Every finding on record at Portsmouth Health and Rehab

Based on observation, interviews, review of the facility's water management plan, review of laboratory test results, and review of the facility weekly logbook documentation of tasks completed, the facility failed to ensure an effective water management and legionella prevention plan were implemented. This had the potential to affect all 75 residents residing in the facility. Findings Include: Review of the facility Water Management Plan, dated 04/18/25 revealed a diagram of the water system, analysis of building water systems, control measures, monitoring/corrective actions, confirmation and documentation. The plan included weekly flushing of all eyewash stations, faucets, and showers not in frequent use, to clean and disinfect the ice machine, check flow and return temperatures at the hot water heater [noting that the hot water heater should not be lower than 140 degrees Fahrenheit (F)], a visual check of the hot water heater internal surfaces, to check the temperature of all running taps, to replace or dismantle, disinfect, clean and eliminate all deposits of scale from aerators or laminar flow faucet attachments, and to measure and record free chlorine levels on the incoming city water supply as well as the most distal location within the facility. Record review of the Water Systems: Testing and Monitoring of Water Management Plan for Legionella from 11/08/25 through 05/30/26 revealed the hot water heater temperatures below 140 degrees F on the following dates: 11/24/25, 12/01/25, 12/08/25, 12/15/25, 12/22/25, 12/29/25, 01/05/26, 01/12/26, 01/19/26, 01/26/26, 02/02/26, 02/09/26, 02/16/26, 02/23/26, 03/02/26, 03/09/26, 03/16/26, 03/23/26, 03/30/26, 04/06/26, 04/17/26, 04/24/26, and 05/07/26. The testing also revealed weekly testing of free chlorine was completed at the hot water tank, not at the incoming city water supply and most distal location, per the water management plan. Review of the weekly flushing documentation from 11/08/25 through 05/30/26 revealed no evidence the showers on the East unit were flushed, or that all the bathroom showers and tubs were flushed.Review of the laboratory testing for Legionella revealed on 04/22/26 the water in room [ROOM NUMBER] was tested for Legionella and on 04/29/26 the sample was positive. On 05/19/26 the water was tested and on 05/28/26 the results received revealed 12 out of 15 water samples were positive for Legionella. The samples ranged from collection sites from the hot water recirculation area, sinks in rooms 100, 113, 218, 219, 230, 318, 319, 320, and 331, the second-floor shower room, and the third-floor shower room. Interview on 06/03/26 at 8:00 A.M. with the Administrator revealed the facility initiated Legionella testing after one year of initiation of the water management plan. The Administrator confirmed upon testing, in total, 13 water samples tested positive for Legionella in the facility. Observation and interview on 06/03/26 at 11:44 A.M. with Maintenance Manager (MM) #17 revealed the hot water temperature testing at the output source was fluctuating between 130 to 132 degrees F. MM #17 also confirmed there were some showers on the east unit not in use that would not turn on and therefore had not been flushed in a long time. Interview with MM #17 on 06/04/26 at 3:10 P.M. confirmed the testing of free chlorine was only being conducted at one place in the facility, at the hot water tank. He further confirmed there was no testing being conducted at the location of the incoming city water supply as well as the most distal location as stated in the facility's water management plan.Interview with MM #17 on 06/04/26 at 3:25 P.M. revealed the facility had not been flushing all the bathroom showers and tubs in the facility prior to the water testing being positive. This deficiency represents non-compliance investigated under Complaint Number 3029107.

Based on closed resident record reviews, hospital discharge instructions, and staff interview, the facility failed to ensure care for nephrostomy tubes was provided in a timely manner. This affected one resident (#77) of one reviewed for hospitalizations. The facility census was 77.Findings include:Closed record review for Resident #77 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included malignant neoplasm of the bladder, hematuria, acute kidney failure, and hydronephrosis with ureteropelvic junction obstruction.Review of the admission Minimum Data Set (MDS) assessment, dated 05/19/25, revealed the resident was assessed to have intact cognition. The resident was assessed to have an indwelling catheter device. Review of the hospital discharge instructions, dated [DATE], revealed instructions for how to care for nephrostomy tubes. Instructions for care of the skin where the tubes exited the body included cleansing the skin surrounding the area where the tubes exited the body using a washcloth or cotton swab with cleanser or soap and water, rinsing the area with water if soap was used, allowing the area to air dry or patting dry gently, then applying one sterile four by four split gauze pad around the tube. Apply a second gauze pad over the first one to cover the tube, tape over the pads with paper tape and pinch the tape around the tube, and lastly tape the tube to the skin below the dressing for support. Review of the physician's orders for the resident revealed no order was put into place for care of the skin surrounding the area where nephrostomy tubes exited the body until 05/20/25. Interview with the Director of Nursing on 07/30/25 at 8:45 A.M. confirmed there had not been orders implemented for the care of the skin surrounding the area where nephrostomy tubes exited Resident #77's body until 05/20/25.

Based on resident record reviews, staff interview, and review of facility policy, the facility failed to ensure resident influenza and pneumococcal vaccinations were offered and administered in a timely and appropriate manner. This affected two residents (#14 and #15) out of the five residents reviewed for immunizations. The facility census was 77.Findings include:1. Record review for Resident #14 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included cerebral infarction, acute kidney failure, and mood disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 06/02/25, revealed the resident was assessed to not be up to date on the pneumococcal vaccination due to the vaccination not being offered. Review of the facility immunization record for the resident revealed no pneumococcal vaccine was documented to have been previously administered. 2. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, hyperlipidemia, and diabetes mellitus. Review of the annual MDS assessment, dated 05/09/25, revealed the resident was assessed to not be up to date on the influenza vaccination due to the vaccination not being offered. Review of the facility immunization record for the resident revealed no influenza vaccine was documented to be administered since 09/27/23. Interview with the Director of Nursing on 07/31/25 at 10:20 A.M. confirmed Resident #14 was not up to date on the pneumococcal vaccine and Resident #15 was not up to date on the influenza vaccine. Review of the facility policy titled Vaccination of Residents, revised 10/2019, revealed refusals of vaccinations shall be documented in the resident's medical record. If the resident receives a vaccine, it shall be documented in the resident's medical record. Review of the facility policy titled Influenza Vaccine, revised 03/2022, revealed between October 1st and March 31st each year the influenza vaccine shall be offered to residents and employees unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. For those who receive the vaccine, the vaccination will be documented in the resident's/employee's medical record. Review of the facility policy titled Pneumococcal Vaccine, revised 10/2023, revealed prior to or upon admission residents are assessed for eligibility to receive the pneumococcal vaccine series. For each resident who receives the vaccine, the vaccination is documented in the resident's medical record. Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control (CDC) recommendations at the time of the vaccination.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report an allegation of sexual abuse to the state survey agency. This affected one (Resident #36) of three residents reviewed for abuse. The facility census was 78. Findings include: Review of the medical record for Resident #36 revealed admitted [DATE] with diagnoses including type two diabetes mellitus, atrial fibrillation, peripheral vascular disease, congestive heart failure and fracture of the right humerus. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #36 dated 04/08/24 indicated the resident had intact cognition. Review of the facility SRIs for 2024 revealed there were no reports related to Resident #36. Interview on 04/23/24 at 9:42 A.M. with the Administrator confirmed the facility investigated an allegation reported by staff on 03/26/24 of an inappropriate relationship between Licensed Practical Nuse (LPN) #10 and Resident #36. Staff had reported the relationship as inappropriate and that they had witnessed LPN #10 hug and kiss Resident #36. During the investigation of the allegation LPN #10 was placed on administrative leave. Further interview with the Administrator confirmed the facility was unable to substantiate abuse. Interview on 04/23/24 at 11:42 A.M. with State tested Nursing Assistant (STNA) #44 confirmed the STNA had heard other staff talking about Resident #36 and LPN #10 having an inappropriate relationship. STNA #44 confirmed she had seen Resident #36 and LPN #10 exit the elevator together and they were both laughing. When the doors opened, the resident thanked the nurse and called her honey. STNA #44 confirmed she reported this to the nurse manager because she felt that something was going on between Resident #36 and LPN #10, some sort of inappropriate relationship. Interview on 04/23/24 at 11:57 A.M. with LPN #111 confirmed she had witnessed LPN #10 hug residents and/or kiss them on the cheek or the forehead, but she didn't think anything of it. LPN #11 confirmed LPN #10 was overly nice to the residents and seemed like she wanted them to like her. Interview with the Administrator and the Regional Director of Operations (RDO) confirmed the Administrator informed the RDO of the allegations made by staff on 03/26/24 regarding LPN #10 and Resident #36. The Administrator confirmed the facility investigated the allegation and did place the alleged perpetrator (AP), LPN #10 on administrative leave pending the investigation. The Administrator confirmed facility did not report the allegation regarding LPN #10 to the state agency, the Ohio Department of Health (ODH.) Review of the facility investigation regarding Resident #36 and LPN #10 dated 03/26/24 revealed the facility interviewed Resident #36 who denied an inappropriate relationship with LPN #10. The facility also interviewed LPN #10, the AP, who also denied having an inappropriate relationship with the resident. The facility interviewed other staff members but was unable to substantiate abuse or any form of mistreatment had occurred. Review of facility policy titled Abuse, Neglect and Exploitation dated 10/24/22 revealed sexual abuse was defined as nonconsensual sexual contact of any type with a resident. The policy stated all alleged violations would be reported to government agencies within specified timeframes.

Based on medical record review and staff interview, the facility failed to ensure resident Pre-Admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected three (Resident #6, Resident #40, and Resident #49) of four residents reviewed for PASRR documents. The census was 72. Findings Include: 1. Resident #6 was admitted to the facility on [DATE]. His diagnoses were dementia, schizoaffective disorder, dysphagia, falls, hyperlipidemia, myocardial infarction, depression, obstructive uropathy, chronic pain, anemia, hypertension, anxiety, dysphagia, altered mental status, acute kidney disease, cervicobrachial syndrome, and restless leg syndrome. Review of his Minimum Data Set (MDS) assessment, dated 07/09/23, revealed he was minimally impaired. Review of medical diagnoses for this resident revealed a new diagnosis of schizoaffective disorder was added on 09/14/21. Most recent PASARR was completed on 04/01/21 and does not reflect this diagnosis. A corrected PASARR was completed on 10/03/23 reflecting the new diagnosis addition. Interview with the Administrator on 10/03/23 at 02:42 P.M. verified a new PASARR should have been completed with the addition of the new diagnosis. 2. Resident #40 was admitted to the facility on [DATE]. His diagnoses were arthritis, dementia, schizoaffective disorder, atherosclerosis, hypertension, hypothyroidism, hyperlipidemia, atrial fibrillation, aortic valve insufficiency, hypokalemia, chronic kidney disease stage 4, macular degeneration, venous insufficiency, congestive heart failure, muscle weakness, abnormalities of gait and mobility, anxiety, depression, and hearing loss. Review of his MDS assessment, dated 07/11/23, revealed he was minimally to moderatelyimpaired. Review of the PASARR from 04/19/23 revealed no indications of schizoaffective disorder diagnosis from the admission PASARR. A new PASARR was not completed with the new diagnosis from 04/19/23. A correct PASARR was completed on 10/03/23 during the survey. Interview with the Administrator on 10/03/23 at 02:42 P.M. verified a new PASARR should have been completed with the addition of the new diagnosis. 3. Resident #49 was admitted to the facility on [DATE]. His diagnoses were cardiomyopathy, schizoaffective disorder, depression, osteoporosis, bipolar disorder, alopecia, anxiety, aphagia, atherosclerosis, cognitive communication deficit, diverticulosis, hypertension, mood disorder, atrial fibrillation, constipation, dementia, and falls. Review of his MDS assessment, dated 07/09/23, revealed she was rarely/never understood. Review of medical diagnoses for this resident revealed a new diagnosis of schizoaffective disorder was added on 04/21/23. Most recent PASARR was completed on 09/14/22 and does not reflect this diagnosis. A corrected PASARR was completed on 10/03/23 reflecting the new diagnosis addition. Interview with the Administrator on 10/03/23 at 02:42 P.M. verified a new PASARR should have been completed with the addition of the new diagnosis.

Based on observation, interview and record review the facility to adequately assess and provide treatment for Resident #64 who had red, dry, flaky scalp. This affected one (Resident #64) of two residents reviewed for activities of daily living. The facility census was 72. Findings include: Review of the medical record for Resident #64 revealed an admitted [DATE] with diagnoses including rhabdomyolysis, dementia without behaviors, pain, dysphagia and fracture of unspecified part of neck of right femur. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #64 required extensive assistance of one person for personal hygiene and was totally dependent on two staff for bathing needs. Resident #64 had a surgical wound with application of dressing and application of ointment/medications other than to feet. Review of the weekly skin integrity checks for Resident #64 dated 09/11/23 indicated Resident #64 had an area to the lower part of head and back region with dry, cracked skin. The weekly skin integrity checks dated 09/13/23 and 09/20/23 revealed no changes to Resident #64 skin. Review of the physician orders for 10/2023 revealed Resident #64 was not ordered any treatment to his red, dry, flaky scalp. Review of the plan of care revealed no plan related to altered skin integrity or risk of altered skin integrity. Observations on 10/02/23 at 11:22 A.M., 10/03/23 at 11:03 A.M. and on 10/04/23 at 10:40 A.M revealed Resident #64 had red scalp with large white flakes in his hair and along his hair line. Interview on 10/03/23 at 11:08 A.M. with Registered Nurse (RN) #125 confirmed Resident #64 had large white flakes in his hair and along his hair line. Interview on 10/04/23 at 10:45 A.M. with Director of Nursing (DON) confirmed Resident #64 had impaired skin integrity as evidenced by large white flakes in his hair and along his hair line.

Based on observation, interview, record review and review of facility policy revealed the facility failed to implement non-pharmacological interventions for Resident #48 prior to administering as needed narcotic pain medications. This affected one resident (Resident #48) reviewed for pain management. The facility census was 72. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including nonalcoholic steathohepatitis (NASH), fatty liver, urinary retention, peripheral vascular disease, chronic kidney disease and gout in left knee. Review of the Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was cognitively intact, required assistance with activities of daily living and had no scheduled or as needed pain medications. Resident #48 did not have any pain. Review of the physician orders dated 09/23 for Resident #48 revealed an order for hydrocodone-acetaminophen (narcotic pain medication) tablet 5-325 milligrams (mg) by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR) for 09/23 for Resident #48 revealed he received hydrocodone-acetaminophen tablet 5-325 mg by mouth at least once a day from 09/01/23 through 09/30/23. There were no non pharmacological interventions implemented or documented as provided before administering the pain medication. Review of the nursing progress notes from 09/01/23 through 09/30/23 was silent on providing non pharmacological interventions prior to administering the pain medication. Review of the plan of care dated 05/22/23 and revised on 09/18/23 revealed Resident #48 needed pain management and monitoring related to NASH, general debility and peripheral vascular disease. The Interventions included administer medication as ordered, monitor for effectiveness of medication, evaluate and establish level of pain on numeric scale, and implement Resident #48 preferred non pharmacological interventions for pain relief-rest, repositioning and relaxation. Interview on 10/02/23 at 2:29 P.M. and 10/03/23 at 9:00 A.M. with Resident #48 revealed the resident had pain and received pain medication when he requested it. Interview on 10/04/23 at 2:03 P.M. with Unit Manager #157 revealed non pharmacological interventions were in the residents care plan. Unit Manager #157 stated the nurse would document the non pharmacological interventions that were attempted on the MAR. Interview on 10/04/23 at 2:28 P.M. with the Director of Nursing confirmed Resident #48 did not receive non pharmacological interventions before administration of narcotic pain medication. Review of the facility policy titled Pain Management dated 09/29/22 revealed non pharmacological interventions would include but no limited to environmental comfort measures, loosening any constrictive bandage, clothing or device, applying splinting, physical modalities, exercises to address stiffness and prevent contractures and cognitive/behavioral interventions such as music, relaxation techniques, activities, diversions, comfort support, teaching the resident coping techniques and education about pain.

Based on observation, interview, and medical record review, the facility failed to provide care and services to address Resident #48's verbalization of being sad and depressed. This affected one resident (Resident #48) reviewed for behavioral-emotional issues. The facility census was 72. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including nonalcoholic steathohepatitis (NASH), fatty liver, urinary retention, peripheral vascular disease, chronic kidney disease and gout in left knee. Review of the Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was cognitively intact and had trouble with sleeping, feeling down, depressed and hopeless, feeling tired with no energy, poor appetite and trouble concentrating. Resident #48 scored 10 on mood assessment indicating moderate depression. Review of the physician orders dated 09/23 for Resident #48 revealed there were no orders for antidepressant medications or other mood disorder medications. There was not any orders related to psychiatric care and treatment. Review of the nursing progress notes from 09/01/23 through 09/30/23 was silent in regards to mood disorder or signs and symptoms of depression. Review of the plan of care dated 06/27/23 revealed Resident #48 felt sad, could not sleep, had no appetite or energy and felt inadequate at times. The interventions included to encourage Resident #48 to get involved in activities related to his interests, help the resident to keep in contact with family and friends, introduce the resident to others with similar interests, offer food and beverages the resident liked and take the time to discuss the residents feelings when he was feeling sad. Interview on 10/03/23 at 9:00 A.M. with Resident #48 revealed he felt down about his life and was sad. Resident #48 became tearful and expressed he was feeling sad. Interview on 10/04/23 at 3:34 P.M. with Social Services revealed she completed the mood section of the MDS assessment. Social Services stated she had visited with Resident #48 several times and he talked more about moving out of the facility and not his feelings. Social Services stated she did not document all the conversations she had with residents as their conversations were private and confidential. Social Services did not provide any documentation of conversations with Resident #48 about his feelings of depression.

Based on observation, interview, medical record review, and facility policy review revealed the facility failed to ensure the proper storage of nebulizer machine mask to prevent contamination and possible infection. This affected one resident (Resident #173)out of one resident reviewed for respiratory care. The facility census was 72. Findings include: Review of the medical record for Resident #173 revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, hypertension and peripheral vascular disease. The Minimum Data Set (MDS) comprehensive assessment was not complete at this time. Review of the physician orders for Resident #173 dated 09/23 revealed an order for ipratropium-albuteral solution 0.5 to 2.5 (3) milligrams (mg) per 3 milliliters (ml) inhale orally four times daily related to acute and chronic respiratory failure with hypoxia and hypercapnia. Review of the Medication Administration Record (MAR) 09/23 revealed Resident #173 received nebulizer respiratory medication as ordered. The plan of care was silent related to providing protective barrier to nebulizer machine breathing mask. Observations made during the annual survey on 10/02/23 at 8:51 A.M., 10/03/23 at 11:14 A.M. and 10/04/23 at 1:18 P.M. revealed Resident #173 nebulizer machine was on the bedside table. The tubing was not dated and the mask was hanging over the side of the table. Interview on 10/04/23 at 1:18 P.M. with Resident #173 revealed the mask did not have a protective barrier to prevent contamination since she had been at the facility. Interview on 10/04/23 at 1:19 P.M. with State tested Nursing Assistant (STNA) #83 confirmed the nebulizer mask was not in a protective barrier for infection control. STNA #83 also confirmed there was not a date on the mask tubing. Review of the facility policy titles Oxygen Administration dated 09/29/22 revealed to change nebulizer tubing and delivery devices weekly and as needed if become soiled or contaminated. Also stated to keep deliver devices covered in plastic bag when not in use.

Based on staff interview, resident interview, observations, medical record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines the facility failed to provide hand hygiene between resident care, while passing meal trays, and to wear gloves with direct resident care. This directly affected eleven Resident's (#36, #1, #29, #22, #28, #39, #272, #273, #53, #270, #271) but had the potential to affect all 59 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/01/22, revealed Resident #1 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of 15 (no cognitive impairment). Resident #1 exhibited behaviors such as verbal behavioral symptoms directed towards others. Resident #1 required limited to extensive assistance of one to two or more staff members for all activities of daily living (ADL) except eating which required set-up and supervision. Review of the care plan dated 02/28/22 revealed Resident #1 had a rectal abscess infection and pneumonia. Interventions included medications as ordered and observation of signs and symptoms of continued or unresolved infection and report to the physician as appropriate. 2. Review of the medical record for Resident #29 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment, dated 01/15/22, revealed Resident #29 had impaired cognition with a BIMS score of four out of 15 (severe cognitive impairment). Resident #29 exhibited behaviors such as inattention, disorganized thinking, and rejection of care. Resident #29 required limited to extensive assistance of one to two or more staff members for all ADL except eating which required set-up and supervision. Review of the care plan dated 01/12/22 revealed Resident #29 had an actual infection and was at risk for infection related to history of [CONDITION(S)] and [CONDITION(S)]. Interventions included antibiotics as ordered and following of the standard precautions according to the facility's infection control manual. Observation on 03/07/22 at 12:17 P.M. revealed blood was drawn from Resident #29's left arm without gloves by Phlebotomist #777 from a contracted laboratory company. She was observed exiting the resident's room without preforming hand hygiene and entering the nurse's station where she was observed filing paperwork into a binder. Phlebotomist #777 then proceeded to exit the facility. Interview on 03/07/22 at 12:22 P.M with Phlebotomist #777 revealed she immediately removed used gloves from her travel lab bag and stated those were the gloves she used to draw blood on Resident #29 but did not clarify why the gloves were not disposed of in the resident's room or why hand hygiene was not preformed prior to exiting the room immediately thereafter. 3. Review of the medical record for Resident #36 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 01/07/22 revealed Resident #36 required assistance with mobility and self-care due to increased weakness, frequent non-compliance with care, mobility needs, frequently refused to stand or assist with mobility needs, and fluctuated in assistance needs. Interventions included assistance with ADL, assistive devices including a wheelchair and wheeled walker at bedside, trapeze to the bed as desired, nail care as needed, right resting hand splint as ordered, and passive range of motion (PROM) to the right hand with care as tolerated. Review of the quarterly MDS 3.0 assessment, dated 01/10/22, revealed Resident #36 had impaired cognition with a BIMS score of seven out of 15 (severe cognitive impairment). Resident #36 exhibited behaviors such as inattention. Resident #36 required extensive assistance of one to two or more staff for all ADL except eating which required set-up and supervision. 4. Review of the medical record for Resident #39 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 01/16/22, revealed Resident #39 had impaired cognition with a BIMS score of three out of 15 (severe cognitive impairment). Resident #39 exhibited behaviors such as inattention and disorganized thinking. Resident #39 required limited to extensive assistance of one to two staff or more staff for all ADL except eating which required set-up and supervision. Resident #39 was occasionally incontinent of bladder and was always incontinent of bowels. Further review of the MDS revealed Resident #39 did not have a pressure injury/ulcer, was at risk for pressure ulcers (ulcer), and did not have any unhealed ulcers. The MDS revealed Resident #39 had a pressure reducing device for the bed but no other skin and ulcer/injury treatments. Observation on 03/07/22 at 11:54 A.M. of State tested Nursing Assistant (STNA) #743 revealed she assisted Resident #39 with drinking water, exited her room then entered Resident #36's room to assist with a Hoyer (mechanical lift) transfer without preforming hand hygiene. Observation on 03/07/22 at 12:01 P.M. of STNA #743 revealed no hand hygiene was preformed after exiting Resident #36's room, before entering Resident #1's room, before assisting Resident #1, after exiting Resident #1's room, or re-entering Resident #1's room once again. Observation on 03/07/22 at 11:55 A.M. with STNA #742 revealed she clipped Resident #28's nails wearing gloves, removed the gloves without preforming hand hygiene, and then proceeded to assist Resident #36 to bed. Observation on 03/07/22 at 12:00 P.M. with STNA #742 revealed new gloves were applied without preforming hand hygiene and care was provided to Resident #28. Interview on 03/07/22 12:01 P.M. with STNA #743 confirmed no hand hygiene was performed before entering Resident #39's, after assisting her with drinking, after exiting Resident #39's room, before or after exiting Resident #36's room, before entering Resident #1's room, or after exiting Resident #1's room, and reentering. Interview on 03/07/22 at 12:10 P.M. with STNA #742 revealed hand hygiene was to be performed before and after entering or exiting a room. She also confirmed she did not perform hand hygiene prior to or after caring for Residents #36 or #28 nor was hand hygiene preformed in between their care. 5. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22 had allergies to [MEDICATION(S)], [MEDICATION(S)], and Sulfa antibiotics. Review of the quarterly MDS 3.0 assessment, dated 01/01/22, revealed Resident #22 was cognitively intact evidenced by a BIMS score of 12. Resident #22 was assessed to require one to two staff assist with transfers, toileting, and mobility. Review of the care plan dated 04/22/21 revealed Resident #22 was at risk for complications related to anticoagulant and antiplatelet medication due to decreased mobility peripheral vascular disease (PVD), and diabetes. Interventions included observe for signs and symptoms of bleeding and apply prolonged pressure venipuncture sites. Observation on 03/07/22 at 10:20 A.M. during facility tour on the third floor revealed Resident #22 came out of his room in his wheelchair with a bloody towel on his right forearm telling STNA #1000 that he was bleeding from a skin tear. STNA #1000 proceeded to take the bloody towel with bare hands from Resident #22. Interview with STNA #1000 on 03/07/22 at 10:20 A.M. revealed she should have had gloves on before touching the towel. STNA #1000 confirmed that was not ideal to be touching the bloody towel with bare hands. 6. Record review revealed Resident #273 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active physician order, dated 03/07/22, revealed Resident #273 was to be on transmission-based precautions. Record review revealed Resident #272 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active physician order, dated 03/07/22, revealed Resident #272 was to be on transmission-based precautions. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active physician order, dated 03/07/22, revealed Resident #53 was to be on transmission-based precautions. Record review revealed Resident #270 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active physician order, dated 03/07/22, revealed Resident #270 was to be on transmission-based precautions. Record review revealed Resident #271 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active physician order, dated 03/07/22, revealed Resident #271 was to be on transmission-based precautions. Observation on 03/07/22 at 11:40 A.M. of the lunch meal being served to five residents (Resident's #53, #270, #271, #272 and #273) residing on the COVID-19 observation unit revealed Hospitality Aide #259 was observed to don a gown, gloves, shoe covers, a face shield, and an N-95 respirator mask with a surgical mask placed over the N-95 mask before entering the COVID-19 observation unit through a plastic barrier. Hospitality Aide #259 then removed a lunch meal tray and entered the room of Resident #53 to deliver the meal. Hospitality Aide #259 then exited the room of Resident #53, removed another lunch meal tray from the cart, and entered the room of Resident #273 to deliver the tray without changing the N-95 mask, surgical mask, gown, gloves, or shoe covers or cleaning the face shield the employee was wearing. Hospitality Aide #259 then exited the room of Resident #273, removed another lunch meal tray from the cart, and entered the room of Resident #271 to deliver the tray without changing the N-95 mask, surgical mask, gown, gloves, or shoe covers or cleaning the face shield the employee was wearing. Hospitality Aide #259 then exited the room of Resident #271, removed another lunch meal tray from the cart, and entered the room of Resident #270 to deliver the tray without changing the N-95 mask, surgical mask, gown, gloves, or shoe covers or cleaning the face shield the employee was wearing. Hospitality Aide #259 then exited the room of Resident #270, removed another lunch meal tray from the cart, and entered the room of Resident #272 to deliver the tray without changing the N-95 mask, surgical mask, gown, gloves, or shoe covers or cleaning the face shield the employee was wearing. Interview with Hospitality Aide #259 on 03/07/22 at 12:05 P.M. verified the employee had donned Personal Protective Equipment (PPE) which included an N-95 respirator mask with a surgical mask placed over it, a gown, gloves, shoe covers, and a face shield prior to entering the COVID-19 observation unit and had not changed the PPE or cleaned the face shield between delivering the lunch meal trays to Resident's #53, #270, #271, #272 and #273. Hospitality Aide #259 stated the residents on the COVID-19 observation unit did not have confirmed infections of COVID-19 and PPE only needed to be changed between residents with active infection with the COVID-19 virus. Interview with Regional Nurse #888 on 03/07/22 at 12:50 P.M. verified Resident's #53, #270, #271, #272 and #273 resided on the COVID-19 observation unit and were on transmission-based precautions due to being newly admitted to the facility and not being up to date with COVID-19 vaccinations per the Centers for Disease Control (CDC) most recent recommendations. Regional Nurse #888 verified PPE including N-95 masks, gowns, gloves, and shoe covers should be changed and face shields cleaned upon exiting the room of each resident residing on the COVID-19 observation unit. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 02/02/22, revealed empiric use of transmission-based precautions (quarantine) was recommended for residents who were newly admitted to the facility if they were not up to date with all recommended COVID-19 vaccine doses. Review of the CDC guidance titled COVID-19, updated 01/16/22, revealed up to date meant a person had received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. Review of the facility policy titled Hand Washing Technique, dated 02/17 revealed all personnel will wash before beginning the treatment/care of a resident and upon completion of such tasks, to prevent the spread of nosocomial infections. Hands should be washed after the removal of gloves or other personal protective barrier equipment. Review of the facility policy titled Disposable Non-Sterile Gloves, dated 02/17, revealed personnel will wear disposable gloves when a barrier between the resident and health care provider was necessary to prevent the transmission of blood and bodily fluids or when handling soiled articles or equipment. Gloves were also to be worn when touching mucous membranes or non-intact skin areas. Review of the facility policy titled Disposable Non-Sterile Gloves, dated February 2017, revealed personnel will wear disposable non-sterile gloves when a barrier between the resident and the health care provider is necessary to prevent the transmission of blood and bodily fluids or when handling soiled articles or equipment.

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to provide nail care, shaving, and haircuts, showers, and mouth care to residents who needed assistance. This affected five (Resident's #5, #9, #33, #28 and #36) of seven residents reviewed for activities of daily living (ADL). The facility census was 59. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 01/25/22 revealed Resident #5 had a physical functioning deficit related to mobility impairment, self-care impairment due to [CONDITION(S)], decreased mobility, weakness, rhabdomyolysis, [CONDITION(S)], history of a [CONDITION(S)] (DVT), depression, failure to thrive, and dementia. Interventions included encourage choices with care, nail care as needed, and personal hygiene assistance of one as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/25/22, revealed Resident #5 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of 15 (moderate cognitive impairment). Resident #5 exhibited behaviors such as inattention, disorganized thinking, and rejection of care. He required extensive assistance of one to two or more staff for all ADL except eating which he required set-up and supervision. Interview and observation on 03/07/22 at 10:12 A.M. with Resident #5 revealed his mustache was grown over his upper lip and was in his mouth. He confirmed he was tired of eating hair from his overgrown mustache. He confirmed he wanted a clean-shaven neck as he pointed out the long hair on his neck and under his chin. He stopped talking to spread his mustache apart and to get the mustache hair out of his mouth before he proceeded to state he was unsure why he had not been shaven or offered to be shaven. This was confirmed with State tested Nursing Assistant (STNA) #742 who was present in the room during the interview with the approval of the resident. Interview and observation on 03/08/22 at 8:54 A.M. with Resident #5 revealed he had not been shaven or offered to be shaven. Interview and observation on 03/08/22 at 4:03 P.M. with STNA #508 of Resident #5 confirmed he was verbally stating he would like to have his neck shaved and his mustache trimmed so the hair did not get into his mouth. Interview and observation 03/09/22 9:30 A.M. with Resident #5 revealed his mustache hair remained over his upper lip, in his mouth, and his neck hair remained. He confirmed he was still waiting for his mustache to be trimmed and his neck hair to be shaved. Interview on 03/09/22 at 11:15 A.M. with the Regional Registered Nurse (RN) #888 revealed there was not an area where shaving was documented in residents' charts, but shaving and facial hair maintenance was to be performed as needed. 2. Review of the medical record for Resident #33 revealed an initial admitted [DATE] and a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment, dated 01/12/22, revealed Resident #33 had impaired cognition with a BIMS score of three out of 15 (severe cognitive impairment). He exhibited behaviors such as inattention and disorganized thinking. Resident #33 required extensive assistance of one staff member for all ADL except eating which he required set-up and supervision. Review of the plan of care dated 01/19/22 revealed Resident #33 had a physical functioning deficit related to fluctuation with mobility impairment, self-care impairment related to weakness, cognition, depression, restless/agitation at times, history of falling, dementia, and [CONDITION(S)]. Interventions included encourage choices with care, nail care as needed, and personal hygiene assistance of one as needed. Interview and observation on 03/07/22 at 10:35 A.M. with Resident #33 revealed his nails were grown past the tips of his fingers, were jagged, had dirt underneath them, and he confirmed he would like his nails cut/trimmed and cleaned. He had mustache hair stubble and confirmed he needed to shave but had not been offered assistance with shaving. Interview and observation on 03/08/22 at 3:59 P.M. with Human Resources (HR)/STNA #90 confirmed Resident #33 had long, jagged, dirty nails, and had facial hair stubble. Observation on 03/08/22 at 4:18 P.M. revealed STNA #508 was clipping and cleaning Resident #33's fingernails after Surveyor intervention. Observation on 03/09/22 at 9:28 A.M. revealed Resident #33 was resting in bed with eyes closed and the facial hair stubble remained. Observation on 03/09/22 at 12:44 P.M. revealed Resident #33 lying in bed with his facial hair stubble remaining. 3. Review of the medical record for Resident #28 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 assessment, dated 01/09/22, revealed Resident #28 had intact cognition with a BIMS score of 15 out of 15 (no impairment). The resident did not have any documented behaviors. The resident required extensive assistance of one to two or more staff for all ADL except eating which he required supervision and one-staff physical assistance. Review of the plan of care dated 01/12/22 revealed Resident #28 had a physical functioning deficit related to mobility impairment, self-care impairment due to decreased mobility, [CONDITION(S)], depression, history of [CONDITION(S)]/collapse, decreased mobility, weakness, history of falls, cardiac issues, obesity, OSA, CKD IV, and chronic respiratory failure with [CONDITION(S)]. Interventions included assistance with ADL as needed and nail care as needed. Interview and observation on 03/07/22 at 10:26 A.M. of Resident #28 revealed his hair was long, approximately to his shoulders, and he stated he was supposed to get his hair cut on 03/07/22. His nails were very long, grown past the tips of his fingers, and he confirmed he would like them to cut. Interview and observation on 03/07/22 at 11:46 A.M. of Resident #28 with STNA #742 confirmed Resident #28's nails needed trimmed, and his hair had grown to approximately shoulder length. Observation on 03/07/22 at 11:55 A.M. revealed STNA #742 clipped Resident #28's nails after Surveyor intervention. Observation on 03/08/22 at 8:56 A.M. of Resident #28 revealed his hair remained grown past his ears approximately to his shoulders. Observation on 03/09/22 at 9:25 A.M. of Resident #28 revealed his hair remained grown past his ears approximately to his shoulders. 4. Review of the medical record for Resident #36 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 01/07/22 revealed Resident #36 required assistance with mobility and self-care due to increased weakness, frequent non-compliance with care, mobility needs, frequently refused to stand or assist with mobility needs, and fluctuated in assistance needs. Interventions included assistance with ADL, assistive devices including a wheelchair and wheeled walker at bedside, trapeze to his bed as desired, nail care as needed, right resting hand splint as ordered, and passive range of motion (PROM) to the right hand with care as tolerated. Review of the quarterly MDS 3.0 assessment, dated 01/10/22, revealed Resident #36 had impaired cognition with a BIMS score of seven out of 15 (severe cognitive impairment). The resident exhibited behaviors such as inattention. The resident required extensive assistance of one to two or more staff for all ADL except eating which he required set-up and supervision. Interview and observation on 03/07/22 at 10:25 A.M. with Resident #36 revealed he was up in his wheelchair waiting on a haircut. His hair had grown past his ears. His nails were orange and were very long, past the tips of his fingers. He confirmed he would like his nails cleaned and cut. Interview on 03/07/22 at 11:44 A.M. with STNA #743 confirmed Resident #36's nails were to be clipped weekly and as needed. Interview and observation on 03/07/22 at 11:46 A.M. with STNA #742 confirmed Resident #36's nails needed trimmed and were orange as a result of him eating cheesy popcorn. Observation on 03/07/22 at approximately 11:54 A.M. revealed STNA #742 was assisting Resident #36 with nail care after Surveyor intervention. Interview on 03/09/22 at 9:26 A.M. with Resident #36 revealed no one was available to cut his hair. Interview on 03/09/22 at 9:37 A.M. with Human Resources and STNA #90 revealed the beautician was available every Monday to cut residents' hair. She revealed residents could request to be seen by the beautician or if the staff thought a resident needed a haircut, they could inform the beautician. She revealed males should have their hair cut every two to three weeks and hair past a male residents' ears would not be acceptable. She also confirmed a male resident should be shaved daily, mustache and beards should be kept clean and trimmed, and facial hair should not be over their lip and in their mouth. Interview on 03/09/22 at 12:59 P.M. with the Administrator revealed haircuts were provided based on resident and family preferences. She stated the beauty shop just reopened after COVID-19 and the hairdresser/beautician came to the facility on Tuesdays but was unable to come to the facility the week of 03/07/22. She stated she was unsure of the last hair cut provided for Resident's #28 and #36. She also stated resident families were permitted to take the residents out of the facility to obtain haircuts. Interview on 03/09/22 at 1:39 P.M. with the Administrator revealed Resident #28 did not have a facility managed account. She continued by stating she spoke with his daughter who confirmed money would be brought into the facility to get the residents haircut. She stated she would check the list for the beauty shop dated 03/09/22 to confirm Resident #36 was on the beautician list because she was unaware that he had been in his wheelchair waiting for a haircut on 03/07/22. Interview on 03/09/22 at 1:51 P.M. with the Administrator revealed the facility had not had beauty care services since March of 2020. She revealed after the facility began allowing visitors according to Centers for Disease Control (CDC) recommendations and after they relicensed and found a beautician, it was around Valentine's Day in 2022 when the beautician started. She stated she was unsure if families were notified of the facility no longer offering hair care services but stated the families were verbally encouraged to take residents out for haircuts/care. The Administrator confirmed Resident #36 was on the list for a haircut but Resident #28 was not. She stated she was not able to provide documentation of either residents last haircut and did not have a haircut or beauty shop policy. Review of the undated facility policy titled Hair Care revealed the frequency of hair care depends on the length and texture of the resident's hair, the duration of the admission, and the resident's condition. Review of the undated facility policy titled Shaving revealed shaving was part of the male resident's usual daily care. Shaving not only reduced bacterial growth on the face but also promoted resident comfort by removing facial hair that can itch and irritate the skin and produce an unkempt appearance. Review of the undated facility provided list titled Beautician Worksheet revealed Resident #36 was listed as wanting a haircut. 5. Review of Resident #9's medical record revealed an initial admitted [DATE] with the latest readmission of 11/03/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had clear speech, sometimes understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior section of the MDS revealed Resident #9 displayed no behaviors, including rejection of care. Resident #9 required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of the plan of care dated 08/02/21 revealed Resident #9 had a mobility and self-care impairment related to [CONDITION(S)] disease, generalized weakness and fluctuations in need of assist. Interventions included oral care twice daily and as needed, dental exams as necessary and provide extensive assist with hygiene, bathing, toileting, and dressing, may require increased assist at times. Review of Resident #9's medical record revealed the resident's scheduled showers were on Monday and Thursday on night shift. Review of Resident #9's February 2022 bathing documentation revealed the resident had not received scheduled bathing on 02/21/22 and 02/24/22. Further review revealed Resident #9 received bed baths; however, the resident's power of attorney (POA) requested showers. Review of the resident's March 2022 bathing documentation revealed Resident #9 had not received scheduled bathing on 03/03/22 and 03/07/22. Further review revealed the resident received bed baths; however, the resident's POA requested showers. On 03/07/22 at 11:20 A.M. interview with Resident #9's POA revealed she has spoken with the facility on multiple occasions regarding the lack of mouth care and the resident receiving showers instead of bed baths. On 03/07/22 at 11:24 A.M. observation of Resident #9 revealed a large amount of whitish debris on her teeth. On 03/08/22 at 4:27 P.M. observation of Resident #9 revealed a large amount of whitish debris on her teeth. On 03/09/22 at 9:22 A.M. observation of Resident #9 revealed a large amount of whitish debris on her teeth. On 03/09/22 at 1:51 P.M. interview with Registered Nurse (RN) #301 verified the large build-up of white debris on Resident #9's teeth. Review of the nurse's note dated 03/09/21 at 3:40 P.M. revealed Resident #9's POA requested she would like her mother to have frequent mouth care/teeth brushing. On 03/10/22 at 11:56 A.M. interview with Regional Nurse #888 verified Resident #9 had not received scheduled bathing and showers as preferred. Review of the undated facility policy titled Oral Care revealed oral care is commonly performed in the morning, at bedtime and after meals. Oral care removes soft plaque deposits and calculus from the teeth, cleans and massages the gums, reduces mouth odor, and provides comfort and reduces the risk of infection.

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to place call lights within resident reach. This affected two (Resident's #39 and #28) of two residents reviewed for call lights. The facility census was 59. Findings include: 1. Review of the medical record for Resident #39 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 01/14/22 revealed Resident #39 was at risk for falls related to being in a new environment, [CONDITION(S)], general weakness, debility, non-compliance with asking for help, and a history of falls. Interventions included Call Don't Fall sign on the wall and call light within reach. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/16/22, revealed Resident #39 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). Resident #39 exhibited behaviors such as inattention and disorganized thinking. Resident #39 required limited to extensive assistance of one to two staff or more for all activities of daily living (ADL) except eating which required set-up and supervision. Resident #39 was occasionally incontinent of bladder and was always incontinent of bowels. Further review of the MDS revealed Resident #39 did not have a pressure injury/ulcer, was at risk for pressure ulcers, and did not have any unhealed pressure ulcers. The MDS revealed Resident #39 had a pressure reducing device for the bed but no other skin and ulcer/injury treatments. Observation and interview on 03/07/22 at 10:40 A.M. revealed Resident #39's call light was in her night stand top drawer and she revealed she was unsure where her call light was located. Observation on 03/08/22 at 8:57 A.M. revealed Resident #39 was resting in bed with her call light pinned to the bed above her right shoulder and a sign on wall across from her read use call light for assistance. Interview and observation on 03/08/22 at 3:52 P.M. with Licensed Practical Nurse (LPN) #999 confirmed Resident #39's call light was pinned to the right of her. LPN #999 stated in the mind set the resident was in on 03/08/22, she would not be able to look and locate her call light to use it. 2. Review of the medical record for Resident #28 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 assessment, dated 01/09/22, revealed Resident #28 had intact cognition with a BIMS score of 15 out of 15 (no impairment). The resident did not have any documented behaviors. Resident #28 required extensive assistance of one to two or more staff for all ADL except eating which he required supervision and one-person physical assistance. Review of the plan of care dated 01/12/22 revealed Resident #28 was at risk for falls related to a new environment, use of medication, history of [CONDITION(S)]/collapse, sleep apnea, depression, [CONDITION(S)], [CONDITION(S)], incontinence, weakness, oxygen use, DM II, decreased mobility, and history of falls with injury. Interventions included call light within reach. Interview and observation on 03/08/22 at 3:47 P.M. revealed Resident #28 asked to hand him the television (tv) remote, his call light was pinned to his bed sheet above his right shoulder. Resident #28 stated he was unable to reach his call light to call for assistance. Interview and observation on 03/08/22 at 3:49 P.M. with Human Resources (HR) #90 confirmed Resident #28's call light was pinned to his bed sheet on his right side and above her shoulder. Resident #28 attempted to reach his call light and was unable to. Resident #28 and HR #90 confirmed the resident was unable to reach his call light. Interview on 03/10/22 at 10:33 A.M. with the Administrator revealed the facility did not have a call light policy. She confirmed call lights should be within reach of each resident. This deficiency substantiates Master Complaint Number OH 892.

Based on staff interview and medical record review, the facility failed to complete a correct Preadmission Screening and Record Review (PASARR). This affected one (Resident #39) of one resident reviewed for PASARR completion. The facility census was 59. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Preadmission Screening and Resident Review Result Notice dated 10/14/21 revealed no indications of serious mental illness and/or developmental disability effective 10/14/21. Further review of the notice revealed no referral had been made for a level II evaluation and antianxiety medication was the only medication marked. Review of the plan of care dated 01/14/22 revealed the resident had the potential for drug related complications associated with use of anti-anxiety medication and anti-psychotic medication. Interventions included monitoring for side effects of the medication and providing the medication as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/16/22, revealed Resident #39 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). The resident exhibited behaviors such as inattention and disorganized thinking. The resident required limited to extensive assistance of one to two staff or more staff for all activities of daily living (ADL) except eating which required set-up and supervision. Resident #39 was occasionally incontinent of bladder and was always incontinent of bowels. Further review of the MDS revealed the resident did not have a pressure injury/ulcer, was at risk for pressure ulcers (ulcer), and did not have any unhealed ulcers. The MDS revealed the resident had a pressure reducing device for the bed but no other skin and ulcer/injury treatments. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the orders revealed an order dated 10/21/21 for 200 mg of [MEDICATION(S)] ([CONDITION(S)] therapy agent) to be administered in the morning for [CONDITION(S)] disorder. Interview on 03/08/22 at 3:27 P.M. with the Administrator confirmed there were no mental disorders marked in section E of the PASSAR dated 10/14/21 and section E revealed Resident #39 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She also confirmed Resident #39 had listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she believed the PASARR was completed in the hospital and the facility did not complete a new PASSAR but instead used the hospital PASARR. She revealed she would check to verify that was correct but believed it was. Interview on 03/08/22 at 4:34 P.M. with Regional Registered Nurse (RN) #888 and the Administrator revealed the PASSAR was only redone if there was a significant change, which the resident had not had. Interview on 03/09/22 at 11:15 A.M. with the Regional RN #888 revealed the PASSAR for Resident #39 was not updated because it was legal for the hospital to do it for the facility. She confirmed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She also stated the facility did not have a PASSAR policy. Interview on 03/09/22 at 1:01 P.M. with Regional RN #888 revealed she did not complete PASSARs and could not answer as to whether the PASSAR should have been redone since the hospital's PASSAR did not have any of resident's psychologic diagnosis. Interview on 03/09/22 at 4:45 P.M. with the Administrator revealed there was no PASARR policy. Interview on 03/10/22 9:50 A.M. with Social Services #256 revealed Resident #39's PASARR should have been completed correctly upon her admission. She also stated the PASARR was not redone if the resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, record review, and policy review the facility failed to create baseline care plans upon admission to the facility. This affected three (Resident's #53, #272 and #273) of the five newly admitted residents reviewed who still resided in the facility. The facility census was 59. Findings include: 1. Record review revealed Resident #53 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #53 revealed a baseline care plan was not completed. 2. Record review revealed Resident #272 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #272 revealed a baseline care plan was not completed. 3. Record review revealed Resident #273 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #273 revealed a baseline care plan was not completed. Interview with Registered Nurse (RN) #801 on 03/08/22 at 4:10 P.M. verified Resident's #53, #272 and #273 did not have a baseline care plan started or completed in their medical record. Interview with Regional Nurse #888 on 03/09/22 at 1:10 P.M. revealed residents newly admitted to the facility were to have baseline care plans implemented and completed within 48 hours of the admission. Review of the facility policy titled Baseline Care Plan and Summary, revised 01/2020, revealed upon admission the admitting clinical team will develop an initial plan of care based on information upon admission. The other members will review and add to the baseline care plan within the first 48 hours of admission. This includes and is not limited to dietary, social services, activities, therapy, and other clinical staff. Within 48 hours the resident, family, and/or responsible party will be given a summary review of the baseline care plan and a copy will be given to the resident, family, and/or responsible party.

Based on observation, record review, staff interview and policy review, the facility failed to develop a comprehensive plan of care in the area of hospice and oxygen use for two (Resident's #9 and #26). This affected two of 22 sampled residents. The facility census was 59. Findings include: 1. Review of Resident #9's medical record revealed an initial admitted [DATE] with the latest readmission of 11/03/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had clear speech, sometimes understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior section of the MDS revealed Resident #9 displayed no behaviors, including rejection of care. Resident #9 required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The assessment indicated Resident #9 was always incontinent of both bowel and bladder. Review of Resident #9's monthly physician's orders for March 2022 identified an order dated 03/02/22 to admitted under hospice care effective 03/02/22. Review of the plan of care dated 03/03/22 revealed the resident is on hospice care related to end of life care. Interventions included respect patient and family wishes. On 03/09/22 at 1:51 P.M. interview with Registered Nurse (RN) #301 verified the care plan addressing the resident's hospice service was not comprehensive. 2. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26 had allergies to penicillin. Review of the nurse's progress notes, dated 01/01/22, revealed Resident #26 required oxygen at two liters per minute (LPM). Review of the nurse's progress notes, dated 02/03/22, revealed Resident #26 complaining of chest congestion, oxygen saturations were 95 percent (%) to 98% on oxygen at two LPM via nasal cannula. Resident #26 was assisted onto the left side for resting, explained the importance of lying face down with COVID-19 but Resident #26 stated she can't sleep on her stomach, she did agree to stay on her side for a while. Resident #26 was alert and oriented to person, place, and time, was eating and drinking on her own, stated her throat was sore with a hoarse voice noted. Nursing will continue to monitor, and the call light was within reach. Review of the MDS 3.0 assessment, dated 02/07/22, revealed Resident #26 had no impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Resident #26 was assessed to require two staff assist with mobility, transfers, and toileting. Review of the physician's order for Resident #26, dated 02/07/22, revealed oxygen vial nasal cannula at two LPM as needed for shortness of breath and cough status post [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan revealed no information addressing Resident #26 having any respiratory issues that warranted administering oxygen. Interview on 03/09/22 at 2:10 P.M. with Regional Registered Nurse #888 confirmed there was no care plan in place addressing Resident #26's respiratory issues or use of oxygen. Review of the facility policy titled Care Plan Preparation revealed a nursing care plan should be written for each patient, preferably within 24 hours of admission, and should be updated and revised throughout the patient stay, based on residents' response. The policy further revealed that the care plan serves as a database for planning assignment, giving change of shift report, conferring to the practitioner or other members of the healthcare team, and documenting patient care.

Based on observation, staff interview, resident interview, medical record review, and facility policy review, the facility failed to update Resident #33's care plan. This affected one (Residents #33) of two residents reviewed for care plans. The facility census was 59. Findings include: Review of the medical record for Resident #33 revealed an initial admitted [DATE] and a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/12/22, revealed Resident #33 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). He exhibited behaviors such as inattention and disorganized thinking. Resident #33 required extensive assistance of one staff member for all activities of daily living (ADL) except eating which required set-up and supervision. Review of the plan of care dated 01/19/22 revealed Resident #33 had impaired communication due to impaired cognition, was alert and oriented with periods of confusion and/or forgetfulness due to dementia, hard of hearing (HOH), dysphagia, [CONDITION(S)], and cognition. Interventions included ensure placement and offer encouragement of hearing aids as needed due to his refusal to leave hearing aids in, hearing consultation as needed, and nonverbal cues as needed. Interview and observation on 03/07/22 at 10:35 A.M. with Resident #33 revealed he was HOH, required the Surveyor to speak directly into his ear, and repeat questions several times before he was able to hear and understand the questions being asked. He did not have hearing aids in his ears, denied having owned hearing aids, and was unable to recall the last time he was evaluated by an audiologist. Interview and observation on 03/08/22 at 4:18 P.M. with Resident #33 revealed he was HOH, required the Surveyor to speak directly into his ear, and repeat questions several times before he was able to hear and understand the questions being asked. State tested Nurse Aide (STNA) #508 was present and when she was asked if Resident #33 had hearing aids, she revealed she was not sure. Interview on 03/08/22 at 4:18 P.M. with Licensed Practical Nurse (LPN) #888 and Human Resources/STNA #90 revealed Resident #33 used to wear hearing aids but threatened to throw his hearing aids out the window, so his Power of Attorney (POA)/ Receptionist #92 took them home. Interview on 03/08/22 at 4:28 P.M. with Receptionist #92 revealed she was the wife of the resident's POA. She revealed Resident #33 had hearing aids that made him hear too good, so he threatened to throw them out. She revealed he last wore them about two to three years ago. Interview on 03/08/22 at 4:34 P.M. with Regional Registered Nurse (RN) #888 and the Administrator confirmed Resident #33 had a care plan stating he had minimal difficulty hearing and hearing aids. They did not deny Resident #33 had greater than minimal hearing difficulty. Review of the undated policy titled Care Plan Preparation revealed a care plan directs a residents nursing care from admission to discharge and was based on nursing diagnosis. The care plan was to be updated and revised throughout the residents stay based on the resident response. Further review of the policy revealed the care plan served as a database used for caring for the resident.

Based on observation, record review, interviews, and policy review the facility failed to administer insulin as ordered by the physician. This affected one Resident (#273) of the five residents reviewed for unnecessary medications. Additionally, the facility failed to identify, assess, and monitor one Resident's (#9) multiple bruising to face and bilateral arms. This affected one Resident (#9) of one resident reviewed for anticoagulant medication side effects. The facility census was 59. Findings include: Record review revealed Resident #273 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Review of the active physician order, dated 03/06/22, revealed Resident #273 was to be administered 20 units of insulin [MEDICATION(S)] in the morning for diabetes. There was an absence of a physician's order to hold the medication for low blood sugar results. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 03/09/22 at 11:12 A.M. with RN #801 verified the morning dose of insulin [MEDICATION(S)] was held due to a blood sugar result of 83 and verified there were no physician's orders to hold the insulin if blood sugar levels were below a certain reading. RN #801 verified the morning blood sugar result for Resident #273 on 03/09/22 was 68 and the insulin [MEDICATION(S)] was administered as ordered with no adverse side effects. RN #801 verified the physician was not notified the morning dose of insulin [MEDICATION(S)] was held on 03/07/22. Review of the facility policy titled Medication Administration General Guidelines, dated 01/2021, revealed medications were to be administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition the nurse call the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. 2. Review of Resident #9's medical record revealed an initial admitted [DATE] with the latest readmission of 11/03/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had clear speech, sometimes understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior section of the MDS revealed Resident #9 displayed no behaviors, including rejection of care. Resident #9 required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of the plan of care dated 08/02/21 revealed Resident #9 was at risk for complications, increased bleeding, excessive bruising related to anticoagulant use. Interventions included apply prolonged pressure to venipuncture sites, monitor medication regimen for medications which increase effects of bleeding and bruising and notify physician if noted, observe for signs and symptoms of bleeding, and obtain and monitor lab/diagnostic work as ordered, report results to physician for follow up as indicated. Review of Resident #9's monthly physician's orders for March 2022 identified orders dated 08/26/21 to observe for signs and symptoms of bleeding during each nursing shift. Notify the physician if the resident has dark/discolored urine, black tarry stools, nose bleeds, vomiting and or coughing up blood or other signs/symptoms of bleeding. An order dated 09/22/21 for weekly skin review, and an order dated 12/03/21 for [MEDICATION(S)] (medication used to thin blood) 20 milligrams (mg) by mouth in the evening for clot prevention. Review of Resident #9's medical record revealed no current wound/skin condition documentation for the bruising to the left side of the resident's face and the multiple bruises to the resident's bilateral arms. On 03/07/22 at 10:20 A.M. an observation of Resident #9 revealed a bruise on the left side of her face next to the left ear and multiple bruises to both arms that were dark red to purple in various stages of healing. On 03/09/22 at 1:34 P.M. interview with Registered Nurse (RN) #301 verified the presence of bruising with no documented identification, assessment, and monitoring of the bruising in the medical record. Review of the nurse's note dated 03/09/21 at 3:40 P.M. revealed a bruise to Resident #9's right dorsal forearm measured 6.5 centimeters (cm) by 9.0 cm and a small bruise to the left cheek and the left hand, middle finger. Physician #888 was also informed of the bruising, and monitoring was initiated. Hospice was to be updated as well.

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to arrange audiology care for Resident #33 who was hard of hearing (HOH). This affected one Resident (#33) of two residents reviewed for ancillary services (hearing/vision). The facility census was 59. Findings include: Review of the medical record for Resident #33 revealed an initial admitted [DATE] and a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/12/22, revealed Resident #33 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). He exhibited behaviors such as inattention and disorganized thinking. Resident #33 required extensive assistance of one staff member for all activities of daily living (ADL) except eating which he required set-up and supervision. Review of the plan of care dated 01/19/22 revealed Resident #33 had impaired communication due to impaired cognition, was alert and oriented with periods of confusion and/or forgetfulness due to dementia, HOH, dysphagia, and [CONDITION(S)]. Interventions included ensure placement and offer encouragement of hearing aids as needed due to his refusal to leave hearing aids in, hearing consultation as needed, and nonverbal cues as needed. Review of the plan of care dated 01/19/22 revealed Resident #33 had behaviors/mood which include signs and symptoms of depression, sad facial expression, agitation, stays in his room, sometimes he got agitated and became verbally aggressive, history of sexual activity in inappropriate places related to dementia and depression, refusal of care at times, sexually verbal comments at times, sexual comments and acts toward staff observed, noted increase in behaviors, physical abuse towards staff, agitation, restlessness and wandering. Interventions included medications as ordered, avoidance of situations/people that are upsetting, notify the physician, and offering a diversion. Interview and observation on 03/07/22 at 10:35 A.M. with Resident #33 revealed he was HOH, required the Surveyor to speak directly into his ear, and repeat questions several times before he was able to hear and understand the questions being asked. He did not have hearing aids in his ears, denied having owned hearing aids, and was unable to recall the last time he was evaluated by an audiologist. Interview and observation on 03/08/22 at 4:18 P.M. with Resident #33 revealed he was HOH, required the Surveyor to speak directly into his ear, and repeat questions several times before he was able to hear and understand the questions being asked. State tested Nurse Aide (STNA) #508 was present and did not deny Resident #33 was HOH and needed hearing aids. When she was asked if the resident had hearing aids, she revealed she was not sure. Interview on 03/08/22 at 4:18 P.M. with Licensed Practical Nurse (LPN) #999 and Human Resources/STNA #90 revealed Resident #33 used to wear hearing aids but threatened to throw his hearing aids out the window, so his Power of Attorney (POA) Receptionist #92 took them home. Interview on 03/08/22 at 4:28 P.M. with Receptionist #92 revealed she was the wife of the resident's POA. She revealed Resident #33 had hearing aids that made him hear too good, so he threatened to throw them out. She revealed he last wore them about two to three years ago, was seen by an ear doctor within the last year, had not retried the hearing aids for a long time but the specific length of time was unknown, and there was no difficulty communicating with him as far as she knew. She confirmed Resident #33 had behaviors and was uncertain if the behaviors could be related to lack of communication due to his hearing impairment. She stated she would find the hearing aids and see if Resident #33 would like to wear them. Interview on 03/08/22 at 4:34 P.M. with Regional Registered Nurse (RN) #888 and the Administrator confirmed Resident #33 had a care plan stating he had minimal difficulty hearing and hearing aids. They did not deny Resident #33 had greater than minimal hearing difficulty. Interview on 03/09/22 at 4:45 P.M. with the Administrator revealed Resident #33 had not been seen by an audiologist since 2021. Interview on 03/10/22 at 10:33 A.M. with the Administrator revealed there was no policy for ancillary services (audiology).

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed apply a WanderGuard (a device to prevent wander-prone residents from leaving unattended) to Resident #33 per physician orders. This affected one Resident (#33) of one resident reviewed for WanderGuards. The facility census was 59. Findings include: Review of the medical record for Resident #33 revealed an initial admitted [DATE] and a re-admitted [DATE]. Diagnoses included dementia, history of falling, type two diabetes, [CONDITION(S)], dysphagia, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] (loss of the ability to identify objects using one or more senses), restless and agitation, hypertension, Alzheimer's disease, major depressive disorder, gastro-[CONDITION(S)] reflux disease, and [CONDITION(S)]. Review of the physician orders for March 2022 revealed an order dated 12/09/21 to check placement and function of the secure alert (WanderGuard) every shift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/12/22, revealed Resident #33 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). He exhibited behaviors such as inattention and disorganized thinking. Resident #33 required extensive assistance of one staff member for all activities of daily living (ADL) except eating which he required set-up and supervision. Review of the plan of care dated 01/19/22 revealed Resident #33 was at risk for elopement related to attempts to leave the living center and wandering. Interventions included secure care (WanderGuard) placement and check placement and functioning per orders. Interview and observation on 03/07/22 at 10:35 A.M. revealed Resident #33 resting in bed with no WanderGuard in place on his person, wheelchair, or walker. He confirmed he did not know of a WanderGuard being placed on him or his assistive devices. Interview and observation on 03/08/22 at 4:18 PM there was no WanderGuard in place on Resident #33's persons, wheelchair, or walker. He confirmed he did not know of a wander guard being placed on him or his assistive devices. Observation on 03/09/22 at 9:28 A.M. revealed Resident #33 resting in bed without a WanderGuard. Interview on 03/09/22 at 9:51 A.M. with Licensed Practical Nurse (LPN) #315 and Assistant Director of Nursing (ADON) #301 confirmed there was no WanderGuard in place on Resident #33's body, wheelchair, or walker, and he had an order for it. They stated it was there but could not locate it during the observation. Review of the facility policy titled Elopement Risk, revised 12/19, revealed if a resident was an elopement risk, the care plan will reflect the interventions (WanderGuard).

Based on staff interview, observations, medical record review, and facility policy review, the facility failed to administer oxygen per physician orders for Resident #26 and failed to store the [CONDITION(S)] (bilevel positive airway pressure) mask properly for Resident #9. This affected two residents (Resident's #9 and #26) of four residents reviewed for respiratory care. The facility census was 59. Finding include: 1. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26 was allergic to penicillin. Review of the nurse's progress note, dated 01/01/22, revealed Resident #26 required two liters of oxygen per minute. Review of the nurse's progress note, dated 02/03/22, revealed Resident #26 complaining of chest congestion, oxygen saturations were 95 percent (%) to 98% on two liters of oxygen per minute via nasal cannula. Resident #26 was assisted onto her left side for resting. Nursing explained the importance of lying face down with COVID-19, Resident #26 stated she can't sleep on her stomach. Resident #26 agreed to stay on her side for a while. Resident #26's blood sugars ranged from 66 to 98 this shift. Resident #26 was alert and oriented to person, place, and time, and was eating and drinking on her own. Resident #26 stated her throat was sore with a hoarse voice noted. Nursing would continue to monitor, and the call light was within reach. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/07/22, revealed Resident #26 had no impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Resident #26 was required two-staff assistance with mobility, transfers, and toileting. Review of the physician's order for Resident #26, dated 02/07/22, revealed oxygen vial nasal cannula at two liters per minute as needed for shortness of breath and cough status post [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan for Resident #26 revealed no documented information related to the resident having respiratory issues that warranted administering oxygen. Observation on 03/07/22 at 10:41 A.M. revealed Resident #26 lying in bed with oxygen on via nasal cannula set at four liters per minute. Observation on 03/08/22 at 9:48 A.M. revealed Resident #26 lying in bed with oxygen on via nasal cannula set at four liters per minute. Observation with License Practical Nurse (LPN) #313 on 03/08/22 at 10:27 A.M. Resident #26 was on four liters of oxygen via nasal cannula. LPN #313 revealed she had been off work for a couple of days, and the report she received from the outgoing nurse was Resident #26 was not feeling well and was required to be on oxygen via nasal cannula between two and four liters per minutes. During the interview LPN #313 verified reviewing the physician's order that Resident #26 should be on two liters of oxygen per minute, not four liters. Review of the facility policy titled Oxygen Administration revealed verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed. 2. Review of Resident #9's medical record revealed an initial admitted [DATE] with the latest readmission of 11/03/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had clear speech, sometimes understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior section of the MDS revealed Resident #9 displayed no behaviors, including rejection of care. Resident #9 required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The assessment indicated Resident #9 was always incontinent of both bowel and bladder. Review of the plan of care dated 08/11/21 revealed Resident #9 had an alteration in respiratory status due to [CONDITION(S)], non-compliant with [CONDITION(S)] and oxygen use. Interventions included administer medications as ordered, observe labs, response to medication and treatments, apply [CONDITION(S)]/oxygen per physician order, monitor oxygen saturations on room air and/or oxygen as ordered and as needed, monitor oxygen flow rate and response, explain risks and benefits of non-compliance and encourage compliance, elevate head of bed to alleviate shortness of breath, labs per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's monthly physician's orders for March 2022 identified orders dated 09/08/21 family may bring in mask for [CONDITION(S)] if one at home, otherwise consult [CONDITION(S)] vendor for proper fitting mask, 12/25/21 oxygen per nasal cannula per [CONDITION(S)] at two to three liters continuously, resident to wear [CONDITION(S)] with all activities/sleep with exception of eating, bathing, and therapy, check every two hours for proper placement with settings at 16/10, backup rate 12 with fiO2 30% on at two to three liters per minute. On 03/07/22 at 10:22 A.M. observation of Resident #9's [CONDITION(S)] machine revealed the mask was uncovered and wedged between the nightstand and the wall. On 03/08/22 at 4:27 P.M. observation of Resident #9's [CONDITION(S)] machine revealed the mask was uncovered and wedged between the nightstand and the wall. On 03/09/22 at 9:22 A.M. observation of Resident #9's [CONDITION(S)] machine revealed the mask was uncovered and wedged between the nightstand and the wall. On 03/09/22 at 1:34 P.M. interview with Registered Nurse (RN) #301 verified the improper storage of the [CONDITION(S)] mask.

Based on observations, medical record review, and staff interview, the facility failed to ensure three residents, (Residents #2, #37, and #52), with pressure ulcers received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. This affected three of three residents reviewed for pressure ulcers This resulted in actual harm to Resident #2, whose pressure ulcer required debridement (removal of dead tissue) and declined from a stage two pressure ulcer (partial-thickness skin loss with exposed dermis; partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) to a stage four pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed). The facility census was 74. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Review of a pressure injury record revealed the resident developed a Stage 2 pressure ulcer on the left hip on 10/03/20 measuring 2.0 centimeters (cm) long by 2.0 cm wide by 0.1 cm deep. A treatment was started to the area on 10/03/20 of cleansing the left hip with normal saline, apply triple antibiotic and cover with dressing every night shift. Review of the treatment administration record revealed no evidence the treatment was completed on 10/06/20, 10/14/20, or 10/17/20. The treatment was discontinued on 10/18/20, even though the pressure area continued. A new treatment to the left hip pressure ulcer was not obtained. There were no notes to indicate why the dressing was discontinued on 10/18/20. A weekly pressure injury assessment on 10/20/20 indicated the area was a Stage 2 pressure ulcer measuring 2.0 cm long by 2.0 cm wide by 0.01 cm deep. On 11/13/20 the left hip was documented as a Stage 2 pressure ulcer measuring 2.0 cm long by 2.0 cm wide by 0.2 cm deep. On 11/24/20 the left hip was documented as a Stage 2 pressure ulcer measuring 0.3 cm long by 0.3 cm wide by 0.1 cm deep. Review of the November treatment administration record revealed a treatment was started again on 11/25/20 to the left hip to cleanse the area, pat dry, apply silver [MEDICATION NAME] cream and cover with a dressing. The resident did not receive a treatment to the left hip from 10/18/20 to 11/25/20, even though the resident had a documented Stage 2 pressure ulcer. Resident #2 was seen by the wound care physician on 12/01/20. The physician documented that the area on the left hip measured 1.0 cm long by 1.0 cm wide by 0.4 cm deep. The area was debrided of necrotic tissue and was staged at a Stage 4 pressure ulcer. On 12/08/20 the wound physician documented the left hip area measured 0.8 cm long by 0.9 cm wide by 0.3 cm deep. Review of the treatment administration record for December 2020 revealed the treatment to the left hip was not documented as completed on day shift on 12/01/20 or 12/05/20. Interview with Licensed Practical Nurse (LPN) #101 on 12/08/20 at 6:15 A.M. revealed there are times when there are only one or two nurses working on the night shift to cover four units with 74 residents. She stated there are times when she is unable to get treatments done. She specifically stated there were times when she was unable to do the treatment for [REDACTED]. Interview with LPN #106 on 12/07/20 at 4:05 P.M. revealed she was an agency nurse and was the nurse for Units 3 East and 3 North for the evening shift (with 23 residents on 3 East and 14 residents on 3 North). She stated she was not aware of any residents having pressure ulcers on units 3 East or 3 North. (The facility identified four residents with pressure ulcers on 3 East and one resident with pressure ulcers on 3 North). Resident #2 resided on 3 East. Interview with the Director of Nursing on 12/09/20 at 2:30 P.M. confirmed there was no documentation as to why Resident #2's treatment to the left hip was discontinued on 10/18/20 and another treatment not ordered until 11/25/20. She stated the resident should have had a treatment to the area. 2. Review of the medical record for Resident #52 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a pressure injury record revealed an assessment on 12/01/20 which indicated the resident had a Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) to the right hip measuring 0.8 cm long by 0.5 cm wide by 0.3 cm deep. A physician's orders [REDACTED]. Observations on 12/08/20 at 10:30 A.M. revealed LPN #107 completing the treatment to the right hip. First the old dressing was removed. The dressing was dated 12/06/20. LPN #107 stated the dressing was to be changed daily and confirmed the dressing was dated 12/06/20. The area on the right hip measured 0.6 cm by 0.7 cm by 0.2 cm deep and appeared superficially open with white tissue covering the area. Review of the treatment administration record revealed the dressing to the right hip was documented as completed on 12/07/20, even though the dressing was dated 12/06/20. 3. Review of the medical record for Resident #37 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review revealed the resident was admitted to the facility with a Stage 3 pressure ulcer on the right thigh. Review of pressure injury weekly assessments revealed the resident currently had two pressure ulcers, one on the right thigh and one on the left thigh. The resident had physician's orders [REDACTED]. Review of the October 2020 orders revealed the treatment in October to the bilateral thighs had been ordered to be done twice daily, once on day shift and once on night shift. Review of the treatment administration records for October 2020 revealed the treatments to the bilateral thighs were not documented as completed on 21 of 53 opportunities. Review of the treatment administration record for November 2020 revealed the treatments to the bilateral thighs were not documented as completed on 8 of 27 opportunities. Review of weekly pressure ulcer assessments did not reveal a decline in the areas. On 12/08/20 the right thigh measured 31 cm long by 16 cm wide and 0.3 cm deep. On 12/08/20 the left thigh measured 1.8 cm long by 0.5 cm wide by 0.2 cm deep. Interview with LPN #101 on 12/08/20 at 6:15 A.M. revealed there are times when there is only one or two nurses working on the night shift to cover four units with 74 residents. She stated there are times when she is unable to get treatments done. She specifically stated there were times when she was unable to do the treatment for [REDACTED]. Interview with LPN #106 on 12/07/20 at 4:05 P.M. revealed she was an agency nurse and was the nurse for Units 3 East and 3 North for the evening shift. (23 residents on 3 East and 14 residents on 3 North). She stated she was not aware of any residents having pressure ulcers on units 3 East or 3 north. (The facility identified four residents with pressure ulcers on 3 East and one resident with pressure ulcers on 3 North). Resident #37 resided on 3 North. Interview with the Director of Nursing on 12/09/20 at 2:30 P.M. confirmed the lack of documentation to indicate the treatment to Resident #37's pressure ulcers was completed as ordered. This deficiency substantiates Complaint Number OH 763.

Based on medical record review, observation, staff interview, resident interview, policy review and review of the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to prevent the development of pressure sores, and failed to provide the treatment and services to promote healing and prevent new sores from developing. Actual Harm occurred when Resident #54 developed in-house deep tissue injuries (described by the NPUAP as persistent non-blanchable deep red, maroon or purple discoloration. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss) to bilateral posterior legs on 01/03/19 caused by pressure from leg braces and lack of physician notification and intervention from staff when redness was first observed on 12/28/18. This affected two of seven sampled residents reviewed for pressure sores (Resident #46 and #54). Findings include: 1. Review of Resident #54's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #54's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/06/18, revealed Resident #54's speech was clear, she understood others, usually understands, and her Brief Interview for Mental Status (BIMS) was 15, indicating intact cognition. Resident #54 did not reject care, required extensive assistance of one staff for bed mobility, she was dependent on two staff to transfer, and she did not walk. Resident #54 was at risk for pressure sores but, did not have any pressure sores. Review of Resident #54's monthly physician order's revealed the resident was supposed to be turned side to side every two hours and her heels were to be floated off the bed. Review of Resident #54's plan of care revealed she was at risk for altered skin integrity related to decreased mobility, frequently non-compliant with turning and repositioning. The listed interventions included weekly skin inspections, pressure reduction mattress, turn and reposition every two hours and as needed, and explain the risks and benefits of non-compliance and encourage compliance. Review of Resident #54's progress notes revealed on 12/21/18 she slid out of her recliner chair and broke both her legs and left knee. On 12/26/18 the resident was seen by an orthopedist who ordered bilateral leg braces that could be removed for a sponge bath, but the knees were not to be bent. On 12/27/18 Resident #54's braces were removed the resident's skin was warm, dry, and intact. Four by four gauze was applied to areas the brace could cause skin issues. On 12/28/18 the note stated redness was noted under the left brace, and an abdominal pad (thick gauze pad) was placed under the brace for padding. There was no notification of the physician or the family of the new red area. On 01/01/19 the progress note stated the back of the left leg had redness. Review of the weekly skin integrity check stated the skin was clear. The initial pressure injury report dated 01/04/19 revealed on 01/03/19 a deep tissue injury was observed on the back of Resident #54's left leg that measured 1.8 centimeters (cm) by 1.7 cm. There was no other description of the wound. Also, a report of the same date revealed on 01/03/19 a deep tissue injury was observed on the back of Resident #54's right leg that measured 1.6 cm by 1.9 cm. The treatment was for the nurses to ensure the brace was in the correct position and the distal end was padded for each leg. On 01/11/19 the right leg wound measured 1.5 cm by 2.0 cm and the left measured 1.7 cm by 1.7 cm there was no other description of the appearance of the wounds. Review of Progress notes from 11/01/18 to 01/15/19 revealed no evidence the resident was non-compliant with turning. Further review of Resident #54's plan of care revealed on 01/04/19 the focus of the pressure ulcers to the back of both legs were due to lower leg splints was added. The interventions included monitor the skin under the braces for breakdown. Pad splints as needed to relieve pressure and ensure proper application of the splints. Review of Resident #54's telephone orders revealed on 01/09/18 a new order was obtained to keep her bilateral legs wrapped for protection making sure wraps go beyond the braces as needed for skin protection. Observation of Resident #54 on 01/13/19 at 3:00 P.M. revealed she was in bed laying on her back. On 01/14/19 at 10:30 A.M. Resident #54 was in bed on her back, at 3:32 P.M. she was on her back. On 01/15/19 at 9:45 A.M. the resident was in bed on her back. Observation with Licensed Practical Nurse (LPN) #542 of Resident #54's deep tissue injuries was made on 01/15/19 between 9:45 A.M. and 10:00 A.M. The left leg wound measured 1.7 cm by 1.0 cm. The wound surface was red, with a rough pitted surface that looked scabbed. The right leg wound measured 1.3 cm by 1.5 cm. The wound surface was red, with a rough pitted surface that looked scabbed. LPN #542 stated the right leg wound looked worse. LPN #542 confirmed the wounds appeared scabbed over. Interview with State tested Nursing Assistant (STNA) #573 on 01/15/19 at 11:15 A.M. revealed Resident #54 turned side to side, used a pillow for positioning, and did not refuse to turn. Interview with LPN #542 on 01/15/19 at 11:25 A.M. revealed Resident #54 had areas on the back of the legs from braces. He stated the intervention was to pad the areas and change the leg wraps as needed. LPN #542 stated Resident #54 was turned every two hours, side to side and rarely complained about it. Interview with this LPN confirmed the resident was on her back this morning. Interview with Resident #54 on 01/15/19 at 11:30 A.M. revealed she turned side to side but it hurt her hips. The Director of Nursing on 01/16/19 at 1:51 P.M. provided no documentation the Resident #54 was non-compliant with turning. 2. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment, completed on 12/31/18, indicated mild cognitive impairment, extensive assistance required with bed mobility, and Resident #46 was at risk for pressure ulcer development. Physician orders included weekly skin review during night shift every Monday. Resident #46 Plan of Care (P[NAME]) identified pressure ulcer risk due to impaired mobility, secondary to left [MEDICAL CONDITION] and incontinence. The identified goal was for Resident #46's skin to remain intact with interventions including: complete Braden scale per policy, weekly skin inspection, treatments as ordered, turn and repositioning schedule per assessment, and weekly wound assessment. The P[NAME] also identified self care impairment with interventions to include float heels off bed with pillows, inspect skin when care provided and report reddened areas, rashes, bruising or open areas to the charge nurse. The weekly skin assessment dated [DATE] indicated Resident #46's skin was clear and no change of condition was assessed. A non-decubitus skin injury report dated 01/02/19 indicated an area to the back of the left heel measuring 2 centimeters (cm) by 2 cm, brown in color with one small pinpoint open area noted with small amount of clear drainage. The report indicated an alteration in skin integrity, non pressure due to resident reported socks were too small. The skin integrity check dated 01/07/19 did not indicate the status of Resident #46 skin check. Review of the facility point of care report on 01/01/19 and 01/02/19 indicated care was provided per P[NAME] every shift. No indication was noted of any concerns regarding skin condition. Nursing progress note dated 01/02/19 indicated when mother was visiting earlier, reported Resident #46 was complaining about his heel and requested Registered Nurse (RN) # 520 to look a the area. The progress note indicated Resident #46's mother was informed a treatment would be initiated, and Resident #46 stated socks were too small. On 01/15/19 at 6:34 A.M. during observation of dressing change to Resident #46's left ankle/foot an open area was observed with distinct areas. No necrotic tissue or slough was present. A small amount of serous sanguineous drainage was noted on the old dressing. No scratch marks or injuries to the surrounding skin was noted. 01/14/19 at 8:36 A.M. Resident #46 stated the dressing to his foot was due to an area on foot due to socks putting pressure on the back of his heel, and now the nurses have to do dressing changes to get the area to heal. On 01/15/19 at 6:34 A.M. RN # 527 reported the area on Resident #46's heel appeared to be healing. RN# 527 stated was informed the area was due to pressure from Resident #46's socks. On 01/15/19 at 3:42 P.M. during an interview with RN #520 and Licensed Practical Nurse (LPN) # 544, RN # 520 reported did not consider area to be pressure, identified area as an abrasion, however unsure of how the abrasion occurred. RN # 520 stated was unsure why 01/01/19 indicated no concerns and area was identified on 01/02/19. RN # 520 and LPN # 544 confirmed the skin assessment completed on 01/07/19 was incomplete. During an interview with the DON on 01/16/19 at 9:28 A.M. she stated the area had been identified as an abrasion and not a pressure area. When asked what caused the abrasion, reported resident had stated due to socks too tight. The DON confirmed the tight socks did meet the definition of pressure. Review of the facility policy 'Wound Prevention Program,' no date, defined at Stage II pressure ulcer as partial thickness skin loss involving epidermis and/or dermis. The area is superficial and presents clinically as an abrasion, blister, scab, or shallow crater; wound base moist and pink, painful, and free of necrotic tissue. Review of the facility 'Wound Prevention Program,' no date, indicated skin was to be assessed every shift and as needed and any identified areas of concern should be reported to the nurse.

Based on observation, record review and interview the facility failed to adequately and timely assess and obtain treatment for [REDACTED]. Actual harm occurred when following the incident the resident complained of increased/severe pain which impacted her ability to attend activities and receive showers. An x-ray obtained on 07/17/18, seven days after the incident revealed a fractured femur and doppler studies completed on 07/17/18 revealed the presence of a [MEDICAL CONDITION] (blood clot). The resident was subsequently transferred to the hospital for treatment and returned to the facility with a brace to her lower leg. This affected one resident (Resident #6) of four residents reviewed for accidents. Findings include: Review of Resident #6's medical record revealed the resident was admitted to the facility 04/25/11 with [DIAGNOSES REDACTED]. Review of the July, (YEAR) Medication Administration Record [REDACTED]. The order was initiated on 05/06/18. Record review revealed a nursing progress note, dated 07/11/18 at 6:07 P.M. in which the nurse documented she had received in report (from another nurse) that the resident had bumped leg when being transferred to wheelchair yesterday, currently complains of left foot and thigh pain. The nurse documented Resident #6's skin was warm and dry with no open areas or discoloration noted. Pedal pulse was palpable and capillary refill was less than three seconds. The nurse documented the resident had refused a range of motion assessment due to increased pain and refused 5:00 P.M. ([MEDICATION NAME]) pain medication due to emesis. There was no evidence the physician was notified of the resident's complaint of pain to the left foot and thigh or refusal of a range of motion assessment due to pain. Record review revealed there was no nursing progress note or information contained in the resident's medical record dated 07/10/18 related to any type of incident or injury sustained by the resident. In addition, there was no evidence the resident's physician was notified of an incident/injury on 07/10/18. There were no nursing progress notes documented between 07/11/18 and 07/14/18. Review of the nursing progress note, dated 7/14/18 revealed the nurse documented the resident was noted to be complaining of pain more frequently and complains during all personal care and transfers. Record review revealed no evidence a nursing assessment was completed at that time. The progress note revealed note in to physician to see about increasing regularly scheduled pain medication to a stronger dose or a stronger medicine. Record review revealed no evidence the physician responded to this note on 07/14/18. The next nursing progress note, dated 07/16/18 revealed the nurse documented the resident was complaining of severe left leg/foot pain status [REDACTED]. Record review revealed no nursing assessment was completed at that time. The note indicated after speaking to the resident's sister, the physician would be contacted. The note indicated the resident's sister insisted an x-ray be completed to rule out a fracture. Record review revealed a physician order, dated 07/16/18 for an x-ray of left femur, tibia/fibula and foot. On 07/17/18 a physician order [REDACTED]. Review of the nursing progress note, dated 07/17/18 (ten days after the incident/injury occurred) revealed the nurse documented an x-ray was not completed yesterday. The note also revealed a new order was received for the narcotic [MEDICATION NAME] 7.5/325 milligrams (mg) to be given routinely by mouth four times a day for two months. The nurse documented a call was placed to re-request the x-ray of the entire left leg as the resident's left leg was now swollen and tender to the touch. The resident's sister was updated and informed that she would be notified once the x-ray was completed. Record review revealed an order, dated 07/17/18 for [MEDICATION NAME] 7.5/325 mg by mouth four times a day for two months. Record review revealed the resident received the [MEDICATION NAME] medication on 07/17/18 as ordered. Record review revealed results of the venous doppler study revealed the resident had an acute [MEDICAL CONDITION] (blood clot) to the left leg. The physician was notified and an order was obtained to send the resident to the hospital related to the [MEDICAL CONDITION]. Record review revealed although the x-ray had been taken, no x-ray results were received at the time the order was received to send the resident to the hospital. Review of a nursing progress note, dated 07/17/18 at 2:30 P.M. revealed the resident was transported to the hospital. The resident was admitted to the hospital and was receiving a [MEDICATION NAME] infusion (for treatment of [REDACTED]. The note also indicated the nurse was notified of x-ray results showing a [MEDICAL CONDITION] distal femur. Review of mobile imaging lower extremity venous doppler report dated 07/17/18 revealed findings of acute [MEDICAL CONDITION] involving left common femoral and popliteal veins. Review of mobile imaging x-ray report dated 07/17/18 revealed findings of a left femur fracture. Record review revealed Resident #6 was re-admitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. The order indicated the immobilizer could be removed for showering. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 dated 07/28/18 revealed a Brief Interview for Mental Status (BIMS) Score of 11 indicating moderate cognitive impairment. The MDS indicated the resident was dependent on two staff members for bed mobility, transfers, and toileting. The resident had no behaviors or rejection of care. Interview on 08/03/18 at 2:32 P. M. with Assistant Director of Nursing (ADON) #45 revealed an incident involving Resident #6 occurred on 07/10/18 when the resident's foot dropped off the foot rest of the wheelchair she was seated in as she was being pushed up to the table in the dining area by a therapy staff member. The ADON verified the incident of injury occurred on 07/10/17 and there was no physician notification of the incident until 07/14/18. However, the physician did not respond at that time. There was no order obtained for an x-ray or venous doppler testing until 07/16/18 after care was requested by the resident's family. The ADON verified the lack of evidence nursing staff monitored/assessed the resident's left leg following the documented complaints of increased pain to the leg/foot following the incident. The ADON also verified an order was obtained for routine [MEDICATION NAME] on 07/17/18 (ten days after the incident) due to the resident's increased and ongoing complaint of pain. During interview with Licensed Practical Nurse (LPN) #57 on 08/02/18 at 11:08 A.M. she stated Resident #6 used to participate in activities until she fractured her ankle. The LPN indicated following the incident she participated less in activities but did not indicate why the decline in participation occurred. LPN #57 also indicated since the fracture had occurred the resident was no longer receiving showers but rather staff was providing bed baths. The LPN indicated the resident was unable to get out of bed, could not shower and staff were providing bed baths instead of showers. Interview on 08/03/18 at 9:15 A.M. with Activity Assistant #44 revealed Resident #6 usually participated in bingo, bible study and music activities but had not been able to attend due to the fractured leg she sustained. Interview on 08/03/18 at 3:46 P.M. with Resident #6 revealed she recalled the incident on 07/10/18 when her leg fell off the wheelchair she was sitting in causing her to have pain in her leg/foot. The resident stated this wheelchair was not her regular wheelchair, that she normally used a motorized adaptive wheelchair but on this date she was placed in a standard wheelchair by staff so that she could get her hair done. During the interview the resident reported at the time of the incident she immediately felt pain which was reported to staff. The resident reported she was ultimately transferred to the hospital and treated for [REDACTED]. At the time of the interview, the resident was observed in bed wearing a brace to her left lower leg.

Based on observation, record review and staff interview the facility failed to timely identify and implement effective interventions to prevent the development of an unstageable pressure ulcer to Resident #9's coccyx. In addition the facility failed to ensure pressure ulcer assessments were completed to include Staging of the ulcer and timely changes to treatments or implementation of new interventions to promote healing of the pressure ulcer. Actual harm occurred when Resident #9, who was dependent on two staff members for activities of daily living including bed mobility and turning and repositioning, developed an unstageable pressure ulcer (area covered with eschar- dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound) without evidence of effective interventions to prevent the development of the ulcer. This affected one resident (Resident #9) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #9's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment. The MDS assessment indicated the resident was dependent on two staff members for bed mobility and toileting and was always incontinent of bowel and bladder. The MDS assessment indicated the resident was assessed as being at risk for skin breakdown and had no unhealed pressure ulcers at that time. Review of the resident's plan of care, dated 07/06/16 revealed the resident was at risk for skin breakdown related to impaired skin turgor and incontinence of bowel and bladder. Interventions included to avoid shearing during transfers and movement, pressure relieving mattress to the bed, keep heels off the mattress, use incontinence products and barrier cream after each episode of incontinence. Review of the resident's physician's orders [REDACTED]. There was no evidence the resident had any skin breakdown or pressure ulcer to the area at this time. The treatment was implemented as a preventative measure. Review of an initial weekly wound assessment, dated 04/08/18 revealed an unstageable pressure ulcer was found to Resident #9's coccyx measuring 1.5 centimeters (cm) in length by 0.8 cm width and covered with eschar. On 04/08/18 a new order for treatment was written that included to cleanse the coccyx with NS, pat dry, apply barrier cream to the affected area and cover with [MEDICATION NAME] every three days and as needed when soiled until resolved. A new intervention to turn side to side only when in bed was also initiated following the development of the unstageable pressure ulcer. Review of the weekly wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's coccyx measured 1.2 cm by 0.5 cm by 0.2 cm with necrotic tissue continuing. The area was described to have eschar with some has come off, area showed scant amount of drainage under it with no depth to it, maybe approximately 0.2 cm deep surrounding tissue pink. Treatment and interventions remained unchanged at that time Review of Resident #9's weekly wound assessment dated [DATE] revealed the pressure ulcer to the coccyx had healed at this time. Review of the resident's quarterly MDS 3.0 assessment dated [DATE] revealed the resident continued to exhibit moderate cognitive impairment, was dependent on two staff members for activities of daily living (ADL's) and was always incontinent of both bowel and bladder. The MDS indicated the resident was at risk for skin breakdown. Review of Resident #9's weekly wound assessment dated [DATE] revealed the pressure ulcer to the resident's coccyx had reopened. The ulcer was assessed to measure two cm in length by one cm width with 0.3 cm depth. There was no staging of the ulcer documented at that time. The facility continued the treatment to cleanse the coccyx with NS, apply [MEDICATION NAME] and change every three days Review of the resident's progress notes revealed an entry dated 05/11/18 documenting the pressure ulcer measured 1.0 cm by 0.5 cm (which was larger than the measurements obtained on 05/08/18). Again there was no staging of the ulcer. There was also no description of the ulcer at this time. And there was no change to the treatment of [REDACTED]. Review of the weekly pressure ulcer record, dated 06/01/18 revealed Resident #9 was assessed to have a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ ruptured blister) pressure ulcer to the coccyx. The ulcer was assessed to measure 1.2 cm in length by 1.0 cm width with 0.5 cm depth (an increase in size from the measurements on 05/08/18 and 05/11/18). There were no changes in treatment at that time. Review of the weekly pressure ulcer record, dated 06/08/18 assessed Resident #9 to continue to have a Stage II pressure ulcer. Measurements at this time revealed the ulcer was larger (had declined) measuring 2.0 cm in length by 0.5 cm width. There were no changes to the plan for treatment at that time and no new interventions to promote wound healing. On 06/13/18 a physician's orders [REDACTED]. Review of the weekly pressure ulcer record revealed on 06/15/18 the resident was seen by the contracted wound care service. The coccyx pressure ulcer was assessed to be a Stage II measuring 2.0 cm in length by 3.0 cm width with less than 0.1 cm depth. New interventions implemented at that time included a gel cushion to the resident's wheelchair and an air mattress to the resident's bed. A recommendation was also made to consult with the Registered Dietician (RD). Review of the weekly pressure ulcer assessment, dated 06/22/18 revealed Resident #9's pressure ulcer had deteriorated and was now assessed to be a Stage III (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. (MONTH) include undermining or tunneling) measuring 3.0 cm in length by 2.0 cm width with 0.1 cm depth. A new treatment order was obtained at that time to cleanse the ulcer with NS, apply [MEDICATION NAME] and cover with dry clean dressing daily. On 06/28/18 (13 days after the recommendation was made), the resident was assessed by the RD, who ordered [MEDICATION NAME] (a protein supplement) two packets per day to promote wound healing. Review of the resident's plan of care revealed the plan was updated on 07/26/18 to reflect the resident had an actual pressure ulcer. The care plan indicated the ulcer was due to the resident requiring assistance with bed mobility and bowel and bladder incontinence. Interventions noted on this care plan included medications per order, low air loss mattress, house wound physician, treatment as ordered, weekly wound assessment and turning/repositioning schedule per assessment. On 08/03/18 at 8:08 A.M. observation of Resident #9 revealed he had a foam dressing in place to the coccyx. The dressing was dry and intact and dated 08/03/18. On 08/03/18 at 1:11 P.M. interview with Assistant Director of Nursing (ADON) #45 verified Resident #9, who was dependent on staff for ADL care including turning and repositioning and who was incontinent of bowel and bladder was assessed to develop a pressure ulcer while residing in the facility that was first found as an unstageable pressure ulcer. The ADON was unable to explain how or why the ulcer was found as an unstageable ulcer when the resident had a preventative treatment to the area ordered prior to the development. The ADON also verified assessments of the pressure ulcer completed in 05/2018 did not include staging and no changes to treatment orders or new interventions were implemented when the pressure ulcer was assessed to decline and increase in size until the resident was seen by a wound consultant group.

Based on observation, review of the portable electric heater manuals, review of the facility census and condition report, resident, staff, family, Medical Director (MD), owner and Supervisor of Service (SOS) of the heating and cooling company interviews, and literature from the National Institutes of Health, the facility failed to ensure the resident environment was free from accident hazards related to portable electric heaters being used unsafely and without monitoring in all resident living units. This resulted in Immediate Jeopardy for all 87 residents residing in the facility when the facility utilized 21 portable electric heaters in all resident living units with no monitoring, resulting in the likelihood of serious injury, harm, impairment or death due to the risk of fire and burns. This affected 87 of 87 residents residing in the facility. On 11/14/16 at 3:14 P.M., the Administrator was notified that Immediate Jeopardy began on 10/26/16 when portable electric heaters were put in use in resident living units including the dementia unit without implementation of monitoring for fire hazards and burns. The facility was aware since July, 2016 the heating system was not functional in the building and did not take immediate corrective action with the impending cold weather. Immediate Jeopardy was removed on 11/15/16 when the facility implemented the following corrective actions: · On 11/14/16 at 7:00 P.M. the Director of Nursing (DON) began staff education of 11 registered nurses (RNs), 24 licensed practical nurses (LPNs), 34 state tested nursing assistants (STNAs), and 15 other staff (discipline not identified) to review safety procedures for portable heaters and cold weather protocols including the following: portable electric heaters are not to be used and if portable electric heaters are in use, they are to be monitored. On 11/16/16 at 7:20 P.M. the DON completed all staff education. · On 11/14/16 at approximately 5:57 P.M. the City Fire Captain #1 arrived onsite followed by the Assistant Chief and Chief #2 and proceeded to inspect the facility. The Fire Chief observed the emergency portable heaters in use within the building. The Fire Chief authorized the temporary use of the heaters until the final boiler installation was complete. The Fire Chief determined the facility ' s fire watch procedures that included monitoring of the portable electric heaters they implemented on 11/14/16 at 7:37 P.M. were sufficient. · On 11/14/16 at 9:00 P.M. three new boilers were operational and central heat was restored to the building per interview with the Administrator and verified through measurement of air temperatures. · On 11/14/16 between 9:06 P.M. and 9:35 P.M. observations revealed no designated staff person monitoring the portable electric heaters in use on the following units: TCU, 2 East, 2 North, and 3 North as indicated in the facility ' s plan to remove the Immediate Jeopardy. · On 11/14/16 at 10:15 P.M. the facility discontinued the use of the portable electric space heaters in the facility per decision of the Administrator. · On 11/15/16 at 9:00 A.M. the three newly installed boilers were inspected and certified by the Department of Commerce. · On 11/17/16 the facility implemented daily boiler checks by the Maintenance Director or his designee that will continue indefinitely and be documented on the daily maintenance log. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more that minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan, were continuing staff education, and were monitoring to ensure continued compliance. Findings include: Review of the facility census and condition report revealed there were 42 residents with dementia related [DIAGNOSES REDACTED]. During a tour of the facility on 11/14/16 at 9:05 A.M. a portable electric heater was observed in the hallway of the Transitional Care Unit (TCU). The heater was set at 75 degrees and was in use. During a tour of four remaining resident living units (3 East, 3 North, 2 East, and 2 North) on 11/14/16 at 9:05 A.M. revealed multiple portable electric heaters being utilized in the hallways and lounges on each of the four resident living units. Observations at this time revealed no monitoring of the portable electric space heaters by facility staff members. The height of the portable electric heaters ranged from 10 inches to 17 inches in height with the infra-red elements reaching mid-shin to the knee of residents ambulating or in wheelchairs. Interview with State tested Nursing Assistant (STNA) #112 on 11/14/16 at 9:15 A.M. revealed the portable electric heaters were being utilized as the facility ' s source of heat. The STNA stated the facility did not have an operational heating system and the facility had been utilizing the portable electric space heaters for the past two weeks. On 11/14/16 at 10:30 A.M. observation of Resident #132 revealed the resident was bent over the portable electric space heater located outside of the resident ' s doorway, Room 324 trying to turn the temperature up on the heater. STNA #112 instructed the resident not to bother the unit. The resident requested the STNA to turn the heat up because the resident was cold and the STNA told the resident she was not allowed. On 11/14/16 at 11:11 A.M. interview with Maintenance Employee (ME) #107 verified the facility was without a heating source since the remaining two functioning boilers had been deemed inoperable on 09/20/16. He stated the facility had three boilers and Boiler #2 was deemed inoperable in 2013 while Boilers #1 and #3 were deemed inoperable on 09/20/16. Maintenance Employee (ME) #107 said the facility had identified a problem with the remaining boilers (#1 and #3) in July, 2016. Observation and interview of Resident #157 ' s family members on 11/14/16 at 12:19 P.M. revealed they were observed removing two portable electric heaters from the nurse ' s station on the TCU. Resident #157 ' s family member reported to the surveyor they had brought the heaters in but were taking them home as the facility would not permit them to use them. On 11/14/16 at 1:40 P.M. interview with the facility MD revealed he was aware the facility had no heat. He said he did see portable electric heating units throughout the facility due to repair work on the heating system. On 11/14/16 at 3:30 P.M. interview with Supervisor of Service (SOS) Employee #3 with the contracted heating and cooling company revealed the company was contracted to install the new boiler system and the completion date was projected as the week of 11/21/16. SOS Employee #3 stated the boilers arrived at the facility on 11/04/16 and the installation began immediately. On 11/14/16 at 3:35 P.M. interview with the SOS Employee #3 revealed the company was contracted to install the facility ' s new boiler system. He said the removal and installation was a late schedule for the time of the year. He said the job was projected to take a month for the completion of the system and the installation was a week ahead of schedule because of being so late in the season. SOS Employee #3 stated he had planned on working all night to get the facility heat. He said he was planning on starting up the boilers tonight but if any leaks occur in the pipes they would have to be shut down again. He said the owner of the company wanted the heat on tonight (11/14/16). He said once the boilers are up running he would still need to program the controls, insulate the pipes and put in vents but the facility would at least have heat. He said the inspector usually comes about a week after the boiler is fired up to inspect the system. Observations on 11/14/16 at 4:00 P.M. revealed a total of 21 portable electric heaters were observed in use located approximately six (6) inches to one (1) foot from the wall in the hallways (facility hallways were noted to be eight feet wide), dining rooms, or lounges of five of five resident units as follows: 1. 3 East (secured Dementia Unit) had one heater in the hallway by Resident Room 319. The heater was plugged into an outlet in Resident Room 319 but the heater was sitting outside the room in the hallway. There was also a heater in the 3 East dining room. At the time of the observation, a temperature meter held in front of the portable electric heater in use in the hallway by Resident Room 319 registered 140 degrees Fahrenheit. The temperature meter had a maximum range of 140 degrees Fahrenheit. There were 24 residents residing on the facility ' s secured dementia unit. 2. 3 North unit had three heaters in the hallway by Resident Room 321. There were two heaters in the lounge area by the nurses ' station, and there were four heaters in the hallway between Resident Rooms 323 and 332. Resident #2 was observed sitting in a wheelchair approximately 1.5 feet from the front of a heater in the hallway. 3. 2 North unit had three heaters in the hallway between Resident Rooms 222 and 230. There was one heater in the lounge area by the nurses ' station. There was one heater in the dining room and there was one heater in the hallway by Resident Room 234. 4. 2 East unit had one heater in the dining room and one heater at the end of the hallway where resident rooms were located. 5. TCU had one heater in the hallway where resident rooms were located. Observation on 11/14/16 at 4:05 P.M. revealed Resident #2 was sitting in a wheelchair in the hallway on the 3 North unit. Resident #2 was observed sitting approximately 1.5 feet in front of a portable electric heater in use in the hallway with the heat directed toward the resident. Interview with the Administrator on 11/14/16 at 4:16 P.M. verified no one was monitoring the portable electric heaters for fire or resident safety while they were in use. Interview with Captain #1 of the City Fire Department on 11/14/16 at 6:10 P.M. revealed that he did not want any portable electric heaters in resident hallways as a fire caused by a heater in the hallway would cut off the resident ' s means of egress from their rooms to an exit. Interview with Chief #2 of the City Fire Department on 11/14/16 at 7:15 P.M. revealed he felt the use of the portable electric heaters were safe to use as a temporary solution to the facility heating problem with the stipulation of one staff member being assigned to each hall to monitor the portable electric heaters on each resident living units. Chief #2 said he felt the temporary use of the portable electric heaters was a safer alternative than evacuating all 87 residents residing at the facility at night. Interview with the Administrator and DON on 11/14/16 at 7:37 P.M. revealed the facility, at this time, had designated one person per unit to monitor the portable electric heaters for fire and resident safety. The Administrator stated the designated person would not be responsible for any direct care nor any other assigned duties and would be present on the unit at all times. This was a mutual agreement between Chief #2 and the Administrator. However, observations on 11/14/16 between 9:06 P.M. and 9:35 P.M. revealed no designated staff person monitoring the portable electric heaters in use on the following units: TCU, 2 East, 2 North, and 3 North. Interview with the Administrator on 11/14/16 at 9:40 P.M. confirmed no designated staff members were monitoring the portable electric heaters in use on the TCU, 2 East, 2 North, and 3 North units. She stated she did not know where the designated staff members were. On 11/14/16 at 10:15 P.M. observation revealed all the portable electric heaters had been removed from use. Interview with the Maintenance Manager #121 on 11/15/16 at 10:15 A.M. confirmed that portable electric heaters were being utilized by the facility since 10/26/16 for heat since the boilers were inoperable. Interview with Resident #122 on 11/15/16 at 1:40 P.M. revealed the building was very cold the last few days and nights. The resident said he had not been sleeping very well because he was worried about the portable electric heaters catching fire. On 11/15/16 at 3:40 P.M. interview with the Administrator verified the facility obtained 25 portable electric heaters and began using them in the facility on 10/26/16 due to no heat in the building. Seven (7) of the portable electric heaters in use were green Patron E 1.5 electric fan heaters. The heater had a sticker on it which stated not to use the heater as a residential or household heater. Review of the product manual for the Patron E 1.5 electric fan heater revealed improper use of the heater could cause serious injury. Instructions stated the heater was hot when in use. To avoid burns, do not let bare skin touch hot surfaces. Keep combustible materials at least six feet from the front of the heater and keep them away from sides and rear. Extreme caution is necessary when the heater is used near children or invalids and whenever the heater is left unattended. Arrange cord away from traffic area and where it will not be tripped over. Do not insert or allow foreign objects to enter any ventilation or exhaust opening as this may cause an electric shock or fire. Patron electric heaters are designed for professional use. The heat is generated in sealed heating elements inside the inner mantle of the heater. Heated air is then distributed by an electric motor driven fan blowing air through the heater. There was no documentation in the product manual to indicate the heating element did not exceed 212 degrees Fahrenheit. Fourteen (14) of the portable electric heaters used by the facility were the Heat Storm infrared electric heaters, model number HS-1500-15M. Instructions on the heaters stated not to place any objects such as furniture, paper, clothes, or curtains closer than three feet to the front of the heater and keep them away from the sides and rear when plugged in. Heaters draw more current than small appliances. Overheating of the outlet may occur even if it has not occurred with the use of other appliances. During use, check frequently to determine if the plug outlet and faceplate are hot. Review of the product manual for the Heat Storm electric heater revealed that if the information in the manual was not followed exactly, an electric shock or fire may result causing property damage, personal injury or loss of life. The manual stated the heater was hot when in use. To avoid burns, do not let bare skin touch hot surfaces. Keep combustible materials, such as furniture, pillows, bedding, papers, clothes, and curtains at least three feet from the front of the heater and keep them away from the sides and rear. Caution: Whenever the heater is left operating and unattended, extreme caution is necessary if children or invalids are nearby. The appliance is not to be used by children or persons with reduced physical, sensory, or mental capabilities, or lack of experience and knowledge, unless they have been given supervision or instruction. Arrange cord away from traffic areas and where it will not be tripped over. Do not insert or allow foreign objects to enter any ventilation or exhaust opening as this may cause an electric shock or fire. Review of literature published by the US National Library of Medicine, National Institute of Health (published 2011) it is widely accepted that elderly burn patients have significantly increased morbidity and mortality. Irrespective of the type of burn injury, the aged population shows slower recoveries and suffers more complications. Age-associated immune dysfunction, immunosenescence, may predispose the elderly burn patients to more infections, slower healing and/or to other complications. Furthermore, pre-existing, age-related medical conditions such as, pulmonary/cardiovascular dysfunctions and diabetes in the elderly are other important factors that contribute to their poorer outcomes after major burn.

Based on observation, medical record review and staff interview, the facility failed to ensure one resident (Resident #27) received the physician ordered treatment to the Stage III pressure ulcer ((full thickness of skin is lost, exposing subcutaneous tissues, presents as a deep crater with or without undermining adjacent tissue) to her coccyx. This affected one of one resident reviewed for pressure ulcers (Resident #27). The facility identified two residents with pressure ulcers. The facility census was 87. Actual harm occurred when Resident #27's Stage II pressure ulcer (partial thickness and or loss of skin layers that presents clinically as an abrasion, blister or shallow crater) declined to a Stage III pressure ulcer when facility staff failed to provide the physician ordered treatment. Findings include: Review of Resident #27's medical record revealed an original admission date of [DATE], latest re-admission on 03/18/15, with the admitting [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 14. The MDS indicated the resident was dependent on staff for bed mobility and toileting and had one Stage II pressure ulcer and one Stage III pressure ulcer. The MDS indicated the facility implemented pressure reduction device to her bed, a turning and repositioning program, nutrition and/or hydration interventions and pressure ulcer care. Review of the resident's pressure ulcer plan of care dated 09/02/16 with the target date of 01/30/17 indicated the facility interventions included: treatment per physician's order and assess the pressure ulcer for location, state and size per facility policy. Review of the resident's monthly physician's orders for November, 2016 revealed no evidence of a current treatment to the Stage III pressure ulcer to the resident's coccyx. Additional review of the physician's orders revealed an order dated 09/07/16 to start a wet saline dressing to the coccyx pressure ulcer twice a day until healed. Review of the weekly wound assessment dated [DATE] revealed the Stage II pressure ulcer to the resident's coccyx area measured 6.5 cm by 8.0 cm with no description of the wound bed documented. The wound was documented as having no exudate or [MEDICAL CONDITION]. Review of the weekly wound assessment dated [DATE] revealed the pressure ulcer declined to a Stage III (full thickness of skin is lost, exposing subcutaneous tissues, presents as a deep crater with or without undermining adjacent tissue) measuring 8.5 cm by 6.5 cm by 0.1 cm with granulation tissue (pink or red tissue with shiny, moist granular appearance). The pressure ulcer had a moderate amount of foul smelling purulent exudate. Review of the resident's weekly wound assessment failed to provide documented evidence of a weekly wound assessment for the weeks of 09/12/16, 09/26/16 and 10/10/16. Review of the resident's Treatment Administration Record (TAR) for September, 2016 revealed the physician ordered treatment to start a wet saline dressing to the resident's coccyx wounds twice a day until healed. This was discontinued on 09/08/16 with no physician's order to do so. There was no physician order to start the [MEDICATION NAME] treatment daily to the resident's pressure ulcers. Further review of the September, 2016 TAR revealed a treatment was not provided to the Stage III pressure ulcer to the resident's coccyx on the following dates: 09/09/16, 09/10/16, 09/14/16, 09/15/16, 09/17/16, 09/18/16, 09/19/16, 09/21/16, 09/24/16, 09/25/16, 09/27/16, 09/29/16 and 09/30/16. Review of the resident's October, 2016 TAR revealed a treatment was not provided to the Stage III pressure ulcer to the resident's coccyx on the following dates: 10/01/16, 10/02/16, 10/04/16, 10/08/16, 10/09/16, 10/14/16, 10/15/16, 10/16/16, 10/22/16, 10/23/16, 10/25/16, 10/26/16, 10/27/16, 10/28/16, 10/29/16, 10/30/16 and 10/31/16. Review of the resident's November, 2016 TAR revealed a treatment was not provided to the Stage III pressure ulcer to the resident's coccyx on the following dates: 11/03/16, 11/07/16, 11/08/16, 11/09/16, 11/14/16, 11/18/16 and 11/19/16. On 11/21/16 at 4:05 P.M. observation of Registered Nurse (RN) #61 and Licensed Practical Nurse (LPN) #104 completing the treatment to the resident's pressure ulcer to her coccyx revealed the RN measured the pressure ulcer on the left side of the coccyx at 1.0 centimeters (cm) by 0.6 cm by 0.2 cm and the wound bed was red with pink edges, the pressure ulcer on the right side of the coccyx measured 0.6 cm by 0.3 cm by less than 0.1 cm with the wound bed being red with pink edges. The LPN then cleansed the wounds again with NS and patted the wounds dry with a 4X4. The LPN then applied a [MEDICATION NAME] dressing to the resident's coccyx. On 11/22/16 at 9:00 A.M. interview with the Director of Nursing (DON) verified pressure ulcer assessments were not completed weekly and verified the Stage III pressure ulcer to the resident's coccyx did not have a current physician ordered treatment. The DON verified the physician order written [REDACTED].

Based on observation, interview and review of medical records, the facility failed to ensure two residents (Resident #76 and #162) received the fluids necessary to maintain proper hydration. This affected two of three residents reviewed for hydration status (Resident #76 and #162). Harm occurred when Resident #76 was not provided sufficient fluids to prevent hydration and required treatment with Intravenous fluids for 48 hours. Findings Include: 1. Record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30 day Minimum Data Set (MDS) 3.0 assessment completed on 11/07/16 indicated Resident #76 had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment and no behaviors were identified on the assessment. Resident #76 was identified as holding food in mouth/cheeks after meals, coughing or choking during meals or when swallowing medications. The resident had a weight loss of 5% or more in the last month, and had received 500 milliliters (ml) per day or less of liquids. A review of the physician admission orders [REDACTED]. The physician ordered the following laboratory work to be completed on 10/13/16: a complete blood count (CBC), Basic Metabolic Profile (BMP), and Magnesium and [MEDICATION NAME] level. The laboratory work was to be repeated every week on Monday. On 10/31/16, the resident had the following abnormal laboratory values: Sodium 146 (normal 136-142); GFR 39.5 (normal >60); RBC 2.99 (normal 3.12-5.0) On 10/23/16 the physician ordered an urinalysis with culture and sensitivity due to nursing staff reported Resident #76's urine was concentrated, cloudy and milky in appearance. The urinalysis indicated Resident #76 had an urinary tract infection and on 10/24/16 the physician ordered [MEDICATION NAME] 500 milligrams (mg) two times daily for three days. On 10/31/16, Resident #76 had a physician order [REDACTED]. The Plan of Care (POC) for Resident #76 identified the resident had cognitive loss and dementia requiring staff to reorient, redirect, and offer verbal and nonverbal cues. Resident #76 was identified as having a potential for dehydration related to decreased intake with interventions to include administer IV fluids as ordered, assess for dehydration, assist with fluids as needed, and encourage fluids. The dietary assessment completed on 10/14/16 by Registered Dietician (RD) #415 estimated Resident #76 required 25-30 kilo calories per kilogram of body weight (kcals/kg), and needed 1613-1920 ml of fluids per day. The dietary assessment indicated Resident #76 consumed 75-100% of meals and 1500 ml of fluids per day which met the estimated daily requirements. The dietary assessment indicated Resident #76 had experienced a weight loss since last admission and would monitor intake and need for supplements. A dietary progress note by RD #415 dated 10/20/16 indicated nursing staff had notified dietary regarding Resident #76 having poor intake and a referral for an appetite stimulant was made. RD #415 progress note dated 11/10/16 indicated Resident #76 weight was 133 pounds, a nine pound weight loss (6.3%) in 30 days. The progress note indicated RD#415 recommended fortified pudding with dinner and 2 Cal HN (a dietary supplement) three times daily. The dietary progress note did not address Resident #76's fluid intake. Review of the fluid intake record from 10/12/16 through 10/31/16 indicated Resident #76 consumed between 120 ml to 1080 ml of fluid per day with an average fluid intake of 576 ml of fluid per day. The Intake and Output Worksheet in Resident #76 medical record indicated a fluid intake of 120 ml to 1540 ml for the same time period with an average daily fluid intake of 839 ml of fluid per day. On 11/18/16 at 10:53 AM, interview with the DON verified staff were documenting resident intake and output on two different forms. The DON verified the amount documented as consumed by Resident #76 was different and she could not provide an explanation as to why. The nursing progress notes on 10/31/16 at 1:47 P.M. indicated Resident #76's physician was contacted regarding poor intake and Resident #76 was not eating well even with staff assistance. Resident #76 was described as pale in color and alert. The nursing progress note on 10/31/16 at 3:34 P.M. indicated the physician's office returned a call and ordered Resident #76 to receive an IV of D 5.5% fluid at 60 ml per hour for 48 hours due to dehydration. On 11/14/16 at 11:45 A.M. Resident #76 was observed with dry, cracked lips and debris was noted on her mouth. On 11/18/16 at 9:26 A.M. Resident #76 was observed sitting at a table in the dining area. State tested Nursing Assistant (STNA) #99 offered Resident #76 something to drink and placed a cup of water on the table in front of Resident #76. Resident #76 picked up the cup and took one drink of water. On 11/18/16 at 10:01 A.M. Resident #76 continued to sit at the table with the cup of water in front of her. No staff were observed to approach Resident #76 and encourage her to take a drink of the water. At 10:30 A.M. on 11/18/16 therapy transport arrived on the unit and took Resident #76 to therapy. No staff member had approached Resident #76 to take a drink of water. During an interview with STNA #99 on 11/18/16 at 10:31 A.M. she stated she was familiar with the care Resident #76 required. STNA #99 reported Resident #76 had required total assistance with eating when first admitted to the facility; however, now the resident required only verbal cueing. STNA #99 stated Resident #76 became distracted very easily and needed constant cueing to keep on task while eating. STNA #99 confirmed she had placed the water in front of Resident #76, and stated she did not encourage her to drink or assist her with the water. STNA #99 confirmed Resident #76 had not drank very much of the water and stated if she would have been encouraged to drink, she would have probably drank more. During an interview with the Director of Nurses (DON) on 11/18/16 at 10:53 A.M. she reported the facility did not have a specific policy regarding encouraging fluids, just to encourage them to drink anytime you were with the resident. When the DON was asked what would be expected when encouraging fluids to a resident who had a [DIAGNOSES REDACTED]. The DON confirmed placing a cup of water in front of a resident with dementia and not cueing the resident to drink would not be encouraging fluids. On 11/21/16 at 1:14 P.M. during an interview with Dietary Manager #72 she reported Resident #76 was receiving 1500 ml of fluid per day per dietary services. Dietary Manager #72 reported when she monitored fluid intake, she used the amount of fluid dietary provided to the resident by dietary services and did not monitor the Fluid Intake Record or Intake and Output sheets on the medical record to obtain a residents fluid intake. The Dietary Manager #72 reported RD #415 used the information she provided when completing her assessments and progress notes. On 11/22/16 at 11:10 A.M. during a phone interview RD #415 reported she did not have access to Resident #76's medical record to answer direct corrections regarding fluid intake. RD #415 stated Dietary Manager #72 provided her with information regarding resident's fluid intake and she did not review the resident's medical record to obtain the actual fluid intake recorded. RD #415 reported she was at the facility eight hours per week and used the information Dietary Manager #72 provided when making recommendations. 2. Review of Resident #162's medical record revealed this resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #162's telephone orders dated 11/10/16 revealed the resident was placed on a 1.2 liter per day fluid restriction. Interview of Resident #162 on 11/15/16 at 4:25 P.M. revealed the resident did not get enough to drink between meals. Observation of Resident #162 on 11/15/16 at 4:25 P.M. revealed the resident had dried cracked lips. Observation of Resident #162 on 11/21/16 at 1:43 P.M. revealed she was in her room and she had dry peeling lips with a sore on her upper lip. Resident #162 was observed at 3:52 P.M. and her lips were still dry and peeling. Observation on 11/22/16 at 10:33 A.M. revealed Resident #162 had dry cracked lips. Interview of Registered Nurse #60 on 11/22/16 at 10:33 A. M confirmed Resident #162 had dry cracked lips. This RN stated the resident's lips were worse earlier this morning. RN #60 stated she told the resident she must be parched. RN #60 stated she gave Resident #162 her a cup of water and she drank it down.