Every finding on record at Terrace View Gardens

Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to timely complete quarterly Minimum Data Set (MDS) assessments. This affected four residents (#44, #76, #14, and #09) out of 24 residents reviewed for MDS assessments. The facility census was 75.Findings include: 1. Medical record review for Resident #44 revealed an admission re-entry date of 03/01/22. Diagnoses include paraplegia, vascular dementia, cognitive communication deficit, type II diabetes mellitus, acute respiratory failure with hypoxia, major depressive disorder, delusional disorder, anxiety disorder, and complete traumatic amputation at level between left hip and knee. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was cognitively intact. The resident was supervision assistance for eating, and oral hygiene, and maximal assistance for toileting, dressing, and personal hygiene. The resident was documented as rejecting care one to three times over seven days. Further record review for Resident #44 revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 03/03/25 and a completion date of 03/18/25. Interview on 02/25/26 at 2:18 P.M. with Licensed Practical Nurse (LPN) #214 verified Resident #44 had a quarterly MDS with an ARD of 03/03/25, an MDS completion date of 03/18/25, and that the MDS was completed late. 2. Medical record review for Resident #76 revealed an admission date of 10/04/23. Diagnoses included Alzheimer's disease, depression, type II diabetes mellitus, unspecified fracture of the lower end of right radius, and major depressive disorder. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #76 had moderately impaired cognition. The resident was supervision assistance for all activities of daily living. She was continent of bladder and bowel and demonstrated no challenging behaviors. Further record review for Resident #76 revealed a quarterly MDS assessment with an ARD of 04/11/25 and a completion date of 04/28/25. Interview on 02/25/26 at 2:18 P.M. with LPN #214 verified Resident #76 had a quarterly MDS with an ARD of 04/11/25, an MDS completion date of 04/28/25, and that the MDS was completed late. 3. Medical record review for Resident #14 revealed an admission date of 04/11/25. Diagnoses included Alzheimer's disease, vascular dementia, psychotic disorder with delusions due to known physiological condition, type II diabetes mellitus, cerebral infarction, unspecified mood disorder, and anxiety disorder. Review of quarterly MDS assessment dated [DATE] revealed Resident #14 was severely cognitively impaired. The resident required supervision assistance for eating, oral hygiene, dressing, transfers, and ambulation, moderate assistance for toileting, and personal hygiene, and maximal assistance for bathing. The resident was frequently incontinent of bladder and bowel, rejected care one to three times a week, and exhibited wandering behaviors daily. Further record review for Resident #14 revealed a quarterly MDS assessment with an ARD of 10/27/25 and a completion date of 11/11/25. Interview on 02/25/26 at 2:18 P.M. with LPN #214 verified Resident #14 had a quarterly MDS with an ARD of 10/27/25, an MDS completion date of 11/11/25, and that the MDS was completed late. 4. Review of the medical record for Resident #09 revealed an admission date of 05/27/25. Diagnoses included encephalopathy, aphasia, dysarthria and anarthria, orthostatic hypotension, hypertension, atrial fibrillation, cerebral infarction, anxiety disorder, depression, type two diabetes mellitus without complications, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and heart failure. Review of the quarterly MDS assessment for Resident #09 dated 11/13/25 revealed the assessment was not completed until 12/01/25. Resident #09 was identified as having severely impaired cognition. Resident #09 was assessed to require supervision for eating, and bed mobility, partial/moderate assistance for oral hygiene, and substantial/maximal assistance for toileting, bathing, dressing, personal hygiene, and transfer. Interview on 02/25/26 at 2:26 P.M. with MDS Nurse – LPN #214 verified the assessment was not completed until 12/01/25. Review of the Resident Assessment Instrument (RAI) Manual 3.0 revealed quarterly assessments must be completed every 92 days and within 14 days from the ARD.

Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to timely complete comprehensive Minimum Data Set (MDS) assessments. This affected three (#04, #07, and #81) out of 24 residents reviewed for assessments. The facility census was 75.Findings include:1. Review of the medical record for Resident #04 revealed an admission date of 01/16/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other generalized epilepsy and epileptic syndromes intractable without status epilepticus, aphasia following cerebral infarction, iron deficiency anemia, hypertension, cerebral infarction, encephalopathy, vitamin d deficiency, depression, type two diabetes mellitus without complications, hyperlipidemia, hypertensive heart disease without heart failure, and chronic respiratory failure with hypoxia.Review of the annual MDS assessment started on 01/27/26 for Resident #04 revealed the assessment was not completed until 02/12/26. Resident #04 was identified as having severely impaired cognition. Resident #04 was assessed to be dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer.Interview on 02/25/26 at 2:25 P.M. with MDS Nurse - Licensed Practical Nurse (LPN) #214 verified the annual assessment was not completed until 02/12/26.2. Review of the closed medical record for Resident #07 revealed an admission date of 12/29/25. Diagnoses included type two diabetes mellitus with other skin ulcer, cellulitis of left lower limb, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other symptoms and signs involving cognitive functions following other cerebrovascular disease, major depressive disorder, vitamin d deficiency, anxiety disorder, Alzheimer's disease with late onset, chronic kidney disease, congestive heart failure, acute respiratory failure with hypoxia, cellulitis of right lower limb, ischemic cardiomyopathy, moderate protein-calorie malnutrition, metabolic encephalopathy, hypothyroidism, hyperlipidemia, and peripheral vascular disease.Review of the admission MDS assessment for Resident #07 started on 01/09/26 revealed the assessment was not completed until 01/16/26. Resident #07 was cognitively intact. Resident #07 was assessed to require supervision for eating, oral hygiene, and personal hygiene, substantial/maximal assistance for toileting, bathing, and lower body dressing, and partial/moderate assistance for upper body dressing, bed mobility, and transfer.Interview on 02/25/26 at 2:22 P.M. with MDS Nurse - LPN #214 verified the assessment was not completed until 01/16/26.3. Review of the closed medical record for Resident #81 revealed an admission date of 12/23/25. Diagnoses included type two diabetes mellitus with ketoacidosis without coma, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, hyperlipidemia, hypertension, acute kidney failure, edema, and chronic kidney disease.Review of the admission MDS assessment for Resident #81 started on 12/31/25 revealed the assessment was not completed until 01/07/26. Resident #81 was identified as having moderately impaired cognition. Resident #81 was assessed to require supervision for eating, oral hygiene, and personal hygiene, partial/moderate assistance for toileting, bathing, upper body dressing, and bed mobility, and substantial/maximal assistance for lower body dressing, and transfer.Interview on 02/25/26 at 2:21 P.M. with MDS Nurse - LPN #214 verified the assessment was not completed until 01/07/26.Review of the Resident Assessment Instrument 3.0 revealed the MDS admission assessment need completed within 14 days of admission. The annual assessment are required at least every 366 days from the Assessment Reference Date (ARD).

Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to timely complete significant change Minimum Data Set (MDS) assessments. This affected three residents (#48, #05, and #11) of four residents reviewed for a significant change. The facility census was 75.Findings include: 1.Medical record review for Resident #48 revealed an admission date of 05/23/23. Diagnoses included encephalopathy, dysphagia, aphasia, cognitive communication deficit, dementia, muscle weakness, chronic pulmonary embolism, and diabetes insipidus. Review of the most recent quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident was maximal assistance for eating, and upper body dressing, dependent for oral hygiene, toileting, bathing, lower body dressing, personal hygiene, transfers, and mobility in a manual wheelchair. Resident #48 was incontinent of bladder and bowel. Further review of Resident #48's record revealed a significant change MDS assessment was required due to a decline in the resident's abilities related to several areas under Activities of Daily Living (ADL). This significant change MDS had an Assessment Reference Date (ARD) of 05/09/25 and a completion date of 05/26/25. Interview on 02/25/26 at 2:18 P.M. with Licensed Practical Nurse (LPN) #214 verified the significant change MDS had an ARD of 05/09/2025, a completion date of 05/26/25, and that the MDS was completed late. 2. Medical record review for Resident #05 revealed an admission date of 09/05/25. Diagnoses included Alzheimer's disease, dementia, cognitive communication deficit, anxiety disorder, aphasia, vascular dementia, metabolic encephalopathy and major depressive disorder. Review of the most recent significant change in status MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident was supervision assistance for eating, bed mobility, transfers, and ambulating 50 feet or less, moderate assistance for oral hygiene, and personal hygiene, and maximal assistance for toileting, and bathing. Resident #05 was frequently incontinent of bladder and bowel. Further review of Resident #05's record revealed the resident registered with hospice care services on 12/24/25, which triggered a significant change MDS assessment. This significant change MDS assessment had an ARD of 01/05/26 and a completion date of 01/19/26. Interview on 02/25/26 at 2:18 P.M. with LPN #214 verified the significant change MDS had an ARD of 01/05/26 and a completion date of 01/19/26. A follow-up interview with LPN #214 on 02/26/25 at 12:19 P.M. verified the significant change in status MDS assessment was triggered by the resident's election of hospice services. 3. Review of the medical record for Resident #11 revealed an admission date of 09/09/22. Diagnoses included non-active primary progressive multiple sclerosis, dysuria, unspecified protein-calorie malnutrition, hypothyroidism, hyperlipidemia, hypertension, anemia, depression, cataract extraction status left eye, and cataract extraction status right eye. Review of the significant change MDS assessment for Resident #11 dated 12/30/25 revealed the assessment was not completed until 01/14/26. Resident #11 was cognitively intact. Resident #11 was assessed to require supervision for eating, and oral hygiene, substantial/maximal assistance for dressing, personal hygiene, and bed mobility, and was dependent on staff for toileting, bathing, and transfer. Review of the physician orders for Resident #11 revealed an order dated 12/17/25 for admission to hospice services. Review of the hospice enrollment form dated 12/23/25 revealed Resident #11 admitted to hospice effective 12/17/25. Interview on 02/25/26 at 2:24 P.M. with MDS Nurse – LPN #214 verified the significant change assessment was not completed until 01/14/26. Review of the Resident Assessment Instrument (RAI) Manual 3.0 revealed a significant change assessment must be completed withing 14 days of identifying the change.

Based on medical record review and staff interview, the facility failed to conduct quarterly care conferences. This affected three (#02, #11, and #68) out of three residents reviewed for care conferences. The facility census was 75.Findings include:1. Review of the medical record for Resident #02 revealed an admission date of 08/01/22. Diagnoses included type two diabetes mellitus without complications, major depressive disorder, hypertension, histoplasmosis, hypothyroidism, hyperlipidemia, anemia, obesity, tachycardia, peripheral vascular disease, post-traumatic stress disorder, anxiety disorder, heart failure, and obstructive sleep apnea.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 was cognitively intact. Resident #02 was assessed to require supervision for eating, partial/moderate assistance for oral hygiene, and upper body dressing, substantial/maximal assistance for toileting, bathing, lower body dressing, personal hygiene, and bed mobility, and was dependent on staff for transfer.Review of the care conference documentation for Resident #02 revealed the only documented care conferences were for 02/22/25, 08/25/25, and 02/18/26.Interview on 02/25/26 at 2:56 P.M. with Licensed Social Worker (LSW) #603 verified the only documented care conferences for Resident #02 were for 02/22/25, 08/25/25, and 02/18/26.2. Review of the medical record for Resident #11 revealed an admission date of 09/09/22. Diagnoses included non-active primary progressive multiple sclerosis, dysuria, unspecified protein-calorie malnutrition, hypothyroidism, hyperlipidemia, hypertension, anemia, depression, cataract extraction status left eye, and cataract extraction status right eye.Review of the significant change MDS assessment dated [DATE] revealed Resident #11 was cognitively intact. Resident #11 was assessed to require supervision for eating, and oral hygiene, substantial/maximal assistance for dressing, personal hygiene, and bed mobility, and was dependent on staff for toileting, bathing, and transfer.Review of the care conference documentation for Resident #11 revealed the only documented care conferences were for 06/24/25 and 09/18/25.Interview on 02/25/26 at 2:54 P.M. with LSW #603 verified the only documented care conferences for Resident #11 were for 06/24/25 and 09/18/25.3. Review of the medical record for Resident #68 revealed an admission date of 10/29/22. Diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, epilepsy unspecified not intractable without status epilepticus, unspecified atrial fibrillation, depression, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, sleep apnea, benign prostatic hyperplasia without lower urinary tract symptoms, non-Hodgkin lymphoma, acute pulmonary edema, hyperlipidemia, chronic obstructive pulmonary disease, cardiomyopathy, and takotsubo syndrome.Review of the quarterly MDS assessment dated [DATE] revealed Resident #68 was cognitively intact. Resident #68 was assessed to require supervision for eating, oral hygiene, and bed mobility, substantial/maximal assistance for toileting, dressing, and personal hygiene, and partial/moderate assistance for transfer.Review of the care conference documentation for Resident #68 revealed the only documented care conferences were for 02/22/25 and 07/03/25.Interview on 02/25/26 at 2:58 P.M. with LSW #603 verified the only documented care conferences for Resident #68 were for 02/22/25 and 07/03/25.

Based on observations, interviews, and facility policy review, the facility failed to ensure enhanced barrier precautions were followed during incontinence care. This affected one (#36) of three residents reviewed for incontinence care. The facility census was 72.Findings include:Review of the medical record for Resident #36 revealed an admission date of 04/24/25. Diagnoses included chronic kidney disease, depression, and transient ischemic attack (TIA).Review of the Five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. This resident was assessed to require supervision with eating, dependent with toileting, transfers, and dressing, and substantial assistance with bathing.Review of section H for bowel and bladder of the Five-Day Medicare MDS assessment dated [DATE] revealed Resident #36 was always incontinent of bowel and bladder.Review of the physician orders for Resident #36 revealed no orders for enhanced barrier precautions (EBP) even though Resident #36 had multiple wounds.Observation on 07/08/25 at 10:32 A.M. revealed incontinence care was completed by Certified Nursing Assistant (CNA) #154 to Resident #36. Resident #36 was in enhanced barrier precautions (EBP) related to multiple wounds. CNA #154 did not apply gown for EBP while providing care.Observation at 07/08/25 at 10:48 A.M. revealed wound care was completed by Licensed Practical Nurse (LPN) #164 to Resident #36 due to the wound being contaminated from bowel movement. LPN #164 did not apply a gown when completing wound care.Interview on 07/08/25 at 10:57 A.M. with CNA #154 verified she did not wear a gown during incontinence care on Resident #36.Interview on 07/08/25 at 11:02 A.M. with LPN #164 verified she did not wear a gown during wound care on Resident #36. Review of the enhanced barrier precautions best practice dated March 2024 revealed enhanced barrier precautions referred to the use of gown and gloves during high-contact care activities for residents with any of the following: infection or colonization with a targeted multi-drug resistant organism (MDRO), chronic wounds, and indwelling medical devices. Examples of high-contact resident care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, and wound care.

Based on medical record review, staff interview, and review of a facility provided article, the facility failed to order and administer medication with an adequate indication for use and in the presence of adverse effects. This affected one (#2) of three residents reviewed for medications. The facility census was 78. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses that included cerebral infarction, attention-deficit/hyperactivity disorder (ADHD), anxiety disorder, congestive heart failure, and obstructive sleep apnea. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Review of a physician order dated 12/29/24 revealed Resident #2 was ordered amphetamine-dextroamphetamine (Adderall), a central nervous system stimulant, 30 milligram (mg) with instructions to give one tablet by mouth once a day for sleep apnea for 30 days. Review of the December 2024 and January 2025 medication administration records (MARs) revealed Resident #2 was administered Adderall 30 mg at 9:00 P.M. from 12/29/24 until 01/14/25 with indication of use for sleep apnea. It was documented Resident #2 refused the scheduled Adderall the evening of 01/13/25. Further review of the December 2024 and January 2025 MARs revealed on 01/15/24 the administration time for Resident #2's Adderall was changed to 9:00 A.M. with an indication of use for sleep apnea. On 01/21/25, Resident #2's Adderall continued to be administered at 9:00 A.M. daily; however, the indication of use for the medication was changed to ADHD. Review of a physical therapy note dated 01/14/25 revealed Resident #2 was sitting in a wheelchair in the common area dozing off. Resident #2 indicated he did not get any sleep the previous night and he was given his Adderall at 8:00 P.M. Further review of the note revealed Resident #2 demonstrated increased fatigue resulting in frequent verbal cues to open his eyes. Interview on 02/01/25 at 9:05 A.M. with Resident #2 revealed he was not able to participate in therapy at times due to being weak and tired. An interview on 02/01/25 at 11:08 A.M. with the Administrator verified Resident #2 was administered Adderall in the evening, but after Resident #2's family expressed concerns about Adderall being administered in the evening, the time was changed to 9:00 A.M. The Administrator verified sleep apnea was the original indication of use when Resident #2 was ordered Adderall on 12/29/24. The Administrator stated she spoke with the doctor and sleep apnea was an uncommon indication for Adderall, but it could be used for sleep apnea. The Administrator verified the indication for use was changed to ADHD when Resident #2's family requested the stimulant medication not be administered in the evening. An interview on 02/01/25 at 11:45 A.M. with Pharmacist #106 stated Adderall was a stimulant, verified the medication should not be administered in the evening, and confirmed sleep apnea was not an indication for use of Adderall. Interview on 02/01/25 at 12:22 P.M. with Occupational Therapist (OT) #103 and Physical Therapy Assistant (PTA) #104 revealed Resident #2 reported being tired, and exhibited exhaustion, activity intolerance, and did not want to get out of bed for therapy. The staff members reported these symptoms were reported to Resident #2's nurse. On 02/03/25 at 12:30 P.M., Medical Doctor (MD) #107 provided an article titled, Stimulants and Sleep, located at, https://www.news-medical.net/health/Stimulants-and-Sleep.aspx. Review of the article revealed stimulants are substances that have an effect on the central nervous system and body, leading to increased alertness and difficulty in getting to sleep. Attention-deficit/hyperactivity disorder (ADHD) is linked to symptoms such as increased sleep latency and daytime somnolence and reduced rapid eye movement (REM) sleep. This deficiency represents non-compliance investigated under Complaint Number OH00161665.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to provide adequate supervision and monitoring for residents which resulted in actual harm to Resident #21 when the facility failed to observe the resident had a heating pad placed against her skin which caused burns to the resident's back and left shoulder. This affected one (Resident #21) of three residents reviewed for accidents. The facility census was 80. Findings: Review of the medical record for Resident #21 revealed she was admitted on [DATE] with diagnoses including malignant neoplasm of pharynx and tonsils, hypertension (HTN), dysphagia, obesity, anemia, benign neoplasm of cranial nerves, anxiety disorder, polyarthritis, Barrett's esophagus, major depressive disorder, gastro-esophageal reflux disease, insomnia, moderate protein-calorie malnutrition, and diabetes mellitus (DM.) Review of the care plan for Resident #21 dated 03/21/22 revealed the resident required assistance with Activities of Daily Living (ADLs) and was at risk for development of complications associated with decreased ADL self-performance related to diagnoses of cancer of the pharynx, dysphagia, and DM. Interventions included the following: assistance with bathing as needed, assistance with bed mobility as needed, assistance with dressing as needed, encourage resident participation while performing ADLs, explain all procedures prior to care, assistance with grooming as needed, monitor for changes in resident's abilities and adjust amount of assistance provided based on resident's needs, notify nursing of any complaints of pain or discomfort, preventative skin care as needed and monitor for any skin breakdown, provide peri-care with each incontinent episode, report declines in resident's ADLs to physician, staff to anticipate needs and assist as needed, assistance with toileting as needed, assistance with transfer as needed, and turning and repositioning as needed. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #21 dated 10/04/23 revealed her Brief Interview of Mental Status (BIMS) score was 14 indicating she was cognitively intact, and the resident required supervision for ADL's including bed mobility. Review of a nurse's progress note for Resident #21 dated 10/26/23 revealed during resident transport, the Emergency Medical Technician (EMT) noticed a heating pad in Resident #21's bedding. The heating pad was warm at the time it was found, and staff suspected Resident #21 had used it during the night. The existence of the heating pad was unknown to staff, and the cord was found under three pillows and plugged in at the head of the resident's bed. Review of a hospital note for Resident #21 dated 10/27/23 per the hospital social worker revealed the resident was admitted to the hospital on 10/26/23 for diagnoses of septic shock, pneumonia and partial thickness burns to the back. Further review of the note revealed the hospital social worker spoke to the resident's representative who indicated he was unaware the resident had purchased the heating pad while still at the facility which had caused the burns to the resident's back. Review of a hospital note for Resident #21 dated 10/29/23 per the hospital physician revealed upon admission on 10/26/23 the resident had burns noted to her back, possibly second degree, with blistering on her thoracic spine and left shoulder. The resident also had redness noted throughout her back upon admission. Review of a Self-Reported Incident (SRI) dated 10/26/23 revealed the facility initiated an investigation of possible neglect for Resident #21 based upon allegations in the hospital notes for the resident which suggested possible neglect due to resident sustaining a burn from a heating pad while at the facility. Further review of the SRI revealed Resident #21 was being transferred from her bed to a stretcher for transport to the hospital when emergency personnel found the resident was laying on a heating pad which was warm to the touch and plugged in behind the resident's bed. Further investigation revealed the facility found a receipt from a department store in Resident #21's room noting the purchase of a heating pad on 10/22/23. Review of the sign out log revealed Resident #21 had signed out on 10/22/23 with a friend. Resident #21 was not able to be interviewed as she was at the hospital at the time of the investigation. Further review revealed the facility interviewed the medical director who believed Resident #21 most likely developed rapidly progressing pneumonia and was unable to feel the sensation of heat from the heating pad and could not reposition herself to prevent injury. The facility took corrective actions but did not substantiate neglect. Interview on 11/01/23 at 2:00 P.M. with the Administrator and the Director of Nursing (DON) confirmed when the nurse was completing her last rounds of the night on 10/26/23 at approximately 7:00 A.M., she noticed Resident #21 was not at her baseline and contacted emergency services. When the emergency services personnel were attempting to transfer Resident #21 for transport one of them noticed a white cord under three pillows plugged in at the head of the bed. Emergency personnel found a heating pad which was plugged in and warm to touch placed against the resident's back. The receipt for the heating pad was located in Resident #21's room and it was determined she had purchased the heating pad on 10/22/23 when she was out with a friend on that date. When the facility was reviewing hospital records accessible to them while Resident #21 remained in the hospital, they saw a notation of possible second degree burns on her back and left arm which had occurred due to the heating pad placed to the resident's back while she was in the facility. Interview confirmed the facility staff had failed to observe Resident #21 had a heating pad placed to her back. They both reported immediate corrective action was taken to ensure no other resident had heating elements in their room which could cause injury. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16 revealed the facility would report and investigate any allegation of abuse or neglect. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. There have been no other residents found with heating elements in their room nor any injury from a heating element since the above incident on 10/26/23. Review of the facility's corrective action plan, completed by the Administrator and the DON, revealed the following actions were implemented and the deficiency corrected as of 10/26/23: An audit was completed of all resident rooms to ensure no resident had any heating elements in their rooms. All residents on the unit were interviewed, found to have no heating elements, and reminded heating elements were not permitted. All residents on the unit who could not be interviewed received a head-to-toe assessment with no concerns. All staff on the unit were interviewed and had no knowledge of Resident #21 having a heating pad. All staff were re-educated regarding heating elements not permitted in resident rooms. Monitoring of rooms began and would continue twice daily to ensure no resident had heating elements in their rooms. Letters were mailed to all resident representatives reminding them heating elements were not permitted in resident rooms. This deficiency represents non-compliance investigated under Complaint Number OH00147805.

Based on medical record review, and interview of facility staff, interview with eye surgery center staff, interview with resident's Power of Attorney (POA), the facility failed to ensure a resident eye surgery was rescheduled as needed. This affected one (#20) of one resident reviewed for eye care. The facility census was 73. Finding include: Review of medical record revealed Resident #20 had an admitted on 11/16/20, with diagnoses including: Down Syndrome, anxiety disorder, metabolic encephalopathy, and dementia. Review of Minimum Data Set assessment dated [DATE], revealed Resident #20 was severely cognitively impaired. Resident #20 was total dependent with one-person physical assist for all care. Review of plan of care dated 12/27/22 revealed Resident #20 was at risk for inability to focus on objects, discriminate color, adjust to changes in light and dark, decreased impaired vision related to highly impaired vision related to cataracts, progression of disease processes and other factors. She was often uncooperative with exams, and other assessments and care. She will not wear glasses. Interventions included keeping the environment free of small objects and clutter, providing a well-lit environment for reading and daily activities, and scheduling eye exams, as necessary. Review of progress note dated 01/06/22, documented by Licensed Practical Nurse (LPN) #111 who had spoken to eye surgery center to see if they would allow an EKG (electrocardiogram) the morning of the procedure. LPN #111 had spoken to anesthesia that stated they could complete it the morning of cataract surgery on 01/20/22. Review of physician progress note dated 01/20/22, documented by Nurse Practitioner #1 revealed an appointment to have surgery on 01/20/22 on right and left eye. Arrival to surgery on 01/20/22 at 8:00 A.M. at eye surgery center. This was for general surgery with general anesthesia on 01/20/22. Review of progress note dated 01/20/22, documented by LPN #75, the transport company canceled Resident #20 transportation to eye surgery at eye surgery center this morning. The entire transport team was called off due to COVID-19. Resident #20's sister was notified. Review of physician progress note dated 12/12/22 revealed Physician #500 had stated Resident #20 had cataracts on 01/22/22. Interview on 04/05/23 at 10:56 A.M., with Resident #20's Power of Attorney (POA) who stated the facility has done nothing to follow up for the eye surgery that was supposed to happen the first time on 01/20/22. Resident #20's POA stated the facility never followed up and rescheduled the eye surgery after it was canceled due to transportation. Interview on 04/05/23 at 3:30 P.M., with Office Personnel #8 stated Resident #20 did not attend the cataract consult on 02/14/23 because the POA stated to put it on hold. Office Personnel #8 stated she had no record to show conversation with family on when the appointment was to be set for future or who she talked to at the eye surgery center. Interview on 04/06/23 at 11:28 A.M., with Eye Surgery Center Registered Nurse (ESCRN) #444, stated the facility did not follow up to reschedule an appointment for Resident #20. ESCRN #444 stated that Resident #20 was supposed to have cataracts removed on 01/20/22 last year. ESCRN #444 stated Eye Physician #400 was family with Resident #20 and new her cognition and how she needed to be scheduled to have anesthesia for her eye surgery due to safety concerns. ESCRN #444 stated she had reached out to Office Personnel #8 and gave information last year, but never heard back from the facility. Interview on 04/06/23 at 4:39 P.M., with Administrator who stated she did not have any other information about Resident #20 follow up surgery appointment to be made. This deficiency represents the non compliance discovered during the investigation of Complaint Number OH00136582.

Based on observation, staff interview, review of online resources per the Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Services (CMS), and review of facility policy, the facility failed to ensure staff wore eye protection and mask correctly in resident areas to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect 75 of 75 residents. The facility census was 75. Findings include: Observation on 10/29/21 at 8:55 A.M., Receptionist #125 was seated at the front desk behind a plexi-glass screen and wore an N95 facemask with eyeglasses. Licensed Practical Nurse (LPN) #488 was observed to wear an N95 facemask with no protective eyewear while preparing to administer medications to first floor residents. State tested Nurse Aide (STNA) #348 was observed to wear an N95 face mask with no protective eyewear while caring for residents on the first floor. Then, Receptionist #125 was observed to walk from behind receptionist desk to first floor nurse's station to inform staff they needed to wear protective eyewear, assembled and handed a face shield to STNA #348, and sat down behind the reception desk without ever donning protective eyewear. Interview on 10/29/21 at 8:55 A.M., with Receptionist #125 verified she, LPN #488, and STNA #348 were not wearing protective eyewear. Receptionist #125 stated the facility was in outbreak status for COVID-19, and the policy stated that all staff wore N95 facemasks and protective eyewear at all times in the building during outbreak status. Receptionist #125 stated she was informed (source unidentified) she did not have to wear protective eyewear because she sat behind a partition. Receptionist #125 verified she left the partition and walked through the facility with out eye protection. Observation on 10/29/21 at 9:00 A.M., revealed Maintenance #235 stepped off the elevator dressed in costume with a ghost face mask and no protective eyewear. When the costume mask was removed, Maintenance #235 wore an N95 facemask underneath the costume mask. Interview on 10/29/21 at 9:02 A.M., Assistant Director of Nursing (ADON) #100 stated the facility policy for PPE while in outbreak status included that all staff wore N95 masks and goggles. Observation on 10/29/21 at 9:30 A.M., revealed STNA #322 held her N95 mask in place with her hands with the bottom loop secured behind her head and the top loop dangling while she walked through the first floor hallway and entered resident room [ROOM NUMBER]. Observation on 10/29/21 at 9:35 A.M., revealed STNA #348 wore a surgical mask with protective eyewear as she walked behind the nurse's station from the floor two hallway. Observation on 10/29/21 at 9:40 A.M., revealed LPN #505 wore a face shield with an N95 mask looped behind her neck and tucked under her chin, not covering her mouth or nose while preparing medications for administration on the third floor. Interview on 10/29/21 from 9:27 A.M. to 9:41 A.M., with the ADON #100 verified Maintenance #235, STNA #322, STNA #348, and LPN #505 did not appropriately wear PPE including N95 facemasks and protective eyewear while in resident care areas on the first, second, and third floors of the building. ADON #100 stated staff had been contacted by telephone two weeks ago and were both notified of outbreak status and educated to PPE requirements when in outbreak status. ADON #100 stated the former DON issued N95 masks and goggles to all facility staff. Review of policy titled, Novel Coronavirus Prevention and Response revised 03/19/21 revealed the facility utilized transmission-based precautions per CDC guidelines. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates revealed the county in which the facility was situated was experiencing a high spread of COVID-19 with a positivity rate of 6.24 percent (%) and was identified as red for the week ending in 10/30/21. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19), at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on staff interview, review of facility policy regarding Covid-19 testing, review of testing logs, and review of Centers for Medicare and Medicaid (CMS) QSO-20-38-NH, the facility failed to ensure Licensed Nurses contracted to perform services at the facility were tested by the facility and/or provided the facility with evidence of routine testing in accordance with facility policy and CMS guidelines prior to providing direct care and services to residents to prevent the potential spread of Covid-19. This had the potential to affect all 57 residents of the facility. Findings include: During an interview with the Administrator and Director of Nursing (DON) on 12/28/20 at 2:45 P.M., a log of all staff tested , including contract/agency staff was requested. The DON stated the facility did use agency staff, that the agency kept records of testing, and also they had to provide evidence of testing. Interview with agency Licensed Practical Nurse (LPN) #78 on 12/29/20 at 1:38 P.M. revealed she was currently working at the facility, and had also worked at the facility a couple other times, and once on the Covid-19 unit. She stated she usually gets tested for Covid-19 by the facility she was working at, usually gets tested on e time a week, but recently that changed to almost every other day. LPN #78 reported that the last time she worked at the facility on the Covid-19 unit she had test results with her, that she carries them on her person in an email. Review of email correspondence from the DON on 12/29/20 at 4:59 P.M. the DON communicated the facility did not log test dates/results for the agency nurses, but did have test results for them. She shared the facility recently started using agency nurses on 12/17/20. The DON provided a list of the names of 10 licensed nurses the facility had used to provide care to residents since 12/17/20. The list did not include the dates the nurses worked at the facility, or record of any Covid-19 test results, or confirmation of negative Covid-19 test results within a time frame that met criteria for bi-weekly testing. The policy also specified that conducting tests under a CLIA certificate of waiver, will report data for all testing completed, for each individual tested . Review of the facility policy and procedure titled Coronavirus Testing dated 11/05/20 specified the facility will implement testing of facility residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19. The policy defined facility staff to include employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility ' s nurse aide training programs or from affiliated academic institutions. Centers for Medicare and Medicaid (CMS) QSO-20-38-NH specifies that Facility staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility ' s nurse aide training programs or from affiliated academic institutions. For the purpose of testing individuals providing services under arrangement and volunteers, facilities should prioritize those individuals who are regularly in the facility (e.g., weekly) and have contact with residents or staff. We note that the facility may have a provision under its arrangement with a vendor or volunteer that requires them to be tested from another source (e.g., their employer or on their own). However, the facility is still required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility ' s testing frequency, as described in Table 2 below. Regardless of the frequency of testing being performed or the facility ' s COVID-19 status, the facility should continue to screen all staff (each shift), each resident (daily), and all persons entering the facility, such as vendors, volunteers, and visitors, for signs and symptoms of COVID-19. Documentation of Testing Centers for Medicare and Medicaid (CMS) QSO-20-38-NH specifies facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests. All residents and staff that tested negative are expected to be retested until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result (see section Testing of Staff and Residents in response to an outbreak above). For staff routine testing, document the facility ' s county positivity rate, the corresponding testing frequency indicated (e.g., every other week), and the date each positivity rate was collected. Also, document the date(s) that testing was performed for all staff, and the results of each test. Document the facility ' s procedures for addressing residents and staff that refuse testing or are unable to be tested , and document any staff or residents who refused or were unable to be tested and how the facility addressed those cases. When necessary, such as in emergencies due to testing supply shortages, document that the facility contacted state and local health departments to assist in testing efforts, such as obtaining testing supplies or processing test results. Facilities may document the conducting of tests in a variety of ways, such as a log of county positivity rates, schedules of completed testing, and/or staff and resident records. However, the results of tests must be done in accordance with standards for protected health information. For residents, the facility must document testing results in the medical record. For staff, including individuals providing services under arrangement and volunteers, the facility must document testing results in a secure manner consistent with requirements specified in 483.80(h)(3).

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents engaged in safe smoking practices during a supervised smoking break. This affected one (#25) out of one resident observed smoking during the survey. The census was 57. Findings include: Review of Resident #25's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #25 dated 07/03/20 revealed resident was cognitively intact and independent and/or required limited assistance with activities of daily living (ADLs). Review of plan of care Resident #25 dated 07/23/18, revealed resident had health risks related to smoking and residents smoking will not cause harm to self or put others at risk. Interventions included facility to provide supervision during resident's smoke breaks Review of smoking assessment for Resident #25 dated 06/27/20 revealed resident required staff supervision with smoking. Observation of the resident's smoke break with Administrator on 08/31/20 at 9:00 A.M. revealed Resident #25 was actively smoking. Further observations revealed Resident #25 was smoking with her paper facemask positioned below her chin while Registered Nurse (RN) #20 was seated directly next to resident. The observation revealed RN #20 was also smoking a cigarette. Interview with Administrator on 08/31/20 at 9:01 A.M. verified Resident #25 was smoking with her paper mask positioned below her chin. Administrator stated RN #20 was tasked with monitoring the resident during her smoke break. Interview with RN #20 on 08/31/20 at 11:35 A.M. verified he was tasked with observation of Resident #25 during her smoke break. RN #20 verified Resident #25 smoked with her paper facemask positioned below her chine. RN #20 stated he was aware of the fire hazards of smoking with a paper masks positioned below resident's chin. RN #20 further stated the incident was an oversight on his part. Review of a facility policy titled Resident Smoking dated 11/28/17 revealed the facility would provide a safe and healthy environment which induced safety as related to smoking.

Based on medical record review, observations, staff interviews, review of facility policy and review of online resources from Ohio Department of Health (ODH), Centers for Medicare and Medicaid (CMS) and Centers for Disease Control (CDC), revealed one randomly observed facility staff (Registered Nurse (RN) #20) failed to wear a facemask during a supervised resident smoke break to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected one (#25) of one resident observed during a supervised smoking break. Facility census was 57. Findings include: Review of Resident #25's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #25 dated 07/03/20 revealed resident was cognitively intact and independent and /or required limited assistance with activities of daily living (ADLs). Observation of the first-floor smoking area with Administrator on 08/31/20 at 9:00 A.M. revealed RN #20 was seated directly next to Resident #25 without a mask place. Further observation revealed RN #20 was also smoking a cigarette. Interview with Administrator on 08/31/20 at 9:01 A.M. verified RN #20 was seated directly next to Resident #25 without a mask in place. Interview with RN #20 on 08/31/20 at 11:35 A.M. verified he was not wearing a facemask while seated directly next to Resident #25 during his smoke break. Review facility policy titled Novel Coronavirus Prevention and Response dated 05/05/20 revealed staff shall wear facemasks in accordance with local, state and national directives. Review of CMS memo titled Nursing Home Guidance dated 04/02/20 revealed all nursing homes shall ensure they are complying with all CMS and CDC guidance related to infection control. Review of coronoavirus.ohio.org revealed(NAME)County was in a level two (orange) public emergency indicating increased exposure and spread of COVID-19. Review of an online resource from the CDC (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html) revealed staff at a minimum were to wear a surgical/medical facemask.

Based on review of weekly menus, observations, resident and staff interviews, the facility failed to ensure the dining room was maintained in a clean and sanitary manner. This affected 20 residents (#3, #5, #7, #8, #9, #14, #17, #18, #20, #21, #37, #39, #43, #49, #50, #53, #56, #58, #60, and #69) observed in the dining room. The facility further failed to keep eight (#300, #302, #303, #306, #308, #312, #314, and #315) resident rooms on the 300 unit in a clean, sanitary and comfortable manner. The facility census was 76. Findings include: 1. Observation on 04/22/19 at 9:00 A.M., of Resident #18 and #39's floors revealed dark black skid marks across the floor. 2. Observation on 04/22/19 at 9:40 A.M., revealed Resident #53's privacy curtain had red and brown stains. 3. Observation on 04/22/19 at 10:00 A.M., revealed Resident #76s bathroom wall on the left side of the room had large dents and holes along with exposed drywall. The edges of the floors had dark black marks. Interview on 04/22/19 at 10:05 A.M., with Resident #76 revealed she had informed staff, including maintenance about the hole in her bathroom wall. 4. Observation on 04/22/19 at 10:20 A.M., revealed Resident #8 and #37's bathroom under the sink had dirt across the edges of the back wall. 5. Observation on 04/22/19 at 10:52 A.M., revealed Resident #20 and #30's both privacy curtains were soiled with spots and food. 6. Review of the facility's weekly menu of meals revealed the dinner meal on 04/21/19 consisted of chicken salad croissant, macaroni salad, lettuce, tomato and fresh strawberries. Observation on 04/22/19 at 11:41 A.M., revealed macaroni was on the dining room floor. The dining room floors were covered with small food particles and debris was noted underneath residents' feet. There were 20 residents (#3, #5, #7, #8, #9, #14, #17, #18, #20, #21, #37, #39, #43, #49, #50, #53, #56, #58, #60, and #69) in the dining room eating lunch. Interview on 04/22/19 at 11:41 P.M., with State tested Nursing Assistant (STNA) #609 verified the macaroni on the dining room floors along with the food particles and debris hanging under dining room tables and under residents' feet. Interview on 04/22/19 at 11:49 A.M., with Housekeeper (HS) #618 revealed she normally wipes off tables, chairs, sweeps and mops the dining room after each meal. However, another housekeeper called in and she had to go to another floor and may have forgotten to sweep and mop the dining room after the dinner meal on 04/21/19. 7. Observation on 04/23/10 at 9:30 A.M., revealed Resident #9's room had drywall exposed and the privacy curtain was covered in stains. Interview on 04/23/19 at 9:35 A.M., revealed Resident #9 reported the exposed drywall had been there since she was admitted on [DATE]. 8. Observation on 04/23/19 at 12:00 P.M., revealed Resident #43 had a large crack in the wall behind the door. The crack had separated the drywall. Interview on 04/25/19 at 11:50 A.M., with Housekeeping/Laundry Supervisor (HD) #617 verified Residents' #18, #39, and #76's floors needed to be cleaned. HD #617 verified Residents' #9, #20, #30, and #53's privacy curtains were in need of washing. The HD verified the cracks and holes in the walls of Residents #9, #43 and #76 rooms. The HD revealed he had not received any service request from staff of any of the rooms besides Resident #76. HD revealed privacy curtains were to be taken down and cleaned when a resident was admitted .

Based on medical record review, observation, and staff interview, the facility failed to ensure treatments were in place to prevent and promote healing of a pressure ulcer. This affected one (#44) of five residents reviewed for pressure ulcers. The facility census was 76. Findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with a re-entry date of 04/21/17. [DIAGNOSES REDACTED]. Review of care plan dated 04/30/17 revealed Resident #44 was at risk for alteration in skin integrity related to [MEDICAL CONDITION], diabetes, dementia, incontinence, history of pressure areas, and mobility impairment. Interventions included assess for pain and provide treatment per physician orders, elevate heels when in bed as needed/tolerated, and pressure relieving boots as tolerated. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed Resident #44 was severely impaired cognitively. Resident #44 had one stage four pressure ulcer. Review of wound evaluation and management summary dated 03/05/19 revealed Resident #44 had a stage four pressure ulcer to the left heel for at least 46 days which resolved as evidenced by anatomic location of previously existing wound revealed [MEDICATION NAME] tissue. Follow up only as needed. No skin abnormalities were documented in the medical record after this date. Review of Resident #44's current physician orders [REDACTED]. The resident was also to have pressure relieving boots to be worn at all times while in bed. The resident was to have heels off the bed as tolerated every shift. On 04/22/19 an order was obtained to cleanse left heel with normal saline and pat dry. Apply foam dressing every night shift. An additional order on 04/22/19 revealed to cleanse right heel and apply skin prep every shift for preventative treatment. Observation on 04/22/19 at 5:00 P.M., revealed Resident #44 was in bed and unable to answer questions do to a confused mental status. Resident #44's heels were flat on the mattress without pressure relieving boots in place. Interview with the Resident #44's family, at the time of the observation, reported the resident had treatments ordered to heels and Resident #44's heels were usually propped up on pillows. Observation on 04/23/19 at 5:27 P.M., revealed Resident #44 was awake in bed visiting with family. The resident's heels were floated off the bed with use of a pillow. There were no pressure relieving boots in place and a bandage to the right heel was coming off, unattached on one side. No treatment was observed to be in place to the left heel. Interview with the resident's family at the time of the observation revealed Resident #44 had pressure relieving boots, and didn't mind wearing them. The family revealed the staff applied them at times. The family opened Resident #44's wardrobe which revealed pressure relieving boots. Observation on 04/23/19 at 5:44 P.M., of pressure ulcer treatment to Resident #44 by Registered Nurse (RN) #637 and Registered Nurse Wound Care Certified (RNWCC) #200 revealed both feet were off the bed with the use of a pillow, a bandage to the right heel dated 04/23/19 was noted, no bandage was in place to the left heel, and no pressure relieving boots were in place which was all verified by RNWCC #200. RN #637 removed the bandage to the right heel which revealed no skin abnormalities. Observation of the left heel revealed a quarter size, four centimeters (cm) by two cm by unable to determine, unstageable pressure ulcer, 100 percent black eschar (dead tissue) to the left outer heel. A dime size amount of yellowish red drainage was observed on the bed sheet. No active drainage was observed. The wound was measured and staged by RNWCC #200. Interview on 04/23/19 at 7:35 P.M. with Licensed Practical Nurse (LPN) #684 reported Resident #44 had a history of [REDACTED]. Early on 04/22/19, the STNA reported observation of a little bit of blood. LPN #684 assessed the left heel and observed a quarter size, black eschar area to the outer left heel but did not observe any drainage. The physician was notified and treatment was obtained for a foam bandage. RNWCC #200 reported Resident #44 had chronic wounds which would heal and reopen. Preventative treatments were in place. The unstageable pressure ulcer to the left heel most likely started as a deep tissue injury, progressed, and opened quickly.

Based on medical record review, observation, staff interview and resident interview, the facility failed to administer oxygen therapy appropriately for one resident (#31) of one reviewed for respiratory services. The facility census was 76. Findings include: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's physician orders [REDACTED]. Review of most recent annual 04/05/19 comprehensive assessment revealed the resident was cognitively intact. The resident was noted to be receiving oxygen therapy at the facility. Observation of Resident #31 on 04/22/19 at 4:02 P.M., revealed the resident was receiving oxygen via nasal cannula at a rate of 4.5 liters per minute via nasal cannula. Observation of Resident #31 on 04/24/19 at 10:18 A.M., revealed the resident's oxygen was noted to be set on 4.5 liters per minute, via nasal cannula. Observation of Resident #31 on 04/24/19 2:30 P.M., revealed the resident's oxygen was set at 4.5 liters per minute, via nasal cannula. Interview and observation with Licensed Practical Nurse (LPN) #633 on 04/24/19 at 2:45 P.M., revealed the LPN said Resident 31's oxygen should be at a flow rate of 2 liters per minute, via nasal cannula. However the resident's oxygen was set at 4.5 liters per minute, via nasal cannula. LPN #633 verified the oxygen therapy was not being administered at the correct level. Interview with the Director of Nursing (DON) on 04/25/19 at 9:40 A.M., confirmed Resident #31 was to have oxygen delivered at 3 liters per minute, via nasal cannula. She verified the physician had been notified the resident had been receiving the wrong flow rate of oxygen.

Based on observation, record review, and staff interview, the facility failed to provide an ongoing program of activities to support the mental and psychosocial well-being of each resident. This involved four residents (#14, #36, #76, #63) of five reviewed for activities, and had the potential to affect all 28 residents on the third floor which was a secured unit for residents with cognitive impairment. The facility census was 82. Findings include: Resident #14 was admitted to the facility in (MONTH) of 2014 with [DIAGNOSES REDACTED]. The facility completed a significant change comprehensive assessment (MDS 3.0) of the residents cognitive and physical functional status dated 04/18/18. The 04/18/18 assessment identified Resident #14 as having short and long term memory problems, moderated cognitive impairment for daily decision making, and requiring one staff person for the completion of all activities of daily living (ADLs), with the exception of eating for which she required only set-up help. Resident #14's activity assessment dated [DATE], completed by Activity Director (AD) #16, was reviewed. AD #16 identified the resident preferred independent and/or group activities of her choice daily. Enjoys playing rummy, bingo, watching movies/news on television, listening to big/band oldies music. AD #16 noted the resident liked to do small crafts with assistance, word search puzzles, attending church related activities, going on outings, as well as attending parties and food socials. Resident #14 had a comprehensive plan of care for activities due to the resident's potential for alteration in activities related to cognitive impairment, impaired mobility, needing assistance to activities, and mood/behavior problems, vision impairment, and other factors. The goal was for the resident to attend one to two group activities of choice per week from the calendar, and daily in/out of room self motivated activities of choice. Resident #76 was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. The facility completed a quarterly comprehensive assessment of the resident cognitive and physical functional status dated 03/31/18. The 03/31/18 assessment identified the resident as being rarely/never understood, having short and long term memory problems, severely impaired cognitive skills for daily decision making, depressed mood, wandering daily, and requiting limited to extensive assist of one staff to complete all activities of daily living. The resident was ambulatory per herself. Resident #76 had a comprehensive plan of care developed for activities per AD #16, with the problem/need identified as having the potential for alteration in activities related to cognitive impairment, impaired communication, impaired decision making, need for supervision, mood/behavior problems, and need for physical assistance. AD #16 noted the resident's interests included church, pet visits, socializing, trips, music, and television/movies. She documented the resident needed assistance and encouragement to attend group activities. The goal was for the resident to do daily in/out of room self-motivated activities of choice, ad attend one to two group activities per week, and to determine feasibility of offering activities of interest to resident that are not currently offered. Interventions included engaging resident in group activities, offering activity programs directed toward specific interests/needs of the residents, offer ongoing structured activity program for intellectual stimulation, and to supervise resident in all activity areas. Resident #63 was admitted to the facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. The facility completed a quarterly comprehensive assessment of the residents cognitive and physician functional ability on 03/21/18. The 03/21/18 assessment identified the resident as having moderate vision impairment, short and long term memory problems, severely impaired cognitive skills for daily decision making, and requiring the physical assistance of one to two staff persons to complete all activities of daily living. The resident was self-mobile on her living unit via a wheel chair. Resident #63 had a comprehensive plan of care developed for activities per AD #16, with the problem/need identified as having the potential for alteration in activities related to cognitive impairment, impaired decision making, impaired mobility, mood/behavior problems, need for assistance, and other factors. She documented her interests included(NAME)music, church, pet visits, being outside, television/movies, special Olympics, outings, interesting in volunteering. The goal was for the resident to do in/out of room self-motivated activities of choice, and attend one to two group activities per week of choice from the calendar. Interventions included offer activity program directed toward specific interest/needs of resident, place resident in appropriate psychosocial group, remove resident from activity if behavior is unacceptable to others, transport to activities, and supervise resident in all activity areas. Resident #36 was admitted to the facility in (MONTH) of 2013 with [DIAGNOSES REDACTED]. The facility completed a quarterly comprehensive assessment of the resident cognitive and physical functional status on 01/31/18. The 01/31/18 assessment identified the resident as having short and long term memory problems, severely impaired cognitive skills for daily decision making, inattention and disorganized thinking, and requiring the physical assistance of one to two staff person to completed all activities of daily living. The resident did not walk, and was mobile via a specialized recliner per staff. Resident #36's activity assessment date 01/25/18 was reviewed. AD #16 completing the assessment noted the resident prefers group and/or independent activities of her choice. She enjoys watching news, talk shows on television, listening to oldies music, attending church related activities, and family and pet visits. Resident #36 had a comprehensive plan of care developed for activities per AD #16, with the problem/need identified as having the potential for alteration in activities related to cognitive impairment, impaired mobility, mood/behavior problems, and other factors. The goal was for the resident to observed one to two group activities of choice per week from calendar. Interventions included offer activity programs directed toward specific interests/needs of the resident, and invite and encourage to attend daily activity groups of interest. Resident #14, #76, #63, and #36 all resided on the third floor of the facility which was a secured unit for residents with cognitive impairment and/or increased safety needs. On 05/01/18, at 9:55 A.M., there were 10 residents sitting in the third floor lounge, including Residents #14, #36, 63, and #76. The activity calendar on the third floor indicated that a sensory stimulation activity was scheduled for 9:30 A.M. The 10 residents were sitting randomly in the lounge while music disc was being played on a portable compact disc player. There was no activity staff or nursing staff present. On 05/01/18, at 10:23 A.M., there was a chair exercise activity being conducted on the second floor of the facility in the dining room. A couple of residents from the third floor were escorted to the second floor for the activity, but Residents #14, #36, #76, and #63 remained on the third floor along with two additional residents sitting in third floor lounge with no planned activities or socialization from activity or nursing staff. On 05/01/18, at 11:05 A.M., Resident #14 continued to sit in the 3rd floor television lounge along with seven other cognitively impaired residents with no activity staff or nursing staff present engaging residents in activities or socializing with residents. A couple residents were watching a talk show, and the remainder were just sitting looking off into space. Resident #14 stated to the surveyor who was sitting amongst the residents why is everyone off in left field, the resident seemed somewhat agitated at the time. On 05/02/18, at 10:08 A.M., there were 11 residents sitting in the lounge of the third floor secured unit in chairs or in their wheel chair, all with varying degrees of cognitive impairment and mobility impairment. There was no activity or nursing staff present engaging residents, there was no planned individual small or large group activity, or one on one activities with residents in progress, Review of the activity calendar posted in the third floor corridor revealed there would be a sensory stimulation activity held in the third floor lounge at 10:30 A.M. At 10:39 A.M. there were nine resident sitting in and around the 3rd floor lounge including Resident #76 and #36. Assistant Director of Nursing, Licensed Practical Nursing (LPN) #21 was asked to view the posted calendar to affirm a sensory stimulation activity was scheduled for 10:30 A.M. LPN #21 affirmed there was a sensory stimulation activity scheduled for the 3rd floor, but it was not being held at that time. On 05/02/18, at 2:04 P.M., an arts and crafts activity was in progress in the second floor dining room. There were five of 28 residents from the third floor present, with nothing scheduled or in progress for the other 23 residents on the third floor. Resident #14, #36, #76, and #63 had not been included in the arts and crafts activity, either to participate or observe. On 05/02/18 at 2:54 P.M., and interview was conducted with Activities Director (AD) #16 regarding how the activity department was meeting the activity needs of the cognitively impaired individuals on the third floor of the facility. The concern being that it was a secured unit and resident did not have the option of moving freely about the facility to attend activities being held on other floors, and/or may not be appropriate/ or desire to leave the 3rd floor for other activities. She stated that the activity department consisted of herself and an activity assistant (AA) #37, and they both worked 40 hours weekly. AD #16 reported that she and AA #37 alternated week ends, and every other Tuesday and Thursday, resulting in one activity staff person present in the facility on Saturdays, Sundays, Tuesday, and Thursdays , and two activity staff persons in the facility on Mondays, Wednesdays, and Fridays to cover all three floors of the facility. She stated that was was hard to get to all three floors on Tuesdays and Thursdays. AD #16 was queried about her duties and she communicated that she was responsible for providing activities for residents, but also responsible for activity progress notes, activity assessments, and care planning for the 82 residents of the facility. The past (MONTH) (YEAR) activity calendar and current (MONTH) (YEAR) activity calendars were reviewed with AD #16, and any routine small or large group activities planned and held for residents on the third floor of the facility. It was noted there was rarely anything planned for after 1:15 P.M. in the afternoon, weekdays or weekends. AD #16 affirmed there were no structured/planned small or large group activities planned to be held on the third floor after about 1:15 P.M. in the afternoon with he exception of Bingo which was held on the third floor at 2:00 P.M. every Thursday. She stated that AA #37 does make rounds in the facility on designated days to conduct one on ones with residents on all floors as scheduled. Residents' ##14, #76, #63, and #36's individual activity participation logs for (MONTH) of (YEAR) were reviewed with AD #16. Review of the activity logs showed documentation that all four residents participated in socialization, current events, television, and radio activities daily. The logs in these activity categories were marked with and X daily indicating the activity occurred. When queried regarding the notation of daily participation in these activities, AD #16 shared these were not necessarily planned activities but activity staff know the residents are involved in these activities daily so it is included as having occurred on their activity logs. It was communicated with AD #16 that on 05/01/18, at 9:55 A.M., in the third floor lounge there was music playing and no activity staff or nursing staff present with the 10 residents present. When queried about the sensory stimulation activity planned for 9:30 A.M. on 05/01/18 she shared that planned sensory stimulation activities should be facilitated by staff, and either activities staff or nursing staff should have been present. She shared the activity would be expected to last about an hour. On 05/02/18 at 3:15 P.M. there were eight residents in the third floor lounge with a talk show playing on the television. Four residents appear to be watching, and four sitting and staring including Resident #76. Resident #63 was sitting at the doorway of another residents room near the nursing station with nothing to do, while Resident #36 was positioned in her specialized chair next to the nursing station rubbing her head and chest. No activity staff, or nursing staff, were present interacting with residents. Resident #76 was not positioned when she could view the television talk show. On 05/02/18 at 3:22 P.M., Resident #76 continued to sit in the lounge staring off into space, and Resident #63 continued sitting in the door way of another resident's room by the nursing station. She would respond to any staff person that spoke to her as they passed by. An interview was conducted with AA #37 on 05/02/18, at 3:30 P.M., on the third floor regarding activities provided for residents on the third floor secured unit. She reported she was currently on the unit to provide small group activity and one on ones. When asked to see the schedule of who she was seeing for one on one activities, she reported that no one on the third floor was scheduled for one on one activities that day. AA #37 then proceeded to conduct a small group ball toss activity in the third floor lounge. When Resident #63 was included in the activity, she actively participated and was smiling. The activity concluded at 3:53 P.M. AA #37 was then interviewed at 3:53 P.M. on 05/02/18 regarding how much time was actually spent by activity staff on the secured third floor unit, providing activities to residents. She reviewed her activity calendars/schedule and reported that included the daily pre-meal activity in the dining room (trivia/puzzlers), sensory stimulation, and reading it was typically about and hour and a half, with the exception of Thursdays when Bingo was held on the third floor. AA #37 shared that there was a box of activity supplies at the nursing station that nursing staff could use with residents at any time. They were not observed in use during three days of survey 04/30/18 through 05/02/18. AA #37 was then asked about the 05/01/18 sensory stimulation activity conducted at 9:30 A.M. and what that included, and how long she was there. She stated that she did not stay long, that she turned the music on and documented who was present for the sensory stimulation/music activity, completed some other duties i.e. checking refrigerators then left the unit.

Based on observation, review of manufacturer drug storage information and staff interview, the facility failed to ensure insulin was properly labeled with an accurate opened date to ensure timely discard of expired medciations. This affected four (#62, #78, #179, #180) of nine residents prescribed insulin on the first floor. The faciltiy census was 81. Findings include: Observation on [DATE] at 3:07 P.M. of the first floor medication cart revealed Resident #62's insulin kwikpen had a date of [DATE] written on the opened sticker with instruction to discard after 28 days. Resident #78's insulin [MEDICATION NAME] prefilled pen for injection had a date of [DATE] written on the opened sticker with instructions to discard after 28 days. Resident #179's insulin kwikpen had a date of [DATE] written on the opened sticker with instructions to discard after 28 days. Resident #180's insulin kwikpen had a date of [DATE] written on the opened sticker with instructions to discard after 28 days. Interview with Registered Nurse (RN) #79 at the time of the observation verified the insulin's were dated as opened after the current date, reported the sticker indicated the date was to be the opened date, and as a result the insulin wouldn't be discarded until after the expiration date. Review of undated manufacturer storage information for Basaglar, [MEDICATION NAME], and Humalog kwikpen insulin's revealed an opened vial or pen (in-use) should be discarded after 28 days.

Based on medical record review, observation, resident and staff interviews, the facility failed to ensure residents were treated with respect and dignity. This affected one (#46 ) of three Residents reviewed for dignity. The facility census was 81. Findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with a re-entry date of 11/24/17 with [DIAGNOSES REDACTED]. Review of face sheet profile revealed Resident #46 was her own responsible party. Review of admission minimum data set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making, limited assistance was required with transfers, toileting, personal hygiene, and a walker and wheelchair were utilized for mobility. Review of smoking data assessment dated [DATE] revealed no assistance or devices were required, smoking per policy. Observation on 04/30/18 at 4:03 P.M. revealed Resident #46 was smoking on the first floor terrace with Resident #42 without staff supervision or smoking appliances. Review of social service progress note dated 04/30/18 at 5:12 P.M. revealed Resident #46 was observed with smoking materials in her possession and provided smoking materials to others which was a violation of the facility smoking policy. Resident #46 was verbally educated on the smoking policy and agreed to follow the policy. Resident #46's daughter was contacted, notified about the situation, and agreed to reinforce plan and notify family/friends of policy. Interview on 05/02/18 at 2:17 P.M. with Resident #46 revealed the resident was alert, oriented, and with intact cognition. Resident #46 reported residents were not permitted to keep smoking materials and supervision was required during smoking. Resident #46 reported she had forgot to turn in her cigarettes upon return to the facility and Resident #42 requested a cigarette so she provided one. Resident #46 reported she found out the facility had contacted and informed her daughter about the rule violation when her daughter called her on the phone. Resident #46 reported she was not asked, did not give permission, and was not happy the facility contacted her daughter about the rule violation. Interview on 05/03/18 at 2:08 P.M. with social service designee (SSD) #51 verified after Resident #46 violated the facility smoking policy, Resident #46's daughter was notified and informed about the incident, smoking policy, and interventions. SSD #51 reported she had informed Resident #46 that she was going to call and inform her daughter about the rule violation and Resident #46 replied oh no. SSD #51 confirmed Resident #46 was cognitively intact, her own responsible party, and did not give permission for the facility to contact her daughter about the rule violation. She reported the daughter was contacted upon direction from management.

Based on medical record review and staff interview, the facility failed to provide written bed hold information to residents when hospitalized . This affected one resident (Resident #54) of two residents reviewed for hospitalization . The facility census was 81. Findings include: Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing, severely impaired vision, clear speech, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and required extensive assistance with activities of daily living (ADLs). A review of Resident #54's medical record on 05/02/18 revealed the resident was hosptalized on [DATE] and returned to the facility on [DATE]. A Bed Hold policy notice provided by the facility contained a hand written note by the facility's Business Office Manager (BOM) that documented notification of the facility's bed hold information was provided to the resident's representative on 03/26/18, three days after the resident was hospitalized . Interview on 05/02/18 at 09:20 A.M. with BOM #18 verified bed hold information was not provided to the resident or representative at the time of the hospitalization , and stated because the resident was hospitalized on a weekend, bed hold information was provided the following Monday. BOM #18 verified the date on the second page of the notice dated 03/24/18 was not the date the information was provided to the resident's representative, but rather the date of hospitalization . BOM #18 verified bed hold information was mailed to the resident's representative on Monday, 03/26/18 by regular mail after the resident was readmitted to the facility.

Based on observation, medical record review, and staff interview, the facility failed to ensure resident assessments were completed accurately. This affected three residents (#31, #45, and #46) of 21 residents reviewed during the survey. The facility census was 81. Findings include: 1. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had minimal difficulty hearing, clear speech, made self understood, usually understood others, had adequate vision with corrective lenses, and had fluctuating periods and severity of inattention and disorganized thinking during the seven day assessment period. Further review of the MDS assessment dated [DATE] revealed question C0100 (section C specific to cognitive patterns) was coded as 1 to indicate the Brief Interview for Mental Status (BIMS)assessment should be conducted. The document revealed all questions of the BIMS assessment were coded with a dash value, indicating the areas were not assessed, despite the MDS indicating the resident had only minimal difficulty hearing, clear speech, made self understood, and usually understood others during the seven days of the assessment. In addition, question D0100 (section D specific to mood) was coded with a dash value to indicate the question was not answered with a yes or no response. The document revealed all questions in the Resident Mood Interview in section D were coded with a dash value indicating the areas were not assessed, despite the MDS indicating the resident had only minimal difficulty hearing, clear speech, made self understood, and usually understood others during the seven days of the assessment period. Observation on 04/30/18 at 10:40 A.M., 05/01/18 at 11:37 A.M., 05/02/18 at 10:39 A.M. and at 3:37 P.M. and on 05/03/18 at 10:14 A.M. revealed Resident #31 was alert, had clear speech, understood conversation, was able to verbally make self understood, and engaged in coherent conversation. Interview on 05/02/18 at 4:31 P.M. with Licensed Practical Nurse (LPN) #12 and Registered Nurse (RN) #92 revealed Resident #31's cognition was intact enough to verbally make needs known and to carry on a conversation. LPN #12 further reported that Resident #31 was confused at times but can carry on an appropriate conversation. Interview on 05/02/18 at 5:30 P.M. with Social Service Designee (SSD) #51 revealed the SSD was responsible for completing sections C and D of the MDS. SSD #51 verified that the BIMS assessment in section C and Resident Mood Interview in section D of the quarterly MDS dated [DATE] were not completed. SSD #51 reported the interviews were not conducted because the resident had fluctuations in attention and thought. 2. Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] documented the resident had adequate hearing and vision, clear speech, made self understood, and understood others. Further review of the MDS assessment dated [DATE] revealed questions C0100 (section C specific to cognitive patterns) and question D0100 (section D specific to mood) were coded as 1 to indicate the Brief Interview for Mental Status and the Resident Mood Interview should be conducted. The document revealed both the BIMS assessment and the Resident Mood Interview were coded with dash values to indicate the areas were not assessed, despite the MDS indicating the resident had adequate hearing and vision, clear speech, made self understood, and understood others during the seven days of the assessment. Observations on 05/02/18 at 9:17 A.M. and on 05/03/18 at 9:42 A.M. revealed Resident #45 with calm, appropriate behavior and verbally conversed with staff and residents. Interview on 05/02/18 at 4:31 P.M. with LPN #12 and RN #92 revealed the resident was cognitively intact to verbally make needs known and to carry on a conversation. Interview on 05/02/18 at 5:30 P.M. with Social Service Designee (SSD) #51 revealed the SSD was responsible for completing sections C and D of the MDS. SSD #51 verified that the BIMS assessment in section C and Resident Mood Interview in section D of the quarterly MDS dated [DATE] were not completed and were coded as not assessed. SSD #51 reported the assessment were not completed because the resident smokes every two hours, was at therapy, took a shower every day, went out with a family member, or had doctor's appointments during the seven days of the assessment period. SSD 51 reported the resident was interviewable, but you have to catch him. SSD #51 verified that the resident was not hospitalized during the assessment period. A review of the MDS 3.0 User's Manual Version 1.15 indicated the BIMS assessment in section C should be attempted when the resident is at least sometimes understood verbally or in writing. The Manual further indicated the Resident Mood Interview should be conducted for residents who are able to be understood. 3. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission minimum data set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making. Review of quarterly MDS dated [DATE] revealed a brief interview for mental status (BIMS) was not assessed. Section B of the MDS revealed Resident #46 had adequate hearing, made self understood, understood others, and had adequate vision. Interview with Resident #46 on 05/01/18 at 11:23 A.M. revealed intact cognitive skills with clear speech, adequate hearing and behavior was calm and appropriate. Interview on 05/03/18 at 2:08 P.M. with social service designee (SSD) #51 and MDS licensed practical nurse (LPN) #19 confirmed the BIMS was not assessed on the quarterly MDS for unknown reasons.

Based on observation, record review, review of facility policy, and interview, the facility failed to ensure physician ordered wound treatments were completed for two (Resident #5 and Resident #51) residents, which delayed wound healing, and failed to ensure positioning devices to relieve pressure were in place as ordered. This resulted in actual harm to Resident #5, as the unavoidable in-house acquired pressure ulcer worsened due to the ordered wound treatments not being completed. The facility identified six residents with pressure ulcers. Findings include: 1. Resident #5 had [DIAGNOSES REDACTED]., [MEDICAL CONDITION], pneumonia, [MEDICAL CONDITION], and a history of a pressure ulcer to the thigh region. Resident #5's Pressure Ulcer Risk Assessment identified the resident as high risk for pressure ulcers. Her plan of care for skin initiated on 03/19/12, identified the resident at risk for impaired skin integrity related to fragile skin, impaired mobility and incontinence. Interventions included to turn and reposition as needed, skin assessment as ordered, pressure reduction devices as ordered, lift sheet on bed/chair for positioning, and incontinence care after each incontinence episode. Her most recent comprehensive assessment dated [DATE] identified Resident #5 as totally dependent on two staff for bed mobility, transfer, and toileting. She needed extensive assist of one for eating, and was incontinent of both bowel and bladder. On 03/09/13, a physician's orders [REDACTED]. There was no documented description of the area in the nursing notes or in the resident's medical record. The Treatment Administration Record (TAR) for March 2013, revealed no documentation the treatment of [REDACTED]. On 03/12/13, the document titled "skin grid non-pressure" identified the resident with a 4 centimeter (cm) in length by 3.5 cm in width by less than 0.1 cm in depth red ruptured blister area on the mid/inner right buttock. The area was documented on the grid by Wound Nurse #10 as perineal [MEDICAL CONDITION] (moisture associated skin damage). The TAR for March 2013, identified a physician's orders [REDACTED]. The progress notation dated 03/12/13, by Wound Nurse #10, documented the resident had an area of perineal [MEDICAL CONDITION] with a ruptured blister on the right mid/inner buttock. The note stated the physician was notified and a new order was obtained for [MEDICATION NAME] dressing. The TAR for March 2013, did not contain documentation the dressing was applied as ordered until Friday 03/15/13, three days later. The Certified Nurse Practitioner (CNP) monthly progress note dated 03/17/13, did not contain any documentation of Resident #5's new open area identified on 03/12/13. On 03/19/13, the "non-pressure skin grid" documented the area to the right buttocks as 4 cm in length by 3.2 cm in width by less than 0.1 cm deep. It identified the wound as an open area with a small amount of slough in the center and the rest of the open area as dark pink. On 03/26/13, the area measured 4 cm in length by 3 cm in width and less than 0.1 cm in depth. It was described as "continues with small amount of slough tissue in wound center". Although the wound had progressed from a blister to an open area with slough, the physician was not notified and no new treatment order was obtained until 03/29/13. The 03/29/13 physician's orders [REDACTED]. May "window pane" (tape around the edges) dressing with Medfix tape to keep intact for three weeks. Review of the skin grids from 03/26/13 though 04/10/13, revealed the pressure sore had increased in size to 5 cm in length by 4 cm in width by less than 0.1 cm in depth. The tissue in the wound was identified as dark gray, slough with no drainage. Review of the April 2013, treatment records revealed the new order from 03/29/13, was not transcribed to the April 2013 TAR. The TAR did not document the dressing changes were being completed and there were no nursing notes of dressing changes, or documentation the dressing changes were being done in accordance with the new physician's orders [REDACTED]. On 04/08/13, a new physician's orders [REDACTED]. On 04/10/13, the skin grid documented the measurements of the wound unchanged. On 04/13/13, the facility put the resident on a low air loss mattress appropriate for a Stage III or Stage IV pressure ulcer. On the 04/17/13 skin grid, Wound Nurse #10 changed the [DIAGNOSES REDACTED]. Wound Nurse #10 documented the pressure ulcer measured 4.5 cm in length by 5 cm in width by 0.5 cm in depth, and documented the area as declining. The resident's CNP was notified and orders were obtained for vitamins, Stress Tabs with Zinc and Vitamin C. The 04/22/13 skin grid documented the pressure ulcer measured 4.5 cm in length, by 5.5 cm in width by 1 cm in depth with a moderate amount of drainage, gray in color and foul smelling. There was no change in treatment documented at this time, although the pressure ulcer had increased in size and color, had drainage and was foul smelling. On 04/25/13, the physician ordered a urine culture and sensitivity due to foul smelling discolored urine. Resident #5 was identified with a positive urine culture for E-Coli and on 04/28/13, was started on antibiotics. On 04/30/13, the skin grid identified the pressure ulcer as a Stage IV measuring 5 cm in length by 4.8 cm in width by 2 cm in depth with moderate gray foul drainage with tunneling and undermining at 3 o'clock and 6 o'clock from the center of the wound. The narrative stated the pressure ulcer had undermining at 3 o'clock, 6 o'clock and 10 o'clock and the depth was 3 cm. Calcium Alginate was added to dressing for drainage and the CNP was notified of progress. The note stated the "open area is [MEDICATION NAME], eschar does remain in upper right quadrant of wound at approximately 1 o'clock. Remainder of wound bed is now pink and exposed enough for staging of wound." The treatment was changed to apply a nickel size amount of Santyl ointment (a [MEDICATION NAME] agent) and lightly pack the wound with calcium alginate and cover with a dry dressing; change daily and as needed. During an interview with Wound Nurse #10 on 05/02/13 at 9:10 A.M., she stated she documented the area originally as an open blister. She said she was referencing a picture in a book that showed an unopened whitish area surrounded by small red areas. She said Resident #5's area appeared to her as perineal [MEDICAL CONDITION] caused by incontinence. The Director of Nursing (DON) present during the interview revealed the facility used the National Pressure Ulcer Advisory Panel (NPUAP) for their reference and documentation from them included the same identifying features of a Stage II pressure ulcer as the facility policy. Interview with State tested Nursing Assistant #23 on 05/02/13, revealed the resident required turning, repositioning, and incontinence checks every two hours. On 05/02/13 at 11:00 A.M., the contracted Wound Nurse #11 was in the facility to evaluate the resident. She said she is contracted to come in and assess pressure sores, review the medical record, and advise treatment. She does not apply the treatment or come on a weekly basis. At this time, Resident #5 was observed with the facility Wound Nurse #10, the CNP, and a family member present. She was repositioned onto her side and the area was examined. The resident's dressing was heavily saturated and had a pungent odor. According to the Wound Nurse #11, the heavy discharge and odor were a result of the calcium alginate. She identified the pressure ulcer as a Stage III, with a red/pink wound bed and an area of 20% slough (dead tissue) at the top. The wound had irregular edges, measuring 3.2 cm in lengthy by 5 cm in width by 0.5 cm in depth. Undermining measuring 5 cm was present at 3 o'clock to 9 o'clock . She stated she did not see any signs or symptoms of infection. Her assessment showed an increase in the depth to the pressure sore, an additional area of undermining and an increase in the undermining of the area already identified. On 05/02/13 at 11:40 A.M., the Power of Attorney (POA) was present and interviewed. He stated that on 04/23/13, he observed Resident #5 soiled in urine with no incontinence brief on. He said the bed sheet was wet with urine, and there was no protection in place to absorb urine resulting in the resident lying in urine and possibly contaminating her dressing and pressure sore. He said the dressing was on the area, but soiled and saturated. Interview with the Director of Nursing (DON) on 05/06/13 at 1:30 P.M., verified the physician's orders [REDACTED]. The facility nursing policy/Procedure Manual for staging of skin for pressure ulcers identifies a Stage II as a "partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, perineal [MEDICAL CONDITION], or excoriation". The facility policy for staging of pressure sores included a Stage III as "full thickness tissue loss. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The document said if eschar or slough are covering the ulcer and preventing adequate staging, it assessed as unstageable. The NPUAP system for staging pressure ulcers indicates that the presence of eschar prevents the accurate staging of the ulcer. These ulcers will be documented as unstageable on the skin grid". 2. Resident #51 had [DIAGNOSES REDACTED]. He required extensive assist of two for bed mobility and transfer, toileting, and was incontinent of both bowel and bladder. The resident required a mechanical lift for transfers and was assessed as high risk for pressure sores. The quarterly comprehensive assessment documented the resident had two unhealed Stage II pressure ulcers. Resident #51's treatment order written on 04/09/13 was to cleanse the open area on the coccyx with Peleverus spray and pat dry; apply Silversorb gel and a dry dressing daily and as needed. On 05/02/13 at 9:25 A.M., Resident #51 was observed in bed. The resident was clean and dry. Wound Nurse #10 was present along with STNA #25 who assisted in rolling the resident onto his side to observe his dressing. The wound to his coccyx was partially covered with a small piece of white material, the wound nurse said looked like [MEDICATION NAME]. There was no dressing on the wound. Wound Nurse #10 verified the resident did not have the dressing on the wound as ordered. During interview STNA #25 said when incontinence care was provided earlier at about 8:55 A.M., the area did not have a dressing on it. The wound nurse cleansed the area and measured it as 1 cm in length by 0.5 cm in width by 0.6 cm in depth. The edges were irregular with white edges and the wound bed was red. The TAR for May 2013, documented the dressing change for 05/01/13 was not signed off as being completed. Wound nurse #10 stated during interview at the time of the observation the dressing change was not signed as completed. A skin sheet dated 05/01/13, and signed by Wound Nurse #10, documented the coccyx wound measured 1 cm in length by 0.8 cm in width, by 0.3 cm in depth. The wound was described as slow healing with no signs or symptoms of infection and was dark pink in color,with the edges of wound pale. On 05/03/13 at 8:30 A.M., Resident #51 was observed in the dining room eating breakfast. He was positioned in his wheelchair, with the mechanical lift pad directly under him. He was slumped back into the chair, with his legs bent and at times placed on the metal foot rest, or off to the side. STNA #27 said they had repositioned him once because he slid down, and verified he looked like he had slid down again. Wound Nurse #10 stated at the time of the observation the resident had a new wedge cushion on order. She said the resident should have Dycem (a non-skid material) underneath him in three layers to keep him from sliding. She stated there was no Dycem between the resident and the mechanical lift pad he was sitting on. Physical Therapist #30 observed the resident at that time. She said his position was "sacral sitting" in which the resident was sitting on the sacrum and not positioned in an upright position. She stated he was not positioned correctly and that he had been assessed for a new wedge cushion. Interview with STNA #27 on 05/03/13 at 9:45 A.M., revealed she had checked the resident about 7:30 A.M. for incontinence. She said she checked him while in the wheelchair by viewing the front of his incontinence product, and the yellow line which changes color when wet. She said the line indicated he was dry. She said the resident was gotten out of bed by the third shift staff and she did not know how long he had been up and in the wheelchair. At 10:15 A.M. Resident #51 was returned to his room and put back in bed. He was incontinent of a small amount of stool. STNA #24 stated the resident was not able to turn and reposition himself in the bed and should be up for meals only, and laid down after he has eaten. Interview with the Director of Nursing (DON) on 05/03/13 at 10:30 A.M., stated the third shift staff get the resident out of bed. She said staff know the residents and they get them up on an individual basis. She said there are no parameters or specific times to get residents out of bed. There is no set time to get someone up when they are to be out of bed for meals only. She said she is at the facility early and the third shift staff start getting residents up at 6:00 A.M. She said the resident has always been gotten out of bed on third shift. Interview with Licensed Practical Nurse (LPN) #31 on 05/03/13, who worked the third shift, said the staff starts between 5:00 and 5:30 A.M. getting residents up for various reasons. She said sometimes Resident # 51 is up at 6:00 A.M. to have his wound treatment completed. STNA #28 stated during interview on 05/03/13 at 10:40 A.M., if she had a resident who was to be out of bed for meals only, she would probably get them up about a half hour early to get them positioned and ready to eat. This deficiency substantiates Complaint Number OH 037.