Every finding on record at Ohio Living Sarah Moore

Based on observation, staff interview, and policy review, the facility failed to maintain a sanitary kitchen. This had the potential to affect all 42 residents who receive food from the kitchen.Findings include:Observation of the kitchen during the initial tour on 03/16/26 at 8:02 A.M. revealed the ice machine had a brown spots and calcium buildup locates inside and above the ice. Additionally, the floors had a buildup of dirt behind the soda machine and the area behind the dishwasher revealed a black substance which appeared to be mold behind the dishwash area and by the soda dispenser. Dust buildup with a black substance was observed over the food heater located on the area on the ceiling.Interview on 03/16/26 at 8:24 A.M. with [NAME] #155 confirmed all observations regarding the ice machine, floor, dishwash area, and dust buildup over the food heater.Interview on 03/17/26 at 4:36 P.M. with Dietary Manager #162 revealed he does not have any logs of cleaning schedules at this time due but stated he was starting a new cleaning schedule.Review of the facility policy titled General Sanitation of Kitchen, dated 2023, revealed food and nutrition services staff were required to maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The procedure outlined that cleaning and sanitation tasks for the kitchen would be assigned to specific positions, with defined frequency for each task. Methods and materials for cleaning and sanitizing were to be written for each task. Employees were to be trained on how to perform cleaning tasks and were required to initial and date tasks on the cleaning schedule when completed.

Based on staff interview, medical record review and facility policy review, the facility failed to ensure a care plan was updated for Resident #20 when she began to exhibit behaviors. This affected one (#20) of 16 residents reviewed for care plans. The facility census was 42.Findings include:Review of Resident #20's medical record revealed an admission date of [DATE]. Diagnoses included vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of Resident #20's progress notes dated [DATE] revealed during a quarterly care conference with Resident #20, Resident #20 has moments of confusion looking for her deceased husband and thinking other residents were her husband, but was easily directed.The progress note dated [DATE] revealed Resident #20 had a behavior outburst during an afternoon movie, noting Resident #20 began to get upset and grab onto another resident which she stated was her boyfriend.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had moderate cognitive impairment. Resident #20 did not exhibit physical behavioral symptoms directed to others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others during the review period.Review of Resident #20's care plan on [DATE] revealed the facility did not have a behavior care plan in place for Resident #20.Interview on [DATE] at 2:01 P.M. with Registered Nurse (RN) #106 confirmed there was not a behavior care plan in place for Resident #20.Review of the facility's care plan policy titled Comprehensive Person-Centered Care Planning, dated [DATE], revealed comprehensive care plan is centered on the resident's needs including: measurable objectives and time frames, receiving behavioral health care and services (includes culturally-competent and trauma- informed) to attain or maintain the highest practicable physical, mental, and psychosocial well- being, in accordance with the comprehensive assessment and plan of care.

Based on resident and staff interviews, record review, and facility policy review, the facility to ensure the residents received bathing as physician ordered and to maintain their activities of daily living (ADL). This affected one (#20) of two residents reviewed for ADLs. The facility census was 42.Findings include: Review of Resident #1's medical record revealed an admission date of 05/28/25. Diagnoses include bilateral primary osteoarthritis of knee, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and bilateral nonexudative age-related macular degeneration.Review of the progress notes dated 08/05/25 revealed when Resident #1 refused all care and slept all shift. The medical record did not indicate Resident #1 refused baths or showers from 08/06/26 to 03/15/26. Review of the physician orders dated 09/05/25 revealed Resident #1 should receive bath/shower two times per week, once a day on Wednesday and Saturday.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition. Resident #1's functional abilities revealed Resident #1 required supervision or touching assistance with shower/baths. Resident #1 did not reject care during the review period.Review of Resident #1's shower sheets from 01/01/26 to 02/28/26 revealed Resident #1 received five showers in January 2026 on 01/03/26, 01/17/26, 01/21/26, 01/24/26, and 01/28/26. Resident #1 refused showers on 01/10/26 due to the resident not feeling good and 01/31/26. In February 2026, Resident #1 received a showers on 02/04/26, 02/14/26, and 02/18./26. The shower sheets did not reflect Resident #1 refused personal hygiene on the days she accepted a shower. Resident #1 should have been offered showers according to physician orders on 01/07/26, 01/14/26, 02/07/26, 02/11/26, 02/18/26, 02/25/26, and 02/28/26. Review of the ADL care plan last updated 02/13/26 revealed Resident #1 had the potential for functional status deficit related to physical deconditioning/generalized muscle weakness, advanced age, history of right sided sciatica with intermittent severe right hip pain, right shoulder pain, osteoarthritis of bilateral knees, impaired vision (near complete blindness), moderate hearing difficulty; and chronic pain disorder. Interventions included the resident will receive appropriate staff support with all functional abilities. Approaches included shower/baths required supervision/touching staff assistance. There was no rejection of care noted in the care plan.Interview on 03/16/2026 at 10:24 AM with Resident #1 revealed she was not receiving showers twice a week per schedule.On 03/17/26, the care plan was updated to reflect Resident #1 resisted care often (showers/baths, assistance with personal hygiene-trimming/shaving facial hairs).Interview on 03/18/26 at 4:40 P.M. with Certified Nursing Assistant (CNA) #133 stated shower sheets were to be filled out for each resident's assigned shower day with completion or refusal of a bath or shower.Interview on 03/19/26 at 10:25 A.M. with the Director of Nursing (DON) stated she expected CNAs to fill out a shower/bath sheet for every shower day for every resident with completion or refusal. The DON confirmed Resident #1 received only three baths/showers for February 2026 and there was no additional documents to support Resident #1 received any further showers in February 2026. Review of the facility's policy titled Activities of Daily Living (ADL) dated 07/17/25 revealed it is the policy of the facility to assist each resident to the extent necessary for completion of ADLs on a daily basis and as needed.

Based on observation, record review and interview, the facility failed to ensure Resident #14, who required staff assistance with activities of daily living (ADL), received adequate and timely care to maintain good personal hygiene including removal of facial hair (shaving). This affected one (Resident #14) of two residents reviewed for ADL. The facility census was 42.Findings include:Review of the medical record for Resident #14 revealed an admission date of 02/16/26. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, cerebral infarction, muscle weakness, and chronic obstructive pulmonary disease.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderate cognitive impairment. Resident #14 was dependent on staff assistance for showering and did not reject care during the review period.Review of the care plan revealed Resident #14 had the potential for functional status deficit related to physical deconditioning, cerebrovascular accident (CVA) with right sided hemiparesis (February 2025), impaired range of motion of right shoulder, generalized muscle weakness, lack of coordination, and moderate cognitive impairment. Interventions included Resident #14 required maximum staff assistance to maintain personal hygiene including combing hair, shaving, applying makeup, washing/drying face and hands.Review of the shower sheets dated 02/17/26, 03/03/26, 03/07/26, and 03/10/26 revealed Resident #14 had not been shaved. There were no other showers sheets from 03/11/26 to 03/16/26.Observation and interview on 03/16/26 at 11:05 A.M. revealed Resident #14 was sitting in her room in her wheelchair with multiple white facial hairs on her chin. Resident #14's spouse stated Resident #14 typically took care of removing the chin hair herself when she was able to.Observation and interview on 03/17/26 at 10:20 A.M. revealed Resident #14 was sitting in her wheelchair in her room with multiple white facial hairs on her chin. Resident #14 stated she wouldn't have chin hair if at home.Interview on 03/17/26 at 10:33 A.M. with Certified Nursing Assistant (CNA) #200 verified Resident #14 had facial hair on her chin. Interview on 03/17/26 at 11:18 A.M. with Licensed Practical Nurse (LPN) #112 stated facial hair on women should be trimmed or shaved if the resident allows them too and should be completed on shower days and as needed. Interview on 03/17/26 at 3:11 P.M. with the Director of Nursing (DON) stated the expectation for facial hair on females was it should be cleaned up just like the men unless the resident refuses and right now there was only one female who refuses (not Resident #14) or resident preference. The DON stated the facial hair should be removed when it is noticed even if it is not a shower day. Review of the facility policy titled Activities of Daily Living (ADL) dated 07/17/25, revealed the facility will assist each resident to the extent necessary for completion o ADLs on a daily basis and as needed.

Based on record review and staff interview, the facility failed to ensure wound treatments were timely initiated for a resident with a pressure ulcer. This affected one (Resident #36) of one resident reviewed for skin impairments. The facility census was 42. Findings include:Review of the medical record for Resident #36 revealed an admission date of 02/22/26. Diagnoses included fracture of right pubis, osteoporosis, fracture of sacrum and stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.) of sacral region. Review of the admission care plan dated 02/22/26 revealed Resident #36 has a ulcer on coccyx. Interventions included pressure-reducing device for chair and bed, surgical wound care and turning and repositioning program. Review of the physician order dated 02/22/26 revealed an order for pressure redistribution mattress to bed and wheelchair. There was no physician order to treat the stage II pressure ulcer. The Braden Scale for pressure ulcer risk, dated 02/22/26, revealed a score of 15, placing Resident #36 at risk for skin impairment. The scoring revealed Resident #36 had no sensory perception impairment, was occasionally moist, was chairfast, had slightly limited mobility, had potential for inadequate nutritional intake, and had concerns related to friction and [NAME] Review of physician visit dated 02/23/26 revealed Resident #36's admitting diagnoses included stage II pressure ulcer on coccyx, and continue to offload to relieve pressure and daily zinc barrier cream. Review of the skin assessment dated [DATE] revealed the stage II pressure ulcer measured 1.8 centimeters (cm) in length, 0.5 cm in width with 0.1 cm in depth. The area showed epithelial tissue, with erythema (redness), with treatment to apply zinc barrier cream. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was moderately cognitively impaired, required substantial/maximal assistance with toileting and was always incontinent of bladder. Resident #37 was identified at risk for pressure areas. From 02/22/26 to 03/01/26, there was no physician order to treat Resident #36's stage II pressure ulcer. The physician orders dated 03/02/26 revealed an order for the coccyx/buttocks gently cleanse, pat dry. Apply zinc barrier cream after each incontinence care every shift. Review of the medication administration records and treatment administration records from 02/22/26 through 03/01/26 revealed Resident #36 did not receive any treatments including zinc barrier cream after each incontinence episode to the stage II pressure ulcer. On 03/02/26, the wound treatments were initiated and documented as completed. The skin assessment dated [DATE] revealed stage II pressure ulcer measured 1.0 centimeters (cm) in length and 0.5 cm in width and 0.1 cm in depth. The area was noted as improving showing epithelial tissue, with erythema (redness), with treatment to apply zinc barrier cream. Interview on 03/18/26 at 8:45 A.M. with Unit Manager #100 revealed she was the nurse who initially assessed Resident #36's wound upon admission and completed routine measuring and monitoring to ensure healing and was responsible for placing physician orders for wound treatments. Interview on 03/18/26 at 11:18 A.M. with the Director of Nursing (DON) confirmed zinc barrier cream was not ordered and documented as completed daily until the physician order was placed on 03/02/26; however, Resident #36's pressure ulcer did not decline. The DON confirmed Unit Manager #100 did not put in the physician order for Resident #36's pressure ulcer when it was initially assessed. The DON confirmed she was unable to provide evidence the skin treatments were performed daily from 02/23/26 through 03/02/26, with an exception of 02/24/26.

Based on staff interview, medical record review, fall investigation review, and facility policy review, the facility failed to complete a thorough status post fall investigation when they failed to identify Resident #34's hematoma on his forehead and did not initiate neurological checks per their facility policy. This affected one (Resident #34) of five residents reviewed for accidents. The facility census was 42.Findings include:Review of Resident #34's medical record revealed an admission date 03/17/23. Diagnoses included spinal stenosis, moderate dementia with agitation, chronic systolic (congestive) heart failure, chronic atrial fibrillation, chronic obstructive pulmonary disease, and bilateral nonexudative age-related macular degeneration.Review of the care plan dated 03/20/23 revealed Resident #34 was at risk for falls due to advanced age, history of vertigo, atrial fibrillation, congestive heart failure, and spinal stenosis; incontinence of bowel and bladder, use of high fall risk medication, visual/auditory impairments, moderate cognitive impairment, required assistance for mobility/transfers and impulsive at times, and was at a high fall risk. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had severe cognitive impairment. Review of the facility's incident/accident log revealed Resident #34 had a fall on 02/12/26.The fall investigation dated 02/12/26 revealed at 5:15 A.M., Resident #34 was found on floor lying supine next to bed, head toward foot of bed, with pillow under his head. Resident #34 was unable to explain how he ended up on the floor. Immediate intervention was Resident #34 was assessed by nurse, requiring assistance of two staff and Hoyer lift to bed. Follow up intervention was low bed. Resident #34 denied hitting head, and there was skin tear to his right elbow. The fall investigation was completed by Registered Nurse (RN) #100. The fall investigation did not note Resident #34 had a hematoma of the scalp and did not initiate neurological checks.Review of Physician Assistant (PA) #24's appointment note dated 02/12/26 revealed Resident #34's chief complaint/reason for visit was due to a fall. Resident #34 was noted with hematoma of scalp and was currently on anticoagulation. Resident #34's daughter declined an emergency room (ER) evaluation as does the resident. Physical exam notes right posterior scalp swelling, tenderness without laceration and musculoskeletal review revealed abrasion and bruise right posterior scapular spine. Assessment and plan notes scalp contusion status post mechanical fall noting neuro checks intact and remains on Plavix and Eliquis (anticoagulants).The skin assessment noted 02/12/26 at 6:34 P.M. completed by Licensed Practical Nurse (LPN) #111 revealed no new skin findings. The skin assessment did not identify Resident #34 had a hematoma of the scalp.The progress notes dated 02/14/26 revealed Resident #34 had complaints of head and neck pain. Administered Tylenol (treats mild pain) with positive results.The follow up appointment dated 02/19/26 with PA #245 revealed Resident #34's chief complaint/reason for visit was a headache status post fall. Resident #34 was seen for follow up after fall and hitting head on 02/12/26. Staff reported Resident #34 with intermittent headaches since Saturday (02/14/26). The headache was near the forehead. Tylenol has been effective when given. Resident #34 was currently on Plavix and Eliquis. PA #245 discussed with Resident #34 and he was adamant he does not want to go to the hospital. His power of attornery (POA) was present. Assessment and plan included acetaminophen 500 milligrams (mg) two tablets three times daily for 10 days, hold Eliquis for 10 days then resume, and remain on Plavix. PA #245 discussed with Resident #34 and POA that they cannot rule out acute brain bleed.Interview on 03/19/26 at 12:25 PM with RN #100 confirmed she did not know Resident #34 suffered a hematoma and headaches requiring the pause of his Eliquis and confirmed neurological checks were not initiated because she was told Resident #34 did not hit his head from Resident #34 or the staff.Review of the facility's policy titled Fall Prevention and Management revised on 01/28/25 revealed at the time of the fall, the nurse will complete a physical assessment to determine if any injury occurred, notify the physician and responsible party, implement an immediate intervention, if resident reports that they hit their head, there is evidence that they hit their head (bump, redness, hematoma, etc.) or it was witnessed they hit their head, or the fall is unwitnessed then neurological checks are to be documented initially and then every two hours for 24 hour on the neurological progress note.

Based on record review, observation, interview, review of manufacturer instructions, and facility policy review, the facility failed to ensure their medication error was below five percent (%). There were three medication errors out of 33 opportunities resulting in a 9.09% medication error rate. This affected three residents (#11, #24. and #29) observed during medication administration. The facility census was 42.Findings include:1. Review of Resident #24's medical record revealed an admission date of 11/29/2023. Diagnoses included dementia and essential (primary) hypertension (HTN). The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had severe cognitive impairment.The care plan dated 02/17/26 revealed Resident #24 was at risk for complications related to HTN. Interventions included to administer antihypertensive medications as ordered (see (medication administration record MAR)).Review of Resident #24's physician orders dated 01/07/26 revealed an order of Metoprolol Succinate (treats HTN) tablet Extended-Release 24-hour (hr), 25 milligrams (mg), administer 12.5 mg. There was no physician order the medication could be crushed. Observation on 03/17/26 at 8:58 A.M. revealed Registered Nurse (RN) #105 removed metoprolol medication card from the medication cart to administer it to Resident #24. The medication card for Metoprolol Succinate 25 mg extended release 24-hr, administer 12.5 mg half tablet stated do not crush or chew. RN #105 stated Resident #24 took pills crushed and metoprolol succinate extended release 24-hr was crushed and administered to Resident #24 in applesauce at 9:01 A.M. The MAR confirmed Resident #24 was administered Metoprolol Succinate tablet Extended-Release 24-hr, 25 mg, administer 12.5 mg on 03/17/26 by Registered Nurse (RN) #105.Interview on 03/17/26 at 9:34 A.M. with RN #105 confirmed she crushed Resident #24's Metoprolol Ssuccinate Extended-Release tablet and administered it to Resident #24.Interview on 03/18/26 at 11:10 A.M. with the Director of Nursing (DON) revealed there was a binder containing list of medications that should not be crushed available on each medication cart.Review of the Food and Drug Administration medication label for Metoprolol Succinate Extended-Release Tablets revised 05/2025 revealed Metoprolol Succinate extended-release tablets are scored and can be divided; however, do not crush or chew the whole or half tablet.2. Review of Resident #11's medical record revealed an admission date of 08/02/24. Diagnoses included gastro-esophageal reflux disease (GERD) without esophagitis.Review of Resident #11's physician orders dated 03/18/25 revealed an order for Pantoprazole tablet (treats GERD), delayed release (DR/EC) 20 milligrams (mg), administer 20 mg once a day. There was no physician order to crush the medication. The care plan dated 02/20/26 revealed Resident #11 has an esophageal disorder. An intervention included to administer medications and return to assess effectiveness.Review of Resident #11's Medication Administration Record (MAR) revealed Resident #11 was administered Pantoprazole on 03/18/26 by Registered Nurse (RN) #103.Observation on 03/18/26 at 8:10 A.M. revealed RN #103 removed Pantoprazole medication card from the medication cart to administer to Resident #11. The medication card for Pantoprazole DR 20 mg tablet stated do not crush or chew. Further observation revealed RN #103 crushed all medications (including Pantoprazole; except Mucinex DM) and administered the crushed medications to Resident #11 in applesauce.Interview on 03/18/26 at 8:18 A.M. with RN #103 confirmed she crushed the Pantoprazole sodium DR 20 mg tablet and administered to Resident #11.Review of the Food and Drug Administration medication label revised 12/2013 revealed the administration instructions stated patients should be cautioned that pantoprazole sodium delayed-release tablets should not be split, chewed, or crushed.3. Review of Resident #29's medical record revealed an admission date of 03/10/26. Diagnoses included type II diabetes with diabetic neuropathy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition and received four insulin injections during the review period. Review Resident #29's physician orders dated 03/10/26 revealed an order for Tresiba Flextouch U-200 (insulin degludec) insulin pen; 200 unit/millimeter (ml) (3.0 mL); amount 20 units; subcutaneous once a day early morning 6:00 A.M. to 10:00 A.M. There was an order for insulin lispro pen 100 unit/ ml; amount per sliding scale.The care plan dated 03/11/26 revealed Resident #29 was at risk for complications related to diabetes mellitus with neuropathy. Interventions included to administer medications as physician order.Observation on 03/19/26 at 7:25 A.M. of medication administration revealed Registered Nurse (RN) #116 did not prime Tresiba pen prior to administering 20 units of Tresiba to Resident #29's left arm.Interview on 03/19/26 at 7:34 A.M. with RN #116 confirmed RN #116 did not prime Tresiba pen prior to administering to Resident #29.Review of the Quick Start Guide and Instructions of Use (IFU) for Tresiba(R) U-100 and U-200 FlexTouch(R) pen revealed prime the pen by turning the dose selector to select two units. Press and hold the dose button until the dose counter shows zero. Make sure a drop appears.Review of the facility's policy titled Subcutaneous Insulin dated 01/2026 revealed after attaching a new needle and expose cap, prime the insulin pen noting priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. Each click is one unit, dial the pen up to two unit, unless otherwise specified by manufacturer, point pen need toward the ceiling and gently tap the side, press the button on the bottom all the way in, you should see a drop of insulin come out, if you do not see the drop, repeat the priming process.

Based on medical record review, review of manufacturer instructions, observation, staff interview, and facility policy review, the facility failed to ensure residents were free of significant medication errors when Resident #29's insulin pen was not primed prior to administration. This affected one (#29) of three residents reviewed for medication administration. The facility identified there were four residents receiving insulin. The facility census was 42.Findings include:Review of Resident #29's medical record revealed an admission date of 03/10/26. Diagnoses included type II diabetes with diabetic neuropathy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition and received four insulin injections during the review period. Review Resident #29's physician orders dated 03/10/26 revealed an order for Tresiba Flextouch U-200 (insulin degludec) insulin pen; 200 unit/millimeter (ml) (3.0 mL); amount 20 units; subcutaneous once a day early morning 6:00 A.M. to 10:00 A.M. There was an order for insulin lispro pen 100 unit/ ml; amount per sliding scale.The care plan dated 03/11/26 revealed Resident #29 was at risk for complications related to diabetes mellitus with neuropathy. Interventions included to administer medications as physician order.Observation on 03/19/26 at 7:25 A.M. of medication administration revealed Registered Nurse (RN) #116 did not prime Tresiba pen prior to administering 20 units of Tresiba to Resident #29's left arm.Interview on 03/19/26 at 7:34 A.M. with RN #116 confirmed RN #116 did not prime Tresiba pen prior to administering to Resident #29.Review of the Quick Start Guide and Instructions of Use (IFU) for Tresiba(R) U-100 and U-200 FlexTouch(R) pen revealed prime the pen by turning the dose selector to select two units. Press and hold the dose button until the dose counter shows zero. Make sure a drop appears.Review of the facility's policy titled Subcutaneous Insulin dated 01/2026 revealed after attaching a new needle and expose cap, prime the insulin pen noting priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. Each click is one unit, dial the pen up to two unit, unless otherwise specified by manufacturer, point pen need toward the ceiling and gently tap the side, press the button on the bottom all the way in, you should see a drop of insulin come out, if you do not see the drop, repeat the priming process.

Based on observations, record reviews, policy review, and staff interviews, the facility failed to ensure staff utilized proper protective equipment (PPE) when providing direct care to Resident #8, failed to utilize a sterile technique for catheter care and store the catheter bag in a sanitary manner, and failed to perform proper hand hygiene after completing a blood glucose check for Resident #29. This affected two (Residents #8 and #29) of three residents reviewed for infection control. The facility census was 42.Findings include:1. Review of the medical record for Resident #8 revealed a re-entry date of 12/20/25. Diagnoses included obstructive reflux uropathy and retention of urine. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition. Resident #8 had an ileostomy (a surgically created opening (stoma) that brings the small intestine (ileum) to the abdominal surface, allowing waste to bypass the colon and drain into an external pouch) and had a suprapubic catheter (a tube inserted through a small, low-abdominal incision directly into the bladder to drain urine when the urethra cannot be used). Resident #8 was dependent on the staff for assistance with his ileostomy bag (stoma pouch) (a medical device worn over a surgically created opening (stoma) in the abdomen to collect waste). Review of the care plan for Resident #8 revealed a focus of enhanced barrier precautions (EBP) will be maintained per facility/organization policy related to suprapubic catheter in place. Interventions included follow any signage posted, maintain all precautions during every episode of care, and use appropriate personal protective equipment (PPE) with every episode of care. PPE will be provided by the facility at the entrance room. The care plan focus area was Resident #8 required indwelling catheter related to benign prostatic hyperplasia (BPH) with urinary retention and obstructive uropathy. Interventions included suprapubic catheter flush with 20 milliliters (ml) sterile water twice a day, avoid obstructions in the drainage, do not allow tubing or any part of the drainage system to touch the floor, keep catheter system a closed system as much as possible, and position bag below level of bladder and provide catheter care as ordered. Review of a physician order dated 12/04/24 for Resident #8 revealed change colostomy bag every Monday, Wednesday, Friday and as needed. An order dated 03/06/25 for EBP related to suprapubic catheter in place every shift. An order dated 12/24/25 for suprapubic catheter flush with 30 ml sterile water every morning once a day. Observation on 03/17/26 at 2:21 P.M. revealed Licensed Practical Nurse (LPN) #112 changed the ileostomy bag for Resident #8. LPN #112 was not wearing a gown during the ileostomy change. There was no signage for EBP on Resident #8's door and there was no PPE by the entrance to Resident #8's room. The PPE was found in Resident #8's bathroom. Interview on 03/17/26 at 3:58 P.M. with LPN #112 verified she did not wear a gown to change Resident #8's ileostomy bag. LPN #112 verified there was no EBP sign in Resident #8's room. LPN #112 verified the EBP drawers with gowns and gloves were in Resident #8's bathroom and it was not visible for staff or visitors to know Resident #8 was on EBP. Observation and interview on 03/18/26 at 8:18 A.M. revealed LPN #111 prepared a syringe for flushing the suprapubic catheter for Resident #8. LPN #111 did not use sterile technique to flush Resident #8's suprapubic catheter. Resident #8's catheter bag was hanging on the edge of his trash can and above his bladder. LPN #111 verified Resident #8's catheter bag was hanging on trash can at the time of the observation. Interview on 03/18/26 at 11:32 A.M. with LPN #111 stated a suprapubic flush was a clean procedure. LPN #111 verified she did not use the sterile technique to flush Resident #8's catheter. LPN #111 stated she did not have eye protection, did not wear sterile gloves or gown, did not use a sterile towel or sterile antiseptic to disconnect and flush the suprapubic catheter. LPN #111 stated she did not know where to look for facility resources to learn how to perform a procedure and stated the facility usually educated her on procedures. Interview on 03/18/26 at 2:19 P.M. with the Director of Nursing (DON) stated the suprapubic catheter changes are a clean procedure. The DON stated she thought the suprapubic flushes were a clean procedure but learned today it was sterile procedure. Review of the facility's policy titled Infection Control-Enhanced Barrier Precautions revised date of 01/07/26 revealed EBP will be followed for the illnesses specified by the Centers for Disease Control and Prevention (CDC). The facility policy titled Infection Control-Enhanced Barrier Precautions revised date of 01/07/26 revealed staff should wear a gown during high-contact resident care dressing, bathing/shower, transferring, providing hygiene, changing linens, changing, briefs or assisting with toileting. The facility policy titled Suprapubic Catheter Care dated 12/15/25 revealed care of an established suprapubic catheter site included daily cleaning. A nurse specially trained in sterile technique and suprapubic catheter care can perform either of these procedures. One who was specially trained in sterile technique and suprapubic catheter replacement can replace a suprapubic catheter if needed. 2. Observation on 03/19/26 at 7:25 A.M. revealed Registered Nurse (RN) #116 performed a blood glucose check on Resident #29. Then, RN #116 removed her gloves, gathered supplies, left Resident #29's room and did not perform hand hygiene. RN #116 placed the used glucometer on the top of the medication cart and used the computer and then obtained Resident #29's insulin pen from cart without performing hand hygiene. Interview on 03/19/26 at 7:34 A.M. with RN #116 confirmed she did not perform hand hygiene after blood sugar check. Review of the facility's policy titled Hand Hygiene, revised 09/15/25, revealed hand hygiene should be performed before direct contact, putting on gloves, or inserting an invasive device, and after removing gloves. The World Health Organization (WHO) recommends using either an alcohol-based hand rub soap and water preparing or handling medications. Review of the facility's policy titled, Glucometer Cleaning, revised 01/07/26 revealed throughout the procedure, perform appropriate hand hygiene, perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other persons.

Based on record reviews, review of facility policy, and staff interviews, the facility failed to follow an antibiotic stewardship program to monitor antibiotic use for the residents. This affected three (#19, #23, and #25) of three residents reviewed for antibiotic stewardship. The facility census was 42.Findings include:1. Review of the medical record for Resident #19 revealed a re-entry date of 01/22/25 with diagnoses included hydrocephalus and presence of cerebrospinal fluid drainage device. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had no cognitive impairment. Review of the care plan for Resident #19 revealed a focus of on prophylactic antibiotics related to history of urinary tract infections. Review of a physician order dated 11/02/24 revealed an order for Macrobid (antibiotic) capsule 100 milligrams (mg) oral once a day. Review of the pharmacy recommendations dated 12/02/25 revealed Resident #19 had received Macrobid 100 mg every day since 11/02/24 for prophylaxis. Please evaluate continued antibiotic prophylaxis beyond six months. The physician response revealed Resident #19's Macrobid was managed by urologist for chronic suppressive therapy. Review of the pharmacy recommendations dated 03/04/26 revealed Resident #19 has been on Macrobid 100 mg oral daily prophylactically since 11/02/24. Please consider discontinuation. The physician response revealed urology follows, no change advised. Interview on 03/18/26 at 11:53 A.M. with the Director of Nursing (DON) stated she was unable to locate any urology notes and spoke to Resident #19 and spouse who stated Resident #19 had not seen a urologist in at least two years. The DON stated per Resident #19's spouse, Resident #19 had several urinary tract infections years ago and her primary care physician at the time started her on Macrobid. At 12:12 P.M., the DON stated Resident #19's last urinary tract infection was when she admitted to the facility in 09/2024. 2. Review of the medical for Resident #25 revealed an admission date of 01/12/26. Diagnoses included urinary tract infection (UTI). The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had severe cognitive impairment and required moderate staff assistance for toileting hygiene. Review of the care plan revealed Resident #25 required a suprapubic catheter related to obstructive and reflux uropathy with a diagnosis of benign prostatic hyperplasia (BPH) with lower UTI. Interventions included to avoid obstructions in the drainage, do not allow tubing or any pat of the drainage system to touch the floor, keep catheter system a closed system as much as possible, position bag below the level of bladder, and report signs/symptoms of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning pain, difficulty urinating, low back/flank pain, malaise, nauseas/vomiting, chills, fever, foul odor, concentrated urine, blood in urine). Review of Resident #25's progress notes dated 02/15/26 to 03/03/26 revealed suprapubic catheter was patent, and draining amber colored urine. Resident #25 had at least three falls within a week with some confusion. The Medication Administration Record (MAR) dated 03/2026 revealed an order dated 03/03/26 for urinalysis (UA) and culture and Sensitivity (C&S) which was collected on 03/05/26. Review of the urine final lab results dated 03/09/26 revealed greater than 100,000 colonies/milliliter (ml) coagulase negative for staphylococci, not saprophyticus, 10,000 to 50,000 colonies/ml candida albicans, and 10,000 to 50,000 colonies ml corynebacterium. The physician order dated 03/10/26 to 03/17/26 revealed an order for Macrobid (antibiotic) capsule 100 milligrams (mg) give one tablet two times a day for seven days for UTI. Review of the Infection Tracker with McGeer's Criteria Version with an event date 03/10/26 and completion date 03/18/26 revealed no criteria was checked for Resident #14, indicating the resident did not meet the McGeer's criteria. Review of Resident #25's MAR revealed his suprapubic catheter was changed on 03/13/26. Interview on 03/18/26 at 11:53 A.M. with the DON who stated there were no urology notes for Resident #25, so she called and spoke with Resident #25's daughter who stated Resident #14 had not been to a urologist since probably 2024. The DON stated Resident #25's suprapubic catheter was changed in the facility. At 2:19 P.M., the DON stated McGeer's criteria number two stated if the current catheter had been changed greater than 14 days, than Resident #14 did not meet McGeer's criteria for an antibiotic according to the form completed. 3. Review of the medical record for Resident #23 revealed an admission date of 01/13/26. Diagnoses included obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms with obstruction and retention, overactive bladder, hematuria, chronic indwelling catheter, and infection and inflammatory reaction due to an indwelling urethral catheter. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact, required substantial or maximal assistance from staff with toileting, had a catheter, and was currently receiving an antibiotic. Review of the hospital record dated 03/14/26 revealed a urinalysis showing amber cloudy urine with a specific gravity of 1.012 and a pH of 6.0. Results included protein negative, glucose negative, bilirubin negative, urobilinogen less than 2.0, blood large, nitrite negative, leukocyte esterase large, white blood cells greater than 180, red blood cells greater than 180, and no bacteria seen. The hospital record also documented diagnoses of hematuria and acute urinary tract infection (UTI). Review of the after visit summary dated 03/14/26 revealed a new order for cephalexin (antibiotic) 500 milligrams (mg) one capsule by mouth four times a day for five days. The physician order dated 03/15/26 revealed cephalexin 500 mg four times a day for five days. Review of the medication administration record revealed Resident #23 received the initial dose on 03/15/26 at 9:00 A.M. and continued scheduled doses at 1:00 P.M. 5:00 P.M. and 9:00 P.M. The resident received all doses up until 03/19/26 at 9:00 A.M. when the order was discontinued. Review of the infection report dated 03/19/26 revealed Resident #23 had a documented diagnosis of a UTI identified as a health care associated infection. The resident did not exhibit any of the required clinical signs for a UTI including fever or hypotension, acute mental status change with leukocytosis, new suprapubic or flank pain, or purulent drainage or genital tenderness. Documentation showed the resident had bloody urine in the emergency room and the hospital ordered an antibiotic that was not necessary. Interview on 03/19/26 at 8:54 A.M. with the Director of Nursing (DON) confirmed the hospital urinalysis from 03/14/26 indicated the resident did not have a UTI and that the antibiotic ordered at hospital discharge was unnecessary. The DON reported she had not reviewed the hospital record and typically continues hospital ordered antibiotics without confirming if they were appropriately ordered. At 9:55 A.M., the DON revealed the physician was notified and the antibiotic was discontinued. Review of the facility policy titled Infection Definitions: Antibiotic Stewardship revised date of 01/07/26 revealed antibiotic treatment will only be considered if the suspected infection meets the McGeer (standardized surveillance definitions used to identify infections in long-term care facilities, such as nursing homes) definitions of and the pathology is strongly suggesting that an infection is of a bacterial nature. Urinary tract infections in a resident with a catheter at least one of the following sub criteria fever, rigors or new onset hypotension, with no alternate site of infection, either acute change in mental status or acute functional decline, with no literate site of infection, new onset suprapubic pain or flank pain or tenderness, purulent drainage from around the catheter or acute pain, swelling or tenderness of the testes, epididymis or prostate and must have urinary catheter specimen culture with at least 100,000 colony

Based on observation and staff interview, the facility failed to ensure trash and recycling was properly contained in the dumpsters. This had the potential to affect all 42 residents residing in the facility.Findings include:Observation of the dumpster area on 03/16/26 at 1:42 P.M. and 2:40 P.M. revealed multiple unbroken cardboard boxes scattered around the air conditioning units. Approximately 20 wet boxes that were not broken down were sitting on the ground next to the dumpster area. Wind had spread some of the boxes across the parking lot, and several were positioned against the chain link fence in the parking lot area. Trash had also accumulated near the air conditioning units on the opposite side of the stairs from the dumpsters. The trash included latex gloves and multiple pieces of unknown debris.Interview on 03/16/26 at 2:40 P.M. with [NAME] #155, confirmed the observations of unbroken cardboard boxes and trash accumulation in the dumpster area.Interview on 03/17/26 at 2:51 P.M. with the Administrator stated the facility did not have a recycling dumpster at this time. He stated staff had been placing boxes on the ground outside the dumpster area. He stated some trash near the air conditioning units was blown in from the community, staff were responsible for picking up any debris that blew up to the building.

Based on observations, staff interview, and facility policy review, the facility failed to follow proper handwashing and glove use during lunch meal service. This had the potential to affect all 45 residents in the facility who receive food from the kitchen. The facility did not have any residents with a physician ordered nothing by mouth (NPO) diet. Findings include: Observation of lunch meal service on 04/17/24 from 11:34 A.M. to 11:55 A.M. revealed Cook #273 completed food temperatures. After obtaining food temperatures, with bare hands, Cook #273 lifted the metal lid that was covering the zucchini casserole dish on the steam table. Cook #273 donned clean gloves. The cook did not wash her hands with soap and water before donning the clean gloves. At 11:43 A.M., Cook #273 unwrapped the tin foil from a baked sweet potato with gloved hands, then used her fingers to open up the sweet potato. Next, Cook #273 was observed touching the peas while plating them to keep them on the plate with the same gloves on. At 11:47 A.M., Cook #273 was observed completing the same tasks, unwrapping the tin foil, using same gloved fingers to open up the sweet potato, and then touching the peas to keep them on the plate while wearing the same gloves. At 11:48 A.M., Cook #273 was observed handling paper meal tickets with the same gloves on and then touched peas while plating them again with the same gloves on. At 11:52 A.M., Cook #273 removed her gloves, threw them in the trash can, and donned a new clean pair of gloves. The cook did not wash her hands with soap and water after removing the gloves and before donning the new clean gloves. At 11:54 A.M., Cook #273 was observed touching a towel that was hanging over the handle of the steamer with gloves on, then, handled a resident's cheeseburger to place on plate with the same gloves on. Interview on 04/17/24 at 4:27 P.M. with Director of Dietary Services (DDS) #207 and Dietary Supervisor (DS) #249 confirmed Cook #273 did not follow appropriate hand hygiene while completing lunch meal service. DDS #207 stated, I saw that too and I tried to intervene when I saw it. DDS #207 stated Cook #273 should have washed her hands before donning clean gloves and after she removed gloves. Also, DDS #207 stated Cook #273 should not have touched any food items directly, even with gloves on. Review of the facility's undated policy titled Disposable Gloves revealed disposable gloves shall be used for only one task and shall be discarded when damaged or soiled or when interruptions occur in operation. Hand washing must occur prior to putting on gloves and whenever gloves are changed or removed. Gloved hands are considered a food contact surface that can become contaminated or soiled. Disposable gloves need to be changed between tasks and as often as hands need to be washed.

Based on observations, review of menu, review of resident diets, review of recipes, staff interviews, and facility policy review, the facility failed to ensure pureed foods and mechanical soft foods were prepared in an appropriate consistency. This affect three residents (#14, 15, and 22) on a pureed diet and two residents (Residents #30 and #32) on a mechanical soft diet. The facility census was 45. Findings include: 1. Review of the menu for the lunch meal on 04/17/24 revealed the planned meal was zucchini casserole or barbecue ribs with baked sweet potatoes, peas, and assorted cookies or sugar-free cookies. Review of the list of residents with current diet orders revealed Residents #14, #15, and #22 had an ordered pureed diet. Review of the pureed casserole recipe, undated, revealed the directions stated to measure freshly cooked/baked casserole portions drained of liquid. Puree well. Add liquid gradually to achieve appropriate consistency. Be sure it is pureed until completely smooth. Observations completed on 04/17/24 from 10:51 A.M. to 11:22 A.M. of pureed zucchini casserole preparation with Cook #273 revealed the regular food processor used for pureed foods was broken and Cook #273 would use a small blender to complete the task. Cook #273 added four scoops of zucchini casserole to a plastic container. There was a pitcher of chicken broth next to the blender. Cook #273 added two scoops of the casserole to the blender with four tablespoons of chicken broth to the blender and began blending. When Cook #273 felt the mixture was properly blended, she removed it from the blender with a clean spatula and placed into another container. At 11:05 A.M., an additional scoop of casserole with two tablespoons of broth were added to the blender. Once, blended, it was placed into the container. At 11:07 A.M., an additional scoop of casserole with two tablespoons of broth were added to the blender. Once blended, it was removed from the blender and placed into the container. The container was placed into the microwave to bring the pureed casserole up to an appropriate temperature. Once the casserole reached the needed temperature, Cook #273 used a clean spatula to pour the pureed casserole into a metal serving container to place into the steamer to keep warm until it was time to be plated. Interview on 04/17/24 at 11:22 A.M. with Cook #273, prior to placing the metal container of pureed casserole into the steamer, confirmed she felt the pureed casserole was an appropriate texture and was prepared to serve it to the residents for lunch meal. This surveyor requested to taste the pureed casserole. Upon observing the mixture in the metal container, there were visible chunks of zucchini and chicken seen. This surveyor tasted a spoonful of the mixture and a small chunk of zucchini was felt in the bite and visible on tongue. Cook #273 confirmed there was a chunk of zucchini. Cook #273 began using a clean spoon to mix up the pureed casserole and stated, I can see it, it is still chunky. I don't need to taste it. At that time, Cook #273 removed the metal container and confirmed the pureed casserole was not an appropriate texture to serve to residents and would need to be pureed again. 2. Review of the menu for the lunch meal on 04/17/24 revealed the planned meal was zucchini casserole or barbecue ribs with baked sweet potatoes, peas, and assorted cookies or sugar-free cookies. Review of the list of residents with current diet orders revealed Residents #30 and #32 had mechanically soft diets ordered. Review of the dietary spreadsheet revealed for a mechanically soft diet, residents should receive six ounces of zucchini casserole. Review of the chicken zucchini casserole recipe revealed ingredients included one six ounce package chicken stuffing mix, a half cup of melted butter, four medium diced zucchinis, three cooked and shredded boneless skinless chicken breasts, one can of cream of chicken soup, one half of a diced onion, and one half cup of sour cream. Observation on 04/17/24 at 12:55 P.M. of Resident #30 in the second floor dining room. Stated tested Nurse Aide (STNA) #214 was present sitting next to the resident. Observed the resident to have plate in front of her with zucchini casserole on it. Resident #30 took a bite of the casserole. The resident began coughing after swallowing the bite of the casserole. STNA #214 asked the resident if she wanted something easier to eat. Interview on 04/17/24 at 1:00 P.M. with STNA #214 confirmed there were visible chunks of zucchini in the casserole dish. Interview via telephone on 04/17/24 at 2:57 P.M. with Speech Language Pathologist (SLP) #400 revealed she was not familiar with the recipe for zucchini casserole. SLP #400 stated any meats or other items in the casserole should be chopped finely in order to be considered mechanical soft. Interview on 04/17/24 at 4:27 P.M. with Director of Dietary Services (DDS) #207 and Dietary Supervisor (DS) #249 confirmed a mechanical soft zucchini casserole had not been prepared for the lunch meal. DDS #207 and DS #249 confirmed the zucchini casserole served to Residents #30 and #32 had chunks of chicken and zucchini in it and was not at an appropriate texture for residents who had a mechanical soft diet order. Review of the facility's undated policy titled Mechanically Altered Diets, revealed mechanically altered diets shall be prepared and served as prescribed by the physician. Pureed: all residents with a physician's order for a pureed diet shall receive pureed, homogenous, and cohesive foods. Food shall be pudding-like. No coarse textures, raw fruits or vegetables, nuts, etc. are allowed. Any foods that require bolus formation, controlled manipulation, or mastication (chewing) are excluded.

Based on observations, record review, staff interview, review of the facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to wear appropriate personal protective equipment and perform proper hand hygiene during care of a resident under transmission-based precautions. This had the potential to affect 27 residents (#1, #6, #8, #9, #16, #17, #18, #19, #20, #23, #25, #28, #30, #31, #33, #34, #90, #92, #93, #94, #95, #96, #240, #241, #242, #243, and #244) receiving care on the second-floor rehab unit and healthcare two. The facility census was 45. Findings include: Review of medical chart for Resident #91 revealed an admitted [DATE]. Diagnoses included enterocolitis due to Clostridioides difficile (C. diff). Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #91 had intact cognition. Resident #91 had bladder and bowel incontinence, and enterocolitis related to C. diff. Resident # 91 required moderate to complete assistance from staff for activities of daily living (ADLs) including toileting, dressing, and transferring. Review of laboratory results finalized on 03/29/24 revealed positive finding of C. diff for Resident #91. Review of Resident #91's progress note dated 03/29/24 revealed Resident #91 was positive for C. diff and that contact precautions were started and all departments were notified. Review of Resident #91's care plan dated 04/16/24 revealed diagnoses of C. diff with risk of complications related to C. diff, bowel incontinence related to loose stools, urinary incontinence related to physical weakness, potential for functional status deficit related to physical deconditioning, and risk for falls. Interventions included following the principles of infection control, placing resident in private room on contact precautions, assessing quality and consistency of diarrhea, avoiding unnecessary diagnostic or therapeutic procedures and devices, following the facility's policies and procedures when cleaning and disinfecting room, equipment and linens, using the least restrictive isolation, practicing good handwashing, having adequate personal protective equipment (PPE), and providing incontinent care. Review of Resident #91's progress notes 03/28/24 to 4/17/24 revealed the resident had loose stools indicating continued active C. diff on 03/28/24, 04/01/24, 04/02/24, 04/08/24, 04/10/24, 04/11/24, 04/13/24, 04/14/24, and 4/15/24. Observation on 04/17/24 at 9:20 A.M. revealed State tested Nursing Aide (STNA) #214 grabbed gloves and entered the room of Resident #91, without performing hand hygiene or donning a gown. STNA #214 exited the room of Resident #91 at 9:35 A.M., without personal protective equipment (PPE) on and placed bags with dirty linens and trash into their designated containers located outside of resident's room. STNA #214 performed hand hygiene using alcohol-based hand sanitizer after dispensing of bags. Interview on 04/17/24 at 9:35 A.M. with STNA #214 confirmed STNA #214 provided care to Resident #91 with only gloves being worn in room. STNA #214 confirmed Resident #91 was on Contact Precautions and signage was posted on door. STNA #214 stated they thought only gloves were needed for care but was not sure and would need to double check. STNA #214 stated gloves, gown, mask, hair covers, and booties should be worn in a room requiring contact precautions. STNA #214 confirmed they were told to wash hands using soap and water but used hand sanitizer instead. Interview on 04/17/24 at 12:25 P.M. with Director of Nursing (DON) confirmed Resident #91 was on Contact Precautions due to C. diff . Interview on 04/17/24 at 12:26 P.M. with Licensed Practical Nurse (LPN) #279 confirmed Resident #91 was on contact precautions until testing comes back negative for C. diff . LPN #279 confirmed the resident has been on Contact Precautions the entire stay. LPN #279 stated they did not remember when their last training on transmission-based precautions was and identified the needed personal protective equipment for care of a resident in contact precautions is gown, gloves and face shield. Subsequent interview on 04/18/24 at 12:04 PM with the DON confirmed the expected personal protective equipment needed to provide care for a resident on contact precautions would be gown, and gloves and the expected order to donning PPE would be gown, then gloves. The DON confirmed the expectation would be for staff to use soap and water for hand hygiene after removing PPE. Review of the staffing assignments for 04/17/24 revealed STNA #214 was assigned to provide care and services to Residents #1, #6, #8, #9, #16, #17, #18, #19, #20, #23, #25, #28, #30, #31, #33, #34, #90, #91, #92, #93, #94, #95, #96, #240, #241, #242, #243, and #244. Review of facility's Infection Control- Contact Precautions policy, revised on 09/13/22, revealed residents with Clostridioides difficile (C. diff), formerly known as Clostridium difficile, should be in contact precautions for the duration of their illness. Contact precautions include using a private room or cohorting with a resident actively infected with the same organism, using gloves and gown when providing care, and completing hand hygiene prior to putting on gloves and after taking them off. Review of the CDC recommended steps to prevent the spread of C. diff in healthcare facilities, found at https://www.cdc.gov/cdiff/clinicians/faq.html#prevent included the use of gowns and gloves when providing care and the use of isolation with contact precautions.

Based on staff interview and record review, the facility failed to provide a resident her physician-ordered nutritional supplements routinely. This affected one resident (#30) of four residents reviewed for nutrition. The facility census was 45. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included dysphagia, chronic obstructive pulmonary disease, Alzheimer's disease, and protein-calorie malnutrition. Review of Resident #30's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. The resident was not on any therapeutic diets. Review of Resident #30's physician order dated 02/15/24 revealed fortified ice cream nutritional supplement was to be given with lunch and dinner twice a day. Review of Resident #30's plan of care revised 03/26/24 revealed she was at nutrition and dehydration risk due to diagnoses, need of nutritional supplement, and mechanically altered diet. Interventions included offering the supplement the doctor ordered. Review of Resident #30's Medication Administration Record (MAR) for March 2024 revealed the fortified ice cream nutritional supplement was not administered 13 times due to the item being unavailable on the following days: once on 03/02/24, 03/03/24, 03/08/24, 03/13/24, 03/21/24, 03/22/24, 03/25/24, 03/30/24, and 03/31/24 and twice on 03/16/24 and 03/27/24. The MAR from 04/01/24 to 04/15/24 revealed the fortified ice cream was not administered five times due to the item being unavailable on the following days: once on 04/09/24, 04/13/24, and 04/14/24, and twice on 04/05/24. Review of Resident #30's progress note dated 03/01/24 to 04/15/24 revealed no notes related to the missing nutritional supplements. Interview on 04/16/24 at 3:32 P.M. with Diet Technician #301 verified Resident #30 had not been given her supplement as ordered. She reported the kitchen had run out of fortified ice cream nutritional supplement at times, but she was unsure how often. She reported when they ran out, the kitchen was substituting it with ice cream, yogurt, or pudding depending on diet texture. She reported the kitchen should have been notifying the nurse when doing this. Interview on 04/17/24 at 10:22 A.M. with Director of Nutrition Services #207 revealed the fortified ice cream nutritional supplement was missing from one to two deliveries a month because of availability. Director of Nutrition Services #207 verified they substituted with ice cream, pudding, or yogurt depending on the diet texture and notified the nurses. Interview on 04/17/24 at 2:37 P.M. with the Director of Nursing (DON) verified that in Resident #30's medical record, there was no way to identify if Resident #30 got a nutritional supplement substitute or did not get anything from the kitchen. She reported the nursing staff was documenting it as unavailable because the supplement was not there and they were not aware of the item being substituted. The DON reported the kitchen had not communicated they were doing substitutions.

Based on medical record review, resident and staff interview, and review of a facility policy, the facility failed to allow a resident to participate in a care planning conference. This affected one (#13) of two residents reviewed for care planning. The facility census was 40. Findings include: Review of Resident #34's medical record revealed and admitted [DATE] with diagnoses to include but not limited to hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was assessed with moderately impaired cognition and required extensive assistance with one staff member for most activities of daily living (ADLs). Review of Resident #34's profile page revealed the resident was his own responsible party and his daughter was his fourth emergency contact. Interview on 06/20/23 at 9:46 A.M. with Resident #13 stated a care conference was scheduled every six months to a year. Interview on 06/21/23 at 11:37 A.M. with Social Service Designee (SSD) #200 state she generally calls the first resident contact to schedule a care conference. SSD #200 stated she called the daughter to schedule a care conference, but the daughter wanted to discuss Resident #13 at the time of call instead of having a care conference. SSD #200 stated she did not follow up with the Resident #13 after speaking to his daughter and Resident #13 was not present during the care conference held over the phone. Review of the facility policy titled, Comprehensive Person-Centered Care Planning, dated 05/01/03 with a revision date of 09/13/22, revealed care planning must involve the resident and/or the representative and be developed by the interdisciplinary team including the physician.

Based on observation, medical record review, and resident and staff interview, the facility failed to provide routine bathing and grooming services for two (#12 and #33) of three residents revealed for activities of daily living. The facility census was 40. Findings include: 1. Review of medical record for Resident # 33 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, chronic respiratory failure, pulmonary fibrosis, and a history of malignant neoplasm of the prostate. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had severe cognitive impairment. Resident # 33 required extensive assistance for bed mobility, transfers, and toilet use, and Resident #33 was dependent on staff for bathing. Review of Resident #33's medical record revealed the resident showers days were scheduled for Monday and Thursday on the day shift. Review of Resident #33's bathing documentation for the past two months revealed Resident #33 was bathed on 05/12/23 and 06/09/23 by facility staff, and on 05/01/23, 05/12/23, 05/22/23, 05/25/23, 06/09/23, 06/14/23, and 06/19/23 by a hospice provider. The resident received nine showers in the past two months and not the scheduled 16 showers the resident was scheduled to receive. Interview with Resident #33 on 06/20/23 at 11:44 A.M. verified the resident did not always receive a shower twice a week as scheduled. Interview on 06/21/23 at 10:12 A.M. with State tested Nurse Aide (STNA) #237 stated most residents received a shower twice a week, and the staff who performed the shower completed a shower sheet and provide it to the nurse. STNA #237 stated the showers were divided between the day and evening shift, and it was on the STNA report sheet when each resident was to be showered. Interview with Registered Nurse (RN) #246 on 06/22/23 at 7:48 A.M. confirmed the facility staff should offer resident showers on their shower day, and if the resident received hospice services, the hospice staff would perform the shower if they were in the faciity on the shower day. RN #246 stated if hospice was not in the facility on the shower day, the facility staff should perform the shower. RN #246 stated there was a new hospice aide for the facility and did not have a schedule from the hospice provider to know what days the hospice aide would be in to visit and provide care to the Resident #33. RN #246 verified Resident #33 did not receive bathing services as scheduled. 47990 2. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses that included a cerebral infarction (stroke), depression, and glaucoma. Review of the most recent MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Further review revealed Resident #12 required extensive assistance of one staff member for grooming. Resident #12 had received hospice care while a resident of the facility since 03/15/22. Observation and interview on 06/20/23 at 11:04 A.M. with Resident #12 revealed noticeable facial hair on the [NAME] and upper lip area that was approximately an eighth of an inch long. Resident #12 stated the staff shave him when they are not too busy and he preferred to be clean shaven, and would absolutely agree to be shaved if offered. Observation and interview on 06/21/23 at 8:15 A.M. with Resident #12 revealed his facial hair was unchanged from the observation on 06/20/23. Resident #12 stated he had not been shaved and no one offered to shave him. Resident #12 stated he wished to be shaved. Interview on 06/21/23 at 10:12 A.M. with STNA #237 stated morning care on days that are not shower days would include cleansing the resident's face, underarms, back and peri-area, and further stated male residents are offered to be shaved on shower days, and shaving was documented on the shower sheets. Interview on 06/21/23 at 10:21 A.M. with STNA #255 stated she was not sure if facility staff or hospice staff was responsible for completing Resident #12's routine showers and grooming. Further interview with STNA #55 at 10:23 A.M. stated she checked with her unit manager and relayed that hospice was responsible for showering hospice residents, but if hospice did not complete the shower, then then facility would do it. STNA #255 was not sure what days hospice staff came into the facility or where the schedules for the hospice aides were kept. Observation on 06/21/23 at 10:26 A.M. revealed Resident #12 sitting in wheelchair in the third floor activity room. The activity room was filled with approximately fifteen other residents who were attending an activity. Resident #12 had facial hair unchanged from earlier observations. Interview on 06/21/23 at 10:28 A.M. with Activity Assistant (AA) #214 stated Resident #12 was a consistent attendant of the facility's activities, and verified Resident #12 looked scruffy with his facial hair. Interview on 06/21/23 at 10:31 A.M. with Registered Nurse (RN) #244 verified Resident #12 was not clean shaven and appeared scruffy. RN #244 stated a hospice staff member was coming to the facility that day. Observation and interview on 06/21/23 at 3:17 P.M. with Resident #12 revealed he remained unshaven. Interview on 06/22/23 at 7:39 A.M. with MDS Manager #246 revealed Resident #12 had a new hospice aide assigned to him from the hospice provider, but the facility has not yet received the hospice aide's schedule. MDS Manager #246 stated the facility staff should offer two showers a week in addition to what hospice staff provided. Interview on 06/22/23 at 8:26 A.M. with MDS Manager #246 revealed the facility had no record of shower sheets for the previous two months for Resident #12 where bathing and grooming tasks provided by the facility would be recorded.

Based on observation, medical record review, resident and staff interview, and review of facility policies, the facility failed to securely store medications for one (#16) of 40 residents observed. The facility census was 40. Findings include: Review of Resident #16's medical record revealed the resident was admitted on [DATE] with diagnoses that include hemiplegia and hemiparesis, cerebral infarction affecting left non-dominant side, anxiety disorder, peripheral neuropathy, rheumatoid arthritis, and weakness. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The resident was assessed as independent with eating. Review of Resident #16's physician orders revealed the resident was ordered the pain medication Tylenol 500 milligrams (mg) three times daily; cranberry supplement 425 mg daily, the antidepressant duloxetine 60 mg daily, the nerve pain medication gabapentin 300 mg three times daily, the proton pump inhibitor Protonix 40 mg daily, the supplement potassium chloride 10 milliequivalents (mEq) daily, and the antidepressant Zoloft 75 mg daily. Interview with State tested Nurse Aide #236 on 06/20/23 at 9:02 A.M. verified there was a medication cup with two pills in the cup on the book shelf in Resident #16's room and the medications should not be left with the resident. Observation and interview with Resident #16 on 06/20/23 at 10:42 A.M. revealed the resident was sitting in her wheelchair with her over the bed table in front of her. Resident #16 was visualized to have a medication cup with two pills sitting on the bookshelf at the end of her over the bed table. Interview with Resident #16 at that time stated the pills were Tylenol and the nurse yesterday left the medication there for her to take and she had forgotten to take them. Resident #16 stated the nurse probably did not know she did not take the pills and verified it was on 06/19/23 at 12:00 P.M. when the nurse left the medication for her to take. Resident #16 verified the pills had sat in her room unsecured since 06/19/23 at 12:00 P.M. Observation of Resident #16 on 06/22/23 at 9:04 A.M. revealed the resident was sitting with the bedside table across her and she was observed to be spooning a yellow substance out of a medication cup and eating the substance. Interview with Resident #16 on 06/22/23 at 9:04 A.M., at the time of the observation, stated she was taking her 10 morning pills, and stated she told the nurse she would take the medication but the nurse did not stay in the room with her while she took the medication. Observation of the hallway on 06/22/23 at 9:04 A.M. revealed there was no nurse in the hallway or at the medication cart which was noted to be past Resident #16's doorway. Interview on 06/22/23 at 9:07 A.M. with Licensed Practical Nurse (LPN) #257 confirmed he gave Resident #16 her medications and she liked to take them at her own pace so he left the medications with the resident to consume on her own. LPN #257 stated he came back to the room to provide the medication to the roommate and was monitoring Resident #16 as she finished her medications. LPN #257 verified he did not stay and observe Resident #16 take her morning medications. Review of the policy titled, Medication Storage, last revised on 09/13/22, revealed the nursing home shall assure safe storage of medications. All prescription medications must be stored under proper temperature controls and secured against unauthorized access. All prescription medicines and drugs, except those that are authorized to be kept at the bedside for self-administration in accordance with residents rights, and shall be kept in locked storage areas and separate from materials that may contaminate the medicines and drugs such as poisonous substances. Review of the policy titled, Medication Administration Orals, dated 2007, revealed to administer oral medications in an organized, accurate and safe manner staff should administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration. Use caution with residents who have difficulty with swallowing.

Based on observation, medical record review, and resident and staff interview, the facility failed to provide a resident with a properly fitted bed to maintain basic comfort. This affected one (#34) of one residents reviewed for beds. The facility census was 40. Findings include: Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses including cutaneous abscess of the right lower limb, cellulitis of the right lower limb, diabetes mellitus, and gout. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was assessed with moderately impaired cognition and required extensive assistance with two staff for most activities of daily living (ADLs) with the exception of transfers which required total dependence. Review of the admission height dated 05/06/23 at 11:38 P.M. revealed Resident #34 measured six feet four inches tall. Observation and interview on 06/20/23 at 9:39 A.M. revealed Resident #34 was lying in bed with his feet pressed against the footboard. Resident #34 confirmed he was six feet four inches tall and needed to be pulled up at least 15 times a day. Interview on 06/20/23 at 9:41 A.M. with Licensed Practical Nurse (LPN) #400 verified Resident #34's feet were against the footboard and a longer bed would be more comfortable. Interview on 06/20/23 at 10:10 A.M. with the Administrator stated he would get Resident #34 another bed because he was a big guy.

Based on record review, interview and policy review, the faciltiy failed to notify the physician of a missed anti-coagulant medication. This affected one (Resident #9) of four sampled residents. The facility census was 45. Findings include: Review of the medical record for Resident #9 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 05/16/19 revealed Resident #9 was on anticoagulant therapy related to Factor V Leiden and a history of [MEDICAL CONDITION]. Interventions included lab tests as ordered, medications administered as ordered and skin inspections [MEDICATION NAME] 30 milligrams (mg)/0.3 milliliters (ml) was ordered to be administered twice a day in the morning and the evening from 12/02/19 through 12/13/19 with a hold on 12/06/19 only, for a procedure. Review of medication administration records (MAR) for (MONTH) 2019 revealed Resident #9 did not receive the [MEDICATION NAME] was not administered on 12/04/19 in either the morning or the evening and was not administered 12/05/19 in the morning. The reason given for the missed administration was medication unavailable. On 12/06/19 at 2:36 [NAME]M. a progress note reported the [MEDICATION NAME] injection had arrived and was administered immediately. This administration was not documented on the SR's MAR but only in the nursing progress notes. Review of the nursing progress notes dated 12/04/19 through 12/06/19, revealed no documentation that Resident #9 had missed both doses of [MEDICATION NAME] on 12/04/19, nor that the physician was notified of those missed doses. A progress note was dated 12/06/19 at 9:37 [NAME]M. that MD #107 was notified that the P.M. dose of [MEDICATION NAME] was not administered on 12/04/19. A phone interview with MD #106 on 12/23/19 at 3:00 P.M. confirmed he had not been notified that Resident #9 had missed both her [MEDICATION NAME] injections on 12/04/19. MD #105 stated he had been notified by the facility on 12/05/19 that Resident #9 had missed one dose of [MEDICATION NAME]. MD #105 also stated he was not informed that the SP received [MEDICATION NAME] at 2:30 [NAME]M. on 12/06/19, the day of her procedure. MD #105 stated he would expect to be notified after one missed dose of a medication. He also stated he would not have given the [MEDICATION NAME] on 12/06/19. Review of the facility's policy titled Notification of Change, dated (MONTH) (YEAR), revealed the physician should be notified if there is a need to alter treatments and notification of changes would be completed and documented in the medical record. This deficiency substantiates Complaint Number OH 841.

Based on medical record review, observation, review of hospital reports, review of facility policy, resident and staff interviews, the facility failed to ensure a resident was free of significant medication errors. This resulted in actual harm when the resident was administered two narcotic medications, in error, resulting in an altered level of consciousness, hospitalization , with needing the administration of [MEDICATION NAME] (to treat an overdose). This affected one (#19) of three residents reviewed for unplanned hospitalization s. The facility census was 32. Findings included: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately impaired cognitively. Continued review of the medical record for Resident #19 revealed the resident had an order for [REDACTED].#19 in (MONTH) through 06/12/18. Review of Resident #19's nursing progress note dated 06/05/18 at 2:17 P.M., revealed a telephone message was left for the resident's daughter to call the facility. The message also revealed the daughter was informed the physician was in the facility, assessed the resident, and new orders were received. At 2:53 P.M., Resident #19's daughter called the facility and was updated on the condition change, and physician orders. The note revealed the daughter wanted to speak with other family members prior to making a determination whether to send the resident to the hospital or not. At 3:16 P.M., the daughter called back and revealed the family wanted the resident to be transported to the Emergency Department (ED). Review of the hospital visit and discharge summary revealed Resident #19 arrived at the hospital, via ambulance, on 06/05/18 at 3:33 P.M. The resident was given two doses of [MEDICATION NAME] per intravenous (IV) route. Resident #19 responded positively to the treatment, and regained normal mental status. The resident was admitted to for a 24 hour observation. Review of the physician's clinical summary upon discharge, revealed the primary [DIAGNOSES REDACTED]. The course of treatment included, suspected metabolic [MEDICAL CONDITION] (abnormal brain function) with clear response to [MEDICATION NAME]. Resident #19's drug screen was positive for Benzodiazepines (hypnotic), [MEDICATION NAME] (narcotic), and opiates (narcotic). The summary further revealed it was suspected the resident was given the medications accidentally at the nursing home. Observation and interview with Resident #19 on 06/12/18 at 10:45 A.M., confirmed she had recently had a hospital stay due to being given the wrong medication by nursing staff at the facility. Interview with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) on 06/12/18 at 10:54 A.M., revealed when the facility received notification from the hospital that Resident #19 had positive drug screen, and an investigation was immediately initiated. Following a thorough investigation by the facility it was determined a medication administration error had occurred. Resident #19 had been given her roommates ordered medications during the morning medication pass on 06/05/18, at approximately 10:41 A.M. Included in the medications administered in error were [MEDICATION NAME] (Schedule IV Benzodiazepine) 0.5 milligram (mg), and [MEDICATION NAME] (schedule II narcotic) 5 mg. The wrong medications were administered by a temporary agency Licensed Practical Nurse (LPN) #108. The LNHA confirmed the error was not identified by the nursing staff at the time of the incident. The LNHA further revealed LPN #108, and another temporary agency Registered Nurse (RN) #106, who inaccurately documented the medications as given, were both banned from the facility, and a complaint report was submitted to the Ohio Board of Nursing. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated as revised 01/01/13, revealed procedures to prevent medication administration errors (Procedure 4.1.1) revealed, Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Additionally, procedure 5.1 revealed during medication administration the staff should take all measures required and applicable including, Identify the resident per facility policy. This deficiency substantiates complaint number OH 459.

Based on medical record reviews and staff interviews, the facility failed to ensure an underweight resident's (#58) significant weight loss was monitored adequately. This resulted in harm when Resident #58 suffered a 21 pound weight loss over a three week period. Additionally, the facility failed to monitor meal intakes for a resident (#53) of three residents reviewed for weight loss. The facility census was 26. Findings include: 1. Review of Resident #58's closed medical record revealed an admission date of [DATE]. Resident #58 was discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the current nutrition care plan revealed Resident #58 had nutrition and dehydration risk due to being a status [REDACTED]. The care plan further revealed to monitor Resident #58's percent of meals consumed and provide nutritional supplement per orders. Review of the Comprehensive Nutritional assessment dated [DATE] revealed Resident #58 weighed 109 pounds and was underweight. The assessment further revealed the ideal body weight for the resident would be 135 pounds. The assessment revealed the resident's consumed food intakes were between 51%-75%. The dietician recommended to add 30 milliliters (mL) of Prostat two times a day and four ounces (oz) House Supplement every day to promote non-significant weight gain towards healthy body mass index as well as wound healing. The assessment further revealed to monitor weekly weights and monitor overall nutritional status per protocol and as needed. Review of the dietary note dated 02/08/17 revealed Resident #58 weight was 98.5 pounds, which indicated a loss of 10.5 pounds since admission. The dietary note further revealed the resident had fair meal intakes and was receiving Prostat Max 30 mL two times a day and four oz of House Supplement daily. The Dietician recommended to increase the House Supplement to four times a day to promote weight gain. Review of Resident #58's recorded meal intakes from 02/01/17 until 02/21/17 failed to reveal they were adequately monitoring meal intakes. There were 14 out of 21 times meal intakes were recorded for breakfast. There were 12 out of 21 times meal intakes were recorded for lunch and there were 10 out of 21 times meal intakes were recorded for dinner. Review of Resident #58's weight on 02/17/17 revealed the resident weighed 88 pounds, which indicated a 21 pound significant weight loss since admission. There was no evidence in the medical record Resident #58 was seen by the Dietician or physician since 02/08/17. Interview on 04/06/17 at 4:15 P.M. with the Director of Nursing (DON) confirmed there was no further follow up by the dietician or physician since 02/08/17 for Resident #58 who continued to lose weight. The DON further confirmed Resident #58's meal intakes were not consistently monitored. 2. Review of the closed medical record revealed Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of Resident #53's nutrition care plan revealed the resident was a nutrition and dehydration risk related to the resident's [DIAGNOSES REDACTED]. Review of the 10/28/16 through 11/16/16 meal intake records for Resident #53 revealed the resident's breakfast intake was only documented eight of 20 days, lunch intake was only documented eight of 20 days, and dinner percentage meal intake was only documented nine of 20 days during Resident #53's stay. During an interview on 04/06/17 at 4:15 P.M., the DON confirmed the missing documentation of Resident #53's meals.

Based on medical record review, staff and physician interview, and review of facility policy, the facility failed to provide care and services for a resident with avoidable pressure ulcer(s). This resulted in actual harm when resident (#44's) stage two pressure ulcer was not treated per physician orders and progressed to a stage three pressure ulcer. This affected one (#44) of three residents reviewed for pressure ulcers. The facility identified three residents who were currently being treated for [REDACTED]. Findings include: Review of Resident #44's closed medical record revealed an admission date of [DATE] and was discharged from the facility on 10/24/15 to another facility. [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE], revealed the resident had moderate cognition impairment and required extensive assistance with two person physical assistance for bed mobility and transferring. The MDS also revealed the resident's skin was intact, was at risk for developing pressure ulcer, and had a pressure reducing device for her chair and bed. Review of the skin risk assessment dated [DATE], revealed the resident was at risk for skin breakdown. Review of the resident's progress notes revealed the resident was identified on 09/12/15 with a new open area to her coccyx and new orders were implemented. There were no measurements of the wound noted in the medical record. Review of the physician orders on 09/12/15, revealed a [MEDICATION NAME] Skin Protectant (ointment) was ordered to be administered topically every shift for a total of three times per day. Review of the resident's pressure ulcer plan of care dated 09/23/15, revealed the resident had a potential for pressure ulcer development from urinary and bowel incontinence, needing staff assistance to toilet, bed mobility deficit, increase risk for pressure ulcer formation from wearing a clam shell back brace, and history of a urinary tract infection. The goal was for the resident to have intact skin, free of redness, blisters or discoloration through the review date of 12/23/15. The approaches with a start date of 09/23/15, included to document and report to the charge nurse the changes in the skin status, follow orders for the prevention and treatment of [REDACTED]. There was no evidence the plan of care was revised after 09/23/15. Further review of the resident's progress notes revealed the resident had a small reddened area to the buttocks on 09/18/15, 09/19/15, 09/20/15, 09/21/15, 09/23/15, 09/25/15, and 09/29/15. On 10/01/15, the note documented the nurse found two open areas on the resident's upper bilateral buttocks and the certified nurse practitioner classified the resident having two, stage two pressure ulcer's (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May present as an intact or open ruptured serum-filled blister). From 10/01/15, when the wounds were identified, through 10/13/15, there were no assessments including measurements on the stage two pressure ulcer and there were no new interventions. On 10/14/15, review of the Provider Wound Assessment and orders form dated 10/14/15, indicated there was a stage three pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss) on the coccyx. The measurements were 1.0 centimeter (cm.) long, 0.5 cm. wide, and 0.2 cm. in depth with 100 percent (%) slough present. The additional order was for Mesalt daily and cover with a abdominal (ABD) pad. There was no physician order for [REDACTED]. Review of the Provider Wound Assessment and orders dated 10/21/15, indicated the coccyx measured 1.8 cm. long, 0.5 cm. wide, and 0.2 cm. in depth and had 10% granulation and 90% slough present and to treat the wound with Mesalt daily with ABD pad. The resident was transferred to a long term care facility on 10/24/15. Interview with the Director of Nursing (DON) on 02/10/16 at 8:43 A.M., confirmed the Wound Physician recommended Mesalt on 10/14/15 and the order for the Mesalt was not ordered until 10/21/15. The Mesalt treatment was written on the 09/15 TAR and not the 10/15 and the medical record did not document the resident received Mesalt to her coccyx wound. The DON stated the Wound Physician does not write physician orders at the facility and just recommends and the facility writes the physician order in the electronic medication administration record. The DON confirmed there was no new interventions implemented since 09/23/15, including when the resident developed a stage two pressure ulcer to the coccyx and when the wound declined from a stage two to a stage three pressure ulcer. The DON confirmed the only measurements of the wounds were on 10/14/15 and 10/21/15 from the Wound Physician. The DON stated they would change the mattress to a alternating mattress when a wound becomes a stage three and confirmed the alternating mattress was not noted in the medical record or updated on the plan of care. Review of the facility's policy titled Prevention, Detection and treatment of [REDACTED]. Interventions were for residents who were dependent on staff to reposition at least every two hours and more frequent positioning may be warranted for individuals who are at higher risk for pressure ulcer development of who show evidence that repositioning at two hour intervals was inadequate. The resident, family member and/or responsible party will be invited to participate in the care planning process. If a resident refuses treatment and/or interventions the resident will be offered counseling on alternative options and/or consequences. The assessment of the pressure ulcer should include the type of ulcer, the ulcer's stage, ulcer's characteristics, progress toward healing and potential complications, presence of infection, presence of treatment of [REDACTED]. With each dressing change or at least weekly an evaluation of the pressure ulcer would be documented. The documentation would include location, staging and date observed and measurements. Unavoidable press ulcer occur when the facility has taken the following steps 1) evaluated the clinical condition and risk factors 2) defined and implemented interventions 3) monitored and evaluated the impact of the interventions and 4) revised the approaches as appropriate.