 03/09/11 at 11:20 A.M., observation of dressing change to pressure ulcers by Registered Nurse (RN) #90 revealed the nurse did not remove pressure relieving boots to perform treatment to right foot or to assess left foot. RN #90 completed treatment/dressing change to Resident #48's coccyx pressure ulcer which measured 2 centimeters (cm) length (l) x 1 cm width (w) x 0.2 cm depth (d) with eschar (dead tissue that is cast off from the surface of the skin) noted in the center of the ulcer that measured 0.3 cm x 0.9 cm. Surrounding skin was pink slough (dead tissue separated from living tissue or ulceration). The area surrounding the rectum was reddened. The sacral pressure ulcer was cleaned with normal saline and a [MEDICATION NAME] dressing was applied. RN #90 then performed a treatment to right great toe. The measurements were 3 cm (l) x 2.8 cm (w) x 0 cm (d) and reddened. There was no open areas or drainage noted to the right great toe. RN #90 applied [MEDICATION NAME] (an antibiotic ointment) to the right great toe and wrapped it with a gauze dressing. At the end of the dressing change, the pressure relieving boot was pulled back and it was discovered there was an area to the right lateral aspect of his right foot and also anterior (dorsal aspect) of right foot. RN #90 stated she was not aware of these areas and stated she did not have an order to treat these areas RN# 90 stated she would have to notify the physician. RN #90 then preformed measurements of these two additional areas. The lateral aspect of the foot contained a dark area that measured 1 cm (l) x 1.8 cm (w) with red surrounding tissue measuring 3 cm (l) x 2.3 cm (w). The anterior surface of the right foot had a dark red area with eschar beginning to develop measuring 0.5 cm (l) x 0.5 cm (w) x 0 (d). There was no open skin or drainage from either of these new areas. RN #90 did not provide any treatment to these areas during the observation. RN #90 did not at any time remove Resident #48's pressure relieving boots to assess the entire left foot or the right foot. On 03/09/11 at 9:10 A.M., interview with RN #10 verified the unit RNs were not permitted to stage pressure ulcers. Their responsibilities were describing length, width, depth, odor and infection of the pressure ulcer and document in the nurse's notes. The MDS Nurses were responsible for staging pressure ulcers and this was only done when the MDS was due. There had been problems with many nurses trying to stage the pressure ulcers. RN #10 also verified there was no skin grid assessment that tracked the progress of pressure ulcers. On 03/09/11 at 11:45 A.M., interview with RN #10 verified she was not aware of these two areas and was checking the nursing admission assessment. On 03/09/11 at 3:13 P.M., interview with Licensed Practical Nurse (LPN) #93 revealed boots should be removed every shift to assess skin condition of feet. This documentation should be noted on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 03/09/11 at 3:30 P.M., interview with RN #10 requested documentation for Resident #48's skin assessment. Requested documentation regarding last time boots were removed who removed them and what time they were removed. RN #10 did not provide any documented evidence of skin assessments. On 03/09/11 at 3:40 P.M., interview and observation with LPN #60 revealed the person completing the resident's treatment should be removing the boots to assess skin or this should occur every shift. She was unable to confirm when boots were last removed. LPN #60 removed the boots for complete observation of Resident #48's skin condition. Removal of the boots revealed three additional facility acquired pressure ulcers to the right foot. Area #1 was a red/pink area to lateral foot superior to the Stage IV ulcer on lateral aspect of right foot. The area measured 0.6 cm (l) x 0.4 cm (w) x 0 (d). Area #2 was a discolored (pink/purplish) lateral anterior surface of foot (non blanchable) LPN #60 stated it was undetermined origin which measured 2 cm (l) x 1.2 cm (w) x 0 (d). Area #3 was a discolored area dark purple at inferior/anterior aspect right foot 1 cm (l) x 0.8 cm (w) x 0 (d). LPN #60 described as triangular (in shape) healing abraised area. LPN #60 affirmed all discolored areas should be noted on assessment in the nursing notes and they were not. On 03/09/11 at 4:29 P.M., interview and observation with RN #10 who accompanied the surveyor to Resident #48's room to assess the right foot pressure ulcers revealed after removing the pressure relieving boots, RN #10 stated she believed the pressure ulcers had gotten worse since she assessed them yesterday (RN #10 provided no documentation of this assessment and it was not noted in the nurses' notes). RN #10 reported she never observed the two new areas on the anterior right foot. RN #10 verified there were additional pressure ulcers on the right foot that had not been assessed. RN #10 stated she was going to change his boots to "waffle boots." Review of Quarterly Assessment completed 03/07/11 indicated the resident's right outer foot was nonblanchable redness measuring 2 cm (l) x 2. 2 cm (w) x 0 cm (d) with a dark purple center that measured 1 cm (l) x 1.5 cm (w) x 0 (d) and a 3 cm (l) x 2 cm (w) nonblanchable redness that wrapped around the right great toe. The assessment indicated an abrasion to the right great toe at base of toenail which measured 2 cm (l) x 3 cm (w) x 0.1 (d). There was no documentation of pressure areas to the anterior aspect of right foot or new area developing on lateral right foot superior to the previously documented pressure ulcer. Review of Pressure Ulcer Policy dated 02/23/99 revealed pressure ulcers must be monitored each shift and recorded in treatment administration record and in clinical notes weekly or as a condition or level of care warrants. Review of the treatment administration record dated March 2011 and nurses' notes dated 03/05/11 through 03/10/11 showed no evidence that pressure ulcers were monitored each shift and documented per policy. On 03/10/11 at 10:35 A.M., interview with State-tested Nurse Aides (STNAs) #94 and #95, who completed activities of daily living for Resident #48 on 03/07/11 and 03/09/11 verified they do provide bed baths to the resident every day from head to toe which include removing socks and/or moon boots. STNA # 94 affirmed that she reported a black pressure area to LPN #20 on 03/07/11 at approximately 10:45 A.M., and STNA #95 affirmed she reported blackened area to right foot to RN #10 on 03/09/11 approximately at 10:00 A.M. On 03/10/11 at 10:45 A.M., interview with LPN #20 affirmed the STNA did report the blackened area to her on 03/07/11 and she had observed the area herself. LPN #20 stated she thought that the area had been assessed when the resident returned from the hospital. LPN #20 reported she assumed the treatment to the foot included the lateral aspect that was blackened. 2. Medical record review revealed Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fourteen day MDS dated [DATE] revealed the resident required extensive assistance of two staff for bed mobility and was admitted with a Stage II pressure ulcer and two unstageable deep tissue injuries. Review of the nursing notes dated 01/10/11, 01/15/11, 01/18/11, 01/29/11, 02/03/11, 02/05/11, 02/20/11, 02/27/11 and 03/06/11 revealed no documented evidence of weekly staging of the resident's pressure ulcers. Review of the pressure ulcer policy, dated 02/23/99, revealed the policy did not include a procedure for documenting the pressure ulcer location, stage, size, drainage, pain, wound bed or wound edge description with each dressing change or at least weekly. On 03/10/11 at 10:00 A.M., interview with RN #10 verified nurses do not document the type of ulcer or the stage of the pressure ulcer in the weekly assessments.