Every finding on record at Rose Lane Nursing and Rehabilitation

Based on observation, interview, review of the facility policy and review of the resident handbook, the facility failed ensure a clean, sanitary and homelike environment. This affected 12 residents (#32, #37, #40, #70, #77, #109, #110, #129, #131, #148, #149 and #159) out of 30 residents residing on the 300-hall (memory care). The facility census was 167.Findings include: Observation on 03/27/26 from 10:08 A.M. to 10:28 A.M. with Housekeeping Supervisor (HS) #303 revealed the following areas of concern:- In Resident #149's room, there was feces on the toilet leading down the bowl of the toilet, and the toilet looked like it had not been cleaned in a while.- In Resident #110's room, there was feces on the floor in front of the toilet.- In Resident #109's room, there was feces over the toilet and an open soiled brief filled with feces in the corner of the bathroom.- In Resident #32 and Resident #37's bathroom, there was feces on and in the toilet, and the toilet was visibly dirty.- In Resident #70, Resident #131 and Resident #159's bathroom, there was urine puddled on the riser over the toilet.- In Resident #77's room, the floor was sticky and had large amounts of food and fecal matter on the floor.- In Resident #40's room, there was a significant putrid odor and fecal matter on and in the toilet and the riser above the toilet.- In Resident #129's toilet, there was a ring with buildup, and the toilet looked like it had not been cleaned in a while.- In Resident #148's toilet, there was splattered fecal matter in the bowl of the toilet that remained even after flushing the toilet.HS #303 verified the above areas at the time of observation and indicated the rooms should not look like this. HS #303 stated housekeeping staff working the 300-hall started at 7:00 A.M., would clean office areas, staff breakroom and the unit dining room before working on the resident rooms. HS #303 confirmed all resident rooms and common areas were to be cleaned seven days a week.Interview on 03/27/26 at 10:09 A.M. with Resident #149 revealed the facility did not clean the bathroom too often and it had been a few days.Interview on 03/27/26 at 10:29 A.M. with Housekeeper #304 with HS #303 present revealed he had been assigned to clean the 300-hall (memory care) yesterday, 03/26/26. Housekeeper #304 stated he looked at all bathrooms and cleaned them all yesterday, but some rooms were 'trash and dash' meaning if the rooms did not look bad (did not further elaborate on what this entailed) then trash was done and floors were not mopped. Housekeeper #304 stated if floors were sticky, they were swept and mopped. Housekeeper #304 was then asked about the rooms identified with concerns this date and stated Resident #40 was aggressive, so her room was not cleaned at all yesterday, 03/26/26, and Resident #129's floor was clean, but he could not recall if her toilet had been cleaned on 03/26/26. Follow-up interview on 03/27/26 at 10:50 A.M. with HS #303 revealed she had last checked Housekeeper #304's work two weeks ago when he had been assigned to the 100 unit and had not checked over his work since.Interview on 03/27/26 at 12:24 P.M. with Certified Nursing Assistant (CNA) #306 did not indicate that Residents #32, #37, #40, #70, #77, #109, #110, #129, #131, #148, #149 and #159 refused housekeeping services.Interview on 03/27/26 at 12:26 P.M. with Unit Manager (UM)/Licensed Practical Nurse (LPN) #307 revealed no one on the unit refused housekeeping services.Interview on 03/27/26 at 12:33 P.M. with CNA #308 revealed while they saw housekeeping daily, the quality of the cleaning done depended on which staff it was. CNA #308 denied any residents refusing housekeeping services this week.Review of the undated document, Daily Cleaning Routine for Resident Rooms, revealed resident rooms are cleaned on a daily basis or as often as needed.bathrooms would be cleaned and stocked with paper supplies and floors would be swept, mopped and buffed.Review of the undated document, Floor Mopping Policy, revealed tiled and ceramic floors would be swept and mopped safely throughout the facility on a daily basis.Review of the undated Skilled Nursing Facility Resident Handbook revealed resident rooms, bathrooms and halls are cleaned on a daily basis by housekeeping staff and a more thorough cleaning is conducted weekly.This deficiency represents noncompliance investigated under Master Complaint Number 2797465 and Complaint Number 2790206.

Based on observation, interview, and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 160 residents who ate meals prepared by the facility's kitchen, as two residents (Resident #3 and #23) were ordered nothing by mouth and did not receive meals from the kitchen. The facility census was 162. Findings include:Observation of the kitchen on 01/28/26 from 2:18 P.M. to 3:16 P.M. revealed the following: at 2:32 P.M. the sanitizing level of a bucket of quaternary cleaner (QUAT) (a disinfectant that uses ammonium compounds) on the three compartment sink was checked with QUAT paper (testing papers made of litmus paper used to measure the concentration level) and was below the required 150-200 parts per million (ppm), at 2:33 P.M. the bucket of QUAT located near the dishwashing station was below the required 150-200ppm, at 2:34 P.M. the bucked of QUAT located in the main food preparation area was below the required 150-200ppm, a layer of dust and grime on the top and side of the juice dispenser, a bulk storage tub of sugar in the main food preparation area was unlabeled, a layer of dust and grime on top of the standing oven and steamer, a layer of grime on the wall near the fryer, a layer of grime on the wall where the hood fire suppression system was mounted, and a box of frozen hash browns was open with the interior bag unsealed.An interview on 01/29/26 at 3:06 P.M. with the Dietary Manager revealed QUAT buckets should be changed every two to three hours, there is a cleaning schedule for the kitchen, and they verified the above findings.Review of the undated facility policy titled Sanitation and Food Handling revealed sanitary conditions will be maintained and cloths when not in use would soak in appropriate sanitizing solution.Review of the facility policy titled Purchasing, Receiving, and Storage Policy, dated 01/2021 revealed all supplies would be clearly labeled.

Based on record review, interview, and observation, the facility failed to provide a dignified dining experience on the Memory Care Unit (MCU), and failed to ensure Resident #9 was provided dignity and respect at all times This affected ten residents (#10, #18, #32, #49, #69, #83, #105, #125, #139 and #142) out of 22 residents observed in the dining room, and one (Resident #9) of one resident reviewed for abuse.Findings include:1.Observation on 01/28/26 at 12:04 P.M. of the MCU dining room revealed 22 residents sitting at seven different tables. Two certified nursing assistants (CNAs), CNA #912 and CNA #937, were passing the trays from the cart in the nearby hallway. Also assisting in the dining room were Activity Director (AD) #817 and Human Resources (HR) #819. Observations on 01/28/26 at 12:05 P.M. of table one revealed Resident #18, Resident #69 and Resident #138 were all seated. Resident #138's family had walked in and took him to another dining area. Resident #69 was eating his meal while Resident #18 was looking around or watching Resident #69. At 12:15 P.M. Resident #18 stood up and walked out of the dining room without eating. Resident #69 returned to the dining room at 12:20 P.M. as Resident #18 was done with his meal and he got up and left. A CNA sat down and assisted Resident #69 with his meal. Observation on 01/28/26 at 12:06 P.M. of table two revealed Resident #32, Resident #83, Resident #125 and Resident #142 were seated. AD #817 was standing over and feeding Resident #83 for about five minutes before sitting down and assisting her once a chair was available. The other three residents did not have their meals yet. At 12:10 P.M. AD #817 and HR #819 were speaking across the table to each other while Resident #32's meal was placed in front of him. HR #819 stated she thought that he would eat it if staff handed him the food or utensil. AD #817 responded I don't think so stating he would eat it if placed in front of him. HR #819 did hand him a sandwich and he started eating it. HR #819 left the dining room. AD #817 continued to help Resident #83. At 12:15 P.M. Resident #125 had his meal in front of him. At 12:18 P.M. Resident #142 received his meal. Observation on 01/28/26 at 12:07 P.M. of table two revealed Resident #10, Resident #49, Resident #105, and Resident #129 were seated. Residents #10, #105 and #129 received their meals at 12:07 P.M. Resident #49 received his meal at 12:17 P.M. Interview on 01/28/26 at 12:50 P.M. with CNA #912 revealed there was no seating chart for the dining room. She stated the trays come on the cart in room order and they grab them off the cart in that order. They do not pass out per table. Interview on 01/28/26 at 12:56 P.M. with Unit Manager (UM) #822 revealed there was not necessarily a seating plan but they tried to be consistent on where residents sat. They passed the trays out as they pulled them off the cart. She verified the meals were not passed out at each table at the same time. Interview on 01/28/26 at 6:00 P.M. with Administrator revealed she was made aware of the concern in MCU dining room. She verified there was no specific facility policy for serving meals in the dining room. 2. Review of the Physical Abuse Self-Reported Incident (SRI) #268796 investigation revealed on 12/18/25 at 3:30 P.M., Resident #9 reported to Licensed Social Worker (LSW) #805 that he was upset with Certified Nursing Assistant (CNA) #903 who provided a shower. Resident #9 felt the CNA should had been more attentive and could have done a better job covering the resident while traveling in the hallway. An abuse and neglect in-service was started. Residents on the 100 and 200 halls were asked if they felt safe with no negative findings. Skin checks were started on residents on the 100 and 200 halls with no negative findings. The physician and family were notified. Review of Resident #9's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, anxiety disorder and other chronic pain. Resident #9 resides on the 200 hall. Review of a text message from Resident #9's daughter to the Director of Nursing (DON) dated 11/05/25 at 4:50 P.M. revealed CNA #903 walked past the daughter three times and ignored the family member who needed ice. CNA #903 was going up the other hallway and talked with another CNA and stared at the family member. It upset the daughter. Review of Resident #9's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and was dependent for showering and bathing. Review of the undated facility witness statement identified as a verbal conversation with CNA #903 revealed on 12/17/25, the aide showered Resident #9 in the shower room on the 400 hall. The resident was transported using a Hoyer mechanical lift into a wheelchair and wrapped in a bath blanket. The resident was then transported using a Hoyer mechanical lift to a shower chair. CNA #803 provided privacy while the resident showered and stood behind the wall. When the resident was finished, the resident was dried and then had another CNA on the 400 hall help Hoyer the resident back into the wheelchair. The resident was wrapped in a blanket and pushed back to the room. CNA #903 then went to the nursing station to ask for help getting the resident back to bed. The resident's feet/back were not washed as the aide thought the resident had done them himself. Review of the undated facility witness statement authored by Resident #9 revealed on 12/17/25, CNA #903 took the resident to a shower room. The resident was completely undressed but wrapped in a blanket. The shower was completed on another hallway due to the size of the shower room. During the shower, CNA #903 stood behind the wall while the resident washed the arms, torso and genital area. Once finished, CNA dried off the resident and transported the resident using a Hoyer mechanical lift back into the wheelchair and then pushed the resident back to the room. Once in the room, CNA #903 left the resident wrapped in a blanket sitting in the doorway in the wheelchair. The aide was gone for approximately 25 minutes. Review of a text message from Resident #9's daughter to the DON dated 12/18/25 at 11:16 A.M. revealed the daughter had received a call from the resident about a CNA the family had problems with before that was not supposed to be dealing with the resident. The CNA gave the resident a shower on 12/17/25 and did stuff to the resident in the morning on 12/18/25. The family did not understand why this happened. Review of a text message from the DON to Resident #9's daughter dated 12/18/25 at 1:49 P.M. revealed the facility talked to the resident and owned up to yesterday's issue with CNA #903 providing care on the 200 hall. The DON did not realize CNA #903 was assigned to the hall so that was the fault of the facility and the staff member was only over there until two and then another staff member took over. The DON also told Resident #9 that she would obtain a statement from the aide and the other residents that were having concerns so that it can be placed in the employee's file. The DON was getting statements, and the concerns would be placed in the file so disciplinary actions of these things would be addressed. Interview on 01/28/26 at 3:15 P.M. with the DON confirmed Resident #9's family member had texted her about CNA #903 on 11/05/25 and she had called the family member back to identify the concern. The DON revealed the resident's daughter had reported on 11/05/25 that they did not want CNA #903 to provide care for the resident. When questioned, the DON stated the facility did not report this to CNA #903 on 11/05/25 because the resident did not report the concern, who was alert and oriented, and the daughter had reported the concern. Interview on 01/29/26 at 6:22 A.M. with CNA #903 confirmed the incident with the shower occurred on 12/17/25 and the aide had told Resident #9 to let him know if he needed help during the shower. CNA #903 felt the resident deserved privacy and was waiting on the other side of the wall to help dry the resident off. CNA #903 confirmed both he and another staff member used a Hoyer mechanical lift and lifted the resident from the shower chair back into the wheelchair following the shower and drying the resident off. The resident was wrapped a bath blanket to roll the resident from the 400 hall shower room to the resident's room on the 200 hall because he forget to bring the resident's clothing to the shower room. CNA #903 indicated when he reached the 200 hall, he placed the resident, who was still wrapped in a bath blanket, in the resident's doorway while he went to get another staff member to assist with the Hoyer mechanical lift. CNA #903 stated the resident was in the doorway approximately 10 minutes while the other staff member finished her work in order to help him. CNA #903 denied intentional abuse or neglect. CNA #903 also confirmed Resident #9 was not provided dignity and respect at all times due to being in visual view of other residents on the 200 hall and sitting in a bath blanket in a wheelchair with no other clothing on. CNA #903 was not aware that he should not have been providing care to Resident #9 per the family's request. Review of CNA #903's schedules from 11/05/25 to 12/18/25 revealed the aide was scheduled the 100 hall on 11/20/25, 11/27/25, 12/18/25 and 200 hall on 12/17/25 (the 100 hall and 200 halls were attached to each other). Review of the Activities of Daily Living (ADLs) policy revised 04/2023 revealed staff to provide assistance to the residents for care that they were no longer able to perform on their own. The facility would encourage as much self-care as the resident was able to perform and assist with the completion of tasks unable to complete. All residents would be provided assistance, as needed, and as indicated on the care plan for bathing, toileting or incontinence care, dressing, eating, grooming, general hygiene, oral care, transfers and ambulation. The level of assistance and self-care would be resident specific.

Based on record reviews, interviews with families and staff and observations on the Memory Care Unit (MCU) the facility failed to provide meaningful activities to Resident #18. This affected Resident #18 and had the potential to affect all 27 residents on the MCU. Findings include:Review of the medical record for Resident #18 revealed an admission date of 03/22/18. Diagnoses included intracranial injury with loss of consciousness of unspecified duration, dementia, dysphagia, aphasia and major depressive disorder. Review of the annual Minimum Data Set (MDS) 3.0 dated 01/13/26 revealed Resident #18 had cognitive impairment. He was independent with walking. Review of preferences for routine revealed snacks were very important, reading and animals were not important and music was somewhat important. Review of the Activity assessment dated [DATE] completed by Resident #18's wife revealed his participation in activities was none. Resident #18 enjoyed motorcycle riding. He watched TV. He would be interested in pet visits. He would respond with prompts and cues. Review of care plan for Resident #18 revealed a goal of engaging in activities (actively or passively) such as 1:1 visits, independent leisure and group activities with assist/set-up as needed. It was initiated 03/29/18 with revision on 02/27/25. Resident #18 also had a goal of interacting with family/significant others and staff initiated on 11/25/2019 and revised on 02/27/25. Interventions included offer conversation and make eye contact, 1:1 visits and encourage participation in activities. Review of his activity participation for the past 30 days revealed the following were checked off: coffee cart (11 times), juice cart (30 times), radio (27 times), T.V. (28), beach ball (1 time), daily chronicle (30), provide new monthly activity calendar (1 time) and nails (3 times). Review of the MCU activity calendar for November 2025, December 2025 and January 2026 revealed activities such as bean bag toss, balloon toss, warm cookies and cocoa, painting, handwashing, movies, music and activities off the unit such as bingo, craft, trivia, Jeopardy and church service on Sundays. No animal visits noted. Interviews on 01/27/26 at 9:46 A.M. and 01/28/26 at 9:04 A.M. revealed Resident #18's family was concerned he was not provided enough activities to keep him busy. She realized he may not participate in an activity the whole time but wanted to see a variety of opportunities. Tour on 01/27/26 at 10:33 A.M. of the MCU revealed a long hallway after you enter the unit. The enclosed dining room was on the right which had seven tables with chairs around them. There was no one in the dining room. Going down the long hallway there were about 5 rooms on either side with some doors utilized by staff only. At the intersection was a small, nursing station on the right. The hallway intersected with another hallway (longer), making a T-shape for the unit. There was a TV lounge with couches and chairs where the hallways met and across from the nursing station. There were seven residents sitting with the TV on. Some residents had their eyes closed. One resident had an overbed table in front of her with some items to fidget with however her eyes were closed and she was not interacting with items. There were several residents wandering around and past the TV lounge including Resident #18. Observation of two activity staff pushing a cart with papers on the unit. They were engaged with each other as one was training the other. They left the unit within 20 minutes. When turning right at the nursing station there was another common room about halfway down called the parlor with a TV, some tables and chairs and some other furniture. Looked out at enclosed courtyard. There were five residents in the parlor with the TV on and the nurse with her medication cart. Several residents were roaming the hallways. The unit had minimal decorations including some framed paintings on walls. The unit had no evidence of seasonal decorations or a posted activity calendar in common area. There was no evidence of music playing in resident rooms including Resident #18's. Interview and observation on 01/27/26 at 10:43 A.M. of Certified Nursing Assistant (CNA) #912 revealed her redirecting wandering residents, including Resident #18, by nursing station. Staff did not offer any activity or task to engage resident. Interview on 01/27/26 at 11:03 with Unit Manager (UM) #822 revealed activities were usually held two to three times on MCU. She stated when there was an entertainer for the whole facility residents from MCU may be taken off the unit. She stated they get a ball out or do exercise by nursing staff. UM #822 stated activities does nails and snacks. Observation on 01/27/26 at 11:11 A.M. revealed two activity staff entered the unit with hydration cart. They left the unit at 11:24 A.M. Observation on 01/28/26 from 9:58 A.M. through 1:00 P.M. revealed no music playing including in Resident #18's room. Observation on 1/28/26 from 10:11 A.M. to 10:23 A.M. of two activity staff passing milkshakes. They were on the unit for less than 15 minutes. Review of the activity calendar revealed arts and crafts were scheduled at 10:00 A.M. There was no observation of this activity. Observation on 01/28/26 of dining room from 12:04pm.-12:57 P.M. revealed Resident #18 sitting at table while table mate ate lunch as he did not have his meal yet. Resident #18 got up after about 15 minutes. He came back at 12:20 P.M. when staff assisted him with his meal that just arrived. Interview on 01/28/26 at 5:42 P.M. with DON revealed she had been at facility for about six months. She stated she sent a letter to families in November to announce a dementia support group. DON stated she had a hydration project she started on MCU. She was researching dementia care and making plans to enhance MCU including using red plates for meals, using shadow boxes for each resident and training staff using well-known dementia expert's education/videos. DON stated she was starting to create a sensory room but it was locked and not available for residents at this time. The program would be used company wide. The program was not in place at this time. Observations and interviews on 01/29/26 from 9:05 A.M.-9:11 A.M. on MCU revealed no one was in the dining room, Interview at 9:10 A.M. with CNA #961 revealed he thought it was nail day and confirmed no activity was happening at the time. Observation of five residents in the TV lounge and no one in the parlor thought the TV was on. Interview on 01/29/26 at 9:11 A.M. with Activity Aide (AA) #829 revealed she was just passing through through the unit. She was not working on the MCU however she said she has in the past. She stated they will be getting nails done at 10:30 A.M. Review of the calendar revealed at 9:00 A.M. was supposed to be baking cookies and cocoa in the parlor and at 10:00 A.M. they were having ice cream in the parlor and 11:30 A.M. was handwashing. Nails were not mentioned for this date. AA #829 stated Resident #18 did not always participate though he may go to a sing-along or a Veteran's program. Interview and observation with AD #817 on 1/29/26 at 9:20am revealed she came to tell surveyor the Activity Aide was on her way over for the 9:00 A.M. activity but she had to complete an assessment that was due first. The AA was also training someone. At 9:22 A.M. AA #826 entered the unit with the hydration cart and snacks. AD #817 continued to say the majority of the morning should be on the unit. She stated in the afternoons they may take from one to six residents off the unit to a larger activity. There were 27 residents on MCU. AD #817 verified the calendar said Baking Cookies and Cocoa at 9:00 A.M., Ice Cream at 10:00 A.M. and Handwashing at 11:30 A.M. She stated she put handwashing on the calendar to help remind team but stated it should be a part of resident care and not considered the activity. Subsequent interview on 01/29/26 at 9:41 P.M. with Activity Director (AD) #817 revealed one of her staff was still in training but that person would be on MCU. Her staff will rotate. She stated activity staff spend the morning on the unit (9 A.M. to 12:00 P.M) as residents were more likely to participate then. She stated it was their goal to keep an activity staff on the unit. AD #817 said they were slowly introducing sensory things saying it's a project. She said there was a locked room on MCU designated for sensory however it was not available yet to residents. AD #817 described her role more as documentation and paperwork though she sometimes did activities especially parties. She stated there were two activity aides plus her Monday through Friday. On the weekends they had one activity aide. Weekend activities included bingo, current events, media room in town square and church. Nursing staff would help bring residents. She stated they did low key stuff on weekends but believed they had enough staff. She stated there were magazines and games throughout the facility. Interview and observations on 01/29/26 at 10:22 A.M. with Registered Nurse #950 revealed activities were getting better but she had previous experience with dementia units that had more gadgets and items to occupy residents. She stated there was a secured room with some sensory items but the facility was still working toward that. Observation of multiple residents coming up to the nursing station, including Resident #18, were redirected after a brief interaction with staff. No opportunities of engagement were offered. There was no observation of music playing on unit or in Resident #18's room. Interview on 01/29/26 at 3:08 P.M. revealed Resident #18's 1:1 included walking with him which lasted about three minutes. She had told the staff not to document those since it was so short. She stated they had not been marking residents as refusals. She said they were starting now. Review of letter sent to family members, dated 11/07/25, and authored by DON revealed they were announcing a dementia support group for families on MCU. It included a bibliography page for families to complete about their loved one. Review of the facility policy titled Activity Programs, last revised 08/2021, revealed Activity Directors shall plan and organize a program of activities for Residents on a group level and for individuals, to meet the objective of the department. The facility shall ensure the following protocol was followed: #2 Residents who were unable or not willing to participate in group programs shall receive 1:1 programming based on their interests, abilities and likes. Residents shall be encouraged but not forced to participate. #3 Resident refusals to participate in activities shall be recorded in the resident record.

Based on interviews, observation and resident handbook the facility failed ensure a clean homelike environment. This affected three residents (Resident #51, #172, and #178) out of five residents reviewed for physical environment. The facility census was 162. Findings Include:1. On 01/27/26 at 10:44 AM Resident #178 room revealed the bedside commode (BSC) had a small amount of urine and bowel movement (BM) in it dried and when the bathroom door was opened there was BM all around the toilet riser, toilet base and on the floor by the toilet. Resident #178 was not in the room at that time. At 10:53A.M. Resident #178 came back from getting her hair done At10:55 A.M. with Register Nurse #821unit manager and Licensed Practical Nurse (LPN) #902 stated Resident #178 takes herself to bathroom. Resident #178 stated yes, she does take herself to the bathroom and it has been a few days ago that she used her BSC. At 10:59 A.M. RN #821 cleaned up the bathroom. Observation at 1:50 P.M. of the BSC in Resident #178's room revealed it still had not been cleaned. No housekeeping has been seen on the hall.Interview on 1/28/26 at 7:53 A.M. with Housekeeper (HK) #860 revealed she worked over the weekend but did not work yesterday. HK #860 revealed on Saturday they worked the 700 and 800 hall and Sunday 200 hall. Resident rooms get cleaned everyday if there is a housekeeper on the hall and usually they have a housekeeper on each hall but on the weekends there may not be. On 01/28/26 at 11:29 A.M. RN #821 verified the BSC in Resident #178 had dried urine and BM in the bottom of the tub. RN #821 stated it should have been cleaned during housekeeping or by the Certified Nurses Assistant (CNA) that was working on the hall.2. On 01/27/2026 at 11:11 A.M. of Resident #51's room revealed the bed sheets and covers have dried brown spots, appear to be dried blood. Resident #51 stated he does not know when they change his sheets he is not in the room.On 1/29/26 at 2:39 P.M. interview with CNA #921 revealed she had been in Resident #51's room and asked him if he needs anything, but he will ring if he needs anything. CNA #921 stated linens get changed on bath days and when needed.On 01/28/2026 at 2:47 P.M. observation of Resident #51 bed sheets with CNA #920 verified small amount of smeared BM on the chuck, and multiple blood spots from Resident #51 scratching himself, also other brown areas on his flat sheet, top sheet and covers. CNA #920 stated his sheet did need to be changed and she had not noticed it during her shift.3. Interview on 01/27/2026 at10:22 A.M. with Resident #172 revealed he had been in the room for about a week. Observation of his room at that time revealed the night light on wall is loose and the electric baseboard was in disarray. The front panel of the electric heater was off at one end, and the coils appeared to be bent. Observation on 01/29/2026 at 8:40 A.M. of Resident #172's room with Maintenance Assistance #874 verified the night light on the wall was loose and the baseboard heater beside the bed was in disarray. The front panel was coming off the front of the heater and was caught on Resident #172's rollator and the coils were bent. Review of the facility Resident Handbook on page 47 revealed resident has a right to a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and clean bed and bath linens that are in good condition.This deficiency represents non-compliance invsetigated under Complaint 2685934.

Based on record reviews, interviews and observations the facility failed to assist Resident #32 with his meal per his care plan. This affected one resident (Resident #32) of one residents reviewed for meal assistance. The census was 162.Findings include: Review of the medical record for Resident #32 revealed an admission date of 09/12/24. Diagnoses included dementia, depression, anxiety, hypertension, need for assistance with personal care and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was cognitively impaired. He required set-up or clean-up assistance with eating. He was dependent for all other activities of daily living. Review of the medical nutritional assessment dated [DATE] revealed Resident #32 weighed 169.8 pounds. He ate 50-100% of meals. He was ordered a house supplement BID. Review of January 2026 orders revealed Resident #32 had an order for regular diet and thin liquids and a 4 ounce house supplement twice a day. Review of monthly weights revealed Resident #32 weighed 167.9 pounds on 11/07/25 and 161.4 on 01/06/26. Review of the care plan initiated on 09/13/24 revealed Resident #32 was at risk for decreased nutritional status and dehydration. Interventions included assisting him with meals and feeding as necessary which was initiated on 09/13/24 and revised on 01/28/26 during the survey after observations by surveyor. Other interventions included monitoring intakes and weight. Interview on 01/27/26 at 3:03 P.M. with Resident #32's daughter revealed the resident needed cued for eating. She stated when she was there for meals, she would put food in his hand and he would eat every time. She was concerned about weight loss. She believed the facility had a plan in place after she mentioned issue to them recently. Observation on 01/28/26 at 12:04 P.M. of the Memory Care Unit (MCU) dining room, where Resident #32 resided, revealed two certified nursing assistants (CNAs) #912 and #937, Activity Director (AD) #817 and Human Resources (HR) #819 passing lunch. Observation on 01/28/26 at 12:06 P.M. revealed Resident #32 was seated at the table. AD #817 was assisting Resident #83 across the table. At 12:10 P.M. AD #817 and HR #819 were speaking across the table to each other while Resident #32's meal was placed in front of him. HR #819 stated she thought that he would eat it if staff handed him the food or utensil AD #817 responded I don't think so stating he would eat it if placed in front of him. HR #819 did hand him a sandwich and he started eating it. HR #819 left the dining room and did not return. AD #817 continued to help Resident #83 across the table from Resident #32. At 12:15 P.M. Resident #32 tried to open up his packet of crackers including biting the wrapper which took him five minutes to do. At 12:21 P.M. Resident #32 was done eating his crackers. He still had a bowl of soup, potato salad and fruit, all of which were untouched. AD #817 gave a verbal cue to him from across the table however he did not attempt to pick up spoon or fork. AD #817 was still assisting other resident. At 12:28 P.M. Resident #32 closed his eyes. At 12:35 P.M., with his eyes still closed, he tried to push back from the table but the front of the chair just lifted in the air then back down. Resident #32's nose was dripping. At 12:36 P.M., CNA #912 asked him if he was done and he mumbled something. CNA #912 gathered his untouched food and removed it from the table. Interview on 01/28/26 at 12:50 P.M. with CNA #912 revealed Resident #32 usually ate independently, they monitored his meal intakes, did not write the meal intake down, but documented what she remembered. CNA #912 revealed Resident #32 ate 50% of his meal today. Interview on 01/29/26 at 9:34 A.M. with AD #817 revealed nursing staff kept her well-informed on who needed assistance. She revealed Resident #32 needed verbal cues but said it depended on the day. AD #817 revealed the resident was not a big eater but could not rule out that he was not eating as a result of not remembering to eat. Interview on 01/29/26 at 10:27 A.M. with Registered Nursing (RN) #950 revealed Resident #32's daughter was active in his care. She stated he ate well on some days but other days he did not. She stated her expectation was to allow him to try to eat on his own and assist him before taking away food. Interview on 01/29/26 at 2:34 P.M. with Director of Nursing (DON) revealed there was no specific policy for activities of daily living. She also verified Resident #32's care plan had an intervention of assisting with meals and to feed resident as needed which was initiated on 09/13/24 and then had a revision date of 01/28/26. Interview on 01/29/26 at 3:30 P.M. with HR #819 revealed she helped pass trays at least once a week as part of facility program. She was a CNA for 25 years. She had seen a CNA place food in Resident #32's hand and saw that it worked for him to start eating. She also stated she knew from experience to try different cues with residents with cognitive impairment. This deficiency represents non-compliance investigated under Complaint 2653004.

Based on observation and interviews the facility failed to ensure resident's received timely assistance to meet their needs. This affected two of two residents (Resident #180 and Resident #181) observed for call lights. The facility census was 162. Findings Include:Observation on 01/28/26 at 11:25 A.M. of the call light monitor on the 500-hall nurse's station revealed Certified Nurse Assistant (CNA) #909 was seating at the desk charting on the computer right next to the call light monitor. CNA #909 then got up and stated she had to answer the call lights. Call lights for room [ROOM NUMBER] (Resident #181) had been on for 34:54 minutes and room [ROOM NUMBER] (Resident #180) call light had been on for 43 minutes. This was verified with Licensed Practical Nurse (LPN) #971.Interview with Register Nurse (RN) #821 on 01/28/26 at11:29 A.M. revealed CNA #884 was on the hall and should have answered the call light. RN #821 verified 35 minutes was too long. RN #821 revealed Resident #181 used the call light frequently.Interview on 01/28/26 at 11:38 A.M. with LPN #902 revealed her pager was on the desk in the nurses station and did not have a chance to check the pager to see if there was a call light that needed answered because she was doing passing medication. LPN #902 revealed when she is not passing medications she will look at her pager and answer call lights.Interview on 01/29/26 at 11:48 A.M. with Resident #180 revealed he had his light on for a very long time because he could not reach his water and his personnel items because the side table was too far away. Resident #180 stated his call light is not answered timely.Interview on 01/29/26 at 11:50 A.M. with CNA #942 revealed she had four residents that needed to get up for therapy and was making her way to Resident #180. CNA #942 stated call lights need to be answered as soon as they can. Interview on 01/29/26 at 11:55 A.M. with CNA #909 revealed she was sitting at the 500-hall nurses station charting and seen on the call light monitor that two call lights need to be answered. She stated she was trying to get some charting completed before she went home and had been sitting there for about five minutes. CNA #909 stated she should have got up and answered the call lights for room [ROOM NUMBER] and 610 due to they had been on for more than 35 minutes.Interview on 01/28/26 at 11:56 A.M. with RN #821 verified 43 minutes was to long for a resident to wait to get their call light answered.

Based on interview and record review the facility failed to ensure Resident #110 was assessed properly after they returned to the facility from the dialysis center. This affected one resident sampled for dialysis care. The facility census was 162.Findings include:Review of the medical record revealed Resident #110 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, diabetes type two, kidney disease, nephritic syndrome (inflammation of the filtering units of the kidneys), and need for assistance with personal care.Review of the physician orders revealed an order dated 10/02/25 that Resident #110 received dialysis at an outside dialysis center every Tuesday, Thursday, and Saturday and the absence of an order to assess the resident on return from the dialysis center.Review of the care plan revealed a revision dated 10/03/25 that Resident #110 received dialysis with the goal of being free from complications related to dialysis and an intervention dated 09/12/25 to monitor vital signs as needed.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #110 was cognitively intact, did not reject care, was independent for most activities of daily living, and received dialysis care.Review of the progress notes from 11/29/25 to 01/28/26 revealed the absence of a post dialysis assessment on 01/27/26, 01/24/26, 01/20/26, 01/17/26, 01/15/26, 01/13/26, 01/10/26, 01/08/26, 01/04/26, 01/02/26, 12/28/25, 12/23/25, 12/16/25, 12/13/25, 12/11/25, 12/06/25, 12/04/25, and 12/02/25; and no evidence that Resident #110 refused a post dialysis assessment.An interview on 01/29/26 at 8:52 A.M. with Licensed Practical Nurse (LPN) #911 revealed they would expect an assessment to be completed when Resident #110 returned from dialysis.An interview on 01/29/26 at 8:57 A.M. with LPN #911 verified the absence of post dialysis assessments in the dialysis communication binder.An interview on 01/29/26 at 12:55 P.M. with the Director of Nursing (DON) revealed the facility does not complete post dialysis assessments.Review of the facility policy titled Dialysis Policy, dated 04/2022 revealed the facility will provide appropriate treatments related to dialysis care and that licensed nursing staff will notify the physician and dialysis center of any abnormal findings.

Based on observation, interview, record review and policy review, the facility failed to ensure enhanced barrier precautions were followed while providing Resident #181 catheter care. This affected one resident (Resident #181) of one resident reviewed for catheter care. Findings include:Review of the medical record for Resident #181 revealed an diagnosis of neurogenic bladder. Orders for indwelling catheter, and on Enhanced Barrier Precautions.Observation of Resident #181's door revealed Resident #181 was on Enhanced Barrier Precautions (EBP) and gown and gloves were to be worn while providing urinary catheter care.Observation on 01/28/2026 3:34 P.M. of Resident #181 indwelling catheter care with Certified Nursing Assistant (CNA) #884 revealed Resident #181 had a sign outside the door stating she was on EBP and a gown and gloves were to be worn while providing catheter care. Observation of CNA #884 revealed she did not wear proper Personal Protection Equipment while providing indwelling catheter care. Interview on 01/28/2026 at 3:42 P.M. with Resident #181 stated staff never wear a gown when providing catheter care.Interview on 01/28/2026 3:47 P.M. with CNA #884 verified Resident #181 was on EBP and she should have worn a gown while providing catheter care. CNA #884 stated she asked prior to completing catheter care and was told she did not need to wear a gown.Review of the facility policy Catheter Care Policy, dated 09/2023 revealed wash hands and don gloves. There was no mention of EBP need to be taken during catheter care.

Based on interview, record review, facility policy, and self-reported incident (SRI) review, the facility failed to timely report an injury of unknown origin. This affected one resident (Resident #175) of three residents reviewed for abuse. The facility census was 151. Findings included: Review of the closed medical record for Resident #175 revealed an admission date of 06/05/25 with diagnosis including but not limited to abscess of bursa right hip, methicillin resistant staphylococcus aureus infection, and Alzheimer's Disease. Resident #175 was discharged to hospital of 06/15/25. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #175 was rarely/never understood. Resident #175 was dependent on staff for all activities of daily living (ADL'S) and always incontinent of bladder and bowel. Review of the care plan dated 06/06/25 revealed Resident #175 had a ADL/self-care deficit due to weakness, dementia, bacteremia, and status post incision and drainage (I/D) right hip. Interventions included check and change every two hours, a mechanical lift with two person assist for transfers, administer medications per orders, encourage participation in ADL'S, observe for pain, and Occupational Therapy (OT) and Physical Therapy (PT) for evaluation and treat. Review of the progress note dated 06/15/25 at 7:05 P.M. called discharge status note, authored by Licensed Practical Nurse (LPN) 301 revealed Resident #175 had a change in condition with a temperature of 102.9 Fahrenheit. Review of the progress note dated 06/15/25 at 10:04 P.M., authored by LPN #400, revealed the hospital emergency department called to ask questions and requested to speak to supervisor and informed her Resident #175 was being admitted to hospital. Review of the progress noted dated 06/16/25 at 01:40 A.M., authored by Director of Nursing (DON), revealed she called the hospital and spoke with the nurse there regarding admitting diagnosis of sepsis along with several fractures to right hip, and hospital nurse verbalized that infection could cause damage to bones. Hospital nurse asked DON about falls and DON reported no falls. Review of the progress note dated 06/16/25 at 09:15 A.M., authored by DON, revealed she contacted Physician #500 regarding update on Resident #175. DON reported Physician #500 revealed due to Resident #174's age and comorbidities, and infection would cause bone breakdown. DON called Resident #175's granddaughter regarding hospitalization, and she verbalized there was no way she would have fallen. Review of the progress note dated 06/16/25 at 5:34 P.M., authored by DON, revealed she attempted several times throughout the shift to speak with hospital staff to get updated. At this time the main priority was Resident #175's abscess and potential surgery for possible drain placements. Cardiologist ordered test to determine whether Resident #175 was a candidate for surgery. Review of the facility submitted SRI history for the month of June 2025 revealed the facility did not report an injury of unknown origin related the hospitals' report of multiple fractures. Review of the investigation started on 06/16/25 revealed all twenty-four nursing staff were interviewed with no knowledge of injury of unknown origin or falls. DON instructed Registered Nurse (RN) #316, unit manager working evening shift to start whole house skin sweeps on all residents. All residents in house had full skin sweeps completed with no negative outcomes. Interview on 06/18/25 at 11:55 A.M. with DON revealed she did not consider Resident #175's three (3) new fractures and dislocated right hip an injury of unknown origin due to Physician #500 revealed it was caused by infection, therefore it was not reported to the state agency. DON reported she did start an investigation originally with interviews and statements but then stopped after the physician's report. DON denied Resident #175 having any falls during her stay. Interview on 06/18/25 at 4:13 P.M. with Physician #500 reported she received a call from the nursing home on [DATE] regarding Resident #175 change in condition of not eating and a temperature. Physician #500 reported she ordered to send the resident to hospital for evaluation. Physician #500 reported she later received a call from DON on 06/16/25 regarding Resident #175 diagnoses of multiple right hip fractures, dislocation of right hip, and infection. Physician #500 reported she does not have privileges at the hospital and the information was provided to her by the DON. Physician #500 reported she believed the infection could cause multiple fractures and hip dislocations. Interview on 06/23/25 at 6:36 A.M. with RN #316 reported she came into work on 06/15/25 for her assigned shift at 11:00 P.M. and received a text from LPN #400 stating she received a call from the hospital regarding Resident #175. LPN #400 confirmed the nurse from the hospital informed her Resident #175 had multiple new fractures to her hip and the entire hip area was dislocated, she reported it, and the hospital nurse wanted the supervisor to call her back. RN # 316 reported she called the hospital back to speak with the nurse, who was on lunch, so she spoke with the the resident physician who confirmed Resident #175 had multiple new fractures to her hip, it was dislocated, and he didn't say if the fractures were traumatic or pathological. RN # 316 reported she let the resident physician know Resident #175 had no reported injury at facility and had a bowel movement on 06/15/25. RN # 316 confirmed the resident physician told her Resident #175 was admitted for sepsis, multiple fractures of hip and hip dislocation. RN #316 reported she contacted DON and left a voice message to call back. RN #316 reported she contacted Assistant Director of Nursing (ADON) and left a voice message to call back and contacted the on call nurse manager RN #282 and reported to her what happened. Interview on 06/23/25 at 9:08 A.M. via phone with Certified Nursing Assistant (CNA) 253 verified she was not interviewed regarding the injury of unknown origin for Resident #175. (CNA) 253 reported on 06/18/25, when the agency entered the building, DON had asked her to write a statement regarding Resident #175 regarding the incident on 06/15/25. Interview on 06/23/25 at 10:26 A.M. with DON confirmed an injury of unknown origin should be reported immediately within two hours. Interview on 06/23/25 at 10:32 A.M. with Regional Nurse #501 confirmed injury of unknown origin should be reported immediately within two hours. Interview on 06/24/25 at 06:37 A.M. with RN #316 confirmed she did not initiate any education with staff. RN # 316 confirmed DON instructed her to begin skin sweeps on all residents and take statements from staff working. Interview on 06/24/25 at 10:37 A.M. with the Administrator confirmed an injury of unknown origin is to be reported with a SRI immediately within two hours. Administrator reported he follows the Ohio Department of Health regulations to report within two hours. Review of facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised 10/2022, revealed an injury is classified as an Injury of Unknown Source when both the following conditions are met: 1. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2. the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over the time. This deficiency represents non-compliance investigated under Complaint Number OH00166746.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, interview, and facility policy review, the facility failed to provide Resident #49 adequate assistance when transferring resulting in a fall with major injury. Actual harm occurred on 01/13/24 when Resident #49, who required assistance of two people for transfers, was transferred from the toilet to a shower chair by one person, resulting in a fall and non displaced fracture on left metacarpal and closed fracture of radius and ulna in left forearm, requiring orthopedic surgery. This affected one (Resident #49) of three residents reviewed for falls. The census was 159. Findings Include: Resident #49 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to hemiplegia and hemiparesis, muscle weakness, need for assistance with personal care chronic obstructive pulmonary disease, cerebrovascular disease, atrial fibrillation, chronic kidney disease (stage II), major depressive disorder, and presence of left artificial knee joint. On 01/18/24 Resident #49's diagnoses were updated to include unspecified fracture of fifth metacarpal bone (non-surgical orthopedic), unspecified fracture of shaft of left ulna (orthopedic surgery), and unspecified fracture of shaft of left radius (orthopedic surgery). Review of Resident #49's care plan, dated 12/13/22, revealed she had an activity of daily living (ADL)/Self Care deficit with an intervention of two person assistance for transfers. Review of Resident #49's Minimum Data Set (MDS) assessment, dated 12/18/23, revealed she was cognitively intact and had an impairment to one side of both her upper and lower extremities. Resident #49 required substantial to maximum assistance with toilet, tub and shower transfers. Review of Resident #49's Fall Risk assessment, dated 08/28/23, revealed a score of 11, which indicated she was a high risk for falls. Review of Resident #49's progress notes, dated 01/13/24, revealed Resident #49 fell and hit her head, causing a slight injury to her head. Resident #49 also complained of pain in her left arm as well. The facility recommended to Resident #49 and her family that she go to the hospital for evaluation, but Resident #49 wanted to have an x-ray in the facility prior to going; her family agreed to respect her wishes. Prior to the x-ray being completed, Resident #49 agreed to go to the hospital for evaluation. Her evaluation at the hospital found she had a non displaced fracture on left metacarpal (five) and closed fracture of radius and ulna in left forearm. She was sent home with pain medication and a referral to follow up with orthopedics. There was no specific information in the progress notes as to how Resident #49 fell . Review of Resident #49 Investigation Summary related to the fall, dated 01/13/24, revealed Resident #49 was being transferred from the toilet to her shower chair by one State tested Nursing Aide (STNA), instead of two staff as required. This was a contributing factor to her fall and injury. Observation on 01/19/24 at 11:26 A.M. of Resident #49 revealed the resident was in her recliner reading. Resident #49 had a sling to left arm and a cast to her wrist being elevated on a pillow. Interview with Resident #49 at this time revealed she fell and broke her arm as well as bumped her head. She went on to explain she went to the hospital and she had broken her wrist and hand bone. Resident #49 explained she uses two people to help move her at any time. Interview with Licensed Practical Nurse (LPN) #101 on 01/19/24 at 2:30 P.M. confirmed there was only one staff person with Resident #49 at the time of the fall. She confirmed her care plan and Kardex (document to assist staff with the care of residents) was for Resident #49 to have two persons during all transfers. She confirmed the outcome of the investigation found that the STNA did not ask for assistance with transferring Resident #49 when she should have. Review of facility Fall Management and Incident Intervention Protocol, dated July 2022, revealed it was the policy of the facility to conduct an investigation into the potential causative factors for each resident incident, including those classified as a fall. In addition, residents will be assessed as to their risk for sustaining a fall. Interventions will be implemented and evaluated in order to decrease the incidence of resident incidents, including falls, and to minimize the risk of injury. Nurse will assess for any injury sustained as a result of the fall after occurrence. Post fall physical assessment may include vital signs, range of motion, skin assessment, assessment of pain, and mental status. All assessment findings should be documented in the clinical record. Movement of the resident from the original site and position of the fall should only take place after assessment finding reveal that it will not cause further injury to do so. Documentation of the assessment findings and initiation of treatment interventions should be completed as appropriate. The physician and family will be made aware of the incident, as soon as possible, and evidence of notification should be documented in the clinical record. Documentation will be completed on the post fall status of the resident following the incident, in the clinical record. Any new interventions will be added to the resident plan of care and will be communicated to the relevant nursing staff. All falls will be reviewed by the focus group. Members will review events of the incident, and discuss possible recommendations and alterations to resident's plan of care, including the appropriateness of PT/OT/Restorative referral. The deficient practice was corrected on 01/15/24 when the facility implemented the following corrective actions: o On 01/13/24 Resident #49, who required assistance of two people for transfers, was transferred from the toilet to a shower chair by one person, resulting in a fall. o On 01/13/24 Resident #49 agreed to go to the hospital for evaluation and her evaluation found she had a non-displaced fracture on left metacarpal (five) and closed fracture of radius and ulna in left forearm. She was sent home with pain medication, a referral to follow up with orthopedics, and later required orthopedic surgery. o On 01/13/24 an Investigation Summary was completed related to the fall which revealed Resident #49 was being transferred from the toilet to her shower chair by one State tested Nursing Aide (STNA), instead of two staff as required. The facility determined this was a contributing factor to her fall and injury. o On 01/13/24, the On-Call Nurse audited 22 staff members to ensure they had gait belts and were carrying their Kardexes, reflecting required assistance for transfers. 21 out of 22 staff members audited on 01/13/24 required follow-up, which was immediately completed. o On 01/13/24, Nurse Managers educated all STNAs and Nurses on Kardex and gait belt use. o Starting on 01/14/24, audits were completed on four staff members to ensure gait belts and Kardexes were utilized. One staff member was reeducated on 01/14/24. Audits from 01/15/24 to 01/18/24 had no issues noted. Audits will be completed for four weeks by the Director of Nursing/Designee. o Starting on 01/14/24, audits were completed on five residents to ensure all fall prevention measures were in place as ordered. All resident audits from 01/14/24 to 01/18/24 had no issues noted. Audits will be completed for four weeks by the Director of Nursing/Designee. o The results of on-going audits will be reviewed by the Quality Assurance Performance Improvement committee to ensure compliance. This deficiency represents non-compliance identified under Complaint Number OH00150058.

Based on medical record reviews, policy review, observations, and interview, the facility failed to ensure services were provided to maintain or improve a resident's range of motion. This affected four (Residents #58, #91, #125 and #127) of five residents reviewed for limited range of motion. Findings include: 1. Review of Resident #58's medical record revealed a diagnoses of right side weakness and paralysis following a stroke and right hand contracture. Review of a care plan initiated 08/28/20 revealed Resident #58 had a self care deficit due to post stroke and right sided weakness and chronic obstructive pulmonary disease. An intervention dated 10/13/20 indicated a right resting hand splint was to be donned six to eight hours as tolerated. Check skin integrity before applying and after removing. A care plan initiated 12/02/20 revealed Resident #58 was at risk for decline in active and passive range of motion. An intervention dated 10/28/22 indicated an intervention for Restorative Nursing Services (RNS) for range of motion (ROM) as tolerated. Review of a therapy referral for Restorative Nursing Services (RNS) dated 10/27/22 revealed at the time of discharge from therapy Resident #58 was tolerating a splint to the right hand six to eight hours with skin checks every shift. Recommendations were made to encourage Resident #58 to stretch the right upper extremity with a therapy tech in all planes. Range with ten second holds working from the shoulder to the hand. Review of therapy restorative records from 08/11/23 to 11/13/23 revealed a RNS passive range of motion program (PROM) was offered/provided 43 times. On 11/13/23 at 10:26 A.M., Resident #58 was observed sitting in a chair with the fingers of her right hand flexed and appeared to have a contracture. Resident #58 stated she did not know if she wore splints or if staff did any exercises/range of motion. There were no splints on. Subsequent observations on 11/13/23 at 12:03 P.M. and 2:06 P.M. and on 11/14/23 at 11:41 A.M., 1:55 P.M., 2:06 P.M. and 2:27 P.M. revealed no splint use. Review of the November 2023 Treatment Administration Record (TAR) revealed the splint was not applied on night shift on 11/13/23. On 11/14/23 at 1:31 P.M., restorative nursing assistant #395 verified Resident #58 was on a restorative program for ROM but the program instruction were not specific to the frequency the program was to be offered. On 11/14/23 at 2:45 P.M., State tested Nursing Assistant (STNA) #391 verified Resident #58 was supposed to wear a hand splint but she had forgotten to offer the hand splint. STNA #391 did not recall applying the hand splint on 11/13/23. At 2:53 P.M., STNA #391 offered to apply the hand splint and Resident #58 agreed. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352 revealed when restorative programs were set up the programs did not designate the frequency they were to offered. It was left up to the restorative aide. When interviewed about gaps/extended periods between the programs being offered LPN #352 stated there were times when the restorative aide was pulled to work the floor or was on vacation. On the morning of 11/15/23, LPN #352 provided restorative assessments dated 04/05/23, 07/05/23 and 10/10/23. On 11/15/23 at 12:37 P.M., LPN #352 verified the restorative assessments provided were all documented on 11/14/23. 2. Review of Resident #125's medical record revealed diagnoses including stroke, heart failure and atrial fibrillation. On 09/08/23 an order was written for a resting left hand splint with wear time as tolerated. A quarterly Minimum Data Set (MDS) assessment revealed Resident #125 had functional limitation in range of motion of both lower extremities and one upper extremity. Resident #125 denied pain over the prior five days. Observations on 11/13/13 at 11:32 A.M., 2:09 P.M. and 2:20 P.M. revealed Resident #125 was observed lying in bed with no splint applied. On 11/13/25 at 2:25 P.M., State tested Nursing Assistant (STNA) #428 stated she had never seen Resident #125 wear a splint and she had not attempted to apply it. STNA #428 indicated she was unsure about Resident #125's ability to tolerate the splint. Subsequent observations on 11/14/23 at 11:48 A.M. and 2:24 P.M. revealed Resident #125 did not have a left hand splint applied. On 11/14/23 at 2:45 P.M., STNA #391 stated Resident #125 was dependent for activities of daily living. STNA #391 indicated Resident #125 would cry out in pain with splint use so it was not being applied. Observations on 11/15/23 at 9:20 A.M. and 9:35 A.M. revealed no splint use. On 11/15/23 at 9:45 A.M., Registered Nurse (RN) #394 verified Resident #125 would not wear the left hand splint because of pain. When RN #394 moved Resident #125's fingers of the left hand to check his fingernails and skin integrity he made a short groaning sound then stopped when RN #394 stopped moving his fingers. Further record review revealed a nursing note dated 11/15/23 at 10:12 A.M. which indicated nursing staff notified the restorative nurse that the splint to Resident #125's left hand was no longer fitting properly. Therapy was notified to evaluate for new orthotics. On 11/15/23 12:37 P.M., LPN #352 stated prior to that morning nobody had reported Resident #125 was not tolerating the use of the hand splint. When the nurse reported it to her LPN #352 asked if staff had been documenting any concerns regarding the splint use. The nurse confirmed for her staff were documenting the splint was being applied. LPN #352 indicated she encouraged the nurse to ensure the use of splints was being documented accurately so issues could be identified and appropriate action taken if they were unable to be utilized. 3. On 11/13/23 at 11:18 A.M., Resident #127 stated he had lost use of his entire left side after a stroke. Resident #127 indicated staff did not routinely provide exercises or don splints to his left arm. Review of Resident #127's medical record revealed diagnoses including left side weakness and paralysis following a stroke, anxiety disorder and depression. Review of a therapy referral for RNS dated 03/28/23 indicated recommendations for a program to encourage a resting hand splint to the left hand for six to eight hours and to do left arm stretching with shoulder flexion/abduction, elbow extension, wrist extension, digit extension and encourage any active range of motion of holds at end range. Review of restorative delivery records from 08/26/23 through 11/13/23 revealed active range of motion services was offered/provided eight times. Restorative records were not provided from 10/14/23 - 10/28/23. Resident #127 was hospitalized from 10/23/23 - 10/28/23. During an interview on 11/14/23 at 1:31 P.M., restorative nursing assistant #395 stated not every resident on caseload received restorative services every day. Restorative nursing assistant #395 verified the program instructions were not specific as to the frequency of the program to be delivered. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352, the restorative nurse, stated restorative programs were set up to be delivered as tolerated. There was no direction as to the frequency the programs were to be offered. LPN #352 stated some residents might need restorative services more often than other residents. LPN #352 verified there were no guidelines/orders for frequency and it would be up to the determination of the restorative aide. When interviewed regarding the gaps in delivery records LPN #352 verified the records did not reflect the restorative program was provided consistently. On the morning of 11/15/23, LPN #352 provided restorative progress notes dated 03/08/23, 06/06/23 and 08/30/23 indicating an evaluation was made of the restorative program. On 11/15/23 at 8:40 A.M., LPN #352 stated she understood the concern about the facility not designating frequency of the programs and the concern the aide was left to determine the frequency the programs were offered and if the aide was qualified to do so. On 11/15/23 at 12:37 P.M., LPN #352 verified all the restorative progress notes indicating an evaluation had been completed were documented on 11/14/23. LPN #352 stated the assessments were time consuming to document but she discussed the residents and made observations with the restorative aide and therapy and would identify if somebody was deteriorating and needed re-evaluated. 39333 4. Record review revealed Resident #91 was admitted on [DATE] to the facility with diagnoses that included but not limited to heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. Review of Resident #91's care plan dated 03/23/21 with a revision date of 08/16/21 revealed Resident #91 was art risk for decline in active range of motion (AROM) and passive range of motion (PROM) related to intolerance, decreases mobility, disease process, lack of motivation and weakness. Interventions included but not limited to assess for progress and need for program quarterly and as needed, explain procedures and equipment, offer physical and verbal cues as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #91 was cognitively intact and required extensive assistance with two staff for mobility and total dependent with two for transfer. Resident #91 had three days of passive range of motion during the seven-day look back period. Review of Resident #91's physician orders for November 2023 revealed functional maintenance program (FMP) for range of motion (ROM) as tolerated. Review of Resident #91's Kardex revealed that Resident #91 stated FMP for ROM as tolerated. Review of Resident #91's Kardex instructions dated 11/12/23 revealed staff to assist Resident #91 to provide Active Range of Motion/Passive Range of Motion to bilateral lower extremities in all planes as tolerated in supine. Perform hip flexion/extension, hip abduction/adduction, knee flexion/extension and ankle plantar flexion/dorsiflexion. Perform ten times reps to each motion or up to resident's tolerance. The number of minutes spent providing ROM was recorded as not applicable. Review of FMP tracking for Resident #91 revealed that not applicable was noted for the following dates: 10/04/23, 10/10/23, 10/11/23, 10/18/23, 11/01/23 and 11/11/23 on both shifts, 10/02/23, 10/03/23, 10/07/23, 10/21/23, 10/22/23, 10/25/23, 11/05/2, 11/06/23, 11/08/23, 11/09/23, 11/12/23 and 11/13/23 on the afternoon shift. There were no refusals on the tracking documentation. Interview on 11/13/23 at 4:04 P.M. with Resident #91 revealed that he had limited range of motion (ROM) to both legs and left arm. Resident #91 stated that at times staff assist him in moving his lower extremities and left arm. Resident #91 stated staff come in when they have time, but it is not consistent. Interview on 11/14/23 at 11:00 A.M. with Resident # 91 revealed that he must do restorative himself. Interview on 11/14/23 at 2:59 P.M. with Restorative Licensed Practical Nurse (LPN) #352 revealed that Resident # 91 is on a FMP. The State tested Nursing Assistants (STNAs) know what is expected of them because it comes up in the Kardex. LPN #352 verified that the documentation of Resident #91's FMP. Interview on 11/19/23 at 7:21 A.M. with Registered Nurse (RN) #348 revealed RN #348 does restorative when it's ordered on the treatment administration record (TAR) and was not aware of any nightshift nurse aides doing any range of motion or movement with residents. Review of the facility's Restorative Nursing policy (revised October 2014) revealed residents and/or family would be encouraged to be as actively involved as possible in their own restorative program. Restorative nursing programs that had been initiated would be maintained until either the goals had been met or, in some cases, until the likelihood that success is not imminent had been determined. Restorative nursing programs would, therefore, be provided for any resident who had been identified as having a need for such service. The services would include consistent and structured programs designed by the Restorative Nurse and carried out by floor aides and specially trained restorative aides on a day to day basis. The restorative nurse or licensed nurse would complete his/her assessment and made recommendations to the physician. A physician's order for the appropriate restorative program would be obtained based on the assessment. The physician order would specify, the content and extent (for example, the type of program, frequency and duration) of the restorative program. The restorative nurse or licensed nurse would develop a comprehensive care plan. The care plan would define functional problem, measurable goal(s) and time frames, interventions include specific approaches, frequency of services, duration and service provider. The restorative nurse or licensed nurse, along with the floor aides or restorative aides, would implement the programs and document on a daily basis. The restorative nurse or licensed nurse would re-evaluate resident restorative programs quarterly, with a significant change and as needed. Progress notes needed to describe the resident's progress/lack of progress toward goal achievement and the effectiveness/lack of effectiveness of the interventions that were utilized. Also identify any obstacles that might be slowing the progress of the restorative program(s). The restorative nurse or licensed nurse, in conjunction with the IDT would review restorative care plans and update, as appropriate, at least quarterly, with a significant change and as needed. Restorative nursing programs would be terminated and/or considered for functional maintenance programs when all goals were successfully met or the likelihood that success was not imminent had been determined.

Based on observation, medical record review, review of schedules and time punches, and interview, the facility failed to ensure there was sufficient staff to consistently provide restorative programs and to respond to call lights in a timely manner. This affected two (Residents #58, #127) of six residents reviewed for activities of daily living and two (Residents #58 and #127) of five residents reviewed for range of motion and one additional resident (Resident #140) who was identified as not having the call light responded to timely. This had the potential to affect all residents. Findings include: 1. During a resident council meeting with Residents #4, #10, #19, #28, #31, #33, #57, #64, #117 and #126 the residents had a majority consensus that the facility did not have sufficient staff with multiple residents reporting it could take up to an hour to get assistance with some residents reporting they were incontinent as a result. Residents reported there had been restorative programs that were not provided because the restorative aide got pulled to the floor and were unable to provide restorative services. On 11/14/23 at 1:31 P.M., Restorative nursing assistant #395 stated she was the only restorative aide for the facility. Restorative nursing assistant #395 stated not every resident received restorative programs every day. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352, the restorative nurse, stated restorative programs were set up to be delivered as tolerated. When interviewed regarding the gaps in delivery records for Resident #58's ambulation and range of motion restorative programs and Resident #127's transfer and range of motion restorative programs, LPN #352 stated sometimes the restorative aide was pulled to work an assignment on the floor. During August and September she believed Restorative nursing assistant #395 was being pulled to work on the floor three to four times a week. LPN #352 verified at times the therapy aide might provide restorative services for a few residents when the restorative aide was not working. Comparison of restorative nursing assistant #395's schedule and time punches which differentiated when restorative nursing assistant #395 worked as a restorative aide and when she worked on the floor revealed since 08/01/23 restorative aide #395 was on vacation from 08/01/23 to 08/05/23. Her scheduled revealed restorative nursing assistant #395 was scheduled the following days but worked the floor as a state tested nursing assistant: 08/07/23 for 8.84 hours 08/08/23 for 6.5 hours 08/10/23 for 9.95 hours 08/21/23 for 10.24 hours 08/22/23 for 8.22 hours 08/25/23 for 1.5 hours 09/09/23 for 9.25 hours 09/18/23 for 8.25 hours 09/26/23 had paid time off 09/29/23 for 8.13 hours 09/30/23 had paid time off 10/03/23 for 8.07 hours 10/17/23 for 8.53 hours 10/24/23 for 2.12 hours The facility identified 14 residents receiving restorative programs, Residents #19, #39, #53, #56, #58, #73, #88, #118, #111, #114, #122, #127, #130, and #137. 35765 2. Review of the medical record revealed Resident #140 was admitted to the facility on [DATE]. Diagnoses are trimalleolar fracture of the left lower leg, kidney disease, diabetes, nonalcoholic steatohepatitis, depression, gout, cystitis, and constipation. Review of the Five-Day Medicare Minimum Data Set assessment dated [DATE] revealed Resident #140 had intact cognition, required two assist with toilet use and was occasionally incontinent of bladder and bowel. Observation of the call light monitor device at the 500 hall nurses' station on 11/15/23 at 8:36 A.M. revealed the call light for Resident #140 was on for 36 minutes. An interview at this time with Registered Nurse #338 verified the call light had been on for 36 minutes. He called over to the 600-hall unit and asked the staff to answer the call light in Resident #140's room. Observation of the call light monitor device at the 500 hall nurse's station on 11/15/23 at 8:50 A.M. revealed the call light of Resident #140 was still on after 50 minutes. On 11/15/23 at 11/15/23 at 8:53 P.M. an interview with Resident #140 stated his call light was still on because he needed the urinal. He stated the Nursing Assistant left it on because she was passing out the breakfast trays so she was not allowed to give him the urinal while she was passing out the trays. He stated he was told it was an Ohio Department of Health regulation. His call light had now been on 53 minutes. On 11/15/23 at 8:57 A.M. an interview with Agency State tested Nursing Assistant #428 revealed she was the only aide on the 600 unit and she was feeding two other residents so she could not get to his call light. She stated the nurse could have answered the call light and given him the urinal. On 11/15/23 at 9:23 A.M. an interview with the Director of Nursing revealed the facility did not have a policy stating the staff cannot take someone to the bathroom while they are passing meal trays. She stated they just need to be aware of infection control. She stated she would like to have all call light answered within five minutes but they do not really have a specific time. She stated she does not really want them going over 15-20 minutes. On 11/16/23 at 11:21 A.M. an interview with the Administrator revealed the call light system was ridiculous and he wanted to go back to the old system. He stated he was confident the call light times will get better once they completely eliminate agency staff.

Based on observation and interview the facility failed to ensure medications were properly secured and stored and failed to ensure expired medications and supplies were timely disposed. This had the potential to effect 11 cognitively impaired and independently mobile residents (Resident #5, #50, #52, #66, #69, #81, #83, #121, #135, #154, and #404) on the the secured dementia unit and all 25 residents on the 100 unit who had the potential to receive the tubersol solution, two residents (#46 and #75) whose medications were expired on the 200 unit, and all 55 residents who reside on the 500, 600, 700, and 800 units who received stock medications from the [NAME] Terrace (500, 600, 700 and 800 units) medication storage room. The facility census was 155. Findings included: 1. Observation of the secure dementia unit on 11/19/23 at 11:08 A.M. revealed the medication cart was left in the hallway outside of room [ROOM NUMBER], unattended while Registered Nurse (RN) #344 was in the medication room down the other hallway with the door closed. There were several residents in the hallway wandering around on the unit. An interview at this time with RN #344 verified she had left the medication cart unattended and unlocked while she went to the medication room to get a medication for a resident. The facility identified 11 cognitively impaired and independently mobile residents (Resident #5, #50, #52, #66, #69, #81, #83, #121, #135, #154, and #404) on the the secured dementia unit. 48565 2. On 11/14/23 at 12:10 P.M., observation of the medication room in the 400 hall revealed one box of Multistix urinalysis dip sticks to test for urinary tract infections with an expiration date of 08/31/23. Licensed Practical Nurse (LPN) #410 verified the urinalysis test strips were expired. Observation of the medication cart in the 400 hall revealed a bottle of Biotene mouth wash, labeled for Resident #46, had an expiration date of 08/03/22. At the time of observation, LPN #410 verified the Biotene was expired. 3. On 11/14/23 at 2:55 P.M., observation of the medication room in the 100 hall revealed an open one milliliter vial of Tubersol (a multi-dose solution used for tuberculosis testing) in the refrigerator. The vial of tubersol was not labeled as to when it was opened. At the time of observation, Registered Nurse (RN) #404 verified the vial was open and was not labeled as to when it was opened. 4. On 11/15/23 at 9:55 A.M., observation of the medication storage room in the 200 hall revealed a bottle of Ketoconazole four ounces without a resident name, with an expiration date August 2023, a 60 gram bottle of nystatin without a resident name that was one quarter full with an expiration date of September 2022, Afrin nasal spray that was labeled with Resident #75's name with an expiration date of August 2023, and a bottle of Flonase nasal spray labeled with Resident #75's name with an expiration date of March 2023. The aforementioned was verified by LPN #330 at the time of observation. 5. On 11/15/23 at 10:25 A.M., observation of the medication storage room for the wing containing the 500, 600, 700, and 800 halls revealed liquid docusate sodium (a stool softener) 473 milliliters, three full bottles unopened with an expiration date of October 2023. The aforementioned was verified by RN #338 at the time of observation. Fifty five residents residing on the 500, 600, 700 and 800 halls received stock medications from the [NAME] Terrace medication storage room . On 11/15/23 at 3:00 P.M., interview with the Director of Nursing (DON) revealed that medication carts and medication storage rooms were to be checked weekly by unit managers for expired medications and non-labeled items.

Based on observations and interviews the facility failed to maintain a clean, sanitary environment This had the potential to affect eight residents (Resident #7, #29, #36, #84, #87, #100, #103, #125) for environment and all 18 residents (Resident #1, #2, #13, #20, #25, #42, #70, #74, #75 #78, #89, #99, #112, #122, #123, #126, #134, #143) on the 200 unit who used the shower room. The facility census was 155. Findings Included: 1. Observations on 11/13/23 at 9:05 A.M., 1:46 P.M., and 3:00 P.M. revealed there was fecal matter on the toilet seat and the floor in front of the toilet in the shared bathroom of Resident #29 and #103. On 11/13/23 at 3:00 P.M. an interview with State tested Nursing Assistant (STNA) #406 verified the fecal matter on the toilet seat and the floor in front of the toilet in the shared bathroom of Resident #29 and #103. She stated the 100 and 200 units did not have a housekeeper today so it was the aides' responsibility to clean up any messes. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed all the units should have at least one housekeeper scheduled daily. She stated every room and bathroom was to be cleaned daily. She stated there should have been a housekeeper on the 100 and 200 Units Further interview on 11/15/23 at 11:00 A.M. with Housekeeping Director #317 revealed on 11/13/23 the housekeeper on the 200 Unit was a no call no show but there should have been a housekeeper working on the 100 Unit. 2. Observations on 11/13/23 at 8:58 A.M., 1:45 P.M., and 3:00 P.M. revealed there was fecal matter on the toilet and toilet seat in the shared bathroom of Resident #7, #87, and #100. On 11/13/23 at 3:00 P.M. an interview with STNA #406 verified the fecal matter on the toilet and toilet seat in the shared bathroom of Resident #7, #87, and #100. She stated the 100/200 Units did not have a housekeep today so it was the aides' responsibility to clean up any messes. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed all the units should have at least one housekeeper scheduled daily. She stated every room and bathroom was to be cleaned daily. She stated there should have been a housekeeper on the 100 and 200 Units Further interview on 11/15/23 at 11:00 A.M. with Housekeeping Director #317 revealed on 11/13/23 the housekeeper on the 200 Unit was a no call no show but there should have been a housekeeper working on the 100 Unit. 3. Observation of the 200 unit shower/tub room on 11/13/23 at 2:31 P.M. revealed there was fecal matter smeared on the wall right beside the tub in three places. There was a hand print and finger mark smears down the wall. An interview at this time with STNA #345 verified there was fecal matter smeared on the wall of the 200 Unit shower/tub room. She stated she would clean it immediately. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed all the units should have at least one housekeeper scheduled daily. She stated every room and bathroom was to be cleaned daily. She stated there should have been a housekeeper on the 100 and 200 Units Further interview on 11/15/23 at 11:00 A.M. with Housekeeping Director #317 revealed on 11/13/23 the housekeeper on the 200 Unit was a no call no show but there should have been a housekeeper working on the 100 Unit. Resident #1, #2, #13, #20, #25, #42, #70, #74, #75 #78, #89, #99, #112, #122, #123, #126, #134, #143 were identified to use the 200 Hall shower/tub room. 4. Observation of the room of Resident #84's on 11/15/23 at 10:35 A.M. revealed several large orange/brown colored stains on the carpet upon entrance in to the room and on the left side of his bed. Further observations at that time revealed the carpet was sticky when you walked across it and the carpet had large wrinkles in it causing it to roll. The resident's family member was at the bedside and she stated it has been like that for awhile. On 11/15/23 at 10:40 A.M. an interview with Maintenance Director #318 revealed he did not take care of the carpet. He stated if it was up to him he would have all the carpet replaced but it was not up to him, it was up to Corporate to make that decison. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed she had told Corporate about the carpet in Resident #84's before but it had been a while so she didn't know the exact date. Further interview on 11/15/23 at 11:00 A.M. with Housekeeping Director #317 revealed she went to look at the carpet in Resident #84's room and verified it was sticky and had stains on it. She stated she asked the resident's family member if she wanted the carpet scrubbed today and the wife stated to do it the next day. She verified the carpet was wrinkled and was rolled in spots. She stated she did speak to Corporate and they stated Resident #84's room was next on the list to have the carpet replaced. 5. Observation on 11/15/23 at 1:15 P.M. revealed the positioning wedge cushion used to prop Resident #125 was soiled with a brown substance covering the wedge An interview at this time with Registered Nurse #394 revealed the wedge had tube feeding solution on it. She verified the wedge was dirty and they were using it to position the resident on his side. She stated they do not put it against his body but between the sheet and bed pad.

Based on observation, medical record review and interview with staff the facility failed to ensure Resident #36's call light was within reach. This affected one resident (Resident #36) of 36 residents observed for call lights. Findings included: Review of the medical record revealed Resident #36 was had an admitted [DATE]. Diagnoses included heart failure, borderline personality disorder, chronic obstructive pulmonary disease, major depressive disorder, schizophrenia, asthma, post-traumatic stress disorder, and auditory hallucinations. Review of the plan of care dated 05/29/14 revealed Resident #36 received psychotropic medication with potential for falls, injury potential for harmful side effects relate to schizophrenia, depression and anxiety. Intervention included to keep (the) call light within reach. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #36 had moderately impaired cognition and she had no upper extremity impairment. Observations on 11/13/23 at 9:44 AM and 10:36 A.M. revealed Resident #36's call light was laying under her bed. On 11/13/23 at 10:40 A.M. an interview with Registered Nurse #324 verified the call light for Resident #36 was under her bed and she was unable to reach the call light.

Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected two residents (Resident #410 and #411) of two residents reviewed for funds conveyance. The facility census was 155. Findings Include: 1. Resident #410 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia, generalized anxiety disorder, schizophrenia, and major depressive disorder. Resident #410 expired at the facility on [DATE]. Review of the business records for Resident #410 revealed a check in the amount of $50.13 was dispersed to the State of Ohio Treasurer on [DATE]. 2. Resident #411 was admitted to the facility on [DATE] with a readmitted [DATE] with diagnoses including, but not limited to, Alzheimer's Disease, major depressive disorder, diabetes mellitus. Resident #411 expired at the facility on [DATE]. Review of the business records for Resident #411 revealed a check in the amount of $32.12 was dispersed to the State of Ohio Treasurer on [DATE]. Interview on [DATE] at 9:13 A.M. with Business Office Manager #372 verified that Resident #410 and #411 funds were conveyed outside of required timeframe of 30 days.

Based on medical record review, policy review, and interview, the facility failed to ensure restorative programs for ambulation and/or transfers were consistently implemented and evaluated for two (Residents #58 and #127) of six residents reviewed for activities of daily living. The facility identified nine residents on restorative ambulation or transfer programs. The census was 155. Findings include: 1. Review of Resident #58's medical record revealed diagnoses including right sided weakness and paralysis following a stroke, chronic obstructive pulmonary disease, polyneuropathy, atrial fibrillation, anemia, and osteoarthritis. Review of a physical therapy (PT) discharge summary dated 08/14/23 indicated interventions provided during PT included activities to promote safe ambulation. Resident #58 had demonstrated improved tolerance to transfers and mobility with a hemi-walker (designed for individuals with the use of only one hand or arm. Lighter than a walker and more stable than a cane) with minimal episodes of loss of balance. The discharge summary indicated to facilitate Resident #58 maintaining her current level of performance and in order to prevent decline, development of and instruction in a restorative nursing program (RNP) for ambulation was completed. Review of a therapy referral for Restorative Nursing Services (RNS) form dated 08/14/23 indicated at the time of discharge from PT Resident #58 was able to ambulate 70-200 feet with a hemi-walker with close stand by assist to contact guard assist for safety and stability with the wheelchair following. Resident #58 required verbal cues for occasional safety awareness. The form indicated precautions for intermittent toe catching. RNS recommendations were made to ambulate with the hemi-walker up to 200 feet with contact guard assistance with the wheelchair following. Use a gait belt and watch for toe catch. RNS staff teaching was completed. The referral was silent as to how often the program was to be offered/provided. Review of restorative delivery records revealed between 08/14/23 and 10/13/23 the ambulation program was offered 22 times. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated walking in the room and in the corridor only occurred once or twice. All balance tests revealed Resident #58 was unsteady and only able to stabilize with staff assistance during transfers and ambulation. There were no evaluations of the restorative ambulation program located in the medical record. Review of a PT evaluation dated 10/13/23 indicated Resident #58 was referred due to a documented decline in function and a recent fall. Resident #58 presented with significant functional limitations that prevented her from returning to her prior level of function in the facility. Resident #58 was demonstrating bilateral lower extremity weakness, impaired balance, impaired functional activity tolerance, and impaired gait pattern with increased episodes of toe catching and decreased step length. Resident #58 was not likely to return to her prior level of function in the facility without skilled PT intervention. On 11/14/23 at 1:31 P.M., Restorative nursing assistant #395 stated she was the only restorative aide for the facility. Restorative nursing assistant #395 stated not every resident received restorative programs every day. Restorative nursing assistant #395 verified the restorative program was not specific to the frequency with which it was to be offered. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352, the restorative nurse, stated restorative programs were set up to be delivered as tolerated. There was no direction as to the frequency the programs were to be offered. LPN #352 stated some residents might need restorative services more often than other residents. LPN #352 verified there were no guidelines/orders for frequency and it would be up to the determination of the restorative aide. When interviewed regarding the gaps in delivery records LPN #352 stated sometimes the restorative aide was pulled to work an assignment on the floor. During August and September she believed Restorative nursing assistant #395 was being pulled to work on the floor three to four times a week. On 11/14/23 at 4:05 P.M., Therapy Director #427 stated therapy did not provide information regarding frequency with which restorative programs were to be offered because if the residents did not receive the services the stated number of days the facility would be cited. Therapy Director #427 stated she did rounds every week for residents on restorative programs and spoke to residents and staff to determine if there had been any declines. Therapy Director #427 stated although therapy had to place some residents back on therapy she could not state with certainty if it was related to failure to provide routine restorative programs. On 11/15/23 at 9:11 A.M., Restorative nursing assistant #395 stated she had been in her current position since February 2023. Restorative nursing assistant #395 stated this date she offered restorative programs every day unless she worked the unit and was only able to offer restorative programs to those residents on the unit to which she was assigned. Restorative aide #395 stated she was not documenting refusals or if a resident was not available. Restorative aide #395 provided no explanation as to why she had previously stated not every resident received restorative programs every day. Restorative nursing assistant #395 stated if the length of the programs ordered exceeded the time she had available to offer the programs she would just alternate days, providing some programs on Monday, Wednesday and Friday and other programs on Tuesday and Thursday then doing the opposite the following week unless the order designated a program was to be provided every day. Therefore, each restorative program would be offered at least five times in a 14 day period. On the morning of 11/15/23, LPN #352 provided restorative progress notes dated 04/05/23, 07/05/23 and 10/10/23 indicating an evaluation was made of the restorative program. On 11/15/23 at 8:40 A.M., LPN #352 stated she understood the concern about the facility not designating frequency of the programs and the concern the aide was left to determine the frequency the programs were offered and if the aide was qualified to do so. On 11/15/23 at 12:37 P.M., LPN #352 verified all the restorative progress notes indicating an evaluation had been completed were documented on 11/14/23. LPN #352 stated the assessments were time consuming to document but she discussed the residents and made observations with the restorative aide and therapy and would identify if somebody was deteriorating and needed re-evaluated. 2. Review of Resident #127's medical record revealed diagnoses including left sided weakness and paralysis following a stroke, hypertension, and type two diabetes mellitus. Review of a care plan initiated 05/01/23 indicated Resident #127 was at risk for decline and needed a transfer program. Interventions included providing a restorative nursing program as tolerated. Review of a PT discharge summary dated 08/25/23 indicated Resident #127 would continue a restorative nursing program (RNP) consisting of standing in the standing frame in the therapy gym up to 30 minutes. Review of restorative delivery records between 08/26/23 and 11/13/23 revealed the restorative transfer program was offered/provided eight times. Restorative records were not provided from 10/14/23 - 10/28/23. Resident #127 was hospitalized from 10/23/23 - 10/28/23. During an interview on 11/14/23 at 1:31 P.M., restorative nursing assistant #395 stated not every resident on caseload received restorative services every day. Restorative nursing assistant #395 stated Resident #127 returned from the hospital with a port coming out of his back and he had not been permitting transfers. Restorative nursing assistant #395 reported Resident #127 was transferring three times a week before being hospitalized . Before going to the hospital Resident #127 was standing for 30 minutes. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352, the restorative nurse, stated restorative programs were set up to be delivered as tolerated. There was no direction as to the frequency the programs were to be offered. LPN #352 stated some residents might need restorative services more often than other residents. LPN #352 verified there were no guidelines/orders for frequency and it would be up to the determination of the restorative aide. When interviewed regarding the gaps in delivery records LPN #352 stated sometimes the restorative aide was pulled to work an assignment on the floor. On 11/14/23 at 4:05 P.M., Therapy Director #427 stated therapy did not provide information regarding frequency with which restorative programs were to be offered because if the residents did not receive the services the stated number of days the facility would be cited. Therapy Director #427 stated she did rounds every week for residents on restorative programs and spoke to residents and staff to determine if there had been any declines. Therapy Director #427 stated although therapy had to place some residents back on therapy she could not state with certainty if it was related to failure to provide routine restorative programs. On 11/15/23 at 9:11 A.M., Restorative nursing assistant #395 stated she had been in her current position since February 2023. Restorative nursing assistant #395 gave conflicting information than what was offered on 11/14/23, stating she offered restorative programs every day unless she worked the unit and was only able to offer restorative programs to those residents on the unit to which she was assigned. Restorative aide #395 stated she was not documenting refusals or if a resident was not available. Restorative aide #395 provided no explanation as to why she had previously stated not every resident received restorative programs every day. Restorative nursing assistant #395 stated if the length of the programs ordered exceeded the time she had available to offer the programs she would just alternate days, providing some programs on Monday, Wednesday and Friday and other programs on Tuesday and Thursday then doing the opposite the following week unless the order designated a program was to be provided every day. Therefore, each restorative program would be offered at least five times in a 14 day period. On the morning of 11/15/23, LPN #352 provided restorative progress notes dated 03/08/23, 06/06/23 and 08/30/23 indicating an evaluation was made of the restorative program. On 11/15/23 at 8:40 A.M., LPN #352 stated she understood the concern about the facility not designating frequency of the programs and the concern the aide was left to determine the frequency the programs were offered and if the aide was qualified to do so. On 11/15/23 at 12:37 P.M., LPN #352 verified all the restorative progress notes indicating an evaluation had been completed were documented on 11/14/23. LPN #352 stated the assessments were time consuming to document but she discussed the residents and made observations with the restorative aide and therapy and would identify if somebody was deteriorating and needed re-evaluated. Review of the facility's Restorative Nursing policy (revised October 2014) revealed residents and/or family would be encouraged to be as actively involved as possible in their own restorative program. Restorative nursing programs that had been initiated would be maintained until either the goals had been met or, in some cases, until the likelihood that success was not imminent had been determined. Restorative nursing programs would, therefore, be provided for any resident who had been identified as having a need for such service. The services would include consistent and structured programs designed by the Restorative Nurse and carried out by floor aides and specially trained restorative aides on a day to day basis. The restorative nurse or licensed nurse would complete his/her assessment and made recommendations to the physician. A physician's order for the appropriate restorative program would be obtained based on the assessment. The physician order would specify, the content and extent (for example, the type of program, frequency and duration) of the restorative program. The restorative nurse or licensed nurse would develop a comprehensive care plan. The care plan would define functional problem, measurable goal(s) and time frames, interventions include specific approaches, frequency of services, duration and service provider. The restorative nurse or licensed nurse, along with the floor aides or restorative aides, would implement the programs and document on a daily basis. The restorative nurse or licensed nurse would re-evaluate resident restorative programs quarterly, with a significant change and as needed. Progress notes needed to describe the resident's progress/lack of progress toward goal achievement and the effectiveness/lack of effectiveness of the interventions that were utilized. Also identify any obstacles that might be slowing the progress of the restorative program(s). The restorative nurse or licensed nurse, in conjunction with the Interdisciplinary Team (IDT) would review restorative care plans and update, as appropriate, at least quarterly, with a significant change and as needed. Restorative nursing programs would be terminated and/or considered for functional maintenance programs when all goals were successfully met or the likelihood that success was not imminent had been determined.

Based on observation, review of the medical record, and interview the facility failed to ensure Resident #134 was transported to a non-emergent emergency room visit for evaluation after a fall and wound dressings were applied as ordered for Resident #46. This affected one resident (Resident #134) of eight residents reviewed for accidents and one resident (Resident #46) of three residents reviewed for pressure ulcers. The census was 155. Findings included: Review of the medical record revealed Resident #134 was admitted to the facility on [DATE]. Diagnoses included lumbar fracture, diabetes, major depressive disorder, osteoarthritis bilateral knees, respiratory failure, and kidney disease. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #134 had intact cognition. Review of the progress note dated 08/25/23 at 2:30 A.M. revealed the nurse was informed by the nursing assistant after answering his call light Resident #134 stated he had fallen out of bed. Upon entering his room he was observed in bed lying on his left side. There were no open injuries seen. Resident #134 stated he had fallen out of bed, went to the bathroom, walked back to bed and his hip had hurt the whole time he was up and moving. His vitals were obtained, all proper parties were notified. The physician ordered a stat x-ray. Review of the radiology report dated 08/25/23 revealed Resident #134 had a unilateral right hip x-ray without the pelvis done at the facility by the mobile service . The report indicated he did not have any acute osseous findings and recommendation was to repeat a multi-view imaging in one week or sooner if clinically warranted especially if symptoms continue to persist or progress. Review of the Change in Function assessment dated [DATE] at 8:49 A.M. revealed the nursing assistants report the resident's right hip pain decreased ability of the resident to complete functional mobility. Review of the Therapy Screen note dated 08/25/23 at 11:00 A.M. revealed Resident #134 had increased right hip pain and a decline in mobility since recent fall. The X-ray of the right hip was negative. Review of the Change in Function assessment dated [DATE] at 7:15 A.M. revealed Resident #134 continued to complain of right hip pain with ambulation and therapy was notified to evaluate. Resident #134 was offered an as needed pain medication and declined and stated his pain was not severe. Review of the Change in Function assessment dated [DATE] at 8:49 A.M. revealed the nursing assistants reported the resident's right hip pain decreased his ability to complete functional mobility. Review of the Therapy Screen noted dated 08/29/23 at 7:47 A.M. revealed Resident #134 was demonstrating increased right hip pain decreasing his ability to complete functional mobility and transfers. Review of the Change in Function assessment dated [DATE] at 8:50 A.M. revealed the nursing assistants reported the resident's right hip pain decreased his ability to complete functional mobility. Review of the Health Status note dated 08/29/23 at 3:18 P.M. revealed the estimated time of arrival for the transport was three to five hours. The residents responsible party and physician were updated. Resident was going to the emergency room (ER) for a magnetic resonance imaging of the head and spine along with an x-ray of the lower body. Review of the Health Status note dated 08/30/23 at 5:30 A.M. revealed the facility received a call from the transport company stating the transport would be out to transport the resident to the ER between 7:00 and 8:00 A.M. The resident and physician were aware. Review of the nurse's note dated 08/30/23 at 6:55 P.M. revealed the transport was called and Resident #134 was on the list to be transported to the hospital but were unable to give an estimated time. Review of the Nurse's note dated 08/31/23 at 11:30 A.M. the transport showed up to transport Resident #134 to the hospital. Review of the radiology cat scan report from the emergency room dated 08/31/23 revealed Resident #134 had an acute comminuted mildly displaced fracture of the right superior pubic ramus with an extension into the pubic body, acute nondisplaced transverse fracture of the right inferior pubic ramus, acute non displaced fracture of the right L5 transverse process and the right S1 articular facet with inferior extension in the right sacral ala. Review of the emergency room report dated 08/31/23 revealed Resident #134 was admitted to the ER for evaluation of right hip pain. The resident stated he fell out of bed on 08/24/23 after having a nightmare. He stated his pain has been localized to the right hip. He stated they did do x-ray at the nursing home but they were negative however his pain was getting progressively worse, He stated prior to the fall he was able to ambulate with a cane but since the fall he has been using a wheelchair the majority of the time. Review of the Nurse's note dated 09/01/23 at 1:18 A.M. revealed Resident #134 returned from the ER with a diagnosis of a multiple pubic rami fracture and fracture of traverse process of lumbar vertebra. He had new orders for Percocet 5-325 milligrams every six hours as needed for five days. Resident was to follow up with the orthopedic surgeon. He was resting in bed with the call light within in reach. The physician was notified. On 11/15/23 at 3:30 P.M. an interview with Resident #134 revealed after his fall, he was in a lot of pain. He stated they did an x-ray the next day and it was negative. He stated he was not able to walk so he was using a wheelchair. He stated he started working with therapy and the pain got worse. He stated therapy told him they thought his pelvis and they decided to send him to the hospital to get an x ray but it took three days to get him transport to the hospital and he does not know why. He stated his pelvis was broken. He stated he used the wheelchair for a while then went to a rollator walker and now he was using a cane. He stated they only had Tylenol to give him but he did not really want to take anything because he does not like to take pain medications. He stated it only really hurt when he tried to walk. On 11/16/23 at 9:25 A.M. an interview with the Director of Nursing revealed they had discussed his condition and the fact the non-emergency transport was taking too long and the resident stated he was okay to wait. She verified there was no documentation he stated he was okay with waiting or the physician stated it was okay for him to wait. On 11/16/23 at 10:10 A.M. an interview with Licensed Practical Nurse #352 revealed Resident #134 had two x-rays done at the facility, one in 08/25/23 and another one done on 08/31/23, with both stating he did not have any fractures. She stated he did not complain of any pain until 08/28/23. She stated he was offered pain medication and declined. She stated he was okay with waiting on the transport but verified there was no documentation the physician was notified or documentation he was okay with waiting for the transport. 48565 2. Record review for Resident #46 revealed an admitted [DATE]. Diagnoses included congestive heart failure, Alzheimer's Disease, protein-calorie malnutrition, anxiety, dysphasia, and peripheral vascular disease. Review of the Braden assessment, dated 09/30/23, revealed a score of 13 (moderate risk for skin breakdown). A review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/02/23, revealed Resident #46 was at risk of developing pressure ulcers and did not have an open area to the skin at that time. A review of the care plan, dated 10/11/23, revealed Resident #46 was to have moisture barrier cream after each incontinent episode, a pressure reducing cushion to wheelchair and bed. Resident #46 was also to have a Braden assessment (a scoring system for the measurement for skin break down potential) quarterly. A review of wound assessments revealed moisture associated skin damage (MASD) acquired 10/12/23. The initial measurements were 1.0 centimeter (cm) long by 1.0 cm wide by 0.1 cm deep. An order for barrier cream and a foam dressing were ordered on this date. Physician orders included a pressure reducing mattress to bed and to cleanse coccyx area with normal saline, pat dry apply topical treatment and cover with bordered foam. The dressing was to be changed three times per week on Tuesday, Thursday, and Saturday and as needed. A review of the weekly skin assessment, dated 11/09/23, revealed the MASD was improving with measurements of 0.3 cm long by 0.3 cm wide by 0.1 cm deep. On 11/13/23 at 9:15 AM, interview with Resident #46 stated she had a sore on her bottom. On 11/13/23 at 1:30 PM, observation revealed Resident #46 did not have a dressing applied to the coccyx. This was verified by Licensed Practical Nurse (LPN) #410 at the time of observation. On 11/16/23 at 8:45 AM, interview with Registered Nurse (RN) #387 and RN #404 revealed direct care staff were notified by nursing of dressing needs during shift report and staff was to notify nursing if a wound dressing was off or soiled.

Based on observations, review of the medical record and interview the facility failed to ensure fall interventions were in place for Resident #36, and failed to ensure medications were not left at the bedside for Residents #147 and #355. This affected three residents (Resident #36, #147 and #335) of eight residents reviewed for accidents. Findings included: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included heart failure, borderline personality disorder, chronic obstructive pulmonary disease, suicidal ideation, major depressive disorder, schizophrenia, asthma, post-traumatic stress disorder, and auditory hallucinations. Review of the physician's orders revealed Resident #36 had an order to have a floor mat to the open side of the bed dated 01/03/23. Review of the plan of care dated 01/16/23 revealed Resident #36 had a potential for falls related to psychotropic medication use, decreased cognition, weakness, decreased mobility, obesity, and arthritis. Interventions included floor mat to open side of the bed. Review of the nurse aide Kardex revealed Resident #36 was to have a floor mat to the open side of the bed. Review of the fall risk assessment dated [DATE] revealed Resident #36 was at a higher risk for falls. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #36 had moderately impaired cognition. Observations on 11/13/23 at 9:44 AM and 10:36 A.M. revealed Resident #36 was sleeping in bed; the left side of her bed was against the wall and the floor mat was not on the floor on the open side of the bed. It was folded up against the wall. On 11/13/23 at 10:40 A.M. an interview with Registered Nurse #324 verified her mat was not on the floor beside her bed. Observation on 11/15/23 at 9:30 A.M. revealed Resident #36 was in bed sleeping, the left side of her bed was against the wall and her fall mat was not on the floor on the open side of the bed. It was folded up at the end of the bed on the floor. On 11/15/23 at 9:31 A.M. an interview with Licensed Practical Nurse #319 verified the fall mat was not on the floor per physician orders. 2. Review of the medical record revealed Resident #147 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, human immunodeficiency virus, atherosclerotic heart disease, chronic kidney disease, and COVID-19. Review of the Admission MDS dated [DATE] revealed Resident #147 had intact cognition. Review of the November 2023 physician's orders revealed Resident #147 did not have an order to have any medications, inhalers, or creams at bedside. Observation on 11/13/23 at 9:10 A.M. and 10:22 A.M. revealed there was a bottle of Ketorolac Tromethamine Ophthalmic Solution 0.5 %, a bottle of saline nasal spray, a Combivent inhale, and an albuterol inhaler on the bedside stand of Resident #147. On 11/13/23 at 10:23 A.M. an interview with Registered Nurse #404 revealed Resident #147 did not have orders for the inhalers, she verified he did not have orders to self-administer any medications or for medication to be left at bedside. On 11/13/23 at 10:24 A.M., an interview with Resident #147 revealed he had been using the inhalers, nasal spray, and eye drops. He stated they all came from the Veterans Administration. 3. Review of the medical record revealed Resident #355 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, severe protein-calorie malnutrition, atherosclerotic heart disease, respiratory failure, COVID-19, depression, anxiety disorder, hypertension, and pulmonary nodule. Review of the Admission MDS assessment dated [DATE] revealed Resident #355 had intact cognition. Reviewed of the November 2023 physician's orders revealed Resident #355 did not have an order to have any medications, inhalers, or creams at bedside. Observation on 11/13/23 at 9:25 A.M. and 10:33 A.M. revealed Resident #355 had a Incruse Ellipta inhaler, a Breo Ellipta inhaler, Combivent Respimat inhaler, ventolin inhaler and mometasone furoate 0.1% cream on his bedside stand. On 11/13/23 at 10:35 A.M. an interview with Registered Nurse #404 revealed Resident #355 only had an order for the Ventolin to be at the bedside, not the other medications. Review of the facility policy titled, Medication Administration Policy, dated 03/22 revealed the policy was to ensure medications were administered in a safe and sanitary manner. The nurse would remain with the resident until are consumed. No medication would be left at bedside with a resident that was not ordered and care planned to self-administer medications.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], review of Nursing Home Guidance from the Centers for Disease Control (CDC), review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo, review of the facility COVID-19 policy, observations and interviews, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19. This resulted in Immediate Jeopardy on [DATE] when the facility did not implement appropriate personal protective equipment (PPE) including disposable gowns, gloves, N95 respirator masks and goggles/face shields while caring for residents, did not ensure a resident who tested positive for COVID 19 (Resident #47) did not reside in a room with a resident who tested negative (Resident #126) without the guardian's knowledge. The facility failed to properly disinfect high touch areas including staff break rooms and common areas including handrails and failed to ensure appropriate hand hygiene. The lack of effective infection control practices to prevent the spread of COVID-19 placed all facility residents at risk for the likelihood of harm, complications/and or death. Facility census was 150. On [DATE] at 4:25 P.M., the Administrator, Director of Nursing (DON), Licensed Practical Nurse (LPN) Infection Preventionist #525, Regional Nurse #559 and Regional Nurse #560 were notified the Immediate Jeopardy began on [DATE] when a widespread pattern of breaks in infection control by multiple staff were observed including improper screening of visitors and staff prior to entrance to facility, incorrect use of reusable isolation gowns, staff not wearing N95 respirator masks and eye protection, breaches in appropriate handwashing, cohorting of COVID-19 positive resident with COVID-19 negative resident without knowledge of guardian, and allowing open visitation during a COVID-19 outbreak. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 6:00 P.M. the DON educated non-nursing department heads, Maintenance Director #438, Director of Therapy #573, Director of Housekeeping and Laundry Services #430, Dietary Manager #412, Activities/Admission and Marketing Director #417 and Social Service Director #532 on proper use of PPE including return demonstration on donning and doffing and hand hygiene. · On [DATE] between 6:15 P.M. and 6:30 P.M. the DON and non-nursing department heads educated all staff members and Oxygen Vendor #540 (in person and via phone). Staff members included all Management team members, all Registered Nurses (RN), all LPNs, all State tested Nursing Assistants (STNAs), all Life Enrichment staff, all Housekeeping and Laundry, all Maintenance, all Dietary, and all Therapy staff. Education included proper use of PPE including proper use/wearing of masks, eye protection, gowns and donning/doffing PPE, hand hygiene between steps if hands become contaminated, immediately after removing all PPE, handwashing during meals, routine handwashing before and after touching contaminated objects, after removing gloves, and location of additional PPE if not available on the units. · Return demonstration for proper use of PPE including how to don and doff, proper mask wearing, use of eye protection, and proper handwashing techniques will be conducted upon re-entry into the facility for all employees and contracted agency staff by the assigned 500-hall nurse and DON or designee. This will be tracked using an all-staff list and the employees name will be checked off the list once the return demonstration is properly completed. A PPE competency form will be completed during this demonstration. Agency staff will always report to the 500-hall nurse. · Contracted staff and vendors will be educated upon entry into the facility by the 500-hall nurse. This will be monitored via a separate tracking log. · Audits will be conducted by Administrator, DON, or designee to ensure proper use of PPE including masks and eye protection on four to five staff members per day for all disciplines on all shifts the first month and then four to five times per week on all shifts for all disciplines for a total of four months. The results of the audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee including Medical Director monthly to ensure and maintain compliance. · On [DATE] at 9:30 A.M., Resident #106's and Resident #126's resident representative or guardian were educated on the risks of remaining in a room with a COVID-19 positive resident including the possibility of hospitalization and death by Regional Director of Operations #560 and LPN Infection Preventionist #525. The two residents refused to move from their rooms after being educated on the risks of exposure and transmission and the possible outcomes that could occur. The physicians were notified, and the local Health Department was notified and stated continued co-habitation was appropriate. Moving forward the facility will ensure that any COVID-19 negative resident who refuses to move from a COVID-19 positive room and/or resident representative/guardian/family members will be thoroughly educated on the risks of exposure, transmission, and illness up to and including hospitalization and possible death by the administrator. Documentation of this education will be entered in the resident's clinical record. · On [DATE] at 11:00 A.M., the DON was educated by Director of Quality Assurance on how to communicate to Central Supply/ Housekeeping and Laundry Services Director #430 if demand for PPE increased for any reason IE. increase in isolation, increase in census, etc. · On [DATE] at 12:00 P.M., reusable gowns were taken out of use and replaced with disposable gowns. · On [DATE] at 2:00 P.M., Screener/STNA #566, was removed from screening and sent home due to failure to properly screen staff and visitors upon entry to the facility. Screener/STNA #566 was brought back into facility on [DATE] at 2:00 P.M. and given disciplinary action for failure to follow proper screening procedures by the Administrator. · On [DATE] at 2:00 P.M., all employees assigned to conduct screening were educated on proper screening procedures by Regional Administrator #575. The 500-hall nurse was assigned to be the designated screener on off hours. Any employee that will be assigned to conduct off hours screening will be educated by the Administrator, DON, or designee on proper screening procedures on their next assigned shift upon entry to the facility. · Audits were assigned to be conducted by Administrator or designee four to five times per day for the first month and then four to five times per week on all shift for a total of four months, to ensure proper screening procedures. The results of the audits will be reviewed by the QAPI committee including Medical Director monthly to ensure and maintain compliance. · On [DATE] at 6:00 P.M., Housekeeping and Laundry Services Director #430 were educated by the Administrator on how to conduct a daily PPE inventory, how to calculate the facility burn rate for all PPE supplies, and ordering additional supplies when needed. The PPE burn rate and daily inventory will be reported to Administrator and DON daily in morning meeting to ensure PPE levels remain compliant with need. The Administrator and DON will report compliance with PPE levels to QAPI committee monthly to ensure and maintain appropriate par levels. · On [DATE] at 6:00 P.M. all high touch surface areas were cleaned throughout the facility by housekeeping staff. · On [DATE] at 6:20 P.M. the Administrator notified all residents via letter and their families via email of the visitation policy and examples of what would qualify as a compassionate care visit. · On [DATE] at 11:00 A.M., the Director of Housekeeping #430 educated all housekeeping staff on appropriate cleaning procedures, definition of high touch areas, and frequency of cleaning high touch areas which is at least once per day or more often if necessary. · On [DATE] at 12:00 P.M., managers were educated by the DON that all compassionate care visits need to be approved by the DON to ensure they met all requirements of compassionate care visitation. · Audits will be conducted by Housekeeping Director #430 or designee four to five times per day for the first month and then four to five times per week on all shifts for a total of four months. The results of the audits will be reviewed by the QAPI committee including Medical Director monthly to ensure and maintain compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of facility documentation revealed a COVID-19 outbreak began on [DATE] when STNA #562 tested positive for COVID-19. On [DATE] there were 21 residents, who were positive for Covid 19. Eight of 24 residents residing on the 100-hall (Residents #40, #47, #72, #82, #96, #114, #119, and #497). Ten of 21 residents residing on the 200-hall (Residents #2, #9, #15, #34, #35, #37, #42, #61, #105 and #132). Three of 25 residents residing on the 300-hall (Residents #25, #63, and #88). Four residents expired with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Review of Resident #126's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was vaccinated for COVID-19 on [DATE] and [DATE]. Review of Resident #126's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition with a Brief Interview Mental Status (BIMS) score of 13. Resident #126 was COVID-19 negative. An Amended Letter of Guardianship form dated [DATE] indicated the resident had a guardian of person. Review of Resident #72's medical record revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was vaccinated for COVID-19 on [DATE] and [DATE]. Review of Resident #72's MDS 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition with a BIMS score of 14. The resident was able to make his own decisions. A friend was listed as emergency contact number one. Review of Resident #72's physician orders revealed an order dated [DATE] indicating the resident was placed in droplet isolation precautions due to COVID-19 positive diagnosis. Review of a statement dated [DATE] revealed Resident #126 signed the statement indicating he was fully aware of the risks of continuing in the current room with a COVID-19 positive roommate (Resident #72). He accepted the risks and indicated he would like to continue to stay where he was. The statement indicated the risks and education had been given to him. The risks were not included on the statement and the resident's signature was not dated. Review of a progress note dated [DATE] at 12:34 P.M. revealed Resident #126 was questioned regarding changing rooms due to roommate (Resident #72) testing positive for COVID-19 on [DATE]. The resident refused the room move. The resident was re-questioned on this date ([DATE]) and the resident continued to refuse. Further review of the medical record revealed no documentation of Resident #126's guardian being informed of the roommate's positive COVID-19 test or risks associated with Resident #126 sharing a room with Resident #72. Interview on [DATE] at 6:46 A.M. with the DON indicated the infection preventionist talked to Resident #126 about the risks and benefits of staying in a room with a COVID-19 positive roommate. The DON said the resident signed an agreement on [DATE] verifying the risks and benefits were explained to the resident. Interview on [DATE] at 7:05 A.M. with LPN Infection Preventionist #525 indicated Resident #126's guardian was not notified because the resident's BIMS score was high enough that he was able to make his own decisions. LPN Infection Preventionist #525 also indicated she discussed the possible risks and benefits with Resident #126 including pneumonia, fevers, and respiratory sickness. Upon further questioning LPN Infection Preventionist #525 confirmed she told the resident of the possibility of hospitalization and death. Interview on [DATE] at 10:00 A.M. with Epidemiologist #567 revealed she had spoken with LPN Infection Preventionist #525 in the past regarding two residents, one COVID-19 positive (Resident #47) and one COVID-19 negative (Resident #106) residing in the same room. At that time, it was her understanding there was no other room available on the same hall for the exposed resident, so she suggested to quarantine the exposed resident in place to prevent the infection from spreading to additional halls. Epidemiologist #567 said it was her understanding from the DON that there would be consistent staffing on the unit where the COVID-19 residents were residing to assist in preventing the spread of COVID-19. Epidemiologist #567 confirmed she was not made aware of Resident #72 who was diagnosed positive for COVID-19 on [DATE] and was rooming with (Resident #126) who was negative for COVID-19. 2. Observation on [DATE] at 9:08 A.M. revealed STNA #487 (who was working on the 400 unit) coming out of a resident room with prescription glasses and no face shield or goggles. Interview with STNA #487 at the time of the observation indicated she started her shift at 7:00 A.M. and the goggles that were provided did not fit over her glasses so she could not wear them. STNA #487 indicated the facility did have a face shield available; however, the administrative staff did not bring her a face shield or bigger goggles. Observation and interview on [DATE] at 9:31 A.M. with Housekeeping/Laundry Supervisor #430 revealed she and the Corporate Central Supply person ordered facility supplies. The facility used disposable and re-washable gowns. There were two storage rooms for PPE, one on 100 hall in the supervisor office and one downstairs in the storage room. Observation of the storage unit downstairs revealed multiple stacked boxes of reusable gowns, two large boxes of disposable gowns, multiple boxes of masks, gloves, goggles, and face shields. Housekeeping/Laundry Supervisor #430 stated, We have never run out of PPE. Observation on [DATE] at 10:19 A.M. revealed LPN #454 on the 300-hall dementia unit in the hallway standing at the medication administration cart. LPN #454 was not wearing eye protection. Interview with LPN #454 at the time of the observation indicated there were five residents residing on the unit who were diagnosed as COVID-19 positive and on isolation precautions. She indicated the facility was supposed to bring her a pair of goggles to wear while she was on the unit. LPN #454 revealed she wore goggles while in COVID-19 positive rooms and stated she requested eye protection from the wound nurse. Interview on [DATE] at 10:23 A.M. with RN #517 indicated the facility did not have enough personal protective equipment (PPE), and the facility did not enforce mask use. Interview on [DATE] at 10:33 A.M. with LPN #543 revealed the facility did not have eye protection that fit her properly because she wore prescription glasses, and the eye protection available did not fit over her prescription glasses. LPN #543's eye protection was observed on the medication administration cart. Interview on [DATE] at 10:42 A.M. with LPN #454 revealed everyone on the 300-hall was supposed to be under quarantine and the residents with isolation carts outside of their rooms were positive for COVID-19 and on isolation. LPN #454 stated they did not wear face shields, gowns, or gloves with the other residents; full PPE was only used with COVID-19 positive residents. LPN #454 was wearing an N95 respirator mask and prescription glasses at the time of the interview. An observation of STNA #487 on [DATE] at 10:47 A.M. revealed STNA #487 was not wearing eye protection and was wearing an N95 respirator mask with the bottom strap of the mask hanging below her chin. Interview with STNA #487 at time of observation revealed the eye protection was so scratched that she could not see when wearing it and she could not secure the bottom strap of the N95 respirator mask correctly because of her hair braids. Observation and interview with LPN #447 on [DATE] at 11:01 A.M. revealed residents on isolation for COVID-19 had two gowns, hanging side by side, on the door, one for the nurse and one for the STNAs. LPN #447 did not know which gown was to be used by which staff member. The facility had no system to designate which gown belonged to which staff. At the end of the day two clean gowns were placed on the doors for the next shift. LPN #447 confirmed Residents #9, #34, #61 and #105's room doors only had one hook to hang the two gowns. The one hook had one gown on top of the other gown. LPN #447 stated, I know we are contaminating our clothes by putting those on every time we go in the room, they are hanging on top of each other, but what are we supposed to do? This is what they told us we have to do, I am worried about taking this home to my family, we are not doing it right and they know it. LPN #447 said when she cared for the other residents on the hall who were not COVID-19 positive, she did not wear a gown. Observation of LPN #447 on [DATE] at 11:43 A.M. revealed she took the top gown on the outside of Resident #34's door and entered the room which was a COVID-19 positive room. Observation on [DATE] between 11:20 A.M. and 12:00 P.M. revealed LPN #447 and STNA #494 distributing lunch trays. Goggles were not disinfected when LPN #447 and STNA #494 exited rooms of COVID-19 positive residents and prior to entering rooms of residents who had tested negative for COVID-19. Interview with LPN #447 and STNA #494 immediately after the observation verified, they had not disinfected their goggles after exiting rooms of COVID-19 positive residents. LPN #447 and STNA #494 indicated they did not clean their goggles until the end of their shift, both stated they were never told they were supposed to clean their eye protection at other times. Observation of Maintenance #436 on [DATE] at 12:14 P.M. revealed he was at the nursing station on the 100 hall making copies. Maintenance Director #436 was not wearing eye protection. Interview with Maintenance Director #436 at the time of the observation confirmed he was not wearing goggles or a face shield; he also indicated he usually implemented the eye protection. The 100 unit had both COVID-19 positive residents who were in isolation precautions and negative residents who were not in quarantine or isolation precautions. Interview on [DATE] at 12:15 P.M. with LPN #67 revealed there were no disposable gowns immediately available. LPN #67 reported staff reused washable gowns on each shift. LPN #67 indicated the PPE bins should be stocked with disposable gowns. Observation on [DATE] at 12:47 P.M. revealed STNA #561 delivering a lunch tray to Resident #129 who was on quarantine for COVID-19. STNA #561 did not perform hand hygiene before delivering the meal tray or upon exiting the room. STNA #561 hung the reusable/washable gown she doffed with the inside of the gown touching the outside of another gown hung on the same hook. STNA #561 did not sanitize her face shield after exiting the room and proceeded to deliver a meal tray to Resident #598's room, who was also in quarantine for COVID-19. Prior to entering Resident #598's room, STNA #561 donned a used gown from the hook on the door. Prior to donning, the inside of the gown was in contact with the outside of another used gown hanging on the door. While in Resident #598's room STNA #561 was observed touching the bed control and over bed table. STNA #561 did not perform hand hygiene or disinfect her face shield on exiting the room. Observation of meal pass on the 100-hall on [DATE] at 1:02 P.M. with LPN Unit Manager #526 revealed STNA #524 donning a reusable cloth gown taken from the hall side of Resident #40's and #96's closed door. Residents #40 and #96 were in droplet transmission-based precautions as of [DATE] due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview at this time with STNA #524 confirmed she accidentally touched her clothing with the gown. Interview on [DATE] at 7:05 A.M. with the DON indicated the facility ordered disposable gowns on [DATE] because they ran out of disposable gowns on [DATE] and had to use washable cloth gowns. The DON confirmed there was no shortage from the supply company that provided the disposable isolation gowns. Interview on [DATE] at 7:05 A.M. with LPN Infection Preventionist #525 indicated on the 100-hall, the cloth isolation gowns should have been hanging inside the resident rooms. LPN Infection Preventionist #525 did not know why the gowns were hanging on the hall side of the doors. Interview on [DATE] at 7:09 A.M. with Laundry #432 indicated the facility had been using cloth isolation gowns for about five months and each floor was responsible to take the contaminated cloth isolation gowns to laundry. Interview on [DATE] at 9:24 A.M. with Housekeeping/Laundry Supervisor #430 revealed resident rooms/bathrooms were cleaned once per shift. Railings and high touch areas in the halls were disinfected three times per week. Housekeeping/Laundry Supervisor #430 stated staff did not have time to do it more than three times per week. Housekeeping/Laundry Supervisor #430 indicated she cleaned the staff breakrooms once per day. Interview on [DATE] at 9:29 A.M. with LPN Infection Preventionist #525 revealed staff stored their masks at the front of the facility, on a table with their name in a brown bag. All staff were to get a new mask every three days. Masks were to be rotated, the staff wore one mask for three days then rotated to the next mask for three days, then the third. Each staff member was responsible for monitoring the order their masks were supposed to be worn and rotated. LPN Infection Control Nurse #525 confirmed the staff were using reusable isolation gowns indicating the staff had been using the reusable gowns since the beginning of the COVID-19 pandemic. The staff were to place the gowns in the soiled container to be washed at the end of their shift and the new shift coming on was to get clean gowns, one for the nurse and one for the STNA. The gowns were to hang on the door of the resident who was in isolation and it was up to the nurse and STNA to know which gown to wear. LPN Infection Control Nurse #525 confirmed the isolation gowns that were hanging on top of each other, used by nurses and STNAs would contaminate each other and the personal clothing of the staff member donning the gown. Observation on [DATE] at 11:42 A.M. revealed a long table located in the front lobby of the facility with 83 small brown paper bags on the table. Fifty-eight of the brown bags were open at the top, exposing a variety of masks, from one to four, located in each opened bag. Some masks were folded in half and some were open with the head bands appearing stretched. Each bag had a name on the outside of the bag. Observation on [DATE] at 11:44 A.M. revealed Oxygen Vendor #540 in Resident #23's room, replacing the oxygen tubing on the resident's oxygen concentrator machine. Oxygen Vendor #540 thanked the resident and left the room without sanitizing or washing his hands prior to leaving the room. Interview with Oxygen Vendor #540 at the time of the observation confirmed he did not wash or sanitize his hands after handling the resident's oxygen tubing or prior to leaving the resident's room. Resident #23 was not in quarantine and was COVID-19 negative. Observation on the 600-unit on [DATE] at 12:00 P.M. revealed the PPE bins located outside of Residents #129, #596 and #597's rooms did not contain hand sanitizer. Interview on [DATE] at 12:20 P.M. with LPN #447 and STNA #494 revealed they worked with residents who were positive for COVID-19 and they took their breaks in the only break room available which was shared by all staff. Observation on [DATE] at 1:11 P.M. revealed STNA #496 delivering a lunch tray to Resident #133. STNA #496 commented she observed a spill and left the room to obtain towels from another room, touching the door handle before returning to the room of Resident #133 to place the towels on the floor. STNA #496 did not perform hand hygiene upon leaving Resident #133's room to obtain salt and pepper from the cart and returning to the room. STNA #496 proceeded to apply salt and pepper to the resident's food and open the milk carton. STNA #496 left Resident #133's room for the second time without washing her hands. STNA #496 proceeded to the common area where she served Resident #18's tray, touching the over bed table and the blanket that was on Resident #18. STNA #496 moved Resident #18's cup that was sitting on the overbed table, removed the plastic wrap over the food, and opened crackers and milk carton. Without washing her hands or using hand sanitizer STNA #496 proceeded to the meal cart and served Resident #111. Interview on [DATE] at 1:17 P.M. with STNA #496 verified she had not performed hand hygiene between residents and stated she was supposed to perform hand hygiene before exiting each room. STNA #496 then obtained a tray and served Residents #194 and #38 without performing hand hygiene. Observation on [DATE] at 6:50 A.M. revealed STNA #566 sitting at a desk monitoring visitors and staff as they entered. Unidentified Staff Members #569, #570 and #571 and Surveyor #572 entered the facility, and each had their temperature taken by STNA #566. STNA #566 documented the name, date, and temperature on a form. No screening questions were asked, and no screening forms were completed for Unidentified Staff Members #569, #570 and #571 or Surveyor #572. STNA #566 said there were no questions to ask. Interview on [DATE] at 9:29 A.M. with LPN Infection Preventionist #525 confirmed there was one breakroom for staff and there were no restrictions for any staff to use the breakroom. LPN Infection Preventionist #525 revealed only compassionate care visits were allowed on the floors with COVID-19 positive residents. Other visitors were permitted to visit indoors on all other halls. LPN Infection Preventionist #525 confirmed there were COVID-19 positive residents and COVID-19 negative residents residing on the 100, 200, 300 and 600 halls. On [DATE] there were three new positive cases, one on 100 hall, one on 300 hall and one on 600 hall. Interviews on [DATE] at 10:00 A.M. and 10:18 A.M. with the DON confirmed family members were visiting residents inside the facility. The DON stated, If the resident does not have COVID-19, all the family has to do is call and say I want to visit and they can visit, they don't need a reason. Every resident visit is considered compassionate care. If the resident has COVID then the visit would be limited for end of life only. The DON indicated high touch areas, including handrails, were cleaned every hour by housekeeping and by nursing staff when housekeeping was not working. Interview on [DATE] at 11:17 A.M. with STNA #566 (the screener who was assessing visitors and staff who entered the facility) confirmed there were three visitors recently who came to visit Resident #3. STNA #566 indicated she assessed the temperatures of all three visitors but did not document two of the temperatures (both children) and completed the screening questionnaire for the adult only. STNA #566 indicated visitors could go to residents' rooms unassisted or monitored. STNA #566 revealed she started her shift at 5:00 A.M. on [DATE]. Her duties were to monitor staff and visitor temperatures. STNA #566 said, When visitors come in, I fill out the name, date and temperature. Observation of STNA #566's desktop revealed to the left there was a staff questionnaire and to the right was a visitor questionnaire. STNA #566 revealed she had been instructed to ask visitors and staff questions and stated, I was told to ask questions but no, I do not always ask everyone, sometimes there's a lot of people, some I did and some I didn't, it just depends. Observation and interview on [DATE] at 11:39 A.M. with Visitor #568 revealed she and her two children were sitting outside with Resident #3. Visitor #568 and her two children were wearing cloth masks, Resident #3 had no mask and was not social distancing with the visitors. Visitor #568 confirmed she was aware of positive COVID-19 residents located on one hall only and was not aware of any other residents in the building having COVID-19. Visitor #568 said she and her children visited frequently. Interview on [DATE] at 11:34 A.M. with RN #517 confirmed residents did get visitors, and the three visitors who arrived to visit Resident #3 went to his room then assisted him to an outdoor area to visit. RN #517 confirmed visitors were not escorted or monitored when visiting the facility. Observation on [DATE] at 1:15 P.M. revealed four unidentified staff members in the break room. Interview on [DATE] at 3:05 P.M. with LPN #454 revealed We get one mask for three shifts. I don't keep the clean masks with the dirty ones. We then put them in the brown bag, at the end of the three days we throw the brown bag away. Interview on [DATE] at 3:07 P.M. with LPN #518 revealed We get three masks, we keep the three in brown bags, we write one two and three on the bags, we put the line through one, two, and three as we use them. After three shifts we change to mask two, we keep the first mask in the same bag, we date the mask, we wear each mask for three shifts. Review of a Team Facilitator Root Cause Analysis (RCA) document dated [DATE] revealed the team members involved in the RCA meeting included the Administrator, DON, LPN Infection Preventionist #525, and Medical Director #565. The RCA was regarding the current COVID-19 outbreak. Interview on [DATE] at 4:21 P.M. with Medical Director #565 revealed he was not part of the RCA completed on [DATE]. Medical Director #565 stated, I was not part of that meeting, I was not aware of it, I was never invited to attend any meeting yesterday. Medical Director #565 revealed he last spoke with the DON, A few weeks ago. Medical Director #565 revealed, At that time I told the DON, lock down, no visitors in the building, the residents are vaccinated, I believe the virus is being spread by visitors and staff. Medical Director #565 confirmed the last positive case of COVID-19 he was made aware of was 10 days ago, he was not made aware of any further cases. Review of the facility policy COVID-19 Eye Protection Usage (goggles or face shield) when the community rate of infection is moderate or substantial as recommended per CDC guidelines dated [DATE] revealed the facility would ensure each staff member was given eye protection at the time the screening questionnaire was completed, before the beginning of the shift, and all eye protection would be sanitized by spraying with liquid sanitizer when removed for any reason and at the end of the shift. Review of the Centers for Medicare and Medicaid Services (CMS) county positivity rate for [DATE] through [DATE] revealed a positivity rate of 11.3 percent (red) indicating 25 plus daily new cases per 100,000 people and unchecked community spread. Review of the facility policy Reusable Personal Protective Equipment COVID 19 Unit dated [TRUNCATED]

Based on observations, medical record review and staff interviews, the facility failed to ensure a pressure ulcer was promptly identified and treated. This resulted in actual harm for Resident #99 who developed an unstagable pressure ulcer to the right heel. This deficient practice affected one (Resident #99) of three residents reviewed for pressure ulcers. The total facility census was 147. Findings include: Review of the medical record revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 3.0 Minimum Data Set (MDS) assessments dated 06/18/13 and 09/20/13 indicated Resident #99 was severely impaired for cognition and was not capable of participating in the brief interview for mental status. Both MDS assessments indicated Resident #99 was at risk for the development of pressure ulcers. The 06/18/13 MDS assessment indicated Resident #99 had no pressure areas at that time. The MDS assessment dated [DATE] revealed the resident had an unstageable pressure ulcer. The MDS assessments indicated Resident #99 required extensive assistance for bed mobility, dressing and hygiene. Review of the "Potential for Impairment of Skin" plan of care included an intervention to monitor skin for breakdown, especially over bony prominences. Both the "Weekly Skin Check" dated 06/28/13 and the "Skin Observation Form" dated 06/30/13 indicated Resident #99's skin remained intact. Review of a document called the "Wound Track" dated 07/02/13 revealed an unstageable pressure ulcer to Resident #99's right heel that measured 3.21 centimeters (cm) by 3.43 cm. in size. (A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissues). Review of the wound tracking notes indicated the wound bed was covered with 100 percent (%) black eschar. (Eschar is necrotic (dead) or devitalized tissue that presents frequently as brown or black and has lost it's usual physical properties and biological activity). The wound was documented as unstageable since the wound bed was covered with eschar and was not visible. Therefore, the depth of the wound bed could not be measured. Review of the "Wound Track" dated 07/02/13 indicated that two new interventions were initiated, including the use of heel protectors while the resident was in bed and no shoe to be worn on his right foot. Review of the most recent "Wound Track" dated 10/18/13 indicated the right heel wound measured 2.17 cm by 1.17 cm in size. The assessment indicated the wound was unstageable, since 100% of the wound bed was covered with eschar. On 10/23/13 at 09:30 A.M., the wound nurse/licensed practical nurse (LPN) #6 was observed providing wound care for Resident #99's right heel pressure ulcer. The right heel wound was observed, measured approximately 2.0 cm by 1.0 cm and was covered with dry, crusty, black eschar. An interview on 10/23/13 at 1:23 P.M. with the Director of Nursing (DON) verified Resident #99's right heel pressure ulcer was discovered on 07/02/13 as unstageable. The DON explained Resident #99's family brought new shoes to the facility the previous weekend. The DON indicated when the wound was discovered on Tuesday, 07/02/13, the wound nurse determined the pressure ulcer developed due to the new, ill-fitting shoes. The DON indicated the family was asked to take the shoes home and an order was written for no shoe to be worn on Resident #99's right foot. The DON acknowledged Resident #99 was dependent for staff to dress the resident each day, including donning his socks and shoes, and staff did not identify the wound until it was unstageable.