Every finding on record at Omni Manor Nursing Home

Based on record reviews and interviews, the facility did not ensure dementia and behavioral health assessments were completed for Residents #7, #13, #22, #37, and #38. This affected five residents (Residents #7, #13, #22, #37, and #38) of the five records reviewed for dementia. The facility census was 116. Findings include:1. Record review for Resident #7 revealed an admission date of 04/22/26 with diagnoses of Alzheimer's disease, dementia, and other abnormalities of gait. Review of the current physician orders revealed Resident #7 had an order to be admitted to the secure unit due to risk of elopement. Further review of the record revealed the Dementia and Behavioral Health Questions evaluation was never completed. 2. Record review for Resident #13 revealed an admission date of 04/14/26 with diagnoses of transient cerebral ischemic attack, dementia, and Alzheimer's disease. Review of the current physician orders revealed Resident #13 had an order to be admitted to the secure unit due to risk of elopement. Further review of the record revealed the Dementia and Behavioral Health Questions evaluation was never completed. 3. Record review for Resident #37 revealed an admission date of 11/22/23 with diagnoses of hypertensive chronic kidney disease, dementia, and mild cognitive impairment. Review of the current physician orders revealed Resident #37 had an order to be admitted to the secure unit due to risk of elopement. Further review of the record revealed the Dementia and Behavioral Health Questions evaluation was never completed. 4. Record review for Resident #22 revealed an admission date of 04/30/26 with diagnoses of transient cerebral ischemic attack, dementia, and Alzheimer's disease with late onset. Review of the current physician orders revealed Resident #37 had an order to be admitted to the secure unit due to risk of elopement. Further review of the record revealed the Dementia and Behavioral Health Questions evaluation was never completed. 5. Record review for Resident #38 revealed an admission date of 01/31/26 with diagnoses other Alzheimer's disease, dysphagia, and type II diabetes. Further review of the record revealed the Dementia and Behavioral Health Questions evaluation was never completed. Interview on 06/10/26 at 1:48 P.M. with Licensed Social Worker (LSW) #508 revealed she was to complete the Dementia & Behavioral Health Questions evaluation upon admission on all new residents and when time permitted for the existing residents.Interview on 06/10/26 at 2:08 P.M. with Corporate Quality Assurance (CQA) #619 confirmed that the Dementia & Behavioral Health Questions evaluations were not completed for Residents #7, #13, #22, #37, and #38.

Based on record review, observation, staff interviews, and review of facility policy, the facility failed to ensure required personal protective equipment (PPE) for droplet isolation precautions was readily available outside the room of Resident #93. This affected one resident (Resident #93) of two residents reviewed for droplet isolation precautions and had the potential to place staff and residents at risk for transmission of infectious disease. The facility census was 116.Findings include:Record review revealed Resident #93 was admitted on [DATE] with diagnoses including infection and inflammatory reaction due to internal right knee prosthesis, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and chronic obstructive pulmonary disease with acute exacerbation.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 was cognitively intact, required substantial to maximal assistance with activities of daily living. Record review identified Resident #93 was placed on droplet isolation precautions on 06/06/26 for symptoms potentially related to COVID 19 while awaiting diagnostic testing. Orders required testing per Centers for Disease Control and Prevention (CDC) guidance and continuation of isolation precautions until negative results or symptom resolution.Observation on 06/08/26 at 10:04 A.M. revealed droplet isolation signage posted on the door of Resident #93's room; however, no PPE was present or available in the hallway prior to room entry, despite the resident having been placed on droplet isolation two days earlier on 06/06/26. Resident #93's door was open at the time of observation.During an interview on 06/08/26 at 10:06 A.M., Licensed Practical Nurse (LPN) #615 confirmed PPE was not available outside the resident's room and stated the facility's expectation is to maintain a fully stocked PPE supply in a dresser or cart outside all isolation rooms so staff can don PPE prior to entry.During an interview on 06/10/26 at 11:15 A.M., the Infection Preventionist (IP) #519 stated PPE and isolation supplies should always be available, and doors should remain closed when a resident is under droplet isolation precautions. The IP confirmed the expectation is that PPE is obtained and placed promptly when isolation orders begin.Review of the facility policy, Procedure for Isolation: Initiation of Isolation, revised 02/17, indicated an isolation caddy, table, or cart containing a 24 hour supply of necessary PPE must be placed outside the resident's room in accordance with CDC guidelines.

Based on record review, interview, and review of the facility policy, the facility failed to provide documentation in resident orders or care plans that oxygen safety measures and weekly tubing changes were in place. This affected three residents (Residents #54, #100, and #123) of four residents reviewed for oxygen use and safety. The facility census was 116.Findings include: 1. Review of the medical record for Residents #54 revealed an admission date of 08/26/25. Diagnoses included hyperlipidemia, hypertension, gastroesophageal reflux disease, and chronic pain syndrome.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 had intact cognition and required extensive assistance for all activities of daily living.Review of the care plan dated 02/26/26 revealed no focus or interventions related to oxygen use.Review of the physician's order dated 06/03/26 revealed an order for oxygen per nasal cannula at two liters per minute for oxygen level less than 92%. No other orders related to oxygen use were observed.2. Review of the medical record for Resident #100 revealed an admission date of 07/16/25. Diagnoses included type two diabetes mellitus, nondisplaced fracture of the head of right radius, and malignant neoplasm of the prostate.Review of the physician's order dated 07/15/25 revealed an order for oxygen at two liters per minute via nasal cannula as needed for shortness of breath. No other orders related to oxygen use were observed.Review of the care plan dated 02/17/26 revealed a focus that a person-centered care plan would be developed for Resident #100. Interventions included providing oxygen at two liters as needed for shortness of breath. No other focuses or interventions were observed related to oxygen.Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #100 had moderate cognitive impairment and required moderate assistance for all activities of daily living.3. Review of the medical record for Resident #123 revealed an admission date of 06/03/26. Diagnoses included intracapsular fracture of the left femur, hemiplegia and hemiparesis following cerebral infarction, alcohol abuse, and hypertension.Review of the physician's order dated 06/03/26 revealed an order for oxygen at two liters per minute via nasal cannula every shift. No other orders for oxygen were observed.Review of the baseline care plan dated 06/03/26 revealed a focus that a person-centered care plan would be developed for Resident #123. Interventions included providing oxygen at two liters continuous. No other focuses or interventions related to oxygen were observed.Review of the five-day MDS 3.0 assessment dated [DATE] revealed no information related to Resident #123's cognition. Resident #123 required moderate to stand by assistance for all activities of daily living.Observations on 06/08/26 revealed the oxygen tubing for Residents #54, #100, and #123 was dated 06/07/26.Interview on 06/09/26 at 1:10 P.M. with Regional Clinical Supervisor #619 and the Director of Nursing (DON) confirmed no orders or care plan focuses were in Resident's #54, #100, and #123's charts. The DON reported that staff do not document when oxygen tubing is changed, but it was completed every Sunday.Review of the facility policy titled :Use of Oxygen, dated March 2011, revealed it was the facility's goal to promote resident safety in administering oxygen. The following guidelines would be observed in oxygen administration including the oxygen cannula or mask requires scheduled changing when used on one resident. They should be changed weekly and as needed. Also, tubing should be kept off the floor. Oxygen equipment should be cleaned regularly, and routine equipment inspection and maintenance should be performed based on manufacturer's recommendations.

Based on record review, interview, and review of the facility policy, the facility failed to ensure Resident #5 was free of significant medication errors. This affected one resident (Resident #5) of one resident reviewed for significant medication errors. The facility census was 116. Findings include:Review of the medical record for Resident #5 revealed an admission date of 01/14/22 with diagnoses including atrial fibrillation, diabetes mellitus and dementia.Review of the care plan for Resident #5 dated 01/14/22 revealed she was on anticoagulant therapy. Interventions included administering her medications as ordered by the physician.Review of the physician's orders for Resident #5 revealed she had an order for Rivaroxaban (anti-coagulation medication for atrial fibrillation) 15 milligrams (mg) at bedtime.Review of the Medication Administration Record (MAR) for Resident #5 revealed staff had not administered her Rivaroxaban on 04/20/26, 04/23/26, 04/24/26, 04/25/26 and 04/26/26. There was a 9 documented on the MAR to review the nursing progress notes for those administrations.Review of the nursing progress notes for Resident #5 revealed her Rivaroxaban 15 mg was not administered on 04/20/26 at 9:14 P.M. due to not being available, on 04/23/26 at 9:16 P.M. due to pending delivery from the pharmacy, on 04/24/26 at 8:40 P.M. due to awaiting delivery from the pharmacy, on 04/25/26 at 10:18 P.M. due to the medication being unavailable and on 04/27/26 at 1:27 A.M. due to not being available. There was no documented evidence the physician was notified related to the medication not being administered.Review of the physician progress note date 05/09/26 revealed no mention of Resident #5's Rivaroxaban not being administered as ordered on the dates listed above.Interview on 06/10/26 at 11:02 A.M. with the Director of Nursing (DON) verified Resident #5's Rivaroxaban was not administered as ordered and the physician was not updated on the dates listed above. Review of the facility policy titled, Medication Administration, revised March 2026, revealed if a resident's prescribed medication was unavailable for any reason, the attending physician must be notified for further instructions/orders.

Based on observation, interviews, record review, and review of facility policies, the facility failed to ensure physician orders were followed for Resident #112's weekly dressing changes for his peripherally inserted central catheter (PICC) line. This affected one resident (#112) of two residents reviewed for PICC line care. The facility census was 116.Findings include:Record review for Resident #112 showed an admission date of 05/23/25 with diagnoses including infection and inflammatory reaction due to an internal left hip prosthesis, acute osteomyelitis of the left femur, methicillin-susceptible Staphylococcus aureus infection, and the presence of a left artificial hip joint.Review of the physician's order dated 05/13/26 revealed an order for the midline (PICC) dressing to be changed within the first 24 hours after insertion, and then weekly on Wednesdays and as needed.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #112 was cognitively intact, required partial to moderate assistance with activities of daily living, and was dependent on staff for toileting.An observation on 06/08/26 at 10:10 A.M. revealed Resident #112's PICC line dressing did not contain a date indicating when it was last changed.During an interview on 06/08/26 at 10:12 A.M., Licensed Practical Nurse (LPN) #507 confirmed the PICC line dressing was not dated and was unable to identify when it was last changed.During an interview on 06/10/26 at 3:04 P.M., Corporate Quality Assurance Nurse #619 confirmed the PICC line dressing was not dated correctly and that it should have been changed on 06/03/26 according to physician orders.Review of the undated facility policy titled Midline/PICC/CVC Catheter Dressing Changes indicated that dressing changes must occur within 24 hours after initial insertion, and then weekly or as needed if the dressing becomes wet, soiled, or loose.

Based on record review, interview, observation and review of the facility policy, the facility failed to thoroughly investigate an allegation of misappropriation of Resident #80's property. This affected one (Resident #80) of one resident reviewed for misappropriation. The facility census was 116.Findings include: Review of the medical record for Resident #80 revealed an admission date of 09/05/24 with diagnoses of dementia and need for assistance with personal care.Review of the undated inventory log for Resident #80 revealed she had eight sweatpants/jeans, four zip-up jackets, one pair of shoes, ten blouses/t-shirts, seven pairs of socks, five sets of pajamas, one pair of slippers, three blankets and one laundry basket.Review of the admission packet dated 09/06/24 under the missing items section, residents were encouraged by the facility to report missing items immediately. The section stated the facility would begin an investigation of the missing item and every effort would be made to locate the item. The admission packet was signed by Resident #80's representative and a facility staff member on 09/06/24.Review of the nursing progress note revealed on 05/05/26 at 5:09 P.M. the nurse reported to Licensed Social Worker (LSW) #508 that Resident #80's son was in the facility to visit and had accused staff of taking Resident #80's gold necklace. LSW #508 stated there was no jewelry listed on her inventory log, and Resident #80's son was not listed on the contact list. She updated Resident #80's daughter about the gold necklace by email.Review of the electronic communication dated 05/05/26 at 5:15 P.M. from LSW #508 to Resident #80's representative revealed the resident's son was at the facility and had accused the staff of taking her gold necklace. LSW #508 stated the staff could not remember the resident having a gold necklace and it was not on the inventory log. LSW #508 had asked Resident #80's representative if the resident had a gold necklace or if she had taken it home with her. On 05/05/26 at 6:57 P.M. Resident 80's representative responded and stated that the son had given the resident a necklace, but she doubted it was gold. She stated the necklace was too large for her neck and she had been wearing it on her wrist tripled up like a bracelet, however, she had not seen it for a while. Resident #80's representative stated she assumed he had taken it home.Interview on 06/09/26 at 2:01 P.M. with LSW #508 verified she had written the progress note related to the missing necklace on 05/05/26. She stated she looked at the inventory log, but the necklace was not listed. She stated she updated the Administration related to the concern.Interview on 06/10/26 at 11:52 A.M. with the Administrator stated Resident #80's inventory log did not have the necklace listed. He stated he also discussed with the staff at morning meeting the potential of a missing necklace following the son's accusation. He stated they were unable to find the necklace after a thorough search. He verified he was unable to provide documentation related to an investigation. Interview on 06/10/26 at 11:54 A.M. with LSW #508 revealed she stated she had talked to the aides on Resident #80's unit and there was no evidence she had a necklace. LSW #508 stated these were verbal communications. She stated she kept a concern log/missing item log with items and the results of the concern. At 12:07 P.M., she provided her concern log/missing item log but there were no entries related to Resident #80's missing gold necklace. She verified she did not fill out anything on the log related to the incident. LSW #508 also stated when receiving items from family members for residents she had not been updating the inventory log to show a correct and current list of what each resident had in their rooms.Observation on 06/11/26 at 9:12 A.M. of Resident #80's personal items with Registered Nurse (RN) #532 revealed there were items in her room that were not included on the personal inventory log. These items included five reading books, the bible, a stuffed flamingo, a partial upper denture, two picture frames, seven blankets, two pair of slippers, two IPADS, a jewelry box with costume jewelry (no gold necklace observed) and five zip-up jackets. RN #532 stated the inventory log would not always get updated as families would bring items in and staff would not update the list. RN #532 verified the log was incorrect.Review of the facility policy titled, Abuse Prevention Practices, revised October 2022, revealed alleged, suspected, or observed abuse, neglect, and or mistreatment of a resident and or their belongings were to be thoroughly investigated by the Administrator and the Director of Nursing (DON) or designee.

Based on record review, interview, observation and facility policy review, the facility failed to report an allegation of misappropriation of Resident #80's personal property to the State Agency. This affected one (Resident #80) of one resident reviewed for misappropriation. The facility census was 116. Findings include:Review of the medical record for Resident #80 revealed an admission date of 09/05/24 with diagnoses of dementia and need for assistance with personal care.Review of the undated inventory log for Resident #80 revealed she had eight sweatpants/jeans, four zip-up jackets, one pair of shoes, ten blouses/t-shirts, seven pairs of socks, five sets of pajamas, one pair of slippers, three blankets and one laundry basket.Review of the admission packet dated 09/06/24 under the missing items section, residents were encouraged by the facility to report missing items immediately. The section stated the facility would begin an investigation of the missing item and every effort would be made to locate the item. The admission packet was signed by Resident #80's representative and a facility staff member on 09/06/24.Review of the nursing progress note revealed on 05/05/26 at 5:09 P.M. the nurse reported to Licensed Social Worker (LSW) #508 that Resident #80's son was in the facility to visit and had accused staff of taking Resident #80's gold necklace. LSW #508 stated there was no jewelry listed on her inventory log, and Resident #80's son was not listed on the contact list. She updated Resident #80's daughter about the gold necklace by email.Review of the electronic communication dated 05/05/26 at 5:15 P.M. from LSW #508 to Resident #80's representative revealed the resident's son was at the facility and had accused the staff of taking her gold necklace. LSW #508 stated the staff could not remember the resident having a gold necklace and it was not on the inventory log. LSW #508 had asked Resident #80's representative if the resident had a gold necklace or if she had taken it home with her. On 05/05/26 at 6:57 P.M. Resident 80's representative responded and stated that the son had given the resident a necklace, but she doubted it was gold. She stated the necklace was too large for her neck and she had been wearing it on her wrist tripled up like a bracelet; however, she had not seen it for a while. Resident #80's representative stated she assumed he had taken it home.Interview on 06/09/26 at 2:01 P.M. with LSW #508 verified she had written the progress note related to the missing necklace on 05/05/26. She stated she looked at the inventory log, but the necklace was not listed. She stated she updated the Administration related to the concern.Interview on 06/09/26 at 2:04 P.M. with the Administrator revealed he remembered the incident, and the necklace was not on the inventory log. He verified he had not updated the State Agency by filing a self-reported incident (SRI) related to potential misappropriation of Resident #80's personal property.Interview on 06/10/26 at 11:52 A.M. with the Administrator again verified he had not filed an SRI with the State Agency. He stated Resident #80's inventory log did not have the necklace listed. He stated he also discussed with the staff at morning meeting the potential of a missing necklace following the son's accusation. He stated they were unable to find the necklace after a thorough search. He verified he was unable to provide documentation related to an investigation. Interview on 06/10/26 at 11:54 A.M. with LSW #508 revealed she stated she had talked to the aides on Resident #80's unit, and there was no evidence she had a necklace. LSW #508 stated these were verbal communications. She stated she kept a concern log/missing item log with items and the results of the concern. At 12:07 P.M., she provided her concern log/missing item log but there were no entries related to Resident #80's missing gold necklace. She verified she did not fill out anything on the log related to the incident. LSW #508 also stated when receiving items from family members for residents she had not been updating the inventory log to show a correct and current list of what each resident had in their rooms.Observation on 06/11/26 at 9:12 A.M. of Resident #80's personal items with Registered Nurse (RN) #532 revealed there were items in her room that were not included on the personal inventory log. These items included five reading books, the bible, a stuffed flamingo, a partial upper denture, two picture frames, seven blankets, two pair of slippers, two IPADS, a jewelry box with costume jewelry (no gold necklace observed) and five zip-up jackets. RN #532 stated the inventory log would not always get updated as families would bring items in and staff would not update the list. RN #532 verified the log was incorrect.Review of the facility policy titled, Abuse Prevention Practices, revised October 2022, revealed alleged, suspected, or observed abuse, neglect, and or mistreatment of a resident and or their belongings were to be reported immediately to the State Agency via the submission of an SRI.

Based on record review, interview and policy review, the facility failed to ensure a safe discharge for residents requiring durable medical equipment including a tube feed pump. This affected one (Resident #5) of four residents reviewed for discharge. The facility census was 104. Findings include:Review of the medical record for Resident #5 revealed an admission date of 04/25/25 and a discharge date of 06/24/25. Diagnoses included need for assistance with personal care, anxiety disorder, dysphagia oropharyngeal phase, and moderate protein-calorie malnutrition. Review of the plan of care dated 04/27/25 noted Resident #5 had the potential for fluid deficit related to receiving nutrition via a gastrostomy tube (G-tube). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] noted Resident #5 had intact cognition. Resident #5 received nutrition via G-tube. Review of the physician order dated 05/29/25 noted Resident #5 was receiving Fibersource (tube feeding supplement) 1.2 continuous at 65 milliliters (ml) per hour. Review of the discharge order/summary dated 06/21/25 noted Resident #5 was to receive Fiber source 1.2 at 65 ml with auto flush of 30 ml every hour. The discharge summary did not indicate Resident #5 would be bolus feeding herself until a tube feed pump was available. The summary indicated no other instructions related to tube feeding or the tube feeding pump. Review of the nursing progress note dated 06/23/25 at 4:15 P.M. noted Resident #5 had received extensive training on preparing and administering medications via G-tube. Resident #5 received education on working the tube feed pump including how to unhook and hook self and start pump. Review of the nursing progress note dated 06/24/25 at 3:22 P.M. noted staff explained to Resident #5 that the feeding supplies were not yet ordered due to insurance not returning a call. Review of the nursing progress note dated 06/26/25 at 5:28 P.M. noted calls were made to several home service agencies who did not offer home services or did not provide tube feeding supplies. The facility would still search for providers. Review of the nursing progress note dated 06/30/25 at 3:00 P.M. noted calls were made to several home service agencies who did not offer home services or did not provide tube feeding supplies. The facility would still search for providers. Resident #5's insurance sent a month's supply of feeding at that point. Review of the nursing progress note dated 07/18/25 at 3:42 P.M. noted the facility was still trying to contact a home health company to provide tube feed and supplies. Interview on 08/09/25 at 9:34 A.M., a family member stated Resident #5 was not able to receive nutrition after being discharged due to not having the pump and being nauseated from the bolus (a method of delivering liquid nutrition into the stomach through a feeding tube using a syringe or gravity) feed. Interview on 08/09/25 at 11:00 A.M., the Director of Nursing (DON) and the Administrator noted there was a slight delay in getting everything for Resident #5. The DON stated staff were going to educate Resident #5 on giving herself a bolus; but Resident #5 left the facility before the education could be provided. The Administrator stated Resident #5 was getting sick from the bolus feeds. Interview on 08/09/25 at 11:36 A.M., Licensed Practical Nurse (LPN) #201 stated she worked the day after Resident #5 was discharged and received a call from Resident #5 stated she did not have the pump. LPN #201 stated she spoke with the dietitian regarding the process for providing bolus feeds to herself. LPN #201 stated Resident #5 was educated weeks before her discharge on how to give herself a bolus feeding. LPN #201 stated the daughter came to the facility that afternoon and picked up a pump the facility provided. Interview on 08/09/25 at 12:33 P.M., Clinical Director (CD) #202 stated no one knew why Resident #5 did not receive a feeding pump upon discharge. CD#202 stated Resident #5 was given approximately 20 bags of feed when she was discharged , CD#202 did state that Resident #5 was getting nauseated from the bolus feeds. CD#202 verified the physician orders indicating Resident #5 was to receive continuous tube feeding. Review of a policy titled Discharge to Home, dated 2008, noted the facility would provide a written summary and verbal explanation of the resident's condition. This deficiency represents non-compliance investigated under Complaint Number 1357084 (OH00167209).

Based on record review, observation, interview and facility policy review, the facility failed to honor residents' preferences for meals. This affected nine Residents (#41, #71, #73, #75, #77, #78, #91, #92 and #104) of ten reviewed for meal preferences. The facility census 119. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included obsessive compulsive disorder, hypertension, mild intellectual disabilities and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was severely cognitively impaired. He required partial to moderate assistance with eating. Review of the medical record for Resident #71 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, and depression. Review of the quarterly MDS assessment dated [DATE] revealed resident #71 was severely cognitively impaired. She required supervision or touching assistance with eating. Review of the medical record for Resident #73 revealed an admitted [DATE]. Diagnoses included dementia, depression, glaucoma and anemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #73 was severely cognitively impaired. He required set up assistance for eating. Review of the medical record for Resident #75 revealed an admitted [DATE]. Diagnoses included dementia, muscle wasting, high cholesterol and diabetes. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #75 was severely cognitively impaired. He was independent in eating. Review of the medical record for Resident #77 revealed an admitted [DATE]. Diagnoses included schizophrenia, history of stroke, depression and urinary incontinence. Review of the quarterly MDS assessment dated [DATE] revealed Resident #77 was severely cognitively impaired. She required set up assistance for eating. Review of the medical record for Resident #78 revealed an admitted [DATE]. Diagnoses included muscle weakness, dementia and kidney disease. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #78 was cognitively intact. Her functional abilities had not yet been fully assessed. Review of the medical record for Resident #91 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, diabetes, kidney failure, malnutrition and depression. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #91 was severely cognitively impaired. He was totally dependent on staff for eating. Review of the medical record for Resident #92 revealed an admitted [DATE]. Diagnoses included depression, dysphagia, constipation and muscle weakness. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #92 was cognitively intact. He required set up assistance for eating. Review of the medical record for Resident #104 revealed an admitted [DATE]. Diagnoses included breast cancer, muscle wasting, kidney disease and dysphagia (difficulty swallowing). Review of the quarterly MDS assessment dated [DATE] revealed Resident #104 was cognitively intact. She required set-up help for eating. Review of the tray tickets for the lunch meal on 04/14/25 revealed Resident #41 was not to receive bread, Resident #71 was to receive extra gravy, Resident #73 wanted extra gravy with meats, Resident #77 did not want gravy, Resident #91 wanted gravy on the side, and Resident #104 did not want rolls. Interviews on 04/14/25 at 10:51 A.M. with Residents #75, #78 and #92 revealed they did not always get what they ordered for meals, and meal preferences were not always honored. Observation on 04/14/25 at 11:25 A.M. revealed lunch was being served which consisted of country fried steak, gravy, potatoes with onions, creamed corn, a roll and chilled cinnamon apples. Preparation of meal service revealed, Resident #41 received a roll with his lunch, Resident #71 did not receive extra gravy with her lunch, Resident #73 did not receive extra gravy with his lunch, Resident #77 received gravy with his lunch, Resident #91 had gravy served top of her country fried steak, and Resident #104 received a roll with her lunch. Interviews at the time of the observations with [NAME] #356 confirmed the above resident preferences were not honored during the lunch service. Review of the facility policy titled Accommodating Religious, Ethnic, Cultural and Personal Preferences dated February 2023 revealed the facility would provide dietary preferences if requested. This deficiency is an incidental finding identified during the complaint investigation.

Based on record review, interview and facility policy review, the facility failed to ensure a thorough investigation of Resident #120 who claimed he hit his head on the ceiling of the van when the transport driver drove over speed bumps while on an appointment on 01/28/25. This affected one resident (#120) of three residents reviewed for accidents. The facility census was 119. Findings include: Review of the medical record for Resident #120 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included malnutrition, osteomyelitis (infection of the bone), muscle weakness, arthritis, kidney disease, and diabetes. Review of the comprehensive Minimum Dat Set (MDS) assessment dated [DATE] revealed Resident #120 was cognitively intact. He was independent with eating, oral hygiene, toileting and showering. Review of the health progress noted dated 01/28/15 revealed Resident #120 had an appointment with the Blood and Cancer Center. Review of the social services progress note dated 01/29/25 revealed Resident #120 reported he hit his head on the ceiling of the van while driving over speed bumps at the prior days' appointment. He also reported he had to bend far to the side, so his head did not hit the ceiling. Interview on 04/14/25 at 2:34 P.M. with Licensed Social Worker (LSW) #404 confirmed she was told by Transport Aide #393 that Resident #120 did not have much space in the facility van between his head and the ceiling, and Resident #120 hit his head during transportation to his appointment on 01/28/25. Interview on 04/14/25 at 2:38 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence in the medical record that Resident #120 was assessed for injury upon hearing him hitting his head on the ceiling of the van on 01/28/25, and no investigation had been completed. He provided two witness statements, not part of the medical record, dated 01/29/25 from LSW #404 and Licensed Practical Nurse (LPN) #414 referencing the incident. LSW #404's witness statement stated, Transport Aide #393 reported that Resident #120 bumped his head while going over speed bumps. Transport Aide #393 and LSW #404 reported this to the nurse on the [NAME] Wing. LPN #414's statement stated, Resident #120 complained of pain to the right hip which is not new. Resident #120 complained of a bumpy ride to and from his appointment the prior day. No visible injuries noted per head-to-toe assessment. Neuro checks were within normal limits. (There was no documented evidence of neurological checks in the medical record. There was also no nursing progress note related to this assessment). Interview on 04/14/25 at 3:59 P.M. with Transport Aide #393 revealed she had no knowledge of Resident #120 hitting his head during transportation to his appointment on 01/28/25 until LSW #404 asked her about it on 01/29/25. Review of the facility policy titled Incident, Accident and Unusual Occurrence/Risk Management Report dated November 2024 revealed the facility would document any accidents including date, time and place of the incident, a description of the accident or incident and assess the resident. Investigation summaries would include the facts of the incident, the resident assessment, intervention by staff to reduce the chance of reoccurrence and additional interventions as necessary. This deficiency represents noncompliance investigated under Master Complaint Number OH00162169.

Based on observation and staff interview, the facility failed to ensure its refuse area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 121. Findings include: Observation of the outside kitchen area with Dietary Supervisor (DS) #168 on 07/29/24 at 9:15 A.M. revealed numerous items of debris including Styrofoam cups, plastic wear and other numerous refuse items around the door where garbage was taken out of the kitchen. A grey cart with wheels had bagged garbage in it that was uncovered. There were grey lids for the cart located in the area. The large dumpster for garbage was overflowing with bagged garbage. The lid for the large dumpster was unable to be closed. DS #168 verified the aforementioned findings at the time of the observation. Interview on 07/29/24 with DS #168 during the observation, revealed the garbage in the small grey bin was not taken to the large dumpster because it was overflowing and there was no room for current garbage to be placed. DS #168 stated the large dumpster was often full. Interview on 07/29/24 at 11:00 A.M. with Regional Administrator (RA) #300 revealed the large garbage dumpster is emptied five times weekly. RA #300 stated the large dumpster is not emptied on the weekends and is picked up mid-morning on Mondays. RA #300 verified there were lids for the gray garbage carts that should be used to keep the carts covered in the event the large dumpster is full.

Based on observation, interview and policy review the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner and that all food was labeled, dated and stored properly. This had the potential to affect 119 residents receiving food from the kitchen. There were two residents identified as receiving nothing by mouth (#29 and #37). The facility census was 121. Findings include: During the initial kitchen tour conducted on 07/29/24 at 9:15 A.M. the following was observed and verified with Dietary Supervisor #168. 1. Drawer one of the right three drawer utensil cabinet for clean utensils storage had visible dirt and grease in it. 2. Drawer three of the left three drawer cabinet contained an open container of chicken stock. The chicken stock was unlabeled as to when it was opened. There was also an open, one pound bag of country gravy mix. The bag of gravy mix was one quarter full and unlabeled as to when it was opened. 3. In the dry storage area there was a one- and one-half pound bag of crispy onions. The bag was one quarter full, opened and undated. 4. In the standup refrigerator located by the door there was a one liter opened bottle of water identified as belonging to a staff member. 5. Ceiling fan noted with heavy buildup of black debris. DS #168 stated the fan worked and they used it. DS #168 turned the fan on, and debris came flying off the fan as the blades were spinning. A review of the policy titled; Storage: Food, Equipment and Utensils (dated February 2019) revealed food, equipment and utensils must be stored in a clean and dry location. The policy also stated all food will be labeled and dated.

Based on record reviews, interviews and observations the facility failed to provide food that was served at a palatable temperature. This had the potential to affect 119 residents as two residents (#29 and #37) received nothing by mouth. The census was 121. Findings include: Interviews on 07/29/24 during the screening process of the annual survey with Resident #45, Resident #48, Resident #55, Resident #71, Resident #74 and Resident # 422 revealed concerns with temperature of the food stating it was often cold. Observation of trayline on 07/30/24 from 4:10 P.M. through 6:00 P.M. revealed staff were not utilizing bases for hot pellets until questioned by surveyor. Interview at 4:12 P.M. with Food Service Manager #168 revealed they did not use those. The staff did use them for tray line at the time however they ran out of bases for the following: North Unit-11 residents, East Unit-12 residents and South Unit-16 residents. The same cart for South Unit also ran out of hot pellets for 16 residents. Observation of the test tray on 07/31/24 revealed it was delivered to the South unit at 12:15 P.M. Registered Dietitian (RD) # 222 and Corporate RD (CRD) #301 were present to test the temperatures. Observation of RD #222 taking the temperatures revealed the sauerkraut was 127 degrees Fahrenheit and the milk was 55 degrees Fahrenheit. Both RD #222 and CRD #301 verified the temperatures. Review of the Resident Council notes from August 2023 through July 2024 revealed comments about food being cold, inconsistent, lacking quality and not matching what the menus states. Review of the facility policy titled Preparing Cold Foods, (dated 03/14/23) revealed safe service cold food must be 41 degrees Fahrenheit or below. Review of the facility policy titled Preparing Hot Foods, (dated 03/14/23) revealed safe service cold food, vegetables must be at least 140 degrees Fahrenheit. This deficiency represents non-compliance investigated under Complaint Number OH00155823.

Based on record reviews,resident council minute review, interviews and observations the facility failed to follow the menu. This affected 15 of 119 residents (#3, #5, #7, #28, #30, #38, #41, #42, #50, #71, #75, #95, #99, #113 and #118) who received meals from the kitchen. There were two residents (#29 and #37) who received nothing by mouth. The census was 121. Findings include: Review of the dinner menu on 07/30/24 revealed sloppy joes, sweet potato waffle fries and corn were on the menu for dinner. The alternate to the main entree was a hot ham and cheese sandwich and mashed potatoes. Observation on 07/30/24 from 4:10 P.M. to 6:00 P.M. revealed the facility ran out of sloppy joes and sweet potato waffle fries during dinner service for 16 residents. They used the four remaining hot ham and cheese sandwiches and mashed potatoes, the alternate, to replace four of them. They used peanut butter and jelly sandwiches for the remaining 12. At the time of the observation, Food Service Director #168 verified the facility did not calculate the proper amount of food needed. The Registered Dietitian (RD) #222 and Corporate RD (#301) were present and told them to use peanut butter and jelly sandwiches. 1. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included pressure ulcer of sacral region, dementia and chronic obstructive pulmonary disorder. Resident #3 was on a regular, no added salt diet. 2. Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, chronic atrial fibrillation and muscle weakness. Resident #5 was on mechanical soft diet. 3. Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, muscle wasting and atrophy and anxiety disorder. Resident #7 was on a regular, no added salt diet. 4. Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included type one diabetes mellitus, essential hypertension and epilepsy. Resident #28 was on a regular diet. 5. Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, dysphagia and muscle weakness. Resident #30 was on a regular diet. Interview on 07/31/24 at 10:14 A.M. with Resident #30 revealed the did not receive a sloppy joe on 07/30/24. She stated it happened regularly where they do not get what the menu says. She stated They give you what they have. It can be cold too. 6. Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included neurocognitive disorder, schizoaffective disorder and contracture of right hand. Resident #38 was on a mechanical soft with pureed meats. The resident did not receive the sweet potato waffle fries. 7. Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included rhabomyolysis, type two diabetes mellitus and hyperlipidemia. Resident #41 was on a regular diet. 8. Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included encephalopathy, mild cognitive impairment and type two diabetes mellitus. Resident #42 was on a regular, no added salt diet. 9. Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included hypertension, congestive heart failure and major depressive disorder. Resident #50 was on a regular diet. He did not receive the sweet potato waffle fries. 10. Review of the medical record for Resident #71 revealed an admitted [DATE]. Diagnoses included atherosclerosis of native artery, other pulmonary embolism and paranoid schizophrenia. Resident #71 was on a regular, no added salt, no concentrated sweets diet. Interview on 07/31/24 at 9:50 A.M. with Resident #71 revealed he received rice and mixed vegetables. He stated they do not always get what was on the menu. 11. Review of the medical record for Resident #75 revealed an admitted [DATE]. Diagnoses included major depressive disorder, essential tremor and anxiety disorder. Resident #75 was on a regular diet. 12. Review of the medical record for Resident #95 revealed an admitted [DATE]. Diagnoses included anemia, gastro-esophageal reflux disease and chronic kidney disease. Resident #95 was on a regular diet with mechanical soft texture. 13. Review of the medical record for Resident #99 revealed an admitted [DATE]. Diagnoses included Alzheimer's Disease, muscle wasting and atrophy and dysphagia. Resident #99 was on a regular diet. 14. Review of the medical record for Resident #113 revealed an admitted [DATE]. Diagnoses included hypertensive chronic kidney disease, irritable bowel syndrome and mild cognitive impairment. Resident #113 was on a mechanical soft diet. 15. Review of the medical record for Resident #118 revealed an admitted [DATE]. Diagnoses included cellulitis, hyperlipidemia and adult failure to thrive. Resident #118 was on a regular diet. Interview on 07/31/24 at 12:20 P.M. with CRD #301 revealed the manager orders and calculates food needs. Review of the Resident Council notes from August 2023 through July 2024 revealed comments about food not matching what the menus states.

Based on review of Notice of Medicare Non-Coverage letters and staff interview, the facility failed to provide residents forty eight (48) hours' notice of their skilled services were no longer covered. This affected three residents (#97, #107 and #122) of three reviewed for liability notices. The census was 121. Findings include: 1. Review of Resident #97's medical record revealed they were admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 03/13/24. The time sensitive, appeal notification letter was signed by Resident #97 but dated by facility staff. Unable to verify accurate date of notification. 2. Review of Resident #107's medical record revealed they were admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 07/25/24. The time sensitive, appeal notification letter was signed by Resident #107 on 07/24/24, not allowing 48 hours' notice of non-coverage. 3. Review of Resident #122's medical record revealed they were admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 03/28/24. The time sensitive, appeal notification letter was signed by Resident #122 but dated by facility staff. Unable to verify accurate date of notification. Interview on 07/31/24 at 3:53 P.M., Bookkeeper #124 verified the letters to the residents did not provide forty eight hours' notice of non-coverage.

Based on record review, interview, and policy review, the facility failed to refund resident funds within 30 days of discharge. This affected two residents (#373 and #374) of seven residents reviewed for resident funds. The facility census was 121. Findings include: #1. Review of resident records for Resident #373 revealed an admitted [DATE] and a discharge date of [DATE]. A review of the Document titled; Choice of Resident Funds Disposition revealed Resident #373 authorized the facility to hold, safeguard and account for personal funds. The document was signed by Resident #373's son on 10/18/19. On 07/31/24 at 12:58 P.M. a review of resident fund balances dated 07/30/24 revealed a balance of $1485.33 for Resident #373. An interview with Bookkeeper #124 at the time of fund review verified an account balance of $1485.33 for Resident #373. Bookkeeper #124 also verified the funds were not refunded within 30 days of discharge and the account was still active. #2. Review of resident records for Resident #374 revealed an admitted [DATE] and a discharge date of [DATE]. A review of the Document titled; Choice of Resident Funds Disposition revealed Resident #374 authorized the facility to hold, safeguard and account for personal funds. The document was signed by Resident #374's daughter on 05/23/21. On 07/31/24 at 12:58 P.M. a review of resident fund balances dated 07/30/24 revealed a balance of $1790.93 for Resident #374. An interview with Bookkeeper #124 at the time of fund review verified an account balance of $1790.93 for Resident #374. Bookkeeper #124 also verified the funds were not refunded within 30 days of discharge and the account was still active. A review of the policy titled; Conveyance of Funds Upon Death (dated January 2024), revealed upon death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds, and a final accounting of those funds.

Based on observation, interview and record review, the facility failed to ensure call lights were within reach. This affected two residents (#45 and #53) of five residents reviewed for call light accessibility and had the potential to affect all residents. The facility census was 121. Findings include: Review of the medical record for Resident #45 revealed an admitted [DATE]. Diagnoses included dementia, depression, chronic obstructive pulmonary disease (COPD) and coronary artery disease. Review of the quarterly minimum data set (MDS) assessment date 06/14/24 revealed the resident was rarely or never understood. She required substantial or maximum assistance for eating and was dependent for oral hygiene of toileting, showering and personal hygiene. Review of the care plan dated 06/14/24 revealed Resident #45 was at risk for falls due to poor safety awareness, history of putting herself on the floor, being combative with care and Alzheimer's. Interventions included therapy referrals as needed, anticipating the residents' needs and ensuring the call light was in reach. Observation on 07/29/24 at 9:31 A.M. revealed Resident #45's call light was wrapped around a plastic guard rail approximately 8 inches from the floor, and not within reach of the resident. Interview at the time of the observation with Housekeeper #146 confirmed Resident #45's call light was not in reach. Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included Alzheimer's, muscle weakness, anemia, depression and difficulty swallowing. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #53 was severely cognitively impaired. She was required partial to moderate assistance for eating and substantial or maximum assistance for toileting, showering and personal hygiene. Review of the care plan dated 05/09/24 revealed Resident #53 was at a high risk for falls due to weakness and poor safety awareness. Interventions included ensuring the call light was reach, assisting with toileting as needed and having commonly used articles within reach. Observation on 07/29/24 at 9:31 A.M. revealed Resident #53's call light was on the floor next to her bed, and not within reach. Interview at the time of the observation with Housekeeper #146 confirmed Resident #53's call light was not in reach of the resident. Review of the facility policy titled Call Light, Use Of (dated March 2024) revealed call lights would be positioned in a convenient place for the resident.

Based on observation and staff interview, the facility failed to ensure posted nursing staff information was updated in a timely manner. This had the potential to affect all residents. The facility census was 121. Findings include: Observation of the posted nursing staff information on 07/29/24 at 7:52 A.M. revealed the posted nursing staff information was dated 07/26/24. Interview on 07/29/24 at 9:34 A.M. with the Director of Nursing (DON) confirmed the posted staffing information had not been updated since 07/26/24. Observation of the posted staffing information on 07/31/24 at 8:20 A.M. revealed the posted staffing information was dated 07/30/24. Interview on 07/31/24 at 9:33 A.M. with the DON confirmed the posted staffing information had not been updated.

Based on closed medical record review and staff interview the facility failed to ensure wound care was completed as ordered. This affected one resident (Resident #150) of three residents reviewed for wound care. The census was 117. Findings include: Review of Resident #150's closed medical record revealed an admitted [DATE] with the diagnoses of antineutrophilic cytoplasmic antibody vasculitis (a rare autoimmune disorder that causes inflammation of the blood vessels), calculus of the kidney, and an abnormal electrocardiogram (test to detect heart rhythm). Review of Resident #150's care plan dated 05/03/23 revealed interventions to include administration of medications and treatments as ordered. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE] revealed intact cognition and the presence of skin tears. Review of the skin assessments revealed the resident had a skin tear to the back of her right hand. Review of the physician orders for Resident #150 revealed an order for wound care beginning on 09/29/23 to cleanse the area to the back of the right hand, apply betadine and Cuticerin (a brand of gauze used for superficial wounds) and cover with an ABD (large gauze pad) and kerlix (gauze wrap) until resolved every day shift. Review of the treatment administration record for October 2023 revealed no evidence of documentation for the above wound care on 10/02/23, 10/10/23, and 10/11/23. An interview with the Registered Nurse #501 on 05/09/24 at 2:03 P.M. verified there was no evidence Resident #150's wound care was completed per orders on 10/02/23, 10/10/23 and 10/11/23. This deficiency represents non-compliance investigated under Complaint Number OH00153046.

Based on record review and interviews the facility failed to ensure wound care was documented as ordered. This affected two residents (Resident #61 and #101) of three residents reviewed for wound care. The facility census was 117. Findings Include: 1. Medical record review for Resident #61 revealed an admitted [DATE]. Resident #61's current diagnoses include congestive heart failure, cerebral infarction (stroke), myocardial infarction (heart attack), neuromuscular dysfunction of the bladder, colostomy, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the 04/02/24 Minimum Data Set (MDS) revealed Resident #61 to be cognitively intact. Review of Resident #61's physician orders revealed an order dated 02/13/24 through 04/23/24 for the sacrum to be cleansed with normal saline, apply drawtec (a dressing that promotes moist wound healing) in a single layer and cover with coversite plus (a waterproof composite dressing that can replace gauze and tape) every shift. A new treatment order was written and completed from 04/24/24 through 04/30/24. Review of the corresponding treatment administration record (TAR) for February 2024 through April 2024 revealed no documentation the treatment was completed on day shift the following dates: 03/02/24, 03/08/24, 03/16/24, 03/23/24, 03/25/24, 03/27/24, 04/02/24, 04/04/24, 04/08/24, 04/11/24, 04/12/24. Further review of the physician orders revealed an order written 04/30/24 to cleanse the sacrum with saline, apply a single layer of drawtec, and cover with coversite plus every shift. Review of the May 2024 TAR revealed the treatment was not documented as completed on day shift 05/02/24, 05/03/24, and 05/05/24 and nightshift 05/06/24. An interview with Resident #61 on 05/09/24 at 11:26 A.M. revealed wound care was performed daily as ordered. An interview with Registered Nurse #501 on 05/09/24 at 2:03 P.M. verified the the treatments/wound care were not documented on the dates indicated. 2. Medical record review for Resident #101 revealed an admitted [DATE]. Current diagnoses include pressure ulcer of the sacral region, neuromuscular dysfunction of the bladder, chronic respiratory failure, dementia, heart failure, mild cognitive impairment, hypertension, and chronic pain syndrome. Review of Resident #101's physician orders revealed an order dated 03/12/24 through 04/02/24 for the sacrum to be cleansed with normal saline, apply durafiber and coversite every shift. Review of the March TAR revealed no documentation the treatments were completed on 03/14/24 and 03/24/24 dayshift and on 03/28/24 night shift. Further review of the physician orders revealed an order dated 04/02/24 through 04/23/24 to cleanse the sacrum with normal saline, apply a single layer of drawtec, cover with a single 4 x 4 filling and coversite plus every shift. Review of the April 2024 TAR revealed no documentation the treatment was completed on 04/04/24, 04/05/24, 04/18/24, and 04/19/24 day shift and 04/15/24, 04/20/24 and 04/21/24 night shift. Review of the physician orders dated 04/23/24 through 04/30/24 revealed an order to cleanse the sacrum with acetic acid, apply drawtec in a single layer, 4 x 4 filling and coversite plus every shift. Review of the April 2024 TAR revealed no documentation the treatment was completed on 04/26/24. Review of the physician orders dated 04/30/24 revealed an order to cleanse the sacrum with acetic acid and apply durafiber AG (silver containing antimicrobial gelling dressing), gauze and coversite plus change every shift. Review of the May TAR revealed no evidence the treatment was documented on 05/02/24, day shift. An interview on 05/09/24 at 1:30 P.M. with Resident #101 verified the treatments were completed as scheduled. An interview with the Registered Nurse # 501 on 05/09/24 at 2:03 P.M. verified wound treatments were not documented as ordered.

Based on observation, record review and interview the facility failed to ensure Resident #100 was provided adequate assistance and proper assistive devices to prevent a fall out of bed with injury. Actual Harm occurred on 12/03/22 when Resident #100, who was cognitively impaired, at risk for falls and assessed to require two staff for bed mobility sustained a fall out of bed while being provided incontinence care by one staff member (State tested Nursing Assistant (STNA) #510). At the time of the incident, STNA #510 also failed to ensure the resident's half side rail was properly locked/in place to aide in bed mobility. The resident landed on the floor and was assessed to have a laceration to her left eye brow requiring transport to the emergency room . Resident #100 was also subsequently assessed to have a nondisplaced fracture to her left medial malleolus (ankle) and distal fibula (lower leg bone in ankle area) as a result of the fall. This affected one resident (#100) of three residents reviewed for falls. The facility census was 108. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, osteoarthritis, and major depressive disorder. Review of the activities of daily living self-care performance deficit care plan, initiated on 04/10/19, revealed Resident #100 was at risk for falls due to her diagnoses, weakness and decreased safety awareness. This care plan indicated Resident #100 required extensive assistance from two staff for bed mobility and for incontinence care which was to be provided in bed. Resident #100 was to have the top two side rails (of the bed) up for assistance with bed mobility. Review of the Minimum Data Set (MDS) 3.0 assessments, dated 01/02/22, 04/02/22, 07/02/22, and 08/08/22 revealed Resident #100 was severely cognitively impaired and required extensive two-person physical assistance for bed mobility (turning/repositioning in bed). Review of the MDS 3.0 assessment, dated 11/07/22 revealed the resident was severely cognitively impaired and continued to be assessed to require extensive assistance from two staff for bed mobility and toilet use. The assessment also revealed Resident #100 was assessed to be always incontinent of bladder and bowel. Review of Resident #100's nursing progress note, dated 12/03/22 at 10:20 P.M. revealed the nursing assistant requested help from this nurse to get Resident #100 off the floor. The nurse indicated when she entered the room, the resident's bed was at waist height and Resident #100 was laying on the floor to the right side of the bed. Resident #100 was assessed and noted to have bleeding from a laceration on her left eyebrow. The nursing assistant told the nurse, she went to roll her over to change her and she didn't realize the bed rail on the bed wasn't locked when she rolled her over, she rolled out of the bed. This note indicated the family and physician were notified and Resident #100 was sent to the hospital for evaluation. Review of a nursing progress note, dated 12/04/22 at 7:05 A.M. revealed Resident #100 arrived back to the facility from the hospital. Resident #100 was assessed to have bruising (ecchymosis) to her left eye and her left ankle. Review of a nursing progress note, dated 12/04/22 at 1:30 P.M. revealed Resident #100's left ankle had increased swelling and pain was noted when touching or moving her left leg/foot. The physician and family were notified and an x-ray was ordered for her left ankle. Review of nursing progress note, dated 12/04/22 at 5:48 P.M. revealed Resident #100's left ankle x-ray was positive for a fracture of the ankle and distal fibula. The physician and family were notified. The physician gave an order for an orthopedic consult. Review of nursing progress note dated 12/05/22 at 12:25 P.M. for Resident #100 revealed the physician ordered Tramadol (an opioid pain medication) 50 milligrams twice a day for pain control. The progress notes for Resident #100 revealed the orthopedic physician's office was called for the consult on 12/05/22 at 3:22 P.M. and were going to call the nursing facility back with an appointment. On 12/06/22 at 1:58 P.M. Resident #100 was observed sitting in her chair in her room. The resident was noted to be only alert and oriented to herself and not interviewable. Resident #100 was observed to have a large black eye covering the left side of her face. A restorative progress note, dated 12/07/22 at 3:00 P.M. revealed Resident #100 was sent to the hospital on 12/03/22 after she fell from bed. Resident #100 returned to the facility (on 12/04/22) and her left eyebrow area had a 2.0 centimeter laceration which had been closed with dermabond, a medical grade glue. On 12/08/22 at 9:20 A.M. interview with the Director of Nursing (DON) and Administrator confirmed STNA #510 was providing incontinence care for Resident #100 on 12/03/22. They verified when STNA #510 turned Resident #100 to her side, the right side rail on the bed was not locked and Resident #100 rolled out of the bed onto the floor resulting in injuries. On 12/08/22 at 10:56 A.M. interview with Corporate MDS Coordinator #617 confirmed Resident 100's annual MDS 3.0 assessment and previous MDS 3.0 assessments in 2022 (01/02/22, 04/02/22, 07/02/22 and 08/08/22) indicated Resident #100 was assessed to require two person physical assistance for bed mobility. This deficiency represents non-compliance investigated under Complaint Number OH00138004.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Disease Control and Prevention (CDC) guidelines, observations, interviews, facility census review, and record review, the facility failed to conduct appropriate infection control practices by failing to ensure residents positive for COVID-19 did not cohort with residents who were negative for COVID- 19. This resulted in Immediate Jeopardy on 08/08/22 when the facility failed to implement effective practices to prevent the spread of COVID-19 when two residents positive for COVID-19 were discovered to have roommates who did not have COVID-19. The lack of effective infection control practice placed two residents (Resident's #36 and #43) at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. The facility census was 110. On 08/18/22 at 4:52 P.M., the Administrator was notified Immediate Jeopardy began on 08/08/22 when the facility did not move two COVID-19 negative resident's (Resident's #36 and #43) out of COVID-19 positive residents' (Resident's #49 and #58) rooms. The Immediately Jeopardy was removed on 08/19/22 when the facility implemented the following corrective actions: · On 08/18/22 at 6:00 P.M. Resident's #36 and #43 were moved to into a room together and placed in quarantine per policy. Residents #49 and #58 were moved into a room together and placed on transmission-based precautions. · 08/18/22 Licensed Practical Nurse (LPN)'s #200 and #209 contacted the responsible parties for both Residents #36 and #43 and notified them of the room change and exposure. · On 08/18/22, LPN #209 audited all resident COVID-19 test results and verified no other COVID 19 positive residents resided in rooms with COVID-19 negative residents. · On 08/18/22 Registered Nurse (RN) #215 reviewed the facility's COVID-19 policies and determined the policies were within accordance with CDC recommendations and CMS guidance. · On 08/18/22, RN #215 reeducated the Director of Nursing (DON), RN #200 and LPN #209 on the facility's COVID-19 policies with special emphasis on the following: Residents who are positive for COVID-19 placed on transmission-based precautions in a room alone or cohorted only with another COVID-19 positive resident. Residents exposed to a COVID-19 positive roommate or another COVID-19 positive resident and not up to date on vaccinations will be placed in a private room in quarantine and tested . Residents who are exposed and up to date on vaccinations will not be placed in quarantine but will encouraged to wear source control and be tested . The responsible party of both the COVID-19 positive resident and the close contact will be updated. · On 08/18/22 the DON and LPN #209 completed a review of all residents in the facility to ensure all residents exposed or identified as close contacts that are not up to date on vaccines were placed in quarantine in accordance with the CDC recommendations. · On 08/18/22 RN #215 verified all current cases of COVID 19 were reported to the local health department. · On 08/19/22, the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, DON, RN's #200 and #215 and LPN #209 to discuss the above changes and plan of action. As of 08/19/22, the facility currently had four COVID 19 positive residents (Resident's #15 #42, #49 and #103). · On 08/19/22 the DON or designee will begin monitoring COVID 19 testing daily and verify any residents who test positive are placed in a private room on transmission-based precautions and the responsible party notified. The DON or designee will also monitor to ensure contact tracing or broad-based protocols are used to identify close contacts who are not up to date and ensure that those individuals are quarantined. · Interviews on 08/22/2 at 9:02 A.M. with LPN's #211 and #213, RN #210 and STNA #212 revealed all knew COVID 19 positive and negative residents were not to share a room. · Observation on 08/22/2 at 9:02 A.M. revealed Residents #49 and #58 roomed together and Residents #36 and #49 roomed together. Although the Immediate Jeopardy was removed on 08/19/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 had impaired cognition. Review of the immunization record revealed the resident refused the COVID-19 vaccine. Review of COVID-19 testing revealed the resident was tested on [DATE], 08/11/22, 08/15/22 and 08/18/22 and all results were negative. 2. Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition. Review of the immunization record revealed she received her second dose of the COVID-19 vaccine on 11/04/21. Review of COVID-19 testing revealed the resident was tested on [DATE], 08/10/22, 08/11/22, 08/15/22 and 08/18/22 and all results were negative. 3. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #49 had impaired cognition. Review of the nurses' notes revealed Resident #49 tested positive for COVID-19 on 08/10/22. 4. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #58 had impaired cognition. Review of the nurses' notes revealed Resident #58 tested positive for COVID-19 on 08/08/22. Review of the facility census revealed Resident's #36 and #58 resided in the same room, and Residents #43 and #49 resided in the same room. On 08/08/22, Resident #58 exhibited signs and symptoms consistent with COVID-19 and was administered a rapid COVID-19 test which came back positive. Resident #58's roommate (Resident #36) was also administered a rapid COVID-19 test because of Resident #58's positive test, and the results came back negative. As of 08/18/22, Resident #36 remained in the same room as Resident #58. On 08/10/22, Resident #49 had complaints of a dry, scratchy throat. A rapid COVID-19 test was administered which came back positive. Resident #49's roommate (Resident #43) was administered a rapid COVID-19 test because of Resident #49's positive test, and the results came back negative. As of 08/18/22, Resident #43 remained in the same room as Resident #49. Interview on 08/18/22 at 4:22 P.M. with LPN #209 revealed Resident's #36 and #43 were offered to move to a different room but chose not to. There was no notification to the families/representatives their roommates were positive for COVID-19, and there was no policy for residents who tested positive for COVID-19 residing with a resident who was negative for COVID-19. They did not ask Residents #49 and #58 if they wanted to move rooms because that has always been their room and to move them would place other residents in the facility at risk for contracting COVID-19. Interview on 08/22/22 at 3:37 P.M. with Resident # 43's daughter revealed her mother has lupus and is very susceptible to illness. She would have wanted her mother moved immediately had she known her roommate tested positive for COVID-19. Review of the facility policy titled COVID-19 preventative measures and management protocol for Ohio, revised 07/01/22, revealed effective cohorting of residents as a core principle of COVID-19 prevention. Review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 02/02/22, revealed ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. This deficiency substantiates Complaint Number OH 080.

Based on observation, interview, record review, and review of facility policy, the facility failed to timely complete a voiding trial, thoroughly monitor urinary output, assess abdominal discomfort or fullness, and properly treat Resident #82's urinary retention. Due to the delay in urinary retention treatment, actual harm occurred on 04/12/22 when Resident #82's abdomen was hard and distended, she grabbed her perineal area, winced and grimaced when her perineal area was touched, had 700 cc urine output when catheterized, the catheter was attached to a drainage bag and fifteen minutes later an additional 800 cc of urine drained into the bag. On 04/13/22 at 9:56 A.M. Resident #82's indwelling catheter was draining dark red, bloody urine, blood pressure was 96/50 with a pulse of 110 and was transported and admitted to the local hospital for evaluation. This affected one resident (Resident #82) out of three residents reviewed for catheter care and services. The facility census was 109. Findings include: Review of Resident #82's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's care plan dated 03/24/22, revealed Resident #82 had an indwelling catheter related to urinary retention, had a possible bladder mass noted in the hospital, and would be followed by urology for a possible cystoscopy (visualize bladder using endoscope). Resident #82 would remain free from catheter related trauma and would show no signs and symptoms of urinary infection through the review date. Interventions included to monitor for signs and symptoms of discomfort on urination and frequency; monitor and document intake and output per facility policy, monitor and document for pain and discomfort due to catheter; monitor, record and report to physician for signs and symptoms of urinary tract infection including pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color. Review of Resident #82's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 had severe cognitive impairment and required the extensive assistance of two staff members for bed mobility and toilet use, and had total dependence of two staff members for transfers. Resident #82 had an indwelling catheter. Review of Resident #82's urology office visit and physician orders on 04/01/22 included Resident #82 was to have a voiding trial, and to remove Resident #82's catheter no later than 7:00 A.M. and the same day she would need to have a renal ultrasound and a bladder ultrasound with a post void (urine) residual. If at anytime Resident #82 was unable to urinate and became uncomfortable it was alright to reinsert the catheter. The results of the ultrasound needed to be called to Urologist #610. The physician instructions were sent with Resident #82 when she returned to the facility. If the catheter was replaced Resident #82 would need monthly catheter changes and as needed. Review of Resident #82's progress notes from 04/01/22 through 04/07/22 did not reveal a voiding trial was initiated and did not reveal Urologist #610 was contacted regarding urology office visit and physician orders written on 04/01/22. Review of Resident #82's progress notes on 04/07/22 revealed Resident #82's incontinence brief was wet. Resident #82 had a catheter and the catheter was clogged and unable to be irrigated. Licensed Practical Nurse (LPN) #602 contacted Urologist #610's office for instructions. LPN #602 was instructed to begin the voiding trial and if Resident #82 failed the voiding trial the catheter was to be reinserted, and the ultrasound of the kidney and bladder cancelled. The note stated Resident #82 was incontinent of urine at 6:45 P.M. Review of Resident #82's physician orders on 04/07/22 revealed begin voiding trial today (04/07/22) and if Resident #82 did not void within eight hours reinsert the catheter and update urology. Additional orders revealed bladder and renal ultrasound with post void residual (PVR) related to retention of urine. Please send results to Urologist #610. Review of Resident #82's progress notes on 04/08/22 at 9:45 A.M. revealed mobile x-ray arrived for the kidney and bladder ultrasound. Review of Resident #82's ultrasound of the kidney and bladder reported on 04/08/22 at 3:51 P.M. revealed the prevoid volume measured 806 cc and Resident #82 could not void (urinate). The medical record contained no evidence the ultrasound results were sent to Urologist #610. Review of Resident #82's progress notes on 04/10/22 at 5:34 P.M. revealed Resident #82 had increased altered mental status, restlessness and fidgeting over the past two days. The notes stated Resident #82 was incontinent of urine and it was foul smelling. Orders from the physician for a urinalysis and a urine culture and sensitivity. Review of Resident #82's physician orders on 04/10/22 revealed collect urine for urinalysis and culture and sensitivity via sterile intermittent catheterization one time only for altered mental status. Additional orders revealed [MEDICATION(S)] tablet ([MEDICATION(S)]-[MEDICATION(S)]) 800-160 milligram, give one tablet via PEG (percutaneous endoscopic gastrostomy tube) tube two times a day for pending urinalysis, altered mental status, foul smelling urine for seven days, start after urinalysis was collected. Review of Resident #82's progress notes on 04/11/22 revealed several notes Resident #82's urine was unable to be obtained due to incontinence. A note at 2:14 P.M. revealed Resident #82 was straight cathed for a large amount dark amber cloudy urine and the urine was sent for a urinalysis and culture and sensitivity. Review of Resident #82's progress notes on 04/12/22 at 5:26 P.M. revealed Resident #82 appeared to be in discomfort and was grabbing her perineal area. Resident #82's abdomen was distended and hard, Resident #82 winced and grimaced when her abdomen was palpated and her urine was dark brown. Tylenol was given for pain, fluids were pushed throughout the shift through the PEG tube. A 16 french (size) catheter was inserted and an immediate return of 700 cubic centimeters (cc) of dark brown foul smelling urine returned. Fifteen minutes later after the catheter was attached to a drainage bag an additional 800 cc of urine drained into the bag. Would update urology on 04/13/22. Review of Resident #82's medical record on 04/12/22 at 8:17 P.M. revealed 500 cc of urine was obtained from the indwelling catheter drainage bag. Review of Resident #82's progress notes on 04/13/22 at 9:00 A.M. revealed Resident #82's indwelling catheter was draining dark red, bloody urine and her blood pressure was 96 (systolic) over 50 (diastolic), pulse was 110. Resident #82 was restless, alert, opened eyes, did not respond (not unusual), the physician was notified and orders were given to transport Resident #82 to the local Emergency Department. Resident #82 was transported to the Emergency Department at 9:56 A.M. Review of Resident #82's progress notes from 04/07/22 through 04/13/22 revealed documentation Resident #82 was incontinent, but there was no documentation about the amount of incontinence observed (small, moderate, large). Further review of the progress notes from 04/07/22 through 04/12/22 did not reveal documentation Resident #82's bladder was evaluated for discomfort, fullness. Review of Resident #82's progress notes from 04/08/22 through 04/13/22 (when Resident #82 was transported to the hospital) did not reveal documentation Urologist #610 was notified of the ultrasound results for her bladder and kidney. Interview on 04/27/22 at 3:28 P.M. with Licensed Practical Nurse (LPN) #602 revealed on 04/07/22 an unidentified State tested Nursing Assistant (STNA) reported to her Resident #82's incontinence brief was wet and she had an indwelling catheter. LPN #602 stated an attempt to irrigate Resident #82's catheter was unsuccessful, the catheter was clogged and removed, and she received physician orders to start a voiding trial. LPN #602 indicated Resident #82 was incontinent of a significant amount of urine after the catheter was removed and an indwelling catheter was not re-inserted. LPN #602 stated Resident #82 was incontinent over the next few days, her urine was foul smelling, a darker color in her incontinence brief, she notified the physician and received orders on 04/10/22 for a urinalysis and culture and sensitivity. LPN #602 indicated it was the end of her shift and she passed on to the night shift nurse the need to obtain Resident #82's urine for urinalysis and culture and sensitivity. The night shift nurse did not collect the specimen and the day shift nurse on 04/11/22 collected the specimen. LPN #602 stated on 04/12/22 an unidentified STNA told her Resident #82's urine was foul smelling, and a dark color when she changed the incontinence brief, and when Resident #82 was evaluated her abdomen was distended and firm. LPN #602 stated she called the physician and received orders to insert a catheter and if there was greater than 240 cc urine, leave the catheter in. LPN #602 stated she catheterized Resident #82, had a return of 700 cc of urine, attached a drainage bag, and Resident #82 drainage bag had another 800 cc of urine in it 15 minutes later. LPN #602 indicated the results of Resident #82's urinalysis and culture and sensitivity had not been reported yet, and the [MEDICATION(S)] was not started until 04/11/22, after the urine was collected for the culture and sensitivity. LPN #602 stated Resident #82 was incontinent of urine since 04/07/22 when the catheter was removed. Interview on 04/27/22 at 4:02 P.M. with LPN #602 revealed the results of Resident #82's ultrasound of her bladder and kidney should have been forwarded to Urologist #610, and she did not know if that had been done. LPN #602 indicated on 04/13/22 Resident #82's urine was very dark and bloody, she notified the physician and Resident #82 was transported to the local hospital Emergency Department. Interview on 04/28/22 at 11:47 A.M. with Family Member (FM) #611 revealed Urologist #610 was Resident #82's urology physician. Interview on 04/28/22 at 2:10 P.M. with the Administrator, Director of Nursing, Assistant Director of Nursing (ADON) #514, and Corporate Quality Assurance Nurse (CQAN) #612 revealed Resident #82 was incontinent of urine from 04/07/22 through 04/12/22 when the indwelling catheter was inserted. CQAN #612 stated Resident #82's urine collection for urinalysis and culture and sensitivity was unable to be obtained until 04/11/22 because she was incontinent. CQAN #612 stated [MEDICATION(S)] was started after the urine sample was collected. CQAN #612 stated Resident #82's ultrasound of bladder and kidney results should have been sent to Urologist #611 and that had not been done. Interview on 04/28/22 at 3:09 P.M. with ADON #514 revealed Resident #82's orders from Urologist #610 on 04/01/22 needed clarification because of issues with incontinence. ADON #514 stated Urologist #610 was called a couple times, but he didn't know if the calls were documented in the medical record. ADON #514 indicated Resident #82's catheter was clogged on 04/07/22 and removed. Review of the facility policy titled, Indwelling Urinary Catheter Removal For Voiding Trial, dated 01/2022, revealed the facility would follow instructions from the attending physician or urinary specialist for the voiding trials, including any orders to straight catheterize to assess for urinary retention, time between voiding for additional notification (usually between six to eight hours) and any other specific instructions such as bladder scan or bladder ultrasound. If the resident was incontinent the nursing staff would document the resident was voiding and the amount of incontinence noted. If no output or minimal output was noted with eight hours of the catheter removal the attending physician would be notified to obtain orders for a straight catheter insertion to assess for retention or to re-insert the catheter. The resident would be assessed for any complaints of pain or burning with urinary output or any discomfort in the abdominal and pelvic area and these would be reported to the physician.

Based on observation, record review and interview the facility failed to implement appropriate pressure reduction interventions for two residents (Residents #179 and #174) Actual harm occurred when Resident #179 developed an unstageable pressure ulcer and Resident #174 had a decline in healing of a pressure ulcer. This affected two of three residents reviewed for pressure ulcers. The facility census was 128. Findings include: 1. Closed record review revealed Resident #179 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #179 had severe cognitive impairment and required extensive assistance of one for bed mobility, transfers, toilet use, personal hygiene and bathing. Resident #179 was occasionally incontinent of bladder and continent of bowel. The MDS indicated Resident #179 was at risk for the development pressure ulcers due to impaired mobility and a fractured right forearm. Review of the plan of care indicated Resident #179's skin integrity would be monitored during activities of daily living and with weekly skin assessments. A review of the admission assessment dated [DATE] revealed Resident #179's skin was intact upon admission. Review of the admitting physician's orders [REDACTED].#179 every two hours while in bed. A telephone order dated 12/18/14 indicated a gel cushion was to be in the wheelchair. Review of the weekly skin assessments dated 12/12/14, 12/19/14, 12/25/14 and 01/02/14 indicated Resident #179's skin was intact. Review of the pressure ulcer weekly tracking grid dated 01/04/15 revealed Resident #179 had an unstageable (full thickness skin or tissue loss-depth unknown) pressure ulcer to the coccyx, first observed on 01/04/15, measuring 0.6 centimeters (cm) in length by 0.4 cm in width by 0.2 cm in depth. The wound bed had yellow slough (a layer or mass of dead tissue separated from surrounding living tissue) with the center measuring 0.3 cm in length by 0.3 cm in width and no drainage or odor. The periwound was red, and Resident #179 complained of pain. Resident #179 was noted to be resistive with hands on care, turning and getting out of bed. A review of the interdisciplinary team notes from 12/11/14 through 01/03/15 revealed no documented evidence of any skin concerns or of Resident #179's refusal to turn, reposition or get out of bed. Review of the discharge MDS dated [DATE] indicated Resident #179 had an unstageable pressure ulcer measuring 0.6 cm in length by 0.4 cm in width that was not present on admission to the facility. An interview with Registered Nurse (RN) #80, the facility wound care nurse, and RN #81 the facility corporate quality assurance nurse on 01/14/15 at 2:40 P.M. verified Resident #179 had developed an unstageable pressure ulcer while in the facility, had not documented or addressed Resident #179's refusal to be turned in bed and remained on a standard pressure reduction mattress rated for a Stage II wound after the unstageable wound was discovered. 2. Resident #174 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the admission physical assessment dated [DATE] revealed Resident #174 had a one cm in length by 1.2 cm in width scabbed area to the coccyx, staged as a Stage II (a lesion caused by unrelieved pressure that results in damage to the underlying tissue) pressure ulcer. A review of the weekly pressure ulcer tracking and assessment form dated 11/10/14 indicated Resident #174 had a Stage II pressure ulcer to the coccyx measuring 0.5 cm in length by 0.5 cm by 0.1 cm in depth. The wound was noted to be 100 percent red with a minimum amount of serous drainage and a moist periwound. The resident had complaints of pain. Resident #174 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the pressure ulcer tracking grid dated 11/27/14 indicated Resident #174 had a Stage III (Full thickness tissue loss) pressure ulcer to the coccyx measuring 1.2 cm in length by 0.6 cm in width by 0.1 cm in depth with a minimum amount of serosanguinous drainage with no odor, The wound bed contained 20 percent yellow slough in the right upper corner and was 80 percent red. The periwound was noted to be moist. Resident #174 had complaints of pain Review of the MDS dated [DATE] revealed Resident #174 had moderate cognitive impairment and required extensive assistance with bed mobility, transfers and hygiene. Resident #174 was frequently incontinent of urine and occasionally incontinent of bowel. The MDS indicated Resident #174 had a Stage III pressure ulcer to the coccyx measuring 1.2 cm in length by 0.6 cm in width x 0.1 cm in depth. A review of the weekly pressure ulcer tracking and assessment form dated 12/08/14 indicated Resident #174 coccyx wound had declined to an unstageable pressure wound with 100 percent yellow slough and a minimum amount of serous drainage and a moist periwound. The coccyx wound measured 1.2 cm in length by 0.6 cm in width by 0.1 cm in depth. Resident #174 had complaints of pain. A review of the weekly pressure ulcer tracking and assessment form dated 12/29/14 indicated an unstageable pressure ulcer to the coccyx measuring 1.0 cm in length by 0.7 cm by 0.1 cm in depth. The wound was noted to be 100 percent yellow slough with a minimum amount of serous drainage, no odor. The periwound was macerated (the softening and breaking down of the skin resulting from prolonged exposure to moisture) with an open skin tear. The resident had complaints of pain. A review of the weekly pressure ulcer tracking and assessment form dated 01/12/15 indicated Resident #174 pressure ulcer to the coccyx had improved to a Stage III ulcer measuring 0.8 cm in length by 0.4 cm by 0.1 cm in depth. The wound was noted to be 100 percent red with a minimum amount of serous drainage. The periwound was clear. During an observation of the coccyx pressure ulcer treatment on 01/14/15 at 2:31 P.M. Resident #174 was observed lying on a standard pressure reduction mattress that was indicated for a Stage II pressure ulcer or less. This observation was verified with RN #80 on 01/14/15 at 2:40 P.M.