Every finding on record at Siena Woods Care Center

Based on observations, policy review, interviews and records reviews, the facility failed to label and date foods stored in resident designated refrigerators and failed to ensure temperatures were obtained daily for the resident designated refrigerators. This had the potential to affect all residents on Unit 400, except Resident #14 who received no food by mouth, and all residents on the Rehabilitation Unit and the Secured Care Unit. The facility total census was 91. Findings include:Observations on 02/09/26 at 10:30 P.M. revealed the refrigerator designated for residents on the Secured Care Unit had a lunch bag unlabeled and undated. There were six opened containers of nutritional supplements dated 12/18/25. The refrigerator temperature log had no temperatures logged for the refrigerator from 02/04/26 through 02/08/26. The ice machine ice scoop did not have ice scoop holder and the ice scoop was stored on a table with the dipper side up. There was a wet towel on the floor at the base of the ice machine.Interview on 02/09/26 at 10:30 P.M., Licensed Practical Nurse (LPN) #33 verified the refrigerator was designated for residents only, and employees' lunches were to be stored elsewhere. LPN #33 verified the lunch bag was not for a resident and the containers of nutritional supplements were expired. LPN #33 verified the refrigerator must be monitored daily for temperature and the temperature log had not been completed four days out of 11 days in February 2026. LPN #33 stated the ice scoop should be stored upright in a holder to permit proper water drainage. LPN #33 stated the ice machine had overflowed earlier in the week and a towel was there to catch the water. LPN #33 verified the towel should not remain on the floor.Observation on 02/12/26 at 8:35 A.M. revealed the resident designated refrigerator on Unit 400 had two bags of unidentified foods with no label and date. There was a box of food dated 01/21/26 with no label. There was one bag of bread which was undated. There were three pitchers of unidentified liquid unlabeled and undated. There was a sign on the refrigerator door which identified the refrigerator for residents and the foods must be labeled and dated.Interview on 02/12/26 at 8:35 A.M., Certified Nursing Assistant (CNA) #56 verified the designated resident refrigerator was for resident food storage only. She verified the foods were undated and unlabeled, the bread was undated, and the three pitchers of liquid were undated and unlabeled.Observation on 02/12/26 at 1:20 P.M. revealed the designated resident refrigerator on the Rehabilitation Unit revealed an open bag of food with no label. There was a opened gallon container of a brown liquid dated 02/07/26. There was no refrigerator temperature log for 02/01/26 through 02/11/26. Interview on 02/12/26 at 1:20 P.M., LPN #107 verified the designated resident refrigerator was only for resident food storage. LPN #107 verified the unlabeled open bag of food and gallon of liquid should have been labeled. She verified there was no refrigerator temperature log for February 2026, and daily temperatures must be monitored. Review of the facility policy titled Food From Approved Source, dated 2022, revealed the facility staff will assist with proper food storage and handling of foods brought into the facility. Food will be dated as appropriate.This deficiency represents non-compliance investigated under Complaint Number OH00165691 (136724).

Based on observation, staff interview and record review, the facility failed to ensure the medication error rate was less than five percent (%). There were six medication errors out of 25 opportunities resulting in a 24% medication error rate. This affected two (#5 and #84) of four residents observed for medication administration. The facility census was 91. Findings include:1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included type one diabetes mellitus, underweight, and tachycardia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact. Review of the physician orders dated 02/05/26 revealed Coreg (carvedilol) 12.5 milligrams (mg) give one tablet by mouth two times a day for beta blocker. Observation and interview with Licensed Practical Nurse (LPN) #66 on 02/11/26 at 10:31 A.M. revealed LPN #66 administered Coreg to Resident #5. LPN #66 confirmed Resident #5's Coreg was ordered to be administered at 9:00 A.M. and she administered it outside the one hour window at 10:31 A.M. 2. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease stage two and type two diabetes mellitus (DM). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 was cognitively intact. Review of physician orders for Resident #84 on 02/11/26 revealed the following medications were to be administered by mouth: duloxetine (antidepressant) oral delayed release 60 milligrams (mg) by mouth one time a day; famotidine (treats heart burn) oral tablet 20 mg by mouth one time a day; MiraLAX (laxative) oral packet 17 gran (gm) give one packet by mouth one time a day; Norvasc (treats high blood pressure) oral 2.5 mg give one tablet by mouth one time a day; and metformin (treats DM) oral tablet give 500 mg by mouth two times a dayObservation and interview with Licensed Practical Nurse (LPN) #59 on 02/11/26 at 11:30 A.M. revealed LPN #84 administered Resident #84's medication through her gastrostomy tube (G-tube). The medications were duloxetine, famotidine, MiraLAX, Norvasc, and Metformin. LPN #59 confirmed she administered the five medications to Resident #84 through the G-tube and were not administered orally. LPN #59 confirmed Resident #84's five medications including metformin were scheduled for 9:00 A.M. and stated she always administers her medications late. Interview on 02/11/26 at 3:13 P.M. with the Director of Nursing (DON) verified there was no order for Resident #84's medications to be administered through the G-tube and were only ordered to be administered by mouth. This deficiency represents non-compliance investigated under Complaint Number 1363724 (OH00165691).

Based on observations, resident and staff interviews, policy review and records reviews, the facility failed to ensure the residents received their adaptive feeding equipment with meals as physician ordered. This affected three (#10, #57, and #79) of three residents reviewed for adaptive equipment. The facility census was 91. Findings include: 1. Record review for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses included atherosclerosis, diabetes, dementia, and osteoarthritis left shoulder and unspecified pain. The Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #79 had intact cognition and required set up assistance for feeding. Review of the physician orders revealed Resident #79 was to receive a two handled cup with spout lid for liquids.Review of the meal ticket for Resident #79 revealed the resident should have received a two handled cup with a spouted lid.Observation and interview on 02/11/26 at 1:30 P.M. revealed Resident #79 received a two handled cup with no lid. The resident had contracted fingers and was unable to get the cup to her mouth safely. Resident #79 received straight handled flatware. Resident #79 stated she had not received a lid with a spout for several weeks. She stated she wanted a lid with a spout so she could continue to feed herself without assistance and stated hot beverages were dangerous for a burn without the spouted lid. The resident said she had not had evaluations for other flatware, and she had difficulty getting the food to her mouth with straight handled spoons and forks. Certified Nursing Assistant (CNA) #43 verified Resident #79 received a cup without the spouted lid as listed on the meal tray ticket. CNA #43 verified Residents #79 did not have a lid with a spout for several weeks and had difficulty drinking from the cup without the spouted lid. CNA #43 verified the resident had difficulty getting food to her mouth without spilling with the straight handled flatware.Observation and interview on 02/12/26 at 8:05 A.M. revealed Resident #79 received a two handled cup with plastic lid covering and not a lid with a spout. The resident had straight handled flatware and was having difficulty getting the food to her mouth without spilling the food. Resident #79 stated she had to remove the plastic lid and would not be able to get the liquid safely to her mouth. She sated she was having difficulty using the straight spoon feeding herself the breakfast cereal. Assistant Director of Nursing (ADON) #1 verified Resident #79 should have received a cup lid with a spout and not a plastic lid covering. ADON #1 stated the resident was spilling the food when using a straight handled spoon and could benefit from an evaluation of adaptive flatware.2. Record review for Resident #10 revealed an admission date of 06/20/24. Diagnoses included chronic kidney disease and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident had intact cognition and required supervision with eating.Review of the physician orders revealed the Resident #10 was to receive food was to be served in separate bowls at mealtimes.Observation and interview on 02/11/26 at 1:35 P.M. revealed Resident #10 received the meat, vegetable and starch on one plate. There was no bowl near Resident #10 and the resident was attempting to feed herself in bed. Resident #10 stated she preferred the food in bowls because she could get the food closer to her mouth while she was in bed. She stated she could better feed herself independently when each food was served in bowls. Certified Nursing Assistant (CNA) #43 verified Resident #10 received all the foods on the plate and the resident should have had the foods in bowls as listed on the meal tray ticket.Observation and interview on 02/12/26 at 8:10 A.M. revealed Resident #10 received all the breakfast foods of egg and meat on the plate. There were not separate bowls for each food item. The resident was in bed attempting to feed herself with the plate on an overbed table.Resident #10 stated she was able to feed herself better when the food was in separate bowls. Interview on 02/12/26 at 8:15 A.M. with Assistant Director of Nursing (ADON) #1 verified Resident #10 should have received foods in separate bowls as listed on the mal tray ticket. ADON #1 verified Resident #10 was able to feed herself better when the resident could hold the bowl closer while eating herself in the bed. 3. Record review for Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease and dysphagia. The Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #57 had intact cognition and was independent with feeding.Review of the physician orders revealed Resident #57 was to receive a regular diet, have cut meats and lid and straws for drinks.Review of the Resident Adaptive Equipment Report, provided by the facility, revealed Resident #57 was to receive weighted gray utensils, drinks with a lid and straw at all meals.Observation and interview on 02/11/26 at 12:50 P.M. revealed Resident #57 received a cup with no straw, the chicken was not cut off the bone and there were no weighted gray handled utensils. The resident was attempting to feed herself in the main dining room. Resident #57 stated she was able to feed herself better when the meat was cut up, she had a straw with her liquids, and she had the weighted utensils. The resident stated the weighted utensils helped when her hands were shaking to keep her independent in feeding herself.Interview on 02/12/26 at 12:50 P.M. with Dietary Manager (DM) #5 verified Resident #57 did not receive a straw with her liquids, the chicken was not cut off the bone and here were no weighted utensils provided for the resident. DM #5 stated it was the responsibility of the staff serving the residents in the dining room to provide the straw and cut the meat for the resident while in the dining room. Review of the facility policy titled Meal Distribution, dated 2023, revealed meals will be assembled with the individualized diet order, plan of care and preferences. Meals are delivered in an accurate manner.

Based on record review, policy review, and resident and staff interviews, the facility failed to ensure activities were offered and or provided for Resident #65. This affected one (#65) of two residents reviewed for activities. The facility census was 91.Findings include:Review of the medical record for Resident #65 revealed admission date of 09/06/23. Diagnoses included multiple sclerosis, morbid obesity and paraplegia. The care plan revealed Resident #65 was dependent on staff for meeting emotional, intellectual, physical, and social need due to cognitive deficits, physical limitations, legally blind and needs assistance with reading and organizing things, one-to-one (1:1) room visits on scheduled days, and activities were offered when visits being completed. An intervention dated 12/26/23 revealed Resident #65 would be provided 1:1 bedside/in-room visits and activities if unable to attend out of room events.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed it was somewhat important to the resident to have books, newspapers, and magazines to read, keeping up with the news, do things with groups of people, and participate in religious services or practices. It was very important to Resident #65 to listen to music she liked.The quarterly MDS assessment dated [DATE] revealed Resident #65 had intact cognition and was dependent upon staff with personal hygiene, required supervision with eating, maximum assistance with bed mobility and was dependent upon staff with transfers and toileting.Review of Resident #65's activity calendar from 04/01/25 to 02/12/26 revealed there were no activities were documented in April 2025. On 05/31/25, it was documented resting-cover over head and no other activities were documented in May 2025. In June 2025, there were two listed activities provided to the resident, which included on 06/11/25 of reading bible verses and on 06/23/26 the activity documented was up watching television. Activity documented on 07/16/25 was up watching television doing good and feeling better. There were no other activities documented in July 2025. There were no activities documented for August 2025. Documentation for 09/01/25 was church service discussion, and on 09/25/25 the activity log documented she was watching television and eating snacks. There was no further documentation for September 2025. There was no documentation for activities in October 2025. The 11/06/25 documentation was Resident #65 was in bed requesting aid to get her up, 11/13/25 documentation was Resident #65 was happy staff were getting her up, 11/17/25 documented Resident #65 was in bed and needed assistance finding her writing tablet. There was no further documentation for November 2025. There was no documentation of activities for the month of December 2025. The next activity was documented on 01/10/26 which documented patient care and on 01/27/26 documentation for activity was doing well and in good spirits. There was no further activity documented as of 02/12/26. Interview on 02/10 /26 at 9:45 A.M. with Resident #65 revealed the facility did not provide her with in room activities as she required.Interview on 02/12/26 at 12:44 P.M. with Activity Manager (AM) #16 revealed Resident #65 was to be offered one-on-one activities in her room three times a week. He acknowledged there was missing documentation to verify activities were offered. AM #16 also acknowledged documenting Resident #65 was watching television, requesting to get up and having the blanket over her head were descriptions and not activities.Review of the facility policy titled Resident Life Enrichment dated 06/05/25 revealed the facility would develop and implement activities which reflect the resident interests and functional abilities, maintain attendance records for activities and evaluate activity effectiveness at least quarterly.

Based on observations, staff interviews, policy review, review of Centers for Disease Control and Prevention (CDC) guidance, and record review, the facility failed to ensure staff were following Enhanced Barrier Precautions (EBP) for high contact care activities with the residents. This affected three (#65, #77, and #84) of three residents reviewed for EBP precautions. The facility census was 91.Findings include: 1. Review of the medical record for Resident #65 revealed an admission date of 09/06/23. Diagnoses included multiple sclerosis, stage four pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle.), morbid obesity, and open wound to left lower leg. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition. Review of the physician orders dated 06/02/25 revealed EBP were ordered for Resident #65 related to colostomy and wound care. Personal Protective Equipment (PPE) was to be worn during high contact care activities with a start date of 06/02/25. Observation of wound care on 02/12/26 at 3:01 P.M. revealed Licensed Practical Nurse (LPN) #25 entered Resident #65's room with wound supplies and placed them on a clean bedside table. LPN #25 did not don a gown and proceeded to wash his hands and informed Resident #65 he was preparing to provide wound care. LPN #25 applied gloves and went to the bedside. He assisted Resident #65 onto her right side and removed an undated dressing. He removed his gloves and washed his hands. He continued to provide wound care when Assistant Director of Nursing (ADON) #1 knocked on the door and offered to assist with positioning of Resident #65. She entered with two gowns in her hands. LPN #25 then stepped away from the bedside, removed his gloves and washed his hands. He took the gown from ADON #1 and both staff donned gowns and completed the dressing change with no additional concerns for infection control. Interview on 02/12/26 at 3:25 P.M. with LPN #25, directly following wound care, verified a gown was not worn at the start of wound care and acknowledged Resident #65's wound care was considered high contact and a gown had been required. Interview on 02/18/26 at 9:01 A.M. with ADON #1 revealed she was the Infection Preventionist at the facility and shared getting staff to follow EBP was an ongoing issue. ADON #1 stated she did provide consistent reminders to staff to follow the policy when she was on the floor. 2. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of bladder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had moderately impaired cognition. Review of Resident #77's physician orders dated 12/18/25 revealed an order for EBP related to an indwelling urinary catheter. Observation and interview on 02/11/26 at 10:45 A.M. revealed Licensed Practical Nurse (LPN) #66 repositioned Resident #77 up in bed and was not wearing a gown. LPN #66 stated she did not wear a gown and only wears the gown for high contact direct care. LPN #66 revealed an EBP sign on cart in doorway of Resident #77's room read 'wear a gown for high contact activity including repositioning. LPN # 66 confirmed a gown should have been worn for repositioning the resident. 3. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE]. Diagnoses included dysphagia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 was cognitively intact. Review of Resident #84's physician orders dated 06/02/25 revealed an order for EBP related to gastrostomy tube (G-tube). Observation and interview on 02/11/26 at 11:54 A.M. revealed Licensed Practical Nurse (LPN) #59 entered Resident #84's room to administer medications to the resident. LPN #59 did not don a gown prior to medicaiton administration. LPN #59 proceeded to administer medications to Resident #84 via G-tibe with no gown. LPN #59 confirmed a gown should have been worn for Resident #84 g-tube administration. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Review of the policy titled Enhanced Barrier Precautions, dated 12/2024, revealed examples of high-contact resident care activities requiring the use of gown and gloves for EBP include providing bed mobility, device care or use and wound care. This deficiency represents non-compliance investigated under Complaint Number OH00165691 (1363724).

Based on observations, interviews, policy review, and records reviews, the facility failed to ensure residents received their therapeutic diets as physician ordered. This affected two (#17 and #68) of three residents reviewed for therapeutic diets. The facility total census was 91. Findings include:1. Record review for Resident #68 revealed the resident was admitted to the facility on [DATE]. The Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #68 had impaired cognition and required maximum assistance from staff with feeding. Review of the physician orders revealed Resident #68 was to receive a regular puree thickened liquid diet and provide gravy with all meals. Review of the meal ticket for Resident #68 revealed the resident should have received extra gravy on the side. Observation and interview on 02/12/26 at 8:18 A.M. revealed Certified Nursing Assistant (CNA) #109 was feeding Resident #68. There was no extra gravy as a side on or near the resident's meal tray. CNA #10 verified verified Resident #68 did not receive extra gravy on the side. CNA #109 stated the resident at times needs additional gravy to ensure a smooth swallow. Observation and interview on 02/11/26 at 1:30 P.M. revealed Resident #68 had few teeth and was being fed CNA #108. There was no extra gravy as a side on or near the resident's meal tray. Observation and interview on 02/18/26 at 8:18 A.M. revealed Resident #68 was being fed by CNA #108. There was no extra gravy as a side on or near the resident's meal tray. There was a pitcher of water at the bedside which was not nectar thickened. CNA #109 verified Resident #68 did not receive extra gravy on the side and the pitcher of water was not thickened. 2. Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, convulsions, cerebral infarction, dementia, and aphasia. The Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #17 had severely impaired cognition and was total dependent on staff for feeding assistance. Review of the physician orders revealed the resident was to receive a regular dysphagia advanced thickened nectar liquid diet. The resident may have regular texture food for pleasure. Observation on 02/11/26 at 1:30 P.M. revealed Resident #17 had few teeth and was being fed Certified Nursing Assistant (CNA) #108. There was a dark soda drink poured into a cup on the bedside table with a straw. The liquid was not thickened. Interview on 02/11/26 at 1:35 P.M. with CNA #108 verified Resident #17's liquid was not thickened. Observation on 02/18/26 at 12:31 P.M. revealed Resident #17 had a dark soda liquid poured into a cup. It was not thickened. Interview on 02/18/26 at 12:35 P.M. with Registered Nurse (RN) #63 verified Resident #17's order permitted regular texture foods for pleasure but did not specify regular liquids. Interview on 02/18/26 at 3:25 P.M. with Speech Therapist (ST) #300 verified Resident #17's physician order for regular pleasure foods did not include regular consistency liquids for pleasure. Review of the facility policy titled Therapeutic Diets, dated 2022, revealed the therapeutic diet is ordered by the physician to increase nutrients or to provide foods residents are able to eat. This deficiency represents non-compliance investigated under Complaint Number OH00165691 (1363724).

Based on observation, record review, and staff interview, the facility failed to ensure the interdisciplinary team determined whether a resident was clinically appropriate to self-administer their own medications prior to allowing a resident to self-administer. This affected one (Resident #11) of four residents reviewed for medication administration. The facility census was 91.Findings include:Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had moderately impaired cognition.Review of the care plan dated 11/14/18 for Resident #11 revealed the resident had an alteration in respiratory status and to administer medications as ordered; observe labs, and response to medication and treatment. The care plan did not state Resident #11 was able to self-administer any medication.Review of the physician orders dated 01/20/25 for Resident #11 revealed an order for albuterol sulfate inhalation nebulization solution (2.5 milligrams (mg)/three milliliters (ml) 0.083% three ml, inhale orally via nebulizer every four hours as needed for shortness of breath and three ml inhale orally via nebulizer three times a day for COPD. The physician orders did not state Resident #11 could self-administer this medication.Observation and interview on 02/12/26 at 8:30 A.M. with Licensed Practical Nurse (LPN) #59 revealed Resident #11 self-administers the nebulizer albuterol sulfate inhalation nebulization solution. LPN #59 stated the nurses fill the chamber with the medication for Resident #11 and when Resident #59 administers the nebulizer, she then lets the nurses know to refill it for the next one. LPN #59 confirmed Resident #11's nebulizer with the medication in the chamber stays in Resident #11's room at all times and night shift and day shift fill it when Resident #11 uses it. Interview on 02/12/26 at 9:19 A.M. with Registered Nurse MDS Coordinator #8 confirmed Resident #11 did not have a physician order to self-administer any of her own medications due to safety.

Based on interview and record review, the facility failed to provide residents with an Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) when their skilled services ended, had skilled days remaining and remained in the facility. This affected two (#31 and #67) of three residents reviewed for beneficiary notices. The facility census was 91.Findings include:1. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy and cognitive communication deficit. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had moderately impaired cognition. Review of the primary payor dated 01/30/26 revealed Resident #31 had Medicare part A. The level of care revealed Resident #31 received skilled services effective 12/22/25 through 02/06/26. On 02/07/26, the payor source changed to MyCare Medicaid [NAME].There was no evidence Resident #31 and/or representative received an SNF ABN when skilled services ended.Interview with Business Office Manager (BOM) #13 on 02/11/26 at 1:30 P.M. confirmed Resident #31 was not given an SNF ABN notice when skilled services ended and confirmed Resident #31 had skilled days left. 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, peripheral vascular disease, and osteomyelitis. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact.Review of the primary payor dated 08/07/25 revealed Resident #67 had Medicare part A. The level of care revealed Resident #67 received skilled effective 08/07/25 through 10/25/25. On 10/26/25, the primary payor source changed to Medicaid.There was no evidence Resident #67 and/or representative received an SNF ABN when skilled services ended.Interview with Business Office Manager (BOM) #13 on 02/11/26 at 1:30 P.M. confirmed Resident #67 was not given an SNF ABN notice when skilled services ended and confirmed Resident #67 had skilled days left.

Based on resident and staff interviews, observation, record review, and policy review, the facility failed to implement Resident #9's care plan interventions for quarter side rails for the resident's bed and develop a mood care plan for Resident #10. The facility census was 91.Findings include- 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy, spinal stenosis, and major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact and was dependent of staff with toileting and bathing, and required supervision with personal hygiene. The care plan dated 08/18/25 revealed Resident #9 required assistance with activities of daily living (ADLs) related to decreased mobility, pain, and self-care deficit. Interventions included a left quarter side rail to assist with bed mobility. Observation and interview on 02/17/26 at 11:00 A.M. with Licensed Practical Nurse (LPN) #103 in Resident #9's room revealed Resident #9's bed did not have the quarter side rails attached his bed as care planned. Interview on 02/18/26 at 8:28 A.M. with Resident #9 revealed he hasn't had a quarter side rail for movement in the last five weeks and Resident #9 confirmed he does need the side rails. Interview and observation on 02/18/26 with the Director of Nursing (DON) in Resident #9's room revealed no quarter side rail on his bed. 2. Review of the medical record for Resident #10 revealed an admission date of 06/20/24. Diagnoses included depression. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. Review of the Prospective Payment System (PPS) discharge assessment dated [DATE] revealed Resident #10 had little interest/pleasure in doing things two to six days and was feeling down, depressed or hopeless for two to six days of the two week look back period. A mood care plan was marked as being in place. Review of the psychosocial quarterly assessment dated [DATE] revealed Resident #10 had little interest/pleasure in doing things for two to six days of the two week look back period. A mood care plan was marked as being in place. The physician orders revealed an order for Mirtazapine (antidepressant) 7.5 milligrams (mg) tablet at bedtime with a start date of 02/04/26. Review of the comprehensive care plan for Resident #10 revealed no documentation a mood care plan had been implemented. Interview on 02/18/26 at 10:17 A.M. with Minimum Data Set (MDS) Nurse #8 verified Resident #10 did not have a mood care plan that had been implemented despite documentation on the psychosocial evaluations and the initiation of an antidepressant medication. Review of the policy titled Care Plans, Comprehensive Person Centered revised 03/2022 revealed the comprehensive, person-centered care plan would include services which would be furnished to attain or maintain physical, mental and psychosocial well-being.

Based on record review, policy review, resident and staff interviews, the facility failed to hold quarterly care conferences for the residents. This affected one (#65) of two residents reviewed for care conferences. The facility census was 91.Findings include:Review of the medical record for Resident #65 revealed an admission date of 09/06/23. Diagnoses included multiple sclerosis. morbid obesity, paraplegia, and open wound to left lower leg. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact and required supervision with eating, maximum assistance with bed mobility and was dependent upon staff with toileting and transfers.The medical record review revealed the last documentation of a care conference for Resident #65 was on 09/03/24.Interview on 02/10/26 at 9:50 A.M. with Resident #65 revealed she did have a concern because a conference had not been offered for a while.Interview on 02/11/26 at 2:19 P.M. with Social Services Designee (SSD) #14 verified Resident #65's last care conference was on 09/03/24. SSD #14 shared the staff member who did the care conferences was no longer employed at the facility and she was in the process of getting them scheduled.Review of the facility policy titled Care Plans, Comprehensive Person Centered, revised 03/2022, revealed a resident has a right to participate in his or her treatment and provided advanced notice of care planning conferences.

Based on observations, policy review, record review and, staff and resident interviews the facility failed to provide residents, who required assistance with activities of daily living (ADL), timely assistance with incontinence care and personal hygiene. This affected two (#45 and #65) of two residents reviewed for ADLs. The facility census was 91.Findings include:1) Review of the medical record for Resident #45 revealed admission date of 01/29/25. Diagnoses included diabetes mellitus type two, chronic kidney disease and hypertension. The five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had impaired cognition. Resident #45 was dependent upon staff with toileting hygiene and was frequently incontinent of bowel and bladder. Review of the care plan revealed Resident #45 required assistance with her ADLs related to a self-care deficit, weakness and decreased mobility. Interventions included for staff to assist with completion with ADLs on a daily basis. Interview on 02/12/26 at 8:55 A.M. with Certified Nursing Assistant (CNA) #56 revealed she was preparing to do resident rounding. She verified the start of her shift was 7:00 A.M. and anticipated providing care for Resident #45 at 9:45 A.M. Observation on 02/12/26 at 9:45 A.M. revealed Resident #45 was in the bathroom with Physical Therapist (PT) #120. Resident #45's bed had a large wet area on the bath blanket in the middle of the bed. The room had a strong smell of urine. Licensed Practical Nurse (LPN) #25 entered the room and knocked on the bathroom door prior to entering. LPN #25 informed Resident #25 he would assist in getting her cleaned up. PT #120 then exited the bathroom. Interview on 02/12/26 at 9:54 A.M. with PT #120 revealed she had entered Resident #45's room to provide a physical therapy evaluation. She shared Resident #45 was laying in bed and her gown was wet with urine. She assisted Resident #45 to the bathroom to assist in getting her out of the wet gown. She verified the bed was wet and a strong odor of urine was prevalent in the room. Observation on 02/12/26 at 9:59 A.M. revealed LPN #25 exited the bathroom with Resident #45. LPN #25 assisted Resident #45 to a chair in the room and informed her he was going to have her sit in the chair until he could get an CNA to change the bed linens. Interview on 02/12/26 at 10:00 A.M. with Resident #45 revealed staff did not change her incontinence product through the night and she had laid in her wet gown until PT #120 came in. Second interview on 02/12/26 at 12:21 P.M. with CNA #56 revealed she did not round with the off going CNA at the start of her shift (7:00 A.M.). She acknowledged she did not know the last time Resident #45 had been provided with incontinence care and verified she had not been in to provide care prior to 9:45 A.M. 2) Review of the medical record for Resident #65 revealed admission date of 09/06/23. Diagnoses included multiple sclerosis, morbid obesity and paraplegia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition and was dependent upon staff with personal hygiene. Interview and observation on 02/10/26 at 10:11 A.M. with Resident #65 revealed she had facial hair stubbles. Resident #65 acknowledged she was aware of her facial hair and stated she did not want to look like a man. Interview on 02/11/26 at 8:32 A.M. with Certified Nursing Assistant (CNA) #108 verified facial hair was present on Resident #65. CNA #108 stated residents get assistance with shaving on their shower days. Observation on 02/12/26 at 7:38 A.M. revealed Resident #65's facial stubbles were still present. Review of the facilities ADL policy titled Activities of Daily Living, Supporting revised 03/2018 revealed residents would be provided with care, treatment and services as appropriate to carry out ADLs. This deficiency represents non-compliance investigated under Complaint Numbers 2715256, 2687005, 2650868 and OH00165691 (1363724).

Based on observation, resident and staff interview, and record review, the facility failed to ensure a resident who had a history of falls had their fall interventions in place. This affected one (Resident #9) of five residents reviewed for accidents. The facility census was 91.Findings include:Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy, spinal stenosis, and major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact and was dependent of staff with toileting and bathing, and required supervision with personal hygiene. Review of Resident #9's care plan dated 06/19/25 revealed the resident has had an actual fall. Interventions included to ensure a reacher (or also known as a grabber and it is designed to help one with limited mobility or bending restrictions to maintain independence) was accessible to the resident while in bed.Review of the physician orders dated 06/20/25 revealed Resident #9 required a reacher in reach of the resident every shift for intervention. Observation and interview on 02/17/26 at 11:00 A.M. with Licensed Practical Nurse (LPN) #103 revealed Resident #9 was lying in his bed and did not have his reacher within reach of him. The reacher was in a chair next to the opposite wall away from Resident #9's bed. LPN #103 confirmed the reacher was not within reach of Resident #9.Interview and observation on 02/18/26 at 10:30 A.M. with the Director of Nursing (DON) revealed Resident #9 was lying in his bed and did not have his reacher within reach of him. The reacher was across in the room. The DON confirmed the reacher was not within reach of Resident #9.This deficiency represents non-compliance investigated under Complaint Numbers 2684676, 2679812 and 2650868.

Based on observation, staff interview, and policy review, the facility failed to ensure garbage and refuse was properly placed inside lidded garbage containers. This had the potential to affect 88 residents. Resident #14, #79, and #103 were on nothing by mouth. The facility census was 91.Findings include:Observation and interview on 02/17/26 at 12:32 P.M. in the kitchen revealed a large garbage bin on wheels with no lid and full of garbage next to a food prep area. There was a garbage bin near a kitchen hand wash station by the freezer and it had garbage sitting on top of the lid, and a garbage bin near hand wash station by kitchen entry doors was full of garbage overflowing, not allowing the lid to close. Kitchen District Manager #120 confirmed there was a garbage bin without a lid, one garbage bin had garbage sitting on the top, and another garbage bin was full of garbage and was overflowing. Review of the facility policy titled Dispose of Garbage and Refuse HCSG 030 revised 02/2025 revealed appropriate lids are provided for all containers and garbage and refuse will be removed from the kitchen area routinely during the day.

Based on medical record review and staff interview, the facility failed to ensure a thorough assessment of a pressure ulcer was completed upon discovery. This affected one (#25) of three residents reviewed for wounds. The facility census was 82. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses of dysphagia, oropharyngeal phase, chronic obstructive pulmonary disease, chronic venous hypertension (idiopathic) with ulcer of the bilateral lower extremity, peripheral vascular disease, and acquired absence of the left leg below the knee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact and required supervision assistance with eating, partial assistance with oral hygiene, and was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, and bed mobility. Review of Resident #25's physician order dated 02/03/25 revealed an order to reduce pressure to the right heel and left stump, float heel/stump off of the bed at all times. Review of Resident #25's progress note dated 02/11/25 at 3:30 P.M. revealed wound care provided for right heel area. Review of the physician order dated 02/11/25, with a discontinue date of 02/19/25, revealed an order for a treatment to the left (right) heel to cleanse area with wound cleanser, pat dry, cover in betadine, and apply boarder gauze. Review of Resident #25's skin observation tool dated 02/12/25 revealed no new skin concerns. Review of Resident #25's subsequent skin observation tool documents dated 02/19/25 revealed no new skin concerns, and on 02/22/25 revealed below the knee amputation with treatment currently in place and moisture associated skin damage with treatment and no new areas. Review of Resident #25's wound observation tool dated 02/24/25 revealed the physician was notified on 02/24/25 of a pressure wound to the right heel with no staging noted and measured 2.5 centimeters (cm) long by 5.0 cm wide by 0.0 cm deep with treatment noted as betadine. Interview on 04/23/25 at 9:49 A.M. with Licensed Practical Nurse (LPN) #501 confirmed on 02/11/25 when the wound on the right heel for Resident #25 was found, an assessment of the wound was not documented in the medical record to include measurements and a description of the wound bed. LPN #501 also confirmed the wound bed was 100 percent black necrotic tissue and dry with no drainage. LPN #501 stated it was the expectation when a new wound was found that a change in condition or skin assessment be completed with the measurements and description of the wound be completed. LPN #501 confirmed a change of condition nor skin assessment on the new pressure area to the right heel was not completed for Resident #25. The facility unable to provide a policy for documentation requirements for a new pressure wound. This deficiency represents non-compliance investigated under Complaint Number OH00164982 and Complaint Number OH00164075.

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure medications were secured in a safe manner. This affected one (#33) of three residents reviewed for medications. The facility census was 82. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, schizoaffective disorder, anemia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had severe cognitive impairment. Resident #33 was independent with oral hygiene, toileting hygiene, dressing, bed mobility, and ambulation. Resident #33 required set-up assistance with eating, bathing, and personal hygiene, and required supervision assistance with transfers. Review of the care plan dated 08/11/22 revealed Resident #33 had impaired cognitive function/dementia or impaired thought processes related to dementia and schizoaffective disorder. Interventions were added on 08/31/24 to administer medications as ordered and observe for side effects and effectiveness. Review of the physician order dated 12/27/19 revealed Resident #33 had an order for the pain medication gabapentin 100 milligram (mg) tablet three times a day by mouth for pain. Review of the physician order dated 02/21/25 revealed Resident #33 had an order for the anti-anxiety medication buspirone 7.5 mg tablet by mouth three times a day for anxiety. Observation on 04/21/25 at 2:33 P.M. in Resident #33's room revealed a medication cup sitting on the bedside table with two pills in it. Interview at the time of the observation with Resident #33 stated she would take the medications. Interview on 04/21/25 at 2:34 P.M. with Licensed Practical Nurse (LPN) #374 confirmed Resident #33 was not approved to self-administer her medications. Interview on 04/21/25 at 2:35 P.M. with LPN #506 confirmed the medications sitting on Resident #33's bedside table were a gabapentin 100 mg tablet and a buspirone 7.5 mg tablet. LPN #506 also confirmed she left the medications on Resident #33's bedside table when she left the room and confirmed Resident #33 was not to administer her own medications. Review of the general guidelines for medication administration policy, dated 06/17/21, revealed medications will be administered by legally-authorized and trained persons in accordance to applicable State, Local, and Federal laws and consistent with accepted standards of practice. The staff should identify the resident, administer medication and remain with resident while medication is swallowed. Never leave medication in a resident's room without orders to do so. This deficiency represents non-compliance investigated under Master Complaint Number OH00165066 and Complaint Number OH00164982.

Based on medical record review and staff interview, the facility failed to ensure residents received food in a form to meet individual needs. This affected one (#101) of three residents reviewed for dietary status. The facility census was 82. Findings include: Review of Resident #101's medical record revealed an admitted [DATE] with diagnoses of acute respiratory failure with hypoxia, aphasia, morbid (severe) obesity due to excess calories, and type II diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was assessed with severe cognitive impairment. Resident #101 was dependent on staff assistance for all activities of daily living (ADLs). Resident had a percutaneous endoscopic gastrostomy (PEG) feeding tube and was not on a mechanically altered or therapeutic diet. Review of Resident #101's admission orders dated 02/13/25 revealed no dietary order was noted. Review of Resident #101's physician order dated 02/13/25 revealed an order for a regular diet, regular texture, and thin liquids consistency. Review of Resident #101's progress note dated 02/14/25 at 12:34 P.M. revealed a change in condition was reported with staff reporting the resident had a coughing episode. The physician was contacted with new orders for a chest x-ray and Resident #101 was to remain nil per os (NPO; meaning nothing by mouth). Review of Resident #101's physician order dated 02/14/25 revealed on order for NPO diet, NPO texture, NPO consistency, the resident has a feeding tube. Interview on 04/22/25 at 11:33 A.M. with Registered Nurse (RN) #327 confirmed Resident #101 was started on a regular diet, regular texture, thin liquid diet on admission on 02/13/25. RN #327 also confirmed the diet order was not on the admission orders, and the regular diet, regular texture, thin liquids diet was started without verifying with the physician whether Resident #101 should be NPO. RN #327 stated Resident #101 was being fed by staff when the resident was coughing and confirmed the resident should have had nothing by mouth. The facility was unable to provide a policy for verifying dietary orders. This deficiency represents non-compliance investigated under Complaint Number OH00164982.

Based on medical record review, staff interviews and review of the Influenza Vaccine Report, the facility failed to offer the annual influenza vaccines to residents. This affected three (#47, #14 and #39) out of three residents reviewed for influenza vaccines and had the potential to affected 80 out of 82 residents residing in the facility, the facility identified two (#16 and #79) residents who were not eligible for the influenza vaccine. The facility census was 82. Findings include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, spondylosis without myelopathy or radiculopathy, lumbosacral region, and unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review of Resident #47's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. 2. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include pressure ulcer of sacral region, stage 3, malignant neoplasm of middle lobe, bronchus or lung, and type 2 diabetes mellitus with diabetic neuropathy. Further review of Resident #14's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. 3. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral atherosclerosis, pressure ulcer of sacral region, stage 4, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review of Resident #39's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. Interview on 01/08/25 at 11:46 A.M. with Assistant Director of Nursing (ADON) #3 confirmed the facility has not offered the residents the annual 2024-2025 influenza vaccine due to losing the infection control nurse approximately six weeks ago and reorganizing the position. Interview with ADON #3 also confirmed the floor nurses were given consent paperwork on 12/30/24 to review with the resident and get their consent for the vaccine. Interview with ADON #3 also confirmed on 01/03/25 pharmacy was notified of the need of 60 additional flu vaccines. ADON #3 confirmed there were some residents not eligible for the annual influenza vaccine as they were newly admitted and received it outside the facility or there are some residents who have refused it. ADON #3 confirmed there was no documentation that Resident #47, #14 and #39 were offered the annual influenza vaccine. Interview on 01/08/25 at 12:10 P.M. with Pharmacy Technician #101 confirmed 20 doses of Afluria and 30 doses of Fluzone were sent to the facility on [DATE], and 50 doses of Afluria were sent to the facility on [DATE]. Review of the Influenza Vaccine report revealed Resident #16 was not eligible for the to receive the influenza vaccine as the resident received the vaccine on 11/06/24. Additionally, Resident #79 refused the influenza vaccine. There was no other documentation that residents were offered the influenza vaccine for the 2024-2025 influenza season. This deficiency represents non-compliance investigated under Complaint Number OH00160725.

Based on medical record review, staff interviews and policy review, the facility failed to ensure medications were administered as physician ordered. This affected four (#47, #66, #80, and #91) out of four residents reviewed for medication administration. Facility census was 93. Findings include: 1. Review of the medical record for Resident #47 revealed an admitted [DATE] with diagnoses of seizures, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and chronic kidney disease, stage 3 unspecified. Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #47 with severe cognitive impairment. Resident #47 required partial assistance with eating and oral hygiene. Resident # 47 required substantial assistance with toileting hygiene, bathing, dressing, bed mobility, and wheelchair mobility. Review of the September 2024 Medication Administration Record (MAR): Levothyroxine Sodium Oral Capsule 25 micrograms (MCG)-give 25 mcg by mouth one time a day, not initialed as completed on 09/20/24; Lexapro Oral Tablet 20 milligrams (MG)-give 1 tablet by mouth one time a day for depression, not initialed as completed on 09/20/24; Lipitor Oral Tablet 40 MG-give 40 mg by mouth one time a day, not initialed as completed on 09/20/24; MiraLax Oral Packet 17 grams (GM)-give 1 packet by mouth one time a day for constipation, not initialed as completed on 09/20/24; Carvedilol Oral Tablet 3.125 MG-give 1 tablet by mouth every 12 hours, not initialed as completed on 09/20/24 morning dose; Gabapentin Oral Capsule 300 MG-give 300 mg by mouth two times a day for nerve pain, not initialed as completed on 09/20/24 morning dose; Lacosamide Oral Tablet 100 MG-give 100 mg by mouth two times a day, not initialed as completed on 09/20/24 morning dose; Levetricetam Oral Tablet 750 MG-give 1 tablet by mouth two times a day, not initialed as completed on 09/20/24 morning dose. 2. Review of the medical record for Resident #66 revealed an admitted [DATE] with diagnoses of moderate protein-calorie malnutrition, pressure-induced deep tissue damage of right heel, pressure ulcer of right buttock, stage 4. Review of the significant change MDS completed on 09/06/24 revealed Resident #66 had moderate cognitive impairment. Resident #66 required supervision assistance with eating, oral hygiene, and personal hygiene, and was dependent on staff assistance for toileting hygiene, bathing, dressing, bed mobility, transfers, and wheelchair mobility. Review of the Resident #66's September 2024 MAR revealed: Atorvastatin Calcium Oral Tablet 10 MG-give 1 tablet by mouth at bedtime for treatment of high cholesterol, not initialed as complete on 09/22/24 at 9:00 P.M.; Cetirizine HCl Oral Tablet 5 MG-give 1 tablet by mouth at bedtime for seasonal allergies, not initialed as complete on 09/22/24 at 9:00 P.M.; Levothyroxine Sodium Oral Tablet 150 MCG-give 1 tablet by mouth one time a day for treatment of thyroid disease, not initialed as complete on 09/23/24 at 6:00 A.M.; Mirtazapine Oral Tablet 15 MG-give 15 mg by mouth at bedtime for depression/appetite, not initialed as complete on 09/22/24 at 6:00 A.M.; Apixaban Oral Tablet 5 MG-give 1 tablet by mouth two times a day for A-Fib, not initialed as complete on 09/22/24 at 9:00 P.M.; Coreg Oral Tablet 6.25 MG-give 1 tablet by mouth two times a day for hypertension, not initialed as complete on 09/22/24 at 9:00 P.M.; Gabapentin Oral Capsule 100 MG-give 1 capsule by mouth two times a day for diabetic neuropathy, not initialed as complete on 09/22/24 9:00 P.M.; and Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG-give 1 tablet by mouth two times a day for Hypertension, not initialed as complete on 09/22/24 9:00 P.M. 3. Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses of pressure ulcer of left buttock, stage 2, pressure ulcer of sacral region, stage 4, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Review of the quarterly MDS dated [DATE] revealed Resident #80 was cognitively intact. Resident #80 required supervision assistance with eating and oral hygiene, required partial assistance with personal hygiene, and was dependent on staff assistance with toileting hygiene, bathing, dressing, bed mobility, and transfers. Review of the September 2024 MAR revealed: Latanoprost PF Ophthalmic Solution 0.005 %-instill 1 drop in both eyes at bedtime for glaucoma, not initialed as complete on 09/25/24 at 6:00 P.M.; Mirtazapine Oral Tablet 7.5 MG-give 7.5 mg by mouth at bedtime for depression, not initialed as complete on 09/25/24 at 6:00 P.M.; Rosuvastatin Calcium Oral Tablet 20 MG-give 20 mg by mouth at bedtime for hyperlipidemia, not initialed as complete on 09/25/24 at 6:00 P.M.; Vitamin D3 Oral Tablet-give 125 mcg by mouth in the evening for supplement, not initialed as complete on 09/25/24 at 6:00 P.M.; Zoloft Oral Tablet 100 MG-give 100 mg by mouth at bedtime for depression, not initialed as complete on 09/25/24 at 6:00 P.M.; Levetricetam Oral Tablet 500 M-give 500 mg by mouth two times a day for seizures, not initialed as complete on 09/25/24 at 6:00 P.M.; Metformin Oral Tablet 500 MG-give two tablet by mouth two times a day for diabetes mellitus type 2, not initialed as complete on 09/27/24 at 9:00 P.M.; Metformin Oral Tablet 500 MG-give 500 mg by mouth two times a day for diabetes mellitus, not initialed as complete on 09/25/24 at 6:00 P.M. 4. Review of the medical record for Resident #91 revealed an admitted [DATE] with diagnoses of pressure ulcer of sacral region, stage 4, depression, unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly MDS dated [DATE] revealed Resident #91 with severe cognitive impairment. Resident requires partial assistance with eating, requires substantial assistance with oral care and personal hygiene, and was dependent on staff assistance with toileting hygiene, bathing, dressing, bed mobility, and transfers. Review of the September 2024 MAR revealed: Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen)-give 1 tablet by mouth one time a day for stage 4 sacrum not initialed as complete on 09/27/24 at 5:00 P.M.; Clobazam Oral Tablet 10 MG-give 1 tablet by mouth two times a day for Seizures not initialed as complete on 09/27/24 at 10:00 P.M.; Clobazam Oral Tablet 10 MG-give 1 tablet via g-tube two times a day for Seizures not initialed as complete on 09/24/24 at 10:00 P.M.; Lacosamide Oral Tablet 200 MG-give 200 mg by mouth two times a day for Seizures, not initialed as complete on 09/27/24 at 10:00 P.M.; Lacosamide Oral Tablet 200 MG-give 200 mg via G-Tube two times a day for Seizures, not initialed as complete on 09/24/24 at 10:00 P.M.; Pregabalin Oral Capsule 150 MG-give 1 capsule by mouth two times a day for seizures / nerve pain, not initialed as complete on 09/27/24 at 10:00 P.M.; and Pregabalin Oral Capsule 150 MG-give 1 capsule via G-Tube two times a day for seizures/nerve pain, not initialed as complete on 09/24/24 at 10:00 P.M. Interview on 10/24/24 at 7:57 A.M. with Licensed Practical Nurse (LPN) #325 confirmed Resident #47, #66, #80, and #91 did not have orders completed as listed on their MAR's. Review of the medication administration policy dated 06/21/17 revealed it is the policy of the facility that medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with acceptable standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00158320.

Based on medical record review, observation, staff interview, and facility policy, the facility failed to provide timely incontinence care. This affected one (#53) of three residents reviewed for incontinence care. The facility census was 81. Findings Included: Review of medical record for Resident #53 revealed an admitted [DATE]. Diagnosis included dementia, psychotic mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was severely cognitively impaired, required partial to moderate assistance for meals, and substantial to maximal assistance for personal hygiene and oral hygiene. Resident #53 was dependent for transfers, bathing, toileting, dressing upper and lower body, and placing shoes on and off. Review of the plan of care dated 08/08/24 revealed Resident #53 was at risk for alteration in elimination due to incontinence. Interventions included to assist with toileting needs daily, keep the call light within reach during toileting, provide incontinence care every shift and as needed for incontinence episodes, increase fluids between meals, laboratory values as ordered, observe for symptoms of urinary tract infection, peri-care after incontinence episodes as needed, and praise and encourage the resident to be as independent as able. Observations on 09/26/24 from 9:05 A.M. through 12:00 P.M. revealed State tested Nurse Aide (STNA) #159 had not provided incontinence care for Resident #53. Further observation at approximately 12:00 P.M. revealed, upon entering Resident #53's room, STNA #159 had already taken Resident #53's dirty sheet and soiled incontinence brief off. Resident #53's soiled bed linens and incontinence brief were in a trash bag on the floor, and when lifted were heavy. Interview with STNA #159 at the time of the observation verified that Resident #53's incontinence brief was heavily saturated with urine when she took it out of the trash bag to show the surveyor and was confirmed by a second surveyor in the room. STNA #159 refused to confirmed she did not check the resident for incontience between 9:05 A.M. and 12:00 P.M. with asked directly. Review of the activities of daily living policy, dated 03/2018, revealed appropriate care and services will be provided who are unable to carry out activity of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support assistance with hygiene, mobility, elimination, dining, and communication. Review of the facility policy titled, Urinary Continence and Incontinence Assessment and Management, dated 08/2022, revealed the physician and staff will provide appropriate services and treatment to help the resident restore or improve bladder function and prevent urinary tract infections to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00157485.

Based on medical record review, staff interview, and policy review, the facility failed to initiate treatment for a pressure ulcer in a timely manner. This affected one (#08) of three residents reviewed for wound care and treatment. The facility census was 81. Findings include: Review of the medical record for Resident #08 revealed an admitted [DATE] with medical diagnoses of moderate protein calorie malnutrition, diabetes mellitus with neuropathy, hypertension, anxiety, and chronic kidney disease. Review of the medical record for Resident #08 revealed a significant change Minimum Data Set (MDS) assessment, dated 09/06/24, which indicated Resident #08 had moderate cognitive impairment and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. The MDS assessment indicated Resident #08 had a stage four pressure ulcer (full-thickness skin and tissue loss) that was not present upon admission. Review of a wound observation assessment, dated 05/30/24, revealed Resident #08 had an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the right buttock which measured 8.0 centimeters (cm) long by 5.0 cm wide by 0.1 cm deep. The assessment revealed a low air loss mattress was in place and the current treatment was to apply calcium alginate. Review of a wound nurse practitioner (NP) note, dated 05/31/24, revealed Resident #08 had an unstageable pressure ulcer to the right buttock due to necrosis (dead tissue). The wound measured 8.0 cm long by 5.0 cm wide by 0.1 cm deep, and a treatment was ordered to apply calcium alginate and cover with gauze and bordered dressing daily. Review of Resident #08's medical record revealed a physician order dated 06/04/24 to cleanse the right buttock wound with wound cleanser, pat dry, apply calcium alginate, and cover with bordered gauze daily. Review of the medical record revealed no documentation to support Resident #08's right buttock pressure ulcer treatment was started until 06/04/24. Further review of a wound NP note, dated 09/26/24, revealed Resident #08 had a stage four pressure ulcer to the right buttock and indicated the wound had improved as evidenced by decreased surface area and decreased undermining. Interview on 09/26/24 at 4:17 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #08 had no documentation to support treatment to the right buttock pressure ulcer was started until 06/04/24. Review of the facility policy titled, Skin and Wound Management Program, effective 02/01/2020, revealed the intent of the program was to promote the prevention of pressure ulcer/injury development, promote the healing of existing pressure ulcers/injuries, and to promote the prevention of development of additional pressure ulcer/injury. This deficiency represents non-compliance investigated under Master Complaint Number OH00158220.

Based on medical record review, observations, staff and physician interviews, policy review, and review of the National Pressure Injury Advisory Panel (NPIAP), the facility failed to ensure interventions were implemented to prevent the development of pressure ulcers for a resident identified at high risk for skin breakdown. The resulted in Actual Harm when Resident #26, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning developed an unstageable deep tissue injury to the right heel on 10/02/23 which worsened to a Stage IV pressure ulcer and developed a Stage III pressure ulcer to the sacrum on 12/14/23 due to inadequate and ineffective pressure ulcer prevention/interventions being in place. This affected one (#26) of five reviewed for pressure ulcers. Facility census was 79. Findings included: Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included non-traumatic brain dysfunction, cerebrovascular atherosclerosis, diabetes disease, aphasic, cerebrovascular accident, and non-Alzheimer's. Review of care plan dated 08/03/23 revealed Resident #26 was at risk for pressure ulcer due to assistance required in bed mobility, bowel incontinence, and Braden score of less than a 18. Interventions were for an air mattress, bed mobility times two person due to air mattress, turn and reposition every one to two hours. Complete Braden Scale per center policy, conduct weekly skin inspection, do not massage over bony prominence. Float heels as tolerated. Provide pressure reducing wheelchair cushion. Provide pressure reduction/relieving mattress. Provide thorough skin care after incontinent episodes and apply barrier cream. Skin assessment to be completed per the facility policy. Review of Braden Score evaluation dated 08/15/23 revealed Resident #26 was at high risk for predicting pressure ulcer. Review of skin observation tool dated 09/30/23 revealed Resident #26 did not have any skin issues. Review of progress notes dated 10/02/23 revealed Resident #26 had a facility acquired right heel area that was darkened. The area measured 4.0 centimeters (cm) by 3.5 cm. The physician was notified and new order to paint bilateral heels with betadine daily and to provide monitoring was given. Review of the first wound physician note dated 10/19/23 revealed Resident #26's right heel was an unstageable (US) deep tissue injury (DTI) that measured 6.0 cm by 6.0 cm and the depth could not be measured. The surface area was 36 cm. On 11/30/23 this wound was documented as a Stage IV pressure ulcer. Review of the care plan dated 10/23/23 revealed to place moon boots on the resident. Review of wound physician's notes dated 12/14/23 revealed Resident #26 had a new area to his sacrum that was in-house acquired that measured 5.0 cm by 6.0 cm by 0.3 cm with a surface area of 30.00 cm that was a Stage III. There was moderate serous exudate with 100% granulation. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was rarely or never understood. The assessment revealed the resident had impairment to his lower extremities and was dependent on staff for bed mobility, transfers, eating and toileting. The resident was assessed to be always incontinent for bowel and bladder. Review of wound physician's notes dated 01/11/24 revealed the right heel wound was a Stage IV that measured 5.0 cm by 3.6 cm by 0.4 cm with a surface area of 18 cm. There was moderate serous exudate. There was 10% thick adherent necrotic tissue, 20% slough, 20 % granulation and 50% bone. Further review of notes revealed the Stage III sacrum was measured 2.5 cm by 4.0 cm times 0.4 cm with a surface area of 10.00. There was moderate serous exudate, 40% slough, and 60% granulation tissue. Further review of Resident #26's medical record revealed an order on the January 2024 Treatment Administration Record (TAR) dated 10/02/23 to float heels while in bed and an entry dated 10/23/23 for heel protectors to bilateral heels every shift two times a day. The record review revealed there was no documented evidence the turning and repositioning was being provided. Observations on 01/08/24 at 10:05 A.M. revealed Resident #26 was sitting up in the common area in a Broda chair leaning to the right side without moon boots on and no pillows on either side of the resident for positioning. At 11:08 A.M. Resident #26 continued in the Broda chair leaning to the right side without moon boots on and no pillows for positioning and was in the same position. At 1:06 P.M., Resident #26 continued in the Broda chair leaning to the right side without moon boots on and had not been repositioned. At 1:47 P.M., Resident #26 was still lying in the Broda chair leaning to the right side and had not been repositioned. Interview with State tested Nursing Aide (STNA) #199 on 01/08/24 at 1:54 P.M. confirmed Resident #26 had been up before 7:00 A.M., before she came to work, and he had not been repositioned in the chair. STNA #199 confirmed she left Resident #26 sit in the Broda chair for seven hours without being turned and repositioned. Observations were made on 01/09/24 at 10:16 A.M. revealed Resident #26 was lying in bed on his back and didn't have any moon boots on his heels and his right heel was lying on his mattress where his pressure ulcer was. There were no pillows in the bed to help reposition Resident #26. At 11:19 A.M., Resident #26 was lying in bed in the same position with no foot boots and no turns observed. Resident #26 had his right heel lying on the bed on his pressure ulcer. At 1:55 P.M. before Resident #26's dressing change the resident continued to lie on his back and didn't have any boots on his heels and his right heel was lying on the bed where his pressure ulcer was. Interview with STNA #199 on 01/09/24 at 2:02 P.M. revealed she took care of Resident #26 yesterday and today. STNA #199 stated she did not turn him or place heel boots on Resident #26 either day because she didn't have time. During the interview STNA #199 looked for Resident #26's moon boots but they were not in the room. Observation of dressing change on 01/09/24 at 2:05 P.M. revealed the dressing for Resident #26's right heel and the sacrum were not dated. Observations revealed Resident #26's right heel looked necrotic with beefy red tissue, and there was a scant amount of serous exudate. When Licensed Practical Nurse (LPN) #104 measured the wound and placed the Q-tip into the wound she stated she felt bone and didn't push anymore into the wound. LPN #104 measured the wound to be 6.0 cm by 5.0 cm by 0.3 cm. Interview with the Licensed Practical Nurse (LPN) #104 on 01/09/24 at 2:30 P.M. confirmed she didn't turn or place boots on Resident #26 today. LPN #104 confirmed the bandages were not dated when they were changed on Resident #26's right heel or the sacrum. LPN #104 confirmed there were no boots in Resident #26's room. LPN #104 stated when she measured Resident #26's wound she felt bone. Observations on 01/10/24 at 8:08 A.M., 10:01 A.M. and at 11:56 A.M. revealed Resident #26 was lying on his back in the bed. Interview with the Director of Nursing (DON) on 01/10/24 at 1:00 P.M. confirmed Resident #26 developed an unstageable pressure ulcer on the right heel which was first discovered on 10/02/23. The DON confirmed the wound physician assessed Resident #26's right heel on 10/19/23 a Stage IV. The DON confirmed Resident #26 developed a Stage III pressure ulcer on the sacrum on 12/14/23. The DON confirmed the Resident #26 didn't have interventions in place to prevent the wounds from developing for the resident. The DON confirmed the lack of pressure ulcer intervention could result in the development of skin breakdown for Resident #26. Interview with the Wound Physician (WP) #205 on 01/11/24 at 9:00 A.M. revealed his expectation for an intervention for a resident who was very high risk for a pressure ulcer would be for moon boots prior to the pressure ulcers. WP #205 stated Resident #26's right heel was down to the bone. After listening to the observations the surveyor had during the survey, he stated Resident #26 should not be up in a Broda chair for seven hours and should have the boots on his heels. Review of the policy entitled Preventions of Pressure Ulcers dated 01/01/23 revealed to reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Choose frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Provide support devices and assistance as needed. Review of the NPIAP dated 2020 revealed to turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. Ensure the heels are free from the bed. Reposition weak or immobile individuals in chairs hourly. Use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers. Further review of NPIAP revealed the definitions for the pressure ulcers were as followed: Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage IV Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuate) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuate) on the heel or ischemic limb should not be softened or removed.

Based on medical record review, review of facility post fall investigation, and staff interviews, the facility failed to use proper technique and assistance when repositioning one resident (#63) during personal care to prevent a fall. Actual harm occurred when Resident #63 was repositioned using an improper technique by one staff member, slid off the side of the bed onto the floor and suffered a facial laceration requiring sutures and a left orbital floor fracture with air-fluid level in the left maxillary sinus. This affected one (#63) of one resident reviewed for falls. The facility census was 79. Findings include: Review of the medical record for Resident #63 revealed she was admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #63's quarterly Minimum Data Set (MDS) assessment, dated 09/11/18, revealed the resident was not able to complete the assessment due to her cognitive deficit. She was assessed to require total care for activities of daily living (ADLs) and required two plus person physical assist with bed mobility and transfers. Review of the current care plan for Resident #63 revealed she was to be turned and re-positioned every two hours. A maxislide was to be used for bed mobility and positioning. Review of the nursing notes on 10/01/18 revealed the nurse was notified Resident #63 was on the floor. Once in the room the nurse observed Resident #63 on the floor to the right side of the bed, lying on her right side in the fetal position with her arms contracted. Her tube feeding was not connected and there was blood on the floor. Resident #63 had an open area to her right eye socket and swelling to the right side of her face and lip. The State tested Nurse Aide (STNA) stated she was performing personal care and had Resident #63 pulled to her side of the bed when the resident starting sliding out of bed and the STNA was unable to stop the fall. The resident was transported to the emergency room via emergency transport. Review of medical records from the hospital for 10/01/18 revealed Resident #63's arrived at the emergency room at 8:56 P.M. [DIAGNOSES REDACTED]. Treatment included a laceration repair of two centimeters in size to the resident's left forehead. The suture repair required a two layer closure with one deep suture and an external running suture. A Computed Tomography (CT) scan of Resident #63's head revealed a left orbital floor fracture with air-fluid level in the left maxillary sinus. The resident discharged back to the nursing facility on 10/02/18 at 12:50 A.M. Review of post fall investigation revealed the fall took place on 10/01/18 at 08:45 P.M. The incident description revealed Resident #63 fell from the bed to the floor on her right side in the fetal position with her arms contracted. She was lying next to the right side of her bed. Her tube feeding was not connected and there was blood on the floor. Her injury was documented as an open area to the right eye socket with swelling to the right side of her face and lip. The cause of the fall was documented as an aide performing personal care with Resident #63 without a second person. Interview with the STNA during the investigation revealed the STNA had the resident pulled close to her to provide care, when turning, the resident began to slide to the opposite side of the bed and the aide was unable to stop the fall from the bed. The investigation revealed the STNA was trained on the proper technique to use when turning residents alone, or to use two staff members for turning. The post fall investigation contained no documentation to indicate if the maxislide was in use at the time of Resident #63's fall. Interview on 10/18/18 at 10:45 A.M., LPN #39 stated Resident #63 was dependent on staff for care, transfers, repositioning, and bed mobility. The resident was heavy and should never have been assisted by only one staff for care. LPN #39 reported Resident #63 should have been receiving two person assist at all times, even prior to her fall.

Based on closed record review and staff interview, the facility failed to ensure a resident was positioned safely in bed during personal care. Actual harm occurred to Resident #90 when the resident was improperly positioned in the bed, resulting in the patient rolling off the bed and striking the wall mounted heater. The resident sustained [REDACTED]. This affected one (#90) of four residents reviewed for accidents. Findings include: Closed record review for Resident #90, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/10/17, revealed the resident had intact cognition. The resident was an extensive assist of two staff for bed mobility and transfers. Review of the fall risk assessment, dated 07/04/18, revealed the resident was a high risk for falls due to history of fall with fracture, impairment of gait or balance, impairment in lower extremity strength, medications and restlessness, resistive to care. Review of the plan of care dated 07/05/18, revealed the resident was at risk for falls due to [MEDICAL CONDITION], complaints of pain, [MEDICAL CONDITION], hypertension and [MEDICAL CONDITION] arthritis. Interventions included therapy as ordered, keep bed in the lowest position, keep call light within reach, non-skid footwear, place frequently used items within reach and mechanical lift for transfers. Review of the nurse's documentation, dated 10/18/17 at 5:24 P.M., State tested Nurse Aide (STNA) (name not identified) notified Licensed Practical Nurse (LPN) #10, that Resident #90, was on the floor. Upon entering the room, the resident was found on her right side in a lying position. The resident was noted to have a laceration above her right eye with bruising and swelling and complained of severe pain in her right shoulder. The resident stated when she was attempting to roll on her side, to allow the STNA to give her care, she was holding onto the mattress to stay on her side, the mattress went down, causing her to roll off the bed. The physician was notified along with the Power of Attorney (POA). Emergency 9-1-1 was called and the resident was transferred to the hospital. Review of the documentation by the triage nurse at the emergency department, revealed the resident had presented in the emergency department from a long term care facility. Resident #90 told the nurse she had been in bed and was rolled to her side when the STNA was changing her. She was holding onto the mattress because she could not reach the bar, she normally holds onto, and rolled out of the bed. The resident hit her right forehead as well as the right upper eyelid on a heater and she had a laceration in both areas. She denied any loss of consciousness. Resident #90 was having pain in her right shoulder and had a large hematoma on the right lateral aspect of her right lower leg. Review of the emergency department's physician's documentation revealed the x-ray of the right shoulder confirmed a proximal humeral fracture. The emergency department physician also confirmed a contusion of the right lower leg, a three centimeter [MEDICAL CONDITION], right upper eyelid laceration and a right facial contusion. The emergency department physician repaired the lacerations to the face with six sutures and derma-bond. A sling was applied to the resident's right arm. Review of nursing documentation dated 10/19/17 at 11:15 P.M. revealed Resident #90 returned to the facility. LPN #16 assessed the resident to have a laceration above her right eye with sutures in place, a laceration with steri-strip in place to her face, a hematoma was observed to the resident's right lower extremity, a sling was in place to her right upper extremity, bruising to her face and right lower extremity noted. On 08/07/18 at 10:00 A.M., a request to review the fall investigation was made regarding Resident #90's fall on 10/18/17. The Director of Nursing (DON) stated the former DON had taken files and papers with her when she left. The current DON was unable to locate the fall investigation. The current DON called their corporate office and was told that they did not have the fall investigation. On 08/07/18, at 4:07 P.M., a telephone interview was conducted with STNA #20 and confirmed she was the STNA giving a bath to Resident #90 on 10/18/17. STNA #20 was the only staff in the room with Resident #90. Resident #90 was turned on her left side laying along the edge of the mattress as STNA #20 washed her back. All at once, Resident #90 started to fall off the bed. STNA #20 stated she could not catch her as she was standing on the opposite of the bed, away from Resident #90. STNA #20 confirmed Resident #90 did strike the low wall mounted heating unit with her head and her right arm. As Resident #90 started to cry out in pain, STNA #20 yelled for help. Once the nurse assessed Resident #90, she then called 9-1-1 and the resident was sent out to the emergency department. Review of facility's undated policy titled Bathing a Patient revealed the staff were to assess the environment for safety, assess staff's ability in moving and positioning the resident and obtain extra help as needed. This deficiency substantiates Complaint Number OH 275

Based on clinical record review, observation and interview, the facility failed to provide supervision and effective interventions for residents with a history of repeated falls. This resulted in harm for one resident (#57) who received a laceration and sutures from an avoidable fall stemming from an interaction with another resident when staff were unavailable to supervise residents interactions on the secured dementia unit. This affected six residents (#57, #52, #43, #89, #63, #70) of 10 sampled residents reviewed for falls. The facility identified 13 residents with falls. Findings include: 1. Review of the clinical record for Resident #57 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. She was assessed to be at risk for falls and her plan of care for falls dated 04/23/08 indicated she had a history of [REDACTED]. It indicated that she was to have no slip socks on in bed and no slip shoes on when up. Staff was to remind her to ask for assistance, make sure her call light was in reach and complete observation checks every one to two hours or as needed. The plan of care had an undated intervention of observation checks every one to two hours or as needed. Review of her most recent Minimum Data Set (MDS) assessment date 03/08/11 revealed a Brief Interview for Mental Status (BIMS) score of 9 indicating moderately impaired cognitive function. She was independent for transfers and ambulation. She required supervision with dressing and limited assistance with toileting. The MDS assessment indicated that she had a fall in the previous 30 days with an injury. She resided on the secured dementia unit in the facility at the time of the assessment. The nurses notes documented on 03/03/11 at 5:00 P.M., "this writer was approached by a family member in the hallway on the unit and the family member stated "you need to get down here". As this writer was walking towards I heard yelling. As this writer got closer, this writer saw resident fall back on the floor hitting head (Resident #57)". The note indicated that the family member was sent to find other staff. The nurse provided first aid and Resident #57 was sent to the emergency room for sutures to a laceration to the back of her head. The post fall investigation form was reviewed and indicated on question #23 what could be done to prevent the fall? that 1. both nurse aids were in the shower room together. 2. additional staffing from 3:00 P.M. to 6:30 P.M. during dinner to monitor increased behaviors during that time. 3. activity personnel to assist with monitoring during this time, and 6. care conference meeting with family to discuss room move to a more appropriate unit. On 03/19/11 at 7:15 P.M., Resident #57 yelled out and was observed on the floor in her same room at the end of the hall on the secured dementia unit. The nurses note indicated that she stated she was confused and getting ready for breakfast, tripped and fell , causing an abrasion on the left third finger. The post fall investigation form indicated the staff's immediate intervention was to increase observation checks to check for proper use of her walker and changes with her gait. The nurses notes documented one note on 03/20/11 at 10:40 A.M. and one note on 03/21/11 at 7: 00 P.M. There was no evidence of increased or additional documentation of checks. The social service notes indicated that on 03/30/11 Resident #57 was moved to a private room on an intermediate care unit. On 4/30/11 at 10:00 A.M. Resident #57 was no longer residing on the secured dementia unit. A nurses note indicated Resident #57 notified staff she was on the floor. She was sitting on the floor with her back to the bed. She stated she slipped off the side of the bed. The note indicated that she did not have shoes or socks on. The nurse's notes revealed there was no injury and the staff educated the cognitively impaired resident on safety and proper foot wear. The post fall investigation form indicated the Resident #57 had care planned interventions that were not in place. The interventions indicated including the bed in the low position, and proper foot wear were repeated. No new interventions were documented at that time. Observation of Resident #57 on 05/17/11 at 8:00 A.M. revealed her ambulating from the dining room on her own with her walker. She was dressed appropriately, had tennis shoes on and her gait was slow and steady. She was alert and pleasantly confused. During interview of Licensed Practical Nurse (LPN) #62 on 05/17/11 at 3:10 P.M. she stated Resident #62 had falls on the dementia unit and had no falls since she was moved to her current room. She stated staff are just aware of Residents #57's fall history and check on her more often. She stated there was no documentation of checks completed every one to two hours or as needed. Interview of the Director of Nursing on 05/20/11 at 3:15 P.M. revealed Resident #57 was on the secured dementia unit when she sustained an injury from a fall. She verified Resident #57 was in her room at the end of the hall, the nurse was in the lounge at the other end of the hall with residents, and both nurse aids assigned to the unit were in the shower room at the time of the incident. She stated another resident had wandered into Resident #57's room and she had gotten upset and was yelling at them to leave. She verified that Resident #57 was agitated by other residents coming into her room. She stated that no staff were in the immediate area to supervise and had not heard the yelling until a family member came up the hall to get someone. She stated Resident #57 was easily upset by some of the wandering behaviors on the secured unit. She verified Resident #57 fell on [DATE] and did not move off of the unit until 03/30/11. She affirmed Resident #57 had a second fall on the secured unit prior to being moved off and affirmed Resident #57 had a third fall after moving in which her care planned fall interventions were not in place. 2. Review of the clinical record for Resident #52 revealed [DIAGNOSES REDACTED]. He had history of a nasal fracture and an orbital fracture. His most recent MDS assessment indicated that he was alert and oriented, continent of bowel and bladder, independent with activities of daily living except for his gastric tube feeding and required supervision when ambulating out of his room. Review of the plan of care indicated on 01/25/07 a problem was identified as: I have fallen in the past. The goal was to be free of falls though 08/11/2011. The approaches indicated to encourage the use of a reacher, encourage to ask for help, place the call light in reach, remind the resident he has fallen before, keep the bed in the low position, use assistive devices (unspecified), non skid slippers and a defined perimeter mattress. Review of the nurses notes indicated Resident #52 had a fall on 01/07/11 at 12:45 P.M. Resident #52 was ambulating in his room independently and was unable to state what happened. He sustained facial lacerations and a left orbital fracture when he hit the trash can during the fall. The intervention was to increase observations of the resident. Review of the clinical record revealed no increased observations were documented. His plan of care indicated to check on him frequently throughout the day. It did not specify how frequently. A fall on 01/26/11 at at 5:20 A.M. resulted in no injury. He slid off the bed attempting to get up to go to the bathroom. The intervention was to place a chair next to the bed and provide him with longer gripper socks since he did not like the footies and had removed them. Resident #52 had a fall on 02/22/11 at 1:25 A.M. resulted in a bruise to his buttocks. He was attempting to pick a piece of candy up off the floor and lost his balance. The water was running in the sink across the room. A defined perimeter mattress was placed on his bed as a result of falling back from the sink onto his buttocks onto the floor at the bed side. Two falls on 03/10/11 at 6:30 A.M. he was sitting on the floor next to the toilet, and at 10:55 P.M. he was sitting on the floor in the shower room and reported he had tried to pick some paper off the floor and slid off the shower chair when the nurse aid had stepped out of the room. The first resulted in a skin tear and a bruise to his right knee and no injury resulted from the second fall. On 04/14/11 at 7:45 P.M. he sustained no injury from an unwitnessed fall that he reported to staff. He stated he was picking something up off the floor but was uninjured and got himself up. For these three falls on 03/10/11 and 4/14/11, he was educated to call staff for assistance. On 04/19/11 at 11:15 P.M. he sustained an abrasion to his right knee from an unwitnessed fall he reported to the nurse 1/2 hour after it happened. The note said he was entering his room and tripped on his walker. The intervention initiated was to use a urinal at night. No evidence of increased supervision or increased frequency of checking on the resident was documented at the time of any of the seven falls reviewed. Staff provided no documentation of frequent checks on Resident #52. The plan of care did not indicate the use of increased supervision, a chair at the bed, or the use of a urinal at night as fall interventions. Three falls on 03/10/11 and 04/14/11 had no new interventions indicated on the post fall investigation form. The timeline provided by Registered Nurse #99 as requested, indicated that the interventions of non skid socks and a chair next to the bed on 01/26/11 were not in place at the time of subsequent falls on 02/22/11 and 03/10/11. Interview of Registered Nurse (RN) #99 on 05/17/11 at 3:05 P.M. revealed that fall interventions for Resident #52 were frequently to educate him to call for assistance. She stated that education had not been effective because he did not like to call staff for help and he usually did not. She affirmed all of the interventions listed on the post fall investigations were not reflected on the plan of care. She was unable to state how a defined perimeter mattress was an effective intervention for a fall backwards from the sink onto his buttocks as described in the nurses notes on 02/22/11, or how using a urinal at night would prevent a fall when ambulating through the doorway into his room as described on 04/19/11. 3. Review of the clinical record for Resident #43 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Her fall plan of care dated 09/27/08 indicated that approaches included: encourage me to ask for help with transfers, floor mat, place bed in lowest position, place my call light in reach, remind me I have fallen in the past, 4/22 (no year) increase supervision when in room and 5/3 (no year) provide Resident a reacher. Her most recent MDS assessment completed on 02/25/11 revealed a BIMS score of 11 indicating moderately impaired cognitive function. Review of her nurses notes revealed that she had two identified falls. On 04/22/11 at 12:15 P.M. she was yelling and staff entered the room and observed her on the floor. She stated she was attempting to pick something up from the floor and slipped out of her wheel chair. She had no injuries. The post fall investigation form indicated that she was assessed, assisted back into her chair and encouraged to call for help. The note indicated that supervision would be increased when she was in her room. Documentation was noted in the nurses notes after that time on a daily basis once or twice daily. On 05/02/11 at 3:45 P.M. an entry indicated that she was again yelling and was observed by staff on the floor in front of her wheel chair. She stated she was trying to pick something up off the floor and slid out of the chair. The post fall investigation form indicated the intervention was to assist the resident back into the wheel chair. It also indicated that the resident was non cooperative and defiant with nursing instruction to use her call light. The next nurses note was dated 05/03/11 at 1:00 A.M. and then on 05/05/11 at 5:00 P.M. Observation of Resident #43 on 05/16/11 at 12:59 P.M. revealed her propelling herself about her room in a wheelchair. She was alert and pleasant. At 3:00 P.M. she was observed in her wheelchair at a table in the common lounge with her husband and requested a cold drink from staff when they passed by. On 3/1711 at 7:50 A.M. she was observed in a low bed with top 1/2 side rails up and a mat on the floor at the bedside. Her call light was in reach and her wheelchair was positioned at the foot of the bed. Her eyes were closed. A reacher was on the bed side table. Interview of LPN #62 on 05/17/11 at 1:00 P.M. revealed that the definition of increased supervision indicated on the care plan was to encourage Resident #43 to come out into common areas and to look in on her when staff walked by the room. She stated it was not documented anywhere. She stated that the intervention of the reacher dated 05/03 was added by the unit manager. She stated Resident #62 had a reacher prior to that and did not use it. She verified that the review dates on all of the plan of care problems were 03/02/11 and 05/02/11. She verified that no new intervention was added after the 05/02/11 fall and that the intervention in place on 04/22/11 for increased supervision was not documented. Interview of Registered Nurse manager #99 on 05/17/11 at 3:05 P.M. verified that Resident #43 had an intervention of increased supervision that was not defined or measurable. She stated that staff checked on her more frequently but did not document it anywhere. She could not state when or how often the resident was checked on. She also verified that she had put in place the intervention of the reacher on 05/03/11 and that the resident already had one and that she did not use it, even with encouragement. 4. Clinical record review completed on 05/20/11 revealed Resident #89 was admitted to the facility on [DATE]. Review of the "Accumulative [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the MDS with a reference date 04/30/11 revealed the resident had difficulties recalling short and long term memories and was severely impaired in daily decision making. Further review of the MDS revealed the resident was frequently incontinent of bowel and bladder, required extensive assistance with transfers, hygiene, and toiletting. Review of the current plan of care revealed Resident #89 wore attends at all times, could not control her bowel and bladder, was at risk for falls and used a wheel chair with assistance. Review of the facility's interventions revealed they would take the resident to the bathroom every four hours during the day and provide peri-care after each incontinent episode. The plan of care was silent to how much assistance the resident required with toiletting. Review of the Nurse's Notes dated 04/12/11 revealed the LPN #68 was called to the resident's room and found the resident laying on the floor on her right side, next to the commode. LPN #68 assessed Resident #68 and noted an abrasion with discoloration on the resident's right knee and a dark purple hematoma with a soft, raised center, located on the resident's right forehead that measured two inches by one and a half inches. Resident #68 had active bleeding from the hematoma site. Review of the facility's post fall investigation dated 04/12/11 revealed the resident did not have a fall in the previous 30 to 90 days, STNA #157 was assigned to care for Resident #89, staff were supposed to assist the resident with transfers, and STNA #157 was the first responder to the resident's fall. The facility identified the fall could have been prevented by not leaving the resident unattended. Observation on 0518/11 at 10:35 A.M. revealed Resident #89 sat in a chair in the lounge; there was a quarter sized dark red scab located on the resident's right forehead. In an interview on 05/19/11 at 1:20 P.M. LPN #68 stated STNA #157 assisted Resident #89 to the bathroom, located in the resident's room. LPN #68 stated STNA #157 walked out of the bathroom and towards the sink located in the resident's room to obtain linens. Resident #89 leaned and fell from the toilet. LPN #68 was notified of the incident by STNA #157. LPN #68 assessed Resident #89 following the fall. LPN #68 stated STNA #157 should not have left the resident unattended. In an interview on 05/19/11 at 1:30 P.M. STNA #157 stated Resident #89 was incontinent of bowel and bladder. STNA # 157 stated she assisted Resident #89 to the toilet around 10:30 A.M. Resident #89 wore non-skid socks. STNA #157 stated Resident #89 was on the toilet and she walked out of the toilet room towards the sink, located in the resident's room, to get linens for the resident that were on the sink. STNA #157 said she heard the resident fall and found her lying on the ground. STNA #157 stated she should have stayed with the resident and not left her unattended in the bathroom, on the toilet. 5. Resident #63 had [DIAGNOSES REDACTED]. Review of his MDS assessment dated [DATE] revealed Resident #63 had unclear speech, moderately impaired vision, with short term memory deficits and moderately impaired cognitive decision making skills. He was assessed to need extensive assist of one for bed mobility, and extensive assist of two for transfer. His balance was assessed as only able to balance during transition/walking with assistance due to unsteadiness. He was assessed as high risk for falls. Review of the medical record did not contain any Physical or Occupation Therapy Assessment, or an assessment of Resident #63's safety in the wheelchair. Review of the nursing notes dated 01/02/11 at 1:05 P.M. documented Resident #63 was found lying on the floor on his left side in the lounge. He reported he was trying to watch TV, and ended up on the floor. He was returned to his wheelchair. His vital signs were taken, range of motion performed and no injuries noted. The resident was documented as having increased jerky/spastic movements. He was returned to his wheelchair. The Event Occurrence report said the intervention was every 15 minute safety checks for 48 hours and vital signs every shift for 72 hours. The physician was called and medication changes were made to his Parkinson's medications. There was no documentation the every 15 minute safety checks were completed and the nursing notes did not document the vital signs for 72 hours were completed. Interview with LPN # 81 on 05/19/11 at 7:30 A.M. stated the safety checks are more frequent observation of the resident either by the STNA or LPN every 15 to 30 minutes. They are to document in the nursing notes, and there is a form to record the time of the check, the form is turned in to the nurse by the STNA and forwarded to the Nurse Manager. On 01/03/11 at 3:00 P.M. nursing notes say the resident was having increased jerky/spastic movements during lunch time, the physician was notified and increased the previous medication ordered on 01/02 (Mirapex). Nursing notes dated 01/04, 01/05 document resident as continuing jerky/spastic movements with a reduction of movements documented on 01/06/11. On 01/07/11 at 2:30 A.M. Resident #63 was found sitting on the floor leaning next to/in front of chair in the TV lounge. Resident #63 stated he," was trying to fix the TV. " He had no injuries. The intervention was for safety observation checks. At 1:45 P.M. on 01/07/11 Resident #63 was found sitting on the floor in front of his wheelchair in the lounge. He was not able to state what happened, but denied hitting his head. He was returned to bed. The Event Occurrence report intervention was for every 15 minute safety checks and vital signs every shift for 24 hours. There was no documentation the every 15 minute vital safety checks were completed and the nursing notes did not have vital signs for 24 hours recorded. At 6:15 P.M. on 01/07/11 Hospice service was called and Resident #63 received a reclining geri chair. Review of the nursing notes and fall interventions revealed Resident #63 was on the 15 safety checks at the time of the second fall. The medical record contained no assessment of the residents safety needs in the geri chair. No information was provided of an assessment by Physical and/or Occupational therapy of the residents strength and positioning in either chair in an effort to reduce his falls. On 02/22/11 at 8:20 A.M. Resident #63 was found on the floor on his right side in the lounge. Resident #63 was assessed as slightly lethargic, confused to time and place. He was noted having jerky/spastic movement, and responding slowly to his name. He was placed in bed. The resident had a medium size hematoma (purple) to the right side of his forehead. His vital signs were completed and range of motion checked. The interventions included every 15 minute safety checks for 24 hours, neurological checks every 4 hours for 24 hours, and vital signs for 72 hours. A neurological assessment flow sheet was submitted with neurological checks and vital signs for 24 hours. There was no documentation provided of the residents vital signs for 72 hours. A safety observation record dated 8:30 A.M. 2/22/11 was marked times 48 hours. Review of the documentation revealed safety checks were completed from 8:30 A.M. on 02/22/11 until 3:00 P.M. (no date), restarted at 11:00 PM (no date) until 7:30 P.M. on 02/24/11. No new interventions were initiated for the resident from his falls from the reclining chair. The nursing note for 02/23/11 at 3:10 P.M. revealed the activity staff heard a yell for help. Resident #63 was found on his buttocks sitting in front of his geri chair. No injuries were noted. The nursing note said Dycem (a slip resistant pad) was added to his chair to prevent further falls. Interview with LPN # 225 on 05/17/11 at 3:10 P.M. verified a fall incident report was not submitted regarding the fall on 02/23/11. On 04/18/11 at 10:45 P.M. Resident #63 was reported lying on the floor in his room. The resident was assessed with [REDACTED]. The nursing notes said "will monitor throughout the night." The next entry on a nursing note was 04/19/11 at 3:00 P.M. It documented the resident was not showing any abnormalities from being found on the floor. Review of a post fall investigation form (no date) revealed the resident had the intervention of a scoop mattress, low bed, and mat next to the bed in place. Interview with the Unit Manager # 98 on 05/17/11 at 11:00 A.M. verified a fall/incident report was not made for the 04/18/11 fall. She said they did not consider it a fall but a "near miss" since the resident fell on to a mat on the floor. Documentation provided with the facility fall packet defines a "near miss" any episode a resident looses their balance and would have fallen if not for staff intervention. This includes lowering to the floor. There were no new interventions documented with the fall from the bed. On 05/16/11 at 10:30 A.M. Resident #63 was observed in a Broda chair in the TV lounge. The chair was in the reclined position. He had his arms extended outward moving his arms in a slow, jerking motion. On 05/17/11 he was observed in bed (low) with a mattress on the floor. No side rails were up. Resident #63 was moving his arms and legs in jerky like spastic movements, and muttering. On 05/19/11 at 7:30 A. M Resident #63 was asleep in his reclining chair in the lounge area. The residents plan of care for falls was silent to the use of Dycem in his chair, low bed, or mats to the floor. It included to use his side rails for mobility, remind to use the call light, place the call light in reach for assistance with toileting, transfers, and encourage to request help for transfers. On 05/17/11 at 11:30 A.M. an interview was conducted with LPN # 86. She revealed the plans of care were not updated, and were not relevant to the resident present cognitive state and abilities. On 05/18/11 at 1:15 during an interview with the DON she provided their fall documentation checklist, and said it was the policy and procedure for fall investigation and documentation used by the facility. She said a component had been added to help investigate and monitor falls (Questions for post fall investigation form) in March. A second policy Accidents and Incidents- Investigating and Reporting (revised August 2006) was also identified as the facility procedure. The fall documentation checklist included to document all information on the medical record. Nursing progress notes include the time of incident, condition of resident, treatment, result of investigation, notification. The care plan is to initiated or updated with date, intervention initiated and goal date. The facility documentation Accidents and Incidents-Investigating and Reporting included if a resident continues to fall, staff will re-evaluate the situation and whether it is appropriated to continue or change current interventions. 6. Resident #70 had [DIAGNOSES REDACTED]. The residents MDS assessment dated [DATE] revealed he had minimal cognitive impairment, and required limited assist of one person for transfer. Resident #70 had a diabetic foot ulcer to the left foot, and an indwelling Foley catheter. Review of a plan of care multidisciplinary programs document revealed the resident was found sitting on the floor next to the bed on 03/01/11. The form documented no injuries to the resident, with interventions being to continue his toileting program, every 15 minute observation checks for 24 hours, and vital signs every shift for 72 hours. The post fall investigation form said interventions already in place included safety checks and therapy orders. The resident complained of ankle pain and an X-ray taken at the facility was negative. Nursing notes on 03/07/11 notes at 12:30 P.M. revealed the resident was found sitting on the floor next to the bed. The resident said he was trying to get into bed to rest. No injuries were noted. The interventions were the 15 minute checks for 24 hours, vital signs for 72 hours and continue strengthening program with physical therapy. A physician's orders [REDACTED]. A care plan dated 03/16/11 documented Resident #70 was found sitting on the floor in the dining room. The interventions included to continue 15 minute safety checks, continue balance/strengthening program/ take the resident to the toilet in advance of need, vital signs every shift x 72 hours, and an anti-anxiety medication as needed. No documentation of 15 minute checks, or documentation of fall investigations were provided for the 03/11, and 03/07/11 falls. No investigation was provided for the 03/16/11 fall. On 05/16/11 at 3:15 P.M. Resident #70 was observed asleep in his bed. The bed was in a low position, with no mat on either side of the bed. On 05/19/11 at 7:40 A.M. Resident #70 was observed in bed asleep. There was no mat on the floor next to his bed. STNA #227 verified Resident #70 did not have the fall intervention of the floor mat in place.

Based on record review, interview, and review of hospital documentation, the facility failed to monitor resident's oral intake and weight and failed to attempt interventions and consult with the physician and dietician, when a resident (#86) exhibited changes in oral intake resulting in an avoidable significant weight loss, and failed to provide interventions and monitor a resident (#38) identified with low [MEDICATION NAME] levels. This involved 2 of 5 residents reviewed for weight loss. The facility identified 6 residents with significant weight loss. Findings include: 1. Review of the medical record of Resident #86 revealed [DIAGNOSES REDACTED]. The resident was totally dependant on staff for personal care including eating and drinking. Review of an interdisciplinary team (IDT) note dated 10/23/10 revealed a meeting was held with the resident's power of attorney (POA) regarding a general decline in the resident's condition including difficulty with eating. The process of obtaining a swallowing evaluation was reviewed and what the recommendations would be reviewed including placement of a gastrostomy tube ([DEVICE]) if the resident was no longer able to eat. The documentation further stated the POA would talk with the family and let the facility know when he made a decision. Review of a swallowing study dated 10/26/10 revealed the resident was able to consume her current diet (mechanical soft) with nectar thick liquids safely with full feed assistance. Interdisciplinary team (IDT) notes dated 12/29/10 stated the POA declined the options discussed earlier and wanted to continue the routine as before. The resident's weight was 163.3 pounds with no significant weight loss at that time. Review of the resident's nutrition plan of care dated 01/11/11, revealed she was identified as having difficulty swallowing and not able to feed herself without assistance. The care planned interventions included to assist the resident with meals, encourage her to take her time drinking fluids, observe for signs and symptoms of aspiration, provide supplements/snacks as ordered and provided diet/liquids as ordered. A nutritional assessment dated [DATE] documented the resident with no significant changes at that time. The assessment stated the resident's weight loss was expected. The dietary technician documented the resident's intake average was 25 to 50 percent and that she was receiving a nutritional supplement (Resource) with meals. She documented the resident had inadequate food/beverage intake related to her progression of dementia. Dietary progress notes dated 01/17/11 stated the resident continued to have episodes of choking/aspiration and that she did well with food but had trouble with liquids. The notes stated the resident's appetite had decreased and she showed little interest in eating but would drink if handed liquids. The notes further stated nursing had addressed a tube feeding with the family and they did not wish it at that time. The notes stated the resident would remain on her current diet with weight loss expected. Review of nurse's notes dated 01/27/11 revealed the resident was observed holding and pocketing food in her mouth, with occasional coughing with attempts to drink honey thickened liquids. Her weight was 161.7 pounds. The next nurse's note entry was dated 02/01/11 and stated the resident continued to pocket food and hold it without swallowing and that stimulation to her throat area was provided with minimal effect. The note stated the resident refused to eat at times and she would continue to be monitored. Nurse's notes dated 02/02/11 at 6:00 P.M. documented the resident ate 20 percent of her dinner and continued to hold food in her mouth needing prompting to swallow food and liquids. Nurse's notes dated 02/05/11 at 12:30 P.M. stated the resident's appetite was poor and that she ate only 20 percent of her lunch and her fluids were served. Nurse's notes dated 02/07/11 at 9:00 P.M. stated the resident ate all 3 meals poorly that day and continued to hold food in her mouth and cough when given honey thick liquids. The documented stated the physician was in to see the resident on 02/09/11 with no new orders given. Review of the physician progress notes [REDACTED]. Nurse's notes dated 02/10/11 at 7:00 P.M. stated the resident's appetite at dinner time was poor, she ate 10 percent of her meal, refused liquids and spit bites of food into her hand. On 02/11/11 at 7:30 P.M., nurse's notes documented the resident continued to hold and pocket food at meals and that honey thick liquids were given. The notes stated food and liquids continued to run out of her mouth and that stimulation to the resident's throat for swallowing was provided. Nurse's notes dated 02/14/11 at 11:30 A.M. stated the resident's appetite was poor, she pocketed food in her mouth and needed much encouragement to swallow. The notes stated the resident let food run out of her mouth and that she continued with honey thick liquids and a pureed diet. There was no documentation to indicate the physician or the dietician were notified of the resident's continued poor intake and swallowing difficulty. There was no documentation of monitoring of the resident's oral intake and nor changes to her dietary orders. On 02/15/11 at 7:30 P.M. the resident's POA requested the nurse observe a change in the resident's condition. The resident was documented with right sided facial drooping. The physician was notified and the resident was subsequently transported to the hospital. Review of the resident's hospital medical history and physical dated 02/15/11, revealed she had right facial drooping of unknown origin and her mucous membranes were dry. The history included that the resident had not taken oral food for the last four days per her POA. Her laboratory test results revealed an elevated sodium of 152, potassium of 3.5 and elevated blood urea nitrogen (BUN) of 27. The history and physical stated the impression of the resident's condition was a [MEDICAL CONDITION] [MEDICAL CONDITION] and hypokalemia. The resident was given intravenous fluids to replace her fluid deficit. Review of a swallowing evaluation dated 02/16/11, revealed the resident had moderate dysphasia (total assistance, supervision or strategies). The evaluation stated the resident may require alternate nutrition secondary to poor cognitive ability and that once food/liquid was placed her in mouth, her swallowing appeared functional. Review of a hospital nutritional assessment dated [DATE] revealed the resident weighed 158 pounds, she needed assistance with feeding and had chewing/swallowing difficulties. According the hospital discharge summary dated 02/19/11, the resident's principal [DIAGNOSES REDACTED]. The documentation revealed the resident had some increased nitrogen in the blood (azotemia) suggestive of dehydration, a urinary tract infection and metabolic [MEDICAL CONDITION]. A CT scan was negative for an acute [MEDICAL CONDITIONS]. The summary further stated the resident improved with intravenous hydration and was started on antibiotics for a urinary tract infection. She was started on appetite stimulants to improve her appetite. The discharge instructions included honey thick liquids, assist with feeding, boost pudding twice a day and as needed. The discharge summary further stated the resident's overall prognosis was poor given her advanced dementia and multiple [MEDICAL CONDITION]'s and that the family may reach a point where they had to decide on a percutaneous endoscopic gastrostomy (PEG) tube to maintain the resident's nutritional status versus other treatment options. The summary stated the resident was not at that point yet. Resident #86 was readmitted to the facility on [DATE] with physician orders [REDACTED]. Further review of the medical record revealed no interventions put in place to monitor the resident's food and fluid intake. There was no readmission assessment completed of the resident's nutritional or hydration needs. On 02/25/11, a physician's orders [REDACTED]. Review of the resident's nutritional progress notes revealed no documentation of weekly re-weights, offering of substitutes if the resident at less than 50 percent nor review by the dietary technician (DT) or registered dietitian (RD) for nutritional intervention. Nurse's notes dated 02/27/11 documented the resident continued with holding food and coughing when fed upon return to the facility. An IDT note dated 02/28/11 stated the resident's POA called about the resident's increased difficulty in swallowing and coughing with eating and wanted to inquire about the feeding tube process. An order was written on 02/28/11 for a speech evaluation. Review of the speech evaluation dated 03/01/11 revealed a recommendation was made for non oral means of nutrition due to severe oral and pharyngeal dysphasia and weight loss per the nurse. The family was made aware and a decision was pending. On 03/02/11, the resident's weight was documented as 136.4 pounds. There was no documented evidence the resident was weighed upon her readmission nor that her weights were being monitored with her continued decreasing oral intake. On 03/02/11 the POA was notified of the resident's weight loss and consented to the placement of the gastrostomy tube. During interview on 05/18/11 at 10:30 A.M., the unit manager/registered nurse (RN) #99 stated the resident's family was informed of the resident's poor intake and the option of a tube feed was discussed over a period of months. She stated the resident was being monitored by the dietary technician who was aware of the resident's food and fluid intake. RN #99 stated they do not monitor and document resident's oral intakes without a physician's orders [REDACTED]. Review of the facility's weight policy dated 12/10/10, revealed the policy stated residents would be weighed monthly within the first seven days of the month and re-weighed if there was a five pound or more difference from the previous weight. Any resident noted to have significant weight loss would be reviewed by the dietary technician (DT) or registered dietitian (RD) to determine the need for appropriate nutritional intervention. The policy further stated all residents noted to have significant weight loss may be weighed weekly for four weeks by nursing staff and would be reviewed by the DT or RD. If the resident's weight did not remain stable, the DT/RD would assess for the possible need of continuing weight or nutritional interventions. All residents would be offered a substitute if they consumed less than 50 percent of the meal served and the charge nurse or DT would be notified if the resident refused a supplement. Lastly, the Nutritional Care team would meet on a monthly basis or more often as needed to address all residents that the DT or RD deemed to be at significant nutritional risk. 2. Clinical record review completed on 05/20/11 revealed Resident #38 was admitted to the facility on [DATE]. Review of the Accumulative [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS) with a reference date 02/10/11 revealed the resident had moderate cognition, required supervision with eating, did not experience significant weight loss, and did not receive a therapeutic diet. Lastly, review of the MDS revealed the resident was at risk of developing pressure sores, currently had one, stage two pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough), and two venous and arterial ulcers. Further review of the assessment revealed he was not receiving a multivitamin, his average daily oral intake was 75%, he was independent with feeding, did not express food dislikes, and had increased protein needs related to his pressure ulcers. Review of Resident #75's plan of care revealed he had open areas on his right lower leg, left heel, ate some meals in the dining room, and could choose what he wanted to eat for his meals each day. Review of the facility's interventions revealed the facility would obtain and monitor lab/diagnostic work as ordered, assist the resident to the dining room each day, provide the resident with a weekly menu, allow the resident to make his own meal choices each day and a regular diet. Review of the Dietary Progress Notes dated 02/13/11 revealed Resident #38 was trying to lose weight and often left 25 percent (%) of his meal uneaten or refused to eat dessert. The resident had recurrent pressure/open areas to his heels resulting in increased protein needs. A recommendation was made for a nutritional amino acid supplement to promote wound healing (Juven). Review of the Nutritional assessment dated [DATE] revealed the resident weighed 217 pounds, had no weight changes, and had open/pressure areas to his heels and coccyx. Further review of the assessment revealed he was not receiving a multivitamin, his average daily oral intake was 75%, he was independent with feeding, did not express food dislikes, and had increased protein needs related to his pressure ulcers. Further review of the Dietary Progress Notes dated 02/21/11 revealed Resident #38 had a vascular area to his right lower leg, superficial open areas, and a scabbed area to his left heel. The note contained no documentation of the resident's acceptance of [MEDICATION NAME] supplement. Review of the laboratory values dated 02/23/11 revealed an [MEDICATION NAME] level of 2.6 grams per deciliter (g/dL) and review of the laboratory values dated 04/09/11 revealed an [MEDICATION NAME] level of 2.3 g.dL (The normal range is 3.4 - 5.4 g/dL). Review of the Dietary Progress Notes dated 04/29/11 revealed Resident #38 had a decreased appetite in the last two weeks, open areas, and deep tissue injuries. The note documented "supplements were offered." Review of the resident's weight revealed the resident experienced gradual weight loss; his weight was 209 pounds on 05/01/11. Review of the Nurse's Note's dated 04/29/11 revealed the resident's "appetite was poor, taking minimal protein in, refuses most supplements as well". Lastly, review of the Dietary Progress Notes dated 05/17/11 revealed "nutrition" was discussed with the resident's evening nurse. The resident refused nutritional supplements such [MEDICATION NAME] and Promod (a protein powder supplement) but sometimes accepted Magic Cups (a frozen nutritional supplement). The Dietary Progress Notes revealed the resident's [MEDICATION NAME] level may be low due to the resident's advanced age, [MEDICAL CONDITION], and low hematocrit and hemoglobin levels. Further, the Dietary Progress Notes revealed the resident sometimes needed assistance with eating, although he often refused it causing fluctuating oral intake. The Dietary Progress Notes revealed Resident # 38''s nurse verified the resident had a blister to his foot and a vascular ulcer "which nutrition will not fix". Review of the resident's clinical record, including nutrition notes, revealed no evidence of what type, when, or for how long a nutrition, vitamin, or mineral supplement was offered and/or administered to the resident and no evidence that the resident received education regarding the importance of consuming protein rich foods, minerals, and vitamins to promote wound healing. Additionally, there was no evidence the resident's declining [MEDICATION NAME] level was addressed by a nutrition professional, no evidence the resident's nutritional needs were assessed based on the extent of his pressure and vascular skin areas, and no evidence the facility attempted to implement nutritional interventions, other than previously refused nutrition supplements, to meet the increased protein needs for Resident #38. Observations on 05/16/11 at 5:35 P.M. and on 05/17/11 at 9:00 A.M. and 12:25 P.M. revealed the resident received a regular diet and fed himself without staff assistance. The resident's oral intake was greater than 50%; there was no observation staff offered the resident a nutritional supplement. In an interview on 05/17/11 at 2:45 P.M. Dietetic Technician (DT) #1 stated she offered Resident #38 Ensure supplements, however the resident refused. DT #1 stated there was not much else she could do (nutritionally) because the resident refused supplements. DT #1 verified she recommended [MEDICATION NAME] supplement as indicated in the Dietary Progress Notes dated 02/13/11 . DT #1 stated she was not aware the resident's [MEDICATION NAME] level dropped from 2.6 to 2.3. DT #1 stated she could start the resident on a multivitamin or zinc supplement. In an interview on 05/17/11 at 2:55 P.M. LPN #72 stated she offered the resident a nutritional supplement, such as an Ensure, when he consumed less than 50% of his meal. LPN #72 also stated the staff did not record the resident;' meal percentage. In an interview on 05/17/11 at 3:03 P.M. RD #300 stated she was getting an update on what the facility had done for the resident, nutritionally, from LPN #222. RD #300 did not mention the resident's current pressure sores, decline in [MEDICATION NAME] level, or vitamin or supplement intake. In an interview on 05/17/11 at 3:05 P.M. LPN #222 stated she tried to offer the resident Ensure supplements [MEDICATION NAME], "off and on" and she was "not sure what all they've tried". LPN #222 verified the resident did not routinely receive any nutritional supplement. In an interview on 05/18/11 at 9:50 A.M. Medical Director #1 stated the bottom line with pressure sores was keeping the pressure off of the areas and nutrition. During an interview on 05/18/11 at 5:20 P.M. LPN #72 stated the resident had an open blister to the left inner heel, one stage two to the left heel that measured 1.00 cm by 0.50 cm with a tiny opening, the vascular are to the right lateral leg that measured 4.50 cm by 3.25 cm with the exposed tendon, one stage two to the left buttock (the epidermis was gone) and a scab to the right buttock. In an interview on 05/19/11 at 4:05 P.M. DT #1 stated she was not aware each of the resident's pressure areas. DT #1 stated the facility staff discussed residents' skin and weight concerns in a monthly meeting, however, she stated Resident #38 was not discussed because he did not have weight loss and the nursing staff informed her the resident's skin concerns could not be helped with nutrition. Lastly, in an interview on 05/19/11 at 5:20 P.M. RN #98 stated the nurses used "nursing judgement" to determine if they should offer the resident a supplement or not. RN # 98 stated they just recently started offering the resident supplements when he ate less than 50% of his meal. RN #98 stated she talked to DT #1 just this week about the resident's decline in [MEDICATION NAME]. Review of the facility's weight policy, dated 12/2010, revealed all newly admitted residents would be weighed upon admission and weekly thereafter for three weeks. They would be re-weighed if there was a five pound or more difference from the previous weight. If the weight did not remain stable during that four weeks the DT or Dietitian (RD) would assess. Additionally, residents would be weighed monthly within the first seven days of the month and re-weighed if there was a five pound or more difference from the previous weight. Any resident noted to have significant weight loss would be reviewed by the DT or RD to determine the need for appropriate nutritional intervention. All residents noted to have significant weight loss may be weighed weekly for four weeks by nursing staff and would be reviewed by the DT or RD. If the resident's weight did not remain stable, the DT/RD would assess for the possible need of continuing weight or nutritional interventions. All residents would be offered a substitute if they consumed less than 50% of the meal served and the charge nurse or DT would be notified if the resident refused a supplement. Lastly, the Nutritional Care team would meet on a monthly basis or more often as needed to address all residents that the DT or RD deemed to be at significant nutritional risk.