Every finding on record at Parkside Health Care Center

Based on record review, interview and review of facility policy, the facility failed to treat residents with dignity and respect. This affected one resident (#224) of four residents reviewed for dignity. The facility census was 68.Findings include:Review of the medical record for Resident #224 revealed an admission date of 06/17/22. Diagnoses included hypertensive heart disease with chronic kidney disease, infectious gastroenteritis, type two diabetes mellitus with diabetic neuropathy, chronic kidney disease stage four, permanent atrial fibrillation, gout and end state renal disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale. A BIMS score of 15 would indicate the resident was cognitively intact. The MDS indicated the resident used a wheelchair for transportation, and was dependent on staff for transfers, bathing and toileting. Review of a care plan for Resident #224, initiated on 06/29/23 and revised 07/21/25, revealed a focus of care for person centered care. This focus of care revealed the resident required two person assist for bed mobility, one person assist for grooming/hygiene, two person assist for toileting and Hoyer lift for transfers. There was a focus of care for self care deficit, which included an intervention to turn and reposition the resident every two hours. The care plan focus for Resident #224 initiated 09/23/25 revealed a potential for pressure ulcer development. Interventions included encouraging and assisting the resident to turn and reposition every two hours while in bed, and to follow facility policies and protocols for prevention/treatment of skin breakdown. The interventions also indicated the staff should encourage/educate the resident regarding the importance of changing positions every two hours and as needed for the prevention of pressure ulcers. Review of a Self Reported Incident (SRI) 267673 dated 11/17/25 revealed Resident #224 reported verbal abuse to the Administrator. She reported Certified Nurse Aide (CNA) #819 had told her she could poop her pants like everyone else here when the resident asked for assistance to the toilet. The resident had been having diarrhea and after assisting to the toilet the CNA allegedly told the resident she had been making up having diarrhea so she would be taken to the restroom first. The statement by the Administrator indicated the resident told her CNA #819 was always mean to her and called her a liar. The investigation included a statement, dated 11/18/25, from CNA #819 revealed she made a statement to the resident I never said your name at all in my conversation with [CNA #657], and do not put words in my conversation with [CNA #657] saying I was talking about her. I said I never said her name and don't accuse me of saying anything about her. On 05/13/26 at 12:38 P.M., an interview with Licensed Practical Nurse (LPN) #439 revealed CNA #819 would get easily overwhelmed. When she did, she would become very short with both residents and staff. On 05/13/26 at 1:41 P.M., an interview with CNA #657 revealed she could not recall the conversation in the bathroom between Resident #224 and CNA #819. She did recall CNA #819 was rude with everyone and was just not a friendly person. She recalled CNA #819 and Resident #224 had back and forthes a few times. On 05/13/26 at 2:14 P.M., an interview with Resident #224 revealed she had multiple incidents where CNA #819 was rude to her and called her a liar. When she had to take an antinausea medication prior to showering after a hospitalization, a nurse had advised her to wait a half hour before showering and she should have relief. CNA #819 came immediately into her room and told her it was now or never to get her shower. She explained she had just been medicated, however the aide told her she did not care and did not have time. When she had an incident of diarrhea, the aide called her a liar. Told her she just needed to poop her pants, then, and they would have to change her like everyone else around here. She indicated CNA #819 had talked like this to her all of the time, and finally she got tired of it and reported it to the Administrator. The resident reported the interactions with the aide made her feel terrible and sad. On 05/13/26 at 4:20 P.M., an interview with CNA #704 revealed she was aware Resident #224 and CNA #819 would butt heads. She did not like how CNA #819 talked with people, and she was like that with everyone. She did note, however, that CNA #819 was especially rude to Resident #224. Review of a facility policy titled Dignity, Respect, and Privacy, revised 05/2024, revealed all residents in the facility would be treated with kindness, dignity, and respected whenever talked with, cared for, or talked about. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2687730.

Based on record review, observation, interview and facility policy review, the facility failed to ensure call lights were within reach of residents to allow them to notify staff of the need for assistance. This affected two residents (#221, #273) of four residents reviewed for call lights. The facility census was 68.Findings include:1.Review of the medical record for Resident #221 revealed an admission date of 07/23/24. Diagnoses included Parkinson's disease without dyskinesia, repeated falls, insomnia, other symbolic dysfunctions, need for assistance with personal care, dysphagia, chronic kidney disease stage three, major depressive disorder, psychotic disorder with delusions, psychotic disorder with hallucinations, and Alzheimer's disease. Review of a quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four on a 0-15 scale. A BIMS score of 4 would indicate severe problems with thinking and memory. The MDS also indicated the resident had behaviors which included physical behavioral symptoms directed towards others such as hitting, kicking, pushing, scratching, grabbing and abusing others, as well as threatening, screaming or cursing at others. Further the resident had behaviors directed at herself such as hitting or scratching herself, pacing, rummaging, screaming and/or disruptive sounds. Review of a care plan initiated 11/22/23 and revised 03/26/26 revealed a person centered plan of care with interventions that included a bed pad or chair alarm to alert staff of unassisted transfers, an assist of two for bathing and bed mobility, incontinence of bowel and bladder, and confusion. She required two assists for toileting and transfers with a Hoyer Lift. She had interventions in place to remind the resident to use the call light and ask for assistance to prevent falls. There was a focus of care for incontinence of bladder. Interventions included checking and changing the resident every two hours and as needed, incontinence care, responding to resident's request to toilet or sign of distress as quickly as possible, and ensuring the call light was within reach. On 05/13/26 at 2:05 P.M., an observation of Resident #221 revealed she was in her wheelchair near her bed. Her call light was over the back of her recliner on the other side of her room. This observation was confirmed by Licensed Practical Nurse (LPN) #439 on 05/13/26 at 2:08 P.M. On 05/13/26 at 4:54 P.M., an interview with LPN #439 revealed the facility did not have an alternative system to use for residents who were not able to effectively use a call light or call pad system. She thought the best thing to do would be to have increased checking in place for the resident. 2. Review of the medical record for Resident #273 revealed he was admitted to the facility on [DATE]. His initial care plans and MDS were being developed. The resident was admitted with diagnoses that included sepsis, difficulty in walking, muscle weakness, need for assistance with personal care, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, metabolic encephalopathy and malignant neoplasm of upper right lung. On 05/13/26 at 2:27 P.M., an observation of Resident #273 revealed he was lying in bed sleeping soundly. His call light was wrapped around the arm of his wheelchair and out of his reach. This observation was confirmed by Certified Nurse Aide (CNA) #657 on 05/13/26 at 2:29 P.M. On 05/13/26 at 2:29 P.M., CNA #657 confirmed the call light for Resident #273 was out of his reach and wrapped around the arm of his wheelchair while he was lying in bed. She removed the call light and placed it near the resident and explained to him where it was located. Review of a facility policy titled Call Lights, Use of, revised 02/2026, revealed the facility would respond in a timely manner to resident's call for assistance. The policy listed equipment as a bedside call light in functioning order and an emergency call light in functioning order, ensuring the resident could reach the call light or cord even if lying on the floor. All facility personnel were to be aware of call lights at all times. The resident should never feel as if the staff were too busy to provide assistance, or offer further assistance before staff left the resident room. When care was provided to the resident, the call light should be placed in a position convenient for the resident to use. The staff should tell the resident where the call light was and show the resident how to use the call light. All new residents were to be oriented to the call light at the bedside. The quality assurance and assessment committee would review any concerns with call light function or response and address any needed systemic changes and audits to attain and maintain compliance. This deficiency represents non-compliance investigated under Complaint Number 2687730.

Based on record review and interview, the facility failed to thoroughly investigate an incident of alleged verbal abuse. This affected one resident (#224) of four residents reviewed for abuse. The facility census was 68.Findings include:Review of the medical record for Resident #224 revealed an admission date of 06/17/22. Diagnoses included hypertensive heart disease with chronic kidney disease, infectious gastroenteritis, type two diabetes mellitus with diabetic neuropathy, chronic kidney disease stage four, permanent atrial fibrillation, gout and end state renal disease. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #224, dated 10/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale. A BIMS score of 15 would indicate the resident was cognitively intact. The MDS indicated the resident used a wheelchair for transportation, and was dependent for transfers, bathing and toileting. Review of a care plan for Resident #224, initiated on 06/24/23 and revised on 07/21/24, revealed a focus of care for person centered care. This focus of care revealed the resident required two person assist for bed mobility, one person assist for grooming/hygiene, two person assist for toileting and Hoyer lift for transfers. There was a focus of care for self care deficit, which included an intervention to turn and reposition the resident every two hours. The care plan initiated a focus of care on 09/23/25 for Resident #224 further revealed a potential for pressure ulcer development. Interventions included encouraging and assisting the resident to turn and reposition every two hours while in bed, and to follow facility policies and protocols for prevention/treatment of skin breakdown. The interventions also indicated the staff should encourage/educate the resident regarding the importance of changing positions every two hours and as needed for the prevention of pressure ulcers. Review of a Self Reported Incident (SRI) 267673 dated 11/17/25 revealed Resident #224 reported verbal abuse to the Administrator. She reported Certified Nurse Aide (CNA) #819 had told her she could poop her pants like everyone else here when the resident asked for assistance to the toilet. The resident had been having diarrhea and after assisting to the toilet the CNA allegedly told the resident she had been making up having diarrhea so she would be taken to the restroom first. The statement by the Administrator indicated the resident told her CNA #819 was always mean to her and called her a liar. The investigation included a statement, dated 11/18/25, from CNA #819, in which she indicated CNA #657 had been present at the time of the reported incident. CNA #819 indicated she made a statement to the resident I never said your name at all in my conversation with [CNA #657], and do not put words in my conversation with [CNA #657] saying I was talking about her. I said I never said her name and don't accuse me of saying anything about her. The investigation of SRI 267673 failed to include a witness statement from the present CNA #657 or a witness statement from her. This was confirmed in an interview with the Corporate Quality Assurance Nurse (QARN) on 05/13/26 at 10:44 A.M. Review of SRI 265706 failed to reveal the name of the alleged perpetrator for an investigation which alleged misappropriation of resident funds. On 05/13/26 at 10:44 A.M., the QARN confirmed the SRI investigation 267673 was an incomplete investigation. It failed to provide a witness statement from the CNA who had been identified as being present in the bathroom at the time of the incident. On 05/13/26 at 12:49 P.M., an interview with the Administrator revealed she did not list the name of the alleged perpetrator in the investigation of SRI 265706, which alleged misappropriation of resident funds. She further verified there was no witness statement or interview of the alleged perpetrator noted. She confirmed this was an incomplete investigation. Review of a facility policy titled Incident, Accident, and unusual occurrence investigation and reporting, revised 11/2024, revealed the purpose was to improve resident care and prevent or minimize re-occurrence of accidents/incidents through investigation, assessment, care planning and implementing interventions. The facility would review injuries/accidents to determine if the injury met the definition of an injury of unknown source which would require reporting to state surveys and certification agency or other officials in accordance with state laws. An investigation would include assessment of the resident, observation of the area and notification of the attending physician and residents Power of Attorney. Any needed interventions would be put into place. The administrator or Director of Nursing (DON) would review the report and the initial investigation. The investigation would be completed and all steps would have been taken to prevent or minimize opportunity for reoccurrence. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2687730.

Based on observation, record review, interview and facility policy review, the facility failed to provide personal care assistance to a resident who was dependent on staff for care needs. This affected one resident (#221) reviewed for activities of daily living assistance needs. The facility census was 68.Findings include:Review of the medical record for Resident #221 revealed an admission date of 07/23/24. Diagnoses included Parkinson's disease without dyskinesia, repeated falls, insomnia, other symbolic dysfunctions, need for assistance with personal care, dysphagia, chronic kidney disease stage three, major depressive disorder, psychotic disorder with delusions, psychotic disorder with hallucinations, and Alzheimer's Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four on a 0-15 scale. A BIMS score of 4 would indicate severe problems with thinking and memory. The MDS also indicated the resident had behaviors which included physical behavioral symptoms directed towards others such as hitting, kicking, pushing, scratching, grabbing and abusing others, as well as threatening, screaming or cursing at others. Further she had behaviors directed at herself such as hitting or scratching herself, pacing, rummaging, screaming and/or disruptive sounds. Review of a care plan initiated 11/22/23 and revised on 03/26/26 revealed a person centered plan of care with interventions that included a bed pad or chair alarm to alert staff of unassisted transfers, an assist of two for bathing and bed mobility, incontinence of bowel and bladder, and confusion. She required two staff assistance for toileting and transfers with a mechanical lift. She had interventions in place to remind the resident to use the call light and ask for assistance to prevent falls. There was a focus of care for incontinence of bladder initiated on 12/05/23 and revised 03/26/26. Interventions included checking and changing the resident every two hours and as needed, incontinence care, responding to resident's request to toilet or sign of distress as quickly as possible, and ensuring the call light was within reach. The care plan also had a focus of care for self-care deficits initiated on 12/05/23 and revised 03/26/26 related to dementia and Parkinson's disease. Interventions included providing assistance for resident to safely perform the task. Monitor the Resident's ability to perform Activities of Daily Living, and assist resident with meals per Activities of Daily Living Plan. Review of the medical record for Resident #221 revealed a task titled Turn and Reposition every two hours. This task indicated over the past month (04/12/26-05/13/26), the task to turn and reposition had been marked as no to indicate not completed on the evening shift on the following dates: 04/16/26, 04/17/26, 04/18/26, 04/19/26, 04/21/26, 04/24/26, 04/27/26, 04/30/26, 05/02/26, 05/03/26, 05/07/26, and 05/12/26. There was no documentation for the day shift on 05/03/26. This was confirmed by the Director of Nursing on 05/13/26 at 12:08 P.M. On 05/13/26 at 11:20 A.M., observation revealed Resident #221 in wheelchair in the dining room. There was a notable odor of urine about her. She was sitting with her spouse who was feeding her lunch. On 05/13/26 at 11:20 A.M., an interview with Resident #221's husband revealed he was her Power of Attorney. He reported he was concerned at times she was not checked for incontinence enough, and that made her bottom sore. He reported she goes a lot and her urine was strong, and she needed to get out of her wet brief as soon as possible, however every time he arrived it seemed like she was wet or soiled and needed to be changed. The facility would get her bottom healed up, and the next thing he knew it was breaking down again, and he felt it was due to the fact they did not change her or check her enough. He also worried if he was not there no one would help her eat. He had come in before and she would be in her room sitting with a tray in front of her and unless he helped her or told her what to do, she did not know how to feed herself on her own. On 05/13/26 at 12:08 P.M., an interview with the Director of Nursing revealed the staff did not chart check and change every two hours. They mark per shift in the electronic medical record (EMR). She confirmed the EMR indicated the identified resident was documented as not having been checked every two hours as noted in the care plan. On 05/13/26 at 12:20 P.M., an interview with Licensed Practical Nurse (LPN) #439 revealed Resident #221 often had behaviors which made it difficult to perform her care. The nursing staff had to keep reminding aides to do the best they could and they may need to go back several times to get the task completed. LPN #439 did not believe Resident #221 had any areas of concern on her bottom at the time. The goal was for the resident to be turned or up in a chair, cream on her bottom, positioned and changed. All of the things for her to be happy and healthy in our facility. She believed turning and repositioning residents was everyone's responsibility. On 05/13/26 at 1:20 P.M., an interview with the Wound Care Nurse, Registered Nurse (RN) #512 revealed Resident #221 had redness to her perineal area and bilateral buttocks. Resident #221 was a heavy wetter, which could only be assisted by frequent checking of the resident and changing her. As the wound care nurse, she did not consider this redness (also referred to as MASD or Moisture Associated Skin Damage) to be a wound, so she did not track it. Despite being a heavy wetter, she felt checking Resident #221 every two hours was sufficient for the resident to be checked for incontinence and changed. On 05/13/26 at 4:50 P.M., an observation and interview of Resident #221 revealed she was in bed with her dinner tray in front of her. She was sitting watching the television and not eating. She had spilled the pink drink on her tray. It appeared she had attempted to feed herself the chicken salad, however it was dropped on the tray and her silverware was lying on the tray. She indicated she was hungry and she attempted to pick up her silverware, but could not do so. When asked what she would do if she needed help, she reported she would call someone. When asked how she would call she stated with the phone and looked for her phone, which she did not have. The call light at this time was within reach. She did not know what to do with the call pad or to use it to call for assistance. This was confirmed by interview with LPN #439 and CNA #549 at the time of the observation. On 05/13/26 at 4:54 P.M., an interview with LPN #439 revealed the facility did not have an alternative system to use for residents who were not able to effectively use a call light or call pad system. She thought the best thing to do would be to have increased checking in place for the resident. She also indicated for Resident #221, because she had an increased amount of urination combined with the inability to use the call light system, should have more frequent checks and change times in place. She confirmed the resident was on an every two hour check and change schedule, however it probably should be more frequently, maybe at least every hour. She further confirmed Resident #221 required assistance to eat and she was not being assisted by anyone. She reported she would find someone to assist the resident. On 05/13/26 at 4:59 P.M., an interview with Certified Nurse Aide (CNA) #549 revealed Resident #221 could not eat independently. The resident had days where she could feed herself, but on those days she required queuing from someone to know to take a bite or to pick up her silverware. Left on her own, the resident would either not eat at all or would spill things all over her tray. Review of a facility policy titled Incontinence Care, revised 02/2026, revealed incontinence care was to prevent infection, odor, and skin irritation and to maintain resident comfort. Moisture barrier was to be applied after incontinence care, and the nurse was to be notified if redness or irritation was new. Review of a facility policy titled Pressure Ulcer Prevention and Care Protocol, revised 09/2025, revealed the licensed nursing staff of the facility would determine the risk of pressure ulcer development in development of the resident's plan of care. Identified risks would be documented in the resident's individualized plan of care. The protocol for protection against pressure ulcers, friction and sheer included but were not limited to: reducing pressure over bony prominences, turning and repositioning of the resident (the resident would be turned and repositioned at least every two hours or as outline in the plan of care based on a resident's individual needs, identified through assessment), assistance with transfers, ambulation and mobility as needed, protection of the skin from mechanical injury through the use of lift sheets, trapeze, etc., and monitoring for pressure caused by positioning or medical devices. The document further indicated a protocol to protect the skin from moisture. The protocol included toileting of the resident per schedule or at least every two hours if the resident was able to be toileted or check and change the resident every two hours and using briefs or absorbent pads to wick away moisture, as well as the use of lotion/cream on dry skin. This deficiency represents non-compliance investigated under Complaint Number 2687730 and 2603753

Based on review of the nursing schedule, the [NAME] Staffing Data Report, the Facility Assessment, the facility punch detail reports and interview, the facility did not ensure a registered nurse (RN) worked eight consecutive hours a day seven days a week. This had the potential to affect all residents. The facility census was 54. Findings include: Review of the [NAME] Staffing Data Report for the second quarter of fiscal year 2025 revealed the facility triggered for no RN hours for 01/19/25, 02/15/16, 02/16/25, and 03/29/25. Interview on 07/31/25 at 2:00 P.M. with the Director of Nursing (DON) revealed the facility was short on RN's every other weekend due to a recent termination; however, the DON personally covered said shifts, and recruitment efforts to hire weekend RNs was ongoing. Review of the nursing schedule for the 03/29/25 revealed no RN was scheduled for that day. Review of the punch detail report for 03/29/25 confirmed six licensed practical nurses (LPNs) each worked at least eight hours; however, it did not reflect a RN worked that day on either the day shift or night shift. Interview on 08/05/25 at 6:10 P.M. with the DON confirmed there was no RN coverage that day. Review of the Facility assessment dated [DATE] revealed the facility would have one full-time RN, DON, one full-time Minimum Data Set (MDS) RN, and one full-time wound care RN as part of the staffing plan. The facility assessment did not speak to weekend RN staffing.

Based on observation, interview, medical record review, and review of the facility policy, the facility failed to ensure proper infection control measures were adhered to during wound care for Resident #51 and catheter care for Resident #76. This affected one resident (Resident #51) of three residents who were reviewed for appropriate care and services for pressure ulcers and one resident (Resident #76) of six residents who had indwelling urinary catheters. The facility census was 54. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 02/17/25 and a re-entry date of 06/25/25. Diagnoses included neuromuscular dysfunction of the bladder, Cauda Equina Syndrome, arthrodesis status (when two or more bones in a joint are surgically fused together), urinary retention, colostomy status, post-traumatic stress disorder (PTSD), radiculopathy and spinal stenosis with neurological claudication of the lumbar region, major depressive disorder, Hodgkin lymphoma, and an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to the right buttock. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/01/25 revealed Resident #51 had intact cognition and was dependent on staff for toileting hygiene and bathing. Further review of the MDS revealed Resident #51 had two stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) and one unstageable deep tissue injury (DTI) (A DTI is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.) and was receiving pressure injury care. Review of the orders revealed an order dated 07/24/25 for Resident #51 to have the right ischial wound cleansed with Vashe wound cleanser-soaked gauze, patted dry, Skin-Prep (creates a protective barrier) applied to the surrounding wound bed, application of silver alginate (antibacterial wound dressing for moderate to heavily exudating wounds), and covered with a foam border dressing daily on day shift and as needed if it was soiled or removed. Observation on 07/30/2025 from 11:18 A.M. to 11:25 A.M. of wound care performed by wound Registered Nurse (RN) #313 revealed RN #313 removed the soiled dressing from the wound, then removed the soiled gloves from both hands, exposing another pair of gloves beneath. RN #313 wore the second pair of gloves (that had been worn underneath the top pair of gloves) to cleanse the wound. Using the same pair of gloves, RN #313 picked up the closed packet of silver alginate that had fallen on the floor and emptied the clean contents from the packaging (the silver alginate dressing) onto the clean field on the overbed table. RN #313 was then observed beginning to remove the right glove (the second layer of gloves) then pausing for a couple seconds while looking around the room. At that time, Nurse Aide Supervisor #362 instructed Student Nurse #399 to hand RN #313 another pair of gloves. RN #313 proceeded to remove and discard the soiled gloves, don a new pair of gloves, and continue with wound care. No hand hygiene was performed between glove changes.Interview on 07/30/25 at 11:35 A.M. with RN #313 confirmed the typical process for gloving and hand hygiene during wound care was to double glove and that it had been the normal process for RN #313 for several years out of habit. RN #313 further revealed that had the dressing supplies not fallen on the ground, wound care would have continued without an actual glove change because the top layer of gloves would have been removed between dirty and clean tasks. During this interview, RN #313 confirmed no hand hygiene was performed between glove changes. Interview on 07/30/25 at 12:20 P.M. with the Director of Nursing (DON) confirmed double gloving was not supposed to be standard procedure and that hand hygiene was to be performed between glove changes. Review of the policy titled Dressing Change (Clean), last revised February 2024, revealed that after the necessary equipment/supplies were set-up for the ordered dressing change, the nurse was to don non-sterile gloves, remove and discard the old dressing, remove gloves, perform hand hygiene, and don a clean pair of gloves prior to cleansing and redressing the wound. The policy further noted that staff were to follow the facility's policy on hand hygiene. 2. Review of the medical record for Resident #76 revealed an admission date of 07/29/25 with diagnoses including permanent atrial fibrillation, oropharyngeal dysphagia, presence of implantable cardiac defibrillator, acute and respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), pulmonary hypertension, chronic kidney disease, need for assistance with personal care, and encounter for palliative care. Review of the assessment titled Admit/Readmit Screener - V 4 dated 07/30/25 revealed Resident #76 was alert and oriented to person, place, time, and situation. Further review of the admission assessment revealed Resident #76 had a 16 French Foley catheter with a five to 10 milliliter (ml) balloon catheter (a flexible indwelling tube inserted into the bladder to drain urine and secured by a balloon inflated with water) which required staff to perform catheter care. Review of the care plan dated 07/30/25 revealed Resident #76 had an indwelling urinary catheter. Interventions included the provision of Foley catheter care every shift and maintaining Enhanced Barrier Precautions (EBP) during direct resident care per facility and Centers for Disease Control and Prevention (CDC) guidelines for the duration of Resident #76's stay or until the indwelling urinary catheter was discontinued. Review of the order dated 07/31/25 revealed Resident #76 was to be on EBP for high contact resident care activities due to an indwelling medical device (Foley catheter). Observation on 07/31/25 from 2:55 P.M. to 3:05 P.M. of catheter care for Resident #76 performed by Certified Nurse Aide (CNA) #390 and assisted by CNA #391 revealed neither CNA donned a gown to perform catheter care. Further observation revealed there was an EBP sign on the room door of Resident #76, along with an organizer for personal protective equipment (PPE). Interview on 07/31/25 at 3:07 P.M. with CNAs #390 and 391 confirmed there was a sign and PPE on the door of Resident #76 and that Resident #76 was supposed to be in EBP because of a Foley catheter, and they did not put gowns on to perform catheter care. During the interview, CNAs #390 and #391 confirmed they should have put on a gown before performing catheter care. Interview on 07/31/25 at 3:57 P.M. with Corporate Nurse #398 confirmed residents with catheters should be in EBP which included donning a gown before providing catheter care. Review of the policy titled Enhance Barrier Precautions (EBP) effective March 2024, revealed EBP required donning of a gown and gloves during high contact resident care activities, including urinary catheter care and care of indwelling devices.

Based on record review and interview the facility did not ensure contact isolation precautions were implemented timely. This affected one of three residents reviewed for infection control, Resident #61. The facility census was 60. Findings include: Review of the medical record revealed Resident #61 was admitted [DATE] with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and parainfluenza virus. Resident #61 required assistance with bathing, dressing, mobility, and toileting. No cognitive deficit was noted, however Resident #61 refused all food and beverages and received hospice care. Review of the hospital after visit summary dated 06/14/24 revealed under the area of continuity of care (COC) instructions Resident #61 was diagnosed with Parainfluenza with an onset date of 06/08/24. Further review of the COC instructions revealed under the area of isolation/infection: isolation. Review of Resident #61's Physician's orders revealed an order dated 06/24/24 indicating enhanced barrier precaution (EBP) during high contact activities related to an indwelling midline medical device for intravenous hydration. Interview on 08/31/24 at 3:20 P.M. with the Infection Preventionist (IP) revealed the nurse who completed the admission was responsible for reviewing the hospital discharge instructions and notifying the IP if there were diagnoses that required isolation including parainfluenza. The IP confirmed he was not made aware Resident #61 was admitted with a diagnosis of parainfluenza and required isolation upon admission. Interview on 08/31/24 at 3:33 P.M. with the Director of Nursing (DON) revealed Resident #61's admission was completed by Registered Nurse (RN) #2 who missed the isolation instructions from the hospital; however, Licensed Practical Nurse (LPN) #21 completed a review of the admission orders on the next shift and noted Resident #61 required isolation. Contact isolation was immediately implemented after LPN #21 reviewed the orders. The DON reported approximately 12 hours passed before the isolation order was implemented from the time of the admission. This deficiency represents non-compliance investigated under Complaint Number OH00155732.

Based on record review, policy review, and interview, the facility failed to ensure appropriate care and treatment of Peripherally Inserted Central Catheters (PICC). This affected three residents (#19, #48 and #60) of three residents reviewed for PICC lines. The facility census was 59. Findings include; 1. Review of Resident #48's medical record revealed a 07/13/23 admission with diagnoses including osteomyelitis, methicillin-resistant staphylococcal aureus, type two diabetes, migraines, gastroesophageal reflux disease, fibromyalgia, urinary incontinence and asthma. The resident was admitted with a PICC line. The infection control log revealed the resident had a wound infection 01/10/24 to a coccyx ulcer. Physician orders included to change the PICC line dressing and cap every Tuesday. Review of the treatment sheets for January, February and March 2024 revealed there was no evidence of a weekly dressing change on 01/23/24, 02/27/24, and 03/12/24. There was no evidence of a cap change on 01/16/24, 01/23/24, 01/30/24, 02/27/24 or 03/12/24. Interview on 03/22/24 at 3:54 P.M. with Corporate Quality Assurance #100 verified there was no evidence of dressing and cap changes as ordered. 2. Review of Resident #19's medical record revealed a 02/23/24 admission with diagnoses including muscle wasting and atrophy, lack of coordination, methicillin-resistant staphylococcal aureus, thoracic spine pain, hyperlipidemia, anxiety disorder, heart disease, arthritis, presence of artificial hip, spinal stenosis, obesity, hypokalemia, hypertension, and gastroesophageal reflux disease. She was admitted with a PICC/Midline with orders for an antibiotic due to an infected hip replacement. Physician orders included to change the PICC line dressing within the first 24 hours of insertion or admission and then to change the dressing and cap weekly every Wednesday. Review of the PICC line dressing change revealed the dressing was changed 02/28/24, 03/03/24, 03/10/24, and 03/19/24. There was no evidence of the cap being changed between admission 02/23/24 and 03/10/23, 19 days after admission. The next cap change was on 03/20/24. Interview on 03/22/24 at 2:54 P.M. with Corporate Quality Assurance #100 verified there was no evidence of dressing and cap changes the day after admission and weekly as ordered. 3. Review of the closed record for Resident #60 revealed a 12/07/23 admission with diagnoses including hypertension, hyperlipidemia, anxiety disorder, chronic kidney disease, polyarthritis, osteoarthritis, pancreatitis, and malignant neoplasm of pancreas. She was admitted postoperatively with an intra-abdominal abscess, JP drain to the abdomen, midline surgical incision, double lumen line to the right arm and was to receive antibiotic therapy. Physician orders included to change the PICC line dressing within the first 24 hours of admission and then to change the dressing and cap weekly every Friday. Review the treatment sheets revealed the dressing and cap were changed the day after admission on 12/08/23. The 12/15/23 signature box was coded 5, refer too progress notes. Review of the progress notes on 12/15/23 included no evidence of a dressing change. There was no evidence of the cap being changed 12/15/23 or 12/22/23. The resident was discharged to the hospital 12/23/23. Interview on 03/22/24 at 2:40 P.M. with Corporate Quality Assurance #100 verified there was no evidence of dressing and cap change 12/15/23 and a cap change 12/22/23. The dressing and cap were not changed weekly as ordered. Review of the facility's undated Midline/PICC catheter dressing changes policy included the dressing was to be changed 24 hours post insertion then every seven days. This deficiency represents non-compliance investigated under Complaint Number OH00151712.

Based on record review, abuse policies review, resident council minutes review, written statements review and interview, the facility failed to ensure allegations of verbal allegations were reported to the Administrator in a timely manner and failed to ensure the allegations were reported to the State Survey Agency. This affected two (Residents #1 and #28) of 12 residents interviewed regarding abuse. The facility census was 62. Findings include: 1. Review of Resident #28's open medical record revealed diagnoses including irritable bowel syndrome with diarrhea, obsessive compulsive disorder ( long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both.), somatization disorder (a form of mental illness that causes one or more bodily symptoms, including pain. The symptoms may or may not be traceable to a physical cause.), adjustment disorder with mixed anxiety and depressed mood, histrionic disorder (personality disorder characterized by a pattern of excessive attention-seeking behaviors), and narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance). Review of an annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had adequate hearing with no hearing devices, was able to make himself understood and was able to understand others. Resident #28 was assessed as cognitively intact. During an interview on 02/27/24 which began at 10:27 A.M., Resident #28 stated the facility had suddenly required two nursing assistants to provide incontinence care for him although he was able to turn in bed and maintain position. Resident #28 stated two staff entered the room one day, with one of the staff members telling the other to just stand there because she was able to provide the incontinence care herself. Resident #28 stated on 02/22/24 State tested Nursing Assistant (STNA) #100 and STNA #105 entered the room to provide incontinence care. Resident #28 requested STNA #100 provide care and STNA #105 only be in the room to watch. STNA #100 claimed she was going to report this to the Administrator because it meant she had to do all the work. Resident #28 alleged when STNA #100 and STNA #105 left the room he heard STNA #100 state (expletive) you but that she said the actual word. Resident #28 stated he believed it was directed toward him. In regard to the allegation of verbal abuse that Resident #28 stated he heard toward himself on 02/22/24, the facility's self-reported incidents were reviewed with none having been submitted since 10/10/23. During an interview on 02/27/24 at 3:03 P.M., Corporate Registered Nurse (RN) #110 verified Resident #28 made the allegation of a staff member stating (expletive) you toward him after leaving Resident #28's room. Corporate RN #110 indicated she told Resident #28 she was required to report the allegation and she phoned the facility and reported the allegation to the Director of Nursing (DON) and Administrator. Corporate RN #110 stated she visited the facility later that day and was told by the Administrator that he handled it and his investigation had indicated it had not happened. Corporate RN #110 verified the facility had failed to report the allegation of verbal abuse to the State survey agency. Review of the facility's Resident Abuse Prevention Practices Policy (revised September 2019) revealed verbal abuse was identified as any use of oral, written, or gestured language that willfully included disparaging and/or derogatory terms to the residents or their families or within hearing distance, regardless of their age, ability to comprehend or disability. An allegation of abuse was required to be reported to the State Agency and all regulatory agencies as required by law. Review of the facility's Abuse Allegation Investigation Policy, dated October 2022, revealed the Administrator or designee was responsible for ensuring the allegation was reported to the State agency. After an investigation was completed and findings were documented, a final report was to be submitted to the State Agency. 2. Review of Resident Council Minutes dated 12/28/23 indicated a resident reported an STNA verbally abused her and noted the Director of Nursing (DON) was notified. The Problem/Complaint Intake Form generated 12/29/23 indicated Resident #1 stated a staff member swore at her. A social service response indicated Resident #1 was spoken to by the social service designee. The social service statement indicated Resident #1 reported it happened a while ago when the staff member was new to the facility and was learning how Resident #1 preferred her care to be done. The note indicated Resident #1 stated that staff member had given her excellent care. The staff member involved was not identified. Another statement (not signed and no indication who wrote the statement) dated 12/29/23 indicated Resident #1 stated it was a misunderstanding, that the aide was new and did not know how Resident #1 liked to be care for. Resident #1 stated she felt safe. During an interview of Resident #1 on 02/27/24 at 12:01 P.M., prior to questioning about the incident referred to in the resident council meeting minutes, Resident #1 pointed to STNA #115 and stated she called her an expletive. Resident #1's tone had changed to a sharper tone compared to the rest of the conversation. During an interview with Activity Assistant #165 on 02/27/24 at 2:38 P.M., she verified she facilitated the December resident council meeting minutes as Activity Director #170 was not working that day. Activity Assistant #165 stated Resident #1 was hesitant to report the incident for fear of getting anybody in trouble but did state an aide called her a nasty name. Resident #1 would not provide the aide's name at that time. Resident #1 indicated she would like to have the aide explain what happened to upset her so much that the aide would call Resident #1 that name. Resident #1 did indicate she believed it was verbal abuse. Activity Assistant #165 stated she reported the allegation to Activity Director #170 the following day (12/29/23) when she returned to work. Activity Assistant #165 stated she was told the next time such an allegation was made she must report it to another supervisor if Activity Director #170 was not available. During an interview with the Director of Nursing (DON) on 02/27/24 at 2:48 P.M., she stated she was not working in December. She had been told Resident #1 thought an aide called her a name but that was not the case. Another witness was in the room. Generally when an allegation of verbal abuse was made, the facility reported the allegation to the State survey agency. During an interview of the Administrator on 02/27/24 at 2:54 P.M., he stated the social worker spoke to Resident #1 and the incident had happened several weeks before it was reported. The name of the aide was not reported at that time and Resident #1 stated she was not afraid. A Facility Reported Incident was not submitted because Resident #1 stated it was a misunderstanding and the staff was providing excellent care. During an interview of Corporate Registered Nurse (RN) #110 on 02/27/24 at 3:03 P.M., she stated she did not know about the allegations made by Resident #1 but the incident was not reported to the State agency.

Based on record review, abuse policies review, resident council minutes review, written statements review and interview, the facility failed to ensure allegations of verbal abuse were thoroughly investigated and failed to remove staff alleged to have committed the abuse pending the completion of a thorough investigation This affected two (Residents #1 and #28) of 12 residents interviewed regarding abuse. The facility census was 62. Findings include: 1. Review of Resident #28's open medical record revealed diagnoses including irritable bowel syndrome with diarrhea, obsessive compulsive disorder ( long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both.), somatization disorder (a form of mental illness that causes one or more bodily symptoms, including pain. The symptoms may or may not be traceable to a physical cause.), adjustment disorder with mixed anxiety and depressed mood, histrionic disorder (personality disorder characterized by a pattern of excessive attention-seeking behaviors), and narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance). Review of a care plan initiated 01/06/22 indicated Resident #28 had a self care deficit as evidenced by weakness related to anxiety disorder, obsessive-compulsive disorder, narcissistic personality disorder and diabetic neuropathy. Interventions included assisting with toileting as applicable and provide only the amount of assistance required to safely perform the task. Review of a care plan initiated 01/06/22 indicated incontinence of bowel due to weakness/psychiatric issues related to anxiety disorder, obsessive-compulsive disorder, narcissistic personality disorder, anemia, severe protein-calorie malnutrition and diabetic neuropathy. Interventions included checking and changing every two hours and as needed. The care plan did not refer to the amount of assistance needed. Review of a care plan initiated 04/07/22 indicated a conflict with staff related to being accusatory of staff, being demanding, being argumentative, refusing medications, refusing showers and or bed baths, refusing to go to doctor's appointments and refusing psychiatric services. Interventions included allowing Resident #28 to talk about his feelings and letting the resident know that staff was empathetic and interacting with Resident #28 in a calm, non-threatening manner. The care plan indicated Resident #28 had accused staff of not providing correct care and talking inappropriately toward staff and yelling at the facility doctor. Review of a care plan initiated 04/07/22 indicated Resident #28 had repeatedly called the police and ombudsman. Resident #28 refused to assist with activities of daily living even with goals to discharge home. Resident #28 was being verbally abusive and accusatory towards staff. Interventions indicated, if reasonable, discuss behaviors with the resident and explain/reinforce why the behavior was unacceptable. Review of a care plan initiated 07/18/22 indicated Resident #28 was verbally aggressive with staff related to narcissistic personality disorder. Interventions included analyzing key times, places, circumstances, and triggers and what de-escalated behavior and document the findings. Assess Resident #28's understanding of the situation. Allow time for the resident to express himself and his feelings toward the situation. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had adequate hearing with no hearing devices, was able to make himself understood and was able to understand others. Resident #28 was assessed as cognitively intact. During an interview on 02/27/24 which began at 10:27 A.M., Resident #28 stated the facility had suddenly required two nursing assistants to provide incontinence care for him although he was able to turn in bed and maintain position. Resident #28 stated two staff entered the room one day, with one of the staff members telling the other to just stand there because she was able to provide the incontinence care herself. Resident #28 stated on 02/22/24 State tested Nursing Assistant (STNA) #100 and STNA #105 entered the room to provide incontinence care. Resident #28 requested STNA #100 provide care and STNA #105 only be in the room to watch. STNA #100 claimed she was going to report this to the Administrator because it meant she had to do all the work. Resident #28 alleged when STNA #100 and STNA #105 left the room he heard STNA #100 state (expletive) you but that she said the actual word. Resident #28 stated he believed it was directed toward him. In regard to the allegation of verbal abuse that Resident #28 stated he heard toward himself on 02/22/24, the facility's self-reported incidents were reviewed with none having been submitted since 10/10/23. Review of a written statement by State tested Nursing Assistant (STNA) #100 dated 02/22/24 revealed when she was in Resident #28's room - in the hall- she stated That's great to STNA #105 in response to the way Resident #28 was acting about staff not being allowed in his room. STNA #100 denied she used profanity in Resident #28's room or the hall regarding him. During an interview with STNA #100 on 02/29/24 at 9:48 A.M., she verified she was asked to write a statement regarding the allegation but she was never asked to leave the unit/stop providing resident care pending the facility conducting an investigation. STNA #100 stated she did not recall there being anybody in the hall at the time but there was a good possibility there might have been other residents in their rooms. During an interview on 02/27/24 at 3:03 P.M., Corporate Registered Nurse (RN) #110 verified Resident #28 made the allegation of a staff member stating (expletive) you toward him after leaving Resident #28's room. Corporate RN #110 indicated she told Resident #28 she was required to report the allegation and she phoned the facility and reported the allegation to the Director of Nursing (DON) and Administrator. Corporate RN #110 stated she visited the facility later that day and was told by the Administrator that he handled it and his investigation had indicated it had not happened. Corporate RN #110 verified the facility had failed to do a thorough investigation although an investigation should have been completed. During an interview on 02/27/24 at 3:16 P.M., the Administrator verified he had not removed staff from providing care while he conducted an investigation. The Administrator stated he got statements from both aides and they both denied the cursing occurred. The Administrator stated he never had problems with the aides and he knew Resident #28's history so he had no reason to suspect the incident occurred. The Administrator verified no additional residents, staff or visitors were interviewed. Review of a witness statement by STNA #105 dated 02/22/24 revealed when walking out of a room (did not identify what room), STNA #100 stated that was great. Resident #28 stated when aides had gone to Resident #28's room he informed her that she (STNA #105) was only allowed to watch care being provided and STNA #100 had to provide all care. STNA #105 documented STNA #100 never made any profanities to or about Resident #28. During an interview with STNA #105 on 02/27/24 at 10:02 A.M., she stated the day of the incident she was asked for a written statement but she and STNA #100 continued to finish the shift like normal. Review of the facility's Resident Abuse Prevention Practices policy (rev. September 2019) revealed verbal abuse was identified as any use of oral, written, or gestured language that willfully included disparaging and/or derogatory terms to the residents or their families or within hearing distance, regardless of their age, ability to comprehend or disability. An investigation would begin immediately after receiving a complaint of abuse. Written statements would be taken and interviews conducted from anyone involved or witnessing the event (alleged victim, alleged perpetrator (if known), witnesses and all who might have knowledge of the allegations). An employee accused of the abuse of a resident would be suspended immediately at the time of the complaint, event or incident by the charge nurse on duty until the investigation was completed. Review of the facility's Abuse Allegation Investigation policy, dated October 2022, revealed the Administrator or designee would ensure steps had been taken to protect the resident from further abuse or retaliation during the investigation, ensure the alleged perpetrator was immediately suspended (staff) pending the investigation. The Administrator or designee was responsible for ensuring the allegation was reported to the State agency, and interviewing all staff, residents and other potential witnesses that might have details regarding the allegation or incident. The policy indicated if a staff member was the alleged perpetrator other staff were to be interviewed about their observations of interactions between the alleged perpetrator and this or other residents as applicable. After the investigation was completed and findings were documented, a final report was to be submitted to the State Agency. 2. Review of Resident Council Minutes dated 12/28/23 indicated a resident reported an STNA verbally abused her and noted the Director of Nursing (DON) was notified. The Problem/Complaint Intake Form generated 12/29/23 indicated Resident #1 stated a staff member swore at her. A social service response indicated Resident #1 was spoken to by the social service designee. The social service statement indicated Resident #1 reported it happened a while ago when the staff member was new to the facility and was learning how Resident #1 preferred her care to be done. The note indicated Resident #1 stated that staff member had given her excellent care. The staff member involved was not identified. Another statement (not signed and no indication who wrote the statement) dated 12/29/23 indicated Resident #1 stated it was a misunderstanding, that the aide was new and did not know how Resident #1 liked to be care for. Resident #1 stated she felt safe. During an interview of Resident #1 on 02/27/24 at 12:01 P.M., prior to questioning about the incident referred to in the resident council meeting minutes, Resident #1 pointed to STNA #115 and stated she called her an (expletive). Resident #1's tone had changed to a sharper tone compared to the rest of the conversation. During an interview with STNA #115 on 02/27/24 at 1:39 P.M., STNA #115 stated she and another aide (STNA #120) were providing care to Resident #1 one day when the resident became aggressive then later accused STNA #115 of calling her a name. During an interview with STNA #120 on 02/27/24 at 2:11 P.M. she indicated she was in the room with Resident #1 and STNA #115 and Resident #1 was informed her head had to be lowered to pull her up in bed. Resident #1 started to yell at STNA #115 who responded she was not trying to be an ass. During an interview of Activity Assistant #165 on 02/27/24 at 2:38 P.M., she verified she facilitated the December resident council meeting minutes as Activity Director #170 was not working that day. Activity Assistant #165 stated Resident #1 was hesitant to report the incident for fear of getting anybody in trouble but did state an aide called her a nasty name. Resident #1 would not provide the aide's name at that time. Resident #1 indicated she would like to have the aide explain what happened to upset her so much that the aide would call the resident that name. Resident #1 did indicate she believed it was verbal abuse. During an interview of the Director of Nursing (DON) on 02/27/24 at 2:48 P.M., she stated she was not working in December. She had been told Resident #1 thought an aide called her a name but that was not the case. Another witness was in the room. Generally, when an allegation of verbal abuse was made, the facility reported the allegation to the State survey agency and documented an investigation. During an interview with the Administrator on 02/27/24 at 2:54 P.M., he stated the social worker spoke to Resident #1 and the incident had happened several weeks before it was reported. The Administrator provided two written statements by a nurse and STNA #115. The Administrator verified no further staff, residents, or potential witnesses were interviewed. During an interview of Corporate Registered Nurse (RN) #110 on 02/27/24 at 3:03 P.M., she stated she did not know about the allegations made by Resident #1 but it did not appear a thorough investigation was completed. During a subsequent interview with the Administrator on 02/27//24 at 3:16 P.M. he verified he did not suspend the STNA accused of calling Resident #1 a derogatory name pending an investigation.

Based on medical record review and interview, the facility failed to provide a timely physical therapy (PT) evaluation to assess for a restorative nursing program. This affected one (Resident #28) of three residents reviewed for restorative nursing services. The facility identified 39 residents receiving restorative nursing programs. The facility census was 62. Findings include: Review of Resident #28's open medical record revealed diagnoses including type two diabetes mellitus with diabetic neuropathy, irritable bowel syndrome with diarrhea, anemia, obsessive compulsive disorder, diabetic retinopathy with macular edema in both eyes, somatization disorder, adjustment disorder with mixed anxiety and depressed mood, histrionic personality disorder, and narcissistic personality disorder. A plan of care initiated 05/25/22 and revised on 01/24/24 indicated Resident #28 required an ambulation restorative program due to weakness related to diabetes with neuropathy. A nursing note dated 07/26/23 at 10:03 A.M. indicated Resident #28 requested his restorative program be placed on hold. Restorative staff informed Resident #28 when he wanted to restart the program he could let them know and it would be re-initiated. A nursing note dated 01/19/24 at 10:53 A.M. indicated Resident #28 stated he would do therapy if it could be done on his response times. Therapy was notified. Review of a Physical Therapy (PT) evaluation dated 02/23/24 revealed Resident #28 was referred to PT by nursing per Resident #28's request to re-establish a restorative ambulation program. The therapist documented at the beginning of the evaluation Resident #28 reported he actually just wanted to be able to walk to the bathroom at a one assist level. Resident #28 was able to ambulate to/from the bathroom/bed with a front wheeled walker at a one assist level. Resident #28 reported he did not want any further PT services but would like to ambulate with restorative. Resident #28 was informed he could be a one assist to and from the bathroom with a front wheeled walker and the therapist would develop a restorative program based on distance ambulated during the evaluation and he could progress from there. During an interview with Resident #28 on 02/27/24 beginning at 10:27 A.M., he stated he had not ambulated since June of 2023. He had felt weak and sick and requested his restorative program be placed on hold in July 2023. Resident #28 stated he spoke with the Administrator and Therapy Manager #130 in January 2024 about wanting to have a restorative program for ambulation re-initiated. No action had been taken. Resident #28 stated he phoned the Corporate Registered Nurse (RN) to discuss his concerns and she had Corporate Physical Therapist (PT) #135 evaluate him on 02/23/24. His restorative program was initiated the following day. During an interview on 02/27/24 at 1:50 P.M., Licensed Practical Nurse (LPN) #125 stated she recalled Resident #28 telling her in January 2024 that he wanted to receive therapy/restorative services. LPN #125 stated she informed the restorative aides. During an interview with the Administrator on 02/27/24 at 3:16 P.M. he verified Resident #28 had spoken to him about wanting his restorative program resumed in January but he did not want him to ambulate until a physical therapist had evaluated him which was completed on 02/23/24. The Administrator indicated he was not certain why there was a delay between the time services were requested and the PT evaluation was completed. During an interview with Therapy Manager #130 on 02/27/24 at 3:31 P.M., she stated therapy had a large skilled case load in January 2024. Residents who needed Medicare Part B services were placed on a target list and evaluations were completed as time allowed. Since there were no safety concerns communicated for Resident #28 he was not immediately evaluated. Therapy Manager #130 reported Resident #28 had been off the restorative program for a long time and nobody had reported a change in condition. When therapy received referrals it was usually due to documentation of a decline or improvement of a resident. Residents with safety risks were considered a higher priority. During an interview on 02/28/24 at 2:36 P.M., Restorative Aide #140 stated she was informed by a nurse that Resident #28 wanted to be placed back on restorative nursing case load and she informed Restorative Nurse #145. Restorative Nurse #145, who was present, stated she informed the therapy director who did not report Resident #28 would have to be placed on a waiting list. Once a PT evaluation was completed, restorative services began the following day. Restorative Nurse #145 stated staff were surprised since Resident #28 had not ambulated for so long that he was able to ambulate 120 feet on 02/24/24. This deficiency represents non-compliance investigated under Complaint Number OH00151354.

Based on medical record review and interview, the facility failed to ensure bathing was offered in accordance with bathing schedules and resident preferences. This affected one (Resident #28) of three residents reviewed for activities of daily living. The facility census was 62. Findings include: Review of Resident #28's medical record revealed diagnoses included type two diabetes mellitus with diabetic neuropathy, irritable bowel syndrome with diarrhea, obsessive compulsive disorder, and anxiety disorder. A care plan regarding development of person-centered care, initiated 12/27/21, indicated Resident #28 required two or more assists for bathing. A care plan initiated 01/06/22 indicated a self care deficit with interventions to bathe per Resident #28's preference. A care plan initiated 04/07/22 indicated Resident #28 had a conflict with staff related to being accusatory of staff, being demanding, being argumentative, and refusing showers and/or bed baths. Review of a plan of care note dated 02/16/23 at 2:46 P.M. indicated Resident #28 requested he have one bed bath a week. The following bathing records were located for the past 30 day period: On 01/26/24 at 2:57 P.M., a nursing note indicated Resident #28 refused a shower, stating he was not feeling well. Staff recorded a bath (type not indicated) on 01/27/24. On 02/02/24 an aide documented Resident #28 was totally dependent for bathing (did not indicate the type of bathing provided). On 02/27/24, aides documented on a shower sheet and in the electronic health record task bar that Resident #28 refused a bath. During an interview on 02/27/24 between 10:27 A.M. and 12:00 P.M., Resident #28 was observed lying in bed with a knit cap covering his head and gloves on both hands. Resident #28 stated he would not take showers due to infection control concerns so he was supposed to get bed baths. Resident #28 stated he wore the gloves due to neuropathy in both hands and he was unable to provide his own bath, hair care or shaving. An odor was noted but Resident #28 also had a bowel movement during that time. Resident #28 stated he was not being offered bed baths on a weekly basis. On 03/01/24 at 9:27 A.M., the Director of Nursing (DON) was informed although bathing records had been requested twice, with some information provided, there was no evidence of Resident #28 being offered a bed bath between 02/03/24 and 02/26/24. The DON did not provide any additional information to support Resident #28 received bed baths per his preference or schedule

Based on observation, review of physician orders, policy review, and interview, the facility failed to ensure medications were available for administration resulting in the omission of four medications being administered out of 25 opportunities resulting in a 16% medication error rate. This affected one (Resident #56) of two residents observed for medication administration. Findings include: During observation of medication administration on 02/27/24 at 8:53 A.M., Licensed Practical Nurse (LPN) #125 was observed preparing medications for administration to Resident #56. LPN #125 searched for, but was unable to locate, the following ordered medications: chewable aspirin 81 milligram (mg), vitamin D 50 micrograms (mcg), bumex 1 mg (mg), fludrocortisone acetate 0.1 mg, and ferrous gluconate 324 mg. LPN #125 stated Resident #56 only had a 14 day supply of medication delivered at any given time. LPN #125 stated she knew she had re-ordered the medications but they were not in the cart. LPN #125 stated when she finished her medication pass she would look to see if any of the medications were available in the starter box. On 02/27/24 at 10:01 A.M., LPN #125 (with assistance of another unidentified nurse) searched the starter box and was able to locate the correct dose of bumex which was administered at 10:06 A.M. The other four medications were not available for administration. At 10:08 A.M. LPN #125 stated pharmacy drop shipped medications in an emergency situation and she would document the medications were held. LPN #125 indicated she would contact pharmacy for delivery that evening. LPN #125 reported she had ordered medications on 02/26/24. (A reorder form with the four medications was unable to be located). Review of the facility's Medication Ordering and Receiving from Pharmacy Provider (not dated) indicated as medication reached a three to five day supply, the reorder sticker is peeled off the prescription and placed on the reorder page. Reorders should be faxed in the morning by 10:00 A.M. Reorders faxed after 10 A.M. would be delivered the next business day unless the medication supply was exhausted and was needed prior to the next delivery. If a new or refill was needed before the next business day, nursing must call the pharmacy and deem the prescription an emergency prescription in order to have it delivered on the same day. The policy indicated for residents who received medication under Medicare Part A pharmacy would deliver medications with a 14 day supply. The medications would be re-ordered by nursing two to four days prior to exhausting the supply. This deficiency represents non-compliance investigated under Complaint Number OH00151064.

Based on observation, medical record review, policy review, and interview, the facility failed to ensure catheter tubing was placed in a manner that would limit the potential for introduction of pathogens. This affected one (Resident #1) of three residents reviewed for urinary tract infections. The facility census was 62. Findings include: Review of Resident #1's open medical record revealed diagnoses including type two diabetes mellitus, flaccid neuropathic bladder, and neuromuscular dysfunction of the bladder. A plan of care related to use of an indwelling catheter was initiated 08/18/23. Interventions included keeping the foley (catheter) tubing free of kinks and keeping the bag covered and off the surface of the floor. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and had an indwelling urinary catheter. A laboratory report for urine collected on 02/19/24 indicated the identification of mixed flora and indicated further work-up and sensitivity testing was not routinely indicated and would not be performed. On 02/27/24 at 9:15 A.M., Resident #1 was observed propelling herself in a wheelchair in the hallway near the therapy department. The urinary catheter tubing was observed dragging on the floor under her wheelchair. At 12:01 P.M., Resident #1 was observed sitting in the wheelchair in her room with the catheter tubing on the floor. While conversing with Resident #64, State tested Nursing Assistant (STNA) #150 delivered her lunch tray and left the room. On 02/27/24 at 12:10 P.M. STNA #150 was asked to return to Resident #1's room and verified Resident #1's catheter tubing was on the floor. At that time, Resident #1 was eating and STNA #150 stated she would wait until after lunch according to Resident #1's request and reposition the catheter tubing. At 1:50 P.M., Resident #1 was observed being propelled down the hall in the wheelchair. Resident #1 stated it is still not fixed. Observations revealed the catheter tubing was touching the floor. At that time, Licensed Practical Nurse (LPN) #125 verified the catheter tubing was on the floor and instructed a different nursing assistant to go reposition the tubing. Review of the facility's policy, Catheter Management (dated June 2012), revealed instructions to never allow the catheter bag to be raised above the level of the bladder or to let the bag or tubing touch the floor. This deficiency represents non-compliance investigated under Complaint Number OH00151064.

Based on record review and interviews the facility failed to develop a comprehensive behavioral care plan for Resident #53 sexual behaviors. This affected one resident (Resident #53) of three residents reviewed for behavior care plans. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder and generalized anxiety disorder. Review of the 5-day Minimum Data Set (MDS) assessment revealed Resident #53 required extensive assistance for bed mobility, dressing and personal hygiene. He was totally dependent for transfers and toilet use. He was independent for locomotion and eating. He was cognitively intact and there were no behaviors noted. Review of October 2023's behavior tracking revealed Resident #53's exhibited behavior of making sexually inappropriate remarks. Review of Resident #53's care plan revealed there was no comprehensive care plan in place for any behaviors related to being sexually inappropriate or making inappropriate sexual comments to others. Interviews on 10/16/23 from 11:35 A.M. through 4:55 P.M. interviews with Licensed Practical Nurse (LPN) #239, LPN #241, Registered Nurse (RN) #200, RN #205, State tested Nursing Assistant (STNA) #244, STNA #259, STNA #269 and STNA #290 revealed Resident #53 was known to staff for making inappropriate sexual comments to the staff, not to the residents. They stated they were not educated on how to manage his behaviors and did not see a care plan in place addressing it. Interview on 10/16/23 at 12:45 P.M. with MDS nurse #200 confirmed there was no behavior care plan in place. She stated social services typically addressed behaviors. She stated social services was out of the building and unavailable for interview during survey. Interviews on 10/16/23 from 12:22 P.M. through 2:45 P.M. with Administrator, Director of Nursing (DON), and Quality Assurance nurse (QA) #201 revealed they were aware Resident #53 would make inappropriate sexual comments to staff.

Based on interview, record review, and policy review, the facility failed to develop and implement an effective discharge plan to ensure intravenous (IV) antibiotic medication was administered. This affected one (Resident #61) of three residents reviewed for discharge. Findings include: Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included hypokalemia, unsteadiness on feet, spinal stenosis, repeated falls, muscle wasting and atrophy, and intraspinal abscess and granuloma. Review of the 14-Day Minimum Data Set (MDS) 3.0 assessment for Resident #61, dated 11/19/22, revealed intact cognition. The resident required extensive, two-person physical assistance with bed mobility, and limited, one-person assistance for toileting and personal hygiene. The resident had no recent weight loss or swallowing issues. The resident received IV therapy. Review of the Care Plan for Resident #61 revealed the resident was on antibiotic therapy related to an intraspinal abscess. Interventions included to administer antibiotic medications as ordered by the physician and to monitor/document side effects and effectiveness every shift. The Care Plan did not reveal any discharge planning. Review of physician order dated 11/22/22, revealed okay to discharge to care of husband. Home health agency (HHA) for physical therapy (PT), occupational therapy (OT), skilled nursing and home health as indicated. Review of social services (SS) progress note, dated 11/22/2022 at 11:47 A.M., revealed Social Services Director (SSD) #102 spoke with Resident #61 and her spouse regarding referral to a HHA to ensure the resident's IV antibiotics (ATB)s would be administered according to orders. The resident and her spouse both agreed to utilize a HHA for skilled nursing services upon discharge. Review of social services (SS) progress note, dated 11/23/2022 at 4:47 P.M., revealed the resident was discharged from the facility on 11/23/22 without proper services in place to enable the administration of her standing order for IV ATBs. SS was informed of questions regarding IV administration of ATB expressed by Resident #61's husband. SS contacted the HHA to confirm the education and administration would be handled for the family. The HHA notified SS that services would not be rendered until Friday, 11/25/22. SSD #102 acknowledged the need for IV ATB every four hours and initiated communication for guidance in the matter. SSD #102 then contacted Resident #61's husband, asking that the resident return to the nursing home facility to have IV ATBs at needed times. SSD #102 expressed to husband and resident how pertinent it was that the resident received the IV doses of medication. SSD #102 notified the necessary individuals of Resident #61 returning to facility. During interview on 12/06/22 at 3:02 P.M., MDS/Registered Nurse (RN) #101 confirmed the plan of care did not include discharge planning. Interview on 12/06/22 at 1:20 P.M. with SSD #102, revealed SSD #102 arranged HHA skilled nursing services assuming this would include IV antibiotic medication administration every four hours. SSD #102 was later informed the HHA could not accommodate IV antibiotic medication administration until 11/25/22. SSD #102 stated within two hours of the resident's discharge from the facility, she became aware of the issue after Resident #61's husband contacted her inquiring about his wife's IV antibiotic medication. SSD #102 notified Resident #61's husband and asked that the resident immediately return to the nursing facility in order to receive her medications as ordered. SSD #102 confirmed the resident returned and received her medications timely and experienced no adverse effects during her absence from the facility. SSD #102 revealed the resident was discharged on [DATE] with a different HHA arranged to provide skilled nursing services including IV ATB therapy. Interview on 12/06/22 at 3:05 P.M. with the Director of Nursing (DON), confirmed Resident #61 was discharged home on 11/23/22 without the appropriate coordination for skilled nursing services arranged to provide IV ATB medication and IV care in the resident's home. The DON further confirmed Resident #61's plan of care was not revised to address discharge planning. Review of the facility's policy, Transfer and Discharge Rights, dated October 2022, revealed except in case of emergency, the resident, the representative, and the attending physician are consulted in advance of the transfer or discharge. Casework services or other means are utilized to assure that adequate arrangements exist for meeting resident's needs through other resources. This deficiency represents non-compliance investigated under Complaint Number OH00137990.

Based on interview, record review, and policy review, the facility failed to provide appropriate treatment to prevent a potential urinary tract infection for a resident with an indwelling urinary catheter. This affected one resident (Resident #36) of three residents reviewed for urinary catheters. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, obstructive and reflux uropathy, kidney failure, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #36, dated 10/01/22, revealed intact cognition. The resident required extensive, two-person physical assistance with bed mobility, transfers, and toileting. Review of the Care Plan for Resident #36 revealed the resident had an indwelling catheter due to obstructive and reflux uropathy with interventions including to keep catheter covered and off of the floor surface. Observation on 12/06/22 at 10:45 A.M. revealed Resident #36's indwelling urinary catheter bag was secured to the bottom of the bed frame, on the left side, and was in contact with the floor. During interview on 12/06/22 at 10:59 A.M., State tested Nursing Assistant #210 confirmed Resident #36's catheter bag was touching the floor. Interview on 12/06/22 at 12:45 P.M. with the Director of Nursing (DON), confirmed Resident #36's catheter bag should not be in contact with the floor. The DON stated the resident requested the catheter bag be secured to the bottom of the bed frame, however, when the resident lowers his bed, the catheter bag can contact the floor surface. The DON confirmed the resident does not have a risk agreement regarding the placement of his catheter bag and the potential risk of contamination. Review of the facility's policy, Catheter, Closed Urinary-Application of a Closed Urinary Drainage Bed Bag, dated January 2012, revealed catheter bags are placed on the side of the bottom half of the bed, below the level of the bladder, and should not touch the floor.

Based on observation, record review, facility policy and procedure review, Centers for Disease Control (CDC) review and interview the facility failed to maintain proper infection control practices, including proper use of N95 masks and hand washing to prevent the spread of infection including COVID-19. This affected two residents (#2 and #57) and had the potential to affect six additional residents (#16, #17, #19, #21, #53, and #58) who resided on the West Wing. The facility census was 59. Findings include: On 10/07/22 at 11:00 A.M. upon entrance to the facility, it was noted the facility was in COVID-19 outbreak status with positive residents noted residing throughout the facility. COVID positive residents had droplet precaution signs on their room doors. There were isolation bins with PPE outside the resident room doors and trash cans in the room. The doors were kept closed for residents who were in isolation for COVID. In addition, there was a hanging device for shields and alcohol pads available for staff to clean their goggles. Review of the current Centers for Disease Control (CDC) guidance revealed for personal protective equipment, health care personnel who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 1. Record review revealed Resident #2 was admitted to the facility on [DATE] from the hospital. The resident tested positive for COVID-19 on 10/05/22. On 10/07/22 at 12:39 P.M. State tested Nursing Assistant (STNA) #157 was observed to apply personal protective equipment (PPE), including a gown and gloves and entered Resident #2's isolation room. Prior to entering the room, STNA #157 was observed to already be wearing an N95 mask and goggles. On 10/07/22 at 12:42 P.M. STNA #157 exited Resident #2's isolation room but did not change her N95 mask or cleanse her goggles. The STNA was observed to put her hand under the hand sanitizer dispenser between resident rooms and rubbed them together as she walked down the hall. Interview with STNA #157 as she was walking down the hall confirmed the STNA failed to change her N95 mask upon exiting the resident's isolation room. STNA #157 indicated there were not any new/clean N95 masks available. However, N95 masks were observed in the isolation bin outside the resident's room. STNA #157 then returned to the room/isolation bin and obtained a new N95 mask. She took off her N95 mask, opened the door to the resident's isolation room, disposed of her N95 mask and applied a new one. STNA #157 did not wash or sanitize her hands between removal of the N95 mask she had on in the isolation room and putting on the new N95 mask. The STNA then proceeded to walk down the hallway. The surveyor stopped the STNA and asked her about cleaning her goggles. The STNA replied she had washed the goggles off in the sink in the bathroom, but stated there was no alcohol to clean them. An additional observation of the isolation bin revealed there was nothing in the bin to clean goggles with. Review of the facility COVID-19 Infection Prevention and Control Measures and Management policy, revised 09/28/22 revealed health care personnel who enter the room of a resident with suspected or confirmed SAR-COV-2 infection should adhere to Standard Precautions and follow transmission based precautions including the use of a N95 mask, gown, gloves and eye protection (goggles or face shield). The health care provider would remove (doff) and dispose of the gloves, gown and facemask when exiting the resident's room following the Center for Disease Control guidance and facility policy and would sanitize eye protection unless disposable. Record review revealed STNA #157's work assignment included care of additional residents, Resident #16, #17, #19, #21, #53, and #58 who resided on the West wing who were not in any type of isolation/quarantine for COVID-19 and could be affected by the employee not properly using PPE after caring for a resident in isolation for COVID-19, including changing or cleaning PPE when exiting the room. 2. Record review revealed Resident #57 was admitted to the facility on [DATE] and had tested positive for COVID-19 on 10/04/22 while hospitalized . On 10/07/22 at 12:37 P.M. Certified Occupational Therapy Assistant (COTA) #158 was observed to apply (don) a gown and gloves and enter Resident #57 isolation room. The resident was noted to be in isolation for COVID-19. At the time of the observation, COTA #158 already had an N95 mask and goggles on. On 10/07/22 at 12:56 P.M. COTA #158 exited the room with the N95 mask and goggles on. The COTA used hand sanitizer from the wall mount near the room and tissues that were on a cart next to the isolation bin to clean her goggles. The surveyor asked about the N95 mask the COTA wore out of the room. COTA #158 indicated she had a clean N95 mask sealed in a bag in her pocket. She stated she put it on after she disposed of her old one. When asked if her hands were considered contaminated from touching the PPE while removing the items in the COVID positive room, COTA #158 verified she applied a clean mask with contaminated hands prior to sanitizing. COTA #158 verified touching a clean mask with contaminated hands would contaminate the clean mask. COTA #158 revealed she visited Resident #57, who was in isolation for COVID-19 as her last resident contact for the day. This deficiency substantiates Complaint Number OH 276.

Based on review of Quality Assessment and Assurance (QAA) sign-in sheets, record review, facility policy and procedure review and interview the facility failed to ensure quarterly QAA meetings were conducted and failed to ensure all required members, including the Medical Director (MD) participated/attended the meetings as required. This had the potential to affect all 58 residents residing in the facility. Findings include: Review of an undated facility Quality Assessment Performance Improvement (QAPI) member list revealed the MD was listed as a member of the facility QAPI committee. The QAPI list revealed the following facility staff/positions were part of the QAPI committee: The Administrator, Director of Nursing, Medical Director (MD), Clinical Director, Nurse Aide Supervisor, QA Coordinator, Nutrition Services Director, Restorative Supervisor, Wound Nurse, Social Services, Pharmacy and Laboratory. The Activity Director, Maintenance Director, MDS, Admissions Director, Housekeeping/Laundry Supervisor, and Rehabilitation Director were included on the facility monthly meeting list. Review of the QAA sign-in sheets from the meetings conducted from 09/2021 to 08/25/2022 revealed there were no sign in sheets available for review for any meetings in September, October, November or December of 2021 to ensure a meeting was held with all required members during this time period. Review of the first quarter (January to March) of 2022 revealed meetings were held on 01/27/22, 02/24/22 and 03/24/22. However, there was no evidence the Medical Director (MD) was in attendance. On 09/30/22 at 9:58 A.M. interview with the DON verified there was no evidence the Medical Director attended a QAPI meeting during the first quarter of 2022. In addition, the DON revealed QAPI meeting had not been held in 2021 as required. On 09/30/22 at 2:50 P.M. interview with the Administrator revealed the previous DON left in August 2021. Registered Nurse (RN) #62 was the acting DON until the current DON started the end of October 2021. The Administrator revealed he did not recall having any QAPI meetings after the DON left in August 2021. Review of the facility Leadership and Communication policy, revised 08/2018 revealed the the team would meet monthly. Per regulation, the facility must have an ongoing QAA committee that included designated key staff members that met at least quarterly. The committee members must consist of the facility Administrator, DON, Medical Director and at least three other staff members.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #3, Resident #5, Resident #9 and Resident #27, who required staff assistance with activities of daily living (ADL) care received timely and adequate nail care to maintain proper hygiene. This affected four residents (#3, #5, #9 and #27) of five residents reviewed for activities of daily living. Findings include: 1. Review of Resident #3's medical record revealed a 02/28/17 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A plan of care, dated 03/20/19 revealed resident care would be provided according to the plan. An intervention revised 07/13/21 included grooming and hygiene would be provided with assist of one (staff). Review of the 07/02/22 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, totally dependent on two staff for bed mobility and transfers and required extensive assistance from one staff for personal hygiene. The assessment revealed the resident had no behaviors. On 09/27/22 at 10:53 A.M. observation revealed all 10 of Resident #3's fingernails were dirty and long. The resident's fingernails were over a quarter inch long with nail polish was coming off. During the observation, the resident stated she had tried to get her nails cut and indicated she had her own polish. On 09/28/22 at 11:24 A.M. observation with Licensed Practical Nurse (LPN) #81 verified all 10 of the resident's fingernails were long and dirty with the middle fingernail of her right hand having the nail partially broken and hanging. Review of the facility Nails, Care of Fingernails policy, dated 11/2021 revealed fingernail care would be done for non diabetic residents by the State tested Nursing Assistant (STNA) during or after the resident shower/bath and as needed. The STNA would examine the nails of the diabetic resident during their shower and inform the nurse of any issues with the residents fingernails. Fingernail care may also be done by STNA during an activity that involved grooming such as spa day, manicure day. 2. Review of Resident #5's medical record revealed an 08/26/16 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care revealed a plan, dated 03/27/19 indicating resident care would be provided according to the plan. An intervention revised 04/27/21 included grooming and hygiene would be provided with assist of one (staff). Review of the 06/28/22 annual MDS 3.0 assessment revealed the resident was independent for daily decision making, required extensive assistance from two staff for bed mobility and transfers and was totally dependent on one staff for personal hygiene. On 09/27/22 at 10:53 A.M. observation of Resident #5's left hand thumb and index finger nails revealed they were dirty with dark debris under her nail beds. The resident's right thumb nail had dark debris under the nail beds. On 09/28/22 at 11:21 A.M. observation with LPN #81 verified the resident's left hand thumb and index finger nail beds were dark with debris as well as her right thumb. Review of the facility Nails, Care of Fingernails policy, dated 11/2021 revealed fingernail care would be done for non diabetic residents by the State tested Nursing Assistant (STNA) during or after the resident shower/bath and as needed. The STNA would examine the nails of the diabetic resident during their shower and inform the nurse of any issues with the residents fingernails. Fingernail care may also be done by STNA during an activity that involved grooming such as spa day, manicure day. 3. Review of Resident #9's medical record revealed a 05/26/21 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A plan of care, (revised 08/21/21) revealed care would be provided according to the plan. An intervention, dated 05/17/21 revealed grooming and hygiene would be provided with assist of one (staff). Review of the 07/07/22 quarterly MDS 3.0 assessment revealed the resident was moderately impaired for daily decision making, had no behaviors and was totally dependent on one staff for personal hygiene. Review of the State tested Nurse Aide TASK documentation revealed on 09/20/22 the resident had a shower and on 09/27/22 the resident had a bed bath. On 09/27/22 at 9:12 A.M. observation revealed Resident #9 had a brace to her left hand. The resident's fingers were curled onto her palm. The resident's finger nails were over a quarter inch long with brown debris in the nail beds the length of some of the nails. At the time of the observation, Resident #9 indicated her fingernails needed cut. The resident also was noted to have white polish coming off. On 09/28/22 at 10:58 A.M. interview with LPN #81 verified all of the resident's fingernails were long and soiled. The LPN indicated it looked like the nails needed to be soaked. On 09/28/22 at 12:37 P.M. interview with State tested Nurse Aide (STNA) #96 verified residents were to have nail care when showers were completed. Review of the facility Nails, Care of Fingernails policy, dated 11/2021 revealed fingernail care would be done for non diabetic residents by the State tested Nursing Assistant (STNA) during or after the resident shower/bath and as needed. The STNA would examine the nails of the diabetic resident during their shower and inform the nurse of any issues with the residents fingernails. Fingernail care may also be done by STNA during an activity that involved grooming such as spa day, manicure day. 4. Review of Resident #27's medical record revealed a 01/16/20 admitted d with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A plan of care, dated 01/29/20 revealed the resident had a self care deficit as evidenced by requiring assistance with activities of daily living due to weakness related to [CONDITION(S)] Disease and dementia with Lewy Bodies. Review of the 07/21/22 quarterly MDS 3.0 assessment revealed the resident was moderately impaired for daily decision making and totally dependent on two staff for bed mobility, transfers, locomotion and dressing. The assessment revealed the resident required limited assistance from one staff for eating and was totally dependent on one staff for personal hygiene. Record review revealed the person centered plan of care was revised 08/28/22 and included care would be provided according to the plan. An intervention (dated 05/17/21) revealed grooming and hygiene would be provided with assist of one (staff). On 09/27/22 at 10:29 A.M. observation revealed the resident had long finger nails on both hands measuring over a quarter inch long. The nails were discolored with debris in the nail beds. On 09/28/22 at 02:47 P.M. interview with Registered Nurse (RN) #76 verified the resident;s fingernails were long and dirty. Review of the facility Nails, Care of Fingernails policy, dated 11/2021 revealed fingernail care would be done for non diabetic residents by the State tested Nursing Assistant (STNA) during or after the resident shower/bath and as needed. The STNA would examine the nails of the diabetic resident during their shower and inform the nurse of any issues with the residents fingernails. Fingernail care may also be done by STNA during an activity that involved grooming such as spa day, manicure day.

Based on record review and interview the facility failed to ensure Resident #16's left leg was properly positioned on the foot rest of her wheelchair to prevent the resident's leg/foot from falling off the foot rest while being transported by staff resulting in an injury to the resident. Actual harm occurred to Resident #16 on 05/29/18 when her left foot fell off the footrest of the wheelchair and her left foot and leg rolled under the wheelchair resulting in a leg fracture. Following the incident, the resident sustained [REDACTED]. This affected one (Resident #16) of 24 residents observed and/or interviewed regarding accidents. Findings include: Review of Resident #16's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was able to make herself understood and she was able to understand others. The MDS 3.0 assessment indicated Resident #16 was moderately cognitively impaired and required extensive assistance from staff for transfers and locomotion on and off the unit. A nursing note, dated 05/30/18 at 9:00 A.M. as a late entry for 05/29/18 at 3:00 P.M. revealed Resident #16 was being taken to the cafe for dinner by a staff member when her left foot fell off the foot rest and her left foot and leg rolled up under her wheelchair. The nursing note indicated Resident #16 started screaming about her knee. The note indicated Resident #16's left knee was very swollen. Physician orders [REDACTED]. A nursing note revealed on 05/29/18 at 11:00 P.M. the Certified Nurse Practitioner (CNP) was notified of the x-ray results. Orders were received for an orthopedic consult, bed rest until further notice and increase [MEDICATION NAME] to 400 mg every four hours as necessary. A CNP note dated 05/30/18 indicated Resident #16 was seen as a follow up after an x-ray indicated a [MEDICAL CONDITION] femur. The CNP documented a consult was ordered with an orthopedist whom Resident #16 had seen in the past. In order to facilitate timely follow up, Resident #16 was being transported to the emergency room for further assessment and treatment of [REDACTED]. An emergency room report dated 05/30/18 indicated the physician decided on applying a brace and sending Resident #16 back to the nursing facility. A nursing note dated 05/30/18 at 5:15 P.M. indicated Resident #16 returned from the hospital. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Resident #16 had orders for Tylenol 650 mg every four hours as necessary for pain but none was administered. Resident #16 received [MEDICATION NAME] on 05/29/18 at 8:00 P.M., 05/30/18 at 8:00 A.M., and 05/31/18 at 2:30 A.M., 2:30 P.M. and 8:30 P.M. for leg pain. On 05/30/18 an order was written for [MEDICATION NAME] (a narcotic pain medication) 5/325 mg three times a day as necessary. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 07/31/18 at 12:08 P.M., interview with State tested Nursing Assistant (STNA) #192 revealed prior to Resident #16 sustaining the fracture, the resident walked in her room. On 08/01/18 at 4:11 P.M., Licensed Practical Nurse (LPN) #130 revealed she was unaware of any concerns regarding Resident #16's feet falling off her footrests prior to the fracture. On 07/31/18 at 3:20 P.M., interview with STNA #113 revealed Resident #16 used to walk from her room to her bathroom with a walker and one assist prior to the fracture of her femur. STNA #113 stated he was the staff member propelling Resident #16 in her wheelchair at the time she sustained the fracture. STNA #113 stated Resident #16 was groggy on 05/29/18. STNA #113 stated Resident #16 had a history of [REDACTED]. STNA #113 stated Resident #16 had straps on the back of the foot rests but they were not used to hold Resident #16's feet in place. On 08/01/18 at 1:54 P.M., interview with STNA #178 revealed prior to Resident #16 sustaining the fracture of her left femur, she had trouble keeping her feet on her wheelchair pedals. Resident #16 would place her feet at the edge of the inner part of the pedals and her feet would drop. On 08/01/18 at 3:59 P.M., interview with Registered Nurse (RN) #101 revealed she was unable to find any documentation indicating Resident #16 had a history of [REDACTED].#113 and #178). On 08/01/18 at 3:59 P.M., interview with Licensed Practical Nurse (LPN) #189 revealed the facility did have footboards available which could have been applied to Resident #16's wheelchair to prevent her foot from sliding off the foot rest during staff assisted transportation.

Based on record review, interview, observation, facility policy review, and manufacturer information, the facility failed to ensure interventions were in place to prevent the development of a pressure sore for Resident #53. Harm occurred when Resident #53 developed a suspected deep tissue injury to his bilateral heels. This affected one of three residents reviewed for pressure wounds. Findings include: Review of Resident #53's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. This order was noted on the December 2014 monthly orders to be continued. Review of the discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #53 required extensive assistance for bed mobility. Review of the hospital leave of absence tracking form revealed Resident was discharged to the hospital 12/01/14 for [MEDICAL CONDITION] and returned to the facility on [DATE]. Review of the hospital's Registered Nurse transfer assessment dated [DATE] revealed Resident #53's skin was intact. Review of the Braden scale dated 12/03/14 revealed a total score of 12. A score of 12 indicates the resident is at high risk for pressure sores. Review of the readmission Physical assessment dated [DATE] revealed skin was pink with poor turgor. The assessment revealed Resident #53's bilateral heels were red and mushy but did not indicate any further assessment of the heels. Review of the nurse's note dated 12/03/14 revealed Resident #53 has limited range of motion to all extremities. Review of the plan of care dated 12/03/14 revealed a problem of potential for further skin breakdown related to soft boggy heels. Approaches for this problem include pressure reduction mattress, turn and reposition resident every two hours, off load heels at all times. Review of the physician orders [REDACTED].#53's heels every shift. Review of the Treatment Administration Record (TAR) for December 2014 revealed no evidence of turning and repositioning every two hours while in bed from 12/03/14 through third shift 12/09/14. There was no evidence on the treatment record of Resident #53's heels being off loaded from 12/03/14 through 12/10/14. Review of the nursing notes from 12/03/14 to 12/10/14 revealed no evidence of Resident #53 being turned and repositioned or Resident #53's heels being elevated. Review of the TAR revealed no evidence of skin prep being applied to Resident #53's bilateral heels. Review of the pressure ulcer tracking grid initial assessment dated [DATE] revealed on this date an unstageable deep tissue injury was noted on the right heel. The form revealed a length of 4.2 centimeters (cm) and a width of 3.4 cm. The wound bed was described as being 95% deep purple and 5% light pink. Observation on 01/21/15 at 1:55 P.M. with RN #14 revealed Resident #53's right heel with an area approximately 3.8 cm long and 3 cm wide. The area was 70% deep purple and 30% medium purple, and the area was intact with edges loosening. Interview on 01/20/15 at 12:45 P.M. with Registered Nurse (RN) #12 revealed RN #12 did complete a treatment to the right heel earlier in the morning on this date. RN #12 revealed the area to the right heel "felt rough" but RN #12 indicated "I didn't really look at it." RN #12 then checked with the wound care nurse and verified Resident #53 does have an unstageable pressure sore on the right heel. Interview on 01/21/2015 at 1:01 P.M. with family member #13 revealed Resident #53 was found to have the heel wound in December 2014. Family Member #13 indicated prior to the wound being found, the resident would sit in the wheelchair with slippers on. Family Member #13 indicated that during the day Resident #53 was not repositioned. Family Member #13 indicated once the wound was noted the staff did show the family how to elevate Resident #53's heels and the slippers were removed. Interview on 01/21/14 at 2:30 P.M. with RN #14 revealed that turning and repositioning, elevation/off loading of heels, and skin prep being applied to the heels would be documented on the TAR. Interview on 01/21/2015 at 2:40 P.M. with RN #15 confirmed there was no evidence in the medical record of Resident #53 being turned and repositioned, off loading of heels, or the skin prep to the bilateral heels being completed. RN #15 indicated that the orders were not reordered on admission and therefore were not transferred to the treatment administration record. Interview on 01/22/14 at 7:40 A.M. with RN #14 revealed Resident #53 had been receiving skin prep to the bilateral heels prior to discharge to the hospital for protection. RN #14 indicated the skin prep should of been continued when readmitted to the facility for protection of Resident #53's heels. Review of the facilities reference for pressure ulcer staging revealed a pressure ulcer pocket reference card from medline. This reference card revealed a suspected deep tissue injury is purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Review of the no-sting skin prep insert revealed indications that it can also be used on heels, elbows and other areas of the body that are at risk of irritation due to friction damage caused by external surfaces such as linen and mattresses.