Every finding on record at Rae Ann Geneva

Based on resident record review, staff interviews, and review of email correspondence, insurance statement and facility policy, the facility failed to ensure the physician did not falsely document and bill for services not provided. This affected one resident (#59) of ten residents reviewed for false billing. The facility census was 55.Findings include:Review of the medical record for Resident #59 revealed she was admitted to the facility on [DATE] with diagnoses that included heart failure, pulmonary fibrosis, and dysphagia. Resident #59 discharged from the facility on 01/16/26.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had a memory problem, modified independence regarding tasks of daily life, and was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 10/31/25 revealed Resident #59 was a long-term resident and was not determined to return to the community.Additional review of Resident 59's medical record revealed she transferred to the hospital on [DATE] for a change in condition and did not return to the facility. The facility stopped billing on 01/30/26.Review of the progress note dated 01/30/26 at 3:13 P.M. revealed Resident #59 was not returning to the facility following her transfer to the hospital on [DATE].Review of the after-visit summary dated 02/01/26 (approximately 16 days after Resident #59 transferred to the hospital without returning and two days after being officially declared discharged from the facility) revealed Resident #59 was examined by Medical Director (MD) #421 in the facility. Resident #59 discussed with MD #412 her closed fracture of the distal end of the left femur, urinary tract infection, acute kidney injury, low sodium levels, pressure ulcer of sacral region, atrial fibrillation, depression, anemia, chronic kidney infection, osteoarthritis, gout, blood clot in legs, hypothyroidism, and her risk for falls. MD #421 recorded Resident #59's blood pressure reading of systolic 128 and diastolic 82, temperature of 98.2 degrees Fahrenheit, a pulse of 84, and respirations of 18.Review of Resident #59's insurance statement of charges billed dated 03/06/26 revealed MD #421 charged for doctor and nursing home care on 02/01/26 and a payment was processed and received.Interview on 04/13/26 at 10:19 A.M. with Admissions Director (AD) #801 verified Resident #59 was a resident in the facility from 12/30/21 until 01/30/26, with her actual date of leaving the facility being 01/16/26. AD #801 stated Resident #59 should not have been billed for any days after 01/30/26.Interview on 04/13/26 at 10:34 A.M. with the Director of Nursing (DON) revealed sometimes MD #421's documentation was not accurate with dates and sometimes it was off by a few days. The DON confirmed and verified Resident #59 was not in the facility at the time the after-visit was completed and acknowledged the documentation regarding the after-visit was incorrect.Interview on 04/13/26 at 2:45 P.M. with the Administrator revealed MD #421 was in the process of writing a retraction statement confirming and verifying he did not see Resident #59 and was in the process of reimbursing Medicare and/or Medicaid for services billed that did not occur. The Administrator revealed MD #421 did not know why he wrote that he visited Resident #59 on 02/01/26 at the facility when she was no longer a resident at that time.Review of the email correspondence dated 04/13/26 at 3:49 P.M. revealed MD #421 reviewed the date of service of 02/01/26 and confirmed and verified he documented seeing Resident #59 at the facility when she had transferred to the hospital with no return on 01/16/26.Review of the facility document titled Charting and Documentation revised July 2017, revealed the facility had a policy in place to document objective, complete and accurate information in the resident medical record. This deficiency represents non-compliance investigated under Complaint Number 2744637.

Based on resident record review, staff interviews, and facility policy review, the facility failed to provide bed hold notifications. This affected two residents (#28 and #59) of three residents reviewed for bed hold notices. The facility census was 55.Findings include:1. Review of the medical record for Resident #28 revealed he was admitted to the facility on [DATE] with diagnoses that included atherosclerosis heart disease, post-laminectomy syndrome, and hypertension. Resident #28 had a designated representative, and care conference person in place.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of seven, that indicated he was alert and oriented with cognition impairment. Resident #28 was impaired on both sides of the upper extremities and dependent on staff for activities of daily living (ADLs).Review of the care plan dated 03/08/26 revealed Resident #28 was a long-term resident and was not determined to return to the community.Review of the progress note dated 08/02/25 at 3:28 P.M. revealed Resident #28 was sent to the hospital via emergency services after a change in condition.Additional review of Resident #28's medical record revealed bed hold notifications of days remaining were not provided to Resident #28 and/or representative upon discharge and/or transfer to the hospital for 08/02/25.2. Review of the medical record for Resident #59 revealed she was admitted to the facility on [DATE] with diagnoses that included heart failure, pulmonary fibrosis, and dysphagia. Resident #59 was discharged from the facility on 01/16/26. Resident #59 had a designated Power of Attorney (POA), representative, and care conference person in place.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had a memory problem, modified independence regarding tasks of daily life, and was dependent on staff for ADLs.Review of the care plan dated 10/31/25 revealed Resident #59 was a long-term resident and was not determined to return to the community.Review of the progress note dated 09/18/25 at 8:35 A.M. revealed Resident #59 was sent to the hospital via emergency services after a change in condition.Review of the progress note dated 11/28/25 at 11:02 A.M. revealed Resident #59 was sent to the hospital via emergency services after a change in condition.Additional review of Resident #59's medical record revealed bed hold notifications of days remaining were not provided to Resident #59 and/or representative upon discharge and/or transfer to the hospital for 09/18/25 and 11/28/25.Interview on 04/13/26 at 10:19 A.M. with Admissions Director (AD) #801 revealed residents that were sent to the hospital and were returning to the facility under Medicaid, received a bed hold notice detailing insurance covered days to hold their bed. All bed hold policies and bed hold notices were in the resident's medical record. AD #801 revealed initially Resident #59 was informed of remaining bed hold days and once her cognition declined, Resident #59's POA was notified thereafter. AD #801 stated Resident #59 and Resident #59's POA were informed of remaining bed hold days for all discharge and/or transfers to the hospital; however, upon review of Resident 59's medical record with AD #801 present, it revealed there were no bed hold notifications for the dates of 09/18/25 and 11/28/25. AD #801 confirmed and verified the above findings at the time of the interview.Review of the facility document titled [NAME]-[NAME] Bed Hold Policy undated, revealed the facility had a policy in place that upon admission and any discharge and/or transfers thereafter, residents and/or representatives would be provided a bed hold letter and policy outlining days remaining.

Based on resident record review, staff interviews, and review of a Self-Reported Incident (SRI), facility incident log, email correspondence, and facility policy, the facility failed to thoroughly investigate an injury of unknown origin. This affected one resident (#59) of three residents reviewed for abuse. The facility census was 55.Findings include:Review of the medical record for Resident #59 revealed she was admitted to the facility on [DATE] with diagnoses that included heart failure, pulmonary fibrosis, and dysphagia. Resident #59 was discharged from the facility on 01/16/26. Resident #59 had a designated Power of Attorney (POA), representative, and care conference person in place.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had a memory problem, modified independence regarding tasks of daily life, and was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 10/31/25 revealed Resident #59 was a long-term resident and at risk for falls due to a history of falls with interventions that included encouraging family visits, participation in interdisciplinary meetings and providing assistance with ADLs.Review of the physician orders dated 01/12/26 revealed Resident #59 was a two-person mechanical lift for transfers and to turn and reposition every two hours as tolerated.Review of the incident log dated from January to April 2026 revealed Resident #59 had an unknown incident dated on 01/16/26.Review of the progress note dated 01/16/26 at 7:32 A.M. revealed at approximately 8:30 P.M. Resident #59 started complaining of pain in the left knee, after she had been checked and changed. Resident #59 was adamant about it and contacted her POA. The POA called and requested Resident #59 be sent to the emergency room (ER) for evaluation. Mobile x-ray was contacted but because of the winter weather could not proceed, so Resident #59 subsequently left the facility at 9:30 P.M. and was admitted to the hospital with a diagnosis of distal fracture of the femur and a urinary tract infection (UTI).Review of the progress note dated 01/26/26 at 6:08 P.M. revealed Resident #59 was transferred to a hospital Intensive Care Unit (ICU).Review of the progress note dated 01/30/26 at 3:13 P.M. revealed Resident #59's POA informed the facility that she would not be returning to the facility.Review of the SRI #269875 dated 01/26/26 revealed an allegation and/or suspicion of an injury of unknown origin after Resident #59 complained of knee pain and was found to have a femur fracture on 01/16/26. Resident #59 complained of left knee pain after receiving personal care from staff and as a result, Resident #59's POA requested she be sent to the hospital for evaluation. Resident #59 was subsequently diagnosed with a distal fracture of the femur and a UTI. Resident #59 started complaining about knee pain approximately 20 minutes after routine night care. Resident #59's roommate, Resident #29, revealed during the check and change, Resident #59 was yelling out and shortly after she was sent out. Certified Nurse Assistant (CNA) #902, who was present at the time of the alleged incident, revealed during check and change she rolled Resident #59 and she started resisting and pushing back and screaming. CNA #902 revealed she then rolled Resident #59 on her back and 20 minutes later she complained of knee pain. According to the SRI, Resident #59's closed fracture of the distal end of the left femur was assessed as most likely secondary to underlying chronic disease processes rather than acute trauma with no reported history of falls or physical injury. Further review of the SRI investigation revealed Resident #59 presented to the ER for left knee pain after being moved by a CNA; however, Resident #59 revealed her leg was pulled back and believed her leg was broken.Review of the email correspondence dated 01/21/26 at 4:31 P.M. revealed the Administrator informed Resident #59's POA that the facility's SRI investigation was completed and no incidents or trauma occurred and the fracture was pathological in nature. However, a contrasting hospital note dated 01/15/26 at 10:59 P.M. revealed Resident #59 had an acute, impacted distal femoral metaphyseal fracture that indicated a recently broken bone due to a specific trauma or injury with recommendation for surgery.Review of a follow-up nursing home note documented by Medical Director (MD) #421 dated 02/01/26 revealed Resident #59 had a recent fall with a fracture to her distal left femur. Resident #59 was provided with a knee immobilizer after declining the recommendation for surgery.Interview on 04/13/26 at 10:34 A.M. with the Director of Nursing (DON) revealed she was unaware how Resident #59 sustained a fracture. The DON revealed that before Resident #59 was sent out to the hospital, she complained about pain and did not have a fall to her knowledge. The DON revealed Resident #59 had been pushing against her bed while care was being provided. The DON, after being questioned on a documented fall and acute fracture in hospital paperwork, revealed MD #421 sometimes got behind on his notes and/or was inaccurate in documenting events. The DON revealed she would reach out to MD #421 for clarification.Follow-up interview on 04/13/26 at 2:30 P.M. with the DON revealed she spoke with MD #421 regarding documenting Resident #59 having a fracture after sustaining a fall in her medical record. The DON revealed MD #421 stated, So, she didn't have a fall? when questioned and was unable to confirm or deny if Resident #59 had a fall. The DON revealed she was unable to provide any other documentation regarding the SRI, the documented fall, and the ambiguity between an acute and/or pathological fracture. The DON confirmed and verified the above findings at the time of the interview.Review of the facility document titled Abuse, Neglect, Exploitation or Misappropriation- reporting and Investigating undated, revealed the facility had a policy in place that all allegations would be thoroughly investigated.

Based on record review, interviews, email correspondence review and facility policy review, the facility failed to release a deceased resident to the correct funeral home. This affected one resident (#58) of three residents reviewed for resident rights. The facility census was 55.Findings include:Review of the medical record for Resident #58 revealed he was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, dementia, and type two diabetes. Resident #58 expired and was discharged from the facility on [DATE].Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had a death in the facility.Review of the care plan dated [DATE] revealed Resident #58 had a long-term placement in the facility and had an advanced directive of Do-Not-Resuscitate Comfort Care Arrest (DNR-CCA) with interventions that included providing comfort, dignity, safety and providing funeral arrangements as needed.Review of the physician order dated [DATE] revealed an order for DNR-CCA.Review of the physician orders dated [DATE] revealed an order to notify hospice care of all concerns, condition changes and/or symptom management. Review of Resident #58's face sheet in the electronic medical record revealed he had end of life care provided through hospice, had a Guardian in place, and had a pre-arranged funeral agreement with a funeral home.Review of the hospice admission document dated [DATE] revealed Resident #58 had a start of care dated [DATE] with a funeral home in place to receive his body at the time of his death. Review of the hospice Client Coordination Note Report (CCNR) dated [DATE] revealed Licensed Social Worker (LSW) #418 completed an initial assessment that revealed Resident #58 was a DNR-CCA and a crematorium was on record to receive his body at the time of death. Review of the progress note dated [DATE] at 12:57 P.M. revealed Licensed Practical Nurse (LPN) #903 confirmed the funeral home was the correct funeral home on file with Resident #58's Guardian. Review of the progress note dated [DATE] at 6:42 P.M. revealed LPN #405 documented Resident #58 had a time of death of 6:40 P.M. and Medical Director (MD) #421 and hospice were notified. Hospice was to notify Resident #58's Guardian and the funeral home. Review of the progress note dated [DATE] at 7:50 P.M. revealed LPN #704 released Resident #58's body to the crematorium. Review of the email correspondence dated [DATE] at 10:21 A.M. revealed Social Services Designee (SSD) #909 contacted hospice Staff Member (HSM) #420 regarding why hospice called the crematorium to pick up Resident #58's body when there were previous arrangements with the funeral home in place. Review of the correspondence revealed the funeral home was calling the facility requesting the body of Resident #58.Interview on [DATE] at 11:42 A.M. with hospice Registered Nurse (RN) #419 revealed Resident #58 was to be released to the crematorium and the information was confirmed with Resident #58's Guardian. RN #419 revealed all communication regarding Resident #58's plan of care was documented in his hospice file. RN #419 was unable to provide documentation regarding an agreement with the crematorium. Interview on [DATE] at 11:58 A.M. with the funeral home Office Manager (OM) #416 revealed Resident #58 was supposed to be released to the funeral home at the time of his death. Resident #58 had pre-arrangements in place, a designated plot, and was not to be cremated. Resident #58's pre-arrangements had been in place since 1987 and was paid in full. Interview on [DATE] at 12:07 P.M. with LPN #903 revealed for residents that were admitted to hospice care, staff nurses were responsible to contact hospice companies at the time of resident's death. Resident #58 was admitted to hospice and had a guardian in place. LPN #903 stated she confirmed with Resident #58's Guardian that the funeral home was in place and was to be contacted at the time of his death. LPN #903 had never spoken to or heard of the crematorium and that she was present in the building at the time of Resident #58's death, but she did not make the call to the funeral home or the crematorium. Interview on [DATE] at 12:17 P.M. with Resident #58's Guardian revealed hospice and the funeral home were in place for end-of-life care for Resident #58. She was never aware of the crematorium until she received a call from them requesting paperwork. Resident #58's Guardian informed the crematorium that Resident #58's body was to be transferred to the funeral home, and he should never have been released to the crematorium. Interview on [DATE] at 12:29 P.M. with LSW #418 revealed she met Resident #58 one time during an initial assessment and confirmed with Resident #58's Guardian that the crematorium was the correct funeral home to be utilized at the time of his death. LSW #418 revealed all information regarding Resident #58's plan of care was confirmed, documented and located in his hospice file. LSW #418 was unable to provide documentation regarding an agreement with the crematorium. Interview on [DATE] at 12:48 P.M. with the crematorium Coordinator (COD) #417 revealed the crematorium picked up Resident #58's body from the facility after the facility contacted them. COD #417 verified there were no agreements, paperwork, pre-arrangements, burial plots, or plans regarding Resident #58. Resident #58's Guardian contacted the crematorium after being informed that the funeral home never received his body at the time of Resident #58 death. Resident #58 was in the crematorium's care for approximately three days before being released to the correct funeral home. COD #417 offered Resident #58's Guardian burial services but was informed services would not be switched. Follow-up interview on [DATE] at 2:51 P.M. with the funeral home OM #416 revealed Resident #58 was to be released to the funeral home upon his death and had pre-arrangements in place. Resident #58 was to be buried instead of cremated, and it further caused confusion because a burial plot was his wish per Resident #58 and his mother. SSD #909 informed the funeral home that the nurse at the time of Resident #58's death could not locate the paperwork regarding what funeral home to contact, so she contacted the nearest funeral home to the facility. OM #416 stated there was no documentation in Resident #58's medical record, hospice service agreement or crematorium agreement that stated he was to be released to the crematorium. Interview on [DATE] at 3:26 P.M. with LPN #405 revealed Resident #58 expired ten minutes before her shift ended. She contacted hospice and was informed hospice would make all the appropriate notifications including contacting the funeral home. LPN #405 stated she left prior to the pick-up of Resident #58's body. Interview on [DATE] at 3:50 P.M. with the Administrator and Director of Nursing (DON) revealed Resident #58 had pre-arrangements upon his death with the funeral home and it was well documented in his medical record. Interview with the Administrator and DON revealed the facility released Resident #58's body to the wrong funeral home and confirmed and verified the above information at the time of the interview.Review of the facility document titled Hospice Program undated, revealed the facility had a policy in place that collaboration with identified hospice services would coordinate care plans for residents receiving hospice services that would reflect the resident's goals and wishes, as stated in his and/or her advance directives and during ongoing communication with the resident and/or representative. Review of the facility document titled Resident Rights undated, revealed the facility had a policy in place that all residents would be treated with kindness, respect, dignity and had a right to a dignified existence, participate and his and/or her care planning and treatment, and exercise his and/or her rights as a resident. This deficiency represents non-compliance investigated under Master Complaint Number 2972803.

Based on resident record review, staff interviews, and facility policy review, the facility failed to ensure the resident record was documented accurately. This affected one resident (#59) of ten residents reviewed for accurate medical records. The facility census was 55.Findings include:Review of the medical record for Resident #59 revealed she was admitted to the facility on [DATE] with diagnoses that included heart failure, pulmonary fibrosis, and dysphagia. Resident #59 was discharged from the facility on 01/16/26.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had a memory problem, modified independence regarding tasks of daily life, and was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 10/31/25 revealed Resident #59 was a long-term resident and was not determined to return to the community.Additional review of Resident 59's medical record revealed she transferred to the hospital on [DATE] for a change in condition and did not return to the facility. Review of the progress note dated 01/30/26 at 3:13 P.M. revealed Resident #59 was not returning to the facility following her transfer to the hospital on [DATE].Review of the after-visit summary dated 02/01/26 (approximately 16 days after transferring to the hospital without returning and two days after being officially declared discharged from the facility) revealed Resident #59 was examined by Medical Director (MD) #421 in the facility. Resident #59 discussed with MD #412 her closed fracture of the distal end of the left femur, urinary tract infection, acute kidney injury, low sodium levels, pressure ulcer of sacral region, atrial fibrillation, depression, anemia, chronic kidney infection, osteoarthritis, gout, blood clot in legs, hypothyroidism, and her risk for falls. MD #421 recorded a blood pressure reading of systolic 128 and diastolic 82, temperature of 98.2 degrees Fahrenheit, a pulse of 84, and respirations of 18.Interview on 04/13/26 at 10:19 A.M. with Admissions Director (AD) #801 revealed Resident #59 was a resident in the facility from 12/30/21 until 01/30/26, with her actual date of leaving the facility being 01/16/26. Interview on 04/13/26 at 10:34 A.M. with the Director of Nursing (DON) revealed sometimes MD #421 documentation was not accurate with dates and sometimes was off by a few days. The DON confirmed and verified Resident #59 was not in the facility at the time the after-visit was completed and acknowledged the documentation regarding the after-visit was incorrect.Interview on 04/13/26 at 2:45 P.M. with the Administrator confirmed and verified the after-visit summary documented in Resident #59 medical record on 02/01/26 was incorrect.Review of the facility document titled Charting and Documentation revised July 2017, revealed the facility had a policy in place to document objective, complete and accurate information in the resident medical record. This deficiency represents non-compliance investigated under Complaint Number 2744637.

Based on record review, interview, review of the hospital records and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the worsening of pressure ulcers, ensure timely and accurate assessments were completed, ensure treatments were implemented timely, and ensure nutritional interventions were implemented as ordered for Resident #313.Actual Harm occurred beginning on 10/07/25 when Resident #313 who was dependent on staff for toileting hygiene, bathing, bed mobility, and transfers returned from the hospital with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) to the coccyx which was not measured or described and had no treatment orders were put in place until 10/13/25 when it was assessed as a worsening Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling). The facility failed to access the coccyx wound consistently and failed to have documented evidence treatments were completed from 11/08/25 through 11/20/25. On 11/21/25 the wound had further deteriorated and was assessed as an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer. The resident was transferred to the hospital on [DATE] for further evaluation of the worsening unstageable coccyx wound and admitted with a worsening decubitus/pressure ulcer.This affected one resident (#313) of three residents reviewed for pressure ulcers. The facility census was 60. Findings include:Review of the medical record revealed Resident #313 was admitted to the facility on [DATE] with diagnoses including legal blindness, osteoarthritis of the bilateral shoulders, dysphagia (04/12/22), nonrheumatic aortic valve stenosis (04/12/22), hypertensive heart disease with heart failure (12/03/22), repeated falls (01/26/23), chronic diastolic congestive heart failure (07/10/23), chronic obstructive pulmonary disease (07/30/24), iron deficiency anemia (07/30/24), cognitive communication deficit (08/27/24), presence of urogenital implants (05/05/25), Non-ST elevation myocardial infarction (10/01/25), chronic kidney disease (Stage three (10/01/25), major depressive disorder, generalized anxiety disorder, hypothyroidism, acute respiratory failure (10/31/25).Review of the care plan initiated on 12/08/23 revealed Resident #313 had impaired skin integrity: bruises easily due to diagnoses of chronic kidney disease, anemia, and Vitamin D deficiency with interventions including provide pressure relieving devices to bed and chair, nutritional interventions per dietary recommendations, identify potential causative factors and eliminate/resolve as possible, notify family and physician of changes, and medications per orders. Review of the nurses note dated 09/18/25 revealed Resident #313 was transferred to the hospital for difficulty breathing and admitted to with diagnoses of pneumonia and possible, myocardial infarction and pulmonary embolism. Review of the re-admission note dated 10/01/25 revealed Resident #313 was readmitted from the hospital with a Stage II pressure ulcer on her coccyx. There were no measurements or descriptions of the wound. Review of the October 2025 treatment administration record (TAR) revealed an order dated 10/02/25 to cleanse Resident #313's coccyx, pat dry and apply zinc to the open area, cover with gentle border foam dressing every Monday, Wednesday, and Friday. The order was not signed off as completed 10/02/25 or 10/03/25.Review of the Medicare 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #313 had severe cognitive impairment, was dependent on staff for toileting hygiene, bathing, bed mobility, and transfers, had an indwelling urinary catheter and was frequently incontinent of bowel. The assessment revealed the resident had no pressure ulcers (however, she had a Stage II pressure ulcer to the coccyx) and was at risk for pressure ulcer development. Per the assessment, the resident had a pressure-reducing device to the bed and chair and no nutritional or hydration intervention to manage skin problems.Review of the nurse's note dated 10/03/25 revealed Resident #313 was transferred to the hospital for shortness of breath. The resident was admitted (to the hospital).Review of the re-admission note dated 10/07/25 revealed Resident #313 was readmitted to the facility with a Stage I pressure ulcer to her sacrum (coccyx) measuring 1.5 centimeters (cm) by 1.5 cm by 0 cm. There was no description of the wound. The resident had an indwelling urinary catheter. Review of the physician's orders revealed an order dated 10/11/25 to cleanse Resident #313's coccyx with normal saline solution (NSS) and apply protective padded dressing Monday, Wednesday and Friday for the open area. (The treatment was not documented as completed on 10/11/25 or 10/12/25). Review of the weekly wound summary dated 10/13/25 (first description of the wound since return from the hospital on [DATE]) revealed a Stage III pressure ulcer to the sacrum (coccyx) measuring 2.0 centimeters (cm) length by 1.0 cm width with an undetermined depth due to the presence of 100% white slough tissue with surrounding skin red and non-blanchable. The certified nurse practitioner (CNP) was updated on the appearance of the wound and would assess it tomorrow. Referral to Wound NP. Per Wound NP Santyl (debriding ointment) and foam dressing daily, air mattress, Prostat 30 milliliters (ml) twice daily (BID). (The Prostat was discontinued on 10/16/25 due to refusals).Review of the medical record revealed Resident #313 was hospitalized from [DATE] through 10/24/25 for acute respiratory failure and hypercapnia. Review of the re-admission assessment dated [DATE] revealed Resident #313 was re-admitted with a Stage II pressure ulcer to the coccyx measuring 2.5 cm by 2.0 cm with no depth measurement or description noted. The resident also had a left buttock suspected deep tissue injury (SDTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) measuring 1.0 cm by 2.0 cm.Review of the physician's orders revealed an order dated 10/24/25 to cleanse Resident #313's sacral (coccyx) wound with NSS or wound cleaner, apply nickel thick amount of Santyl to wound and cover with alginate. Apply zinc to the surrounding area and cover with foam dressing once daily. (The wound care was signed off as completed 10/25/25 through 10/31/25). Review of the weekly wound summary dated 10/31/25 revealed resident #313's coccyx wound was a Stage III pressure ulcer measuring 2.5 cm by 3.0 cm by 0.3 cm. The wound was noted to appear worse in appearance and measurement. The right buttock (location corrected from left buttock on 10/24/25) was described as a SDTI measuring 2.5 cm by 4.0 cm, skin intact and non-blanchable. CNP updated on appearance and worsening of wound. She had seen it this week during rounds. The dietitian was notified of the wound on 10/27/25 and recommended Boost nutritional supplement three times a day (TID). Review of the TAR for November 2025 revealed physician's orders dated 10/24/25 through 11/07/25 to cleanse the sacral (coccyx) wound with NSS or wound cleanser, apply nickel thick amount of Santyl to wound and cover with alginate, apply zinc to the surrounding area and cover with a foam dressing daily. There was not treatment ordered or signed off to the sacrum (coccyx) from 11/08/25 until 11/21/25. There was an order dated 11/07/25 through 11/21/25 to cleanse Resident #313's right buttock with NSS, apply collagen with sacral dressing along with coccyx wound dressing daily. Review of the medical record revealed no further assessments of the wounds until 11/13/25. Review of the TAR for November 2025 revealed there was no treatment to the coccyx ordered or signed off from 11/08/25 through 11/13/25.Review of the weekly wound progress note dated 11/13/25 revealed Resident #313's sacrum (coccyx) was a Stage III pressure ulcer per provider measuring 2.0 cm by 2.0 cm by 0.3 cm with 90% slough and 10% granular tissue. Right buttock has a Stage II pressure ulcer measuring 23 cm by 2.5 cm by 0.1 cm, 100% epithelial tissue. Treatment was to cleanse the wound to the coccyx NSS or wound cleanser, apply nickel thick Santyl to coccyx wound and cover with alginate (this treatment to the Stage III pressure area on the coccyx was not transcribed or signed off as completed), apply collagen to right buttock wound and cover entire area with sacral foam or six by six foam dressing daily, air mattress to bed, Boost Plus TID, Magic cup (nutritional supplement) daily, and multivitamin daily, Previous wound care Nurse Practitioner # 699 in to assess and no new orders noted. Improved in measurements. Appearance remains the same. Resident #313's daughter updated by phone on improvement, and wound NP #699 being in with no new orders. Also, told her new wound company would be starting next Friday and would follow weekly.Review of the TAR for November 2025 revealed there was no treatment to the coccyx ordered or signed off from 11/13/25 through 11/20/25.Review of the facility weekly wound summary dated 11/21/25 revealed Resident #313's coccyx wound was now unstageable measuring 2.4 cm by 2.0 cm by 0.4 cm, no drainage sacrum. Orders to cleanse area with NSS, place 1/4 strength Dakin's (antimicrobial)-soaked gauze to wound bed, cover with gentle border dressing BID. Doxycycline (antibiotic) 100 milligrams (mg) BID for 10 days. Sacrum x-ray to rule out osteomyelitis.Review of the Healing Partners skin and wound note dated 11//21/25 authored by Wound NP #601 revealed information necessary for today's visit was obtained from nursing staff, per patient's medical record, the patient. Reason for visit: new skin and wound consult on current resident. First Evaluation of existing wound by new provider. The wound care team was consulted for the following wound: left buttock pressure ulcer Stage II acquired 10/24/25; coccyx pressure ulcer unstageable, previous Stage III. Undergoing wound care treatment as ordered. Air mattress in place. On nutritional supplements. Resident #313 has lost almost 20 pounds since August. At the time of visit, the resident was awake and alert, resting in bed. Of report, resident's daughter is Power of Attorney (POA), who is actively involved with her care. Upon today's assessment, the coccyx wound presents with 100% slough, redness and warmth to the peri-wound area. Sharp debridement is warranted. Nursing staff called daughter and obtained verbal consent for sharp debridement with request pain med to be given prior to debridement. Pain med was given. The wound care team came back for debridement. Nursing reports that daughter refused palliative care/hospice care. Pre-debridement measurement of the coccyx wound was 2.1 cm by 2.0 cm by 0.4 cm; post-debridement measurement was 2.1 cm by 2.0 cm by 0.8 cm. A selective debridement was performed. Removal of biofilm/necrotic tissue using forceps, scalpel, scissors was performed to keep the wound in an active state of healing. No bleeding noted. The site was cleaned and dressing was applied. The nursing staff were given detailed ulcer care instructions and asked to monitor the ulcer for any signs or symptoms ofprolonged bleeding or debridement intolerance. The patient tolerated the procedure well with no noted complications at the time of encounter. Treatment to the left buttock was cleanse with NSS, apply collagen to the base of the wound, secure with sacral dressing, change three times a week and as needed. Treatment to the coccyx wound was cleanse with NSS apply Barrier cream to peri-wound, 1/4 Dakin's moistened gauze to base of the wound, and secure with gentle border dressing. Serial debridement expected. Stage IV expected as more necrotic tissue is debrided. Workup for osteomyelitis: Complete Blood Count (CBC) w/differential, complete metabolic panel (CMP) on Monday 11/24/25. Add Erythrocyte Sedimentation Rate (ESB) and C-Reactive Protein (CRP). X-ray of sacrum/coccyx rule out osteomyelitis. Doxycycline 100 mg BID for 10 days and Probiotic to prevent C-Diff.Review of the Doctor/CNP note dated 11/21/25 revealed the CNP was notified of the x-ray results: the visualized sacrococcygeal segments are in good alignment. Degenerative changes are identified. No osseous erosions are present. The sacroiliac joints are normal. No acute abnormalities.Review of the Doctor/CNP note dated 11/22/25 revealed spoke with Resident #313's daughter, and she was concerned about nausea as of late. PRN Zofran (antinausea) given with little effects. New order for PRN Phenergan (antinausea). Fluid intake less than usual. The resident took in 200 cubic centimeters (cc) supplement with breakfast, about 120cc of lunch supplement. Solid food bites only for each meal. 240 cc in other liquids taken in at this time. New order for intravenous (IV) D5NS 0.9% 80cc / hour for one liter. Resident states she is having discomfort on the roof of her mouth and tongue. No areas of concern noted on roof of mouth, dry dark patches noted to tongue. New order for nystatin (antifungal).Review of the Doctor CNP note dated 11/24/25 revealed the CNP was notified about abnormal lab results of low Albumin of 3.4, high Blood Urea Nitrogen (BUN) of 36, high Creatinine of 1.30, low sodium of 134, high Chloride of 32, low Red Blood Cell of 3.17, low Hemoglobin of 9.6, a low Hematocrit of 28.8, all other labs within normal limits and concerns from resident's daughter. The following orders were started and Resident #313's daughter notified. New orders: Invanz Injection Solution Reconstituted (Ertapenem Sodium) (antibiotic) use 500 mg intravenously (IV) one time a day related to urinary tract infection (UTI) for two days 100 ml for 30 minutes AND use 500 mg IV one time only related to UTI. Vitamin C, zinc, multivitamin, iron, and aspirin placed on hold for seven days to see if these medications are contributing to nausea. Repeat labs ordered for 11/26/26 (CBC w/ differential and basic metabolic panel (BMP). Suspected bacterial pneumonia and wound infection.Review of the nurse's note dated 11/25/25 at 3:58 P.M. revealed the IV access team called at this time regarding still no nurse out to facility to assess midline. Reported they were going to reach out to nurse assigned and call facility back.Review of the nurse's note dated 11/25/25 at 4:31 P.M. revealed as this nurse was assessing the Midline IV to change the dressing due to soiling, this nurse started to take off the soiled dressing, and the Midline IV came out of resident's arm. Midline IV intact. No bleeding at site noted. No pain reported. The CNP was notified that we were waiting on the IV access team.Review of the Doctor CNP note dated 11/25/25 revealed the CNP was notified of the Midline IV not being intact. Gave verbal order for one dose of Invanz 500 mg (antibiotic) intramuscular (IM) times one dose and to start Invanz 500 mg IV daily times three days to start tomorrow evening.Review of the nurse's note dated 11/25/25 at 6:47 P.M. for urinalysis culture and sensitivity (UA C/S) reordered for tomorrow 11/26/25 due to the previous UA C/S was contaminated. Order faxed over to lab at this time.Review of the nurse's note dated 11/26/25 at 12:27 A.M. revealed a new Midline IV was started. Review of Resident #313's wound assessment report dated 11/27/25 signed by Wound NP #601 revealed the coccyx wound was an unstageable pressure ulcer measuring 2.5 cm by 2.0 cm by 1.1 cm with 100% slough, with undermining 1.2 cm from six o'clock to six o'clock, the peri-wound had erythema, warmth to touch. The treatment was changed to cleanse with NSS, apply barrier cream to peri-wound, and 1/4 Dakin's moistened gauze to the wound with a gentle boarder dressing BID.Review of the TAR for November 2025 revealed the treatment order to the coccyx was signed off as completed from 11/21/25 through 11/27/25.Review of the facility weekly wound summary dated 11/28/25 revealed Resident #313's coccyx would remained unstageable measuring 2.5 cm by 2.0 cm by 1.1 cm with 100% slough, with undermining 1.2 cm from six o'clock to six o'clock, the peri-wound had erythema, warmth to touch. The treatment was changed to cleanse with NSS, apply barrier cream to peri-wound, and 1/4 Dakin's moistened gauze to the wound with a gentle boarder dressing BID. Recommend sending the resident to the hospital for further evaluation for osteomyelitis.Review of the nurse's note dated 11/28/25 at 10:32 A.M. revealed Wound Nurse #600 rounding with Wound NP #601. Per recommendation of the Wound NP, Resident #313 to be sent to emergency department (ED) for further imaging and treatment. Resident denies pain at this time. ADON #671 assisted with paperwork, calling report to ED. ADON #671, wound nurse call and update daughter. Daughter in agreement. Review of the nurse's note dated 11/28/25 at 11:02 A.M. squad in to transport Resident #313 to ED.Review of the nurse's note dated 11/28/25 at 6:57 P.M. revealed Resident #313 was admitted to the hospital for wound care and antibiotics. Review of the hospital records revealed Resident #313 was admitted to the hospital for a sacral wound infection measuring 3.0 cm by 2.0 cm. Mild erythema around the wound edges. No significant pus draining from the wound. Packing removed and replaced with a wet to dry dressing. CT scan confirmed interval worsening of her decubitus ulcer from 10/09/25. Impression Stage IV decubitus ulcer. No obvious active infection. Chronic wound with eschar. Agree with Dakin's quarter percent solution to wound and cover with foam border dressing daily. Will reevaluate and consider bedside removal of eschar. Eventual DuoDERMdressing based on the patient's overall condition. No indication for surgical intervention at this time. Urinalysis was negative for UTI. Review of the plan of care created on 12/01/25 (first plan of care regarding wounds) revealed Resident #313 re-admitted from the hospital with a Stage III pressure ulcer related to immobility and decline in condition. On 11/21/25 wound downgraded to unstageable wound. Interventions included foam cushion when up in Broda chair, administer medications as ordered and monitor/document for side effects and effectiveness, apply bilateral foot pillows when in bed, assess/record/monitor wound healing at least every week, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the physician, follow facility policies/protocols for the prevention/treatment of skin breakdown, inform the resident/family/caregivers of any new area of skin breakdown, monitor dressing frequently to ensure it is intact and adhering, report lose dressing to treatment nurse, monitor nutritional status, serve diet as ordered, monitor intake and record, obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated, resident requires: supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort, and utilize low loss air mattress with siderailsReview of the re-admission note dated 12/03/25 revealed resident #313 was readmitted to the facility with orders for IV Vancomycin (antibiotic) for wound infection and bacterial pneumonia. CT scan in the hospital showed worsening of sacral decubitus ulcer and possible pneumonia. Admit for further workup and IV antibiotics. Review of the weekly wound summary dated 12/05/25 revealed the coccyx wound is a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling) measuring 2.1 cm by 1.5 cm by 1.2 cm with 40% granulation and 60% slough. The wound is improving with undermining 2.2 cm from six o'clock to six o'clock. The peri-wound erythema much improved, pink brown skin, hyperpigmentation, no warmth. No new orders. Treatment barrier cream to the peri-wound, Santyl, calcium alginate rope gently place to the wound bed and undermining, cover with a foam dressing daily. Review of the plan of care revised on 12/09/25 revealed Resident #313 re-admitted from the hospital with a Stage III pressure ulcer related to immobility and decline in condition. On 11/21/25 wound downgraded to unstageable wound. On 12/05/25 wound upgraded to Stage IV per provider. No new interventions were listed.Review of the weekly wound summary dated 12/12/25 revealed the coccyx wound is a Stage IV measuring 2.1 cm by 1.5 cm by 1.2 cm with 50% granulation and 50% slough. The wound is improving with undermining 2.2 cm from six o'clock to six o'clock. The peri-wound erythema much improved, pink brown skin, hyperpigmentation, no warmth. No new orders. Continue current supplements. Review of the weekly wound summary dated 12/19/25 revealed the coccyx wound was a Stage IV measuring 2.1 cm by 1.2 cm by 1.1 cm with 60% granulation and 40% slough. The wound was improving with delayed wound closure with undermining 2.25 cm from six o'clock to six o'clock. There was a moderate amount of yellow drainage. Treatment was to cleanse the coccyx wound with NSS, apply Medi-honey, alginate roping, apply barrier cream to the peri-wound and cover with a foam dressing.Review of the weekly wound summary dated 12/26/25 revealed the wound was a Stage IV measuring 2.1 cm by 1.2 cm by 1.1 cm with 60 % granulation and 40 % slough. The wound was improving with delayed wound closure with undermining from six o'clock to six o'clock . There was moderate amount of yellow drainage. Treatment was to cleanse the coccyx wound with NSS, apply Medi-honey, alginate roping, apply barrier cream to the peri-wound and cover with a foam dressing. No new orders. Resident # 313 was medicated one hour prior to wound care. Review of the weekly wound summary dated 01/02/26 revealed the coccyx wound was a Stage IV measuring 2.2 cm by 1.0 cm by 1.1 cm with 70% granulation and 30% slough. The wound is improving with delayed wound closure with undermining 2.5 cm from six o'clock to six o'clock. There was a moderate amount of yellow drainage. Treatment was to cleanse the coccyx wound with NSS, apply Medi-honey and pack with Hydrofera Blue (wet with NSS). Apply barrier cream to the peri-wound and cover with a foam dressing times three days Monday, Wednesday, Friday and as needed. Resident #313's wound could not be observed as she was admitted to the hospital on [DATE] and not available during the survey.Interview on 01/07/26 at 9:42 A.M. with the Director of Nursing (DON) revealed the facility did not have an in-house wound care team from July or August 2025 until November 2025. Licensed Practical Nurse (LPN) #600 was assessing all facility wounds with the assistance of Registered Nurse (RN) #638. The DON revealed orders were being managed by Medical Director #697 and Nurse Practitioner (NP) #698 or previous Wound NP #699 for wound care until Healing Partners started in November. The DON verified orders were not transcribed and a lapse of treatment did occur while transitioning of wound care team.Interview on 01/07/26 at 11:05 A.M. with LPN #600, the facility wound care nurse, revealed Resident #313 was very well known to her. However, she was unable to stage wounds and completed rounds with RN #638 to provide assessment and staging wounds. Wound care orders were followed from current Wound NP #698 or previous Wound NP #699. Interventions included and air mattress, every two hour turns, and Broda chair to relieve pressure, supplements Boost/Med pass, foot pillows, and continued lab work. LPN #600 revealed an x-ray was done on 11/21/25 in the facility to rule out osteomyelitis, and Resident #313 was sent to hospital on [DATE] for further (wound care) treatment. LPN #600 stated she noticed the wound worsening around one of the re-admissions from hospital. She notified the resident's daughter of the wound condition and plans to treat. LPN #600 proceeded to treat per orders from Wound NP #698 or hospital. Two incidents of bedside debridement by Wound NP #601 on 12/26/25 and 01/02/26 occurred. Resident #313 had increased pain during debridement and pain medication was administered one hour prior to debridement.Interview with Dietitian #665 on 01/07/26 at 11:59 A.M. revealed Resident #313 had numerous changes to supplements. Resident #313 would be ok for a few days and then decide she didn't like them. She had gone round and round about what she would accept and what she wouldn't. Resident #313 was hospitalized a lot recently and had been declining, but Resident #313's weight had stabilized, intakes varied daily, but good approximately about 25-100% with supplements. She was monitoring her weight loss due to fluid changes. Since December, after re-admission from hospital, she had concerns with wounds, which were improving. She had no concerns about staff feeding her and consistency with staff and fed her well. Resident #313 was on fluid restriction, but that was discontinued about three weeks ago. Resident #313 had orders to assess weight weekly for four weeks with each hospitalization and re-admission, but she was weighed more often than that. Dietitian #665 had been concerned about Resident #313's weight since October, and diet orders have been changed to nectar thick liquids, but she was now receiving regular liquids. Dietitian #665 attended weekly discussions at morning meeting and provided the facility with the weight change list. ADON #671 or LPN #600 were notified to enter into the medical record. Resident #313's daughter provided Juven (nutritional supplement) stating, give her Juven if she refuses the others which was not an appropriate substitution for the Ensure. Dietitian #665 indicated Resident #313 would need to eat a lot in order for Juven to work. She indicated that facility staff always follow through with nutritional recommendations. Dietitian #665 feels Resident #313 and her daughter were both barriers to treatment/plan of care.Interview with Wound NP #601 on 01/08/26 at 12:32 P.M. revealed concerns of Resident #313's coccyx wound upon initial assessment on 11/21/25. Wound NP #601 revealed the wound was unstageable and Resident #313 was ordered lab work, x-ray, and antibiotics. Resident #313 was medicated for pain and bedside debridement was performed without issues or concerns. Wound care treatment orders were placed, and coccyx wound was improving. But Resident #313 was sent to hospital for surgical debridement. Wound NP #601 indicated Resident # 313 had chronic complex medical history and poor nutrition contributing to wound care complications. Wound NP #601 did not believe the wound was a Kennedy ulcer.Interview with CNP #698 on 01/08/26 at 1:00 P.M. revealed she was aware of the gap in Resident #313's wound care from the end October to end of November 2025. CNP #698 observed coccyx wound over a two-to-three-week period. Resident #313 had mostly supplements for intake and poor intake. CNP #698 indicated the wound progressed quickly likely in part she believed due to Resident #313's malnutrition and documented refusals to get out of bed per Resident #313 and her daughter's request. CNP #698 encouraged Resident #313 to be out of bed for meals.Review of the facility policy titled Pressure Injuries Prevention, dated April 2020, revealed the facility would conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium trochanter, etc.) This deficiency represents non-compliance investigated under Complaint Number 2701482.

Based on personnel record reviews and staff interviews, the facility failed to ensure a staff member working in the capacity of a Certified Nursing Assistant (CNA) met the state and federal requirements prior to providing direct resident care. The facility permitted CNA #674 to perform CNA duties without successfully completing the competency evaluation and obtaining an active CNA certification. This had the potential to affect all residents residing in the facility. The facility census was 60.Findings include:Interview with the Human Resources (HR) Director #628 on 01/07/26 at 11:13 A.M. revealed CNA #674 was hired at the facility on 07/26/24. He completed first Nurse Aide Training class on 07/23/24; he later took his test but did not pass the written portion of the test. The HR Director further stated CNA #674 tested again but again did not pass the written portion of the test. The HR Director stated CNA #674 did not show up to take his third test and was unable to test again until he took entire Nurse Aide Training class again. CNA #674 completed the entire Nurse Aide Training class again on 06/17/25 and subsequently failed the written portion of the test again. The HR Director stated CNA #674 was terminated on 01/05/26. Interview with HR Director #628 further revealed CNA #674 was not listed in the Nurse Aide Registry as he had no certification as he was unable to pass the test. CNA #674 was employed at the facility for 17 months and provided care to residents throughout the facility. Review of the personnel record for CNA #674 revealed certificates of completion for two Nurse Aide Training classes but no Nurse Aide Registry check verification.This deficiency represents noncompliance investigated under Complaint Numbers 2603290 and 1387209 (OH00166324).

Based on record review, observation, interview, facility policy review, review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff used appropriate infection control practices for Resident #305 during incontinence care and Resident #337 during wound care. This affected two residents (#305 and #337) of three residents reviewed for infection control and had the potential to affect all 60 residents residing in the facility.Findings include:1. Review of the medical record revealed Resident #305 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, fall on same level, unspecified, subsequent encounter, encounter for other orthopedic aftercare cardiomegaly, muscle weakness (generalized),other symbolic dysfunctions, cognitive communication deficit, need for assistance with personal care, vascular dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, gastro-esophageal reflux disease without esophagitis, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified osteoarthritis, unspecified site, hyperlipidemia, unspecified major depressive disorder, recurrent, unspecified essential (primary) hypertension, presence of cardiac pacemaker other insomnia, low back pain, unspecified, personal history of pulmonary embolism, anemia, unspecified personal history of COVID-19, vitamin D deficiency, unspecified, vitamin B12 deficiency anemia, unspecified disorder, unspecified, other cervical disc degeneration, unspecified cervical region age-related, osteoporosis without current pathological fracture, nonrheumatic mitral (valve) insufficiency, and abdominal hernia without obstruction or gangrene. Review of the Minimum Data Set (MDS 3.0) assessment dated [DATE] revealed Resident #305 has an impaired cognition; she was dependent on staff for activities of daily living (ADL) and always incontinent of bowel and bladder and dependent for continence care. Observation and interview on 01/06/26 from 10:54 A.M. to 11:05 A.M. of Resident #305 for incontinence care revealed Licensed Practical Nurse (LPN) #604 and Certified Nurse Aide (CNA) # 647 placed the supplies on a barrier on the bedside table, pulled the curtain and washed their hands. The procedure was explained and permission granted for observation. Clean gloves were donned, and Resident #305's clothing and soiled brief were removed. LPN #604 explained the procedure and wiped Resident #305 front to back. At 10:58 A.M. Resident #305 was rolled and CNA #647 wiped the resident front to back. A clean brief was applied. At 10:59 A.M. CNA #647 doffed gloves and applied clean gloves without washing her hands to obtain new pair of pants for Resident #305. Pants were applied without difficulty. At 11:01 A.M. LPN #604 doffed soiled gloves and hand hygiene was performed. At 11:02 A.M. CNA #647 removed the soiled linens and removed trash. At 11:04 A.M. LPN #604 confirmed she did not apply clean gloves or use proper hand hygiene between the soiled brief and the clean brief. At 11:05 A.M. CNA #647 confirmed she did not apply clean gloves or use proper hand hygiene between the soiled brief and the clean brief. 2. Review of the medical record revealed Resident #337 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease with heart failure and stage I through stage IV chronic kidney disease, or unspecified chronic kidney disease, type II diabetes mellitus with diabetic nephropathy, schizoaffective disorder, depressive type, dependence on renal dialysis, other cord compression, spinal stenosis, cervical region, post-traumatic stress disorder, chronic, atherosclerotic heart disease of native coronary artery without angina pectoris, gastro-esophageal reflux disease without esophagitis, heart failure, unspecified, neuromuscular dysfunction of bladder, unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, hyperlipidemia, unspecified, hypothyroidism, unspecified, essential (primary) hypertension, arteriovenous fistula, acquired. Review of Resident #337's care plan dated 12/15/25 revealed a goal to promote wound healing. Right lateral wound care orders as follows for wound right lateral ankle pressure ulcer/injury. Cleanse with normal saline, apply Skin-Prep to base of the wound, secure with bordered foam, change three times per week, and as needed (PRN). Review of the physician's orders revealed an order dated 12/15/25 for enhanced barrier precautions (EBP). Review of the Minimum Data Set (MDS 3.0) assessment dated [DATE] revealed Resident #337 was cognitively intact and was independent for all activities of ADL. Resident #337 had one Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) on her right lateral ankle, pressure reduction interventions in place. Observation of wound care on 01/07/26 at 10:55 A.M. though 11:02 A.M. revealed signage on the door for EBP. LPN #600 did not don proper protective equipment (PPE) prior to wound care for Resident #337. At 10:55A.M. the bedside table was sanitized, a barrier was placed and supplies were gathered. At 10:56 A.M. LPN #600 performed hand hygiene, and donned clean gloves. No additional PPE was donned. The soiled dressing with a date of 01/05/26 was removed and discarded. The soiled gloves were doffed and hand hygiene performed, and clean gloves were donned. The right lateral ankle wound was cleansed with normal saline; Skin Prep was applied with foam dressing and dated 01/07/26. The trash was pulled and discarded, gloves doffed, and hand hygiene performed. Interview on 01/07/26 at 11:02 A.M. with LPN #600 confirmed she did not don proper PPE prior to performing wound care for Resident #337. Interview on 01/07/26 at1:03P.M. with the Director of Nursing (DON) confirmed the facility had a policy in place confirming PPE was required to be used for wound care. Review of the undated facility policy titled Standard Precautions revealed when to perform hand hygiene to include before and after direct contact with a resident's intact skin, after contact with body fluids or excretions, and after glove removal. Review of Hand Hygiene in Healthcare Settings, Healthcare Providers, Glove Use, last reviewed 01/08/21, from the Centers for Disease Control and Prevention, located at https://www.cdc.gov/handhygiene/providers/index.html revealed gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene during patient care if gloves become visibly soiled with blood or body fluids following a task and moving from work on a soiled body site to a clean body site on the same patient. This deficiency was an incidental finding identified during the complaint investigation.

Based on medical record review, review of the facility policy and staff interview, the facility failed to report injury of unknown origin to the State Survey Agency as required. This affected one (Resident #313) of one resident reviewed for an injury of unknown origin. The facility census was 60.Findings include:Review of Resident #313's medical record revealed an admission date of 01/07/22 with diagnoses including local infection of the skin and subcutaneous tissue, acute on chronic systolic (congestive) heart failure, pulmonary fibrosis, dysphagia, hypoxemia, hypertensive heart disease with heart failure, gout, anemia, age-related osteoporosis, major depressive disorder, generalized anxiety disorder, hypothyroidism, chronic pain syndrome, chronic kidney disease, acute respiratory failure with hypoxia, myocardial infarction, osteoarthritis of knee, cognitive communication deficit, chronic obstructive pulmonary disease (COPD), repeated falls, and legal blindness.Review of Resident #313's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 00 which indicated severe cognitive impairment. Further review of the MDS also revealed the resident was dependent on staff for all activities of daily living (ADL) and mobility.Review of Resident #313's progress note dated 06/05/25 revealed she was complaining of pain in her right knee, and x-rays of her right knee were subsequently ordered. The x-rays were performed on 06/06/25 and results revealed a broken osteophyte in superior margin of patella, likely chronic, moderate osteoarthritis of right knee joint.Interview with the Director of Nursing (DON) #623 on 01/08/25 at 2:17 P.M. revealed staff was unaware how Resident #313's knee injury occurred. The DON also revealed an investigation was conducted, but no facility self-reported incident was submitted to the State Survey Agency as required.Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised April 2021, revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not result in abuse or result in serious bodily injury. This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, interview and review of facility policy, the facility failed to ensure the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings. This had the potential to affect all 66 residents residing at the facility. Findings included: Review of QAPI meeting attendance sign in sheets dated 12/27/23, 01/16/24, 02/20/24, 03/19/24, 04/16/24, 05/22/24, 06/26/24, 07/24/24, 08/02/24, 09/25/24, 10/24/24, 11/26/24, 12/27/24, 01/23/25, 02/25/25, 03/26/25, and 04/22/25 revealed the Medical Director/Primary Care Physician (PCP) #600 did not attend the above meetings. Interview on 05/18/25 at 3:58 P.M. with Administrator verified the Medical Director/PCP #600 did not sign any of the QAPI meeting attendance sheets and she had no evidence from 12/27/23 to 04/22/25 that he attended a QAPI meeting at least quarterly. Review of the facility policy labeled, Quality Assurance and Performance Improvement (QAPI) Program- Design and Scope, dated February 2020, revealed the facility QAPI program was ongoing, comprehensive and addresses all care and services provided by the facility. The policy did not identify the required members including the medical director that needed to attend the QAPI meeting and/ or identify the frequency of how often the required members were to attend.

Based on observation, interview and record review, the facility failed to maintain the building floors in safe and clean condition. This had the potential to affect all 66 residents residing in the facility. Findings include: Review of a floor repair quote dated 03/22/25 revealed the quote included installation of vinyl floor tiles to the facility's front areas, halls and nurses' stations, but it did not seem to include repair to resident rooms. Observation on 05/19/25 at 1:37 P.M. of the environment revealed the following: The front foyer and entry way had various dark soiled areas with one large area near the right front entrance door. Multiple areas of the floor appear worn and scratched. There were various scuffs, and two small circular areas cracked and sunken. The carpeted area in the building front near the dining room which included the television area and around the nurses' station had multiple small and large dark stained areas. The floor which borders the front of the nurses' station outward approximately two feet slopes downward toward the nurses' station desk which posed a fall hazard to all residents who ambulated through there. Interview on 05/19/25 at 2:10 P.M. with Licensed Practical Nurse (LPN) #351 verified the floor sloped toward the nurses' station and had for quite a while, which was a fall hazard for residents. LPN #351 reported having tripped because of it but was uncertain if any residents had done the same. The floor in the Concord Hall area between the kitchen and laundry area appeared soiled, dark and worn. Throughout the rest of the hallway there were various scuff marks, scratches and worn areas of the floor with multiple dark stains and cracked floor tiles. rooms [ROOM NUMBERS] had dark soiled areas at the entrances. room [ROOM NUMBER] had various stained discolorations and floor scratches. room [ROOM NUMBER] had dark soiled areas inside the room near the bed. The floor in the Hummingbird Lane area had large dark soiled areas which appeared stained at the hallway entrance. There were multiple cracks in the floor tiles with some tiles sunken closest to where the fire doors were located. room [ROOM NUMBER] had small cracks in the floor tiles at the entrance. room [ROOM NUMBER] had dark soiled stains at the room entrance and a small crack in the floor tile near the bottom of the bed by the room door. Throughout the hallway there were multiple various scuff marks, some small and large with discolored stained areas. The floor in the Northern Lights area had multiple various scuffs and small and large dark stained discolored areas, some worn, most notably at room [ROOM NUMBER]'s entrance. room [ROOM NUMBER] had an elongated crack in the floor going across the hall from the room's entrance with the floor sunken where cracked. room [ROOM NUMBER] had a small floor area with an imprint of what appears to be tire tread from the nearby electric wheelchair. room [ROOM NUMBER] had a quite large crack in the floor tile which transversed from the room entrance into the room toward the bathroom area. The floor had sunken in some areas with the cracked tile. At the hallway entrance just inside the fire doors adjacent to rooms [ROOM NUMBERS] were multiple cracked tiles with missing pieces which covered a floor area of approximately 11 tiles. room [ROOM NUMBER] had floor tile crack just inside the room door and dark stained areas near the door entrance and bed. room [ROOM NUMBER]'s entrance area had approximately five cracked floor tiles. The hallway floor between rooms [ROOM NUMBERS] had approximately four cracked tiles. room [ROOM NUMBER]'s entrance had cracked floor tiles across with dark soiled stained areas and scuff marks throughout the room. The back of the hallway had multiple various cracked floor tiles with scuff marks on the floor and small dark soiled areas. room [ROOM NUMBER] had multiple cracked floor tiles and dark soiled areas. The emergency exit at the back of the hallway had chipped and cracked floor tile with pieces of the floor tiles pulled away and scattered across the doorway. Some areas of the floor were sunken or raised up due to the floor damage. Observation and interview on 05/19/25 at 2:38 P.M. with Housekeeping Director (HD) #359 of the environment verified the above observations. HD #359 indicated the floors were scrubbed at least once monthly but could not confirm it received deep cleaning routinely each month. HD #359 reported the floors were mopped daily, but denied any staffing issues which would cause a lack in routine floor deep cleaning each month. HD #359 further reported the carpeted floors were cleaned once weekly but the stains were permanent. HD #359 also acknowledged being aware of the floor sloping toward the nurses' station by the dining room, and agreed it was a fall risk for the residents. Interview on 05/19/25 at 4:08 P.M. with the Administrator confirmed knowledge of the above observations. The Administrator acknowledged discussing the floor status with the owners and a plan to obtain quotes for floor replacement but was unaware of any formal plan with dates. Review of a text message involving the facility's administration dated 05/09/25 revealed the Administrator being asked if she wanted the flooring done with an affirmative response.

Based on record reviews, observations, interviews and facility policy review, the facility failed to revise care plans for Residents #3 and #25 to include the use and monitoring of seat belts and alarms as restrictive devices and failed to complete comprehensive care plans within the required timeframe (within 21 days after admission) for Residents #60 and #70. This affected four (Residents #3, #25, #60 and #70) out of four residents reviewed for comprehensive care plan completion and revision. The facility census was 66. Findings include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, speech and language deficits following cerebrovascular disease, chronic kidney disease and vascular dementia. Review of a physician order dated 09/17/24 indicated Resident #3 had a Velcro seat belt to the wheelchair for positioning and safety. Review of the quarterly Minimum Data Set (MDS) assessment completed 03/19/25 revealed Resident #3 had moderate cognitive impairment. Review of the care plan updated on 04/18/25 indicated Resident #3 had impaired cognition with fluctuation including poor decision making, poor impulse control and a communication problem so staff had to anticipate needs. Resident #3 also had potential for falls related to limited mobility, impaired balance and coordination due to right-sided hemiplegia. Staff were to anticipate Resident #3's needs, be sure a call light was in reach and apply a Velcro seat belt to the wheelchair for positioning and safety. There was no plan of care to monitor the seat belt as necessary, appropriate or least restrictive. Observation on 05/18/25 at 9:50 A.M. revealed Resident #3 sitting in a wheelchair watching television with a seat belt secured with Velcro at the waist. Review of the Treatment Administration Record (TAR) from April 2025 to May 2025 revealed Resident #3's seat belt was in place each shift. Interview on 05/19/25 at 4:35 P.M. with the Director of Nursing (DON) verified Resident #3 had a Velcro seat belt ordered, and the care plan only referenced the seat belt as a fall intervention without any plan for monitoring or assessing the device as necessary, appropriate or least restrictive. Interview on 05/20/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #364 verified Resident #3 wore a seat belt daily while up in the wheelchair and had it for several months, and it was used to prevent the resident from getting up unassisted. 2. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus type two, dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of a physician order dated 09/17/24 indicated Resident #25 had an alarming Velcro seat belt to the wheelchair for positioning and safety. Another physician order dated 03/17/25 specified an additional pressure alarm was applied to the wheelchair for safety. Review of the Quarterly MDS assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Review of the care plan updated on 04/18/25 indicated Resident #25 had impaired cognition including poor memory and poor choices. Resident #25 also had potential for falls related to limited range of motion of the right lower extremity, poor balance and poor safety awareness. Staff were to be sure a call light was in reach and maintain a pressure alarm to the wheelchair to alert staff to unassisted rising. The alarming Velcro seat belt was not addressed in the plan of care, and there was no plan to monitor either the seat belt or pressure alarm as necessary, appropriate or least restrictive. Review of the TAR from April 2025 to May 2025 revealed Resident #25's seat belt and additional pressure alarm was in place each shift. Interview on 05/19/25 at 4:35 P.M. with the DON verified Resident #25 had an alarming Velcro seat belt and pressure alarm ordered, and the care plan did not address these devices as being in place or removed, nor any plan for monitoring or assessments. Observation on 05/20/25 at 1:37 P.M. with CNA #364 of Resident #25 verified there was no physician ordered seatbelt or pressure alarm in place for safety or positioning. Interview at the time of the observation with CNA #364 could not state when or why the devices were not in place. An interview on 05/20/25 at 1:52 P.M. with Resident #25 denied remembering when the alarm or seat belt was last used or whether being able to release the seat belt when it was in place. Interview on 05/20/25 at 1:54 P.M. with Registered Nursing (RN) #431 confirmed both the seat belt and pressure alarm devices were not in place as ordered and were signed off on the TAR as being checked and in place as safety interventions. RN #431 indicated the devices were removed some time ago but could not identify when but remembered it was because Resident #25 was no longer trying to get up without assistance. Review of the progress notes from September 2024 to May 2025 revealed no documentation to identify the removal of the alarming seat belt or pressure alarm for Resident #25. Observation on 05/21/25 at 12:13 P.M. of Resident #25 being transported to the dining room via wheelchair revealed no visible seat belt or alarming device in place. 3. Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses including hypertensive heart disease, chronic pain syndrome and asthma. Review of the admission MDS assessment dated [DATE] revealed it was completed on 10/04/24. The care area assessment and care plan were completed on 10/04/24. This was outside of the required timeframe for completing comprehensive care plans. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Residents #60's care plan was completed late, outside of the required 21 days after admission timeframe. 4. Review of the medical record for Resident #70 revealed an admitted [DATE] with diagnoses including intraspinal abscess and granuloma, diabetes mellitus type two and chronic pain syndrome. Review of the admission MDS assessment dated [DATE] revealed it was completed on 04/29/25. The care area assessment and care plan were completed on 04/29/25. This was outside of the required timeframe for completing comprehensive care plans. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Residents #70's care plan was completed late, outside of the required 21 days after admission timeframe. Review of the facility policy, Using the Care Plan, revised August 2006, revealed the care plan was used in developing the resident's daily care routines and was available to staff who have responsibility for providing care or services to residents.

Based on record reviews, interviews and facility policy review, the facility failed to complete and submit Minimum Data Set (MDS) assessments within the required timeframes. This affected 11 (Residents #11, #20, #21, #22, #26, #29, #41, #42, #60, #62 and #70) out of 11 residents reviewed for MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] and diagnoses included Parkinsonism, dementia and diabetes mellitus (DM) type two. Review of the quarterly MDS assessment for Resident #11 with an ARD (assessment reference date) of 12/31/24 revealed it was completed on 02/13/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 12/31/24. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #11's assessment was not completed timely. 2. Review of the medical record for Resident #20 revealed an admitted [DATE] and diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and hypertensive heart disease. Review of the annual MDS assessment for Resident #20 with an ARD date of 01/30/25 revealed it was completed on 03/06/25 and the CAA (care area assessment) completed on 03/06/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after the ARD on 01/30/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #20's assessment and CAA were not completed timely. 3. Review of the medical record for Resident #21 revealed an admitted [DATE] and diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, COPD and chronic pain syndrome. Review of the significant change MDS assessment for Resident #21 with an ARD date of 01/03/25 revealed it was completed on 02/04/25 and the CAA completed on 02/04/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after determination of change in resident status on 01/03/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #21's assessment and CAA were not completed timely. 4. Review of the medical record for Resident #22 revealed an admitted [DATE] and diagnoses included COPD and DM type two. Review of the quarterly MDS assessment for Resident #22 with an ARD date of 01/02/25 revealed it was completed on 02/26/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 01/02/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #22's assessment was not completed timely. 5. Review of the medical record for Resident #26 revealed an admitted [DATE] and diagnoses included hypertensive heart disease, dementia and Alzheimer's disease. Review of the annual MDS assessment for Resident #26 with an ARD date of 12/31/24 revealed it was completed on 02/14/25 and the CAA completed on 02/14/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after the ARD on 12/31/24. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #26's assessment and CAA were not completed timely. 6. Review of the medical record for Resident #29 revealed an admitted [DATE] and diagnoses included degeneration of nervous system due to alcohol, COPD and hypertensive heart disease. Review of the significant change assessment with an ARD date of 11/25/24 revealed it was completed on 01/15/25 and the CAA completed on 01/15/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after determination of change in resident status on 11/25/24. Review of the quarterly MDS assessment for Resident #29 with an ARD date of 12/31/24 revealed it was completed on 02/14/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 12/31/24. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #29's assessments and CAA were not completed timely. 7. Review of the medical record for Resident #41 revealed an admitted [DATE] and diagnoses included epilepsy, dementia, DM type two and congestive heart failure. Review of the quarterly MDS assessment for Resident #41 with an ARD date of 01/03/25 revealed it was completed on 02/03/25 and submitted on 03/20/25. The assessment was not completed within the required timeframe which was within 14 days after the ARD of 01/03/25, and it was not submitted timely which was within 14 days after completion on 02/03/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #41's assessment was not completed or submitted timely. 8. Review of the medical record for Resident #42 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included hypertensive heart disease and dementia. Review of the annual MDS assessment for Resident #42 with an ARD date of 01/02/25 revealed it was completed on 02/19/25 and the CAA completed on 02/19/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after the ARD of 01/02/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #42's assessment and CAA were not completed timely. 9. Review of the medical record for Resident #60 revealed an admitted [DATE] and diagnoses included hypertensive heart disease, chronic pain syndrome and asthma. Review of the admission MDS assessment for Resident #60 with an ARD date of 09/12/24 revealed it was completed on 10/04/24 and the CAA completed on 10/04/24. The assessment and CAA were not completed within the required timeframe which was within 14 calendar days after admission on 09/06/24. Review of the quarterly MDS assessment for Resident #60 with an ARD date of 01/08/25 revealed it was completed on 03/13/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 01/08/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #60's assessments were not completed timely. 10. Review of the medical record for Resident #62 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included metabolic encephalopathy and COPD. Review of the admission MDS assessment for Resident #62 with an ARD date of 01/05/25 revealed it was completed on 01/13/25 and the CAA completed on 01/13/25. The assessment and CAA were not completed within the required timeframe which was within 14 calendar days after admission on 12/29/24. Review of the discharge return not anticipated MDS assessment for Resident #62 dated 01/30/25 revealed it was completed on 03/26/25. The assessment was not completed within the required timeframe which was within 14 days after discharge on 02/04/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #62's assessments were not completed timely. 11. Review of the medical record for Resident #70 revealed an admitted [DATE] and diagnoses included intraspinal abscess and granuloma, DM type two and chronic pain syndrome. Review of the admission MDS assessment for Resident #70 with an ARD date of 04/08/25 revealed it was completed on 04/29/25 and the CAA completed on 04/29/25. The assessment and CAA were not completed within the required timeframe which was within 14 calendar days after admission on 04/01/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #70's assessment was not completed timely. Review of the facility policy, Comprehensive Assessments, revised March 2022 revealed comprehensive assessment were conducted in accordance with criteria and timeframes establish in the Resident Assessment Instrument (RAI) User Manual including admission assessments which must be completed by day 14.

Based on record reviews and interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments in the required timeframe (within 92 days from the previous assessment). This affected nine (Residents #11, #20, #21, #22, #26, #29, #41, #42 and #60) out of 11 residents reviewed for quarterly MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] and diagnoses included Parkinsonism, dementia and diabetes mellitus (DM) type two. Review of the MDS assessments for Resident #11 revealed the last quarterly assessment completed was dated 12/31/24. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #11 had no quarterly assessment completed after 12/31/24 within the required timeframe. 2. Review of the medical record for Resident #20 revealed an admitted [DATE] and diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and hypertensive heart disease. Review of MDS assessments for Resident #20 revealed an annual assessment was completed dated 01/03/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #20 had no quarterly assessment completed after 01/03/25 within the required timeframe. 3. Review of the medical record for Resident #21 revealed an admitted [DATE] and diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, COPD and chronic pain syndrome. Review of MDS assessments for Resident #21 revealed a significant change assessment was completed dated 01/03/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #21 had no quarterly assessment completed after 01/03/25 within the required timeframe. 4. Review of the medical record for Resident #22 revealed an admitted [DATE] and diagnoses included COPD and DM type two. Review of MDS assessments for Resident #22 revealed the last quarterly assessment completed was dated 01/02/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #22 had no quarterly assessment completed after 01/02/25 within the required timeframe. 5. Review of the medical record for Resident #26 revealed an admitted [DATE] and diagnoses included hypertensive heart disease, dementia and Alzheimer's disease. Review of MDS assessments for Resident #26 revealed an annual assessment was completed dated 12/31/24. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #26 had no quarterly assessment completed after 12/31/24 within the required timeframe. 6. Review of the medical record for Resident #29 revealed an admitted [DATE] and diagnoses included degeneration of nervous system due to alcohol, COPD and hypertensive heart disease. Review of MDS assessments for Resident #29 revealed the last quarterly assessment completed was dated 12/31/24. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #29 had no quarterly assessment completed after 12/31/24 within the required timeframe. 7. Review of the medical record for Resident #41 revealed an admitted [DATE] and diagnoses included epilepsy, dementia, DM type two and congestive heart failure. Review of MDS assessments for Resident #41 revealed the last quarterly assessment completed was dated 01/03/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #41 had no quarterly assessment completed after 01/03/25 within the required timeframe. 8. Review of the medical record for Resident #42 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included hypertensive heart disease and dementia. Review of MDS assessments for Resident #42 revealed an annual assessment was completed dated 01/02/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #42 had no quarterly assessment completed after 01/02/25 within the required timeframe. 9. Review of the medical record for Resident #60 revealed an admitted [DATE] and diagnoses included hypertensive heart disease, chronic pain syndrome and asthma. Review of MDS assessments for Resident #60 revealed the last quarterly assessment completed was dated 01/08/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #60 had no quarterly assessment completed after 01/08/25 within the required timeframe.

Based on record review, review of insulin manufacture guidelines, observation, interview and review of facility policy, the facility failed to ensure insulin was dated after opening and failed to ensure insulin was disposed of per manufacture guidelines. This affected four (Residents #8, #11, #63, and #131) out of nine (Residents #5, #8, #11, #12, #41, #47, #63, #129, and #131) that had their insulin on the East and/or North medication cart. This had the potential to affect 12 (Residents #5, #8, #10, #11, #12, #41, #46, #47, #63, #129, #131, and #179) that had orders for insulin. The facility census was 66. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including dementia, diabetes and hypertension. Review of the May 2025 physician's orders revealed Resident #11 had an order dated 11/22/24 for Lantus solution (insulin) 100 units per milliliter (ml) inject eight units subcutaneously (SQ) once a day due to diabetes. Review of the care plan revealed Resident #11 had the potential for hypoglycemia and/or hyperglycemia related to diabetes. Interventions included Accu checks (blood sugar checks) as ordered, diabetic medications as ordered and monitoring for side effects and effectiveness. 2. Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses including diabetes, hypertension and congestive heart failure. Review of the May 2025 physician's orders revealed Resident #63 had an order for Lispro injection solution (insulin) 100 units per ml inject SQ per sliding scale for diabetes. Review of the care plan dated 02/13/25 revealed Resident #63 had diabetes. Interventions included diabetes medications as ordered by the physician, and monitoring side effects and effectiveness. 3. Review of medical record for Resident #131 revealed an admitted [DATE] with diagnoses including malignant neoplasm of bronchus or lung, and diabetes. Review of the May 2025 physician's orders revealed Resident #131 had an order for Lantus solution pen- injector (insulin) 100 units per ml inject 20 units SQ one time a day due to diabetes. Review of the undated care plan revealed Resident #131 had diabetes. Interventions included diabetes medications as ordered by the physician, and monitoring, documenting, and reporting signs of hypoglycemia and hypoglycemia to the physician. 4. Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including diabetes and congestive heart failure. Review of the May 2025 physician's orders revealed Resident #8 had an order for Degludec insulin solution pen-injector 100 units per ml inject 50 units SQ one time a day due to diabetes. Review of the undated care plan revealed Resident #8 had diabetes and was insulin dependent. Interventions included diabetes medications as ordered and monitoring, documenting, and reporting signs of hypoglycemia and hypoglycemia to the physician. Observation on 05/19/25 at 7:55 A.M. of the East medication cart with Licensed Practical Nurse (LPN) #351 revealed Resident #11's Lantus insulin pen was opened but not dated as to when it was opened, and Resident #63's Lispro insulin pen was opened and dated as opened 04/15/25. Interview on 05/19/25 at 7:55 A.M. with LPN #351 verified the above findings and revealed all insulin should be dated when it is opened. She revealed she thought insulin was only good for 30 days after it was opened but was not sure. Observation on 05/19/25 at 12:13 P.M. of the North medication cart with Registered Nurse (RN) #431 revealed Resident #131's Lantus insulin pen was opened but not dated as to when it was opened. The cart also had Resident #8's Degludec insulin pen that was also opened but not dated. Interview on 05/19/25 at 12:13 P.M. with RN #431 verified the above findings and revealed all insulin should be dated when it is opened. She revealed she was unable to determine when the insulin was opened to track when it should be discarded. Review of the Lantus insulin drug manufacture guidelines, dated 08/2022, revealed after the Lantus was opened, keep at room temperature and after 28 days throw the opened Lantus away even if it has insulin in it. Review of the Degludec insulin drug manufacture guidelines, dated 11/24, revealed storage after use recommended to keep at room temperature or refrigerated for up to eight weeks. The guideline recommended to dispose after eight weeks even if there was insulin left in the pen. Review of the Lispro insulin drug manufacture guidelines, dated 2023, revealed store opened insulin pen at room temperature and throw away the pen after 28 days even if there was still insulin left in it. Review of the facility policy labeled, Administering Medications, dated April 2019, revealed when opening a multi-dose container, the date opened was to be recorded on the container. The expiration date and/or beyond use date on the medication label was checked prior to administration. Review of the facility policy labeled, Storage of Medications, dated November 2020, revealed the facility was to store all drugs and biologicals in a safe, secure, and orderly manner. There was nothing in the policy regarding ensuring insulin was dated when opened and how long insulin was good for after opening.

Based on record review, interview, review of the facility self-reported incident (SRI) and review of the facility policy, the facility failed to ensure Primary Care Physician (PCP) #600 was notified of Resident #9's unknown injury. This affected one (Resident #9) out of one resident reviewed for notification of change in condition. The facility census was 66. Findings included: Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including congestive heart failure, muscle weakness, cirrhosis of liver, diabetes, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had impaired cognition. She required substantial to maximum assistance with toileting hygiene and lower dressing. She required partial to moderate assistance with transfers. Review of the nursing note dated 04/28/25 authored by Licensed Practical Nurse (LPN) #404 revealed Resident #9 had scattered discoloration noted during her shower. She had large discoloration to her right side including right forearm, right arm, right inner thigh, and right breast. She also had bruising on the inside of her left arm. The note revealed administration was notified, but there was no documented evidence that PCP #600 was notified of the bruising. Review of the undated care plan revealed Resident #9 had the potential for bleeding and bruising related to antiplatelet medication. Interventions included administering medications as ordered, holding medication as indicated, and monitoring for signs of bleeding/ bruising and reporting to the physician. Review of the May 2025 physician's orders revealed Resident #9 had an order for Plavix (blood thinner) 75 milligram (mg) tablet by mouth one time a day for the prevention of deep vein thrombosis (blood clot). Review of SRI tracking number 259787 with a date of discovery of 04/28/25 revealed the facility filed an incident involving Resident #9 having an injury of unknown source. The SRI revealed on 04/28/25 at 12:23 P.M. Resident #9 was in the shower room and had a large discoloration to her right side including her right forearm, right arm, right breast and right inner thigh. She also had discoloration on the inside of her left arm. Resident #9 was unaware of how the bruises occurred and denied pain. The SRI revealed the bruises were likely from a gait belt and assistance with transfers as well as Resident #9 was on Plavix. The SRI was unsubstantiated for abuse. There was no documented evidence that PCP #600 was notified of the bruising and unknown injury. Review of the incident report dated 04/28/25 and completed by LPN #404 revealed Resident #9 had scattered discoloration noted during her shower. She had large discoloration to her right side including right forearm, right breast and right inner thigh. She also had bruising to her left upper arm. Resident #9 was unaware when it had happened and denied pain. The immediate action indicated that the Director of Nursing (DON) and Administrator were notified. There was no documented evidence that PCP #600 was notified of the bruising. Interview on 05/20/25 at 7:53 A.M. with Resident #9 revealed she denied any abuse or that staff was rough during her care. She had no recollection of the incident on 04/28/25 regarding the bruising but stated, probably bumped something as she revealed, I bruise easy, always have. Interview on 05/20/25 at 4:08 P.M. with the DON verified there was no documented evidence that PCP #600 was notified of Resident #9's unknown injury (bruising to her right side including right forearm, right breast, right inner thigh and bruising to her left upper arm) that was discovered on 04/28/25. She revealed she was unsure why the nurse did not contact PCP #600 as she stated, it should have been done. Review of the facility policy labeled, Anticoagulation- Clinical Protocol, dated November 2018, revealed the staff and physician would monitor for possible complications in residents who were being anticoagulated and manage related problems. The policy revealed if a resident showed signs of excessive bruising, hematuria (blood in urine), or other evidence of bleeding the nurse would discuss the situation with the physician before giving the next scheduled dose of medication. The policy also revealed the physician would order measures to address any complications. Review of the facility policy labeled, Change in a Resident's Condition or Status, dated February 2021, revealed the facility promptly notified the resident, and the resident's physician of changes in the resident's medical/mental condition or status. The policy revealed the nurse would notify the resident's physician when there was an accident or incident involving the resident, discovery of injuries of unknown source, and/or need to alter resident's medical treatment.

Based on record reviews, interviews and facility policy review, the facility failed to provide residents and representatives with a written summary of the baseline care plan. This affected two (Residents #76 and #77) of two residents reviewed for baseline care plans. The facility census was 66. Findings include: 1. Review of the medical record for Resident #76 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included nonrheumatic aortic valve stenosis, nonrheumatic mitral valve insufficiency, pulmonary hypertension, nonrheumatic tricuspid valve insufficiency, chronic obstructive pulmonary disease, atrial fibrillation, and congestive heart failure (CHF). Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was rarely or never understood. The baseline care plan dated 02/18/25 included Resident #76's use of antibiotics for a urinary tract infection, diuretics due to CHF, cognitive status and needs for activities of daily living assistance. Review of the family conference form dated 02/21/25 revealed there was a conference held with Resident #76's family to discuss the resident's care. However, there was no evidence Resident #76, and the resident's representative received a written summary of the baseline care plan. Review of the nursing progress notes from February 2025 to March 2025 revealed no indication Resident #76 and the resident's representative received a written summary of the baseline care plan. Interview on 05/20/25 at 4:03 P.M. with MDS Coordinator #333 verified Resident #76 and the resident's representative did not receive a written summary of the baseline care plan. 2. Review of the medical record for Resident #77 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included myocardial infarction type two, malignant neoplasm of prostate, severe protein-calorie malnutrition, pulmonary fibrosis, and chronic kidney disease stage two. Review of the Admission MDS assessment dated [DATE] revealed Resident #77 had moderate cognitive impairment. The baseline care plan dated 02/05/25 included Resident #77's fall risk, plan for discharge, advanced care planning, wound prevention, cognitive status and needs for activities of daily living assistance. Review of the family conference form dated 02/06/25 revealed there was a conference held with Resident #77's family to discuss the resident's care. However, there was no evidence Resident #77, and the resident's representative received a written summary of the baseline care plan. Review of the nursing progress notes for February 2025 revealed no indication Resident #77 and the resident's representative received a written summary of the baseline care plan. Interview on 05/21/25 at 10:04 A.M. with MDS Coordinator #333 verified Resident #77 and the resident's representative did not receive a written summary of the baseline care plan. Review of the facility policy, Care Plans - Baseline, revised March 2022, revealed residents and/or representatives are provided a written summary of the baseline care plan in a language the resident/representative can understand.

Based on record review, interview and facility policy review, the facility failed to complete an annual Minimum Data Set (MDS) assessment in the required timeframe (within 366 days from the previous comprehensive assessment) for Resident #22. This affected one (Resident #22) out of 11 residents reviewed for comprehensive MDS assessments. The facility census was 66. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease and diabetes mellitus type two. Review of the MDS assessments for Resident #33 revealed the last comprehensive assessment completed was an annual MDS assessment dated [DATE]. There was no comprehensive assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #22 had no comprehensive assessment completed since 04/01/24 within the required timeframe. Review of the facility policy, Comprehensive Assessments, revised March 2022, revealed comprehensive assessments were conducted in accordance with criteria and timeframes establish in the Resident Assessment Instrument (RAI) User Manual, and Annual assessments were completed at least every 366 days.

Based on record review, interview and facility policy review, the facility failed to ensure as needed (PRN) psychotropic medication was reviewed by a practitioner after 14 days for necessity and appropriateness. This affected one (Resident #33) out of five residents reviewed for psychotropic medications. The facility census was 66. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder recurrent, adjustment disorder with anxiety, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 had severe cognitive impairment. Review of the care plan last reviewed on 03/12/25 revealed Resident #33 had potential for adverse effects from antianxiety medications and used PRN antianxiety medications for anxiety. Interventions included administering medications as ordered by a physician and monitoring/documenting side effects and effectiveness. Review of the physician orders for Resident #33 revealed a routine order dated 09/23/24 for Vistaril (a sedative/hypnotic which is a psychotropic) 25 milligrams (mg) twice daily for anxiety or agitation. Another order was added on 04/01/25 for Vistaril 25 mg every six hours PRN for anxiety or agitation. There was no duration ordered for the psychotropic. Review of the pharmacy recommendation dated 04/07/25 revealed a pharmacist requested Resident #33's PRN order for Vistaril 25 mg every six hours for anxiety be reviewed by a practitioner after 14 days as required for psychotropics. The physician did not review the medication as recommended until 05/08/25 when the physician ordered the medication to continue for three months due to anxiety. Review of the Medication Administration Record (MAR) for April 2025 indicated the PRN Vistaril order was administered on 04/07/25 and 04/29/25. Further review of the physician orders for Resident #33 revealed the PRN Vistaril order dated 04/01/25 which had no duration was changed on 05/09/25 to Vistaril 25 mg every six hours PRN for anxiety or agitation for a duration of three months. Review of the physician progress notes from 04/01/25 to 05/08/25 revealed no review of the PRN psychotropic after 14 days as required. Interview on 05/21/25 at 12:17 P.M. with Director of Nursing (DON) verified Resident #33's PRN psychotropic medication (Vistaril) was not reviewed by the physician within 14 days as required. The DON confirmed the pharmacist recommendation on 04/07/25 was not addressed timely until 05/08/25 in which the psychotropic medication continued until then. Review of the facility policy, Antipsychotic Medication Use, revised December 2016, revealed residents would not receive PRN doses of psychotropic medications unless the medication was necessary to treat a specific condition documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days required the practitioner to document the rationale for the extended order, and the duration of the PRN order would be indicated within the order.

Based on observation, interviews, record review and facility policy review, the facility failed to routinely assess seat belts and alarms for necessity, appropriateness and least restrictive. This affected two (Residents #3 and #25) out of two residents reviewed for restraints. The facility identified 13 residents (#4, #5, #9, #11, #16, #25, #26, #29, #33, #38, #52, #64 and #135) who had seat belts or alarms as restrictive devices. The facility census was 66. Findings include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, speech and language deficits following cerebrovascular disease, chronic kidney disease and vascular dementia. Review of a physician order dated 09/17/24 indicated Resident #3 had a Velcro seat belt to the wheelchair for positioning and safety. Additional medical record review for Resident #3 revealed there were no assessments completed upon application of the seat belt on 09/17/24 or thereafter for necessity, appropriateness or least restrictive. Review of the quarterly Minimum Data Set (MDS) assessment completed 03/19/25 revealed Resident #3 had moderate cognitive impairment. Review of the care plan updated on 04/18/25 indicated Resident #3 had impaired cognition with fluctuation including poor decision making, poor impulse control and a communication problem so staff had to anticipate needs. Resident #3 also had potential for falls related to limited mobility, impaired balance and coordination due to right-sided hemiplegia. Staff were to anticipate Resident #3's needs, be sure a call light was in reach and apply a Velcro seat belt to the wheelchair for positioning and safety. There was no plan of care to monitor the seat belt as necessary, appropriate or least restrictive. Observation on 05/18/25 at 9:50 A.M. revealed Resident #3 sitting in a wheelchair watching television with a seat belt secured with Velcro at the waist. The resident was unable to explain why a seat belt was in place, but when encouraged, pulled the seat belt apart with the left hand due to the right sided paralysis. Review of progress notes from September 2024 to May 2025 revealed no documentation to justify the use of or monitoring of the seat belt for Resident #3. Review of the Treatment Administration Record (TAR) from April 2025 to May 2025 revealed Resident #3's seat belt was in place each shift. Review of the nursing assistant Kardex (summary of resident information) effective 05/19/25 indicated to apply a Velcro seat belt in the wheelchair for safety. Interview on 05/19/25 at 4:35 P.M. with Director of Nursing (DON) verified Resident #3 had a Velcro seat belt ordered without any assessments to ensure it was not a restraint, necessary, appropriate and least restrictive. The care plan only referenced the seat belt as a fall intervention without any plan for monitoring or assessing the device to determine when or if the resident was able to self-release the seat belt. During the interview, the DON wrote a physician order for the nurses to monitor Resident #3's seat belt once every quarter to ensure it was not a restraint by checking to see if the resident could self-release it on command. The DON confirmed restrictive devices such as seat belts were to be assessed when applied and at least quarterly to ensure it was not a restraint. Review of the physician order written by the DON on 05/19/25 specified Resident #3 was able to release the seat belt on command and if not, it was to be reported. This check was to be completed daily every three months on the first of the month for three days, and it was to begin on 06/01/25. Interview on 05/20/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #364 confirmed Resident #3 wore a seat belt daily while up in the wheelchair and had for several months, and it was used to prevent the resident from getting up unassisted. 2. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus type two, dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder. Review of a physician order dated 09/17/24 indicated Resident #25 had an alarming Velcro seat belt to the wheelchair for positioning and safety. Another physician order dated 03/17/25 specified an additional pressure alarm was applied to the wheelchair for safety. Review of the Quarterly MDS assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Additional medical record review for Resident #25 revealed there were no assessments completed upon application of either the alarming seat belt on 09/17/24 or the pressure alarm on 03/17/25, and none thereafter for necessity, appropriateness or least restrictive. Review of progress notes from September 2024 to May 2025 revealed no documentation to justify the use of either the alarming seat belt or pressure alarm for Resident #25 or to monitor those devices. Review of the TAR from April 2025 to May 2025 revealed Resident #25's seat belt and additional pressure alarm was in place each shift. Review of the care plan updated on 04/18/25 indicated Resident #25 had impaired cognition including poor memory and poor choices. Resident #25 also had potential for falls related to limited range of motion of the right lower extremity, poor balance and poor safety awareness. Staff were to be sure a call light was in reach and maintain a pressure alarm to the wheelchair to alert staff to unassisted rising. The alarming Velcro seat belt was not addressed in the plan of care, and there was no plan to monitor either the seat belt or pressure alarm as necessary, appropriate or least restrictive. Review of the nursing assistant Kardex for Resident #25 effective 05/19/25 indicated to maintain a pressure alarm to the wheelchair to alert staff to unassisted rising. The physician ordered seat belt was not noted on the Kardex. Interview on 05/19/25 at 4:35 P.M. with the DON verified Resident #25 had an alarming Velcro seat belt and pressure alarm ordered without any assessments to ensure it was not a restraint, necessary, appropriate and least restrictive. The care plan did not address these devices with any plan for monitoring or assessments. During the interview the DON was in the process of adding physician orders for nurses to monitor Resident #25's seat belt once every quarter to ensure it was not a restraint by checking to see if the resident could self-release it on command. The DON stated restrictive devices such as seat belts and alarms were to be assessed when applied and at least quarterly to ensure it was not a restraint. Review of the physician order written by the DON on 05/19/25 specified Resident #25 was able to release the seat belt on command and if not, it was to be reported. This check was to be completed daily every three months on the first of the month for three days, and it was to begin on 06/01/25. Observation on 05/20/25 at 1:37 P.M. with CNA #364 of Resident #25 verified there was no physician ordered seatbelt or pressure alarm in place for safety or positioning. Interview at the time of the observation with CNA #364 could not state when or why the devices were not in place. An interview on 05/20/25 at 1:52 P.M. with Resident #25 denied remembering when the alarm or seat belt was last used or whether being able to release the seat belt when it was in place. Interview on 05/20/25 at 1:54 P.M. with Registered Nursing (RN) #431 confirmed both the seat belt and pressure alarm devices were not in place as ordered and were signed off on the TAR as being checked and in place as safety interventions. RN #431 indicated the devices were removed some time ago but could not identify when but remembered it was because Resident #25 was no longer trying to get up without assistance. A second review of the progress notes from September 2024 to May 2025 revealed no documentation to identify the removal of the alarming seat belt or pressure alarm for Resident #25. Observation on 05/21/25 at 12:13 P.M. of Resident #25 being transported to the dining room via wheelchair revealed no visible seat belt or alarming device in place. Review of the facility policy, Use of Restraints, revised April 2017, revealed prior to placing a resident in restraints there will be a pre-restraining assessment and review to determine the need. The assessment will be used to determine possible underlying causes of the problematic medical symptoms and if there are less restrictive interventions that may improve the symptoms. Physical restraints include devices that a resident cannot remove. When indicated the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation of the need will be documented. Review of the facility policy, Managing Falls and Fall Risk, revised March 2018, revealed position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy, and staff will document each resident's response to interventions intended to reduce falls or the risks of falling. If interventions were successful in preventing falling, staff would continue the interventions or reconsider whether the measures were still needed.

Based on closed medical record review, policy review and interview the facility failed to ensure accurate and comprehensive pressure ulcer assessments were completed in order to determine appropriate treatment and interventions to prevent the decline of pressure ulcer. Actual harm occurred as the pressure ulcer, to the heel of Resident #56 deteriorated from a blister to a broken blister before being comprehensively assessed, and then became necrotic (unstageable). The ulcer was assessed to be painful to the resident. This affected one resident (Resident #56) of 4 residents reviewed for alterations in skin integrity. Findings include: Review of Resident #56's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #56's Braden scale/skin risk assessment, dated 03/15/16 at 6:00 P.M. revealed the resident was assessed at moderate risk to develop pressure ulcers. Resident #56's admission assessment dated [DATE] at 6:00 P.M. revealed he had a surgical incision on his right hip and bruising on his outer right calf. Comments revealed: Right hip three incisions, closed, dry sterile dressing (DSD) applied no drainage. The admission assessment was signed by Registered Nurse (RN) #210. On 03/15/16 at 7:38 P.M. RN #210 documented, a small area was noted to Resident #56's right heel. A DSD was applied for comfort. The note indicated the wound nurse would assess for added direction. There was no documentation of the size or description of the wound at that time. Review of the facility's Pressure Sore Care procedure dated May, 2009 revealed Be sure to document: a. location, b. size, c. appearance, d. drainage, e. odor, f. inflammation, g. undermining, h. push pull note. Review of Resident #56's electronic medical records revealed the wound nurse, Licensed Practical Nurse (LPN) #100 did not see the resident's heel ulcer until 03/28/16 (13 days after the area was first noted), when at 2:28 P.M., she documented in a weekly progress note broken blister to the right heel 5.0 centimeters (cm) in length by 5.0 cm in width by 1.0 millimeter (mm) in depth. There was scant amount of blood drainage to the heel and the surrounding skin was intact. LPN #100 did not describe the stage of the pressure ulcer and did not describe the color or condition of the wound base. LPN #100 indicated the treatment at that time was to pad and protect the area. Under progress, LPN#100 wrote will monitor area, wife aware of area to heel that it was present on admission. Review of Resident #56's plan of care dated 04/05/16 revealed a potential for alteration in skin integrity related to limited mobility, incontinence, skin fragility, right heel wound, and poor appetite. Interventions included to apply pressure relieving air mattress to the bed with half side rails every shift, apply pressure relieving products such as cushions, foot pillows, gerisleeves every shift as ordered and Prafo Boot to the right heel. Use heel protectors until Prafo comes in per therapy/MD. On 04/05/16 at 11:27 A.M., LPN #100 described Resident #56's right heel wound as 5.0 cm in length by 5.0 cm in width by less than 1.0 millimeter (mm) in depth. There was scant amount of blood drainage to the heel and the surrounding skin was intact. The treatment indicated the area was padded and protected, an air mattress was in place and a Prafo (pressure reducing ankle foot orthotic) boot was on order. Progress indicated: will monitor area, resident when in chair pushed heels down on foot pads of wheelchair, Prafo boot on order. On 04/05/16 a progress note at 4:51 P.M. indicated a podiatrist was in to see and evaluate Resident #56's heel. The podiatrist note for 04/05/16 revealed the following: Subjective: Patient examined in wheel chair. Patient is poor historian. Patient admitted for right [MEDICAL CONDITION]. Per nursing staff when patient is in wheelchair he will push his heels down on foot pads of wheel chair, and can be very active. Patient denies being diabetic. No other pedal complaints at this time. Objective: Right foot exam: Vascular: Pulses palpable 2/4. Capillary fill time less than three seconds. Hair growth noted to digits. No varicosities noted. Skin/(Derm): Unstageable pressure ulcer noted to right lateral plantar heel measuring 5.5 cm by 4.1 cm by depth that could not be determined. No bone exposed. Intact necrotic eschar noted - stable. No clinical signs of infection noted. Scant bloody drainage, no malodor, no tracking, no tunneling. No other wounds or open [MEDICAL CONDITION]. Assessment: Unstageable pressure ulcer, right foot, pain in limb. The plan noted by the podiatrist indicated to pad and protect area, continue in offloading boot. Offload area when resting in bed. Patient currently on the [MEDICATION NAME] a urinary tract infection. Will consider Santyl (a [MEDICATION NAME] wound topical agent). Will follow up with patient in one week. Interview with Resident #56's daughter-in-law via telephone on 04/26/16 at 12:35 P.M. revealed she was present when RN #210 completed the admission assessment for Resident #56 and she was not made aware of the blister on the resident's right heel. She indicated she was made aware of the blister close to a week after the resident's admission and was informed it was about the size of a quarter. When the resident was sent to the emergency roiagnom on [DATE], she was surprised to see that his whole heel was black when the nurse took off the dressing. Interview with RN #210 on 04/26/16 at 3:45 P.M. confirmed Resident #56's daughter-in-law was present at the time of admission. RN #210 indicated she had applied a dressing on the resident's right heel blister at that time. However, RN #210 confirmed she did not measure the wound as she made a note for the wound nurse to follow up. During the onsite investigation, the facility provided no evidence the wound nurse looked at the wound until 03/28/16. Resident #56 treatment administration record did not refer to a treatment to pad and protect the right heel until 03/28/16. Interview with the director of nursing (DON) on 04/25/16 at 5:06 P.M. revealed she had been on vacation and had first looked at Resident #56's wound with LPN#100 on 03/28/16. This deficiency substantiates Complaint Number OH 941.