Every finding on record at Pickaway Manor Care Center

Based on record review, observation, resident and staff interviews, wound physician interview, review of wound notes, review of hospital records, review of information from the National Pressure Injury Advisory Panel (NPIAP), review of specifications for air mattresses, and policy review, the facility failed to ensure the physician ordered treatments were completed as directed and failed to ensure interventions were implemented to prevent the development of, worsening of and promote the healing of an avoidable facility acquired pressure ulcer for Resident #5. Resident #5 was at risk for pressure ulcer development and dependent on staff for activities of daily living (ADLs) including transfers, and toileting and required max assist with bed mobility, turning and repositioning, and had a known sacrum stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough, a yellowish, stringy dead tissue or eschar, a layer of dead, dry tissue that forms a dark leathery scab over the ulcer may be present on some parts of the wound bed. Often includes undermining and tunneling). This resulted in Immediate Jeopardy and actual harm when the facility failed to implement effective interventions to prevent the development of and adequately treat an avoidable facility acquired pressure ulcer to right lateral thigh. On 08/14/25, Resident #5 developed a facility acquired deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) pressure ulcer to right thigh. This was assessed and staged by Licensed Practical Nurse (LPN) #1010. On 08/21/25 the deep tissue injury (DTI) to right thigh progressed to stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). The facility continued incorrect treatment orders for the pressure ulcer areas resulted in declining of both areas of sacrum and right thigh, and hospitalization on 09/23/25 for osteomyelitis. Due to continued incorrect treatments, the wound deteriorated, and Resident #5 was hospitalized again on 10/23/25 for ongoing osteomyelitis and sepsis to a stage IV wound on the sacrum. Resident #5 had increased pain to right hip/thigh and the pressure wound increased drastically in size, developed necrosis (death of tissue) of right lateral thigh stage III pressure ulcer, and myositis (muscle inflammation caused by injury or infection). Resident #5 was still being treated for both pressure ulcer areas. Actual Harm occurred to Resident #41, who was at risk for pressure ulcer development and/or alteration in skin integrity when the facility failed to provide the necessary care and services for the prevention and development and then worsening of a Stage III pressure ulcer. Resident # 41 assessed by LPN #1010 with an in-house facility acquired avoidable coccyx pressure ulcer, with no staging on 08/26/25. On 08/28/25, Wound Physician #1127 assessed and staged the coccyx pressure ulcer as a stage III. In addition, harm also occurred on 09/22/25 when Resident #41 was assessed with a blister to the left heel by LPN #1110. On 09/25/25, Wound Physician #1127 assessed the left heel as an in-house facility acquired avoidable deep tissue injury progressing to a stage III then unstageable due to incorrect treatments and care. Lastly, the facility did not ensure pressure ulcer prevention measures and care were in place and accurate for Residents #99 and #82. This affected four residents (Residents #5, #41, #99, and #82) of five residents reviewed for pressure ulcer care. The facility census was 84. On 01/14/26 at 10:14 A.M., the Administrator, Regional Clinical Services (RCS) Registered Nurse (RN) #1128, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/14/25 when the facility failed to provide correct treatment orders, accurate assessments, and necessary interventions to Resident #5 to prevent an avoidable facility acquired pressure ulcer to right thigh and the declining of that pressure ulcer as well as a known stage IV pressure ulcer to sacrum resulting in hospitalization on 09/22/25 for osteomyelitis/sepsis. Resident #5 returned to the facility 09/26/25 and was sent back to the hospital on [DATE] with continued inaccurate treatments and necessary interventions to prevent worsening of the pressure ulcers and was found to have possible osteomyelitis of the sacrum stage IV pressure ulcer and soft tissue necrosis and myositis to the right lateral thigh unstageable pressure ulcer. Resident #5 returned to the facility on [DATE] and continued to have inaccurate treatments and necessary interventions to prevent worsening of the pressure ulcers as of 01/07/26. The Immediate Jeopardy was removed on 01/14/26 when the facility implemented the following corrective actions: -On 01/13/26 at 2:00 P.M., Skin sweeps initiated by Unit Manager LPN #1010, Unit Manager LPN #1032, Assistant Director of Nursing (ADON) and Registered Nurse (RN) #1001 on all residents in house. All skin sweeps were completed by 5: 30 P.M. with any new areas noted and reported to the provider. Results of skin sweeps revealed seven residents with skin issues: one skin tear, one venous ulcer, one scratch, one excoriation, two deep tissue injuries (DT)2I, one stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) and one blister. Residents with areas found on skin sweep included Residents #57, #29, #36, #76, #69, #5 and #9. -On 01/13/26 at 2:43 P.M. the DON spoke via phone with Wound Physician #1127 and went over all current treatment orders for residents under her care. All treatment orders currently ordered are correct. Total of seven residents including Residents #5, #87, #77, #83, #5 and #57 had orders clarified. -On 01/13/26 at 2:45 P.M. the DON educated via phone, Wound Physician #1127on writing treatment orders more specific. - On 01/13/26 at 2:50 P.M. the DON reviewed air mattress manuals for setting information. - On 01/13/26 at 3:00 P.M., education started by the DON for licensed nurses when clarifying wound orders to ensure documentation to support the notification, air mattress settings are correct, orders entered and care planned, pressure reducing interventions are in place, LPN's cannot stage pressure ulcers or assess them, they must be completed by an RN and assessments need to be completed on admission for wounds to include measurements length, width, and depth and a description of wound. Five of ten RNs were educated in person, and five of ten RNs were educated via phone. 11 of 19 LPNs were educated in person and eight of 19 educated via phone. This was completed by 7:00 P.M. - On 01/13/26 at 3:00 P.M. education started by the DON for certified nursing assistants (CNA) on ensuring pressure reducing interventions are in place and not to change air mattress settings. 22 of 49 CNAs were educated in person with 27 of 49 CNA's educated via phone. This was completed by 7:00 P.M. - All staff not educated will be educated prior to the next working shift by the DON or designee. - On 01/13/26 at 3:40 P.M. Regional Nurse #1054 and Regional Clinical Services RN #1128 audited all air mattresses to ensure proper air mattress settings are in place. Any abnormalities were corrected at that time. All orders are in place, care planned and on Kardex. Floor nurses will monitor settings moving forward to ensure proper settings in place. Current residents with air mattresses included Residents #28, #57, #32, #42, #73, #82, #33, #1, #15, #39, #2, #34, #90, #31, #87, #20, #99, #85, #71, #41, #5, #77 and #72. - On 01/13/26 at 4:00 P.M. the DON reviewed via phone all other treatment orders currently ordered with the resident's' providers who included Medical Director Physician #1129, Physician #1130 and the wound clinic and all are appropriate. A total of 21 residents were reviewed. -On 01/13/26 at 4:40 P.M. the DON notified Medical Director Physician #1129 of the facility plan via phone during an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting. In attendance were the DON, Administrator, Medical Director Physician #1129 (via phone), Regional Nurse #1054 and Regional Clinical Services RN #1128. - On 01/14/26 at 10:45 A.M. Regional Nurse #1054 assessed Resident #5 for new skin impairments, pressure reducing interventions in place and proper air mattress settings. No abnormalities were found. - On 01/14/26 at 11:00 A.M. Regional Nurse #1054 reviewed Kardex and care plans for those at risk via Braden score and current residents with pressure ulcers for appropriate interventions in place. - DON will oversee the wound prevention and treatment process moving forward. - ADON will go on wound rounds to ensure compliance with wound prevention and treatment process. - DON/designee will audit five resident's wound documentation and treatment orders weekly to ensure correct orders are entered, and wound assessments are being completed timely for four weeks. - DON/designee will audit five resident's air mattresses weekly to ensure proper settings are in place for four weeks. - DON/designee will audit five residents to ensure pressure reducing interventions are in place weekly for four weeks. - Audits will be reviewed in QAPI and changes made as needed. Although the Immediate Jeopardy was removed on 01/14/26, the facility remained out of compliance at Severity Level 3 (actual harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #5, revealed an admission date of 12/03/24. Diagnoses included type 2 diabetes, central cord syndrome at cervical 5 level of cervical spinal cord, specified disorder of muscle, generalized anxiety disorder and major depressive disorder. Review of the care plan revised on 07/11/25 revealed Resident #5 was at risk for pressure injury formation with interventions including encourage resident to turn and reposition frequently as resident tolerates and low air loss mattress on bed with no mattress settings identified. Review of Resident #5's Braden Scale for Predicting Pressure Sore Risk dated 08/01/25 revealed a score of 13 which was moderate risk for skin breakdown. The scale was 6 (high risk) to 23 (no risk). Review of the medical record from 12/03/24 to 08/13/25, revealed Resident #5 was totally dependent for bed mobility, at risk for pressure ulcers and had a sacrum stage III pressure ulcer present upon admission. Review of the physician's orders through that time revealed no order for a low air loss mattress or turning and repositioning. There were incorrect treatment orders. Pressure ulcer assessment and staging were being completed by LPN #1010. and the sacrum stage III ulcer had deteriorated to a stage IV. Review of the skin and wound evaluation for Resident #5 dated 08/14/15 at 1:56 P.M. by Unit Manager LPN #1010 revealed a sacrum stage IV pressure ulcer that measured 6.7 centimeters (cm) by 6.6 cm by 4.5 cm with a wound bed composition of 90 percent granulation and 10 percent slough. Review of the skin and wound evaluation for this resident dated 08/14/25 at 3:24 P.M. by Unit Manager LPN #1010 revealed an avoidable deep tissue injury of the right lateral thigh, in house acquired that measured 4 cm by 3.3 cm. Review of the medical record for Resident #5 dated 08/14/25 revealed the wound consultant physician did not assess her that week as well as no other documentation for assessing and staging the sacrum stage IV pressure ulcer and the right outer thigh deep tissue injury by another physician and/or Registered Nurse. The orders for treatments were obtained by Physician #1130, and the wound consultant physician office was not contacted for treatment. Review of the physician order for Resident #5 dated 08/14/25 at 7:09 P.M. revealed a treatment for the right outer thigh deep tissue injury to cleanse with normal saline, paint with Betadine, a povidone-iodine, and cover with dressing every shift. Review of the physician orders for this resident dated 08/14/25 at 8:10 P.M. revealed a treatment for the sacrum stage IV pressure ulcer to cleanse with normal saline, pack with Dakin's Solution (no strength percent was mentioned in the order) moistened gauze, cover with a dressing and change every shift. Review of the physician orders and progress notes for Resident #5 from 08/14/25 through 08/20/25 revealed no clarification to a physician of the percentage of the Dakin's Solution used for the treatment of the sacrum stage IV pressure ulcer. Review of the treatment administration record (TAR) for Resident #5 dated 08/14/25 through 08/20/25 revealed the incorrect treatment order was administered for the sacrum stage IV pressure ulcer. Review of the physician order for Resident #5, dated 08/20/25 at 9:42 A.M. revealed a treatment for the sacrum stage IV pressure ulcer of Dakin's solution, 0.125 percent solution, apply topically every shift to come from the pharmacy. Review of the wound consult visit notes revealed Resident #5 was seen by Wound Physician #1127 on 08/21/25 with no time stamp. Resident #5 still had a sacrum stage IV pressure ulcer and measured 6.7 cm by 6.6 cm by 4.5 cm with the wound bed tissue composition as 80 percent granulation and 20 percent slough. A treatment plan of moistened gauze with Dakin's solution 0.25 percent, pack the wound with an entire kerlix roll and cover with dry dressing every shift and as needed. A new area assessed as a right lateral thigh stage III pressure ulcer measured 2.2 cm by 2.9 cm by 0.1 cm with the wound bed tissue composition as 50 percent epithelial, 30 percent granulation and 20 percent slough. A treatment plan of cleanse with normal saline or sterile water and apply wound gel to wound bed, cover with a dry dressing (no frequency). Review of the medical record for Resident #5 revealed no clarification/addendum with the Wound Physician #1127 of the right lateral thigh stage III pressure ulcer treatment frequency. Review of the physician orders for Resident #5, dated 08/22/25 at 8:47 A.M. revealed a treatment for the right lateral thigh stage III pressure ulcer of cleanse with normal saline, apply wound gel to wound bed, cover with a dry dressing every shift. Review of the physician orders for this resident, dated 08/22/25 at 08:49 A.M. revealed a treatment for the sacrum stage IV pressure ulcer of moistened gauze with Dakin's solution, no strength noted, and to pack the wound with an entire kerlix roll and cover with a dry dressing every shift and as needed. Review of the TAR for Resident #5 dated 08/22/25 through 08/28/25 revealed the incorrect treatment order was administered for the sacrum stage IV pressure ulcer. Review of the wound consult visit notes revealed Resident #5 was seen by Wound Physician #1127 on 08/28/25. The sacrum stage IV pressure ulcer and right lateral thigh stage III pressure ulcer with no major changes, treatment orders to continue from the 08/21/25 visit note. Review of the medical record for Resident #5 revealed no clarification/addendum with Wound Physician #1127 of the right lateral thigh stage III pressure ulcer treatment frequency. Review of the TAR for Resident #5 dated 08/29/25 through 09/03/25 revealed the incorrect treatment order was administered for the sacrum stage IV pressure ulcer. Review of the wound consult visit notes revealed Resident #5 was seen by Wound Physician #1127 on 09/04/25. The sacrum stage IV pressure ulcer measured 7.1 cm by 6.9 cm by 6.5 cm with the wound bed tissue composition as 80 percent granulation and 20 percent slough. A treatment plan for implementing negative wound therapy every Tuesday, Thursday and Saturday. Apply at 125 millimeters of Mercury (mmHg) continuously and pack wound completely with black foam. The right lateral thigh stage III pressure ulcer measured 3.1 cm by 1.6 cm by 0.2 cm with the wound bed tissue composition as 50 percent epithelial, 30 percent granulation and 20 percent slough. A treatment plan of cleanse with normal saline, apply nickel thick Santyl (a debriding agent) and cover with a dry dressing every day and as needed. Review of the physician's orders for Resident #5 dated 09/04/25 through 09/19/25 revealed Santyl was never ordered to come from the pharmacy. Review of the TAR for Resident #5 dated 09/04/25 through 09/06/25 revealed the incorrect treatment order was administered for the sacrum stage IV pressure ulcer and the right lateral thigh stage III pressure ulcer. Review of the physician's orders for Resident #5, dated 09/06/25 at 01:23 P.M. revealed a treatment order for the right lateral thigh of cleanse with normal saline, apply nickel thick Santyl and cover with dry dressing every day and as needed. Review of the physician orders for this resident, dated 09/06/25 at 1:25 P.M. revealed a treatment for the sacrum stage IV pressure ulcer of cleanse with Dakin's solution (no percent was mentioned in the order), apply black foam to wound, connect wound vac at 125mmHg continuous on Tuesday, Thursday and Saturday. Review of the TAR for Resident #5 dated 09/06/25 through 09/10/25 revealed the incorrect treatment order was administered for the sacrum stage IV pressure ulcer and the right lateral thigh stage III pressure ulcer. Review of the wound consult visit notes revealed Resident #5 was seen by Wound Physician #1127 on 09/11/25. The sacrum stage IV pressure ulcer measured 5.3 cm by 5.9 cm by 5 cm with the wound bed tissue composition as 80 percent granulation and 20 percent slough. Treatment to continue from 09/04/25 visit note. The right lateral thigh was assessed as an unstageable pressure ulcer and measured 1.2 cm by 2 cm by no depth with the wound bed tissue composition as 20 percent epithelial and 80 percent slough. Treatment to continue from 09/04/25 visit note. Review of the TAR for Resident #5 dated 09/11/25 through 09/13/25 revealed the incorrect order was administered for the sacrum stage IV pressure ulcer. Review of the TAR for this resident dated 09/11/25 through 09/17/25 revealed the incorrect treatment order was administered for the right lateral thigh stage III pressure ulcer. Review of the wound consult visit notes revealed Resident #5 was seen by Wound Physician #1127 on 09/18/25. The sacrum stage IV pressure ulcer had deteriorated and measured 6.1 cm by 7 cm by 5.5 cm with the wound bed tissue composition as 50 percent granulation and 50 percent slough. The wound had odor; bone can be palpated and tunneling at 7 o'clock to 9 o'clock and 5 cm in length. Treatment plan cleanse with normal saline, apply Calcium Alginate and Santyl, pack the wound with a complete roll of moistened gauze of Dakin's solution 0.25 percent with a dry dressing every shift. On the second dressing change, leave Calcium Alginate and Santyl in the wound bed and pack with the complete roll of moistened gauze of Dakin's solution 0.25 percent. The right lateral thigh was a stage III pressure ulcer and had deteriorated, measuring 2.9 cm by 1.8 cm by 0.2 cm with the wound bed tissue composition as 20 percent epithelial, 50 percent granulation and 30 percent slough. Overall, the wound deteriorated (enlarged, bruising) but less slough, so it was staged as a stage III pressure ulcer. Treatment plan to add Calcium Alginate to the nickel thick Santyl with dry dressing daily. Review of the physician order for Resident #5 dated 09/19/25 at 8:13 A.M. revealed a treatment for the sacrum stage IV ulcer cleanse with normal saline, apply Calium Alginate and Santyl in the wound bed, pack with Dakin's solution (no percent mentioned) moistened gauze and apply Triad paste (a hydrophilic wound dressing) to the peri wound, cover with a dressing every shift. Review of the medical record for Resident #5 revealed no clarification/addendum with Wound Physician #1127 of the sacrum stage IV pressure ulcer Dakin's Solution strength. Review of the physician orders for this resident revealed no Dakin's solution was ordered to come from the pharmacy and the treatment plan from Wound Physician visit dated 09/18/25 for the right lateral thigh stage III pressure ulcer was not ordered. Review of the TAR for Resident #5 dated 09/19/25 through 09/22/25 revealed the incorrect treatment was administered for the sacrum stage IV pressure ulcer and the right lateral thigh stage III pressure ulcer. Review of the hospital records for Resident #5 revealed on 09/19/25 she was sent to the hospital emergency room for a urinary tract infection; blood cultures were drawn and sent back to the facility. On 09/22/25, this resident was sent back to the hospital due to positive blood cultures. During the hospital stay, the resident was diagnosed with osteomyelitis of the sacrum pressure ulcer with sepsis. The treatment plan was to not administer antibiotics at this time but treat with wound dressing changes. The sacrum stage IV pressure ulcer measured 7.5 cm by 8 cm by 3.7 cm and undermining at 7 o'clock. The wound bed composition was 90 percent non-granulated tissue and 10 percent bone with brown drainage. The right outer thigh wound was assessed as an unstageable pressure ulcer and measured 3 cm by 3 cm by 0.1 cm. The wound bed composition was 100 percent slough with brown/black drainage. Review of the discharge instructions from the hospital dated 09/26/25 revealed for the sacrum stage IV pressure ulcer treatment of cleanse with Vashe, a hypochlorous wound cleanser, apply wound vac at 150mmHg continuously and change three times a week. The right lateral thigh assessed as unstageable pressure ulcer treatment of cleanse with Vashe wound cleanser, apply Santyl with a Mepilex (a soft silicone foam dressing) dressing daily. Review of the physician orders dated 09/26/25 revealed the treatment for right lateral thigh unstageable wound was not ordered as well as no order for a low air loss mattress with air settings and to turn and reposition. Review of the physician order for Resident #5 dated 09/27/25 at 12:01 A.M. revealed a treatment for the sacrum stage IV pressure ulcer to apply Dakin's Solution 0.125 percent three times a week. Review of the TAR for Resident #5 dated 09/27/25 through 10/02/25 revealed the incorrect treatment was administered for the sacrum stage IV pressure ulcer and the right lateral thigh unstageable pressure ulcer. Review of Resident #5's Braden Scale for Predicting Pressure Sore Risk dated 09/29/25 revealed a score of 13 on a scale of 6 (high risk) to 23 (no risk). The resident was at moderate risk for skin breakdown. Review of the skin and wound evaluation for Resident #5 dated 09/30/25 at 2:44 P.M. by Unit Manager LPN #1010 revealed a right lateral thigh unstageable pressure ulcer measuring 2 cm by 3.4 cm by undetermined depth with a wound bed composition of 90 percent eschar and 10 percent slough. Review of the skin and wound evaluation for this resident dated 09/30/25 at 2:52 P.M. by Unit Manager LPN #1010 revealed a sacrum stage IV pressure ulcer that measured 7 cm by 7.5 cm by 6 cm with a wound bed composition of 70 percent granulation and 30 percent slough. Review of the wound consult visit notes revealed Resident #5 was seen by Wound Physician #1127 on 10/02/25. The sacrum stage IV pressure ulcer measured 7 cm by 9.1 cm by 6 cm with the wound bed tissue composition 70 percent granulation and 30 percent slough. The wound had an odor. The treatment plan was cleanse with normal saline, pack with an entire roll of Kerlix gauze moistened with Dakin's solution 0.25 percent every shift. The right lateral thigh stage III pressure ulcer measured 2.6 cm by 2.8 cm by 0.2 cm with the wound bed composition 80 percent granulation and 20 percent slough. The treatment plan was to cleanse with normal saline, apply collagen to wound bed and cover with a dressing. No frequency of the wound dressing change was listed. Review of the physician order for Resident #5 dated 10/02/25 at 12:38 P.M. revealed a treatment for the sacrum stage IV pressure ulcer cleanse with normal saline, pack wound with entire roll of kerlix moistened in Dakin's solution (no percent) apply Triad paste to peri wound and apply dressing every shift. Review of the physician orders for this resident dated 10/02/25 at 12:39 P.M. for the right lateral thigh stage III pressure ulcer cleanse with normal saline, apply collagen, cover with a dressing every day. Review of the medical record for Resident #5 revealed no clarification/addendum with the Wound Physician #1127 for the sacrum stage IV pressure ulcer Dakin's solution strength and to add Triad paste as well as the right lateral thigh stage III pressure ulcer treatment frequency. Review of the TAR for Resident #5 dated 10/03/25 through 10/09/25 revealed the incorrect treatment was administered for the sacrum stage IV pressure ulcer and the right lateral thigh stage III pressure ulcer. Review of the wound consult visit notes revealed Resident #5 was seen by Wound Physician #1127 on 10/09/2. The sacrum stage IV pressure ulcer had no major changes. Continue treatment plan from 10/02/25 visit note. The right lateral thigh stage III pressure ulcer measured 2.3 cm by 2.64 cm by 0.1 cm with wound bed tissue composition 40 percent granulation and 60 percent slough. The wound continued to have odor with increased slough, so the treatment plan was to cleanse with Dakin's solution 0.25 percent, apply nickel thick Santyl with Silver Alginate and a dry dressing daily. Review of the physician order for Resident #5 dated 10/10/25 at 8:52 A.M. revealed a treatment for the right lateral thigh stage III pressure ulcer of cleanse with normal saline, apply Santyl and Silver Alginate and cover with a dressing daily. Review of the physician orders for this resident dated 10/10/25 through 10/16/25 revealed Santyl never was ordered to come from the pharmacy. Review of the physician order for Resident #5 dated 10/14/25 at 7:00 A.M. revealed a treatment for the sacrum stage IV pressure ulcer for Dakin's solution 0.125 percent, apply topically every shift. Review of the TAR for Resident #5 dated 10/10/25 through 10/16/25 revealed the incorrect treatment was administered for the sacrum stage IV pressure ulcer and the right lateral thigh stage III pressure ulcer. Review of the wound consult visit notes revealed Resident #5 was seen by Wound Physician #1127 on 10/16/25. The sacrum stage IV pressure ulcer measured 6.39 cm by 7.58 cm by 4.5 cm with wound bed tissue composition 80 percent granulation and 20 percent slough. The wound now has odor and is tunneling 4 cm at 9 o'clock. Treatment order to continue as 10/02/25 visit of cleanse with normal saline, pack with an entire roll of Kerlix gauze moistened with Dakin's solution 0.25 percent, change every shift. The right lateral thigh stage III ulcer had deteriorated and measured 3.12 cm by 3.25 cm by 1.5 cm with wound bed tissue composition of 100 percent. The wound continued to have odor and debridement was completed. The treatment plan was to cleanse with Dakin's solution 0.25 percent and apply Dakin's solution 0.25 percent moistened gauze to wound bed and apply dry dressing every shift. Review of the physician order for Resident #5 dated 10/16/25 at 2:55 P.M. revealed a treatment for the right lateral thigh stage III pressure ulcer to cleanse with normal saline, pack wound with Dakin's solution (no percent) moistened gauze, cover with foam dressing and apply Triad paste to peri wound every shift. Review of the physician order for Resident #5 dated 10/20/25 at 7:52 A.M. revealed a treatment for the sacrum stage IV pressure ulcer cleanse with normal saline, pack with Dakin's solution (no percent) apply Triad paste to peri wound and cover with a dressing evert shift. Review of the progress note for Resident #5 dated 10/23/25 at 5:41 P.M. by LPN #1038 revealed an X-ray of the right hip was completed this shift for pain. Results show a possible right femoral fracture. Order to send to the emergency room. Review of the emergency room notes for Resident #5 on 10/23/25 revealed a Computed Tomography (CT) scan of the right hip with no fracture, but possible osteomyelitis of both pressure ulcer areas. The right lateral thigh pressure ulcer measured 6.2 by 3.8 by 7.2 with suspicion of fat necrosis. The sacrum pressure ulcer had no measurements completed. Resident #5 had an elevated white blood cell count of 14,000 (normal 4,500 to 11,000) and significant pain of the sacral area. Antibiotics started, discussed with family to transfer to a different hospital. Resident #5 was transferred to another hospital and review of those hospital notes from 10/24/25 through 10/28/25 revealed possible osteomyelitis of the sacrum stage IV pressure ulcer and soft tissue necrosis and myositis to the right lateral thigh pressure ulcer. Wound care consulted and dressing changes were the most appropriate course of action for treatment at this time. The sacrum stage IV pressure ulcer measured 9.5 cm by 7.5 cm by 6 cm with 4.5 cm of undermining and the right lateral thigh unstageable pressure ulcer measured 4cm by 4 cm by 3.2 cm. Review of the after-visit summary dated 10/28/25 revealed a treatment for the sacrum and right thigh pressure ulcers of cleanse and pat dry. Pack wounds with Vashe wound cleaner moistened Kerlix gauze and cover with a dry dressing and change twice a day and as needed. Review of the skin and wound evaluation for Resident #5 dated 10/30/25 at 11:17 A.M. by Unit Manager LPN #1010 revealed a right lateral thigh stage III pressure ulcer that measured 3.52 cm by 2.9 cm by 2.5cm with tunneling of 5 cm. The wound bed composition of 60 percent granulation and 40 percent slough. Review of the skin and wound evaluation for this resident dated 10/30/25 at 11:17 A.M. by Unit Manager LPN #1010 revealed a sacrum stage IV pressure ulcer measured 6.8 cm by 6.74 cm by 4.5 cm with tunneling at 4.5 cm. The wound bed composition was 90 percent granulation and 10 percent slough. Review of the physician orders for Resident #5 from 10/28/25 through 11/06/25 revealed treatment order for the sacrum stage IV pressure ulcer and the right lateral thigh unstageable pressure ulcer from the after-visit summary were never ordered as well as no order for a low air loss mattress and to turn and reposition. Review of the medical record for Resident #5 revealed no clarification to continue treatment orders for the sacrum stage IV pressure ulcer and the right lateral thigh unstageable pressure ulcer from prior to hospital admission on [DATE]. Review of the TAR for Resident #5 dated 10/28/25 through 11/6/25 revealed the incorrect treatment was administered for the sacrum stage IV pressure ulcer and the right lateral thigh stage III pressure ulcer. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment. Resident #5 required substantial or maximal assistance with shower and bathing, and bed mobility, and was totally dependent for toilet hygiene and transfers. Review of the medical record for Resident #5 revealed from 11/06/25 to present revealed no physician's orders for a low air loss mattress, to turn and reposition and incorrect treatment orders. Further review of the medical record also revealed staging and assessing pressure ulcers by an LPN #1010. During an observation on 01/05/26 at 11:09 A.M., Resident #5 was lying in bed on her back, resting with her eyes closed. The air mattress was set at four. During an observation on 01/06/26 at 10:23 A.M., Resident #5 was lying in bed on her back, resting with her eyes closed. The air mattress was set at four. During an observation on 01/07/26 at 11:00 A.M., 1:00 P.M, and 2:56 P.M., Resident #5 was lying in bed on her left side with a wedge under her right side. The air mattress was set on at four and alternating pressure. During an interview on 01/07/26 at 2:58 P.M. with CNA #1070 verified Resident #5 had been on her left side for hours and was not turned. The care plans are where the turn and reposition information for residents are found but some are to turn as needed. If she is working another unit, it is hard to de[TRUNCATED]

Based on record review, staff interview, and facility policy review, the facility failed to implement and maintain a comprehensive Quality Assurance Improvement Program (QAPI) program and plan to address care issues and/or concerns in the facility. This had the potential to affect all 84 residents who reside in the facility. The facility census was 84.Review of the Quality Assurance (QA) committee attendance records for the previous 12 months revealed QA meetings were held at the end of each month starting with January 2025. Specifically for the September 26, 2025, meeting, review of prevention/interventions for residents with pressure ulcers were discussed, but Resident #41 and Resident #5 were not discussed separately and identified as ongoing issues with their care.The findings for the annual survey, dated 01/05/26 revealed noncompliance in the area of pressure ulcer care, which included prevention and treatments, resulting in substandard quality of care with an Immediate Jeopardy beginning on 08/14/25 for Resident #5, and an Actual Harm, beginning on 08/26/25 to Resident #41.The facility was unable to provide evidence, including documentation, of its ongoing QAPI program's implementation with the pressure ulcer care of Resident #5 and Resident #41.Interview on 01/14/26 at 2:08 P.M. with the Regional Clinical Services #1128 verified for the past year of QAPI meetings, no residents were identified as ongoing issues and care for their pressure ulcers. The facility did review all residents with pressure ulcers and care to make sure interventions and treatments were in place on September 26, 2025, and Resident #41 and Resident #5 were included but was not individually identified as concerns for pressure ulcer care.Interview via telephone on 01/15/26 at 2:10 PM with the Director of Nursing revealed during the September 26, 2025, QAPI meeting, it was discussed for all residents with pressure ulcers, based on their Braden scales and skin conditions, they were reviewed to make sure interventions were in place for care. During QAPI meetings, care for residents are discussed such as skin issues, but no resident was ever brought to their attention for ongoing concerns by any staff member including Unit Mangers who oversee the care of the residents on their halls. Review of the facility policy titled Quality Assurance Performance Improvement dated 10/24/2022 revealed the facility developed and maintains an effective, comprehensive, data-driven quality assurance and performance improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The QAPI program shall utilize the best available evidence to design and measure indicators of quality and have facility goals that reflect process of care and facility operation that have been shown to be predictive of desired outcomes for residents. The QAPI plan will include written policies and procedures for feedback, data collection and monitoring including adverse event monitoring.

Based on medical record reviews, interviews, and facility policies, the facility failed to ensure Licensed Practical Nurses (LPN's) acted within their professional standards and their scope of training related to pressure ulcer wound assessments and staging's. This affected four Residents (#5, #41, #99, and #82) out of six reviewed for pressure ulcer assessments and staging's by facility staff. The facility census was 84. 1. Review of the medical record for Resident #5, revealed an admission date of 12/3/24. Diagnoses included but were not limited to type 2 diabetes, central cord syndrome at cervical 5 level of cervical spinal cord, specified disorder of muscle, generalized anxiety disorder and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 out of 15 which suggested moderate cognitive intactness. The resident was assessed to require substantial/maximal assistance with shower/bathe self, bed mobility, and total dependence for toilet hygiene and transfers. Review of the skin and wound evaluation for Resident #5 dated 02/03/25 by Unit Manager LPN #1010 revealed a sacrum stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer measured 6.7 centimeters (cm) by 1.4 cm by 1.4 cm. Review of the skin and wound evaluation for Resident #5 dated 08/14/25 by Unit Manager LPN #1010 revealed a sacrum stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough, a yellowish, stringy dead tissue or eschar, a layer of dead, dry tissue that forms a dark leathery scab over the ulcer may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer measured 6.7 cm by 6.6 cm by 4.5 cm. Further review of the skin and wound evaluation for this resident dated 08/14/25 by Unit Manager LPN #1010 revealed a deep tissue injury of the right lateral thigh, in house acquired that day measured 4 cm by 3.3 cm by no depth. Review of the skin and wound evaluation for Resident #5 dated 09/30/25 by Unit Manager LPN #1010 revealed a sacrum stage 4 pressure ulcer measured 7.0 cm by 7.5 cm by 6 cm. Further review of the skin and wound evaluation for this resident dated 09/30/25 by Unit Manager LPN #1010 revealed a right lateral thigh unstageable pressure ulcer measured 2.0 cm by 3.4 cm by undetermined depth. Review of the skin issue assessment for Resident #5 dated 10/30/25 by Unit Manager LPN #1010 revealed a sacrum stage 4 pressure ulcer measured 6.8 cm by 6.74 cm by 4.5 cm with tunneling at 4.5 cm. Further review of the skin issue assessment for this resident dated 10/30/25 by Unit Manager LPN #1010 revealed a right lateral thigh stage 3 pressure ulcer measured 3.52 cm by 2.9 cm by 2.5cm with tunneling 5 cm. Review of the skin issue assessment for Resident #5 dated 11/19/25 by Unit Manager LPN #1010 revealed a sacrum stage 4 pressure ulcer measured 7.25 cm by 7.04 cm by 5 cm. Further review of the skin issue assessment for this resident dated 11/19/25 by Unit Manager LPN #1010 revealed a right lateral thigh stage 3 pressure ulcer measured 4.42 cm by 3.1cm by 5 cm. Interview on 01/13/26 from 1:02 P.M. through 2:01 P.M. with the Director of Nursing (DON), Regional Nurse #1054 and the Regional Clinical Services Registered Nurse #1127 verified an LPN completed staging and measurements for Resident #5's pressure ulcers on: 02/01/25, 08/14/25, 09/30/25, 10/30/25 and 11/19/25. 2. Review of the medical record for Resident #41, revealed an admission date of 08/22/25. Diagnoses included but were not limited to type 2 diabetes mellitus with diabetic neuropathy, displaced unspecified condyle fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing, major depressive disorder, senile degeneration of brain, anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 05 out of 15 which indicated severe cognitive impairment. The resident was assessed to require partial/moderate assistance with shower/bathe self, bed mobility, substantial/maximal assistance with transfers and total dependence with toilet hygiene. Review of the skin and wound evaluation for Resident #41 dated 08/26/25 by Unit Manager LPN # 1010 revealed a coccyx pressure with no staging measured 4.6 cm by 4.3 cm by 0.1 cm. Review of the skin and wound evaluation for Resident #41 dated 09/24/25 by Unit Manager LPN # 1010 revealed the left heel deep tissue pressure injury facility acquired on 09/22/25 measured 6.7 cm by 6.3 cm by no depth. Review of the skin issue assessment for Resident #41 dated 12/23/25 by Unit Manager LPN #1010 revealed the left heel deep tissue pressure injury measured 9.07 cm by 10.04 cm by no depth. Review of the skin issue assessment for Resident #41 dated 12/31/25 by Unit Manager LPN #1010 revealed the left heel deep tissue pressure injury measured 5.05 cm by 6.21 cm by no depth. Interview on 01/08/26 at 3:10 P.M. with the DON and Regional Nurse #1054 verified on 08/26/25, 09/24/25, 12/23/25 and 12/31/25 an LPN staged and measured the left heel pressure ulcer for Resident #41. 3. Review of the medical record for Resident #99, revealed an admission date of 12/30/25. Diagnoses included but were not limited to pressure ulcer of sacral region, chronic kidney disease, need for assistance with personal care, and chronic systolic heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated cognitive intactness. The resident was assessed to require partial/moderate assistance with bed mobility, substantial/maximal assistance with toilet hygiene, shower/bathe self and total dependence on transfers. This resident was also assessed to have a stage 3 pressure ulcer on admission. Review of the skin issues assessment for Resident #41 dated 12/31/25 by Unit Manager LPN #1010 revealed a stage 3 pressure ulcer on admission measured .79 cm by .72 cm by .1 cm. Interview on 01/08/26 at 8:21 A.M. with the DON verified an LPN completed the pressure ulcer measurement and assessment for Resident #99 on 12/31/25. 4. Review of Resident #82's medical record revealed an admission date of 08/06/25 and diagnoses including atherosclerotic heart disease, Atrial fibrillation, peripheral vascular disease, diabetes, pulmonary hypertension, hypertension, hyperlipidemia, major depressive disorder, and acquired absence of other left toes. Review of Resident #82's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status score (BIMS) of eight out of 15 indicating the resident was moderately cognitively impaired. Further review of the MDS revealed Resident #82 required partial/moderate assistance with bed mobility and was dependent on facility staff for toileting hygiene and transfers, was always incontinent of bladder and bowel, and was at risk for pressure ulcers but had none at the time of the assessment. Review of Resident #82's progress notes revealed a note written on 11/05/25 at 5:30 P.M. by LPN #1066 that stated LPN #1066 found the left heel open when the nurse was completing the preventative treatment to the heels. The area measured four centimeters (cm) in length, three cm in width and had a depth of 0.1 cm. LPN #1066 cleansed the area with normal saline and patted it dry. Medical grade honey was applied to the wound, and the wound was covered with an abdominal dressing pad and wrapped with kerlix. The resident's medical provider and responsible party were notified of the wound. Review of Resident #82's progress notes revealed a note written on11/05/25 at 5:35 P.M. by LPN #1032 for completion of the Braden scale, used to assess the resident's risk of developing pressure ulcers, with a score of 14 indicating the resident had a moderate risk of developing pressure ulcers. Review of Resident #82's progress notes a note written on11/06/25 at 12:30 P.M. by LPN #1032 revealed the resident had a new skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as an unstageable pressure injury presenting as a deep tissue injury acquired in house. The wound measured 2.05 cm in length 1.69 cm in width and had no depth. Review of Resident #82's progress notes a note written on11/12/25 at 9:55 A.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as an unstageable pressure injury presenting as a deep tissue injury acquired in house. The wound measured 2.88 cm in length 2.88 cm in width and had no depth. Review of Resident #82's progress notes a note written on11/19/25 at 12:25 P.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as an unstageable pressure injury presenting as a deep tissue injury acquired in house. The wound measured 1.56 cm in length 1.72 cm in width and had no depth. Review of Resident #82's progress notes a note written on11/26/25 at 1:59 P.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as an unstageable pressure injury presenting as a deep tissue injury acquired in house. The wound measured 1.81 cm in length 2.19 cm in width and had no depth. Additional care section in the note stated, mattress with pump. Review of Resident #82's progress notes revealed a note written on12/02/25 at 10:24 A.M. by LPN #1032 for completion of the Braden scale, used to assess the resident's risk of developing pressure ulcers, with a score of 15 indicating the resident had a mild risk of developing pressure ulcers. Review of Resident #82's progress notes a note written on12/02/25 at 1:37 P.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as a stage three pressure ulcer/injury with full thickness loss acquired in house. The wound measured 3.77 cm in length 3.56 cm in width and 0.2 cm in depth. The wound had a moderate amount of clear watery drainage, and the wound bed was pink or red. An additional care section in the note stated, mattress with pump. Review of Resident #82's progress notes a note written on12/10/25 at 12:27 P.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as a stage three pressure ulcer/injury with full thickness loss acquired in house. The wound measured 3.45 cm in length 3.55 cm in width and 0.2 cm in depth. The wound had a moderate amount of clear watery drainage, and the wound bed was pink or red. An additional care section in the note stated, mattress with pump. Review of Resident #82's progress notes a note written on 12/17/25 at 12:43 P.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as a stage three pressure ulcer/injury with full thickness loss acquired in house. The wound measured 3.18 cm in length 2.45 cm in width and 0 cm in depth. The wound had a moderate amount of clear watery drainage, and the wound bed was pink or red. An additional care section in the note stated, mattress with pump. Review of Resident #82's progress notes revealed a note written on12/20/25 at 2:37 P.M. by LPN #1032 for completion of the Braden scale, used to assess the risk of developing pressure ulcers, with a score of 16 indicating the resident had a mild risk of developing pressure ulcers. Review of Resident #82's progress notes a note written on12/24/25 at 10:35 A.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as a stage three pressure ulcer/injury with full thickness loss acquired in house. The wound measured 4.46 cm in length 3.23 cm in width and 0 cm in depth. The wound had a moderate amount of clear watery drainage, and the wound bed was pink or red. Further review of the progress note revealed Resident #38 had a new skin issue to her right heel. The type of skin issue was a pressure ulcer injury acquired in house. The wound was 1.2 cm in length, 4.8 cm in width and 0 cm in depth. The wound had a light amount of clear watery drainage. Review of Resident #82's progress notes a note written on12/31/25 at 12:44 P.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as a stage three pressure ulcer/injury with full thickness loss acquired in house. The wound measured 4.61 cm in length 3.21 cm in width and 0 cm in depth. The wound had a light amount of clear watery drainage, and the wound bed was pink or red. Further review of the progress note revealed Resident #38 had a new skin issue to her right heel. The type of skin issue was a pressure ulcer injury acquired in house and staged as an unstageable pressure ulcer/injury slough and or eschar. The wound was 1.2 cm in length, 4.8 cm in width and 0 cm in depth. The wound had no drainage, and the wound bed was pink or red. Review of Resident #82's progress notes a note written on 01/07/26 at 3:07 P.M. by LPN #1032 revealed the resident had a skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as a stage three pressure ulcer/injury with full thickness loss acquired in house. The wound measured 2.16 cm in length 2.69 cm in width and 0.2 cm in depth. The wound had a light amount of clear watery drainage, and the wound bed was pink or red. Further review of the progress note revealed Resident #38 had a new skin issue to her right heel. The type of skin issue was a pressure ulcer injury acquired in house and staged as an unstageable pressure ulcer/injury slough and or eschar. The wound was 1.74 cm in length, 2.17 cm in width and 0 cm in depth. The wound had a light amount of clear watery drainage, and the wound bed was pink or red. Interview on 01/08/26 at 9:00 A.M. with the Director of Nursing revealed the Unit Managers, who are Licensed Practical Nurses (LPN), are assessing and staging pressure ulcers weekly and on admission during the week, for the residents when the Wound Doctor does not see them and/or if the Wound Doctor does not see them at all for care. Review of the facility policy titled Skin and Wound Guidelines revised 03/20/24 revealed pressure injuries are evaluated and documented by a licensed nurse and are evaluated weekly by the wound team or a licensed nurse per state and federal regulations. Review of the facility job description for the job title Licensed Practical Charge Nurse in the Nursing Department last revised 01/01/2012 revealed no pressure ulcer wound assessments which include measuring, staging and assessments to be part of their role statement, essential activities and tasks, knowledge, skills, abilities and qualifications. Review of the facility job description for the job title Unit Manager in the Nursing Department last revised 01/01/2012 revealed no pressure ulcer wound assessments which include measuring, staging and assessments to be part of their role statement, essential activities and tasks, knowledge, skills, abilities and qualifications.

Based on observation, staff interview, and review of facility provided food storage policies, the facility failed to ensure food was protected from potential spoilage and/or contamination in the areas of food storage and food preparation. This had the potential to affect all 83 residents who received food from the kitchen. The facility census was 84. Findings include:Observation on 01/05/26 at 8:40 A.M. revealed an opened bag of small frozen pizzas was stored with the bag open, exposing the food to air and potential contaminants in the reach-in freezer. Further observation at this time revealed a bag of frozen chicken fingers was also stored with the bag open, so that the food was exposed to air and there was no date marking on the opened bag of chicken fingers. Interview on 01/05/26 at 8:41 A.M. with Dining Services Manager #1011 revealed food items such as the frozen pizzas and frozen chicken fingers should be date-marked once they have been opened. Further interview at this time verified foods should be stored in closed containers or otherwise wrapped to protect from potential contamination. Observation on 01/05/26 at 8:45 A.M. revealed three bags of sandwich buns stored on the bread rack with a 12/30/25 best by date marked on the original packaging from the manufacturer of the bread. Further observation at this time revealed the buns were firm to the touch, indicating potentially stale texture or otherwise decreased quality of the food. Interview on 01/05/26 at 8:47 A.M. with Dining Services Manager #1011 revealed the facility does not necessarily follow a first in, first out procedure for rotating and using bread products, though the facility does receive bread products several times per week. Observation on 01/05/26 at 8:50 A.M. of the walk-in cooler revealed two heads of lettuce appeared to be wilted and brown, with no date marking to indicate either when the lettuce was first received or the discard/use-by date. Further observation at this time revealed a block of yellow cheese that had been removed from original packaging and then wrapped in plastic wrap with no date marking on the wrapping. Interview on 01/05/26 at 8:52 A.M. with Dining Services Manager #1011 verified the cheese and lettuce in the walk-in refrigerator should have date marking on the packaging while in storage. Observation on 01/05/26 at 8:54 A.M. of the walk-in freezer revealed one large box of frozen hamburger patties was stored with the box and bag open so that the food items were exposed to air and potential sources of contamination in the freezer. This finding was verified with the Dietary Manager at the time of the observation. Observation on 01/05/26 at 8:56 A.M. of the top of the prep cooler in the center of the kitchen revealed multiple food items had been stored without any date marking. These food items included one package of deli ham, one package of bologna, one package of boiled eggs, one block of yellow cheese covered in plastic wrap, one block of white cheese covered in plastic wrap, and one container of sliced onions. Observation on 01/05/26 at 8:58 A.M. revealed Dining Services Manager #1011 removed all food items that were not date marked in the prep cooler and asked nearby kitchen staff to ensure the items were discarded in the trash. Further observation at this time revealed the Dietary Manager reminding kitchen staff to make sure food items are date marked for storage in coolers. Observation on 01/05/26 at 9:00 A.M. revealed two squeeze bottles of sauces/dressings in the bottom of the prep cooler at the center of the kitchen, with date marking on the containers that indicated preparation in November of 2025. Interview on 01/05/26 at 9:02 A.M. with Dietary Services Manager #1011 revealed the two bottles of dressing in the prep cooler from November 2025 were employee food items and verified these employee food items were being stored in the same refrigerated unit with foods that are prepared for and served to residents. Observation on 01/07/26 at 11:18 A.M. revealed [NAME] #1102 was wearing a hairnet while plating foods for lunch service, but the hairnet was only seen covering the back portion of her hair where the employee's hair was pulled up into a bun. Observation at this time revealed the majority of [NAME] #1102's head was not covered by a hairnet as the cook went to the hot food service line to measure food temperatures for lunch service and began preparing plates for residents. Observation on 01/07/26 at 11:20 A.M. revealed [NAME] #1102 was wearing a glove on only her right hand while taking temperatures of food items on the hot service line for lunch service. Further observation at this time revealed [NAME] #1102 used her bare hand to open an alcohol prep pad to clean the tip of her thermometer used to measure food temperatures. Observation then revealed the torn alcohol pad wrapper fell directly into a tray of pureed green beans when [NAME] #1102 went to take a temperature of the food item after having been held with the cook's bare hand. [NAME] #1102 then used their gloved hand to remove the wrapper from the food item but kept the food item for service. Interview on 01/07/26 at 11:25 A.M. with Dining Services Manager #1011 revealed she had noticed that [NAME] #1102 was wearing a hairnet, but the hairnet was not covering the employee's hair during lunch service. Further interview at this time revealed cooks and other food service staff should be wearing hairnets that cover their hair and/or beards if applicable when preparing food for residents, to prevent possible contamination of foods. Observation on 01/08/26 at 9:50 A.M. revealed multiple food items were opened with no date marking in the activity room refrigerator. These food items included two containers of French onion dip, two bags of salami, one bag of cheese cubes, and one container of salsa. Interview on 01/08/26 at 9:52 A.M. with the Activities Director #1059 verified there were multiple food items for residents kept in the activity room refrigerator that were not labeled or date marked properly, and the foods in the activity room refrigerator should be labeled and date marked to prevent potential spoilage or contamination. Review of the facility policy titled Food Storage with an approval date of 04/01/22 and policy replacement date of 12/26/22 revealed foods must be rotated using the first in first out storage method (FIFO), where oldest foods are used first and newer items are stored behind older food items. Further review of this policy revealed guidelines for food labeling and dating must be adhered to by all food service personnel and closely monitored by the food service manager. Additional review of this policy revealed arrival dates should be placed on all foods removed from the case at the time of delivery, and all foods removed from original packing must have an arrival date. If food has a manufacturers expiration date, an open date will be added to the label.

Based on medical record reviews, observations, interviews, and facility policies, the facility failed to perform hand hygiene before and after wearing contact precautions when passing a lunch tray to Resident #21. This had the potential to affect 5 other residents at the facility in contact precautions who received lunch trays for meals. The facility also failed to ensure enhanced barrier precautions were ordered timely for eight Residents (#5, #41, #99, #46, #64, #52, and #82) out of eight who required enhanced barrier precautions. This had the potential to affect 5 other residents in enhanced barrier precautions. The facility census was 84.1. Review of the medical record for Resident #21 revealed the resident was admitted on [DATE] with diagnoses that included severe chronic kidney disease, acidosis, and anemia amongst other diagnoses. Further review of the resident record revealed the resident had an active order for contact precautions during the time of the survey due to an active diagnosis of a methicillin-susceptible staphylococcus aureus (MSSA) infection in the bloodstream, referred to as MSSA bacteremia. Observation on 01/07/26 at 12:40 P.M. of the contact precautions signage posted on the door of Resident #21's room revealed everyone must clean their hands, including before entering and when leaving the room, and that providers and staff must also put on a gown and gloves before room entry and then discard the gown and gloves before room exit. Observation on 01/07/26 at 12:41 P.M. revealed Certified Nursing Assistant (CNA) #1003 entered Resident #21's room to deliver a lunch tray. Observation at this time revealed the CNA did not perform any type of hand hygiene before donning a gown and gloves prior to entering the room to deliver the tray, or after doffing the gown and gloves when leaving the room. Further observation at this time revealed CNA #1003 returned to the meal delivery cart in the hallway and continued to pass out trays for lunch service immediately after doffing the gown and gloves worn in Resident #21's room. Interview on 01/07/26 at 12:49 P.M. with Dining Services Manager #1011 verified they had seen CNA #1003 enter and exit Resident #21's room without performing hand hygiene as indicated by the signage on the door. Review of the facility policy titled hand hygiene (issued 08/01/22) and last revised on 04/14/23 revealed the purpose of the policy was to provide guidelines to staff for proper hand hygiene techniques that will aid in the prevention and transmission of infections. Further review of this policy revealed hand hygiene is indicated before and after removing personal protective equipment (PPE), including gloves. 2.Review of the medical record for Resident #5, revealed an admission date of 12/03/24. Diagnoses included but were not limited to type 2 diabetes, central cord syndrome at cervical 5 level of cervical spinal cord, specified disorder of muscle, generalized anxiety disorder and major depressive disorder. Review of the progress note for Resident #5 dated 04/25/25 revealed this resident returned to the facility from a hospital stay. Review of the skin and wound evaluation for Resident #5 dated 04/25/25 revealed a sacrum stage 4 pressure ulcer. Review of the physician order for Resident #5 dated 04/30/25 revealed enhanced barrier precautions ever shift due to wound. Interview on 01/07/26 at 2:59 P.M. with the DON confirmed Resident #5 was readmitted to the facility on [DATE] and had a pressure ulcer with no order for enhanced barrier precautions ordered until 04/30/25. 3. Review of the medical record for Resident #41, revealed an admission date of 08/22/25. Diagnoses included but were not limited to type 2 diabetes mellitus with diabetic neuropathy, displaced unspecified condyle fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing, major depressive disorder, senile degeneration of brain, anxiety disorder. Review of the skin and wound evaluation for Resident #41 dated 08/25/25 revealed a coccyx (no staging) pressure ulcer wound. Review of the physician order for Resident #41 dated 09/03/25 revealed enhanced barrier precautions every shift due to wound. Interview on 01/08/26 at 8:01 A.M. with the DON confirmed Resident #41 was assessed to have a pressure ulcer wound on 08/25/25 and no order for enhanced barrier precautions were ordered until 09/03/25. 4. Review of the medical record for Resident #99, revealed an admission date of 12/30/25. Diagnoses included but were not limited to pressure ulcer of sacral region, chronic kidney disease, need for assistance with personal care, and chronic systolic heart failure. Review of the admission assessment for Resident #99 dated 12/30/25 revealed a coccyx pressure ulcer (no staging and measurements). Review of the physicians order for Resident #99 dated 01/01/26, to start on 01/02/26, revealed enhanced barrier precautions every shift due to a wound. Interview on 01/08/26 at 8:02 A.M. with the DON confirmed Resident #99 was assessed to have a pressure ulcer wound on admission [DATE] and no order for enhanced barrier precautions were ordered until 01/01/26 with a start date of 01/02/26. 5. Review of the medical record for Resident #46 revealed an admission date of 12/11/2025. Diagnoses included multiple sclerosis, heart disease, and chronic obstructive pulmonary disease. Review of the skin issue progress note dated 12/30/2025 at 3:16 P.M. revealed Resident #46 has a new in-house acquired pressure ulcer located on their coccyx. This pressure wound was noted as a stage 3 (full thickness loss) measuring 0.52 centimeters (cm) in length by 1.01 cm in width by 0.1 cm in depth with the area totaling 0.49 cm. Review of the nursing progress note dated 01/01/2026 at 8:35 A.M. that Resident #46 had been transferred to the hospital for evaluation due to a change in condition where she was noted to be admitted . Continued review of nursing progress notes and physician orders revealed no evidence to indicate enhanced barrier precautions had been implemented due to this residents pressure wound. Interview on 01/08/26 at 8:01 A.M. with the DON confirmed Resident #46 was assessed to have a pressure ulcer wound on 12/30/2025 and no order for enhanced barrier precautions were implemented. 6. Review of the medical record for Resident #52 revealed an initial admission date of 12/04/2025 with a re-entry date of 12/20/2025. Diagnosis included an intraspinal abscess, methicillin susceptible staphylococcus aureus infection and an open surgical wound of the lower back and pelvis. Review of Resident #52's nursing progress notes and physician orders revealed no evidence of enhanced barrier precautions being implemented for this resident who was noted to have multiple open surgical wounds. Interview on 01/08/26 at 8:01 A.M. with the DON confirmed Resident #52 was admitted to the facility with multiple surgical wounds which would require enhanced barrier precautions upon admission which were never implemented or ordered. 7. Review of the medical record for Resident #64 revealed an admission date of 05/23/2025 and a discharge date of 01/09/2026. Diagnosis included peripheral vascular disease, stage 3 pressure ulcer of the sacral region, and a stage 3 pressure ulcer of the left heel. Review of nursing progress notes and physician orders revealed no evidence to indicate that enhanced barrier precautions had been ordered or implemented for Resident #64 who was noted with multiple pressure wounds. Interview on 01/08/26 at 8:01 A.M. with the DON confirmed Resident #64 was admitted to the facility with multiple pressure wound which would require enhanced barrier precautions upon admission but were never ordered or implemented. 8. Review of Resident #82's medical record revealed an admission date of 08/06/25 and diagnoses including atherosclerotic heart disease, Atrial fibrillation, peripheral vascular disease, diabetes, pulmonary hypertension, hypertension, hyperlipidemia, major depressive disorder, and acquired absence of other left toes. Review of Resident #82's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status score (BIMS) of eight indicating the resident was moderately cognitively impaired. Further review of the MDS revealed Resident #82 required partial/moderate assistance with bed mobility and was dependent on facility staff for toileting hygiene and transfers, was always incontinent of bladder and bowel, and was at risk for pressure ulcers but had none at the time of the assessment. Review of Resident #82's physician's orders revealed an order dated 12/03/25 for enhanced barrier precautions. Review of Resident #82's progress notes revealed a note written on 11/05/25 at 5:30 P.M. by Licensed Practical Nurse #1066 that stated LPN #1066 found the left heel open when the nurse was completing the preventative treatment to the heels. The area measured four centimeters (cm) in length, three cm in width and had a depth of 0.1 cm. LPN #1066 cleansed the area with normal saline and patted it dry. Medical grade honey was applied to the wound, and the wound was covered with an abdominal dressing pad and wrapped with kerlix. Review of Resident #82's progress notes a note written on11/06/25 at 12:30 P.M. by LPN #1032 revealed the resident had a new skin issue to her left heel. The type of skin issue was a pressure ulcer/injury staged as an unstageable pressure injury presenting as a deep tissue injury acquired in house. The wound measured 2.05 cm in length 1.69 cm in width and had no depth. In an interview on 01/08/2026 at 8:00 A.M. the Director of Nursing (DON) verified Resident #82 developed a wound on 11/05/25 and enhanced barrier precautions were not put place until 12/03/25. Review of the facility policy titled Enhanced Barrier Precautions dated 09/30/2025 revealed residents admitted to the facility with or during their stay with a wound will be placed in enhanced barrier precautions with a physician order.

Based on medical record review, and staff interview, this facility failed to ensure meal intakes were being monitored to ensure residents highest nutritional status. This affected one (Resident #84) of the one resident reviewed for nutrition. The facility census was 84. Findings include:Review of the medical record for Resident #84 revealed an admission date of 05/09/2023. Diagnoses included dementia, end stage renal failure, and osteoporosis. Review of the plan of care dated 11/02/2023 revealed Resident #84 was at risk for malnutrition related to end stage renal disease. Resident continues to refuse nutritional supplements. Interventions include to provide and serve diet as ordered, monitor and record intakes for every meal, and alert dietician if consumption is poor for more than 48 hours. Review of the plan of care dated 12/22/2025 revealed Resident #84 has renal insufficiency related to end stage renal disease. Interventions include to consult with dietary to regulate protein, sodium, and potassium intake. Review of Resident #84's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #84 required set up or clean up assistance for eating meals. Resident #84 was noted to be 59 inches tall and weighted 117 pounds with no noted weigh loss or gain. Review of Resident #84's breakfast intake from 12/14/2025 through 01/10/2026 revealed no meal intake percentage was documented for 14 of the 30 days reviewed. Review of Resident #84's lunch intake form 12/14/2025 through 01/10/2026 revealed no meal intake percentage was documented for 16 of the 30 days reviewed. Review of Resident #84's dinner intake from 12/14/2025 through 01/10/2026 revealed no meal intake percentage was documented for 14 of the 30 days reviewed. Continued review of Resident #84's meal and snack intake from 12/14/2025 through 01/10/2026 revealed no snacks were offered or documented as consumed. Interview on 01/12/2026 10:28 A.M. interview with Certified Nursing Assistant (CNA) #1017 revealed when a resident is done eating, staff will pick up the meal tray and then write the intake percentage on that meal slip. When that staff member gets a chance, they will then enter the meal intake percentage, most likely, at the end of their shift. Interview on 01/12/2026 10:49 A.M. with Regional Nurse (RN) #1054 confirmed there was multiple days of missing meal intakes for Resident #84. RN #1054 also confirmed that this resident was at a risk for nutritional decline due to medical history and their meal percentage intake needed to be closely monitored.

Based on interview and record review the facility failed to properly maintain an indwelling catheter for one resident (#21) of one sampled for catheter use. The facility census was 84. Findings include: Review of Resident #21's medical record revealed an admission date of 11/04/25, re-entry date of 01/01/26 and diagnoses including chronic kidney disease stage five hydronephrosis, carrier or suspected carrier of methicillin susceptible staphylococcus aureus, urinary tract infection, bacteremia, benign prostatic hyperplasia, obstruction and reflux uropathy, retention of urine and hypotension. Review of Resident #21's admission minimum data set (MDS) dated [DATE] revealed a brief interview for mental status score (BIMS) of 15 indicating the resident had intact cognition. Further review of the MDS revealed Resident #21 had no behaviors during the assessment look back period, required supervision or touching assistance with showering/bathing and was independent with all other activities for daily living, had an indwelling catheter, was continent of bowel, had no pain in the five days prior to the assessment and had no skin issues.Review of Resident #21's physician's orders revealed an order dated11/04/25 to change the resident's foley catheter on day shift every 30 days.Review of Resident #21's treatment administration record (TAR) for December of 2025 revealed the order for the residents catheter change was to have been completed on 12/10/25, however no initials were on the TAR for that day to indicate the catheter change was completed.Review of Resident #21's nursing progress notes for the month of December revealed no evidence the catheter change was completed.In an interview on 01/14/25 at 11:42 A.M. Licensed Practical Nurse (LPN) #1038 revealed that if a monthly task could not be completed the resident's medical provider would be notified and an order obtained to complete the task at a different time and/or date, so the task was not missed for that month.In an interview on 01/14/25 at 1:15 P.M. the Director of Nursing confirmed the catheter was not changed in December as ordered.

Based on observation and interview the facility failed to maintain a resident's call light within reach. This affected one resident (#25) of one sampled for call light placement. The facility census was 84.Findings include:Review of Resident #25's medical record revealed an admission date of 09/14/18, a re-entry date of 11/03/22 and diagnoses including hypertensive heart disease with heart failure, vascular dementia, major depressive disorder, history of falling, hypothyroidism, orthostatic hypotension, and other abnormalities of gait and mobility.Review of Resident #25's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status score (BIMS) of three out of 15 indicating the resident had severe cognitive impairment. Further review of the MDS revealed the resident required set up help for eating, partial/moderate assistance with moving about in the bed and was dependent on staff for toileting hygiene tasks and transferring between her chair and bed. Resident #25 was always incontinent of bladder and bowel, had not had pain in the past five days prior to the assessment, had not fallen since the last assessment, has no pressure areas or other skin issues and was receiving diuretic medication.An observation on 01/05/2026 at 11:59 A.M. revealed Resident #25 to be in bed and the call light to be on the floor.An observation on 01/05/2026 at 2:30 P.M. revealed Resident #25 to be in bed and the call light to be on the floor.An observation on 01/06/2026 at 9:00 AM revealed the call light wrapped around the bed rail with the call button between the bed rail and the mattress and Resident #25 seated in the recliner by the bed and unable to reach the call light.An observation on 01/06/2026 at 2:40 P.M. revealed the call light wrapped around the bed rail with the call button between the bed rail and the mattress and Resident #25 seated in the recliner by the bed and unable to reach the call light.An observation on 01/07/2026 at 9:20 A.M. revealed Resident #25 in bed (low bed) with the head of the bed elevated and the call light wrapped around the bedrail, bedrail in low position and call button between the mattress and the rail. With the head of the bed elevated the call light was behind and out of sight of the resident as well as out of reach.An observation on 01/07/2026 at 11:34 A.M. revealed Resident #25 in bed (low bed) with the head of the bed elevated and the call light wrapped around the bedrail, bedrail in low position and call button between the mattress and the rail. With the head of the bed elevated the call light was behind and out of sight of the resident as well as out of reach.An observation on 01/13/2026 at 8:00 A.M. revealed Resident #25 resting in bed and the call light to be draped over the resident's recliner chair. In an interview at the time of the observation the Director of Nursing (DON) confirmed the call light was draped over the recliner while the resident was resting in bed and unbale to reach the call light.

Based on medical record review, staff interview, and dialysis communication documents, this facility failed to ensure orders and recommendations for residents receiving dialysis services were followed. This affected one (Resident #84) of the one resident reviewed for dialysis. The facility census was 84. Findings include: Review of the medical record for Resident #84 revealed an admission date of 05/09/2023. Diagnoses included end stage renal disease, dependence on renal dialysis, and hypertension. Review of the plan of care dated 05/10/23 revealed Resident #84 was at risk for bleeding internally or externally related to medication. Interventions included to administer medication as ordered, contact primary care physician immediately if coffee ground emesis is observed, monitor for signs and/or symptoms of bleeding, monitor vital signs, and labs. Review of the plan of care dated 05/10/25 revealed Resident #84 required dialysis treatments related to end stage renal disease. Interventions include to administer medication as order, check access site for lack of thrill or bruit, monitor for evidence of infection, swelling or excessive bleeding, check and change dressing daily at access site, coordinate dialysis care with center, diet per physician orders, do not draw labs or check blood pressure (BP) in dialysis port site arm, and encourage to rest after dialysis. Review of the nursing progress note dated 12/26/2025 at 10:40 P.M. created by Licensed Practical Nurse (LPN) #1094 revealed a Change in Condition documentation indicating a change in this resident's skin status evaluation which was noted as other as well as noting that this resident claimed it occurred after dialysis. Review of Resident #84's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #84 was noted to receive dialysis services. Review of Resident #84's recorded blood pressure checks from 10/14/2025 through 01/12/2026 revealed her blood pressure had been checked or measured 123 times using her left arm, which was the arm where the dialysis access port was located. Interview on 01/12/2026 12:18 P.M. with Resident #84 revealed staff do check her blood pressure in both her right and left arm. Resident #84 claimed she had a bracelet on her left arm that says No blood pressure or lab draws Observation on 01/12/2026 at 12:18 P.M. of Resident #84 confirmed a bracelet was in place around her left wrist indicating no blood pressure checks and no lab draws on that arm. Interview on 01/12/2026 11:47 A.M. with Regional Nurse (RN) #1054 and Licensed Practical Nurse (LPN) #1010 confirmed there were multiple documented blood pressure checks which were being completed on Resident #94's left arm which was the arm her dialysis port was in. Resident #84 was also noted to have a wrist band on that wrist indicating no blood pressure or blood draws for that arm.

Based on observation, interview and record review the facility failed to implement fall interventions as ordered. This affected two residents (#38 and #84) of two sampled for falls. The facility census was 84. Findings Include: 1. Review of Resident #38's medical record revealed an admission date of 07/30/20, a re-entry date of 11/25/23, and diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, vascular dementia, anxiety disorder, and congestive heart failure. Review of Resident #38's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status score (BIMS) of 13 indicating the resident was cognitively intact. Further review of the MDS revealed the resident required supervision or touching assistance with toileting hygiene, bed mobility, and transfers, had no pain in the five days prior to the assessment, had not fallen since the previous MDS assessment and had no skin issues at the time of the assessment. Review of Resident #38's physician's orders revealed an order dated 02/09/24 for the resident to have a perimeter mattress to her bed for safety every shift.Review of Resident #38's fall care plan revealed an intervention dated 06/27/24 for the resident to have a perimeter mattress to her bed. Review of Resident #38's progress notes written on 11/19/25 at 2:02 P.M. by Licensed Practical Nurse (LPN) #1066 revealed LPN#1066 was standing at the nurse's station and heard Resident #38 yell calling out for help. LPN#1066 went down hall to investigate and found the resident in her room on the floor beside the bed. LPN#1066 assisted Resident #38 up from the floor to her wheelchair. A head-to-toe assessment was completed and the resident was found to have an abrasion to her left knee and to the forth and fifth toes of her right foot. Review of Resident #38's progress notes written on 01/07/26 at 11:10 P.M. revealed Resident #38's roommate came out into hallway calling for staff. Staff entered the room and found the resident on the floor on her bottom beside the bed. Resident #38 stated she was sitting on the side of her bed trying to look under her bed for her tv remote and slipped onto the floor. Resident #38 was found to have a penny sized abrasion to the left elbow. An observation on 01/05/2026 at 10:43 A.M. revealed Resident #38's bed was against the wall to the left of the door with the foot of the bed by the door. Resident #38 was lying on her right side, sideways in the bed at the middle of the bed with her buttocks at the edge of the bed not against the wall. A perimeter mattress was not present on her bed. An observation on 01/06/26 at 09:20 A.M. revealed Resident #38 was not present in her room. A perimeter mattress was not present on her bed. An observation on 01/06/26 at 2:00 P.M. revealed Resident #38 was not present in her room. A perimeter mattress was not present on her bed. An observation on 01/07/2026 at 9:31 A.M. revealed Resident #38 was not present in her room. A perimeter mattress was not present on her bed. An observation on 01/07/2026 at 11:33 A.M. revealed Resident #38 was resting in bed on her right side facing the wall. A perimeter mattress was not present on her bed. An observation on 01/08/2026 at 10:52 A.M. revealed Resident #38 resting in bed on her right side, curled into the middle of the bed with her buttocks at the edge of the bed. A perimeter mattress was not present on her bed. In an interview on 01/08/2026 at 10:52 A.M. the Director of Nursing (DON) verified the mattress on Resident #38's bed was not a perimeter mattress. 2. Review of the medical record for Resident #84 revealed an admission date of 05/09/2023. Diagnosis included osteoporosis, hypotension, and a pain to bilateral lower extremities. Review of Resident #84's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #84 was noted with impairment to one of the upper extremities and required the use of a wheelchair. Resident #84 required substantial to maximal assistance for toileting hygiene and bathing, and partial to moderate assistance for personal hygiene and bed mobility. Review of the plan of care dated 05/10/23 revealed Resident #84 was at risk for falls and potential for injury related to decreased mobility, the use of assistive device, needing assist of staff status post hospital admit on 11/2023, with confusion and encephalopathy secondary to a urinary tract infection and being treated with intravenous antibiotics. Interventions included to completed 15-minute checks as directed and needed, placing a 9-inch fall matt at bedside, keeping residents' bed in a low position with fall mat when occupied. Observation completed on 01/07/2026 at 2:00 P.M. revealed Resident #84 lying in bed where the bed was noted to be elevated off the floor and not in the lowest position. Observation completed on 01/12/2026 at 10:25 A.M. of Resident #84 revealed this resident laying supine in bed, resting with eyes open. Resident #84's bed was noted to be elevated in the air during this observation. Interview on 01/12/2026 10:42 A.M. with Licensed Practical Nurse (LPN) #1033 confirmed Resident #84 was resting quietly in bed and her bed was not in the lowest position as per care plan for fall interventions indicated it needed to be.

Based on medical record review, hospital record review, review of the University of Pittsburgh Medical Center information, review of facility policy and procedures, and staff interviews, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition on 05/21/25 involving Resident #22, when the resident was assessed to have a decline in health including lethargy, a poor appetite, confusion, increased hallucinations, and low oxygen saturation, without evidence of timely or adequate interventions and medical treatment. This resulted in Immediate Jeopardy and serious life-threatening harm, and/or injuries when Resident #22 developed new deep tissue injuries (DTIs) and suffered a continued decline in health status. Resident #22 continued to display a deterioration in condition between 05/22/25 and 05/29/25 that was not comprehensively addressed and individualized medical interventions provided. Consequently, on 05/29/25 at 9:30 P.M., Resident #22 was transferred to the hospital where she was admitted with diagnoses of adrenal crisis, human meta pneumonia with septic shock, acute hypoxic respiratory failure, metabolic encephalopathy, where she received treatment in the intensive care unit (ICU) and was intubated requiring a ventilator for breathing from 05/29/25 until 06/02/25. This affected one (#22) of four residents reviewed for a change in condition. The total facility census was 87. On 07/14/25 at 1:48 P.M., the Administrator, Regional Clinical Services Director (RCSD) #170, Regional Nurse #170, and Director of Nursing (DON) were notified Immediate Jeopardy began on 05/21/25 when staff identified Resident #22 exhibited a change in condition, developed new DTIs, and experienced a decline in health status without evidence of timely or adequate interventions and medical treatment. On 05/22/25, Resident #22 had hallucinations and increased confusion. Resident #22 continued to have symptoms and decline in her condition on 05/24/25 when she was lethargic and 05/27/25 with a poor appetite and the inability to take her medications without assistance. On 05/28/25, Resident #22 returned to the facility from dialysis with blue fingertips and oxygen (O2) saturation of 71% (normal 95-100%), oxygen was applied at two liters per nasal cannula and the facility was unable to reassess for effectiveness because the pulse oximeter could not get a reading. The physician was notified and gave no new orders. On 05/29/25, Resident #22 continued with confusion, blue fingertips, and hallucinations and she declined to go to scheduled physician appointments due to feeling too tired, having a decline in health, blue fingertips and hallucinations. On the evening of 05/29/25, Resident #22 had blue fingertips, and Licensed Practical Nurse (LPN) #129 was unable to ascertain an oxygen saturation level for the resident, the resident's blood pressure was 76/57 millimeters of mercury (mm/Hg) [normal range 120/80 mm/Hg] and her pulse was 51 beats per minute [normal range 60-100 beats per minute]. Resident #22 was very confused and could not put sentences together. Physician #166 was notified and 911 was called. Upon arrival to the facility, Emergency Medical Services (EMS) workers were unable to ascertain a blood pressure reading for Resident #22 and her blood sugar was 56 milligrams per deciliter (mg/dL) [normal range 70-99 mg/dL]. Resident #22 was transported to a local hospital, then transferred to a larger hospital where she was admitted for treatment of admitting diagnoses of adrenal crisis, human meta pneumatic pneumonia with septic shock, acute hypoxic respiratory failure, and acute metabolic encephalopathy. Resident #22 received treatment in the intensive care unit (ICU) and was intubated requiring a ventilator for breathing from 05/29/25 until 06/02/25. The Immediate Jeopardy was removed on 07/15/25 when the facility implemented the following corrective actions: On 05/29/25, Resident #22 was sent to the emergency room (ER) and returned to the facility 6/09/25 and continues to receive dialysis three times weekly. On 07/14/25, Resident #22's clinical assessment was completed by LPN #133 and was noted to be within normal limits for this resident. On 07/14/25, LPN #129 (the nurse responsible for Resident #22's direct care on 05/28/25 when the resident's O2 saturation dropped to 71%) was re-educated by the DON on Change in Condition Notification policy and procedure with emphasis on documentation relative to resident's change in condition in medical record related to resident's progress notes in the medical record. On 07/14/25, the DON/Designee reviewed 13 residents in the 30 day look back period for notification of change in condition. On 07/14/25, all current residents (87 residents) in the facility were reviewed by the DON/Designee for change in condition/notification. Any issues identified were corrected at the time of discovery. This was completed prior to 1:30 P.M. on 07/14/25. Beginning on 07/14/25, resident Progress Notes will be reviewed by the DON/Designee daily to ensure all notification and new orders are documented for all residents change in condition. E-interact Change in Condition user defined assessment (UDA) documentation is separated into three sections. Section 1 includes signs and symptoms identified, vital sign evaluation, general background information. Section 2 includes resident evaluation which includes mental status evaluation and functional status evaluation, based on signs and symptoms identified, other body system domains can be assessed. Section 3 includes a review of information and provider notifications. E-interact Change in Condition UDA will be reviewed daily for all residents who are identified with a change in condition by the DON/Designee to ensure all new orders and notifications are documented. On 07/14/25, the DON/Designee educated facility nursing staff on Change in Condition Notification policy and procedure by 2:30 P.M. on 07/14/25. Three (3) registered nurses (RNs) were educated in house, seven (7) RNs were educated via phone, seven (7) LPNs were educated in house, nine (9) LPNs were educated via phone, 11 certified nurse aides (CNA)s were educated in house, 44 CNAs were educated via phone. All RNs, LPNs, and CNAs that were educated via phone must sign off on education prior to working their next shift. Beginning on 07/14/25, Progress Notes will be reviewed on all current residents by the DON/Designee daily to ensure all notification and new orders are documented for residents change in condition. E-interact Change in Condition UDA documentation will be reviewed daily for all residents by the DON/Designee to ensure all new orders and notifications are documented. On 07/14/25 at 4:00 P.M., a meeting was conducted with DON, ADON, LPN #129, Regional Nurses, Medical Director and Administrator to review the incident for Resident #22. Education was provided to LPN #129 regarding change in condition and notification documentation in the medical record. On 07/14/25, the Change in Condition Notification policy was reviewed by the DON, Senior [NAME] President of Clinical Services, Medical Director, and RCSD #170 to ensure the policy was comprehensive and accurate. There were no changes made at this time. Beginning on 07/15/25, audits will be completed by the DON/Designee daily for two weeks, then five times per week for two weeks, then three times per week for two weeks, then two times per week for two weeks, then PRN (as needed) to ensure change in condition notification occurs timely. Beginning on 07/15/25, results of the audits will be forwarded to the Quality Assurance Performance Improvement Committee meeting by the DON/Designee monthly for three months for immediate follow up. On 07/15/25 at 2:01 P.M., 2:03 P.M., 2:05 P.M., 2:09 P.M., and 2:11 P.M., interviews with CNA #111, CNA #120, CNA #108, LPN #180, and LPN #115 revealed the staff had received education from the facility on resident change in condition and notification.? The CNAs interviewed reported that if they identify a change in a resident's condition, they are to report that to the nurse. If the nurse doesn't address it (assess the resident), the CNA will report the resident change in condition up the chain of command (manager). The LPNs that were interviewed revealed they had received education on resident change in condition and notification.? The LPNs reported they are to complete comprehensive assessments of residents identified with a change in condition, report the change in condition to the resident's physician or medical provider (and the resident's family), receive orders, and can go up the chain of command if needed. Although the Immediate Jeopardy was removed on 07/15/25, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, rheumatoid arthritis, chronic embolism and thrombosis of other specific veins and tachycardia. Review of an order dated 08/17/22 revealed Resident #22 had a Do Not Resuscitate Comfort Care Arrest (DNRCCA) in place. The order was discontinued on 06/03/25. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22's cognition remained intact, she had no behaviors (including hallucinations), she needed set-up help for eating and oral hygiene, was dependent for toileting hygiene, required maximum assistance for bathing and lower body dressing, moderate assistance for upper body dressing, and required supervision for personal hygiene. Resident #22 was also identified to be at risk for pressure ulcers. Review of a note dated 05/21/25 at 8:11 A.M. by LPN #129 revealed during routine skin care, new deep tissue injuries (DTIs) were noted to Resident #22's right flank and right upper thigh as well as a skin tear to her right flank. Resident #22 did not have complaints of pain to the areas and there were no signs or symptoms of infection noted. The skin tear was cleaned with normal saline, patted dry, xeroform and foam dressing were applied and the DTIs had triad paste applied. Resident #22 was noted to have a decline in health, went to dialysis three times a week, and received a new order to have a blanket between her and the Hoyer pad. Resident #22's physician (#166) and responsible party were made aware. There were no new orders. Review of vital signs taken on 05/21/25 at 11:39 P.M. revealed Resident #22 had respirations of 16 breaths per minute, a pulse of 68 beats per minute (bpm), oxygen saturation of 93% on room air, and a blood pressure of 102/60 mm/Hg. Review of a nursing note dated 05/22/25 at 6:43 A.M. by LPN #133 revealed Resident #22 was up and hallucinating most of the night about men fighting in her room, and the dialysis nurses laughing at her and shaking her chair. One-on-one intervention was attempted resulting in a brief discussion with Resident #22 who would then return to hallucinations and asked the nurse to get the men out of her house. There was no evidence that the resident's physician was notified. Review of vital signs taken on 05/22/25 at 12:02 P.M. revealed Resident #22 had a blood pressure of 87/46 mm/Hg, pulse of 78 bpm, and oxygen level and respirations were not checked. Review of a nursing note dated 05/22/25 at 12:55 P.M. by LPN #129 revealed Resident #22 was noted to have increased confusion and was talking about people in her bathroom. No other concerns were noted and there was no evidence the physician was notified. Review of a nursing note dated 05/23/25 at 7:47 A.M. by LPN #129 revealed dialysis called and stated their physician would like to discontinue Resident #22's order for nifedipine (medication used to treat high blood pressure). Resident #22, responsible party and the physician were made aware. There were no new orders. Review of vital signs for 05/23/25 revealed Resident #22's vital signs were not checked. Review of a nursing note dated 05/24/25 at 11:19 A.M. by Registered Nurse (RN) #117 revealed Resident #22 was resting in bed with her eyes closed, she was lethargic but did wake up when spoken to. Resident #22 received her medications and skin treatments. There was no evidence that Resident #22's physician was notified she was lethargic. Review of Resident 22's vital signs taken on 05/24/25 at 1:39 A.M. revealed a blood pressure of 86/50 mm/Hg, at 7:51 A.M. a blood pressure of 81/59 mm/Hg, at 11:28 A.M. a blood pressure of 93/64 mm/Hg and a pulse of 62 bpm, and at 10:44 P.M. Resident #22 had a blood pressure of 103/59 mm/Hg. Resident #22's oxygen level and respirations were not checked. Review of vital signs taken on 05/25/25 revealed Resident #22 had a blood pressure of 97/62 mm/Hg at 8:24 A.M., 92/68 mm/Hg at 1:16 P.M. and a pulse of 69 bpm, and a blood pressure of 97/64 mm/Hg at 10:29 P.M.; however, oxygen saturation and respirations were not checked. Review of vital signs taken on 05/26/25 revealed Resident #22 did not have her respirations or oxygen saturation checked; her pulse was 72 bpm at 12:05 P.M.; and her blood pressure was 121/70 mm/Hg at 9:55 A.M., 112/70 mm/Hg at 12:05 P.M., and 106/64 mm/Hg at 10:55 P.M. Review of a nursing note dated 05/27/25 at 12:45 P.M. by LPN #115 revealed Resident #22 had a very poor appetite and the nurse attempted to help the resident put her medications in her mouth because Resident #22 kept dropping her pills and water. LPN #115 had to pick up the pills from the bed a couple of times. Resident #22 denied pain and was in bed with her eyes closed most of the morning. There was no evidence that Resident #22's physician was notified. Review of vital signs taken on 05/27/25 revealed Resident #22 had a blood pressure of 100/58 mm/Hg at 10:18 A.M., 97/57 mm/Hg at 12:20 P.M., and 90/52 mm/Hg at 11:34 P.M.; her oxygen saturation was not checked; her pulse was 68 bpm at 12:20 P.M.; and her respirations were not checked. Review of a nursing note dated 05/28/25 at 3:31 P.M. by LPN #129 revealed Resident #22 was noted to have blue fingertips when she returned from dialysis. Oxygen was applied at two liters per minute via nasal cannula and Resident #22 was minimally responsive. Resident's oxygen saturation was 71%. When LPN #129 went back to recheck oxygen levels after applying oxygen, the machine could not get a reading. Resident #22's fingers were cool, and LPN #129 attempted to warm her fingers with no success. The resident's responsible party was notified and requested a hospice consult. Resident #22's physician (#166) was notified and gave no new orders. Vital signs taken on 05/28/25 revealed Resident #22's respirations were 16 breaths per minute at 11:24 P.M.; her pulse was 78 bpm at 12:28 P.M. and 70 bpm at 11:24 P.M.; her oxygen saturation was 93% at 11:24 P.M. with oxygen via nasal cannula; and her blood pressure was 101/72 mm/Hg at 12:28 P.M. and 104/56 mm/Hg at 11:23 P.M. Review of a nursing note dated 05/29/25 at 1:18 A.M. by LPN #133 revealed Resident #22 was resting in bed with her eyes closed. She was confused and unable to communicate her needs. Vital signs were within normal limits and respirations were even and unlabored with oxygen in place. Resident #22 did need to be fed her meals. Care was provided per the plan of care. There was no evidence that Resident #22's physician was notified of the resident's confusion and need for assistance with meals. Review of a nursing note dated 05/29/25 at 6:29 A.M. by LPN #133 revealed Resident #22 continued to have blue fingertips and nail beds. Resident #22 was receiving oxygen at two liters per minute via nasal cannula. LPN #133 was able to warm Resident #22's fingers enough to get an oxygen reading of 93%. Resident #22 was very confused and having hallucinations, it took much coaxing to get her to take her pills but after three attempts, Resident #22 did take her medications. There was no evidence that the Resident #22's physician was notified of her blue fingers, hallucinations, and confusion. Review of a nursing note dated 05/29/25 at 8:04 A.M. by LPN #129 revealed Resident #22 had two appointments scheduled for vein mapping on this date but she refused to go because she was too tired. Resident #22 had a decline in health, fingertips were blue, oxygen was in place, and she was having hallucinations. Resident #22 requested to have her appointments rescheduled and both offices were called. Resident #22's responsible party and physician were notified. There were no new orders. Review of vital signs taken on 05/29/25 revealed Resident #22's blood pressure was 106/62 mm/Hg at 8:47 A.M. and 76/57 mm/Hg at 9:29 P.M.; her oxygen was 93% at 12:16 A.M. and 92% at 2:50 P.M. both with oxygen via nasal cannula; her pulse was not documented; and her respirations were not documented. Review of a nursing note dated 05/29/25 at 9:30 P.M. by LPN #122 revealed upon entering Resident #22's room, she had blue fingertips, and they were unable to get an oxygen reading. Resident #22's blood pressure was also very low at 76/57 mm/Hg, and she had a pulse of 51 bpm. She was very confused and having a hard time putting sentences together. Resident #22's physician was made aware and gave orders to send to the emergency department for evaluation. Nine-one-one (911) was called and Resident #22's responsible party was notified. Upon emergency medical services (EMS) arrival, they obtained her blood sugar which was 56 mg/dL, and they could not obtain a blood pressure. Review of a nursing note dated 05/30/25 at 3:08 A.M. by LPN #122 revealed the nurse at the emergency room notified her Resident #22 was being transferred to a larger hospital with concerns of adrenal crisis. All parties were made aware. Review of a nursing note dated 05/30/25 at 3:51 A.M. by LPN #122 revealed Resident #22 also had elevated troponin, TSH, an acute urinary tract infection (UTI), and hypoglycemia. All parties were made aware. Review of a nursing note dated 06/09/25 at 3:18 P.M. by LPN #129 revealed the physician, ambulance and dialysis were all notified of Resident #22's readmission to the facility. Review of a hospital Discharge summary dated [DATE] at 11:42 A.M. revealed Resident #22 presented to a local emergency room on [DATE] for confusion, hypoglycemia, and she was transferred to this hospital for a concern of adrenal crisis. Resident #22 was admitted to the intensive care unit, and she had acute hypoxic respiratory failure with intubation and septic shock. Her admitting diagnoses were secondary adrenal insufficiency, septic shock with a UTI, Human Metapneumovirus/Strep/E.coli Pneumonia (E.coli and proteus were in her urine, E.coli was in her sputum, and pneumonia had strep), acute hypoxic respiratory failure and was intubated on arrival due to mental status, extubated on 06/02/25 and weaned to room air, and acute metabolic encephalopathy. Review of a MDS dated [DATE] revealed Resident #22's cognition remained intact, she had no behaviors, and she required set up for eating, supervision for oral hygiene, dependent on staff for toileting hygiene, maximum assistance for bathing, moderate assistance for upper body dressing, maximum assistance for lower body dressing, dependent on staff for applying footwear, and maximum assistance for personal hygiene. Interview on 07/11/25 at 2:08 P.M. with Certified Nursing Assistant (CNA) #101 revealed Resident #22 was super, super confused for a while. She was unsure why Resident #22 was hospitalized . Interview on 07/11/25 at 2:13 P.M. with LPN #115 revealed that if she encountered a resident with a low oxygen saturation, she would apply oxygen or a bipap and call the doctor immediately because that is a sign of respiratory distress/exacerbation. LPN #115 stated the facility does not normally treat respiratory distress. LPN #115 stated if she was unable to get a resident's oxygen reading, she would grab another machine, and if she still couldn't, she would send the resident to the hospital immediately using her nursing judgement, then call the doctor. LPN #115 stated Resident #22 made her own decisions for a long time; however, when she started dialysis, she would talk with her brother to make decisions, then she was so confused she could not make decisions. LPN #115 stated Resident #22 is better now and making her own choices. Interview on 07/11/25 at 2:25 P.M. with LPN #129 revealed she was the nurse on 05/28/25 providing care to Resident #22 when Resident #22's oxygen level was at 71%. LPN #129 stated when someone has low oxygen, she applies oxygen, calls the physician and follows orders. LPN #129 stated Resident #22 was not on oxygen prior to 05/28/25 and had no history of using ventilators or oxygen. LPN #129 confirmed Resident #22 having low oxygen levels was a big change for her. LPN #129 stated she tried to warm Resident #22's fingers and she spoke with dialysis who also noted she had blue fingertips. LPN #129 stated Resident #22 was making her own decisions until she had a decline. LPN #129 stated she does not make any decisions without talking to the doctor first and it is up to the doctor to determine if someone needs to go to the hospital or not. LPN #129 stated if she did not document anything in her notes, the physician did not give orders at the time. LPN #129 also confirmed multiple notes did not indicate the physician was notified of Resident #22's change in status. Interview on 07/11/25 at 2:43 P.M. with LPN #110 revealed if a resident had blue fingers and an oxygen saturation level of 71%, it would likely be a medical emergency. LPN #110 stated his course of action would be to apply oxygen even if the residents do not have an as needed order because they are obviously in distress, reach out to the doctor, and more than likely call 911. When asked if the resident had a full code status or DNRCCA in place and the doctor did not give orders to send out, LPN #110 stated he would use his nursing judgement to send a resident in respiratory distress out (to the hospital to be evaluated). Interview on 07/11/25 at 3:33 P.M. with Physician #166 revealed he could not recall specifically what the facility did or did not make him aware of regarding Resident #22. Physician #166 stated he could not recall why he did not give new orders to send Resident #22 to the hospital. Physician #166 stated it was likely the facility administered oxygen and her saturation went up. When informed the nurse could not get a follow up reading (oxygen saturation) on Resident #22, Physician #166 did not have a response. Physician #166 stated if the facility called him regarding Resident #22 having hallucinations, out of every resident in the building, he would care the least about her having hallucinations because she is schizophrenic and has hallucinations at times. When asked about worsening hallucinations in conjunction with other symptoms such as low oxygen levels, poor appetite and lethargy, Physician #166 stated she's always discolored, I don't know if they document that though. Interview on 07/11/25 at 3:52 P.M. with Dialysis Manager (DM) #150 revealed the dialysis center had noticed a decline in Resident #22's health as well. DM #150 stated prior to 05/21/25, they had sent Resident #22 to the hospital multiple times, and they were unable to identify a problem and would send her back. DM #150 stated when Resident #22 went to the hospital on [DATE], she did not think she would ever come back but she is like a whole new person since her recovery. DM #150 reviewed notes at this time and revealed on 05/16/25, a discussion about Resident #22's low blood pressure was had, and a referral was sent to cardiology as well as new orders to take blood pressure twice daily from Friday-Sunday. On 05/19/25, the dialysis physician rounded and decreased blood pressure medications and a message was left with the facility to update them on the new orders. On 05/21/25, an order was received to discontinue nifedipine (blood pressure medication) due to low blood pressures. On 05/23/25, DM #150 spoke with the facility who did not stop the nifedipine but would discontinue it immediately and monitor blood pressures. On 05/28/25, dialysis called the facility for a medication change due to a need to discontinue atenolol and start Coreg. DM #150 stated dialysis is not required to check oxygen levels, but they did notice Resident #22 had some discoloration to her fingers. Interview on 07/14/25 at 8:40 A.M. with Resident #22 revealed she was unable to recall the entire timeframe she was sick, she does not know when it started or when she was sent out. Resident #22 stated this was abnormal for her because she usually knows what's going on. Resident #22 stated she asked the facility what happened, but they didn't tell her. Resident #22 stated it was like out of nowhere she took a nosedive. Resident #22 stated she does have a history of hallucinations, but it is not anything too bad. Resident #22 stated it is not normal for her to be lethargic, confused, have a poor appetite, have blue fingertips, or unable to form sentences. Resident #22 stated she had never needed to wear oxygen prior to her illness. Interview on 07/14/25 at 8:54 A.M. with LPN #133 revealed she worked with Resident #22 throughout the timeframe of 05/21/25 through 05/29/25. LPN #133 stated it was normal for Resident #22 to have hallucinations. LPN #133 stated during a certain period of time, it was Resident #22's baseline to be confused, unable to communicate, and blue fingertips. LPN #133 stated Resident #22's confusion and lethargy were due to dialysis. Interview on 07/14/25 at 10:06 A.M. with LPN #122 revealed she worked with Resident #22 the night she was sent out. LPN #122 stated she sent Resident #22 out on 05/29/25. LPN #122 stated when she reported for her shift, she was informed Resident #22 wasn't doing very well, had to be fed her meals, was on oxygen now, and her fingers were blue. LPN #122 stated the aides got her during the night because Resident #22 was out of it and her fingers were super blue. LPN #122 stated Resident #22 did not know where she was, thought she was seeing her dead son and calling out for him. LPN #122 stated she got one low blood pressure but could not recall what it was. When she attempted to recheck the blood pressure, she was unable to get one at all. LPN #122 stated she called Physician #166 who gave the order to send Resident #22 to the hospital. LPN #122 stated EMS came and they could not get blood pressure either and made the comment they had never seen their blood pressure cuff go so low. LPN #122 stated her initial thought was Resident #22 was in respiratory failure because her fingers were so blue. LPN #122 stated she worked with Resident #22 about one week prior to this incident and the resident had a major change (within that week). LPN #122 stated she was shocked because Resident #22 could make her own decisions for the most part with some confusion. Resident #22 had worse hallucinations than normal, and she does not hallucinate often unless something clinical is going on with her. LPN #122 stated Resident #22 never used oxygen before. LPN #122 stated since starting dialysis, Resident #22's blood pressure had been running lower, but not as low as it was during 05/29/25. LPN #122 stated Resident #22 was not diabetic and she would not have even considered checking her blood sugar. LPN #122 stated she reviewed the documentation for the previous week (05/21/25- 05/29/25) and was very frustrated with everything and thought if Resident #22 had gone out several days sooner, she may not have needed to be intubated. LPN #122 stated a comment was made Resident #22 was a DNRCCA and waiting for a hospice consult; however, Resident #22 stated she was not ready to die. LPN #122 stated if she had been working while Resident #22's oxygen was 71%, she would have called the doctor to get orders and send her out. If the doctor did not give the order, LPN #122 would have used nursing judgement and sent her anyway. Interview on 07/14/25 at 10:27 A.M. with RN #117 revealed she does not often work the floor but knew Resident #22 has had blood pressure issues and wasn't feeling well since starting dialysis. RN #117 stated Resident #22 had no complaints, but she was lethargic when she worked with her. RN #117 stated she was sure she notified the physician and notification should be documented. Review of a statement dated 07/14/25 by LPN #129 revealed Resident #22's physician was notified about the change of condition on 05/28/25 and was in agreeance that resident had been declining over the last few weeks after starting dialysis. The physician gave the okay for Resident #22 to have oxygen and for a hospice consultation. No other orders were given at that time. (This was not part of Resident #22's medical record). Review of an undated statement by Physician #166 revealed regarding the timeframe of 05/22/25 through 05/29/25 relating to Resident #22's health, he was kept aware of her condition and goals through verbal reports, Resident #22 had been weighing the option of hospice and at no point did Physician #166 feel he was inadequately made aware of Resident #22's condition and the timing of the ER visit and hospitalization on 05/29/25 was not inappropriate to the overall clinical scenario. Review of a policy titled Change in Condition dated 08/09/23 revealed the nurse will notify the resident, their physician, and a representative when there is a change in condition including a significant change in the resident's physical, mental or psychosocial status such as deterioration which includes life-threatening conditions or clinical complications. The nurse will document in the resident's medical record information relative to the resident's change in condition and a comprehensive assessment will be completed if the change is significant. The definition of significant change in condition means the condition will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and it impacts more than one area of the resident's health status and requires interdisciplinary review and/or revision to the care plan. Immediately is determined to be as soon as practicable after the resident has been adequately assessed, necessary emergent care or treatment is rendered, and the resident's safety has been secured. Review of the University of Pittsburgh Medical Center website (https://www.upmc.com/services/divsion-infectious-diseases/conditions/sepsis) dated 2025 revealed the six main symptoms of sepsis are shortness of breath; fever, chills, or feeling very cold; high heart rate or low blood pressure; extreme pain or discomfort; sweaty or clammy skin; and being confused or feeling a bit lost.? Sepsis is an emergency blood infection that can lead to death within hours without proper treatment.? Sepsis can progress quickly and cause death within 12 hours and the risk of death increases by 7.6% for every hour that passes without treatment and getting quick treatment can be the difference between life and death.? Four types of infection that are more likely to lead to sepsis include pneumonia, a UTI, skin infections and gut infections. Those at a higher risk for sepsis include people 65 or older, weakened immune systems, have had a recent severe illness or hospital stay, or chronic illnesses such as lung disease or kidney disease.? This deficiency represents non-compliance investigated under Complaint Number 1356449.

Based on record review, review of a video recording from an in-room camera, family interview, staff interview, and policy review, the facility failed to honor a resident's known preference on not having a male caregiver assist her with personal care. This affected one (#73) of three residents reviewed for choices/personal preference. The facility census was 71. Findings include: Review of Resident #73's medical record revealed the resident was admitted to the facility on [DATE]. She remained in the facility until 08/27/24, when she was transferred to another nursing facility at the request of the resident and her family. Her diagnoses included schizophrenia, depression, obesity, congestive heart failure, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, and repeated falls. Review of Resident #73's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and adequate hearing. She was usually able to make herself understood and was usually able to understand others. She was not indicated to have any behaviors or was known to reject care during the seven days of the assessment period. She had a functional limitation in her range of motion on one side of her lower extremities. She was always continent of her bowel and occasionally incontinent of her bladder. Review of Resident #73's care plans revealed she had a care plan in place for having an alteration in elimination related to debility and generalized weakness. She had a history of being occasionally to frequently incontinent of her bladder. Interventions included the need to assist with toileting and hygiene needs as needed (PRN) and to perform incontinence care per facility protocol. It did not specify any preferences the resident had on who assisted her with personal care. Further review of Resident #73's care plans revealed she had a care plan in place for having an activities of daily living (ADL) self-care performance deficit related to decreased mobility, use of assistive devices, assist of staff, obesity, epilepsy, schizophrenia, depression, and incontinence. Interventions included the resident having video monitoring in her room, providing assistance with ADLs (toileting, personal hygiene, and bathing) every shift and prn, transfer with a two person assist for toilet use, scheduled toileting program before meals, after meals, at bedtime, and PRN. The ADL care plan did not specify the resident's preference on who was to assist her with ADL care. Review of Resident #53's kardex (care information provided to the aides on each resident to guide the provision of care) revealed the resident was known to have video monitoring in her room. She required a one person assist with bathing and a two person assist with toileting transfers. They were to assist the resident with toileting and hygiene needs PRN. The kardex did not communicate to the staff the resident's preference to only have female caregivers assist her with personal care. Review of a video recording (Video #4) that was not dated or timed when recorded, and was obtained from Resident #73's in room camera, which lasted 16 seconds, revealed a male State tested Nursing Assistant (STNA) entering the resident's room in response to the resident using her call light for assistance. The STNA in the video was identified by the Director of Nursing (DON) as being STNA #300. The clock that was on the wall in the resident's room indicated the recording took place at 12:55 P.M., as it was daylight outside the window shown in the video. The video showed the resident asking for a nurse to take her to the bathroom upon STNA #300 entering her room. He was noted on the video to respond to the resident's request with what and the resident replied I want a nurse to take me to the bathroom. STNA #300 was heard telling the resident that he was a nurse, as he began to push the resident in her wheelchair towards the doorway. The resident was heard saying oh no. The video recording ended when they were heading in the direction out of her room. On 09/09/24 at 9:54 A.M., an interview with Resident #73's Power of Attorney (POA) for healthcare revealed she did make it known to the facility that it was Resident #73's preference not to receive personal care services from male caregivers. She had spoken with the facility's Social Services Coordinator #120 and a nurse supervisor, LPN #200 about it, but it continued to occur. She confirmed video recordings from the resident's in room camera did show male caregivers assisting with the resident's personal care. On 09/09/24 at 1:15 P.M., an interview with STNA #99 revealed Resident #73 may have possibly said something about not wanting male caregivers to provide care to her. She did not hear it personally from the resident or her family, but did hear from other staff members that was what the resident's preference was. She reported the did have some residents that did not want male caregivers to provide care to them. In that event, they would switch out and have a female caregiver do it. She stated the residents had the right to make choices on who assisted them with personal care. She was not aware of any situations in which a male caregiver (aide) provided care to any female residents, if the female resident did not want them to. There may be times when there was only one aide on the hall and it may be a male. The resident would either have to wait or go ahead and have the male aide provide the care to them, if they couldn't or did not want to wait. On 09/09/24 at 2:16 P.M., an interview with LPN #250 revealed Resident #53 was known to want female caregivers only when assisting with personal care. If a male aide answered her call light, the resident would say she wanted a female to assist her. On 09/09/24 at 4:45 A.M., an interview with STNA #300 revealed he started working at the facility for about a month now. He was there during the end of Resident #53's stay in the facility and was assigned to work her unit/ hall on day shift. The resident was an extensive assist with her care. She was continent for the most part, but was known to have accidents at times. She would let the staff know when she was needing to go to the bathroom. He was aware the resident preferred female staff to render personal care to her, but indicated he has had to assist her with personal care. He has done everything for her, but give her a shower. He indicated it just depended on the day, if she wanted female staff or not. He re-confirmed the resident did make it known that she preferred female employees to provide her with personal care. He was then asked, if it was known the resident preferred personal care by female staff only, why would it be that there were times he assisted in her personal care. He replied female staff were not always readily available. Sometimes he would have to help her, which included taking her to the bathroom. He would do that, if the other female employees were busy helping other residents at the time. He was asked if he could not notify the other female staff, when Resident #53 was needing assistance with personal care, and take over the care of the other resident the female staff were assisting, as long as that other resident was okay with receiving care from a male aide. He stated he supposed he could have done that, but it did not occur to him to do so. He was asked to review Video #4 during the interview and confirmed that was him in the video. He acknowledged the resident was heard telling him she wanted a nurse to take her to the bathroom on two separate occasions during the video. He further acknowledged the resident stated oh no when he informed her he was going to take her to the bathroom as he was a nurse. He confirmed he did assist the resident with going to the bathroom, after the video recording ended. He was informed the residents had the right to choose who provided care to them and there were some female residents that may not be comfortable with a male aide assisting them with personal care. He was also informed that the resident's had the right to indicate personal preferences when it came to accepting care from male caregivers and their preferences and right to make choices about the care they received should be honored. On 09/10/24 at 9:30 A.M., Video #4 was reviewed with the facility's DON. She acknowledged Resident #53 was heard telling STNA #300 a couple of times that she wanted the nurse to take her to the bathroom, when STNA #300 told her that he would take her. She further acknowledged the resident was heard saying oh no when the STNA #300 said he would take her. She confirmed it was known by the facility's staff that the resident preferred female caregivers to assist her with her personal care. She agreed the residents had the right to choose if they did not want a male caregiver to assist them with personal care. She also agreed the male aide should have gotten the assistance from another female aide to help the resident to the bathroom. He could have relieved the female aide, with whatever care she was doing, so Resident #53's preference for a female caregiver to assist her with personal care could be honored. On 09/10/24 at 3:15 P.M., an interview with Social Services Coordinator #120 revealed she had been the facility's acting social worker for the past three years. She was aware of Resident #53's POA voicing concerns with several issues about her care. It was discussed in a care conference held on 08/13/24, that the resident did not want male caregivers to assist with her personal care. On 09/10/24 at 4:54 P.M., an interview with LPN #200 revealed she was the unit manager for the hall Resident #53 resided on when she was in the facility. She started in that role August 2023, so she was there for the duration of the resident's stay. She claimed the resident would go back and forth on allowing male caregivers to provide care to her. She then went to a point where she did not want male caregivers to provide personal care to her before she went to not wanting them in her room at all. She could not recall exactly when the resident made it known that she did not want male caregivers to assist her with her personal care. She stated it was made known shortly before the resident had an in room camera installed. Review of the facility's policy on Accommodations of Needs issued 08/21/23 revealed the facility would treat each resident with respect and dignity and would evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences would be accommodated to the extent possible. The resident's needs and preferences should be evaluated upon admission and reviewed on an ongoing basis. In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the resident's wishes. This deficiency represents non-compliance investigated under Complaint Number OH00157409.

Based on medical record review, observations, and staff interview, the facility failed to ensure catheter tubing was stored properly/appropriately to prevent the spread of infection. This affected one (Resident #283) out of one resident reviewed for urinary catheters. The facility census was 75. Findings include: Review of the medical record for Resident #283 revealed an initial admitted [DATE] and a readmitted [DATE]. Resident #283's medical diagnoses included sepsis, obstructive and reflux uropathy, delirium, disorientation, and altered mental status. Review of the care plan, dated 04/19/24, revealed Resident #283 had an indwelling catheter. Interventions included to complete catheter care per facility protocol. Review of the Catheter Evaluation, dated 04/22/24, revealed Resident #283 had an indwelling catheter. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/25/24, revealed Resident #283 had severely impaired cognition and scored a two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #283 was dependent on staff for toileting and personal hygiene. Resident #283 had an indwelling catheter. Observations on 05/05/24 at 4:10 P.M. and on 05/06/24 at 3:07 P.M. revealed Resident #283 was laying in bed and the catheter tubing was hanging down on the left side of the bed, close to the wall, touching the floor. Observations on 05/07/24 at 10:06 A.M. and 10:09 A.M. revealed Resident #283 was laying in bed and the catheter tubing was hanging down on the left side of the bed, close to the wall, touching the floor mat that had been placed next to the resident's bed. Interview on 05/07/24 at 10:09 A.M. with Licensed Practical Nurse (LPN) #212 confirmed Resident #283's catheter tubing was laying on the floor mat by Resident #283's bed. LPN #212 confirmed the catheter tubing should be stored in a position where it can be kept off the floor and floor mat.

Based on medical record review and staff interview, the facility failed to ensure Pre-Admission Screening and Resident Review (PASRR) documents were accurate. This affected one (Resident #56) out of one resident reviewed for PASRR documents. The census was 75. Findings include: Review of the medical record for Resident #56 revealed Resident #56 was admitted to the facility on [DATE]. Resident #56's diagnoses included but were not limited to chronic obstructive pulmonary disease, acute and chronic respiratory failure, cerebral infarction, hemiplegia and hemiparesis, epilepsy, bipolar disorder, major depressive disorder, anxiety disorder, and schizoaffective disorder. Review of Resident #56's Minimum Data Set assessment, dated 04/05/24, revealed she had a severe cognitive impairment. Review of Resident #56's PASRR document, dated 11/14/22, revealed it was completed by another nursing facility. Review of the PASRR document, under Section E, revealed the only diagnoses listed for Resident #56 was panic or other severe anxiety disorder and major depressive disorder. Review of the PASRR document revealed the following diagnoses were not included on the document: bipolar disorder and schizoaffective disorder, which were present upon Resident #56's admission on 02/03/23. Interview with Social Services Coordinator #185 on 05/07/24 at 1:53 P.M. and 2:22 P.M. confirmed the PASRR document dated 11/14/22 was Resident #56's most recent PASRR. She confirmed Resident #56 had diagnoses of bipolar disorder and schizoaffective disorder were not listed on PASRR document from the other nursing facility and no new PASRR was completed for Resident #56 . Interview with Social Services Coordinator #185 on 05/08/24 at 1:15 P.M. revealed she updated Resident #56's PASRR document on 05/07/24 and Resident #56 did trigger for a level II review.

Based on medical record review, staff interview, and facility policy review, the facility failed to notify the physician when a resident experienced a significant weight change. This affected one (Resident #76) out of three residents reviewed for nutrition. The census was 75. Findings include: Review of the medical record for Resident #76 revealed Resident #76 was admitted to the facility on [DATE]. Resident #76's diagnoses included but were not limited to unspecified severe protein-calorie malnutrition, chronic kidney disease, pulmonary hypertension, cardiomegaly, congestive heart failure, atrial fibrillation, edema, cardiomyopathy, and hypertension. Review of Resident #76's Minimum Data Set (MDS) assessment, dated 02/03/24, revealed she was cognitively intact. Review of Resident #76's weights revealed she had the following weights recorded: 135 pounds on 01/29/24 , 147.2 pounds on 02/05/24, and 157 pounds on 02/12/24. Review of Resident #76's nutritional notes and documentation, dated 01/29/24 to 02/16/24, revealed no evidence to support the physician was notified of Resident #76's significant weight gain of 12.2 pounds (nine percent [%]) from 01/29/24 to 02/05/24 and significant weight gain of 22 pounds (16.3%) from 01/29/24 to 02/12/24. Interview with Corporate Dietitian #148 on 05/08/24 at 11:25 A.M. and 11:57 A.M. confirmed there was no evidence to support the physician was notified of Resident #76's significant weight gains between 01/29/24 to 02/12/24. Review of the facility Change in Condition Notification policy, dated 08/09/23, revealed the nurse will notify the resident, the resident's physician/practitioner, and the resident's designated representative when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter the resident's medical treatment significantly.

Based on medical record review, staff interviews, review of hospital records, and review of facility policy, the facility failed to conduct a thorough investigation of falls to determine the root cause analysis to identify potential hazards to reduce and/or eliminate falls with major injury. This resulted in Actual Harm when Resident #19's falls on 12/21/22 and 12/22/22 were not thoroughly investigated to include a root cause analysis being done to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls without injury, and the resident sustained an unwitnessed fall with injuries on 12/28/22. Subsequently, Resident #19 was transferred to a local emergency department (ED) where the resident was diagnosed with a new acute intertrochanteric fracture of the left proximal femur. Additionally, the facility failed to ensure two other residents (#01 and #73) falls were thoroughly investigated to include a root cause analysis being completed which placed the residents at risk for more than minimal harm that did not result in actual harm to the resident. This affected three (#19, #01 and #73) of three residents reviewed for falls. The facility census was 77. Findings included: 1. Medical record review for Resident #19 revealed an admitted [DATE]. Medical diagnoses included right hip intertrochanteric hip fracture, heart failure, hypertension, renal failure, and diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 was severely cognitively impaired. Resident #19 required extensive assistance with two-person assistance for bed mobility, transfers, and toilet use. Resident #19 was not steady and only able to stabilize with staff assistance for moving on and off the toilet and moving from a seated to standing position. Review of the fall risk assessment dated [DATE], revealed Resident #19 was a high risk for falls. Review of the care plan dated 12/02/22 for Resident #19, revealed the resident was at risk for falls and potential injury related to decreased mobility, use of assistive devices, assistance of staff, and recent hospital admission with right hip fracture. The care plan was updated on 12/22/22 to include anticipate needs every shift, evaluate for non-slip pad for wheelchair as needed, fall evaluation per protocol, neurological (neuro) checks as ordered, non-skid strips by the bed side, and to notify physician and family of a fall. The care plan was updated on 01/13/23 to include encourage non-skid socks when the resident was out of bed and fall mat to the floor. Review of the progress note dated 12/21/22 at 2:55 P.M., revealed State tested Nursing Assistant (STNA) #98 reported she heard yelling and found Resident #19 sitting on her buttocks, with her back up against the bed and legs out in front of her. When STNA #98 was talking with the resident, the resident stated she got up to use the bedside commode and when she was going back to bed, she slipped and fell . The resident was noted to have non-skid socks on, but they were not pulled all the way up on her feet. STNA #98 and Registered Nurse (RN) #110 assisted the resident off the floor and back into the bed. The resident's range of motion and vital signs were normal, and neuro checks were initiated per policy. Review of the facilities fall investigation dated 12/21/22, revealed the same documentation as the 12/21/22 progress notes and the resident was alert to person, situation, and there was furniture in the way. The resident's predisposing physiological factors were gait imbalance, weakness and incontinence and the predisposing situation factors were ambulating without assistance. A new intervention was to revise toileting schedule which was implemented on 12/21/22. The notes indicated there were no witnesses to the fall and the physician and family were notified. The investigation revealed no documented evidence of a root cause analysis being completed for the fall. Review of the progress notes dated 12/22/22 at 7:00 P.M. for Resident #19, revealed Licensed Practical Nurse (LPN) #103 was called to the resident's room by STNA #145. Documentation indicated STNA #145 was transferring Resident #19 to the bed when resident started to fall and STNA #145 assisted the resident to the floor. The resident was observed by LPN #103 sitting on her buttocks on the floor beside the bed with no injuries noted. Review of the facilities fall investigation dated 12/22/22 for Resident #19, revealed the same documentation as the 12/22/22 progress note and the resident was oriented to person, place, and there was furniture in the way. Documentation indicated the resident's predisposing physiological factors were gait imbalance, weakness, and impaired memory and the resident's predisposing situation factors were during a transfer. A new intervention was to revise the toileting schedule. The investigation revealed no documented evidence of a root cause analysis being completed for the fall. Review of the progress note dated 12/28/22 at 4:09 P.M., revealed LPN #106 heard Resident #19 calling for help, and when the nurse arrived to the resident's room, the nurse found the resident sitting on the floor, lying on her right side and the resident was yelling out in pain. Documentation indicated the resident stated her left hip hurt and rated the pain at a 10 (zero equals no pain and 10 equals worse pain) and the resident stated she could not move her leg. The physician was notified, and the nurse received orders to send the resident to the hospital. The resident was placed in the bed and the intervention was to encourage resident to not transfer without assistance. The physician, and the family were notified. Review of the progress note dated 12/28/22 at 4:53 P.M., revealed Resident #19 was sent out to the hospital. Review of the hospital summary dated 12/28/22, revealed Resident #19 reported she was transferring from the chair to the bed when she tripped and landed on her left side. The resident reported that she could not move her left hip/leg and reported the pain as eight out 10. The resident had x-rays of bilateral hips with the pelvis which revealed a new intertrochanteric fracture of the left proximal femur. Documentation indicated her internal fixation of the intertrochanteric fracture of the proximal right femur was stable and the resident was admitted to the hospital. Review of the facilities fall investigation dated 12/28/22 for Resident #19, revealed resident stated she was trying to get back to bed after going to the bathroom. Resident #19's predisposing physiological factors were gait imbalance, weakness, current urinary tract infection, impaired memory and the resident's predisposing situation factors were during a transfer and ambulating without assistance. A new intervention was for a fall mat to be placed on the floor next to the bed starting on 12/28/22. The investigation revealed no documented evidence of a root cause analysis being completed for the fall. 2. Medical record review for Resident #01 revealed an admitted [DATE]. Medical diagnoses included aphasia, malnutrition, cerebral edema, and a brain mass (tumor). Review of the five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 was moderately cognitively impaired. Resident #01 was an extensive assistance with two-person physical assistance for bed mobility and transfers, required one-person extensive physical assistance for toileting, transferring on and off the toilet, surface to surface transfers, moving from a seated to a standing position and resident was not steady and only able to stabilize with staff assistance. The MDS indicated the resident was transferred to the hospital on 11/19/22 and readmitted to the facility on [DATE]. Review of the fall assessments dated 11/13/22, 11/19/22, 11/23/22 and 12/28/22 for Resident #01 revealed the resident was a high risk for falls. Review of the progress note dated 11/19/22 at 6:01 A.M., revealed Resident #01's roommate came into the hallway and alerted an unknown STNA that the resident was on the floor in her room. Resident #01 stated she was trying to use the bathroom and slipped and hit her head. The resident was assessed and there were no apparent injuries noted. Resident #01's vital signs and range of motion were within normal limits (WNL). The resident was assisted to the restroom and back into bed. Neuro checks were initiated, and the in-house supervisor, physician and family were notified at 6:01 A. M. Resident #01 was sent out to the hospital at 6:16 A.M. for evaluation and returned to facility on 11/23/22. Review of the facilities fall investigation dated 11/19/22 for Resident #01, revealed the same documentation as the 11/19/22 progress note, and furniture was in the way. Resident #01's predisposing physiological factors were gait imbalance, impaired memory, recent illness, and weakness. Resident #01's predisposing situation factors were ambulating without assistance during a transfer. A new intervention was to revise the resident's toileting schedule. The investigation revealed no documented evidence of a root cause analysis being completed for the fall. Review of interdisciplinary team (IDT) meeting dated 11/21/22, revealed a new intervention of toileting was implemented for Resident #01 and physical and occupational therapy evaluation referrals were completed. Review of the hospital records dated 11/23/22, revealed Resident #01 had a fall at the facility and hit her head. It was unclear of the cause of the fall, but the resident was a high risk for falls. A computed tomography (CT) scan for the head and cervical spine were noted to be non-acute for any injuries. Review of a handwritten facility document titled pain assessment dated [DATE], which the facility identified as being Resident #01's care plan, revealed activity as tolerated, low bed with mat at the bedside floor and use caution with transitions. Further review of this document, updated on 12/07/22, revealed scheduled toileting plan as directed and do not leave unattended on the toilet. Review of the progress note dated 12/28/22 at 3:34 P.M. for Resident #01, revealed the nurse was alerted by an unknown STNA that the resident had fallen on her bottom in the bathroom attempting to transfer herself. Resident #01 stated resident did not hit her head, but her bottom was sore. The resident sustained a skin tear on her left elbow which measured 5 centimeters (cm) by 1.5 cm. The skin tear was cleansed with normal saline and covered with an abdominal pad (ABD) and wrapped with kerlix and Coban and the resident tolerated it well. Neuro checks were started at the time of the incident, resident's vital signs were within normal limits and the resident was placed in her wheelchair. Interventions for the fall were to not leave the resident unsupervised in the bathroom and to encourage the resident to use the call light for help while using the bathroom. The physician, and the Power of Attorney (POA) were notified. Review of the fall investigation dated 12/28/22 for Resident #01, revealed the same documentation as the 12/28/22 progress note, and furniture noted to be in the way. Resident #01's predisposing physiological factors were gait imbalance, impaired memory, confusion, and predisposing situation factors were ambulating without assistance during a transfer. A new intervention was to not leave resident unsupervised in the bathroom. Resident #01's description of the fall revealed she was trying to get into her wheelchair from the toilet. The investigation revealed no documented evidence of a root cause analysis being completed for the fall. 3. Medical record review for Resident #73 revealed an admitted [DATE]. Medical diagnoses included orthopedic conditions, heart failure, diabetes, arthritis, Parkinson's disease, and non-Alzheimer's dementia. Review of the admission MDS assessment dated [DATE], revealed Resident #73 was cognitively intact. The resident's functional status required extensive two-person physical assistance for bed mobility, transfers, and toilet use. Review of the fall risk assessments dated 11/26/22, 01/05/23, and 01/18/23 revealed Resident #73 was a high risk for falls. Review of the fall care plan dated 11/28/22 for Resident #73, revealed resident was at risk for falls and potential injury due to new environment and needed assistance for activities of daily living. Interventions dated 12/09/22, revealed to anticipate needs every shift, educate the resident and family if a fall occurred and what to do, monitor for gait or ambulation changes and assist if needed, monitor for signs and symptoms of side effects for medication, notify the physician following a fall, provide frequent supervision to help reduce the risk of a fall, physical therapy to evaluate and treat, remind resident to request assistance for transfers if resident was alert and can comprehend the instructions. Interventions dated 01/05/23 revealed for the bed to be up against wall and a fall mat to the floor at bedside. Review of the progress note dated 01/05/23 at 6:26 A.M., for Resident #73, revealed the resident had her legs hanging over the bed with her feet on the mat and she stated she needed to use the bathroom. The notes indicated the resident was assisted to the bathroom. Review of the progress note dated 01/05/23 at 6:42 A.M., revealed Resident #73 was found on the floor beside the bed. The bed was in the lowest position and there were no visual injuries. There were no signs and symptoms of pain or discomfort, residents' range of motion was normal, and the resident displayed some confusion when asked what happened. Resident #73 stated she fell out of her car on Route 270. The physician and family were notified and a new intervention was for the bed to be up against the wall with floor mat on the floor. Review of the facilities fall investigation dated 01/05/23 for Resident #73, revealed the same documentation as the 01/05/23 progress note, and the resident was oriented to person, with predisposing physiological factors identified as gait imbalance and incontinent. The investigation revealed no documented evidence of a root cause analysis being completed for the fall. Review of the progress note dated 01/18/23 at 2:49 P.M., revealed Resident #73 had fallen and was found on the floor at 12:46 P.M. sitting on the floor between the wheelchair and bed. Two aides assisted the resident to the wheelchair and then to the bed. A head-to-toe assessment was completed and there were no injuries, resident denied pain, and said she hit her head on the dresser. The resident had redness noted on her head, neuro checks were initiated, and the physician and the family were notified. Review of facilities fall investigation dated 01/18/23, revealed Resident #73 was found on the floor in between the wheelchair and bed. There were two aides who assisted the resident up to the wheelchair and then to the bed. A head-to-toe assessment was completed with no injuries noted. The resident denied pain and said she hit her head on the corner of the dresser. Resident #73 had redness noted to her head, was alert to person, neuro checks were initiated, and the physician and family were notified. The resident stated she was trying to transfer herself from the wheelchair to the bed and said her legs would not hold her up and she fell to the floor. Resident #73's predisposing physiological factors were weakness, current urinary tract infection, incontinent, recent change in medication, recent change in condition, recent illness and predisposing situation factors were during a transfer and ambulating without assistance. The investigation revealed no documented evidence of a root cause analysis being completed for the fall. Interview with the Director of Nursing (DON) on 02/08/23 at 2:22 P.M. verified the facility did not have documentation of a root cause analysis for Residents #19's falls on 12/21/22, 12/22/22 and 12/28/22. The DON additionally verified the facility did not have documentation of a root cause analysis for Resident #01's fall on 11/19/22 or Resident #73's falls on 01/05/23 and 01/18/23. The DON stated they talked about the falls and the root cause analysis in their IDT meetings, but it was not documented anywhere. Review of facility policy titled Accident/Incident-Prevention/Fall Risk revised 12/20/22, revealed the facility would provide a safe, secure environment regarding all incidents and accidents. The facility staff is responsible for assessing the patient/resident's fall risk and implementing proactive interventions as well as new interventions should an incident or accident occur. This deficiency represents non-compliance investigated under Complaint Number OH00139030.

Based on medical record review, staff and resident interviews, review of facility Self-Reported Incidents (SRI's), and policy review, the facility failed to ensure a thorough investigation was completed when an allegation of abuse was made to staff. This affected one resident (#2) of three residents reviewed for abuse. The census was 77. Findings included: Medical record review for Resident #2 revealed an admitted [DATE]. Medical diagnoses included, but not limited to, heart failure, coronary artery disease, and dementia, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 was rarely or never understood. Resident #2 required extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. Review of the progress notes from 12/29/22 to 12/30/22 for Resident #2, revealed no documented notes regarding abuse. Review of a statement for an incident dated 12/29/22 and written by Assistant Director of Nursing (ADON) #152 and Licensed Practical Nurse (LPN) #84, revealed Resident #35 reported to LPN #174 that State tested Nursing Assistant (STNA) #88 was being mean to Resident #2 (Resident #35's roommate). The statement indicated LPN #174 reported the allegation to the ADON #152. The statement indicated ADON #152, and LPN #84 went to resident's (#2 and #35) room and interviewed both residents. The statement indicated STNA #88 swatted at Resident #2's hand while she fed her. Further review of the statement revealed pain and skin assessments were completed for Resident #2. Review of facilities SRI's revealed no SRI was created for the allegations of abuse on 12/29/22. Interview with STNA #88 on 02/06/23 at 1:14 P.M. denied slapping Resident #2's hand. STNA #88 stated she was not suspended during the investigation but moved to another hall and did not go back to Residents #2's room. Interview with Resident #35 on 02/06/23 at 1:23 P.M., revealed STNA #88 was in the room with Resident #2 with the curtain open and the aide was facing Resident #35 when she observed STNA #88 smack Resident #2 on her hand because the resident was trying to help feed herself while STNA #88 fed her. Resident #35 stated STNA #88 smacked Resident #2's hand two more times and the aide made statements to the resident if she was going to keep trying to feed herself, then she would remove the tray and stop feeding her. Resident #35 stated the aide removed the tray from the resident and stopped feeding her. Resident #35 stated it was not right for STNA #88 to treat Resident #2 that way and she not only observed the smacks but heard the three smacks. Resident #35 revealed she reported the allegations of abuse by STNA #88 to LPN #174. Interview with the Director of Nursing (DON) on 02/06/23 at 1:26 P.M., revealed she was not working when the incident happened on 12/29/22. DON stated Resident #2 was swatting at the STNA #88. DON verified Resident #2's record did not contain any documented notes about the incident. DON stated the investigation only included a statement of the interviews, a pain and skin assessment for Resident #2. DON confirmed an SRI for the abuse allegations was not submitted and confirmed there was not a thorough investigation completed. Additionally, the DON confirmed LPN #174 did not create a statement of the allegations and STNA #88 was never interviewed. Additionally, DON reported the STNA was moved to another hall and was not suspended pending the outcome of the investigation. DON stated witness statements were not collected because the facility took what LPN #174 said and put it in the statement dated 12/29/22 written by ADON #152 and LPN #84. Interview with LPN #174 on 02/06/23 at 1:47 P.M. revealed Resident #35 made allegations that that STNA #88 was feeding Resident #2 and while STNA was feeding Resident #2, the STNA smacked Resident #2 three times on the hand. Resident #35 reported that STNA said if resident was going to keep trying to feed herself, then STNA #88 was not going to help the resident eat. LPN #174 stated she felt like the incident was verbal and physical abuse and reported the allegations to ADON #152. LPN #174 stated after the incident, the management only removed the STNA #88 from the hall and allowed her to continue working. Review of policy entitled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Property dated 10/01/22, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the patient/resident's medical symptoms. Policy indicated if a staff member was accused or suspected, then facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. Facility would investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source. Once the Administrator and the state agency are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days. Investigation protocol includes Interview the patient/resident, the accused, and all witnesses. If the allegation involves abuse/neglect, interview other residents, as appropriate, to determine if they may have been affected by the accused staff member or resident. This deficiency represents non-compliance investigated under Complaint Number OH00139030.

Based on medical record review, review of facility Self-Reported Incidents (SRI's), staff and resident interviews, and policy review, the facility failed to ensure allegations of abuse was reported to the state agency timely as required. This affected one resident (#2) of the three residents reviewed for abuse. The census was 77. Findings included: Medical record review for Resident #2 revealed an admitted [DATE]. Medical diagnoses included, but not limited to, heart failure, coronary artery disease, and dementia, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 was rarely or never understood. Resident #2 required extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. Review of the progress notes from 12/29/22 to 12/30/22 for Resident #2, revealed no documented notes regarding abuse. Review of a statement for an incident dated 12/29/22 and written by Assistant Director of Nursing (ADON) #152 and Licensed Practical Nurse (LPN) #84, revealed Resident #35 reported to LPN #174 that State tested Nursing Assistant (STNA) #88 was being mean to Resident #2 (Resident #35's roommate). The statement indicated LPN #174 reported the allegation to the ADON #152. The statement indicated ADON #152, and LPN #84 went to resident's (#2 and #35) room and interviewed both residents. The statement indicated STNA #88 swatted at Resident #2's hand while she fed her. Further review of the statement revealed pain and skin assessments were completed for Resident #2. Review of facilities SRI's revealed no SRI was created for the allegations of abuse on 12/29/22. Interview with STNA #88 on 02/06/23 at 1:14 P.M. denied slapping Resident #2's hand. STNA #88 stated she was not suspended during the investigation but moved to another hall and did not go back to Residents #2's room. Interview with Resident #35 on 02/06/23 at 1:23 P.M., revealed STNA #88 was in the room with Resident #2 with the curtain open and the aide was facing Resident #35 when she observed STNA #88 smack Resident #2 on her hand because the resident was trying to help feed herself while STNA #88 fed her. Resident #35 stated STNA #88 smacked Resident #2's hand two more times and the aide made statements to the resident if she was going to keep trying to feed herself, then she would remove the tray and stop feeding her. Resident #35 stated the aide removed the tray from the resident and stopped feeding her. Resident #35 stated it was not right for STNA #88 to treat Resident #2 that way and she not only observed the smacks but heard the three smacks. Resident #35 revealed she reported the allegations of abuse by STNA #88 to LPN #174. Interview with the Director of Nursing (DON) on 02/06/23 at 1:26 P.M., revealed she was not working when the incident happened on 12/29/22. DON stated Resident #2 was swatting at the STNA #88. DON verified Resident #2's record did not contain any documented notes about the incident. DON stated the investigation only included a statement of the interviews, a pain and skin assessment for Resident #2. DON confirmed an SRI for the abuse allegations was not submitted and confirmed there was not a thorough investigation completed. Additionally, the DON confirmed LPN #174 did not create a statement of the allegations and STNA #88 was never interviewed. Additionally, DON reported the STNA was moved to another hall and was not suspended pending the outcome of the investigation. DON stated witness statements were not collected because the facility took what LPN #174 said and put it in the statement dated 12/29/22 written by ADON #152 and LPN #84. Interview with LPN #174 on 02/06/23 at 1:47 P.M. revealed Resident #35 made allegations that that STNA #88 was feeding Resident #2 and while STNA was feeding Resident #2, the STNA smacked Resident #2 three times on the hand. Resident #35 reported that STNA said if resident was going to keep trying to feed herself, then STNA #88 was not going to help the resident eat. LPN #174 stated she felt like the incident was verbal and physical abuse and reported the allegations to ADON #152. LPN #174 stated after the incident, the management only removed the STNA #88 from the hall and allowed her to continue working. Review of policy entitled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Property dated 10/01/22, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the patient/resident's medical symptoms. The facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in the policy. In cases where a crime is suspected, the Administrator will report the same to local law enforcement in accordance with Center's Crime Reporting policy. Policy indicated if a staff member was accused or suspected, then facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. Policy indicated for allegations involving Neglect, Exploitation, Mistreatment, Misappropriation of resident property and Injuries of Unknown Source will be reported to ODH immediately, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00139030.

Based on medical record review, staff and resident interviews, review of facility Self-Reported Incidents (SRI's), and policy review, the facility failed to implement their abuse policy when an allegation of abuse was not timely reported to the state agency and not thoroughly investigated. This affected one resident (#2) of three residents reviewed for abuse. The census was 77. Findings included: Medical record review for Resident #2 revealed an admitted [DATE]. Medical diagnoses included, but not limited to, heart failure, coronary artery disease, and dementia, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 was rarely or never understood. Resident #2 required extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. Review of the progress notes from 12/29/22 to 12/30/22 for Resident #2, revealed no documented notes regarding abuse. Review of a statement for an incident dated 12/29/22 and written by Assistant Director of Nursing (ADON) #152 and Licensed Practical Nurse (LPN) #84, revealed Resident #35 reported to LPN #174 that State tested Nursing Assistant (STNA) #88 was being mean to Resident #2 (Resident #35's roommate). The statement indicated LPN #174 reported the allegation to the ADON #152. The statement indicated ADON #152, and LPN #84 went to resident's (#2 and #35) room and interviewed both residents. The statement indicated STNA #88 swatted at Resident #2's hand while she fed her. Further review of the statement revealed pain and skin assessments were completed for Resident #2. Review of facilities SRI's revealed no SRI was created for the allegations of abuse on 12/29/22. Interview with STNA #88 on 02/06/23 at 1:14 P.M. denied slapping Resident #2's hand. STNA #88 stated she was not suspended during the investigation but moved to another hall and did not go back to Residents #2's room. Interview with Resident #35 on 02/06/23 at 1:23 P.M., revealed STNA #88 was in the room with Resident #2 with the curtain open and the aide was facing Resident #35 when she observed STNA #88 smack Resident #2 on her hand because the resident was trying to help feed herself while STNA #88 fed her. Resident #35 stated STNA #88 smacked Resident #2's hand two more times and the aide made statements to the resident if she was going to keep trying to feed herself, then she would remove the tray and stop feeding her. Resident #35 stated the aide removed the tray from the resident and stopped feeding her. Resident #35 stated it was not right for STNA #88 to treat Resident #2 that way and she not only observed the smacks but heard the three smacks. Resident #35 revealed she reported the allegations of abuse by STNA #88 to LPN #174. Interview with the Director of Nursing (DON) on 02/06/23 at 1:26 P.M., revealed she was not working when the incident happened on 12/29/22. DON stated Resident #2 was swatting at the STNA #88. DON verified Resident #2's record did not contain any documented notes about the incident. DON stated the investigation only included a statement of the interviews, a pain and skin assessment for Resident #2. DON confirmed an SRI for the abuse allegations was not submitted and confirmed there was not a thorough investigation completed. Additionally, the DON confirmed LPN #174 did not create a statement of the allegations and STNA #88 was never interviewed. Additionally, DON reported the STNA was moved to another hall and was not suspended pending the outcome of the investigation. DON stated witness statements were not collected because the facility took what LPN #174 said and put it in the statement dated 12/29/22 written by ADON #152 and LPN #84. Interview with LPN #174 on 02/06/23 at 1:47 P.M. revealed Resident #35 made allegations that that STNA #88 was feeding Resident #2 and while STNA was feeding Resident #2, the STNA smacked Resident #2 three times on the hand. Resident #35 reported that STNA said if resident was going to keep trying to feed herself, then STNA #88 was not going to help the resident eat. LPN #174 stated she felt like the incident was verbal and physical abuse and reported the allegations to ADON #152. LPN #174 stated after the incident, the management only removed the STNA #88 from the hall and allowed her to continue working. Review of policy entitled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Property dated 10/01/22, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Policy indicated if a staff member was accused or suspected, then facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. The facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in the policy. Facility would investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source. Once the Administrator and the state agency are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days. Investigation protocol includes Interview the patient/resident, the accused, and all witnesses. If the allegation involves abuse/neglect, interview other residents, as appropriate, to determine if they may have been affected by the accused staff member or resident. This deficiency represents non-compliance investigated under Complaint Number OH00139030.

Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to ensure one resident (#64) did not have their Potassium pill crushed. This affected one (#64) of four residents who received Potassium. Additionally, the facility failed to ensure a dose of [MEDICATION(S)] insulin was administered to one resident (#63). This affected one (#63) of eight residents who received [MEDICATION(S)] insulin. The census was 81. Findings included: 1. Medical record review for Resident #64 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was moderately cognitively impaired. Resident #64 required extensive assistance for bed mobility and toilet use, total dependence for transfers, and supervision for eating. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/08/22 at 8:22 A.M. revealed Licensed Practical Nurse (LPN) #156 crushed Resident #64's potassium tablet and gave it to the resident in applesauce. Interview on 06/08/22 at 8:25 A.M. LPN #156 confirmed she crushed the potassium tablet for Resident #64 because he preferred it to be crushed because it was easier for him to swallow. Interview on 06/08/22 at 10:00 A.M. with the Director of Nursing (DON) revealed it would be the expectation of the facility to not crush an ER Potassium without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of undated facility policy titled, Crushing Medication, solid oral medications could be crushed if authorized by the prescribing physician, unless crushing renders the resultant product to be unsafe. The crushing of an ER medication may render the medication administration unsafe. The physician requesting to crush medication against warnings from the manufacturer of the medication, will write a specific order to crush the medication and document in the progress notes the risks and benefits of this type of medication preparation. 2. Medical record review for Resident #63 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly MDS assessment dated [DATE] revealed Resident #63 was cognitively intact. Resident #63 required extensive assistance for bed mobility and toilet use, total dependence for transfers, and independent for eating. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M.,12:00 P.M. and 4:00 P.M. for diabetes, 151-200 give 4 units, 201-250 give 6 units, 251-300 give 10 units, and 301-350 to give 12 units, and 351-400 to give 14 units. In addition, the resident was ordered [MEDICATION(S)] Kwik pen U 200 (Insulin [MEDICATION(S)]) insulin pen, 200 unit/ml to give 25 units subcutaneous three times a day at 8:00 A.M., 12:00 P.M. and 4:00 P.M. Observation on 06/08/22 at 8:15 A.M. of medication administration for Resident #63 revealed Registered Nurse (RN) #63 drew up 25 units of [MEDICATION(S)] for the resident and proceeded to go into the resident's room and administered the insulin to her. The resident's blood sugar level was at 183. Interview on 06/08/22 at 8:20 A.M. with the RN #63 revealed she should have given Resident #63, four units of [MEDICATION(S)] in addition to the scheduled 25 units and did not see the order. Review of undated facility policy titled, Administration Standards for Medications, revealed medication would be administered in a safe manner that meets all regulatory guidelines and National Patient Safety Goals. The facility staff should understand and observe for the correct dose of medication. This deficiency substantiates Complaint Numbers OH 580 and OH 266.