Every finding on record at St Clare Commons

Based on record review, staff interview, facility policy review and review of the facility's Self-Reported Incident #273370, the facility failed to ensure two staff were present during resident transfers using a mechanical lift. This affected one (#16) of three residents reviewed for mechanical lift transfers. The facility census was 54.Findings include:Review of the medical record for Resident #16 revealed an admission date of 09/17/24 with diagnoses of Alzheimer's disease, congestive heart failure, epilepsy, anxiety, dementia, and Bell's Palsy.Review of the comprehensive annual Minimum Data Set (MDS) assessment, dated 02/13/26, revealed Resident #16 had severely impaired cognition and was dependent on staff for transfers. Review of the care plan initiated 03/19/25 and revised 08/24/25 revealed Resident #16 had an activities of daily life self care performance deficit related to dementia and limited mobility. Interventions included: transfer, I require a mechanical lift and two assist for transferring.Review of the facility's Self-Reported Incident (SRI) #273370 revealed Resident #16's family member reported a concern regarding Resident #16 being transferred via mechanical lift by one staff person. Review of the facility's investigation revealed a written statement from Certified Nursing Assistant (CNA) #120 confirming she transferred Resident #16 using a mechanical lift by herself. Additional review revealed the facility provided written counseling to CNA #120 for corrective action for not using two staff while transferring Resident #16. Further review revealed the facility provided education to staff regarding the facility's policy regarding transfers using a mechanical lift.Interview on 05/12/26 at 2:24 P.M. with the Administrator confirmed the facility's policy was to have two staff assisting when transferring residents with a mechanical lift. Interview on 05/13/26 at 2:09 P.M. with Staff Development Coordinator (SDC) #140 revealed staff were actively being trained to use the mechanical lift with two staff assisting each resident. SDC #140 stated she would begin audits of staff to determine compliance with the facility's mechanical lift use after training of all CNAs was completed.Review of the policy Lifting Machine, Using a Mechanical, approved 05/22/25, revealed at least two nursing assistants were needed to safely move a resident with a mechanical lift. This deficiency represents non-compliance investigated under Complaint Number 2992483.

Based on observation, review of meal order ticket, staff interview, and facility policy review, the facility failed to provide meals per resident preferences. This affected one (#11) of one resident reviewed for food preferences and had the ability to affect all residents that receive food from the kitchen. The facility identified all 51 residents receive meals from the kitchen. The facility census was 51.Findings include:Review of Resident #11's medical record revealed an admission date of 09/17/24. Diagnoses included Alzheimer's, congestive heart failure, anxiety, and seizures.Review of Resident #11's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a cognitive deficit. The resident was dependent on staff for all care.Review of Resident #11's most recent care plan revealed the resident required supervision and sometimes feeding assistance. Observation of breakfast service on 03/25/26 at 7:35 A.M. revealed Resident #11 was served pureed sausage, scrambled eggs, pureed toast, and cranberry juice in the appropriate divided place, sippy cup, and build up silverware. Review of Resident #11's meal ticket dated 03/25/26 revealed the resident would be served yogurt, 1/2 a banana, tea daily, and no juice or soda.Interview with Certified Nursing Assistant (CNA) #208 on 03/25/26 at 7:43 A.M. verified Resident failed to be supplied the ordered food and was served juice. CNA #208 stated the residents' preferences changed often.Review of the facility policy titled Accommodation of Food Preferences revised 03/25/26 revealed alternate menu items shall be available to accommodate individualized resident needs, food preferences, including religious, ethnic and cultural food preferences, restrictions, and requests. Resident's food preferences shall be listed in the tray ticket system ither manually or electronically. This violation represents non-compliance investigated under Complaint Number 2727791.

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure discontinued narcotics were properly disposed of in a timely manner. This affected eight (#28, #30, #38, #62, #63, #65, #70, and #71) of eight residents reviewed for narcotic medications and who had the narcotic medication discontinued. The facility census was 51.Findings include:1. Review of Resident #71's medical record revealed an admission date of [DATE]. The resident expired on [DATE].Review of Resident #71's medical record revealed a physician's order dated [DATE] for Tramadol oral tablet 50 milligrams (mg) to be administered by mouth twice daily for pain.Observation of the 100-hall medication cart on [DATE] at 7:02 A.M. with Licensed Practical Nurse (LPN) #251 verified 15 Tramadol tablets remained in the medication cart for Resident #71. LPN #251 verified Resident #71 had passed away in the facility on [DATE].2. Review of Resident #28's medical record revealed an admission date of [DATE]. Diagnoses included end stage renal disease, congestive heart failure, malignant neoplasm of the kidney, prostate, and retroperitoneum. Resident #28 was discharged from the facility on [DATE].Review of Resident #28's physician order dated [DATE] revealed an order for Tramadol hydrochloride (HCL) tablet 50 mg to be administered by mouth every 12 hours for pain between seven and 10. The medication was discontinued on [DATE].Observation on [DATE] at 7:10 A.M. of the 300 hall medication cart with LPN #251 revealed there were 22 tablets of the 50 mg Tramadol HCL tablets in the locked drawer of the medication cart belonging to Resident #28.3. Review of Resident #38's medical record revealed an admission date of [DATE]. Diagnoses included anxiety, hemiplegia, hemiparesis, and adjustment disorder.Review of Resident #38's medical record revealed an order dated [DATE] for oxycodone-acetaminophen (narcotic pain reliever) oral tablet 10-325 mg to be administered by mouth four times a day for pain while awake.Review of Resident #38's medical record revealed the oxycodone-acetaminophen was discontinued on [DATE].Observation of the 300-hall medication cart on [DATE] at 7:10 A.M. with LPN #251 revealed 22 tablets of Resident #38's discontinued oxycodone-acetaminophen were stored in the locked narcotic drawer of the medication cart.4. Review of Resident #62's medical record revealed an admission date of [DATE]. Diagnoses included dementia, schizophrenia, atrial fibrillation, and congestive heart failure. The resident was transferred out of the facility on [DATE] and did not return.Review of Resident #62's medical record revealed a physician's order dated [DATE] for Tramadol 50 mg, the medication was discontinued on [DATE].Observation of the 300 hall medication cart on [DATE] at 7:10 A.M. with LPN #251 revealed 23 tablets of Tramadol 50 mg remained in the cart belonging to Resident #62.5. Review of Resident #30's medical record revealed an admission date of [DATE]. Diagnoses included hip fracture, dementia, anxiety, bipolar, and diabetes mellitus. The resident expired in the facility on [DATE].Observation of the 300 hall medication cart on [DATE] at 7:10 A.M. with LPN #251 revealed Resident #30 still had 29 tablets of Tramadol (opioid pain medication) 50 mg, 31 tablets of Lorazepam (antianxiety) 0.5 mg, and a full unopened bottle of liquid Morphine Sulfate (opioid analgesic) was in the locked narcotic drawer.Interview with LPN #251 on [DATE] at 7:12 A.M. verified Residents #28 and #62 had been discharged from the facility, Resident #30 passed away, and the discontinued medication for Resident #30 remained in the medication cart as the nurses were waiting for nursing management to remove the resident's narcotics from the medication cart.6. Review of the medical record for Resident #70 revealed an admission date of [DATE] with diagnoses of thoracic vertebra fracture, quadriplegia, contracture, and stiffness of left shoulder. Resident #70 was discharged to an assisted living facility on [DATE].Review of the physician order initiated [DATE] and discontinued [DATE] revealed Resident #70 was prescribed oxycodone-acetaminophen, 5-325 mg tablet with directions to give one tablet by mouth every four hours as needed for pain.Observation of the 200 hall medication cart with LPN #229 on [DATE] at 7:25 A.M. revealed there were 20 oxycodone-acetaminophen 5-325 mg tablets belonging to Resident #70 in the narcotic drawer of the medication cart. 7. Review of the medical record for Resident #63 revealed an admission date of [DATE] with diagnoses of Alzheimer's disease, dementia, chronic kidney disease, and peripheral vascular disease. Resident #63 expired under hospice care on [DATE].Review of the physician order initiated [DATE] revealed Resident #63 was prescribed morphine sulfate (concentrate) oral solution 20 mg per milliliter (mg/ml). The medication was to be administered 0.25 ml by mouth every four hours as needed for pain/shortness of breath regarding end of life symptoms.Review of the physician order initiated [DATE] and discontinued [DATE] revealed Resident #63 was prescribed Ativan (lorazepam) oral tablet 0.5 mg, one tablet was to be administered by mouth every four hours as needed for shortness of breath/anxiety/agitation. The medication was ordered for 14 days.Observation on [DATE] at 7:25 A.M. with LPN #229 of the 200 hall medication cart revealed 28 Lorazepam 0.5 mg tablets and an unopened bottle of liquid morphine sulfate was stored in the 200 hall medication cart belonging to Resident #63.8. Review of the medical record for Resident #65 revealed an admission date of [DATE] with diagnoses including migraine, osteoarthritis, heart disease, and Parkinsonism. Resident #65 discharged to another long-term care facility on [DATE].Review of the physician order initiated [DATE] revealed Resident #65 was prescribed Percocet oral tablet 10-325 mg (oxycodone with acetaminophen) with the resident to be administered one tablet by mouth two times a day, at 9:00 A.M. and 9:00 P.M. for pain. Review of the physician order initiated [DATE], and not yet discontinued, revealed Resident #65 was prescribed Percocet oral tablet 10-325 mg (oxycodone with acetaminophen), one tablet by mouth every 12 hours as needed for pain at 2:00 P.M. and 2:00 A.M., as needed.Observation of the 200 hall medication cart on [DATE] at 7:27 A.M. with LPN #229 revealed in the locked narcotic drawer of the medication cart there were 22 tablets of Percocet for Resident #65. Interview with LPN #229 on [DATE] at 7:27 A.M. following the observation of the 200 hall medication cart verified Residents #70, #63 and #65 were no longer in the facility and that each of the residents had narcotic medications in the medication cart. Interview on [DATE] at 8:23 A.M. with the Interim Director of Nursing (IDON) revealed she was aware expired narcotics remained in the nurse's carts. The IDON stated the secured drawer in her office was missing the second key and therefore the narcotics could not be stored securely except in the double locked medication carts. The IDON stated expired narcotics were always destroyed onsite and would require two nurses or a nurse and a pharmacist to destroy the narcotics.Telephone interview Pharmacist #308 on [DATE] at 2:03 P.M. revealed every facility varied as how the narcotics were disposed of for expired and discharged residents. The Pharmacist stated those medications were not to be kept in the medications carts and should be disposed of as soon as possible. Review of the facility policy titled Controlled Medications revised on [DATE] revealed discontinued controlled substance medications are removed from the patient care area and temporarily stored at the facility in a securely locked area until such time that they are destroyed as directed by state law. This was an incidental finding identified during the Complaint Survey completed [DATE].

Based on record review and staff interview the facility failed to complete non-pharmacological interventions prior to administering as needed psychotropic medications to residents. This affected three (#11, #30, and #60) of four residents reviewed for psychotropic medications. The facility census was 51.Findings include:1. Review of Resident #30's medical record revealed an admission date of 12/08/25. Diagnoses included hip fracture, dementia, anxiety, and bipolar. Review of Resident #30's medical record revealed a physician's order dated 02/11/26 for non-pharmacological interventions to be documented for monitoring as needed. Non pharmacological interventions included relaxation, quiet room, massage, food, fluids, music, repositioning, involve in activity, medication for pain, other to be documented in the progress nursing notes. Review of Resident #30's medical record revealed a physician's order dated 03/10/26 for Ativan 0.5 milligrams (mg) to be administered every four hours as needed for anxiety for 14 days. Review of Resident #30 Medication Administration Record (MAR) revealed the Ativan 0.5 mg was administered on 03/18/26 at 9:21 P.M., 03/19/26 at 2:50 P.M., 03/20/26 at 2:50 P.M., 03/21/26 at 12:40 A.M. and 1:41 P.M. and on 03/22/26 at 12:40 P.M. Review of Resident #30's MAR and nursing progress notes revealed the medical record was absent of non-pharmacological interventions prior to the administration of the as needed Ativan on 03/18/26, 03/19/26, 03/20/26, 03/21/26, and 03/22/26. 2. Review of Resident #11's medical record revealed an admission date of 09/17/24. Diagnoses included Alzheimer's disease and anxiety. Review of Resident #11's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident utilized anti-anxiety medications. Review of Resident #11's current physician orders revealed an order dated 09/17/24 for non-pharmacological interventions including relaxation, quiet room, massage, food, fluids, music, toileting, repositioning, involve in activity, medication for pain, other to be documented in the progress nursing notes as needed for monitoring and an order dated 11/20/25 for Ativan 0.5 mg tablets, give 0.25 mg by mouth every four hours as needed for anxiety. Review of Resident #11's MAR dated December 2025 revealed on 12/10/25 at 3:28 A.M. and on 12/12/25 at 3:28 A.M. and 11:25 P.M. the resident was medicated with as needed Ativan. Review of the Resident #11's MAR and nursing progress notes dated 12/10/25 through 12/12/25 were absent of non-pharmacological interventions prior to the administration of the as needed Ativan. 3. Review of Resident #60's medical record revealed an admission date of 03/13/26. Diagnoses included dementia, hypertension, and incontinence. Review of Resident #60's MDS and care plan revealed the documents were in progress. Review of Resident #60's current physician orders revealed an order dated 03/17/26 for non-pharmacological interventions to be completed which included relaxation, quiet room, massage, food, fluids, music, toileting, repositioning, involve in activity, medication for pain, other to be documented in the progress nursing notes. Further review of the physician orders revealed orders dated 03/23/26 for Ativan oral tablet 0.5 mg to be administered by mouth one time a day for anxiety and give 0.5 mg by mouth every four hours as needed for anxiety for 14 days. Review of Resident #60's nursing progress notes and the MAR revealed as needed Ativan was administered on 03/15/26 at 7:33 P.M. with no alternate non-pharmacological interventions documented prior to the Ativan administration. Interview with the Interim Director of Nursing (IDON) on 03/25/26 at 1:22 P.M. verified the staff failed to complete or document the resident's non-pharmacological interventions prior to the administration of Ativan. The IDON revealed the facility had no specific policy related to completing non-pharmacological interventions prior to administering psychotropic medications, adding but physician orders must be followed. This deficiency represents non-compliance investigated under Complaint Number 2727791.

Based on observation, record review, staff interview, and review of the daily menu, the facility failed to ensure residents on a pureed diet received the planned menu. This affected three (#11, #15, and #56) of three residents identified on a pureed diet. The facility census was 51. Findings include:1. Review of the medical record for Resident #56 revealed an admission date of 02/08/24 with diagnoses of Alzheimer's disease, hypertension, chronic obstructive pulmonary disease, restlessness and agitation, anxiety, dementia, and dysphagia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had severe cognitive impairment, was dependent on staff for eating, activities of daily living and mobility.Review of the current physician orders revealed an order dated 03/20/26 for a regular diet with pureed texture, nectar consistency, with liquids provided via straw, and an order dated 02/26/26 for med pass 2.0, 120 milliliters (ml) twice daily for weight loss, give before lunch and before dinner.2. Review of the medical record for Resident #11 revealed an admission date of 09/17/24, diagnoses included Alzheimer's disease, coronary artery disease, congestive heart failure, end stage renal disease, type II diabetes mellitus, and anxiety. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #11 had severe cognitive impairment, was dependent for activities of daily living, required set up assistance and supervision for meals. Review of Resident #11's physician orders revealed orders dated 11/18/25 for the resident to have a regular diet with pureed texture, to use a divided plate and sippy cup, and to be fed for all meals.3. Review of the medical record for Resident #15 revealed an admission date of 09/27/24, diagnoses included hypertension, insomnia, nontraumatic subarachnoid hemorrhage, repeated falls.Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment, required supervision and touching assistance for meals, was dependent for toileting and transfers. Review of the physician orders revealed Resident #15 had an order dated 4/21/25 for a magic cup with meals for weight loss and an order dated 10/30/24 for a regular diet with pureed texture. Interview on 03/24/26 at 11:10 A.M. with [NAME] #303 revealed she prepared the pureed meals for Resident #11, Resident #15 and Resident #56. [NAME] #303 stated residents on a pureed diet received the same menu items (in pureed form) as residents on a regular diet.Observation of the daily menu provided by Dietary Manager #302 on 03/24/26 at 11:13 A.M. revealed the evening meal was oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake.Observation on 03/24/26 at 4:42 P.M. revealed Resident #56 in the dining room with a plate of pureed food in front of her, one mound of green puree, one mound of orange puree, and one mound of beige puree. Resident #56 also had a nutrition supplement ice cream. Continued observation of Resident #34's regular-texture meal revealed fried chicken, mashed sweet potatoes, and asparagus spears. Interview on 03/24/26 at 4:44 P.M. with Dietary Aide (DA) #301 revealed the dessert was chocolate banana marble cake. DA #301 stated no pureed cake was available for Resident #56.Interview on 03/24/26 at 5:00 P.M. with [NAME] #305 revealed the evening meal was pureed by the morning cook, [NAME] #303. [NAME] #305 called [NAME] #303 on the telephone to ask [NAME] #303 what vegetables were prepared for residents on a pureed diet for the evening meal. [NAME] #305 stated [NAME] #303 prepared a broccoli blend for the three residents on a pureed diet. Additionally, [NAME] #305 stated no pureed cake was prepared and the pureed dessert was ice cream. Interview on 3/26/26 at 2:45 P.M. with [NAME] #310 confirmed Residents on a pureed diet should receive the same menu items as residents on a regular diet, except when accounting for preferences or allergies. Further, [NAME] #310 confirmed asparagus could be pureed to an appropriate texture for residents on a pureed diet.Review of the facility policy titled Meal Supervision and Assistance, revised 02/18/26 stated the resident will be prepared for a well-balanced meal in a calm environment, location of preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and ensure an enjoyable event. When serving the resident, staff are to check the tray prior to serving the food to the resident to ensure they are receiving the correct diet and that the food is in the consistency that is ordered. This deficiency represents non-compliance investigated under Complaint Number 2727791.

Based on record review, personnel file review, staff interview and policy review, the facility failed to investigate an allegation of verbal abuse. This affected one (#65) of four residents reviewed for abuse. The facility census was 51.Findings include:Review of the medical record for Resident #65 revealed an admission date of 07/23/25 and a discharge date of 03/02/26 with diagnoses of atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism.Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/28/26, revealed Resident #65 had intact cognition. Review of Resident #65's care plan, initiated 07/29/25, and revised 08/12/25, revealed Resident #65 elected to have video monitoring in his room.Review of Resident #65's progress notes, dated 12/01/25 through 12/22/25, revealed no evidence of verbal abuse by staff.Review of the personnel file, on 03/26/26 at approximately 11:45 A.M., for Licensed Practical Nurse (LPN) #221 revealed a Corrective Action Report (CAR), signed 01/01/26. Review of the CAR revealed LPN #221 received written counseling for incidents on 12/01/25 and 12/22/25 violating rules of conduct and behavior. Further review revealed LPN #221 was observed on 12/01/25 on video shouting at the resident and using foul/curing language. Further review revealed a family member of submitted a written concern on 12/22/25 regarding LPN #221's behavior toward them. Additional review of the CAR revealed the statement This behavior is disrespectful, abusive and unprofessional.Interview on 03/26/26 at 12:00 P.M. with the Interim Director of Nursing (IDON) and concurrent review of the CAR confirmed the situation met the criteria for a self-reportable incident due to the description of abusive behavior. Interview on 03/26/26 at 12:13 P.M. with the Administrator, and concurrent review of the CAR signed 01/01/26, revealed she could not determine which resident was involved in the incident.Interview on 03/26/26 at 12:18 P.M. with Human Resources Director (HRD) #313, and concurrent review of the CAR signed 01/01/26, revealed HRD #313 signed the document along with a former Director of Nursing. HRD #313 stated Resident #65 was the resident affected by the behavior identified in the written counseling for LPN #221.Follow-up interview on 03/26/26 at 2:36 P.M. with the Administrator confirmed the facility could not provide evidence of an investigation into the incidents affecting Resident #65 and Resident #65's family member on 12/01/25 and 12/22/25, respectively. Review of the facility's policy, Abuse, Neglect and Exploitation, approved 05/22/25, defined verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. Further review revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.This was an incidental finding identified during the Complaint Survey completed 03/26/26.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure residents received feeding assistance in a dignified manner. This affected one (#56) of three residents reviewed for feeding assistance. The facility census was 51.Findings include:Review of the medical record for Resident #56 revealed an admission date of 09/27/24 with diagnoses of Alzheimer's disease, stroke, anorexia, dysphagia, and dementia with agitation.Review of the quarterly Minimum Data Set assessment, dated 01/01/26, revealed Resident #56 had severely impaired cognition and required supervision/touching assistance for eating.Review of the care plan initiated 02/22/24, and revised 08/28/25, revealed Resident #56 had an activity of daily life self-care performance deficit related to dementia. Interventions stated the resident requires maximum assistance and may need to be fed by staff. Observation on 03/25/26 at 7:22 A.M. revealed Certified Nursing Assistant (CNA) #300 taking Resident #56's breakfast tray into the room and walking out to continue to pass other resident's trays.Observation on 03/25/26 at 7:37 A.M. revealed Resident #56 sitting up in bed with CNA #300 sitting next to Resident #56's bed. Resident #56's overbed table was in front of CNA #300 and CNA #300 was wearing an earbud in her left ear, visible from the doorway, and was holding her cell phone up while watching a video. CNA #300 was not actively feeding Resident #56. Concurrent interview with CNA #300 confirmed she was watching social media on her personal phone. Continued observation revealed CNA #300 asked Resident #56 if she would like eggs. Resident #56 nodded and opened her mouth. CNA #300 fed Resident #56 a bite of yogurt. Concurrent interview with CNA #300 confirmed she offered eggs and provided yogurt. Further observation revealed Resident #56's eyes were closed periodically during the meal and CNA #300 would lift a bite of food to Resident #56's mouth and hold it there without notifying Resident #56 she was providing another bite of food. Alternatively, Resident #56 would open her mouth, possibly in anticipation of a bite of food, and CNA #300 would spend time cleaning off the spoon and attempting to load the spoon with a new bite of food without verbalizing what was happening or about to happen for Resident #56. Interview on 03/25/26 at 8:02 A.M. with the Interim Director of Nursing (IDON) confirmed staff should not watch their cell phones while providing resident care. Review of the policy, Meal Supervision and Assistance, reviewed 02/18/26, revealed the facility would provide a relaxing, enjoyable environment during mealtime.This was an incidental finding identified during the Complaint Survey completed 03/26/26.

Based on record review, staff interview, review of a personnel file, review of camera footage, policy review, and review of Self-Reported Incident #272120 the facility failed to ensure residents were free from verbal abuse. This affected two (#11 and #65) of four residents reviewed for abuse. The facility census was 51.Findings include:1. Review of Resident #11's medical record revealed an admission date of 09/17/24. Diagnoses included Alzheimer's, congestive heart failure, anxiety, and seizures. Review of Resident #11's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a cognitive deficit. The resident was dependent on staff for all care. Review of Resident #11's most recent care plan revealed she had pain related to osteoarthritis in multiple sites. The resident had an activity of daily living care performance deficit related to confusion, dementia, and limited mobility. Interventions included two staff members to reposition and turn in bed, and the resident required a mechanical lift with two staff members for transfers. Review of Resident #11's room revealed the family had a camera installed to ensure proper care. In addition, the family provided a personal care companion to stay with the resident several hours a day. Review of a video tape provided by Resident #11's family revealed on 03/15/25 at Licensed Practical Nurse (LPN) #219 was assisting Certified Nursing Assistant (CNA) #312 with care. On Video #1 at 0:16 seconds LPN #219 was providing incontinence care and in a loud voice told Resident #11 to stop squeezing her butt cheeks. At 0:24 seconds LPN #219 yelled Daughter, you need to tell her to stop squeezing her butt cheeks. During incontinence care LPN #219 was viewed throwing the dirty wash clothes over the bed and onto the bare floor. LPN #219 then said in a loud voice at 2:24 on the video I am not an aide. I'm doing the best I can! Resident #11 was observed grunting, moaning, and crying out. Resident #11 was also swinging her arms around in the air. The resident was non-verbal. At 2:34 on the video the family care giver came over to comfort the resident, speaking to her calmly and holding her hand. Resident #11 then calmed down. Review of Video #2 dated 03/15/25 revealed two CNAs (#311 and #312) were providing care for Resident #11. At 2:03 CNA #311 referred to Resident #11's daughter as the spy stating we have to do care this way because That's how her spy wants it done. At 1:45 in the video CNA #311 informed CNA #312 that Resident #11's daughter was not allowed in the facility and could not even visit Resident #11 on her birthday. This conversation was completed while providing care for Resident #11 and transferring her from the bed to wheelchair via mechanical lift. Review of the videos and interview with the interim Director of Nursing on 03/26/26 at 10:10 A.M. verified the actions and speech of LPN #219 and CNA #311 were unprofessional and abusive. 2. Review of the medical record for Resident #65 revealed an admission date of 07/23/25 and a discharge date of 03/02/26 with diagnoses of atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism. Review of the quarterly MDS assessment, dated 01/28/26, revealed Resident #65 had intact cognition. Review of Resident #65's care plan, initiated 07/29/25, and revised 08/12/25, revealed Resident #65 elected to have video monitoring in his room. Review of the personnel file, on 03/26/26 at approximately 11:45 A.M., for LPN #221 revealed a Corrective Action Report (CAR), signed 01/01/26. Review of the CAR revealed LPN #221 received written counseling for incidents on 12/01/25 and 12/22/25 due to violating rules of conduct and behavior. Further review revealed LPN #221 was observed on 12/01/25 on video shouting at the resident and using foul/cursing language. Further review revealed a family member of submitted a written concern on 12/22/25 regarding LPN #221's behavior toward them. Additional review of the CAR revealed the statement This behavior is disrespectful, abusive and unprofessional. Interview on 03/26/26 at 12:00 P.M. with the Interim Director of Nursing (IDON) and concurrent review of the CAR confirmed the situation met the criteria for a self-reportable incident due to the description of abusive behavior. Interview on 03/26/26 at 12:18 P.M. with Human Resources Director (HRD) #313, and concurrent review of the CAR signed 01/01/26, revealed HRD #313 signed the document along with a former Director of Nursing. HRD #313 stated Resident #65 was the resident affected by the behavior identified in the written counseling for LPN #221. Review of the facility's policy, Abuse, Neglect and Exploitation, approved 05/22/25, defined verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. This was an incidental finding identified during the Complaint Survey completed 03/26/26.

Based on record review, personnel file review, staff interview and policy review, the facility failed to report an allegation of verbal abuse to the state agency as required. This affected one (#65) of four residents reviewed for abuse. The facility census was 51.Findings include:Review of the medical record for Resident #65 revealed an admission date of 07/23/25 and a discharge date of 03/02/26 with diagnoses of atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism.Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/28/26, revealed Resident #65 had intact cognition. Review of Resident #65's care plan, initiated 07/29/25, and revised 08/12/25, revealed Resident #65 elected to have video monitoring in his room.Review of Resident #65's progress notes, dated 12/01/25 through 12/22/25, revealed no evidence of verbal abuse by staff.Review of the personnel file, on 03/26/26 at approximately 11:45 A.M., for Licensed Practical Nurse (LPN) #221 revealed a Corrective Action Report (CAR), signed 01/01/26. Review of the CAR revealed LPN #221 received written counseling for incidents on 12/01/25 and 12/22/25 violating rules of conduct and behavior. Further review revealed LPN #221 was observed on 12/01/25 on video shouting at the resident and using foul/curing language. Further review revealed a family member of submitted a written concern on 12/22/25 regarding LPN #221's behavior toward them. Additional review of the CAR revealed the statement This behavior is disrespectful, abusive and unprofessional.Interview on 03/26/26 at 12:00 P.M. with the Interim Director of Nursing (IDON) and concurrent review of the CAR confirmed the situation met the criteria for a self-reportable incident due to the description of abusive behavior. Interview on 03/26/26 at 12:13 P.M. with the Administrator, and concurrent review of the CAR signed 01/01/26, revealed she could not determine which resident was involved in the incident.Interview on 03/26/26 at 12:18 P.M. with Human Resources Director (HRD) #313, and concurrent review of the CAR signed 01/01/26, revealed HRD #313 signed the document along with a former Director of Nursing. HRD #313 stated Resident #65 was the resident affected by the behavior identified in the written counseling for LPN #221.Follow-up interview on 03/26/26 at 2:36 P.M. with the Administrator confirmed the facility did not report the incident to the state agency.Review of the facility's policy, Abuse, Neglect and Exploitation, approved 05/22/25, defined verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. Further review revealed the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.This was an incidental finding identified during the Complaint Survey completed 03/26/26.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff were trained on the use of mechanical lifts. This affected one (#25) of three residents reviewed for mechanical lift use. The facility identified 28 residents who were dependent on a mechanical lift for transfers. The facility census was 54.Findings include: Review of the medical record for Resident #25 revealed an admission date of 05/01/25. Diagnoses included dementia, muscle weakness, and depression.Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/05/25, revealed Resident #25 was cognitively impaired and was assessed to require partial assistance from sitting to standing.Review of the care plan dated 05/01/25 revealed Resident #25 had an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance, dementia, fatigue, and impaired balance. Interventions included maximum assistance of one to two staff to transfer.Observation on 11/25/25 at 9:18 A.M. revealed Certified Nursing Assistant (CNA) #300 attempted to transfer Resident #25 from the bed to the wheelchair to get to the bathroom. CNA #300 attempted to stand Resident #25 by taking both hands and pulling him from sitting to standing. CNA #300 attempted three times to have Resident #25 stand, with Resident #25 sitting back on the bed each time. CNA #300 then obtained a mechanical lift and transferred Resident #25 to the wheelchair and then to the bathroom, without a second staff present during the use of the mechanical lift. Interview on 11/25/25 at 10:32 A.M. with the Administrator revealed two staff should be present to assist with a mechanical lift transfer. The Administrator confirmed the facility did not provide mechanical lift training to CNA #300. Interview on 11/25/25 at 1:04 P.M. with CNA #300 revealed Resident #25 was typically able to stand and pivot into the wheelchair; however, the resident sometimes required more assistance. CNA #300 verified she transferred Resident #25 using a mechanical lift without a second staff and further stated the facility did not provide training on the use of mechanical lifts when hired into the facility. Review of the facility policy titled, Lifting Machine, Using a Mechanical, dated 05/22/25, revealed, at least two nursing assistants were needed to safely move a resident with a mechanical lift. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility.This deficiency represents non-compliance investigated under Complaint Number 2676960.

Based on observation, resident interview, staff interview, medical record review, review of Resident Council meeting minutes, and review of facility policy, the facility failed to ensure residents who were dependent for care received showers as scheduled. This affected three (#1, #25, and #31) of three residents reviewed for showers. The facility census was 54.Findings include:1. Review of Resident #1's medical record revealed an admission date of 07/23/25. Diagnoses included atrial fibrillation, weakness, and parkinsonism (causes movement problems such as tremors, stiffness and slow movements and balance issues).Review of the Minimum Data Set (MDS) assessment, dated 10/28/25, revealed Resident #1 was cognitively intact and required maximal (staff) assistance with activities of daily living (ADLs).Review of the care plan, revised on 08/12/25, revealed Resident #1 had and ADL self-care performance deficit related to parkinsonism. Interventions included providing a sponge bath when a full bath or shower could not be tolerated, and the resident required maximum (staff) assistance for shower/bath.Review of Resident #1's bathing documentation for November 2025 revealed the resident was scheduled to receive a bed bath every Tuesday and Friday on day shift. Further review of the documentation revealed Resident #1 received a bed bath on 11/04/25 and 11/18/25 (two of eight opportunities). Additional review revealed no evidence Resident #1 was provided a bed bath on any other days in November 2025. Observation on 11/25/25 at 8:30 A.M. of Resident #1 revealed the resident had long fingernails with dirt under them. Resident #1 had dry skin on his head and face.Interview on 11/25/25 at approximately 8:35 A.M. with Resident #1, with a family member present, revealed his last bed bath was about one week ago, when his family member provided him one. Resident #1 stated he could not recall the last time that staff washed his entire body. Resident #1's family member stated the resident would go weeks without a bed bath and the concerns had been expressed to the Administrator and the Director of Nursing (DON) on multiple occasions, without resolution.Interview on 12/01/25 at 1:50 P.M. with the Director of Nursing (DON) verified that Residents #1 did not receive showers as scheduled. The DON further confirmed issues with showers had been brought to her and the Administrator's attention and education had been given to staff; however, no evidence was provided related to the education or any corrective action taken by the facility.2. Review of the medical record for Resident #25 revealed an admission date of 05/01/25. Diagnoses included dementia, muscle weakness, and depression.Review of the quarterly MDS assessment, dated 11/05/25, revealed Resident #25 was cognitively impaired. Resident #25 was assessed to require substantial (staff) assistance for toileting, bathing, and personal hygiene.Review of the care plan, dated 05/01/25, revealed Resident #25 had an ADL self-care performance deficit related to activity intolerance, dementia, fatigue, and impaired balance.Review of the shower documentation for November 2025 revealed Resident #25 was scheduled for showers on Monday and Thursdays. Further review revealed no evidence Resident #25 received showers on 11/10/25, 11/13/25 or 11/24/25.Observation on 11/25/25 at 10:30 A.M. revealed Resident #25 was sitting in the common area with food visible on his shirt and face. Interview on 12/01/25 at 1:50 P.M. with the DON verified that Resident #25 did not receive showers as scheduled. The DON further confirmed issues with showers had been brought to her and the Administrator's attention and education had been given to staff; however, no evidence was provided related to the education or any corrective action taken by the facility.3. Review of the medical record for Resident #31 revealed an admission date of 01/13/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke), retention of urine, and anxiety.Review of the quarterly MDS assessment, dated 11/21/25, revealed Resident #31 was cognitively intact. Resident #31 was assessed to be (staff) dependent for ADLs.Review of the care plan dated 01/15/25 revealed Resident #31 had an ADL self-care performance deficit related to hemiplegia, limited mobility, pain, and stroke.Review of Resident #31's shower documentation for November 2025 revealed he was scheduled for showers on Wednesdays and Saturdays on first shift. Further review revealed Resident #31 received a shower on 11/15/25, 11/19/25, and 11/29/25 (three of eight opportunities). There was no evidence Resident #31 was provided any additional showers during the month of November 2025.Observation on 11/25/25 at 9:55 A.M. revealed Resident #31 was sitting in his wheelchair in the common area. Resident #31 had hair that appeared unkept and white flakes were observed on his shirt. Interview on 12/01/25 at 1:00 P.M. with Resident #31's family member revealed the resident went seven to eight days without having a shower on multiple occasions. The family member stated they would have to provide the resident a shower themselves, including transferring the resident. The family member stated the most recent shower they provided was on 11/27/25 and that was because the resident had not been showered since 11/19/25. The family member stated they provided all care for the resident when they were visiting because the staff did not do it. Resident #31's family member stated they had expressed their concerns to the Administrator and DON on multiple occasions, without any resolution. Interview on 12/01/25 at 1:50 P.M. with the DON verified that Residents #31 did not receive showers as scheduled. The DON further confirmed issues with showers had been brought to her and the Administrator's attention and education had been given to staff; however, no evidence was provided related to the education or any corrective action taken by the facility.Review of the Resident Council meeting minutes dated 11/20/25 revealed residents voiced concerns related to showers not being completed. Review of the facility policy titled Resident Showers dated 12/01/25, revealed residents would be provided showers as per request or as per facility schedule protocols.This deficiency represents noncompliance investigated under Master Complaint Number 2676960 and Complaint Number 2663701.

Based on observation, resident interview, staff interview, review of the medical record, and review of facility policy, the facility failed to provide timely incontinence care. This affected one (#1) of three residents reviewed for incontinence care. The facility census was 54.Findings include:Review of Resident #1's medical record revealed an admission date of 07/23/25. Diagnoses included atrial fibrillation, weakness, and parkinsonism (causes movement problems such as tremors, stiffness and slow movements and balance issues).Review of the Minimum Data Set (MDS) assessment, dated 10/28/25, revealed Resident #1 was cognitively intact and required maximal (staff) assistance with activities of daily living (ADLs).Review of the care plan, dated 07/23/25, revealed Resident #1 had bowel incontinence related to mobility. Interventions included to assist with toileting as needed.Review of a wound care progress note dated 11/20/25 revealed Resident #1 was seen for an area on his buttocks, with a new diagnosis of irritant dermatitis due to body fluid.Interview on 11/25/25 at 8:30 A.M. with Resident #1 revealed the staff did not provide timely incontinence care and he sat in his own bowel movement for hours. The resident stated he had two areas on his buttocks that were the result of not receiving timely incontinence care.Observation on 12/01/25 at 8:50 A.M. revealed Resident #1's call light was on. Concurrent interview with Resident #1 revealed he pushed his call light at approximately 8:45 A.M. because he had a bowel movement and needed assistance with clean up and changing his brief. Continuous observation revealed at 10:00 A.M., Certified Nursing Assistant (CNA) #100 responded to Resident #1's call light (one hour and 10 minutes after the observation began). CNA #100 was observed to have an ear bud in her left ear and was looking at her cellular (cell) phone. Interview on 12/01/25 at 10:00 A.M. with CNA #100 revealed she was unable to respond to Resident #1's call light timely because she had other residents to take care of. CNA #100 was unable to state what an acceptable call light response time was and stated she would get to them when she could. Continued observation revealed the Director of Nursing (DON) entered the resident's room to assist with incontinence care. Resident #1 was observed to have two scabbed areas on his buttocks.Interview on 12/01/25 at 1:50 P.M. with the DON revealed an acceptable time to wait for assistance after a call light was activated was 10 minutes. The DON confirmed and hour and 10 minutes was not acceptable to wait for care. Further interview with the DON verified Resident #1 had scabbed areas on his buttocks.Review of the facility policy titled, Call Lights: Accessibility and Timely Response, revised 12/01/25, revealed all staff members who see or hear and activated call light were responsible for responding. If the staff member could not provide what the resident desired, the appropriate personnel should be notified.This deficiency represents noncompliance investigated under Master Complaint Number 267960 and Complaint Number 2663701.

Based on family, provider, and staff interview, medical record review, and policy review, the facility failed to ensure transportation to medical appointments. This affected one (#31) of three residents reviewed for outside medical appointments. The facility census was 54. Findings include:Review of the medical record for Resident #31 revealed an admission date of 01/13/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, retention of urine, and anxiety.Review of the quarterly Minimum Date Set (MDS) assessment, dated 11/21/25, revealed Resident #31 had intact cognition. Resident #31 was (staff) dependent for activities of daily living (ADLs). Review of the Nurse Practitioner (NP) progress note date 05/05/25 revealed Resident #31 was seen for a follow-up evaluation of diabetes with neuropathy (damage to nerves outside the brain that causes pain, tingling and numbness in hands and feet), and left hemiparesis. Further review revealed Resident #31 had left shoulder pain likely due to osteoarthritis and stiffness. The NP referred Resident #31 to Physical Medicine and Rehabilitation (PMR) for evaluation and possible Botox injections.Review of the nurse progress note dated 10/31/25 revealed transportation arrived to the facility at 8:30 A.M. to take Resident #31 to his PMR appointment, however the driver stated that the van could not accommodate Resident #31's wheelchair. The appointment had to be rescheduled.Interview on 12/01/25 at 1:00 P.M. with Resident #31's family member revealed the resident was referred to PMR for Botox injections due to pain from contractions. Since that referral, Resident #31 had missed three appointments due to transportation not showing up or not having the right van for transportation.Interview on 12/01/25 at 2:00 P.M. with PMR Staff #700 revealed Resident #31 was referred for Botox injections due to pain. An initial appointment was scheduled for 07/03/25. The facility cancelled the appointment on 07/03/25 and rescheduled for 07/23/25. The facility cancelled the appointment on 07/23/25 and rescheduled it to 07/24/25. Resident #31 was scheduled for a follow-up appointment on 08/13/25 and the appointment was cancelled and rescheduled for 09/03/25. Lastly, PMR #700 stated a 10/31/25 follow-up appointment was cancelled and rescheduled by the facility.Interview on 12/01/25 at 3:00 P.M. with the Director of Nursing (DON) revealed Resident #31 had an appointment at PMR on the facility calendar for 07/03/25 and 08/13/25, with no documentation as to why Resident #31 missed the appointments. The DON verified the appointment on 07/23/25 was cancelled because the facility arranged transportation did not show and the appointment on 10/31/25 had to be rescheduled because the facility arranged transportation did not bring a vehicle that could accommodate the resident's wheelchair. Review of the facility policy titled, Provision of Physician Ordered Services, dated 10/24/25, revealed in instances where consultations were not able to be performed on-site, the facility would work with the resident and their family to secure appropriate transportation arrangements for appointments.This deficiency represents non-compliance investigated under Complaint Number 2663701.

Based on observation, review of the dietary spreadsheets (DS), medical record review, and staff interview, the facility failed to ensure correct portion sizes for meals. This affected one (#3) of three residents reviewed for portion sizes. The facility census was 54.Findings include:Review of the medical record for Resident #3 revealed an admission date of 09/17/25. Diagnoses included Alzheimer's disease, chronic kidney disease, and epilepsy.Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/25, revealed Resident #3 had severe cognitive impairment.Review of the care plan dated 09/18/24 revealed Resident #3 had nutritional problems or a potential nutritional problem related to Alzheimer's and received a mechanically altered diet related to dysphagia. Interventions included providing diet as ordered, and monitoring intakes.Review of the DS for 11/25/25 revealed the lunch meal for a pureed diet was six ounces of pureed baked potato soup, six ounces of pureed [NAME] Marzetti (pasta dish), four ounces of pureed home fried potatoes, four ounces of pureed seasoned broccoli, and four ounces of sherbert ice cream.Observation on 11/25/25 at 12:00 P.M. of the lunch meal service revealed Dietary Aide (DA) #201 served a pre-plated pureed meal to Resident #25. Further observations revealed the portion sizes appeared small. Upon Surveyor request, DA #201 measured the meal served to Resident #25, with the [NAME] Marzetti being less than two ounces and the pureed vegetable being less than two ounces. Continued observation with DA #201 revealed the serving utensils used to serve the pureed meal included a four ounce scoop for the [NAME] Marzetti (six ounces was identified on the DS), a three ounce scoop for the soup (six ounces was identified on the DS) , a two ounce scoop for the broccoli (four ounces was on the DS), and a spoon with no serving size was utilized for the potatoes (four ounces was identified on the DS).Interview with DA #201 on 11/25/25 at 12:05 P.M. confirmed Resident #25's meal was less than two ounces of [NAME] Marzetti and less than two ounces of the vegetable. DA #201 further confirmed the serving utensils used for lunch were randomly selected and DA #201 eyed the portions. DA #201 was unaware of what the serving sizes were to be for lunch.Interview on 11/25/25 at 1:58 P.M. with Dietary Manager (DM) #200 confirmed staff should use color coded serving utensils with specific serving sizes and follow the DS.This deficiency represents non-compliance investigated under Master Complaint Number 2676960 and Complaint Number 2663701.

3. Review of the medical record revealed Resident #42 was admitted on [DATE]. Diagnoses included acute diastolic heart failure, essential hypertension, and osteoarthritis. Review of the MDS assessment, dated 05/16/25, revealed the resident was cognitively intact and required partial/moderate assistance with toileting, showering, lower and upper body dressing, personal hygiene, and applying footwear. Observation on 06/23/25 at 9:27 A.M. revealed Resident #42 in the recliner chair in the resident room and the call light on the floor near the bed. The call light was not within reach. Interview on 06/23/25 at 9:29 A.M. with Resident #42 verified she utilizes her call light. Interview on 06/23/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #284 verified the call light was on the floor and not within reach of the resident. Interview on 06/25/25 at 2:09 P.M. with Licensed Practical Nurse (LPN) #207 verified Resident #42 does utilize her call light. Review of policy, Call Lights: Accessibility and Timely Response, dated 02/11/25, verified staff will ensure the call light is within reach of residents and secured as needed. Based on observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure residents had call lights within reach for use. This affected three (#40, #42, and #45) of three residents observed for call lights within reach. The facility census was 57. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 01/13/25 with diagnoses of anxiety, diabetes mellitus, cerebral vascular accident (CVA) (stroke), viral hepatitis, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #40 revealed he was cognitively impaired and was dependent for all care. Observation on 06/23/25 at 9:45 A.M. of Resident #40 revealed his call light laying on the floor and not within reach. 2. Review of the medical record for Resident #45 revealed an admission date of 02/25/25 with diagnoses of atrial fibrillation, anxiety, and prostate cancer. Review of the quarterly MDS assessment dated [DATE] for Resident #45 revealed he was cognitively impaired. Observation on 06/23/25 at 10:00 A.M. of Resident #45 revealed his call light was draped over call box and not within reach. Interview on 06/23/25 at 10:47 A.M. with Registered Nurse (RN) #295 verified the call light for Resident #40 and Resident #45 were not within reach. RN #295 verified Resident #40 and Resident #45 both utilized their call lights.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to notify the physician of medication error. This affected one resident (#54) reviewed for notification to provider of a change. The facility census was 57. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver, chronic kidney disease, peptic ulcer (ulcer in the lining of the stomach) and prostate cancer. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Interview on 06/24/25 at 9:09 A.M. with Resident #54 stated he does not recall receiving his bedtime medication on 06/23/25. Review of the nursing progress notes for Resident #54 revealed no documentation of physician notification of the missed medication. Interview on 06/24/25 at 4:29 P.M. with Licensed Practical Nurse (LPN) #205 stated she did not administer Resident #54's bedtime medication on 06/23/25 and did not notify the physician of the omission of the bedtime medication. Review of the facility policy titled, Adverse Consequence and Medication Errors, revised 04/14 revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Examples of medication errors include omission-a drug is ordered but not administered. The attending physician is notified promptly of any significant error.

Based on observation, resident interview, staff interview, medical record review, and review of the facility policy, the facility failed to ensure medications were administered as ordered. This affected one (#54) resident reviewed for medication error. The facility census was 57. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver, chronic kidney disease, peptic ulcer (ulcer in the lining of the stomach) and hypotension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Review of the current physician orders from 06/25 for Resident #54 revealed he was ordered the following medication for bedtime: lantus insulin 12 units subcutaneously (subQ) (used to control diabetes mellitus), patoprazole sodium delayed release 40 milligrams (mg) (used for stomach ulcers), rifaximin 550mg (used for cirrhosis of the liver), lactulose oral solution 30 milliliters (ml) (used for elevated ammonia levels from liver disease), and midodrine 5mg (used for low blood pressure to raise the blood pressure). Interview on 06/24/25 at 9:09 A.M. with Resident #54 stated he did not recall receiving his bedtime medication on 06/23/25. Review of the Medication Administration Record (MAR) for Resident #54 for 06/23/25 revealed all medications prescribed for bedtime administration were signed off as administered by LPN #205. Review of the video surveillance footage for Resident #54's room from 06/23/25 at 5:13 P.M. until 06/24/25 at 1:25 A.M. revealed no nurse arrived to administer Resident #54's bedtime medication. Interview on 06/24/25 at 4:29 P.M. with Licensed Practical Nurse (LPN) #205 verified she worked the evening shift on 06/23/25 from 6:00 P.M. until 06/24/25 at 6:30 A.M. and was responsible for providing care to Resident #54. LPN #205 further stated she did not administer the bedtime medication to Resident #54. LPN #205 stated the resident had visitors and she did not want to interrupt the visit and she had already prepared the medication and signed the MAR as administered and meant to go back to Resident #54 to administer the medication after the visitors left but got busy and forgot. Review of the nursing progress notes dated 06/24/25 at 6:00 A.M. documented as late entry for Resident #54 revealed medications were missed. Writer pulled hs (hour of sleep) medications, resident wasn't ready to take them at that time he had visitors. Writer forgot to return with hs medications during the shift. Review of the facility policy titled, Medication Administration, revised 12/24 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state as ordered by the physician. Ensure the six rights of medication administration are followed to include right resident, right drug, right dosage, right route, right time, and right documentation. Sign MAR after administration. Review of the facility policy titled, Adverse Consequence and Medication Errors, revised 04/14 revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Examples of medication errors include omission-a drug is ordered but not administered. The attending physician is notified promptly of any significant error.

Based on observation, resident interview, staff interview, medical record review, and review of the facility policy the facility failed to ensure significant medications were administered as ordered. This affected one (#54) resident reviewed for significant medication error. The facility census was 57. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver with ascites (fluid build up in the abdomen from a failing liver), chronic kidney disease, and hypotension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Review of the current physician orders from 06/25 for Resident #54 revealed he was ordered the following medication for bedtime: lantus insulin 12 units subcutaneously (subQ) (used to control diabetes mellitus), rifaximin 550mg (used for cirrhosis of the liver), lactulose oral solution 30 milliliters (ml) (used for elevated ammonia levels from liver disease), and midodrine 5mg (hold for systolic blood pressure (BP) above 130 millimeters of Mercury (mmHg) (used for low blood pressure to raise the blood pressure). Review of the care plan initiated 04/25 for Resident #54 revealed he was care planned for liver disease related to liver cirrhosis, bruise and bleed easily, and have a history of ascites. Interventions in place included medications as ordered for liver cirrhosis and ascites. Review of the hospital records for Resident #54 from his most recent hospitalization from 06/11/25 through 06/15/25 revealed his diagnoses for admission were altered mental status and abnormal laboratory results. Further review of the hospital records revealed an ammonia level of 103 micromoles per liter (Umol/L) (normal 18-72). Further review of the hospital medical record revealed Resident #54's mentation was altered and with treatment of elevated ammonia level with lactulose, the mentation of Resident #54 improved and the ammonia level also improved to 56Umol/L (within normal range of 18-72). Interview on 06/24/25 at 9:09 A.M. with Resident #54 stated he does not recall receiving his bedtime medication on 06/23/25. Review of the Medication Administration Record (MAR) for Resident #54 for 06/23/25 revealed all medications prescribed for bedtime administration were signed off as administered. Further review of the MAR revealed Resident #54 had a blood pressure reading of 101/63 mmHg and should have received the midodrine 5mg for hypotension according to the parameters to only hold midodrine 5mg for a systolic blood pressure greater than 130mmHg. Review of the video surveillance footage for Resident #54's room from 06/23/25 at 5:13 P.M. until 06/24/25 at 1:25 A.M. revealed no nurse arrived to administer Resident #54's bedtime medication. Interview on 06/24/25 at 4:29 P.M. with Licensed Practical Nurse (LPN) #205 verified she worked the evening shift on 06/23/25 from 6:00 P.M. until 06/24/25 at 6:30 A.M. and was responsible for providing care to Resident #54. LPN #205 further stated she did not administer the bedtime medications to Resident #54. LPN #205 stated the resident had visitors and she did not want to interrupt the visit and she had already prepared the medication and signed the MAR as administered and meant to go back to Resident #54 to administer the medication after the visitors left but got busy and forgot to go back and administer the bedtime medication. Review of the nursing progress notes dated 06/24/25 at 6:00 A.M. documented as late entry for Resident #54 revealed medications were missed. Writer pulled hs (hour of sleep) medications, resident wasn't ready to take them at that time he had visitors. Writer forgot to return with hs medications during the shift. Review of the facility policy titled, Adverse Consequence and Medication Errors, revised 04/14 revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Examples of medication errors include omission-a drug is ordered but not administered. The attending physician is notified promptly of any significant error. Review of the facility policy titled, Medication Administration, revised 12/24 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state as ordered by the physician. Ensure the six rights of medication administration are followed to include right resident, right drug, right dosage, right route, right time, and right documentation. Sign MAR after administration.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure podiatry care services. This affected one (#22) of one resident reviewed for podiatry. The facility census was 57. Findings include: Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included displaced transverse fracture of shaft of left femur subsequent encounter for closed fracture with routine healing, type two diabetes mellitus without complications, unilateral primary osteoarthritis, bilateral primary osteoarthritis of hip, chronic systolic (congestive) heart failure, adult failure to thrive, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 06/09/25, revealed the resident was moderately cognitively impaired. Observation on 06/25/25 at 1:58 P.M. revealed Resident #22's left foot toes were long, thick, and curling under the toes. Interview on 06/25/25 at 2:50 P.M. with Licensed Social Worker (LSW) #299 verified there had been no attempts to have Resident #22 on the podiatry list. Interview on 06/25/25 at 4:00 P.M. with the Director of Nursing (DON) verified Resident #22's nails were in need of trimming and would require a podiatrist. Review of policy, Podiatry Services, date implemented 06/25/25, verified residents will receive proper treatment and care within professional standards of practice to maintain mobility and good foot health. Residents requiring foot care who have complicating diseases processes will be referred to qualified professionals such as a podiatrist, doctor of medicine, or doctor of osteopathy.

Based on record review, review of late medication report, interview, and policy review, the facility failed to ensure medications were administered in a timely manner. This affected four (#2, #33, #36, and #54) of four residents reviewed for late medications. The facility census was 56. Findings include: 1. Review of medical record for Resident #2 revealed an admitted [DATE] with diagnoses including but not limited to hypertensive heart disease with heart failure, chronic kidney disease, atrial fibrillation, congenital malformation of the heart, hypertension, and fibrothorax. Review of current physician orders revealed furosemide 40 milligrams (mg) daily at 7:00 A.M. (water pill), Jardiance 10 mg daily at 8:00 A.M. (diabetes), metoprolol tartrate 25 mg twice daily at 9:00 A.M. and 9:00 P.M. (blood pressure), amiodarone 200 mg daily at 9:00 A.M. (heart), and apixaban 2.5 mg twice daily at 9:00 A.M. and 6:00 P.M. Review of late medication report dated 03/31/25 revealed the above listed medications were administered at 11:38 A.M. 2. Review of medical record for Resident #33 revealed an admitted [DATE] with diagnoses including but not limited to acute respiratory failure with hypoxia, peripheral vascular disease, rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, dysphagia, and major depressive disorder. Review of current physician orders revealed metoprolol tartrate 25 mg one half tablet twice daily at 6:45 A.M. and 6:45 P.M., Trelegy Ellipta 200-62.5-25 micrograms(mcg)/act daily at 7:00 A.M. (asthma), Jardiance 10 mg daily at 8:00 A.M., multivitamin with minerals daily at 9:00 A.M., ferrous sulfate 325 mg daily at 9:00 A.M., bumex 1 mg daily at 9:00 A.M. (water pill), aspirin 81 mg daily at 9:00 A.M., and ipratropium-albuterol 0.5-2.5 (3) mg/3 milliliters (ml) via nebulizer every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. (asthma). Review of late medication report dated 03/31/25 revealed the above listed medications were administered at 11:31 A.M. Review of late medication report dated 04/01/25 revealed Jardiance 10 mg and ipratropium-albuterol was administered at 9:27 A.M. and ipratropium-albuterol was administered at 3:24 P.M. 3. Review of medical record for Resident #36 revealed an admitted [DATE] with diagnoses including but not limited to type one diabetes, peripheral vascular disease, heart failure, hypertension, major depressive disorder, and personal history of diabetic foot ulcer. Review of current physician orders revealed insulin lispro 100 unit/ml per sliding scale 151-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10 units, 401-999 12 units before meals and at bedtime. Review of late medication report dated 03/31/25 revealed insulin lispro was ordered at 7:30 A.M. was administered at 9:31 A.M. after breakfast. 4. Review of medical record for Resident #54 revealed an admitted [DATE] with diagnoses including unspecified severe protein-calorie malnutrition, congestive heart failure, chronic kidney disease stage three, anxiety, major depressive disorder, and chronic obstructive pulmonary disease. Review of current physician orders revealed zoloft 100 mg daily at 8:00 A.M. (depression), ferrous sulfate 325 mg at 8:00 A.M., ondansetron 4 mg at 8:00 A.M. (nausea), tylenol 325 mg at 9:00 A.M., vitamin B 12 1000 mcg at 9:00 A.M. and folate 1 mg at 9:00 A.M. Review of late medication report dated 04/01/25 revealed the above listed medications were administered at 11:20 A.M. Interview on 04/02/25 at 3:35 P.M. with the Director of Nursing (DON) verified the late medications for Residents #2, #33, #36 and #64. Review of policy titled, Medication Administration, revised 12/30/24 revealed administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. This deficiency represents noncompliance investigated under Complaint Number OH00162010.

Based on record review, staff interview, and review of facility policy, the facility failed to conduct a thorough investigation to determine potential hazards and resident-specific interventions to reduce and/or eliminate falls with injury. Additionally, the facility failed to update a resident's care plan with person centered fall interventions to potentially prevent future falls. This resulted in Actual Harm for one resident when Resident #34 experienced a fall on 07/12/23 which was not investigated to implement effective interventions to potentially prevent future falls. As a result of the fall, Resident #34 sustained a fracture of the nasal bones and a spleen laceration Grade 3 from this fall. Additionally, the facility failed to complete a fall investigation for Residents #43 and #42 to potentially prevent future falls. This affected three (Residents #34, #43, and #42) of three residents reviewed for falls. Lastly, the facility failed to ensure staff were knowledgeable of a resident's transfer requirements to potentially prevent falls. This affected one (Resident #42) of one resident reviewed for staff competence. The facility census was 50. Findings include: 1. Review of the medical record of Resident #34 revealed an admitted [DATE] with a hospital stay from 07/12/23 to 07/18/23. Diagnoses include dementia without behavioral disturbance, difficulty in walking, generalized muscle weakness, fracture of the nasal bones, and encounter for other orthopedic aftercare. Resident #34 was admitted to the skilled nursing facility from the attached assisted living facility after having experienced a fall with a femur fracture in late May of 2023. Following the fracture, Resident #34 had surgery and was then admitted to the nursing home on 06/02/23. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was cognitively impaired and required extensive assistance for transfers and activities of daily living (ADLs). Review of the fall risk assessment dated [DATE] revealed Resident #34 was at high risk for falls. Review of the care plan for Resident #34, initiated on 06/05/23 with no updates, revealed the resident was at risk for injury related to falls due to gait/balance problems. Interventions included the following: PT (physical therapy) evaluate and treat as ordered and PRN (as needed), be sure call light is within reach when in room and encourage to use it before attempting to transfer, and the need to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate and as needed for continued appropriateness per therapy recommendations. Review of the progress note dated 07/12/13 at 11:42 A.M. written by the Director of Nursing (DON) revealed Resident #34 was transferred to the ER (emergency room ) for an evaluation after a fall. Review of a Skilled/Episodic Note dated 07/12/23 at 1:30 P.M. written by agency Registered Nurse (RN) #352 revealed an ice pack was placed on Resident #34's nose and the resident was transported to the ER for an evaluation and treatment. The resident's skin was intact, and she was dependent for toileting and required substantial/maximal assistance with sit to lying and lying to sitting on the side of the bed. Review of the hospital history and physical dated 07/12/23 revealed Resident #34 fell out of her chair after PT at her nursing home. Resident #34 had baseline dementia and did not remember the fall. She complained of facial pain. The resident denied loss of consciousness, denied hitting her head, however had a facial abrasion, and a small one-centimeter laceration to the bridge of her nose and bilateral ecchymosis (bruising) around her eyes. Resident #34 was also experiencing left sided weakness on the initial examination. A cervical collar was in place related to hitting her head. Per the medication administration record, Resident #34 was on Plavix (anticoagulant) and Aspirin 81 milligrams. The hospital provided diagnoses of solid organ injury splenic laceration Grade 3 and nasal laceration/nasal bone fracture. Interview on 10/10/23 at 3:04 P.M. with Project Manager (PM) #300 revealed when reviewing the facility fall investigation, there were no witness statements documented. PM #300 was not employed at the facility at the time of the fall and investigation so could only go by what was documented. The investigation revealed Resident #34 was in her wheelchair, unable to give location, and an activity staff member, unable to give name, notified the nurse (RN #352). Resident #34 was found face down in front of her wheelchair, conscious. Resident #34 was transported to the ER for evaluation. The report revealed RN #352 completed an assessment (ABCs [airway, breathing, and circulation]) and sent Resident #34 to the ER as soon as possible. The report indicated the fall was unwitnessed, the fall risk assessment was high, and Resident #34 had non-skid socks on. The report indicated RN #352 turned Resident #34 on her back, obtained vital signs (blood pressure and pulse) and placed a cold washcloth on her nose. The skin was broken, and blood was coming from the open area. PM #300 confirmed no witness statements were in the investigation. PM #300 stated the report was initiated on 07/12/23 at 11:00 A.M. The investigation was closed on 07/24/23 by the Executive Director. Interview on 10/10/23 at 3:44 P.M. with Physical Therapy Assistant (PTA) #351 and Therapy Program Manager (TPM) #350 revealed PTA #351 worked with Resident #34 on 07/12/23 from 8:32 A.M. to 9:02 A.M. and toileted her in that time frame. After the session was complete, PTA #351 left Resident #34 in her wheelchair in the common area of the 100 hall. PTA #351 was unsure of whom she had let know (aide or nurse) Resident #34 was in the common area but would not leave the area without having told someone. Interview on 10/11/23 at 9:00 A.M. with the (DON) verified Resident #34's care plan was not revised to include person-centered interventions to prevent future falls, following the fall on 07/12/23. The DON further verified the care plan was not person-centered for Resident #34 and had generic fall interventions listed. Review of the facility policy titled Fall Prevention Program dated 10/20/22 revealed each resident will be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When a resident experiences a fall the facility will: assess the resident; complete a post fall assessment; complete an incident report; notify physician and family; review the resident's care plan and update as indicated; document all assessments and actions; and obtain witness statements in the case of injury. 2. Review of the medical record of Resident #43 revealed an admitted [DATE]. Diagnoses include progressive supranuclear ophthalmoplegia, Parkinson's disease, abnormalities of gait and mobility, muscle weakness, and bipolar disorder. Review of the quarterly MDS dated [DATE] revealed Resident #43 was cognitively intact and required extensive assistance of two staff for transfers, bed mobility, and toileting. Walking in the room did not occur. Review of the care plan for Resident #43, initiated 01/17/23, revealed a focus of at risk for injury related to falls due to deconditioning and gait/balance problems. Interventions included as follows: PT evaluate and treat as ordered or PRN; be sure call light is within reach when in room and encourage to use it before attempting to transfer; educate resident/family about safety reminders and what to do if a fall occurs; the need to be evaluated for and supplied appropriate adaptive equipment or devices as needed, re-evaluate as needed for continued appropriateness per therapy recommendations; encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated; ensure resident is wearing appropriate footwear when out of bed; make sure floor/path is clutter free and properly lighted. Review of the progress note dated 07/23/23 at 10:13 A.M. revealed Resident #43 had a witnessed fall. No visual injuries or complaints of pain at the time of the injury. Further review of the medical record revealed no fall investigation to determine the root cause of the fall and identify potential interventions to prevent future falls was completed. Interview on 10/10/23 at 4:53 P.M. with PM #300 revealed no fall investigation had taken place and the only documentation of Resident #43's fall was the progress note dated 07/23/23. 44815 3. Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses of cerebral infarction and dementia. Resident #42 was admitted under the care of hospice. Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had impaired cognition and required extensive assistance of two people for bed mobility and transfers. Further review revealed Resident #42 had no falls since the previous assessment. Review of the fall risk assessments completed 03/24/23, 05/05/23 and 09/28/23 revealed Resident #42 was at high risk for falls. Review of the care plan for Resident #42 revealed she was at risk for falls. Interventions included keeping the bed in a low position while she was in it and keeping her call light within reach. Further review revealed Resident #42 had an activities of daily life (ADL) self care performance deficit related to fatigue and limited mobility. Interventions included encouraging Resident #42 to use the bell to call for assistance and for staff to praise all efforts at self care. The care plan did not identify the type of assistance Resident #42 needed for transfers. Review of the MDS Kardex Report dated 07/06/23 revealed Resident #42 required extensive physical assistance of two or more people for transfers. Review of the facility's Incident Log revealed Resident #42 fell on [DATE] and 09/28/23. Review of a progress note dated 07/03/23 revealed Resident #42 fell out of bed in her room, was assessed and treated for pain, and the family was notified. Further review of the medical record revealed no evidence a fall investigation was completed. Observation on 10/10/23 at 10:30 A.M. revealed Resident #42 dressed and sitting in her wheelchair. Further observation revealed State tested Nurse Aide (STNA) #313 pushing Resident #42 in her wheelchair from the dining table to the common area to watch television. Observation on 10/10/23 at 10:41 A.M. revealed Resident #42 in her room sleeping in a recliner. Interview on 10/10/23 at 10:44 A.M. with STNA #313 revealed she worked for a staffing agency, but worked frequently enough at the facility to be familiar with Resident #42. STNA #313 stated Resident #42 was able to transfer from the wheelchair to the recliner with one staff providing assistance, and STNA #313 transferred Resident #42 by herself from the wheelchair to the recliner where Resident #42 was sleeping. Interview on 10/10/23 at 1:41 P.M. with the Interim Director of Nursing (IDON) revealed she spoke with the nurse who wrote the progress note on 07/03/23 and confirmed Resident #42 fell on [DATE]. The IDON stated the nurse was busy and failed to complete an incident report or Fall Risk Assessment after Resident #42's fall. The IDON confirmed the facility was unaware of Resident #42's fall on 07/03/23 and did not conduct an investigation into the fall. Interview on 10/10/23 at 2:07 P.M. with the IDON confirmed Resident #42's care plan did not reflect the type and amount of assistance Resident #42 needed to complete ADL tasks, such as transferring. Continued interview with the IDON revealed STNAs relied on the kardex to determine the type of assistance each resident required for ADL tasks. Continued interview with the IDON confirmed the MDS Kardex Report for Resident #42 revealed she required extensive physical assistance of two people for transfers. Review of the policy, Fall Prevention Program, revised 10/20/22, revealed the nurse would indicate on the care plan and the kardex the resident's fall risk and interventions. Further review revealed after a fall, the facility would complete a post-fall assessment, complete an incident report, and document all assessments and actions.

Based on observation, resident and staff interview, medical record review, hospital record review, review of the National Pressure Injury Advisory Panel 2019 Reference Guide, and review of the facility policies, the facility failed to timely assess and provide treatments for a resident's pressure ulcers and failed to ensure interventions were implemented to heal a resident's pressure ulcer and prevent skin breakdown. This resulted in Actual Harm when Resident #54 had a pressure ulcer worsen from a stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) after no treatment interventions were implemented. Additionally, one resident (#47) did not have a pressure reduction intervention in place as ordered and care planned. This affected two (#47 and #54) of three residents reviewed with pressure ulcers. The facility identified three residents in the facility with pressure ulcers. The facility census was 53. Findings include: 1. Review of Resident #54's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #54 was discharged from the facility on 05/30/22. Review of an admission Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #54 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a wound care plan dated 03/23/22 revealed Resident #54 was admitted to the facility with multiple pressure ulcers to the lower extremities with interventions to monitor wounds with dressing changes and as needed, provide treatments as ordered, and apply pressure reduction to the bed and chair. Review of the care plans dated 03/24/22 revealed Resident #54 had stage IV pressure ulcers to the left heel, posterior leg, and left medial ankle, and stage three pressure ulcers to the right gluteal fold, right calcaneus (heel), and left second toe. All six care plans had interventions to provide treatment as ordered per wound care. Review of the assessments used to predict the development of pressure ulcers revealed Resident #54 was at a very high risk for the development of pressure ulcers on 03/10/22, at high risk on 03/17/22, and at moderate risk on 03/31/22. Review of an admission nursing assessment completed on 03/10/22 revealed Resident #54 was admitted with a stage III pressure ulcer to the left lower leg measuring 10.0 centimeters (cm) long by 5.0 cm wide by 0.5 cm deep; a stage III pressure ulcer to the right lower buttocks measuring 2.0 cm long by 1.0 cm wide by 0.5 cm deep; a skin tear to the top of the left second toe measuring 1.0 cm long by 1.5 cm wide; a dry scab to the top of the left foot measuring 0.5 cm long by 1.0 cm wide; a dry scab to the left outer ankle measuring 1.0 cm long by 1.0 cm wide; a dry scab to the left upper posterior calf measuring 1.0 cm long by 2.0 cm wide; a dry scab to the right heel measuring 2.0 cm long by 4.0 cm wide; and a stage III pressure ulcer to the left heel measuring 2.0 cm long by 2.0 cm wide by 0.5 cm deep. Review of the wound assessments dated 03/15/22 revealed Resident #54 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the wound care assessments and notes, from a wound provider outside the facility, revealed Resident #54 was seen on 03/16/22, 03/30/22, 04/27/22, 05/18/22, and 05/25/22. Further review of the assessments revealed Resident #54's wounds were measured and assessed at each visit and treatments were reviewed. Between 03/16/22 and 05/18/22, all of Resident #54's wounds showed improvement with size and no wound progressing to a more advanced stage. Resident #54's left medial ankle wound was healed on 03/16/22, the left second toe wound was healed on 03/30/22, and the right heel wound healed on 04/27/22. Review of the weekly skin observations in the electronic medical record dated 03/24/22, 04/14/22, 05/12/22, and 05/19/22 revealed no evidence Resident #54's pressure ulcers were assessed or measured, and there was no documentation of any new skin impairment on the assessments Review of a physician order dated 04/21/22 revealed Resident #54's wounds were to be measured weekly on Thursdays. Review of a wound care assessment and notes dated 05/18/22 from a wound provider outside the facility revealed Resident #54 had a new wound on the lower back. The new wound was acquired on 05/18/22 and assessed as a stage II pressure ulcer on the coccyx measuring 0.9 cm long by 0.8 cm wide by 0.1 cm deep. There were no wound treatments ordered for this wound by the outside provider at this time. Review of the physician orders dated between 05/18/22 and 05/25/22 revealed there were no orders for treatment to Resident #54's coccyx wound. Review of Resident #54's medical record revealed there was no evidence the facility identified Resident #54's stage II pressure ulcer on the coccyx. There were no assessments or measurements of the new coccyx pressure ulcer by the facility during this time. Review of a wound care assessment dated [DATE] from the wound provider outside the facility revealed Resident #54's coccyx wound worsened and was now an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) with small (between 1% and 33%) granulation tissue, large (between 67% and 100%) necrotic tissue, adherent slough, and measured 5.1 cm long by 5.2 cm wide by 0.1 cm deep. The wound bed was not able to be visualized. The outside wound care provider ordered Resident #54's coccyx wound to be cleansed with normal saline and an antimicrobial wound dressing cut to fit the wound and secured with tape on 05/25/22. The order instructions indicated if the wound was dry to moisten the dressing with normal saline and if the wound was wet to place the dressing in dry. The order instructions indicated this treatment was to be completed three times per week. Review of a nursing progress note dated 05/27/22 revealed Resident #54 was to have an x-[CONDITION(S)] (x-ray) completed on the left foot and coccyx to rule out [CONDITION(S)] (bone infection). Review of a physician order dated 05/28/22 revealed Resident #54 was ordered to have the coccyx wound cleansed with normal saline and an antimicrobial wound dressing cut to fit the wound, covered with an absorbent pad, and secured with tape every Monday, Wednesday, and Friday. The order instructions indicated if the wound was dry to moisten the dressing with normal saline and if the wound was wet to place the dressing in dry. Review of a physician order dated 05/28/22 revealed Resident #54 was ordered a treatment to clean a wound with normal saline, apply an antimicrobial dressing cut to fit the wound, cover with gauze, and secure the dressing with tape. The order did not specify what wound was to have the ordered treatment applied to and the indication only noted it was for wound care. Review of the treatment administration record (TAR) from May 2022 revealed Resident #54 had no treatments applied to the coccyx wound between 05/18/22 and 05/25/22. Additionally, there was no documentation of Resident #54's coccyx wound being changed on Monday, 05/30/22, as ordered. The ordered treatment beginning on 05/28/22 was documented as completed on 05/28/22 and 05/29/22; however, the May 2022 TAR did not specify what wound the treatment was applied to. Review of the radiology results dated 05/29/22 revealed Resident #54's coccyx x-ray showed no coccygeal depressed fracture or [CONDITION(S)]. Review of the laboratory values obtained in the facility on 05/30/22 revealed Resident #54 had a complete blood count with differential taken and revealed white blood cell counts were within normal range. Review of a nursing progress note dated 05/30/22 revealed Resident #54 displayed confusion, had low blood pressure, and an elevated temperature. Resident #54 was taken to the hospital for evaluation and treatment on 05/30/22 and did not return to the facility. Review of the hospital records dated 05/30/22 revealed Resident #54 was sent to the hospital for low blood pressure and altered mental status. Resident #54 had multiple odiferous wounds, an unstageable sacral wound, and bilateral heel wounds. There were pressure ulcers noted to the sacrum and right buttock with eschar (dead tissue) partially peeling away. There was no surrounding redness or purulent (white, yellow, or brown colored fluid indicative of and infection). Review of the laboratory tests completed in the hospital on 05/30/22 revealed Resident #54 had a slightly elevated white blood cell count, low [MEDICATION(S)] levels, and normal lactic acid levels. Resident #54's principle admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an operative note from the hospital on 05/31/22 revealed Resident #54 underwent surgical debridement of the wounds on the sacral, gluteal, and left lower extremity regions with healthy, punctate (dotted) bleeding noted at each debridement site. Interview on 06/12/22 at 12:34 P.M. with Director of Nursing (DON) #1 verified Resident #54's wounds were not assessed weekly while he was in the facility. DON #1 stated Resident #54 saw a wound care provider outside of the facility that may have assessments and she would attempt to look for additional assessments. At the time of the survey exit, no additional wound assessments or measurements were provided by the facility. Subsequent interview on 06/12/22 at 4:23 P.M. with DON #1 verified the facility did not have any treatments in place for Resident #54's coccyx wound and verified between the wound assessments on 05/18/22 and 05/25/22 the wound worsened from a stage two pressure ulcer to an unstageable pressure ulcer. 2. Review of Resident #47's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE] revealed Resident #47 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan dated 04/21/22 revealed Resident #47 was at risk for skin breakdown with a pressure ulcer noted to the left heel. The care plan interventions included administering treatments as ordered, offloading the heels, and providing pressure relieving devices to the bed and chair. Review of an assessment used to predict pressure ulcer development dated 04/08/22 revealed Resident #47 was assessed at risk for pressure ulcer development. Review of an admission nursing assessment dated [DATE] revealed Resident #54 had a stage III pressure ulcer to the left heel measuring 2.2 cm long by 5.3 cm wide by 0.2 cm deep. Further review of Resident #47's wound assessments and measurements revealed the left heel wound was only assessed on 04/21/22 and 06/09/22. Review of the wound assessment completed 06/09/22 revealed Resident #47's left heel wound remained a stage III pressure ulcer and did not increase significantly in size. Review of a physician order dated 04/08/22 revealed staff were to always offload Resident #47's heels with pillows or padded boots. Observation on 06/12/22 at 8:37 A.M. revealed Resident #47 sitting in his wheelchair in his bedroom with a dressing noted to his left foot with his heel and bottom of his foot directly on the footrest. Further observation of Resident #47's bedroom revealed a padded boot laying on a chair in his room under the window. Interview on 06/12/22 at 8:37 A.M. with Resident #47 stated the padded boot was supposed to be on his left foot and stated he was not sure why the staff did not put the padded boot on him. Resident #47 verified he did not refuse the boot and stated he required staff assistance to put it on. Interview on 06/12/22 at 8:40 A.M. with Registered Nurse (RN) #100 stated the nurse aide assigned to care for Resident #47 on 06/12/22 did not mention anything to her about Resident #47 refusing his padded boot. Observation on 06/12/22 at 8:42 A.M., with RN #100, revealed Resident #47's padded boot was located on the chair in the bedroom. RN #47 verified the boot should be applied to Resident #47's left foot and was not sure why it was not on. Interview on 06/12/22 at 12:26 P.M. with State tested Nurse Aide (STNA) #367 verified she was assigned to provide care to Resident #47 and verified Resident #47 did not refuse care for her on 06/12/22. Interview on 06/12/22 at 1:50 P.M. with Assistant Director of Nursing (ADON) #1 verified she recently began working in the facility and took over the role of monitoring resident wounds. ADON #1 stated she was not aware when residents went out to outside wound providers, they did not always measure the wounds. ADON #1 verified Resident #47's left heel wound was not assessed and measured weekly. Observation on 06/12/22 at 2:13 P.M. revealed RN #100 completed the wound dressing on Resident #47's left heel wound. Observation of the wound revealed no signs of infection, no slough or drainage, and healthy tissue in the wound bed and surrounding area. RN #100 completed Resident #47's left heel dressing as ordered and followed all infection control precautions. Review of the National Pressure Injury Advisory Panel 2019 Reference Guide revealed a good practice statement is for individuals with a Category/Stage III or greater heel pressure injury, elevate the heels using specifically designed heel suspension device offloading the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. Guidelines related to Assessment of Pressure Injuries and Monitoring of Healing revealed to assess the pressure injury initially and re-assess at least weekly to monitor progress toward healing. Review of a facility policy titled Wound Care, revised October 2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Staff should verify there is a physician's order for the procedure, review the resident's care plan to assess for any special needs of the resident, and assemble the equipment and supplies as needed. Review of the facility policy titled Prevention of Pressure Injuries, revised April 2020, revealed the resident should be assessed on admission for existing pressure injury risk factors, repeating the risk assessment weekly and upon any changes in condition. Staff should conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factors, and prior to discharge. Staff should inspect the skin daily when performing or assisting with personal care or activities of daily living and inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). The staff should evaluate, report, and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. This deficiency substantiates Master Complaint Number OH 111.

Based on observations, resident and staff interviews, medical record reviews, and review of facility policies, the facility failed to provide adequate nursing staff to provide wound treatments, turning and repositioning, timely and adequate bathing assistance, transfer assistance, assistance with response to resident call lights, incontinence care, and complete necessary COVID-19 respiratory assessments. This resulted in Actual Harm to one resident (#34) when facility staff did not provide wound treatments and turning and repositioning as physician ordered and did not complete timely monitoring of Resident #34's left hip pressure ulcer and Resident #34's left hip wound subsequently deteriorated into a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed). Additionally, Resident #09 did not receive pressure ulcer treatments as ordered, which placed the resident at risk for potential deterioration of the wound that did not result in actual harm at this time. This affected two (#09 and #34) of three residents reviewed for pressure ulcers. In addition, three (#18, #42, and #45) of five residents were not provided showers and assistance with transfers to get out of bed, who were dependent on staff for assistance with activities of daily living, one (#31) of three residents was not provided incontinence care who was dependent on staff for incontinence care and one resident (#41) was randomly observed not to have the call light answered for over a half hour due to staff being in other resident's rooms. Furthermore, two (#42 and #45) of four residents were not provided COVID-19 respiratory assessments per physician orders. This placed five (#18, #31, #41, #42, and #45) residents at risk for potential harm and/or negative health outcomes, which did not rise to the level of actual harm, when staff was not available to provide the required assistance with care. The facility census was 50. Findings include: 1. Review of Resident #34's medical record revealed a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 09/23/20, revealed Resident #34 was cognitively intact, dependent on two staff for the completion of activities of daily living for transfers and required extensive assistance by two persons for bed mobility. Review of the wound clinic wound assessment, dated 10/26/20, revealed Resident #34 was assessed with [REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer to the left hip measuring 2.3 centimeters (cm.) long by 3.3 cm. wide by 1.9 cm. deep. A treatment order was provided for Resident #34 to have the old wound dressing removed, the wound and peri-wound area cleansed, antifungal powder applied to the peri-wound, an absorbent dressing as the primary dressing with a absorbent pad secured over the dressing and secured with a cover roll. The order was to be completed daily and was in place for one week. There was a note on the wound assessment indicating Resident #34 should be repositioned every two hours from side to side. The wound clinic wound assessment, dated 11/02/20, revealed Resident #34's wound order was changed to remove the old dressing, cleanse the peri-wound area, apply an absorbent dressing with bordered foam cover, and changed daily for one week. The wound clinic wound assessment, dated 11/09/20, revealed Resident #34's left hip wound remained a Stage III pressure ulcer and with no changes to the wound treatment order from 11/02/20 and was ordered to be changed daily and extended for another week. Review of the November 2020 treatment administration record (TAR) revealed no documentation of a wound treatment completed to Resident #34's left hip pressure ulcer on 11/02/20 and 11/18/20 through 11/30/20. There were 14 treatments not marked as completed in 11/2020. Review of the wound clinic wound assessment, dated 11/23/20, revealed Resident #34's left hip pressure ulcer was now a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) wound measuring 2.0 cm. long by 3.0 cm. wide by 1.0 cm. deep with undermining of the wound measuring 2.5 cm. The wound was described as a full thickness wound with exposed subcutaneous tissue and tendon and a beefy red granulated wound bed with slough. Resident #34's wound treatment continued to be for staff to remove the old dressing, cleanse the peri-wound area, apply an absorbent dressing with bordered foam cover, and changed daily for two weeks. Review of the physician order, dated 11/24/20, revealed Resident #24 was to be educated and encouraged to reposition with assistance every two hours to offload pressure. The ordered included if Resident #34 refused to be repositioned, her family was to be notified and documented in the nursing progress notes. Review on the wound clinic wound assessment, dated 12/07/20, revealed Resident #34's left hip pressure ulcer remained a Stage IV pressure ulcer measuring 2.5 cm. long by 3.3 cm. wide by 1.2 cm. deep. The wound treatment order was to remain the same as ordered on [DATE] and remain an order for [REDACTED].>Review of the December 2020 TAR revealed no documentation of any wound treatments completed to Resident #34's left hip wound between 12/01/20 and 12/19/20. Additionally, there was no documentation of Resident #34 being repositioned on 12/02/20 for four consecutive hours twice between 2:00 A.M. and 6:00 A.M. and between 8:00 P.M. and 12:00 P.M., on 12/03/20 for six consecutive hours between 12:00 A.M. and 6:00 A.M., on 12/16/20 for four consecutive hours between 8:00 P.M. and 12:00 P.M., on 12/17/20 for six consecutive hours between 12:00 A.M. and 6:00 A.M., and on 12/18/20 for four consecutive hours between 2:00 A.M. and 6:00 A.M. Review of the nursing progress notes dated between 11/01/20 and 01/12/21 revealed no documentation of Resident #34's left hip wound treatments being completed for the dates missing in November and December 2020 TARS, as well as no documentation of Resident #34 refusing to be repositioned, including documentation of notification to the family, in the medical record during this time frame. There was no documentation in the medical record of Resident #34's left hip ulcer being assessed between 12/07/20 and 12/21/20. Review of the nurse practitioner progress note, dated 01/05/21, revealed Resident #34 reported to the nurse practitioner she recently went to the wound care specialist out of the building and they were very concerned about how her wounds were not improving. Resident #34 indicated the wound clinic was concerned she was not getting turned enough or may be sitting in her urine for too long which made Resident #34 very upset. Observation on 01/12/21 at 7:49 A.M. revealed Resident #34 was in her room with the light off and could be observed laying on her back. Observation at 9:05 A.M. revealed Resident #34 remained in the same position in bed. Interview on 01/12/21 at 9:06 A.M. with Resident #34 stated she was supposed to have wound treatment completed everyday but, on many days, her wound treatments were not done. Resident #34 stated she needed help with repositioning in bed and staff did not always come into her room to help her turn. Resident #34 stated she sometimes was not turned for hours at a time and stated she had not been repositioned since around 4:00 A.M. on 01/12/21. Resident #34 stated no staff had entered her room since the first shift staff started their day. Interview on 01/12/21 at 9:14 A.M. with Stated tested Nurse Aide (STNA) #670 verified she had not been in Resident #34's room to provide any care or reposition her since she started her shift at 6:00 A.M. on 01/12/21. STNA #670 stated she was the only nurse aide on the hall and had other residents that she needed to provide care for. Interview on 01/12/21 at 10:51 A.M. with Licensed Practical Nurse (LPN) #200 stated all wound care treatments were supposed to be documented in the electronic TAR. LPN #200 stated she was not always able to get to all the resident's wound treatments, including Resident #34's wound treatments, because she was often the only nurse for two halls, and she could not get all the resident care done. 2. Review of Resident #09's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 11/16/20, revealed Resident #09 had intact cognition, was independent with bed mobility and transfers, was assessed at risk for pressure ulcer development, and was assessed with [REDACTED]. Review of a physician order [REDACTED].#09 was to have her coccyx wound cleansed with normal saline, patted dry, a medicated treatment applied, and covered with a foam dressing and changed daily. Review of a December 2020 TAR revealed no documentation of Resident #09's pressure ulcer treatment being completed on 12/07/20, 12/17/20, 12/18/20, and 12/31/20 as ordered. Interview on 01/06/21 at 12:00 P.M. with LPN #200 verified Resident #09's pressure ulcer treatment was not completed on 12/31/20. LPN #200 stated she was the only nurse for two halls on that day and could not get to all her resident treatments. LPN #200 verified there was no documentation in the medical record of Resident #09's wound treatment being completed on 12/07/20, 12/17/20, and 12/18/20 as well. Interview on 01/06/21 at 12:23 P.M. with Resident #09 verified she had a pressure ulcer on her coccyx that she had for a long time. Resident #09 stated the nurses were not changing the dressing everyday like they were supposed to. Interview on 01/07/21 at 8:15 A.M. with LPN #900 stated Resident #09's wound treatments were supposed to be completed every day. LPN #900 stated there were times when she returned to work from being off that Resident #09's pressure ulcer treatment was not completed but could not give any specific dates. Review of an undated policy titled, Pressure Ulcer Prevention and Treatment, revealed the facility will provide care based on the resident's comprehensive assessment. Pressure ulcer prevention will include skin assessments and turning and repositioning the resident. Staff should avoid positioning residents directly on the pressure ulcer. 3. Review of Resident #18's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recently complete Minimum Data Set (MDS) assessment completed 11/16/20 revealed Resident #18 was cognitively intact and required physical help in part of her bathing activity using two person plus assistance. Review of an activities of daily living (ADL) self-care deficit care plan dated 10/29/20 revealed Resident #18 required assistance with ADLs an indicated she was legally blind. Review of a shower schedule revealed Resident #18 was scheduled to receive showers on Tuesdays and Saturdays on first shift (6:00 A.M. to 2:00 P.M.) Review of nurse aide documentation from December 2020 revealed Resident #18 received three showers during in the month on 12/01/20, 12/19/20, and 12/22/20. Review of nurse aide documentation from January 2021 indicated Resident #18 was showered on 01/05/21. Review of a nursing progress note dated 01/06/21 revealed Resident #18 was not showered on 01/05/21 as indicated in the nurse aide documentation. The documentation of a shower given on 01/05/21 was entered in error. Interview on 01/05/21 at 3:39 P.M., with Resident #18 verified she needed staff assistance with her showers and stated she had not been showered for over a week. Resident #18 stated she was supposed to have showers on the day shift every Tuesday and Saturday and verified she was supposed to have a shower on 01/05/21 but did no one came to assist her with her shower. Observation on 01/05/21 at 3:39 P.M., during interview with Resident #18, revealed her hair was flat, matted, and appeared greasy and oily. Interview on 01/05/21 at 3:00 P.M., with Registered Nurse (RN) #500 stated Resident #18 was supposed to have a shower completed on 01/05/21 but there were no staff available to assist with the shower. LPN #500 stated she and another nurse aide were the only staff working on the hall the entire first shift. LPN #500 stated Resident #18 was scheduled to receive two showers each week, and stated it had been over a week since her last shower. Interview on 01/06/21 at 12:37 P.M., with State tested Nurse Aide (STNA) #260 verified she and LPN #500 were the only staff members working on their hall on 01/05/21 and verified she did not have any time to give Resident #18 her shower during her shift. STNA #260 verified LPN #500 did not assist with any resident showers on 01/05/21. 4. Review of Resident #42's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a MDS assessment completed 09/02/20 revealed Resident #42 had severely impaired cognitive skills for daily decision making and required extensive two person plus assistance with transfers. Review of a physician order [REDACTED].#42 was to have a COVID-19 respiratory assessment completed every shift. Review of Resident #42's COVID-19 respiratory assessments revealed no assessment was completed on 12/31/21. Review of nurse aide documentation from December 2020 and January 2021 revealed no documentation of Resident #42 being transferred from surface to surface on 12/01/20, 12/02/20, 12/05/20, 12/06/20, 12/07/20, 12/10/20, 12/11/20, 12/12/12, 12/18/20, 12/19/20, 12/23/20, 12/26/20, 12/31/20, 01/01/21, 01/03/21, and 01/04/21. 5. Review of Resident #45's medical record revealed an admitted on 03/21/16. [DIAGNOSES REDACTED]. Review of a MDS assessment completed 10/08/20 revealed Resident #45 was cognitively impaired and required extensive assistance with two person plus assistance. Review of a ADL self care deficit care plan dated 03/20/17 revealed Resident #45 required extensive assist of two staff members with all transfers. Review of a physician order [REDACTED].#45 was to have a COVID-19 respiratory assessment completed every shift. Review of Resident #45's COVID-19 respiratory assessments revealed no assessment was completed on 12/31/21. Review of nurse aide documentation from December 2020 and January 2021 revealed Resident #45 was no transferred from surface to surface on 12/01/20, 12/02/20, 12/03/20, 12/05/20, 12/06/20, 12/07/20, 12/10/20, 12/11/20, 12/12/20, 12/18/20, 12/23/20, 12/31/20, 01/01/21, 01/02/21, 01/03/21, and 01/04/21. Interview on 01/05/21 at 9:56 A.M., with LPN #200 stated there are not enough staff members to assist residents from their bed during the day so some days residents are left in their bed all day long. LPN #200 verified Resident #42 and #45 are residents that require staff assistance to get up from bed, and the facility did not always have enough staff to get them up. LPN #200 verified Resident #42 and #45 were not gotten up and out of bed on multiple days in December 2020 and January 2021. LPN #200 verified Resident #42 and #45's COVID-19 respiratory were not completed on 12/31/21 because she was the only nurse working two units and could not get her assessments completed. Review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, revealed residents who are unable to carry out activities of daily living independently will received the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (including bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), and elimination (toileting). 6. Observation on 01/05/21 at 1:28 P.M., revealed Resident #41 activated his call light from his bed room. Further observation revealed no staff members visible on the hall where Resident #41 resided. Resident #41's call light continued to sound for 29 minutes and no staff members were observed going in and out of resident rooms on the hall and there were no other facility staff members observed walking onto the unit during this observation. Observation at on 01/05/21 at 1:57 P.M., revealed a nurse aide (STNA #311) walked onto the unit to being her second shift (2:00 P.M. to 10:00 P.M.). STNA #311 was not aware where the staff members assigned to Resident #41's hall on first shift were located as she just began her shift and had not received report. Observation on 01/05/21 at approximately 2:00 P.M., revealed STNA #311 entered Resident #41's bedroom to answer his call light with Resident #41 requesting a soda pop to drink. STNA #311 provided Resident #41 with a soda pop per his request at this time. Interview on 01/05/21 at 2:06 P.M., with LPN #200 stated she and the two nurse aides on the hall were in another resident's room performing wound care that was extensive and required all staff members. LPN #200 verified there were not other staff members on the hall to answer call lights while they were providing care. LPN #200 stated administrative staff and staff members from other halls rarely assist with answering call lights during her shift. 7. Review of Resident #31's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recently complete Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was severely cognitively impaired and required extensive two plus person assistance with toileting. Review of an activities of daily living (ADL) care plan dated 10/24/18 revealed Resident #31 required assistance with toileting. Interview on 01/05/21 at 4:17 P.M., with Resident #31 stated the nurses and nurse aides do the best they can with her care but voiced no complaints. During interview with Resident #31, she voiced she thought she was wet (incontinent of urine). Observation on 01/05/21 at 4:25 P.M., revealed State tested Nurse Aide (STNA) #777 entered Resident #31's to check for incontinence. Further observation revealed Resident #31 was incontinent of urine and had completely saturated her incontinence brief, her moisture barrier pad, her bed sheets and blankets, as well as her offloading pillows. STNA #777 performed incontinence care and performed a complete bed and clothing change for Resident #31. Interview on 01/05/21 at 4:58 P.M., with Registered Nurse (RN) #500 stated Resident #31 was supposed to checked for incontinence and assisted with toileting at least every two hours. RN #500 stated she was working with only one nurse aide and not all resident care was being completed. RN #500 stated she was not aware the last time Resident #31 was checked for incontinence but verified it was before 2:00 P.M. on 01/05/21 because that is when the nurse aide went home and she was left as the only staff member on the hall. Interview on 01/06/21 at 12:37 P.M., with State tested Nurse Aide (STNA) #260 stated residents were supposed to be checked every two hours for incontinence or assisted with toileting. STNA #260 stated she checked Resident #31 for incontinence a little before 1:00 P.M. on 01/05/21 and remembered she was the last resident she provided care for before she completed her documentation and left around 2:00 P.M. Review of a facility policy titled, Perineal Care, dated February 2018, revealed the purpose of the procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review of a facility staffing policy dated October 2017 revealed staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. This deficiency substantiates Master Complaint Number OH 974, Complaint Number OH 887, Complaint Number OH 867, and Complaint Number OH 210.

Based on observation, resident and staff interviews, medical record review, and review of the facility's policy, the facility failed to provide wounds treatments as ordered by a physician, failed to assist residents with turning and repositioning as ordered, and failed to timely assess residents with wounds. This resulted in Actual Harm to one resident (#34) when facility staff did not provide wound treatments and turning and repositioning as physician ordered and did not complete timely monitoring of Resident #34's left hip pressure ulcer including measuring/staging the wound and Resident #34's left hip wound subsequently deteriorated into a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed). Additionally, one resident (#09) did not receive pressure ulcer treatments as ordered to a Stage III pressure ulcer which placed the resident at risk for potential deterioration of the wound that did not result in actual harm at this time. This affected two (#09 and #34) of three residents reviewed with wounds. The facility identified five residents with pressure ulcers. The facility census was 50. Findings include: 1. Review of Resident #34's medical record revealed an admission date of [DATE] and a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 09/23/20, revealed Resident #34 was cognitively intact, dependent on two staff for the completion of activities of daily living for transfers and required extensive assistance by two persons for bed mobility. The resident was assessed at risk for pressure ulcer development, had pressure ulcers, and had interventions including pressure reduction to the bed and chair, and application of nonsurgical dressings other than to the feet. Review of the wound management care plan, dated 05/22/20, revealed Resident #34's wound would be measured at regular intervals and wound treatment provided as ordered. Review of the wound clinic wound assessment, dated 10/26/20, revealed Resident #34 was assessed with [REDACTED].) long by 3.3 cm. wide by 1.9 cm. deep. A treatment order was provided for Resident #34 to have the old wound dressing removed, the wound and peri-wound area cleansed, antifungal powder applied to the peri-wound, an absorbent dressing as the primary dressing with a absorbent pad secured over the dressing and secured with a cover roll. The order was to be completed daily and was in place for one week. There was a note on the wound assessment indicating Resident #34 should be repositioned every two hours from side to side. Review of the wound clinic wound assessment, dated 11/02/20, revealed Resident #34's left hip wound remained a Stage III pressure ulcer measuring 2.0 cm. long by 3.5 cm. wide by 1.0 cm. deep. The wound order was changed to remove the old dressing, cleanse the peri-wound area, apply an absorbent dressing with bordered foam cover, and changed daily for one week. Review of the wound clinic wound assessment, dated 11/09/20, revealed Resident #34's left hip wound remained a Stage III pressure ulcer measuring 2.0 cm. long by 3.0 cm. wide by 0.1 cm. deep with undermining of the wound measuring 0.9 cm. and with no changes to the wound treatment order from 11/02/20 and was ordered to be changed daily and extended for another week. The wound was described as full thickness loss with exposed subcutaneous tissue and beefy red granulation with some pink granulation covered with [MEDICATION NAME] in the wound bed. There was no documentation of Resident #34 being seen in the wound clinic again until 11/23/20. Review of the electronic medical record revealed Resident #34's physician order [REDACTED]. Review of the facility wound care assessment, dated 11/16/20, revealed Resident #34's left hip wound remained a Stage III pressure ulcer measuring 2.0 cm. long by 3.0 cm. wide by 0.1 cm. deep with no changes to the physician order. Review of the November 2020 treatment administration record (TAR) revealed no documentation of a wound treatment completed to Resident #34's left hip pressure ulcer on 11/02/20 and 11/18/20 through 11/30/20. There were 14 treatments not marked as completed in 11/2020. Review of the wound clinic wound assessment, dated 11/23/20, revealed Resident #34's left hip pressure ulcer was now a Stage IV (full-thickness skin and tissue loss) wound measuring 2.0 cm. long by 3.0 cm. wide by 1.0 cm. deep with undermining of the wound measuring 2.5 cm. The wound was described as a full thickness wound with exposed subcutaneous tissue and tendon and a beefy red granulated wound bed with slough. Resident #34's wound treatment continued to be for staff to remove the old dressing, cleanse the peri-wound area, apply an absorbent dressing with bordered foam cover, and changed daily for two weeks. Review of the physician order, dated 11/24/20, revealed Resident #24 was to be educated and encouraged to reposition with assistance every two hours to offload pressure. The ordered included if Resident #34 refused to be repositioned, her family was to be notified and documented in the nursing progress notes. Review on the wound clinic wound assessment, dated 12/07/20, revealed Resident #34's left hip pressure ulcer remained a Stage IV pressure ulcer measuring 2.5 cm. long by 3.3 cm. wide by 1.2 cm. deep. The wound treatment order was to remain the same as ordered on [DATE] and remain an order for [REDACTED].>Review of the December 2020 TAR revealed no documentation of any wound treatments completed to Resident #34's left hip wound between 12/01/20 and 12/19/20. Additionally, there was no documentation of Resident #34 being repositioned on 12/02/20 for four consecutive hours twice between 2:00 A.M. and 6:00 A.M. and between 8:00 P.M. and 12:00 P.M., on 12/03/20 for six consecutive hours between 12:00 A.M. and 6:00 A.M., on 12/16/20 for four consecutive hours between 8:00 P.M. and 12:00 P.M., on 12/17/20 for six consecutive hours between 12:00 A.M. and 6:00 A.M., and on 12/18/20 for four consecutive hours between 2:00 A.M. and 6:00 A.M. There was no documentation in the medical record of Resident #34's left hip ulcer being assessed between 12/07/20 and 12/21/20. Review of the wound clinic wound assessment, dated 12/21/20, revealed Resident #34's left hip wound remained a Stage IV pressure ulcer measuring 2.1 cm. long by 2.9 cm. wide by 1.2 cm. deep. Review of the January 2021 TAR revealed no documentation of Resident #34 being repositioned on 01/01/21 for four consecutive hours between 12:00 P.M. and 4:00 P.M., on 01/03/21 for eight consecutive hours between 8:00 A.M. and 4:00 P.M., on 01/06/21 for four consecutive hours twice between 12:00 A.M. and 4:00 A.M. and between 12:00 P.M. and 4:00 P.M., on 01/08/21 for two hours between 2:00 A.M. and 4:00 A.M., on 01/10/21 for four consecutive hours between 12:00 A.M. and 4:00 A.M., and on 01/11/21 for two hours between 2:00 A.M. and 4:00 A.M. Further review of the January 2021 documentation revealed there was no documentation of Resident #34 being repositioned since 4:00 P.M. on 01/11/21. Review of the nursing progress notes dated between 11/01/20 and 01/12/21 revealed no documentation of Resident #34's left hip wound treatments being completed for the dates missing in November and December 2020 TARS, as well as no documentation of Resident #34 refusing to be repositioned, including documentation of notification to the family, in the medical record during this time frame. Review of the nurse practitioner progress note, dated 01/05/21, revealed Resident #34 reported to the nurse practitioner she recently went to the wound care specialist out of the building and they were very concerned about how her wounds were not improving. Resident #34 indicated the wound clinic was concerned she was not getting turned enough or may be sitting in her urine for too long which made Resident #34 very upset. Observation on 01/12/21 at 7:49 A.M. revealed Resident #34 was in her room with the light off and could be observed laying on her back. Observation at 9:05 A.M. revealed Resident #34 remained in the same position in bed. Interview on 01/12/21 at 9:06 A.M. with Resident #34 stated she was supposed to have wound treatments completed everyday but, on many days, her wound treatments were not done. Resident #34 stated she needed help with repositioning in bed and staff did not always come into her room to help her turn. Resident #34 stated she sometimes was not turned for hours at a time and stated she had not been repositioned since around 4:00 A.M. on 01/12/21. Resident #34 stated no staff had entered her room since the first shift staff started their day. Interview on 01/12/21 at 9:14 A.M. with Stated tested Nurse Aide (STNA) #670 verified she had not been in Resident #34's room to provide any care or reposition her since she started her shift at 6:00 A.M. on 01/12/21. STNA #670 stated she was the only nurse aide on the hall and had other residents that she needed to provide care for. Interview on 01/12/21 at 10:51 A.M. with Licensed Practical Nurse (LPN) #200 stated all wound care treatments were supposed to be documented in the electronic TAR. LPN #200 stated she was not always able to get to all the resident's wound treatments, including Resident #34's wound treatments, because she was often the only nurse for two halls, and she could not get all the resident care done. Interview on 01/12/21 at 11:06 A.M. with Intermittent Director of Nursing (IDON) #2 verified there was no documentation of wound treatments completed for Resident #34's left hip wound on 11/02/20, 11/18/20 through 11/30/20, and 12/01/20 through 12/19/20. IDON #2 verified during the time frame when there was no documentation of wound treatments completed to Resident #34's wound, it worsened from a Stage III to a Stage IV pressure ulcer. Observation on 01/12/21 at 2:10 P.M. revealed LPN #200 was providing Resident #34's wound dressing change. Observation of the wound on Resident #34's left hip revealed a Stage IV pressure ulcer with undermining to the upper right portion of the wound. The wound had a beefy red wound bed with subcutaneous tissue and tendon exposed. There was no odor, drainage, or signs of infection. 2. Review of Resident #09's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 11/16/20, revealed Resident #09 had intact cognition, was independent with bed mobility and transfers, was assessed at risk for pressure ulcer development, and was assessed with [REDACTED]. Review of the care plan, dated 10/17/20, revealed Resident #09 had actual skin breakdown with interventions including performing treatments as ordered. Review of the wound assessment, dated 10/18/20, revealed Resident #09 had a Stage III pressure ulcer on her coccyx measuring 1.7 cm. long by 1.3 cm. wide by 0.7 cm. deep. Review of the physician order, dated 11/04/20, revealed Resident #09 was to have her coccyx wound cleansed with normal saline, patted dry, a medicated treatment applied, and covered with a foam dressing and changed daily. Review of the December 2020 TAR revealed no documentation of Resident #09's pressure ulcer treatment being completed on 12/07/20, 12/17/20, 12/18/20, and 12/31/20 as ordered. Review of the wound assessments dated between 10/18/20 and 12/31/20 revealed Resident #09's pressure ulcer was assessed at least weekly, remained the same stage, was not infected, and showed no increase in size. Interview on 01/06/21 at 12:00 P.M. with LPN #200 verified Resident #09's pressure ulcer treatment was not completed on 12/31/20. LPN #200 stated she was the only nurse for two halls on that day and could not get to all her resident treatments. LPN #200 verified there was no documentation in the medical record of Resident #09's wound treatment being completed on 12/07/20, 12/17/20, and 12/18/20 as well. Interview on 01/06/21 at 12:23 P.M. with Resident #09 verified she had a pressure ulcer on her coccyx that she had for a long time. Resident #09 stated the nurses were not changing the dressing everyday like they were supposed to, but stated the wound was not causing her any pain and it had not worsened. Interview on 01/07/21 at 8:15 A.M. with LPN #900 stated Resident #09's wound treatments were supposed to be completed every day. LPN #900 stated there were times when she returned to work from being off that Resident #09's pressure ulcer treatment was not completed but could not give any specific dates. Observation on 01/07/21 at 10:43 A.M. revealed LPN #900 performing a dressing change on Resident #09's pressure ulcer. Observation of Resident #09's wound revealed a healing Stage III pressure ulcer with no odor or drainage noted. Review of an undated policy titled, Pressure Ulcer Prevention and Treatment, revealed the purpose of the policy was to promote the prevention of pressure ulcer development, promote the healing of pressure ulcers that are present and to prevent the development of additional pressure ulcers. The facility will provide care based on the resident's comprehensive assessment. Pressure ulcer prevention will include skin assessments and turning and repositioning the resident. Staff should avoid positioning residents directly on the pressure ulcer. All treatments initiated by nursing staff requires a physician order. Wounds will be treated per the facility wound protocol unless otherwise directed by the physician. This deficiency substantiates Master Complaint Number OH 974, Complaint Number OH 849, and Complaint Number OH 210. This deficiency represents continued noncompliance from the survey dated 09/09/20.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure interventions for pressure reduction were consistently implemented, ensure skin assessments were conducted under assistive devices to ensure no breakdown was occurring, failed to timely obtain a treatment once skin breakdown occurred, and failed to provide continuous ongoing monitoring and assessment of a pressure injury which became open. This resulted in actual harm when staff did not consistently apply a pressure reducing boot and when the boot was applied staff did not complete assessments of the skin under the boot, which resulted in the development of a pressure injury/deep tissue injury to the right heel for one (#1) out of four residents reviewed for skin breakdown. Additionally, staff failed to provide repositioning to prevent skin breakdown for one (#3) out of four residents reviewed for skin breakdown. The facility census was 51. Findings include; 1. Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment, dated 06/09/20, identified Resident #1 as alert, oriented, able to make needs known, and dependent on two staff for the completion of activities of daily living including transfer and positioning. The assessment noted the resident with one unstageable deep tissue injury. Pressure relieving measures were documented to the bed, chair and a turning repositioning program was in place. Review of the activity of daily living plan of care, updated 10/30/17, addressed the need for assistance with activity of daily living. Intervention at that time included to provide skin care to keep clean and prevent skin breakdown. Apply specialized boots to bilateral feet while in bed. Review of the plan of care,dated 12/01/17, addressed the resident's risk for skin breakdown due to incontinence, decreased bed mobility and [MEDICAL CONDITION]. Interventions included: applying protective skin ointment following incontinent care, observe skin daily with care and bathing, if redness, areas of pressure or a rash are present notify nurse, pay special attention to heels. Review of the medical record revealed no evidence indicating the specialized boots were applied as indicated in the plan of care. Review of a nurses' note dated 07/12/20 at 2:32 A.M. documented State tested Nursing Assistant (STNA) #400 stated the resident had a wound on the right heel. Upon further evaluation of the resident, the nurse documented the resident with a pressure wound measuring one inch diameter and black in color on the right heel. The resident denied pain at the time. The nurse documented the specialized boots were on and the residents legs elevated. Review of the physician orders [REDACTED].M. when the physician ordered skin prep to be applied to the resident's bilateral heels. Additionally, the physician ordered to keep soft heel suspension boots on at all times and use pillows to suspend heels in bed. Review of the right heel assessment on 07/14/20 described the wound to be a deep tissue injury(DTI). The DTI measured 3.0 centimeters (cm) long by (x) 3.5 cm wide with 0 (zero) depth. The medical record contained no documentation of ongoing skin assessments being conducted regarding the skin condition under the resident's boots or of the boots being consistently applied prior to the discovery of the DTI on 07/12/20. Review of wound center physician documentation on 07/20/20 revealed Resident #1 was evaluated for chronic wounds to the buttocks, hip and the deep tissue injury to the right heel. Further review of the medical record noted the resident to be transported to the hospital for evaluation on 07/20/20 at 8:50 P.M. The resident did not return to the facility until 07/30/20. There was no documented assessment of the right heel upon return to the facility. Review of wound center physician documentation on 08/10/20 noted the resident was assessed by the wound center physician and the right heel ulcer measured 2.5 cm by 3.0 cm by 0.1 cm in depth. There was no description of the wound's color, any drainage, or the stage of the wound. Review of wound center physician documentation on 08/24/20 noted the resident was assessed by the wound center physician and the right heel ulcer measured 2.3 cm by 2.9 cm by 0.1 cm in depth. There was no description of the wound's color, any drainage, or the stage of the wound. Review of the facility wound status report for 08/25/20 identified Resident #1's right heel to be a pressure ulcer measuring 2 cm by 2 cm with depth increased to 0.2 cm deep. The report did not identify the stage of the pressure ulcer or a description of the ulcer. Review of the medical record revealed the facility was not completing an assessment and obtaining measurements of Resident #1's right heel on a weekly basis. Interview on 09/09/20 at 9:30 A.M., the Director of Nursing (DON) verified no documentation could be provided indicating skin assessments were being conducted under the resident's boots until a DTI was discovered on 07/12/20 to the right heel. There was no documentation the right heel wound was timely evaluated and treatment applied until 07/14/20. The DON verified there was no evidence of any assessment of the right heel by the facility staff once the resident began being treated by the wound care center. The DON verified the wound care center notes did not contain a description of the wound on Resident #1's right heel. Review of the undated facility policy titled Skin Risk Prevention, revealed skin inspections will be completed during showers per STNA, who will report alterations in skin integrity to the nurse. The nurse will make an observation of the area and initiate treatment per physician notification. 2. Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment, dated 07/03/20, identified Resident #3 with moderate cognitive impairment and required extensive assistance of one staff for transfer and positioning. The assessment also indicates the resident is not at risk for developing pressure ulcers or injuries with a turning and repositioning program in place. Review of the plan of care, revised 04/24/19, identified Resident #3 to be at risk for skin breakdown related to immobility. Interventions included, educating to move off right side, encourage repositioning routinely and as needed, and follow facility policies/protocols for prevention/treatment of [REDACTED]. Observation on 09/08/20 at 9:50 A.M. revealed State tested Nurse Aide (STNA) #101 repositioned Resident #3 to the left side. Continued observations at 12:10 P.M. and 1:30 P.M. noted the resident remained in bed positioned to the left. Interview on 09/08/20 at 1:30 P.M., STNA #101 verified she had not repositioned Resident #3 since 9:50 A.M. STNA#101 then proceeded to the resident's room and repositioned the resident to the right. Observation of the resident's skin identified red areas to the left hip, buttock, ankle, forehead and elbow. Observation on 09/08/20 at 1:40 P.M. with Licensed Practical Nurse (LPN) #201 verified the red areas to Resident #3's left hip, buttocks, ankle, forehead, and elbow. Review of a Skin Observation Tool noted on 09/08/20 at 3:22 P.M. Resident #3 was identified to have a reddened are to the left elbow, front of the left knee, the left lateral knee, and the left hip all measuring 1 centimeter (cm) in diameter. Review of the undated facility policy titled Skin Risk Prevention, revealed prevention included turning and repositioning the resident. This deficiency substantiates Complaint Number OH 557.

Based on medical record review, staff interviews, review of the Emergency Medical Service (EMS) report, and facility policy review, the facility failed to provide the necessary care and services when staff delayed the immediate initiation of Cardiopulmonary Resuscitation (CPR) for one (#78) resident who was found unresponsive, without a pulse and respirations, and who was a Full Code status. This resulted in Immediate Jeopardy (death) for one (#78) of two residents reviewed who required CPR in the event of a cardiopulmonary arrest. The facility identified a total of 18 residents who were a Full Code status. The facility census was 43. On [DATE] at 5:18 P.M., the Administrator, Director of Nursing (DON), and Corporate Nurse #341 were notified Immediate Jeopardy began on [DATE] at 9:15 A.M. when Resident #78 was found unresponsive, without a pulse or respirations, and Registered Nurse (RN) #312 failed to immediately initiate CPR or call 911. The Immediate Jeopardy was removed on [DATE] at 9:08 P.M. when the facility implemented the following corrective actions: On [DATE] at 6:30 P.M., the administrative staff completed a chart audit of all current residents to ensure the correct code status was on the chart via a sticker and also in the electronic chart. On [DATE] at 7:00 P.M., all personnel files of licensed nursing staff and therapy staff were audited to verify current CPR certification status. On [DATE] at 7:00 P.M., the DON provided one-on-one education for RN #312 for not initiating CPR immediately on Resident #78. RN #312 resigned following the education. The administration reported the incident to the Board of Nursing on [DATE]. On [DATE] at 9:08 P.M., in-service education for all nursing staff and therapy staff regarding the Emergency Procedure - Cardiopulmonary Resuscitation (CPR) policy and paging overhead for Code Blue was completed. On [DATE] between 9:30 A.M. and 10:05 A.M., interviews with Licensed Practical Nurse (LPN) #308, State tested Nursing Assistant (STNA) #219, RN #313 and LPN #301, revealed they were knowledgeable regarding the procedure of where to check for a resident's code status and the procedure for initiating CPR. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (No actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan to investigate all deaths and monitor to ensure ongoing compliance. Findings include: Review of Resident #78's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #78's undated Resuscitation Identification form, which was located in the front of her medical record, indicated her code status was handwritten on the form as being a Full Code. Review of Resident's #78 electronic record indicated the resident's code status on the face sheet was also a full code. Review of the nursing progress note dated [DATE] at 3:44 P.M. written by RN #312 documented Resident #78 returned to the facility by wheelchair from [MEDICAL TREATMENT] due to not being able to transfer from the wheelchair to the [MEDICAL TREATMENT] chair. The transportation driver came to the door where RN #312 was assisting another resident. When RN #312 finished with the resident she was working with, she went to the door and the driver stated Resident #78 was back in her room from [MEDICAL TREATMENT]. RN #312 saw two STNA's headed to the resident's room with a mechanical lift. STNA #227 came out immediately and called for RN #312. RN #312 went to the room and tried to arouse the resident with no response. RN #312 did a sternal rub with no response. RN #312 ran to get a blood pressure cuff etc. and came back to the resident's room. RN #312 put the blood pressure cuff on the resident's wrist then listened to the resident's heart. There was no heartbeat and the blood pressure reading was zero. RN #312 moved the blood pressure cuff to the resident's other wrist and it also read as zero. RN #312 palpated for a pulse and there was no pulse. She then instructed STNA #200 to go to the nurse's station to find out the resident's code status. STNA #200 returned and told RN #312 Resident #78 was a full code. RN #312 and STNA #227 moved the resident to the floor and RN #312 began compressions until the DON came to the resident's room with the crash cart. Nine-one-one (911) was called and compressions and breaths were continued until the EMS arrived and took over care of the resident. EMS pronounced the death at 9:55 A.M. Interview with STNA #227 on [DATE] at 11:00 A.M., verified she worked on [DATE] from 6:00 A.M. to 2:00 P.M., floating between the 100 and 200 halls. She stated the Facility Transportation Driver (#350) saw her in the hallway and told her Resident #78 was back from [MEDICAL TREATMENT] and in her room. He stated she was very sleepy and wanted to make sure someone knew to put her in bed so she did not fall out of her wheelchair. She stated she put the laundry she had in her hand in the dirty utility room, obtained a mechanical lift, and entered Resident #78's room with STNA #200. She stated she was in front of the resident and the resident's head was down. The resident did not respond to her name. She stated she said to STNA #200, I think she passed. She stated STNA #200 stayed with Resident #78 while she went to get RN #312. RN #312 had medication in her hand and asked STNA #227 if it was an emergency. STNA #227 stated it was an emergency and RN #312 put the medication in the medication cart and entered the room. Resident #78 was not breathing when RN #312 entered the room. RN #312 stated she forgot her blood pressure cuff and she left the room to get the cuff. She returned to the room with a wrist blood pressure cuff and placed it on Resident #78's wrist. RN #312 switched the blood pressure cuff to Resident #78's other arm and was unable to obtain a blood pressure or pulse in either arm. She then asked STNA #200 to go to the nurse's station and check Resident #78's code status. While STNA #200 was gone, RN #312 continued an attempt to obtain a blood pressure and pulse on Resident#78 without success. STNA #200 returned to Resident #78's room and stated Resident #78 was a Full Code. STNA #200, STNA #227, and RN #312, placed Resident #78 on the floor and RN #312 began CPR. STNA #227 stated she did not know the exact time she found Resident #78 unresponsive. She estimated the time to be approximately 9:10 A.M. Interview with RN #312 on [DATE] at 11:30 A.M., verified she worked [DATE] from 7:00 A.M. until 7:00 P.M. She stated Resident #78 was not in the facility when she reported to work on [DATE] because she was at [MEDICAL TREATMENT]. She stated the [MEDICAL TREATMENT] unit called on [DATE] and stated Resident #78 was on her way back to the facility as [MEDICAL TREATMENT] staff were unable to get Resident #78 transferred from her wheelchair to the [MEDICAL TREATMENT] chair as the mechanical lift pad under the resident was not compatible with the [MEDICAL TREATMENT] center's mechanical lift. Resident #78 was very sleepy and unable to assist with the transfer. RN #312 stated she does not remember what time she received the call from the [MEDICAL TREATMENT] center. She stated she was administering medication in the room next to Resident #78's room when STNA #227 came out into the hallway and stated she needed her in Resident #78's room immediately. She stated the resident whom she was administrating medication to at the time, revealed the electronic Medication Administration Record [REDACTED].M. RN #312 stated she entered Resident #78's room, called the resident's name and she did not respond. RN #312 stated she did a sternal rub on Resident #78 with no response from the resident. RN #312 stated she forgot her blood pressure cuff so she left the room to get it off of the medication cart located outside of Resident #78's room. She returned to the resident's room and placed a wrist blood pressure cuff on Resident #78's wrist and did not get a reading or hear a pulse. RN #312 stated she thought Resident #78's code status was a full code, however, she was not sure so she sent STNA #200 to the nurses station to verify the resident's medical record to confirm the resident's code status. She stated while STNA #200 was gone, she continued to try to obtain a blood pressure and a pulse and was unsuccessful. RN #312 stated when STNA #200 returned and confirmed Resident #312 was a full code, STNA #227 assisted her with placing Resident #78 on the floor and she began CPR. STNA #227 went to get the DON who was in a meeting at the front of the building. RN #312 stated the DON arrived with the crash cart and LPN #310. RN #312 stated LPN #310 called 911 at this time. RN #312 was unable to remember the time the resident returned from [MEDICAL TREATMENT], the time Resident #78 was found unresponsive by STNA #227, the time CPR was initiated, or the time 911 was called. She also verified the documentation regarding the incident on [DATE] at 9:15 A.M., was not charted in the record until [DATE] at 3:44 P.M. She further verified she did not document the time Resident #78 returned from [MEDICAL TREATMENT], when she was found unresponsive, when CPR was initiated, or when 911 was called. Interview with the DON on [DATE] at 12:00 P.M., verified there was no documentation of the time Resident #78 returned from [MEDICAL TREATMENT], when she was found unresponsive, or when CPR was initiated. She verified she did not investigate the events surrounding Resident #78's death, however, she estimated it was approximately 9:15 A.M. when Resident #78 was found unresponsive. On [DATE] at 5:30 P.M., during a phone interview, STNA #200 verified she was working on [DATE] during the day shift from 6:00 A.M. to 2:00 P.M. STNA #200 stated she does not know what time Resident #78 returned from [MEDICAL TREATMENT]. She stated STNA #227 asked her to assist with putting Resident #78 to bed using a mechanical lift. She stated STNA #227 went to get the mechanical lift and they entered the resident's room. She stated she could not remember the time they entered Resident #78's room. STNA #200 stated the resident was gone when they entered the room. She defined gone as deceased . She stated STNA #227 went out of the room to get RN #312. RN #312 entered the room quickly and stated she forgot her blood pressure cuff. STNA #200 stated RN #312 did not check Resident #78 for a pulse when she entered the room; however, it was apparent the resident was not breathing. RN #312 came back into the room and took the resident's blood pressure with a wrist blood pressure cuff which read zero. She stated RN #312 asked her to go to the nurse's station and see what the resident's code status was. STNA #200 stated she went to the nurse's station and found Resident #78's medical record which indicated she was a full code. She stated she returned to Resident #78's room and assisted in lowering Resident #78 to the floor and verified RN #312 began performing CPR. Review of the medical record and observation of the resident's room revealed the nurse's station was located approximately 100 feet from the resident's room and was a private room. On [DATE] at 9:00 A.M., an interview with Facility Transportation Driver #350 verified he took Resident #78 to [MEDICAL TREATMENT] on [DATE]. He stated Resident #78 left the facility at 7:15 A.M. and arrived at the hospital [MEDICAL TREATMENT] unit at approximately 8:00 A.M. He stated Resident #78's [MEDICAL TREATMENT] treatment was scheduled for 8:00 A.M. He stated he received a call from the [MEDICAL TREATMENT] unit at 8:15 A.M., as he was leaving the hospital parking lot and was told to come back and get the resident as they could not transfer her from the wheelchair into the [MEDICAL TREATMENT] chair and could not do her treatment. He stated he returned to the [MEDICAL TREATMENT] unit and transported the resident back to the facility. He verified he records on the transportation log when he takes a resident out of the facility and where they go. However, he does not log the time he returns with the resident. Review of the facility Transportation Log revealed there was no return times on any of the residents transported on [DATE] through the current date. He stated he did not know the exact time Resident #78 returned to the facility on [DATE]. He estimated the time was between 9:10 and 9:15 A.M. and stated it took approximately 40 minutes to drive from the [MEDICAL TREATMENT] unit to the facility. He further indicated he did not notice anything unusual about Resident #78 other than she was sleepy. Review of the Patient Care Report/Detailed form revealed the EMS response to the 911 call for Resident #78 regarding a [MEDICAL CONDITION], indicated the fire department/EMS received a call on [DATE] at 9:22 A.M. The call was dispatched at 9:24 A.M. EMS arrived in Resident #78's room at 9:34 A.M. to find Resident #78 without a pulse and unresponsive. EMS was told by the facility CPR was initiated by the facility on [DATE] at 9:15 A.M. Resident #78 never regained a pulse or signs of life during the resuscitation. EMS called the local hospital to obtain permission to stop CPR. CPR was discontinued at 10:04 A.M. Review of one (#7) additional resident who was a Full Code status and was found unresponsive and without a pulse, revealed the facility initiated CPR immediately. The facility identified there were no other residents with a Full Code status who had expired since [DATE]. Review of the facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation dated [DATE], indicated if a resident was found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR. This deficiency substantiates Complaint Number OH 266.