Every finding on record at Otterbein Gahanna

Based on observation, staff interview, and facility policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect 16 (#7, #8, #12, #13, #14, #16, #20, #22, #28, #31, #35, #40, #44, #46, #49, and #51) of 16 residents residing in houses with 300 and 500 numbered rooms. The facility census was 52.Findings include: 1. Observation on 05/04/26 at 10:07 A.M., of one of the five campus kitchen refrigerators was conducted with Certified Nurse Aide (CNA) #165. Observation revealed multiple cheese products in the refrigerator were stored without open dates and the packaging was noted to use the cheese within three to five days after opening. The Italian cheese was received on 03/26/26 with no open date and expired 09/13/26. The whole milk mozzarella cheese was received on 04/04/26 with no open date. The non smoked provolone cheese was received on 04/17/26 with no open date. The finely cut Parmesan cheese was received on 04/17/26 with no open date and expired 09/01/26. The thick cut Mexican cheese was received on 04/24/26 with no open date, and the expiration date could not be seen. Additional refrigerated items also lacked complete labeling. The margarine was received on 05/01/26 with no open date and expired 09/19/26. The cottage cheese was received on 05/01/26 with no open date and a use by date of 05/27/26. The Amish potato salad was received on 04/24/26 with no open date and a use by date of 05/15/26. The hashbrowns and peas were received on 04/20/26 with no open date and no expiration date. Dry goods, including flour, powdered sugar, and brown sugar, were stored in containers that had no labels or dates. Interview on 05/04/26 at 10:30 A.M. with CNA #165 confirmed the items found in the refrigerator did not have open dates. She reported labels were placed on the items but were not fully filled out, and she was unsure of the correct process for labeling food. On 05/04/26 at 10:31 A.M. interview was conducted with Dietary Technician #499 and stated information about specific facility policies regarding food labeling could not be provided. During the interview, Dietary Technician #499 then instructed CNA #165 that all food items in the refrigerator must have a completed label with the received date, open date, and use by date. Review of food storage best practice policy, dated 09/2022, revealed foods that fall outside the given guidelines of four to seven days are to follow disposal guidelines per united states department of agricultural guidelines revealing butter at two months, salad dressing at three months, ketchup at one year, mayonnaise at two months. 2. Observation of the one of the five campus kitchens was conducted between 11:50 A.M. and 1:10 P.M. on 05/04/26. The kitchen storage room contained a package of Hawaiian sweet rolls that were dated with an expiration of 05/02/26 and a package of delicatessen (deli) rolls dated with an expiration of 04/29/26. The refrigerator in the resident facing part of the kitchen housed a container of cottage cheese labeled with an expiration of 04/28/26, an opened package of diced ham with no open date, and an open package of bacon with no open date. Interview with Dietary Technician #119 was conducted between 11:50 A.M. and 12:41 P.M. on 05/04/26. Dietary Technician #119 confirmed the expiration dates on the Hawaiian sweet rolls, deli rolls, and cottage cheese. Interview was conducted with Dietary Technician #119 at approximately 1:01 P.M. on 05/04/26 and confirmed the open package of diced ham and open package of bacon had no open date. Review of the facility food storage policy and procedure, revised May 2013, revealed all food was (to be) labeled and dated properly to assure stock rotation and prevent food illnesses.

Based on observation, resident interview, staff interview, medical record review, and review of a facility procedure, the facility failed to ensure residents received adequate and routine hair care. This affected one (#17) of three residents reviewed for personal care. The facility census was 52.Findings include:Review of the medical record for Resident #17 revealed an admission date of 05/26/21. Diagnoses included other sequelae of cerebral infarction, hemiplegia affecting the left non-dominate side, type II diabetes mellitus with diabetic neuropathy, major depressive disorder, chronic obstructive pulmonary disease, and atherosclarotic heart disease of a native coronary artery without angina pectoris.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact. The resident was assessed to require setup or cleanup assistance for eating, was dependent care for toileting, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and required substantial/maximal assistance for personal hygiene. The MDS assessment indicated there was no rejection of care behavior exhibited.Review of care plan for Resident #17, revised 12/16/21, revealed a focus area for activities of daily living (ADL) self-care and/or physical mobility performance deficit due to fatigue, hemiplegia, impaired balance, and shortness of breath. The focus noted Resident #17 had a right leg above the knee amputation. Interventions noted Resident #17 required assistance with bathing/showering and she wanted a sponge bath when a full bath or shower could not be tolerated. The care plan also noted Resident #17 required staff assist with personal hygiene and oral care.Observation and interview on 05/04/26 at 4:09 P.M. revealed Resident #17 was laying in bed and her primary care concern was her hair. Resident #17 stated her hair was matted and she could not sleep on it. She stated anytime the staff want to wash her hair she would tell them it was matted and she needed it fixed, but the staff never fix it. Observation of Resident #17's hair appeared uncombed and unwashed.Observation and interview on 05/05/26 at 4:34 P.M. revealed Resident #17 still had uncombed, unwashed hair. She stated she usually received bed baths but she did not remember on which days. Resident #17 stated she did not have one that day.Observation and interview on 05/06/26 at 11:12 A.M. revealed Resident #17 was in her room in bed with her hair remaining uncombed, unstyled, and sticking straight up in the air. She confirmed her hair was not washed the previous day when she had a bed bath. Resident #17 gave permission for the surveyor to bring a nurse aide into room to talk about her hair.On 05/06/26 at 11:35 A.M. a review of the shower sheet for Resident #17 dated 05/05/26 revealed no mention of hair care.Observation and interview on 05/06/26 at 11:33 A.M., revealed Certified Nurse Aide (CNA) #191 went into Resident #17's room with the surveyor and confirmed Resident #17 appeared to have unwashed hair and it should have been cared for when she had her bed bath the previous evening. CNA #191 confirmed the shower sheet did not have reference to hair care. CNA #191 stated she told Resident #17 she would help her get dressed. CNA #191 confirmed she had not done anything with the resident's hair that morning but would give Resident #17 a shampoo shortly.Observation and interview on 05/06/26 at 11:45 A.M. with Coach #108 confirmed resident hair should be washed as part of bathing. The surveyor and Coach #108 went to Resident #17's room to see her hair and Coach #108 confirmed it did not appear that her hair had been washed and it should have been as part of the bed bath. Coach #108 confirmed neither the online tracking for baths and showers nor the shower sheets had a space to indicate that a resident's hair was washed. Review of facility procedure titled, Tub baths and showers, revised 05/19/25, revealed no instructions regarding hair care.This deficiency represents non-compliance investigated under Complaint Number 2786179, Complaint Number 2581715, and Complaint Number 2682720.

Based on medical record review, review of dialysis documents, staff interview, and facility policy review, the facility failed to ensure required pre and post dialysis vital signs were completed as ordered. This affected one (Resident #1)of one residents reviewed for dialysis services. The facility census was 52. Findings include:Record review revealed Resident #1 was admitted on [DATE] with diagnoses including end stage renal disease, type II diabetes mellitus, morbid obesity, and acquired absence of the right leg below the knee.Review of the physician order dated 02/02/26 documented Resident #1 was to attend dialysis on Monday, Wednesday, and Friday, with a scheduled pick up time of 11:10 A.M. and treatment starting at 12:00 P.M.Review of the Minimum Data Set (MDS) assessment completed 03/31/26 indicated Resident #1 was severely cognitively impaired and dependent on staff for all activities of daily living (ADL) care needs.Review of the care plan initiated 11/10/25 revealed Resident #1 required monitoring of vital signs as directed, encouragement to attend scheduled dialysis appointments, monitoring for bleeding, infection, or complications at the dialysis access site, and monitoring and reporting of changes in condition related to renal disease and dialysis, including abnormal laboratory values, shortness of breath, edema, weight changes, and mental status changes.Review of physician orders dated 02/06/26 revealed Resident #1 was required to have a Pre Dialysis Communication Form completed every Monday, Wednesday, and Friday in the morning, and a Post Dialysis Communication Form completed every Monday, Wednesday, and Friday in the evening, with dialysis records received by the facility.Review of Resident #1's dialysis forms revealed no documentation of post dialysis vital sign assessments on 04/29/26, 04/24/26, 04/22/26, and 04/08/26, and no documentation pre dialysis vital signs on 04/24/26.Interview with the Director of Nursing (DON) on 05/11/26 at 5:43 P.M. confirmed Resident #1 had missed post dialysis vital signs on 04/29/26, 04/24/26, 04/22/26, and 04/08/26, and missed pre dialysis vital signs on 04/24/26. The DON further confirmed the resident's medical record did not contain documentation explaining why the vital signs were not completed. The DON also confirmed Resident #1 attended dialysis on all dates where vital signs were missed and the vital signs were required per physician order.Review of the dialysis policy, dated 11/17/25, revealed the facility was required to provide ongoing assessment and oversight of the resident before and after dialysis treatment, including monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices.

Based on observation, staff interview, and medical record review, the facility failed to ensure skin integrity interventions were implemented as care planned and ordered and failed to ensure medical appointments were scheduled and completed as required. This affected one (#22) of two residents reviewed for skin integrity and one (#40) of one residents reviewed for medical appointments. The facility census was 52.Findings include:1. Review of the medical record for Resident #22 revealed an admission date of 03/31/26 with diagnoses including metabolic encephalopathy, protein calorie malnutrition, type II diabetes mellitus, chronic kidney disease, anxiety, pressure ulcers of the left hip and other sites, and a history of falls.Review of the Minimum Data Set (MDS) assessment completed 03/31/26 indicated Resident #22 was severely cognitively impaired, dependent on staff for all activities of daily living (ADLs) care needs, at risk for pressure injuries, and utilized a pressure reducing mattress with ongoing wound care.Review of the care plan dated 03/31/26 revealed Resident #22 had impaired skin integrity and was at risk for further impairment due to diabetes mellitus, impaired cognition, altered nutritional status, weakness, decreased functional mobility, poor safety awareness, and a history of recurrent falls. Interventions included administering treatments as ordered and monitoring for effectiveness.Review of the Braden Scale document dated 04/30/26 revealed Resident #22 had slightly limited sensory perception, was constantly moist, was chairfast, had very limited mobility, probably inadequate nutrition, and had a potential problem with friction and shear, placing the resident at high risk for pressure injury.Review of the weekly skin observation document dated 04/29/26 revealed Resident #22 sustained a left antecubital skin tear measuring 0.75 centimeters (cm) in length by 0.5 cm in width, with treatment orders given.Review of Resident #22's physician order dated 04/30/26 revealed instructions to cleanse the left forearm wound with saline or wound cleanser, pat dry, apply calcium alginate with silver directly into the wound bed, and cover with a bordered foam gauze dressing every day shift.Review of the progress note dated 05/01/26 at 5:04 P.M. revealed a new skin alteration measuring 0.5 cm in length by 0.5 cm in width and 0.1 cm in depth. Treatment orders were received, and an order was obtained for geri sleeves (protective sleeves) to both upper extremities every shift.Review of Resident #22's physician order dated 05/01/26 confirmed geri sleeves were ordered to the bilateral arms each shift.Review of Resident #22's physician order dated 05/02/26 revealed a right lower arm alteration with instructions to cleanse the wound with saline or wound cleanser, pat dry, apply calcium alginate with silver directly into the wound, and cover with a bordered gauze dressing every shift.Observation on 05/04/26 at 10:33 A.M. of Resident #22 revealed bilateral arm dressings were in place and labeled 05/02/25. The resident was seated upright in a geri chair without protective sleeves in place as ordered.Interview on 05/04/26 at 12:20 p.m. with Certified Nursing Assistant (CNA) #165 confirmed the resident's dressings were dated 05/02/26 and that the resident was not wearing geri sleeves as ordered. CNA #165 reported she was unaware of how the resident obtained the skin alterations and did not know the resident was ordered to wear geri sleeves for skin protection.Interview on 05/04/26 at 12:21 p.m. with Neighborhood Concierge (NC) #177 confirmed Resident #22's dressing was dated 05/02/26 and the resident was not wearing geri sleeves. NC #177 stated she was unaware the resident required those devices.Interview on 05/04/26 at 12:22 P.M. with Social Worker #183 revealed Resident #22 had bilateral skin tears and the physician order required daily dressing changes. Social Worker #183 reported she was unsure if hospice had changed the order.2. Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, depression, and neuropathy.Review of the MDS assessment dated [DATE] revealed Resident #40 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. The resident was assessed to require staff assistance for bathing and grooming, and was independent for mobility.Review of the nursing progress notes for Resident #40 revealed the resident was admitted directly from a hospitalization from 12/17/25 through 12/22/25. Review of Resident #40's after visit summary dated 12/22/25 revealed the resident was directed to follow-up with a nephrologist within one month. Review of the nursing progress notes from 12/22/25 through 04/11/26 did not reveal any nephrology appointments for Resident #40.Review of Resident #40's medical record revealed the resident was hospitalized on [DATE] through 04/07/26.During an interview with the Director of Nursing (DON) on 05/11/2026 at 4:34 P.M. she confirmed she was not able to locate a nephrology or urology appointment for Resident #40 between 12/22/25, when she was discharged from the hospital to the facility, and 03/29/26, when she was re-admitted to the hospital.

Based on medical record review and staff interview, the facility failed to ensure treatments for pressure ulcers were completed as ordered. This affected one (Residents #22) of three residents reviewed for skin integrity. The facility census was 52.Findings include:Review of the medical record for Resident #22 revealed an admission date of 03/31/26 with diagnoses including metabolic encephalopathy, protein calorie malnutrition, type II diabetes mellitus, chronic kidney disease, anxiety, pressure ulcers of the left hip and other sites, and a history of falls.Review of the Minimum Data Set (MDS) assessment completed 03/31/26 revealed Resident #22 was severely cognitively impaired, was dependent on staff for all activities of daily living (ADL) care needs, was always incontinent, was at risk for pressure injuries, had five unstageable pressure ulcers (obscured full-thickness skin and tissue loss) and diabetic foot ulcers, and utilized a pressure reducing mattress with ongoing wound care.Review of Resident #22's nutritional screening document dated 04/06/26 revealed no nutritional concerns.Review of the wound physician note dated 04/22/26 revealed Resident #22 had an unstageable right lateral knee pressure ulcer measuring 1.5 centimeters (cm) long (L) by 1.6 cm wide (W) by 0.1 cm and deep (D) with a total surface area of 2.40 cm2. An updated order was entered for calcium alginate with silver and silicone foam border dressing to be changed once daily.Review of Resident #22's physician order dated 04/23/26 revealed instructions to cleanse the right knee with normal saline or wound cleanser, apply calcium alginate with silver directly into the wound bed ensuring full contact, and cover with a bordered foam dressing.Review of the Resident #22's April 2026 treatment administration record (TAR) revealed missed treatments for the right knee on 04/25/26, 04/26/26, 04/27/26, and 04/28/26.Review of the wound physician note dated 04/29/26 revealed Resident #22's right lateral knee ulcer measured 2.4 cm L by 2.2 cm W by 0.1 cm D with a total surface area of 5.28 cm2., and a change in treatment was ordered.Review of the Braden Scale document dated 04/30/26 revealed Resident #22 was slightly limited in sensory perception, constantly moist, chairfast, has very limited mobility, probably inadequate nutrition, and a potential problem with friction and shear, placing the resident at high risk for pressure injury.Review of Resident #22's physician order dated 05/02/26 revealed the resident was admitted to hospice services.Interview on 05/06/26 at 2:30 P.M. with the facility Wound Nurse and the Regional Nurse confirmed all information related to Resident #22's wound on the right knee, including the treatment frequency changed per the 04/22/26 wound physician note and that daily dressings were not documented as completed from 04/25/26 through 04/28/26. The Wound Nurse confirmed she was the nurse who rounded weekly with the Wound Nurse Practitioner and was responsible for entering wound care orders into the medical record. Interview on 05/06/26 at 4:54 P.M. with the Wound Nurse Practitioner revealed he was aware documentation did not show completion of the 04/25/26 through 04/28/26 right knee dressings for Resident #22's wound. He denied concerns, stating the dressing appeared clean and intact, and he believed treatments were completed. He confirmed the wound increased in surface area but felt it was related to the resident's decline and subsequent hospice admission. He denied concerns with the facility's wound treatment practices.This deficiency represents non-compliance investigated under Master Complaint Number 2963198, Complaint Number 2682720, Complaint Number 2581724, and Complaint Number 2581715.

Based on observation, resident and staff interview, and medical record review, the facility failed to maintain a homelike environment by ensuring interventions were in place per the care plan to prevent repeated uninvited and unwanted visitors into resident rooms. This affected one (Resident #17) of three residents reviewed for resident rights. The facility census was 52. Findings include:Review of the medical record for Resident #17 revealed an admission date of 05/26/21. Diagnoses included other sequelae of cerebral infarction, hemiplegia affecting the left non-dominate side, type II diabetes mellitus with diabetic neuropathy, major depressive disorder, chronic obstructive pulmonary disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact. The resident was assessed to require setup or cleanup assistance for eating, required dependent care for toileting, showering/bathing, upper body dressing, lower body dressing, and putting on/taking off footwear, required and substantial/maximal assistance for personal hygiene.Review of care plan for Resident #17, revised 12/16/21, revealed a focus area of activities of daily living (ADL) self-care and/or physical mobility performance deficit due to fatigue, hemiplegia, impaired balance, and shortness of breath. The focus noted Resident #17 had a right leg above the knee amputation. An intervention initiated 01/24/23 included a Velcro stop sign placed across the resident's door to deter wandering elders from coming in her room.Review of a care conference summary for Resident #17 dated 04/09/26 at 11:09 A.M. revealed a summary of social services included she just wanted an elder to stay out of her room.Observation on 05/05/26 at 4:34 P.M. revealed Resident #48 was in a wheelchair in Resident #17's room. Resident #17 was in bed. Resident #48 left the room upon surveyor arrival. The only sign on the door to the room belonging to Resident #17 was a sign for enhanced barrier precautions. Resident #48 did not sanitize his hands when he left the room.During an interview on 05/05/26 at 4:38 P.M., Resident #17 stated she did not want Resident #48 in her room. She stated did not matter whether the door was closed, he would just open it and come in. Resident #17 stated sometimes Resident #48 said he was going to bed but then he would not leave her room. Resident #17 stated Resident #48 did not touch her but he would talk and she could not hear her television.Review of the medical record for Resident #48 revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral atherosclerosis, dementia, Alzheimer's disease with late onset, chronic obstructive pulmonary disease, major depressive disorder, generalized anxiety disorder, psychotic disorder with delusions due to known physiological condition, peripheral vascular disease, human immunodeficiency virus (HIV).Review of the most recent MDS assessment dated [DATE] for Resident #48 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The resident was assessed to be independent on transfers, used a manual wheelchair, and required setup or clean-up assistance for wheeling 50 feet.Review of a care conference summary for Resident #48 dated 03/31/26 at 12:10 P.M. revealed in the social services section there was discussion about not going into other people stuff and room without gaining permission.During an interview on 05/06/26 at 11:45 A.M. Coach #108 (who manages nurse aides) stated Resident #48 was going into Resident #17's every night about a month ago and told him not to go in her room but the resident continued doing it. Coach #108 stated the nurse aides are supposed to check every hour and they should have caught that Resident #48 was in Resident #17's room. Coach #108 stated in the beginning Resident #17 liked Resident #48 being in her room. She stated she did not know why they were no longer using the Velcro barrier or why it was listed under ADLs on the care plan.During an interview on 05/06/26 at 3:08 P.M. Resident #17 stated she never said she liked or wanted Resident #48 to come into her room. She stated Resident #48 gets on her nerves and she cannot hear the television. Resident #17 stated the facility management told her they were going to address it and it still continued happening.During an interview on 05/07/26 at 7:02 A.M. Certified Nurse Aide (CNA) #186 stated he worked third shift and had seen Resident #48 in Resident #17's room after 11:00 P.M. more than twice. CNA #186 stated he was told by management to tell Resident #48 not to do that. CNA #186 stated when he would find Resident #48 in Resident #17's room, he would ask Resident #48 to leave. CNA #186 stated he knew Resident #17 did not want Resident #48 in her room, especially late at night when she was trying to sleep.During an interview on 05/07/26 at 11:02 A.M., the Administrator confirmed there had been previous discussion regarding how Resident #48 would go into the room of Resident #17. The Administrator denied that it was an ongoing concern and stated Resident #17 gave conflicting messages.Observation and interview on 05/07/26 at 12:49 P.M. revealed Resident #17 had an 8.5 inch wide by 11 inch long paper stop sign taped to her door. The door was open and Resident #17 was not in the room. CNA #191 confirmed the stop sign was to deter Resident #48 from entering the room. CNA #191 confirmed he could open doors and had a habit of going into Resident #17's room. During an interview on 05/11/26 at 5:26 P.M. CNA #188 stated Resident #48 had habit of going into Resident #17's room at least once per shift on most days. CNA #188 stated knew Resident #17 did not like it, so he would go in and ask Resident #48 to leave the room. CNA #188 stated it was the past couple of months that it had been happening.Observation and interview on 05/11/26 at 10:48 A.M. revealed a Velcro stop sign across the doorway of Resident #17's room. CNA #191 confirmed Resident #17 was unavailable for interview due to hospitalization.This deficiency represents non-compliance investigated under Complaint Number 2590038.

Based on medical record review and staff interview, the facility failed to accurately complete a level one Pre-admission Screening and Resident Review (PASARR) documents for residents with serious mental illness diagnoses as required. This affected two (#5 and #36) of two residents reviewed for PASRRs. The facility census was 52.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 03/04/25. Diagnoses included unspecified dementia, bipolar disorder (dated 04/15/25), and muscle weakness.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. The resident was assessed to require supervision or touching assistance for showering/bathing, setup or clean-up assistance for upper body dressing, supervision or touching assistance for lower body dressing and putting on/taking off footwear, and setup or cleanup assistance for personal hygiene. Resident #5 was noted to have bipolar disorder. Review of the care plan entry dated 11/10/25 for Resident #5 revealed the resident had a mood problem due to bipolar disorder.Review of the physician orders for Resident #5 revealed an order dated 11/13/25 for quetiapine fumarate (antipsychotic) tablet 25 milligrams (mg) to be given a half tablet (12.5 mg) at bedtime.Review of the PASARR form for Resident #5 dated 03/03/25 revealed, under Section E: Indications of serious mental illness, had no boxes checked. Additionally, under the question regarding psychotropic medications, no boxes were checked.2. Review of the medical record for Resident #36 revealed an admission date of 01/04/24. Diagnoses included hypothyroidism, disorganized schizophrenia (dated 01/04/24), hypertensive hear disease without heart failure, generalized anxiety, drug induced subacute dyskinesia, other specified phobia.Review of the MDS assessment dated [DATE] revealed Resident #36 had moderate cognitive impaired. The resident was assessed to require setup or cleanup assistance for eating and required dependent care for oral hygiene, toileting, showering, upper body dressing, lower body dressing, putting on footwear, and personal hygiene. Review of active diagnoses list revealed a diagnosis of schizophrenia.Review of facility medical record documentation for Resident #36 revealed the most recent PASARR on file was completed on 01/03/24. The document listed Resident #36 had a mood disorder and no other mental health diagnoses.Interview on 05/07/26 4:10 P.M. with Quality of Life Coordinator #183 and the Administrator confirmed the most recent PASRR for Resident #5 was completed on 03/03/25 and did not note the resident had bipolar disorder. They also confirmed Resident #5 had an order for quetiapine fumarate tablet 25 mg and the PASARR did not have anti-psychotics checked. Quality of Life Coordinator #183 also confirmed the most recent PASARR completed for Resident #36 was on 01/03/24, and it did not include the resident's diagnosis of schizophrenia. Quality of Life Coordinator #183 confirmed both Resident #5 and Resident #36's PASARR documents should have been completed and/or updated with accurate diagnoses and medications.

Based on medical record review, staff interview, and review of the Resident Assessment Instrument manual, the facility failed to complete a significant change Minimum Data Set assessment in a timely manner following the identification of a significant change in condition. This affected one (Resident #53) of one residents reviewed for significant changes. The facility census was 52.Findings include: Review of Resident #53's medical record revealed an admission date of 01/09/24 with diagnoses including cerebrovascular disease, hypertension, anxiety, and epilepsy. Review of a document titled, Residential Hospice Agreement, revealed Resident #53 was enrolled in hospice services on 03/03/26 with a terminal diagnosis of cerebrovascular disease.Review of current physician orders revealed Resident #53 had an order to admit to hospice with a terminal diagnosis of cerebrovascular disease on 03/04/26.Review of the significant change Minimum Data Set (MDS), with assessment reference date (ARD) 03/25/26, revealed Resident #53 had severe cognitive impairment. Continued review of the MDS assessment revealed Resident #53 experienced signs and symptoms of delirium including inattention and altered level of consciousness which fluctuated in frequency and severity during the seven day lookback period, which was indicated as a worsening in condition. Resident #53 was dependent on staff for all care. Resident #53 was receiving hospice services, which was indicated as a new service since the last MDS assessment.Review of the Resident Assessment Instrument (RAI) manual revealed a significant change in status assessment should be completed on the 14th day after determining that a significant change in resident condition occurred. The RAI manual provided guidance that the ARD should be no later than the determination date plus 14 calendar days.Interview on 05/11/26 at 4:33 P.M. with the Director of Nursing (DON) confirmed the significant change MDS assessment for Resident #53 should have had an ARD 03/18/26, which would have been the maximum of 14 calendar days after the identification of the significant change event on 03/03/26. The DON stated the facility did not have a MDS policy and followed the guidelines in the RAI manual.

Based on resident record review, review of pharmacy recommendations, and staff interviews, the facility failed to ensure pharmacy recommendations were reviewed and acted upon timely. This affected two (Resident #2 and Resident #8) of five residents reviewed for unnecessary medications. The facility census was 52.Findings include: 1. Review of the electronic medical record for Resident #2 revealed an admission date of 06/09/23 with diagnoses including dementia of unspecified severity without behaviors, bipolar disorder, insomnia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment with signs and symptoms of delirium present during the seven day lookback period. Further review of the MDS assessment revealed during the seven day lookback period, the resident experienced delusions indicating psychosis and physical, verbal, and other behaviors which impacted himself and other residents. Review of the pharmacist recommendation dated 10/17/25 revealed a recommendation to trial discontinue the medication bupropion 150 milligrams (mg) one tablet daily in the morning for depression and monitor the resident's response. On 10/22/25 the physician signed the recommendation agreeing to reduce the dosage to 100 mg daily. Review of the medication administration record (MAR) for October 2025 and November 2025 revealed Resident #2 continued to receive bupropion 100 mg daily until 11/20/25. Review of the pharmacist recommendation for Resident #2 dated 12/19/25 revealed a recommendation to change the dosage of divalproex 375 mg one tablet twice per day for bipolar disorder to 250 mg in the morning and 375 mg at bedtime and monitor the resident's response. The recommendation was signed by the Director of Nursing (DON) but was not dated and did not indicate agreement or disagreement with the recommendation. On 02/03/26, the recommendation was signed by Certified Nurse Practitioner (CNP) #419 agreeing with the pharmacist's recommendation. Review of Resident #2's MARs from December 2025 through May 2026 revealed on 02/03/26 the divalproex order was changed to 250 mg in the morning and 375 mg in the evening. Review of Resident #2's pharmacist recommendation date 03/25/26 revealed a recommendation to reduce the dosage of melatonin three (3) mg two tabs at bedtime (six (6) mg total) to five (5) mg total at bedtime. The recommendation was not responded to or signed by the physician. Review of Resident #2's MARs from March 2026 and April 2026 revealed Resident #2 continued to received melatonin 6 mg at bedtime until 04/06/26. On 04/07/26, the resident began receiving melatonin 5 mg at bedtime. Interview on 05/11/26 at 4:11 P.M. with the DON confirmed the recommended dosage reduction of bupropion was not completed until 30 days after the physician agreed to the recommendation. The DON confirmed the previous DON signed the pharmacy recommendation for divalproex and confirmed CNP #419 agreed with the recommendation and signed it on 02/03/26. The DON confirmed the divalproex reduction began on 02/03/26. The DON confirmed there was not a signed copy of the recommendation to reduce melatonin to 5 mg at bedtime. 2. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, dementia, hypertension, hyperlipemia, anxiety, bipolar disorder, and obstructive and reflux uropathy. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 6. Review of Resident #8's pharmacist recommendation dated 08/20/25 revealed a recommendation to trial a reduction the prescribed clonazepam 0.25 mg twice daily to once daily. The undated prescriber's response to the recommendation was an agreement of the recommendation. Review of Resident #8's physician orders revealed the order of clonazepam was changed to once daily on 04/28/26. Review of Resident #8's pharmacist recommendation dated 06/18/25 revealed a recommendation to trial a reduction of the prescribed divalproex 250 mg twice daily to once daily. The prescriber's response to the recommendation, dated 07/18/25, was an agreement of the recommendation. Review of Resident #8's physician orders revealed the order of divalproex was changed to once daily on 08/24/25. During an interview on 05/11/26 at 4:11 P.M. with the DON, she confirmed the reduction of Resident #8's clonazepam 0.25 mg was not completed until six months after the recommendation was sent. The DON also confirmed the recommendation to reduce the frequency of divalproex to once daily did not occur for Resident #8 until greater than 60 days after the recommendation was made. Review of the facility policy titled, Medical Regimen Review Policy, approved 11/13/17, revealed the physician or designee should respond to the recommendations within fourteen days of the pharmacist's review date, but no longer than the next regularly scheduled physician visit.

Based on medical record review and staff interview, the facility failed to ensure medications were administered as ordered to prevent significant medication errors. This affected two (Resident #13 and Resident #1) of three residents reviewed for medication management. The facility census was 52.Findings include:1. Review of the medical record for Resident #13 revealed an admission date of 12/16/25 and a readmission date of 04/25/26. Diagnoses included encephalopathy, osteomyelitis of the left ankle and foot, type one diabetes mellitus, acute kidney failure, and a non pressure chronic ulcer of the left foot with necrosis of bone.Review of hospital records dated 04/21/26 revealed Resident #13's hemoglobin A1C was 8.5 milligrams per deciliter (mg/dl).Review of Resident #13's hospital after visit summary dated 04/25/26 included an order for insulin thirty units injected once each morning.Review of Resident #13's care plan dated 04/25/26 documented a diagnosis of diabetes mellitus and interventions to administer diabetes medications as ordered, monitor for side effects and effectiveness, check blood sugar as ordered, and maintain the prescribed diet.Review of a progress note dated 04/26/26 at 6:48 A.M. documented Resident #13 arrived with the hospital order for insulin thirty units every morning. The nurse wrote she was concerned about the high dose, notified the on call provider, and was instructed to hold the insulin until the rounding provider clarified the order.Review of a physician order dated 04/26/26 revealed staff were to check Resident #13's blood sugar two times a day.Review of Resident #13's medication administration record (MAR) from 04/25/26 through 04/30/26 showed that no insulin was administered during this period.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively impaired, had one venous or arterial ulcer, and has a diagnosis of diabetes mellitus.Review of Resident #13's blood sugar results revealed blood sugar levels beginning immediately readmission to the facility on [DATE] included 171 mg/dL on 04/25/26 at 6:25 P.M.; on 04/26/26 the results were 200 mg/dL at 2:49 P.M. and 198 mg/dL at 7:27 P.M.; on 04/27/26 the results were 176 mg/dL at 10:53 A.M. and 364 mg/dL at 7:55 P.M.; on 04/28/26 the results were 215 mg/dL at 9:04 A.M. and 289 mg/dL at 8:26 A.M.; on 04/29/26 the results were 224 mg/dL at 10:05 A.M. and 247 mg/dL at 8:03 A.M.; on 04/30/26 the results were 243 mg/dL at 8:46 A.M. and 319 mg/dL at 9:40 A.M.; on 05/01/26 the results were 218 mg/dL at 10:09 A.M. and 270 mg/dL at 9:22 A.M.; on 05/02/26 the results were 148 mg/dL at 7:47 A.M. and 257 mg/dL at 8:43 P.M.; and on 05/03/26 the results were 228 mg/dL at 8:38 A.M., 228 mg/dL at 8:39 A.M., and 345 mg/dL at 8:18 A.M. All of these reading indicated elevated levels of blood sugar values.Review of a progress note dated 05/03/26 at 3:06 P.M. documented Resident #13 had a blood sugar of 323 mg/dL. The provider was notified and issued a one time sliding scale order, and four units of insulin were administered.Review of Resident #13's progress note dated 05/04/26 at 12:03 A.M. documented a blood sugar of 345 mg/dL. The provider was notified and eight units of insulin were given. At that time, a routine insulin order still had not been entered into the resident's medical record.Review of a physician order dated 05/04/26 was entered for Resident #13 to reveive Novolog FlexPen 100 units per milliliter to be used on a sliding scale. The order instructed staff to give two units when blood sugar was between 151 and 200 mg/dL, four units for 201 to 250 mg/dL, six units for 251 to 300 mg/dL, eight units for 301 to 350 mg/dL, and ten units for 351 to 400 mg/dL, and to notify the provider if the blood sugar was above 400 mg/dL.Review of Resident #13's medication administration record (MAR) showed insulin was administered routinely starting on 05/04/26 at 8:00 A.M.Interview on 05/07/26 at 3:43 P.M. with the Administrator and Assistant [NAME] President of Quality (AVPQ) #193 confirmed Resident #13's routine insulin was not followed up on upon readmission when the nurse identified insulin order was excessive until 05/04/26, and they confirmed two as needed insulin orders were placed on 05/03/26 and 05/04/26.Interview conducted on 05/11/26 at 3:59 P.M. with the Director of Nursing (DON) confirmed an insulin order for Resident #13 was not routinely administered until 05/04/26, and confirmed blood sugars acquired prior to that date would require insulin coverage per physician order. 2. Review of the medical record for Resident #1 revealed an admission date of 11/04/25 with diagnoses of end stage renal disease, type II diabetes mellitus, hypertension, and morbid obesity.Review of the care plan dated 11/10/25 revealed Resident #1 had altered cardiovascular status related to hypertension. Interventions included administering medications as ordered. The care plan also identified the resident received anticoagulant therapy and was at increased risk for bleeding. Interventions included administering medications as ordered and monitoring for side effects and effectiveness.Review of the physician order dated 11/04/26 revealed Eliquis 2.5 milligram (mg) oral tablet, one tablet by mouth two times a day for atrial fibrillation, with administration scheduled in the morning and evening.Review of Resident #1's MAR for January 2026 revealed Eliquis 2.5 mg was not administered during the evening administration on 01/26/26.Review of Resident #1's MAR for February 2026 revealed Eliquis 2.5 mg was not administered on 02/09/26 and 02/23/26 during morning administration.Review of Resident #1's MAR for April 2026 revealed Eliquis 2.5 mg was not administered on 04/24/26 during morning administration.Review of Resident #1's MAR for May 2026 revealed Eliquis 2.5 mg was not administered on 05/05/26 during morning administration.Interview with the DON on 05/11/26 at 5:43 P.M. confirmed she was unable to obtain additional information regarding Resident #1's missed Eliquis administrations on 01/26/26, 02/09/26, 02/23/26, 04/24/26, and 05/05/26. This deficiency represents non-compliance investigated under Complaint Number 2786179, Complaint Number 2734185, and Complaint Number 268270.

Based on observation, staff interview, medical record review, review of a drug manufacturer instructions, and facility policy review, the facility failed to ensure insulin pens were appropriately stored in medication cart. This affected one (#12) of one residents reviewed for insulin storage. The facility census was 52.Findings include:Review of the medical record revealed Resident #12 was admitted on [DATE] and had diagnoses that included type II diabetes, hemiplegia, and anemia. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact.Observation of the room temperature medication cart in one of the five campus houses was conducted at 9:15 A.M. on 05/05/26. There were two Novolog FlexPen insulin aspart 100 units per milliliter (u/mL) injector pens found in the medication cart. Both pens were labeled as belonging to Resident #12 and both were labeled as being opened 02/28/26.Interview with Licensed Practical Nurse (LPN) #163 at approximately 9:15 A.M. on 05/05/26 confirmed the Resident #12's insulin pens were labeled as opened on 02/28/26.Review of the manufacture information for Novolog FlexPens 100 u/mL, dated 2023, revealed that in-use (opened) products should be stored at room temperature for (up to) 28 days.Review of facility policy titled, Storage of Medications, dated January 2026, revealed medications are (to be) stored safely, securely, and properly following manufacturer's recommendations. Further review revealed outdated, contaminated, or deteriorated medications are (to be) immediately removed from inventory.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure laboratory (lab) services were timely in reporting lab results to meet resident needs. This affected one (#42) of three residents reviewed for bowel and bladder care needs. The census was 52.Findings include: Review of the electronic medical record for Resident #42 revealed an admission date of 12/19/24. Diagnoses included parkinsonism, type II diabetes, protein-calorie malnutrition, acute kidney failure, and retention of urine.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderate cognitive impairment, was always incontinent of bowel and bladder, and was dependent on staff for personal hygiene, toileting, and showering tasks.Review of nursing progress notes on 05/03/26 at 3:45 P.M. revealed Resident #42 complained of a burning sensation during urination. Vital signs were obtained and were reported to be within normal limits. The on-call physician was notified, and new orders were given to promote hydration, administer UTI-STAT (supplement to support urinary tract health), and to obtain a urinalysis with culture and sensitivity (UA C&S) to check for a urinary tract infection (UTI). The progress note revealed the UA C&S would be collected on regular lab day without indication of the specific date. The progress note also included education for nurses and nurse aides to monitor for changes including urination patterns, discomfort, altered mental status, and signs and symptoms of infection.Continued review of nursing progress notes on 05/05/26 at 2:10 A.M. (created and entered on 05/06/26 at 5:31 A.M.) revealed a urine sample was obtained from Resident #42 via straight catheterization and was sent to the lab. Further review of Resident #42's progress notes revealed no other notes related to possible UTI.Interview on 05/05/26 at 1:51 P.M. with Resident #42 revealed she had had a history of frequent UTIs but had not had any in the past two weeks. Resident #42 confirmed she had burning during urination recently and was tested for a UTI. Resident #42 stated she was feeling okay on this date.Observation on 05/07/26 at 12:52 P.M. revealed Resident #42 experienced nausea and vomiting during lunch. Certified Nurse Aide (CNA) #180 called the nurse, who administered anti-nausea medication at 1:12 P.M. and was reported as effective at 5:42 P.M.Review of Resident #42's medical record on 05/11/26 revealed lab results for UA C&S had not returned. Continued review revealed no other progress notes regarding Resident #42's status.Interview on 05/11/26 at 4:00 P.M. with the DON confirmed Resident #42's UA C&S had not been returned and confirmed lab results do not normally take that long to return. The DON confirmed she was not aware Resident #42 experienced vomiting on 05/07/26 and was not aware of Resident #42's current condition. At the time of exit on 05/13/26 at 10:50 A.M. the facility had not provided the results of Resident #42's UA C&S and the resident was not receiving further monitoring or treatment for a suspected UTI.

Based on observation, medical record review, emergency medical services run report review, hospital documentation review, staff interview, resident representative interview, and review of meal menus and food recipes, the facility failed to ensure a thorough procedure was implemented to ensure staff members did not serve food items to residents with specific food allergies and intolerances. This affected two (#64 and #23) of three residents reviewed for food allergies. The facility census was 52.Findings include: 1. Review of the medical record for Resident #64 revealed an initial admission date of 03/13/25 and discharge date of 04/04/25 with a readmission date of 06/27/25 and second discharge date of 07/12/25. Diagnoses included urinary tract infection, calculus of a kidney, type II diabetes mellitus with diabetic autonomic polyneuropathy, autoimmune thyroiditis, generalized anxiety disorder, and depression. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed she was cognitively intact. The resident was assessed to be independent on eating and oral hygiene and needed substantial/maximal assistance for toileting and showering; supervision or touching assistance for upper body dressing; and partial/moderate assistance for lower body dressing. Review of Resident #64' care plan initiated 03/13/25 revealed no care plan focus of food allergy in care plan. Review of the nutritional screen dated 03/24/25 at 1:49 P.M. revealed Resident #64 was noted to have an allergy to strawberries. Review of the physician progress note dated 03/17/25 revealed Resident #64 was allergic to sumatriptan, sulfasalazine, sulfamethozazole/trimethorprim, sulfa antibiotics, strawberry, penicillin G, and penicillin. Review of the progress note dated 03/20/26 at 5:01 P.M. revealed Resident #64 alerted a nurse to her face getting hot and her throat and tongue feeling swollen. The resident was questioned and Resident #64 informed the nurse of her eating ice cream of three flavors which included strawberries. The nurse alerted the certified nurse practitioner (CNP) with an order for epinephrine one (1) milliliter (mL) stat (immediately) given. The note revealed Resident #64 was resting in bed with symptoms improved and the physician, the Director of Nursing (DON), and family were all notified. Review of the progress note dated 03/20/25 at 6:49 P.M. revealed the nurse spoke with Resident #64's daughter about the swelling to the resident's mouth and tongue and spoke with the CNP and ordered stat 25 milligrams Benadryl and 40 milligrams prednisone. The nurse spoke with daughter about sending Resident #64 to the hospital, and the daughter stated they should monitor the resident and if anything changes they will send her to the hospital. Review of the progress note dated 03/21/25 at 6:53 A.M. revealed the nurse monitored Resident #64 all night with symptoms improving and the resident slept through night with no discomfort. Review of the progress note dated 03/24/25 at 2:35 P.M. revealed a nutrition note that Resident #64 had an allergy to strawberries. Review of the after visit summary dated 06/27/25 from Resident #64's hospitalization prior to her move back into the facility revealed the resident was noted to have an allergy to strawberry with facial swelling. Review of the care conference summary dated 07/02/25 for Resident #64 revealed in the nursing section a notation that said no strawberry as the resident was allergic to them. Review of progress note dated 07/06/25 at 6:38 P.M. for Resident #64 revealed the resident was alert and oriented with tingling of the tongue and slurred speech after dinner. Resident #64 and a family member requested to be sent to local hospital for evaluation and treatment. Review of the emergency department notes dated 07/06/25 for Resident #64 revealed the resident received 50 milligrams of Benadryl via intravenous (IV) route via emergency medical services (EMS) prior to arriving at the emergency department. Resident #64 arrived at the emergency department at 6:49 P.M. and was noted to have some wheezing. She was diagnosed as having an allergic reaction and was given a breathing treatment, Pepcid, and 125 milligrams of Solu-Medrol (fast-acting corticosteroid used to treat acute inflammation and severe allergies). Resident #64 was kept at the emergency room until 11:39 P.M. for monitoring. Per the after visit summary, Resident #64 was given new prescriptions for diphenhydramine (Benadryl), epinephrine 0.3 milligrams (Epipen), and famotidine (Pepcid). The after visit summary noted resident had allergy to strawberries with facial swelling. Review of the physician progress note dated 07/07/25 by Physician #300 revealed the notation that Resident #64 had an allergic reaction to strawberries the prior day. He noted she went to the hospital and was given IV Benadryl and breathing treatments. He wrote he asked the staff to put up a sign indicating the resident was allergic to strawberries. He documented the resident still had a scratchy throat that day and he would have her take an additional dose of Benadryl and additional vitamin C 1000 milligrams. Review of the provider progress note dated 07/08/25 at 8:00 A.M. revealed the provider saw Resident #64 as a follow up after a recent emergency room visit due to concerns for allergic reaction after drinking four to five ounces of strawberry juice. Per the note, the resident was told it was artificial flavoring but the resident felt her tongue was swelling and was having difficulty swallowing. Resident #64 was given Benadryl via EMS with improvement in symptoms once arriving to the emergency department. Review of the nutritional screen dated 07/08/25 at 4:18 P.M. revealed Resident #64 was noted to have an allergy to strawberries. During a telephone interview on 05/05/26 at 9:07 A.M., the daughter of Resident #64 stated when her mom was in the facility in March 2025, Resident #64 was served strawberries but did not eat them and then Neapolitan ice cream (chocolate, vanilla, strawberry). She said Resident #64 knew she was allergic to strawberries but her mom did not know the ice cream would affect her and when she had a reaction, the nurse was responsive and got an order for EpiPen and Benadryl. She said when Resident #64 returned to the facility in June 2025 she was served strawberry flavored juice and only took a sip and had a small reaction and so she told staff about it. The daughter stated the staff assured her they removed all the strawberry products. Then a few days later on 07/06/25, Resident #64 was served the juice again and had a more severe reaction from the juice. The daughter stated the nurse did not have Benadryl or an EpiPen and did not want to send her to the hospital. During an interview on 05/05/26 at 5:06 P.M., Dietary Technician (DT) #119 stated the Diet Type Report listed a resident's name, room number, diet type, consistency, allergies and any additional directions, and was printed on Thursdays or if there are changes and put in the front of the dietary binder at each house. DT #119 stated food coordinators meet with the elders on Tuesdays and order groceries on Wednesdays for new menus that start on Fridays. DT #119 stated with the Greenhouse Model (nursing home model with homelike setting), they still will have food that a resident was allergic to within the house and i was everyone's responsibility to make sure they check the list to ensure they are not giving a resident a food they are allergic to. During an interview on 05/07/26 at 1:08 P.M. Certified Nurse Aide (CNA) #191 stated she had the allergies memorized, but noted there are agency workers who may not check the binder for the resident's allergies. During an interview on 05/07/26 at 4:47 P.M. Coach #108 (who manages the CNAs) stated she knew about the situation with Resident #64's strawberry allergy but did not remember the dates. She stated she heard the resident who was allergic to strawberries was given fruit punch that had strawberries in it. Coach #108 did not know about the incident with the strawberry ice cream; she had only heard about the time the resident was served a bowl of strawberries and the punch. She stated they cleaned out the refrigerator and the pantry to remove the strawberries because they did not want any mistakes to be made. Coach #108 remembered talking to the nurse aides about checking the dietary sheets. Review of the undated four page instruction document for the CNAs on family style dining titled, Convivium (Family Style Dining), revealed a section titled, From start to finish, which included detailed instructions such as cook according to menu, cook enough food to serve your residents, modified diet textures get prepared and placed into their own serving dishes, and the dining room table gets wiped down and sanitized. Another section titled, Workflow of Elder Assistant duties, (with elder assistant (EA) the title given to this facility's CNAs) listed details such as both EAs start preparing and making meal in kitchen, one EA gets called to assist the elder, and the other EA continues with kitchen tasks. Another section titled, Diets and preferences, suggested alternate menu items for elders (residents) who do not like the primary menu item. The final page had a checklist of the elements that should be reviewed when serving with a yes or no column checklist. Items listed included questions about food appearance, whether the meal was passed family style, whether second helpings offered. Further review of the Convivium Family Style Dining instructions revealed no mention of checking food allergies while preparing or serving meals. During an interview on 05/11/26 at 10:30 A.M. the Administrator confirmed nurse aides and nurses were agency when the strawberry items were served last summer. She stated they did change the process, she just was not able to find the root cause analysis or the documentation of how the process changed. During an interview on 05/11/26 at 10:41 A.M., Dietician #305 confirmed there was no mention of checking allergies in the step-by-step instruction sheet on the Convivium documentation or checklist. He stated they take allergies very seriously and the training on allergies was covered in orientation. He was unsure of whether there was anything in orientation regarding how to identify signs of allergic reaction. Review of the undated Nutrition and Food Service orientation training on allergies included a single slide that revealed there were three places to check if the elder has food allergies including to check the diet order in the binder to see if the resident has any allergies, check the nutrition task in the electronic charting system, and ask the nurse as this was critical with new residents on the weekends and the dietary technician had not been in the neighborhood to print the new diet orders; this can be deadly so please check. During an interview on 05/11/26 at 11:31 A.M., the Administrator confirmed the orientation training on allergies was a single slide and the training information did not suggest when in the process of preparing or serving the food that the food allergies should be reviewed. She confirmed the Convivium Family Style Dining document also did not mention checking for allergies. During a telephone interview on 05/11/26 at 2:10 P.M., CNA #144 stated she remembered there was an incident with an resident who had a reaction to a strawberry drink. She said it was either herself or her partner who served the resident. CNA #144 stated she did not know the resident was allergic to strawberry. She stated it was always in the binder, but maybe she did not check. She stated after it happened the manager spoke to everyone. During an interview on 05/11/26 at 5:26 P.M. CNA #188 stated he had heard about Resident #64's strawberry allergy but did not know the details. He stated they had the resources to check allergies but he was not sure if everyone cared enough to check the binders. During a telephone interview on 05/12/26 at 12:51 P.M. Resident #64's daughter stated the first time her mom just took a sip of the juice in July 2025, the resident felt a tingling in her tongue and asked about it and they had confirmed it was strawberry flavor. She stated maybe they did not update the information but she knew she and Resident #64 had told the facility that the resident was allergic to anything strawberry flavored. She stated on 07/06/26, her mom was eating dinner in the room and was served the drink. She stated Resident #64 should have asked if the drink had strawberry but she could not fault her mom for trusting those who were caring for her. During an interview on 05/12/26 at 2:44 P.M., Licensed Practical Nurse (LPN) #311 said she still remembered Resident #64's face was red when she saw her after the resident had eaten the Neapolitan ice cream in March 2025. She stated Resident #64 did not know that she would have a reaction to the ice cream because it said artificial on the front but when they looked at the fine print of the ingredients they discovered it had real strawberries. LPN #311 stated she called the doctor and got an EpiPen and Benadryl order and was monitoring the resident every five minutes because she was worried about her. She stated she gathered the staff and let them know they needed to look at the ingredients to things. LPN #311 stated she was surprised even after she spoke with the staff about the severity of the allergy, she still caught staff walking to Resident #64's room the next day with a bowl of strawberries. She was grateful that she caught them before they gave it to her. 2. Review of the electronic medical record for Resident #23 revealed an admission date of 07/05/22 with diagnoses including senile degradation of the brain, severe protein-calorie malnutrition, dysphagia, and diverticulosis of the intestine. On 07/06/22, Resident #23 was identified as having moderate lactose intolerance which results in nausea. Review of the annual MDS assessment completed on 02/12/26 revealed Resident #23 had mild cognitive impairment and was independent with eating tasks. Review of Resident #23's physician orders revealed dietary orders for a regular diet, regular texture, and thin liquids. Further review revealed no other dietary alerts regarding lactose intolerance. Further review revealed no orders for anti-allergy medications (Benadryl, etc.), lactase enzyme supplements (Lactaid, etc.), or epinephrine to treat potential lactose intolerance. Review of Resident #23's care plan revealed the resident was at risk for changes to nutrition and hydration for reasons including lactose allergy with exceptions. There were no goals or interventions relating to the lactose allergy, severity, or offering non-dairy alternatives. Review of the lunch menu on 05/04/26 revealed the main entrée was pepperoni pizza casserole, a side salad, and garlic bread. Review of the dinner menu of the same day revealed the main entrée was a cheesesteak sandwich, onion rings, and mixed fruit. The dessert option was an ice cream bar. Observation on 05/04/26 at 1:02 P.M. revealed Resident #23 was served a portion of pepperoni pizza casserole for lunch. Observation on 05/04/26 at 4:33 P.M. revealed Resident #23 was served a cheesesteak for dinner. Interview on 05/04/26 at 4:45 P.M. with CNA #137 confirmed dinner was a cheesesteak and no alternates were served to residents in the house. Review of the lunch menu on 05/07/26 revealed the main entrée was lasagna, California blend vegetables, and garlic bread. Observation on 05/07/26 at 12:59 P.M. revealed Resident #23 was served a portion of lasagna, vegetables, and garlic bread. Interview on 05/07/26 at 1:02 P.M. with CNA #180 confirmed Resident #23 has a lactose allergy. CNA #180 stated the lasagna had no cheese in it. Review of the recipe for pepperoni pizza casserole revealed the entrée was made with eight cups of mozzarella cheese. Review of the recipe for lasagna revealed the entrée was made with 32 ounces of cottage cheese, three cups of mozzarella cheese, and 0.5 cups of parmesan cheese. Interview on 05/11/26 at 9:00 A.M. with the Administrator confirmed pepperoni pizza casserole, cheesesteak, and lasagna all contained cheese. This deficiency represents non-compliance investigated under Complaint Number 2562223.

Based on medical record review, resident and staff interview, review of the incident and accident log, and policy review, the facility failed to ensure weekly skin assessments were accurately documented in the medical record and failed to ensure the medical record was complete related to resident incident documentation. This affected one (Resident #1) of one residents reviewed for assessment accuracy. The facility census was 52.Findings include:1. Record review revealed Resident #1 was admitted on [DATE] with diagnoses including end stage renal disease, type II diabetes mellitus, morbid obesity, and acquired absence of the right leg below the knee. Review of Resident #1's physician order dated 11/04/25 revealed the resident was ordered weekly skin assessments to be completed by a licensed nurse. Review of Resident #1's care plan dated 11/05/26 identified the resident had potential impairment of skin integrity with interventions including completing weekly skin screens. Review of an assessment used to predict development of pressure ulcers dated 01/27/26 revealed Resident #1 had a moderate risk for pressure sore development.Review of a physician order dated 02/02/26 revealed Resident #1 was to attend dialysis on Monday, Wednesday, and Friday, with a scheduled pick up time of 11:10 A.M. and treatment starting at 12:00 P.M. Review of the Minimum Data Set (MDS) assessment completed 03/31/26 indicated Resident #1 was severely cognitively impaired, was dependent on staff for all activities of daily living (ADLs) care needs, was at risk for pressure injuries, and utilized a pressure reducing mattress with ongoing wound care.Review of a dialysis treatment record dated 04/22/26 revealed Resident #1 was at dialysis from 12:14 P.M. until 4:19 P.M.Review of a progress note dated 04/22/26 at 12:33 P.M. documented the wound physician intended to observe Resident #1's current skin alterations; however, the wound could not be assessed because the resident was at dialysis.Review of the weekly skin observation tool dated 04/22/26 at 12:40 P.M. revealed Resident #1's assessment was documented as completed, indicating no skin irregularities or new areas were present and current skin areas were being treated per physician orders.Interview with the Director of Nursing (DON) on 05/11/26 at 5:43 P.M. revealed the facility attempted to contact the nurse who documented Resident #1's skin assessment on 04/22/26; however, the nurse could not be reached. The DON confirmed the nurse could not have completed the assessment at the documented time because Resident #1 was not in the facility. The DON also confirmed the assessment omitted skin areas that were documented both the previous week (04/16/26) and the following week (04/27/26), and therefore the 04/22/26 assessment lacked legitimacy. Review of the facility's skin care management procedure, dated 12/09/22, revealed weekly skin assessments are to be completed and documented in the forms tab to identify new or potential areas of concern.2. Further review of Resident #1's medical record revealed progress notes from 04/22/26 through 04/25/26 with no documentation of a foot scan, swelling, injury, or assessment related to Resident #1's reported accident.Review of Resident #1's assessments from 04/22/26 through 04/25/26 revealed no skin check recorded.Review of Resident #1's physician order dated 04/23/26 revealed a diagnostic foot scan was ordered for a swollen foot and toes. Review of the radiology report dated 04/23/26 revealed no acute fracture was identified.Review of Resident #1's physician order dated 05/01/26 revealed instructions to monitor the left foot bruising and assess for pain, and to notify the nurse practitioner if the bruising did not heal.Review of Resident #1's progress note dated 05/01/26 at 1:59 P.M. revealed the results were sent to the nurse practitioner, and the foot issue appeared to be due to a chronic condition.Review of Resident #1's psychiatric note dated 05/01/26 revealed the resident reported a significantly swollen foot after striking it against a vehicle while facility staff were attempting to transport her to dialysis. The note documented that an x ray had been completed but results were not yet finalized, and the resident reported her foot was extremely swollen and she was unable to use it.Review of the incident and accident log from 04/20/26 through 04/25/26 revealed no documentation of an incident involving Resident #1.Interview with Resident #1 on 05/05/25 at 9:45 A.M. revealed the resident reported an accident occurred a couple of weeks prior. The resident stated she was waiting for staff to assist her out of the van and became impatient, then began moving her power wheelchair. She stated she misjudged the distance between her foot pedal and the back of one of the seats and struck her foot. The resident stated an x ray was completed to ensure her foot was not broken. She reported her foot was feeling better but still had some bruising.Interview on 05/11/26 at 2:05 P.M. with the Administrator, Director of Nursing, and Social Worker #183 confirmed Resident #1 had an order for an x ray of her foot due to swelling and bruising on 04/23/26. They confirmed the medical record contained no documentation pertaining to the incident, including skin assessments, physician notes, an accident report, interviews, or any investigation. The Administrator confirmed the medical record should contain detailed information regarding this event.This deficiency represents non-compliance investigated under Complaint Number 1397524 (OH00167475).

Based on observation, medical record review, staff interview, and review of a Centers for Disease Control and Prevention sign, the facility failed to ensure infection control measures were utilized for residents on enhanced barrier precautions. This affected one (#13) of eight residents reviewed for infection control. The facility census was 52.Findings include: Review of the medical record for Resident #13 revealed an admission date of 12/16/25 with diagnoses including encephalopathy, osteomyelitis of the left ankle and foot, type one diabetes mellitus, sepsis due to Escherichia coli, peripheral vascular disease, and a non pressure chronic ulcer of the left foot with necrosis of bone. Review of the care plan dated 04/26/26 revealed Resident #13 had impaired skin integrity related to a chronic vascular would of the left great toe, with interventions to utilize enhanced barrier precautions. Further review revealed staff will follow proper hand hygiene, don gloves and gown to minimize microorganism transmission, and remove personal protective equipment (PPE) prior to exiting when preforming high contact resident care activities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively impaired, dependent on staff for toileting, required substantial to maximal assistance for sit to stand transfers, was frequently incontinent of bowel and bladder, and had one venous/arterial ulcer. Review of Resident #13's physician order dated 04/28/26 directed staff to follow enhanced barrier precautions and to wear gloves and a gown when providing treatment or care related to the non pressure ulcer on the left foot. Observation on 05/04/26 at 2:55 P.M., revealed Certified Nurse Aide (CNA) #165 and CNA #140 entering Resident #13's room revealed both staff entered without applying PPE. A contact isolation sign was posted outside the resident's room instructing staff to put on PPE before entering. Observation and interview on 05/04/26 at 3:02 P.M. revealed CNA #165 and CNA #140 inside Resident #13's room without PPE. Both CNAs stated they had just removed Resident #13 from the toilet and were preparing to complete a pivot transfer into the bed. CNA #165 and CNA #140 completed the hands on transfer without wearing PPE, with their hands and lift belt in direct contact with the resident's clothing. Interview on 05/04/26 at 3:06 P.M. with CNA #165 and CNA #140 confirmed the signage was posted outside the room and that staff were required to apply PPE, including gloves and a gown, before providing care. Interview on 05/04/26 at 3:08 P.M. with Social Worker (SW) #183 confirmed PPE should be applied before entering Resident #13's room. SW #183 confirmed the signage was posted at the door. Interview on 05/07/26 at 5:02 P.M. with the Director of Nursing (DON) and SW #183 revealed Resident #13's isolation status of contact isolation was incorrect and was intended only for hypervigilance to prevent infection; however, staff were still required to follow enhanced barrier precaution guidance, which included wearing PPE during direct resident care due to the resident's wound. Review of undated enhanced barrier precautions signage from the Centers for Disease Control and Prevention (CDC) revealed staff are required to wear gloves and a gown for high contact resident care activities, including changing briefs, assisting with toileting, and transferring. This deficiency represents non-compliance investigated under Complaint Number 2581715.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents received appropriate care and services related to maintain adequate foot care. This affected one (#20) of one residents reviewed for foot care services. The facility's census was 52.Findings include:Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including depression, diabetes mellitus, hypertension, congestive heart failure, Parkinson's disease, history of falling, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed as dependent for toileting ,and bathing, moderate assistance for upper body dressing and dependent on staff for lower body dressing. Review of the care plan dated 02/06/26 revealed Resident #20 had a self-care deficit related to congestive heart failure, heart disease, and hypertension and required staff assistance with activities of daily living tasks.During an interview with Resident #20 on 05/04/26 at 4:05 P.M. she stated she had not had her toe nails cut in about a year. Resident #20 denied having a podiatrist visit during her facility stay. Observation of the toe nails on each of the resident's big toes revealed they had grown about 1/2 inch past the resident's toe.Review of the care conference notes dated 03/09/26 and 11/06/25 reflect no mention of podiatry services.During an interview with Social Worker (SW) #183 on 05/07/26 at 4:06 P.M., she confirmed Resident #20 had not been seen for any podiatry services because her son had not signed a release for the provider. SW #183 stated she sent the consent form to the resident's son on 08/08/25, but denied inquiring about the consent form since then. When asked why Resident #20 could not sign the consent herself based on her intact cognition, SW #183 stated she just noticed that and she had not considered the option.During a conversation on 05/11/26 at 11:21 A.M., with Resident #20 and Licensed Practical Nurse (LPN) #163, the resident mentioned her toe nails had gone so long without a trim that they have broken. She said the toe nails were causing her discomfort by scratching the skin on the sides of her toes. LPN #163 confirmed the resident's toe nails were long in length and said she would see about having someone cut her toenails. LPN #163 said due to the resident having diabetes mellitus, the facility's policy was that a provider must cut them.This deficiency represents non-compliance investigated under Complaint Number 2590038.

Based on record review, interview, and policy review, the facility failed to ensure a comprehensive, resident centered treatment plan was implemented to support identified needs related to enteral nutrition and failed to maintain appropriate parameters to accurately assess nutritional status. This affected two (Resident #44 and Resident #60) of three residents reviewed for nutrition. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #44 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia. On 03/18/25 Resident #44 weighed 228 pounds. A nutrition/dietary note dated 03/20/25 at 11:33 A.M. revealed Resident #44 was ordered nothing by mouth and received enteral support as the sole source of nutrition. Resident #44 received Osmolite (therapeutic nutrition that provided complete and balanced nutrition for tube feeding (enteral nutrition) residents) 1.5 cal (caloric density of 1.5 calories per milliliter) at 80 milliliter per hour (ml/hr) for 20-hours a day with 300 ml water flushes every four hours. Resident #44's weight had been more stable since mid-December after Resident #44 was ordered nothing by mouth. On 04/15/25 Resident #44 weighted 228 pounds. Review of the medication administration record (MAR) revealed on 04/21/25 at 8:00 AM the Osmolite 1.5 was marked with the number 9 which indicated to see other/progress notes. The administration note dated 04/21/25 at 3:52 P.M. revealed Osmolite 1.5 was not available. Further review of the MAR and progress notes revealed no evidence of the Osmolite being administered at a later time on 04/21/25 or the physician or registered dietician being notified Osmolite was not available for Resident #44. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #44 had cognitive impairment and required a feeding tube. An interview on 06/12/25 at 9:19 A.M. with Licensed Nursing Home Administrator (LNHA) verified the MAR was marked as the Osmolite was not administered. The LNHA stated she thought a case of Osmolite had been obtained from another facility around that time. The LNHA provided invoices for Osmolite. Review of invoice number (#)77582734 revealed Osmolite was ordered on 04/24/25 and delivered on 04/28/25. The LNHA stated an agency nurse had been working on 04/21/25 and multiple attempts had been made to contact the nurse to verify Osmolite had not been administered but the attempts were unsuccessful. Please note, the facility did not identify the agency nurse they had attempted to contact. An interview on 06/12/25 at 2:24 P.M. with Registered Dietician (RD) #502 verified he was not notified Resident #44 did not receive Osmolite on 04/21/25. On 06/12/25 at 3:27 P.M., the Director of Nursing (DON) contacted the surveyor and stated Licensed Practical Nurse (LPN) #155 had worked on 04/22/25 and reported that a new nurse (unidentified) worked 04/21/25 and was unable to find the Osmolite, but the Osmolite was available in the store room. An interview on 06/12/25 at 5:01 P.M. with LPN #155 revealed she had worked day shift on 04/22/25 and a new nurse (unidentified) had worked on 04/21/25. LPN #155 stated the new nurse could not find the Osmolite that was in the storage room but the Osmolite was available. LPN #155 stated she worked 04/22/25, 04/23/25, and 04/24/25 and noticed the Osmolite was almost gone on 04/24/25 so pharmacy drop shipped the Osmolite. On 06/13/25 at 10:56 A.M. the DON notified the surveyor that it was not an agency nurse but according to the schedule facility nurse LPN #131 worked on 04/21/25. LPN #131 used an agency badge to log into the computer because she did not have a facility badge. The DON verified the documentation revealed Osmolite was not administered and there was no documentation of the physician or registered dietician being notified. An interview on 06/13/25 at 11:07 A.M. with LPN #131 stated she was a facility nurse but used an agency nurse badge to log in to document in the electronic medical record on 04/21/25. LPN #131 stated she documented incorrectly and the Osmolite was administered to Resident #44. LPN #131 verified she had documented the Osmolite was not available and was not administered but was unable to say why there was no documentation in the medical record to support that the Osmolite was administered on 04/21/25. Review of enteral tube feeding, continuous, gastrostomy and jejunostomy policy revised 11/18/24 revealed documentation associated with gastrostomy and jejunostomy continuous enteral tube feeding problems or complications include the name of the practitioner notified, date and time of the notification, prescribed interventions, and the response to those interventions. 2. Review of the medical record revealed Resident #60 was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses that included osteoarthritis of right knee, hypertension, type 2 diabetes, shortness of breath, seizures, major depressive disorder, neurocognitive disorder with Lewy Bodies, dementia, chronic obstructive pulmonary disease, and retention of urine. Plan of care dated 03/21/25 revealed Resident #60 was at risk for malnutrition. Interventions included diet as ordered, monitor oral intake and document any negative findings, and monitor weight weekly for one month and then monthly. An order dated 03/21/25 revealed Resident #60 was to be weighed weekly for four weeks on Mondays. On 03/21/25 Resident #60 weighed 239 pounds. The Medicare 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #60 was cognitively intact. The medical record revealed no evidence of Resident #60 being weighed after 03/21/25. An interview on 06/12/25 at 1:36 P.M. the DON verified Resident #60 was not weighed weekly as ordered. The weight policy dated 12/02/21 revealed people will be weighed weekly for the first four weeks to establish a baseline weight. If weekly weights are requested, they will be done on a daily basis or weekly based on the day the initial weight was obtained. The weight will be recorded in the electronic medical record. This deficiency represents non-compliance investigated under Complaint Number OH00164452.

Based on observation, record review, interviews, and policy review, the facility failed to provide a comprehensive and individualized pressure ulcer plan to aid in the prevention and/or treatment of pressure ulcers. This affected two (Resident #4 and #50) of three residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnosis that included multiple fractures of pelvis, osteoporosis, and psoriasis. An admission summary dated [DATE] at 6:35 P.M. revealed Resident #4 was admitted to the facility with a pelvic fracture and open reduction and internal fixation of the left hip. Resident #4 had a pressure ulcer to the coccyx. A new skin observation form dated 04/30/25 at 11:47 P.M. revealed Resident #4 was admitted with a skin tear to the coccyx that measured two centimeters (cm) long and one cm wide and surgical incision to the left thigh. An admission screen and baseline care plan dated 05/01/25 at 1:42 A.M. revealed Resident #4 had an area to the coccyx. No description or measurement of the area was documented. A plan of care dated 05/01/25 revealed Resident #4 had the potential for skin breakdown and was admitted with a surgical wound to the left hip. Interventions included treatments as ordered and turn and reposition frequently and as needed, moisture barrier to perineal and buttocks after incontinence, and weekly skin screening. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had cognitive impairment and a Stage III (full thickness skin loss) pressure ulcer that was present upon admission. The initial wound evaluation dated 05/06/25 revealed Resident #4 had a Stage III pressure ulcer to the sacrum that measured 5.5 cm long, 2.8 cm wide, and 0.1 cm deep. There was a moderate amount of serous (thin, watery, and clear or slightly yellow fluid) exudate. A treatment was put in place for the wound to be cleansed, patted dry, calcium alginate (highly absorbent to maintain a moist wound environment) applied and covered with a gauze island bordered dressing. Recommendations included a low air loss mattress to be put in place. Review of physician orders revealed treatment orders were entered on 05/06/25 but an order for a low air loss mattress was not provided. A plan of care plan updated on 05/09/25 revealed Resident #4 had the potential for skin breakdown. Resident #4 was admitted with a Stage III pressure injury to the sacrum and a surgical wound to the left hip. Interventions included treatments as ordered, turn and reposition frequently and as needed, moisture barrier to perineal and buttocks after incontinence, and weekly skin screening. A wound evaluation dated 05/15/25 revealed Resident #4 had a Stage III pressure ulcer to the sacrum that measured 4.5 cm long, two cm wide, and 0.1 cm deep. An observation on 06/04/25 at 12:25 P.M. of the treatment to Resident #4's sacrum revealed no concerns. An air mattress was not observed to Resident #4's bed. An observation on 06/11/25 at 12:28 P.M. revealed an air mattress was not in place to Resident #4's bed. An interview on 06/11/25 at 12:33 P.M. with Certified Nursing Assistant (CNA) #106 revealed she frequently provided care for Resident #4. CNA #106 verified Resident #4 did not have a low air loss mattress and CNA #106 could not recall there ever being one to Resident #4's bed. An interview on 06/12/25 at 9:26 A.M. with the Director of Nursing (DON) verified Resident #4 was admitted on [DATE] and a skin tear was documented to Resident #4's coccyx. The DON verified there was no documentation of a treatment to Resident #4's coccyx. The DON also verified a treatment was not put in place until 05/06/25 when Resident #4 was evaluated by the wound doctor on 05/06/25. The area was identified as a Stage III pressure ulcer to Resident #4's sacrum. The DON verified there was not an order put in place for the low air loss mattress as recommended by the wound doctor on 05/06/25. 2. Review of the medical record revealed Resident #50 was admitted on [DATE] with diagnoses that included atrial fibrillation, mild protein-calorie malnutrition, disorders of bone density, and dysphagia. A physician order dated 09/25/24 revealed Resident #50 was to have a low air loss mattress in place. A plan of care dated 10/03/24 revealed Resident #50 had actual impairment to skin integrity of the sacrum. Interventions included keep skin clean and dry, monitor location, size, and treatment of skin injury, a low air loss mattress, and treatment documentation was to include the measurement of each area of skin breakdown included the width, length, depth, type of tissue and exudate and any other notable changes or observations. Weekly skin screenings were to be completed. Further review of the medical record revealed a wound management summary dated 01/28/25 that indicated the Stage III pressure ulcer to Resident #50's sacrum was resolved. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 had severe cognitive impairment. The MDS also revealed Resident #50 was at risk for the development of pressure ulcers. Resident #50 had no current pressure ulcers. Review of the Body audit forms dated 05/04/25, 05/07/25, 05/11/25, and 05/14/25 revealed no skin concerns. A shower sheet dated 05/19/25 revealed no skin concerns. A weekly skin assessment dated [DATE] revealed Resident #50 had an on going open area to the coccyx. There was no additional information regarding the pressure ulcer. A nursing note dated 05/31/25 at 4:10 P.M. revealed Resident #50 had a red rash on their back. A skin assessment was completed and two small open areas were also found to Resident #50's coccyx. The one open area measured 0.5 cm long, 0.3 cm wide, and the other measured one cm long and 0.8 cm wide. The wound doctor was notified and the areas were cleansed with normal saline, calcium alginate was applied, and the area was covered with a gauze island bordered dressing A wound evaluation and management summary dated 06/01/25 revealed at the request of the referring provider, a thorough wound care assessment and evaluation was performed. Resident #50 had a Stage III pressure ulcer to the sacrum that measured 2.7 cm long, 2.3 cm wide, and 0.2 cm deep. There was moderate serous exudate. The area was to be cleansed with normal saline, calcium alginate applied, and covered with a bordered gauze. A low air loss mattress was to be in place. The summary revealed Resident #50 weighed 116 pounds. An observation on 06/04/25 at 8:54 A.M. revealed Resident #50's air mattress was beeping and flashing and had an error code. An observation and interview on 06/04/25 at 10:23 A.M. with Licensed Practical Nurse (LPN) #155 verified the low air loss mattress to Resident #50's bed was making a beeping sound and showed an error code. Interview on 06/04/25 at 2:06 P.M. with Licensed Nursing Home Administrator (LNHA) verified the bed had been fixed that morning after surveyor intervention. An observation and interview on 06/04/25 at 2:19 P.M. the DON verified the air mattress setting for Resident #50 was set for a person that weighed 210 to 220 pounds. The DON verified Resident #50 weighed probably between 110 and 120 pounds. An additional interview on 06/11/25 at 8:35 A.M. with the DON verified a skin assessment on 05/26/25 revealed Resident #50 had an open area to the coccyx and the medical record revealed no further documentation of the open areas or a treatment being put in place until 05/31/25. The DON stated the wound physician evaluated Resident #50 on 06/01/25 and identified the two areas as one area and put a treatment in place at that time. Review of the skin assessment policy dated 11/17/22 revealed a thorough head to toe skin assessment was to be completed upon admission, weekly, upon any identified significant change and as needed. Review of the skin management procedure revised 12/09/22 revealed staff should remain alert to potential changes in the skin condition and should evaluate and document the identified changes: an evaluation of the site, the status of the area around the ulcer, and presence of possible complications. The physician will be notified of all skin areas of concern and consulted for treatment orders. The use of the wound clinic or specialist may occur for those areas in which the physician makes a referral. This deficiency represents non-compliance investigated under Complaint Number OH00164452.

Based on record review, interviews, and policy review, the facility failed to notify the physician and/or registered dietician when Resident #44 did not have physician ordered enteral nutrition available and failed to report Resident #48's weight loss. This affected two (Resident #44 and Resident #48) of three residents reviewed for change in condition. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #44 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia. On 03/18/25 Resident #44 weighed 228 pounds. A nutrition/dietary note dated 03/20/25 at 11:33 A.M. revealed Resident #44 was ordered nothing by mouth and received enteral support as the sole source of nutrition. Resident #44 received Osmolite (therapeutic nutrition that provided complete and balanced nutrition for tube feeding (enteral nutrition) residents) 1.5 cal (caloric density of 1.5 calories per milliliter) at 80 milliliter per hour (ml/hr) for 20-hours a day with 300 ml water flushes every four hours. Resident #44's weight had been more stable since mid-December after Resident #44 was ordered nothing by mouth. On 04/15/25 Resident #44 weighted 228 pounds. Review of the medication administration record (MAR) revealed on 04/21/25 at 8:00 AM the Osmolite 1.5 was marked with 9 which indicated to see other/progress notes. The administration note dated 04/21/25 at 3:52 P.M. revealed Osmolite 1.5 was not available. Further review of the MAR and progress notes revealed no evidence of the Osmolite being administered at a later time on 04/21/25 or the physician or registered dietician being notified Osmolite was not available for Resident #44. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #44 had cognitive impairment and required a feeding tube. An interview on 06/12/25 at 9:19 A.M. with Licensed Nursing Home Administrator (LNHA) verified the MAR was marked as the Osmolite was not administered. An interview on 06/12/25 at 2:24 P.M. with Registered Dietician (RD) #502 verified he was not notified Resident #44 did not receive Osmolite on 04/21/25. On 06/13/25 at 10:56 A.M. the DON verified the documentation revealed Osmolite was not administered and there was no documentation of the physician or registered dietician being notified. Review of notification of change of condition policy revised 11/22/21 revealed the facility will immediately inform the resident, consult with the resident's physician, nurse practitioner or clinical nurse specialist, and resident representative when there is a need to alter treatment significantly such as the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. Review of enteral tube feeding, continuous, gastrostomy and jejunostomy policy revised 11/18/24 revealed documentation associated with gastrostomy and jejunostomy continuous enteral tube feeding problems or complications include the name of the practitioner notified, date and time of the notification, prescribed interventions, and the response to those interventions. 2. Review of the medical record revealed Resident #48 was admitted on [DATE] with diagnoses that included senile degeneration of brain and vascular dementia. On 04/07/25 Resident #48 weighed 189 pounds Review of a plan of care dated 04/08/25 revealed Resident #48 was at risk for malnutrition. Interventions included to offer a substitute if Resident #48 did not like what was being served. If food intake decreased, family and friends would be encouraged to bring in food and fluids that Resident #48 liked. Review of the admission MDS dated [DATE] revealed Resident #48 had significant cognitive impairment and had no weight loss. A nutrition/dietary note dated 04/15/25 at 4:40 P.M. revealed Resident #48 received a no added salt diet. Resident #48's meal intakes varied from 50 to 75-percent, and Resident #48 weighed 189 pounds. No new recommendations were made at this time. Review of the resident's weights revealed: On 04/22/25 Resident #48 weighed 188 pounds. On 04/23/25 Resident #48 weighed 178 pounds. On 04/29/25 Resident #48 weighed 176 pounds On 05/01/25 Resident #48 weighed 176 pounds On 06/09/25 Resident #48 weighed 180 pounds. An interview on 06/12/25 at 9:12 A.M. with the DON and the LNHA revealed an agency nurse worked on 04/07/25 and 04/22/25. The agency nurse was contacted after the surveyor inquired about the weight loss and the nurse stated they remembered that they typed in the wrong weight on 04/07/25 and 04/22/25. The LNHA verified there was nothing in the medical record indicating the weights had been entered incorrectly on 04/07/25 and 04/22/25. The DON verified the EMR revealed Resident #48 had a 10 pound weight loss in one day and 12 pound weight loss in seven days without anyone being made aware of the weight loss. The DON stated the registered dietician would usually be notified of weight changes and would review the weight changes at least weekly. The DON verified the last nutrition/dietary note was dated 04/15/25. Review of notification of change of condition policy revised 11/22/21 revealed the facility will immediately inform the resident, consult with the resident's physician, nurse practitioner or clinical nurse specialist, and resident representative when there was a significant change in the resident's physical, mental, or psychosocial status. Review of the weight policy dated 12/02/21 revealed the food coordinator, DON/Health Care Coordinator (HCC), and/or Dietician/Tech will request reweighs for those persons with significant weight changes (5% in 30 days or 10% in 180 days) and/or fluctuation for three to five pounds. The reweighs will be completed by the 10th of the month. If a significant weight change was noted, the dietitian and/or diet technician will then proceed with the following as appropriate: observe person regarding weight change, speak with person at mealtime, make recommendations for interventions, and document in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00164452.

Based on record review, hospital record review, interview, and policy review, the facility failed to ensure medications were necessary prior to administration and were administered per orders, non-pharmalogical interventions were attempted prior to administration of as needed pain medication and residents did not experience adverse effects from prescribed medications that resulted in hospitalization. This affected one (Resident #60) of three residents reviewed for narcotic medication use. The facility census was 54. Findings include: Review of the hospital prescription (from the resident's hospitalization prior to admission to the facility) dated 03/19/25 revealed Resident #60 was ordered Dilaudid two milligram (mg) every four to six hours as needed for pain. Review of the medical record revealed Resident #60 was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses that included osteoarthritis of right knee, hypertension, type 2 diabetes, shortness of breath, seizures, major depressive disorder, neurocognitive disorder with Lewy Bodies, dementia, chronic obstructive pulmonary disease, and retention of urine. Review of physician orders revealed Resident #60 was ordered Flexeril (muscle relaxer), hydroxyzine (antihistamine) 25 mg at bedtime for itching, Buspar (antianxiety) five mg three times a day, Cymbalta (antidepressant) 20 mg twice a day, Dilaudid two mg give one mg every four hours as needed for pain from 03/21/25 through 03/25/25, pain monitoring included observe for pain. If pain was present, treat trying non-pharmacological interventions prior to medicating if appropriate, such as an ice pack, warm compress, repositioning, massage, distraction activity, and other. Document interventions in the progress note and document the number of interventions tried every shift. Resident #60 was also ordered Celebrex (nonsteroidal anti-inflammatory) 200 mg every 24 hours as needed for pain, Abilify (antipsychotic for major depressive disorder) two mg daily, Effexor (antidepressant) 225 mg at bedtime, and Trazodone (antidepressant) 250 mg at bedtime. Review of the medication monitoring/control record revealed Resident #60 was ordered Dilaudid two mg by mouth every four to six hours as needed for pain. The medication monitoring/control record revealed Resident #60 was administered Dilaudid two mg on: 03/22/25 at 2:00 P.M. 03/23/25 at 9:41 P.M. 03/24/25 at 10:00 A.M. 03/24/25 at (illegible time) 03/25/25 at 2:00 P.M. Review of the medication administration record (MAR) revealed Resident #60 was ordered Dilaudid one mg every four hours as needed for pain from 03/21/25 to 03/25/25. The only documentation on the MAR for Dilaudid one mg being administered was on 03/23/25 at 9:41 P.M. for a seven out of ten (on a 0-10 pain scale with 0 indicating no pain and 10 indicating the worst pain the resident has felt) pain rating. The MAR revealed no documentation of Celebrex being administered from 03/22/25 to 04/01/25. The Medicare 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #60 was cognitively intact. The MDS also revealed Resident #60 received antipsychotic, antianxiety, antidepressant, and opioid medications. On 03/26/25 a new order was received to discontinue Resident #60's Dilaudid one mg every four hours as needed and to start Dilaudid two mg twice a day for pain. The medication monitoring/control record revealed Resident #60 was administered Dilaudid two mg on 03/26/25 at 2:00 P.M. Resident #60 was administered Dilaudid two mg twice a day on 03/27/25 through 03/30/25. The MAR revealed Resident #60 was administered Dilaudid two mg twice a day from 03/26/25 at 2:00 P.M. to 03/31/25 at 9:00 A.M. for zero out of ten pain. A DON/Health Care Coordinator Note dated 03/31/25 at 4:40 P.M. revealed the DON and physician had an in-depth conversation with Resident #60's son-in-law. Resident #60's medications were reviewed and several medications were reduced in milligrams and some were discontinued. Resident #60 had increased lethargy and altered mental status. The physician explained that the amount of medication Resident #60 was on was not recommended. The physician wanted to decrease and discontinue medications. Review of physician orders revealed Resident #60's Flexeril and Hydroxyzine were discontinued and Dilaudid 2 mg twice a day was decreased to Dilaudid one mg in the morning on 03/31/25. On 04/01/25 Resident #60's Dilaudid two mg twice a day was discontinued and a new order was received for Dilaudid one mg every four hours as needed for pain. A plan of care dated 04/01/25 revealed Resident #60 was at risk for acute/chronic pain. Interventions included to administer analgesia as ordered and a half an hour before treatments or care, monitor for side effects of pain medication, and monitor and report loss of appetite and weight loss. A nursing note dated 04/01/25 at 9:00 P.M. revealed Resident #60's wife called and requested Resident #60 be sent to the emergency department because Resident #60 had not been feeling well all day. Resident #60 was alert to self and trying to get out of bed. Resident #60 had no facial expression of pain. A nursing note dated 04/01/25 at 9:45 P.M. revealed Resident #60's wife arrived at the facility to take Resident #60 to the hospital. Resident #60's wife stated Resident #60 looked dehydrated and his condition was getting worse. Resident #60's wife called 911 and had Resident #60 transported to the hospital at 10:43 P.M. Review of the hospital records dated 04/02/25 revealed Resident #60 had a positive opioid screening. Resident #60 appeared delirious and had an altered mental status. Resident #60 had acute metabolic encephalopathy likely due to narcotic pain medication use. The plan was to hold Dilaudid and monitor resident. Buspar, Trazodone and Meclizine were to also be held. The initial testing was unrevealing, it was suspected that Dilaudid was causing worsening of mentation status. A hospital psychiatry consult note dated 04/08/25 revealed Resident #60 presented to the hospital with altered mental status. Over the past few days, Resident #60's mental status had improved. Resident #60 denied hallucinations today but stated he had visual hallucinations a few days ago. Resident #60 was oriented to person, place, month and only off two days of the exact date. The hospital Discharge summary dated [DATE] revealed Resident #60 had altered mental status that was probably related to polypharmacy. Trazodone, Buspar, Abilify, and Dilaudid were discontinued. Resident #60's pain was controlled with Tylenol (for mild pain) in the hospital. The discharge therapy notes revealed Resident #60 was able to complete range of motion and could tolerate the right knee range of motion to usually 90 degrees of flexion. An interview on 06/04/25 at 1:55 P.M. with Physician #500 stated the Dilaudid Resident #60 received was just a drop in the bucket compared to the other medications Resident #60 took. Physician #500 stated the psychiatric medications had been ordered by a veterans administration doctor, so Physician #500 did not want to discontinue them. Resident #60 had pain with movement and Dilaudid was scheduled because Resident #60 did not ask for the pain medication. An interview on 06/04/25 at 2:06 P.M. with the DON verified the order from the hospital was Dilaudid two mg as needed. The order was incorrectly entered by the nurse on 03/21/25 for Dilaudid two mg to give one milligram every four hours for pain. The DON stated the order should have continued to be Dilaudid two mg (however, the discrepancies with the order, the MAR and the controlled record were never clarified). The DON verified the only administration of the as needed Dilaudid from 03/22/25 to 03/25/25 documented on the MAR was on 03/23/25 at 9:41 P.M. The DON verified the medication monitoring/control record revealed Dilaudid two mg had been administered five times from 03/22/25 to 03/25/25 without documentation to support the resident was having pain. The DON also verified the pain monitoring documentation revealed Resident #60 had zero pain except on 03/23/25. The DON also verified there was no documentation of non-pharmalogical interventions being attempted before the administration of Dilaudid. The Medication Administration policy revised 11/09/21 revealed prior to administration, the medication and dosage schedule on the MAR is compared with the medication label. If the label and the MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for correct dosage schedule. This deficiency represents non-compliance investigated under Complaint Number OH00164452.

Based on staff interview, medical record review, and facility policy review, the facility failed to timely address a change in resident condition. This affected one Resident (#58) of three residents reviewed for timely addressing changes in condition. Actual harm occurred when Resident #58 began having hallucinations and was subsequently discharged to the hospital. The facility census was 56. Findings include: Review of the medical record for Resident #58 revealed an admitted [DATE] and a discharge date of [DATE] after expiring at the hospital. The resident was sent to the hospital on 04/28/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 was cognitively intact and without behaviors, and required extensive assistance of two or more staff members for activities of daily living (ADLs). Further review of all the MDS assessments revealed no change in condition MDS. Review of the plan of care dated 08/19/20 revealed Resident #58 had the potential for skin breakdown related to RA and current pressure ulcer. Interventions included administration of treatments per orders, monitor effectiveness of the treatments, and inform the provider if the area worsened or did not respond to treatment. Further review of the care plan revealed Resident #58 was on antibiotic therapy related to [CONDITION(S)]. Interventions included administration of antibiotics as ordered and monitoring effectiveness every shift. Resident #58 was at possible nutrition risk due to her health status, significant weight change on 04/22/22, tooth pain, and wound. Interventions included assisting Resident #58 with easy-to-eat foods due to tooth pain, medications as ordered, supplements per orders, and monitor by mouth intake and report negative findings. The care plan also indicated Resident #58 was admitted with a Stage 4 coccyx pressure ulcer. Interventions included treatments per orders, assess/monitor wound healing, measure length, width and depth and report declines to the physician, air mattress, encourage/assist with turning/repositioning, and if the resident refused treatments confer with the resident, Interdisciplinary team, and family to determine the reasoning. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 03/31/22 at 1:35 P.M. by RN #115 revealed a Rheumatology consult referral was made. Review of the progress note dated 04/04/22 at 4:07 P.M. and 4:54 P.M. by the Director of Nursing (DON) revealed Resident #58's daughter was informed of the resident's tooth pain especially with chewing and an appointment was scheduled. Review of the progress note dated 04/06/22 at 12:35 P.M. by Registered Dietitian Technician (RDT) #999 revealed Resident #58 had eating difficulties related to tooth pain. A dental appointment was scheduled for later in the month. It was recommended to switch from Ensure clear to Ensure [MEDICATION(S)] three times per day. Review of the progress note dated 04/10/22 at 7:52 A.M. by RN #159 revealed greenish drainage noted on the Resident #58's dressing and multiple areas of skin breakdown on the resident's buttocks. Further review of the note revealed Resident #58 refused dressing change on 04/09/22. Review of the progress note dated 04/11/22 at 1:50 A.M. by RDT #999 revealed Resident #58 suffered a significant weight loss of 18 pounds (10%) in one month. Further review of the note revealed Resident #58 was having difficulty eating related to tooth pain, so a dental appointment was scheduled (the resident eventually refused the appointment stating there was nothing wrong with her teeth per progress note). Ensure clear was changed to Ensure [MEDICATION(S)] three times per day. Review of the progress note dated 04/11/22 at 4:32 P.M. by RN #172 revealed a new order was obtained to culture the resident's wound. Review of the Resident #58's ADL tasks revealed Resident #58 ate 0-25 percent (%) most of her meals from 04/11/22 until she was discharged on [DATE]. There were eight meals in which the resident ate 26-50% of her meals from 04/11/22 through 04/28/22. Further review of the ADL tasks revealed from 04/01/22 through 04/28/22 revealed Resident #58 drank zero milliliters (ml) on one occasion and drank between 120 ml and 960 ml for all other documented meals. Review of the progress note dated 04/12/22 at 5:49 A.M. by Licensed Practical Nurse (LPN) #104 revealed Resident #58 had several multiple open areas, varying in size, on her bilateral buttocks and complained of pain. The area was treated, and the nurse practitioner (NP) and DON were notified. There was no order placed for the open areas until 04/14/22. Review of the progress note dated 04/14/22 at 5:32 A.M. by RN #115 revealed a hematology consult was sent. Review of the laboratory work dated 04/14/22 revealed Resident #58's white blood cell count (WBC) was 10.6 (normal range 4.5-10.8), Red blood cells (RBC) was 3.59 (normal range 3.90-5.40), hemoglobin 10.5 (normal range 12.0-16.0), hematocrit 32.8 (normal range 36.0-48.0), Sed Rate was 57 (normal range 0-20). Review of the weekly skin observation tools dated 04/14/22 and 04/21/22 revealed Resident #58 had a poor skin turgor (a symptom of dehydration). Review of the progress note dated 04/20/22 at 3:21 A.M. by LPN #173 revealed Resident #58 was sent to the hospital for an evaluation for altered mental status, low blood pressure 96/56 (normal 120/80), and consistent complaints of pain. Review of the progress note dated 04/20/22 at 9:03 A.M. by LPN #173 revealed Resident #58 returned from the hospital without new orders. Review of the progress note dated 04/21/22 at 5:43 P.M. by the DON revealed Resident #58 refused to go to dental appointment, stating there is nothing wrong with my teeth, they do not bother me or cause me any discomfort. (Per the 04/27/22 progress note the appointment was rescheduled for 05/13/22). Review of a late entry by LPN #173 for 04/25/22 at 2:29 P.M. (documented on 04/29/22 at 1:31 P.M.) revealed she was informed by the Elderly Assistant (EA) Resident #58 had not had urine output all shift, report was passed to the oncoming shift for continuous monitoring. Review of a late entry by LPN #173 for 04/26/22 at 9:42 A.M.(documented on 04/29/22 at 1:44 P.M.) revealed the nurse was informed during her shift, Resident #58 had no urine output so during the medication pass Resident #58 was encouraged to drink water and keep hydrated. Review of a late entry by LPN #173 for 04/27/22 at 11:44 A.M. (documented on 04/29/22 at 1:49 P.M.) revealed the nurse noted Resident #58 had no urine output, dry lips, and dry mouth. The EA confirmed Resident #58 had no urine output. Resident #58's power of attorney (POA) was informed and encouraged to provide moisturizing lip balm. Review of the progress note dated 04/27/22 at 5:41 P.M. by the DON revealed Resident #58's daughter/POA reported Resident #58 was voicing seeing people on the ceiling. The physician was notified, and blood work was ordered for the morning of 04/28/22. Review of a late entry by LPN #173 for 04/28/22 at 9:35 A.M. (documented on 04/29/22 at 2:01 P.M.) revealed Resident #58's grandson had concerns regarding Resident #58's and LPN #173 called the physician to speak with the grandson. Review of a late entry by Physician #900 for 04/28/22 at 10:00 A.M. (documented on 05/01/22 at 10:38 P.M.) revealed Physician #900 spoke with Resident #58's grandson regarding the family's concerns regarding the resident's weakness and lack of appetite. The physician explained the resident's weakness was a gradual process over the last few months since a urinary tract infection ([CONDITION(S)]) and falls. Resident #58 was started on an appetite stimulant the week prior. The resident's sacral wound was chronic, managed with wound care, turned into an infection which was managed with antibiotics. Resident #58 also suffered from a flare of RA which was unaffected by pulsed doses of [MEDICATION(S)] (anti-[CONDITION(S)]). Resident #58 was scheduled for a Rheumatology appointment, which transportation did not show up for, so Resident #58 was scheduled a telehealth visit the following week. Resident #58 continued her RA medications, and took [MEDICATION(S)] and [MEDICATION(S)] as needed for pain management. The progress note indicated the physician explained how the above issues lead the resident to a gradual decline in strength and health. Resident #58 was recently sent to the hospital, was administered fluids, and returned to the facility. Increasing her appetite stimulant, adding another stimulant, placing a nasogastric tube, or a percutaneous endoscopic gastrostomy tube (PEG) for feedings were also discussed. The grandson determined he wanted to trial an increase in the appetite stimulant. The physician also explained to the grandson, Resident #58 had blood work pending and depending on the results, intravenous (IV) fluids may be ordered. The physician also revealed the grandson was given the option of sending Resident #58 to the hospital immediately, but the grandson agreed to wait for the results of the blood work. The physician indicated he also spoke with the NP who would be at the facility to evaluate Resident #58, review the blood work results, and discuss with the resident and family the next steps in treatment. Review of a late entry by LPN #173 for 04/28/22 at 1:31 P.M. (documented on 04/29/22 at 1:38 P.M.) revealed Resident #58 had a telehealth appointment with the Rheumatology office and new orders were received for [MEDICATION(S)] 15 mg weekly after obtaining renal panel blood work. Resident #58 was advised to continue [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The grandson was present at the time of the call. Review of the office visit note for Resident #58 dated 04/28/22 by NP #777 revealed Resident #58 was seen for abnormal laboratory work, was alert and oriented, and was informed if her repeat laboratory work resulted abnormal, she would be sent back to the hospital for an evaluation. The resident's daughter was present at bedside and had to convince Resident #58 to go to the hospital for an evaluation since the resident did not want to go initially. Review of the laboratory work dated 04/28/22 revealed Resident #58 white blood cell count (WBC) was 12.7 (normal range 4.5-10.8), Red blood cell count (RBC) was 3.29 (normal range 3.90-5.40), hemoglobin 9.3 (normal range 12.0-16.0), hematocrit 30.1 (normal range 36.0-48.0), INR 7.1 (normal range 2.5-2.5 on aggressive anticoagulant). The report revealed unsuccessful attempts to contact the nurse were made four times beginning at 1:53 P.M. and eventually the results were faxed to the facility. Interview on 06/08/22 at 2:07 P.M. with the DON confirmed Resident #58 had several open areas to her buttock according to the 04/11/22 notes but no order for treatment was placed until 04/14/22. She also confirmed progress notes dated 04/25/22,04/26/22 and 04/27/22 revealed Resident #58 was found to have dry lips, dry mouth, and no urine output, but nothing was done outside of monitoring and recommending the daughter bring in lip moisturizer. Interview on 06/08/22 at 3:33 P.M. with the DON and RN #172 revealed the NP was notified of the wounds on 04/10/22 and they were told to have the wound doctor see resident on the 10th and continue with zinc ointment. The facility was unable to provide evidence of the NP being notified and the order. They confirmed Resident #58 was on antibiotic for her coccyx wound infection and was sent to the hospital on 04/28/22 as a result of elevated WBC. Assistant Vice President Clinicals #800 joined the interview and she and the DON confirmed the progress notes by LPN #173 revealed the resident had no urine output during her shifts on 04/25/22 through 04/27/22 and the only interventions included passing the information to the oncoming nurse and informing the POA of the need for moisturizing lip balm. The DON revealed Resident #58 was not really drinking sufficiently so laboratory work was ordered. The DON was unsure of Resident #58's cause of death. RN #173 revealed she observed Resident #58 on the morning of 04/28/22 and she was her normal self, she also reported the medical director reported although Resident #58 had abnormal labs, he did not anticipate her death. Interview on 06/08/22 at 3:58 P.M. with NP #777 revealed she saw Resident #58 on 04/28/22 around noon. The resident's daughter was present at bedside. Resident #58 was alert and oriented, and stated she did not want to go to the hospital. NP #777 informed the resident they would send her to the emergency department (ED) after getting the results of her laboratory work if the lab work was abnormal. NP #777 did not send the resident to the ED prior to the blood work results because they sent the resident to the ED on 04/20/22 and she was sent back and this time NP #777 wanted something to go with the resident to reveal her condition. The NP did not dispute the need for treatment during 04/25/22 through 04/27/22 when Resident #58 was observed to have no urine output for eight hours. She also did not dispute the notes revealing the physician or provider was not notified and interventions were not implemented until 04/27/22 when the resident's daughter reported Resident #58 was seeing people on the ceiling and blood work was ordered. Review of facility policy titled Notification of Change of Condition revised 11/22/21 revealed the facility was to immediately inform the resident, consult with the resident's physician, nurse practitioner, or clinical nurse specialist, and resident's representative when there was a significant change in the resident's physical status such as deterioration in health. This deficiency substantiates Complaint Number OH 160.

Based on record review, review of facility policy and interview the facility failed to ensure adequate and timely interventions were in place and provided to prevent weight loss for Resident #2 and Resident #33. This affected two residents (#2 and #33) of three residents reviewed for nutrition. Actual Harm occurred when Resident #2, who weighed 136.6 pounds on 11/18/20 sustained a severe 18.6 pound/13.6 percent (%) weight loss in thirty days. On 12/18/20 the resident weighed 118 pounds. There was no evidence a nutritional supplement was administered as ordered, intakes were not being monitored and weights were not being obtained as ordered during this time period to promote weight gain and prevent additional weight loss. Findings include: 1. Review of the medical record for Resident #2 revealed a readmission date of [DATE] with [DIAGNOSES REDACTED]. The resident's weight on 10/25/20 was 135.6 pounds. Review of the plan of care dated 10/26/20 revealed Resident #2 was at nutritional risk due to his health status. Interventions included diet as ordered, monitor intake and document negative findings, and monitor weight weekly for a month then monthly and document negative findings. Review of the plan of care, revised 11/06/20 revealed Resident #2 was at risk for changes to nutrition and hydration due to protein calorie malnutrition. Interventions included chocolate Ensure (nutritional supplement) three times a day and encouraging the resident to eat and drink by offering food, fluids and snacks. Review of an order audit report for Resident #2 revealed Ensure at an unspecified time and an unspecified amount was originally queued by Diet Technician #127 on 10/27/20 but was not confirmed by a nurse until 11/06/20. This order was discontinued on 11/16/20. On 11/16/20 Ensure was once again ordered at an unspecified time and unspecified amount but this time it was not acknowledged until 12/15/20. An additional order audit report revealed an order upon re-admission for weekly weights for four weeks. The order details revealed weights should be completed every seven days on Monday and scheduled from 10/25/20 to 11/22/20. Review of the resident's electronic task documentation revealed Resident #2 was offered snacks on five occasions between 11/01/20 to 12/28/20. Review of the Treatment Administration Record (TAR) for November 2020 revealed weights were to be completed on 11/01/20, 11/08/20 and 11/15/20. However, 11/01/20 was left blank and 11/08/20 and 11/15/20 were marked as not applicable. Review of the comprehensive nutritional screen, dated 11/03/20 revealed Resident #2 was at risk for nutritional deficits due to a [DIAGNOSES REDACTED]. The assessment indicated Resident #2 was receiving Ensure twice a day to better meet calorie and protein needs. Review of the quarterly nutritional screen, dated 11/18/20 revealed Resident #2 was receiving Ensure with meals to better meet calorie needs. The resident's monthly weight on 11/18/20 revealed the resident weighed 136.6 pounds. The monthly weight on 12/18/20 revealed the resident weighed 118 pounds which reflected an 18.6 pound/13.6% severe weight loss in 30 days. Review of physician's orders [REDACTED].#2 had an order for [REDACTED]. Review of the progress notes from 10/24/20 to 12/28/20 revealed no documentation related to Resident #2's weight loss or intake. Additionally, there was no documentation to indicate the resident's physician or responsible party were notified of the weight loss. Review of meal intakes records from 11/01/20 to 12/28/20 revealed only 60 of 174 meals were documented. For the 13 meals documented from 11/21/20 to 11/30/20 the resident was documented as eating 26-50% on four occasions and 0-25% on nine occasions. On 12/28/20 at 2:57 P.M. interview with Licensed Practical Nurse (LPN) #150 revealed Resident #2 did not receive any type of nutritional supplement and had not received any supplements since his admission. During an interview on 12/29/20 at 11:15 A.M. and 1:00 P.M. with the Director of Nursing (DON), the DON revealed she was unsure if the physician had been notified of Resident #2's weight loss but stated the dietitian should be notifying the physician of weight loss. The DON confirmed the order for Ensure for Resident #2 should have been clarified as there was no amount listed, and also verified there was no evidence the supplement had been given to the resident from October through 12/28/20. The DON was unsure why there had been a delay in the approval for Resident #2's supplement, stating it usually was approved the same day. The DON confirmed the inconsistent documentation of meal intake and revealed documentation was discussed in meetings with staff every month. On 12/29/20 at 11:40 A.M. interview with the Dietitian revealed Diet Technician #127 and himself can put orders in the queue for nutritional interventions and then the nurse has to approve it. He stated he monitors intake of supplements on the MAR because when dietary staff put in the order, they put in percent consumed. The Dietitian reported that usually intakes of meals were documented better. The Dietitian revealed he had not notified the physician of Resident #2's weight loss, he stated nursing staff should be notifying the physician of significant weight changes. On 12/29/20 at 1:05 P.M. interview with Diet Technician #127 revealed she was unsure who put in the order for the supplement for Resident #2 and she was unsure why the order was discontinued and restarted on 11/16/20. Diet Technician #127 revealed she thought Resident #2's supplement was as needed. She confirmed the dietitian's note on 11/03/20 said the supplement should be given two times a day and her note on 11/18/20 said with meals, Diet Technician #127 was unsure what caused the discrepancy. Diet technician #127 revealed she normally goes by the electronic medical record for intake of supplements and does try to talk to residents during mealtime. Diet Technician #127 revealed Resident #2 had recently had COVID-19 and his weight loss could have been related to that, but she had not monitored him for changes during that time period. Review of facility policy titled Weights Policy and Procedure, revised May 2013 revealed elders were to be weighed weekly for the first four weeks of their admission to establish a baseline weight. Monthly weights were to be taken by the 5th of each month 2. Review of the medical record for Resident #33 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of weight records revealed on 06/01/20 Resident #33 weighed 160 pounds. On 07/01/20 the resident weighed 160.2 pounds. On 08/03/20 the resident weighed 151.8 pounds. On 09/04/20 the resident weighed 146 pounds. Review of the annual MDS 3.0 assessment, completed on 10/03/20 revealed Resident #33 had severe cognitive impairment. On 10/06/20 the resident weighed 149.6 pounds. Review of the plan of care, revised on 10/22/20 revealed Resident #33 was at nutrition and hydration risk due to history of significant weight loss associated with variable intake, history of refusing meals and assistance at times, increased needs due to frequent walking and being easily distracted at meals. Interventions included encouraging the resident to drink fluids and eat snacks between meals and during activities, giving snacks that the resident can walk with and snack with as needed, and help the resident with cueing or assistance as needed. On 11/12/20 the resident weighed 141 pounds. Review of the tasks and progress notes revealed no snacks were documented as having been offered to the resident from 11/28/20 to 12/28/20. Review of progress notes revealed a note on 11/23/20 by Diet Technician #127 addressing Resident #33's weight loss and recommending Ensure with meals to meet the residents needs. Review of the progress notes from 11/10/20 to 12/28/20 revealed no evidence the physician was notified of the resident's weight loss. Review of the December 2020 physician's orders [REDACTED]. Review of MAR from 11/23/20 to 12/28/20 revealed Resident #33 was receiving and accepting Ensure twice a day. On 12/18/20 the resident weighed 134.4 pounds which reflected a 7.9 % severe weight loss in 90 days and a 16% severe weight loss in 180 days. Review of meal intake records from 12/14/20 to 12/28/20 revealed of 42 possible meals, intakes were documented for 14. On 12/28/20 at 11:30 A.M. interview with Elder Assistant (EA) #107 revealed Resident #33 required supervision at meals. EA #107 additionally revealed Resident #33 was supposed to receive snacks in between meals. The EA was unable to provide evidence snacks were being provided to the resident. On 12/29/20 at 11:40 A.M. interview with the dietitian revealed he had not notified the physician of Resident #33's weight loss. The dietitian revealed nursing staff were responsible for notification to family and the physician of significant weight changes. The dietitian revealed Resident #33 was very reliant on snacks, as she gets up from meals and wanders away. On 12/29/20 at 11:15 A.M. and 1:00 P.M. interview with the DON revealed she was unsure if the physician had been notified of Resident #33's weight loss. The DON reported that she thought the dietitian was responsible for notification of weight change. The DON confirmed the inconsistent documentation of meal intake and the lack of evidence the resident was provided snacks as care planned which had the ability to contribute to the resident's weight loss. This deficiency substantiates Complaint Number OH 982.

Based on observation, record review, policy review and staff and family interview the facility failed to implement adequate skin risk interventions for Resident #26, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning, to prevent the development and subsequent infection of a pressure ulcer to the resident's left shoulder/scapula area. Actual harm occurred on [DATE] when the resident was assessed by a wound specialist to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left scapula. However, the pressure ulcer had been first identified by Licensed Practical Nurse (LPN) #21 on [DATE] who failed to comprehensively assess, notify the physician or implement a treatment. The pressure ulcer subsequently declined and was assessed to have an infection present on [DATE]. However, no effective treatment for [REDACTED]. This affected one resident of three residents reviewed for pressure ulcers. Findings include: Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial plan of care (POC) dated [DATE] revealed Resident #26 was at risk for skin breakdown and had no skin impairment at that time. Interventions included a weekly skin assessment, turn and reposition every two hours and as needed and a low air loss mattress to the bed. Review of the Braden scale (used for predicting pressure ulcer risk), dated [DATE] revealed Resident #26 was at high risk for skin breakdown with a score of 16. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #26 had impaired cognition and was at risk for pressure ulcers or injuries. Further review revealed Resident #26 required extensive assistance from two staff for bed mobility, transfers and bathing. The MDS revealed Resident #26 did not have any pressure ulcers present at the time of the assessment. Review of the task section of the electronic medical record, where state tested nursing assistant (STNA) staff document care provided revealed the resident (per family/resident request) was to receive a bath daily. Review of a [DATE] nursing progress note revealed Resident #26 had a skin tear to the left scapula that measured 2.2 centimeters (cm) in length by 3.1 cm width. The note revealed the nurse applied a foam dressing and the nurse practitioner (NP) was notified. Review of the facility provided documentation revealed there was no determination as to how the skin tear occurred at that time or any additional description of the skin tear. Review of the medical record revealed no weekly skin assessment was conducted on [DATE] or [DATE] as care planned. Review of the [DATE] treatment administration record (TAR), Medication Administration Record [REDACTED]. In addition, review of the medical record revealed Resident #26 did not received a bath on [DATE], [DATE] and [DATE]. There was also no documented evidence on the TAR from [DATE] to [DATE] the resident was being turned and repositioned by staff every two hours and as needed or that a low air loss mattress was in place to the resident's bed. The facility provided an undated/unsigned typed piece of paper with Licensed Practical Nurse (LPN) #21's name written at the top of it. The paper revealed on the night of [DATE], Resident #26's wife had called multiple times in regards to a wound located on the resident's left upper back. The paper noted the resident's wife told the nurse if she was here she would be taking the picture herself. The documentation on the paper revealed the nurse decided that because the wife would be taking the picture anyway if we did not have the visitor restrictions. The typed paper revealed education was provided to the nurse in regards to sending pictures to family members. However, the paper did not include any information as to what the picture was of, did not include a copy of the picture taken or any type of a description of the resident's left upper back at that time. There was no corresponding nursing progress note from LPN #21 dated [DATE]. No evidence the physician was notified of any type of skin impairment on [DATE] and no evidence any type of treatment was initiated at that time. Attempts to contact LPN #21 during the complaint investigation were unsuccessful. Review of a nursing progress note, dated [DATE] at 1:09 P.M. revealed a physician order [REDACTED]. On [DATE] a physician order [REDACTED].#26. Review of the TAR revealed the low air loss mattress was obtained/initiated on [DATE] even though it had been a care planned intervention since [DATE]. Review of an initial wound physician note, dated [DATE] revealed Resident #26 had an unstageable pressure ulcer to the left scapula that measured 2.4 cm in length and 4.4 cm in width with an obscured depth. According to the National Pressure Injury Advisory Panel (NPIAP) an unstageable pressure ulcer has obscured tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. A new treatment order of Santyl ([MEDICATION NAME] ointment) and calcium alginate (to maintain a moist environment to promote healing) was obtained to be applied to the wound. The wound was to be covered with a dry clean dressing and changed daily and as needed. The facility provided a second undated/unsigned typed document with LPN #31's name written at the top. This document revealed a phone conversation was held with LPN #31 on Friday evening [DATE]. During the conversation, the nurse revealed the elder aide (EA) brought to her attention an area on Resident #26's left upper back area. (The document did not include the date the EA brought this to LPN #31's attention). The document revealed the nurse took measurements of the area and applied a dressing to said skin tear. The document also revealed the nurse practitioner was notified towards the end of the nurse's shift, however no treatment was put into the computer because the nurse hadn't heard back from nurse practitioner. The document revealed this nurse notified the resident's wife. Review of the document revealed that although the conversation was held with the nurse on [DATE], it did not include on what date the EA had notified her of the area, did not include the measurements or description of the area and did not include what type of dressing was applied by the nurse. Review of the wound physician note, dated [DATE] revealed Resident #26 had an unstageable pressure ulcer to the left scapula that measured 2.0 cm in length and 4.2 cm in width. The wound bed tissue was assessed to be 20% granulated and 80% slough. Review of the wound progress note, dated [DATE] revealed Resident #26 had an unstageable pressure ulcer to the left scapula that measured 2.4 cm in length and 4.6 cm in width. The wound bed tissue was 100% slough. The pressure ulcer healing status was described as deteriorated with the peri wound noted to be macerated (cause to grow thinner or waste away) and a moderate amount exudate (fluid that has seeped out). Review of the wound progress note, dated [DATE] revealed Resident #26 had an unstageable pressure ulcer to the left scapula that measured 2.5 cm in length and 4.2 cm in width. The wound bed continued with 100% slough with a moderate amount of exudate. Review of the wound progress note, dated [DATE] revealed Resident #26 had a sharp instrument debridement (removal) of slough of 50% and 50% revealing a Stage III (involves full thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer to the left scapula that measured 2.8 cm in length, 3.7 cm in width, and 0.1 cm in depth. Review of the wound progress note, dated [DATE] revealed Resident #26 had an unstageable pressure injury to the left scapula that measured 3.5 cm in length, 4.5 cm in width, and 0.1 cm in depth. The wound bed appearance had 10% granulation and 90% slough with a moderate amount of exudate. Review of the wound progress note, dated [DATE] revealed Resident #26 had an unstageable pressure injury to the left scapula measuring 3.0 cm in length, 3.5 cm in width, and the depth was unable to determine (UTD). The wound bed continued with 40% granulation and 60% slough with minimal amount of exudate. The healing status was noted to be deteriorated. Review of the wound progress note, dated [DATE] revealed Resident #26 had an unstageable pressure injury to the left scapula measuring 3.5 cm in length, 3.5 cm in width, and UTD depth. The wound bed continued with 10% granulation and 90% slough with moderate amount of exudate. Review of the wound progress note, dated [DATE] revealed Resident #26 had an unstageable pressure injury to the left scapula measuring 4.0 cm in length, 3.5 cm in width, and UTD depth. The wound bed continued with 10% granulation and 90% slough with moderate amount of exudate. The physician discussed Resident #26's wound with staff. Resident #26 was not refusing treatments and the physician would continue to look for reasons for pressure ulcer deterioration. No additional information was provided following this note related to the cause of the deterioration. Review of the quarterly MDS 3.0 assessment, dated [DATE] revealed Resident #26 had one unstageable pressure ulcer. Further review of the MDS 3.0 revealed Resident #26 had severely impaired cognition and required extensive assistance from staff with bed mobility, transfers and bathing. Review of the wound progress note, dated [DATE] revealed Resident #26 had a Stage III pressure ulcer to the left scapula measuring 2.9 cm in length. 4.0 cm in width, and 0.6 cm depth. The wound bed had 50% granulation and 50% percent slough with (new) tunneling (wound that has a channel that tunnels from the wound into the muscle or subcutaneous tissue) 0.5 cm at 9 o'clock with moderate amount of exudate. Record review revealed no evidence the treatment to Resident #26's pressure ulcer was changed between [DATE] and [DATE] even with the noted deterioration and presence of tunneling. In addition, review of the TAR during this time period revealed no evidence the resident was being turned and repositioned every two hours or as needed or that new interventions were implemented to decrease pressure to the left shoulder/scapula area. Review of a nurse's note, dated [DATE] revealed Resident #26 had a temperature of 100.4 Fahrenheit (F). The note indicated the nurse practitioner (NP) and Assistant Director of Nursing (ADON) were notified of signs of infection to the resident's wound with increased drainage, pain and fever and purulent exudate. However, there was no evidence the NP addressed the change in condition of the pressure ulcer at that time. On [DATE] (two days after the resident was assessed to have new onset fever, increased drainage and purulent exudate) an order was obtained for a wound culture and the resident was ordered an antibiotic, [MEDICATION NAME] 300 milligrams (for a wound infection). Review of the wound progress note, dated [DATE] revealed Resident #26 had a Stage III pressure injury to the left scapula measuring 4.0 cm in length, 3.0 cm in length, and 0.5 cm in depth. The wound bed had 60% granulation and 40% slough with moderate amount of exudate. Debridement was performed to remove 20% slough. Staff reported there was purulent (consisting of pus) drainage and the note revealed culture was taken. Review of a nursing progress note, dated [DATE] revealed the facility was contacted by the laboratory and notified another wound culture specimen for Resident #26 was needed as the specimen tube to collect the wound culture that had been sent to the lab was expired. Review of Resident #26's laboratory testing, revealed on [DATE] at 3:22 P.M. lab results revealed heavy growth of streptococcus pyogenes (group A) (gram positive bacteria), moderate growth [DIAGNOSES REDACTED] pneumoniae (gram negative bacteria), moderate growth lactose fermenter (gram negative bacteria), moderate growth diptheroid bacillus (gram positive bacteria). Record review revealed the wound was susceptible to the antibiotic [MEDICATION NAME] but resistive to the antibiotic [MEDICATION NAME]. Review of the nurse's notes, dated [DATE] at 9:59 P.M. (over 24 hours later) revealed Resident #26's lab results were received and a copy was sent to the NP and DON. No new orders were received as at that time. A nurse's note, dated [DATE] at 6:29 A.M. revealed new orders for Resident #26 were obtained from the NP for the antibiotic, [MEDICATION NAME] ,[DATE] twice daily for ten days. The note indicated the resident would also continue on the [MEDICATION NAME]. On [DATE] at 9:27 A.M. LPN #1 was observed completing the dressing change to Resident #26's left shoulder/scapula pressure ulcer. LPN #1 was observed applying gloves without first washing her hands. LPN #1 then placed dressing supplies consisting of Santyl, calcium alginate and package of 4x4 gauze on the bedside stand without a protective barrier in place. The bedside stand was observed to have cracker crumbs and unidentifiable food debris scattered about. LPN #1 then placed a bottle of wound cleanser on Resident #26's bed. LPN #1 proceeded to turn the resident on to his right side and removed the soiled dressing. At the time of the treatment observation, LPN #1 did not obtain measurements of the pressure ulcer. However, the ulcer was noted to have observable depth present. The soiled dressing was placed it in the trash can located near the bed. LPN #1 then reached for the wound cleaner and gauze and proceeded to cleanse the wound. LPN #1 then applied the Santyl ointment with her same gloved finger to the wound bed and covered the wound with the calcium alginate and outside dressing. Interview with LPN #1 verified she did not use a barrier to place dressing supplies on the bedside stand or wash her hands prior to putting her gloves on, after removing the soiled dressing or after the procedure. On [DATE] at 9:37 A.M. interview with Resident #26 revealed he had pain at times when the wound dressing (to the left shoulder/scapula) was being changed. Resident #26 stated he did not get out of bed and did not remember if staff turned him. On [DATE] at 10:00 A.M. interview with STNA #10 revealed Resident #26 was dependent on staff to turn and reposition him. STNA #10 revealed other residents in the facility had turn and reposition tasks documented in their electronic medical record, but Resident #26 did not. On [DATE] at 10:11 A.M. an interview with the Corporate Director of Nursing (DON) revealed the expectation and facility policy for wound dressing changes included to use a barrier at the bedside and to wash hands before, during and after dressing changes. Review of the Hand Hygiene policy and procedure, dated [DATE] revealed to reduce the spread of infection hand hygiene was to be preformed during routine patient care including before and after having contact with patient's intact skin, after contact with blood and bodily fluids or excretions, mucous membranes, non-intact skin or wound dressings. On [DATE] at 4:45 P.M. interview with Resident #26's family revealed she was aware the resident had a pressure ulcer to his shoulder area. During the interview, the family member voiced concerns she did not believe staff were turning and repositioning the resident as frequently as necessary. The family member stated on multiple occasions she had to call the facility and request the resident be turned as he had not been turned or repositioned for a long period of time. On [DATE] at 1:44 P.M. Resident #26 was transferred to the hospital due to an acute change in condition. The resident was found unresponsive by staff. The resident was admitted to the hospital and returned to the facility on [DATE] at 3:50 P.M. Review of hospital record documentation, dated [DATE] revealed Resident #26 had an unstageable pre-hospital acquired wound, to the left upper back. The wound was described as full thickness skin loss measuring 4.8 cm in length by 3.0 cm width by 0.9 cm depth, most likely pressure injury stage 4 over scapula with moderate amount of serosanguinous drainage. The wound bed was noted to have 5% exposed muscle, 45% thickening yellow slough and 50% red tissue. On [DATE] at 4:47 P.M. interview with the DON revealed staff education had been completed on [DATE] because it was identified that weekly skin assessments were not being completed for residents. The DON revealed Resident #26 was not safe to shower or use a bedside commode and there was an order in place for the resident to have a daily bath. The DON verified there was no evidence Resident #26 received a bed bath on [DATE], [DATE] or [DATE]. The DON verified if bathing and weekly assessments had been completed as ordered, it would have been opportunity for the pressure ulcer to have been discovered prior to it being identified as an unstageable pressure ulcer by the wound physician on [DATE]. The DON verified the order for treatment on [DATE] to the right shoulder was written in error and should have been for the left shoulder/scapula area. The DON also verified the plan of care and interventions for Resident #26 to be turned and repositioned every two hours and a low air loss mattress to the bed were not being followed which also contributed to the development of the unstageable pressure ulcer. On [DATE] at 4:18 P.M. interview with the DON verified the pressure ulcer to Resident #26's left shoulder/scapula became infected, per the note on [DATE]. However, a viable specimen was not collected until [DATE] and an order for [REDACTED]. This deficiency substantiates Complaint Number OH 850.

Based on record review of two open medical records and two closed medical records [REDACTED]. The facility failed to provide comprehensive and ongoing treatment and monitoring of weight changes for Resident #28 related to a medical [DIAGNOSES REDACTED].#35 and failed to ensure comprehensive and on-going monitoring and care following an acute change in condition for Resident #36. Actual harm occurred on [DATE] when Resident #28 was transferred from an outside clinic appointment (which had been set up by a family personal caregiver) as a direct hospital admission for treatment of [REDACTED]. Hospital documentation noted the resident was assessed to have a 40 pound weight gain, extensive anasarca (general swelling throughout the body), facial droop and wet lung sounds. Prior to this hospitalization , the resident had an order for [REDACTED].#28, #34, #35 and #36) of five residents reviewed for quality of care and treatment. Findings include: 1. Record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#28 to be weighed daily (related to the [DIAGNOSES REDACTED]. Review of the plan of care for Resident #28 revealed there was no care plan developed related to [MEDICAL CONDITION] or the order for daily weights. Review of the treatment administration record (TAR) revealed daily weights were not documented as being completed as ordered. Review of the [DATE] TAR revealed daily weights were documented on 14 of 30 days during the month. Review of the Dietary Technician (DT) notes, dated [DATE] at 11:53 A.M. revealed Resident #28 had a 30-day weight warning for an 8.7% weight gain of 13 pounds. Review of the nurse practitioner (NP) note, dated [DATE] revealed Resident #28 had mild wheezing and laboratory testing was ordered for exacerbation (acute increase in severity of a problem) of [MEDICAL CONDITION]. Review of the laboratory tests, dated [DATE] revealed a BNP (a blood test used to monitor congested heart failure) level of 1369, normal limit range per this laboratory was ,[DATE]. There was no evidence a comprehensive plan was developed at this time to address the resident's [MEDICAL CONDITION] or abnormal laboratory testing. Review of the nursing progress note, dated [DATE] revealed Resident #28 was transferred to the hospital for low oxygen saturation levels and elevated blood pressure of ,[DATE] (normal range is 140 to 160/ 60 to 80). The resident returned to the facility on [DATE]. Review of the hospital records, revealed a record dated [DATE] which indicated Resident #28 was treated at the hospital for exacerbation of [MEDICAL CONDITION]. Review of the discharge summary revealed orders to call the physician of weight gains of two pounds overnight or five pounds in a week. The summary record revealed Resident #28 was to be weighed daily with similar clothes and the weights were to be recorded. Record review revealed no evidence the resident's plan of care or orders were updated to reflect the discharge summary physician notification of a two pound weight gain overnight or five pound weight gain in one week. Review of the [DATE] TAR revealed daily weights were documented on 11 of 31 days ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]). The resident's weight on [DATE] was documented to be 186.2 pounds. The resident's weight on [DATE] was documented to be 180 pounds, on [DATE] the resident's weight was 177 pounds and on [DATE] the resident's weight was documented to be 192.3 pounds (a 15 pound weight gain in two days). There was no evidence the physician was notified of this weight gain. Resident #28 was hospitalized from [DATE] to [DATE] as a result of a fall with fracture. Record review revealed the resident was seen by the nurse practitioner on [DATE] and [DATE]. Neither of the nurse practitioner progress notes acknowledged the resident's weights, weight gain, fluid status or plan related to [MEDICAL CONDITION] and/or [MEDICAL CONDITION] monitoring. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #28 had severe cognitive impairment and required extensive assistance from two staff for bed mobility, transfers and toileting. Review of the [DATE] TAR (from [DATE] to [DATE]) revealed daily weights were only obtained on [DATE] and [DATE]. The resident's weight on [DATE] was documented to be 193.3 pounds which was noted to be a 13.3 pound weight gain from 30 days prior ([DATE] to [DATE]). Record review revealed on [DATE] Resident #28 was seen by the cardiologist. The progress notes from the visit revealed the resident was being seen in the office on this date. She had been seen in the hospital last week ([DATE]) with evidence of right sided heart failure with anasarca, was given an intravenous dose of the diuretic, [MEDICATION NAME] 40 milligrams and returned to the nursing home facility. At the time of the visit on [DATE], the resident's assistant (personal caregiver) was present. The resident was very drowsy at the time of the appointment. The cardiologist noted the resident was significantly hypervolemic (an abnormally increased volume of blood) with mostly right-sided features which the cardiologist noted he suspected was multifactorial including sodium dietary indiscretion. The assessment/plan revealed the cardiologist discussed the importance of daily weight monitoring with close assessment of her volume status. The note revealed the cardiologist also highly recommended dietary sodium restriction and to resume care with the heart failure clinic. Record review revealed following this cardiology visit, no dietary changes were made and there was no evidence of daily weight monitoring or close assessment of volume status. On [DATE] Resident #28 was seen by the nurse practitioner. Review of the nurse practitioner note revealed no mention of the cardiologist findings or recommendations, no evaluation of the resident's weights or weight/fluid status and no coordination of care related to the [DIAGNOSES REDACTED]. On [DATE] at 1:36 P.M. interview with Resident #28's personal caregiver (a family friend who had been handling medical appointments for the resident) revealed she had significant concerns related to Resident #28's increase in weight and disclosed she was at the facility (on this date) to follow the resident to a cardiology appointment she had made for the resident at the heart failure clinic. Review of the nursing progress notes from [DATE] to [DATE] revealed at no time was the physician or the NP made aware weight gain identified for Resident #28. On [DATE] at 1:45 P.M. during an interview with the Director of Nursing (DON) the concern was shared daily weights were not completed as ordered and that nursing staff was not accurately and timely communicating the resident's weight gains to the physician and/or nurse practitioner to implement treatment/interventions for the resident's [MEDICAL CONDITION] resulting in repeated hospitalization s for exacerbation of [MEDICAL CONDITION]. The DON was unable to provide any additional information as to why weights were not being done daily for Resident #28. The DON revealed all of the resident's weights were recorded in point click care (PCC) in the electronic medical record (EMR) as noted above. The DON also verified there was no written evidence to support the resident's physician or nurse practitioner had been notified of any of the actual weights/weight gain that had been identified for Resident #28. Review of a physician note from the heart failure clinic, dated [DATE] at 2:30 P.M. revealed due to the extensive anasarca (general swelling throughout the body), facial droop and wet lung sounds the resident was being sent directly to the hospital via Emergency Medical Services (EMS). Record review revealed the resident was admitted to the hospital for treatment of [REDACTED]. On [DATE] at 1:00 P.M. interview with Resident #28's personal caregiver verified the resident was sent directly to the hospital form the heart failure clinic appointment on [DATE]. On [DATE] at 8:32 A.M. interview with Registered Nurse (RN) #1 revealed she did not know the current policy regarding what to do if a resident had a significant weight loss or gain. Review of the hospital discharge summary dated [DATE] revealed Resident #28 was admitted to the hospital on [DATE] as a direct admission from the cardiologist for concerns of a 40 pound weight gain. Resident #28 was admitted with a [DIAGNOSES REDACTED]. On [DATE] at 10:49 A.M. interview with the DON verified Residents #28 recent complications of [MEDICAL CONDITION] were directly related to accountability of staff not performing the task of daily weights and communicating with the physician and DON of any negative outcomes including weight gain. Review of the notification of change of condition policy dated [DATE] revealed the facility will immediately consult the resident's physician for a significant change in the resident health, deterioration in health or clinical complications. Review of the weight policy dated [DATE] revealed the physician requesting weekly or daily weights would specify the length of time weekly or daily weights were to be completed and provide instructions for nursing to follow regarding fluctuating weights. 2. Closed medical record review revealed Resident #36 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the [DATE] 3:00 A.M. progress note revealed the resident could not urinate, abdomen was distended and pain was noted upon palpation. The resident was straight catheterized for 1450 milliliters of tea colored urine. On [DATE] at 1:59 P.M. a nursing progress note revealed the resident had not urinated and was straight catheterized for 1000 milliliters of urine. On [DATE] at 5:57 A.M. the resident appeared distressed. Pain medication was administered and the resident's urine was assessed to be coffee ground color. The resident was encouraged to drink water. The nurse practitioner visited and the resident's urine was assessed to be red/bright orange. Urinalysis was pending and irrigation ordered. On [DATE] at 12:46 P.M. the family spoke to the nurse with concerns of the resident having an infection and wanted blood work done to check white blood cell levels and additional labs. The family also verbalized concerns with oxygen use at that time. Orders were received for stat laboratory testing including a complete blood count and basic metabolic panel and to wean the resident off oxygen. The note indicated the nurse attempted to take the resident's oxygen off and the oxygen saturation dropped to 85% within ,[DATE] minutes. The resident was placed back on oxygen at two liters per minute. Review of the Medication Administration Record [REDACTED].M. vital signs were not entered and coded #5 which indicated to see progress notes. There were no medications documented as administered from 3:00 P.M. forward. The administration record was marked #6 indicating the resident was in the hospital. The 5:00 P.M. blood sugar was not obtained and coded hospitalized . Record review revealed no nursing progress notes were completed between [DATE] at 12:46 P.M. and 10:52 P.M. The 10:52 P.M. nursing note indicated the resident was sent to the hospital due to [DIAGNOSES REDACTED] (low blood glucose level). The note revealed the resident was unresponsive. Resident #36's urine was bright red and orange. The family member was present when the resident was sent to the hospital. On [DATE] at 12:50 P.M. interview with Resident #36's daughter revealed her and her sister arrived for a window visit on [DATE] at about 5:00 P.M. and a nurse was in the resident's room. The daughter revealed EMS was called and the resident was responding at that time. She indicated EMS told her her mother's blood sugar was 38. She revealed their mother was taken from the facility to the hospital by EMS at 5:30 P.M. and was pronounced dead at 5:49 P.M. She stated she didn't know if the resident made it out of the EMS vehicle alive. The daughter said Resident #36's cause of death was failure to thrive. On [DATE] at 1:14 P.M. interview with the Director of Nursing (DON) verified the lack of nursing progress notes to determine the resident's condition and that the resident was being comprehensively monitored with timely care provided beginning on [DATE] when the resident was noted to have a change in condition until the resident was discharged to the hospital. The DON verified the progress note made it look like the resident went out of the facility at 10:52 P.M. (However, the family reported and the DON confirmed the resident left the faciity on [DATE] at approximately 5:30 P.M. and was pronounced dead at the hospital at 5:49 P.M.). In addition, the DON verified the note indicated the resident left the facility due to [DIAGNOSES REDACTED], but the resident's record did not include what the resident's blood sugar was. The DON also verified the Medication Administration Record [REDACTED]. The DON verified the record was inaccurate and incomplete, the time of transfer was not accurate and there was not documentation of the events leading to the transfer to ensure the resident was being comprehensively monitored, assessed and provided care related to an acute change in condition. 3. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the pain assessment completed on [DATE] revealed the resident had no pain. Review of a nursing progress note, dated [DATE] at 10:56 P.M. revealed the resident complained of pain to his perineal area. His scrotum and penis were very painful. Green discharge from the tip of his penis was noticed. The note documented the nurse practitioner was notified. On [DATE] at 2:11 P.M. a nursing progress note revealed the nurse was notified the resident had been screaming in pain while urinating. A state tested nursing assistant (STNA) confirmed the resident's penis hurt. The note indicated the nurse practitioner (NP) was notified. On [DATE] at 10:35 P.M. a progress note revealed the NP ordered a urinalysis with culture and sensitivity. However, the note indicated the urine was not collected (at that time) because the lab was only coming to the facility on Monday, Wednesday and Friday, so it would be collected tomorrow. On [DATE] at 1:00 P.M. a nursing progress note revealed the resident refused to get changed and was screaming. The note indicated the oncoming nurse would collect the resident's urine specimen. On [DATE] at 4:45 P.M. the nursing progress note revealed the resident had been screaming and using inappropriate words towards staff stating staff needed to be in his room as soon as he pushed his pendant. On [DATE] at 9:20 P.M. the nursing progress note revealed the nurse tried to get a clean urine catch but there was no success. The note revealed she would try again. On [DATE] at 1:06 P.M. a new order was obtained for [MEDICATION NAME] powder for a rash around the resident's groin area. Review of the Medication Administration Record [REDACTED]. There was no evidence of any follow-up assessments of the green penis drainage after [DATE] or painful penis and scrotum after [DATE]. There was no follow up of the facility not obtaining the urinalysis/culture and sensitivity. The next pain assessment, dated [DATE] revealed the resident exhibited pain levels of five and two on a ,[DATE] scale with 10 being the worse pain. The assessment revealed the resident received the [MEDICATION NAME] Tylenol 325 milligrams two tablets for [MEDICAL CONDITION] with effect. Review of Resident #34's [DATE] quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, had verbal behaviors one to three days, required extensive assistance from two staff for bed mobility and transfers and walking only occurred one to two times during the assessment period. Resident #34 was assessed to be two person staff assist and utilized a wheelchair and walker with lower extremity impairment on one side. The assessment also documented the resident rarely had moderate pain in the last five days. No pain medication was given routinely or as needed during the assessment reference period. On [DATE] at 6:10 P.M. interview with the Director of Nursing (DON) verified there was no follow up assessment or treatment of [REDACTED]. The DON verified the record failed to document the resolution of pain or the green drainage. The DON revealed staff had re-assessed the resident's penis /scrotum on [DATE] (after surveyor intervention) and noted no pain or drainage at that time. On [DATE] at 5:07 P.M. during a follow up interview with the DON, the DON verified the facility had not ever obtained the urinalysis on [DATE]. There was no evidence of the nurse practitioner addressing the urinalysis not being obtained. In addition, the DON verified the facility had not provided any type of pain management on [DATE] at 10:56 P.M. when the resident's scrotum and penis were described as very painful with green discharge from the tip of his penis. The facility did not provide pain management on [DATE] at 2:11 P.M. when the nursing note revealed the nurse was notified the resident had been screaming in pain while urinating and the STNA confirmed his penis hurt. The DON verified there was a failure to provide continued assessments of the pain and drainage. Verification also occurred no medication or pain management was provided for the complaint of painful urination. 4. Review of Resident #35's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired away on [DATE]. Review of the nursing progress note revealed a note, dated [DATE] the nurse on duty noticed that both of the residents lower legs and foot were swollen with 2 plus (+) [MEDICAL CONDITION] (the pressure leaves an indentation of ,[DATE] millimeters that rebounds in fewer than 15 seconds). The note revealed the nurse practitioner was notified and ordered [MEDICATION NAME], a diuretic. On [DATE] at 3:00 A.M. a nursing progress note revealed the resident appeared to be restless and short of breath. The note revealed the resident had 4+ [MEDICAL CONDITION] (the pressure leaves an indentation of 8 mm or deeper) to bilateral lower extremities). The note revealed the nurse practitioner was notified at 03:20 A.M. and new orders were obtained for a stat chest x-ray. [MEDICATION NAME] 40 mg was ordered daily for five days for [MEDICAL CONDITION] and an order was also obtained for the antibiotic, [MEDICATION NAME] 500 mg for seven days for shortness of breath. Record review revealed no evidence of an assessment or monitoring of the resident's [MEDICAL CONDITION]/health status between [DATE] and [DATE]. On [DATE] at 6:29 P.M. interview with the DON verified there were no specific assessments for [MEDICAL CONDITION] between [DATE] and [DATE]. The DON included if there was an assessment it would have been entered in the progress notes. This deficiency substantiates Complaint Number OH 233.