Every finding on record at Sienna Skilled Nursing & Rehabilitation

Based on review of medical records, facility policy review, and interview, the facility failed to ensure appropriate discharge plans were in place to meet residents post discharge needs. This affected three residents (Residents #148, #153, and #161) of three residents reviewed for discharge. The facility census was 78.Findings Include:1. Review of the closed medical record for Resident #148 revealed admission to facility on 06/18/26 for diagnoses including chronic respiratory failure, lung disease, heart failure, high blood pressure, oxygen dependence, anxiety, irregular heart rate, and constipation.Review of the Minimum Data Set (MDS) 3.0 initial comprehensive assessment completed on 06/25/26 for Resident #148 revealed a brief interview for mental status (BIMS) score of 14/15 indicating no cognitive impairment. Further review of the MDS 3.0 assessment revealed Resident #148 required substantial to maximum assistance from staff for bathing, dressing, and bed mobility. Resident #148 had dependent mobility while at facility and required the use of a wheelchair and continuous oxygen use. Resident #148 discharge plan was to return to the community. The assessment also indicated that the preliminary discharge planning occurred with Resident #148 only and no family involvement.Resident #148's progress noted dated 07/24/26 at 12:50 P.M. and authored by the Social Services Designee (SSD) #524 revealed Resident #148 requested discharge on [DATE]. The progress note further revealed Resident #148 declined home health services despite explanation of the benefits for home health services. SSD #524 ordered a wheelchair bedside commode through a local medical equipment company to be delivered to Resident #148 home and noted Resident #148 son would be picking her up from the facility.Resident #148's progress note dated 07/24/26 at 5:15 P.M. revealed Resident #148 was discharged from the facility to home via facility transportation services.Further review of the progress notes revealed no other documentation after the nursing progress noted dated 07/24/26 at 5:15 P.M. until a progress note was entered on 07/27/26 at 2:33 P.M. by SSD #524 revealing a notation that a referral was made to adult protective services (APS). There was no indication of why APS was notified.Interview on 08/18/26 at 12:55 P.M. with an anonymous source revealed that Resident #148 was not discharged to her home on [DATE] but instead was left at an elderly neighbor's home by the facility staff including a driver, a certified nursing assistant and the business office manager.Interview on 08/18/26 at 1:06 P.M. with Resident #148's daughter, who lives in North Carolina, revealed she was not made aware of any discharge plan on 07/24/26 and had not spoken with anyone at the facility since the initial care conference after her Resident #148 admission to the facility. Resident #148's daughter revealed she initially was going to have Resident #148 move to North Carolina with her on discharge and that her brother couldn't take care of Resident #148 anymore. Resident #148's daughter reported that she herself had to recently have a procedure and was not able to take Resident #148 home until she recovered herself and thought Resident #148 was going to be at the facility longer. Resident #148's daughter reported that she was made aware after Resident #148 discharge to the neighbors on 07/27/26 when subsequently Resident #148 was taken to the hospital by emergency squad due to breathing difficulty while at the neighbor's home. Resident #148 expired on 08/03/26.Interview on 08/18/26 at 1:21 P.M. with Business Office Manager (BOM) #318 revealed she met the facility transportation van and Resident #148 at the resident's home. BOM #318 reported she was concerned for Resident #148 since her son had not come to pick her up and she lived in the area, so she wanted to make sure Resident #148 was okay on her way home. BOM #318 also reported that Resident #148 asked her personally to take her home after her son did not show up and would not answer phone calls or return messages. BOM #318 reported that Resident #148 was insisting she be discharged and was asking everyone for a ride home. BOM #318 further revealed Resident #148's son arrived right after the transportation van arrived and reported to BOM #318 that Resident #148 could not stay at home because there was no electricity and the Resident required continuous oxygen. BOM #318 reported the son went and spoke with the neighbor across the street and then came out and spoke to Resident #148 and told her she would need to go to the neighbors for a while. BOM #318 reported that Resident #148 agreed to the change in plans and was taken to the neighbor's home by the transportation driver. BOM #318 revealed she did not enter Resident #148's home, did not enter the neighbor's home, and she did not speak with the neighbor about Resident #148 staying there. BOM #318 then reported she went home. BOM #318 revealed she did not notify anyone at the facility about the change in the discharge plan or that Resident #148 was taken to the neighbor's home and not her own. BOM #318 reported she did notify SSD #524 on Monday 07/27/26 of her concerns about the electricity and having to leave Resident #148 at the neighbor's home. BOM #318 reported SSD #524 replied that she was going to notify adult protective services. Interview on 08/18/26 at 1:23 P.M. with Transportation Driver (TD) #346 revealed he did transport Resident #148 to her home on [DATE] after 5:00 P.M. and upon arrival met the BOM #318 and Certified Nursing Assistant (CNA) #342 at the resident's home. TD #346 revealed Resident #148's son was at the resident's home and told the staff to take Resident #148 to the neighbor's home. TD #346 was could not recall why the son wanted Resident #148 to go the neighbor's home but reported that Resident #148 agreed to go to the neighbors and TD #346 proceeded to take Resident #148 to the neighbors across the street in her wheelchair. TD #346 revealed at that time he took Resident #148 into the neighbor's house in her wheelchair and then left. TD #346 denied speaking with the neighbor himself. TD #346 denied reporting to anyone at the facility the events and that Resident #148 was left at a neighbor's home instead of her own home as planned. TD #346 also agreed that the scenario was highly unusual and he had never had to take a resident to another location at the last minute before.Interview on 08/18/26 at 1:55 P.M. with CNA #342 revealed on 07/24/26 she was going home from work around 5:00 P.M. and agreed to drive her car to Resident #148's home so the transportation van could follow her. CNA #342 reported she lived nearby Resident #148 and the cell phone reception was not good in the area and if the driver got lost, he wouldn't be able to call anyone. CNA #342 then reported she arrived at the same time as the transportation van to Resident #148 home and BOM #318 was there and so was Resident #148's son. CNA #342 further revealed the son said Resident #148 could not stay in the home because the son hadn't gotten anything ready and did not have any food in the house. CNA #342 also reported that the son told Resident #148 she would have to go and stay with the neighbor until he could get things taken care of and Resident #148 agreed. Further interview with CNA #342 revealed TD #346 then took Resident #148 to the neighbor's home in her wheelchair. CNA #342 reported she talked with BOM #318 about social things for a few minutes then left. CNA #342 denied going into the neighbor's home or speaking with the neighbor. CNA #342 revealed she was asked to pick up another shift during this time and agreed and returned to the facility where she reported the events and situation related to Resident #148 to the Director of Nursing (DON).Interview on 08/18/26 at 4:26 P.M. with the DON revealed she was made aware of Resident #148 being taken to her neighbor's home on [DATE] by CNA #342 when CNA #342 returned to the facility to work that evening. The DON verified she was aware of the reported concerns of Resident #148 not having food or electricity at her own home but did not do anything with that information until Monday 07/27/26 when she reported it to the SSD #524 during morning report. The DON revealed she did not have any concerns about the resident being at the neighbor's home and confirmed there was no documentation or evidence that anyone from the facility had spoken with the neighbor to determine the safety of the resident. DON verified there was no documentation in Resident #148 medical record indicating the events occurring with the change in discharge plan and that there was no documentation of why APS was notified. DON confirmed there was no documentation in the medical record that the community medical provider was notified about the discharge status of Resident #148. Interview on 08/18/26 at 4:30 P.M. with SSD #524 revealed she was not made aware of Resident #148 being transported to the neighbor's home until Monday 07/27/26. SSD #148 reported she received a phone call from the neighbor's granddaughter on Monday 07/27/26 asking why Resident #148 was left with her elderly grandmother whose husband had just passed away, and that her grandmother could not and should not be caring for Resident #148. SSD #524 reported that she was also notified by staff on Monday 07/27/26 of Resident #148 being left at the neighbor's but could not recall if she was notified by staff or the neighbor's granddaughter first about the situation and then SSD #524 immediately put in an APS referral due to concerns about the food and electricity.2. Review of the closed medical record for Resident #153 revealed admission to the facility on [DATE] with diagnoses including respiratory failure, lung disease, anxiety, anemia (low blood count), opioid abuse, bipolar disorder (mood fluctuates), hoarding disorder, and fibromyalgia (chronic diffuse nerve pain).Review of the MDS 3.0 initial comprehensive assessment completed on 07/24/26 for Resident #153 revealed a BIMS score of 15/15 indicating no cognitive impairment. Further review of the MDS 3.0 assessment revealed Resident #153 required partial to moderate assistance from staff for bathing, dressing, and supervision with transfers and walking. The assessment revealed Resident #153 discharge plan was to return to the community. The assessment also indicated the preliminary discharge planning occurred with Resident #153 only and no family involvement.Resident #153's progress note dated 07/30/26 at 12:50P.M. revealed Resident #153 was discharged from the facility to home and was picked up and transported by her community case worker on 07/30/26.Review of discharge summary for Resident #153 completed on 07/30/26 by Registered Nurse (RN) #566 and cosigned by Licensed Practical Nurse (LPN) #300 revealed an outpatient physical therapy (PT)/occupation therapy (OT) prescription was provided to the resident on discharge. The discharge summary under the activity tab, stated caution when ambulating (walking), transferring. There was no evidence information was provided regarding the locations and contact numbers for outpatient therapy services. There was no evidence of transport information or contact numbers offered for assistance with outpatient services.Interview on 08/18/26 at 12:00 P.M. with SSD #524 revealed that almost every resident who was discharged from the facility would be set up with home health services. SSD #524 further revealed that there was an issue sitting up home health sometimes because there was only one home health agency in the area that would accept Medicaid insurance and most times the agency was full and could not accept new referrals. SSD #524 revealed when this happened she would notify the resident about not being able to get home health and notify the nursing staff to get a script for out-patient physical and occupational therapy services and put the script in the resident's discharge folder.Interview on 08/18/26 at 12:30 P.M. with the Physical Therapist (PT) #103 revealed she was unaware that residents on Medicaid insurance were being sent to outpatient therapy services on discharge. PT #103 reported that she recommended home health service due to residents not always being able to navigate the distance to outpatient services or physically be ready for out-patient therapy services and was not notified if the plan changed to outpatient.Interview on 08/18/26 at 12:35 P.M. with the Speech Language Pathologist (SLP) #101 who was covering as the director of therapy department while the regular manager was on vacation, and who also worked full time at the facility for the past 10 years, revealed she was unaware that Medicaid insured residents were being sent to outpatient therapy services due to no availability of in-home therapy services.An attempt to interview Resident #153's case manager was made on 08/18/16 at 2:50 P.M. without success. The whereabouts and health status of Resident #153 at the time of survey were unknown. Interview on 08/18/26 at 3:12 P.M. with LPN #300 revealed he had worked at the facility for six years and generally worked on the skilled nursing unit. LPN #300 revealed on average he would discharge residents 1-2 times per week. LPN #300 confirmed he provided each resident with a discharge packet and a copy of their discharge summary and then reviewed the discharge summary with the resident and family if present. LPN #300 denied going over outpatient therapy options with resident who were prescribed outpatient PT/OT services and reported social services takes care of that part.Interview on 08/18/26 at 3:15 P.M. with SSD #524 revealed she did not provide a list or contact information for outpatient therapy services for residents to contact on discharge. SSD #524 denied explaining to residents that they would need transportation 2-4 times per week for outpatient therapy or offering information on transportation options and referrals. SSD #524 further reported that transportation was difficult to set up for residents on Medicaid insurance and that many of the Medicaid managed care insurances usually only contracted with specific transportation providers and that the residents would call the number on their insurance cards to set up transportation with Medicaid providers. SSD #524 denied explaining this process to Residents who were prescribed outpatient therapy and that were on managed Medicaid services.Interview on 08/18/26 at 4:20 P.M. with DON confirmed there was no evidence in Resident #153's medical record that information was provided for options of outpatient services and contact information as well as transportation information and contact numbers if needed.3. Review of the closed medical record for Resident #161 revealed admission to the facility on [DATE] with diagnoses including respiratory failure, lung disease, diabetes, anxiety, delusional disorder, poor circulation with swelling and ulcers of the lower legs, high blood pressure, heart disease, and fibromyalgia (chronic diffuse nerve pain).Review of the MDS 3.0 initial comprehensive assessment completed on 07/03/26 for Resident #161 revealed a BIMS score of 15/15 indicating no cognitive impairment. Further review of the MDS 3.0 assessment revealed Resident #161 required substantial to maximum assistance from staff for bathing, dressing, bed mobility, transferring, and standing. Resident #148 used a wheelchair for navigation and required staff supervision with use. The comprehensive assessment revealed that Resident #161 discharge plan was to return to the community. The assessment also indicated that the preliminary discharge planning occurred with Resident #161 only and no family involvement.Review of the social services progress noted dated 08/07/26 at 1:39 P.M. and authored by SSD #524 revealed Resident #161 was planned for discharge on [DATE] and the SSD attempted to set up home health services but the only local agency that would accept Resident #161 insurance was full and would not accept resident for services. SSD #524 further noted a prescription for outpatient PT/OT services would be provided on discharge.Review of discharge summary for Resident #161 completed on 08/09/26 by RN #566 and cosigned by LPN #300 revealed that the only local home health agency that accepted Resident #161 insurance was full and unable to accept Resident #161 for services. As a result, an outpatient PT/OT script was provided for the resident on discharge. The discharge summary for Resident #161 revealed activity limitations to include, caution when ambulating, transferring, and assistive devices device use to including wheelchair for home use. There was no evidence of any information provided regarding therapy locations and contact numbers for outpatient therapy services. There was no evidence of transport information or contact numbers offered for assistance with outpatient services.Interview on 08/18/26 at 12:00 P.M. with SSD #524 revealed that almost every resident who was discharged from the facility would be set up with home health services. SSD #524 further revealed that there was an issue sitting up home health sometimes because there was only one home health agency in the area that would accept Medicaid insurance and most times the agency was full and could not accept new referrals. SSD #524 revealed when this happened she would notify the resident about not being able to get home health and notify the nursing staff to get a script for out-patient physical and occupational therapy services and put the script in the resident's discharge folder.Interview on 08/18/26 at 12:30 P.M. with the Physical Therapist (PT) #103 revealed she was unaware that residents on Medicaid insurance were being sent to outpatient therapy services on discharge. PT #103 reported that she recommended home health service due to residents not always being able to navigate the distance to outpatient services or physically be ready for out-patient therapy services and was not notified if the plan changed to outpatient.Interview on 08/18/26 at 12:35 P.M. with the Speech Language Pathologist (SLP) #101 who was covering as the director of therapy department while the regular manager was on vacation, and who also worked full time at the facility for the past 10 years, revealed she was unaware that Medicaid insured residents were being sent to outpatient therapy services due to no availability of in-home therapy services.Interview on 08/18/26 at 3:12 P.M. with LPN #300 revealed he had worked at the facility for six years and generally worked on the skilled nursing unit. LPN #300 revealed on average he would discharge residents 1-2 times per week. LPN #300 confirmed he provided each resident with a discharge packet and a copy of their discharge summary and then reviewed the discharge summary with the resident and family if present. LPN #300 denied going over outpatient therapy options with resident who were prescribed outpatient PT/OT services and reported social services takes care of that part.Interview on 08/18/26 at 3:15 P.M. with SSD #524 revealed she did not provide a list or contact information for outpatient therapy services for residents to contact on discharge. SSD #524 denied explaining to residents that they would need transportation 2-4 times per week for outpatient therapy or offering information on transportation options and referrals. SSD #524 further reported that transportation was difficult to set up for residents on Medicaid insurance and that many of the Medicaid managed care insurances usually only contracted with specific transportation providers and that the residents would call the number on their insurance cards to set up transportation with Medicaid providers. SSD #524 denied explaining this process to Residents who were prescribed outpatient therapy and that were on managed Medicaid services.An attempt to interview Resident #161 was made on 08/18/26 at 2:47 P.M. and 3:34 P.M. without success. The whereabouts and health status of Resident #161 was unknown at the time of survey.Interview on 08/18/26 at 4:20 P.M. with DON confirmed there was no evidence in Resident #161's medical record that information was provided for options of outpatient services and contact information as well as transportation information and contact numbers if needed.Review of the policy titled, admission Discharge, and Transfer, and undated, revealed, the facility will assure that sufficient preparation and orientation is provided to the resident for a safe and orderly transfer or discharge.This deficiency represents non-compliance investigated under Complaint Numbers 3131151 and 3124875.

Based on closed medical record review, facility policy review, and interview, the facility failed to ensure resident discharge summaries were conveyed to the community healthcare providers upon discharge. This affected two residents (Residents #153 and #161) of three residents reviewed for discharge. The facility census was 78.Findings Include:1. Review of the medical record for Resident #153 revealed admission to the facility on [DATE] with diagnoses including respiratory failure, lung disease, anxiety, anemia (low blood count), opioid abuse, bipolar disorder (mood fluctuates), hoarding disorder, and fibromyalgia (chronic diffuse nerve pain).Review of the Minimum Data Set (MDS) 3.0 initial comprehensive assessment completed on 07/24/26 for Resident #153 revealed a BIMS score of 15/15 indicating no cognitive impairment. Further review of the MDS assessment revealed Resident #153 required partial to moderate assistance from staff for bathing, dressing, and supervision with transfers and walking. The assessment revealed Resident #153 discharge plan was to return to the community. The preliminary discharge planning occurred with Resident #153 only and no family involvement.Review of the medical record for Resident #153 revealed a planned discharge from the facility on 07/30/26.Review of discharge summary for Resident #153 completed on 07/30/26 by Registered Nurse (RN) #566 and cosigned by Licensed Practical Nurse (LPN) #300, listed the resident's community physician and their phone number with a notation for Resident #153 to call and make a follow up appointment with the primary care doctor in 7-10 days as well as the pulmonary doctor. There was no evidence a copy of the discharge summary was provided to the community/follow up medical provider. There was a check box (not checked) for discharge notification called to community medical doctor. Interview on 08/18/26 at 12:00 P.M. with the Social Services Designee (SSD) #524 revealed she did not provide any communication or discharge summaries to the community providers and that would be the responsibility of the nursing department.Interview on 08/18/26 at 3:12 P.M. withLPN #300 revealed he had worked at the facility for six years and generally worked on the skilled nursing unit. LPN #300 also reported that on average he would discharge residents 1-2 times per week. LPN #300 denied providing a copy of the discharge summary to the community providers when discharging residents.Interview on 08/18/26 at 4:20 P.M. with the Director of Nursing (DON) revealed that the discharge process included the nursing staff providing the discharge summary that included reconciled medications to the residents/families on discharge and that the resident/families would be responsible for providing the information to their community medical provider during their follow up appointments. The DON confirmed the facility did not have a process for providing all community medical providers with a recapitulation of the resident's information on discharge from the facility. 2. Review of the medical record for Resident #161 revealed admission to the facility on [DATE] with diagnoses including respiratory failure, lung disease, diabetes, anxiety, delusional disorder, poor circulation with swelling and ulcers of the lower legs, high blood pressure, heart disease, and fibromyalgia (chronic diffuse nerve pain).Review of the MDS 3.0 initial comprehensive assessment completed on 07/03/26 for Resident #161 revealed a (BIMS) score of 15/15 indicating no cognitive impairment. Further review of the MDS 3.0 assessment revealed Resident #161 required substantial to maximum assistance from staff for bathing, dressing, bed mobility, transferring, and standing. Resident #161 used a wheelchair for navigation and required staff supervision with use. The assessment revealed Resident #161's discharge plan was to return to the community. The preliminary discharge planning occurred with Resident #161 only and no family involvement.Review of the medical record for Resident #161 revealed a planned discharge from the facility on 08/09/26.Review of discharge summary for Resident #161 completed on 08/09/26 by RN #566 and cosigned by LPN #300, listed her community physician and their phone number with a notation for Resident #161 to call and make a follow up appointment with the primary care doctor in 7-10 days as well as a scheduled appointment with a specialist on 08/19/26 at 1:30 P.M. There was no evidence a copy of the discharge summary being provided to the community/follow up medical provider. There was a check box (not checked) for discharge notification called to community medical doctor. Interview on 08/18/26 at 12:00 P.M. with the SSD #524 revealed she did not provide any communication or discharge summaries to the community providers and that would be the responsibility of the nursing department.Interview on 08/18/26 at 3:12 P.M. with LPN #300 revealed he had worked at the facility for six years and generally worked on the skilled nursing unit. LPN #300 also reported that on average he would discharge residents 1-2 times per week. LPN #300 denied providing a copy of the discharge summary to the community provider when discharging residents.Interview on 08/18/26 at 4:20 P.M. with the DON revealed that the discharge process included the nursing staff providing the discharge summary that included reconciled medications to the residents/families on discharge and that the resident/families would be responsible for providing the information to their community medical provider during their follow up appointments. The DON confirmed the facility did not have a process for providing all community medical providers with a recapitulation of the resident's information on discharge from the facility. Review of the policy titled admission Discharge, and Transfer, and undated, revealed no evidence in the procedure for transfer or discharge to notify the community medical provider of resident discharge or providing the community medical provider with a copy of the discharge summary or a recapitulation.This deficiency represents non-compliance investigated under Complaint Numbers 3131151 and 3124875.

Based on temperature logs, policy and interview, the facility failed to consistently monitor food and drink serving temperatures. This affected all but one Resident #15 who did not receive nutrition from the kitchen. The census was 80.Findings include: Tour of the kitchen was on 2/5/26 at 8:19 A.M. Review of the food temperature log revealed the following:On 01/23/26 there were no coffee temperatures recorded for the dinner meal.On 01/28/26 there were no food or drink temperatures recorded for dinner.On 01/29/26 there were no food or drink temperatures documented for breakfast or lunch.On 01/30/26 there were no food or drink temperatures documented for the whole day.On 01/31/26 there were no food or drink temperatures for the dinner meal recorded.On 02/01/26 there were no food or drink temperatures recorded for the dinner meal. On 02/02/26, 02/03/26 and 02/04/26 there were no food or drink temperatures logged for the dinner meal. Interview 02/05/25 at 8:45 A.M. interview with Dietary Manager #153 verified there were days the food and drink temperatures were not recorded. Interview at 2:10 P.M. revealed she found seven individual sheets of paper with temperatures written on them that were not recorded on the daily logs. She identified five of them had dates on them. Four of the seven sheets did not have the milk or coffee temperature recorded. She included some staff are writing the temperatures on a sheet of paper and not writing them in the daily log. Review of the facility ' s undated Food Temperature Logs Policy included food temperatures of cold and hot items will be recorded on all menu items for meal service. This deficiency represents non-compliance investigated under Complaint Number 2734445.

Based on observation, interview and policy review, the facility failed to ensure medications were stored to prevent access by unauthorized persons. This had the potential to affect 23 (Residents #3, #16, #19, #23, #24, #26, #27, #28, #31, #33, #35, #39, #47, #49, #50, #51, #54, #64, #65, #67, #71, #72, and #73) residents who the facility identified as cognitively impaired and independently mobile. The census was 80.Findings include: During the tour on 02/05/26 at 7:52 A.M., Registered Nurse (RN) #140 was observed walking away from her medication cart and entering a room down the hall out of sight of the cart. The medication cart was left unlocked.On 02/05/26 at 7:54 A.M., RN #140 returned to the medication cart and verified she had left the medication cart unlocked and unattended.The facility identified Residents #3, #16, #19, #23, #24, #26, #27, #28, #31, #33, #35, #39, #47, #49, #50, #51, #54, #64, #65, #67, #71, #72, and #73 as being cognitively impaired and independently mobile.Review of the facility ' s Storage of Medication policy, dated January 2025, revealed in order to limit access to prescription medications, only licenses nurses, pharmacy staff and those lawfully authorized to administer medications were allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access. This deficiency represents non-compliance investigated under Complaint Number 2734445.

Based on observation, record review and interview, the facility failed to ensure physician ordered interventions were implemented for the treatment of edema. This affected one (Resident #44) of three residents reviewed for skin impairment. The census was 80.Findings include: Review of Resident #44's medical record revealed a 10/22/26 admission with diagnoses including chronic obstructive pulmonary disease, hypertensive heart disease, weakness, type 2 diabetes, heart failure, and arthritis.Review of the 01/28/26 Quarterly Minimum Data Set Assessment revealed the resident was independent for daily decision making, no upper or lower extremity impairment, dependent for shower, substantial/maximum assist for upper body dressing and lower body dressing, personal hygiene, rolling, sitting on side of bed, and chair and toilet transfer. Review of the 12/09/25 weekly skin check included resident bilateral legs cracking and seeping clear liquid.Review of the 12/10/25 Health Status Note included resident ' s bilateral lower extremities noted to be edematous and hard with scant clear drainage. Review of Physician orders included compression stockings on in the morning and off at bedtime every day and night shift for edema to legs starting 12/10/25. Interview 02/09/25 at 10:30 A.M. with Certified Nurse Aide (CNA) #166 revealed the resident was retaining a lot of fluid in her legs. Observation 02/09/26 at 10:40 A.M. with Resident #44 revealed she did not have compression stockings on. Her lower legs were edematous and red. She had some thin scabs on her left lower shin. Interview with the resident revealed her skin itched and she scratches causing the scabs on her legs.Interview and observation 02/09/26 at 1:38 P.M. with Resident #44 revealed she has never worn compression hose at the facility. She said no one asked her about wearing them. She stated at her old facility they would wrap her legs for the edema. She did not have compression stockings on.Review of the Treatment Record revealed it was signed off for 02/09/26 the resident had compression stockings on.Interview 02/09/26 at 1:41 P.M. with CNA #166 revealed she has never seen the resident with compression stockings. She included there were not any in her room and it doesn't come up on their electronic charting to apply the stockings.Interview 02/09/26 at 1:44 P.M. with Registered Nurse #135 verified she signed the treatment sheet that the resident had compression stockings on when she did not. Interview 02/09/26 at 3:45 P.M. with Resident #44 revealed she was told they were going to start putting compression hose on her in the morning.This deficiency represents non-compliance investigated under Complaint Number 2734445.

Based on observation, medical record review, interview and policy review the facility failed to provide a summary of baseline care plans to residents and/or responsible parties. This affected two (Residents #13 and #44) of three residents reviewed for care planning.Findings include: 1. During an interview on 02/05/26 at 11:35 A.M., Resident #13 ' s power of attorney (POA) stated he did not recall anybody discussing Resident #13 ' s medications with him as part of the care conference/review of the plan of care when Resident #13 was admitted . The POA indicated he did not recall being offered or given a copy of the summary of the baseline care plan. Review of Resident #13 ' s medical record revealed diagnoses included Alzheimer ' s disease and dementia. Review of Resident #13 ' s admission assessment dated [DATE] indicated Resident #13 was confused and was oriented to person only. Review of Resident #13 ' s Multidisciplinary Care Conference form dated 12/24/25, staff documented the Social Service Designee (SSD) #167 and Physical Therapy Assistant (PTA)/Rehab Director #185 were present. Two of Resident #13 ' s sons participated by phone (one being the POA). The notes indicated medications were among the items discussed. The notes revealed Resident #13 was offered a copy of the plan of care. On 02/05/26 at 5:46 P.M., SSD #167 verified the multidisciplinary care conference notes indicated a copy of the baseline care plan was offered to Resident #13 but verified Resident #13 was very confused and had poor vision. SSD #167 stated the form only had an option of marking a copy was offered to the resident or that the resident received a copy. SSD #167 verified there was no evidence a copy was provided to Resident #13 ' s POA. 2. Review of Resident #44's medical record revealed a 10/22/26 admission with diagnoses including chronic obstructive pulmonary disease, hypertensive heart disease, weakness, dependence of ventilator, cerebrovascular disease, alopecia, chronic respiratory failure, morbid obesity, gout, type 2 diabetes, gastroesophageal reflux disease, heart failure, hypothyroidism, rheumatoid arthritis, presence of artificial right elbow, hip joint, artificial knee joint and arthritis. Review of the 10/24/25 Multidisciplinary Care Conference, baseline care plan, included a therapist, social service designee and Minimum Data Set Assessment nurse were present. The conference revealed they discussed admission, goals,therapy, discharge, health and code status. She declined ancillary services. The form was marked plan of care reviewed and resident offered copy of plan of care. There was no indication of the initial goals being based on admission orders, or a review of physician orders including dietary orders being reviewed. There was no evidence of the facility providing the resident and their representative with a copy of the baseline care plan. Review of the 01/28/26 Quarterly Minimum Data Set Assessment revealed the resident was independent for daily decision making, no upper or lower extremity impairment, dependent for shower, substantial/maximum assist for upper body dressing and lower body dressing, personal hygiene, rolling, sitting on side of bed, and chair and toilet transfer. The resident was dependent for 150 feet wheeled in wheelchair. Interview and observation on 02/09/26 at 1:38 P.M. with Resident #44 revealed the facility did not go over her medications or treatments at the conference. She included she was not asked if she wanted a copy and was not she has never worn compression hose at the facility. She said no one asked her about wearing them. She stated at her old facility they would wrap her legs for the edema. She did not have compression stockings on at the time of the interview. Interview 02/09/26 at 4:41 P.M. with Social Service Designee #167 revealed she was not employed at the facility at the time of the October Care Conference. She verified the facility does not provide a copy of the baseline careplan unless requested. She verified there was no evidence in the notes of the physician orders, medications, treatments, or dietary orders being reviewed during the meeting. Review of the facility's undated Care Plan and Advanced Care Plan Process included the resident and/or sponsor will sign the care conference form to verify they were present and reviewed the care plan. The policy did not address giving the resident a copy as regulated This deficiency represents non-compliance investigated under Complaint Number 2734445.

Based on observation, record review and interview, the facility failed to maintain an accurate medical record. This affected one (Resident #44) of eight records reviewed. The census was 80.Findings include: Review of Resident #44's medical record revealed a 10/22/26 admission with diagnoses including chronic obstructive pulmonary disease, hypertensive heart disease, weakness, type 2 diabetes, heart failure, and arthritis.Review of the 01/28/26 Quarterly Minimum Data Set Assessment revealed the resident was independent for daily decision making, no upper or lower extremity impairment, dependent for shower, substantial/maximum assist for upper body dressing and lower body dressing, personal hygiene, rolling, sitting on side of bed, and chair and toilet transfer. Review of the 12/09/25 weekly skin check included resident bilateral legs cracking and seeping clear liquid.Review of the 12/10/25 Health Status Note included resident ' s bilateral lower extremities noted to be edematous and hard with scant clear drainage. Review of Physician orders included compression stockings on in the morning and off at bedtime every day and night shift for edema to legs starting 12/10/25. Further review of the Treatment Administration Record were 13 days in January, 01/01/26, 01/02/26, 01/05/26, 01/09/26, 01/15/26, 01/17/26, 01/18/26, 01/20/26, 01/22/26, 01/23/26, 01/27/26, 01/29/26 and 01/30 26 and seven days in February, February 1st through the 6th and 02/09/26 of the first nine days in February the staff documented the compression hose were on when the resident was not provided compression stockings during her stay.Interview 02/09/25 at 10:30 A.M. with Certified Nurse Aide (CNA) #166 revealed the resident was retaining a lot of fluid in her legs. Observation 02/09/26 at 10:40 A.M. with Resident #44 revealed she did not have compression stockings on. Her lower legs were edematous and red. She had some thin scabs on her left lower shin. Interview with the resident revealed her skin itched and she scratches causing the scabs on her legs.Interview and observation 02/09/26 at 1:38 P.M. with Resident #44 revealed she has never worn compression hose at the facility. She said no one asked her about wearing them. She stated at her old facility they would wrap her legs for the edema. She did not have compression stockings on.Review of the Treatment Record revealed it was signed off for 02/09/26 the resident had compression stockings on.Interview 02/09/26 at 1:41 P.M. with CNA #166 revealed she has never seen the resident with compression stockings. She included there were not any in her room and it doesn't come up on their electronic charting to apply the stockings.Interview 02/09/26 at 1:44 P.M. with Registered Nurse #135 verified she signed the treatment sheet that the resident had compression stockings on when she did not. Interview 02/09/26 at 3:45 P.M. with Resident #44 revealed she was told they were going to start putting compression hose on her in the morning.This deficiency represents non-compliance investigated under Complaint Number 2734445.

Based on closed medical record request, medical request fee schedule and interview, the facility failed to ensure ease of access in obtaining medical records. This affected one (Resident #83) of three residents reviewed for medical record request. The facility census was 82.Findings include: Review of Resident #83's closed medical record revealed an admission date of 07/14/25 with diagnoses including peripheral vascular disease, hypertensive heart disease without heart failure, encephalopathy, difficulty walking, dysphagia (difficulty swallowing), atherosclerotic heart disease, kidney disease, alcohol abuse and chronic peripheral disease. The resident was discharged from the facility on 08/27/25.Review of the 08/04/25 admission Minimum Data Set Assessment revealed the resident was severely impaired for daily decision making and utilized a wheelchair and front wheeled walker for mobilityReview of a Medical Records Release Authorization Form dated 09/12/25 included a request for physical and occupational therapy reports. The reports were to be released to the resident's family and the form was signed by Resident #83.Interview on 02/05/26 at 3:31 P.M. with Resident #83's daughter revealed therapy cut her father saying he was able to walk but when she brought him home he was unable. He was starting home health for therapy and they wanted to see what the facility was doing with him so she requested the records from the facility. She was told her dad would need to come to the facility and sign a release form as they would not accept a verbal request. Since he was not moving well and it was very cold, she did not get him there until 09/12/25. The daughter stated she was pretty sure the therapist told her it would cost 60 to 80 dollars to get a copy of the therapy records and due to the reported cost, they did not get a copy of the records.Interview on on 02/05/26 at 3:45 P.M. with the local Steubenville Library revealed it cost 15 cents per page to make black and white copies and 50 cents per page to make color copies at the library.Interview on 02/05/25 at 4:52 P.M. with Medical Records (MR) #155 revealed when a family member requests a copy of a medical record they sign a release form and the form is sent to Quality Assurance and legal. MR #155 shared the business office had a price sheet they followed for the cost of medical record copies but MR #155 does not tell them the price of the copies. Interview on 02/09/26 at 12:30 P.M. with the Administrator revealed therapy was a contracted company employed by the facility and used a different computer system. They would set the price for obtaining their medical records and she did not know what their price was or if it met the requirement but the facility used the state fee requirements and not federal. She further verified they required the resident to sign a release form unless they had a power of attorney. The Administrator also verified the facility's fee structure included additional fees for locating records. Lastly, the Administrator verified the facility required the resident to sign the request unless they have a legal representative to sign as the facility would not accept a verbal request.Interview 02/09/26 at 2:23 P.M. with Corporate Business Office #182 included when family or a resident request copies of the medical records a lot of time they do not charge depending on the amount of pages. It is a decision of corporate so, the facility business office would not be able to give the resident/representative a price. Therapy is separate because it is by a third party. The request goes through the facility medical records department, obtained and sent to the requesting agency. When it comes to the cost, it is processed through the agency based on pages.Review of the facility's Medical Records Release Authorization Form included this form must be fully completed before signing. If authorization is not complete, signed and dated, it may be returned and result in my information not being released until completed.Review of the fee structure revealed it was based on the Consumer Price Index in accordance with the Ohio Revised Code Section 3701.742. It included a fee structure for request made by a resident or resident representative up to $3.88 per page. There was a fee schedule for other than by the resident or residents personal representative with an initial fee which shall compensate for the records search. The initial fee was $23.94 and a per page cost up to $1.58.This deficiency represents non-compliance investigated under Complaint Number 2734445.

Based on medical record review, observation, interviews, review of the National Pressure Injury Advisory Panel (NPIAP) guidelines and facility policy review, the facility failed to ensure comprehensive and accurate pressure ulcer assessments. The facility also failed to ensure treatments were implemented timely and pressure-relieving interventions were implemented per the care plan. This affected one (Resident #7) of three residents reviewed for pressure ulcers. The facility census was 75. Findings include:Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right femur fracture, chronic kidney disease, anemia, diabetes, protein-calorie malnutrition, dementia, heart disease, venous insufficiency, and pressure ulcer. Review of Resident #7's consents revealed on 08/15/25 the resident signed consent to be seen by the wound nurse. Review of Resident #7's impaired skin integrity/pressure ulcer plan of care related to diabetes, dementia, chronic kidney disease, anemia, neuropathy, fistula, surgical site hip, moisture-associated skin damage (MASD), and left heel dated 08/15/25 and revised 09/17/25 revealed interventions including treatments per order, pressure reduction devices as ordered, and inspect the skin during daily routine care. Review of Resident #7 re-admission skin grid pressure ulcer assessment dated [DATE] revealed the resident had a new suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing) on the sacrum that measured 1.5 centimeters (cm) by 1.5 cm by 0.01 cm (skin not intact). The area was noted to be red, non-blanchable, no drainage noted, possible sheering injury around area. Foam placed and wound nurse to be consulted. There was no documented evidence that the physician was notified or that the wound nurse was consulted until 09/26/25. Further review of Resident #7's orders revealed the resident was ordered a pressure reducing cushion on 08/21/25. Review of Resident #7's weekly skin observation dated 08/27/25 revealed the resident's skin was intact. The area for previously identified and newly acquired areas was left blank. Review of Resident #7's admission and five-day [NAME] Data Set (MDS) dated [DATE] revealed the resident did not have a pressure ulcer; however, was assessed to be at risk for developing a pressure ulcer/injury. The resident had pressure-reducing devices for the chair and bed. The resident was receiving an application of a non-surgical dressing to an area other than the feet. Review of Resident #7's dietary note dated 08/28/25 revealed no evidence of skin alterations. Review of Resident #7's skin grid non-pressure assessment dated [DATE] revealed the resident had MASD on the sacrum that was acquired on 08/21/25 that measured 1.2 cm by 1.2 cm by 0.1 cm. There was no documented evidence of the amount of drainage, odor, tunneling/undermining, or description of the wound or physician notification. Review of Resident #7's weekly skin observation dated 09/03/25 revealed the resident's skin was not intact. The resident had MASD and a surgical area. There was no documented evidence of descriptions of the wounds. Review of Resident #7's weekly skin observation dated 09/10/25 revealed the resident's skin was not intact. The resident had MASD, surgical area and a newly acquired pressure and surgical area. There was no documented evidence of descriptions of the wounds. Review of Resident #7's skin grid non-pressure assessment dated [DATE] revealed the resident had MASD on the sacrum that was present on admission [DATE]) that measured 1.1 cm by 1.3 cm by 0.1 cm. There was moderate drainage, the type of drainage was not identified. No odor or tunneling/undermining. There was no description of the wound or evidence the physician was notified. Review of Resident #7's actual skin impairment integrity/pressure ulcer related to MASD, left heel/sacrum plan of care dated 09/17/25 revealed interventions including complete skin documentation per facility policy, provide wound care per physician order, and refer to wound physician as needed. Review of Resident #7's weekly skin observation dated 09/17/25 revealed the resident's skin was not intact. The resident had MASD and pressure previously identified. There were no descriptions of the wounds. Review of Resident #7's skin grid non-pressure dated 09/19/25 revealed the resident had MASD on the sacrum that was acquired on 08/21/25 that measured 1.0 cm by 1.2 cm by 0.1 cm and 100% granulation. There was scant drainage, type not of drainage not identified. No odor or tunneling. There was no evidence that the physician was notified. Review of Resident #7's weekly skin observation dated 09/24/25 revealed the resident's skin was not intact. The resident had MASD and pressure previously identified. There were no descriptions of the wounds. Review of Resident #7's weekly skin grid pressure ulcer assessment for 08/28/25, 09/04/25, 09/11/25, 09/18/25, and 09/25/25 revealed no evidence a skin pressure ulcer assessment was completed on the sacrum. Review of Resident #7's weekly skin grid pressure dated 09/26/25 revealed the resident had a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) on the sacral region that originated on 08/21/25 that measured 2.5 cm by 4.5 cm by 0.2 and was a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) per the wound nurse consult dated 09/26/25. The area was 90% granulation, 10% slough, and peri wound moist and fragile. There was moderate serosanguinous drainage with no odor. The wound status since last assessment was left blank and no evidence that the physician was notified. Review of Resident #7's medication and treatment record and orders dated 08/21/25 to 09/30/25 revealed no evidence a treatment was implemented to the sacrum area from 08/21/25 to 09/03/25. Review of Resident #7's wound nurse consult note dated 09/26/25 revealed the wound nurse completed a telehealth visit due to unavailability or difficulty with coordinating in person evaluation. The initial assessment revealed the wound on the sacral area was a stage III due to there being 10% slough covering the wound bed. The area was not measured. There was moderate serosanguinous drainage, and the skin was moist and fragile. The treatment plan would change to silver alginate covered with silicone dressing daily and as needed. Recommend a pressure reduction cushion in wheelchair. Review of Resident #7's physician progress notes dated 08/21/25 to 09/30/25 revealed no evidence the physician had mentioned or assessed the pressure ulcer on the sacrum. Observation of Resident #7 on 09/29/25 at 1:48 A.M., with Licensed Practical Nurse (LPN) #108 revealed the resident was up in her wheelchair in therapy. Therapy stood the resident up, and there was no pressure relieving cushion in the resident's wheelchair. The resident had a [NAME] Virginia (WV) stadium cushion that was flat. The LPN and therapy staff confirmed the WV stadium cushion was flat and not a proper pressure relieving cushion. Interview on 09/29/25 at 12:52 P.M., with LPN #108 and Interim Director of Nursing (DON) #140 and New DON #200, who started today, confirmed Resident #7 was re-admitted on [DATE] with a pressure ulcer on the sacrum. The LPN reported he recently just took over wounds and was not certified in wound care. The LPN confirmed on 08/28/25 09/04/25, 09/11/25, 09/18/25 or 09/25/25 he did not complete the weekly pressure ulcer assessment form; however, he was still learning and documented the area on the non-pressure form as MASD instead of pressure. Interim DON #140 confirmed there was no documented evidence the resident's physician had accessed the pressure ulcer, and the wound nurse did not assess the pressure ulcer until 09/26/25 due to the resident was in dialysis on the day the wound nurse visits the facility. LPN #108 and DON confirmed there was no evidence a treatment was implemented to the sacrum from 08/21/25 until 09/03/25. DON #140 reported she felt the non-pressure assessments were comprehensive even though the assessment did not document the stage of the pressure nor was it comprehensive to include all details regarding the description of the wound (wound bed appearance, edge of wound, type of drainage, etc.). Interview on 09/29/25 at 3:35 P.M., LPN #120 confirmed the admission and five-day MDS dated [DATE] was inaccurate and did not reflect the resident's pressure ulcer on the sacrum on admission [DATE]. LPN #120 reported she would modify the MDS assessment. Review of the facility's undated policy and procedure titled Skin Measurement/Skin Grid revealed the facility would maintain an active record or any pressure ulcer/wound that was discovered upon admission or that developed during the course of the residents' stay. This is to monitor the progress of healing of the pressure ulcer and determine the need for alternative treatment methods. The wound would be measured and assessed for the wound characteristics. The physician and responsible party would be notified of the new skin development and an order for treatment would be obtained. The initial and every seven days assessment/measurements are documented on the electronic form. Review of the facility's undated policy and procedure titled Staging of Pressure Ulcers revealed the facility would assess each resident's skin condition and measure the skin area as indicated in the regulatory guidelines and National Pressure Injury Advisory Panel (NPIAP) guidelines. Review of the facility's undated policy and procedure titled Pressure Ulcer Prevention and Risk Identification revealed if a new skin area was identified on the assessment or during any other type of care or service, the licensed nurse would initiate a skin grid/measurement flow record. The skin grid would be updated every seven days until the area was resolved. The physician and responsible party would be notified by the licensed nurse promptly of the newly identified skin area and treatment would be initiated according to the physician order. A care plan would be developed and updated routinely with identified skin risk and/or actual wound development. Intervention would be implemented as indicated by the physician and as determined by the Interdisciplinary team. Review of the NPIAP wound documentation guidelines dated 02/2027 revealed when charting a description of a pressure ulcer the following components should be part of your weekly assessment: location, stage, dimensions, undermining/tunneling, wound base descriptions, drainage, wound edges, odor, pain, and progress. This deficiency represents non-compliance investigated under Complaint Number 2608722.

Based on observation, staff interview and facility policy review the facility failed to store food in a sanitary manner. This had the potential to affect all 79 residents residing in the facility, as the facility identified zero residents with an order for nothing by mouth (NPO). The facility's census was 79. Findings Include: During the initial kitchen tour conducted on 08/04/25 from 8:30 A.M. to 8:50 A.M. observations revealed in the dry food/canned food storage three cans of 66.5 ounces (oz) of tuna each were dented along the seal and stored in the main storage area for resident foods to be used for meal preparation. In the walk-in freezer there was an opened box of beef patties with the plastic storage bag opened exposing approximately 20 frozen beef patties to the cardboard box and the freezer air. In the walk-in cooler there was an opened box of bacon with the plastic bag cut opened exposing the bacon to the cooler air and the cardboard box. On the plate and cup storage rack sat a closed container of topical pain ointment medication Icy Hot. In the food preparation refrigerator near the steam table was an opened undated unlabeled container of half-eaten seafood salad with the sell by date of 07/31/25.An interview on 08/04/25 at 8:45 A.M. with Dietary [NAME] (DC) #244 confirmed the dented cans of tuna, the opened boxes with exposed beef patties and bacon, the Icy Hot container located on the clean plates and cups storage and the undated, unlabeled container of seafood salad in the food preparation refrigerator. DC #244 stated stored food had to be secured in the boxes or the plastic bags and personal items should not be stored on shelves in the kitchen or in the food preparation refrigerator.Review of the facility's policy titled, Food Handling undated revealed food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized.

Based on record review, observations, staff interviews, and facility policy review the facility failed to maintain the dignity of three residents (Resident #42, #64, and #75) during the lunch service in the dining room, and failed to ensure dignity of a resident was maintained by not removing facial hair for one resident (Resident #66) out of four residents reviewed for dignity. The facility census was 79. Findings include: 1. Review of Resident #42's medical record revealed admission to facility on 02/01/23 with diagnoses of heart disease, pulmonary hypertension, chronic obstructive pulmonary disease, speech and language deficits, stroke, and gastric reflux. Review of Resident #42's physician orders revealed an order for a regular diet, mechanical soft texture, regular thin liquids consistency. Review of Resident #42's most recent Minimum Data Set (MDS) 3.0 assessment revealed no cognitive impairment. Resident #42 required meal set up for all meals and was independent with a wheelchair for mobility. 2. Record Review of Resident #64 revealed admission to facility on 5/28/25 with most recent reentry of 6/24/25 for diagnoses of high blood pressure, heart failure, dysphagia (difficulty swallowing), anemia (low blood count), and weakness. Diet order was for mechanical soft texture, regular thin liquids. Record Review of Resident #75 revealed admission to facility on 3/11/25 with diagnoses of broken pelvis, atrial fibrillation (irregular heartbeat), anemia, weakness, diabetes mellitus, and Non-[NAME] lymphoma (cancer of white lymph system). Diet order was for regular diet, mechanical soft texture, regular (thin liquid) consistency. Observation on 08/04/25 from 12:01 P.M. to 12:30 P.M. revealed lunch service being served to residents in the dining room. Residents were observed sitting at six tables with three to four residents sitting at each table awaiting lunch meal service with Activity Aide (AA) #234 visiting with several residents. The tables were clear of drinks, silverware, and place settings. The open sided tray cart filled with the resident's meal trays was delivered to the dining room, at that time AA #234 left the room stating she was not a certified nursing assistant and could not pass the meal trays. Observation on 08/04/25 at 12:10 P.M. revealed Certified Nursing Assistant (CNA) #255 entered dining room and began serving the meal trays from the tray cart. The first table to be served had four female Residents awaiting tray pass. CNA #255 provided trays to three of four Residents at the first table, omitting tray pass to Resident #42. CNA #255 proceeded to pass trays to the second table for two Residents, then approximately 10 minutes later CNA #255 returned to first table to provide a tray to Resident #42 where the three other Residents had already begun consuming their meals. CNA #255 then returned to finish passing trays to the remaining Residents at the second table. CNA #255 began to pass trays to the third table with four Residents, including Resident #75, and one guest. CNA #255 could not locate Resident #75's tray and proceeded to complete tray pass for the other three residents at the third table. CNA #255 continued to serve the residents sitting at the remaining tables. At 12:15 P.M. Resident #64's spouse stood up and asked if she could please assist CNA #255 in tray pass due to the amount of time it was taking. Resident #64's spouse was told politely she could not. Resident #64 and his spouse then exited the dining room to find where Resident #64's tray had been sent. At 12:25 P.M. Resident #64 and his spouse returned to the dining room accompanied by the Activities Director #226 carrying Resident #64's tray, which had been placed on the room tray cart for service in his room. The guest of Resident #75 asked the Activities Director #266 if she would assist in locating Resident #75's meal tray. At 12:28 P.M. CNA #255 left dining room with Resident #75 not being served a tray and did not return. At 12:30 P.M. the Activities Director #226 returned with Resident #75's tray, which had been sent out on the room tray cart for service in the rooms, and put the whole tray on the table without removing the contents (plates, drink cup, and silverware) from the tray and removing the tray from the table. The remaining Residents at table three had their trays removed after their plates, cups, and silverware were placed on the table. Resident #75 verbalized to her guest, this is (expletive). At 12:30 P.M. all Residents in dining room had received their lunch meal. Interview on 08/05/25 at 3:00 P.M. with CNA #255 confirmed during lunch meal on 08/04/25 the residents had not been served a table at a time and several residents did not receive their lunch meal trays at the same time as the other residents seated in the dining room. CNA #255 stated she does not generally work in the dining room during mealtimes and was not trained on tray pass in the dining room. CNA #255 was not aware of completing tray service to one table prior to beginning another table. Review of the facility's policy titled Meal Service undated revealed no procedure for tray/meal pass to ensure the dignity of Residents. Review of the facility's policy titled Resident Rights undated revealed the facility is to assure the resident's personal dignity, well-being, and self-determination is maintained and Residents are knowledgeable regarding The [NAME] of Rights. 3. Review of Resident #66's medical record revealed admission date 12/28/23 with diagnoses including but not limited emphysema and Alzheimer's dementia. Review of Resident #66's MDS 3.0 assessment dated [DATE] revealed Resident #66 had impaired cognition, no behaviors were marked for refusal of care and required substantial to maximum assistance from staff to complete personal hygiene tasks including shaving. Review of Resident #66's Activities of Daily Living (ADL) care plan dated 01/05/24 revealed Resident #66 required assistance with ADLs related to impaired cognition with interventions implemented including staff assistance with daily personal hygiene tasks including shaving as needed. Further review revealed no care plans implemented for behaviors and/or refusals of care by Resident #66. Review of Resident #66's personal hygiene task documentation dated 07/05/25 to 08/04/25 revealed Resident #66 received partial to dependent assistance from staff to complete daily personal hygiene, there were no entries to reflect refusal of care by Resident #66. Observation on 08/04/25 at 11:30 A.M. revealed Resident #66 (a female resident) lying in bed watching television. Resident #66 had glasses in place and had dark facial hair to her top lip covering the entire top lip as a mustache. Interview on 08/04/25 at 11:40 A.M. with Resident #66 revealed the staff usually assists with shaving off her facial hair, staff had not assisted with shaving facial hair in several days. Resident #66 stated it bothered her when the staff does not assist with shaving off facial hair and she does not like to be seen with facial hair in place. Interview on 08/04/25 at 3:30 P.M. with Licensed Practical Nurse (LPN) #221 confirmed Resident #66 had dark facial hair to her top lip like a mustache. LPN #221 stated staff should be offering to shave the residents during bathing and when needed. Review of the facility's policy titled Personal Care Bathing undated revealed, Residents are interviewed during the admission process, quarterly, and as needed regarding the frequency they want for bathing and the type of bathing that they prefer, i.e., shower, bath, or bed bath. Nailcare, oral care, and shaving are also offered during routine personal care and bathing, and as needed. Review of the facility's policy titled Resident Rights undated revealed, To assure the resident's personal dignity, well-being and self- determination is maintained to assure the resident's are knowledgeable to rights and responsibilities in this regard.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure infection control was maintained during medication administration for Resident #2 and #72, during incontinence care for Resident #61 and when caring for Resident #75 during contact isolation. This affected four residents (#2, #72, #61 and #75) of 24 residents observed for infection control. The facility census was 79. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 03/23/22. Diagnoses included but not limited to pulmonary hypertension and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition. Observation on 08/06/25 at 8:39 A.M. with LPN #279 during medication administration revealed she had taken the medicine cup with medications into Resident #2 ' s room to administer. LPN #279 donned gloves without performing hand hygiene first. Interview on 08/06/25 at 8:59 A.M. with LPN #279 confirmed she did not wash her hands before donning gloves. Interview on 08/06/25 at 9:11 A.M. with Director of Nursing (DON) confirmed hand hygiene was to be performed before and after glove usage. Interview on 08/11/25 at 9:29 A.M. with Assistant Director of Nursing (ADON) #208 confirmed hand hygiene was to be performed before and after glove usage. Review of facility policy, Handwashing, undated, revealed to maintain a high standard of hygiene in patient care through thorough handwashing procedures to include before and after physical contact with a resident. 2. Review of the medical record for Resident #72 revealed an admission date of 08/07/24. Diagnoses included but not limited to malignant neoplasm of pancreas, atrial fibrillation, and unspecified jaundice. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #72 had intact cognition. Review of the physician orders for July 2025 for Resident #72 revealed an order for Pantoprazole Sodium (used to treat conditions involving excessive stomach acid production) oral tablet delayed release (DR) 40 milligram (MG) to administer one tablet every day. Observation on 08/06/25 at 8:20 A.M. with LPN #279 during medication administration revealed she was removing Pantoprazole Sodium 40 mg from the package, and she could not get it out, so LPN #279 used her bare hand to touch the tablet to pull it out from the package and placed the tablet in the medicine cup. LPN #279 entered Resident 72 ' s room and administered the medication to the resident. Interview on 08/06/25 at 8:59 A.M. with LPN #279 confirmed she used her bare hand to remove the Pantoprazole Sodium 40 mg from the medication package and administered to Resident #279. LPN #279 confirmed she should have used gloves to remove the medication. Interview on 08/06/25 at 9:11 A.M. with DON confirmed staff were not to use their bare hands to touch residents ' medication Interview on 08/11/25 at 9:29 A.M. with ADON #208 confirmed staff were not to use their bare hands to touch residents ' medication Review of facility policy, Handwashing, undated, revealed to maintain a high standard of hygiene in patient care through thorough handwashing procedures to include before and after physical contact with a resident 3. Review of the medical record for Resident #61 revealed an admission date of 04/12/24. Diagnoses included but not limited to anemia, chronic obstructive pulmonary disease, chronic kidney disease stage 3 and congestive heart failure. Review of the admission MDS 3.0 assessment revealed Resident #61 had intact cognition, and was dependent for toileting assistance and always incontinent of bladder and bowel. Review of the care plan dated 06/20/25 revealed Resident #61 had bladder incontinence. Interventions included to remain clean and odor free and skin remain intact, administer treatments per physician orders and assist with toileting and incontinence care as needed. Observation on 08/06/25 at 1:44 P.M. of incontinence care for Resident #61 revealed Certified Nursing Assistant (CNA) #214 while performing incontinent care had removed her gloves and applied new gloves without performing hand hygiene. Interview on 08/06/25 at 1:57 P.M. with CNA #214 confirmed she did not perform hand hygiene before applying gloves during incontinence care. Interview on 08/06/25 at 2:33 P.M. with the DON confirmed staff were to perform hand hygiene before and after glove usage. Interview on 08/11/25 at 9:29 A.M. with the ADON #208 confirmed staff were to perform hand hygiene before and after glove usage. Review of facility policy, Incontinence Care, undated, revealed staff are to wash hands and don gloves. 4. Review of the medical record for Resident #75 revealed an admission date of 06/02/25 with diagnoses including Vancomycin-resistant enterococci (VRE) in her urine (type of bacteria that is resistant to the antibiotic Vancomycin), heart disease and diabetes mellitus. Review of the urine culture dated 07/31/25 and reported on 08/03/25 revealed Resident #75 had VRE in her urine. Review of the physician ' s orders for Resident #75 revealed an order for contact isolation for VRE dated 08/03/25. Observations on 08/04/25 at 8:48 A.M. and 08/04/25 at 3:31 P.M. revealed a sign prior to entering Resident #75 ' s room stating that she was on enhanced barrier precautions (providers and staff must clean their hands before entering and leaving the room, wearing gown and gloves for high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care and wound care). There was no signage stating that Resident #75 was on contact precautions. Interview on 08/04/25 at 3:32 P.M. with Certified Nursing Assistant (CNA) #268 verified Resident #75 had contact isolation. She stated staff did not have to wear personal protective equipment (PPE) when going into the room, only when doing care on the resident. Interview on 08/04/25 at 3:35 P.M. with Licensed Practical Nurse (LPN) #267 verified Resident #75 was on contact isolation. She stated staff had not placed the correct isolation sign on the door and were not wearing PPE when going into Resident #75 ' s room. Review of the facility policy titled, Transmission-Based Precautions, dated September 2024, revealed contact precautions reduced the risk of transmission of microorganisms by direct or indirect contact. Staff were to wear gloves and gowns at all times and perform hand washing prior to entering the room and before leaving the room.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician for four (Residents #2, #5, #24, #54) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 03/23/22 with diagnoses including diabetes mellitus, heart failure, depression and history of falling. Review of the physician ' s orders for Resident #2 revealed she had an order for Prozac 20 milligrams (mg) (an antidepressant) once daily dated 04/04/23 and Trazodone 50 mg (an antidepressant) at bedtime dated 11/24/22. The Trazodone was discontinued on 11/20/24. Review of the pharmacy recommendation titled Note To Attending Physician/Prescribed, dated 08/07/24 revealed the pharmacist recommended to consider a gradual taper of Resident 2 ' s antidepressant Prozac 20 milligrams (mg). The recommendation was left blank and was not signed or dated by the physician. Review of the pharmacy recommendation titled Note To Attending Physician/Prescribed, dated 11/13/24 revealed the pharmacist recommended a consideration of a gradual taper of Resident 2 ' s antidepressants Prozac 20 mg and Trazodone 50 mg. The recommendation was left blank and was not signed or dated by the physician. Review of the pharmacy recommendation titled Note To Attending Physician/Prescribed, dated 05/31/25 revealed the pharmacist recommended a consideration of a gradual taper of Resident 2 ' s antidepressant Prozac 20 mg. The recommendation was left blank and was not signed or dated by the physician. Review of the pharmacy recommendation titled Note To Attending Physician/Prescribed, dated 07/31/25 revealed the pharmacist recommended a consideration of a gradual taper of Resident 2 ' s antidepressant Prozac 20 mg. The recommendation was left blank and was not signed or dated by the physician. Interview on 08/07/25 at 9:50 A.M. with the Director of Nursing (DON) verified she had printed them off of the pharmacy website during the survey. She was unable to verify if the physician had been provided with the pharmacy recommendations when the facility had received them on the dates listed above. Review of the facility policy titled, Psychotropic Drug and Unnecessary Drug Use, undated, revealed the consulting pharmacist would report any irregularities specific to unnecessary medications to the physician and these reports would be acted upon in a timely manner. The policy stated the physician would document the rationale in the medical record for the continued use of those medications. 2. Review of records for Resident #5 revealed an admission date of 05/14/20. Diagnoses included but not limited to chronic respiratory failure with hypoxia, unspecified psychosis, and anxiety disorder. Review of the physician orders for June 2025 revealed an order for Seroquel (an antipsychotic used to treat mental health conditions) 25 milligram (MG) by mouth (PO) at bedtime (HS). Review of the monthly pharmacy review dated 06/28/25 indicated Resident #5 had orders for Seroquel 25 milligram mg by (PO) at (HS). The pharmacy requested an attempt at a trial discontinuation of Seroquel. There was nothing under the area for physician response indicating whether the physician accepted or declined the recommendations, no rationale, not signed and not dated. Interview on 08/07/25 at 9:50 A.M. with DON revealed reviewed gradual dose reeducation (GDR) from pharmacy that were to be given to the physician. There was one form provided for this resident provided by the DON. She stated she had printed them off from the pharmacy during the survey. She was unable to state if the physician had seen the provider form. She verified the physician had not agreed/disagreed, provided a rationale, signed and dated the form. Review of facility policy Psychotropic Drug & Unnecessary Drug Use, undated, revealed the physician will documents the use of the medication benefits the well-being of the resident and the benefit outweighs the risk, or documents contraindications for reductions in the medical record. 3.Review of the medical record for Resident #24 revealed admission date 02/10/25 with diagnoses including but not limited osteomyelitis of vertebra, Multiple Sclerosis (MS), heart failure, sepsis, and depression. Resident #24 had intact cognition and was non-ambulatory. Review of Resident #24 ' s physician orders dated 08/01/25 to 08/30/25 revealed an order dated 07/22/25 for anti-depressant medication Sertraline (Zoloft) 50 milligrams (mg) give one tablet by mouth in the morning for depression. Review of Resident #24 ' s pharmacist ' s health status progress notes revealed the pharmacist completed a Medical Record Review (MRR) on the following dates 04/18/25, 05/31/25 and 07/31/25 with no recommendations issued. Further review revealed the pharmacist issued recommendations following the completion of MRRs on 04/09/25, 06/29/25, and 02/18/25. Review of an email dated 08/06/25 from the pharmacy to the DON revealed Resident #24 had an admission order for antipsychotic medication Zyprexa on 02/13/25 which was discontinued in May 2025 and reinstated on 07/16/25 and then discontinued on 07/19/25. There was no further documentation to review concerning any of the pharmacy recommendations made on 02/18/25, 04/09/25, and 06/29/25. An interview on 08/07/25 at 9:50 A.M. with the DON confirmed there were no further documentation for review for Resident #24. The DON stated she had printed the forms off from the pharmacy during the survey and she was unable to state if the physician had seen the provider forms. 4. Review of medical record for Resident #54 revealed admission to the facility on [DATE] and reentry on 10/09/24 with diagnosis including acute respiratory failure, chronic obstructive pulmonary disease, morbid obesity, history of pulmonary emboli (blood clot in lung), deep vein thrombosis (blood clot in leg), gastric reflux, insomnia (difficulty sleeping), other depressive disorder, and other psychoactive substance dependence in remission, bilateral hand contractures, and Amyotrophic Lateral Sclerosis. Review of medication orders updated on 08/07/25 for Resident #54 revealed Resident #54 was prescribed Paxil (anti-depressant) 20 milligrams (mg) daily at bedtime. Review of pharmacist completed health status notes for Resident #54 dated 07/10/24 through 8/07/25 revealed monthly pharmacy medication reviews completed on 07/10/24 (no recommendations made), 09/13/24 (recommendations made), 10/09/24 (no recommendations made), 11/13/24 (recommendations made), 12/05/24 (recommendations made 01/13/25 (admission review completed with no recommendations), 04/29/25 (recommendations made), 05/31/25 (no recommendations made), 06/29/25 (no recommendations made), 07/31/25 (no recommendations made). Review of pharmacy form titled MD recommendations dated 12/05/25 and printed on 12/09/24 for Resident #54 revealed initial pharmacist requesting review of the anti-depressant Paxil 20 mg every night for gradual dose reduction (GDR). There was no documentation by the physician of review of information and there were no new orders or rationale for no dose reduction obtained. Review of Resident #54 ' s progress notes dated 12/01/24 to 04/30/25 revealed no documentation or follow up being completed for the pharmacy recommendations dated 12/05/24 and 04/29/25. Interview on 08/06/25 at 3:30 P.M. with DON confirmed there was no documentation of the recommendation form dated 04/29/25 being reviewed and addressed by the physician. The DON also confirmed there was no physician follow-up to the recommendations made on 12/05/24 in the medical record. Review of the facility policy titled Psychotropic Drug and Unnecessary Drug Use, undated revealed the facility pharmacist will assess each Resident ' s medical record and medication regimen monthly and report irregularities or recommendations for gradual dose reduction to the attending physician, facility medical director, and the Director of Nursing. These findings will be acted upon in a timely manner by the attending physician acknowledging in writing review of the information/recommendations and actions taken or why no action was taken.

Based on record review and interview, the facility failed to ensure the surety bond was greater than the personal funds managed by the facility. This had the potential to affect all 53 residents (Residents #2, #3, #4, #5, #8, #9, #11, #14, #16, #18, #19, #20, #22, #25, #26, #28, #29, #31, #32, #35, #36, #38, #40, #42, #43, #44, #45, #47, #48, #50, #52, #53, #54, #55, #56, #58, #59, #63, #64, #65, #66, #68, #70, #72, #73, #74, #76, #77, #80, #83, #86, #88 and #97) who had their funds managed by the facility. The facility census was 79. Findings include:Review of the surety bond purchased by the facility on [DATE] revealed they were insured for $50,000 for resident funds. This bond expired on [DATE]. Review of the Resident Funds Management Service Trial Balance, from [DATE] through [DATE] revealed the balances were greater than $50,000 on [DATE] and [DATE]. The balance showed $62,318.40 on [DATE] and $70,729.40 on [DATE]. Interview on [DATE] at 10:08 A.M. with the Business Office Manager (BOM) #273 revealed June of 2025 the facility had switched ancillary service providers and the billing had changed. She stated this caused the resident funds to show higher amounts of money in the account as not all the provider bills had been paid. She verified the funds were in the account and the balances were correct on the dates listed above.

Number of residents sampled: Number of residents cited: Based on observation, staff interview and facility policy review the facility failed to maintain a clean homelike environment in resident's rooms by leaving visibly soiled privacy curtains hanging. This affected five residents (Residents #24, #45, #59, #66 and #78) out of 79 residents reviewed for environment. The facility's census was 79. Findings Include: Observation on 08/06/25 at 1:25 P.M. revealed Resident #24's privacy curtain was soiled with several large dark circular stains visible from the doorway and from the bed, where Resident #24 was lying.Interview on 08/06/25 at 1:30 P.M. with Certified Nursing Assistant (CNA) #235 confirmed the visibly soiled privacy curtain in Resident #24's room. CNA #235 stated housekeeping usually will change out the soiled privacy curtains for clean ones as needed.Observations on 08/06/25 from 2:05 P.M. to 2:25 P.M. revealed visibly soiled privacy curtains in the rooms of Residents #45, #59, #66 and #78. Each privacy curtain was observed with dark stains visible from the doorway.Interview on 08/06/25 at 2:27 P.M. with Housekeeping and Laundry Director (HLD) #270 confirmed the visibly soiled privacy curtains located in the rooms of Residents #45, #59, #66 and #78. HLD #270 stated the privacy curtains are to be laundered every two weeks and as needed. Currently the facility was in the process of purchasing enough privacy curtains to have a rotating laundry schedule for each privacy curtain in the facility.Reviewed the facility's policy titled, Housekeeping Cleaning and Disinfection of Environmental Surfaces dated 01/11/21 revealed Walls, blinds, privacy and window curtains in resident areas will be cleaned when these surfaces are visibly soiled.

Based on interview, record review and review of the facility policy, the facility failed to ensure a thorough investigation was completed for a fall. This affected one (Resident #5) out of one resident reviewed for falls. Facility census was 79. Findings include:Review of the medical record for Resident #5 revealed an admission date of 05/14/20. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, and asthma with exacerbation. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Activities of daily living (ADL's) included substantial assistance for shower, dressing and hygiene and dependent for toileting assistance. Resident #5 was a Hoyer lift (mechanical lift) for transfers. Review of the physician orders for July 2025 revealed Resident #5 was a Hoyer lift for transfers, bilateral turning bars for bed mobility assist, bed in lowest position, mat to right side of bed due to history of falls, perimeter mattress, frequent assessment of bed height to ensure it's in lowest position and remind resident not to change height of bed, and Compass Palliative Care.Review of the care plan dated 03/22/24 revealed Resident #5 was at risk for falls and potential injury related to valgus deformity right leg, chronic obstructive pulmonary disease (COPD), asthma, emphysema, shortness of breath, history of falls, history of cerebral vascular accident, scoliosis, morbid obesity, incontinence, and bone density disorder. Interventions included keep commonly used articles within easy reach, maintain a clear pathway, mat to floor right side of bed, educational attempts of education regarding compliance, educate resident and family on negative outcomes related to non-compliance, explain all procedures before starting, bed in lowest position when occupied, frequent assessment of bed height to ensure its in lowest position and remind resident not to change height of bed, move room close to nurses station, and perimeter mattress to bed.Review of the facility fall investigation report dated 03/22/25 at 3:30 A.M. revealed Licensed Practical Nurse (LPN) #241 was called to Resident #5's room by Certified Nursing Assistant (CNA) #237. LPN #241 found Resident #5 on the floor lying in supine position next to her bed. LPN #241 observed deformity to right lower leg just below knee on medial side and one just above ankle. LPN #241 did an assessment to include good pedal pulses to lower leg and immobilized with pillows. Emergency Medical Services (EMS) were called immediately. Resident #5 was unable to provide description of what happened. Immediate intervention included first aide and EMS contacted to transport to hospital for evaluation. All notifications to Physician, family, and DON completed. There were no witness statements from staff included in the investigation. Interview on 08/06/25 at 9:11 A.M. with Director of Nursing (DON) confirmed the falls investigation for Resident #5 was missing the staff statements. DON reported she was unable to find the staff statements and she had the Assistant Director of Nursing (ADON) #208 call the staff today to get their statements. Interview on 08/11/25 at 9:29 A.M. ADON #208 confirmed the falls investigation wasn't thorough due to no staff statements being completed. ADON #208 confirmed she contacted the staff on 08/06/25 via phone for their statements. Interview on 08/11/25 at 12:20 P.M. via phone with LPN #241 revealed she was notified immediately by CNA #237 regarding a fall with Resident #5. LPN #241 reported she immediately assessed Resident #5, provided first aide and sent to hospital for evaluation. LPN #241 reported falls interventions were in place and the new immediate falls intervention was first aide and sent to hospital for evaluation. LPN #214 reported she returned the same day with a fracture, sling and follow up appointment scheduled with orthopedic physician. LPN #241 confirmed she was never interviewed or asked for a statement until 08/06/25 when ADON #208 called her by phone for her statement.Review of facility policy, Fall Management, undated, revealed if a fall occurs, the licensed nurse will assess the resident for injury from the fall and initiate an investigation of the reason for the fall.

Based on observation, record review and interview, the facility did not ensure appropriate treatment and equipment were provided to Resident #54 for bilateral hand contractures to prevent further decrease in range of motion. This affected one resident (#54) of one resident reviewed for range of motion/mobility. The facility census was 79. Findings Include:Review of the medical record for Resident #54 revealed admission to facility on 11/22/23 and reentry on 10/09/24. Pertinent diagnoses included bilateral hand contractures and Amyotrophic Lateral Sclerosis (ALS).Review of the physician orders from 11/22/23 to 08/07/25 for Resident #54 revealed there were no orders for bilateral hand splints. Further review revealed an order dated 04/14/2 for referral to a hand specialist for bilateral hand contractures. Review of the Occupational Therapy (OT) Discharge summary dated [DATE] for services 10/16/24 to 11/08/24 revealed Resident #54 was treated for bilateral hand contractures and bilateral hand splints were initiated for four to six hours per day. Resident #54 was provided with an exercise program for hands and staff education was provided on splint use. No restorative nursing program was recommended. Review of a nursing progress note dated 04/14/25 revealed Resident #54's physician made rounds and Resident #54 was complaining of difficulties moving hands and splints were ineffective.Further review of the medical record nursing progress notes, OT treatment notes, and aide tasks grids for April 2025 through August 2025 for Resident #54 revealed no documentation of refusals by Resident #54 in regard to wearing of bilateral hand splints after OT recommendations.Review of the Physical Therapy (PT) Discharge summary dated [DATE] for services dated 04/23/25 through 06/20/25 revealed physical therapy recommendations for restorative nursing program for restorative splint and brace program to bilateral hands. Review of the PT discharge summary further revealed a recommendation for bilateral resting hand splints, complete range of motion program before performing splint/brace program, monitor skin and circulation, report to nurse if any edema, swelling, or skin discolorations and refer to OT and PT as needed. Patient to wear splints at night as tolerated.Review of Occupational Therapy treatment notes dated 07/20/25 through 07/31/25 revealed Resident #54 was receiving treatment for bilateral hand contractures. Review of occupational therapy treatments notes further revealed Resident #54 reported the current hand splints not fitting correctly and Resident #54 was being measured for new, better fitting splints. Review of Resident #54 care plan report dated 02/23/25 and revised on 07/12/25 revealed Resident #54 was non-compliant related to not wearing hand splints and interventions by nursing staff to include education by staff to Resident on rationale for use and negative outcomes if not used, explanation of benefits of use, and notification to physician of non-compliance. Further review revealed there was not a splint use care plan implemented to review. Observation on 08/04/25 at 9:30 A.M. revealed Resident #54 sitting on the side of bed having just completed breakfast. There were two teal green hand splints observed lying on the chair seat opposite the bed. Resident #54 was observed with contractors to four fingers on bilateral hands.Interview on 08/04/25 at 9:30 A.M. with Resident #54 revealed hand splints did not fit correctly so he was unable to wear the splints due to not fitting. Resident #54 reported that he recently started occupational therapy, and the facility was working on getting him a new pair of hand splints that would fit better but does not know when they were ordered. Interview on 08/06/25 at 1:55 P.M. with the Therapy Director (TD) #281 confirmed there was no nursing documentation reflecting the use of bilateral hand splints following the completion of OT and/or Physical Therapy (PT) services on 10/16/24, 04/24/25, and 06/20/25 for Resident #54. TD #281 also confirmed there and been no communication between therapy services and the nursing department for use of and education of placement for the clinical staff to place the bilateral hand splints for Resident #54.Interview on 08/06/25 at 2:00 P.M. with the Director of Nursing (DON) confirmed there were no physician orders for bilateral hand splints on/after 10/16/25, on/after 04/24/25, on/after 6/20/25. DON confirmed there was no Restorative Nursing Program for hand splints after physical therapy recommendation on 06/20/25. DON confirmed there was no documentation of Resident #54 refusal to wear bilateral hand splints in the nursing notes, no documentation of interventions completed from care plan dated 02/23/25 and revised on 07/12/25 related to Resident #54's non-compliance, and no documentation of physician notification that the hand splints were not being worn by Resident #54.

Based on record review,staff interviews, and facility policy review, the facility failed to complete weekly skin assessments for Resident #39 who the facility identified as having surgical wounds upon admission. This affected one Resident (Resident #39) out of one resident reviewed for skin impairment. The facility census was 79.Findings Include: Review of the medical record for Resident #39 revealed admission date of 06/06/25 with diagnoses of aftercare for surgical repair of fracture to right ankle, atrial fibrillation (an irregular heartbeat), diabetes mellitus type two, chronic osteomyelitis, esophageal varices (bleeding of small blood vessels in the esophagus, liver cirrhosis (chronic liver damage), and congestive heart failure. Review of the Comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #39 was cognitively intact and required partial to moderate assistance with personal care and bathing. Resident #39 required a wheelchair or crutches for mobility and was non-weight bearing to right foot.Review of Resident #39's admission skin assessment dated [DATE] revealed documentation and description of multiple surgical incisions to right foot and ankle, callous to right heel, callous to bottom right foot under great toe, right great toe bruised and purple in color, and raised, scaley, cracked area to top and bottom of left great toe. Review of Resident #39's routine weekly skin assessments dated 06/13/25 and 06/20/25 revealed no documentation or description of specified wounds. There were no weekly wound tracking/assessments created and/or completed for Resident #39's surgical wounds to be assessed by the facility wound nurse.Review of Resident #39's progress notes revealed on 06/23/25 Resident #39 was transferred to the hospital for treatment to surgical wounds on the right foot. Review of Resident #39's hospital documentation revealed Resident #39 returned to the facility on [DATE] with new wound care treatment orders. Interview on 08/07/25 at 2:35 P.M. with facility Assistant Director of Nursing (ADON) #208 revealed all Residents are to have a skin assessment completed within 24 hours of admission and if any abnormalities or wounds present staff are to notify the ADON #208. ADON #208 will then complete a more in-depth assessment of wounds, verify treatment orders as needed and initiate weekly wound tracking assessments to further monitor the wound.Interview on 08/07/25 at 2:40 P.M. with the Director of Nursing (DON), confirmed there were no wound assessments/tracking completed weekly for Resident #39 prior to being hospitalized on [DATE]. Review of the facility's policy titled Skin Assessment undated revealed skin assessments are to be completed within 24 hours of admission and every 7 days for any skin abnormalities.

Based on record review and interview, the facility failed to provide showers per resident preference and shower schedule. This affected one (Resident #27) of four residents reviewed for activities of daily living (ADL's). The facility census was 79. Findings include:Review of the medical record for Resident #27 revealed an admission date of 06/25/25 with diagnoses including heart failure, chronic respiratory failure, diabetes mellitus, history of falling and difficulty walking. Review of the care plan dated 06/25/25 for Resident #27 revealed she required assistance with ADL's related to shortness of breath, weakness and history of falls. Interventions included for staff to assist her as needed daily with hygiene and showering her as per the facility policy weekly. Review of the document Shower Preference, dated 06/25/25, revealed Resident #27 preferred to have three showers weekly in the morning. Review of the document Shower Schedule, undated, revealed Resident #27 was scheduled to have showers on Monday and Thursday on night shift. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed it was very important for the resident to choose between showers, bed baths, tube baths and sponge baths. Resident #27 required substantial to maximum assistance from staff for showers. Review of the shower documentation from 07/09/25 through 08/06/25 for Resident #27 revealed she had not received her scheduled showers on 07/10/25, 07/14/25 and 07/31/25. Review of the nursing progress note dated 08/05/25 at 3:17 A.M. for Resident #27 revealed she had refused her shower three times on nightshift as she had gotten a shower on dayshift. Interview on 08/04/25 at 10:59 A.M. with Resident #27 revealed she was scheduled to have her showers at night. She stated she had updated the staff when she was admitted that she wished to have her showers in the morning. Resident #27 also stated she wished to have three showers a week and the facility had only scheduled her to have two showers a week. Interview on 08/06/25 at 12:15 P.M. with the Director of Nursing (DON) verified Resident #27's shower preference sheet stated she wanted three showers a week in the morning. She also verified Resident #27 was not getting her showers as scheduled or per her preference. Review of the facility policy titled, Personal Care/Bathing, undated, revealed residents were interviewed during the admission process, quarterly and as needed regarding the frequency they wanted showers. The policy also stated residents would receive personal care according to their plan of care to promote dignity, cleanliness and general well-being.

Based on record review and interview, the facility failed to ensure Resident #86's personal funds were forwarded to the resident's estate within 30 days. This affected one (Resident #86) of one resident reviewed for personal funds after death. The facility census was 79. Findings include:Review of the medical record for Resident #86 revealed an admission date of 01/09/24 with diagnoses including chronic obstructive pulmonary disease (COPD), dementia and heart disease. Resident #86 passed away at the facility on 06/09/25. Review of the Resident Funds Management Service Trial Balance, dated 08/06/25 revealed Resident #86 had a balance of $613.71.Interview on 08/06/25 at 10:58 A.M. with Business Office Manager (BOM) #273 verified Resident #86's personal funds of $613.71 were not dispersed to her estate within 30 days.

Based on observation, medical record review, interview, and policy review the facility failed to ensure urinary catheter care was provided and failed to assess the resident's urinary status and condition when the resident experienced no urinary output for two days and minimal output the third day resulting in transfer to the hospital for treatment of a clogged urinary catheter. This affected three residents (#14, #66, and #80) of three residents reviewed for urinary catheters. Actual Harm occurred on 02/12/25 when the facility failed to provide timely and necessary indwelling urinary catheter care to Resident #80 resulting in increased pain and the resident being transferred to the hosptial. Hospital care included replacing the urinary catheter, treatment with continuous bladder irrigation, and pain management due to the facility failure to properly and timely irrigate the urinary catheter, accurately assess the resident's condition, and monitor urinary output. Findings Include: 1. Closed medical record review revealed Resident #80 was admitted on [DATE] with diagnoses including chronic lymphocytic leukemia of B-Cell, stage four chronic kidney disease, malignant neoplasm of kidney and brain, neuromuscular dysfunction of bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident discharged to the hospital on 02/27/25 and did not return to the facility. Review of Resident #80's alternation in elimination plan of care initiated 02/07/25 and revised on 04/22/25 (after the resident discharged from the facility) revealed to assess for abdominal distention as needed initiated on 04/22/25, change Foley catheter per physician orders and as needed initiated on 02/07/25, empty Foley catheter every shift and as needed initiated on 02/07/25, irrigation per physician orders initiated on 04/22/25, and medicate per physician order initiated on 04/22/25. Review of the five-day minimum data set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of four indicating the resident had severe cognitive impairment. The assessment also revealed the resident had an indwelling urinary catheter (Foley catheter). Review of Resident #80's urinary output dated 02/2025 revealed no output was documented for 02/10/25 or 02/11/24, and only 100 ml on 02/12/25. Review of Resident #80's progress note authored by the Assistant Director of Nursing (ADON) dated 02/11/25 at 10:49 A.M., revealed the resident's urine in the foley was clear, yellow, and patent. The note included the resident had not had any significant changes in the last 24 hours. Review of Resident #80's progress note authored by Licensed Practical Nurse (LPN) #104 dated 02/12/25 at 11:35 A.M., revealed urine was normal. There had not been any significant changes in the last 24 hours with the resident. Review of Resident #80's progress note authored by LPN #104 dated 02/12/25 at 3:45 P.M., revealed the resident continued to have bright red blood draining into the Foley. The physician was notified and stated if the bleeding or discomfort continued tomorrow to send the resident to the emergency room and keep attempting to flush the Foley. Review of Resident #80's progress note authored by Registered Nurse (RN) #102 dated 02/12/25 at 7:00 P.M., revealed the family came to the nurse's station just after shift change around 6:35 P.M. and asked for the resident's Foley to be irrigated. The author informed the family that she would be down as soon as possible. The wife also asked if there was anything else that could be done and the author informed her that the doctor said that staff could send the resident to the emergency room . The wife stated, No I don't want him going over there. The author told the wife once again she would be down as soon as possible. At 6:50 P.M., a certified nursing assistant (CNA) came and told the author that the resident's wife told her that if her husband was not sent to the emergency room within 20 minutes she was going to call the police about the lack of care. The transport company was called, and the resident left the facility via stretcher at 7:00 P.M. Review of Resident #80's progress note authored by RN #102 dated 02/12/25 at 11:42 P.M., revealed the resident returned from the emergency room with a new three way 16 french Foley and continuous bladder irrigation (CBI) was done at the emergency room . New orders to follow up with the urologist within one week. Review of Resident #80's emergency room notes dated 02/12/25 revealed at 7:16 P.M. and 7:30 P.M. the resident's blood pressure was 132/91 mg/Hg and pulse was 118 (beats per minute). The resident's wife reported his heart rate was normal for him, but he was also in pain from his distended bladder. The resident appeared quite uncomfortable and was administered Toradol 15 milligrams (mg) IV for pain, Urispas and Pyridium for bladder spasms. A bladder scan was performed at 7:32 P.M., that indicated the resident had greater than 600 milliliters (ml) of urine in the bladder. At 8:43 P.M., there was minimal drainage noted from the foley catheter after multiple attempts to flush the current catheter. A three-way catheter was placed. Several small and moderate size clots were noted in the tubing with flushes. The note included continuous bladder irrigation (CBI) ordered. At 10:56 P.M., CBI was completed with 2500 ml of clear pale colored urine returned. Review of Resident #80's hospital discharge summary records dated 02/12/25 revealed the resident was seen for Foley malfunction and the resident was brought in from the skilled nursing facility for complaints of blood in his urine after having his catheter removed today. There was a large amount of gross red blood noted in the catheter bag. The resident was in pain from a distended bladder. The bladder scan noted greater than 600 milliliters (ml) of urine. It was noted the resident had a clot blocking the catheter passage. A triple-lumen catheter was placed instead of a two way which can be irrigated properly. The discharge summary included to follow-up with urologist in one week. Further review of Resident #80's progress notes dated 02/12/25 revealed no evidence the urinary Foley was changed or irrigated and no documented evidence included as to when the blood was first noted in the Foley. Review of Resident #80's orders and medication and treatment administration records dated 02/2025 revealed no evidence Resident #80's Foley catheter was changed by facility staff or irrigated. Further review revealed on 02/12/25 LPN #104 administered Tylenol 650 milligrams (mg) at 3:54 P.M., for a pain rated an eight out of 10 (1-10 pain scale). The follow up indicated the Tylenol was effective however there was no time noted when the medication was effective or pain rating noted. Interview on 04/21/25 at 9:29 A.M. with Resident #80's wife (a retired nurse) revealed on 02/11/25 she noticed blood in the resident's Foley bag. Staff told her it was due to the resident pulling on his Foley sometime during the night. On 02/12/25 when she came to visit her husband she stated there was blood in the Foley bag. She stated she had to beg for the nurse to irrigate and change the Foley. LPN #104 attempted to irrigate the Foley while the resident was in his wheelchair, which was not effective. The wife reported the resident should have been laid down in bed to properly irrigate the Foley. The LPN got blood on the floor in the resident's room and did not clean it up. LPN #104 then changed the Foley about 2:00 P.M. and no urine was ever obtained, just frank blood. There was no urine output for the rest of the afternoon. The wife asked the evening change shift nurse (Registered Nurse (RN) #102) to check the blood and she reported she would get to it later that she had discharges, tube feeds, and had no time to check the blood with no urine out in the foley bag. The resident's wife stated the resident was in so much pain she had requested the resident to go to the emergency room . The emergency room inserted a three-way catheter and continuously flushed the catheter until it was clear. The resident was transported back to the skilled facility. RN #102 never came back to the room to check the resident in. The emergency squad remarked that nurse should have come back to check the resident in. The next day, 02/13/25 the wife stated she had spoken to the Director of Nursing (DON) who defended the nurses stating the nurse had to triage care. Interview on 04/22/25 at 1:52 P.M., with Licensed Practical Nurse (LPN) #104 revealed she recalled Resident #80. The LPN recalled the resident had blood in his Foley bag for a couple days because he was attempting to get out bed unattended and was pulling on his Foley. The LPN confirmed she had changed the resident's urinary Foley and attempted to irrigate the Foley without success. The LPN reported the resident ended up going to the emergency room for treatment. Interview on 04/23/25 at 7:21 A.M., with the Director of Nursing (DON) confirmed there were no orders to change Resident #80's Foley or irrigate the Foley. The DON confirmed the resident had 100 ml output on 02/12/25 and there was no documentation of urine output on 02/10/25 or 02/11/25. The DON also confirmed there was no documented evidence the physician was notified the Foley irrigation was not successful or the resident had no output after the Foley was changed. The DON confirmed to irrigate a Foley the resident should have been laid down and irrigation should not have been attempted while the resident was sitting up in a wheelchair. Review of the facility's policy titled Foley Catheter Care, undated, revealed the Foley catheter bag would be changed as needed, the catheter would be replaced as needed, or in accordance with physician orders. The staff would monitor intakes and output and record finding on the MAR, as needed. The staff would observe and report to the licensed nurse any signs or symptoms of UTI to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output. 2. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of the bladder, cerebrovascular disease, diabetes, chronic kidney disease, and paralysis. Review of Resident #66's alteration in elimination (indwelling Foley catheter) dated 09/26/25 and revised on 04/21/25 revealed to empty Foley catheter every shift and as needed, irrigation per physician orders, monitor for signs and symptoms of urinary tract infection (UTI) including foul smelling urine. Report to physician to seek diagnoses and treatment promptly. Review of Resident #66's infection care plan related to indwelling Foley catheter dated 09/26/24 revealed to monitor for signs and symptoms of UTI: foul smelling urine, cloudy urine, sediment, and decreased output. Review of Resident #66's urinary output revealed at 5:20 A.M. on 04/22/25 the resident had 500 ml of urine output. Review of Resident #66's progress notes dated 04/21/25 and 04/22/25 revealed no evidence of milky urine. The last urinary assessment completed was dated 03/23/25 that indicated the resident had a Foley catheter that was draining cloudy yellow urine. Review of Resident #66's progress notes dated 04/22/25 and 04/23/25 revealed no evidence the physician had followed up on the resident's foul milky urine. Review of Resident #66's orders and medication and treatment administration orders dated 03/2025 to 04/2025 revealed no evidence to change the Foley drainage bag or irrigation. The Foley was last changed on 03/13/25. Observation on 04/22/25 at 7:18 A.M. of Resident #66's Foley catheter with Certified Nurse Aide (CNA) #113 revealed the urine was not visible due to the Foley bag was tinted and the urine was not visible. This observation was confirmed with CNA #113. At this time, CNA #113 emptied the Foley catheter and the urine was milky in color and had a strong odor. Resident #66 had 150 ml out (was just emptied at 5:20 A.M). Observation on 04/22/25 at 7:40 A.M. of Resident #66 with the DON revealed the bag was tinted and the urine was not visible. The DON requested the nurse to change out the bag and tubing and to update the doctor on the resident's urine being milky and see if he wanted a urinalysis. Interview on 04/22/25 at 10 :00 A.M. with Licensed Practical Nurse (LPN) #173 and the DON revealed LPN #173 changed the Foley bag but had not faxed the doctor yet regarding the milky urine. The DON confirmed the order to change the urinary bag, and irrigation was just added today. Interview on 04/22/25 at 10:51 A.M. LPN #161 revealed she had provided care to Resident #66 last week and her urine was orange in color which was normal for her because she had a diagnosis diabetes. Interview on 04/23/25 at 8:45 A.M., with the DON revealed the nurse had faxed the physician yesterday (04/22/25) regarding the resident's urine being milky and had an odor, however there was no evidence the physician had responded back to the fax yet. Interview on 04/23/25 at 9:16 A.M., with the DON revealed the physician had called back this morning and he wanted a urinalysis with a culture and sensitivity to be done tomorrow since the resident was not having symptoms. Interview on 04/28/25 at 10:20 A.M., with the DON via email revealed Resident #66's urine culture and sensitivity was positive for Proteus Vulgaris (Bacteria) and Klebsiella Aerogene (Bacteria) on 04/26/25 and the physician ordered Cipro 250 mg twice daily for seven days this morning (04/28/25). Review of the facility's policy titled Foley Catheter Care, undated, revealed the Foley catheter bag would be changed as needed, the catheter would be replaced as needed, or in accordance with physician orders. The staff would monitor intakes and output and record finding on the MAR, as needed. The staff would observe and report to the licensed nurse any signs or symptoms of UTI to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output. 3. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, multiple sclerosis, neuromuscular dysfunction of bladder and heart failure. Review of Resident #14's alteration in elimination care plan related to supra pubic catheter and neuromuscular bladder dated 09/26/24 revealed to change appliance per physician orders, intermittent catheterization per orders, irrigation per physician orders and change supra pubic catheter every 30 days in the morning, if unable to get in, send the resident to the hospital per physician. Review of the urology note dated 03/18/25 revealed to change supra pubic catheter every 30 days in the A.M. If unable to get in, send the resident to the hospital per urologist in the morning every 30 days. Review of Resident #14's current orders dated 04/2025 revealed no evidence of orders to change the resident's catheter every 30 days, irrigation, or changing equipment (bag). Interview on 04/21/25 at 1:10 P.M., with the DON confirmed the resident did not have current orders to change the supra pubic catheter every 30 days, irrigation, or changing the catheter bag. The DON reported the resident was hospitalized last month and the orders were not re-written on re-admission. Interview on 04/22/25 at 7:15 A.M., with the DON revealed the resident had to be sent to the emergency room due to staff attempted to change the supra pubic catheter but were not successful. The last time the resident's catheter was changed was on 03/22/25 because he refused to have it changed on 03/21/25. Review of the facility's policy titled Foley Catheter Care, undated, revealed the Foley catheter bag would be changed as needed, the catheter would be replaced as needed, or in accordance with physician orders. The staff would monitor intakes and output and record finding on the MAR, as needed. The staff would observe and report to the licensed nurse any signs or symptoms of UTI to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output. This deficiency represents non-compliance investigated under Master Complaint Number OH00164936, Complaint Number OH00164233.

Based on observation, record review and interview the facility to implement effective pain management for one resident (Resident #78) who was admitted to the facility following surgery to her back. Actual harm occurred on 10/15/19 when the facility failed to provide physician ordered narcotic pain medication for post-operative pain resulting in the resident sustaining uncontrolled pain (rated a 15 on a scale of 1 to 10 with 10 being the most severe) affecting the resident's well being and ability to sleep. This affected one of three residents reviewed for pain management. Findings include: Review of Resident #78's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Admission Packet V8 Pain Assessment, dated 10/15/19 revealed the resident complained of mild pain rated a three on a 1-10 pain scale (one being pain hurt a little bit to 10 being the pain hurts the worst) with the pain being in the lower back from a lumbar two through sacral five spinal fusion on 10/08/19. The assessment revealed activity made the pain worse. Review of the nursing progress notes, dated 10/15/19 revealed Resident #78 arrived to the facility at 7:00 P.M. with a surgical site to her lower back with 24 staples. The resident's orders were verified with Nurse Practitioner (NP) #150. Review of the Medication Administration Record [REDACTED].M. and on 10/16/19 at 3:27 [NAME]M. The medication was assessed to be effective at 9:21 P.M. on 10/15/19, two minutes after administration, and ineffective after the 3:27 [NAME]M. dose. Further review of the nursing progress notes, dated 10/15/19 at 9:23 P.M. revealed a message was left with the pharmacy after hours to return a call regarding medication authorization to pull (from contingency supply) for the resident's medication. No additional pharmacy notification attempts were documented until 10/16/19 at 5:47 [NAME]M. when the facility received authorization from the pharmacy to pull two [MEDICATION NAME] tablets from the contingency stock for Resident #78. Record review revealed no physician notification was documented related to the resident's pain complaints or the facility's inability to provide medications as ordered. On 10/16/19 at 5:42 [NAME]M., Resident #78's call light was observed on while at the medication cart with Licensed Practical Nurse (LPN) #100. At the time of the observation, LPN #100 stated Resident #78 was unhappy with her because she was unable to get the resident's medication from the pharmacy. LPN #100 stated Resident #78 was admitted around 7:00 P.M. on 10/15/19 which was after hours for the pharmacy. The LPN stated the day shift nurse verified medication orders with the Nurse Practitioner before she left her shift but the pharmacy closed before the resident arrived. LPN #100 stated she called the pharmacy twice and left messages both times to get authorization from the on-call pharmacist to pull the [MEDICATION NAME] from the contingency stock but the pharmacy never returned her calls. The LPN stated the resident had a recent spinal fusion and was unable to have effective pain management due to [MEDICATION NAME] not being available for administration. The LPN verified the resident had complaints of pain throughout the night not relieved by the as needed Tylenol that was also ordered (for headache). On 10/16/19 at 9:05 [NAME]M. interview with Resident #78 revealed she had been in pain all night. The pain began after she arrived to the facility. The resident revealed her pain was tolerable on admission since she had received pain medication from the hospital prior to her discharge. The resident stated her pain continued to escalate throughout the night reaching an unbearable rating of 15 on a 1-10 pain scale. The resident was tearful during the interview stating she was unable to get any sleep during the night because of her intense pain and crying from the pain. The resident stated she had an over-the-counter medication called unker cream she had used at home for many years to help with her back and restless and aching legs. The resident stated she asked the nurse if she could use the cream to get some relief and try to get some sleep but the nurse told her she was unable to have the cream without a physician's orders [REDACTED]. Further interview revealed the resident considered calling her husband to bring in her pain medication from home but was hopeful her medication would arrive from the facility pharmacy. However, she did not receive pain medication until approximately 6:00 [NAME]M. on this date (10/16/19). On 10/16/19 at 9:48 [NAME]M. interview with NP #150 verified the resident's post-operative pain would definitely warrant the use of narcotics especially due to how recent her procedure was. Further interview revealed the resident had multiple co-morbidities that would also contribute to the resident's increased pain levels. Lastly, the NP stated her expectation would be for the facility to administer medications as ordered or to contact her if ordered medications were not available resulting in pain to the resident. On 10/16/19 at 2:00 P.M. interview with the Director of Nursing (DON) revealed her expectation would be for the resident to have an effective pain management regimen. On 10/16/19 at 3:16 P.M. interview with Pharmacy Director (PD) #500 revealed the pharmacy has an after-hours triage line that is contacted after pharmacy hours. The line staff reach out to a pharmacist, if needed. Further interview revealed staff were available and it was very rare to have to leave a message for the pharmacy and not speak to a live operator. Lastly the PD revealed if a message was left, a return call was provided to the facility for follow-up. The PD revealed no calls were logged from the facility until the DON contacted the pharmacy for the authorization to pull this morning (on 10/16/19). Review of the Inventory Summary dated 10/16/19 revealed the RX Now (a passcode controlled machine that dispenses medications in an emergent or contingent situation) contained [MEDICATION NAME] 5/325 mg. Review of the Emergency Pharmacy Service and Emergency Kit policy dated 09/2010 revealed emergency pharmaceutical service was available on a 24-hour basis. Emergency needs for medication were met by using the nursing care center's approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy was contacted if an emergency arouse requiring immediate pharmacist consultation regarding medications ordered and needed prior to the next scheduled pharmacy delivery. This deficiency substantiates Complaint Number OH 535.

Based on record review and interview the facility failed to provide one resident (Resident #23), who required staff assistance for activities of daily living, adequate assistance during toileting and locomotion to prevent accidents. Actual Harm occurred on 12/03/18 when Resident #23 was being assisted in the bathroom by State tested Nursing Assistant (STNA) #600. After assisting the resident to stand, the STNA let go of the resident, resulting in the resident falling. The resident exhibited increased pain, resulting in an emergent hospital visit and [DIAGNOSES REDACTED]. Actual Harm occurred on 02/15/19 when Resident #23 was being escorted by STNA #553 in her wheelchair to the dining room without her required right foot pedal, resulting in the resident's foot bending under the wheelchair resulting in an ankle fracture. In addition, facility failed to provide adequate supervision and follow-up investigation related to wandering behavior exhibited by Resident #19. This affected two of six residents reviewed for accidents. Findings include: 1. a) Record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was intact. The assessment indicated the resident required extensive two person assistance with transfers and toileting, and had impairment on one side of the upper and lower extremity. Review of Resident #23's health status note, dated 12/03/18 at 7:05 P.M. revealed the nurse was called to the resident's room by STNA #600 and notified that the resident had fallen. On entering the room, the nurse observed the resident lying on the bathroom floor with her right shoulder and head against the door frame. Resident #23 complained of pain to the right hip and ringing in the ears. Resident #23 continued to verbalize pain in the right hip throughout the assessment, and orders were obtained to transfer the resident to the emergency room . Review of Resident #23's x-ray report, dated 12/03/18 revealed the resident had a comminuted right intertrochanteric fracture (right [MEDICAL CONDITION]). Review of the facility fall investigation related to Resident #23's fall on 12/03/18 revealed STNA #600's hand written witness statement, dated 12/03/18 indicating she took Resident #23 to bathroom to get ready for bed. The STNA was providing care without assistance. The statement indicated Resident #23 stood up off the toilet just fine, but when the STNA turned away to get toilet paper off the back of the toilet, the resident started to fall. STNA #600 stated she tried to grab her but was not quick enough and the resident landed hard on her right hip. The fall investigation contained no evidence STNA #600 was using a gait belt. Review of the health status note, dated 12/04/18 at 11:09 A.M. revealed the interdisciplinary team noted the resident was in the bathroom with STNA #600 assisting with peri care and changing the resident into bed clothes. Resident #23 stated she was holding onto the bar when her right leg gave out and she fell on to her right side landing on floor. Resident #23 had a history of [REDACTED]. Resident #23's right hip and shoulder were slightly reddened. Resident #23 was sent to the emergency room and was admitted with a right [MEDICAL CONDITION]. Review of Resident #23's health status note, dated 12/08/18 at 5:43 P.M. revealed the resident was readmitted to the facility and was yelling out in pain stating she could not do this anymore and stated both hips hurt. The note indicated the resident had been medicated for pain one hour prior and it was ineffective. Resident #23 was sent to the emergency room for a change in condition. Review of Resident #23's health status note, dated 12/10/18 at 5:30 P.M. revealed she returned to the facility and had new orders obtained for pain management. The resident had orders for the narcotic [MEDICATION NAME] 10 milligrams as needed every four hours ordered on [DATE] and [MEDICATION NAME] immediate release 10 milligrams as needed every four hours ordered on [DATE]. Review of Resident #23's Mediation Administration Record for (MONTH) (YEAR), revealed she received [MEDICATION NAME] daily for pain relief starting on 12/08/18. Review of Resident #23's quarterly MDS 3.0 assessment dated [DATE] revealed the resident's cognition was intact and she was totally dependent on staff for transfers. b.) Review of Resident #23's health status note, dated 02/15/19 at 3:00 P.M. revealed the resident complained of pain to her right foot. The resident's right foot was assessed and noted to have swelling and slight bruising to the top of foot. The right side was the resident's flaccid side and the resident was not able to lift her foot with normal range of motion. When asked what happened the resident stated she was being pushed to the dining room in her wheelchair by STNA #553 and her foot dropped and bent under the wheelchair. New physician orders [REDACTED]. Review of Resident #23's health status note, dated 02/15/19 at 5:25 P.M. revealed the resident continued to complain of right ankle and foot pain. Staff were waiting for the x-ray to be done and the resident was medicated for pain. Resident #23 stated the medication did not help much. Review of Resident #23's health status note, dated 02/15/19 at 10:02 P.M. revealed x-ray results of the right foot showed acute bimalleolar fractures (ankle fractures). New physician orders [REDACTED]. Review of Resident #23's x-ray results dated 02/15/19 confirmed she had acute bimalleolar fractures. Review of Resident #23's health status note, dated 02/16/19 at 11:52 P.M. revealed the interdisciplinary team noted the resident stated the fracture occurred on 02/15/19 when her foot fell under the wheelchair. Review of the facility fall investigation regarding Resident 23's injury on 02/15/19 revealed Resident #23 stated she was being pushed to the beauty shop to get her hair done in her wheelchair, the beauty shop was closed so she asked STNA #553 to push her to the dining room instead. While pushing her in her wheelchair, her right foot dropped to the ground (flaccid side) and her right foot bent under her. Resident #23 stated she usually had her foot pedal on the right side but after she was assisted to the wheelchair, staff forgot to put it back on. Review of STNA #553's Employee Performance Conference, dated 02/16/19 revealed the reason for the conference was to inform the STNA to make sure foot pedals were on for all residents with foot drop/strokes as Resident #23 had sustained a fracture of her right ankle. Review of Resident #23's health status note, dated 02/18/19 at 2:11 P.M. revealed the resident returned to the facility in a right leg below the knee hard cast, complained of numbness and denied pain unless her foot was moved. Following the injury, Resident #23 required a mechanical (Hoyer) lift for transfers. Interview on 04/11/19 at 8:12 A.M. with Resident #23 revealed when she fell in (MONTH) (YEAR) she was getting in the wheelchair off the commode, and she did not have any support because the STNA let her go. Resident #23 revealed her pain could not be managed after she broke her hip and she stated she had never had pain like that before. Resident #23 revealed when she injured her ankle in (MONTH) 2019 the STNA's forgot to put the foot pedal on her wheelchair and they wheeled her down to get her hair done. Resident #23 revealed her foot got heavy, it slipped to the floor and it went under the wheelchair, but the STNA kept pushing her in the chair. Resident #23 revealed her ankle still hurt, she had swelling to the area and and her doctor explained the pain in her hip and ankle had also gone to her knee which resulted in knee pain. Interview on 04/11/19 at 8:20 A.M. with the Director of Nursing (DON) revealed even though the MDS 3.0 assessment from (MONTH) (YEAR) revealed the resident required extensive assistance from two staff for transfers and toileting she believed the resident only required one person assistance with transfers and toileting when she fell on [DATE]. The DON confirmed the STNA was assisting the resident with peri care and the resident was hanging on the grab bar and then fell on to her right side onto the floor when she could no longer support herself to stand. The DON revealed when Resident #23 sustained the ankle fracture on 02/15/19 the STNAs that transferred her to her wheelchair did not put her foot pedal on her wheelchair as required. Interview on 04/11/19 at 10:17 A.M. with the DON revealed all staff should use a gait belt during transfers, and should keep a hold of the gait belt when transferring. The DON did not know if STNA #600 had used a gait belt and confirmed the STNA did not have a hold of Resident #23 while assisting the resident prior to her falling on 12/03/18. 2. Record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a plan of care dated 11/06/18 revealed Resident #19 was as risk for falls with the potential for injury related to a history of falls. Interventions included to keep the resident in the common area to monitor for attempts to stand unassisted. Review of the quarterly MDS 3.0 assessment, dated 02/09/19 revealed Resident #19 had severely impaired cognition and required extensive assistance from staff for all activities of daily living. Review of a nursing progress note, dated 02/12/19 at 5:52 A.M. revealed Resident #19 was found in the kitchen by the on duty nurse at around 4:30 A.M. with a variety of dishes scattered across the floor. The resident appeared to have over turned a service cart in the kitchen. The resident was combative with the nurse when the nurse attempted to remove her from the area and she continued to wander after being removed from the kitchen. An interview on 04/11/19 at 2:41 P.M. with Dietary Manager #512 revealed the main door to the kitchen out in the lobby was locked every night at 9:00 P.M. when the dietary staff left for the night. However, the two doors into the kitchen from the resident's dining room were not locked at night. He indicated those doors were left unlocked in case nursing staff needed to get into the kitchen. An interview on 04/11/19 3:15 P.M. with the DON revealed there was never an investigation completed when Resident #19 was found in the kitchen unsupervised. She indicated no interventions were implemented following the incident to prevent Resident #19 or any other resident from entering the kitchen unsupervised again.

Based on record review and interview the facility failed to implement an effective pain management program for Resident #35 resulting in increased pain. Actual harm occurred when Resident #35's pain medication, [MEDICATION NAME] was not available to administer, the resident reported an increase in her pain which was uncontrolled/unrelieved and described as the worst pain ever. The resident was subsequently transferred to the hospital per her request for pain management that was not being effectively managed by the facility. This affected one resident (Resident #35) of two residents reviewed for pain management. Findings include: Record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's physician's orders [REDACTED]. Record review revealed an alteration in comfort due to chronic pain comprehensive care plan, initiated 10/05/17, which revealed the resident should have medications as ordered to manage pain, facility staff should monitor effectiveness of interventions, and facility staff should monitor levels of increased pain and notify physician. Review of Resident #35's health status progress note, dated 11/04/17 revealed Resident #35's physician was notified of the need for a prescription for [MEDICATION NAME] (pain medication) to continue the medication until the resident was able to receive a medication prescription from an outside pain clinic. An order was received for [MEDICATION NAME] 10 milligrams (mg) three times a day. Review of Resident #35's electronic Medication Administration Record [REDACTED].M. revealed Resident #35's [MEDICATION NAME] medication was unavailable and the physician was aware. Resident #35's eMAR progress note, dated 11/06/17 at 8:33 A.M. and 10:49 A.M. revealed the facility needed a prescription for Resident #35's [MEDICATION NAME] medication. Resident #35's eMAR progress note dated 11/06/17 at 7:37 P.M. revealed the [MEDICATION NAME] medication was unavailable and the physician was aware. Resident #35's health status progress note, dated 11/06/17 at 9:27 P.M. revealed Resident #35 was repeatedly yelling out in severe pain to her legs and arms and stated it was the worst pain she had ever been in. Resident #35's physician was paged, and a new order was received to give a one time dose of two [MEDICATION NAME] 5-325 mg tablets. Within an hour after administering the medications, Resident #35 began screaming out and crying again saying it barely helped her. Resident was very emotional and continued to complain of body aches. Staff documented they provided comfort, massaged legs, and offered snack, and interventions which were unsuccessful. Resident #35's health status progress note, dated 11/06/17 at 10:15 P.M., revealed the resident was insisting to be sent to the emergency room to get pain shot, and was ordered to send to the emergency room for pain evaluation. Resident #35's Medication Administration Record [REDACTED]. Resident #35's (MONTH) eMAR revealed her pain was monitored every shift. During the day on 11/06/17 Resident #35's pain level was identified to be at a level five and her pain at night was identified to be at a level 10. Record review revealed the facility received an order for [REDACTED].#35 did receive [MEDICATION NAME] for pain as needed on 11/05/17 and 11/06/17. Resident #35's physician progress notes [REDACTED]. Resident #35 wanted to come to the emergency room for pain medication. Resident #35 had chronic bilateral lower extremity pain, and after the [MEDICATION NAME] was discontinued at the facility, she started having increased pain and thought she was withdrawing. An additional hospital physician note dated 11/07/17 revealed Resident #35 stated she could not get the [MEDICATION NAME] pain medication prescription signed by the facility physician because it had been prescribed by a pain service physician. Resident #35's physician orders, dated 11/09/17 revealed she was ordered [MEDICATION NAME] HCI tablet 10 mg, two tablets by mouth every eight hours for pain. Resident #35's health status progress note, dated 12/07/17 revealed the facility spoke to the pain clinic and the clinic refused to give the prescription for [MEDICATION NAME] until the resident was seen at the office. An additional health status progress note, dated 12/07/17 revealed Resident #35's physician stated he would not give the prescription for pain medication due to laws. The physician stated if Resident #35 started to withdraw to send her to the emergency room and she could get pain medication there. There were no evidence in the medical record any attempt was made prior to 12/07/17 to ensure Resident #35 did not run out of [MEDICATION NAME] or evidence of an interdisciplinary team, including the resident, physician and nursing staff plan to develop an effective pain management program if the use of [MEDICATION NAME] was not going to be provided for the resident. Review of Resident #35's (MONTH) (YEAR) eMAR revealed she did not receive [MEDICATION NAME] as ordered on [DATE] at 10:00 A.M. or on 12/08/17 at 6:00 A.M., 2:00 P.M. or 10:00 P.M. Review of Resident #35's most current quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/13/18 revealed the resident's cognition was intact, she required extensive assistance to total dependence from staff with activities of daily living and she was on a pain medication regimen. The assessment revealed the resident had occasional pain. Interview on 04/17/18 at 11:22 A.M. with Resident #35 revealed she had concerns related to receiving pain medication. The resident stated the facility had run out of her [MEDICATION NAME] pain medication in the past, resulting in hospitalization . Resident #35 revealed the facility was out of [MEDICATION NAME] at the time of the interview and stated she had not had a dose of the medication since 04/16/18. Resident #35 revealed she gets [MEDICATION NAME] (pain medication) as needed, but it was only ordered once every eight hours as needed and did not help to alleviate her pain like the [MEDICATION NAME] did. Resident #35 revealed her back was starting to hurt, and her legs were hurting more than usual. Resident #35 was concerned she would go through withdraw without the [MEDICATION NAME] medication and stated she was worried she would have an aneurysm. Resident #35 revealed she has been going the pain clinic for [AGE] years and stated her pain was well controlled with the use of [MEDICATION NAME]. Interview on 04/17/18 at 4:12 P.M. with the Director of Nursing (DON) confirmed Resident #35 was out of her [MEDICATION NAME] medication on 11/05/17 and 11/06/17 leading to the resident's request to be sent to the hospital for uncontrolled pain and to receive a pain shot. The DON revealed nursing staff did not notify her the medication was unavailable until the resident was sent out to the hospital. The DON revealed Resident #35 was a patient at an outside pain clinic, but in (MONTH) (YEAR), the facility primary care physician was writing the prescriptions for [MEDICATION NAME] and the resident was not being seen at the pain clinic. Interview with the DON on 04/17/18 at 4:12 P.M. confirmed Resident #35 missed four doses of [MEDICATION NAME] from 12/07/17 through 12/08/17. The DON revealed the pain clinic would not write the prescription for [MEDICATION NAME] because they were informed the facility physician was writing the prescription and managing the resident's pain at the time. The DON revealed however, that the facility physician had also stopped writing the [MEDICATION NAME] prescription during that time period. The DON revealed she was unaware Resident #35 was going to be out of her [MEDICATION NAME] medication until she actually ran on out 12/07/17. Review of Resident #35's health status progress note, dated 04/13/18 revealed a completed prescription for [MEDICATION NAME] was faxed to the pharmacy. Review of Resident #35's (MONTH) (YEAR) eMAR revealed she did not receive the 2:00 P.M. and 10:00 P.M. dose of [MEDICATION NAME] as ordered on [DATE] and did not receive her 6:00 A.M. or 2:00 P.M. dose of of [MEDICATION NAME] as ordered on [DATE]. Interview on 04/17/18 at 5:03 P.M. with DON confirmed Resident #35 had been without [MEDICATION NAME] medication since yesterday 04/16/18. The DON stated she was unaware that the medication had run out.

Based on observation, medical record review and interview the facility failed to comprehensively assess and implement individualized interventions for limited range of motion to prevent newly acquired contractures for one resident (Resident #8). Actual Harm occurred when Resident #8 developed a hand contracture that was not recognized or evaluated by the facility. This affected one resident (Resident #8) of one resident reviewed for contractures. Findings include: Medical record review revealed Resident #8 was admitted to the facility with bilateral knee contractures, shoulder pain, muscle weakness, history of left arm humerus fracture, rhabdomyolysis, and [MEDICAL CONDITION]. The resident's functional limitation in range of motion assessment indicated Resident #8 had upper extremity impairment on one side however didn't indicate which side or area. Resident #8 also had bilateral impairment on the lower extremity however the assessment didn't indicate the area. Resident #8 was assessed to require extensive assistance to total dependence from staff for activities of daily living. Observation on 04/16/18 at 10:45 A.M., revealed Resident #8's left hand appeared contracted. There was no evidence of splints or devices in-place. Observation of Resident #8's left hand on 04/19/18 with the Director of Nursing (DON) and Registered Nurse (RN) #64 confirmed the third and fourth digits (fingers) of the resident's left hand were contracted. RN #64 attempted to extend the third and fourth fingers without success. The resident voiced it was painful. The DON reported the contracture was new and stated she had recently assisted the resident with meals and did not note the contracture at that time. Observation on 04/19/18 at 10:35 A.M., of Resident #8 with Physical Therapist Assistance (PTA) #107 confirmed the third and fourth fingers were contracted. PTA #107 attempted to extend the resident's fingers and Resident #8 verbalized pain. PTA #107 reported she would provide education to her staff to request the floor staff to assist with the screenings if there was evidence of abnormalities. Review of Resident #8's progress notes and evaluation dated 03/01/18 to 04/19/18 revealed no evidence of contractures or abnormalities to the left hand. Review of the therapy screen, dated 04/10/18 reveled no changes were noted per nursing staff. Resident #8 was dependent for mobility and a Hoyer lift was utilized for transfers. The resident had knee contractures but had refused knee splints prior. Review of the therapy screen dated 04/19/18 revealed Resident #8 had joint mobility, impaired ability to open and close hand, manipulate objects, and raise arms overhead to the side and across body. The resident required evaluation for possible contracture or tripper finger of third and fourth fingers with verbal pain with stretching. Therapy will screen and possible evaluation for splinting. Review of Resident #8's State tested nursing assistant (STNA) documentation dated 03/18/18 to 04/18/18 (last 30 days) revealed the resident was to receive active assistance with range of motion to bilateral upper extremities and passive range of motion to lower extremities with daily activities of daily living. Further review revealed Resident #8 only received range of motion 14 out of 30 days. There was no evidence the resident had refused. Review of Resident #8's care plan revealed a plan for active assist range of motion restorative program to left upper extremity due to risk of impaired functional range of motion related to pain, decreased motivation, decreased effort for [DIAGNOSES REDACTED]. The intervention included to provide range of motion and therapy referral as needed. Resident #8 also had a care plan for risk for decline in range of motion related to history of rhabdomyolysis. The intervention was assessing range of motion and mobility quarterly and as needed, provide and encourage the resident to participate in active range of motion to bilateral upper and lower extremities, refer to therapy as ordered and as needed. Restorative programs as written. Interview on 04/18/18 at 3:24 P.M. and 3:57 P.M., with RN #64 confirmed the care plans were incorrect and the resident was not receiving restorative therapy; however was to receive range of motion with daily care. RN #64 verified the resident had only received 14 days of range of motion out of 30 days per the STNA documentation and she was to receive range of motion daily. Interview on 04/19/18 at 10:07 A.M., with PTA #107 revealed facility staff had not reported any concerns with the resident's left hand. The PTA confirmed a quarterly therapy screen was performed on 04/10/18 however the contractions were not marked. PTA #107 reported therapy staff were not permitted to physically touch the resident during the screening and they go by what the staff report to them.