Every finding on record at Scioto Rehabilitation & Care Center

Based on observations, review of facility work orders, review of temperature logs, and staff interviews, the facility failed to ensure that kitchen equipment was maintained in a working manner. This had the potential to affect 92 of 102 residents who received food/beverages from the kitchen. The facility census was 102 residents.Findings include: 1. Observations on 06/08/26 from 8:19 A.M. to 8:39 A.M. revealed that there was approximately six inches of stagnant gray water on the garbage disposal near the handwashing sink. The gray water had a layer of dark gray opaque thick substance on the top of the water. An interview with [NAME] #121 on 06/08/26 at 8:21 A.M. confirmed that there was gray stagnant water on the garbage disposal with a layer of dark gray opaque substance on the top of the water. [NAME] #121 revealed that the garbage disposal had not been working for approximately one week, and he stated that the kitchen staff was physically removing the water build up periodically with the assistance of a plastic mug. 2. Observations in the walk-in freezer on 06/08/26 at 8:22 A.M. revealed that the external thermometer of the freezer read 45 degrees Fahrenheit (F). No internal thermometer could be located in the walk-in freezer. Other related findings in the walk-in freezer included:- Melted popsicles had dripped over three boxes and all of the popsicles were in liquid form. - An opened bag of raw chicken was semi-frozen to the touch.- An opened bag of cubed cooked chicken was thawed and spongy to the touch through the bag. - An opened bag of cooked breaded chicken was semi-frozen to the touch. An interview with [NAME] #121 on 06/08/26 at 8:25 A.M. confirmed the above findings in the walk-in freezer. An observation of the walk-in freezer on 06/08/26 at 4:15 P.M. revealed that the external thermometer read 28 degrees F and no internal thermometer was found. An interview with Dietary Manager #128 on 06/08/26 at 4:15 P.M. confirmed the above findings in the walk-in freezer. An interview with the Maintenance Director #174 on 06/08/26 at 4:17 P.M. confirmed that the freezer compressor was not working. Observations on 06/09/26 at 7:44 A.M. revealed that the walk-in freezer was registering at 10 degrees F. An interview with the Dietary Manager #128 on 06/09/26 at 7:44 A.M. revealed that the internal thermometer was located inside the walk-in freezer. Surveyor asked Dietary Manager #128 if the dietary department was going to start monitoring the internal temperatures of the food in the walk-in freezer. Observations of the walk-in freezer on 06/11/26 at 1:38 P.M. revealed that the external thermometer on the freezer registered 23 degrees F. The internal thermometer of the walk-in freezer registered 20 degrees F. An interview with the Dietary Manager #128 on 06/11/26 at 1:38 P.M. confirmed that the above findings of the walk-in freezer. An interview with Maintenance Director #174 on 06/11/26 at 1:42 P.M. revealed that the part for fixing the freezer has been ordered, but it was not yet installed. Maintenance Director #174 revealed that each time that the door to the freezer was opened, warm air was let into the freezer. Review of the walk-in freezer temperature logs for May 2026 revealed that on 05/14/26, the morning temperature of the freezer registered 17 degrees F. On 05/21/26, the morning temperature of the freezer registered 15 degrees F. On 05/28/26, the evening temperature of the freezer registered 20 degrees F. On 05/29/26, the morning temperature of the freezer registered 15 degrees F. Review of the freezer temperature logs for June 2026 revealed on 06/05/26, the evening temperature of the freezer registered 21 degrees F. On 06/06/26, the morning temperature of the freezer was 20 degrees F and the evening temperature of the freezer was 35 degrees F. On 06/07/26, the morning freezer temperature was 12 degrees F and the evening freezer temperature was 17 degrees F. Review of three months of work orders revealed that the freezer temperatures were down as of 06/05/26. On 06/08/26, Maintenance Director #174 resolved the work order by commenting, Compressor acting up. Defrost good temps current. 3. Observations on 06/08/26 at 8:25 A.M. of the walk-in refrigerator door revealed that the door had a panel that was broken and peeling away from the door. Observations on 06/08/26 at 8:27 A.M. of a shelf revealed that a wall shelf was broken and hanging off of the wall. Several popped screws were off of the wall. An interview with [NAME] #121 on 06/08/26 at 8:30 A.M. confirmed the above findings in the walk-in refrigerator. An interview with the Maintenance Director #174 on 06/08/26 at 4:17 P.M. revealed that he had fixed the walk-in refrigerator panel to the door and removed the shelf that had been hanging off of the wall. 4. Observations of the dishwasher on 06/08/26 at 8:30 A.M. revealed that the thermometer gauges on the dishwasher were not working. Observations in the kitchen on 06/08/26 at 9:32 A.M. revealed a temperature disc was ran through the dishwasher twice and registered the highest temperatures of 105.6 degrees Fahrenheit (F) and 106.8 degrees F. An interview with Dietary Manager #128 on 06/08/26 at 9:33 A.M. confirmed that the dishwasher did not reach the minimum wash temperature of 120 degrees for chemical sanitizing. Observations of the dishwasher in the kitchen on 06/09/26 at 9:30 A.M. revealed that the maximum temperature of the dishwashing cycle reached 107 degrees F and 102.3 degrees F during two consecutive wash cycles. An interview with Dietary Manager #128 on 06/09/26 at 9:37 A.M. confirmed the above findings in the dishwashing area. Observations of the dish machine on 06/11/26 at 1:35 P.M. of the temperature disc that was ran through the dishwasher revealed a high temperature of 110.3 degrees F. An interview with Dietary Aide #125 on 06/11/26 at 1:36 P.M. confirmed that the dish washing temperature was 110.3 degrees F. An interview with Dietary Manager #128 on 06/11/26 at 1:38 P.M. confirmed that the dish washing temperature was 110.3 degrees F.

Based on observations, staff interviews, review of freezer temperature logs, review of work orders, and review of facility policy, the facility failed to ensure food was stored and prepared in a clean and sanitary manner related to labeling/dating opened foods and utilizing wet equipment to prepare food, failed to maintain safe food storage temperatures for the freezer, and failed to maintain effective dishwashing temperature levels for sanitary dishwashing. This had the potential to affect 92 out of 102 residents who received food/beverages from the facility's kitchen. The facility census was 102 residents.1. Observations on 06/08/26 from 8:19 A.M. to 8:39 A.M. revealed that there was approximately six inches of stagnant gray water on the garbage disposal near the handwashing sink. The gray water had a layer of dark gray opaque thick substance on the top of the water. An interview with [NAME] #121 on 06/08/26 at 8:21 A.M. confirmed that there was gray stagnant water on the garbage disposal with a layer of dark gray opaque substance on the top of the water. [NAME] #121 revealed that the garbage disposal had not been working for approximately one week, and he stated that the kitchen staff was physically removing the water build up periodically with the assistance of a plastic mug. 2. Observations in the walk-in freezer on 06/08/26 at 8:22 A.M. revealed that the external thermometer of the freezer read 45 degrees Fahrenheit (F). No internal thermometer could be located in the walk-in freezer. Other related findings in the walk-in freezer included:- Melted popsicles had dripped over three boxes and all of the popsicles were in liquid form. - An opened bag of raw chicken was not labeled or dated. The chicken was semi-frozen to the touch.- An opened bag of cubed cooked chicken was not labeled or dated. The chicken was thawed and spongy to the touch through the bag. - An opened bag of cooked breaded chicken was not labeled or dated. The chicken was semi-frozen to the touch. An interview with [NAME] #121 on 06/08/26 at 8:25 A.M. confirmed the above findings in the walk-in freezer. An observation of the walk-in freezer on 06/08/26 at 4:15 P.M. revealed that the external thermometer read 28 degrees F and no internal thermometer was found. An interview with Dietary Manager #128 on 06/08/26 at 4:15 P.M. confirmed the above findings in the walk-in freezer. An interview with the Maintenance Director #174 on 06/08/26 at 4:17 P.M. confirmed that the freezer compressor was not working. Observations on 06/09/26 at 7:44 A.M. revealed that the walk-in freezer was registering at 10 degrees F. An interview with the Dietary Manager #128 on 06/09/26 at 7:44 A.M. revealed that the internal thermometer was located inside the walk-in freezer. Surveyor asked Dietary Manager #128 if the dietary department was going to start monitoring the internal temperatures of the food in the walk-in freezer. Observations of the walk-in freezer on 06/11/26 at 1:38 P.M. revealed that the external thermometer on the freezer registered 23 degrees F. The internal thermometer of the walk-in freezer registered 20 degrees F. An interview with the Dietary Manager #128 on 06/11/26 at 1:38 P.M. confirmed that the above findings of the walk-in freezer. An interview with Maintenance Director #174 on 06/11/26 at 1:42 P.M. revealed that the part for fixing the freezer has been ordered, but it was not yet installed. Maintenance Director #174 revealed that each time that the door to the freezer was opened, warm air was let into the freezer. Review of the walk-in freezer temperature logs for May 2026 revealed that on 05/14/26, the morning temperature of the freezer registered 17 degrees F. On 05/21/26, the morning temperature of the freezer registered 15 degrees F. On 05/28/26, the evening temperature of the freezer registered 20 degrees F. On 05/29/26, the morning temperature of the freezer registered 15 degrees F. Review of the freezer temperature logs for June 2026 revealed on 06/05/26, the evening temperature of the freezer registered 21 degrees F. On 06/06/26, the morning temperature of the freezer was 20 degrees F and the evening temperature of the freezer was 35 degrees F. On 06/07/26, the morning freezer temperature was 12 degrees F and the evening freezer temperature was 17 degrees F. Review of three months of work orders revealed that the freezer temperatures were down as of 06/05/26. On 06/08/26, Maintenance Director #174 resolved the work order by commenting, Compressor acting up. Defrost good temps current. Review of an undated facility policy titled, Food Receiving and Storage, revealed that food services will maintain clean food storage areas at all times. All foods stored in the freezer will be covered, labeled and dated with a use-by date. The freezer must keep frozen foods frozen solid. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day. 3. Observations of the dishwasher on 06/08/26 at 8:30 A.M. revealed that the thermometer gauges on the dishwasher were not working. Observations in the kitchen on 06/08/26 at 9:32 A.M. revealed that the dishwasher was washing the breakfast dishes for the facility's residents. A temperature disc was ran through the dishwasher twice and registered the highest temperatures of 105.6 degrees Fahrenheit (F) and 106.8 degrees F. An interview with Dietary Manager #128 on 06/08/26 at 9:33 A.M. confirmed that the dishwasher did not reach the minimum wash temperature of 120 degrees for chemical sanitizing. Observations of the dishwasher in the kitchen on 06/09/26 at 9:30 A.M. revealed that the dishwasher was washing the resident's breakfast dishes. Observations revealed that the maximum temperature of the dishwashing cycle reached 107 degrees F and 102.3 degrees F during two consecutive wash cycles. An interview with Dietary Manager #128 on 06/09/26 at 9:37 A.M. confirmed the above findings in the dishwashing area. Observations of the dish machine on 06/11/26 at 1:35 P.M. revealed that the staff was washing the residents' lunch dishes. Observation of the temperature disc that was ran through the dishwasher revealed a high temperature of 110.3 degrees F. An interview with Dietary Aide #125 on 06/11/26 at 1:36 P.M. confirmed that the dish washing temperature was 110.3 degrees F. An interview with Dietary Manager #128 on 06/11/26 at 1:38 P.M. confirmed that the dish washing temperature was 110.3 degrees F. An interview with the Administrator on 06/11/26 at 1:54 P.M. revealed that he was now aware of the dish machine temperatures and walk in freezer temperatures not meeting minimum temperature requirements and that he would immediately get a plan into place to monitor the internal temperatures of the foods in the freezer and to properly wash and sanitize the dishes. The Administrator revealed that he would consult with the corporate management team and get a plan into effect immediately. Review of the undated facility policy titled, Dishwashing Machine Use, revealed that low temperature machines will wash and rinse at State and Federal temperatures for low temperature dishwashers. 4. Observations of pureed food preparation on 06/09/26 from 9:33 A.M. to 9:40 A.M. revealed that [NAME] #121 used a food processor bowl to puree hamburger patties. [NAME] #121 confirmed that the hamburger patties were products from the freezer. On 06/09/26 at 9:37 A.M., [NAME] #121 washed the food processing bowl in the dishwasher and did not wait for the food processing bowl to air dry. The wet food processing bowl was used to puree mixed vegetables for the residents. An interview with [NAME] #121 on 06/09/26 at 9:40 A.M. confirmed that he had used a wet food processing bowl to puree the mixed vegetables. An interview with Dietary Manager #128 on 06/09/26 at 9:40 A.M. revealed that he would educate the dietary staff about waiting for dishes to air dry since the facility was relying on chemical sanitizing methods. Review of twelve months of infection control surveillance logs did not show any outbreaks of food borne illness.

Based on observations, staff interviews, and review of facility pest control contract and service records, the facility failed to ensure effective pest control in the kitchen. This had the potential to affect 92 of 102 residents who received food/beverages from the kitchen. The facility census was 102 residents. Findings include: Review of the pest control agreement dated 01/29/24 revealed that the pest control program did not cover flies. These special problems will be treated as needed and charged on a discounted basis from the regular service fee. Review of six months of pest control records revealed that the kitchen had not been treated for fruit flies. Observations of the dishwasher area on 06/08/26 at 8:30 A.M. revealed that approximately 15-20 fruit flies were sitting on the dishwashing sanitizing bucket. An interview with [NAME] #121 on 06/08/26 at 8:30 A.M. confirmed the presence of fruit flies in the dishwashing area. Observations of the dishwashing sanitizing solution bucket on 06/09/26 at 9:35 A.M. revealed that there were approximately 20 fruit flies on the bucket. An interview with Dietary Manager #128 on 06/09/26 at 9:37 A.M. confirmed the above findings in the dishwashing area. Observations of the dish machine on 06/11/26 at 1:35 P.M. revealed that the chemical sanitizing bucket revealed approximately 20-25 fruit flies on the bucket. An interview with Dietary Aide #125 on 06/11/26 at 1:36 P.M. confirmed the presence of fruit flies and stated that the kitchen had had fruit flies for a while now.An interview with the Administrator on 06/11/26 at 1:54 P.M. revealed that he was unaware of any fruit fly problems in the kitchen.

Based on medical record review, observation, interview, and facility policy review, the facility failed to maintain infection control when Resident #42's urinary catheter bag was on the floor. This affected one resident (#42) of two residents reviewed for urinary catheters. The facility census was 102.Findings include: Review of Resident #42's medical record revealed an admission date of 12/25/22. Medical diagnosis included neuromuscular dysfunction of the bladder.Review of Resident #42's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #42's section H revealed the resident had an indwelling catheter in place and was always incontinent of bladder and bowel.Review of Resident #42's care plan revealed the resident had a urinary catheter due to dysfunction of bladder, and the resident would have reduced risk of complications of catheter use.Observation on 06/08/26 at 4:40 P.M. revealed Resident #42's urinary catheter bag resting on the floor.Interview with Certified Nursing Assistant (CNA) #223 on 06/08/26 at 5:25 P.M. confirmed Resident #42's urinary catheter bag was resting on the floor and then offered to move the catheter bag to hang off of the trash can instead.Review of the facility's policy titled, Urinary Catheter Care dated 02/2024 confirms staff should be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were in place to maintain or improve Resident #38's ability to communicate/hear. This affected one resident (#38) of one resident reviewed for vision and hearing. The facility census was 102.Findings include:Review of Resident #38's medical record revealed an admission date of 10/01/22 with diagnoses including adult failure to thrive, dementia, osteoarthritis, and protein calorie malnutrition. Review of the physician order dated 03/28/24 revealed an order to put in hearing aid every day shift.Review of Resident #38's plan of care dated 10/16/25 revealed the resident had the potential for impaired communication related to hearing loss. Interventions included adjusting tonal quality of voice to make self-understood, allowing time to express self, hearing aids, and assisting with placement and maintenance of hearing aides as needed.Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of the Medication Administration Record (MAR) on 06/10/26 at 2:30 P.M. revealed Licensed Practical Nurse (LPN) #322 indicated he had put in Resident #38's hearing aids.Interview and observation on 06/10/26 at 2:50 P.M. with LPN #322 revealed he was unsure where Resident #38's hearing aids were. Observation of Resident #38 revealed they were not in place. LPN #322 verified they were not in place and he began looking around the room. He reported he was unable to locate them and verified he had documented that they were in place without ensuring they were.Interview and observation on 06/10/26 at 2:55 P.M. with Unit Manager #149 revealed Resident #38's hearing aids were stored in the medication storage room. She reported that all the nurses should know this, however, she verified there was no way new nurses or agency staff (which they used) would be aware of their location. Unit Manager #149 revealed she would update the order to include where they were located.

Based on interview, medical record review, and policy review, the facility failed to ensure Resident #2 and #15's care plans comprehensively addressed their medications and/or medical conditions. This affected two residents (#2 and #15) of five residents reviewed for unnecessary medications. The facility census was 102.Findings include:1. Review of Resident #15's medical record revealed an admission date of 10/04/25 with diagnoses including anxiety disorder, protein-calorie malnutrition, cirrhosis of liver, alcohol dependence, depression, and chronic obstructive pulmonary disease. Review of Resident #15's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Medications included antianxiety, antidepressant, hypnotic, diuretic, and anticonvulsant.Review of Resident #15's physician order dated 03/05/26 revealed an order for Imitrex 25 milligrams (mg) one tablet by mouth every 24 hours as needed for migraines and an order dated 04/29/26 for Gabapentin 600 mg one tablet by mouth every eight hours for neuropathy.Review of Resident #15's plan of care revealed it did not address the resident's neuropathy or migraines.Interview on 06/11/26 at 11:34 A.M. with MDS nurse #194 verified the plan of care did not address the indications for Resident #15's neuropathy or migraine pain medications.Review of the policy 'Comprehensive Person-Centered Care Plans' dated July 2024, revealed the care plan was to include identified problem areas and risk factors associated with identified problems.2. Review of Resident #2's medical record revealed an admission date of 02/06/26 with diagnoses including convulsions, chronic heart failure, end stage renal disease with dependence on renal dialysis, bipolar disease, adult failure to thrive, generalized anxiety disorder, and muscle weakness. Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #2's physician orders starting 02/07/26 revealed an order for Cephalexin oral tablet 250 milligrams (mg) one tablet by mouth one time a day for dialysis prophylaxis.Review of Resident #2's physician order dated 02/07/26 revealed an order for levetiracetam oral tablet 250 mg one time a day for seizures.Review of Resident #2's physician order dated 02/09/26 revealed an order for Divalproex 500 mg every eight hours for seizures.Review of Resident #2's plan of care revealed it did not address the resident's long term antibiotic use or convulsions/seizures.Interview on 06/11/26 at 11:34 A.M. with MDS Nurse #194 verified the care plan did not address long term antibiotic use. Additionally, it was verified that the care plan did not address his diagnosis of convulsions or the medication he took for this.Review of the policy 'Comprehensive Person-Centered Care Plans' dated July 2024, revealed the care plan was to include identified problem areas and risk factors associated with identified problems.

Based on interview, record review, and review of hospital documentation, the facility failed to ensure the physician was notified when intravenous access was not able to be obtained during a change of condition for Resident #130. This affected one resident (#130) of one resident reviewed for change in condition. The facility census was 102. Findings Include:Record review for Resident #130 revealed this resident was admitted to the facility on [DATE], and discharged on 05/15/26, with diagnoses including bipolar disorder, dementia, psychotic disturbance, mood disturbance, and anxiety, diabetes, Parkinson's disease and muscle weakness.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require staff assistance with completing self-care tasks and mobility.Review of the care plan dated 04/21/26 revealed Resident #130 was at risk for a nutritional problem. Interventions included monitoring the resident and the resident's lab work and report to the physician signs of malnutrition.Review of the physician orders for Resident #130 revealed an order dated 05/14/26 at 7:50 P.M. to infuse normal saline 75 milliliters per hour for one liter of fluid.Further review of the medical record for Resident #130 revealed no documented evidence as to why the resident would need a normal saline infusion. Review of Resident #130's progress notes revealed on 05/15/26 at 3:57 A.M. the facility's nursing team was unable to insert an intravenous catheter into Resident #130 to start the ordered saline infusion. The team obtained permission from the Director of Nursing (DON) to contact an outside provider to attempt to insert the intravenous (IV) catheter. Review of the progress notes did not reveal the physician was notified that the order was not being fulfilled.Further review of Resident #130's medical record revealed no documented evidence that an outside provider was contacted or that IV access was obtained or infused while the resident was in the facility. There was also no evidence regarding the residents transfer to the hospital. Review of Resident #130's hospital medical record dated 05/15/26 at 10:31 A.M. revealed the resident presented lethargic, confused and hypoxic, requiring supplemental oxygen (oxygen saturation 88% at time of emergency department admission on [DATE]). Review of the physician notes revealed complications from medication side effects, dehydration/acute kidney injury, and exacerbation of Parkinsons syndrome were considered but the resident was ultimately diagnosed with metabolic encephalopathy and acute kidney injury. She was provided a bolus of IV fluids and appeared significantly better and she was discharged . The resident did not return to the facility. Interview with a family member of Resident #130 on 06/10/26 at 4:44 P.M. confirmed Resident #130 was experiencing weakness and hallucinations on 05/13/26. The resident reported seeing a gunman outside of her window, which no one else observed. She stated the resident was transferred to the hospital on [DATE] as the resident looked ill appearing. An interview on 06/10/26 at 5:40 P.M. with Certified Nursing Assistant (CNA) #227 confirmed on 05/14/26, around 10:00 A.M., Resident #130 reported experiencing stomach discomfort. She was also still experiencing hallucinations. CNA #227 said she immediately reported these observations to the nurse, Registered Nurse (RN) #213.During an Interview with RN #213 on 06/10/26 at 4:15 P.M. he recalled on 05/14/26 a CNA told him the resident had a stomachache and was having trouble urinating. RN #213 completed an assessment and called the provider who ordered the IV. He stated night shift was to carry out the new order for the IV. During an interview on 06/11/26 at 2:35 P.M. with Physician #27 confirmed there was not a notification to his team that the facility was unable to start the intravenous catheter timely, which meant they were not able to provide the resident was fluids as ordered and timely. He stated he was made aware that Resident #130 was hospitalized in the morning, after that the resident was already sent out, due to a family members request for hospitalization.This deficiency represents noncompliance investigated under Complaint Number 3029033.

Based on a resident record review, staff interview and review of a facility policy, the facility failed to ensure that a resident's protein supplement was administered per orders to promote wound healing. This affected one resident (#12) out of three residents reviewed for pressure ulcers. The facility census was 102 residents.Findings include: Review of a resident record revealed Resident #12 was admitted to the facility on [DATE] and had diagnoses that included acute respiratory failure with hypoxia and anoxic brain damage. Review of Resident #12's care plan dated 08/25/25 revealed that Resident #12 was at risk for a nutritional problem related to being reliant on enteral nutrition as a sole source of nutrition support, skin impairment and being enrolled in hospice services. An intervention listed was to provide and serve supplements as ordered starting on 09/08/25. Review of Resident #12's nutrition assessment dated [DATE] revealed that it was recommended to add ProStat (a nutrition supplement that provides 15 grams of protein per 30 milliliters and promotes tissue healing) 30 milliliters (ml) twice daily for additional protein and skin integrity support. Review of Resident #12's pressure ulcer assessment dated [DATE] revealed that Resident #12 had a stage III (broken through the top two layers of skin) pressure ulcer on her right buttock that was discovered on 10/04/25. Review of Resident #12's physician orders dated 10/29/25 revealed that Resident #12 was prescribed ProStat 60 ml for additional protein and skin integrity support via gastrostomy tube once daily due at 6:00 P.M. Review of Resident #12's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition could not be assessed. Resident #12 was assessed as having a gastrostomy tube and receiving over 51% of her estimated caloric needs via gastrostomy tube. Resident #12 was assessed as having one unhealed stage IV pressure ulcer (full thickness tissue loss). Review of Resident #12's April Medication Administration Record (MAR) revealed that Resident #12 was given 30 ml instead of 60 ml on 18 out of 30 administrations. Review of Resident #12's May MAR revealed that Resident #12 was given 30 ml instead of 60 ml on 25 out of 31 administrations. Review of Resident #12's June MAR revealed that Resident #12 was given 30 ml instead of 60 ml on 9 out of 10 administrations. An interview with Licensed Practical Nurse (LPN) #160 on 06/11/26 at 8:20 A.M. confirmed that LPN #160 administered Prostat to Resident #12 via her gastrostomy tube in a total daily amount of 30 ml. LPN #160 revealed that the usual orders were for 30 ml via gastrostomy tube. An interview with the Director of Nursing on 06/11/26 at 8:24 A.M. confirmed that Prostat was frequently administered at 30 ml instead of 60 ml. An interview with Diet Technician #311 on 06/10/26 at 11:29 A.M. revealed that not receiving a liquid protein supplement as ordered could affect the wound healing process. Review of a facility policy titled, Skin and Wound Management, revised on January 2025, revealed that nurses will ensure that orders, interventions and treatments for skin and wounds are implemented as ordered. This deficiency represents noncompliance investigated under Complaint Number 3022566 and 3012559.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #40, who was identified as a supervised smoker, did not have smoking materials on her person. This effected one resident (#40) of four residents reviewed for accident hazards. The facility's census was 102.Findings Include: Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, congestive heart failure, chronic obstructive pulmonary disease, muscle weakness muscle. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require minimal staff assistance for bathing and dressing.Review of the progress notes of Resident #40 dated 06/04/26 revealed a staff member observed Resident #40 falling asleep holding a cigarette. The resident's nurse manager was notified. A skin assessment was completed on the resident with no findings.Review of Resident #40's Smoking Evaluation, dated 06/04/26 revealed the resident must be supervised while smoking.Review of the care plan dated 06/08/26 revealed Resident #40 had a potential for safety hazard or injury related to smoking. Interventions included resident may only smoke with family or staff supervision.Observations on 06/08/26 at 12:16 P.M. and 3:50 P.M. revealed Resident #40 with a package of cigarettes on her bedside table in her room. Observations on 06/09/26 at 10:26 A.M. and 5:10 P.M. revealed Resident #40 with a package of cigarettes in her room. During an interview with the Director of Nursing (DON) on 06/09/26 at 5:29 P.M. revealed she confirmed Resident #40 was not safe to smoke without supervision. She also confirmed Resident #40 had cigarettes in her possession. She said the resident was non-compliant with the smoking policy and when staff noticed she had cigarettes, staff would take them from her. Review of the facility's policy Smoking Policy, revised April 2025, revealed for residents deemed supervised smokers, their smoking materials will be labeled and held by the nursing staff or a designee.

Based on review of resident medical records, observations, interviews, and review of facility policies, the facility failed to meet the nutritional recommendations and had a delay in implementing nutrition recommendations for Resident #89. Additionally, the facility did not provide enteral feedings as ordered for Resident #96. This affected two residents (#89 and #96) out of three residents reviewed for nutrition.Findings include: 1. a. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE] and had diagnoses that included tracheostomy and gastrostomy statuses and protein calorie malnutrition. Review of Resident #89's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #89 had a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognitive status. Resident #89 was assessed as having a feeding tube that meets over 51% of Resident #89's estimated calorie needs daily. Review of Resident #89's care plan dated 12/01/25 revealed the resident was at risk for nutritional problems related to gastrostomy status, dysphagia, and the resident relied on the percutaneous endoscopic gastrostomy (PEG) tube as a sole source of nutritional support. Interventions included to provide tube feed as ordered, dietician to evaluate and make diet change recommendations as needed, and administer medications as ordered.Review of Resident #89's Nutrition assessment dated [DATE] revealed that Resident #89 was NPO (unable to eat food by mouth), 143 pounds (lbs) and receiving an enteral feeding of Jevity 1.5 calories at 55 milliliters (ml) per hour (hr) via gastrostomy tube. The enteral feedings were well tolerated and provided Resident #89 with 1974 calories per day, which was meeting 100% of Resident #89's caloric needs. The recommendation was to continue the same enteral and nutrition plan of care. Review of Resident #89's physician orders, that were transcribed into the medical record by Licensed Practical Nurse) LPN Unit Manager #72 dated 01/07/26 and discontinued on 01/30/26, revealed that Resident #89 was ordered Jevity 1.5 calories at 25 ml per hour continuous tube feeding via gastrostomy tube. Review of Resident #89's nursing progress notes revealed no indication for enteral feeding intolerance and no documentation about why Resident #89's enteral nutrition feeding rate was changed to 25 ml/hr on 01/07/26. Review of Resident #89's nutrition progress notes dated 01/29/26 revealed that Resident #89's weight was stable at 144.3 lbs. Resident #89 was receiving Jevity 1.5 calories at 25 ml/hr continuous rate, and the dietitian recommended to change Resident #89's enteral nutrition orders to Jevity 1.5 calories (cal) at 55 ml/hr as previously ordered. Review of Resident #89's physician order dated 01/30/26 revealed that the dietitian clarified the resident's tube feeding order as Jevity 1.5 cal at 55 ml/hr continuous. Review of Resident #89's weight on 02/08/26 revealed that Resident #89 weighed 135.2 lbs. Review of Resident #89's nutrition progress notes dated 02/12/26 revealed that Resident #89 had lost a significant amount of weight of 5.7% in less than one month. The current physician order of Jevity 1.5 cal at 55 ml/hr continuous feeding was in place as previously recommended and it was recommended to continue with current nutrition plan of care. An interview with Diet Technician #311 on 06/10/26 at 10:19 A.M. confirmed that Jevity 1.5 cal at 25 ml/hr would have provided Resident #89 with 898 calories per day from 01/07/26 to 01/30/26 which would have provided Resident #89 with approximately 50% of his estimated caloric needs daily and could have led to significant weight loss. Diet Technician #311 revealed that Resident #89 did not have any enteral feeding intolerances to the previous continuous enteral regimen of Jevity 1.5 cal at 55 ml/hr. An interview with Licensed Practical Nurse (LPN) Unit Manager #172 on 06/10/26 at 2:20 P.M. revealed that he did not recall why he transcribed the order for Resident #89 to receive Jevity 1.5 cal at 25 ml/hr on 01/07/26. LPN Unit Manager #172 confirmed that Resident #89 received Jevity 1.5 cal at 25 ml/hr from 01/07/26 to 01/30/26. To his knowledge, Resident #89 did not have any intolerance to Jevity 1.5 cal at 55 ml/hr as received prior to 01/07/26. b. Review of weights from 02/17/26 through 05/17/26 revealed that Resident #89 steadily gained weight until he weighed 146.9 lbs on 05/17/26. Review of nutrition progress note dated 04/10/26 revealed that the dietitian recommended to increase Resident #89's protein supplement to 30 milliliters (ml) twice daily. Review of the nutrition progress note dated 04/28/26 revealed that the dietitian re-recommended to increase Resident #89's protein supplement to 30 ml twice daily. Review of nutrition progress note dated 05/01/26 revealed that the dietitian was awaiting the pending recommendation for Resident #89's protein supplement to 30 ml twice daily. Review of Resident #89's physician orders revealed that Resident #89 was prescribed a protein supplement 30 ml twice daily on 05/15/26, over a month after the initial recommendation was made by the dietitian. An interview with Licensed Practical Nurse (LPN) Unit Manager #172 on 06/10/26 at 2:20 P.M. revealed that he met with the diet technician weekly and reviewed nutrition recommendations. The LPN confirmed Resident #89's protein supplement 30 ml twice daily was started untimely on 05/15/26. 2. Review of a resident medical record revealed Resident #96 was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, hemiplegia and gastrostomy status. Review of Resident #96's care plan dated 02/10/26 revealed the resident was at risk for nutritional problems related to gastrostomy status, dysphagia, and the resident relied on the percutaneous endoscopic gastrostomy (PEG) tube as a sole source of nutritional support. Interventions included to provide tube feed as ordered, dietician to evaluate and make diet change recommendations as needed, and administer medications as ordered.Review of Resident #96's MDS 3.0 assessment dated [DATE] revealed Resident #96's cognitive status was unable to be assessed as he was never understood. Resident #96 was assessed as receiving over 51% of his caloric needs via gastrostomy tube and did not have behaviors of being resistant to care. Review of Resident #96's nutrition assessment dated [DATE] revealed that Resident #96 ate nothing by mouth and received Osmolite 1.5 cal at 60 ml/hr continuous enteral feeding to meet 100% of his caloric needs daily. Review of Resident #96's physician orders dated 02/24/26 revealed that Resident #96 was ordered a continuous enteral feeding via gastrostomy tube of Osmolite 1.5 cal at 60 ml/hr. Observations on 06/10/26 from 10:45 A.M. to 11:14 A.M. and from 11:31 A.M. to 11:57 A.M. revealed that Resident #96's enteral feeding pump was not administering the enteral feeding. A red flashing light that read system error was visible on the pump monitor screen. An interview with LPN #160 on 06/10/26 at 11:57 A.M. confirmed that Resident #96's enteral feeding pump was not administering the enteral feeding as ordered. LPN #160 revealed that the enteral feeding had been malfunctioning all day. An observation on 06/10/26 from 2:00 P.M. to 2:12 P.M. revealed that Resident #96's enteral feeding pump was not administering enteral feeding to Resident #96. A yellow flashing light that read feed error was displayed on the monitor. An interview with LPN #160 on 06/10/26 at 2:12 P.M. confirmed that Resident #96's enteral feeding pump line was not administering enteral feeding as ordered. Review of Resident #96's weights revealed that he weighed 107.9 lbs on 02/06/26, the date of his admission. The medical record was silent for monthly weights through 06/09/26. An interview with Diet Technician #311 on 06/10/26 at 10:19 A.M. revealed that she was not aware of any barriers or preferences to weighing Resident #96. Diet Technician #311 revealed that it was her expectation that residents be weighed on a monthly basis at minimum and that Resident #96 had not been weighed since admission. An interview with LPN Unit Manager #172 on 06/10/26 at 2:20 P.M. revealed that he did not know of any barriers to weighing Resident #96 and revealed that residents were weighed monthly. LPN Unit Manager also confirmed Resident #96 had not been weighed since admission. An interview with the Director of Nursing on 06/10/26 at 2:30 P.M. revealed that residents were weighed monthly unless they refused. Review of the facility policy titled, Weight Assessment and Intervention, dated September 2024, revealed that the nursing staff will measure resident weights on admission, then weekly times a total of four weeks. If no weight concerns are noted at that point, weights will be measured monthly thereafter. Any weight change of 5% or more since the last weight will be retaken for confirmation. If the weight change is desirable, this will be documented and no change in the care plan will be necessary. Interventions for undesirable weight loss shall be based on consideration of the following: resident choice and preferences, nutrition and hydration needs of the resident, functional factors, environmental factors, need for diet modifications, use of supplementation and/or feeding tubes. Review of the facility policy titled, Enteral Nutrition, revised January 2014, revealed that the recommendation to use an enteral feeding will be based on the results of the nutritional assessment and be consistent with current standards of practice, treatment goals and facility policies. The dietitian will estimate calorie, protein, nutrient and fluid needs and determine whether the resident's current intake is adequate to meet his or her nutritional needs. The dietitian will monitor residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance nutritional adequacy of enteral feedings. This deficiency represents noncompliance investigated under Complaint Number 3022566.

Based on medical record review, observations, interviews, and review of facility policy, the facility failed to implement nutritional recommendations to promote weaning off of enteral feedings for Resident #66 and failed to ensure appropriate care of a feeding tube when a water flush was not completed as ordered before and after medication administration for Resident #89. This affected two residents (#66 and #89) out of three residents reviewed for enteral nutrition. The facility census was 102 residents. Findings include: 1. Review of a resident medical record revealed that Resident #66 was admitted to the facility on [DATE] and had diagnoses that included dysphagia and protein calorie malnutrition. Review of Resident #66's care plan dated 02/03/26 revealed that Resident #66 was at risk of nutritional problem related to a history of cerebral infarction, received a mechanically altered diet and enteral nutrition support. The care plan indicated that Resident #66 felt hungry after meals and was ordered double protein portions. A goal included for Resident #66 to consume at least 75% of her meals. Interventions included to provide diet as ordered, to provide tube feeding per order, for the dietitian to evaluate and make dietary change recommendations as needed. Review of Resident #66's physician order dated 04/28/26 revealed that Resident #66 was prescribed Osmolite 1.5 calories at 30 milliliters (ml) per hour (hr) continuous feeding and a regular diet order with double protein portions. Review of Resident #66's nutrition assessment dated [DATE] revealed that Resident #66 consumed 25 to 100% of her meals on a regular diet with double protein portions and also received Osmolite 1.5 at 30 ml/hr continuous feeding. Review of Resident #66's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #66 had a Brief Interview for Mental Status score of 11, indicative of moderate cognitive impairment. Resident #66 was assessed as receiving enteral nutrition, meeting between 26 and 50% of her daily estimated calorie needs and also a mechanically altered diet. Review of Resident #66's nutrition progress note dated 06/04/26 revealed that Resident #66 had gained a significant amount of weight as 16.1% in one month. Resident #66 was noted to request real food. The dietitian recommended for Resident #66 to change enteral nutrition regimen to further accommodate mealtimes and hunger/fullness cues. Dietitian recommended to change enteral nutrition to Osmolite 1.5 at 40 ml/hr for 18 hours daily and to be off of her enteral feeding from 12:00 P.M. to 6:00 P.M. daily. Review of Resident #66's physician orders revealed no orders related to the dietician recommendation to change the enteral nutrition to Osmolite 1.5 at 40 ml/hr for 18 hours daily and to be off of her enteral feeding from 12:00 P.M. to 6:00 P.M. daily. Observations of Resident #66 on 06/08/26 at 10:30 A.M. and 1:15 P.M. revealed that Resident #66 was not connected to her enteral feeding pump and was sitting up in the common area. Observation of Resident #66 on 06/08/26 at 4:39 P.M. revealed that Resident #66 was connected to her enteral feeding pump, which was administering Osmolite 1.5 calories at 30 ml/hr, as per the order from 04/28/26. Observation of Resident #66 on 06/09/26 at 1:45 P.M. revealed that Resident #66 was not connected to her enteral feeding pump and was sitting up in the common area. An interview with Licensed Practical Nurse (LPN) #323 on 06/09/26 at 1:48 P.M. confirmed that Resident #66's enteral feeding was not being administered as ordered. An interview with Diet Technician #311 on 06/10/26 at 11:29 A.M. revealed that there were no known barriers to changing Resident #66 to a cyclic enteral feeding to promote hunger cues and wean from enteral feedings. An interview with LPN Unit Manager #172 on 06/10/26 at 2:20 P.M. confirmed that Resident #66's current orders were for Osmolite 1.5 calories at 30 ml/hr and that the dietitian had made recommendations to change Resident #66's enteral feeding to a cyclic tube feeding, six days prior on 06/04/26. An interview with the Director of Nursing (DON) on 06/10/26 at 2:39 P.M. confirmed that there were no known barriers to wean Resident #66 off of continuous enteral feedings. The DON confirmed that Resident #66 enjoyed eating by mouth and disliked being connected to her enteral feeding. Review of a facility policy titled, Enteral Nutrition, dated January 2014, revealed that the dietitian will determine whether the resident's current intake is adequate to meet his or her nutritional needs. The enteral nutrition will be ordered by the physician based on the recommendations from the dietitian. The dietitian will monitor residents who are receiving enteral feedings and make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. 2. Review of Resident #89's medical record revealed an admission date of 09/30/25. Medical diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential (primary) hypertension, paroxysmal atrial fibrillation, heart failure, gastro-esophageal reflux without esophagitis, gastrostomy status, dysphagia following cerebral infarction, muscle weakness, neuromuscular dysfunction of the bladder, acute and chronic respiratory failure with hypoxia, tracheostomy status, and prediabetes. Review of Resident #89's physician orders revealed an order dated 01/31/26 for a percutaneous endoscopic gastrostomy (PEG) tube flush with 10 cubic centimeters (cc) of water before and after medication administration every shift. Review of Resident #89's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #89's MDS section K revealed Resident #89 had a feeding tube in place. Review of Resident #89's care plan revised on 06/24/26 revealed Resident #89 was at risk for nutritional problems or potential nutritional problems with goals that the resident would have no significant weight changes noted and would tolerate feedings without nausea, vomiting and diarrhea or increased residuals. Interventions included to administer medications as ordered, monitor and document side effects and effectiveness, and flush tube per order. Review of Resident #89's physician orders revealed orders for the following medications due at 9:00 A.M.: aspirin oral capsule 81 milligrams (mg) daily, acetaminophen oral tablet 325 mg with instructions to give two tablets twice daily, ascorbic acid 500 mg twice daily, famotidine oral tablet 20 mg twice daily, multivitamin-minerals oral tablet 1 tablet daily, zinc sulfate oral capsule 50 mg daily, senna 8.6 mg with instructions to give two tablets once daily, Lipitor oral tablet 40 mg daily, baclofen oral tablet 5 mg three times daily, metoprolol tartrate oral tablet 25 mg with instructions to give half of a tablet twice daily, meclizine Hcl oral tablet 25 mg twice daily, guaifenesin oral liquid 200mg/5ml, ProStat supplement 30 ml twice daily, polyethylene glycol 3350 powder 17 grams daily, oxycodone Hcl oral tablet 5 mg twice daily. Observation of medication administration on 06/10/26 at 9:08 A.M. revealed Licensed Practical Nurse (LPN) #160 checked the residents blood pressure then combined all of Resident #89's crushed medications and administered the combined medications via PEG tube while adding 30 cc of sterile water to the medication mixture. LPN #160 did not flush the PEG tube prior to medication administration, during medication administration, or following medication administration. The tube appeared to be clogged and had resistance after the second syringe of medication, the nurse had to pull back with the syringe before administering more medication. Interview on 06/10/26 at 11:55 A.M. with LPN #160 confirmed they did not flush the PEG tube prior to administration, during administration and/or after administration. Review of the facility's policy, Administering Medications through an Enteral Tube revised on 12/2024 revealed after residual volume was verified, flush the tubing with 15-30 ml (cc) of warm sterile water or the prescribed amount. If administering more than one medication, flush with 15 ml (or prescribed amount) warm sterile water or purified water between medications. When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml (or prescribed amount) warm sterile or purified or purified water.

Based on interview, medical record review, and review of facility policy and procedure, the facility failed to timely administer ordered pain medications for Resident #117. Additionally, the facility failed to implement nurse practitioner pain recommendations in a timely manner and failed to timely reschedule pain management appointments for Resident #61. This affected two residents (#61 and #117) of three residents reviewed for pain management. The facility's census was 102. Findings Include: 1. Record review for Resident #117 revealed the resident was admitted to the facility on [DATE] with diagnoses including pain in right leg, displaced fracture of the right tibia, unspecified mood disorder, bipolar disorder, anxiety disorder, gastroparesis and muscle weakness. Review of the care plan dated 06/05/26 revealed Resident #117 was at risk for pain related to osteoarthritis and right tibial and fibula fracture. Interventions included administer medications per physician orders. Review of the physician orders of Resident #117 revealed an ordered dated 06/05/26 for Buprenorphine HCl tablet, or Subutex, a pain reliever used to treat opioid use disorder, 2 milligrams (mg) sublingually with instructions to place 6 tablets under the tongue daily for 10 days. Review of Resident #117's reported pain levels revealed a pain level of seven out of 10 (on a scale of zero to 10, zero being no pain and 10 being the worst pain) on 06/04/26 at 1:00 A.M., a pain level of 10/10 on 06/05/26 at 8:55 A.M., and 7/10 on 06/05/26 at 5:30 P.M. and 6:00 P.M. Review of the Medication Administration Record of Resident #117 revealed she did not receive the medication from the facility on 06/05/26. Her first dose was not administered by the facility until 06/06/26. Interview with the Director of Nursing (DON) on 06/10/26 at 4:58 P.M. confirmed there was a delay with the Buprenorphine HCl Sublingual Tablet because the pharmacy used by the facility required a prescription from the facility's provider. They were not able to reach the facility doctor until the end of day on 06/05/26 so the medication was not delivered until the morning of 06/06/26. Review of the facility's policy, Pain-Clinical Protocol, revised 07/24, revealed the physician will order appropriate medication interventions to address the resident's pain. 2. Review of a resident medical record revealed that Resident #61 was admitted to the facility on [DATE] and had diagnoses that included arthritis multiple sites, malignant neoplasm of kidney and secondary malignant neoplasm of lung. Review of Resident #61's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #61 had a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognitive status. Resident #61 was assessed as having pain that occasionally limited his day to day activities and rated his pain level as a 9 on a scale of zero to 10 (zero being no pain and 10 being the worst pain). Review of Resident #61's physician orders dated 04/01/26 revealed that Resident #61 was prescribed acetaminophen (a non-opioid pain reliever) 500 milligrams (mg) two tablets every six hours as needed for pain with non-pharmacological interventions encouraged. Review of Resident #61's physician orders dated 04/16/26 revealed that Resident #61 was prescribed a lidocaine external patch for pain relief 4% apply to knees topically every 24 hours for mild pain. Review of Resident #61's physician orders dated 04/23/26 revealed that Resident #61 was prescribed Oxycodone HCl (an opioid pain reliever) 10 mg one tablet every four hours as needed for moderate to severe pain. No non-pharmacological pain relief interventions were prompted to be given in the physician order for the narcotic. Review of Resident #61's April Medication Administration Record revealed that Resident #61 had recorded pain levels of 8 or higher on 27 occurrences. Review of Resident #61's provider progress note dated 04/29/26 revealed that Resident #61 had nociceptive pain in the bilateral legs and it was discussed with the DON. The nurse practitioner recommended starting Voltaren gel (a nonsteroidal anti-inflammatory drug (NSAID) topical pain reliever). Review of Resident #61's provider progress note dated 05/04/26 and 05/06/26 revealed that Resident #61 had nociceptive pain in the bilateral legs and it was discussed with the DON. The nurse practitioner recommended starting Voltaren gel on 05/04/26 and 05/06/26. Review of Resident #61's physician orders dated 04/29/26 to 06/09/26 revealed no orders for the Voltaren gel. Review of Resident #61's psychiatric provider progress note dated 05/11/26 revealed that Resident #61 complained of pain and revealed that Resident #61's mood improved when he was not in pain. The psychiatric provider informed nursing, who confirmed that Resident #61 had already been given his pain medication thirty minutes prior. Review of nursing progress notes dated 05/11/26 revealed that Resident #61 had a pain appointment scheduled for 05/28/26. Review of Resident #61's psychiatric provider progress note dated 05/18/26 revealed that Resident #61 continued to report unmanaged pain. Review of Resident #61's physician orders dated 05/05/26 revealed that Resident #61 was referred to a pain clinic. Review of Resident #61's physician orders dated 05/24/26 revealed there were orders for gabapentin (a nerve pain medication) two tablets three times daily. Review of Resident #61's May 2026 MAR revealed pain levels of 8 or above on 79 occasions. Review of the MAR revealed that the referral to the pain clinic was made on 05/08/26. Review of Resident #61's medical record revealed he had not been seen by the pain clinic as planned on 05/28/26. Review of Resident #61's physician orders and June MAR revealed that Resident #61 had not been re-scheduled for his pain clinic appointment. An interview with Resident #61 on 06/08/26 at 10:35 A.M. revealed that the facility had failed to manage his pain levels since admission. Resident #61 stated that the facility was aware that he was to see a specialist, but he had still not been able to see the pain specialist to date. An interview with Licensed Practical Nurse (LPN) Unit Manager #172 on 06/09/26 at 11:10 A.M. revealed that Resident #61 had an appointment to see the pain clinic specialist in late May 2026; however, once Resident #61 went to the appointment, the pain clinic could not see him due to a lack of photo identification. LPN Unit Manager #172 confirmed that he had not yet re-scheduled Resident #61's pain specialist appointment. LPN Unit Manager #172 revealed that he was unaware of the nurse practitioner recommendations made on 04/29/26, 05/04/26 and 05/06/26 for Voltaren gel. LPN Unit Manager #172 confirmed that there were no consistent nonpharmacological pain relief interventions in place for the as needed narcotic pain relief. A follow-up interview with LPN Unit Manager #172 on 06/09/26 revealed that, after surveyor intervention, he had called the pain clinic and Resident #61 was now re-scheduled for a pain specialist appointment on 06/10/26 at 7:30 A.M. Review of Resident #61's physician orders revealed that on 06/09/26, Resident #61 had orders for an appointment with a pain specialist. Review of Resident #61's physician orders dated 06/09/26 revealed that Voltaren external gel 1% was prescribed to apply to Resident #61's bilateral knees and ankles topically two times a day for pain, as was recommended by the Nurse Practitioner on 04/29/26, 05/04/26, and 05/06/26. An interview with LPN # 164 revealed that although she offered nonpharmacological interventions (NPI) when she worked with Resident #61, the NPI did not usually relieve Resident #61's pain. An interview with Resident #61 on 06/11/26 at 10:15 A.M. revealed that the pain specialist that he visited on 06/10/26 had recommended imaging of his legs to investigate the source of his pain. Review of a facility policy titled, Pain- Clinical Protocol, revised July 2024, revealed that the physician will order appropriate non-pharmacologic interventions to address the resident's pain. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions. If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support.

Based on interview, record review, and review of facility policy, the facility failed to ensure Resident #2 had an appropriate indication for long term antibiotic use. This affected one resident (#2) of five residents reviewed for unnecessary medication. The facility census was 102.Findings include:Review of Resident #2's medical record revealed an admission date of 02/06/26 with diagnoses including convulsions, chronic heart failure, end stage renal disease with dependence on renal dialysis, bipolar disease, adult failure to thrive, generalized anxiety disorder, and muscle weakness. Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition.Review of Resident #2's hospital discharge paperwork dated 02/03/26 revealed no evidence he was prescribed antibiotics.Review of Resident #2's physician orders dated 02/07/26 to 03/17/26 and starting again 03/18/26 revealed an order for Cephalexin oral Tablet 250 milligrams (mg) one tablet by mouth one time a day for dialysis prophylaxis. There was no end date documented.Review of Resident #2's 02/07/26 progress notes and assessments revealed no documentation related to the initiation of Cephalexin.Review of Resident #2's Medication Administration Record (MAR) for February 2026, March 2026, April 2026, May 2026, and 06/01/26 to 06/09/26 revealed the resident regularly received Cephalexin as ordered.Review of Resident #2's progress note by Nurse Practitioner (NP) #280 dated 03/17/26 revealed the resident was on Cephalexin prophylactically.Review of Resident #2's plan of care on 06/10/26 revealed it did not address his antibiotic use. Review of Resident #2's medical record from 02/07/26 to 06/10/26 revealed no documentation indicating why Resident #2 needed an antibiotic for dialysis.Interview on 06/08/26 at 8:56 A.M. and on 06/10/26 at 7:00 A.M. with the Director of Nursing (DON) revealed she was the infection control designee. She verified Resident #2 was on a long-term antibiotic and that antibiotic use for dialysis was not typical. The DON reported she had asked the practitioners about the purpose of the antibiotic and they had always told her it was prophylactic. On 06/10/26 at 3:59 P.M. she stated she had spoken to the practitioner about documented justification of the antibiotic. The DON stated the practitioner referred her to the 03/17/26 progress note, which she verified repeated that it was for prophylactic use. The DON was unable to identify why an antibiotic was needed prophylactically for this resident and what his specific risk was.Review of the policy 'Antibiotic Stewardship' dated December 2023, revealed it was the purpose of the program to monitor the use of antibiotics in the residents. Antibiotic orders were to include the drug name, the dose, frequency of administration, the start and stop date or number of days of therapy, route of administration and the indication for use.

Based on observation, interview, medical record review, facility policy review, and review of medication labels, the facility failed to ensure a medication error rate below 5 percent (%). Out of 27 opportunities for error, two errors were made to equal a medication error rate of 7.4%. This affected two residents (#29 and #89) of two residents observed for medication administration. The census was 102.Findings include:1. Review of Resident #29's medical record revealed an admission date of 05/18/26. Medical diagnoses include chronic obstructive pulmonary disease, acute diastolic (congestive) heart failure, muscle weakness, obstructive sleep apnea, essential (primary) hypertension, anxiety disorder, depression, gastro-esophageal reflux disease, and acute and chronic respiratory failure with hypoxia. Review of Resident #29's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.Review of Resident #29's physician orders revealed an order for acetaminophen extended release (ER) oral tablet 650 mg give one tablet by mouth every six hours as needed.Observation on 06/10/26 at 8:25 A.M. with Licensed Practical Nurse (LPN) #160 revealed Resident #29 was given acetaminophen regular strength 650 mg one tablet from the over-the-counter facility supply.Interview on 06/10/26 at 11:45 A.M. with LPN #160 confirmed he gave Resident #29 acetaminophen regular strength 650 mg tablet and not the ordered acetaminophen extended release 650 mg tablet.Review of the facility's policy titled, Medication Administration Policy revised on 02/2026 revealed the individual administering medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.2. Review of Resident #89's medical record revealed an admission date of 09/30/25. Medical diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential (primary) hypertension, paroxysmal atrial fibrillation, heart failure, gastro-esophageal reflux without esophagitis, gastrostomy status, dysphagia following cerebral infarction, muscle weakness, neuromuscular dysfunction of the bladder, acute and chronic respiratory failure with hypoxia, tracheostomy status, and prediabetes. Review of Resident #89's physician orders revealed an order dated 01/31/26 for a percutaneous endoscopic gastrostomy (PEG) tube flush with 10 cubic centimeters (cc) of water before and after medication administration every shift. Review of Resident #89's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #89's MDS section K revealed Resident #89 had a feeding tube in place.Review of Resident #89's care plan revised on 12/01/25 revealed the resident had impaired neurological status related to hemiparesis with interventions to monitor for and report significant changes to neurological status, such as dizziness, to the physician, and administer medications as ordered. Review of Resident #89's physician orders revealed orders for meclizine Hcl oral tablet 25 mg twice daily due at 9:00 A.M. at 9:00 P.M. for dizziness, among multiple other medications due. The order did not state that it was to be crushed, and the order did not state it was a chewable tablet form.Observation and interview on 06/10/26 at 8:55 A.M. with Licensed Practical Nurse (LPN) #160 confirmed she crushed Resident #89's meclizine tablet, among other medications, for administration.Observation of medication administration on 06/10/26 at 9:08 A.M. revealed LPN #160 administered all of Resident #89's crushed medications (including the meclizine tablet) via PEG tube.Interview on 06/10/26 at 12:47 P.M. with Pharmacist #400 confirmed the form of meclizine sent for Resident #89 should not be crushed.Review of the facility's policy, Administering Medications through an Enteral Tube revised on 12/2024 revealed medications were not to be crushed for administration through an enteral tube unless verified with the pharmacy. It noted that tablets that must be crushed prior to administration through an enteral tube required a specific order related to crushing. Review of the meclizine medication label revealed the medication comes in two forms, tablet and chewable tablet. The label noted the medication must be swallowed whole, unless it's the chewable tablet form to which it should be chewed or crushed completely before swallowing.This deficiency represents noncompliance investigated under Complaint Number 3022566.

Based on observation, interview, medical record review, review of resident meal tickets, review of food ingredients, and facility policy review, the facility failed to ensure Resident #54 was not provided food they were allergic to. This affected one resident (#54) of one resident reviewed for food concerns. This facility census was 102.Findings include:Review of Resident #54's medical record revealed an admission date of 10/05/25. Medical diagnoses included unspecified protein-calorie malnutrition, type II diabetes with diabetic neuropathy, hyperlipidemia, depression, and essential hypertension.Review of Resident #54's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.Review of Resident #54's allergies listed in the medical record revealed food allergies of arabica coffee extract and onions, and a drug allergy to codeine with no reaction manifestations listed.Review of Resident #54's progress note dated 05/22/26 revealed the facility confirmed the resident experienced itching from codeine, anaphylaxis from coffee extract, and diarrhea from onions. Review of Resident #54's meal ticket on 06/09/26 at 11:25 A.M. revealed the resident had an allergy to onions. Observation on 06/09/26 at 12:02 P.M. revealed Resident #54 was served two containers of salsa with a burrito meal. Resident #54 stated to staff I cannot have them, I am allergic.Interview on 06/09/26 at 12:02 P.M. with Certified Nursing Assistant (CNA) #198 confirmed Resident #54 received two containers of salsa that contained onions that he was allergic to, with his lunch tray.Review of the Heinz salsa sauce and dip ingredients list revealed onions were an ingredient of the salsa sauce and dip. Review of the facility's policy titled, Food Preferences and Special Diets dated 12/2023 revealed residents have the right to refuse foods offered and residents should be given substitutions for disliked or restricted foods.

Based on observation, interview, record review, review of the controlled medication log, and review of facility policy, the facility failed to ensure residents Medication Administration Records (MAR) were accurate. This affected two residents (#29 and #79) of five residents reviewed for unnecessary medications. The facility census was 102.Findings include: 1. Review of Resident #79's medical record revealed an admission date of 05/21/25 with diagnoses including depression, mood disorder due to known physiological condition with depressive features, anxiety disorder, type two diabetes mellitus, and restlessness and agitation. Review of Resident #79's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #79's physician order started 02/14/26 revealed an order for Nuedexta 10 milligrams (mg) one capsule by mouth every 12 hours for suspected pseudobulbar effect. Review of Resident #79's MAR for May 2026 revealed Nuedexta was not administered in the morning on 05/21/26 but was administered in the evening, it was not administered at all on 05/22/26, it was administered twice on 05/25/26 and 05/26/26, it was not administered at all on 05/25/26 and 05/26/26, it was administered twice on 05/27/26, it was administered once on 05/28/26, it was not administered at all on 05/29/26, and it was administered once on 05/30/26 and 05/31/26. Review of Resident #79's progress note dated 05/21/26 at 10:56 A.M. revealed Nuedexta was not in stock because the pharmacy needed prior authorization to send the medication. Review of Resident #79's MAR for 06/01/26 to 06/09/26 revealed Nuedexta was given twice on 06/01/26 and 06/02/26 and once on 06/03/26. Nuedexta was administered once on 06/03/26 and twice on 06/04/26. There was an order to hold the medication from 06/05/26 to 06/10/26. Interview on 06/11/26 at 1:40 P.M. with Unit Manager #149 revealed Resident #79's Nuedexta had been out of stock since the note on 05/21/26, stating any documentation since then indicating it had been administered was incorrect as it was not in the building. 2. Review of Resident #29's medical record revealed an admission date of 05/12/26. Medical diagnosis included anxiety. Review of Resident #29's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #29's physician orders revealed an order for diazepam oral tablet 10 mg with instructions to give one tablet by mouth every six hours as needed (PRN) for anxiety for 14 days. Review of Resident #29's Controlled Medication Log revealed the residents PRN diazepam 10 mg was documented as administered on 06/10/26 at 5:30 A.M. Review of Resident #29's June 2026 MAR revealed the residents PRN diazepam 10 mg was not documented as administered on 06/10/26 at 5:30 A.M. Observation on 06/10/26 at 7:45 A.M. revealed Resident #29 asked for a PRN diazepam. Licensed Practical Nurse (LPN) #160 advised Resident #29 he received a dose this morning at 5:30 A.M. according to the controlled medication log. Interview on 06/10/26 at 9:30 A.M. with LPN Unit Manager #172 confirmed the residents PRN diazepam was not documented in the Medication Administration Record (MAR) upon the 06/10/26 5:30 A.M. administration but was logged in the controlled medication log, and should be documented in both. Review of the facility's policy titled, Medication Administration Policy revised 02/2026 revealed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one. Further review of the policy revealed, as required or indicated for the medication, the individual administering the medication would record the following in the resident's medical record: the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug.

Based on review of a resident record, observations, family interview, staff interview and review of a facility policy, the facility failed to ensure that a resident's nails were filed and maintained in a clean and sanitary manner per his preferences. This affected one resident (#5) of three residents reviewed for activities of daily living (ADLs).Findings include:Review of a resident medical record revealed Resident #5 was admitted to the facility on [DATE] and had diagnoses that included aphasia, vascular dementia, chronic obstructive pulmonary disease, and hemiplegia and hemiparesis following cerebral infarction.Review of Resident #5's care plan dated 09/10/25 revealed Resident #5 had ADL self-care performance deficits related to chronic obstructive pulmonary disease and generalized weakness. A goal listed for Resident #5 was that Resident #5's ADL needs would be met through the next care plan review. An intervention listed was to assist Resident #5 with ADLs including grooming and personal hygiene. Review of Resident #5's functional abilities and goals assessment dated [DATE] revealed that Resident #5 had impaired range of motion on both sides of his upper extremities. Resident #5 was assessed as being dependent for personal hygiene. Review of Resident #5's Minimum Data Set (MDS) 3.0 dated 05/20/26 revealed Resident #5's cognitive skills for daily decision making were severely impaired. Resident #5 was assessed as needing partial to moderate assistance for personal hygiene. Review of Resident #5's personal hygiene task for the past 30 days revealed that four days of personal hygiene care were documented on 06/08/26, 06/09/26, 06/10/26, and 06/11/26. Resident #5 was documented as being dependent for personal hygiene. An interview with Resident #5's family member on 06/08/26 at 1:40 P.M. revealed that they were concerned about Resident #5's nail care. The family member communicated that Resident #5 preferred his nails short and clean. Observations of Resident #5's nails on 06/08/26 at 10:16 A.M., 06/09/26 at 8:13 A.M. and 1:40 P.M. revealed that Resident #5's nails were approximately a half centimeter long and had a dark substance under the nails of both hands. An interview with Registered Nurse (RN) #192 on 06/09/26 at 1:40 P.M. confirmed that Resident #5's nails had a dark substance under the nails and were long. RN #192 revealed that she would file and clean Resident #5's nails. Review of a facility policy titled, Activities of Daily Living, Supporting, dated August 2023, revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview, medical record review, review of facility infection control log, and review of facility policy, the facility failed to ensure antibiotic stewardship was followed. This affected 2 of 4 residents (6 and #28) reviewed on the infection control log for the months of December 2025 through May 2026. The facility census was 102.Findings Include:Review of the infection control log for December 2025 through April 2026 revealed the facility tracked the residents who received antibiotics during the months. It included the residents' name, room number, date, type of infection, antibiotic, nosocomial, and community acquired. The facility utilized an Infection Screening Evaluation for each resident who received an antibiotic treatment for an infection. The form determined whether the clinical findings of the resident met either McGeer's or Loeb's criteria for antibiotic use. The following residents were identified on the log as receiving antibiotic treatment for infections but did not meet McGreer's or Loeb's criteria:1. Resident #6 who admitted on [DATE], was prescribed and administered Doxycycline Hyclate (an antibiotic medication) on 12/01/25 to treat a toe infection. The resident completed treatment with fourteen doses of the medication. The disposition of the Infection Screening Evaluation form determined the antibiotic did not meet either McGeer's or Loeb's criteria.2. Resident #28 who admitted on [DATE], was prescribed and administered Doxycycline Hyclate on 12/01/25 to treat sinusitis. The resident completed treatment with ten doses. The disposition of the Infection Screening Evaluation form determined the antibiotic did not meet either McGeer's or Loeb's criteria.Interview on 06/11/26 at 2:28 P.M. with Director of Nursing (DON) confirmed, as the facility's infection control designee, when a resident infection was reported/discovered she entered the applicable information on the Infection Screening Form which was often left incomplete, meaning the antibiotic did not meet McGeer's or Loeb's infection criteria. She stated she did not have any further conversations with the prescriber about the resident not meeting the criteria for an antibiotic when this occurred. She confirmed Resident #6 and Resident #28's infections did not meet criteria for antibiotic use. Review of the policy 'antibiotic stewardship' dated 12/2023, revealed orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community.

Based on closed medical record review, interview and facility policy review, the facility failed to ensure the physician and the resident representative was notified of a change in condition. This affected one resident (#30) of three residents reviewed for change in condition. The facility census was 116. Findings Include:Review of the closed record for Resident #30 revealed an initial admission date of 01/22/26 with the diagnoses including but not limited to protein calorie malnutrition, depression, congestive heart failure, obstructive sleep apnea, metabolic encephalopathy, anemia, atrial fibrillation, pleural effusion, acute respiratory failure with hypoxia, hypertension, hyperlipidemia, myotonic muscular dystrophy and rheumatoid arthritis. Review of the resident's discharged physician orders identified orders dated 01/22/26 suction tracheostomy routinely and as needed for excessive secretions change tracheostomy inner cannula every shift and as needed size six cuffed or cuffless, tracheostomy care every shift and as needed, change tracheostomy ties every [NAME] and Thursday on day shift and 01/23/26 oxygen via tracheostomy mask at 4 liters continuously every shift. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was in a persistent vegetative state/no discernible consciousness. The assessment indicated the resident was always incontinent of both bowel and bladder. The resident received oxygen therapy, suctioning and tracheostomy care. Review of the progress note dated 01/31/26 at 7:33 P.M. revealed the resident's tracheostomy was found laying on the floor bedside his bed. The resident was noted to have mild respiratory distress and an oxygen saturation rate of 78%. The nurse immediately initiated emergency tracheostomy protocol. The nurse inserted a new size six tracheostomy tube without complications. The resident's oxygen saturation rate improved to 96%. The nurse documented the resident tolerated the procedure well and the resident was placed on close supervision. Review of the medical record revealed no documented evidence the resident's primary care physician (PCP) or family representative was notified the resident's tracheostomy was on the floor, the resident's mild respiratory distress and a new tracheostomy was inserted. On 03/10/26 at 3:15 P.M., an interview with the Director of Nursing (DON) verified the resident's PCP or family representative was not notified of the resident's tracheostomy was on the floor, the resident's mild respiratory distress and a new tracheostomy was inserted. Review of the facility's policy titled, Change of Condition Policy, dated 09/24 revealed the facility will promptly identify, assess and respond to any significant change in a resident's physical, mental or psychosocial condition. The licensed nurse will ensure timely notification of the physician and resident representative and implement appropriate interventions to maintain the resident's health and safety. This deficiency represents non-compliance investigated under Complaint Number 2735768.

Based on observation, medical record review, interviews and facility policy review, the facility failed to ensure one resident who was dependent on staff received routine nail care. This affected one resident (#100) of three residents reviewed for activities of daily living. The facility census was 116. Findings Include:Review of the medical record for Resident #100 revealed an initial admission date of 09/23/25 with the latest readmission of 01/10/26 with the diagnoses including but not limited to end stage renal failure, congestive heart failure (CHF), diabetes mellitus, hypertension, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea, major depressive disorder and fracture of lower end of right femur. Review of the plan of care dated 11/03/25 revealed the resident exhibited unsafe and unhygienic behavior during incontinence care, including smearing fecal matter and placing soiled fingers in mouth, which increases risk of infection, skin breakdown and cross contamination. Interventions included administer medications as ordered. Observe for effectiveness and side effects, approach resident using calm, reassuring communication to reduce agitation during incontinence care, educate on the risks of putting fecal matter in his mouth and give non-judgmental support. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident was dependent on staff for showers. On 03/09/26 at 11:07 A.M., an interview and observation with Resident #100 revealed the resident's nails were long, jagged and had a brown substance under the nail. The resident's stated, they will not cut my nails. On 03/09/26 at 1:32 P.M., an interview with the Director of Nursing (DON) verified the resident's nails were long, jagged with a brown substance under them. The DON stated she would cut the resident's nails. On 03/10/26 at 11:21 A.M., an observation of Resident #100 revealed the resident's nails remained long, jagged with a brown substance under them. Review of the facility policy titled, Nail Care, dated 07/24 revealed the purpose of the policy was to ensure residents receive safe and appropriate nail care to promote comfort, hygiene and prevent infection or injury. Nursing staff or trained nursing assistants may provide routine fingernail care, including cleaning and trimming. This deficiency represents non-compliance investigated under Complaint Number 2735768 and 2715847.

Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of avoidable pressure ulcers, timely identify areas of new skin impairment, promote optimal healing, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection. Actual Harm occurred beginning on 11/19/24 when Resident #54, who had moderate cognitive impairment and was at high risk for pressure ulcer development, was assessed to have a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer to the right buttocks that originated from Moisture Associated Skin Damage (MASD). Due to a lack of individualized and effective interventions, on 11/26/24 Resident #54's right buttock pressure ulcer expanded to a bilateral buttock pressure ulcer. On 12/03/24 the pressure ulcer progressed to a Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) bilateral buttock pressure ulcer without evidence of adequate and individualized pressure ulcer prevention interventions being in completed prior to the deterioration/progression. Actual harm occurred on 10/29/24 when Resident #163 who had severe cognitive impairment, was dependent on staff for toileting and transfers, was assessed and documented to be at high risk for pressure ulcer development but had no individualized plan developed to prevent pressure ulcers was identified to have of an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the sacrum. The facility failed to create and implement an individualized plan to prevent the pressure ulcer resulting in the development and identification of the unstageable ulcer. Actual harm occurred on 08/13/24 when Resident #89, who was at high risk for pressure ulcer development and had a history of unstageable pressure ulcers, developed a new Stage III pressure ulcer to the right ischium. On 08/08/24, the resident's prescribed air mattress malfunctioned and was replaced with a regular bed and a gel overlay, which failed to provide adequate pressure relief. On 08/12/24, a new air mattress was ordered, but documentation on 08/13/24 indicated the replacement air mattress also malfunctioned, causing the resident's buttocks to come into direct contact with the metal bed frame. This resulted in tissue breakdown and the development of the new Stage III pressure ulcer. The facility failed to ensure timely replacement and proper functioning of pressure-relieving equipment, resulting in the development of the Stage III pressure ulcer. This affected three residents (#54, #89, and #163) of five residents reviewed for pressure ulcers. The facility census was 109. Findings include: 1.Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including a wedge compression fracture of thoracic (T)11-T12 vertebra, chronic respiratory failure, urinary tract infection (UTI), unspecified combined systolic and diastolic heart failure, benign prostatic hyperplasia with lower urinary symptoms, atrial fibrillation, hypertension (HTN), left bundle-branch block, low back pain, bilateral primary osteoarthritis of first carpometacarpal joints, malignant neoplasm of prostate, vitamin D deficiency, presence of cardiac pacemaker, repeated falls, hyperlipidemia, major depressive disorder, constipation, wedge compression fracture of first lumbar vertebra, chronic obstructive pulmonary disease (COPD), tinea unguium, and psoriasis vulgaris. Review of the skin risk/Braden Scale Assessment (a tool used to assess a resident's risk of developing pressure ulcers), dated 7/10/24 revealed Resident #54 was assessed to be at mild risk for pressure injury. Review of a nursing progress note dated 07/10/24 at 7:48 P.M. revealed Resident #54 admitted to the facility with an excoriating skin rash all over back area down to coccyx and blisters on the coccyx. Zinc oxide cream and Triad paste (a zinc oxide based hydrophilic paste for light to moderate levels of wound exudate/drainage used to help maintain an optimal wound healing environment) were to be applied on rash twice daily. Review of the physician orders revealed the following orders were in place: Zinc Oxide External cream 10% apply to lower back topically two times a day for excoriating rash with a start date of 7/11/24. Ammonium lactate external cream 12% apply to upper and lower back topically as needed for soilage with a start date of 07/12/24 and an end date of 07/19/24. Review of the Medication Administration Report (MAR) for Resident #54 revealed no evidence the physician orders for Ammonium lactate external cream 12% was administered at all during incontinence episodes during this time period. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/29/24 revealed Resident #54 had moderately impaired cognition, required moderate (staff) assistance with toileting, moderate (staff) assistance with upper extremity dressing, maximum (staff) assistance with lower extremity dressing, maximum (staff) assistance with putting on and taking off footwear, and had no pressure ulcers. A skin risk/Braden Scale Assessment completed on 11/01/24 which revealed a high risk for pressure injury development. Review of the comprehensive care plan for Resident #54 revealed a focus on potential alterations in skin integrity. The goal was to prevent skin breakdown through comprehensive review. Interventions included (on 07/10/24) educate resident/family on skin breakdown risk factors and preventative measures, encourage floating heels while in bed, pressure-reducing cushion to the chair, pressure-reducing mattress to the bed, assist with hygiene, including peri-care as needed and barrier cream during showers and after incontinent episodes. A plan of care (dated 08/08/24) revealed the resident had current area of skin impairment to the right buttock. The goal was to heal the existing impairment and prevent further skin breakdown and infection with a target date of 10/08/2024. Interventions included (on 08/08/24) to initiate wound treatment, continue as ordered by the medical director or nurse practitioner, observe and document wound character weekly, and monitor for clinical changes such as infection or worsening of the wound, (on 11/08/24) encourage repositioning as tolerated, (on 11/19/24) apply barrier cream after each incontinent episode and encourage repositioning with pillows as tolerated, (on 12/04/24) air mattress to bed, monitor for proper functioning, and (12/17/24) encourage resident to allow staff to reposition every two hours. Review of Bed Mobility task documentation from 11/24/24 to 12/23/24 for Resident #54 revealed staff documented the resident was totally dependent on staff for bed mobility during this time period. The resident had orders for Triad Hydrophilic wound dress external paste (wound dressings) apply to bilateral buttocks topically every shift for wound care with a start date of 09/11/24 and an end date of 10/30/24. Triad Hydrophilic wound dress external paste (wound dressings) apply to bilateral buttocks topically as needed for incontinence with a start date of 09/11/24 and an end date of 10/30/24. Triad Hydrophilic wound dress external paste (wound dressings) apply to bilateral buttocks topically as needed for soilage with a start date of 10/17/24 and an end date of 12/17/24. Review of a nursing progress note dated 10/09/24 revealed Resident #54 returned to the facility with a skin tear on the right arm and a reddish spot on the buttock with no open area. Review of the skin assessments from contracted Wound Provider #1050 for Resident #54 revealed the following information: 10/16/24: Initial assessment: Wound on the right buttock diagnosed as Moisture-Associated Skin Damage (MASD) 9.0 centimeters (cm) length by (x) 3.5 cm width x <0.1 cm depth. Irritant contact dermatitis due to fecal, urinary, or dual incontinence. Treatment orders: Cleanse area, pat dry, apply zinc barrier cream (20% or greater) every shift and as needed (PRN). No new interventions or changes to the resident's plan of care were noted at this time. 10/30/24: Right buttock pressure ulcer still diagnosed as MASD. 12.0 cm length x 10 cm width x <0.1 cm depth. Additional treatment: Triad paste to buttocks every day and PRN. However, record review revealed no documented evidence of the Triad paste being provided as needed after incontinence episodes between July and 10/30/24. 11/19/24: Right buttock pressure injury progressed to a Stage II pressure ulcer (related to exposed dermis) 11 cm length x 9.0 cm width x 0.1 cm depth. Irritant contact dermatitis due to fecal, urinary, or dual incontinence. Record review revealed no additional interventions were implemented to address the resident's fecal/urinary/dual incontinence to prevent skin breakdown. 11/26/24: Right buttock pressure injury remained at Stage II, 13 cm length x 11 cm width x 0.1 cm depth, treatment orders remained the same on this date. 12/03/24: Right buttock worsened to a Stage III (full thickness) pressure ulcer, 9.0 cm length x 13 cm width x 0.1 cm depth with 90% granulation and 10% slough. Treatment remained the same. Record review revealed no additional or new interventions were implemented to prevent additional skin breakdown and/or to promote healing. 12/10/24: Right buttock pressure ulcer remained at Stage III, 8.0 cm length x 5.0 cm width x 0.1 cm depth with 100% granulation. Irritant contact dermatitis due to fecal, urinary, or dual incontinence. Resident agreeable to air mattress. Wound physician measured the entire wound region, reporting eight pressure ulcers with skin bridges and MASD resolved. Treatment orders: Triad paste open to air, reapply triad paste as needed, air mattress in place. 12/17/24: Right buttock pressure ulcer remained at Stage III, 8.0 cm length x 4.5 cm width x 0.1 cm depth with 100% granulation. Comments and treatment remain the same. Review of the Medication Administration Report (MAR) for Resident #54 revealed no evidence the physician orders for Triad Hydrophilic wound dress external paste (wound dressings) was administered at all during incontinence episodes from July 2024 to December 2024. On 12/19/24 at 1:54 P.M., observation of Resident #54's Stage III pressure ulcer to the right buttocks revealed the wound bed was red with active bleeding on the incontinence brief. Further observation revealed the physician ordered treatment of Triad following each incontinence episode was not in place. Interview with Registered Nurse (RN) Wound Nurse #500 during the time of the observation verified the resident was provided incontinence care prior to entering the room for the wound observation and the physician ordered treatment of Triad was not in place. Interview on 12/18/24 at 2:35 P.M. with the Wound Doctor (WD) #122 verified Resident#54's wound started as MASD and turned to an open Stage II pressure ulcer wound on 11/19/24. He stated he doesn't remember seeing blisters on his initial assessment. WD #122 stated they were doing zinc barrier and then collogen. He stated there were multiple open areas and the wound changed to a bilateral wound on 11/26/24, but stated there was not a wound on the left buttock only multiple wounds on the right buttock. WD#122 stated he did not measure each area. During the interview, the WD revealed the wound was not being offloaded so it would not heal properly. He stated the Triad paste should be applied on during changes and soilage and stated there were eight separate wounds but since they were in the same area he measured the wounds as one big area. He stated the Triad paste and leaving the areas open to air was the current treatment. Additionally, WD #122 stated the area around the wound wasn't MASD so he didn't want adhesive on the skinned area around the wound. Review of the medical record revealed the facility did not implement the wound/skin prevention interventions as listed in the care plan for Resident #54. The care provided to Resident #54 was also not consistently delivered as planned, resulting in the progression of the MASD to a Stage III pressure ulcer. Despite the progression of Resident #54's skin alteration from Moisture-Associated Skin Damage (MASD) to a Stage II pressure ulcer and then Stage III pressure ulcer, no changes were made to the wound treatments implemented for the resident. The wound, was initially assessed as MASD on 10/16/24, progressed to Stage II on 11/19/24 and later to Stage III on 12/03/24, yet the same treatment plan was followed without modification. Specifically, the use of zinc barrier cream and Triad paste was continued, even after the wound had deepened and required more advanced management. No adjustments were made in the frequency or nature of wound care, nor was the offloading of pressure more rigorously addressed. As a result, the wound failed to heal properly and worsened in severity. 2. Review of the medical record for Resident #163 revealed an initial admitted [DATE] with a latest readmission of 12/01/24 with diagnoses including gastrostomy malfunction, asthma, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, syncope and collapse, repeated falls, cerebrovascular accident (CVA) with left sided hemiplegia, anxiety disorder, dysphagia, aphasia, hypertension, and hypothyroidism. Review of the resident's plan of care dated 10/12/24 revealed the resident had the potential for pressure ulcer development related to CVA with hemiparesis. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown, incontinence care check and change for incontinence on a routine basis and as needed, turn and reposition as ordered and use lifting device to reduce friction. Review of the resident's readmission admission assessment with baseline care plan dated 10/17/24 revealed the resident was readmitted on [DATE] with no pressure ulcers. Review of a revised plan of care (originally dated 10/17/24) revealed the resident had an actual area of skin impairment related to pressure to sacrum and unstageable pressure ulcer to the resident's left elbow that was present on admission from the hospital and resident prefers to lay on his back most of the day. Interventions included air mattress as ordered on 10/29/24, encourage to reposition as tolerated, evaluate for pain and provide pain relieving interventions as ordered, initiate wound treatment, continue treatment as ordered by the physician/nurse practitioner (NP), limit time out of bed, nursing to observe the wound dressing daily to ensure that the dressing remains intact and that there are no signs/symptoms of infection or increased drainage, observe for clinical changes, such as infection and/or worsening of wound, pressure reducing cushion to chair, refer to dietician to determine need/no need for dietary intervention and skin observation and document on bath/shower days, charge nurse to notify the wound nurse, physician and family of any new areas. Review of the resident's Braden scale dated 10/24/24 revealed a score of 15 indicating the resident was at risk for skin breakdown. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was dependent on staff for bed mobility, toileting and transfers. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had no skin issues. The facility implemented a pressure reducing device to his bed. Review of the progress note dated 10/29/24 at 7:54 A.M. revealed the nurse performed a weekly skin assessment and discovered an open area to sacrum measuring 2.0 centimeters (cm) by 2.0 cm. The area was cleansed with normal saline (NS) and pad and protect order initiated. The physician and wound nurse were made aware of the wound. Review of the skin observation dated 10/29/24 revealed the resident was found to have a pressure ulcer to his sacrum measuring 2 cm by 2 cm. The observation contained no description or staging of the wound. Review of the facility's incident report dated 10/29/24 revealed the nurse performed an ordered weekly skin assessment and discovered open area to sacrum. The resident was unable to verbalize when the area started or how the area occurred as the resident was unaware of the area. The area was cleansed with NS and pad and protect order initiated. The physician and wound nurse were made aware of the wound. Review of the weekly pressure skin grid dated 10/30/24 revealed the resident was found to have a Stage III pressure ulcer to the sacrum measuring 1.6 centimeters (cm) by 1.4 cm by 0.2 cm with the wound bed being 100% slough. The peri-wound was within normal limits. The wound had a moderate amount of serosanguineous drainage. The facility implemented the treatment cleanse, apply Santyl, cover with normal saline (NS) soaked gauze. Review of the weekly pressure skin grid dated 11/05/24 revealed the Stage III was now classified as an unstageable pressure ulcer measuring 1.0 cm by 1.5 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a moderate amount of serous exudate. No changes to the treatment were made at this time. Review of the weekly pressure skin grid dated 11/12/24 revealed resident had an unstageable pressure ulcer measuring 1.0 cm by 1.0 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a moderate amount of serosanguineous exudate. There were no changes to treatment at this time. The resident was discharged to an acute care hospital on 11/14/24 and readmitted to the facility on [DATE]. Review of the resident's monthly physician orders for December 2024 identified orders dated 11/11/24 cleanse right sacrum with normal saline, pat dry, apply nickel thick Santyl to wound bed, cover with saline moistened gauze then cover with a clean dry dressing daily and as needed, 11/13/24 air mattress to bed, ensure proper functioning every shift and 12/04/24 enhanced barrier precautions (EBP) every shift due to wound. Review of the skin observation dated 12/01/24 revealed the resident was readmitted to the facility with a previously identified wound to the sacrum. Further review revealed no comprehensive assessment (measurements/description) of the pressure ulcer was completed upon re-admission to the facility. Review of the readmission pressure skin grid dated 12/02/24 revealed the unstageable pressure ulcer to the resident's sacrum measured 1.5 cm by 1.5 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a minimal exudate. The facility resumed the previous treatment to cleanse wound, apply Santyl and cover with NS soaked gauze. Review of the re-admission pressure skin grid dated 12/03/24 revealed the unstageable pressure ulcer to the resident's sacrum measured 1.3 cm by 1.3 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a minimal exudate. The facility did not determine if the wound had improved, declined or remained unchanged. The facility made no changes to the treatment. Review of the re-admission pressure skin grid dated 12/10/24 revealed the unstageable pressure ulcer to the resident's sacrum measured 1.3 cm by 1.0 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a minimal exudate. The facility determined the wound had improved and made no changes to the treatment. Review of the re-admission pressure skin grid dated 12/17/24 revealed the unstageable pressure ulcer to the resident's sacrum measured 1.2 cm by 1.0 cm with the depth being unable to determine due to the wound bed being 100% slough but able to see tips of granulation. The wound had a minimal exudate. The facility determined the wound had improved and made no changes to the treatment. On 12/18/24 at 9:32 A.M., observation of Registered Nurse Wound Nurse (RNWN) #500 and Unit Manager (UM) #214 provide the physician ordered treatment to the resident's unstageable pressure ulcer revealed RNWN #500 donned personal protective equipment (PPE) (gown), entered the room washed their hands and donned gloves. RNWN #500 cleansed the resident's bedside table with a sani-wipe, washed her hands and donned gloves. She then placed a barrier on the table and set-up the required supplies. RNWN #500 removed the soiled dressing to the sacral wound. The wound was quarter sized with pink edges and a yellow center. She then washed her hands and donned a pair of gloves and cleansed the wound with NS and a 4X4, pat dry. RNWN #500 then washed her hands and donned gloves. She then used a tongue depressor and placed Santyl on the center of the wound, covered the wound with a NS soaked gauze and covered the wound with a bordered gauze dressing. On 12/18/24 at 1:39 P.M., interview with the Interim Director of Nursing (IDON) and Registered Nurse Wound Nurse (RNWN) #500 revealed the sacral wound was actually an unstageable pressure ulcer when the wound was discovered, however the wound physician documented the wound as a Stage III pressure ulcer. The IDON and RNWM #500 revealed they were unaware of why the staff had not identified the pressure ulcer prior to an unstageable pressure ulcer. The facility provided no evidence of an individualized skin breakdown prevention program for the resident. 3. Review of the medical record revealed Resident #89 was admitted on [DATE] and readmitted on [DATE], with diagnoses including paraplegia, epilepsy, heart failure, atrial fibrillation, hypertension, muscle weakness, and a colostomy and indwelling catheter in place. Resident #89 was admitted (on 04/03/24) with a Stage III pressure ulcer to the right ischium which measured 4.5 cm in length X 1.5 cm in width, and 1.5 cm in depth. The pressure ulcer healed on 06/04/24. On 07/10/24, a skin risk/Braden Scale Assessment indicated the resident was at mild risk for pressure injury development. However, a follow-up skin assessment conducted on 11/01/24 identified the resident as being at high risk for pressure injury development. Review of the comprehensive care plan for Resident #89 revealed a focus on skin integrity, specifically addressing areas of skin impairment related to pressure on the sacrum and right ischium, as well as non-pressure concerns on the right second toe. The goal was to heal the current impairment and prevent further skin breakdown. Interventions included on 04/04/24 pressure reducing cushion to chair, Prevalon boots to bilateral lower extremities as tolerated, monitor for pain and provide pain-relieving interventions as ordered. On 04/24/24 check function of air mattress every shift was added and revised on 11/19/2024. On 04/27/24 ask resident about pain level prior to dressing change procedure, medicate if needed and air mattress as ordered. On 08/08/24 the care plan was updated to include observe and document the character of the wound weekly, observe for clinical changes, such as infection and/or worsening of wound, and initiate wound treatment as ordered by the medical director (MD)/Nurse practitioner (NP). On 11/08/24 encourage repositioning as tolerated, and on 12/13/24 apply shoes for outside doctor appointments were added. The care plan also had a focus on enhancing the overall management of skin integrity, including interventions initiated on 04/04/24 of daily skin observation and documentation on bath/shower days, on 11/19/24 padding to the right lateral wheelchair, on 12/04/24 to limit time out of bed, and implement enhanced barrier precautions due to wound and colostomy. On 12/17/24 encouraging the resident to allow staff to reposition every two hours was added to the resident's plan of care. Review of the 10/01/24 Minimum Data Set (MDS) 3.0 assessment revealed Resident #89 was cognitively intact and required extensive (staff) assistance with personal care, including bed mobility, transfers, toileting, and sitting to lying positions. a.Review of a nursing progress note on 08/08/24 at 10:36 A.M. noted Resident #89's air mattress was noted to be malfunctioning and per the nurse practitioner discontinue the air mattress and order gel mattress. An order was placed with a medical supply company. Review of a nursing progress note on 08/13/24 at 10:46 A.M. noted the wound nurse conducted a weekly wound assessment for Resident #89 on this date. A new pressure injury was identified on the resident's right ischium. The wound bed presented with 100% granulation tissue, measuring 5.0 cm in length by 1.5 cm in width with 0.1 cm depth. A new order was provided to cleanse the wound with normal saline (NS) or wound cleanser (WC), pat dry, apply Calcium Alginate to the wound bed, and cover with a foam dressing. The dressing was to be changed daily (QD) and as needed (PRN). Additionally, the assessment revealed an issue with the air mattress placed beneath the resident. The mattress was noted to be deflated at the buttocks area, causing pressure on the metal frame, which was not detected by the pump's alarm for low pressure. The resident, who was alert and oriented (A&O x 4) was paraplegic and unable to feel sensations below the waist. A new order was provided to replace the malfunctioning air mattress. The resident was assisted out of bed and into a wheelchair. The medical supply company was contacted and requested to replace the air mattress. The mattress was replaced, and the new air mattress was confirmed to be functioning properly. Interview with Resident # 89 on 12/23/24 at 8:13 A.M. revealed he could feel when the air mattress failed as he was able to feel it on his back and he felt with his hands that the bed was deflated. He stated he alerted the staff, and it took approximately an hour for them to respond. The resident stated the bed had no audible alarm or any other type of notification that he was aware of when it malfunctioned. During the interview, the resident voiced concerns that staff did not actually observe his skin during repositioning. Interview on 12/24/24 at 12:10 P.M. with Wound Nurse #500 confirmed on 08/08/24 she found the resident's air mattress was losing air, so the Certified Nurse Practitioner (CNP) ordered a gel overlay to put on a regular mattress. Wound Nurse #500 noticed the gel overlay was dispersing but not offloading for the wound, so she ordered a new air mattress that came on 08/12/24. That bed malfunctioned on 08/13/24 and a new bed was ordered. The resident was on regular mattress with a gel overlay for four days. The resident developed a Stage III pressure ulcer as a result. b. In addition, review of the care provided to Resident #89 related to pressure ulcers revealed the following concerns with treatments not completed as ordered: Santyl External Ointment 250 Unit/GM (Collagenase) with orders to apply to right ischium topically every day shift for wound care was not completed on 10/04/24,10/06/24, 10/08/24, 10/21/24, 11/07/24, 11/12/24 or 11/14/24. Right Ischium: Cleanse with NS, pat dry. Apply Santyl (nickel thick) to wound bed then moistened gauze and cover with clean dry dressing daily and as needed was not completed on 10/04/24, 10/08/24, 10/21/24, 10/24/24 or 11/06/24. Monitor Right Ischium, Bilateral buttocks, left 2nd toe for s/s of infection. If noted, report to NP/MD & management/wound nurse every shift was not completed on 10/17/24, 11/07/24 or 12/11/24. Interview on 12/23/24 at 3:44 P.M. with Wound Nurse #500 verified the dates of the missed wound treatments and interventions and stated there was no justification for the missed wound care and treatments. c. Review of the skin grid pressure assessments and wound provider assessment for Resident #89 revealed the following: 10/16/24 Skin grid assessment: Wound assessed as unstageable, measuring 1.7 cm length x 1.7 cm width x unable to determine depth; described as healing, the wound was documented to have 40 % slough and 60 % granulation tissue. MD #610 was documented as the practitioner who assessed the wound. 10/16/24 Wound provider assessment: Wound assessment and plan: Unstageable pressure wound, 2.0 cm length x 1.7 cm width x depth unknown, 40% granulation and 60% slough in wound bed, noted as healing. Treatment cleanse wound with normal saline or sterile water, Santyl nickel thick layer- cover with moist gauze and cry clean dressing every day and PRN. Assessment documented by MD #610. 11/05/24 Skin grid assessment: Wound classified as Stage III, measuring 0.2 cm length x 0.2 cm width x <0.1 cm depth; noted as improved the wound was documented to have 100 % epithelial tissue present with a new treatment ordered and WD #122 was documented as the practitioner who assessed the wound. 11/05/24 Wound provider assessment: Wound assessment and plan: Stage IV wound, 0.2 cm length x 0.2 cm width x <0.1 cm depth, noted as healing. Full thickness with exposed underlying structure. 100% epithelial tissue in wound bed. Treatment Barrier cream twice daily and as needed. Assessment completed by WD #122. 12/03/24 Skin grid assessment: Wound became unstageable, measuring 2.0 cm length x 1.5 cm width x unable to determine depth; noted decline by facility assessment, the wound was documented to have 70 % slough and 30% granulation tissue present and to continue with the current treatment. WD #122 was documented as the practitioner who assessed the wound. 12/03/24 Wound provider assessment: Wound assessment and plan: Stage 4 pressure wound, 2.0 cm length x 1.5 cm width x 0.2 cm depth, 30 % granulation and 70 % slough in wound bed. Wound documented as same/stable. No documentation present why stage was changed from Stage 3 to Stage 4. Assessment completed by WD #122. Interview on 12/24/24 at 10:15 A.M. with the Regional Nurse #504 and Interim Director of Nursing (IDON) #506 revealed there were discrepancies between the wound nurse and wound physicians' assessment. They stated the wound nurse and wound physician should be communicating those differences and additionally verified the wound nurse and wound physician are not communicating their differences in assessment. Review of the Skin and Wound Management Policy dated October 2024 revealed the purpose of the Skin and Wound Management policy was to provide an approach in the prevention and management of pressure injuries and skin alterations using the nursing process and other strategies to assist in identifying residents at risk for developing pressure injuries. This approach was in accordance with State and federal regulations. Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. The physician would assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.). The physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. The physician would guide the care plan as appropriate, especially when wounds were not healing as anticipated or new wounds develop despite existing interventions. The deficiency identifies non-compliance with Complaint Number OH00160119. 32654

Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to maintain a safe accident free environment and prevent a fall with injury for Resident #20. Actual Harm occurred on 05/03/24 when Resident #20 sustained a fracture of metatarsal bone and talus as a result of a fall sustained when the resident stepped from the transportation bus onto an unstable milk crate placed by facility staff, when exiting the transportation bus. Following the incident, Resident #20 complained of left knee and right foot pain and bruising was noted on her right ankle. Nursing noted Resident #20 had right extremity swelling, bruising, and uncontrolled pain, rating her pain an eight on a scale of one to 10 prior to her being sent to the hospital for evaluation and treatment. This affected one resident (#20) of three residents reviewed for accidents. The facility census was 108. Findings include: Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including age-related osteoporosis, anemia, pain in left hip, history of falls, and stroke. Review of the physical therapy (PT) treatment notes dated 02/05/24 revealed Resident #20 was discharged from physical therapy (PT) with safe functional mobility throughout facility with and without an assistive device. Resident #20 could safely ambulate unlimited distances using a front wheeled walker on uneven surfaces with modified independence. Review of the care plan dated 02/22/24 revealed Resident #20 was at risk for fall related to injury due to history of falls and medication use. Interventions included keeping the call light within reach and observe medication use for side effects that may increase fall risk, therapy screens, and update physician as indicated regarding change in condition/treatment needs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had intact cognition. The assessment revealed Resident #20 required partial assistance from staff with mobility and sit-to-stand. Review of Fall Risk evaluation assessment dated [DATE] revealed Resident #20 was at low risk of falls. The assessment revealed Resident #20 was ambulatory, had normal balance, and had no reported falls within the past three months. Review of a progress notes dated 05/03/24 revealed the facility received a call from the dialysis center regarding a fall Resident #20 encountered during transfer off the bus. Resident #20 complained of left knee pain and bruising was noted on her right ankle. This resident was sent to the hospital after returning from dialysis for further evaluation related to injuries. Review of an incident report dated 05/03/24 revealed Resident #20 was complaining of pain to her right foot. Predisposing factors revealed uneven surface and lost balance. Nursing noted Resident #20 had right extremity swelling, bruising, and uncontrolled pain. The resident was sent to hospital for x-rays related to injury. Pain was noted at eight out of ten (with 10 being the most severe pain). Review of the hospital records dated 05/03/24 for Resident #20 revealed the resident was admitted due to complaint of right ankle injury from fall. This injury was sustained after stepping out of facility transportation bus onto a milk carton placed by their bus driver. This milk carton was unstable and flipped over under Resident #20's feet. The hospital records noted Resident #20 complained of pain rated a 10 out of 10. The physical exam revealed right ankle swelling present, tenderness over lateral malleolus, base of fifth metatarsal, and anterior [NAME]-fibular ligament. The x-ray report dated 05/03/24, revealed partially visualized fractures at the fifth metatarsal base, fourth metatarsal, third metatarsal, and second metatarsal. Probable avulsion type fracture arising from the anterior process of the talus. Resident #20 was hospitalized until 05/07/24 when she was discharged back to the facility. Review of the physician order dated 05/08/24, revealed Resident #20 was ordered non-weight bearing to right leg due to fracture of right foot. There was also a dressing order for the right foot/leg dressing to be changed every shift. Interview on 06/18/24 at 7:36 A.M. with Resident #20 revealed prior to the incident (on 05/03/24), she had no issues getting off the bus. On 05/03/24, she was stepping down off the bus, the facility transport assistant placed a milk crate under her to help with the step. After placing her second foot on the crate it flipped out from underneath her. When she fell , she was assisted up, and she stated she had refused to go to the hospital until after she received dialysis. When finished with dialysis, she was transported to the facility where nursing staff sent her out to the hospital. Resident #20 stated she was in tremendous pain due to the fall. Interview on 06/18/24 at 8:48 A.M. with Transport Driver #328 confirmed Resident #20 fell due to an unstable crate that he had placed at the steps of the transport bus. Transport Driver #328 indicated the milk crate had not been used previously as a transfer aide, and he confirmed the milk crate was not an appropriate transfer device. Interview on 06/18/24 at 10:38 P.M. with Licensed Practical Nurse (LPN) #252 confirmed prior to Resident #20's fall, she was independent with ambulation and required no assistance with getting on and off the bus. LPN #252 confirmed the dialysis center called the facility on 05/03/24 due to the reported incident of fall. LPN #252 stated Resident #20 told her she fell when stepping off the bus onto an unstable milk crate. Interview on 06/18/24 at 11:32 A.M. with Director of Nursing (DON) #224 confirmed Resident #20 fell due to stepping onto an unstable milk crate. Interview on 06/18/24 at 11:20 A.M. with the Administrator revealed he was notified of Resident #20's fall. The Administrator stated he spoke with Transportation Driver #328 about the incident, where he was informed to never use inappropriate transfer devices for ambulation. The Administrator confirmed the crate should not have been placed to use as a step for the resident. This deficiency represents non-compliance investigated under Complaint Number OH00154301.

Based on medical record review, review of wound culture results, review of Magnetic Resonance Imaging (MRI) results, review of hospital records, review of wound assessments, interviews with residents and staff, and facility policy review, the facility failed to timely treat a wound infection and osteomyelitis (a bone infection), as well as ensure outside medical appointments with the wound clinic and infectious disease physician were not missed, and failed to notify the physician of the missed appointments. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on [DATE] when Resident #22 was diagnosed with a left foot wound infection, was subsequently diagnosed on [DATE] with osteomyelitis, and did not receive treatment for either. This affected one resident (#22) of three residents reviewed for missed appointments and changes in condition. The facility census was 86. On [DATE] at 4:08 P.M., the Director of Nursing (DON), [NAME] President (VP) of Clinical Services #275, and Regional Director of Clinical Compliance #278 were notified Immediate Jeopardy began on [DATE] when Resident #22's results from a wound culture completed at Wound Clinic (WC) #200 were positive for a wound infection, which was resistant to oral antibiotics; the resident was referred to Infectious Disease (ID). Resident #22 missed two scheduled appointments at WC #200 on [DATE] and [DATE] and missed two scheduled appointments at ID on [DATE] and [DATE]. A Magnetic Resonance Imaging (MRI) was completed on [DATE] and showed osteomyelitis of Resident #22's left fifth metatarsal (long bone on the outside of the foot that connects to the small toe). Resident #22 was not treated with antibiotics for the wound infection or osteomyelitis. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: On [DATE] at 4:30 P.M., Resident #22 was sent to the emergency room (ER) via emergent transport for assessment and treatment. On [DATE] at 9:00 A.M., an Ad Hoc Meeting was held with the interdisciplinary team (IDT) which included Medical Director #219, Minimum Data Set (MDS) Coordinator #292, the DON, Registered Nurse (RN) #293, Licensed Practical Nurse (LPN) #210, LPN #233, Registered Dietitian (RD) #295, and Speech Therapy Director (STD) #297. The IDT reviewed the concern for Resident #22, interventions, education provided, audits completed and agreed with the plan. The Medical Director requested audits to continue monthly with no stop date once 12 weeks of audits had been completed. On [DATE], the DON/designee assessed all resident charts and residents with current infections, residents with appointments outside the facility that were rescheduled, residents who have had testing done outside the facility, residents who had wounds and/or had changes in condition related to wounds/infection between [DATE] and [DATE] to identify any like residents. These resident charts were audited to ensure no orders, treatments/interventions, appointments, and/or test results were missed. Any discrepancies or missed items were fixed immediately. On [DATE], education was initiated on expected actions to be completed upon any residents' return from an appointment. This education was provided to facility and agency nurses. The education was completed on [DATE] and would be ongoing. All facility nurses were educated. All agencies were provided with education and a reminder to view and sign the binder with the education at the start of their next shift. Read receipts were obtained and show all emails were read by the agencies. The education will be ongoing. On [DATE], the DON initiated for all new nurse hires to be educated during orientation and then added to the employee messaging system. This would be ongoing. On [DATE] the facility implemented a plan for agency nurses to be educated using the Education Binder kept at each nurse's station as was the facility current practice with all education. The agency would also continue to be provided with all education via email by the DON/Designee with a read receipt requested. Agency nurses were to sign attestation in the binder during their next shift. On [DATE] the facility implemented a plan for any updates or changes to be provided to all nurses as needed. All nurses would attest to receiving education electronically or via a signature sheet. On [DATE], the DON audited all current residents to determine those residents with current infections. From those found using the facility criteria, audits were then completed to determine if appropriate treatment was in place if indicated. Any findings were identified, remedied and the resident/representative and physician were notified. Ongoing audits would be completed when new infections were identified to ensure treatment was appropriate. These patients would be identified by the Infection Preventionist (IP) nurse as well as during clinical meeting by running the orders listing report and reviewing progress notes. Audits were also initiated for the notifications to ensure completeness as well as appropriate interventions. On [DATE], the DON and Unit Managers began auditing appointments. The audits were completed on [DATE] and would continue ongoing. The audits looked at the following information: did resident attend appointment, were there barriers to obtaining transportation for appointment, were any needed appointments scheduled and transportation available, was the appointment rescheduled, and did a visit summary accompany the resident when returned from the appointment, is there a follow up scheduled, is transport for the follow up scheduled, did staff notify the provider and resident/representative of changes with appointments date/time and reason for changes, any changes in condition and any new diagnosis or new orders/treatments. On [DATE], an Ad Hoc meeting was held with the IDT team to discuss the allegation of noncompliance. The staff who attended the meeting included Medical Director #219, Minimum Data Set (MDS) Coordinator #292, the DON, Registered Nurse (RN) #293, Licensed Practical Nurse (LPN) #210, LPN #233, Registered Dietitian (RD) #295, and Speech Therapy Director (STD) #297. On [DATE] the facility implemented a plan indicating in the event of a loss of communication, the call multiplier program would include not only family as had been prior practice but would also now include healthcare personnel. Resident Representative contact information would be added by [DATE]. The facility purchased a wheelchair transport vehicle to assist with transports. A plan for any drivers to be trained and their license and driving record verified before their first trip. The ability to drive the van would be assigned to a select few personnel who passed the safeguards put in place such as driving record, and job performance, as well as any other item listed in the policy. The transport vehicle was purchased on [DATE] and as of [DATE] the facility was awaiting delivery. On [DATE] the facility implemented a plan to provide outside healthcare personnel with contact information for the Executive Director and DON to be attached to the appointment paperwork packets. This would serve as an alternate means to promote continuity of care if healthcare personnel offices were unable to reach the facility via the normal communication path. On [DATE] the facility implemented a plan to review policies and processes regarding wounds, transportation, labs/test results, appointments, etc. as appropriate. By [DATE], all initial compliance audits were completed. On [DATE], ongoing compliance audits would be initiated in relation to all appointments, test results, infections, interventions, change in condition and transport issues. This would be completed by the DON/Designee, Executive Director, and clinical team. The audits would be completed weekdays for four weeks, twice weekly for four weeks, weekly for four weeks, and will continue monthly thereafter. A plan for all audits to be reviewed by the Quality Assurance and Process Improvement team monthly was implemented. Deficiencies would be discussed and remedied . Ad Hoc meetings would be held as needed. Staff who were found to be out of compliance would receive further education and/or progressive discipline per company policy. The facility corporate clinical nurses will provide support to the DON/Designee as needed. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #22 revealed an initial admitted [DATE] and a readmitted [DATE]. Resident #22 had medical diagnoses which included peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), non-pressure chronic ulcer of left heel and midfoot, Type II diabetes mellitus, acquired absence of right leg above knee, end stage renal disease, and dependence on renal dialysis. Resident #22 was admitted to the hospital on [DATE] for acute encephalopathy and was treated for a urinary tract infection and was discharged back to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #22 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment revealed Resident #22 required extensive assistance to total dependence from one to two staff to complete activities of daily living (ADLs) and was independent with eating and locomotion on and off the unit. Resident #22 used an electric wheelchair. Resident #22 was at risk for developing pressure ulcers/injuries and the assessment reflected Resident #22 had a diabetic foot ulcer. Interventions in place included a pressure reducing device for bed, nutrition or hydration intervention, and applications of ointments/medications other than to feet, and application of dressings to feet. Review of the physician's orders, including completed and discontinued orders, revealed Resident #22 had no orders for any antibiotics for his left foot ulcer. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated [DATE] and [DATE] revealed Resident #22 had not been administered any antibiotics. Review of a progress note from Wound Clinic (WC) #200, dated [DATE], revealed Resident #22 was seen for a wound check and dressing change. Resident #22 was noted to have an ulcer to his left foot for several months. The wound measured 6.1 centimeters (cm) long, 3.5 cm wide, and 0.4 cm deep without an odor present. Resident #22 had the wound debrided during the appointment with post-procedure measurements of 6.2 cm long, 3.6 cm wide, and 0.5 cm deep. The assessment and plan included wound aerobic and wound anaerobic cultures of the skin ulcer of the left foot with the fat layer exposed and Magnetic Resonance Imaging (MRI) without contrast of the left foot and ankle. An ambulatory referral to Infectious Disease (ID) was pending review. Review of the After-Visit Summary from WC #200, dated [DATE], revealed Resident #22 had a wound aerobic culture (aerobic bacteria are usually found in wounds close to the skin surface) and wound anaerobic culture (anaerobic bacteria cannot grow in the presence of oxygen and are usually found in deeper wounds and abscesses) completed for the skin ulcer to the left foot with the fat layer exposed. Referrals for an MRI of the left foot and ankle without contrast were made and scheduled for [DATE] at 12:45 P.M. A follow-up appointment was scheduled for [DATE] at 1:00 P.M. Potential signs and symptoms of infection included: increased odor, drainage, and pain or redness to the wound. Review of the results of the wound aerobic culture, collected on [DATE] and resulted on [DATE], revealed Resident #22 had light growth of Pseudomonas aeruginosa (a bacterium that can cause disease in plants and animals, including humans). The gram stain result showed: many white blood cells (WBC), a few epithelial (skin) cells, a few gram-positive bacilli, moderate gram-positive cocci, and moderate gram-negative bacilli (types of bacteria). The susceptibility revealed the bacterium were susceptible to intravenous (IV) antibiotics only. Review of the progress notes dated from [DATE] to [DATE] revealed on [DATE] at 12:40 P.M., Resident #22 returned from Wound Clinic #200 with a new order for Santyl moistened gauze dry dressing to the left foot. The order was in place and Certified Nurse Practitioner (CNP) #217 was made aware. On [DATE] at 1:35 P.M., Resident #22's dressing was noted to be changed at the wound clinic. There were no other notes related to Resident #22's left foot wound. Review of the progress note from WC #200, dated [DATE], revealed Resident #22 was seen for a wound check and dressing change. Resident #22's left foot wound measured 5.4 cm long, 3.5 cm wide, and 0.4 cm deep. Resident #22's wound was debrided during the appointment. Post-debridement measurements were 5.5 cm long, 3.5 cm wide, and 0.5 cm deep. Review of the After-Visit Summary from Wound Clinic (WC) #200, dated [DATE] and provided by LPN #210, revealed Resident #22 had another follow up appointment scheduled at WC #200 for [DATE] at 1:45 P.M. and had an MRI of the left foot and ankle scheduled on [DATE] at 12:45 P.M. Review of the fax cover letter and After Visit Summary, dated [DATE] and received from MSW #206 at WC #200 via email on [DATE] at 9:53 A.M., revealed the updated paperwork showed a scheduled appointment at ID on [DATE] at 10:15 A.M. Review of Wound Observation Evaluation, dated [DATE], revealed Resident #22's left foot wound was worsening. Granulation tissue (beefy red) and slough tissue were present. Slough covered 50% of the wound bed. There was a moderate amount of serosanguinous (thin watery fluid that is pink in color due to presence of small amounts of red blood cells) drainage noted. Wound measurements were noted as 4.3 cm long, 6.1 cm wide, and 0.4 cm deep. The peri-wound tissue was macerated (occurs when skin is in contact with moisture for too long, looks lighter in color and wrinkly). Review of the plan of care, revised [DATE], revealed Resident #22 had impaired skin integrity related to a diabetic foot ulcer to the left foot with history of osteomyelitis. Interventions included to include resident and/or responsible party in treatment plan and update as indicated by change in condition or treatment, measure area every week, record size/color/presence and characteristics of drainage, observe for signs of improvement or decline in healing, consult with physician as needed regarding improvement or decline in condition, effectiveness of treatment and/or need for treatment order change, monitor/document location/size/treatment, report abnormalities, failure to heal, signs and symptoms of infection to physician, and wound care appointments at wound center per scheduled date and time. Review of Nurse Daily Wound Evaluations, dated from [DATE] to [DATE], revealed the assessments dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident #22's left foot wound had an odor present. Additionally, on [DATE] the wound bed was noted to be tan and pale pink. On [DATE], the wound bed was noted to be green and yellow. On [DATE], the wound bed was noted to be yellow and pale pink. A moderate amount (,d+[DATE]%) of drainage was noted on all of the assessments. Review of the results of the MRI of Resident #22's left foot, completed on [DATE] and reported on [DATE], revealed there are MRI findings compatible with osteomyelitis involving the remaining proximal shaft and base of the fifth metatarsal. Review of Resident #22's medical record revealed no evidence Physician/Medical Director #219 and/or CNP #217 were notified of Resident #22's missed appointments with WC #200 and ID. Review of the hospital records from the hospitalization on [DATE], revealed Resident #22 presented to the hospital with osteomyelitis. An MRI was performed on [DATE] which showed a soft tissue ulceration, osteomyelitis involving fifth metatarsal shaft and base, large amount of soft tissue swelling, and no abscess. Resident #22's white blood cells were 11.86 and were noted to be high. Resident #22 was started on Vancomycin and Zosyn in the emergency department on [DATE] and treatment was to continue. Resident #22 had waxing and waning mental status throughout [DATE] with worsening mental status and a blank staring gaze and unresponsiveness on [DATE]. Resident #22's encephalopathy was noted to be likely due to infection versus uremia. The hospital scheduled medications included Zosyn extended infusion 3.375 grams (g) intravenously (IV) every 12 hours and Vancomycin 0.4 mg oral every evening and one each IV as indicated by pharmacokinetics. IV Vancomycin was ordered to be given 500 mg IV during final hour of dialysis on [DATE] and 1000 mg IV during final hour of dialysis on [DATE]. IV Zosyn was administered on [DATE]. Resident #22's bone culture was growing Corynebacterium striatum (a bacteria). On [DATE] at 3:25 P.M., infectious disease indicated Resident #22 could be discharged on IV Vancomycin and IV Cefepime (antibiotics) with dialysis through [DATE] and continued wound care. Review of list of residents with their attending physicians provided by the DON on [DATE] revealed Resident #22's physician was Physician/Medical Director #219. Interview on [DATE] at 2:39 P.M. with LPN #260 revealed the facility had phone system issues around March or [DATE]. Incoming calls were being dropped by the facility landline. Fax machines were located in the business office and the DON's office. LPN #260 was not sure if any of the fax machines were impacted by the phone system issues. LPN #260 stated Resident #22 went to outside appointments at a wound clinic. LPN #210 scheduled the transportation for Resident #22's appointments. LPN #260 stated he was Resident #22's regular nurse. LPN #260 indicated Resident #22 had a chronic left foot wound and Resident #22 was not receiving any antibiotics for any infections at the time of the interview. Interview on [DATE] at 3:23 P.M. with LPN #210 revealed Resident #22 missed a scheduled appointment at Wound Clinic #200 on [DATE] due to not being able to arrange transportation. LPN #210 confirmed there had not been any follow up with the physician, or CNP regarding the missed appointment. The appointment was rescheduled for [DATE]. LPN #210 confirmed she was not aware of an ID appointment scheduled on [DATE]. The interview further revealed for the better part of three weeks, the facility was missing phone calls and faxes. LPN #210 stated the facility began experiencing the phone and fax problems around the end of March or the beginning of [DATE]. LPN #210 was not aware of anything the facility had done to ensure outside providers would be able to reach the facility during that timeframe. LPN #210 confirmed she was notified of the scheduled appointment with ID on [DATE], however, she was not able to obtain transportation for Resident #22 for that appointment. LPN #210 rescheduled the appointment for [DATE] but was not able to obtain transportation for that appointment either. LPN #210 confirmed Resident #22 missed the scheduled ID appointment on [DATE] due to not having transportation. LPN #210 revealed the plan was for Resident #22 had an appointment scheduled on [DATE] with infectious disease. LPN #210 stated this was the next available appointment when transportation could be arranged for Resident #22. Interview on [DATE] at 4:11 P.M. via telephone with the Administrator confirmed the facility began having issues with their phones at the beginning of [DATE]. The Administrator stated residents and resident representatives were notified of the issues via a mass notification. The Administrator confirmed no outside providers were included in the notification. The Administrator stated the issues with the phone system caused phone calls to be dropped and voicemails were not being saved. The Administrator stated she was not sure if fax machines were affected or not and indicated the fax machines had separate phone lines. Interview on [DATE] at 5:21 P.M. via telephone with the Administrator confirmed new phones were delivered on [DATE] and installed on [DATE]. The Administrator confirmed the phone system issues were identified on [DATE] and were resolved on [DATE]. Interview on [DATE] at 5:31 P.M. with the DON confirmed the phone system issues started at the beginning of April and new phones were installed at the end of [DATE]. The DON stated the phones worked intermittently during that timeframe. Incoming phone calls were being dropped and voicemails were affected as well. The DON stated she was not able to retrieve any voicemails. The DON stated faxes were received on the business office fax machine but was not sure if any other fax machines were able to receive faxes. The DON revealed Resident #22 had chronic wound issues with his feet related to diabetes and non-compliance with diet and taking medications. The DON reported Resident #22 was compliant with accepting wound care treatments. The DON stated she was not aware of any current wound infections and did not think Resident #22 was taking any antibiotics. The DON indicated Resident #22 went to an outside wound clinic for wound care appointments and needed to be transported via stretcher due to exceeding weight limits for wheelchair transportation. The DON stated sometimes the facility needed to reschedule appointments due to not being able to obtain transportation. Interview via email on [DATE] at 10:13 A.M. with the DON confirmed Resident #22 missed his scheduled appointment at WC #200 on [DATE] due to the facility being unable to obtain transportation for the appointment. Interview on [DATE] at 1:18 P.M. via telephone with Master's Social Worker (MSW) #206 (from WC #200) revealed when Resident #22's wound culture results were received on [DATE] and were positive for a wound infection, the wound physician wanted Resident #22 to be referred to ID for treatment because the infection was resistant to oral antibiotics and likely needed to be treated with intravenous (IV) antibiotics. A referral was made to ID, however, the ID office was not able to communicate with Resident #22 or the facility to notify them of the need for Resident #22 to be seen. ID attempted several times to reach the facility to notify them of Resident #22's appointment which was scheduled on [DATE]. On [DATE], when Resident #22 was at WC #200 for a follow-up appointment, MSW #206 discussed the wound infection with Resident #22 and the need to see ID for treatment. Resident #22 informed MSW #206 that the facility phones had been down. Resident #22 missed the ID appointment on [DATE] due to not being able to reach the facility to notify anyone of the appointment. ID notified WC #200 via fax that Resident #22 had missed the appointment. MSW #206 confirmed the facility had not followed up with WC #200 to obtain the wound culture results for Resident #22. MSW #206 stated Resident #22 was released by the nurse on [DATE] before the After-Visit Summary was updated with the rescheduled appointment information with ID. MSW #206 called the facility on [DATE] and notified a nurse (identified as LPN #213) that Resident #22 had an ID appointment scheduled on [DATE]. The nurse was not able to confirm a valid fax number, therefore, only a verbal notification was provided of the appointment. Interview on [DATE] at 2:01 P.M. via telephone with Office Manager (OM) #211 from the ID office confirmed a referral was received from WC #200 for Resident #22 on [DATE]. OM #211 attempted to call the facility several times on [DATE] to notify them of the scheduled ID appointment for Resident #22 on [DATE]. OM #211 also attempted to fax the appointment information to the facility several times but the fax would not go through. OM #211 stated the facility did not answer any of the phone call attempts and she was not able to leave a voicemail. OM #211 followed up with WC #200 in an attempt to obtain additional contact information for the facility and to notify WC #200 of the difficulty reaching the facility to inform them of the scheduled appointment. Resident #22 had a scheduled follow up appointment at WC #200 on [DATE] and MSW #206 agreed to notify Resident #22 at that appointment of the scheduled ID appointment on [DATE] but Resident #22 missed his appointment at WC #200 on [DATE]. Therefore, Resident #22 missed the scheduled ID appointment on [DATE] due to the inability to reach the facility to notify them of the appointment via fax or phone. Interview via email on [DATE] at 2:26 P.M. with the DON confirmed the fax number used by MSW #206 was at a nurse's station and the fax machine was no longer in use and had been moved prior to the phone system issues. Interview on [DATE] at 10:55 A.M. with Resident #22 revealed he just returned to the facility from the hospital on [DATE]. Resident #22 confirmed he had missed at least four appointments in April and [DATE] due to transportation not being set up. Resident #22 stated his cell phone does not work so the only way to reach him was to contact the facility. Resident #22 denied knowledge of the results of the wound cultures that were completed on [DATE]. Resident #22 denied knowledge of the results of the MRI to his left foot that was completed on [DATE]. Resident #22 stated he was not aware of any infections in his left foot. Resident #22 stated he never refused wound treatments because I don't want to lose my other leg. Interview via telephone on [DATE] at 11:50 A.M. with CNP #217 revealed she was familiar with Resident #22. CNP #217 stated the resident had a left foot wound that was being followed by an outside wound clinic. CNP #217 did not complete wound rounds with LPN #210. CNP #217 stated she had not been notified of any concerns related to Resident #22's wound. CNP #217 stated she was not aware Resident #22 had wound cultures completed that had a positive result for a wound infection. CNP #217 stated she was not aware Resident #22 had an MRI completed which showed osteomyelitis in Resident #22's left foot. CNP #217 stated she was not aware Resident #22 had missed appointments with the wound clinic or with ID due to transportation issues. Interview on [DATE] at 12:13 P.M. with Physician/Medical Director #219 revealed he was not familiar with Resident #22. Interview on [DATE] at 1:07 P.M. with Wound CNP #225 revealed Resident #22 had not been on her wound rotation since [DATE] because the resident requested to be seen at WC #200. Interview on [DATE] at 1:40 P.M. with LPN #210 revealed she completed weekly wound rounds on Resident #22. LPN #210 stated Resident #22 returned from appointments at WC #200 with an After-Visit Summary that did not provide much information. LPN #210 confirmed the After Visit Summary on [DATE] showed the resident received wound cultures at the appointment but she was not aware of any issues. LPN #210 confirmed she had not followed up to obtain the results of the cultures. LPN #210 stated, if there was something wrong, they should have called the facility to let us know. LPN #210 confirmed she had not completed any follow up to obtain the results of the MRI that was completed on Resident #22's left foot and was not aware the results showed osteomyelitis. Interview on [DATE] at 4:40 P.M. with Wound Physician #320 revealed she has seen Resident #22 off and on over the last couple of years. The interview revealed Resident #22 sometimes misses scheduled appointments at the wound clinic. Wound Physician #320 indicated the last time she saw Resident #22 was on [DATE]. She indicated she saw Resident #22 on [DATE] and had wound cultures completed as a normal procedure because she had not seen Resident #22 in a while and he had a chronic wound on his left foot. On [DATE], she was made aware of Resident #22's wound culture results and she wanted Resident #22 to be seen by the infectious disease physician since the bacteria was resistant to oral antibiotics and only intravenous antibiotics would work. She stated on [DATE], she ordered an MRI because of a computed tomography (CT) scan was done in [DATE] and showed something may be unusual with Resident #22's left foot and recommended an MRI was completed. She stated when there is a bone infection, you can treat it with extended IV antibiotic use or by excising and removing the infected bone. She indicated Resident #22 was not agreeable to further surgeries. She indicated a delay in treatment of Resident #22's osteomyelitis and wound infection would increase Resident #22's risk for negative outcomes such as worsening infection and/or the need for amputation. Facility policies were requested related to transportation and missed medical appointments however, the facility did not have any policies in place. Review of the facility policy, Notification of Changes, dated [DATE], revealed the facility policy stated, the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Furthermore, Circumstances requiring notification include: significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: life-threatening conditions, or clinical complications. Circumstances that require a need to alter treatment. This may include: new treatment, discontinuation of current treatment due to: adverse consequences, acute condition, or exacerbation of a chronic condition. Additional considerations: Competent individuals: the facility must contact the resident's physician. When a resident is mentally competent, this resident should designate a representative/family member who should be notified of significant changes in the resident's health status that would prevent them from being able to notify them personally. This deficiency represents non-compliance investigated under Complaint Number OH00142523.

Based on closed medical record review, staff interviews, and policy review, the facility failed to assess Resident #196's newly identified pressure ulcers and implement interventions/treatments to aid in the healing of existing pressure ulcers. Actual Harm occurred on 11/14/22 when the facility failed to provide assessment and treatment to the resident's pressure ulcer resulting in the pressure ulcer declining to a Stage III pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) to the coccyx. This affected one resident (#196) of three residents reviewed for pressure ulcers. Findings include: Review of the closed medical record for Resident #196 revealed an admitted [DATE] with medical diagnoses of diabetes mellitus (DM) with neuropathy, right below the knee amputation (BKA), morbid obesity, end stage renal disease (ESRD) and dependence on dialysis. The medical record revealed Resident #196 discharged from the facility, against medical advice, on 12/06/22. Review of the medical record for Resident #196 revealed an admission Minimum Data Set (MDS) assessment, dated 10/19/22, which indicated Resident #196 was cognitively intact. The MDS revealed Resident #196 required extensive staff assistance with bed mobility, dressing, toileting and Resident #196 was dependent upon staff for transfers and bathing. The MDS also indicated Resident #196 was admitted with surgical wound and had no other skin issues. Review of the medical record for Resident #196 revealed a potential for impaired skin care plan, dated 10/25/22, due to diabetes mellitus and reduced bed mobility. Interventions included apply cushion to wheelchair, assist resident with turning and repositioning on routine rounds and as needed, and assist with toileting and incontinence care on routine rounds and as needed. Review of the care plans for Resident #196 revealed no documentation to support the facility had a care plan to address Resident #196's pressure ulcer or treatment to the wound. Review of the medical record for Resident #196 revealed a nurse's note dated 10/12/22 at 6:13 P.M. which stated Resident #196 admitted with a surgical wound to right BKA. The note also stated Resident #196 had an area to the buttock (not identified right or left buttock) measuring 1.2 centimeters (cm) by 2.2 cm and an area to the gluteal crest measuring 6 cm by 2 cm. The two areas had no staging documented. Review of the medical record for Resident #196 revealed a physician order dated 10/12/22 to clean areas to right buttock and gluteal crest fissure with soap and water and apply barrier cream every shift, after incontinence episodes, and as needed. Further review of the medical record for Resident #196 revealed a nurse's note dated 10/29/22 at 10:03 A.M. which documented the dressing was changed to Resident #196 coccyx per Resident 196's request. Review of the medical record for Resident #196 revealed no documentation to support a physician order for dressing to be applied to coccyx. Review of the medical record for Resident #196 revealed a nurse's note dated 11/14/22 at 8:24 P.M. which stated Resident #196 was seen at the wound clinic for a weekly check and evaluation and new orders were received for the wound to buttocks. A nurse's note dated 11/15/22 at 11:23 A.M. stated the facility wound nurse was notified that Resident #196 had a new pressure ulcer to his coccyx. The note continued to state Resident #196 refused to allow the facility wound nurse to assess the wound due to the wound was assessed by a doctor on 11/14/22 at the clinic. Review of the medical record for Resident #196 revealed a wound observation evaluation dated 11/14/22 which stated Resident #196 had a Stage III pressure ulcer to coccyx, measuring 3.5 cm by 1.5 cm by 0.1 cm and slough was present in the wound bed. Further review of the medical record for Resident #196 revealed Resident #196 refused wound observation evaluations of the coccyx wound to be completed on 11/21/22 and 11/28/22 and Resident #196 was not available for wound observation evaluation on 12/05/22. Review of the medical record for Resident #196 revealed no documentation to support the facility assessed the areas to buttocks and gluteal crease fissure from 10/12/22 through 11/13/22. Further review of Resident#196's physician orders revealed an order dated 11/15/22 for treatment to the right buttock and gluteal crease fissure to cleanse wound to buttocks with saline or soap and water, pat dry, place medi honey alginate to wound bed and cover with bordered dressing daily. Review of the medical record for Resident #196's revealed the October 2022 and November 2022 treatment administration record (TAR) revealed no documentation to support the facility provided the treatment to right buttock and gluteal crest fissure as ordered from 10/12/22 through 11/14/22. Review of the November 2022 TAR revealed treatment dated 11/15/22 to cleanse wound to buttocks with saline or soap and water, pat dry, place medi honey alginate to wound bed and cover with bordered dressing daily. Further review of Resident #196's November 2022 TAR, revealed no documentation to support the treatment to the buttocks was completed on 11/17/22, 11/18/22, and 11/22/22. Interview on 12/29/22 at 8:15 A.M. with Director of Nursing (DON) confirmed Resident #196's medical record did not have documentation to support treatment was provided to the area on the buttock and gluteal crease from 10/12/22 to 11/14/22. The DON confirmed the facility did not complete assessments of the area on the buttock or gluteal grease from 10/12/22 until 11/15/22. The DON confirmed a new treatment was ordered on 11/15/22 after the area developed into a Stage III pressure ulcer. The DON also confirmed the medical record did not contain a care plan to address the pressure ulcer or treatment. Review of facility policy titled Pressure Surveillance, revised 04/01/22, revealed the purpose of the policy is to prevent, identify, report, and investigate any new or worsened pressure injuries in the facility. The policy stated registered nurses and licensed practical nurses would participate in surveillance through assessment of residents and reporting changes in condition to the resident physicians and management staff. The policy stated surveillance activities include pressure injury/wound assessments and medication and treatment records. This deficiency represents non-compliance investigated under Complaint Number OH00138198.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview the facility failed to ensure Resident #63's side rails were maintained in a safe manner and in good repair to prevent an injury during a staff assisted transfer. Actual harm occurred on 05/13/22 when Resident #63, who was dependent on staff assistance for transfers sustained an extensive laceration to her right leg during a staff assisted transfer from the wheelchair to bed when her leg scraped against metal on the side rail which was missing a protective black covering. As a result of the injury, the resident was immediately transferred to the hospital via 911 for treatment which included multiple surgeries and a skin graft. The resident was hospitalized for 23 days for treatment before being readmitted to the facility. This affected one resident (#63) of three sampled residents. Findings include: Review of the medical record for Resident #63 revealed an initial admitted [DATE] with the latest readmission of 06/05/22 with diagnoses including unspecified open wound to right lower leg, infection surgical site, skin transplant status, chronic venous hypertension with ulcer of bilateral lower extremity, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] of liver, [CONDITION(S)], [CONDITION(S)], severe [CONDITION(S)], pulmonary hypertension, gout, chronic pain, difficulty walking, weakness, anxiety disorder, major depressive disorder and chronic [CONDITION(S)]. Review of the plan of care, dated 01/19/22 revealed the resident was at risk for falls due to requiring assistance with ambulation and an unsteady gait. Interventions included assist resident with wheelchair or walker for mobility as needed, assist resident with wearing proper footwear, include resident and/or responsible party in treatment plan, keep call light within reach, non-skid gripper socks when not wearing shoes, observe medication use for side effects that may increase fall risk, remind resident to ask for assistance with activities of daily living (ADLs) as needed, therapy screens as needed, update physician as indicated regarding change in condition/treatment needs. Review of the Assessment of Classification of Device, dated 04/19/22 revealed the resident used one-fourth to one-half mobility bars on her bed as enabler/assistive device. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/25/22 revealed the resident had clear speech, understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The assessment revealed the resident required extensive assistance of two staff for bed mobility, was dependent on two staff for transfers and ambulation did not occur. Review of a nurse's note, dated 05/13/22 at 6:30 P.M. and authored by Licensed Practical Nurse (LPN) #194 revealed the resident was being assisted by two State tested Nursing Assistants (STNAs) when the resident caught her leg on the bed rail and ripped it open. The note indicated the wound was dressed and the resident was sent to a local emergency room (ER) for an evaluation. There was no written assessment/description (including measurements) of the injury in the nursing progress note. Review of the facility investigation, dated 05/13/22 at 6:30 P.M. revealed the resident was being transferred into bed from her wheelchair by two STNAs. The residents' leg caught on the bed rail and ripped it open. The resident stated the incident occurred while getting into bed. The wound was dressed and the resident was sent via 911 to the local ER. The investigation indicated the cause of the injury was the bed rail was missing a cap which covered the end of the metal bed rail. Review of STNA #212's statement regarding the incident, dated 05/23/22 revealed herself and STNA #152 transferred the resident from her wheelchair into her bed using a gait belt. STNA #212 was in front of the resident while STNA #152 was behind the resident. The resident was holding onto the side rail during the transfer. After the transfer, STNA #212 noticed the resident hit the metal on the side of her bed and her leg was bleeding. LPN #194 was notified immediately. Review of LPN #194's statement, dated 06/07/22 revealed she obtained statements from STNA #152 and STNA #212 regarding the incident. The statement indicated STNA #152 and STNA #212 were using a two person assist (to transfer) and the resident stated, ouch. When the resident was in bed, STNA #212 looked at the area and it was bleeding. The STNA immediately got the nurse who assessed the area, called the Nurse Practitioner (NP) and got an order to send the resident to the ER for an evaluation. On 06/06/22 at 3:20 P.M. interview with the Director of Nursing (DON) revealed the resident was readmitted from the hospital on 06/05/22 after treatment of a laceration to her leg that occurred during a two person assist transfer. The DON indicated the resident's leg must have scooted over and went up against the side rail. She said the side rail was not broken, but the black cap had come off and was missing, exposing the metal of the side rail. The DON revealed the resident had vascular issues with her legs which was not a good combination. The DON revealed following the incident, all resident bed side rails had new black caps installed and maintenance staff had to hammer them in place to prevent them from coming out again. She confirmed the resident's treatment included multiple surgeries including a skin graft to the right leg as a result of the injury. On 06/06/22 at 4:05 P.M. interview with Resident #63 regarding the incident that occurred on 05/13/22 revealed the resident said she had asked the aides to use the Hoyer to transfer (to bed) her because she was so tired and they told her no. She said the one aide took the rail off, she took two steps and they pulled her back putting a hole in her leg. The resident revealed due to health issues she didn't have a lot of feeling in the area and didn't feel a lot of pain but stated she did have to go to the hospital because of how bad the injury was and how much it was bleeding. The resident revealed she had just returned (yesterday) from the hospital where she had four surgeries and a skin graft to fix the hole in her leg. On 06/07/22 at 10:23 A.M. interview with STNA #212 revealed on 05/13/22, Resident #63 was up in her wheelchair and she wanted to go to bed. She said herself and STNA #152 assisted the resident to bed. STNA #212 revealed she was standing in front of the resident and STNA #152 was behind her. The resident wanted to use the side rail to hold on to. She said they transferred her and when she went to put her legs into bed, she saw all the blood. The STNA revealed when she looked at the resident's side rail on the bed she saw the black cap was missing on the metal side rail. On 06/07/22 at 10:30 A.M. interview with STNA #152 revealed on 05/13/22 she was standing behind Resident #63 and had placed a gait belt on the resident. STNA #212 was standing in front of the resident. STNA #152 revealed during the transfer, Resident #63 said, ouch and when she looked down, she saw a lot of fluid. STNA #152 revealed she looked at the side rail bar and saw the resident's skin inside the metal pipe of the rail. She said she ran down the hallway and got the nurse while STNA #212 tied a towel around the resident's leg. STNA #152 revealed 911 was called immediately and the resident was transferred to the hospital. On 06/07/22 at 10:40 A.M. interview with LPN #194 revealed on 05/13/22 the STNA staff came out of Resident #63's room and said the resident needed to go to the hospital. She said when she to the resident's room, she observed fluid and adipose tissue from the resident on the side rail. She said the side rail was up and the staff had caught the resident's leg on the side rail. LPN #194 revealed the side rails can flip up out of the way or fold down when being used. LPN #194 revealed another nurse assisted to apply a dressing to leg laceration while she called 911. The LPN revealed she did not think the STNAs noticed the resident's leg had gotten caught during the transfer. The LPN revealed following the incident, staff identified the the protective black cap over the end of the rail was missing, resulting in metal from the rail being exposed. Record review revealed the resident was receiving physical therapy at the time of the incident. Therapy documentation and interview with Physical Therapist (PT) #226 on 06/07/22 at 11:30 A.M. revealed the resident should be transferred either with staff assistance or a mechanical (Hoyer) lift depending on her status at the time of the transfer. Therapy staff noted at times a Hoyer pad was placed under the resident when in the wheelchair in the event the Hoyer was needed for transfers (if the resident was unable to stand and pivot transfer) but indicated the resident was assessed to be able to transfer with staff assistance without the use of the Hoyer lift also. Review of the facility policy titled Proper Use of Side Rails, dated 04/01/22 revealed it was the policy of the facility to utilize a person-centered approach when determining the use of side rails, also known as bed rails. Alternative approaches were attempted prior to installing a side or bed rail. If used the facility ensured correct installation, use and maintenance of the rails. The deficient practice was corrected on 05/20/22 when the facility implemented the following corrective actions: · On 05/13/22 Resident #63 was sent to the emergency room for evaluation and treatment. The resident was admitted to the hospital and returned to the facility on [DATE] with treatment orders in place for her right leg. · On 05/14/22 Director of Maintenance (DOM) #120 completed an audit on all resident bed rails in the facility and placed temporary caps on those missing black caps. · On 05/17/22 DOM #120 ordered replacement parts for all bed rails in the facility. · On 05/18/22 the DON began staff education related to monitoring surroundings/equipment for jagged edges/missing parts before resident transfers. · On 05/19/22 at 2:25 P.M. a mass text with education was sent to all staff to monitor surroundings/equipment for jagged edges/missing parts before resident transfers and to notify management immediately if any issues were found. · On 05/20/22 the permanent (replacement) parts arrived at the facility and DOM #120 installed new permanent caps to the all resident bed rails. · The facility management continued audits of side rail end cap checks on 05/20/22, 05/23/22, 05/24/22, 05/25/22, 05/26/22, 05/27/22, 05/30/22, 05/31/22, 06/01/22, 06/02/22 and 06/03/22. This deficiency substantiates Complaint Number OH 835.

Based on record review, facility policy and procedure review and interview the facility failed to provide a comprehensive and individualized pressure ulcer prevention and treatment program for Resident #87 and Resident #1. The facility failed to prevent the development of avoidable pressure ulcers, failed to ensure pressure ulcer assessments were comprehensive, treatment orders were obtained and/or provided as ordered. Actual Harm occurred on 01/24/22 when Resident #87, who was at risk for skin breakdown was assessed to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the coccyx. Upon admission (01/03/22) the resident had a red abrasion noted to the right buttocks with no evidence of treatment/interventions being implemented at that time. On 01/10/22 the area to the right buttocks was identified to be a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer and the resident developed a new Stage II pressure ulcer to the left (buttocks) side. The resident's pressure ulcers were not assessed the week of 01/16/22. On 01/24/22 the two areas had deteriorated and bridged into one large unstageable pressure ulcer to the coccyx. This affected two residents (#1 and #87) of three residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #87's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged home on 02/02/22. Review of Resident #87's admission skin assessment, dated 01/03/22 revealed the resident had a red abrasion on right buttock and pressure areas (not staged) to the bilateral heels. An additional comment indicated the resident's heels were red. There were no additional assessments of these three areas at that time. Review of wound observation notes revealed no evidence of skin assessments for the abrasion or heel areas. A wound observation note, dated 01/10/22 (seven days after admission) revealed Resident #87 had a Stage II pressure on the left gluteal that measured 1.0 centimeter (cm) in length by 1.0 cm width with 0.1 cm depth. The wound tissue was assessed to be granulated (beefy red) and with a small amount of serous drainage. The note also revealed a Stage II pressure ulcer on the resident's right gluteal that measured 3.8 cm in length by 1 cm width with 0.1 cm depth. The wound bed was granulated and there was small amount of serous drainage. New orders were received at that time for [NAME]-[NAME] Oil Ointment (deodorize and protectively cover) topically every night and covered with a foam dressing. There was no evidence of assessments of the bilateral heels. Review of Resident #87's admission Minimum Data Set (MDS) 3.0 assessment, dated 01/10/22 revealed the resident was a risk for pressure ulcers and had two Stage II pressure ulcers present on admission. Review of Resident #87 impaired skin integrity plan of care (undated) revealed the resident had pressure on the coccyx. Interventions included apply treatment as ordered, elevate heels when in bed, include resident/responsible party in treatment plan, measure areas every week record size, color, presence and characteristics of drainage and consult with physician as needed. The week of 01/16/22 there was no evidence the resident's skin, including an assessment of the resident's heels or left and right gluteal pressure ulcers were assessed. On 01/24/22 the resident was noted to have one pressure ulcer to the coccyx assessed as an unstageable pressure ulcer measuring 7.2 cm in length by 4.4 cm width with no depth noted. The area was noted to be brown, black, leather, scab-liked with a small amount of serous drainage. New orders were received for to apply a nickel size amount of Santyl (debridement agent) to coccyx wound, cover with calcium alginate and secure with a foam dressing. On 01/31/22 the coccyx wound measured 7.1 cm in length by 4.2 cm width with no depth noted. The peri-wound was red, wound edges were irregular and the wound tissue was 100% necrotic with a small amount of serous drainage noted. No changes were made to the treatment at that time. There was no evidence of any assessment of the resident's heels. Review of Resident #87's physician note, revealed on 01/20/22 the resident had wounds/pressure to bilateral heels and bottoms with [CONDITION(S)] per nursing. A 01/26/22 and 02/01/22 note revealed the resident had wounds/pressure to the bilateral heels but failed to include any evidence of the pressure ulcer to the gluteal/coccyx area. In addition, review of Resident #87's nursing progress note, dated 01/22/22 revealed the resident was noted to have a new Stage II pressure ulcer on the back of the left upper side of the ear. The skin appeared open and slightly shallow and tender to touch. The ulcer appeared to have been caused by the resident's oxygen cord. The area was cleansed with normal saline, a dry dressing applied and the cord was moved to the back of the resident's head and away from the back of the ears. Further review of the record revealed no evidence of additional pressure ulcer assessments, order for treatment, physician or family notification or updated plan of care related to this area. Review of Resident #87's discharge MDS 3.0 assessment, dated 02/02/22 revealed the resident had the same two Stage II pressure ulcers that were present on admission. On 03/08/22 at 12:52 P.M. interview with Resident #87's daughter revealed her father was discharged home on 02/02/22 without any type of wound dressing supplies or treatment orders. The daughter reported the resident had pressure ulcers to his buttocks, ear and heels at the time of discharge. The daughter also indicated it was the resident's son who had first pointed out the pressure on the resident's ear to the nurse. The daughter reported she had told the facility the resident was starting to break down on his buttocks on admission, however the facility did not address her concerns. She had asked the facility to make an appointment for her father to see a podiatrist for his heels, but the facility never made the appointment and told her he could not be seen because he had COVID. On 03/09/22 at 7:59 A.M. interview with Registered Nurse (RN) #300 confirmed the resident admission assessment indicated Resident #87 had pressure ulcers (red) to the bilateral heels and a red abrasion to the right buttocks. The assessment did not include staging, measurement, or assessments of the wounds at that time. There was no evidence of any treatment to the abrasion on the buttocks until 01/10/22 when the resident was identified to have developed a Stage II to the left and right gluteal. The RN reported the area on the right gluteal was in the same area that was on admission. The left gluteal was a new area. The gluteal areas were not assessed the week of 01/16/22 and on 01/24/22 the wounds had declined and bridged into one large unstageable area to the coccyx. The RN verified there was no assessment, orders or updated care plan regarding the progress note on 01/22/22 related to the pressure ulcer to the left ear. The RN reported she thought maybe the heels were not really pressure on admission, however the assessment on admission was not comprehensive. The facility was applying skin prep to the heels as a preventative measure per the orders. During the interview RN #300 confirmed the discharge MDS was inaccurate, as the resident had an unstageable pressure ulcer at that time. RN #300 revealed the facility had identified a concern with wounds on 01/26/22 and conducted a five minute in-service for seven licensed practical nurses (LPN) on obtaining orders for wounds and ensuring treatments were done per orders. The facility had identified concerns at the same time with the wound nurse and had recently brought back the previous wound nurse around 01/24/22. 2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Slough or eschar may be present on some parts of the wound bed) to left and right buttocks, [CONDITION(S)] and diabetes. Review of Resident #1's treatment administration records (TAR) and physician's orders, dated 02/2022 revealed the resident was ordered treatment to the left and right buttocks to include cleansing the wound with vashe solution, pat dry, apply collagen, and cover with a foam dressing twice daily. Record review revealed on 02/02/22 day shift, 02/04/22 night shift, 02/05/22 day shift, 02/10/22 dayshift, and 02/24/22 the resident did not receive treatment to the left and right buttocks as ordered. On 03/09/22 at 11:32 A.M. interview with the Director of Nursing (DON) confirmed there was no evidence Resident #1 had received treatments on the above days as ordered by the physician. Review of the facility policy titled Pressure Ulcers/Skin Breakdown, dated 04/2018 revealed the nurse should describe and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudate or necrotic tissue and current treatment. The physician would evaluate and document the progress of the wound healing. This deficiency substantiates Complaint Number OH 448.

Based on observation, medical record review, staff and resident interview, the facility failed to prevent the development of an unstageable pressure ulcer to Resident #52's left heel. This affected one of three residents reviewed for pressure ulcers (Resident #52). Harm occurred when Resident #52's left heel pressure ulcer declined from a Stage II pressure area to an unstageable pressure ulcer from his foot pressing against the footboard of his bed. Findings Include: Review of Resident #52's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the resident's admission MDS 3.0 assessment dated [DATE] indicated the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a BIMS score of 12. The MDS indicated the resident had not rejected care, required extensive assistance with bed mobility, was at risk for skin breakdown and had one Stage II pressure ulcer. The MDS indicated the facility implemented the following interventions: pressure reduction device to his bed, pressure ulcer care, application of ointment/medications and application of a dressing to his feet. Review of the resident's care plans revealed Resident #52 had actual and/or potential for impaired skin integrity. Review of the resident's admission nursing evaluation dated 04/14/17 revealed the resident was admitted with no pressure ulcers. The resident was assessed as being at risk for skin breakdown. Review of the resident's monthly physician's orders [REDACTED]. On 04/25/17 an order was obtained for an alternating pressure air mattress and encourage the resident to turn and reposition every two hours. Review of the resident's weekly wound observation evaluation dated 04/20/17 indicated the facility discovered a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) pressure ulcer to the resident's left heel measuring 3.4 centimeters (cm) by 4.3 cm by 0.1 cm. On 04/24/17 the wound progressed from a Stage II pressure ulcer to an unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough; yellow, tan, gray, green or brown and/or eschar; tan, brown or black in the wound bed.) pressure ulcer measuring 4.0 cm by 4.6 cm with 75% necrotic tissue. The treatment to the wound was changed to silver gel due to silver alginate drying wound too much. On 05/01/17 the pressure ulcer to the resident's left heel remained an unstageable wound measuring 4.0 cm by 3.0 cm and the tissue was 100% necrotic. On 05/04/17 the pressure ulcer measured 3.2 cm by 3.2 cm by 0.1 cm and was covered with 100% necrotic tissue. On 05/11/17 the pressure ulcer measured 3.3 cm by 4.3 cm by 0.1 cm and continued to have necrotic tissue and was now classified as a deep tissue injury. On 05/16/17 at 12:30 P.M. observation of Licensed Practical Nurse (LPN) #105 providing the physician ordered pressure ulcer treatment revealed the LPN measured the unstageable wound as 4.0 centimeter (cm) by 3.3 cm and was 100% eschar. On 05/16/17 at 12:40 P.M. interview with Resident #52 revealed the resident said the pressure ulcer on his left heel started because the bed he had on admission was too small. He said they finally took the foot board off and put an air mattress on it after he complained a few times. On 05/16/17 at 12:47 P.M. interview with LPN #105 verified Resident #52's area to his left heel was caused from resting on the foot board of the bed because the bed was too small for the resident. This deficiency substantiates Complaint Number OH 164.

Based on observation, record review and interview, the facility failed to ensure services were in place to prevent a decline in range of motion for Resident #27. This resulted in actual harm when the resident demonstrated additional decrease in range of motion when the degree of his contractures prevented the usage of splinting devices made for him. This affected one resident (Resident #27) of five residents reviewed for range of motion. Findings Include: Record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified Resident #27 being totally dependant for all activity of daily living, requiring supervision for eating, impaired mobility on both sides with functional imitation in range of motion both upper and lower. The Braden Scale for predicting pressure score risk had a score of 14 indicating Resident #27 was at moderate risk for pressure sore development. Resident #27 was identified as having very moist skin and very limited mobility. The current plan of care for Resident #27 revealed the resident had a potential for skin impairment related to contractures. The plan of care included an intervention to place a wash cloth to the left hand every morning and remove every night and to apply a knee splint at night. Review of the medical record for Resident #27 revealed an Occupational Therapy (OT) evaluation dated 04/05/13. On 10/22/15 at 4:15 P.M. Registered Nurse (RN) #610 revealed this was the most current evaluation completed and confirmed that there were no other evaluations available for review. The OT evaluation dated 04/05/13 revealed Resident #27 was referred due to decreased left upper extremity hand positioning with present hand splint. The evaluation revealed the resident had limited positioning of left hand in an old splint. The assessment identified Resident #27 as having flexion of the left wrist as 30 - 30 degrees, with a normal value of 60-80 degrees. The functional limitations identified Resident #27 having a broken-down, worn-down hand/wrist splint and limited positioning of the thumb. The short term goal and long term goal identified Resident #27 to be fitted/positioned with a new left upper extremity hand/wrist orthotic and informal nursing inservices for skin integrity and contracture management. There was no further documentation regarding the new left upper extremity splint or inservice for staff regarding management for skin integrity and contracture management. Review of OT progress note, dated 07/03/15 indicated no significant changes and the therapy note dated 07/21/15 identified an OT referral regarding wheelchair positioning for meals. The OT progress note from 07/03/15 and 07/21/15 did not address contractures to Resident #27 left upper extremity or brace to lower extremity. Review of an OT Evaluation completed on 10/21/15 by Occupational Therapist Registered, Licensed (OTRL) #629 revealed Resident #27 was referred from nursing due to contracture management, splint. The evaluation identified that the resident had been using a washcloth for a splint in 2014, the the resident was a long term resident at this facility and stated contractures had increased in severity. The assessment identified Resident #27 as needing to be reassessed for a left upper extremity (LUE) splint due to contractures in the left digits and the resident being unable to wear the current splint due to increased contractures. On 10/21/15 a Physical Therapy Evaluation was completed by Physical Therapist (PT) #634 after a referral from nursing related to difficulty in applying the splint to the left lower extremity (LLE). The assessment identified that Resident #27 had been active in therapy since 2013 and stated that current splints did not fit the resident in a functional way. PT #634 recommended that Resident #27 wear a knee extension splint and a theraboot on the left knee, right knee, left foot and on the right foot for night hours in order to reduce abnormal tone prior to splint application. The assessment also recommended to modify the splint device and to establish a wearing schedule. On 10/23/15 at 12:54 P.M. interview with PT #634 confirmed there were no previous evaluations available for review. PT #634 also confirmed that she had no previous physical therapy documentation for Resident #27. On 10/23/2015 at 8:50 A.M. during an interview with State tested Nursing Assistant (STNA) #148 she revealed she was familiar with Resident #27 and provided care for him often. STNA #148 reported that Resident #27 was normally up in his chair when she arrived at work. STNA #148 stated that Resident #27's right leg was contracted and he may also have a contracture to one of his arms but she was not positive. STNA #148 stated that Resident #27 had no restorative nursing care provided by the STNA. STNA #27 stated she was not sure if his contracture was getting worse, she stated he does not have a brace to his left leg, however she felt he needed one. STNA #27 stated she had mentioned Resident #27 needing a brace for his leg to the nurse and nothing had been done so she just let it go. On 10/23/15 at 9:35 A.M. interview with Licensed Practical Nurse (LPN) #25 revealed she was familiar with the resident and provided care for Resident #27. LPN #25 stated the left leg brace was not fitting well at this time and felt it had been this way since July 2015. LPN #25 stated this had been reported to the day shift LPN who told therapy approximately one week ago. LPN #25 confirmed there was no documentation of this report. She stated that on night shift, Resident #27 often becomes upset when she attempts to apply the splint. LPN #25 stated that Resident #27 was unable to voice pain and you had assess how he was acting to determine if he was in pain and she felt his resistance to the brace was due to pain. LPN #25 stated the LLE brace was normally applied around 9:30 P.M. and removed around 5:00 A.M. LPN #25 stated that she often positioned pillows between his thighs when he was laying in bed to keep them separated which also seemed to help him relax. LPN #25 stated that she has found that although the wash cloth is not ordered to be placed in his left hand during the night, when it is applied, he seems to relax more. On 10/23/15 at 11:17 A.M. interview with LPN #215 revealed she was familiar with Resident #27 and stated she was aware of the contracture of his left hand, however she was unsure regarding any therapy he was receiving. LPN #215 reviewed the medical record and stated that Resident #27 was not receiving therapy at this time. LPN #215 described Resident #27 left hand as the thumb lying across the palm of the hand and his fingers were drawn down and the hand rotated towards the resident. LPN #215 stated she was aware of a brace for Resident #27 hands however it did not fit appropriately and stated that therapy was aware of this. When asked about Resident #215's left leg, she stated that he needed a new brace for his leg because the current brace does not fit correctly. She reported that she was aware of this from the night shift staff and felt physical therapy had been advised that the LLE splint was not fitting correctly. When asked if she had noticed a change in Resident #27 contractures, she stated that she felt his condition may have changed, requiring him to need new splints. Resident #27 was observed on 10/21/15 at 3:52 P.M. resting in his bed. There was no splinting device in Resident #27 hand. The left hand was contracted, the thumb was observed to be under the fingers and the fingers were placed against the palm of the hand, Their was no endentions or embedding marks noted on the hand. Resident #27 was observed in the dining room feeding him self with his right hand and a wash cloth roll in place with his left hand on 10/22/15 at 8:31 A.M. On 10/22/15 at 10:09 A.M. Resident #27 was in the TV lounge area. A wash cloth was in place in the left hand and Resident #27 was observed partially extending the fingers of his right hand to adjust his glasses. On 10/23/2015 at 12:47 P.M. during an interview the director of nursing (DON), she confirmed the order for left knee splint and left hand roll. The DON stated she had not been told about any concerns regarding the brace for Resident #27's LLE nor concerns regarding a splint for his LUE. The DON stated she receives report from the nurses every morning and these concerns had not been voiced nor had they been documented on the 24 hour report. The DON stated that there had been no discussion in Interdisciplinary Team (IDT) meeting regarding Resident #27's splints. The DON reviewed the therapy notation for the IDT meetings and confirmed that their was no mention of a leg brace and only addressed a wash cloth for the LUE. The DON confirmed that their was no documentation that Resident #27 was receiving range of motion at this time. During an interview on 10/23/15 at 12:54 P.M., Licensed Speech Therapist (SLP) #617 stated that Resident #27 could be evaluated by physical therapy (PT) at any time. SLP #617 stated that PT had completed an evaluation on Resident #27 on 10/21/15 addressing the brace to the LLE after he had been referred earlier in the week by nursing. SLP #617 confirmed that she was not present during the evaluation, however she had been told that he had been referred to have an evaluation on the LLE brace due to Resident #27 being unable to extend his leg and therefore the brace was not fitting correctly.

Based on observation, record review and interview, the facility failed to prevent a decline of bowel incontinence which resulted in actual harm to Resident #124 when the resident went from always continent of bowel to being incontinent of bowel. The facility also failed to ensure coordination of medication administration for Resident #85 who received outpatient [MEDICAL TREATMENT]. This affected one resident (Resident #124) of three residents reviewed for incontinence and one resident (Resident #85) of one resident reviewed for [MEDICAL TREATMENT]. Findings include: 1. Review of Resident #124's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the bowel and bladder program screener dated 03/06/15 revealed a score of 7 which reflected the resident was a candidate for schedule toileting/timed voiding. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/13/15 revealed the resident needed limited assistance of one staff for toilet use, was on no toileting program and always continent of bowel. On 09/03/15 a bowel and bladder program screener was completed with a score of 7 indicating the resident was a good candidate for retraining. A quarterly MDS 3.0 assessment completed on 09/25/15 revealed the resident was not on a toileting program, needed extensive assistance of one for toileting and was now occasionally incontinent of bowel. The current plan of care revealed the resident had incontinence of bowel and bladder related to inability to communicate needs, cognitive deficit, impaired mobility and medication side effects. The care plan was dated 02/15/15 and revised on 04/06/15 with a goal that the resident would have soft, formed bowel movements every one to three days, the resident would be clean, dry and odor-free. Interventions were for staff to assist resident to toilet every two hours and as needed. Observation on 10/21/2015 at 3:00 P.M. revealed the resident was sitting in a geriatric chair with shorts and a shirt on. The resident's clothes appeared dry but the resident continued to have a strong urine odor that could be noted before even getting close to him. The odor was reported, by the surveyor, to the State tested nursing assistant (STNA). The STNA then took the resident to the room and and used a mechanical (Hoyer) lift to assist the resident to bed. The STNA indicated they were going to put the resident on a bedpan as this was the first time he had told her he had to go, he was always incontinent of bowel and bladder. The resident was placed on a bed pan and the STNA left the room. Interview on 10/26/15 at 12:04 P.M. with Registered Nurse #610 revealed the resident was not on any type of bowel program. Interview with Minimum Data Set (MDS) nurse #80 on 10/22/15 at 12:01 P.M. revealed no bowel program had been initiated when the resident declined from being always continent of bowel to incontinent of bowel. She stated staff just have him on a check and change program every two hours. The MDS nurse verified the resident was a good candidate for a retraining program and again verified the resident had not been placed any type of program following the assessed decline in bowel continence. 2. Record review revealed Resident #85 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated she was cognitively intact. She also received [MEDICAL TREATMENT]. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no evidence the physician or [MEDICAL TREATMENT] center were aware that medications were not being administered. Review of the undated care plan for [MEDICAL TREATMENT] showed no evidence of coordination with [MEDICAL TREATMENT] or physician regarding medication administration. Review of [MEDICAL TREATMENT] communication sheets showed no communication from the facility that medication doses were held. Interview with Resident #85 on 10/26/2015 at 9:52 A.M. revealed she did not get her morning doses of medication on [MEDICAL TREATMENT] days. Interview with Licensed Practical Nurse (LPN) #9 on 10/26/2015 at 10:09 A.M. revealed the nurse held the morning doses of medications on [MEDICAL TREATMENT] days because the resident was not in the building. She confirmed there was no order for or coordination with the [MEDICAL TREATMENT] center regarding specific medication administration. She confirmed there was no evidence in the medical record that the physician was aware that medications were held on [MEDICAL TREATMENT] days.

Based on observation, record review and interview the facility failed to ensure individualized bladder programs were in place for Resident #124 to restore normal bladder function and prevent decline in bladder status. This resulted in actual harm to Resident #124 when the resident exhibited a decline in bladder status from being occasionally incontinent of bladder to frequently incontinent of bladder. This affected one residents (Resident #124) of three residents reviewed for bladder incontinence. Findings include: 1. Review of Resident #124's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the bowel and bladder program screener dated 03/06/15 revealed a score of 7 which reflected the resident was a candidate for schedule toileting/timed voiding. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident needed limited assistance of one staff for toilet use, was on no toileting program and occasionally incontinent of bladder. On 09/03/15 a bowel and bladder program screener was completed with a score of 7 indicating the resident was a good candidate for re-training. A quarterly MDS 3.0 assessment completed on 09/25/15 revealed the resident was not on a toileting program, needed extensive assistance of one for toileting and was now frequently incontinent of bladder. The plan of care revealed the resident was incontinent of bowel and bladder related to inability to communicate needs, cognitive deficit, impaired mobility and medication side effects. The care plan was dated 02/15/15 and revised on 04/06/15 with a goal that the resident would be clean, dry and odor-free. Interventions included for staff to assist the resident to toilet every two hours and as needed. Observation on 10/21/15 at 11:32 A.M. revealed there was a extremely strong urine odor in the room. Observation on 10/21/2015 at 3:00 P.M. revealed the resident was sitting in a geri chair with shorts and a shirt on. The residents clothes appeared dry but the resident continued to have a strong urine odor that could be noted before even getting close to him. The odor was reported, by the surveyor to the State tested nursing assistant (STNA). The STNA then took the resident to the room and used a mechanical lift (Hoyer) to assist the resident back to bed and stated they were putting him on the bedpan. She stated this was the first time he had told her he had to go to the bathroom, he was always incontinent of bowel and bladder. The adult brief was extremely wet when removed. Resident was placed on bed pan and the STNA left the room. STNA #114 stated the room smelled like a men's locker room and was not sure what the odor was from. Registered Nurse #610 confirmed on 10/26/2015 at 12:04 P.M. the resident was not placed on any type of bladder program to prevent additional decline or following the above identified decline. Interview with Minimum Data Set (MDS) nurse #80 on 10/22/15 at 12:01 P.M. revealed no bladder program had been initiated when the resident's continence status declined. She stated they just have him on a check and change every two hours. MDS #80 revealed Resident #124 was a good candidate for retraining and again verified no bladder training program had been implemented for the resident following the above assessed decline in bladder continence.

Based on observation, record review and interview the facility failed to prevent the development of pressure ulcers and provide necessary care and treatment to promote healing and prevent worsening of pressure ulcers for Resident #18 and Resident #118. Harm occurred to Resident #18 when the facility failed to properly identify, assess and implement treatment for [REDACTED]. This affected two residents (Resident #18 and #118) of three residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 11/24/14 at 3:40 P.M. revealed the resident was lying in bed on her left side, with a pillow behind her back and an air mattress on the bed. On 11/25/14 at 8:51 A.M., the resident was observed lying on her back in bed in a hospital gown sleeping. There were "moon boots" (pressure reducing boots) lying on the bedside table but not on the resident at that time. At 9:28 A.M. on 11/25/14, observation revealed the resident was being bathed by State tested nursing assistant (STNA) #3 and the moon boots were on the resident at this time. Interview with STNA #3 revealed the moon boots were not on the resident when she started the resident's bath this morning. Review of Resident #18's plan of care related to skin integrity revealed the resident was not supposed to be lying on her back. She was to be wearing boots to protect her heels and was to be turned and repositioned every two hours. She was also supposed to have weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue and exudate and notify physician as needed. A skin risk assessment, dated 09/23/14 revealed the resident was at high risk for skin breakdown. A progress note written on 09/23/14 revealed the resident had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer to the coccyx which measured 1.2 centimeters (cm) in length by 0.5 cm width with 0.1 cm depth. New orders were received to cleanse with normal saline and apply [MEDICATION NAME] every other day and as needed. On 09/26/14 weekly skin round notes revealed the resident had an area on buttocks measuring 2.5 cm in length by 2.3 cm width with 0.1 cm depth. The notes revealed treatment in place. On 10/03/14 weekly skin round notes revealed no new areas and the area to the coccyx was not mentioned. Right and left buttocks were documented as no issues On 10/10/14 weekly skin notes revealed no new areas were noted and the coccyx wound was not mentioned or measured as per the interventions included in the plan of care. Right and left buttocks were documented as no issues. On 10/17/14 the skin notes revealed the resident had a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer to the coccyx. Record review revealed on 11/11/14 orders were obtained for a culture and sensitivity of the pressure ulcer. Record review revealed there were no laboratory results for the culture and sensitivity in the resident's medical record. Interview with the director of nursing (DON) on 11/25/14 at 1:15 P.M. revealed the culture and sensitivity that was ordered on [DATE] was not completed. A note dated 11/11/14 from an outside contracted wound consultant company revealed the resident was seen, with the pressure ulcer assessed and orders for an antibiotic, Bactrim for ten days. The resident's pressure ulcer measurements revealed an ulcer that measured 3.5 cm in length by one cm width with one cm depth with tunneling from 6:00, deepest point one cm. The ulcer was assessed to have 50% granulation tissue, 50% slough tissue, a small amount of drainage and was assessed to be a Stage IV with no odor and serosanguineous drainage. This reflected a deterioration in the pressure ulcer. On 11/25/14 at 10:08 A.M., interview with the director of nursing (DON) revealed staff identified a pressure ulcer to the resident's coccyx on 09/23/14 and there were no further measurements of the area until 10/17/14. The DON was unable to explain why staff stated the ulcer was acquired on 10/17/14 when it was acquired on 09/23/14. She stated she felt the staff needed more training on pressure ulcers and documentation. She was asked what happened between 09/26/14 and 10/17/14 when the wound worsened from a Stage II to a Stage IV wound. She stated she was not here during some of that time as she was out for about 10 days but stated she was aware the physician had debrided the wound. However, record review revealed the wound worsened on 10/17/14 and was not debrided until 10/28/14. The plan of care, initiated 09/25/14 revealed the resident had actual impairment to skin integrity of the coccyx and red mushy heels. Interventions put in place were heel protectors to bilateral heels The care plan was updated on 10/21/14 to include the ulcer presented as tunneling. The care plan reflected the resident had a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer, although a Stage III ulcer was not documented anywhere else in the clinical record. The care plan also revealed to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The care plan also revealed to complete weekly treatment documentation to include measurement of each area of skin breakdown to include width, length, depth, type of tissue and exudate and as needed to notify physician. The care plan was also updated to avoid positioning the resident on her back. Interview with corporate clinical registered nurse #65 on 11/25/14 confirmed Resident #18 did not have any further interventions put in place and documentation was not completed with wound measurements as per the plan of care from 09/26/14 until 10/17/14. She confirmed the wound worsened from a Stage II to a Stage IV pressure ulcer during that time. She also confirmed the culture and sensitivity documented as being completed by the wound care physician was not done. On 11/25/14 at 3:00 P.M. observation of a dressing change for Resident #18 by physician #13 revealed the physician #13 tried to position the bed in a higher position and the bed was not working and would not rise up. The bed was in low position. The physician completed the dressing change on his knees at the bedside. Nurse #15 was gathering supplies for the physician. The nurse was not prepared and was having trouble finding the correct dressings and other items such as tape. Physician #13 applied gloves but did not change his gloves or wash his hands throughout the dressing change. There was no dressing noted on the resident at the beginning of the procedure. Physician #13 measured the wound with two Q-tip applicators, cleansed the wound by instilling normal saline into the wound and patted dry with gauze. The normal saline container was placed in the trash bag at the bedside. The physician told the nurse #15 she had the wrong calcium alginate dressing and stated the order was for calcium alginate AG. The nurse was unable to find this on the cart and the physician then requested she use a calcium alginate AG dressing she had in her pocket that was used for Resident #110, the resident they had changed a dressing on prior to this resident. The physician stated, "we only used half of it". Nurse #15 handed the physician the dressing he requested and it was then torn in half. Half of it was used to pack the wound when the physician used his gloved finger to pack the wound and did not use an applicator to pack the wound. The second half was used to place over the packed wound. dressing was then applied over the top of the wound. The physician removed his gloves and disposed of the trash bag. The physician stated at the time of the dressing change on 11/25/14 at 3:00 P.M. he was using another resident's dressing when he requested this from the nurse and did not change his gloves throughout the procedure. 2. Review of Resident #118's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. The resident had [DIAGNOSES REDACTED]. On 10/05/14 an order was received for skin prep to the heels every shift, every day for skin prevention. The nursing admission assessment revealed no pressure ulcers to the resident's heels were present on admission. The resident was identified as very high risk for skin breakdown. Record review revealed on 10/05/14 a blister was noted to the resident's heel. However, there was no documentation of the area until 10/13/14. The care plan dated 10/20/14, revealed the resident was at risk for impaired skin integrity but did not address the skin breakdown the resident already had. Turning and repositioning documentation does not reveal the resident was turned every two hours as per the plan of care. There was no evidence the heels were floated as per nurses recommendations on 10/13/14. The resident's care plan was not revised for the blister that developed on 10/05/14 until 10/24/14 at which time turning and repositioning was initiated. Record review revealed the resident was unable to reposition self while in bed. On 10/23/14 a physician's orders [REDACTED]. Review of the medication and treatment administration records revealed the staff did not sign off the resident was turned and repositioned every two hours consistently. No observations could be made since the resident had been discharged . The lack of evidence of turning and repositioning every two hours and lack of care plan revisions to include new interventions and to accurately reflect the residents care and needs were confirmed by the director of nursing (DON) on 11/24/14 at 2:30 P.M. This deficiency substantiates Complaint Number OH 028.

Based on medical record review, observation, resident interview, staff interview, wound certified nurse practitioner interview, and review of the facility guidelines for prevention and treatment of [REDACTED]. This resulted in Actual Harm to six residents, Resident #74 who developed two coccyx wounds that worsened, Resident #7 who developed a suspected deep tissue injury on the coccyx, Resident #222 who had a heel wound that worsened to a suspected deep tissue injury, Resident #178 who had a heel wound that worsened to unstageable, Resident #62 who had a heel wound that worsened, and Resident #19 who had a coccyx wound that worsened. The facility also failed to complete wound treatments as ordered for one resident, Resident #193. These deficient practices affected seven of eight residents reviewed with pressure ulcers, of 11 residents in the facility with in-house acquired pressure ulcers. Findings include: 1. Review of the clinical record revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The skin plan of care (POC) dated [DATE] contained interventions including to apply protective or barrier cream as ordered, encourage and assist the resident to turn and reposition every two hours and as needed, provide the resident with treatment/preventive treatment, and reflected a history of skin breakdown. A Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed Resident #74 had no risk for skin breakdown. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had no unhealed pressure ulcers Stage one or higher; the resident was not on a turning and repositioning program; no pressure reducing device for chair; rejection of care had not been exhibited; the resident was cognitively intact; required extensive assistance with activities of daily including bed mobility and transferring; and was incontinent of bowel. The [DATE] physician orders [REDACTED]. Review of the June and [DATE] treatment administration records (TARs) revealed 18 treatments were missed in June on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] x 2, [DATE], [DATE], [DATE], [DATE], [DATE] x 2, [DATE], [DATE], and [DATE]; and five treatments were missed in July on [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of weekly skin round sheets completed on [DATE] revealed Resident #74's right and left buttocks were intact and reddened. On [DATE] at 8:15 A.M., a wound assessment was completed and revealed the left buttock had a newly developed pressure ulcer. The ulcer measured 2.5 centimeters (cm) by 3.0 cm by 0.1 cm, and was described to have [MEDICATION NAME] and slough tissue present, was moist and the ulcer was a Stage II wound. Another wound assessment completed on [DATE] at 9:42 A.M. revealed the right ischium/buttock had a newly developed unstageable pressure ulcer. The wound measured 8.0 cm by 8.0 cm by 0.2 cm. The wound was described to have granulation tissue present, and 60% necrosis and/or slough in the wound bed. The treatment ordered for both ulcers on [DATE] was to cleanse with normal saline, pat dry, apply Hydrogel, cover with foam dressing, and complete twice a day. The treatment stated to change Hydrogel to Santyl as soon as the medication arrived at the facility. The Santyl did not arrive until [DATE], eight days after the physician ordered it. Review of the [DATE] TAR for Resident #74 revealed the [DATE] wound treatment orders for the left and right buttocks ulcers had two missing treatments on [DATE] and [DATE]. This was confirmed by Unit Manager #1 in an interview on [DATE] at 9:24 A.M. An interview with Unit Manager #1 on [DATE] at 9:24 A.M. revealed Resident #74 was not on a turn and reposition schedule. The unit manager stated the resident used to be noncompliant with turning and repositioning. The resident would be started on one on [DATE] and this would require the state tested nurse aides (STNAs) to sign off they were completing this task. An interview with Resident #74 on [DATE] at 3:56 P.M. stated the nurses did not always do his treatments to his buttocks. The resident stated he needed assistance with transfers and had asked the STNAs to help move him. At times the STNAs had refused stating he was " too heavy " to move. The resident stated some STNAs reminded and encouraged him to turn and reposition and some did not. He said they often did not wake him up to remind him to turn and reposition. An interview with Licensed Practical Nurse (LPN) #6 and LPN #7 on [DATE] at 9:05 A.M. revealed the night shift nurse did not have time to do the residents' treatments so when the day shift nurse came in they did the resident ' s treatment together on [DATE] at approximately 7:00 A.M. Interviews with STNAs #3, #4 and #5 on [DATE] and [DATE] stated Resident #74 was compliant with turning and repositioning. STNA #3 stated the resident would often tell her how to turn and reposition him and what position he had been in recently. An observation of the wound treatment change for Resident #74 on [DATE] at 11:30 A.M. revealed LPN #2 measured the wounds and completed the dressing changes. LPN #2 washed her hands and donned gloves prior to removing the soiled dressings on the two wounds on Resident #74's left buttock and the one wound on the right buttock. Wearing the same gloves, the LPN cleansed all three wounds with normal saline and did not wash her hands or change her gloves between the three different sites. After cleansing all three wounds with normal saline, she removed the old gloves. She applied clean gloves and used a measuring device to measure the resident's wounds. Then, wearing the same gloves, she applied Hydrogel cream to the adhesive dressing and then applied a dressing to each of the three wounds, wearing the same gloves for all three wounds. The right buttocks wound measured 9 cm by 8 cm, the depth was not measurable. The left lower buttocks wound measured 4 cm by 4 cm by less than 0.1 cm deep. LPN #2 used Hydrogel skin product and not Santyl that was ordered by the physician for treatments to the two wounds. An interview with LPN #2 on [DATE] at 3:30 P.M. confirmed she did not wash her hands after removing the soiled dressings and cleansing the wounds on Resident #74's buttocks. She confirmed she failed to wash her hands or change gloves between providing wound care to Resident #74's three pressure ulcers and confirmed Hydrogel skin product was used to treat the wounds. The facility policy regarding Dressings, Dry/Clean, dated [DATE], was reviewed. The policy stated that after the old dressing was removed, hands should be washed and dried thoroughly before proceeding to the clean dressing. An interview with Wound Care Certified Nurse Practitioner (CNP) #8 on [DATE] at 1:26 P.M. revealed the right buttocks wound measured 8.7 cm by 9.2 cm and depth unable to be determined, with ,[DATE]% slough present. The left buttocks had two wounds. The left lower pressure ulcer measured 0.5 cm by 0.3 cm by 0.1 cm and the upper left buttock area was incontinence-associated [MEDICAL CONDITION]. The Wound CNP stated the wounds developed because of incontinence, prolonged pressure, and no wound care, and repositioning and turning and education would be important to heal the wounds. Review of Wound Care CNP #8's recommendations dated [DATE] for Resident #74 included to obtain a wound culture of the right ischium/buttock area. The facility completed the recommendations for the wound culture on [DATE] and four days later on [DATE] the wound culture was obtained. This was confirmed by Unit Manager #1 on [DATE] at 8:30 A.M. The facility ' s Guidelines For Prevention of Pressure Ulcers dated 2001 and revised in [DATE], stated pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent of the tissue. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious condition for the resident. The facility should have a system/procedure to assure assessments are timely and appropriate, and changes in condition are recognized, evaluated, reported to the nurse practitioner, physician, and family, and addressed. General preventative measures for a resident in bed included to change position at least every two hours or more frequently if needed and for a resident in a chair included to change position at least every hour and use foam, gel, or air cushion as indicated to relieve pressure. Documentation in the resident ' s medical record was to include the following information: the type of skin care given, the date and time skin care was given, the position in which the resident was placed, the name and title of the individual who gave the care, any change in the resident ' s condition, how the resident tolerated the procedure, and if the resident refused the care and reasons why. 2. Review of the medical record revealed Resident #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A plan of care for risk for impaired skin integrity dated [DATE] contained interventions including for staff to encourage the resident to turn and reposition at least every two hours and as needed, and to encourage her to float her heels while in bed. Review of the Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed the resident was at mild risk of developing a pressure sore. Review of the MDS assessment dated [DATE] revealed Resident #7 was cognitively intact, required supervision with set up help only for bed mobility, to transfer, and to walk in her room. This resident was independent to walk in the corridor. The assessment revealed the resident did not have any pressure sores. Review of the bath and skin reports revealed on [DATE] this resident ' s coccyx was red. The bath and skin report dated [DATE] revealed the resident ' s coccyx had redness with open sores. The medical record contained no additional information or new orders regarding the open sores. The bath and skin report dated [DATE] did not identify any redness or open areas. On [DATE] Resident #7 developed a pressure ulcer on the coccyx that was documented as a suspected deep tissue injury (SDTI) (purple or maroon, localized area of discolored intact skin or blood filled blister due to damage of under lying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler, as compared to adjacent tissue). There was no assessment or description of the pressure sore in the resident ' s record. Review of physician's orders [REDACTED]. This treatment was administered on [DATE] and [DATE]. The next documented treatment for [REDACTED]. Review of the Pressure Ulcer Skin Grid stated the date of origin for the coccyx wound was [DATE] and the wound developed in the facility. On [DATE] the coccyx was staged as an SDTI that measured 5 cm long by 6 cm wide and 0.1 cm deep. The area was described as purple and red with two small openings measuring 0.5 cm by 0.5 cm by 0.1 cm deep. The document indicated a new treatment was ordered. The record contained no new treatment order. The resident's care plan was updated to reflect the resident had a coccyx pressure ulcer on [DATE]. Review of the [DATE] TAR revealed the coccyx treatment was not administered on [DATE], 06,,[DATE], [DATE], and [DATE]. Review of the Pressure Ulcer Skin Grid entry dated [DATE] indicated the coccyx ulcer measured 4.8 cm by 6 cm by 0.1 cm deep. The areas was described as improving, with granulation tissue present. A telephone order was obtained on [DATE] to cleanse the coccyx wound with normal saline, apply Santyl (a [MEDICATION NAME] agent) to yellow wounds and cover with a foam dressing once a day. The Santyl was not obtained by the facility until [DATE]. Review of the Pressure Ulcer Skin Grid entry dated [DATE] indicated Resident #7 ' s coccyx was described as an unstageable wound that measured 4.4 cm by 3.9 cm by 0.1 cm deep. The coccyx wound appeared red with yellow/white slough. Resident #7 was observed on [DATE] at 10:33 A.M. in bed on her right side. The head of her bed was elevated, her feet were on the bed and her knees were resting on top of each other. At 12:28 P.M. the resident was in the same position. At 2:40 P.M. the resident was on her back, her heels were on the mattress and her knees were together with nothing to prevent skin on skin contact. Observation on [DATE] at 7:53 A.M. revealed Resident #7 was in bed on her back and her heels were on the bed. At 8:00 A.M. the resident was seated in a wheel chair with a non-pressure reducing cushion in the seat of the wheel chair. At 12:00 P.M. the resident was in bed on her back, with heels on the mattress. The resident was in the same position at 2:00 P.M. and at 3:45 P.M. Interview of Resident #7 on [DATE] at 8:32 A.M. revealed she repositioned herself. She stated the staff did not encourage her to turn and reposition, and they did not encourage her to elevate her heels off the mattress. The resident also stated she did not like the food in the facility. Interview of STNA #15 on [DATE] at 9:30 A.M. revealed the resident turned herself and they did not encourage her to turn and they did not encourage her to elevate her heels. The STNA stated the resident did not resist care and was cooperative. She stated the resident did not eat well. Resident #7 ' s coccyx was observed by a surveyor on [DATE] at 10:45 A.M. The ulcer measured 2.7 cm by 2.0 cm by 0.1 cm deep, and the center was open with white slough. Interview of Registered Nurse (RN) # 11 on [DATE] at 10:47 A.M. confirmed the staff was to encourage Resident #7 to turn and reposition, and elevate her heels. RN #11 confirmed there was no assessment or documentation of the coccyx wound until [DATE]. Interview of Director of Rehabilitation #10 on [DATE] at 2:13 P.M. revealed Resident #7 did not have a pressure relieving cushion in her wheel chair but one would be obtained that day. 3. Review of the medical record of Resident #222 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] revealed Resident #222 had left foot pain and the Braden Scale For Predicting Pressure Sore Risk assessment indicated the resident was not risk for the development of a pressure sore. The admission nursing assessment stated the resident had no pressure sores, but she had a surgical wound on her left great toe. Review of the MDS assessment dated [DATE] revealed Resident #222 was cognitively intact, and required extensive assistance of two or more staff members for bed mobility and to transfer. The MDS assessment stated the resident did not have any pressure sores. Review of Resident #222 ' s plan of care revealed on [DATE] a plan for skin integrity was developed. The interventions included staff to inspect and chart skin integrity every week and as needed, encourage the resident to float her heels while in bed, and encourage her to turn every two hours. A plan of care for actual skin break down was developed but was not dated. This plan identified an area to the right heel as a deep tissue area with interventions that included assess for pain, check footwear for proper fit, and if resident was using a device check the skin every two hours. Review of Weekly Skin Rounds for [DATE] revealed Resident #222 ' s right heel was intact on [DATE]. Review of the Pressure Ulcer Skin Grid revealed the right heel wound developed on [DATE]. The wound was described as a SDTI that measured 6.5 cm by 5.0 cm and no depth. The area was deep purple and red. Review of physicians orders revealed on [DATE] orders were obtained to pad and protect the right heel as indicated by the 3 inch by 3 inch purple area, and to treat the right heel with skin prep twice a day and cover with thick dressing every shift and use heel lift boots at all times. The heel lift boots could be removed for hygiene as indicated by a blister and for preventive care. On [DATE] a telephone order was obtained to cleanse Resident #222 ' s right heel with normal saline, pat dry, swab with [MEDICATION NAME], cover with a thick dressing and wrap with kerlix daily and as needed. On [DATE] a physician's order [REDACTED]. Review of the TARs for May and [DATE] revealed the heel treatment was not administered on [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]. On [DATE] the right heel measured 5.3 cm by 4.2 cm and no depth. There was no documentation of the appearance of the wound. On [DATE] the heel description was changed to unstageable from SDTI, measured 5 cm by 6 cm by 0.1 cm deep with another area described as 1 cm by 0.5 cm with no depth and necrotic. The heel was described as pink with red areas and one black area. On [DATE] the heel was described as a SDTI that measured 5 cm by 6 cm and no depth with a 1.0 cm by 0.5 cm necrotic area. On [DATE] the heel was described as 5 cm by 5.9 cm and 0.1 deep no necrotic tissue was identified. Review of physician's orders [REDACTED]. There was no documentation this treatment was administered two times as ordered on [DATE] to [DATE], and [DATE] to [DATE]. On [DATE] the heel was described as a SDTI that appeared worse with necrotic tissue and measured 4 cm by 3.2 cm by 0.1 deep. On [DATE] the area on the heel was not staged, measured 3.6 cm by 2.9 cm by 0.1 cm. On [DATE] the heel was described as SDTI with no necrotic tissue. On [DATE] the area measured 1.9 cm by 1.5 cm by 0.1 cm and was described as a SDTI with necrotic tissue. Observation of the wound on [DATE] by the surveyor with Wound Care Nurse #1 revealed the area measured 1.7 cm by 1.8 cm by <0.1 cm deep and had necrotic tissue. Resident #222 was observed on [DATE] at 12:27 P.M. in bed on her back and no heel boots on. At 2:39 P. M. the resident was in bed on her back, her heels were on the mattress. On [DATE] at 7:54 A.M. the resident was in bed on her left side and her heels were on the mattress. Observation on [DATE] at 7:32 A.M. revealed the resident was in bed on her left side with no boots and her heels were on the mattress. Interview of Licensed Practical Nurse (LPN) #13 on [DATE] at 7:45 A.M. revealed Resident #222 was supposed to wear the boots at all times. The nurse stated the resident always wore her boots. She was compliant with wearing the boots and with turning. LPN #13 accompanied the surveyor to Resident #222 ' s room and confirmed the boots were not on the resident. The LPN asked the resident why her boots were off. The resident replied she had the boots on her all day and all night and her foot was hurting so the STNAs took them off. LPN #13 stated the STNAs did not report to him that the resident complained of pain and they had removed the boots. This nurse confirmed the resident's heels were on the mattress and were not elevated. Interview of RN #11 on [DATE] at 10:47 A.M. confirmed the lack of documentation regarding the treatment being administered as ordered. Interview on [DATE] at 3:13 P.M. of STNA #5 revealed Resident#222 was compliant with care and she wore her boots daily without problems. The staff member stated the resident repositioned herself on her own and she never complained of pain. The STNA stated he did not encourage her to turn or reposition. 4. Review of the medical record revealed Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #193's admission nursing assessment dated [DATE] revealed the Braden Scale For Predicting Pressure Sore Risk indicated the resident was at moderate risk for pressure sore development. The admission nursing assessment revealed the resident had a pressure ulcer that measured 0.9 cm by 0.4 cm by 0.1 deep and described as pink on her right buttocks . This area was documented as healed on [DATE]. Review of Resident #193 ' s plan of care dated [DATE] for potential skin breakdown revealed it included interventions of inspection of skin integrity every week and as needed, and apply barrier lotion after incontinent episodes. Review of the physician orders [REDACTED]. On [DATE] this order was changed to derm-cerin to redness every shift and as needed, may be applied by STNA. Review of physician's orders [REDACTED]. Review of the medical record revealed on [DATE] Resident #193 was admitted to hospice services due to idiopathic [MEDICAL CONDITION]. Review of the Weekly Skin Rounds sheets revealed in [DATE] Resident #193 ' s skin was only evaluated on [DATE] and no skin issues were identified. On [DATE] the weekly skin rounds sheet for Resident #193 revealed a treatment was in place for redness to buttocks. The weekly skin rounds sheets for [DATE], [DATE], and [DATE] stated the resident ' s buttocks were red. The [DATE] weekly rounds sheet stated the resident had a pressure ulcer to coccyx area and a treatment was in place. Review of [DATE] treatment administration (TAR) record for Resident #193 revealed the foam dressing to the coccyx every other day was not applied as ordered in [DATE] on [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]. Review of telephone orders revealed on [DATE] a treatment to the right buttocks was ordered to be changed to cleanse right buttocks with normal saline pat dry, apply hydrogel and cover with a foam dressing. Review of the [DATE] TAR ' s revealed this treatment was not applied three times as ordered on [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]. The [DATE] TAR had a treatment with a date of [DATE] for the right buttock cheek to cleanse with normal saline, pat dry, apply a small amount of hydrogel, and cover with a foam dressing twice a day. There was no physician's order [REDACTED]. On [DATE] physician ' s treatment order called for the right buttock cheek to be cleansed with normal saline, pat dry, apply a small amount of hydrogel, cover with a foam dressing every other day. Review of the [DATE] TAR revealed this treatment was not applied on 10 times as ordered ([DATE], [DATE], [DATE] to ,[DATE], [DATE], [DATE], and [DATE]. There was no documentation regarding the right buttocks wound until [DATE] when a note on the TAR described the coccyx as black in color with no drainage was noted, but odor was noted. This resident expired on [DATE]. Interview of RN #11 on [DATE] at 3:55 P.M. confirmed there was no evidence the right buttock wound was assessed and documented on until [DATE]. Interview of the DON on [DATE] at 11:05 A.M. confirmed there was no documented evidence of a physician's order [REDACTED]. The DON confirmed the TARs in the computer or hand written were the only documentation of treatments being administered. She confirmed the blanks on the TARs indicated the treatment was not administered. 5. Review of the clinical record revealed Resident #178 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden Scale for Predicting Pressure Ulcer Risk assesssments dated [DATE] and [DATE] revealed the resident was at mild risk for developing a pressure ulcer. Review of the MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact, and needed extensive assistance of one person for bed mobility and transfers. Review of the Plans of Care revealed there was an alteration in skin integrity plan but it addressed a surgical wound and did not address the resident being at risk for other skin breakdown. Review of physician's orders [REDACTED]. Review of the [DATE] TAR revealed Resident #178 did not receive the skin prep treatment to her heel on [DATE] on either shift, [DATE] and [DATE] on the night shift, [DATE] day shift, [DATE] either shift, and on day shift on [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 1:30 P.M. RN #99 reviewed the TAR and stated they either did the treatment and didn't document it or didn't do the treatment. There was no way to tell by looking at the records. Review of the Wound Observation Tool dated [DATE], revealed Resident #178 had an unstageable left heel pressure ulcer that measured 2.3 cm long by 2 cm wide by 0.1 cm deep. The facility identified the resident had the open area to her heel on [DATE]. There was no documentation of this wound, measurements and description, or orders for treatment until [DATE]. This was confirmed by LPN #77 on [DATE] at 12:35 P.M. Review of physician's orders [REDACTED]. A new care plan was developed on [DATE] for the pressure ulcer to the left heel. The goal was the ulcer will show signs of improvement. Interventions included pressure reduction mattress, change in position every two hours when in bed or room chair, weekly skin checks, heels up off bed, and report or document any non compliance. Review of physician's orders [REDACTED]. This order was changed on [DATE] to swab with [MEDICATION NAME], cover with abdominal (ABD) pad and wrap with [MEDICATION NAME] to left heel every day. Observation on [DATE] at 10:00 A.M. revealed Resident #178 was lying on left side in bed, moon boots on both feet, and her granddaughter was at the bedside. The granddaughter stated the resident developed the left heel ulcer at the facility sometime in the three weeks before she went to the hospital. The resident was hospitalized from [DATE] to [DATE]. Observation on [DATE] at 11:45 A.M. of Resident #178's left heel revealed an area to the back of the left heel which was deep purple, appeared as an old blood blister, skin intact around wound, slight peeling at the edge. No dressing was on the wound and the moon boot was in place. Interview with LPN #77 on [DATE] at 12:35 P.M. verified Resident #178 was hospitalized from [DATE] to [DATE] and the Wound Observation Tool dated [DATE] was completed on readmission. He confirmed there was no documentation found of the wound prior to hospitalization . 6. Review of the clinical record revealed Resident #62 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Braden Scale For Predicting Pressure Ulcer Risk in Home Care assessment dated [DATE] revealed the resident was at risk for pressure ulcer development. Review of physician orders [REDACTED]. The plan of care dated [DATE] revealed the resident was at risk for skin integrity impairment. The goal was for the resident to develop clean and intact skin, free from irritation and trauma. Interventions included document any noncompliance or resistance to care, monitor for skin breakdown, educate regarding turning and repositioning, dietary interventions, encourage to float heels in bed, apply protective barrier lotion after incontinence episode, encourage to turn and reposition and treatments per orders. Review of the Pressure Ulcer Skin Grid dated [DATE] revealed the resident developed an unstageable pressure ulcer measuring 2.5 cm long by 2.0 cm wide by no depth noted, on the right heel. The wound was described as intact, darkened area. Interventions to promote healing included air mattress, turning and repositioning every two hours and skin prep to both heels. Review of the TAR for [DATE] revealed the skin prep was to be applied to the heel twice a day. It was not delivered twice a day on 17 of the 30 days in June. Review of the Pressure Ulcer Skin Grid dated [DATE] revealed the heel wound measured 2.0 cm long by 1.5 cm wide by no depth noted, and was described as having serous drainage, intact, well approximated, no drainage. Interventions included air mattress, and encourage to turn and reposition every two hours and as needed. The care plan was revised on [DATE] for pressure ulcer development of the right heel. The goal was for signs of healing and to be free from infection. Interventions included heel lift boots, and weekly documentation to include measurements. Review of the [DATE] TAR revealed the heel lift boots were to be worn at all times and there were 17 days there was no evidence the heel boots were worn as ordered. The Wound Observation Tool dated [DATE] revealed the heel wound measured 4.0 cm long by 0.4 cm wide by 0 cm deep, with necrotic tissue. The Wound Observation Tools dated [DATE]. [DATE], [DATE] revealed no change. The Weekly Skin Round sheet dated [DATE] at 6:26 A.M. revealed right and left heel were marked as intact. Summary was documented as no skin issues noted. This was confirmed by the DON on [DATE] at 2:00 P.M. as being an inaccurate skin assessment. The DON confirmed the resident does have a pressure area to the right heel. The Weekly Wound Observation Tool dated [DATE] revealed Resident #62 was evaluated by a wound consultant and had an unstageable pressure ulcer on the right heel. The wound now measured 5.5 cm long by 2.5 cm wide, no depth noted, with necrotic tissue present. Review of the physician's orders [REDACTED]. The treatment order was to cleanse with normal saline, pat dry, apply z