Every finding on record at Shelby Pointe

Based observation and staff interview the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 43 residents residing in the facility. The census was 43. Findings include: An environmental tour was conducted on 12/31/24 between 12:55 P.M. and 2:25 P.M. with the Administrator. Observation of the exterior of the facility revealed the second window from the furthest east point of the building on the north side of the East Hall revealed the window screen was off its track and laying propped up against the building in an unsecured manner. Observation of the interior of the facility revealed the light ballast cover on the East Hall right before the egress exit revealed it contained dirt, debris, various dead bugs, and was partially cracked. Continued observation of Resident #23 and Resident #33's bedroom revealed missing molding around the boarders of the wall air conditioning and heating unit with deteriorating and eroding sheetrock from the edges and also gaps between the interior wall and exterior wall. Observation of Resident #25 and Resident #31's bedroom revealed significant gouges, indentations, and missing sheetrock behind Resident #31's headboard, and there was missing molding around the boarders of the wall air conditioning and heating unit deteriorating and eroding sheetrock from the edges and also gaps between the interior wall and exterior wall. Interview with the Administration on 12/31/24 between 12:55 P.M. and 2:25 P.M. verified all of the above environmental findings.

Based on medical record review and staff interview, the facility failed to ensure a resident met established criteria for use of an antibiotic medication prior to administration. This affected one (#8) of one residents reviewed for urinary tract infections (UTIs). The facility census was 43. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, chronic respiratory failure, major depressive disorder, other generalized epilepsy, cachexia, generalized anxiety disorder, bipolar disorder, and depression. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #8's urinalysis collected on 12/10/24, and with results obtained on 12/11/24, revealed the urine was abnormal in color and clarity, with urobilinogen, nitrite, leukocyte esterase, bacteria, and calcium oxalate crystals noted. Review of Resident #8's progress note dated 12/11/24 revealed there was a new order for the antibiotic Macrobid 100 milligrams (mg) twice a day for five days pending a culture and sensitivity. Review of Resident #8's physician order dated 12/11/24 to 12/11/24 revealed an order for Macrobid 100 mg by mouth twice a day for UTI for 10 administrations pending a culture and sensitivity. Review of Resident #8's physician order dated 12/11/24 to 12/14/24 revealed an order for Macrobid 100 mg one time only for UTI pending culture and sensitivity and give 100 mg by mouth two times a day for nine administrations. Review of Resident #8's document titled, Revised McGeer Criteria for Infection Surveillance Checklist, dated 12/12/24, revealed the UTI criteria were not met. Further review of the document revealed without a catheter residents had two meet two criteria for treatment symptoms and a microbiologic criteria and Resident #8 did not meet the criteria. Review of Resident #8's physician order dated 12/12/24 to 12/13/24 revealed an order for Macrobid 100 mg one time only upon returning from procedure. Review of Resident #8's nurse practitioner note dated 12/14/24 revealed the resident's culture and sensitivity was positive for Escherichia coli (E. coli) and extended-spectrum beta-lactamase (ESBL) with minimal sensitivities. She was treated with Macrobid pending the culture and the culture and sensitivity indicated other medications were appropriate. The Macrobid was to be discontinued. Review of Resident #8's plan of care dated 12/24/24 revealed the potential for urinary tract infections related to poor toileting habits, history of UTIs, and reoccurring UTIs. Interventions included administering antibiotics as ordered, assessing urinary status, providing fluids throughout the day, and monitoring for signs of infection. Review of Resident #8's medication administration record (MAR) for December 2024 revealed Macrobid was administered twice on 12/11/24, 12/12/24, and 12/13/24. Review of Resident #8's medical record revealed no indication the physician or nurse practitioner was informed that Resident #8 did not meet the criteria for antibiotics. Interview on 12/31/24 at 2:32 P.M. with the Director of Nursing (DON) verified facility's criteria had not been met for an antibiotic related to Resident #8's UTI.

Based on observation, staff interview, medical record review, review of investigations, and review of a facility policy, the facility failed to ensure fall interventions were in place as ordered and care planned, failed to ensure falls were properly investigated, and failed to ensure interventions to prevent future falls were appropriate to the nature of the incident. This affected one (#8) of two residents reviewed for falls. The facility census was 43. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, chronic respiratory failure, major depressive disorder, other generalized epilepsy, cachexia, generalized anxiety disorder, bipolar disorder, and depression. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and had two or more falls since admission. Review of the physician order dated 03/28/24 revealed an order for non-skid strips in front of the toilet. Review of Resident #8's plan of care dated 04/10/24 revealed the resident was at risk for falls characterized by history of falls and injury, pain, use of psychotropic medications, unsteady gait, weakness, and ambulating without assistance. Interventions included keeping the bed in the lowest position, colored tape to wheelchair breaks, encouraging to be up by he nurses station, encouraging to toilet after smoke break, a fall mat to the bedside, personal alarm to the chair, visual reminder in bathroom and room to remind to call for assistance, removing the wheelchair from room while in bed (initiated 07/22/24 and revised 10/08/24), and educating the staff on proper placement of wheelchair when in bed (initiated 09/10/24 and revised 10/08/24). Review of Resident #8's progress note dated 07/21/24 revealed she was found laying on her stomach in her room. She reported she was getting out of bed and tripped over her wheelchair. A visual reminder to use the call light for assistance was implemented. Review of Resident #8's fall investigation dated 07/21/24 revealed the resident fell while getting out of bed when she tripped over her wheelchair. Additional interventions included educating to use call light for assistance and removing the wheelchair from the room when the resident was in bed. Review of Resident #8's progress note dated 08/03/24 revealed the nurse was notified the resident had fallen. She was on the floor between her bed and wheelchair. She stated she was transferring and fell to the floor as the resident reported she wanted to go to the bathroom. The intervention was to reeducate staff on removing the resident's wheelchair from the room while she was in bed. Review of Resident #8's progress note dated 08/31/24 revealed the resident remained on neurological checks that were initiated at 3:15 A.M. from the previous shift. She had no apparent injuries and range of motion was within normal limits. There was no further documentation related to this incident. Review of Resident #8's progress note and fall investigation dated 11/22/24 revealed the resident was found on the floor in the bathroom as she was going into the bathroom in her wheelchair. She reported she tried to go to the bathroom by herself and hit the back of her head. The intervention implemented was to maintain a low bed at all times. Observation on 12/30/24 at 1:55 P.M. and 3:41 P.M. revealed Resident #8 in bed with her wheelchair next to the bed. Further observation at 3:41 P.M. revealed there were no non-skid strips in front of the toilet and no signs in the bathroom or room reminding the resident to ask for assistance. Interview on 12/30/24 at 3:41 P.M. with Licensed Practical Nurse (LPN) #110 verified the wheelchair was next to Resident #8's bed, and verified there were no non-skid strips in front of the toilet or signs in the bathroom or room to remind the resident to ask for assistance. She reported she was unsure if the resident put herself in the bed or not, but verified staff were to remove the wheelchair. Interview on 12/31/24 at 1:31 P.M. with the Director of Nursing (DON) verified the wheelchair was not removed from the room while the resident was in bed at the time of Resident #8's fall on 08/03/24. The DON additionally verified there was a fall on 08/31/24 and there was no documentation or investigation for the incident. The DON additionally verified a low bed was an inappropriate intervention for Resident #8's fall on 11/22/24 which took place in the bathroom. Review of the undated policy titled, Managing falls and fall risk, revealed the staff were to implement a resident-centered fall prevention plan to reduce the specific risk factor of falls for each resident.

Based on medical record review and staff interview, the facility failed to adequately monitor a resident's targeted behaviors as ordered. This affected one (#3) of two residents reviewed for mood and behavior. The facility census was 43. Findings include: Review of Resident #3's medical record revealed an admitted [DATE] and diagnoses including cerebral palsy, major depressive disorder, moderate protein-calorie malnutrition, type two diabetes mellitus, anxiety, dysphagia, unspecified mood disorder, and metabolic encephalopathy. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #3's physician order dated 08/09/24 revealed an order to monitor daily behaviors. Review of Resident #3's plan of care dated 08/23/24 revealed the resident required the use of psychotropic medications with potential for adverse reactions related to adjustment disorder with depressed mood, anxiety, decline in health status, decline in mood and behavior, depression, impaired coping skills, and schizoaffective disorder. Interventions included offering non-pharmacological interventions to manage anxiety, giving medications as ordered, evaluating effectiveness and side effects of medications, and monitoring resident mood and behavior every shift and document on any behaviors. Review of Resident #3's physician order dated 08/27/24 revealed an order for Vistaril 50 milligrams (mg) one capsule two times a day for anxiety. Review of Resident #3's physician order dated 10/15/24 revealed an order for Depakene oral solution 250 mg two times a day for mood affective disorder and 500 mg at bedtime for adjustment disorder with depressed mood. Review of Resident #3's physician order dated 11/05/24 revealed an order for lorazepam 0.5 mg one tablet three times a day for anxiety. Review of Resident #3's physician order dated 12/11/24 revealed an order for Zoloft 50 mg one tablet in the morning related to adjustment disorder with depressed mood. Review of Resident #3's physician order dated 12/11/24 revealed an order for Zoloft 100 mg one time a day for depression. Review of Resident #3's December 2024 medication administration record (MAR) between 12/03/24 to 12/30/24 revealed behaviors were present on 12/04/24, 12/05/24, 12/09/24, 12/10/24, 12/13/24, 12/14/24, 12/15/24, 12/18/24, 12/19/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, and 12/29/24; however, there was no indication what the actual behaviors were. Review of Resident #3's progress notes from 12/03/24 to 12/29/24 revealed there was no indication of what behaviors occurred on 12/04/24, 12/05/24, 12/09/24, 12/13/24, 12/14/24, 12/18/24, 12/19/24, 12/23/24, 12/24/24, 12/25/24, and 12/26/24. Interview on 01/02/25 at 11:00 A.M. with the Director of Nursing (DON) verified when Resident #3 displayed behaviors the nursing staff was supposed to be describing the behaviors that occurred and verified there was no documentation to support what the resident's behaviors were on the specified dates in December 2024.

Based observation and staff interview, the facility failed to maintain total visual privacy for residents. This affected two (#33 and #39) of 38 residents residing in semi-private rooms in the facility. The census was 43. Findings include: 1. Observation of resident rooms on 12/31/24 between 12:55 P.M. and 2:25 P.M. with the Administrator revealed there was no privacy curtain around Resident #39's bed to ensure total visual privacy. Further observation revealed Resident #39 shared the room with Resident #11. 2. Observation of resident rooms on 12/31/24 between 12:55 P.M. and 2:25 P.M. with the Administrator revealed there was no privacy curtain around Resident #33's bed to ensure total visual privacy. Further observation revealed Resident #33 shared the room with Resident #23. Interview on 12/31/24 at approximately 2:25 P.M. with the Administrator verified Resident #33 and Resident #39's beds did not have curtains around them to ensure total visual privacy.

Based on observation and staff interview, the facility failed to ensure all required postings were displayed in the facility in a manner which was accessible at all times. This affected all 44 residents residing in the facility. The facility census was 43. Findings include: Observation on 01/02/25 at 1:22 P.M., of all facility common areas and hallways revealed there was no posted contact information for pertinent state agencies and advocacy groups, such as the State Survey agency, the State licensure office, adult protective services, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. An interview with the Administrator on 01/02/25 at approximately 1:23 P.M. verified there was no list of pertinent state agencies and advocacy groups posted.

Based on review of the facility assessment document and staff interview, the facility failed to ensure its facility assessment contained all required information. This had the potential to affect all 43 residents. The facility census was 43. Findings Include: Review of the current facility assessment document revealed the assessment did not contain specific staffing needs for each shift, such as day, evening, night and shifts. The assessment also did not contain information on how the facility would develop and maintain a plan to maximize recruitment and retention of direct care staff. Interview with the Administrator on 12/31/24 at 8:15 A.M. verified the assessment did not contain all required information.

Based on medical record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review (PASRR) status was correctly coded on the Minimum Data Set (MDS) assessment. This affected eight (#1, #11, #16, #18, #25, #30, #36, and #41) of 43 residents reviewed for MDS assessment accuracy. The facility census was 43. Findings Include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, type two diabetes, and epilepsy. Review of the PASRR level two evaluation from the state PASRR agency dated 10/24/23 revealed Resident #1 was ruled out from further review indicting Resident #1 did not have a serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition. Review of section A of Resident #1's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, Yes, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The facility subsequently answered, Yes, to the area of, Level II PASRR conditions: Serious Mental Illness, for Resident #1. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, paranoid schizophrenia, and epilepsy. Review of the PASRR level two evaluation from the state PASRR agency dated 11/09/23 revealed Resident #11 had a level two mental illness. Review of section A of Resident #11's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 3. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizophrenia, and mood disorder. Review of the PASRR level two evaluation from the state PASRR agency dated 09/01/23 revealed Resident #16 had a level two mental illness. Review of section A of Resident #16's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 4. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses that included dementia, type two diabetes, and mood disorder. Review of the PASRR level two evaluation from the state PASRR agency dated 10/02/24 revealed Resident #18 was ruled out from further review, indicating Resident #18 did not have a SMI, ID, DD, or related condition. Review of section A of Resident #18's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, Yes, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The facility subsequently answered, Yes, to the area of, Level II PASRR conditions: Serious Mental Illness, for Resident #18. 5. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, major depressive disorder, anxiety disorder, and other sexual disorder. Review of the PASRR level two evaluation from the state PASRR agency dated 11/13/23 revealed Resident #25 had a level two mental illness. Review of section A of Resident #25's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 6. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, major depressive disorder, and anxiety disorder. Review of the PASRR level two evaluation from the state PASRR agency dated 10/26/23 revealed Resident #30 had a level two mental illness. Review of section A of Resident #30's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 7. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, major depressive disorder, anxiety disorder, and other sexual disorder. Review of the PASRR level two evaluation from the state PASRR agency dated 11/04/24 revealed Resident #36 had a level two mental illness. Review of section A of Resident #36's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 8. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses that included dementia with psychotic disturbance, major depressive disorder, and schizoaffective disorder. Review of the PASRR level two evaluation from the state PASRR agency dated 11/27/24 revealed Resident #41 had a level two mental illness. Review of section A of Resident #41's most recent comprehensive MDS assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Interview with Social Service Designee (SSD) #152 on 12/31/24 at 1:15 P.M. verified the PASRR status for Resident #1, Resident #11, Resident #16, Resident #18, Resident #25, Resident #30, Resident #36, and Resident #41 were coded incorrectly on the MDS assessments.

Based on observations, staff interviews and contractor interviews, the facility failed to ensure the low temperature dishwasher was functioning properly to sanitize the dishes and utensils. This had the potential to affect all 38 residents who the facility identified as receiving meals from the facility. The facility also failed to handle, prepare, distribute, and serve food in accordance with professional standards for food service safety. This affected seven residents (#4, #5, #8, #12, #14, #21 and #26) who the facility identified as receiving mechanical soft diets. The facility census was 38. Findings include: 1) Observation of the low temperature dishwasher on 10/10/23 at 8:47 A.M. with Dietary Manager (DM) #351, revealed DM #351 attempted to get a reading of the sanitizer on the test strips and the strips did not register any parts per million (ppm) to ensure concentration of the sanitizer was correct. DM #351 indicated the dishwasher should be registering at 50 PPM on the test strips for proper sanitation. DM #351 verified the findings at time of observation. Observation and interview on 10/12/23 at 11:11 A.M. with Chemical Company Technician (CCT) #422, revealed the sanitizer line running to the dishwasher had a hole in it and the tubing was pinched off restricting the flow of sanitizer going into the dishwasher. CCT #422 stated that the dish machine should register at 50 ppm for sanitization and when he arrived, the dishwasher was registering at zero PPM. 2) Observation of tray line on 10/12/23 at 11:45 A.M. revealed Cook #342 was scooping up the cold chicken salad into her gloved hand and placing the chicken salad on the lettuce situated on the plates. Interview with Cook #342 at the same time indicated she did not know the correct portion size for the chicken salad because the daily spreadsheet was in DM #351's office, so she used her gloved hand. Cook #342 verified she was using her gloved hand to scoop out the chicken salad and plate it. Interview with DM #351 on 10/12/23 at 11:50 A.M. verified Cook #342 was plating the mechanical soft foods with her gloved hand and should have used an appropriate four-ounce food scooper.

Based on observations, interviews and record reviews, the facility failed to serve food at the proper portion size to meet the resident's nutritional needs. This affected seven residents (#4, #5, #8, #12, #14, #21 and #26) who the facility identified as receiving mechanical soft diets. The facility census was 38. Findings include: Observation of tray line on 10/12/23 at 11:45 A.M. revealed Cook #342 was scooping up the cold chicken salad into her gloved hand and placing the chicken salad on the lettuce situated on the plates. Interview with Cook #342 at the same time indicated she did not know the correct portion size for the chicken salad because the daily spreadsheet was in Dietary Manager (DM) #351's office. Cook #342 verified she was using her gloved hand to scoop out the chicken salad and plate it. Interview with DM #351 on 10/12/23 at 11:50 A.M. revealed the daily spreadsheet was in his office. DM #351 verified the mechanical soft diets should have received four ounces of cold chicken salad. DM #351 verified Cook #342 was plating the mechanical soft foods with her gloved hand and without an appropriate four-ounce food scooper.

Based on observation, record review and staff interview, the facility failed to ensure call lights were within reach and accessible for residents. This affected four residents (#02, #30, #14, and #15) of 38 residents reviewed for call light placement. Findings Include: 1) Record review for Resident #02 revealed the resident was admitted on [DATE] with diagnoses that included, but not limited to, major depressive disorder, chronic obstructive pulmonary disease (COPD), schizophrenia, and personality disorder. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 07/21/23 for Resident #02, revealed the resident had severely impaired cognition and required extensive assistance of one staff member for mobility, transfer, and toilet use. Observation and interview of Resident #02 on 10/10/23 at 9:25 A.M., revealed the resident was lying in bed and his call light was lying on the floor under the bed. Resident #02 stated that she used the call light when she could find it. The call light was noted to be out of reach of Resident #02. Interview with Assistant Director of Nursing (ADON) #333 on 09/25/23 at 10:09 A.M. verified Resident #02's call light was out of reach and the resident couldn't access her call light. 2) Record review for Resident #30 revealed the resident was admitted on [DATE] with diagnoses that included, but not limited to, vascular dementia, wasting and atrophy, anxiety, and major depressive disorder. Review of the most recent MDS assessment 3.0 dated 07/28/23 for Resident #30, revealed the resident had severely impaired cognition and required extensive assistance of two staff for mobility, transfer, and toilet use. Observation of Resident #30 on 10/10/23 at 9:32 A.M., revealed the resident was lying in bed and his call light was behind the dresser. The call light was noted to be out of reach of Resident #30. Interview with Licensed Practical Nurse (LPN) #340 on 10/10/23 9:32 A.M., verified Resident #30's call light was out of reach and the resident couldn't access the call light. 3) Record review for Resident #14 revealed the resident was admitted on [DATE]. Diagnoses included schizoaffective disorder, restlessness and agitation, depression, mood disorder, dysphagia, difficulty in walking, unspecified convulsions, and muscle weakness. Review of the fall risk assessments dated 08/05/23, 08/15/23, 10/04/23, and 10/09/23 for Resident #14 revealed the resident was at high risk for falls. Review of the quarterly MDS assessment 3.0 dated 09/13/23 for Resident #14, revealed the resident was cognitively impaired and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the plan of care dated 08/14/23 for Resident #14, revealed the resident was at risk for falls. Interventions included anti-tippers to wheelchairs, re-educate resident to use call light, and call light in reach when in room. Observation on 10/10/23 at 9:32 A.M., revealed Resident #14 was lying in bed and his call light was not within reach. The call light was located behind a nightstand which was centrally located against a wall of the room and not near the resident. During an interview with ADON #333 at the same time, verified Resident #14's call light was not within reach and should have been. Review of the active October 2023 physician orders for Resident #14 revealed an order for encouraging the resident to use call light for staff assistance with activities of daily living. 4) Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, vascular dementia, restlessness and agitation, depression, muscle weakness, and difficulty in walking. Review of the MDS assessment 3.0 dated 08/16/23 for Resident #15, revealed the resident was cognitively impaired and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of a fall risk assessment dated [DATE] for Resident #15, revealed the resident was at high risk for falls. Observation on 10/10/23 at 9:25 A.M. revealed Resident #15 was lying in bed and his call light was not within reach or near the bed. The call light was located on top of a nightstand which was located on the other side of a curtain which was used to divide the room. During an interview with the ADON #333 at the same time, verified Resident #15's call light was not within reach and should have been. Review of the undated facility policy titled Answering the Call Light, revealed staff would ensure that resident call lights were accessible to the resident when in bed, from the toilet, from the shower or bathing facility from the floor.

Based on observations and staff and resident interviews, the facility failed to ensure resident's equipment was clean and in good repair. This affected three residents (#07, #08 and #30) of the 38 residents observed during the initial screening process. The census was 38. Finds Included: 1) Observation of Resident #08 on 10/10/23 at 11:08 A.M. revealed the resident's wheelchair was dirty with grime and crumbs around the wheels, foot pedals, and seat cushion. Interview with Resident #8 at the same time, revealed his wheelchair had never been cleaned and it would be nice if it was clean. 2) Observation of Resident #07 on 10/10/23 at 11:29 A.M. revealed the resident wheelchair was dirty with dried food, liquid and grime on wheelchair wheels, foot pedals and the arm rests and the left arm rest was torn. Interview with Resident #7 at the same time, revealed her wheelchair had not been cleaned for a long time. 3) Observation of Resident #30 on 10/12/23 at 8:10 A.M. revealed the resident's wheelchair was dirty with dried food and covered in grime on wheels, cushion, and the wheelchair frame. Interview with Maintenance Director #304 on 10/12/23 at 8:15 A.M. verified the above concerns related to unkept resident's wheelchairs. Interview with the Administrator on 10/12/23 at 8:25 A.M. revealed there was no formalized plan for cleaning the resident's wheelchairs and there was no log of when the resident's wheelchairs had been cleaned or were scheduled to be cleaned. The Administrator stated there was no policy for cleaning resident wheelchairs.

Based on record review and staff interview, the facility failed to submit a new Pre-Admission Screening and Resident Review (PASARR) when a resident received a new diagnosis of schizoaffective disorder. This affected one resident (#27) of three residents reviewed for PASARR. The facility census was 38. Findings include: Record review for Resident #27, revealed the resident was admitted to the facility on [DATE]. Diagnoses included other psychoactive substance abuse and alcohol abuse. Further review of the medical record revealed a new diagnosis of schizoaffective disorder which was added for Resident #27 on 11/16/21. Review of the annual Minimum Data Set (MDS) assessment 3.0 dated 07/01/23 for Resident #27, revealed the resident was cognitively impaired and had verbal behavioral symptoms directed toward others. Review of the electronic and paper medical records for Resident #27 revealed no evidence a new PASARR was completed when the resident received a new diagnosis of schizoaffective disorder. Interview on 10/11/23 at 11:51 A.M. with Social Service Designee (SSD) #349 verified a new PASARR should have been completed when Resident #27 was diagnosed with schizoaffective disorder. Interview on 10/12/23 at 7:45 A.M. with the Administrator verified Resident #27 should have a new PASARR completed/submitted upon receiving a new mental health diagnosis and did not.

Based on medical record review, review of the Self-Reported Incident, review of hospital records, staff interviews, observations, and policy review, the facility failed to ensure a resident with dementia was provided person-centered interventions to prevent the resident from wandering into the rooms of other residents and potentially being harmed. Actual harm occurred when Resident #34 wandered into the room of Resident #43, and Resident #43 then pulled Resident #34 to the ground causing Resident #34 to receive an inferior dislocation of the left shoulder, and a closed traumatic displaced fracture of the proximal end of the left humerus. This affected one (#34) of three residents reviewed for dementia care. The facility census was 42. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE], with diagnoses including Alzheimer's disease, dementia, cognitive communication deficit, unspecified psychosis, restlessness and agitation, and depression. Review of the admission Minimum Data Set (MDS) assessment, dated 10/14/22, revealed Resident #34 had severely impaired cognition. The resident required supervision/setup help only for most of the activities of daily living (ADL). The assessment noted the resident was not steady but able to stabilize without assistance for walking and did not use any mobility devices such as a wheelchair. The resident had a history of wandering and refusal of care. Review of Resident #34's plan of care, dated 10/21/22, revealed Resident #34 wandered with no discernable, rational purpose. Interventions included redirecting and cueing as needed. Review of the nurse progress notes dated 10/08/22, 10/09/22, 10/23/22, and 10/24/22, revealed Resident #34 wandered into the rooms of other residents on numerous occasions. Review of the nurse progress notes dated 10/31/22 and timed at 6:24 P.M., documented Resident #34 had went into Resident #43's room and Resident #43 grabbed Resident #34 and pulled her to the ground. Resident #34 was holding her arm with tears in her eyes and refused to move her arm or shoulder. Resident #34 was sent to the local emergency department for evaluation. Review of the nurse progress notes dated 10/31/22 and timed at 10:35 P.M., documented the hospital reported Resident #34 had a dislocation and fractured left humerus. Review of the hospital documentation dated 10/31/22 documented Resident #34 was diagnosed with an inferior dislocation of the left shoulder and closed traumatic displaced fracture of proximal end of the left humerus. Resident #34 was prescribed Hydrocodone-acetaminophen (Norco) 5-325 milligrams (mg) every four hours as needed for pain. Review of the nurse progress notes dated 10/31/22 and timed at 11:00 P.M., revealed Resident #34 returned to the facility and was total lifted into bed. Review of the nurse progress notes dated 11/02/22 and timed at 2:54 P.M., revealed Resident #34 was holding and guarding her left arm with grimacing facial expressions and calling out left arm pain. Resident #34 was offered and refused pain medication. 2. Review of the medical record for Resident #43 revealed an admitted [DATE], with diagnoses included schizoaffective disorder, unspecified intellectual disabilities, paranoid schizophrenia, delusional disorders, bipolar II disorder, hallucinations, impulsiveness, and dementia. Review of the admission MDS assessment, dated 09/14/22, revealed Resident #43 was severely cognitively impaired and required supervision for activities of daily living. The resident had verbal and physical behaviors directed toward others. Review of Resident #43's plan of care, dated 09/12/22, revealed Resident #43 exhibited behavioral symptoms not easily altered and potentially harmful to resident or others: verbally abusive toward others, physically abusive toward others, resistive to care, non-compliant with drug and treatment regiment, refusal of care, scratching and biting staff, agitation, hallucinations, and impulsiveness. Goals included resident's anger and verbally abusive behavior would not escalate into combative behaviors that could result in injury to self or others, resident's physically abusive behavior would be decreased/eliminated with interventions and would not harm self or others. Interventions included determining causative situations for behavior and avoiding or optimally managing them and redirecting and cueing as needed. Review of Resident #43's nurse progress notes dated 09/08/22 through 10/31/22 revealed Resident #43 was verbally and/or physically aggressive with staff and/or residents who entered her room on numerous occasions. Review of the nurse progress notes dated 10/31/22 and timed at 6:30 P.M., documented Resident #34 was seen entering Resident #43's room at approximately 5:55 P.M. Resident #43 grabbed Resident #34 and pulled her to the ground. Resident #43 was yelling at Resident #34 and telling Resident #34 to get out of her room. Review of the Self-Reported Incident (SRI) dated 11/01/22 and timed at 3:53 P.M., revealed an incident occurred between Resident #34 and Resident #43 on 10/31/22 at approximately 5:55 P.M. The investigation revealed Resident #34 entered the room of Resident #43. Resident #43 began yelling and telling Resident #34 to get out of her room. Resident #34 would not leave, and Resident #43 grabbed Resident #34 and pushed her to the ground. Resident #34 was holding her arm, appeared to have tears in her eyes, and when asked if she was in pain stated yes. Resident #34 was sent to the emergency department for evaluation/treatment. The facility unsubstantiated physical abuse. Resident #34's room was moved closer to the nurse station. No other interventions were implemented to prevent further occurrences. Observation on 11/16/22 at 6:44 A.M., revealed Resident #34 was in a wheelchair and propelling herself down a hallway of the facility. Resident #34 wandered into the room of Resident #32 who was sleeping in his recliner at the time. Resident #34 eventually wandered back out of the room and down the hallway. No staff were out in the hallway or in the area at the time. State tested Nurse Aide (STNA) #120 then approached and stated, be careful if you're going into that room-he is a [NAME]. Interview on 11/16/22 at 6:52 A.M., with STNA #120 revealed there were not enough staff to properly supervise residents to keep them safe. STNA #120 reported Resident #34 wandered into other resident rooms all the time and the residents get upset and aggravated; but staff just tell the other residents to ring their call light and if Resident #34 wandered into their room staff would come get her. Interviews on 11/16/22 from 5:45 A.M. to 10:30 A.M., with Licensed Practical Nurse (LPN) #114, STNA #120, and STNA #132, revealed there was not enough staff to provide adequate supervision to keep residents safe or to keep Resident #34 from wandering into the rooms of other residents. Staff reported Resident #43 does not like anyone in her space and would often become verbally and/or physically aggressive upon staff entering the resident's room. Staff also verified Resident #34 wandered throughout the facility and into other resident rooms on a regular basis and the only intervention that had been implemented following the incident with Resident #43, was Resident #34's room being moved closer to the nurse station and further from Resident #43's room. Staff reported Resident #34 was up and walking prior to the incident with Resident #43 and had since been in a wheelchair due to unsteadiness. Staff also reported Resident #34 now requires more assistance with all ADLs than she previously had and did not have full range of motion of her left arm. Review of the policy titled Dementia - Clinical Protocol, revised December 2017, revealed the interdisciplinary team would adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, etc. This deficiency represents non-compliance investigated under Master Complaint Number OH00137493 and Complaint Number OH00137473.

Based on observations, kitchen cleaning forms and schedule review and staff interviews, the facility failed to keep the food services carts clean. This could potentially affect 42 of 42 residents residing in the facility as all resident receive food from the kitchen. The facility census was 42. Findings include: Observation on 11/17/22 at 6:34 A.M., of the kitchen, revealed two metal carts that are used to transport the food down the hallways to the residents were not clean. The metal carts were both observed with a large amount of dried liquid and food particles throughout the carts, especially on the sides and bottom. Interview on 11/17/22 at 6:43 A.M., with Dietary Supervisor (DS) #140 confirmed there was a large amount of dried food and splashes of liquids throughout the metal kitchen carts. DS #140 stated the carts are on the daily cleaning schedule to be wiped down and deep cleaned once a month. DS #140 stated the hose outside that was used for the deep cleaning broke at the water source and therefore the deep cleaning of the carts has no been completed since around June 2022. The interview identified the facility is getting a power washer to clean the carts, but that has no occurred yet. Review of the form titled Daily Cleaning Schedule identified clean and sanitize delivery carts daily. The schedule was reviewed for the week of 11/13/22 through 11/17/22 and the cart cleaning was signed off daily. This deficiency represents the noncompliance investigated under Complaint Number OH00133588.

Based on observations, activities calendar reviews and staff interviews, the facility failed to provide planned and organized activities per the activities calender. This had the potential to affect 10 (#4, #13, #14, #16, #17, #18, #22, #24, #25 and #26) of 10 residents identified to typically attend group activities, with the planned activities program. The facility census was 42. Findings include: Review of the activities calendar for 11/16/22, identified a ball toss was scheduled for 10:00 A.M. Observations on 11/16/22 from 10:00 A.M. to 10:11 A.M., revealed activities staff was passing snacks/refreshments and there was no ball toss taking place. Review of the activities calendar dated 11/17/22 identified Social Fun was listed for an activity at 9:00 A.M. and Awake Church at 10:00 A.M.; ball toss at 2:00 P.M. and Rummy at 6:00 P.M. Interview on 11/17/22 at 7:00 A.M., with Activities Director (AD) #150 revealed she has been an activities assistant for the past 5 years but was recently promoted. AD #150 verified the posted November 2022 activities calendar and stated she has no idea what Social Fun consists of. AD #150 verified Social Fun is listed on the activities calendar every day at 9:00 A.M. AD #150 verified the first smoke time of the day is also at 9:00 A.M. AD #150 stated she passes snacks out at 9:30 A.M. and then again at 1:30 P.M. AD #150 stated the resident have access to things to do in the main dinning room area, on their own. The area was observed with AD #150 and confirmed she could not locate any playing cards and that rummy was listed for 6:00 P.M. tonight. AD #150 identified residents take the cards frequently and she does not know where they are. Observations on 11/17/22 at 8:16 A.M., revealed seven residents were sitting, eating in the main dinning room area. The television was observed to be on MTV with heavy metal music playing in the back ground. The observation continued off and on through 12:48 P.M. Observations on 11/17/22 at 9:08 A.M. and 10:06 A.M., revealed no group activities were occurring in the facility that were scheduled on the activities calendar. Interview on 11/17/22 at 12:48 P.M. with the Administrator verified MTV was playing on the television and he is not sure if the residents wanted that on there or not. Observation on 11/17/22 at 2:11 P.M., revealed no group activities were occurring. Interview on 11/17/22 at 2:11 P.M., with the Administrator regarding the lack of planned group activities that were listed on the calendar revealed he would look into this. Observation on 11/17/22 at 2:20 P.M., of the main dinning room, identified there was a group of resident bowling with AD #150. The observation identified the residents were actively participating in the activity. This deficiency represents the noncompliance investigated under Complaint Number OH00133588.

Based on medical record review, Self-Reported Incident (SRI) review, policy review, resident and staff interviews, the facility failed to timely report an allegation of physical abuse of a resident to the State Survey Agency, Ohio Department of Health (ODH). This affected four (#16, #19, #34 and #43) of four residents reviewed for potential abuse. The facility census was 42. Findings include: Review of Resident #16's medical record revealed an admitted [DATE], with medical diagnoses including: bipolar disorder, schizophrenia, Parkinson's disease and PTSD (post traumatic stress disorder). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #16 was cognitively intact. Review of Resident #16's progress notes dated 09/25/22 at 4:42 P.M., identified Resident #16 was coming back from smoking and another resident (Resident #19) grabbed her hair and pulled it. Interview on 11/17/22 at 11:37 A.M., with Resident #16 was asked if anyone had ever abused her and she identified yes. Resident #16 identified Resident #19 came up behind her several weeks ago, coming inside after smoking, and pulled the back of her hair. Resident #16 confirmed the back of her head was sore for days after the incident. Resident #16 confirmed she is scared of Resident #19 as she is violent. Resident #16 confirmed all the residents go out to smoke together. Interview on 11/16/22 at 6:52 A.M., with State tested Nursing Assistant (STNA) #120 revealed she was present on 09/25/22, when Resident #19 was behind Resident #16 in the hallway. Resident #16 was moving slowly in her wheelchair and Resident #16 grabbed the back of her hair and pulled a whole handful of hair. STNA #120 stated staff separated the residents at that time. STNA #120 identified she is unaware of any changes that were made after the incident to ensure this does not occur again. Interviews on 11/17/22 at 1:26 P.M., with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing, confirmed they were all aware of the incident that occurred on 09/25/22 between Resident #16 and Resident #19. The staff confirmed they did not start an investigation or a self reported incident and have any evidence of any changes made to ensure continued abuse did not occur. The staff confirmed the only documentation of the incident is located in Resident #16's progress notes and there was no investigation to identify the cause and or changes made to ensure residents are not abused by Resident #19. Review of Resident #19's medical record identified admission to the facility 04/02/19, with diagnoses including: history of traumatic brain injury resulting from motor vehicle accident (MVA), schizoaffective disorder, dementia, anemia, arthritis, anxiety, aggression, seizure disorder and history alcohol abuse. Review of the MDS assessment revealed Resident #19 is not cognitively intact and does not elicit recognizable words. Resident #19's medical record and written plan of care identified she usually propels herself around in a wheelchair that includes a harness due to leaning forward. The plan of care identified Resident #19 is prone to anger and aggression. The plan included document all behaviors displayed by resident and their response to the interventions; attempt to identify and eliminate the triggers that are causing the escalating behaviors and document all interactions with the resident including what triggered the aggression and what strategies worked to resolve it. Review of Resident #19's progress notes dated 09/25/22 at 4:12 P.M., identified Resident was yelling as loud as she can Hey, Hey. The notes identified activities staff reported Resident #19 thinks she needs to be the first person in line to go out to smoke and was blocking other residents. The notes identified when the activities staff asked Resident #19 to move back, the resident started screaming and cussing and would not move. Review of the policy titled Resident to Resident Abuse policy, dated February 2018, identified all altercations including those that may represent resident-resident abuse shall be investigated and reported to the Director of Nursing and Administrator. The policy identified residents should be separated; identify what happened, including what might have lead to aggressive conduct on the part of the individuals involved in the altercation; notify each residents representative and the attending physician; Review the events and possible measures to prevent additional incidents; makes changes to the plan of care; document all interventions and their effectiveness; document the incident, findings and corrective measures taken in the medical record. Interview on 11/17/22 at 1:26 P.M., with the DON confirmed the facility did not report the incident to the required agency. 44454 2. Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, cognitive communication deficit, unspecified psychosis, restlessness and agitation, and depression. Review of the admission Minimum Data Set (MDS) assessment, dated 10/14/22, revealed Resident #34 had severely impaired cognition. The resident required supervision with a majority of the activities of daily living. The resident had a history of wandering and refusal of care. Review of the nurse progress notes dated 10/31/22 and timed 6:24 P.M., documented Resident #34 had went into Resident #43's room and Resident #43 grabbed Resident #34 and pulled her to the ground. Resident #34 was holding her arm with tears in her eyes and refused to move her arm or shoulder. Resident #34 was sent to the local emergency department for evaluation. Review of the nurse progress notes dated 10/31/22 and timed 10:35 P.M., documented the hospital reported Resident #34 had a dislocation and fractured left humerus. Review of the hospital documentation dated 10/31/22 documented Resident #34 was diagnosed with an inferior dislocation of left shoulder and closed traumatic displaced fracture of proximal end of left humerus. Resident #34 was prescribed Hydrocodone-acetaminophen (Norco) 5-325 milligrams (mg) every four hours as needed for pain. Review of Self-Reported Incident (SRI) #228740 dated 11/01/22 and timed 3:53 P.M. revealed an incident occurred between Resident #34 and Resident #43 on 10/31/22 at approximately 5:55 P.M. The investigation revealed Resident #34 entered the room of Resident #43. Resident #43 began yelling and telling Resident #34 to get out of her room. Resident #34 would not leave and Resident #43 grabbed Resident #34 and pushed her to the ground. Resident #34 was holding her arm, appeared to have tears in her eyes, and when asked if she was in pain stated yes. Resident #34 was sent to the emergency department for evaluation/treatment. The facility unsubstantiated physical abuse. Resident #34's room was moved closer to the nurse station. No other interventions were implemented to prevent further occurrences. A confidential interview with a staff member on 11/16/22 at 6:18 A.M. revealed the facility always investigated allegations of physical abuse but never timely. The staff member reported the facility did not report the SRI until Resident #34 was confirmed to have a fracture/dislocation. Interview on 11/21/22 at 12:02 P.M., with the Director of Nursing (DON) verified physical abuse was alleged for Resident #34 on 10/31/22 at approximately 5:55 P.M. and the facility did not initiate the SRI until 11/01/22 at approximately 3:53 P.M. The DON reported she did not realize the incident was required to be reported within the two-hour timeframe since she believed Resident #43 lacked the mental capacity to wilfully inflict injury on Resident #34--therefore she waited until Resident #34 was diagnosed with a fracture and dislocation to initiate the SRI. Review of the facility policy titled Abuse Prevention Program, revised February 2018, revealed any allegations of abuse would be reported within timeframe's as required by federal requirements. This deficiency represents non-compliance investigated under Complaint Number OH00133588.

Based on resident council meeting minutes review, resident and staff interviews, the facility failed to consider and act upon residents concerns identified during September, October and November 2022, in resident council meetings. The facility is identified to have from four to seven residents at various times whom attend the resident council meetings. This affected 10 (#1, #14, #8, #16, #21, #22, #24, #25, #26 and #31) of 42 residents who have attended the residents council meetings in the past three months. The facility census was 42. Findings include: Review of the resident council meeting minutes from September through November 2022 identified residents expressed the following concerns: having to wait until 12:00 A.M. for 10:00 P.M. coffee; aides needing to remind nurses about pain pills; Geri-chairs and alarms; clothing getting mixed up; residents cannot get some food alternatives; the cubed ham tasting bad; residents having hard time getting trays timely; Administrator hard to track down, aides short staffing often because of call offs; takes a while to get light bulb changed and the food is not always hot. Further review of the minutes identified no follow up and or acknowledgment of the resident's concerns from the September, October and November 2022 meeting minutes. Interview on 11/17/22 at 8:37 A.M., with the Administrator revealed he has been asking the staff for the follow up to the resident council meeting and has not gotten any. The Administrator stated the staff should be filling out a concern form for each issue and providing it to the manager of that section. The Administrator stated all concerns from resident council should be looked into. Review of the resident council meeting minutes dated 10/06/22 revealed under the housekeeping/laundry section identified Resident #14 had concerns that clothing keeps getting mixed up. Interview on 11/17/22 at 8:55 A.M., with Resident #14 revealed the staff keep putting her clothing on her roommate (Resident #13). Resident #14 stated when she tells the staff, they just brush it off, but it is a big deal to her. Resident #14 stated she feel like the staff are not taking her seriously. Resident #14 stated she shares a closet with Resident #13 and thinks that laundry staff put the clothing in the wrong section and that is why this is occurring. Interview on 11/17/22 at 9:40 A.M., with the Administrator and the Director of Nursing (DON) revealed the DON did tell him an incident occurred, where staff put Resident #14's clothing on Resident #13. The Administrator stated the facility is only aware of the one incident. The DON stated there is a new housekeeper and this incident occurred a few days ago and Resident #14 had complained in the Resident Council meeting minutes in 10/06/22. The Administrator verified there is no follow up they could locate to address the concerns expressed by the residents in the council meeting minutes. The Administrator stated the concerns listed in the council meeting minutes were not brought to her to address the concerns. This deficiency represents the noncompliance investigated under Complaint Number OH00133588.

Based on medical record review, policy review, resident and staff interviews, the facility failed to thoroughly investigate and report an allegation of physical abuse of one resident to another. This affected two (#16 and #19) of four residents reviewed for potential abuse. The facility census was 42. Findings include: Review of Resident #16's medical record revealed an admitted [DATE], with medical diagnoses including: bipolar disorder, schizophrenia, Parkinson's disease and PTSD (post traumatic stress disorder). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #16 was cognitively intact. Review of Resident #16's progress notes dated 09/25/22 at 4:42 P.M., identified Resident #16 was coming back from smoking and another resident (Resident #19) grabbed her hair and pulled it. Interview on 11/17/22 at 11:37 A.M., with Resident #16 was asked if anyone had ever abused her and she identified yes. Resident #16 identified Resident #19 came up behind her several weeks ago, coming inside after smoking, and pulled the back of her hair. Resident #16 confirmed the back of her head was sore for days after the incident. Resident #16 confirmed she is scared of Resident #19 as she is violent. Resident #16 confirmed all the residents go out to smoke together. Interview on 11/16/22 at 6:52 A.M., with State tested Nursing Assistant (STNA) #120 revealed she was present on 09/25/22, when Resident #19 was behind Resident #16 in the hallway. Resident #16 was moving slowly in her wheelchair and Resident #16 grabbed the back of her hair and pulled a whole handful of hair. STNA #120 stated staff separated the residents at that time. STNA #120 identified she is unaware of any changes that were made after the incident to ensure this does not occur again. Interviews on 11/17/22 at 1:26 P.M., with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing, confirmed they were all aware of the incident that occurred on 09/25/22 between Resident #16 and Resident #19. The staff confirmed they did not start an investigation or a self reported incident and have any evidence of any changes made to ensure continued abuse did not occur. The staff confirmed the only documentation of the incident is located in Resident #16's progress notes and there was no investigation to identify the cause and or changes made to ensure residents are not abused by Resident #19. Review of Resident #19's medical record identified admission to the facility 04/02/19, with diagnoses including: history of traumatic brain injury resulting from motor vehicle accident (MVA), schizoaffective disorder, dementia, anemia, arthritis, anxiety, aggression, seizure disorder and history alcohol abuse. Review of the MDS assessment revealed Resident #19 is not cognitively intact and does not elicit recognizable words. Resident #19's medical record and written plan of care identified she usually propels herself around in a wheelchair that includes a harness due to leaning forward. The plan of care identified Resident #19 is prone to anger and aggression. The plan included document all behaviors displayed by resident and their response to the interventions; attempt to identify and eliminate the triggers that are causing the escalating behaviors and document all interactions with the resident including what triggered the aggression and what strategies worked to resolve it. Review of Resident #19's progress notes dated 09/25/22 at 4:12 P.M., identified Resident was yelling as loud as she can Hey, Hey. The notes identified activities staff reported Resident #19 thinks she needs to be the first person in line to go out to smoke and was blocking other residents. The notes identified when the activities staff asked Resident #19 to move back, the resident started screaming and cussing and would not move. Review of the policy titled Resident to Resident Abuse policy, dated February 2018, identified all altercations including those that may represent resident-resident abuse shall be investigated and reported to the Director of Nursing and Administrator. The policy identified residents should be separated; identify what happened, including what might have lead to aggressive conduct on the part of the individuals involved in the altercation; notify each residents representative and the attending physician; Review the events and possible measures to prevent additional incidents; makes changes to the plan of care; document all interventions and their effectiveness; document the incident, findings and corrective measures taken in the medical record. Interview on 11/17/22 at 1:26 P.M., with the DON confirmed the facility did not document any investigation into the 09/25/22 incident between Resident #16 and Resident #19, notification to the families or physician and put interventions into place to prevent additional incidents. This deficiency represents the noncompliance investigated under Complaint Number OH00137493.

Based on observations, resident and staff interviews, the facility failed to maintain personal privacy of medical information by posting a visible sign containing personal medical information. This affected one (#26) of 42 residents observed in the facility. The facility census was 42. Findings include: Observation on 11/17/22 at 7:25 A.M., revealed Resident #26's room had a sign posted on the wall outside the room that identified Absolutely no meals, snacks or drinks in Resident #26's name room . The sign listed Resident #26's actual name. Interview on 11/17/22 at 7:40 A.M., with Resident #26 revealed he has no idea why the sign is posted outside of his room. Resident #26 confirmed he is not permitted to have snacks in his room and he is not sure of the reason. Interview on 11/17/22 at 7:44 A.M., with the Director of Nursing (DON) verified there is a sign posted in the corridor of the facility, outside of Resident #26's room. The DON stated Resident #26 has coughing episodes at times, but confirmed the sign posted in the hallway is undignified. The DON stated Resident #26 is on a regular diet. The DON stated she has removed the sign before off the door and was not aware that someone had placed the sign back on the door. This deficiency represents the noncompliance investigated under Complaint Number OH00133588.

Based on medical record review, review of facility policy, surveyor observation and staff and family interview interview, it was determined the facility failed to provide interventions to prevent the development and/or worsening of pressure ulcers for three (#29, #110 and #118) of four residents reviewed for pressure ulcers of a total of four residents currently identified with pressure ulcers in the facility. This resulted in actual harm for Resident #29 who developed a Stage 3 pressure ulcer to the coccyx and an unstageable pressure ulcer to the right heel. This also resulted in actual harm for Resident #110 who developed a Stage 3 pressure ulcer to the right heel. Findings include: 1. Review of the medical record for Resident #29 revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. On 04/12/11, a Braden Scale form was completed to assess the risk for pressure ulcer development. A score of 12 or less indicated high risk. Resident #29 scored 21 for low risk due to no impairment with sensory deficit, occasional moist skin, ability to walk outside the room and inside the room, no limitations in making major and frequent changes in position, adequate nutrition, and no apparent problem moving in bed or chair. A Minimum Data Set (MDS) assessment dated [DATE], assessed the resident as having memory deficits, no behaviors that interfered with care, requiring extensive assistance of one person for bed mobility, limited assistance with transfers and ambulation with a walker, and extensive assistance with dressing and hygiene. The MDS indicated the resident was at risk for developing pressure ulcers. Review of the nurses notes revealed the resident had been up and about using a merry-walker. On 06/22/11 at 2:00 P.M., the nurse documented Resident #29 was exhibiting lethargy. On 07/06/11 at 12:22 P.M., the nurse documented the resident had a 100.3 degree Fahrenheit (F) fever and was in bed sleeping most of the shift. The resident was noted to be out of the facility for a CT scan on 07/07/11 and was administered an injection of an antibiotic. On 07/07/11, the resident was noted to be in bed at 1:54 P.M. and 6:09 P.M. as he was undergoing urological testing. Further review of the nurses notes on 07/08/11 at 9:28 A.M., documented Resident #29 had "a few red spots newly opened superficial noted on bottom". A topical treatment of [REDACTED]. The first documented assessment of the open areas regarding a description of the pressure ulcer was not completed until 07/10/11, two days later. The nurses note dated 07/10/11 at 12:35 A.M., documented the area as a Stage I pressure area with open denuded (exposed by erosion) skin to the coccyx and bilateral lower buttocks. (A Stage I is actually defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence.) According to the definition, this pressure ulcer was not a Stage I due to the skin being open and not intact. A Stage 2 pressure ulcer is defined by a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough. There were no documented measurements of the open areas in the nurses notes, treatment records or on any other form available to the staff. On 07/10/11, the nurses note indicated a physician telephone order dated 07/10/11 was received for the "Stage 1 denuded right and left buttocks/coccyx". The order was for [MEDICATION NAME] ointment twice daily until healed. There was no further documentation of the area in the nurses notes until 07/13/11 at 9:45 A.M. At this time, it was documented the buttocks/coccyx wound area increased with blue, redness and dimensions. There was no measurements documented and no evidence the physician or family was notified of the worsening of the pressure sore condition. Review of the physician order [REDACTED]. Review of the untitled wound form dated 07/17/11, documented the first assessment of measurements, nine days after discovery. The wound was documented as 3.3 centimeters (cm) in length by 2.2 cm. in width, with no depth measured. There was no stage documented. The wound was described as having "yellow slough, slightly moist with drainage and odor, surrounding tissue open and reddened, blue". The next measurement of 07/24/11, documented a "questionable Kennedy ulcer" as a Stage 2. The wound was documented as having "slough" in the center and had enlarged to 3.8 cm. in length by 3.1 cm. in width, with no depth measured. On 07/31/11, the pressure ulcer was "unstageable" measuring 10 cm. in length by 7.0 cm. in width. The inside center slough area had a moderate amount of yellow gray drainage and odor with surrounding tissue red. (A Stage 3 pressure ulcer is defined as full thickness tissue loss. Subcutanious 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 and tunneling.) Documentation revealed on 08/01/11, a [DEVICE] was initiated. The last documented measurement of the wound was documented on 08/06/11. The area measured 13.5 cm. in length by 12.8 cm. in width with "yellow slough and eschar and moderate drainage". The surveyor did not request removal of the wound vac for measurements on 08/11/11. Observations made by two surveyors on 08/09/11 at 1:55 P.M., 3:10 P.M., 4:35 P.M., 5:35 P.M., and 6:10 P.M., revealed the resident was positioned on his back, without significant relief of pressure to the coccyx area for a period of 4 hours and 15 minutes. The resident was laying on the air mattress with a thin bed pillow under his right arm. Review of the plan plan of care (undated) noted the open wound "Kennedy Ulcer". Interview with Registered Nurse (RN) #7 (plan of care nurse) on 08/11/11 at 9:00 A.M., verified she could not state the date the plan of care for the sacral ulcer was initiated. She verified an air mattress was initiated 07/22/11, however, was not noted on the care plan. She verified there were no interventions for turning and repositioning off of the back or side to side upon the resident's gradual decline in June 2011, or after the pressure sore developed. She revealed the plans of care for pressure ulcers all state "actual/potential pressure ulcers" and the interventions are generalized and not revised with individualized interventions specific to the residents' needs. She stated she had just started to use point click care for documentation of pressure ulcers and was not sure how to date or add revisions. She verified that she had not attempted to update the printed plans by writing the new dated revisions with a pen. She stated any revised care plans would be kept in the computer for the nurses to review, but that the State tested Nurse Aides (STNA) did not have access to the care plans. She verified the STNA's use a hand written list for devices on each unit. She further stated she could not produce a plan of care to address prevention of pressure ulcers prior to July 2011. Interview with the Director of Nursing (DON) on 08/11/11 at 8:00 A.M., verified the resident was placed on Hospice due to a [DIAGNOSES REDACTED]. She revealed the resident had become bed bound early in July 2011 due to a gradual decline in mobility and back pain. She stated the Hospice nurses told her the resident had a "Kennedy" ulcer on his sacral area which made it unavoidable. She stated she was not initially aware of what a Kennedy ulcer was, but accepted the Hospice diagnosis. (Online definitions of "Kennedy Ulcers" at www.bedsorefaq.com/what-is-a-Kennedy-terminal ulcer revealed Kennedy ulcers develop when people are dying and/or succumbing to death within 24-48 hours of their onset. The Kennedy ulcers may form a blister to a Stage 4 within 4 hours.) Further interview with the DON revealed she had interviewed the staff who were to be repositioning Resident #29 on 08/09/11. The staff told her they tried to reposition him, but were not able to maintain the position with the thin bed pillow. She verified the staff had not attempted the use of a firmer wedge cushion or bolster to assist the resident to maintain significant repositioning off of the affected sacral area for comfort and healing. Further review of the medical record for Resident #29 revealed he developed an unstageable right heel ulcer after the sacral ulcer. Nurses notes dated 07/15/11 at 10:45 A.M., revealed a "new area on the right heel, slightly boggy" measuring 2.0 cm. in length and 1.8 cm. in width, medium blue/red. Interview with RN #7 on 08/11/11 at 9:00 A.M., verified there was no preventive care plan developed for prevention of heel ulcers upon risk. She further verified there was no acute care plan developed to address the treatment and care of the right heel ulcer. Review of documented assessments on the Treatment Administration Records (TAR) dated 07/15/11, 07/21/11, 07/28/11 and 08/06/11 revealed the area was increasing in size on the right heel. On 08/06/11, the heel wound measured 2.6 cm. in length by 2.7 cm. in width and was blue/brown in color and boggy to the touch. Review of a telephone order dated 07/15/11, revealed a heel lift boot to the right foot at all times. The plan of care was not revised to include this new intervention and there was no documented evidence the resident's spouse was notified of the new treatment. Two surveyors observed Resident #29 on 08/09/11 at 1:55 P.M., 3:10 P.M., 4:35 P.M., 5:35 P.M. and 6:10 P.M., and on 08/10/11 at 8:30 A.M., 9:55 A.M., 10:55 A.M., 12:05 P.M., 1:35 P.M., 3:10 P.M., 4:00 P.M., 5:00 P.M. and 6:00 P.M. During these observation times, Resident #29 was laying in bed with heel protector bows applied, not heel lift devices and the feet were directly on the air mattress. Observation of Resident #29 on 08/11/11 at 7:15 A.M., revealed the resident was in bed with heel lift devices applied and the heels were still directly on the mattress with a thin bed pillow under the resident's legs. Interview with the DON on 08/11/11 at 7:15 A.M., revealed between 08/10/11 and 08/11/11 she had obtained a set of heel lift devices and inserviced staff on the use of the boots early in the morning on 08/11/11. She then verified that the heel lift devices were applied, but the heels were still directly on the mattress, not floated. She verified she was not aware of the 07/15/11 physician order [REDACTED]. She stated the Treatment Administration Record revealed the nurses had been initialing the treatment of [REDACTED]. Interview with State tested Nurse Aide (STNA) #2 on 08/11/11 at 8:15 A.M., verified she frequently worked the East unit where Resident #29 resides. She stated she was not aware of Resident #29 using heel lift boots. Observation of the right heel on 08/11/11 at 9:00 A.M. with the DON, revealed the wound measured 2.5 cm. in length by 2.6 cm. in width and was unstageable. The area was dark brown with an approximate 1 cm. boggy yellowish center. Interview with the Regional DON on 08/11/11 at 11:30 A.M.,. verified the facility failed to implement timely documentation of assessments of the size and description of the pressure ulcers, failed to develop preventive and active plans of care for the pressure ulcers, failed to implement care and devices as ordered to prevent development and worsening of pressure ulcers for Resident #29 and documented incorrectly regarding the application of the heel lift boots. Review of the policy entitled, "Skin Prevention and Management of Pressure Ulcers", effective 01/14/05, revealed the interdisciplinary team are to use the individual assessments to develop and implement a comprehensive care plan that reflects each resident's identified needs. Residents with pressure ulcers are to be reviewed at the weekly Risk Management team (nursing, dietary, social services) meeting. The care process is to be reviewed to assure that efforts are made to stabilize, reduce, or remove underlying risk factors. The interdisciplinary team is to assure that assessments are timely and appropriate, that interventions are implemented, monitored, and revised as appropriate and changes in condition are recognized, evaluated, reported to the practitioner and addressed. The policy stated the Quality Assurance Committee is to help the facility evaluate existing strategies to reduce the development and progression of pressure ulcers and ensure facility policies and procedures are consistent with current standards of practice. 2. Review of the medical record for Resident #110 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #110 was admitted for rehabilitation from a hospital stay. Review of the admission nursing assessment identified no skin wounds. Resident #110 was described in the record as alert with occasional confusion with easy reorientation, able to transfer with one assist and use walker and needing assistance with dressing, hygiene and mobility due to shortness of breath and weakness. A Braden Scale assessment form for predicting pressure ulcer development risk was completed on 03/07/11. The assessment indicated the resident had some sensory impairment, rarely had moist skin, spent a majority of time in bed, was able to make position changes and ate poorly. The resident was identified as low risk for skin breakdown". Review of the undated plan of care revealed the resident had a plan in place to address skin integrity. Interview with RN #7 on 08/10/11 at 4:30 P.M., revealed she completes all the MDS assessments and plan of care information. She verified there was no date of initiation of the plan of care for Resident #110 regarding skin integrity, but estimated that it was approximately three months prior to the goal date of 06/10/11. She stated the resident was at high risk for pressure ulcer development on admission due to his diagnoses. She revealed the potential alteration in skin integrity plan of care developed for Resident #110 had generic interventions such as diet/supplementation, monitoring nutrition, pressure mattress, pillow supports for positioning, keeping linens clean, use lift sheet, encourage out of bed as tolerated, avoiding hot water, removing soiled briefs/incontinent care, monitoring labs. She verified the interventions stated the staff were to do weekly skin assessments for skin irritation, redness, bruises, scratches and open areas and conduct a weekly assessment of feet. She stated there were no interventions listed for the nurse aides such as turning and repositioning and monitoring at risk skin areas such as bony prominence's (heels/coccyx) during care, nor floating of the heels for a resident at high risk for developing pressure ulcers. Review of the Treatment Administration Records for March 2011, revealed an intervention for weekly skin assessments. The initial assessment was completed on 03/07/11, however, there were no initials on 03/14/11, 03/21/11 or 03/28/11 to indicate the assessments had been completed. Review of the nurses notes dated 03/20/11 at 2:36 P.M., documented she had encouraged the resident to have good nutrition due to skin integrity as the right heel was purple but not open. There was no documented evidence of any notification to the physician and family regarding the new pressure ulcer on the right heel, no documented assessment of the measurements of the wound and no evidence of a treatment being initiated. Interview with RN #11 (who documented the note on 03/20/11 at 2:36 P.M.) on 08/10/11 at 11:25 A.M., verified she did make that entry regarding the right heel. She verified the area appeared dark purple as in deep tissue injury. She revealed there was no documented evidence the physician or family was notified of the skin impairment on 03/20/11. She further stated she did not measure the area or initiate a treatment. RN #11 could not attest as to why the right heel was not discovered at a lesser degree of injury by staff prior to 03/20/11. Nurses notes dated 03/21/11, 03/24/11, 03/27/11 and 03/28/11 document the use of heel protectors but no description of the area was completed until 04/02/11 at 2:00 P.M. by the the treatment nurse (LPN #10). The note documented the "resident's right heel area is medium blue with red non-blanchable" and "bilateral heel protectors on". There was still no evidence of a measurement of the area and no notification to the family. A physician telephone order was documented on 04/02/11 stating to "monitor right heel pressure area, bilateral heel protectors on while in bed". There was no evidence the family was notified of the new treatment order. Review of the wound form documented the first measured assessment of the right heel on 04/03/11, 15 days after the area was discovered on 03/20/11. On 04/03/11, the right heel ulcer was measured at 2.0 cm. in length, 2.2 cm in width and described as a "Stage 1 with tissue dark red/blue hue, unstageable and boggy". (A Stage 1 is actually defined as intact skin with non-blanchable redness of a localized are usually over a bony prominence.) Interview with RN #7 on 08/10/11 at 4:30 P.M., verified the area to the right heel was unstageable (unstageable is defined as a pressure ulcer with suspected deep tissue injury). There was no evidence that an acute plan of care was developed to address the unstageable right heel ulcer including interventions and treatments. These were also no interventions or treatments documented in the plan of care or Treatment Administration Record that addressed the pressure area. Review of the physician order [REDACTED]. The order was to cleanse with normal saline, apply topical antibiotic ointment and gauze every other day and as needed until healed. The next measurement dated 04/10/11, indicated enlargement of the heel ulcer to 3.6 cm. in length, 3.0 cm. in width and had dark red blue tissue that was non-blanchable and boggy. The area was assessed as a Stage 1. A physician telephone order was documented on 04/12/11 to turn and reposition every two hours and as needed. This new treatment order was not revised on the plan of care, as verified during interview with RN #7 on 08/10/11 at 4:30 P.M. Review of the assessment dated [DATE], described worsening of the right heel ulcer. The area measured 3.6 cm. in length, 3.0 cm. in width, with eschar at the center and a quarter of the wound with yellow slough. There was no evidence in the medical record or physician orders [REDACTED]. Interview with the DON on 08/10/11 at 3:30 PM, verified there was no documented evidence of weekly measurements by the treatment nurse after 04/24/11. The DON provided the next documented assessment of the wound on a form entitled "Weekly Wound Tracking Worksheet". The area was assessed on 05/13/11 and increased in size 3.8 cm. in length, 3.7 cm. in width and a new treatment for [REDACTED]. The note also stated Resident #110 was non-compliant with the heel protectors. On 05/23/11, 10 days later, the areas was assessed as having the same measurements. The next documented assessment provided by the DON's form was 06/23/11, 31 days later. The area was 3.8 cm. in length, 3.3 cm. in width with eschar. On 07/27/11, 34 days later, the area had the same dimensions. The last documented measurement was 08/04/11 and the area increased to 4.4 cm. in length by 3.9 cm. in width with eschar/yellow slough. The resident was sent to the wound clinic, however, the facility was not able to provide evidence of when the visit first occurred. Physician orders [REDACTED]. There was no revision of the care plan to address floating of the heels or use of suspension boots. There was no documentation in the nursing notes or plan of care of refusal of treatment or education on the importance of floating the heels. There was documentation on the DON's form that Resident #110 refused the boots. Interview with Resident #110 on 08/09/11 at 4:40 P.M., revealed he was aware of the "sore" heel. He stated that on a scale from 1-10 (little to extreme pain) he rated the pain at a "4", "except during dressing changes when it was a 43". He stated he was not advised to float his heels prior to developing the sore and didn't realize the importance of doing that. He stated that he would be willing to try to float the heels some of the time, but did like the freedom to turn occasionally. Interview with the resident's family on 08/09/11 at 6:05 P.M., verified he did not recall being informed of exactly when the sore heel started. He stated he knew it was painful for his dad and that now it will probably not heal due to his compromised health. Observations of Resident #110 on 08/09/11 at 4:40 P.M., 5:38 P.M. and 6:05 P.M. and 08/10/11 at 8;20 A.M., 9:55 A.M., 10:55 A.M., 11:55 A.M. 1:30 P.M., 2:30 P.M., and 4:00 P.M. revealed there was no pillows or devices in the bed to encourage or allow the resident to float his heels. Observation of the right heel wound with the treatment nurse (LPN #10) and RN #11, on 08/10/11 at 2:30 P.M., revealed the area was on the Achilles area of the heel, appearing as a large necrotic ulcer with black eschar and yellow slough measuring 4.8 cm. in length and 3.7 cm. in width. Interview with the two nurses during the treatment observation revealed there was no intervention for prevention of the heel ulcer upon admission. They stated after the heel ulcer was discovered, the facility attempted one type of suspension boot that the resident did not like. RN #11 verified no devices for suspension had been attempted that would provide sufficient floating of the heels and allow the opportunity for easy turning and maintaining lift. The medical record included results of an arterial exam of 07/19/11, which stated Resident #110 had critical limb-threatening ischemia on the right side, suggesting that the patient does not have adequate blood flow for wound healing. Hospice was initiated 08/04/11. Review of the policy entitled, "Skin Prevention and Management of Pressure Ulcers" effective 01/14/05, revealed the facility was to promote the prevention of pressure ulcer development. The policy instructs the interdisciplinary team are to use the individual assessments to develop and implement a comprehensive care plan that reflects each resident's identified needs. Residents with pressure ulcers are to be reviewed at the weekly Risk Management team (nursing, dietary, social services) meeting. The care process is to be reviewed to assure that efforts are made to stabilize, reduce, or remove underlying risk factors. The interdisciplinary team is to assure that assessments are timely and appropriate, that interventions are implemented, monitored, and revised as appropriate and changes in condition are recognized, evaluated, reported to the practitioner and addressed. The policy stated that the Quality Assurance Committee is to help the facility evaluate existing strategies to reduce the development and progression of pressure ulcers and ensure that facility policies and procedures are consistent with current standards of practice. Interview with the Assistant Director of Nurses on 08/10/11 at 3:30 P.M. and interview with the Regional Director of Nurses, on 08/11/11 at 11:30 A.M., verified Resident #110 was assessed with [REDACTED]. They verified there was no evidence on the plan of care upon admission that attention was paid to prevention of heel ulcers by floating the feet, given the high risk with [MEDICAL CONDITION] and other diagnoses. They verified the TAR indicated weekly skin assessments were not done after admission in March 2011. They revealed that although the heel ulcer was documented in the nurses notes 03/20/11, there was no measured assessment, no notification to the physician or family, no treatment initiated, and no revision to the care plan or interventions put in place to promote floating of the heels. They verified the treatment order for bilateral heel protectors was not sufficient to provide relief of pressure to protect and promote healing of the Achilles ulcer. They further stated there was no measured assessment until 04/03/11. Lastly, they verified that, although Resident #110 had disliked the type of suspension boots and pillows that were offered, no other lift devices had been pursued that may have been more acceptable to him that would have allowed more ease with turning and still providing heel lift to prevent worsening of the ulcers. 3. Review of the medical record for Resident #118 revealed an admission date of [DATE], following a motor vehicle accident which caused a herniation to his lumbar spine that resulted in a fusion prior to admittance. Review of hospital nurses' notes dated 04/20/11 revealed the resident had not walked since January 2011 and had a Stage 2 pressure ulcer on his right buttocks. Resident #118 was admitted to the facility for rehabilitation following surgery. Additional [DIAGNOSES REDACTED]. Resident #118 has an indwelling urinary catheter (Foley) and currently wears briefs due to bowel incontinence. Review of the facility computer generated nursing admission assessment, dated 04/29/11, revealed documentation that Resident #118 had no skin issues. However, review of a handwritten nursing admission assessment, also dated 04/29/11, revealed conflicting documentation that Resident #118 had open area on the middle of the right buttocks. A Braden Scale assessment, completed on 04/29/11, indicated the resident had a score of 15, which was considered at low risk for the development of pressure ulcers. In addition, the initial minimum data set (MDS) assessment dated [DATE] indicated Resident #118 had a Stage I pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence.) The MDS assessment also indicated the resident was at risk for developing pressure ulcers. The assessment noted a pressure reducing device was on the bed and that he was receiving ulcer care. Further review of the record failed to include documented evidence of any assessments of the size and description of the Stage I pressure ulcer identified on the admission nursing assessment of 04/29/11 and the MDS of 05/09/11. Review of Resident #118's care plan revealed there was no plan documented with a date that related to the initial MDS of 05/09/11. Interview with the registered nurse (RN) #7 on 08/10/11 at 9:30 A.M., verified there were no dates on the plan of care (POC) to indicate when the plans were developed. She stated that it could be approximately determined by calculating back three months from the goal date. The only plan of care for skin integrity had a goal date of 10/07/11, which would calculate to an approximate development date of 07/07/11. Therefore, no plan of care was developed to address the plan required by the MDS assessment date of 05/09/11. There was no plan developed to address the resident's risk for development of pressure sores, nor the Stage 1 pressure ulcer identified on the 05/09/11 MDS assessment. Review of the record failed to document evidence of any assessment of the size and description of the Stage 1 ulcer identified on the MDS of 05/09/11. There was also no documented evidence regarding the area on the buttocks as indicated on the physician order [REDACTED]. Review of the form entitled "Nurse's Weekly Skin Assessments" for the month of May 2011 revealed no mention of any redness or open areas to Resident #118's skin. However, review of the facility form entitled "CNA (Certified Nursing Assistant) Daily Skin Inspection" for May 2011 revealed three days of open areas to the buttocks on 05/10/11, 05/11/11 and 05/15/11. The form also revealed two days of redness to the buttocks on 05/19/11 and 05/23/11. There were 23 days where the resident's skin was not documented as being assessed by the state tested nurse aides (STNA's) in May 2011. There was also no evidence of reporting by the STNA's to the nurse regarding the open area noted on 05/10/11, 05/11/11 and 05/15/11 and no assessments of the resident's skin when impairments were noted. There was also no evidence of a plan of care developed to address these areas. Review of nurses' notes for June 2011 revealed no mention of any type of skin issues or assessments that were completed. The "Weekly Nurse's Skin Assessment" form, dated 06/24/11, was not completed and there was no "CNA Daily Skin Assessment " form completed by the STNA's in June 2011. Further review of nurses' notes revealed that on 07/05/11, a treatment for [REDACTED]. The form entitled "Nurse's Weekly Skin Assessment" dated 07/15/11, revealed that no assessment was completed for this week. Furthermore, there was no "CNA Daily Skin Assessment" form for July 2011 located in the chart. Review of the MDS assessment dated [DATE] indicated Resident #118 was still at risk for pressure ulcers. The assessment noted the resident had a pressure ulcer that healed and that pressure reducing mattress was on the bed. Review of the "CNA Daily Skin Inspection" form for August 2011 revealed the STNA's had observed redness to the buttocks on seven days; 08/02/11, 08/03/11, 08/0511, 08/06/11, 08/07/11, 08/08/11, and 08/09/11. On 08/05/11, Licensed Practical Nurse (LPN) #10, the treatment nurse documented on the "Weekly Skin Assessment" form documented the resident's skin was intact. However, she then noted the buttocks/anal area was light red and denuded (exposed by erosion). During interview on 08/09/11 at 10:00 A.M., Resident #118 stated he had a pressure ulcer on his buttocks that the facility was not treating. He indicated his family was providing the band aids and creams and the STNA's applied the treatment. On 08/09/11 at 2:46 P.M., the surveyor observed STNA #84 weigh Resident #118. During the procedure, STNA #84 observed and reported to the surveyor that the resident had an open area to his buttocks. At 3:20 P.M. on 08/09/11, LPN #71 and LPN #79 were observed while changing the resident's indwelling urinary catheter. The Regional Director of Nursing (DON) appeared at the bedside and asked if she could look at the resident's buttocks. Permission was granted and the resident was rolled completely over onto his right side revealing a quarter sized open area on the right buttocks which was seeping purulent drainage onto the sheets. The area was not measured at this time but potential treatment was discussed with the nursing staff, family and resident. At this time, Resident #118's spouse informed the Regional DON that she had been bringing in cream and band aids to cover the open area which had been there off and on since he was admitted [DATE]. Interview with STNA #61 on 08/10/11 at 6:10 P.M., revealed on 08/06/11 and 08/07/11 during the second shift, she changed the brief and cleansed the buttocks of Resident #118. She stated she observed redness on the right buttock and applied the pericare cream, however, did not report it to the nurse. Interview with Registered Dietician (RD) #1 on 08/11/11 at 11:45 A.M., s