Every finding on record at The Laurels of Gahanna

Based on medical record review, review of the facility's Self-Reported Incidents (SRIs), policy review, and staff interviews, the facility failed to timely report an injury of unknown source to the State Survey Agency, Ohio Department of Health (ODH). This affected one (#55) of three residents reviewed for abuse. The facility census was 81.Findings include:Medical record review revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis and convulsions.The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was severely cognitively impaired and was dependent upon staff for bed to chair transfer.Review of the Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 07/08/26 at 6:50 A.M. revealed Registered Nurse (RN) #85 reported Resident #55 sustained a bump on the right side of the forehead. The injury was discovered during repositioning in bed. The form did not state how the injury occurred.Review of the nursing note dated 07/08/26 by RN #315 revealed Resident #55 was seen for a bump on the head. The bump measured four centimeters (cm) in length by four cm in width and it was raised with a red abrasion of approximately two cm. in length above the resident's right eyebrow. Neurological checks were in place and ice was in place for swelling as needed. The note did not state how the injury occurred.The nursing note dated 07/11/26 by Licensed Practical Nurse (LPN) #75 revealed the interdisciplinary team (IDT) discussed the incident (Resident #55's bump on the head). Physician orders were given by the Nurse Practitioner for neurological checks and to monitor for signs and symptoms of seizure. The note did not state how the injury occurred.Review of the facility's SRIs from 07/08/26 to 07/31/26 revealed the facility did not report the injury of unknown origin to Resident #55's head to ODH.Interview on 08/03/26 at 6:10 P.M. with Certified Nurse Assistant (CNA) #67 confirmed it was unknown how the injury occurred to Resident #55's head and stated it did not happen during repositioning in bed.Interview on 08/04/26 at 7:47 A.M. with RN #85 confirmed it was unknown how the injury happened to Resident #55's head and stated it was discovered during a repositioning in bed.Interview on 08/04/26 at 12:34 P.M. with the Administrator confirmed the facility did not report the injury of unknown origin to Resident #55's head in July 2026. Review of the facility policy titled Ohio Resident Abuse Policy (revised 07/22/26) revealed Injuries of Unknown Source must be reported immediately to the Administrator, Director of Nursing (DON) and the applicable State Agency.This deficiency represents non-compliance investigated under Master Complaint Number 3097723 and Complaint Number 3095397.

Based on medical record review, staff interview, and policy review, the facility failed to complete neurological checks as recommended by the primary clinician related to a resident's head injury. This affected one (#55) of three residents reviewed for abuse. The facility census was 81.Findings include:Medical record review revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis and convulsions. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was severely cognitively impaired.Review of the Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 07/08/26 at 6:50 A.M. revealed Registered Nurse (RN) #85 reported Resident #55 sustained a bump on the right side of the forehead. The recommendations listed from Primary Clinician were to apply ice pack every 15 minutes for 24 hours (as tolerated), neurological checks every hour, and monitor for seizures.Review of the nursing note dated 07/08/26 by RN #315 revealed Resident #55 was seen for a bump on the head. The bump measured four centimeters (cm) in length by four cm in width and it was raised with a red abrasion of approximately two cm. in length above the resident's right eyebrow. Neurological checks were in place and ice was in place for swelling as needed. The nursing note dated 07/11/26 by Licensed Practical Nurse (LPN) #75 revealed the interdisciplinary team (IDT) discussed the incident (Resident #55's bump on the head). Physician orders were given by the Nurse Practitioner (NP) for neurological checks and to monitor for signs and symptoms of seizure. There were no physician orders for neurological checks for Resident #55 from 07/08/26 to 07/11/26.Review of Resident #55's neurological assessments with the first entry beginning on 07/08/26 at 5:30 A.M The sheet documented neurological data following facility protocol until 4:30 A.M. on 07/10/26. The protocol on the sheet instructed the user to complete neurological observations every 15 minutes for four trials, every 30 minutes for trials, every hour for four trials, every four hours for four trials, and every eight hours for two days. The form did not have the last three required neurological checks - on 07/10/26 for two shifts and on 07/11/26 for one shift were missing.Interview on 08/03/26 at 2:52 P.M. with the Director of Nursing (DON) confirmed that the Neurological Assessment Sheet for Resident #55 was incomplete and there were no neurological assessments completed twice on 07/10/26 and one for 07/11/26. The DON confirmed there was no physician orders for neurological checks written as directed by the NP.Review of the facility policy titled Neurological Checks Policy (revised 03/31/26) revealed neurological checks are indicated to monitor for potential irregularities in neurological status in the event of unknown head trauma. The policy further stated, unless otherwise ordered by the physician, the frequency of neurological assessments will be once every shift for 72 hours post occurrence.This deficiency represents non-compliance investigated under Complaint Number 3095397.

Based on medical record review, staff interview, facility policy review, and Elder Abuse Act regulation review, the facility failed to report allegations of misappropriation to law enforcement in a timely manner. This affected two (Residents #85 and #101) of three resident investigations reviewed. The census was 98. Findings Include:1.Resident #85 was admitted to the facility on [DATE]. Her diagnoses were urinary tract infection, klebsiella pneumoniae, bacteremia, muscle wasting, muscle weakness, hypertensive heart and chronic kidney disease, congestive heart failure, sciatica, atherosclerotic heart disease, chronic kidney disease, polyneuropathy, hyperlipidemia, vitamin D deficiency, major depressive disorder, insomnia, arthritis, anemia, polyarthritis, and retention of urine. Review of her minimum data set (MDS) assessment, dated 05/20/26, revealed she was cognitively intact. Review of Resident #85's self reported incident (SRI) investigation documentation found that she made an allegation of misappropriation to the facility on [DATE]. She initially reported that she was missing between $30 and $40 from her personal items while she was in the hospital. The facility completed the SRI to the state agency on 05/15/26, but law enforcement was not notified until 05/22/26 when an online theft report was made. 2. Resident #101 was admitted to the facility on [DATE]. His diagnoses were pleural effusion, congestive heart failure, acute and chronic respiratory failure, muscle weakness, lack of coordination, cognitive communication deficit, atherosclerotic heart disease, atrioventricular block, chronic kidney disease, atrial fibrillation, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease, Type II Diabetes, major depressive disorder, hyperlipidemia, ischemic cardiomyopathy, and dependence on supplemental oxygen. Review of his minimum data set (MDS) assessment, dated 04/20/26, revealed he was cognitively intact. Review of Resident #101's SRI investigation documentation found that his family made an allegation of misappropriation to the facility on [DATE]. They reported that he had his wallet with two credit cards, two blank checks, two quarters, cell phone, watch, jewelry and all his clothing that he had prior to his hospital admission/discharge from the facility. The facility completed the SRI to the state agency on 06/05/26, but law enforcement was not notified until 06/08/26 when an online theft report was made. On 06/09/26, the facility received notification that their online submission was rejected and had to contact local law enforcement via telephone to make the report, which they did. Interview with Administrator on 06/22/26 at 2:30 P.M. stated their abuse policy does not have anything specific regarding a timeframe to report allegation to law enforcement. He confirmed that Resident #85's misappropriation allegation was reported eight days after the initial report to them was made. Also, he confirmed Resident #101's allegation was reported five days after the initial report to them was made. He confirmed the elder abuse act was not specified in their abuse policy regarding reporting timelines to law enforcement. Review of facility Abuse Prohibition Policy, dated 10/14/22, revealed each residents shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the administrator and reported to the appropriate state agencies, physician, families, and/or representative. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. Review of Elder Abuse Act regulation review revealed each covered individual shall report to the Secretary and 1 or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime (as defined by the law of the applicable political subdivision) against any individual who is a resident of, or is receiving care from, the facility. If the events that cause the suspicion: (A) result in serious bodily injury, the individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; and (B) do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion. This deficiency represents non-compliance investigated regarding complaint number 3040495.

Based on medical record review, facility investigative document review, staff interview and facility policy review, the facility failed to complete a thorough investigation regarding an allegation of misappropriation. This affected one (Resident #101) of three residents reviewed for misappropriation allegations. The census was 98. Findings Include:Resident #101 was admitted to the facility on [DATE]. His diagnoses were pleural effusion, congestive heart failure, acute and chronic respiratory failure, muscle weakness, lack of coordination, cognitive communication deficit, atherosclerotic heart disease, atrioventricular block, chronic kidney disease, atrial fibrillation, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease, Type II Diabetes, major depressive disorder, hyperlipidemia, ischemic cardiomyopathy, and dependence on supplemental oxygen. Review of his minimum data set (MDS) assessment, dated 04/20/26, revealed he was cognitively intact. Review of Resident #101's SRI investigation documentation found that his family made an allegation of misappropriation to the facility on [DATE]. They reported all of the resident's personal belongings were missing. This included Resident #101's wallet with two credit cards, two blank checks, two quarters, cell phone, watch, jewelry and all his clothing. The investigation reveaeld Resident #101 was sent to the hospital via Emergency Medical Services (EMS) on 05/07/26 and his belongings were in the room at the facility then. The findings from the investigation determined the facility concluded the report to be unsubstantiated since none of the items have been located, the credit cards/checks have not been used, and all items appear to have been together and the box is either missing or was accidentally disposed. Facility staff continue to search for his belongings. Interview with Administrator on 06/22/26 at 2:30 P.M. and 2:50 P.M. confirmed they completed the investigation, but he was not certain how they came to the conclusion that the housekeeping staff put Resident #101's personal belongings in a box and removed them from his room. He confirmed their typical policy was for housekeeping staff to put all resident personal items in a box, and place it in a secure location until the resident came back to the facility or the resident/representatives came to pick them up. He confirmed at the time the investigation was completed, he could not confirm that the personal items were actually placed in a box and secured for Resident #101's family. He confirmed the facility did an investigation and determined the misappropriation allegation was unsubstantiated due to the facility's inability to find the personal items and there was no evidence that the bank accounts associated with the credit cards and blank checks had been used. He confirmed after the surveyor requested to speak with the housekeeping supervisor about the room cleaning and removal of resident personal items process, that on this day Resident #101's items had been located as staff looked in a location they had not looked in prior. He also confirmed as part of the investigation, he could not find Resident #101 personal inventory log to identify what personal items he had in the facility. Interview with Housekeeping Supervisor #105 on 06/22/26 at 3:10 P.M. revealed his staff had cleaned out Resident #101's room and placed his personal items in a box for safe keeping. He confirmed when Resident #101's family came to the facility to collect the items, they could not find them. He confirmed his staff took possession of them for safekeeping. He confirmed he looked in one of the locked closets that they place resident personal items in when ta resident is discharged , and he either overlooked it or it had been covered by other items in that closet, but he found them this day. Review of facility Abuse Prohibition Policy, dated 10/14/22, revealed each residents shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the administrator and reported to the appropriate state agencies, physician, families, and/or representative. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. All new employees will have criminal background and reference checks completed prior to starting employment. All employees will receive resident rights and abuse training at the time of hire and at least annually thereafter. Allegations by anyone who becomes aware of misappropriation of resident property must immediately report it to his/her administrator. An incident report will be completed. A preliminary, on-site investigation will be initiated within 24 hours of any report. The administrator or director of nursing/designee shall initiate the Incident and Accident Investigation form and take the following actions to ensure that the investigation is conducted effectively. The investigation may consist of a review of the completed incident report, an interview with the person reporting the incident, interviews with any witnesses to the incident, an interview with the resident (if possible), a review of the resident's medical record, an interview with staff members having contact with the resident during the period/shift of the alleged incident, interviews with the resident's roommate, family members, and visitors, and a review of all circumstances surrounding the incident. The administrator or the director of nursing/designee will keep the resident or his/her representative informed of the progress of the investigation. The Administrator, Director of Nursing/designee will compile a final summary of all investigations and report the finding at the quality assurance performance improvement committee meeting. This deficiency represents non-compliance investigated regarding complaint number 3040495.

Based on record review, resident and Power of Attorney (POA) interview, staff interview, contractor interview, admission documentation review, contractor documents, and facility policy review, the facility failed to ensure a resident had the right to personal privacy and confidentiality of his or her personal and medical records. This affected one (Resident #95) of three residents reviewed for HIPAA. The facility census was 95.Findings include:Review of the medical record for Resident #95 revealed an admission date of 09/09/25. Diagnoses included cognitive communication deficit, history of transient ischemic attack and cerebral infarction, and end stage renal disease.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] Resident #95 had a Brief Interview for Mental Status (BIMS) score of 11, indicating she had moderate cognitive impairment.Review of Resident #95's record revealed the resident was appointed a healthcare POA on 08/19/25 and financial POA on 09/21/25. Both documents appointed the same individual as POA. The Financial POA document revealed the POA was effective immediately.The facility was unable to provide documentation of consent by the POA for Resident #95's information to be shared with Contract Company #500. Interview on 04/15/26 at 3:20 P.M., Resident #95's POA confirmed she did not provide consent for Resident #95's face sheet to be shared with Contract Company #500. The POA stated Contract Company reached out to the resident's bank and insurance company without her consent.Interview on 04/15/26 at 1:06 P.M. with Float Business Office Manager (BOM) #315 confirmed Resident #95 had a POA. BOM #315 confirmed a face sheet was provided to Contract Company #500 on 03/12/26 without the consent of the POA to provide HIPPA related information to outside provider.Interview on 4/15/26 at 4:00 P.M. with Resident #95 revealed she has significant memory issues, inconsistent recall, and missing details, and reported she communicated these limitations to the contractor (CR #312) multiple times. Resident #95 was unaware that the contractor (CR #312) had her face sheet prior to the meeting (03/19/26) and stated she felt unhappy and uneasy knowing they had her personal information without her knowledge.Interview on 04/15/26 at 4:04 P.M. with CR #312 confirmed his company received Resident #95's face sheet from the facility. Review of the facility policy titled HIPAA (Health Insurance Portability and Accountability Act) Policy Regarding Use and Disclosure of PHI for Treatment, effective 10/11/2021, revealed the facility may not disclose an individual's PHI (protected health information) without written authorization.This deficiency represents non-compliance investigated under Master Complaint Number 2974805.

Based on record review, staff interview, resident and power of attorney (POA) interview, contractor interview, review of POA document, and facility contract review, the facility failed to ensure the decisions of the resident representative (POA) were given the same consideration as if the resident made the decision themselves. This affected one (Resident #95) of three residents reviewed for resident representative involvement in facility appointed contracted services. The facility census was 95.Findings include:Review of the medical record for Resident #95 revealed an admission date of 09/09/25. Diagnoses included cognitive communication deficit, history of transient ischemic attack and cerebral infarction, and end stage renal disease.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] Resident #95 had a Brief Interview for Mental Status (BIMS) score of 11, indicating she had moderate cognitive impairment.Review of the face sheet for Resident #95 dated 03/12/26 revealed a POA was not listed for the resident.Review of Resident #95's record revealed the resident was appointed a healthcare POA on 08/19/25 and financial POA on 09/21/25. Both documents appointed the same individual as POA. The Financial POA document revealed the POA was effective immediately.Review of the admission Agreement for Resident #95 revealed the document was signed by the residents' POA and not the resident.Interview on 04/15/26 at 12:12 P.M. with Resident #95's POA revealed the POA received a telephone call from Resident #95 on 03/19/26 reporting an individual (Contract Representative (CR) #312) was present in her room. CR #312 had Resident #95 sign paperwork and the resident was concerned stating she did not understand what she was signing. The POA stated they spoke to CR #312 and identified them as being from a contractor that assisted with Medicaid applications. The POA reported informing CR #312 of being Resident #95's POA, the resident was unable to sign paperwork for themselves, and requested that the paperwork be left in the residents' room to be reviewed by the POA and the resident. The POA reported no knowledge of the contracted company prior to this interaction and had not asked for the facility to assist with reapplying for Medicaid for Resident #95. The POA received a notification from Resident #95's insurance that an individual was requesting financial information for insurance regarding the resident signed document dated 03/19/26. The POA further revealed going to one of Resident #95's banks out of concern and was notified by them that they had also received a request asking for Resident #95's banking information. Interview on 04/15/26 at 1:06 P.M. with Float Business Office Manager (BOM) #315 confirmed Resident #95 had a POA. BOM #315 further confirmed the facility has a contract with the company CR #312 was affiliated with. BOM #315 revealed the facility made referrals to the contractor to assist the resident and/or POA with applying to or renewing Medicaid for residents residing in the facility and confirmed Resident #95 was referred to them. BOM #315 confirmed a face sheet was provided to CR #312 dated 03/12/26 and confirmed the face sheet did not have a POA identified. BOM #315 confirmed CR #312 met with Resident #95 on 03/19/26. BOM #315 confirmed the POA was not present during the time CR #312 was meeting with Resident #95.Additional interview on 04/15/26 at 3:20 P.M. with Resident #95's POA revealed the POA was not notified of the referral made to the contractor affiliated with CR #312 nor notified that CR #312 would be coming to meet with Resident #95. The POA further revealed they did not sign a consent or additional paperwork to work with the contractor affiliated with CR #312.Interview on 4/15/26 at 4:00 P.M. with Resident #95 revealed the has significant memory issues, inconsistent recall, and missing details, and reported she communicated these limitations to the contractor multiple times on 03/19/26. Resident #95 informed the contractor she was unable to sign the paperwork herself and her POA needed to review and sign it. She reported that, despite this, she ended up signing the documents without understanding what she was signing. The resident recalled the contractor asking questions about her past work history and whether she had life insurance and kept probing for additional information while typing on a computer. Resident #95 was unsure of the accuracy of information she provided and repeatedly told him she could only provide limited details. Resident #95 reported she was very unwell during the interaction with the contractor and was not herself. She stated her POA hadn't asked for assistance with the application, and she wanted her POA to review all paperwork and contract to ensure she was not making any poor decisions. Resident #95 reported it was later learned that the contractor contacted her bank and previous employers, reportedly seeking information regarding length of employment, pay, and position. Resident #95 was unaware that the contractor had her face sheet prior to meeting her and stated she felt unhappy and uneasy knowing they had her personal information without her knowledge.Interview on 04/15/26 at 4:04 P.M. with CR #312 confirmed the contractor they were affiliated with was contracted with the facility and they assist the facility's residents, when referred, with Medicaid applications. CR #312 reported the facility submits a referral for a resident, provides the resident's face sheet, and what month Medicaid was needed to begin. CR #312 reported if a resident has a POA or a Legal Guardian, this was usually notated on the residents' face sheet. CR #312 confirmed meeting with Resident #95 independently on 03/19/26 and was unable to confirm whether a POA was identified on the resident's face sheet. CR #312 revealed prior to appointments they will attempt to reach out to family or designated people but stated they did not speak to Resident #95's POA prior to the appointment. CR #312 reported Resident #95 was able to answer identification questions and seemed knowledgeable about their healthcare and financial information and therefore believed the resident was able to sign their own paperwork. CR #312 confirmed the POA was called by the resident during the time they were together on 03/19/26 and confirmed the POA identified themselves as the POA and stated the resident should not be signing their own paperwork.The facility was unable to provide documentation of signed consent by the POA for Resident #95 to work with the contractor.Review of the contract, not dated, between the facility and CR #312's affiliated contractor confirmed there was an active contract between both parties. The contractor offers Medicaid processing and filing services.This deficiency represents non-compliance investigated under Master Complaint Number 2974805.

Based on observations, record review, resident and staff interviews, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and policy review, the facility failed to accurately assess and provide timely interventions to prevent the development of pressure ulcers or healing of existing pressure ulcers; and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. This resulted in Actual Harm to Residents #37 and #117 who were at risk for pressure ulcers and dependent on staff for toileting. Resident #37 developed three unstageable pressure ulcers (Slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). Resident #117 developed one pressure ulcer as a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed). This affected three (Residents #37, #82, and #117) of three residents identified with in-house acquired wounds. The facility census was 111.Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 11/26/25. Diagnoses included chronic kidney disease, muscle weakness, type two diabetes mellitus, acute respiratory failure with hypoxia, and systolic heart failure. Review of the hospital records from 11/18/25 to 11/26/25 revealed on 11/25/25, a wound consult identified multiple wounds. Resident #37 had wounds including a skin tear on the left buttock, and it was burgundy and denuded with redness. The coccyx showed brown ecchymosis discoloration. Preventive measures included turning every two hours, keeping skin cleansed dry and protected, using a low air loss mattress with a maximum of two linen layers, and avoid briefs to reduce moisture-related breakdown. The nursing comprehensive evaluation completed 11/26/25 by Licensed Practical Nurse (LPN) #900 documented Resident #37 had no skin conditions and had the potential for skin breakdown. Review of the physician orders dated 11/26/25 revealed wound care practitioner and podiatry to evaluate and treat as indicated. There were no physician orders to treat any skin breakdown on the left buttocks or coccyx as indicated in hospital records on 11/25/25. Review of the care plan initiated on 11/26/25 revealed Resident #37 was at risk for impaired skin integrity or pressure injury related to actual skin impairment on bilateral buttocks, bilateral heels, bilateral medial feet, and coccyx. Limitations included impaired bed mobility, episodes of bowel and bladder incontinence, chronic kidney disease, and diabetes mellitus. Interventions were documented as follows: on 11/26/25, the care plan was initiated for impaired skin integrity and pressure injury risk. There were no specific interventions included in the care plan until 12/02/25. A second skin check was completed on 11/27/25 by LPN #900 and no skin issues were identified on Resident #37. The Braden Scale for pressure ulcer risk, dated 11/27/25, revealed a score of 16, placing the resident at risk for skin breakdown. The scoring revealed Resident #37 was very limited with mobility, skin was occasionally moist, walks occasionally, has adequate nutrition and potential problem related to friction and shear. The physician order dated 11/27/25 directed follow up skin assessment on day shift for three days and cleanse skin with normal saline, pat dry, and apply Triad at dime thickness. The skin area for the treatment was not specified. The Skin Issues Evaluation completed 11/28/25 by Unit Manager (UM) #307 identified moisture associated skin damage (MASD) on the right buttock with progress noted as new wound present on admission, measuring 4.24 centimeters (cm) in length and 2.16 cm in width with no depth. The surface area measured 4.26 square (sq)cm. The MASD on the left buttock with progress noted as new wound present on admission, measuring 5.28 cm in length, 3.78 in width with no depth. The surface area 8.75 sq cm. The physician orders dated 11/28/25 revealed to cleanse wound (location not specified) with normal saline, pat dry, apply zinc oxide, and leave open to air every shift as needed. This order continued through 12/01/25. The Skin Issues Evaluation completed 11/30/25 by Registered Nurse (RN) #319 and 12/01/25 documented MASD on left and right buttocks. There were no measurements on these two wounds. The physician orders dated 12/01/25 revealed the bilateral buttocks were to be cleansed with normal saline, pat dry, apply zinc oxide, and leave open to air every shift as needed. This order continued until 12/14/25. The Skin Issues Evaluations completed 12/02/25 by LPN #280 documented MASD on left and right buttocks. There were no measurements on these two wounds. On 12/02/25, the care plan had updated interventions including weekly head-to-toe skin assessments, observing skin during shower or care, notifying the nurse of new areas of skin breakdown, placing a pressure reduction mattress on the bed, providing incontinence care and applying protective ointment, and turning and repositioning every care round and as needed. Review of the admission Minimum Data Set (MDS) completed 12/03/25 documented Resident #37 was mildly cognitively impaired, dependent on staff for toileting, and was frequently incontinent of bowel and bladder. Resident #37 was at risk for developing pressure areas and did not have any pressure ulcers. The Skin Issues Evaluations completed 12/03/25 by LPN #280 documented MASD on left and right buttocks. There were no measurements on these two wounds. The physician order dated 12/03/25 directed weekly skin assessment on day shift on Wednesdays. The progress notes dated 12/08/25 completed by RN #260 revealed Resident #37 had MASD on rear left thigh and right thigh. RN #260 documented these were present upon admission; However, there was no mention in the medical record these two areas were identified prior to 12/08/25. There was also no treatment order for these two newly identified wounds and no measurement of these wounds. The skin check evaluation completed 12/10/25 completed by LPN #900 documented MASD on the left and right buttock. A second evaluation completed on 12/10/25 by LPN #900 documented the same information. Review of the activities of daily tasks from 11/26/25 to 12/12/25 revealed Resident #37 received routine incontinence care by staff. The Skin Issues Evaluation completed 12/12/25 by Wound Nurse #303 identified a new pressure ulcer on the rear right thigh and measured 1.06 cm in length, 1.26 cm in width, and no depth. The surface area was 0.99 sq cm. A new pressure ulcer was acquired in house on the coccyx, and measured 1.33 cm in length, 1.65 cm in width with no depth. The surface area was 1.66 sq cm. There was a third new pressure ulcer acquired in house on the left buttock, acquired in house, 2.09 cm in length, 5.42 cm in width with no depth. The surface area was 6.51 sq cm. The three new pressure ulcers were not staged. The progress note dated 12/12/25 revealed Wound Nurse Practitioner (WNP) #502 was notified of the findings and new wound care treatments were ordered and initiated. The resident was educated on the importance of wound care, offloading, and pressure reduction. Risk versus benefits were reviewed, including risk of worsening skin breakdown, delayed healing, and infection if pressure relief measures are not followed, versus benefits of ongoing treatment and prevention of further injury. The resident verbalized understanding. Interventions were in place, including pressure relief measures, routine skin monitoring, and continuation of wound care per order. All responsible parties have been notified. Resident #37 will continue to be monitored for any changes in skin integrity per the care plan. The physician order dated 12/12/25 revealed for the coccyx, right rear thigh, and left buttocks wounds, there were new orders to cleanse with normal saline, apply silver calcium alginate, and cover with silicone dressing daily and as needed until resolved. The physician order dated 12/14/25 revealed there was a new order for an alternating pressure mattress and set it to four. The care plan had a new intervention added on 12/15/25 for an alternating pressure mattress with a setting of four. The Skin Issues Evaluation completed 12/18/25 by Wound Nurse #303 identified the right rear thigh pressure ulcer as unstageable and measured 1.68 cm. length, 1.22 cm. width, 0.1 cm. depth The coccyx pressure ulcer measured 0.83 cm. length, 1.44 cm. width, 0.1 cm. depth, and surface area 0.94 sq cm, and there was no tunneling or undermining. The left buttocks measured 1.4 cm. length, 1.1 cm. depth, and surface area 2.01 sq cm, and there was no tunneling or undermining. WNP #502's progress note dated 12/18/25 revealed the right rear thigh, coccyx, and left buttocks were staged as unstageable pressure ulcer. The care plan had a new intervention added on 12/22/25 for a pressure reduction cushion to be added to the wheelchair. The physician order dated 12/23/25 revealed Prostat (protein supplement) two times a day for wound healing. The Skin Issues Evaluation completed 01/08/26 revealed the right rear thigh wound healed. The unstageable pressure ulcer on the coccyx measured 0.84 cm in length, 0.63 cm in width, 0.1 cm in depth. The surface area was 0.4 sq cm, and there was no undermining or tunneling. The unstageable pressure ulcer on the left buttocks measured 4.44 cm in length, 3.67 cm in width with no depth. The surface area 5.03 sq cm, and there was no undermining or tunneling. During an interview on 01/08/26 at 10:15 A.M., Resident #37 reported awareness of wounds on feet and buttock. Resident #37 reported the wound care nurse practitioner had seen him and reported wounds were cleaned by staff. During an interview on 01/08/26 at 3:46 P.M., WNP #502 confirmed the facility notified her of Resident #37's wound on 12/12/25, and WNP #502 completed her first in house assessment on 12/18/25. WNP #502 voiced nursing staff did not identify Resident #37's wounds timely. During an interview on 01/12/26 at 10:26 A.M., the Director of Nursing (DON) confirmed licensed nursing staff did not capture Resident #37's wounds timely. The DON confirmed nursing staff did not complete a thorough skin assessment, and if completed the areas would have been identified timely. During an interview on 01/12/26 at 10:55 A.M., Corporate Nurse #501 confirmed wounds were not identified on Resident #37 until 12/12/25, and the wound nurse did not stage and assess the wounds until 12/18/25. Corporate Nurse #501 confirmed nursing staff did not complete a thorough skin assessment, and if completed the areas would have been identified timely. During an interview on 01/12/26 at 12:16 P.M., Central Supply #205 confirmed Resident #37 required usage of adult briefs for incontinence care needs. The hospital recommended to avoid use of adult briefs to reduce moisture related breakdown. During an interview on 01/13/26 at 1:44 P.M., LPN #900 confirmed completion of skin assessments on 11/27/25 and 12/10/25 and noted there were no significant concerns on buttocks besides MASD. During an interview on 01/13/26 at 1:51 P.M., RN #319 confirmed she completed a skin assessment on 11/30/25 for Resident #37 and [NAME] bilateral buttocks with MASD. During an interview on 01/13/26 at 2:02 P.M., UM #307 confirmed nursing staff did not identify Resident #37's wounds timely. UM #307 confirmed a skin assessment documented on 11/28/25 noted no skin impairments and the hospital report dated 11/27/25 reported skin issues on bilateral buttocks. UM #307 confirmed a complete follow-up skin assessment was not done. UM #307 stated the wound nurse did not see Resident #37 prior to 12/12/25 because there were no open areas documented, and once an open area was identified, the wound nurse becomes involved in the resident's care. 2. Review of Resident #117's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, cognitive communication deficit and need for assistance with personal care. Review of the admission MDS assessment dated [DATE] revealed Resident #117 was cognitively intact. Resident #117 was dependent on staff for toileting hygiene and frequently incontinent of bowel and bladder. Resident #117 was at risk for developing pressure injuries, but did not have any pressure injuries, venous or arterial ulcers at that time. The nursing progress notes dated 11/28/25 revealed Resident #117 was sent to the hospital due to diaphoresis, fever, and elevated heart rate. The hospital records dated 11/28/25 to 12/01/25 revealed Resident #117 was treated in the hospital for sepsis pneumonia. The hospital records contained no documentation Resident #117 had any pressure ulcers or skin alterations. The nursing readmission assessment dated [DATE] revealed Resident #117 had no skin conditions. The nursing assessment noted Resident #117 would be turned and repositioned every two hours and as needed, and weekly head-to-toe skin assessments would be completed. The skin checks on 12/03/25 revealed Resident #117 had a new Moisture Associated Skin Damage (MASD) area to both buttocks measuring 4.89 cm in length by 2.81 cm in width and 0.1 cm in depth. The physician orders dated 12/04/25 revealed her coccyx should be cleaned with normal saline, patted dry, apply zinc oxide and leave open to air. The skin assessment dated [DATE] revealed Resident #117 had MASD to her coccyx measuring 2.36 cm in length by 2.1 cm in width and no depth recorded. The physician orders dated 12/15/25 revealed a treatment order for a hydrocolloid dressing to be applied every three days and as needed to coccyx area. The care plan dated last updated 12/15/25 revealed Resident #117 was at risk for impaired skin integrity and pressure injury related to impaired bed mobility, incontinence of bowel and bladder, neuropathy and a history of skin breakdown to the coccyx. The interventions to help minimize risk of skin breakdown included conduct weekly head-to-toe skin assessments, observe skin with showers and care and notify nurse of any new skin breakdown, and to turn and reposition Resident #117 every two hours and as needed. Review of the shower and bath tasks dated 12/18/25, 12/22/25 and 12/25/25 revealed Resident #117 did not have any open skin areas. The skin assessments dated 12/20/25 through 12/27/25 revealed Resident #117 continued to have MASD on her coccyx, though no measurements were made of the skin impairment. On 12/29/25, the skin issues assessment revealed the MASD to her coccyx had progressed to a stage III pressure injury. The stage III pressure injury was assessed as in-house acquired and measured 1.6 cm in length by 1.49 cm in width. There was no depth recorded. The physician orders dated 12/29/25 revealed the coccyx area should be cleaned with soap and water or normal saline and a hydrogel honey cover with sacrum silicone/ foam dressing should be applied daily and as needed. Wound Nurse Practitioner (WNP) #502's wound assessment dated [DATE] revealed Resident #117 had a stage III pressure ulcer to her sacral region which was 80 percent granulation tissue and 20 percent slough. The size was 0.51 cm in length by 0.83 cm in width by 0.19 cm in depth. During an interview on 01/08/26 at 3:55 P.M., Assistant Director of Nursing (ADON) #315 revealed there had been some recent staffing changes with the nurse at the facility who oversaw wounds. The wound nurse at the facility prior to 12/31/25 had been a licensed practical nurse (LPN), who was not wound certified. During an interview on 01/08/26 at 2:39 P.M., WNP #503 revealed the first time WNP #503 saw Resident #117 was on 01/08/26. WNP #503 revealed a wound nurse practitioner or doctor had not been in the facility for the past two weeks due to the holiday schedule. WNP #503 revealed the facility nurses would have overseen monitoring wound progression during this time. WNP #503 revealed when she examined Resident #117's pressure ulcer on 01/08/26, it was small, but the injury was still staged as a stage III pressure injury. WNP #503 revealed she had no new treatment orders for Resident #117's pressure injury. During a follow up interview on 01/09/26 at 12:57 P.M., WNP #503 revealed MASD can worsen into a stage III pressure injury if a resident was not being turned and repositioned consistently. She confirmed that if a resident was being monitored with check and changes every two hours, the wound could have been caught at stage II (a partial-thickness skin loss presenting as a shallow open wound that exposes the dermis, the middle layer of skin) pressure ulcer. During an interview on 01/09/26 at 4:06 P.M., the Director of Nursing (DON) revealed that during the week of 12/21/25 and the week of 12/28/25, she had LPNs in the facility staging pressure ulcers, which they should not do. 3. Review of Resident #82's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, cerebral infarction, and adult failure to thrive. Review of the quarterly nursing assessment dated [DATE] revealed Resident #82 had no skin abnormalities present. The Braden scale assessment dated [DATE] revealed Resident #82 was at risk for developing pressure ulcers. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 had severe cognitive impairment. Resident #82 was dependent on staff for toileting hygiene, lower body dressing, and putting on footwear, and substantial maximal assistance for bed mobility. The physician order dated 10/16/25 revealed to encourage Prevalon boots (a pressure relieving offloading boot) to feet as tolerated on every shift daily. The care plan dated 01/17/23 revealed Resident #82 was at risk for impaired skin integrity/pressure injury related to weakness and impaired mobility. Interventions included to encourage to float heels while in bed and assist as needed. Observation of Resident #82's peri care on 01/07/26 from 3:13 P.M. to 3:23 P.M. revealed Resident #82 was not wearing offloading boots. An interview with Certified Nursing Aide (CNA) #268 and CNA #304 on 01/07/26 at 3:27 P.M. revealed Resident #82 does not have any offloading boots at all and has reddened skin areas to her bilateral heels. Observation of Resident #82 on 01/08/26 from 8:22 A.M. to 9:16 A.M. revealed Resident #82 was not wearing offloading boots or floating her heels off the bed. During an interview on 01/08/26 at 9:16 A.M., Licensed Practical Nurse (LPN) LPN #255 confirmed Resident #82 was not wearing her offloading boots or floating her heels. During an interview on 01/08/26 at 9:26 A.M., Wound Nurse Practitioner #503 revealed Resident #82's left heel was reddened, but it was blanchable. Review of the NPUAP guidelines dated 2014 revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the facility policy titled Skin Management, revised on 08/14/24, revealed upon admission, all residents are evaluated for skin integrity and this is documented in the electronic health record. Appropriate preventative measures will be implemented, and the interventions will be documented. Residents admitted with any skin impairment will have appropriate interventions implemented to promote healing and a physician's order for treatment. Ongoing monitoring and evaluation are provided to ensure optimal guest outcomes. The Certified Nursing Aide will report any new skin impairment to the licensed nurse that is identified during daily care. Residents with pressure injuries and lower extremity ulcers will be evaluated, measured, and staged weekly. The care plan may address preventative devices. This represents non-compliance investigated under Complaint Numbers 2711068 and 2701180.

Based on record review, resident, family, and staff interviews, and policy review, the facility failed to implement an individualized skin program to ensure necessary care and services were provided to timely identify the resident's skin breakdown, including diabetic ulcers and failed to provide necessary and care services to a resident who was not to receive food by mouth due to an esophageal repair. In addition, the facility failed to provide timely care and services to a resident's chest tube drain. Actual harm occurred to Resident #37, who had a history of amputation, required substantial/maximal assistance with lower body dressing, and had a diagnosis of diabetic polyneuropathy when the facility failed to identify four arterial wounds the hospital had identified prior to admission. 16 days after admission, the facility identified the four arterial wounds on the right heel, left heel, right medial foot, and left medial foot had deteriorated since hospitalization. This affected one (Resident #37) of nine residents identified with skin impairments, one (Resident #132) of eight residents who required enteral feedings, and one (#8) of one resident reviewed for chest tube drains. The facility census was 111.Findings include: Review of the medical record for Resident #37 revealed an admission date of 11/26/25. Diagnoses included chronic kidney disease, muscle weakness, type two diabetes mellitus, acute respiratory failure with hypoxia, and systolic heart failure. Review of the hospital records from 11/18/25 to 11/26/25 revealed on 11/25/25, a wound consult identified multiple wounds. Resident #37 had a deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue.) to the left heel measuring 5.5 centimeters (cm) in length by five cm in width with a surface area of 21.6 2 square (sq) cm with purple non blanchable erythema with red peri wound. The right heel had a deep tissue injury measuring 2.5 cm in length by one cm in width with a surface area 1.96 sq cm with purple non- blanchable erythema with red peri wound. The left plantar foot had an unstageable pressure injury (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) measuring 5.5 cm in length by 9.5 cm in width with a surface area of 41.04 sq cm with serosanguinous drainage with pink moist tissue with purple non blanchable areas and red peri wound. The right plantar foot had a wound measuring two cm in length by 3.5 cm in width with a surface area of 5.5 sq cm with purple non blanchable erythema with red peri wound. Treatments were in place to treat the wounds. Hospital records documented peripheral neuropathy and height related foot contact with the bed frame with a low air loss surface and bed extender ordered. Past medical history included ulcer of foot due to type two diabetes mellitus noted 11/03/19, ulcer of foot noted 11/10/19, amputated toe noted 06/06/22, and magnetic resonance imaging (MRI) dated 10/14/19 of the left foot with impression of osteomyelitis involving the second toe and cellulitis. The After Visit Summary (AVS) for hospital stay from 11/18/25 to 11/26/25 revealed a heart and vascular specialist appointment scheduled for 12/03/25 at 11:30 A.M. The nursing comprehensive evaluation dated 11/26/25 by Licensed Practical Nurse (LPN) #900 revealed no skin conditions were identified. The physician orders dated 11/26/25 revealed wound care practitioner and podiatry to evaluate and treat as indicated. There were no physician orders to treat any skin breakdown to the feet and heels until 12/12/25. The care plan dated 11/26/25 revealed Resident #37 was at risk for impaired skin integrity or pressure injury related to actual skin impairment on bilateral heels bilateral medial feet with limitations including impaired bed mobility, chronic kidney disease, and diabetes mellitus. There were no specific interventions included in the care plan until 12/02/25. The second skin check was completed on 11/27/25 by LPN #900 and no skin issues were identified on Resident #37. The Skin Issues Evaluation completed 11/28/25 by Unit Manager (UM) #307 identified no skin breakdown on both heels and feet. The skin issues evaluation dated 11/30/25 by Registered Nurse (RN) #319 identified no skin breakdown on both heels and feet. The physician orders dated 12/01/25 revealed a heart and vascular appointment scheduled on 12/03/25 at 11:00 A.M. The medical records dated 12/02/25 through 12/04/25 revealed no documentation pertaining to illness or the resident's refusal to attend the cardiology and vascular specialist appointment. The vital signs summaries dated 12/02/25 through 12/04/25 revealed blood pressure, heart rate, temperature and blood sugar without abnormalities. The dialysis record dated 12/03/25 at 11:30 A.M. documented the treatment was tolerated with hypotension resolved. On 12/02/25, the care plan had updated interventions including weekly head-to-toe skin assessments, observing skin during shower or care, notifying the nurse of new areas of skin breakdown, placing a pressure reduction mattress on the bed, and turning and repositioning every care round and as needed. The admission Minimum Data Set (MDS) assessment, dated 12/03/25, revealed Resident #37 was mildly cognitively impaired, required substantial/maximal assistance with lower body dressing, and did not have any open skin areas. The physician order dated 12/08/25 revealed the vascular appointment rescheduled for 02/13/26. The skin check evaluation dated 12/10/25 revealed completion of a foot evaluation with no new skin issues found. The progress note dated 12/12/25 revealed areas to bilateral heels and bilateral medial forefoot were noted and the resident stated these areas were present at the hospital. Resident #37 stated they were caused because he was too tall for the for the hospital bed resulting in increased pressure to the feet. Wound Nurse Practitioner (WNP) #502 was notified, and new wound care treatments were ordered and initiated. The wound nurse progress notes dated 12/12/25 completed by Wound Nurse (WN) #303 revealed there were four new diabetic ulcers found. There was a new in-house acquired diabetic foot ulcer of left medial forefoot and measured 8.16 cm in length by 5.21 cm in width with a surface area 31.72 sq cm. The second new in-house acquired left heel diabetic foot ulcer and measured 3.9 cm in lengthy by 3.61 cm in width with a surface area of 11.1 sq cm. The third new in-house acquired right medial forefoot diabetic foot ulcer and measured 5.7 cm in length by 2.83 cm in width with a surface area of 7.69 sq cm. The fourth new in-house acquired right heel diabetic foot ulcer and measured 14.8 cm in length by 15.9 cm in width with a surface area 170.77 sq cm. The physician orders dated 12/12/25 revealed the bilateral heels were to be cleansed with normal saline apply gauze soaked in betadine cover with absorbent dressing and secure with kerlix and as needed until resolved. The bilateral medial feet were to be cleansed with normal saline apply gauze soaked in betadine cover with absorbent dressing and secure with kerlix. The skin issues evaluation dated 12/18/25 by WN #303 revealed the wounds have not been evaluated and were in house acquired. The diabetic foot ulcer of left medial forefoot measured 4.51 cm in length by 7.69 cm in width with a surface area 21.13 sq cm. The left heel diabetic foot ulcer measured 3.99 cm in length by 2.45 cm in width with a surface area of 7.37 sq cm. The right medial forefoot diabetic foot ulcer measured 3.61 cm in length by 7.27 cm in width with a surface area 9.82 sq cm. The right heel diabetic foot ulcer measured 1.62 cm in length by 1.52 cm in width with a surface area 1.87 sq cm. Additional recommendations included heel suspension or protection devices, pressure reducing device for bed, bilateral heels to be always floated for offloading. WNP #502's progress note dated 12/18/25 revealed initial assessment completed on right medial forefoot, left medial forefoot, and left and right heels. Ulcers to be treated with betadine, continue supportive care, frequent repositioning, heels elevated off the bed, pressure relief measures and proper nutrition and hydration to support wound healing. Some wounds may be unavoidable due to advanced age, chronic illnesses, immobility, or poor circulation which increased risk of skin breakdown and impaired healing. The progress note dated 01/08/26 revealed updated measurements for four diabetic foot ulcers. The diabetic foot ulcer of left medial forefoot measured 3.78 cm in length by 3.39 cm in width by 0.1 cm depth with a surface area 8.22 sq cm. The left heel diabetic foot ulcer measured 3.59 cm in length by 2.87 cm in width by 0.1 cm in depth with a surface area of 7.6 sq cm. The right medial forefoot diabetic foot ulcer measured 2.56 cm in length by 1.06 cm in width and a surface area of 1.12 sq cm. The right heel diabetic foot ulcer measured 2.13 cm in length by 1.34 cm in width by 0.1 cm in depth and a surface area of 2.14 sq cm. During an interview on 01/08/26 at 10:15 A.M., Resident #37 had wounds present on his feet and buttocks, which were currently being seen by the wound care nurse practitioner. The resident reported his bed was not extended upon initial admission to the facility that caused discomfort, and that some wounds obtained were related to the bed not being extended and stated the facility extended his bed later in his admission. During an interview on 01/08/26 at 3:46 P.M., WNP #502 confirmed she was notified of the wounds on 12/12/25 and completed her own in house assessment on 12/18/25. WNP #502 stated she had concerns nursing staff did not identify wounds timely and skin issues located on his feet may never heal due to the resident's history. During an interview on 01/09/26 at 9:33 A.M., the Administrator confirmed Resident #37 missed his vascular appointment on 12/03/25 due to the resident reporting he was ill. The Administrator confirmed the medical record did not contain evidence supporting the resident was ill. During an interview on 01/09/26 at 12:03 P.M., Assistant Director of Nursing (ADON) #315 stated Resident #37 was supposed to have an appointment on 12/03/25 but it was cancelled due to the resident reporting he was not feeling good and confirmed there was no documentation of the resident reporting illness. ADON #315 confirmed the resident attended dialysis on that day with no abnormalities noted on the dialysis sheet and confirmed vital signs were within normal limits the day before and the day after the expected appointment. During an interview on 01/09/26 at 4:42 P.M., Certified Nursing Assistant (CNA) #214 confirmed Resident #37 had a cardiology and vascular appointment scheduled for 12/03/25. CNA #214 confirmed all resident appointments were kept inside a calendar. Review of the scheduled appointment calendar with CNA #214 revealed Resident #37's appointment was not transcribed in the book. During an interview on 01/12/26 at 10:26 A.M., the Director of Nursing (DON) confirmed licensed nursing staff did not capture Resident #37 wounds timely, and confirmed the wound identified on 12/12/25 were the same wounds found on discharge wound assessment from the hospital documented on 11/25/25. The DON confirmed nursing staff did not complete a thorough skin assessment and if completed in its entirety the areas would have been identified timely and treatment would have been initiated sooner. During an interview on 01/12/26 at 10:55 A.M., Corporate Nurse (CN) #501 confirmed wounds were not identified on Resident #37 until 12/12/25. The wound nurse and nurse practitioner did not stage and assess the wounds until 12/18/25. CN #501 confirmed nursing staff did not complete a thorough skin assessment and if completed the areas would have been identified timely, with treatments ordered after. During an interview on 01/13/26 at 1:44 P.M., LPN #900 confirmed completion of skin assessments on 11/27/25 and 12/10/25 and noted no skin impairments were identified on feet. During an interview on 01/13/26 at 1:51 P.M., RN #319 confirmed completion of skin assessment 11/30/25 for Resident #37 and stated she did not check his feet during the skin check and should have. During an interview on 01/13/26 at 2:02 P.M., Unit Manager (UM) #307 confirmed nursing staff did not identify Resident #37's wounds timely and reported the four wounds were identified on 12/12/25. UM #307 confirmed the impairments were documented on hospital paperwork the day prior to admission and stated nursing should not have missed them. UM #307 confirmed that a skin assessment was completed by him on 11/28/25, noted no new skin impairments, and reported a foot assessment was not completed because the resident did not want to do it at the time. He confirmed a complete follow-up skin assessment was not done and stated the wound nurse did not see Resident #37 prior to 12/18/25 because there were no open areas documented. Review of the policy titled Skin Management, dated 09/19/24, revealed residents with wounds or pressure injury and those at risk for skin compromise are identified evaluated and provided appropriate treatment to promote prevention and healing with ongoing monitoring and evaluation provided to ensure optimal resident outcomes. 2. Review of the medical record for Resident #132 revealed an admission date of 12/24/25 and a discharge date of 12/30/25. Diagnoses included perforation of the esophagus, hypothyroidism, fibromyalgia, asthma, gastro-esophageal reflux, and obstructive sleep apnea. The Hospital Discharge summary dated [DATE] at 3:00 P.M. indicated Resident #132 was hospitalized for repair of cervical spine pseudoarthrosis with hardware failure. Resident #132 then developed an esophageal perforation, neck abscess, mediastinal abscess that cultured positive for Candida albicans and Prevotella. A gastrostomy tube was placed on 12/04/25. The After Visit Summary (AVS) summary dated 12/24/25 indicated medications were to be given orally. Review of the physician's orders for Resident #132 revealed on 12/24/25, there was an order for nothing by mouth (NPO). The following physician orders were ordered to be administered by mouth: Calcium plus Vitamin D3 (vitamin) oral tablet 500-5 milligrams (mg) – micrograms (mcg) one time a day. Docusate Sodium (stool softener) oral capsule 100 mg one time a day. Fluconazole (antifungal medication) oral tablet 200 mg two tablets by mouth once a day, Levothyroxine Sodium (treats hypothyroidism) oral tablet 100 mcg one tablet by mouth once a day. Loratadine (treats allergies) oral tablet 10 mg one tablet once a day. Hydroxychloroquine Sulfate (fibromyalgia) oral tablet by mouth twice a day. Pregabalin (fibromyalgia) oral capsule 50 mg one capsule twice a day. Venlafaxine HCL (antidepressant) oral tablet 37.5 mg one tablet twice a day. Review of the Medication Administration Record (MAR) for Resident #132 for December 2025 revealed the following medications were given orally on 12/24/25 at 9:00 P.M. by Licensed Practical Nurse (LPN) #220: Loratadine Hydroxychloroquine Sulfate, Pregabalin and Venlafaxine HCL. On 12/25/25 at 9:00 A.M., the following medications were administered orally by LPN #280 : Calcium + Vitamin D3, Docusate Sodium Fluconazole, Levothyroxine Sodium, Loratadine Hydroxychloroquine Sulfate, Pregabalin and Venlafaxine HCL. There was no documentation in the medical record for clarification from physicians and/or hospital if medications should be administered by mouth or by gastrostomy tube because of the NPO order. There was no documentation in the medical record if the medications were administered through gastrostomy tube despite the nurses signing off that they administered the medications by mouth. On 12/25/25 at 1:32 P.M., the physician orders were changed to administer medications through the gastrostomy tube. There were no physician's orders for gastrostomy tube care, enteral feeding and water flush orders, or neck incision care orders until 12/26/25. The progress notes dated 12/29/25 at 7:45 P.M. written by Unit Manager (UM) #307 documented Resident #132 was found to have open food and drink containers at her bedside after an episode of vomiting. Resident #132 was educated about not eating or drinking (NPO) and an order was received from the on-call nurse practitioner for a chest X-ray. The order for the chest x-ray was placed 12/29/25 at 6:42 P.M. with the reason indicated NPO drinking fluid and the symptoms indicated were food in trachea causing other injury. The reason for portability was indicated as Patient weak/non-ambulatory (altered mental status/behavioral issues). There was no mention of a facility food tray being in Resident #132's bedside. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) had not yet been completed. Review of the emergency room documentation from Hospital #1 dated 12/30/25 revealed Resident #132 presented to the emergency room with complaints of nausea, vomiting, and purulent draining from her surgical neck wound over the past few days. Resident #132 was accompanied by her emergency contact #1 who stated Resident #132 has been intermittently lethargic and confused over the past few days. Computerized Tomography (CT) scans of the head and neck were obtained due to increased confusion, increased wound drainage, and suspicion that the infection may be causing intermittent metabolic encephalopathy. CT of the head showed no acute intracranial process. CT of the neck soft tissue with contract showed a 1.5 centimeters length by 0.6 cm width by 2.1 cm depth abscess at the right thoracic inlet (opening at the top of the chest on the right side, a vital junction between neck and chest) extending to the right superior mediastinum (upper, central chest area above the heart), just to the right of the trachea. There is a sinus tract extending to the skin surface and probable open wound anteriorly. The findings were discussed with the on-call Ear, Nose, Throat (ENT) physician, and recommendations were made to transfer to a facility (Hospital #2) that could manage the potential need for a flap surgery procedure. A request for Resident #132's medical records from Hospital #2 was made during the survey and was not received as of 01/15/25. During an interview on 01/09/26 at 3:03 P.M., Nurse #234 stated she was working in the evening on 12/29/25 and knew about an incident that happened that night. A new Certified Nursing Assistant (CNA) (unidentified) was working that evening and did not know Resident #132 was NPO. The CNA delivered a room tray to Resident #132. Resident #132 started to have a choking episode and complications from the feeding and had to send to the hospital. Nurse #234 was going to document the incident note, but her supervisor told her not to document this in the medical record and indicated it would cause the facility to be shutdown (by the State Survey Agency.) So, the nurse did not document the incident in Resident #132's medical record. During an interview on 01/12/26 at 11:25 A.M., LPN #280 revealed she could not remember how medications were administered to Resident #132 on 12/25/25. LPN #120 confirmed she documented the medications were given by mouth in the MAR. During an interview on 01/12/26 at 12:00 P.M., Registered Nurse (RN) #271 revealed Resident #132 was admitted [DATE] and was the nurse who received a verbal nursing report called from the hospital. The nursing report indicated all medications and feedings should be given through the gastrostomy tube. The paperwork the resident brought with her from the hospital indicated a tube feeding the facility did not have on hand, so LPN #220 called the registered dietitian to obtain an order for Glucerna (enteral nutrition). RN #271 confirmed he reported to LPN #220 to administer medications via gastrostomy tube and RN #271 did not record this nursing report in the medical record. RN #271 stated he did not administer medications to Resident #132 on 12/24/25. During an interview on 01/12/26 at 1:10 P.M., Resident #132's Emergency Contact #1 revealed Resident #132 was alert most of the time but was easily confused. No one from the family or friends [NAME] her any food or drink to the facility because everyone knew she was not to take anything by mouth. When Resident #132 was admitted to the facility, she had no active drainage from her neck wound. By the time she went to the emergency room on [DATE], there was copious amounts of green draining from the wound on her neck. On 12/29/25, Emergency Contact #1 and another friend from church saw food and drink on her bedside table and saw Resident #132 drank some Sprite. Emergency Contact #1 stopped Resident #132 from continuing to eat or drink anything by mouth. Resident #132 then started to have nausea and vomiting. On 12/30/25, Resident #132 was sent to the emergency room for further evaluation. Resident #132 in the Medical Intensive Care Unit (ICU) until two days ago (01/10/26) when she transferred out to a regular room. During an interview on 01/12/26 at 4:45 P.M., LPN #220 revealed she could not remember how medications were administered to Resident #132 on 12/24/25 at 9:00 P.M. LPN #220 confirmed she documented the medications were given by mouth in the MAR. During an interview on 01/13/26 at 8:30 A.M., the Director of Nursing (DON) and Corporate Nurse #501 revealed the evening medications on 12/24/25 and morning medications on 12/25/25 were documented as administered orally then in the afternoon on 12/25/25 the medications were changed to be administered through the gastrostomy tube. The orders were initially transcribed from the AVS to be administered orally then later changed to gastrostomy tube. The DON was unable to find any enteral feeding ordered or documentation of administration of administration enteral feeding until 12/26/25 at 7:00 P.M. There was documentation in the medical record Resident #132 ate or drank orally on 12/29/25 and confirmed there was no investigation in it either. The DON stated it was something that would be an incident and should be investigated. During an interview on 01/13/26 at 9:02 A.M., LPN #210 revealed she completed a second skin assessment on Resident #132 on 12/24/25 and there was no enteral feeding being administered to Resident #132 at that time. During an interview on 01/13/26 at 10:42 A.M., Unit Manager (UM) #307 confirmed Resident #132 was admitted [DATE] with a gastrostomy tube and was to receive NPO and had a surgical wound on her neck. A floor nurse obtained an enteral feeding formula of Glucerna on 12/24/25 and UM #307 confirmed the conversation with the dietician was not documented anywhere in the medical record. UM #307 confirmed there was no documentation of administering enteral feedings from 12/24/25 until 12/26/25 in the medical record. UM #307 confirmed the initial medications orders included medications to be given by mouth. RN #307 stated on 12/29/25, Resident #132 was found to have open containers of food and beverages on the bedside table between 5:00 and 6:00 P.M. Family was present in the room with Resident #132. A stat order for chest X-ray was placed on 12/29/25 around 7:00 PM. Resident #132 had no symptoms of distress. The X-ray was a precaution. The next morning 12/30/25, the X-ray was yet completed. There were no signs or symptoms of aspiration but there was increased green draining from Resident #132's neck wound so the physician decided to send Resident #132 to the emergency room for further evaluation and treatment. RN #307 stated because Resident #132 decided to take a drink on her own this would not consider it an incident. During an interview on 01/13/26 at 12:14 P.M., RN #315 confirmed orders for enteral feedings and gastrostomy tube care were placed on 12/26/25. RN #315 stated it was part of her chart review process. If something was missing, then RN #315 placed the order to be sure the charting was complete. 3. Review of the medical record for Resident #8 revealed an admission date of 11/07/25. Diagnoses included plural effusion, end stage renal disease, chronic respiratory failure, heart failure, gastro-esophageal reflux disease, and malignant neoplasm of bone and left breast. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact, required continuous oxygen administration and required substantial/maximal assistance with bathing. Review of the hospital After Visit Summary (AVS) dated 12/06/25 through 12/13/25 revealed staff were required to drain PleurX (chest drain) three times per week. Staff should drain up to 1,000 milliliters (ml.) or one bottle each time. If you drain 200 ml or less for three days in a row, call the office. Keep a drainage log including the date and time, amount of fluid drained, color of the fluid, and symptoms. The progress note dated 12/14/25 revealed Resident #8 had a PleurX drain (chest drain) noted to left upper flank area that was covered with dressing. No signs or symptoms of infection noted. The physician order dated 12/14/25 revealed to monitor the left flank for infection and cleanse with normal saline, pat dry and apply dressing. The physician visit dated 12/16/25 revealed a drain has placed for long term drainage secondary to it being a malignant effusion for persistent drainage. Staff were to monitor for complications such as dislodgement, obstruction or infection. The progress note dated 12/16/25 revealed medical director in and assessed the residents' PleurX drain. An order was given to monitor site for signs and symptoms of infection. The resident will be set up with interventional radiology to have drain removed or changed. There were no physician orders to drain Resident #8's PleurX three times per week and no evidence the PleurX was drained from 12/13/25 to 12/22/25. The physician order dated 12/23/25 revealed left flank PleurX to be drained every shift every Monday, Wednesday and Friday. Drain up to 1,000 ml. each time tube was drained. Do not exceed amount notify physician if draining less than 200 ml. The progress note dated 12/23/25 revealed the nurse assessed PleurX drain, the left flank tube was drained, output of 900 ml. The resident tolerated it well, no shortness of breath noted. Resident to complete PleurX draining every Monday, Wednesday and Friday. no infection noted at site. The care plan created updated 01/07/26 revealed Resident #8 had a potential for difficulty breathing and risk for respiratory complications related to the use of oxygen, diagnoses of chronic heart failure, chronic hypoxic respiratory failure, pleural effusions and history of smoking. Interventions included pleurex drain to left flank staff were required to monitor site for infection, drain as ordered, and notify of low drainage output. Interview on 01/07/26 at 3:47 P.M. with Regional Nurse #500, Corporate Nurse #501 and Assistant Director of Nursing (ADON) #315 confirmed Resident #8 was readmitted to the facility on [DATE], and the PleurX drain was not drained until 12/23/25. Physician orders for draining the PleurX were not entered until 12/23/25. ADON #315 stated the physician was notified on 12/16/25 that staff were unable to drain the PleurX. The physician advised the resident would be evaluated by interventional radiology for possible removal or replacement of the drain. ADON #315 reported she understood PleurX drain management but explained the drain arrived with a protective sheath over the tube, which prevented connection to the drainage kit. On 12/23/25, ADON #315 removed the sheath and successfully drained the PleurX without radiology intervention. ADON #315 stated she was unaware the sheath was intended to be removed and served as protection against external contamination. She confirmed the drainage tube was functional the entire time but she lacked knowledge on how to drain it given the circumstance. ADON #315 acknowledged that attempts to drain the PleurX prior to 12/23/25 were not documented in the medical record and confirmed the drain was not managed according to hospital discharge instructions. This deficiency represents non-compliance under Complaint Numbers 2711068 and 2701180.

Based on medical record reviews, resident and staff interviews, and review of facility policy, the facility failed to conduct admission and quarterly care conferences in a timely manner. This affected five (Residents #8, #34, #45, #48, and #75) of five residents reviewed for care planning. The facility census was 111 residents.Findings include: 1. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] and diagnoses included cerebral infarction, hemiplegia and hemiparesis, and need for assistance with personal care. The Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed Resident #34 was cognitively intact. Review of Resident #34's care conferences in the medical record revealed Resident #34 had his most current care conference on 03/28/25. The progress notes revealed there were no care conferences held for Resident #34 after 03/28/25. An interview with Social Services Director #243 on 01/07/25 at 5:18 P.M. confirmed Resident #34 did not have any care conferences since 03/08/25. 2. Review of Resident #45's medical record revealed he was admitted to the facility on [DATE] and diagnoses included end stage renal disease, polyneuropathy and acquired absence of right leg above knee. The Minimum Data Set (MDS) MDS 3.0 comprehensive assessment dated [DATE] revealed Resident #45 had intact cognition. Review of Resident #45's care conferences in the medical record revealed there was no record of care conferences held with Resident #45. Review of Resident #45's progress notes revealed there was no record of care conferences held with Resident #45. An interview with Resident #45 on 01/05/26 at 9:05 A.M. revealed Resident #45 was upset that he had not had a care conference with the facility and he was uninformed about the progression of his discharge planning. An interview with Social Services Director #243 on 01/07/25 at 2:09 P.M. confirmed Resident #45 did not have any care conferences since admission and could not provide proof that discharge planning had been discussed with Resident #45. 3. Review of Resident #75's medical record revealed the was admitted to the facility on [DATE] and diagnoses included cognitive communication deficit, traumatic brain injury, and need for assistance with personal care. Review of Resident #75's care conferences in the medical record revealed the only care conference held was on 10/22/25 and there was no care conference held within 72-hours of his admission date of 09/01/25. An interview with Social Services Director #243 on 01/07/26 at 2:09 P.M. confirmed the only care conference held was on 10/22/25 and there was no care conference held within 72-hours of his admission date of 09/01/25. 4. Review of the medical record for Resident #8 revealed an admission date of 11/17/25 with diagnoses including plural effusion, end stage renal disease, chronic respiratory failure, heart failure, and malignant neoplasm of bone and left breast. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact and had a plan to discharge to the community. Review of 72-hour admission conference dated 12/02/25 revealed responsible party, social services and MDS nurse were present at meeting. Interview on 01/07/26 at 2:50 P.M. with Discharge Planner (DP) #249 confirmed admission care conferences should be completed within 72 hours of admission. 5. Review of Resident #48's medical record revealed an admission date of 08/23/23. Diagnoses include complete lesion T7-T10 level of thoracic spinal cord, paraplegia, obstructive and reflex uropathy and neuromuscular dysfunction of bladder. Resident of Resident #48's care conferences revealed Resident #48 had conferences completed on 09/24/24, 11/25/24, and 02/27/25.There were no care conferences held after 02/27/25. Interview on 01/07/25 at 2:09 P.M. with Social Services Director #243 confirmed Resident #48 did not have his quarterly care conferences and the last care conference was held on 02/27/25. Review of the facility's policy titled Care Planning Conference, dated 03/03/25, revealed the purpose of care planning conference on admission, quarterly, annually, and with a significant change and as needed, the interdisciplinary team will hold a care planning conference with the resident, family, or representative in participation. The care conference will be used to identify the resident's potential or actual problems, needs, goals, and discharge plans. Interdisciplinary care conferences will be held for the following reasons: admission, annually, quarterly, significant change, discharge as needed, and as needed.

Based on medical record review, observations, resident representative and staff interviews and review of facility policy, the facility failed to provide a resident who was dependent on staff assistance with personal hygiene received adequate and timely assistance with nail care. This affected one (Resident #75) of three residents reviewed for activities of daily living (ADL). The facility census was 111 residents.Findings include: Review of Resident #75's medical record revealed he was admitted to the facility with diagnoses including schizophrenia and mental health disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition. Resident #75 required moderate assistance from staff for personal hygiene and did not have rejection of care. Review of Resident #75's functional ability care plan dated 09/01/25 revealed Resident #75 required assistance with self-care related to his impaired cognition and impaired mobility. A listed intervention dated 09/01/25 was to keep Resident #75's fingernails trimmed and clean. The care plan listed Resident #75 as requiring substantial or maximal assistance with personal hygiene. The cognitive care plan dated 09/14/25 revealed Resident #75 had severely impaired cognition. A listed goal was to anticipate Resident #75's needs based on his past preferences. Observations of Resident #75 on 01/05/26 at 10:03 A.M. revealed Resident #75's fingernails were long and jagged.An interview with Resident #75's spouse/ representative on 01/05/26 at 11:28 A.M. revealed Resident #75 preferred to keep his fingernails short and trimmed. A subsequent observation of Resident #75 on 01/06/25 at 9:21 A.M. revealed Resident #75's fingernails were long and jagged.An interview with Licensed Practical Nurse (LPN) #210 on 01/06/26 at 9:27 A.M. confirmed Resident #75's fingernails were long and jagged. An interview with Unit Manager (UM) #307 on 01/06/26 at 9:48 A.M. stated Resident #75 was cooperative with grooming and nail care. Review of a facility policy titled Standards of Certified Nursing Assistant (CNA) Practice, revised 08/15/23, revealed CNAs provide services and care for residents under the supervision of the licensed nurse. The CNA assists the resident in activities of daily living, such as grooming and nail care. This deficiency represents noncompliance investigated under Complaint Number 2701180.

Based on observation and interview the facility failed to ensure food was served at a palatable temperature. This had the potential to affect 104 residents who consumed food from the kitchen the facility identified three residents (#2, #84, and #92) who ate nothing by mouth.Findings include: Interview on 08/06/25 from 12:25 P.M. to 12:55 P.M. with Resident #96 and #97 revealed the food was not always hot when it got to them. Interview with Resident #102 revealed the food was often cold and lunch on that day had been cold as well.Observation on 08/06/25 at 12:30 P.M. revealed the last trays being passed on the E Hall, the cart was open and remained open as Certified Nursing Assistant (CNA) #106 passed the trays. She finished the trays at 12:39 P.M.Observation on 08/06/25 at 12:41 P.M. of a test tray with Dietary Manager #130 revealed the stuffed pepper was 119 degrees Fahrenheit (F), the peas were 102 degrees F, and the [NAME] was 103 degrees F. All foods were cold when sampled.Interview on 08/06/25 at 12:41 P.M. with Dietary Manager #130 verified the foods were not at an appropriate temperature. She reported in the kitchen the foods were at least 175 degrees F and should be 140 degrees F when it got to the residents. She reported all carts had left the kitchen by 12:00 P.M.Interview on 08/07/25 at 1:01 P.M. with Resident #48 revealed the food was not always hot when it got to her.Review of the menu for 08/06/25 revealed it included one stuffed pepper, four ounces of rice, four ounces of diced vegetables, and four ounces of bread pudding.This deficiency represents noncompliance investigated under Complaint Number 1399441.

Based on observation, interview, review of dishwasher manual, review of sanitation instructions, and facility policy review, the facility failed to maintain a clean and sanitary kitchen and sanitize dishes in an appropriate manner. This had the potential to affect 104 residents who consumed food from the kitchen. The facility identified three residents (#2, #84, and #92) who ate nothing by mouth. The facility census was 107.Findings include: 1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed multiple concerns in the kitchen including:a. Multiple broken baseboards including one next to the three compartment sink, one across from the entry way, and one to the right of the oven. Dietary Manager #130 verified this at time of observation.b. The three-compartment sink was leaking from the bottom into a bucket on the floor. The area surrounding this bucket was a rusty brown color and had a build up of dirt. The wall behind the three-compartment sink was chipped. Dietary Manager #130 verified the sink was leaking and the area was unclean,' she believed they were planning on replacing the whole area.c. Throughout the kitchen there were multiple areas of the ceiling covered in splatters. Dietary Manager #130 reported she thought maintenance was responsible for this.d. Under tables, equipment, and the mixer that were up against the wall revealed the floor had a buildup of dirt, food debris, and disposable items like twist ties and plastic bags. Dietary Manager #130 verified this observation.e. The steamtable from below the food prep surface was unclean, there was food splatter and crumbs. Dietary Manager #130 verified this and reported thy were prioritizing the food surfaces when cleaningf. The Robot Coup food processor base had food splatter on it. Dietary Manager #130 verified this.g. The side of the convection oven was covered in grease splatter. Dietary Manager #130 verified this.h. The hood vents had a build-up of grease and dust. Dietary Manager #130 verified this and said she believed maintenance was responsible for this.Interview on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 verified the kitchen was not clean. She reported they were short staffed and had been prioritizing everyday cleaning over deep cleaning.Review of the policy ‘Dietary Cleaning and Sanitation' dated 11/19/21 revealed food-contact surface areas should be washed, rinsed, and sanitized after each use, before switching to another food type, or when the tool or items being used may have become sanitized. The dietary manager was responsible for inspecting the kitchen for sanitation.2. Observation 0n 08/06/25 from 9:40 A.M. to 10:08 A.M. of the kitchen revealed Dietary Aide #226 putting away trays that had been removed from the dishwasher. There was one rack of trays remaining on the clean side of the dishwasher and next to it were piles of soiled cups. Dietary Manager #130 put a rack of trays into the dishwasher and ran it, it was very soapy and soap leaked out of the front into a bucket. During the first run of the dishwasher the temperature was at 110 degrees Fahrenheit (F) and she was unable to verify the sanitation level as the strip did not change color. Dietary Manager #130 did not check the temperature at that time. The second time she ran the dishwasher the temperature reached 120 degrees F, but once again the strip did not register sanitation level. The dishwasher had pumps connected to the tubing for the sanitizer, this pump was not observed moving during the first three runs of the dishwasher. During the second observation Dietary Manager #130 began pressing a button above the pumps and by the fourth run, the pump was moving and sanitizer was observed going into the dishwasher sump. However, the test strip did not change color. Dietary Manager #130 verified this was a chemical dishwasher and she was unable to verify sanitation level. Interview with Dietary Aide #226 verified she had washed dishes in the dishwasher but had not checked the sanitation level or temperature that morning.Observation and interview on 08/06/25 from 1:07 P.M. to 1:50 P.M. revealed Dietary Manager #130 did not think the sanitation strips were working right, she reported they did not change color when she dipped it directly into the sanitizer. The dietary aides were observed putting dishes through the dishwasher, the three-compartment sink was empty. Dietary Manager #130 verified she was still unable to verify the dishwasher was running appropriately and the aides were using it anyways. The dietary manager reported she expected the dietary aides to check the sanitation level and temperature of the dishwasher with the first rack of dishes in the morning, she verified this had not been done. Dietary Manager #130 reported the sanitizer had been delivered yesterday and the staff connected it. She reported the machine determined the mount of chemicals and other than connecting the sanitizer nobody in the facility had to do anything.Interview on 08/06/25 at 2:23 P.M., 2:47 P.M., and 3:27 P.M. with Plant and Maintenance Director #129 revealed he was unaware of any concerns with the dishwasher. He reported when a new chemical was connected to the dishwasher kitchen staff should be checking that its pumping and press the button above the pump to get it moving if it is not.Review of the dishwasher sanitation log provided on 08/06/25 at 2:50 P.M. revealed for 08/06/25 it was indicated that the dishwasher was at the appropriate temperature and sanitation level for breakfast and lunch. Interview with Dietary manager #130 at that time verified this was incorrect and she was unsure how she knew if the forms were ever being completed accurately if the aides were documenting it was working when it was not.Observation and interview on 08/06/25 at 3:35 P.M. with Plant and Maintenance Director #129 and [NAME] Serviceman #232 revealed the [NAME] serviceman brought his own test strips and the dishwasher was running appropriately. [NAME] Serviceman #232 stated if the previous sanitizer was run to empty then there may have been air in the tube preventing sanitizer from coming out. This would require using the button above the pump to get things moving. When it is working right, sanitizer comes out immediately when the button is pressed. He reported dipping the test strips directly into the sanitizer would be ineffective because the test strip requires water. Additionally, he reported soap coming out the front of the dishwasher could have been related to a clog that fixed itself, as this was no longer occurring. Review of the chemical instructions for SparClean Sanitizer revealed the dishwasher's chemical dispensing device could be adjusted to ensure to meter the proper amount of product into the machine.Review of the owner's manual for the dishwasher revealed the minimum wash temperature was 120 degrees F and chemical sanitizer concentration should be 50 parts per million (ppm) to 100 ppm.This violation represents noncompliance investigated under Complaint Number 1399439.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure kitchen equipment was in working order and a system was in place to track maintenance requests. This had the potential to affect 104 residents who consumed food from the kitchen the facility identified three residents (#2, #84, and #92) who ate nothing by mouth. The facility also failed to ensure a safe and clean environment when 35 resident rooms had missing transition strips from residents to hallways. This affected 48 residents (#1, #3, #4, #6, #7, #10, #11, #12, #13, #19, #20, #26, #27, #31, #33, #36, #39, #42, #43, #44, #45, #46, #47, #53, #54, #55, #56, #57, #58, #77, #78, #85, #88, #89, #90, #91, #93, #95, #96, #97, #98, #99, #100, #103, #104, #105, #106, and #107) of 107 residents residing in the facility.Findings include: 1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed the disposal connected to the dishwasher was being replaced. Dietary Manager #130 reported the disposal had been down for over a month. The three-compartment sink was leaking from the bottom into a bucket on the floor. Additionally, the food prep sink was leaking into the sink. Dietary Manager #130 reported the sinks had been leaking for over a month and she had told maintenance.Interview on 08/06/25 at 2:23 P.M., 2:47 P.M., and 3:56 P.M. with Plant and Maintenance Director #129 revealed he was unaware of leaks in the kitchen. He reported they fixed a leak in the three compartment sink the previous week and was unaware it was leaking again. He reported for the disposal he called the company when he was aware it was down, which was on 07/07/25. The company came out that day and sent a quote on 07/09/25. He reported the quote was approved on 07/24/25. He was unsure why there was a delay in approving it.Interview on 08/07/25 at 10:00 A.M. with the Administrator revealed there were no maintenance work orders to track when requests were submitted and completed. He reported staff called, texted, or found maintenance to notify him of any concerns.Review of the service order for Advanced Mechanical Plus dated 07/07/25, revealed they arrived to work on the garbage disposal and found the unit down. The unit motor was locked and leaking water. An order for a new disposal was to be submitted.Review of the quote from Advanced Mechanical Plus dated 07/09/25 revealed replacement of and maintenance to the disposal would cost $4,468.66.Review of an email to Plant and Maintenance Director #129 on 08/06/25 revealed a timeline for the disposal. On 07/07/25 it was reported that there was a problem with the garbage disposal. On 07/08/25 there was a request for a quote. On 07/09/25 the quote was finished and emailed to a corporate staff member. On 07/23/25 the corporate staff member was emailed to follow up on the quote. On 07/24/25 the corporate staff member approved the quote.Review of the policy ‘Maintenance and Repairs of Equipment in Nutritional Services Department' dated 12/19/24 revealed the nutritional professional will notify the maintenance department in writing of any equipment issues. 2. Observation on 08/11/25 at 8:51 A.M., 9:59 A.M., 10:42 A.M., 2:50 P.M., and 4:20 P.M. revealed 35 resident rooms containing residents #1, #3, #4, #6, #7, #10, #11, #12, #13, #19, #20, #26, #27, #31, #33, #36, #39, #42, #43, #44, #45, #46, #47, #53, #54, #55, #56, #57, #58, #77, #78, #85, #88, #89, #90, #91, #93, #95, #96, #97, #98, #99, #100, #103, #104, #105, #106, and #107 were missing the transition strips from the room to the hallway. Some of these rooms had a wide gap between the flooring of the hallway and the flooring of the bedroom and some of them had a build-up of a black sticky residue. Interview on 08/11/25 at 4:20 P.M. with the Administrator verified the missing transition strips. He reported some of the flooring had been replaced up to a year and a half ago and they had been working on ordering new strips.This deficiency represents noncompliance investigated under Complaint Number 1399439.

Based on observation, interview, review of kitchen staffing schedule, review of dishwasher sanitation log,and review of staff personnel file revealed the facility failed to employ sufficient staff to maintain a clean kitchen. Additionally, they failed to ensure staff were competent to ensure the dishwasher was running appropriately and qualified to be a cook. This had the potential to affect 104 residents who consumed food from the kitchen. The facility identified three residents (#2, #84, and #92) who ate nothing by mouth. The facility census was 107.Findings include:Findings include:1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed multiple concerns in the kitchen including:a. Multiple broken baseboards including one next to the three-compartment sink, one across from the entry way, and one to the right of the oven. Dietary Manager #130 verified this.b. The three-compartment sink was leaking from the bottom into a bucket on the floor. The area surrounding this bucket was a rusty brown color and had a buildup of dirt. The wall behind the three-compartment sink was chipped. Dietary Manager #130 verified the sink was leaking and the area was unclean,' she believed they were planning on replacing the whole area.c. Throughout the kitchen there were multiple areas of the ceiling covered in splatters. Dietary Manager #130 reported she thought maintenance was responsible for this.d. Under tables, equipment, and the mixer that were up against the wall revealed the floor had a buildup of dirt, food debris, and disposable items like twist ties and plastic bags. Dietary Manager #130 verified this observation.e. The steamtable from below the food prep surface was unclean, there was food splatter and crumbs. Dietary Manager #130 verified this and reported thy were prioritizing the food surfaces when cleaningf. The Robot Coup food processor base had food splatter on it. Dietary Manager #130 verified this.g. The side of the convection oven was covered in grease splatter. Dietary Manager #130 verified this.h. The hood vents had a build-up of grease and dust. Dietary Manager #130 verified this and said she believed maintenance was responsible for this.Interview on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 verified the kitchen was not clean. She reported they were short staffed and had been prioritizing everyday cleaning over deep cleaning. She stated they needed one cook and two aides in the morning and in the afternoon and they did not often have that. They were really short on cooks and she had been filling in.Review of the kitchen schedule from 07/08/25 to 08/05/25 revealed on 07/08/25 there was no morning cook and only one aide in the afternoon, on 07/09/25 there was no afternoon aides, on 07/10/25 there was no morning cook and only one afternoon aide, on 07/11/25 there was no morning cook and only one morning aide, on 07/12/25 there was no afternoon aides, on 07/13/25 there were no afternoon aides, on 07/14/25 there was only one afternoon aide, on 07/15/25 there was no morning cook and only one afternoon aide, on 07/16/25 there was no morning cook, on 07/17/25 there was no morning cook and only one afternoon aide, on 07/18/25 there was no morning cook and only one morning aide, on 07/19/25 there was no morning cook and only one afternoon aide, on 07/20/25 there was only one aide in the morning and afternoon, on 07/21/25 there were no afternoon aides, on 07/22/5 there was no morning cook and only one aide in the afternoon, on 07/23/25, there was no morning cook and only one aide in the afternoon, on 07/24/25 there was no morning cook and no afternoon aides, on 07/25/25 there was no morning cook and only one aide in the morning and afternoon, on 07/26/25 there was no morning cook and only one aide in the morning and afternoon, on 07/27/25 there was no morning cook, only one morning aide, and no afternoon aides, on 07/28/25 there was no morning cook and no afternoon aides, on 07/29/25 there was no morning cook, only one morning aide, and no afternoon aides, on 07/30/25 there was no morning cook and only one morning aide, on 07/31/25 there was no morning cook and only one afternoon aide, on 08/01/25 there was no morning cook and only one morning aide, on 08/02/25 there was no morning cook and only one afternoon aide, on 08/03/25 there was no morning cook and only one morning aide, on 08/02/25 there was no morning cook and only one afternoon aide, on 08/03/25 there was no morning cook and only one afternoon aide, on 08/04/25 there were no scheduled cooks and only one afternoon aide, and on 08/05/25 there was no morning cook and one afternoon aide.2. Observation 0n 08/06/25 from 9:40 A.M. to 10:08 A.M. of the kitchen revealed Dietary Aide #226 putting away trays that had been removed from the dishwasher. There was one rack of trays remaining on the clean side of the dishwasher and next to it were piles of soiled cups. Upon four attempts at running the dishwasher Dietary Manager #130 was unable to confirm the sanitizer was running at an appropriate level. Interview with Dietary Aide #226 verified she had washed dishes in the dishwasher but had not checked the sanitation level or temperature that morning.Interview on 08/06/25 from 1:07 P.M. to 1:50 P.M. revealed Dietary Manager #130 revealed she expected the dietary aides to check the sanitation level and temperature of the dishwasher with the first rack of dishes in the morning.Review of the dishwasher sanitation log provided on 08/06/25 at 2:50 P.M. revealed for 08/06/25 it was indicated that the dishwasher was at the appropriate temperature and sanitation level for breakfast and lunch. Interview with Dietary manager #130 at that time verified this was incorrect and she was unsure how she knew if the forms were ever being completed accurately if the aides were documenting it was working when it was not.3. Interview on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed they were short staffed and were particularly short on cooks. She reported Dietary [NAME] #123 was actually a dietary aide, however, they had been sharing the roll of cook. Dietary [NAME] #123 worked as the sole cook on the weekends.Interview on 08/06/25 from 12:25 P.M. to 12:55 P.M. with Resident #96 revealed the food was not great. Interview with Resident #97 revealed the food was awful. Interview with Resident #102 revealed the food was not good.Review of Dietary [NAME] #123's personnel file revealed she was hired on 04/27/22 as a dietary aide. The only job description in her personnel file was dietary aide, there was no evidence she had received training as a cook.Interview on 08/06/25 at 3:50 P.M. with the Administrator verified Dietary [NAME] #123 was not trained as a cook. He reported he was unaware of this and she had been in the position when he started.This deficiency represents noncompliance investigated under Complaint Number 1399439.

Based on observation, interview, and review of dishwasher sanitation logs, the facility failed to ensure the dietary manager was competent to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 104 of 107 residents who consumed food from the kitchen the facility identified three residents (#2, #84, and #92) who ate nothing by mouth. The facility census was 107.Findings include: 1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed multiple concerns in the kitchen including:a. Multiple broken baseboards including one next to the three-compartment sink, one across from the entry way, and one to the right of the oven. Dietary Manager #130 verified findings at time of the observation.b. The three-compartment sink was leaking from the bottom into a bucket on the floor. The area surrounding this bucket was a rusty brown color and had a build up of dirt. The wall behind the three-compartment sink was chipped. Dietary Manager #130 verified the sink was leaking and the area was unclean, she believed they were planning on replacing the whole area and stated she had told maintenance of the issue.c. The food prep sink had a leak from the faucet into the sink. Dietary Manager #130 verified the leak and reported maintenance was aware.d. Throughout the kitchen there were multiple areas of the ceiling covered in splatters. Dietary Manager #130 reported she thought maintenance was responsible for this.e. Under tables, equipment, and the mixer that were up against the wall revealed the floor had a buildup of dirt, food debris, and disposable items like twist ties and plastic bags. Dietary Manager #130 verified this observation.f. The steamtable from below the food prep surface was unclean, there was food splatter and crumbs. Dietary Manager #130 verified this and reported they were prioritizing the food surfaces when cleaningg. The Robot Coup food processor base had food splatter on it. Dietary Manager #130 verified this at time of observation.h. The side of the convection oven was covered in grease splatter. Dietary Manager #130 verified this at time of observation.i. The hood vents had a build-up of grease and dust. Dietary Manager #130 verified this and said she believed maintenance was responsible for this.Interview on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 verified the kitchen was not clean. She reported they were short staffed and had been prioritizing everyday cleaning over deep cleaning.Interview on 08/06/25 at 2:23 P.M., 2:47 P.M., and 3:56 P.M. with Plant and Maintenance Director #129 revealed he was unaware of leaks in the kitchen. 2. Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. of the kitchen revealed Dietary Aide #226 putting away trays that had been removed from the dishwasher. There was one rack of trays remaining on the clean side of the dishwasher and next to it were piles of soiled cups. Dietary Manager #130 put a rack of trays into the dishwasher and ran it, it was very soapy and soap leaked out of the front into a bucket. During the first run of the dishwasher the temperature was at 110 degrees Fahrenheit (F) and she was unable to verify the sanitation level as the strip did not change color. Dietary Manager #130 did not check the temperature at that time. The second time she ran the dishwasher the temperature reached 120 degrees F, but once again the strip did not register sanitation level. The dishwasher had pumps connected to the tubing for the sanitizer, this pump was not observed moving during the first three runs of the dishwasher. During the second observation Dietary Manager #130 began pressing a button above the pumps and by the fourth run, the pump was moving and sanitizer was observed going into the dishwasher sump. However, the test strip did not change color. Dietary Manager #130 verified this was a chemical dishwasher and she was unable to verify sanitation level. Interview with Dietary Aide #226 verified she had washed dishes in the dishwasher but had not checked the sanitation level or temperature that morning.3.Observation and interview on 08/06/25 from 1:07 P.M. to 1:50 P.M. revealed Dietary Manager #130 did not think the sanitation strips were working right, she reported they did not change color when she dipped it directly into the sanitizer. The dietary aides were observed putting dishes through the dishwasher, the three-compartment sink was empty. Dietary Manager #130 verified she was still unable to verify the dishwasher was running appropriately and the aides were using it anyways. The dietary manager reported she expected the dietary aides to check the sanitation level and temperature of the dishwasher with the first rack of dishes in the morning, she verified this had not been done. Dietary Manager #130 reported the sanitizer had been delivered yesterday and the staff connected it. She reported the machine determined the mount of chemicals and other than connecting the sanitizer nobody in the facility had to do anything.Interview on 08/06/25 at 2:23 P.M., 2:47 P.M., and 3:27 P.M. with Plant and Maintenance Director #129 revealed he was unaware of any concerns with the dishwasher. He reported when a new chemical was connected to the dishwasher kitchen staff should be checking that its pumping and press the button above the pump to get it moving if it is not.Review of the dishwasher sanitation log provided on 08/06/25 at 2:50 P.M. revealed for 08/06/25 it was indicated that the dishwasher was at the appropriate temperature and sanitation level for breakfast and lunch. Interview with Dietary manager #130 at that time verified this was incorrect and she was unsure how she knew if the forms were ever being completed accurately if the aides were documenting it was working when it was not.Observation and interview on 08/06/25 at 3:35 P.M. with Plant and Maintenance Director #129 and [NAME] Serviceman #232 revealed the [NAME] serviceman brought his own test strips and the dishwasher was running appropriately. [NAME] Serviceman #232 stated if the previous sanitizer was run to empty then there may have been air in the tube preventing sanitizer from coming out. This would require using the button above the pump to get things moving. When it is working right, sanitizer comes out immediately when the button is pressed. He reported dipping the test strips directly into the sanitizer would be ineffective because the test strip requires water. Additionally, he reported soap coming out the front of the dishwasher could have been related to a clog that fixed itself, as this was no longer occurring. This deficiency represents noncompliance with Complaint Number 1399439.

Based on observation, open and closed medical record review, interviews, hospital summary review and facility policy review, the facility failed to provide medical treatment with a change in condition, monitor, assess and ensure treatment was provided for skin conditions for one resident (#108). Additionally, the facility failed to report concerns with a transfer and monitor a bruise for Resident #109 who was on an anticoagulant (a medication that thins the blood) therapy. The facility also failed to monitor and assess a skin tear and bruise for Resident #106. Further review revealed the facility failed to ensure hospice information was available for review for Resident #79. This affected three residents ( #106,#108 and #109) of three residents reviewed for skin conditions and one resident (#79) of one resident reviewed for hospice. The facility census was 107.Findings Include:1.Review of the closed medical record for Resident #108 revealed an initial admission date of 04/26/25 with the latest readmission of 06/13/25 with the diagnoses including but not limited to other mechanical complication of surgically created arteriovenous (AV) fistula, acquired absence of other left toes, encounter for orthopedic aftercare following surgical amputation, generalized muscle weakness, hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease ,end stage renal disease (ESRD), diabetes mellitus, pressure induced deep tissue injury (DTI)( persistent non-blanchable deep red, maroon or purple discoloration) to left heel, DTI to left ankle, atrial fibrillation, anemia, opioid use, depression, urinary tract infection (UTI), chronic obstructive pulmonary disease (COPD), pulmonary hypertension, long term use of anticoagulants, dependence on renal dialysis, chronic congestive heart failure, peripheral vascular disease, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, cardiomyopathy, hyperlipidemia and atherosclerotic heart disease. Review of the closed medical record and hospital records revealed Resident #108 had a history of peripheral vascular disease with procedures to improve blood flow dating back to 2021. The resident had procedures as recently as 11/24. Review of the resident’s admission nursing comprehensive evaluation dated 04/26/25 revealed the resident was admitted to the facility with generalized scabbing to the front of his right and left leg and both his arms from the resident scratching in various stages of healing. Review of the resident’s comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident required substantial/maximal assistance with toileting, bathing, dressing, bed mobility and transfers were not attempted. The assessment indicated the resident was at risk for skin breakdown and had no skin issues. The facility implemented a pressure reducing device to his bed. Review of the progress note dated 05/09/25 at 12:15 P.M., revealed the resident was observed on the floor in his room in front of the bathroom door. The resident was alert but confused and able to follow instructions to some extent. The resident had a skin tear to his right elbow and left upper ankle. Review of the progress noted dated 05/09/25 at 2:09 P.M. revealed skin assessment completed after recent fall and an area observed to left great toe, top of left toes and right elbow and a treatment was put in place. Review of the struck (due to inaccurate documentation) out skin and wound evaluation dated 05/09/25 revealed the resident was observed to have a deep tissue injury (DTI) to the left first digit measuring 1.9 centimeter (cm) by 1.8 cm and described as 100% epithelial tissue. The wound had no exudate and the peri-wound edges appeared flush with wound bed or as a slopping edge. The facility implemented the treatment to cleanse the area with normal saline (NS), apply a providone iodine soaked gauze, cover with ABD pad, wrap with Kerlix and secure with tape daily and as needed. Review of the medical record revealed no comprehensive assessment or treatment for the skin tears to the right elbow and the left ankle. Review of the resident’s discharge physician orders identified an order to cleanse the left great toe with normal saline (NS), pat dry, apply betadine soaked gauze, cover with ABD pad, wrap with kerlix and secure with tape daily and as needed for wound care. Review of the plan of care dated 05/09/25 revealed the resident had an actual impaired skin integrity related to pressure injury to left great toe. Interventions included conduct skin assessment weekly and measure area(s) and document characteristics, enhanced barrier precautions (EBP), observe for signs of discomfort with dressing changes and administer pain medication as ordered, refer to dietitian as needed and treatment as ordered. Review of the progress note dated 05/09/25 at 2:45 P.M. revealed the resident was observed on the floor at the nurses station. The resident was confused and disoriented. The resident could not remember what he was trying to do before he fell. Review of the medical record revealed no evidence the facility identified the change in the resident’s mental status. Review of the progress note dated 05/13/25 at 1:38 P.M. revealed the resident’ dialysis treatment was cut short for 30 minutes when he experienced seizure like symptoms according to dialysis nurse. The treatment was discontinued per nephrologist’s order. The resident’s blood pressure was 168/96. Review of the resident’s medical record revealed no documented evidence the facility identified the change in condition with the presentation of the seizure like symptoms with no history of seizures and the increased blood pressure. Further review revealed no assessment of the resident’s change of condition. Review of the change in condition progress note dated 05/13/25 at 7:02 P.M. revealed the resident was having difficulty breathing and oxygen saturation rate was 66% on room air. Two liters of oxygen was administered and his oxygen saturation rate increased to 95%. The physician on call was notified but the resident’ daughter who was at the facility visiting insisted the resident be sent to the local emergency room (ER) for an evaluation. The on call physician was made aware and the resident was sent to the local acute care hospital for an evaluation. Review of the Telehealth progress note dated 05/13/25 revealed the resident’s oxygen saturation rate dropped to 66% on room air. The resident was placed on four liters of oxygen and his oxygen saturation rated increased to 92%. The resident was confused and short of breath. The resident’s family was at bedside and insisted on the resident being sent to the local ER for an evaluation. Review of the hospital summary for encounter date of 05/13/25 through 05/29/25 revealed the resident was found with multiple vascular wounds to his left foot and was status post left lower extremity angiogram with left external iliac artery stent placement, superficial femoral artery (SFA)/popliteal laser atherectomy, left SFA balloon angioplasty, left popliteal artery sent, and left peroneal balloon angioplasty on 05/22/25. The amputation of the left toes was deferred at that time due to the vascular surgeon felt the toes were salvageable. Review of the resident’s readmission nursing comprehensive evaluation dated 05/29/25 revealed the resident was admitted to the facility with open sores from scratching to the right antecubital area and right elbow. The evaluation did not address the multiple vascular wounds to his left foot. Review of the progress note dated 05/30/25 at 5:41 P.M. revealed the resident’s second skin check was completed and redness was observed to the sacral area. Scabbed areas were observed to his bilateral arms and legs. Blackened areas were observed to his left first, second and third toes. A vascular consult was scheduled and orders to monitor were in place. Review of the medical record revealed no comprehensive assessment of the first, second and third toes of the left foot. Additionally, the facility did not begin monitoring the his toes until 06/02/25. Review of the Nurse Practitioner (NP) progress note dated 06/04/25 revealed she noted the resident was alert, oriented, answering questions appropriately, but appeared drowsy. The resident kept his eyes closed and reported he did not feel good. The resident’s vital signs were stable except his oxygen saturation was 86% on room air. The resident’s AV fistula to his right arm was swollen, warm to touch and painful. The fistula had a positive bruit and thrill. The resident was being transferred to the local ER for differential diagnoses of cellulitis versus deep vein thrombosis (DVT) at the fistula site. Review of the resident’s five-day MDS assessment dated [DATE] revealed the resident had no cognitive impairment. The assessment indicated the resident was at risk for skin breakdown, had no skin issues. The facility implemented pressure reducing device to bed and application of ointments/medications other than to feet. Review of the hospital summary from 06/04/25 through 06/13/25 revealed the resident was admitted to due to a malfunctioning AV fistula. On 06/05/25 the resident was found to have bilateral legs/feet ischemic ulcers versus deep tissue injury (DTI) that presented with dark, hard, intact skin to the left first, second and third toes, the right first and second toes. The resident presented with purple/red areas to heels and anterior toes. Further review on 06/09/25 revealed the resident had worsening dry gangrene of the left first to third toes and recommended vascular to reevaluate for a total metatarsal amputation (TMA) and the resident underwent a TMA on 06/12/25. There were no orders from the hospital for any antibiotics. Review of the resident’s skin and wound evaluation dated 06/13/25 revealed the resident was readmitted to the facility with an unstageable pressure ulcer to the resident’s right heel. The wound was described as having slough and/or eschar. The assessment had no measurements for the wound. Review of the resident’s medical record revealed no evidence a physician ordered treatment was put in place following the readmission to the facility on [DATE] until 06/16/25. Review of the resident’s discontinued physician ordered identified orders dated 06/16/25 cleanse left lateral ankle with normal saline (NS), pat dry, apply medihoney and calcium alginate, cover with ABD pad and wrap with Kerlix daily and as needed for wound care, cleanse left toe amputation surgical site with NS, pat dry, cover with ABD pad, wrap with kerlix and secure with ace wrap daily and as needed, cleanse wounds to right first and second toes with NS, pat dry, apply betadine and leave open to air daily for wound care, cleanse wound to right heel with NS, pat dry, apply medihoney and calcium alginate, cover with bordered gauze daily and as needed and cleanse left heel with NS, pat dry, apply betadine soaked gauze, cover with ABD pad, wrap with kerlix daily and as needed. Review of the NP progress note dated 06/16/25 revealed the NP progress notes had not addressed the TMA surgical site or the wounds to the resident’s feet and ankle. Review of the progress note dated 06/16/25 at 9:18 P.M. revealed the second skin assessment completed for admission on [DATE] revealed areas to left heel, left lateral ankle, right heel, right first toe and right second toes were observed. The surgical incision was closed with 25 staples related to left amputation of toes is approximated with some swelling and bruising. Review of the medical record revealed no comprehensive assessment of the wounds to his right first and second toes. Review of the medical record revealed no evidence the resident was evaluated by the facility Wound Nurse Practitioner (WNP) while at the facility on 06/19/25. Review of the resident’s five-day MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident was dependent for toileting, bathing, transfers, required substantial/maximal assistance with dressing and required partial/moderate assistance for bed mobility. The assessment indicated the resident was at risk for skin breakdown and had two unstageable pressure ulcers on admission and one deep tissue injury present on admission. The MDS did not address the vascular wounds to the resident’s right first and second toes. Review of the NP progress note dated 06/23/25 revealed the resident was being seen at the request of the nurse due to changes in mental status and dropping oxygen saturation rate of 77%. The resident was placed on three liters of oxygen via nasal cannula and his oxygen saturation rate dropped to 71%. The resident was not answering questions or following commands. The resident was non-verbal and only yells out like he was in pain. The note indicated the resident definitely had a major decline in his baseline. The resident was sent to the ER via emergency medical services (EMS). Review of the hospital Discharge summary dated [DATE] provided by the facility revealed the resident was readmitted to the local acute care hospital for altered mental status and sepsis likely source left foot postop infection/worsening gangrene. The resident’s family indicated the had had an altered mental status for the past four days. The resident was scheduled for a left above knee amputation (AKA) pending family approval. The resident was started on broad spectrum antibiotics for a white blood cell count (WBC) of 27.9. However the resident deteriorated rapidly and was noted to have bradypnea and bradycardia upon returning from CT scan with rapid apnea. The resident was pronounced at 7:55 P.M. on 06/23/25. The primary cause of death was cardiopulmonary arrest and the secondary cause was severe sepsis from left foot gangrene. Further review of the medical record revealed no physician or NP addressed the resident’s wounds or monitored the resident’s laboratory tests for changes in condition while in the facility. On 08/06/25 at 10:08 A.M., an interview with the Registered Nurse (RN) #147 revealed she functioned as the facility wound nurse. The RN said she monitors pressure ulcers and vascular wounds and the floor nurses monitor the others skin conditions. On 08/06/25 at 11:10 A.M., an interview with Nurse Practitioner (NP) #235 revealed her hours at the facility were Monday through Friday from 7:00 A.M. to 1:00 P.M. since February 2025. She said she had no part of wounds as the facility has a WNP. On 08/12/25 at 9:05 A.M., an interview with the Director of Nursing verified all wound should be assessed and monitored. The DON verified the surgical wound, vascular wound, skin tears and pressure ulcer should be assessed weekly and as needed and a treatment in place until the wounds are healed. The DON verified the resident’s change in condition was not addressed in a timely manner. 2. Review of the medical record for Resident #79 revealed an initial admission date of 12/17/20 with the diagnoses including but not limited to multiple sclerosis, diabetes mellitus, vitamin D deficiency, anxiety disorder, encounter for palliative care, opioid use, pain, cerebellar ataxia, history of falling, severe protein malnutrition, hypertension, chronic pain syndrome and adult failure to thrive. Review of the resident’s comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was dependent on staff for all activities of daily living (ADL). Review of the weekly skin and wound evaluation dated 08/07/25 revealed the resident was found to have a pressure ulcer to the right lateral elbow that had worsened in size. The note indicated the resident had a skin tear medial to the wound bed and it conjoined with the pressure ulcer which was the reasoning for the larger measurements in surface area. Review of the medical record revealed no documentation on when the skin tear was found or how the skin tear occurred. On 08/11/25 at 12:10 P.M., interview with Registered Nurse (RN) #147 verified the facility had no documentation of when and how the skin tear occurred. On 08/12/15 at 12:45 P.M., an interview with the Director of Nursing (DON) revealed she spoke with Registered Nurse (RN) #128 and the wound was from the resident’s Broda chair because her hospice company documented her up in the chair on 08/02/25 and she called the resident’s company and requested the resident’s hospice notes. The DON also verified the resident's hospice company does not provide documentation of the visit to the facility. 3. Review of the medical record for Resident #106 revealed an initial admission date of 08/04/25 with the diagnoses including but not limited to anemia, acute duodenal ulcer with hemorrhage, constipation, depression, diabetes mellitus, seasonal allergic rhinitis, hyperlipidemia, glaucoma, COPD, CHF, presence of coronary angioplasty implant and graft, ASHD, ischemic cardiomyopathy, CKD, insomnia, nicotine dependence, alcohol dependence, anxiety disorder. Review of the resident’s admission nursing evaluation dated 08/04/25 revealed the resident was admitted to the facility with a skin condition to his left elbow. The assessment did not indicated what the skin condition was or assess the skin condition. The assessment indicated the resident had no cognitive deficit. Review of the baseline plan of care contained with the admission nursing evaluation dated 08/04/25 revealed the resident had actual skin breakdown. Interventions included apply (specify: pressure relieving/reducing mattress, pillows, etc.) to protect the skin while in bed, encourage good nutrition and hydration in order to promote healthier skin, provide dietary supplements as ordered, observe location, size and treatment of skin injury, report abnormalities, failure to heal and signs/symptoms of infection, maceration, etc. to physician. Review of the baseline plan of care contained with the admission nursing evaluation dated 08/04/25 revealed the resident had the potential for skin breakdown. Interventions included Braden scale per protocol, conduct weekly head to toe skin assessments, documents and report abnormal findings to the physician, follow facility policies/protocols for the prevention/treatment of skin integrity, provide diet as ordered, observe and document food acceptance and offer supplements as needed and turn and reposition every (blank) hours and as needed. Review of the resident’s skin and wound total body skin assessment for 08/05/25, 08/06/25 and 08/11/25 revealed no new skin issues were identified. Review of the progress note dated 08/05/25 at 8:17 P.M. revealed the second skin assessment was completed and an area to the left elbow was observed. Orders for treatment and the treatment was in place. The note indicated bruising was also observed to bilateral arms. Further review of the resident’s progress notes revealed no entry indicating what the area to the left elbow was identified as. Review of the resident’s physician orders for August 2025 identified an order dated 08/05/25 to cleanse the skin tear to the left elbow with normal saline, pat dry, apply xeroform and cover with bordered gauze daily and as needed. Further review of the physician orders revealed no order to monitor the bruising to the resident’s bilateral arms. On 08/12/25 at 11:32 A.M., an interview with the Director of Nursing (DON) verified the resident had no assessment of the skin tear and no monitoring of the skin tear and bruising. 4.Review of Resident #109’s medical record revealed an admission date of 01/15/25 and a discharge date of 04/13/25 with diagnoses including pneumonia, cognitive communication deficit, generalized anxiety disorder, and chronic respiratory failure. Review of Resident #109’s five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #109’s plan of care dated 01/27/25 revealed the resident was at risk for abnormal bleeding/bruising related to medication use. Interventions included administering medications as ordered, observing for signs of complications such as bruising, and obtaining labs as ordered. Review of Resident #109’s plan of care dated 03/02/25 revealed they were at risk for fall related injury and falls related to gait and balance problems, history of falls, incontinence, diagnoses, and psychoactive drug use. Interventions included administering medications as ordered, anticipating and meeting needs, assessing risk level, completing fall risk assessment, dose reduction as appropriate, encouraging appropriate footwear, encouraging to use reacher for items out of reach, following fall protocol, and therapy evaluation and treatment as ordered. Review of Resident #109’s physician order dated 03/21/25 to 04/14/25 revealed an order for Apixban (an anticoagulant) 2.5 milligrams (mg) one tablet by mouth twice a day for atrial fibrillation. Review of Resident #109’s progress note dated 04/10/25 revealed the resident had bruises on the left side of her upper body from using a gait belt during transfer by staff. The resident denied any pain from the bruises. An X-ray was ordered by the Certified Nurse Practitioner (CNP) to rule out any fracture. Review of Resident #109’s progress note dated 04/11/25 revealed an order to discontinue the order for an X-ray to the arm. The resident did not have any falls or incidents that could cause injuries. Review of Resident #109’s interdisciplinary team note dated 04/11/25 revealed the team met to review a bruise noted to the residents left upper body. It was noted that there was a bruise to her left underarm that extended under her left breast. After speaking with the resident and Certified Nursing Assistant (CNA) it was revealed that during a transfer from the bed to the wheelchair the resident's knees gave out. The CNA tightened the gait belt and guided the resident to the wheelchair to prevent a fall. Intervention was to offer and encourage two person assistance with all transfers. Review of Resident #109’s medical record revealed no measurement of the bruise or further monitoring. Review of Resident #109’s hospital notes dated 04/13/25 revealed a CT scan was done. The resident was found to have a chest wall hematoma that was being monitored to ensure it was not spreading. Interview on 08/07/25 at 10:28 A.M. with Assistant Director of Nursing (ADON) #128 revealed initially they thought the resident had an unwitnessed fall, so an X-ray was ordered. When they figured out what happened the nurse practitioner cancelled the X-ray because the resident had not fallen. They were notified of the bruising by therapy and the actual incident occurred on 04/09/25. ADON #128 stated she brought the CNA to the residents room and had her explain what happened. She had the resident had started to fall and the gait belt started to slide up and it tightened around her breast area. They educated the CNA that she should have let the nurse know of the incident. She verified there was no monitoring of the bruise, but stated it was a big bruise and they would have noticed if it had gotten bigger. She indicated it was from the waist up to the shoulder. She reported the incident happened quickly and she would not have wanted the resident to fall. Review of the facility policy titled, Skin Management, last revised 08/14/24 revealed a skin tear is an opening or break in the skin due to friction, shear or trauma and is technically a separation of the epidermis and dermis. All skin tears will be evaluated, documented and treated based on physician orders. On occurrence all skin tears will be reported to the licensed nurse, an incident and accident report is to be completed, the licensed nurse is responsible for documenting skin tears upon occurrence and monitoring on a weekly basis until healed. This deficiency represents noncompliance related to complaint 2580593, 2574352, and 1399347.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to develop a detailed and comprehensive care plan for Resident #19, #26, #27, #34, #79, and #108. This affected six residents (#19, #26, #27, #34, #79, and #108) of 19 resident records reviewed. The facility census was 107.Findings include: 1.Review of Resident #108’s medical record revealed an admission date of 04/26/25 and a discharge date of 06/24/25 with diagnoses including muscle weakness, end stage renal disease with dependence on dialysis, type two diabetes mellitus, fracture of sacrum, pressure induced deep tissue damage of left heel, pressure ulcer of left ankle, chronic obstructive pulmonary disease, alcohol abuse, and peripheral vascular disease. Review of Resident #108’s five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #108’s plan of care dated 04/26/25 revealed ‘preferred name’ was at risk for complications related to dialysis. Interventions included encouraging him to go for the scheduled appointments, observing for signs of fluid retention, observing for signs of infection to access site, observing for bruising or bleeding, and palpitating for the presence of thrill and listen for bruit as needed. The plan of care was not specific to the resident, did not include where he went to dialysis, how to contact them, or when he was to go to dialysis. Review of Resident #108’s plan of care dated 04/26/25 revealed ‘preferred name’ was at risk for pain; it did not indicate why the resident was at risk for pain. Interventions included nonpharmacological interventions to prevent and manage pain as needed, anticipating residents’ need for pain relief, notifying if interventions are unsuccessful, observing and reporting changes in routine, and observing for side effect of pain meds. The plan of care was not specific to the resident. Review of Resident #108’s plan of care dated 04/26/25 revealed ‘preferred name’ was at risk for fall related injury and falls, it did not indicate why the resident was at risk. Interventions included dycem to wheelchair, encouraging appropriate footwear, keeping a safe environment, moving closer to nurses’ station, and offering and encouraging toileting after breakfast. The plan of care was not specific to the resident. Review of Resident #108’s medical record revealed he had been in the facility for over 14 consecutive days from 4/26/25 to 05/13/25. Interview on 08/11/25 at 1:07 P.M. with MDS Nurse #215 verified Resident #108’s care plan was not specific to the resident. She reported this was due to him being in and out of the facility with hospitalizations. 2. Review of Resident #34’s medical record revealed an admission date of 04/18/25 with diagnoses including chronic heart failure, chronic obstructive pulmonary disease, muscle weakness, chronic kidney disease stage four, anxiety disorder, and chronic respiratory failure. Review of Resident #34’s quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #34’s plan of care dated 04/18/25 revealed ‘preferred name’ was incontinent of bowel and bladder; the plan of care did not indicate what this was related to. Interventions included only brief usage and checking every two hours and as needed for incontinence. Review of Resident #34’s plan of care dated 04/18/25 revealed ‘preferred name’ had a functional ability deficit and required assistance with self-care and mobility; the plan of care did not indicate what this was related to. There were no interventions related to this. Review of Resident #34’s plan of care dated 04/18/25 revealed ‘preferred name’ was at risk for fall related injury and falls, the plan of care did not indicate what this was related to. There were only two interventions providing two-person assistance with ambulation and mechanical lift for transfers. Interview on 08/11/25 at 1:07 P.M. with MDS Nurse #215 verified her care plan was not complete. She reported she thought the other MDS nurse had completed it, and she had not. 3. Review of Resident #26’s medical record revealed an admission date of 06/18/25 with diagnoses including chronic heart failure, acute respiratory failure, end stage renal disease, diabetes mellitus, and depression. Review of Resident #26’s MDS 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #26’s plan of care on 08/11/25 revealed it did not address any discomfort or pain the resident experienced or oxygen usage. Review of Resident #26’s physician order dated 07/23/25 revealed an order for hydrocodone-acetaminophen 325 milligrams (mg) one tablet by mouth every eight hours as needed for pain. Interview on 08/11/25 at 1:07 P.M. with MDS Nurse #215 verified Resident #26 did not have a pain plan of care and should have. 4. Review of Resident #27’s medical record revealed an admission date of 06/06/25 with diagnoses including metabolic encephalopathy, chronic respiratory failure, chronic heart failure, and moderate protein-calorie malnutrition. Review of Resident #27’s comprehensive MDS assessment dated [DATE] revealed he had intact cognition. Review of the plan of care dated 6/6/25 revealed ‘preferred name’ had a functional ability deficit and required assistance with self-care mobility, it did not indicate what this was related to. Interventions did not include the residents specific activity of daily living needs. Interview on 08/12/25 at 11:08 A.M. with MDS Nurse #215 verified the care plan was not complete. 5. Review of the medical record for Resident #19 revealed an initial admission date of 04/24/25 with the diagnoses including but no limited to congestive heart failure, atrial fibrillation, hypertension, rheumatoid arthritis, insomnia, hyperlipidemia, vascular dementia, osteoporosis, arthritis, constipation, sensorineural hearing loss and adult failure to thrive. Review of the resident’s admission nursing comprehensive evaluation dated 04/18/25 revealed the resident was continent of both bowel and bladder. Review of the resident’s comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for toileting and transferring to the toilet was not attempted. The assessment indicated the resident was frequently incontinent of both bowel and bladder. Review of the quarterly nursing comprehensive evaluation dated 07/18/25 revealed the resident was continent of both bowel and bladder. Review of the resident’s quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for toileting and transferring to the toilet. The assessment indicated the resident was always incontinent of both bowel and bladder. Review of the plan of care revealed the resident had no care plan addressing resident's bowel and bladder function. On 08/12/25 at 1:14 P.M., interview with the Minimum Data Set (MDS) Coordinator #215 verified the resident had no plan of care addressing her bowel and bladder incontinence. 6. Review of the medical record for Resident #79 revealed an initial admission date of 12/17/20 with the diagnoses including but not limited to multiple sclerosis, diabetes mellitus, vitamin D deficiency, anxiety disorder, encounter for palliative care, opioid use, pain, cerebellar ataxia, history of falling, severe protein malnutrition, hypertension, chronic pain syndrome and adult failure to thrive. Review of the plan of care dated 07/23/25 revealed the resident had actual impaired skin integrity related to pressure injury stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) right gluteus and right lateral elbow. Interventions included observe for signs of discomfort with dressing changes and administer pain, refer to Dietician as needed, specialty bed as ordered and treatment as ordered. Review of the Wound Nurse Practitioner (WNP) progress note dated 07/24/25 at 8:00 A.M. revealed the resident was found to have an unstageable (Known but not stageable due to coverage of wound bed by slough and/or eschar pressure ulcer to the right gluteus measuring 2.3 cm by 1.9 cm by 0.1 cm and the wound was described as being 30% granulation and 70% slough. The wound had a moderate amount of serosanguineous drainage. The NP ordered the treatment cleanse with NS, apply Therahoney and calcium alginate and cover with bordered foam daily and as needed. Review of the WNP progress note dated 07/31/25 at 8:00 A.M. revealed the resident was found to have an unstageable pressure ulcer to the right gluteus measuring 3.1 cm by 1.7 cm and the wound was described as being 30% granulation and 70% slough. The facility determined the wound had deteriorated. The progress note also indicated the resident was found to have an unstageable pressure ulcer to the right elbow measuring 1.8 cm by 1.2 cm was described as being 10% granulation and 90% slough. The wound had a moderate amount of serosanguineous exudate. Review of the WNP progress note dated 08/07/25 at 8:00 A.M. revealed the resident was found to have an unstageable pressure ulcer to the right gluteus measuring 2.6 cm by 2.0 cm and the wound was described as being 30% granulation and 70% slough. The wound had a moderate amount of serosanguineous drainage. The facility determined the wound had deteriorated. The progress note also indicated the resident was found to have an unstageable pressure ulcer to the right elbow measuring 2.3 cm by 1.9 cm by 0.1 cm and was described as being 30% granulation and 70% slough. The wound had a moderate amount of serosanguineous exudate. On 08/12/25 at 1:14 P.M., interview with the Minimum Data Set (MDS) Coordinator #215 verified the resident's plan of care reflected the resident having a stage II pressure ulcer instead of the actual unstageable pressure ulcer. Review of policy ‘Care planning’ dated 03/03/25 revealed the care plan must be specific, resident centered, individualized and unique to each resident. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner. This affected four residents (#10, #11, #12, #67) of 107 residents. The facility census was 107.Findings include:1.Review of Resident #10's medical record revealed an admission date of 12/14/23 with diagnoses including spinal stenosis, anxiety disorder, cognitive communication deficit, depression, and type two diabetes mellitus.Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition.Observation on 08/11/25 at 2:50 P.M. of Resident #10's room revealed a build up debris under her bed including bits of plastic. 2.Review of Resident #11's medical record revealed the resident admitted on [DATE] with diagnoses including unspecified mood disorder, type two diabetes mellitus, cerebral infarction, aphasia, and hemiplegia and hemiparesis affecting left non-dominant side.Review of Resident #11's five-day MDS 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition.Observation on 08/11/25 at 2:50 P.M. of Resident #11's room revealed brown splatters next to Resident #11's bed and her bedside table was covered in numerous white stains. 3.Review of Resident #12's medical record revealed an admission date of 06/04/22 with diagnoses including Alzheimer's disease, muscle weakness, dysphagia, legal blindness, and cerebrovascular disease.Review of Resident #12's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition.Observation on 08/11/25 beginning at 10:42 A.M., 2:50 P.M., and 4:20 P.M. of Resident #12's room revealed her comforter had multiple yellow stains and had food caked on it. The wall next to her bed had unidentifiable black splatters covering it.4.Review of Resident #67's medical record revealed an admission date of 08/25/21 with diagnoses including dysphagia, cerebral infarction, unspecified dementia, major depressive disorder, and hemiplegia and hemiparesis affecting left non-dominant side.Review of Resident #67's five-day MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition.Observation on 08/11/25 at 4:20 P.M. of Resident #67's room revealed the wall next to her bed had brown splatters and under her bed had a buildup of dust and various items including straws and bits of plastic. Additionally, her bedside table was covered in unidentifiable stains. Interview on 08/11/25 at 4:20 P.M. with the Administrator verified the above observations in resident rooms.Review of the policy ‘Housekeeping Services' dated 07/11/25 revealed thorough scrubbing was to be used for all environmental surfaces cleaned in resident areas. Areas to be cleaned in resident rooms included all horizontal flat surfaces, over bed tables and walls should be spot cleaned if visibly soiled. This deficiency represents noncompliance investigated under Complaint Number 1399441.

Based on open and closed record review and interviews, the facility failed to ensure bowel and bladder tracking to reflect an accurate reflection of the resident's bowel and bladder function. This affected three residents (#19, #59 and #108) of three residents reviewed for decline in bowel and bladder function. Additionally, the facility failed to timely assess and treat a urinary tract infection (UTI) for Resident #38. This affected one resident (#38) of three residents reviewed for UTI's. The facility census was 107.Findings Include:1.Review of the medical record for Resident #19 revealed an initial admission date of 04/24/25 with the diagnoses including but no limited to congestive heart failure, atrial fibrillation, hypertension, rheumatoid arthritis, insomnia, hyperlipidemia, vascular dementia, osteoporosis, arthritis, constipation, sensorineural hearing loss and adult failure to thrive. Review of the resident’s admission nursing comprehensive evaluation dated 04/18/25 revealed the resident was continent of both bowel and bladder. Review of the resident’s comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for toileting and transferring to the toilet was not attempted. The assessment indicated the resident was frequently incontinent of both bowel and bladder. Review of the quarterly nursing comprehensive evaluation dated 07/18/25 revealed the resident was continent of both bowel and bladder. Review of the resident’s quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for toileting and transferring to the toilet. The assessment indicated the resident was always incontinent of both bowel and bladder. Review of the plan of care revealed the resident had no care plan addressing her bowel and bladder incontinence. 2. Review of the medical record for Resident #59 revealed an initial admission date of 12/06/24 with the diagnoses including but not limited to diabetes mellitus, encounter for other orthopedic aftercare, end stage renal disease, hypertension, cardiomegaly, chronic obstructive pulmonary disease, hypothyroidism, insomnia, peripheral vascular disease, dysphagia, atrial fibrillation and dependence on renal dialysis. Review of the resident’s admission nursing comprehensive evaluation dated 12/06/24 revealed the resident was continent of both bowel and bladder. Review of the resident’s comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident required supervision or touch assistance with toileting and partial/moderate assistance to transfer on and off the commode. The assessment indicated the resident was occasionally incontinent of both bowel and bladder. Review of the quarterly nursing comprehensive evaluation dated 03/06/25 revealed the resident was continent of both bowel and bladder. Review of the resident’s quarterly MDS assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident required supervision or touch assistance with toileting and transfers on and off the commode. The assessment indicated the resident was frequently incontinent of both bowel and bladder. Review of the medical record revealed no interventions implemented by the facility to restore the resident’s bowel and bladder function to his baseline of occasionally incontinent of both bowel and bladder. Review of the plan of care dated 04/06/25 revealed the resident had episodes of bowel and bladder incontinence, bladder frequent, bowel frequent and incontinence was likely to fluctuate. Interventions included resident uses disposable briefs, change frequently and as needed, check resident frequently and as needed for incontinence, wash, rinse and dry perineum, change clothing as needed after incontinence episodes, observe for signs/symptoms of urinary tract infection (UTI), observe skin with each incontinent episode and report any redness, skin integrity changes, rash, pain, etc. to the nurse, provide incontinence care with each incontinent episode and apply moisture barrier as needed. Review of the quarterly nursing comprehensive evaluation dated 06/06/25 revealed the resident was continent of both bowel and bladder. Review of the resident’s quarterly MDS assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident required supervision or touch assistance with toileting and transfers on and off the commode. The assessment indicated the resident was frequently incontinent of bowel and occasionally incontinent of bladder. Review of the medical record revealed no interventions implemented by the facility to restore the resident’s bowel and bladder function to his baseline of occasionally incontinent of both bowel and bladder. Review of the medical record revealed no evidence a bowel and bladder assessment was completed. 3. Review of the closed medical record for Resident #108 revealed an initial admission date of 04/26/25 with the latest readmission of 06/13/25 with the diagnoses including but not limited to other mechanical complication of surgically created arteriovenous (AV) fistula, acquired absence of other left toes, encounter for orthopedic aftercare following surgical amputation, generalized muscle weakness, hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease or end stage renal disease, end stage renal disease (ESRD), diabetes mellitus, pressure induced deep tissue injury (DTI) to left heel, (DTI to left ankle unstageable, atrial fibrillation, anemia, opioid use, depression, urinary tract infection, chronic obstructive pulmonary disease, open-angle glaucoma right eye, asthma, pulmonary hypertension, dependence on renal dialysis, chronic congestive heart failure, peripheral vascular disease, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, cardiomyopathy, hyperlipidemia, constipation and atherosclerotic heart disease. Review of the resident’s admission nursing comprehensive evaluation dated 04/26/25 revealed the resident was admitted to the facility continent of both bowel and bladder. Review of the resident’s comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident required substantial/maximal assistance with toileting, bathing, dressing, bed mobility and transfers were not attempted. The assessment indicated the resident was frequently incontinent of bladder and frequently incontinent of bladder. Review of the resident’s admission nursing comprehensive evaluation dated 05/29/25 revealed the resident was readmitted to the facility incontinent of both bowel and bladder. Review of the plan of care dated 05/30/25 revealed the resident was at risk for discomfort or adverse side effects, receives antibiotics related to UTI. Interventions included administer medications as ordered, any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions, monitor every shift for adverse reaction, observe for emergence of undesired microorganisms, causing secondary infections such as oral thrush, colitis, and vaginitis and report to physician as indicated. Review of the resident’s five day MDS assessment dated [DATE] revealed the resident had no cognitive impairment. The assessment indicated the resident required partial/moderate assistance with toileting, bathing, substantial/maximal assistance with dressing, bed mobility and transfers. The assessment indicated the resident was frequently incontinent of bladder and always incontinent of bowel. Review of the resident’s readmission nursing comprehensive evaluation dated 06/13/25 revealed the resident was readmitted to the facility continent of both bowel and bladder. Review of the resident’s five-day MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident was dependent for toileting, bathing, transfers, required substantial/maximal assistance with dressing and required partial/moderate assistance for bed mobility. The assessment indicated the resident was always incontinent of both bowel and bladder. On 08/12/25 at 11:13 A.M., interview with Minimum Data Set (MDS) Coordinator #215 revealed the facility documents on the resident's bowel and bladder continence once a shift. She revealed she bases the residents bladder incontinence on the two entries entered daily and they tend to fluctuate. The MDS Coordinator revealed the facility does not track the resident's bowel and bladder function with each episode during the MDS seven day window. The MDS Coordinator verified the facility does not complete bowel and bladder assessments or participate in a restorative or maintenance program to maintain resident's baseline continence. 4. Review of Resident #38’s medical record revealed an admission date of 04/16/21 with diagnoses including schizoaffective disorder, paranoid personality disorder, dementia, delirium, anxiety disorders, and encephalopathy. Review of Resident #38’s Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #38’s plan of care dated 12/21/23 revealed the resident was incontinent of bladder and bowel related to aging process. Interventions included using disposable briefs, checking every two hours and as needed for incontinence, and providing incontinence care with moisture barrier as needed. Review of Resident #38’s change of condition progress note dated 07/22/25 revealed the resident was complaining of left side and lower back pain. There was a new order for polyethylene glycol for constipation and a Kidney, ureter, and bladder (KUB) x-ray. Review of Resident #38’s KUB results dated 07/23/25 revealed the resident had a nonobstructive bowel gas pattern. Review of Resident #38’s medical record from 07/24/25 to 07/27/25 revealed no further mention of the resident’s left sided pain. Review of Resident #38’s physician order dated 07/28/25 revealed an order for a urinary analysis with culture and sensitivity for urinary tract infection (UTI). Review of Resident #38’s progress notes from 07/28/25 to 08/09/25 revealed no further mention of a UTI. Review of Resident #38’s urine culture collected 07/29/25 and reported 08/01/25 revealed it did not indicate any bacteria present in the urine but, it indicated what the bacteria was sensitive to. Review of Resident #38’s urine screen and culture collected 08/05/25 and reported 08/07/25 revealed her results were abnormal, and she had bacteria present that was sensitive to specific bacteria, however, no bacteria was listed. Review of Resident #38’s lab result reported 08/06/25 revealed the resident had Escherichia coli in her urine. Review of Resident #38’s nurse practitioner note dated 08/08/25 revealed the resident was on ciprofloxacin for a urinary tract infection. The nurse practitioner suspected the flank pain was more musculoskeletal in nature. Interview on 08/11/25 at 12:00 P.M. with the Director of Nursing (DON) revealed on 07/22/25 or 07/23/25 the resident reported flank plan. This was thought to be constipation, so when it came back negative they reassessed her and decided to check for a UTI. It came back negative so she was checked for a urinary tract infection. The first results on 08/01/25 came back without the organism, so they sent it back. She was unsure of what happened with the lab and verified there was no documentation of the nurse practitioner or physician being notified of any results. Additionally, there was no documentation of the physician or nurse practitioner’s plans after the negative KUB results. From the negative KUB to an order for a urinary analysis there was five days. This deficiency represents noncompliance investigated under complaint 2580593 and 2574352.

Based on observation, record review, interview and facility policy review, the facility failed to ensure call lights were accessible for use. This affected two residents (#32 and #79) of 14 sampled residents. The facility census was 107.Findings Include:1. Review of the medical record for Resident #79 revealed an initial admission date of 12/17/20 with the diagnoses including but not limited to multiple sclerosis, diabetes mellitus, vitamin D deficiency, anxiety disorder, encounter for palliative care, opioid use, pain, cerebellar ataxia, history of falling, severe protein malnutrition, hypertension, chronic pain syndrome and adult failure to thrive. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. On 08/08/25 at 10:18 A.M., observation of Resident #32 revealed the resident's call light was laying on the floor at the bottom of the bed out of the resident's reach. Interview with Certified Nursing Assistant (CNA) #203 verified the resident's call light was out of reach. 2. Review of the medical record for Resident #32 revealed an initial admission date of 06/20/25 with the diagnoses including but not limited to metabolic encephalopathy, generalized muscle weakness, cognitive communication deficit, tremor, white matter disease, moderate protein calorie malnutrition, hypertensive heart disease without failure, hyperlipidemia, constipation and need for assistance with personal care. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. On 08/12/25 at 9:30 A.M., observation of Resident #32 revealed the resident's call light was clipped to the enabler bar hanging down out of the resident's reach. On 08/12/25 at 9:35 A.M., interview with Registered Nurse (RN) #172 verified the resident's call light was not within reach. Review of the facility policy titled, Call Lights, dated 03/12/25 revealed call light will be placed within the resident's reach and answered in a timely manner.This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on closed record review, interview, and policy review the facility failed to ensure Resident #100, a newly admitted resident received hemodialysis services timely and as recommended by the hospital at the time of the resident's hospital discharge and failed to ensure timely and ongoing monitoring of the resident's hemodialysis access site for patency and/or signs of infection. This affected one resident (#100) of three residents reviewed for dialysis services. The facility census was 96. Actual harm occurred on 08/14/24 when the facility failed to ensure Resident #100 received hemodialysis treatments as ordered (between 08/10/24 and 08/14/24) resulting in an acute change in the resident's condition, including a swollen abdomen, generalized edema throughout the resident's body and presence of excessive fluid requiring transfer to the hospital for hemodialysis. The resident did not return to the facility after being transferred to the hospital. Findings include: Review of the closed medical record for Resident #100 revealed the resident was admitted to the facility on Saturday 08/10/24 with diagnoses including acute osteomyelitis, altered mental status, end stage renal disease, type two diabetes mellitus with hyperglycemia requiring long term use of insulin, ascites, hepatomegaly with splenomegaly and chronic kidney disease. Record review revealed the resident received hemodialysis. Review of hospital discharge record from the resident's hospitalization [DATE] to 08/10/24 revealed the resident was to follow up with dialysis services with a current dialysis schedule of Tuesday, Thursday, and Friday. Review of communication email dated 08/09/24 to the facility-based dialysis center admissions revealed Admissions Coordinator #170 notified the dialysis center the resident would be admitting on 08/10/24. The facility-based dialysis center performed dialysis treatments on Monday, Wednesday, and Fridays. Review of an admission assessment completed 08/10/24 revealed the resident was admitted due to osteomyelitis and was identified with dialysis access via arteriovenous (AV) shunt with a positive bruit and thrill. Review of the physician's orders with a start date of 08/13/24 (three days after admission) revealed liberal renal/cardiac consistent diet with double protein. There was also an order dated 08/12/24 (two days after admission) for staff to check bruit and thrill to left upper arm. And to observe fistula to left upper arm for thrombosis bleeding, stenosis, infection, steal syndrome and aneurysm. An additional order dated 08/12/24 (two days after admission included an order for the medication Velphoro (for chronic kidney disease). Lastly, an order dated 08/12/24 included the resident was to receive hemodialysis in house Monday, Wednesday and Friday. Review of the medication administration record (MAR) revealed Resident #100's fistula was first assessed beginning on 08/12/24 during night shift and continued until discharge on [DATE]. Review of a plan of care created on 08/12/24 revealed Resident #100 was at risk for complications related to the need for dialysis. A second plan of care revealed the resident was at nutritional and/or dehydration risk related to end-stage renal disease on hemodialysis. Neither care plan included any interventions. Review of an eINTERACT transfer form dated 08/14/24 revealed Resident #100 was exhibiting edema (new or worsening) of the abdomen. The form noted the resident had dialysis treatments on Monday, Wednesday, and Fridays and had a fistula to his left arm with provider recommendation to send to the hospital for evaluation. Review of a progress note dated 08/14/24 revealed Resident #100 ordered to be sent out to a local hospital for dialysis. Abdomen noted to be distended. Review of dialysis schedule for 08/12/24 and 08/14/24 revealed Resident #100 was not on the list to receive dialysis services on these dates. Review of 5-day Minimum Data Set (MDS) 3.0 assessment completed 08/28/24 revealed Resident #100 was cognitively intact and required assistance with activities of daily living. Interview on 09/30/24 at 11:06 A.M. with Admissions Coordinator #170 revealed an email was sent to the dialysis center informing the clinic of Resident #100's admission on 08/10/24; however, Admissions Coordinator #170 did not confirm with the clinic the resident had been admitted to the facility on [DATE]. Admission Coordinator #170 said the resident was marked as pending during the duration of his stay and due to the pending status, the resident was not placed on the dialysis schedule to receive dialysis treatment. Admissions Coordinator #170 revealed facility staff were expected to notify dialysis of new admissions to put them as active in the system. Interview on 09/30/24 at 11:19 A.M. with Licensed Practical Nurse (LPN) #268 revealed Resident #100 was admitted on [DATE] on her shift. Through review of the hospital record, it was identified the resident required dialysis services. LPN #268 informed the Director of Nursing (DON) who the LPN stated was responsible for dialysis admissions on the weekend, and did not hear an update back. LPN #268 confirmed she was responsible for putting in initial physician orders upon admission for residents to receive dialysis, LPN #268 confirmed she put in all admitting orders including the orders for dialysis on 08/10/12 and called the physician to verify. She did not see that the orders were verified by the physician by the end of her shift and she pass the information on to the oncoming nurse. The oncoming nurse was unable to be reached for interview by the surveyor. LPN #268 confirmed the next on-shift nurse was informed the resident was a dialysis patient. Interview on 09/30/24 at 2:33 P.M. with the DON denied working in the facility from 08/10/24 to 08/13/24. Upon her return (on 08/14/24), she stated she was informed Resident #100 had not received dialysis services as required and would require transfer to the hospital. The DON confirmed facility nursing staff should confirm with the dialysis clinic when a resident was physically in the building so they could remove them as pending in the dialysis system and add them to the schedule. The DON confirmed the resident did not receive two of his scheduled dialysis treatments, on 08/12/24 and 08/14/24 as per the order obtained on 08/12/24 for hemodialysis treatments every Monday, Wednesday and Friday. Interview on 09/30/24 at 11:29 A.M. with the dialysis admissions coordinator revealed the clinic had been informed Resident #100 was planning on admitting to the facility on [DATE]. The Admissions coordinator denied facility staff followed-up to confirm the resident was actually admitted on [DATE] and required dialysis services to begin. Interview on 09/30/24 at 12:58 P.M. with the dialysis nurse revealed she was made aware on 08/14/24 Resident #100 had been admitted to the facility and did not receive scheduled dialysis treatment as ordered. Resident #100 was assessed by the dialysis nurse after notification and was found to have a swollen abdomen and generalized edema throughout his body. The dialysis nurse voiced Resident #100 did not look good due to the excessive fluid, and he would need to go to the hospital to receive dialysis treatment. The dialysis nurse said the resident was marked as pending in the system and facility staff did not notify the clinic he was admitted . Interview on 09/30/24 at 2:35 P.M. with the administrator confirmed the facility provided dialysis services on Monday, Wednesday and Friday when Resident #100 was admitted due to a low number of resident requiring dialysis services. Interview on 09/30/24 at 3:10 P.M. with Registered Nurse #143 revealed facility best practice for when a dialysis resident was admitted to the facility was to walk down to the clinic located in the facility and confirm with staff in-person and ask when the resident could receive treatment. Interview on 09/30/24 at 3:17 P.M. with Unit Manager #149 confirmed facility staff were required to confirm with the dialysis clinic that a resident had been admitted to the facility so they could remove the resident's pending status. Review of hemodialysis policy dated 09/26/23 revealed hemodialysis was a potentially life-saving procedure that removed blood from the body and circulated it through a purifying dialyzer, then returned the blood to the body. Staff were required to obtain a physician's order for hemodialysis upon admission. This deficiency represents non-compliance investigated under Complaint Number OH00156992 and Complaint Number OH00156955.

Based on medical record review, review of hospital medical records, observations, resident and staff interviews, and facility policy review, the facility failed to provide timely treatment and care in response to resident's change in condition resulting in hospitalization s. This resulted in actual harm for Resident #37, who was admitted to the facility on [DATE], was sent to the hospital from an outside appointment on 07/18/23 due to abdominal distention and a concern for a bowel obstruction related to multiple days of having no bowel movements and no treatment. Resident #37 received a computed topography (CT) scan of her abdomen in the emergency department which revealed a bowel obstruction. A gastrointestinal (GI) consult was completed, and Resident #37 received surgery for a loop colostomy to be placed. This resulted in actual harm when Resident #6, who was initially admitted on [DATE] and readmitted to the facility on [DATE], reported to the facility staff he was having a stroke on 02/25/24 and requested to be sent out to the hospital. Registered Nurse (RN) #732 did not send Resident #6 out to the hospital as requested or inform the physician of Resident #6's desire to go to the hospital. Resident #6 had a history of cerebral infarction (CVA) (stroke). Physician Assistant (PA) #620 assessed Resident #6 on 02/26/24 and found the resident presented with dysarthria, significant left facial droop, and significant left side hemiparesis, likely consistent with an acute CVA. Resident #6 was sent to the hospital where a diagnosis of acute CVA was confirmed. This resulted in actual harm for Resident #85, who was initially admitted on [DATE] and readmitted to the facility on [DATE], was transferred to the hospital on 04/17/24 at approximately 6:45 P.M. due to an altered mental status after the facility was unable to obtain STAT (immediate) laboratory values ordered by the provider. Resident #85 was nearly unresponsive, hypotensive (low blood pressure), tachycardic, and febrile with a temperature of 104.8 degrees Fahrenheit upon arrival at the hospital. Resident #85 was diagnosed with septic shock related to a catheter associated urinary tract infection (CAUTI) and was admitted to the hospital. Resident #85 remained in the hospital for further treatment until 04/22/24. This affected three residents (#37, #6 and #85) of four residents reviewed for changes in condition. The facility census was 101. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted on 03/07/19. Diagnoses include colostomy status (07/21/23), malignant neoplasm of brain (03/07/19), abnormal posture (07/28/23), constipation (03/07/19), and encounter for surgical aftercare following surgery on the digestive system (07/28/23). Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had impaired cognition and scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #37 required setup or clean-up assistance from staff with eating; supervision or touching assistance with oral hygiene; substantial or maximum assistance with upper body dressing; and was totally dependent on staff assistance to complete toileting, bathing, lower body dressing, bed mobility, and transfers. Resident #37 did not have an ostomy and was always incontinent of bowel and bladder. Review of the clinical census for Resident #37 revealed the resident was hospitalized from 07/18/23 until 07/28/23 (ten days). Review of the Medication Administration Record (MAR) dated July 2023 revealed Resident #37 received Miralax Oral Powder 17 grams (GM) per scoop daily for constipation and Senna Oral Tablet 8.6 milligrams (mg) daily for constipation. Resident #37 had an additional order for Bisacodyl Rectal Suppository 10 mg every 24 hours as needed (PRN) for constipation. The PRN suppository was not administered to Resident #37 in the month of July 2023. Review of the Treatment Administration Record (TAR) dated July 2023 revealed Resident #37 had an order to please schedule abdominal computed tomography (CT) scan related to abdominal distention dated 06/29/23. This order was not marked as completed. An additional order to obtain the results of the abdominal CT scan completed on 07/14/23 and upload to Resident #37's medical record for review by the physician/Certified Nurse Practitioner (CNP) dated 07/18/23. This order was marked as completed on 07/18/23. Review of Toileting Documentation dated July 2023 revealed Resident #37 had normal stools on 07/01/23. No bowel movements were documented from 07/02/23 through 07/05/23 (four days). Loose stools were documented on 07/06/23 and 07/07/23. No bowel movements were documented from 07/08/23 through 07/10/23 (three days). A loose stool was documented on 07/11/23. No bowel movement was documented on 07/12/23. Loose stools were documented on 07/13/23 and 07/14/23. No bowel movements were documented from 07/15/23 through 07/17/23 (three days). A loose stool was documented on 07/18/23. Review of progress notes dated from 07/01/23 through 07/31/23 revealed on 07/13/23 at an unknown time, Resident #37 was seen by CNP #612 for follow up on abdominal distention. A previous kidney, ureter, and bladder (KUB) x-ray showed progressed colonic ileus (a motility disorder that causes a nonmechanical obstruction in the colon) with moderate stool burden. Scheduled Miralax and Senna medications (laxatives) were ordered. Outputs were to be monitored. If no improvement, consider an abdominal CT scan. No worsening of symptoms or issues were noted but not resolved. A CT scan of the resident's abdomen was scheduled for 07/14/23. On 07/14/23 at 6:14 P.M., Resident #37 was noted to have returned from an abdominal CT scan appointment at around 12:00 P.M. with no new orders. On 07/18/23 at 9:00 A.M., Resident #37 was noted to leave the facility to attend an outside appointment. On 07/18/23 at 5:36 P.M., Resident #37 was noted to be sent to the hospital from her appointment. Resident #37 was in the emergency room and was awaiting a bed. Review of the hospital records dated 07/19/23 revealed Resident #37 had a diagnosis of bowel obstruction. Resident #37 presented to the emergency room from her neuro oncology appointment due to abdominal distention and concern for a bowel obstruction. An abdominal CT scan was completed and showed continued sigmoid colon dilation with transition point in the distal sigmoid colon, which may represent partial obstruction. A gastrointestinal (GI) consult was recommended. An abdominal x-ray was completed on 07/18/23 which showed gaseous colonic dilation that had increased compared to the recent CT scan. A large amount of stool burden was found especially in the right hemicolon. A GI consult was completed on 07/19/23. The risk for perforation was too high to perform a flexible sigmoidoscopy (a diagnostic procedure that allows a doctor to examine the lower colon and rectum) and planned for a loop colostomy surgery completed on 07/21/24. On 07/28/23 at 1:35 P.M., Resident #37 returned to the facility from the hospital. Review of the After Visit Summary (AVS) dated 07/28/23 revealed Resident #37 was discharged from the hospital with a colostomy in place. Review of the care plan, (initially dated 10/21/19) and revised 07/29/23, revealed Resident #37 was at risk for constipation related to decreased mobility, medication side effects, and rectal mass on 10/21/19. Interventions included administer medications as ordered, increase fiber and fluid intake, observe for signs and symptoms of bowel obstruction: abdominal distention, decreased appetite, and/or diarrhea with continued feelings of fullness and report findings to the physician, record bowel movement pattern after each occurrence describing amount and consistency. The revised care plan dated 07/29/23 revealed Resident #37 was at risk for complications related to a colostomy in place related to a small bowel obstruction (SBO). Interventions included change colostomy bag as needed, check for proper fit of colostomy bag to stoma, empty colostomy bag every shift and as needed, observe for air in the colostomy bag frequently and release as needed, observe for bowel movement and document, report a lack of bowel movement to nursing and physician, observe for diarrhea, constipation, dehydration, and pain every shift, observe for ostomy functioning, and observe stoma site and surrounding skin during each change for warmth, redness, or tenderness. Review of a follow-up surgical note, dated 08/15/23, revealed Resident #37 had a post-operative visit after creation of a loop transverse colostomy. A follow-up flexible sigmoidoscopy which did not reveal any masses or strictures. Interview on 05/22/24 at 3:33 P.M. with the Director of Nursing (DON) revealed if a resident did not have a bowel movement for three days, the physician or CNP should be notified, and any ordered PRN laxatives or suppositories should be administered. Interview on 05/23/24 at 10:35 A.M. with the DON confirmed Resident #37 had documented normal stools on 07/01/23 followed by not having a bowel movement for several days and then having loose stools until the resident was sent to the hospital on 07/18/23 from an outside appointment. The DON confirmed loose stools could be a sign of a bowel obstruction when the resident was noted to be able to form normal stools previously. The DON confirmed Resident #37 did not receive a PRN suppository when she was noted without a bowel movement for at least three days in a row. A facility policy related to treatment of constipation and/or treatment for a change in condition was requested at the time of the survey, however, the facility did not have any policies which addressed either area. 2. Review of the medical record for Resident #6 revealed an initial admitted on 12/12/22 and a readmitted to the facility on [DATE]. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and paralysis on one side of the body) (03/02/24), cerebral infarction (CVA) (stroke) (03/02/24), dysarthria following cerebral infarction (slurred speech) (03/02/24), and dysphagia following cerebral infarction (difficulty swallowing) (03/02/24). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #6 had impaired cognition and scored an 11 out of 15 on the BIMS assessment. Resident #6 did not have any impairments in his upper extremities and had an impairment on one side of his lower extremity. Resident #6 required setup or clean-up assistance from staff with eating, upper body dressing, and personal hygiene; substantial or maximal assistance with bathing, bed mobility, lower body dressing, and transfers; and total dependence on staff to complete oral hygiene and toileting. Review of Resident #6's clinical census revealed the resident was hospitalized from 02/26/24 to 03/02/24 (six days). Review of the MAR dated February 2024 revealed Resident #6 received Aspirin 81 milligrams (mg) daily and Plavix 75 mg daily (an antiplatelet medication). Review of the progress notes for Resident #6 revealed on 02/25/24 at 3:20 P.M., Registered Nurse (RN) #732 noted a change in condition evaluation due to Resident #6 being tired, weak, confused, and drowsy. Resident #6's vital signs were blood pressure 137/76, pulse 72, respiration rate 18, temperature 97.6, pulse oximetry 98%, and blood glucose 181 (on 01/19/23). Resident #6 verbalized that he was having a stroke around 3:20 P.M. Range of motion (ROM) was performed, and the resident was able to raise both arms and legs. Resident #6 denied any pain. The physician was informed and recommended to continue to monitor Resident #6. On 02/26/24 at an unknown time, PA #620 completed an acute visit with Resident #6 with a chief complaint of weakness. PA #620 noted the nursing staff reported that the resident complained yesterday (02/25/24) that he may have had a stroke. On exam today, Resident #6 had dysarthria, had significant left-sided hemiparesis with left-sided facial droop. Resident #6 did have a history of prior CVA and was currently treated with Plavix and Aspirin. It is unclear when Resident #6 was last known well. National Institute of Health (NIH) stroke score is 15. (The scoring range is zero to 42 points, with higher numbers indicating a greater severity. A score of five to 15 represents a moderate stroke). The physical exam noted left sided facial droop and loss of left nasolabial fold (a skin crease that runs from the bottom of the nose to the outer corner of the mouth) with an asymmetric smile, ROM at baseline, left upper and lower extremity weakness, and confusion. Resident #6's presentation was likely consistent with an acute CVA and he would be sent to the emergency department for further management. Resident #6 was sent to the hospital via stretcher at 1:10 P.M. on 02/26/24. Review of the hospital records dated 02/26/24 revealed Resident #6 presented to the hospital at 1:33 P.M. for evaluation of stroke-like symptoms. The resident had dysarthria, facial droop, and left-sided weakness that started yesterday (02/25/24). The resident's wife was at bedside and reported symptoms had started on Thursday, 02/22/24 or Friday, 02/23/24 but worsened on 02/25/24. Deep vein thrombosis prophylaxis with sequential compression devices (SCD's) (shaped like sleeves that wrap around the legs and inflate with air). Resident #6 required admission due to concern of stroke-like symptoms and urinary tract infection (UTI) due to posed a threat to life and organ dysfunction. Review of the After Visit Summary (AVS) dated 03/02/24 revealed Resident #6 had a diagnosis of stroke (cerebrum). Resident #6's medications were changed to stop taking Plavix and start taking Apixaban (Eliquis) (an anticoagulant). Recommended dysphagia (difficulty swallowing) treatment. A regular diet and mildly thickened liquids was recommended. Review of the progress note dated 03/02/24 at 4:15 P.M. revealed Resident #6 returned to the facility. On 03/04/24 at an unknown time, PA #620 completed a follow-up visit with Resident #6 with a chief complaint of urinary tract infection (UTI) and CVA. A magnetic resonance imaging (MRI) of the brain showed a faint area of restricted diffusion in the right aspect of the [NAME] (any obstruction of blood supply to the [NAME], whether or acute or chronic, causes pontine infarction, a type of ischemic stroke) with chronic pontine, cerebellar, and cerebral infarcts and extensive small vessel disease. Resident #6 was alert and oriented but did have dysarthria and dysphagia secondary to CVA. Resident #6 could consume regular solids with thickened liquids. Resident #6 was also noted to have multidrug-resistant Klebsiella and Pseudomonas UTI and had completed antibiotics. Resident #6 still had significant left-sided hemiparesis. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #6 had impaired cognition. Resident #6 had impairments on both sides of his upper extremities and impairment on one side of his lower extremity. Resident #6 required substantial or maximal assistance with upper body dressing and personal hygiene and total dependence on staff with lower body dressing and bathing. Review of the care plan, revised 03/11/24, revealed Resident #6's history of CVA or monitoring for signs and symptoms of a stroke was not addressed in the resident's care plan. Interview on 05/21/24 at 10:23 A.M. with Resident #6 revealed he had a stroke in February 2024. Resident #6 stated he knew he had one and reported it to the facility staff. Resident #6 stated he requested to go to the hospital but the staff did not send him out due to needing approval from the physician and the physician was off. Resident #6 stated he was not sent out to the hospital for two days. Resident #6 stated prior to having the stroke, he was able to do almost everything for himself and now he is way worse. Interview on 05/23/24 at 1:32 P.M. with PA #620 confirmed he had not been notified Resident #6 complained of having a stroke on 02/25/24 until he saw the resident on 02/26/24. PA #620 stated he was not sure which on-call physician had been contacted as there were not any notes entered on 02/25/24. PA #620 stated he could not confirm when exactly Resident #6's symptoms started but confirmed when he did see Resident #6 on 02/26/24, he definitely showed signs of a stroke and that is why he sent the resident to the emergency room . PA #620 stated he educated the DON on the importance of identifying signs and symptoms of a stroke and responding quickly to strokes as they are one of the biggest emergencies that could occur in the facility. PA #620 stated the facility staff reported to him Resident #6 did not have any signs of a stroke on 02/25/24 but he was still thinking about that one. Interview via telephone on 05/23/24 at 4:14 P.M. with RN #732 confirmed Resident #6 complained he was having a stroke and requested to be sent out to the hospital. RN #732 assessed Resident #6, checked his vital signs, and ROM. RN #732 stated Resident #6 was able to raise arms and legs and stuck out his tongue. RN #732 notified the on-call provider of the resident's report of having a stroke, his vital signs, and that his ROM was normal. RN #732 confirmed she did not inform the on-call provider of Resident #6's request to be sent to the hospital. RN #732 stated the on-call provider instructed to continue monitoring Resident #6. RN #732 stated she and State tested Nurse Aide (STNA) #630 monitored Resident #6 three times during her shift from 7:00 A.M. to 7:00 P.M. RN #732 stated she notified the night-shift nurse on 02/25/24 and PA #620 the following day on 02/26/24. Interview on 05/23/24 at 4:13 P.M. with the DON confirmed PA #620 did have a conversation with her regarding Resident #6's reporting of having stroke symptoms. The DON stated RN #732 informed the on-call provider and did verify with the resident that he could move his arms and legs and took his vital signs. PA #620 suggested providing stroke education to the staff. The DON confirmed she provided RN #732 with a teachable moment. After RN #732 received the additional education, she did show improvement when she noted another resident who had symptoms of a CVA and was sent out to the hospital timely. Interviews with the on-call provider, PA #609, STNA #630, and the night shift nurse, RN #669, were attempted but unsuccessful. Review of the facility policy titled, Notification of Change, dated 02/14/24, revealed the facility must inform the resident, consult with the resident's practitioner, and notify the resident's representative when there was a change in status including a significant change in the resident's physical, mental, or psychosocial status. The policy did not address providing timely treatment when a resident experienced a change in condition. No other facility policies were provided at the time of the survey. 3. Review of the medical record for Resident #85 revealed an initial admitted on 06/08/23 and a readmitted on 04/22/24. Diagnoses include infection and inflammatory reaction due to indwelling urethral catheter (04/22/24), urinary tract infection (04/22/24), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (06/08/23), neuromuscular dysfunction of bladder (06/08/23), and retention of urine (06/08/23). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored a 15 out of 15 on the BIMS assessment. Resident #85 required total dependence on staff to complete toileting. Resident #85 had an indwelling catheter. Review of the clinic census for Resident #85 revealed the resident was hospitalized from 04/17/24 to 04/22/24 (five days). Review of the TAR dated March 2024 revealed Resident #85's Foley catheter was changed on 03/28/24 as ordered. Review of the MAR dated April 2024 revealed Resident #85 received Finasteride Oral Tablet five milligrams (mg) daily for BPH as ordered and Tamsulosin Hydrochloride Oral Capsule 0.4 mg daily for BPH as ordered. There was no order to monitor urine outputs from Resident #85's Foley catheter. Review of the TAR dated April 2024 revealed Resident #85 received Foley catheter care every shift (twice a day) as ordered, Resident #85's Foley catheter was noted to be straight draining every shift as ordered. Review of blood pressures (BP's) revealed on 04/16/24 at 7:53 A.M., Resident #85's BP was 116/73. On 04/17/24 at 7:10 A.M., his BP was 112/66 and at 1:49 P.M., Resident #85's BP was 99/81. There were no additional BP's documented. Review of oxygen saturations (O2 sats) revealed on 04/16/24 at 7:53 A.M., Resident #85's O2 saturation was 95% on room air. On 04/17/24 at 7:10 A.M., his O2 saturation was 89% on room air and at 3:56 P.M., Resident #85's O2 saturation was 90% on room air. There were no additional O2 saturations documented. Review of pulse rates revealed on 04/16/24 at 7:53 A.M., Resident #85's pulse was 59 beats per minute (bpm). On 04/17/24 at 7:10 A.M., it was 122 bpm and at 1:55 P.M., Resident #85's pulse was 108 bpm. There were no additional pulse rates documented. Review of meal and fluid intakes dated April 2024 revealed Resident #85 was noted to eat 51-75% of all three meals and drank between 220 and 230 mL of fluid at each meal on 04/16/24. On 04/17/24, Resident #85 ate 26-50% of breakfast and drank 230 milliliters (mL) of fluids. Resident #85 did not eat or drink anything at lunch and refused dinner. Resident #85 did not drink any fluids at dinner. Review of the Change in Condition Evaluation dated 04/17/24 and completed by Registered Nurse (RN) #733 revealed Resident #85 experienced a change in condition which started on the morning of 04/17/24. The resident was lethargic. Vital signs included blood pressure (BP) 99/81, pulse 108, apical heart rate 110, temperature 97.6, and oxygen saturation was 90% on room air. Resident #85 had all of the following: a systolic BP below 100, a heart rate above 100, a temperature above 100, and signs and symptoms suggested possible sepsis. Functional changes indicated included: needed more assistance with Activities of Daily Living (ADL's), decreased mobility, a decline in the ability to perform mobility, bowel and bladder, dressing, and eating. The symptoms were noted as having a recent onset without resolving spontaneously. The symptoms were noted as staying the same. The clinician was notified on 04/17/24 at 12:12 P.M. and ordered complete blood count (CBC) and basic metabolic panel (BMP) labs. Resident #85's wife was notified on 04/17/24 at 1:38 P.M. of the change in condition. Review of the Transfer Form dated 04/17/24 and completed by RN #733 revealed Resident #85 was discharged to the hospital from the facility on 04/17/24 at 7:49 P.M. due to abdominal pain. The resident had a pain level of four out of ten where ten was the worst pain imagined. Resident #85 was not alert. Review of the progress notes revealed on 04/17/24 at 3:48 P.M., a change in condition note was entered for Resident #85 by the DON. Resident #85's BP was 99/81 at 1:49 P.M. and pulse oximetry (ox) was 90% on room air at 3:56 P.M. Resident #85's mental status was noted as other. Resident #85 needed more assistance with completing ADL's and had decreased mobility. CBC and BMP labs were ordered. On 04/17/24 at 4:03 P.M., RN #733 noted Resident #85 was lethargic since this morning and unable to awake after several attempts. Vital signs were taken. BP 99/81, pulse 108, respiration rate 16, temperature 97.6, and oxygen saturation was 90%. The on-call physician was notified and ordered STAT (immediate) CBC and BMP labs. The family was notified and will continue to monitor. The electronic MAR (e-MAR) notes dated 04/17/24 from 7:24 P.M. to 7:27 P.M. revealed Resident #85 was not able to swallow his evening medications and the medications were held. Review of the hospital records revealed Resident #85 presented to the ED on 04/17/24 at 7:49 P.M. with altered mental status after the resident was found fairly unresponsive at the facility. When Resident #85 was seen in the ED, no history could be obtained. Resident #85 was found to have evidence of septic shock and was admitted . Resident #85 was diagnosed with septic shock with an acute UTI (later determined on 04/21/24 to be due to bactermia with E. Coli and Proteus bacteria). Initial assessment and treatment indicated Resident #85 was hypotensive (low blood pressure) with a blood pressure in the 60's and 70's despite adequate volume resuscitation, was fairly febrile with a temperature as high as 104.8 degrees Fahrenheit, and was tachycardic upon arrival at the ED. Vital signs were: BP 74/53, heart rate 121, respiration rate 17, temperature 104.8, O2 sat 97%. Resident #85's Foley catheter was exchanged in the ED and over a liter of urine came out, likely indication Resident #85's Foley catheter was clogged on arrival. Initial treatment included: the resident was started on norepinephrine (or noradrenaline, a neurotransmitter and hormone used for blood pressure support), admitted for further evaluation and treatment, a urinalysis with significant pyuria (contains high levels of white blood cells or pus) was completed, a culture had been obtained and Resident #85 would be started on broad-spectrum antibiotics, and continue vasopressor support. On 04/17/24 at 8:00 P.M., RN #733 noted Resident #85 was sleeping all day which was unusual for him. An assessment was completed. The on-call physician was notified. STAT CBC and BMP labs were ordered. Resident #85's condition continued to decline, and the physician ordered to send the resident to the emergency room (ER) for further evaluation. Resident #85 was transferred to the hospital via Emergency Medical Services (EMS) at 6:45 P.M. The physician, DON, and family were notified. On 04/22/24 at 7:29 P.M., Resident #85 returned to the facility from the hospital at approximately 4:40 P.M. The resident had a Foley catheter in place. On 04/23/24 at an unknown time, Medical Doctor (MD) #750 completed a history and physical visit with Resident #85. The chief complaint was a catheter associated urinary tract infection (CAUTI) with sepsis. Resident #85 was seen for readmission after hospitalization for sepsis related to urinary catheter infection with cystitis (inflammation of the bladder, usually caused by a bladder infection). Resident #85 would complete the course of oral antibiotic therapy for the CAUTI of Cefdinir Oral Capsule 300 mg. Dark amber urine was noted in the Foley bag. On 04/24/24 at an unknown time, PA #620 completed an acute visit for UTI with Resident #85. Resident #85 was receiving Cefdinir (an antibiotic) 300 mg twice daily through 05/01/24 for treatment of his UTI. The Foley catheter was now draining yellow-colored urine. Review of lab results for Resident #85 revealed the STAT labs ordered on 04/17/24 had not been completed. Review of the care plan (originally dated 06/09/23) and revised on 05/07/24 revealed Resident #85 was at risk for UTI and catheter-related trauma due to having an indwelling catheter. Interventions included change catheter and tubing per facility policy, enhanced barrier precautions (added on 05/07/24), may irrigate catheter for occlusion as ordered (added on 05/07/24), observe and document for pain or discomfort due to catheter, observe and document output as per facility policy (added on 05/07/24), observe, record, and report to the physician signs or symptoms of UTI including: pain, burning, red tinged urine, cloudiness, no output, deepening of urine color, increased temperature, foul smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns, position catheter bag and tubing below the level of the bladder and observe for any kinks each shift, and provide catheter care per policy. Interview via telephone on 05/22/24 at 9:40 A.M. with RN #733 confirmed she first saw Resident #85 at approximately 8:30 A.M. on 04/17/24. RN #733 was able to wake Resident #85 up, the resident took his medications, and then fell back asleep. RN #733 stated Resident #85 did eat breakfast, but not as much as usual. RN #733 next saw Resident #85 around lunch time for his next dose of medications which was around 12:30 P.M. RN #733 stated Resident #85 was not able to be aroused at that time. RN #733 stated the aide then reported Resident #85 had not eaten lunch. RN #733 checked on the resident again around 1:00 P.M. and Resident #85's vital signs were taken and were within normal limits (WNL). RN #733 notified the on-call provider who directed the nurse to continue monitoring Resident #85. RN #733 stated she checked on Resident #85 every two hours and checked the resident's vital signs but did not document them. RN #733 stated she tried to arouse Resident #85 but the resident would not wake up. Around dinner time, Resident #85 still would not wake up to eat dinner and did not take any medications. RN #733 stated Resident #85's vital signs also became abnormal. RN #733 stated the resident's catheter bag had been emptied and the catheter was draining but she could not recall how much it was draining or the color of the urine. RN #733 contacted the on-call provider again around dinner time and at that time, Resident #85 was sent out to the hospital. Interview on 05/22/24 at 4:35 P.M. with the DON and Regional Nurse (RGN) #810 confirmed outputs from Resident #85's Foley catheter had not been monitored prior to the resident being sent out to the hospital on 04/17/24. The staff would only monitor outputs if there was a physician order. Interview on 05/23/24 at 1:15 P.M. with PA #620 revealed Resident #85 had a history of UTI's. PA #620 stated signs of possible sepsis may include a sudden, significant change in a resident's vital signs. PA #620 would be particularly interested in the resident's blood pressure, heart rate, and temperature. PA #620 stated when he ordered staff to monitor a resident, he would expect that resident to be checked on every two hours, including checking and documenting vital signs. Interview via telephone on 05/23/24 at 2:46 P.M. with PA #607 confirmed he was the on-call provider for the facility from 1:00 P.M. to 7:00 P.M. on 04/17/24 when Resident #85 was transferred to the hospital. PA #607 stated when RN #733 first contacted him, he ordered STAT (immediate) CBC and BMP labs. PA #607 expected the labs to be completed and resulted within four hours, but he did not receive any results before Resident #85 was sent to the hospital. PA #607 stated RN #733 contacted him again later and reported Resident #85 was still lethargic. At that time, he agreed to have the resident sent to the hospital. PA #607 stated he did not give RN #733 specific instructions on how frequently he wanted Resident #85 to be checked on or vital signs to be obtained. PA #607 stated he felt it was understood the nurse would continue watching the resident because there was clearly a change in his condition that needed to be addressed. Interview via email on 05/28/24 at 12:39 P.M. with the DON confirmed STAT labs were expected to be drawn within four hours and then resulted within another four hours after being drawn. Physicians, PA's, or Certified Nurse Practitioner's (CNP's) who ordered the labs or the on-call provider scheduled depending on when the results are reported to the facility should be notified immediately of any critical or abnormal lab results. The DON confirmed the STAT lab turnaround times had not been communicated to the on-call providers to her knowledge. A facility policy related to responding to a change in condition was requested at the time of the survey, however, the facility did not have a policy. The deficiency represents non-compliance related to allegations contained in Complaint Number OH00153177.

Based on closed medical record review, review of equipment use instructions review of a facility investigation and interviews, the facility failed to ensure Resident #216 was safely transported to prevent a fall with injury. Actual harm occurred on 05/30/23 when State tested Nursing Assistant (STNA) #241 was transporting Resident #216 while seated on the seat of a wheeled (rollator) walker, the wheels of the walker got caught on the threshold to the shower room, resulting in the walker flipping over and the resident falling backwards onto the floor hitting his head and back. The resident was subsequently transported to the hospital for evaluation and diagnosed with bilateral subdural hematoma and a closed left seventh rib fracture requiring medical interventions. This affected one resident (#216) of five residents reviewed for falls. The facility census was 106. Findings include: Review of the closed medical record for Resident #216 revealed an admitted [DATE] and discharge date of [DATE]. Resident #216 had diagnoses including syncope and collapse, weakness, abnormalities of gait and mobility, cerebral infarction, and transient cerebral ischemic attack. Review of Resident #216's physician's medication orders for May 2023 revealed an order for Aspirin 81 milligrams (mg) daily for myocardial infarction and Clopidogrel Bisulfate (Plavix), which prevents platelets from sticking together and forming a clot 75 mg tablet, daily for myocardial infarction. Review of the plan of care dated 05/26/23 revealed Resident #216 was at risk for fall related injury and falls. Interventions included to encourage resident to wear appropriate footwear as needed, keep environment as safe as possible with even floors, free from spills and/or clutter, adequate lighting, call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. Provide resident with activities that minimize the potential for falls while providing diversion and distraction, Physical/Occupational therapy to evaluate and treat as ordered and as needed. The care plan was updated on 05/30/23 to reflect the use of a wheelchair as needed for transfers. Review of Resident #216's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was independent with daily decision making and displayed no memory concerns or behaviors. The assessment revealed Resident #216 required supervision from one staff member for bed mobility, transfers, toilet use, personal hygiene, limited assistance from one staff member for ambulation and dressing. The assessment did not identify any impairment to bilateral upper and/or lower extremities and noted the resident required the use of a wheelchair for mobility. Review of an incident and accident investigation form dated 05/30/23 at 4:50 A.M. revealed Resident #216 was ambulating with his rollator to the shower, his legs felt weak, and he sat on the seat of the rollator. STNA #241 pushed him on the rollator to the shower room. The wheel on the rollator got stuck on the threshold and the resident fell back. An assessment of the resident was completed along with neuro-checks and vital signs. The physician was contacted who gave an order to administer pain medication (Tramadol) every six hours as needed for pain. The investigation noted no orders or recommendations were made to send the resident to the emergency room for evaluation. Review of a nurse's note dated 05/30/23 at 6:00 A.M. created by Licensed Practical Nurse (LPN) #13 revealed, Guest was sitting in the walker and aide was pushing the walker with guest on the hallway to give him a shower. The wheels from the walker got stuck where the floor is connected. [NAME] tipped over and the guest fell on his back and hit his head. Vitals within normal limits. Neuro checks started and continue. Guest able to move all the extremities and walk around with assistance. Guest has an abrasion on the back of the head. Son notified and Medical Director made aware. Review of a summary of staff interview for STNA #241 dated 05/30/23 revealed the resident was walking to the shower room using his rollator, he said he felt weak in the legs and sat down on the rollator seat. The summary revealed we were very close to the shower room, so I pushed him by his rollator into the shower room, the wheels got caught on the threshold and he fell on his back. An addendum was added to the employee's statement during the onsite investigation (dated 06/23/23) which included the resident stated to STNA #241 just push me the rest of the way, while he was seated on the rollator. The employee stated she thought because he requested, then it was his right, he was alert and oriented. On 05/30/23 (exact time unknown) the resident left the facility with his son to go to a pre-scheduled physician appointment. Review of a nurse's note dated 05/30/23 at 2:03 P.M. created by LPN #174 revealed the resident had a scheduled appointment that his son transported him to. At this appointment the resident was sent to hospital on 05/30/23. Review of the physician's office progress note dated 05/30/23 revealed Resident #216 was being seen for follow up on recent stay at hospital for a fall. Follow up after two recent hospitalization s on 05/22/23 and 05/24/23 for generalized weakness, multiple falls, urinary tract infection and confusion. He was discharged to a rehab facility for Physical Therapy (PT) and strengthening. States he fell again this morning- was being pushed on the seat of his walker down to the rehab and the walker tipped forward causing him to fall off the front onto the back of his head. The resident reported head pain and left rib pain. He reported headache and denied any loss of consciousness. Due to the severity of his fall and blood thinner usage, it was recommended he be seen at the emergency department for a cat scan (CT) scan and evaluation of his ribs. The resident agreed and was taken to emergency department via wheelchair. Review of the emergency department notes dated 05/30/23 revealed Resident #216 presented with left rib pain as well as posterior head and neck pain. He was being pushed on his walker, it tipped over and he hit the back of his head. No loss of consciousness. He takes Aspirin and Plavix. Impression: Traumatic subdural hemorrhage without loss of consciousness and closed fracture to ribs, left side. X-ray revealed possible sixth and seventh rib fracture and admit for observation. Review of chest x-ray imaging dated 05/30/23 revealed in the result, Probable minimally displaced lateral left 7th rib fractures. No associated effusion or pneumothorax. Review of the CT of the head and C-spine of the left rib dated 05/30/23 revealed bilateral subdural hematoma, worse on the right. Patient was neurologically intact, airway was intact, does not require intubation. X-ray interpreted as no pneumothorax, possible sixth and seventh rib fracture. Review of hospital discharge summary dated 06/01/23 at 1:52 P.M. revealed the discharge final diagnoses included acute bilateral subdural hematomas, and acute left 7th rib fracture. The hospital course summary revealed, Patient is an [AGE] year-old male status post ground level fall. Patient states he was being pushed by a staff member at facility in his walker when they hit a bump and patient fell out and hit the back of his head. The patient was taken to hospital for evaluation. CT found bilateral subdural hematoma and CT found left 7th rib fracture. Patient was transferred to another hospital for further trauma evaluation with nursing consulted who managed the patient conservatively. The nurse signed off with a plan for outpatient follow up in 4-6 weeks. Interview on 06/20/23 at 9:30 A.M. with the Director of Nursing (DON) revealed when a resident experiences a fall that is witnessed and the resident is noted to hit their head, no matter what, neuro checks would be completed and it was up to the physician who was notified if the resident was to be sent out to the hospital even if that resident was on blood thinners or not. Continued monitoring would occur. On 06/20/23 at 10:22 A.M. an attempt to call Physician #300 who provided the order for Tramadol for Resident #216 on 05/30/23 after fall was made. The call was unsuccessful and the physician did not call the surveyor back. On 06/20/23 at 10:27 A.M. attempts to call STNA #241 and LPN #13 were also unsuccessful with no return call. On 06/21/23 at 3:30 P.M. interview with Certified Medical Assistant (CMA) #299 revealed CMA #299 worked for the medical group where Resident #216 had a follow up appointment on 05/30/23. CMA #299 revealed she completed the intake for this patient on 05/30/23 and after being told by the resident what occurred (the fall at the nursing home), the decision was made to send him to the emergency room (ER) for evaluation. The resident told her he was sitting on a wheeled walker and the person pushing him hit a bump and he was catapulted out of the chair and hit his back and head. CMA #299 indicated since the patient was on blood thinners, it was best for him to go to the ER for evaluation. Review of user instructions and warranty document for a Basic Steel Rollator with 8 wheels rolling walker revealed under Safety Instructions, General Cautions: Do not self-propel the rollator while seated. Rollators are intended for individual use only and are not to be used as a wheelchair. Serious injury to the user and/or damage to the rollator's frame or wheels may result from improper use. All wheels must be in contact with the floor and/or ground at all times. This will ensure the rollator is properly balanced. Seat Cautions: The brakes must be in the lock position before sitting on the seat. Do not use seat to transport people or objects. This deficiency represents non-compliance investigated under Complaint Number OH00143418.

Based on observation, medical record review, staff interview, policy review and review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, the facility failed to implement an effective pressure ulcer prevention and treatment program for Resident #47 and Resident #63. Actual harm occurred on 01/02/23 when Resident #47, who was mildly cognitively impaired and dependent on staff for turning and repositioning, was identified to have an open area to the buttocks. The area was not staged, and no treatment orders were implemented. On 01/05/23 the resident was assessed to have a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present) pressure ulcer to the buttocks. The facility failed to implement effective preventive pressure ulcer interventions for the resident, failed to implement timely skin assessments, and failed to implement a treatment timely following the identification of the Stage III pressure ulcer following the resident's re-admission to the facility status post an above the knee amputation. This affected two residents (Resident #47 and Resident #63) of four residents reviewed for pressure ulcers. Findings include: 1. Medical record review for Resident #47 revealed an admitted [DATE] with medical diagnoses included diabetes mellitus, chronic kidney disease, peripheral vascular disease, cognitive communication deficit, weakness, severe protein calorie malnutrition, and absence of right leg above the knee amputation. Review of physician's progress note dated 12/09/22 revealed Resident #47 was to go out for elective surgery planned for 12/12/22 for a right above the knee amputation right (AKA). Further review of the notes revealed he left the facility for surgery on 12/12/22 and returned to the facility on [DATE]. Review of care plan dated 12/20/22 revealed the resident had actual impairment to his skin post surgery. Interventions were to apply a pressure reducing mattress, pillows to protect the skin while in bed, encourage good nutrition and hydration in order to promote healthier skin, provide dietary supplements, and to turn and reposition every two hours and as needed. The location of the skin impairment was the right AKA. Review of Medicare 5-day Minimum Data Set (MDS) 3.0 assessment, dated 12/27/22 revealed Resident #47 was moderately cognitively impaired. His functional status was extensive assistance for bed mobility, and toilet use with one-person assistance. He was supervision for eating. He was always incontinent for bowel and bladder. He wasn't coded for any skin issues on this MDS. Review of bed bath for Resident #47 revealed on 12/30/22 he did not have skin impairment to his buttocks. Review of skin assessment dated [DATE] for Resident #47 revealed there was an area that measured 6.0 centimeters (cm) by 4.9 cm with no depth. There was not any description or where this wound was and it was not staged. The wound was later identified as being located on the buttocks. Review of physician orders and Treatment Medication Record (TAR) dated 12/20/22 through 01/02/22 revealed there was not preventive measures in place to prevent a pressure ulcer. There was not any evidence the resident was being turned or repositioned. Review of physician orders and the TAR dated 01/02/23 revealed there was not a treatment implemented for the left and right buttocks wound. Review of wound physician's progress notes dated 01/05/23 revealed it was reported last week Resident #47 needed evaluation and management of the right and left buttocks wound. The resident had been mostly bed bound since his right AKA and has not been able to turn and reposition himself. The buttocks had been treated with Triad Paste. Further review of the wound notes dated 01/05/23 revealed Resident #47's left buttock was a Stage III pressure ulcer that measured 6.2 cm by 0.2 cm with 100% granulation with light serosanguinous drainage peri-wound area was pink and intact, wound edges were attached. There was not any tunneling or undermining, no odor or signs of infection, the new order was to cleanse with normal saline, pat dry, and apply Triad Paste and leave open to air twice a day. New interventions were to place an air mattress to bed, turn and reposition every two hours and provide protein liquid twice a day for wound healing. Further review of the wound notes dated 01/05/23 revealed Resident #47's right buttock was Stage III pressure ulcer that was 3.7 cm by 0.2 cm with 100% granulation, light serosanguinous drainage, peri-wound area was pink and intact and the wound edges were attached. There wasn't any tunneling or undermining and no odor or signs of infection. The treatment was to cleanse with normal saline, pat dry, apply Triad Paste and leave open to air twice a day. New interventions were to place an air mattress to bed, turn and reposition every two hours and provide protein liquid twice a day for wound healing. Observation of a wound care treatment for Resident #47 on 01/11/23 at 10:28 A.M. revealed there was a light amount of drainage and beefy red parts to the left and right buttocks. The skin looked like it had been peeled back on his buttocks. The wound nurse, Licensed Practical Nurse (LPN) #241, cleaned his buttocks with normal saline and placed Triad paste on the areas. Interview with the LPN #241 on 01/11/23 at 10:45 A.M. revealed when Resident #47 came back from the hospital on 12/20/22 he didn't have any skin impairment on his buttocks. She confirmed there wasn't any preventive orders in place when he returned from the hospital to prevent a buttocks wound. She said on 01/02/23 an aide approached her and said come and take a look at the residents' bottom and it was discovered he had breakdown. She said she measured the area and thought there was a treatment in place for the Triad paste, but she should have done it herself so to be sure it was done. She confirmed she didn't stage the wound because she waited for the nurse practitioner to come in on 01/05/23 to put in the description of the wound and the stage. She said on the skin assessment dated [DATE] she didn't put where the area was but the measurement was for the left and right buttock and then when the wound nurse came into the facility she separated the areas out to different areas. She said the staff were not doing their job with turning and repositioning the resident because he didn't have any skin impairment on his buttocks when he returned back from the hospital. Interview with State tested Nursing Aide (STNA) #289 on 01/11/23 at 11:23 A.M. revealed turning and repositioning was not getting done due to lack of staff. Review of the physician order for Resident #47 revealed the air loss mattress was not in place until 01/15/23. Interview with LPN #241 on 01/19/23 at 7:50 A.M. revealed the air loss mattress should have been placed on the bed before 01/15/23 since the wound nurse had ordered it on 01/05/23. Interview with Wound Nurse Practitioner (WNP) #501 on 01/19/23 at 7:58 A.M. revealed the first time she saw Resident #47 he had two Stage III pressure ulcers on his left and right buttocks. She stated the facility notified her on 01/02/23 and an order for the Triad Paste was given. She was unaware the Triad Paste was not implemented. She confirmed the air loss mattress should have been ordered on 01/05/23 and placed on the resident's bed. She stated Resident #47 was very compromised after his surgery for his amputation and he had to learn to live without the leg. She stated he could move around really well before the surgery, but after the surgery he needed help with turning and repositioning. She thought his lack of turning and repositioning could be a factor in the development of the wounds on his buttocks. She didn't feel like there was enough staff to do the turns but only knew the aides were always rushing around to complete their tasks. Review of policy entitled, Skin Management, dated 12/15/22, revealed it is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. A weekly total body skin evaluation was completed for each resident by the licensed nurse. The licensed nurse would document findings of the skin evaluation. Review of the NPIAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014 Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure. Further review revealed Stage 3 Pressure Injury is a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. 2. Review of the medical record for Resident #63 revealed an admitted [DATE] with medical diagnoses of right sided hemiparesis following cerebral infarction (CVA), diabetes mellitus (DM), dysphagia, aphasia, hypertensive chronic kidney disease, hyperlipidemia, chronic kidney disease stage 3, and benign prostate hypertrophy. Review of the medical record for Resident #63 revealed a physician order dated 01/20/22 to encourage Prevalon boot (pressure reducing boots) placement to bilateral feet every shift. Review of the medical record for Resident #63 revealed no documentation to support the facility implemented Prevalon boots as ordered. Review of the medical record for Resident #63 revealed an at risk for impaired skin integrity care plan due to decreased mobility, CVA with right hemiparesis, and decreased range of motion (ROM) to bilateral lower extremities (BLE). Interventions included an air mattress, conduct weekly head to toe skin assessments, and skin prep as ordered to left knee, right knee, right foot and second toe. Review of the medical record for Resident #63 revealed a skin and wound assessment dated [DATE] which stated Resident #63 had a diabetic ulcer to great toe on right foot which healed 09/28/22. No other wound areas noted. Review of the medical record for Resident #63 revealed an assessment titled, Skin and wound total body skin assessment, dated 12/01/22, which stated resident had no new wounds. Observation on 01/08/23 at 1:57 P.M. revealed Resident #63 lying in bed, wearing a hospital gown. Resident #63 did not have Prevalon boots to bilateral lower extremities in place. Observation on 01/09/23 at 1:42 P.M. revealed Resident #63 lying in bed, wearing a hospital gown. Resident #63 did not have Prevalon boots to bilateral lower extremities in place. Observation on 01/10/23 at 8:25 A.M. revealed Resident #63 lying in bed, wearing a hospital gown. Resident #63 did not have Prevalon boots to bilateral lower extremities in place. Interview on 01/10/23 at 9:11 A.M. with Registered Nurse (RN) #16 confirmed Resident #63 had an order for Prevalon boots to BLE and to encourage the resident to wear the boots. RN #16 confirmed Resident #63 did not have Prevalon boots to BLE and RN #16 stated she could not recall the last time the resident wore the boots. Review of the policy titled, Skin Management, revised 12/15/22, stated guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. This deficiency represents non-compliance investigated under Master Complaint Number OH00139431 and Complaint Number OH00139427.

Based on record review, observation, staff interview, review of facility policy, review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and review of an online resources regarding pain in dementia residents, the facility failed to ensure Resident #15's pain was managed during a dressing change to a Stage III pressure ulcer. Actual Harm occurred on 01/09/23 when Resident #15 was not medicated for pain prior to wound care which resulted in the resident exhibiting signs (yelling out, moaning and grimacing) of severe pain. This affected one resident (#15) of one resident reviewed for pain management. Findings include: Review of Resident #15's medical record revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, respiratory failure, lack of coordination, dysphagia following nontraumatic intracerebral hemorrhage, attention and concentration deficit following nontraumatic intracerebral hemorrhage, memory deficit following nontraumatic intracerebral hemorrhage, epilepsy, chronic obstructive pulmonary disease, anxiety, depression, pressure ulcer of sacral region, Stage III, attention to gastrostomy. Review of the care plan dated 10/21/22 revealed Resident #15 was at risk for pain related to Stage III pressure ulcer on her coccyx which she was unable to verbalize. Interventions included to anticipate resident's need for pain relief as needed and respond immediately to any complaint of pain. Observe and report any signs or symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing), and report abnormal findings to the physician. Review of Resident #15's physician orders dated 11/27/22 revealed an order to cleanse sacrum wound with normal saline, pat dry, lightly pack with Dakin's soaked gauze, cover with clean dressing every day shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognition. Her functional status was listed as totally dependent on staff for all activities of daily living. The MDS also revealed Resident #15 had one Stage III pressure area to her coccyx upon admission. Review of the physician orders dated 01/2023 revealed orders for Oxycodone HCl Tablet five milligrams (mg), give 0.5 tablet via percutaneous endoscopic gastrostomy tube every four hours for pain. Review of the Medication Administration Record (MAR) for Resident #15 revealed no pain medication was given on 01/09/23 prior to 12:10 P.M. Observation of a dressing change to Resident #15's coccyx wound on 01/09/23 from 12:10 P.M. through 12:25 P.M., revealed Licensed Practical Nurse (LPN) #241 started to undress the coccyx wound when Resident #15 started moaning, yelling out and grimacing in pain. The surveyor asked the LPN if she had medicated the resident for pain before starting and LPN #241 revealed she had not. During the wound dressing change Resident #15 continued to moan and grimace and yell out for staff to stop. Review of Resident #15's medical record revealed no evidence the resident's pain was assessed from the wound observation. Interview on 01/09/23 at 12:10 P.M. with LPN #241 confirmed Resident #15 had not been given any pain medication before her first dressing change. She revealed it was her responsibility to make sure the resident received her pain medication prior to wound care so the pain was more tolerable. LPN #241 confirmed Resident #15 was in pain during her procedure and she did not stop the dressing change. Review of the facility policy titled, Pain Management, dated 07/09/23, revealed the staff would implement the care plan, monitor the guest/resident, and administer therapeutic interventions for pain control. The nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Review of the NPUAP guidelines dated 2014 page 161 at https://npiap.com/general/custom.asp?page=2014Guidelines in the section regarding Pain Management for Residents with Pressure Ulcers revealed staff should organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Set priorities for treatment. Pain management includes performing care after administration of pain medication to minimize pain experienced and interruptions to comfort for the individual. Review of online resource at https://www.mdapp.co/pain-assessment-in-advanced-dementia-painad-scale-calculator-550/ revealed the Pain Assessment in Advanced Dementia Scale (PAINAD) scale was a reliable tool for pain evaluation in dementia patients. The original study defines scores between zero and 10, where zero means no pain and 10 means severe pain. The scale administrator is asked to observe the patient for five minutes, either at rest, during a relaxing activity, during caregiving activities or administration of pain medication. PAINAD items include descriptions of breathing (independent of vocalization), negative vocalization, facial expression, body language, and consolability.

Based on observation, medical record review, staff and family interview, and policy review, the facility failed to implement timely interventions to decrease the risk for falls for Resident #256 who was a new admission and identified to have a history of falls and cognitive impairment. Actual harm occurred to Resident #256 when there was not a baseline care plan with fall interventions implemented, resulting in an unwitnessed fall on 12/31/22 and hospitalization where she was found to have a right fibular fracture. This affected one resident (Resident #256) of four residents reviewed for falls. The census was 106. Findings include: Medical record review for Resident #256 revealed an admitted [DATE] with admitting diagnoses including displaced Trimalleolar fracture of right lower leg. Further diagnoses included history of falling, esophageal varices, renal insufficiency, cognitive communication deficit, and cirrhosis of the liver. Review of Nursing Comprehensive Evaluation upon admitted d 12/28/22 revealed it was not completed. Review of 48 hours baseline care plan for Resident #256 revealed there wasn't any evidence of a care plan within 48 hours of admission. Review of progress note dated 12/31/22 at 3:05 A.M. revealed Resident #256 was found on the floor sitting with legs facing backwards and she stated she was trying to go to the bathroom and slid from the bed. The staff were unable to pick her up off the floor due to the position she was sitting and called emergency services to come and pick her up off the floor and took her to the hospital for evaluation. Review of the hospital records dated 12/31/22 for Resident #256 revealed she had an unwitnessed fall at the facility and a right knee x-ray showed Proximal Fibular Fracture. It was agreed to place a knee immobilizer since she had a cast on this same leg from a recent operation. Review of the fall investigation, not dated, revealed Resident #256 was observed on the floor in her room and said she was trying to get up out of bed to go to the bathroom and slid off the side of the bed. She was sitting on the floor with legs facing backwards. She was a new admission and her mental status was the same as on admission which was alert and slightly confused. She was bare footed at the time of the fall. The last time she was toileted was at 11:00 P.M. and she was continent when she was found on the floor. Her vital signs were within normal limits. There wasn't a root cause analysis for the fall. Review of Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #256 was moderately cognitively impaired. She was an extensive assistance for bed mobility, total dependence for transfers, and toilet use. She was independent for eating. She was always incontinent for bladder and bowel. She was coded for not steady for surface o surface transfers and required stabilization with staff and used a wheelchair. Observation and attempted interview with Resident #256 on 01/08/23 at 10:00 A.M. revealed she was lying in bed and was confused and couldn't answer appropriately to the questions for the interview. Interview with family at the time of the observation revealed the resident fell and had a major injury on the early morning of 12/31/22 and broke her leg and was sent out to the hospital. He stated this fracture was to the same leg that had a fracture fixed before coming to the facility. He revealed she was confused and was on Lactulose because of her ammonia levels, which was an ongoing problem for the resident. He stated ever since the resident fell at the facility he has stayed 24/7 to ensure she stayed safe. Review of physician notes dated 01/10/23 revealed Resident #256 sustained an open right trimalleolar ankle fracture (prior to admission) on 12/06/22 and on 12/21/22 there was a planned orthopedic procedure for the right ankle. Interview on 01/17/23 at 11:03 A.M. with Director of Nursing (DON) revealed they placed the resident on one on one when she came back from the hospital following the fall on 12/31/22 because of her confusion and didn't want her to get back out of the bed and fall. She confirmed there wasn't a 48 hour care plan initiated, no fall interventions in place, and no fall assessment was completed. She further confirmed the resident had metabolic encephalopathy and was on Lactulose for it and had periods of confusion and admitted this was an unsafe practice for the resident. She admitted there wasn't a root cause analysis determined for the fall and she would have to change her fall investigation report form to reflect this. Interview with the admitting Licensed Practical Nurse (LPN) #229 on 01/17/23 at 3:40 P.M. revealed she admitted Resident #256 on 12/28/22. She said she was on orientation on the evening of 12/31/22 but couldn't remember the nurse who was her mentor. She stated she didn't put in the baseline care plan for Resident #256 on this night. She admitted the resident wasn't alert and oriented and should have put in a care plan and assessment at the very least for falls. Interview with LPN #17 on 01/17/23 at 3:53 P.M. revealed she cared for Resident #256 on 12/31/22. She stated she only saw her between 7:00 P.M. to 8:00 P.M. that evening for a medication administration until she had the fall around 3:05 A.M. She stated the resident was slightly confused when she administered her medication. Interview with State tested Nursing Aide (STNA) #500 on 01/17/23 at 3:59 P.M. revealed she cared for Resident #256 on 12/31/22 at the time of her fall. She said she saw her around 11:00 P.M. and changed her. She stated the resident's husband stated he was tired and wanted to go home for some rest and wasn't going to stay the night with the resident. The aide said she received in report the resident was confused and may want to keep a close eye on her. She said she checked on the resident but didn't know what time and didn't have documentation of it either. She stated she heard a loud boom at about 3:00 A.M. and found the resident was barefooted and slid off of the bed on to the floor and had to be sent out to the hospital. She stated she had the bed in low position. Attempted to interview Registered Nurse (RN) #502 on 01/19/23 at 10:30 A.M. who was the trainer on 12/31/22 but she wasn't available. Review of policy entitled, Fall Management, dated 08/18/22, revealed each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. 1. The licensed nurse will evaluate residents for fall risk upon admission and re-admission, quarterly, annually and with a significant change in condition. 2. Residents identified at risk for falls will have an initial plan of care developed to meet each guest/resident's needs. Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall.

Based on record review, policy review, and facility staff interview the facility failed to obtain ordered laboratory testing for one of three residents reviewed for change in condition (Resident #10). Actual harm occurred to Resident #10 when the facility failed to obtain ordered laboratory testing resulting in a delay in treatment; Resident #10 was sent to the acute care hospital and admitted to the intensive care unit (ICU) for [CONDITION(S)] and high blood sugar. Findings Include: Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 05/17/22 admission Minimum Data Set 3.0 (MDS) revealed Resident #10 was not able to complete the brief interview for mental status, had no behaviors, required extensive assist for bed mobility, transfers, toileting and personal hygiene and was dependent on staff for eating, received enteral feeding. The resident was coded as having therapy services. Review of Resident #10's progress notes revealed on 05/18/22 at 5:59 P.M. the resident was noted to have [CONDITION(S)] in his arm. The practitioner was called, facility staff were to monitor, and family was noted to be made aware. The medical record revealed the facility completed a Situation, Background, Assessment, Recommendation (SBAR) tool on the resident on 05/19/22 and the tool indicated the resident had [CONDITION(S)] with the interventions to elevate and have laboratory testing completed. The SBAR indicated the resident was seen by the nurse practitioner on this day. Review of a progress note dated 05/20/22 at 2:06 P.M. revealed Resident #10 had a new order for laboratory testing including a comprehensive metabolic panel (CMP), Complete Blood Count (CBC) and an [MEDICATION(S)], due to bilateral [CONDITION(S)] and the family was aware. Review of a progress note dated 05/23/22 at 12:00 A.M., by the medical practitioner, revealed the resident was being seen as a follow up. The resident was noted to have non-pitting [CONDITION(S)], his tongue was coated with a white substance and speech therapy was present. Resident #10 had been trying to remove the white substance with a toothbrush, the note confirmed the resident is nothing by mouth (NPO). The medical practitioner reviewed resident systems, and medications. The note indicated Resident #10 had pulses at 2+ all extremities bilaterally (no [CONDITION(S)]), resident following with eyes and following commands with left arm. Change was to initiate [MEDICATION(S)] 200 mg one time, then [MEDICATION(S)] 100 mg daily for six days. The note was signed on 05/24/22 at 6:19 P.M. Review of the resident Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The vital signs were reviewed and there were not any that were noted to be widely varied from the other readings. There was no evidence in the medical record the laboratory testing ordered on 05/20/22 was completed. During an interview with the director of nursing (DON) on 06/08/22 at 11:15 A.M. it was revealed the laboratory testing ordered for Resident #10 on 05/20/22 did not occur. The DON was asked if the physician was notified that the labs were not completed and the DON stated she did not see that documentation. The DON confirmed the resident was sent to the hospital on 05/25/22 when he spiked a fever. The DON stated the resident was not sent to the hospital for the [CONDITION(S)] which the labs were ordered for. The resident had been having a change in his mental status that was being monitored at the facility since 05/16/22 and the day his temperature spiked orders were given to send him to the hospital. The DON verified Resident #10 was admitted to the hospital for [CONDITION(S)] and a very high blood sugar. Resident #10 was sent from the emergency room to the ICU. The DON additionally confirmed the [MEDICATION(S)] (antifungal) that was ordered for the resident's newly diagnosed thrush from the nurse practitioner on 05/24/22 was not initiated as the resident was sent to the hospital. Review of facility policy titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 048. This deficiency is evidence of continued non-compliance from the survey dated 04/21/22.

Based on record review, interview and review of the facility policy, the facility failed to timely identify an acute change in condition for Resident #201 and seek immediate medical attention for the resident who was subsequently transferred to the hospital following family intervention and diagnosed with a [CONDITION(S)] ([CONDITION(S)]). Actual Harm occurred on 04/14/22 when Resident #201, who was previously alert and oriented and able to communicate conversationally was noted by direct care staff to exhibit an acute change in condition including moaning, groaning, inability to converse, and lethargic. Nursing staff failed to comprehensively assess the resident at the time of the change or notify the resident's physician. On 04/14/22 at approximately 9:50 A.M., Resident #201's daughter arrived onsite and voiced concerns of the described condition change. The resident's daughter called 911 and with the assistance of the Emergency Medical Technician (EMT), the daughter determined the resident was unable to move her arms and was unable to squeeze the daughter's hand with her right hand. The resident was transferred to the hospital and admitted for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 04/21/22 the resident remained hospitalized . Findings include: Review of the medical record for Resident #201 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Comprehensive Evaluation dated 04/07/22 at 2:34 P.M. completed by Licensed Practical Nurse (LPN) #302 revealed Resident #201 required one-person physical assistance for bed mobility and two-person assistance for transfers. Resident was alert to person, place and time and was cooperative. Resident's speech was clear, and hearing was adequate. Resident had weakened right and left lower extremities; no weakness was noted to upper extremities. Review of the plan of care dated 04/07/22 revealed the resident had an activity of daily living self-care performance deficit and required assistance with activities of daily living. Interventions included to encourage resident to participate to the fullest extent possible with each interaction. Resident was at risk for cardiac complications related to multiple cardiovascular diseases. Goal was resident would be free of complications through the review date. Review of physician orders for the month of April 2022 identified orders for: 1. [MEDICATION(S)] 100 milligrams (mg) one tablet by mouth one time a day for hypertension. 2. [MEDICATION(S)] 50 mg tablet give one tablet by mouth one time a day for hypertension. 3. [MEDICATION(S)] 10 mg tablet give one tablet one time a day for hypertension. 4. Vital signs every night shift 5. Physical Therapy (PT) five to six times a week for eight weeks for other abnormalities of gait. 6. Occupational Therapy (OT) five to six times a week for eight weeks for muscle weakness. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 50 mg tablet was refused on 04/14/22 and [MEDICATION(S)] 100 mg was refused 04/14/22. Review of the progress notes dated 04/08/22 at 12:00 A.M. completed by Physician Assistant (PA) #195 revealed Resident #201 was alert and oriented to person, place and time. Resident vital signs included a blood pressure of 138/84 and a heart rate of 51 beats per minute (bpm). Record review of the skilled nursing note dated 04/13/22 at 2:34 P.M. completed by Registered Nurse (RN) #304 revealed resident was alert and verbal. Resident had no behaviors and received PT and OT. Blood pressure was 140/72 and the pulse was 74 bpm. Review of the hospital transfer summary dated 04/14/22 at 10:30 A.M. completed by LPN #303 revealed resident had an altered mental status, seemed different than usual, had stroke/[CONDITION(S)] new neurological signs, talked, communicated less, tired, weak, confused or drowsy that started on 04/14/22 on night shift. 04/14/22 at 8:00 A.M. the blood pressure was 140/70, pulse was 70, temperature was 97.0. LPN #303 documented: I was told by the night nurse that the guest was crying and screaming all night. I went into the guest room to ask her if she wanted her A.M. medications and she proceeded to tell me no and shook her head no, I also asked if she was in any pain or if she wanted pain medication. she said no, I didn't notice any change in mental status or physical change. Record review of the transfer form dated 04/14/22 at 11:36 A.M. completed by LPN #303 revealed Resident #201 was transferred to the hospital on 04/14/22 at 10:00 A.M. for altered mental status. Interview on 04/20/22 at 2:55 P.M. with Resident #201's daughter revealed Resident #201 had a massive [CONDITION(S)] and was still in the hospital and not doing well. Interview on 04/20/22 at 3:10 P.M. with LPN #303 revealed she started her shift on 04/14/22 at 7:00 A.M.; Between 8:15 A.M. and 8:30 A.M. she went into Resident #201's room to administer medications. Resident #201 refused her medications. LPN #303 revealed she assessed the blood pressure and pulse, and they were normal. Resident #201 was moaning and groaning but she also refused her pain medications. Resident was lying in bed with the head of the bed raised, her head was tilted. LPN revealed she then continued her medication pass for the other residents. During the medication pass, the daughter and husband came in to visit Resident #201. LPN #303 revealed, They found (LPN #302). He took her blood pressure which was high. He came and got me, I went over, they asked what was going on, how long was she like that. I told them the night shift nurse reported she moaned all night; I was under the impression she did this routinely. The daughter took her phone out and said she wanted to call the squad. LPN #311 said if they want to, they can. She (the daughter) called 911. When I saw her (Resident #201) when the daughter was there, she was the same as that morning when I saw her, she was no different. The family felt she was out of it, I thought she was the same. She was able to answer questions, yes or no, she was just moaning and tired. She was not droopy. LPN #303 stated, I didn't think it was a concern, she was normally alert and oriented but did not talk much, she moaned all morning. LPN confirmed she would have not called the physician if the family would not have come in because she believed this was the residents normal. Record review of Resident #201's medical records revealed no observation or assessment was documented regarding the resident by the night shift nurse, RN #304, who worked with Resident #201 on 04/13/22 from 11:00 P.M. to 7:00 A.M. on 04/14/22. Interview on 04/20/22 at 3:20 P.M. with LPN #311 revealed Resident #201's daughter approached him on the morning of 04/14/22 around 10:00 A.M. and asked what was going on. LPN #311 revealed he was not the residents nurse but went in her room to check on her. Resident #201 was moaning. He went and got the Unit Manager, (RN #312), and she also came to the room. LPN #311 confirmed he assessed Resident #201's blood pressure but did not recall what it was and did not document it. LPN #311 confirmed he had worked with Resident #201 in the past and the moaning was not normal for the resident. LPN #311 revealed Resident #201 normally had been talking, having full conversations. That morning she could only say yes or no. LPN #311 confirmed he noticed a change in condition for Resident #201 when he went in her room on 04/14/22 after the family got him. LPN confirmed a neurological assessment was completed while LPN #303 was in the room. Interview on 04/20/22 at 3:35 P.M. with Assistant Director of Nursing (ADON) RN #312 revealed she went into Resident #201's room on 04/14/22 around 10:00 A.M. after the nurses got her. ADON #312 revealed she was familiar with Resident #201 and prior to the change in her condition that morning, she was able to converse, and did not moan. ADON #312 revealed when she entered the room, the daughter was on the phone with the Emergency Medical Technician (EMT). The daughter and EMT were trying to see if she (Resident #201) was able to move her arms, she was not able to but before she was able. The daughter also tried to get the resident to squeeze her hand, Resident #201 could squeeze the left hand but not the right. ADON revealed Resident #201 could answer yes or no questions at that time but she had slurred speech. ADON #312 confirmed Resident #201 had a change in condition and confirmed LPN #303 was in the room while the daughter and EMT completed the assessment. Interview on 04/20/2022 at 3:42 P.M. with Speech Therapist (ST) #313 confirmed on 04/11/22 she completed a speech evaluation for Resident #201 and the resident had clear speech, was cognitively intact and could carry a full conversation. Interview on 04/20/22 at 3:45 P.M. with Physical Therapist (PT) #314 confirmed the last day of PT was on 04/13/22. Resident #201 had range of motion to the upper extremities with normal functional limits including the right and left hand which also had normal functional limits. Resident #201 had no contracture's. Interview on 04/20/22 at 4:10 P.M. with Administrator revealed she spoke with RN #304 regarding Resident #201. RN #304 revealed Resident #201 began moaning around 6:00 A.M. on 04/14/22. RN #304 offered the resident pain medication. Resident #201 refused. RN #304 did not notify the physician. RN #304 passed the information to the oncoming nurse at 7:00 A.M. Interview on 04/21/22 at 10:18 A.M. with State tested Nursing Aide (STNA) #318 confirmed she was Resident #201's STNA on 04/14/22 starting at 7:10 A.M.; STNA #318 revealed when she got to work, she would check on everyone of her assigned residents. At around 7:30 A.M. she entered Resident #201's room and found Resident #201, moaning and groaning. STNA #318 revealed she worked with Resident #201 the day prior and she never moaned, she was able to talk fine. She was trying to get Resident #201 to talk. Resident #201 would answer yes or no but she would go in and out of it and sometimes not answer. Her eyes would open halfway only when she tried to arouse her. STNA #318 stated, I noticed a definite change. STNA #318 confirmed she notified LPN #303 at around 7:30 A.M. of the change in Resident #201's condition; she then went on and passed breakfast trays. Review of facility policy titled Change in status, dated 08/20/21, revealed any change from baseline in a residents status must be identified and addressed. At minimum, the assessment should include reviewing the medical record, asking how the resident feels and what symptoms they have, obtaining vital signs, observing the residents overall condition including function and cognition and exploring complaints. The deficiency substantiates Complaint Number OH 026

Based on closed record review and interview the facility failed to adequately monitor and implement effective interventions related to an area of skin impairment, identified to be a boil to Resident #47's left upper rear thigh area. Actual harm occurred when the lack of comprehensive assessment and monitoring resulted in the impaired area deteriorating from an abscess to a multiloculated hematoma/abscess [MEDICAL CONDITION], requiring hospitalization and surgery. This affected one resident (Resident #47) of three sampled residents reviewed for wound care. Findings include: Review of Resident #47's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of the nursing comprehensive head to toe assessment documentation, dated 02/15/19, 02/24/19 and 03/04/19 identified under section K skin, Resident #47 had redness with no open areas to the groin area. Review of the nursing comprehensive head to toe assessment for Resident #47, dated 03/23/19, documented a rear left upper thigh bump. The physician and family were notified. Review of the nursing progress notes for Resident #47 dated 03/23/19, documented the physician was notified regarding a bump to the resident's left upper rear thigh. The notes revealed an order for [REDACTED]. An order dated 03/25/19 was obtained for the antibiotic, Bactrim DS 800-160 milligrams (mg), give one tablet two times per day for folliculitis and suspected [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) related to the area on the resident's thigh. Review of the nursing progress notes, dated 03/29/19 revealed the resident was out of the facility with family and needed to visit an urgent care due to the boils on the left thigh busting. The notes documented no new orders at that time Review of the nurse practitioner's (NP) note, dated 03/29/19 revealed Resident #47 was seen by the NP for boils to the upper thigh. The progress note indicated the resident had a fungal infection, [MEDICAL CONDITION] was acute and worsening and had started the antifungal medication [MEDICATION NAME] on 03/25/19. The NP also documented the resident had Acute Folliculitis and [MEDICAL CONDITION] and was started on the antibiotic Bactrim for ten days. Review of the nursing progress notes for Resident #47 revealed the resident was admitted to the hospital for a fecal transplant on 04/15/19. The resident returned to the facility on [DATE]. Review of the nursing comprehensive head to toe assessment for Resident #47, dated 04/23/19 identified the resident's groin with excoriation beneath abdominal folds. An order was obtained for antifungal powder. Review of the comprehensive head to toe assessment for Resident #47, dated 05/07/19 identified no skin issues. Review of the nursing progress notes for Resident #47 revealed the resident was admitted to the hospital from 05/20/19 through 05/28/19 for confusion, lethargy and increased temperature. The resident was again hospitalized from [DATE] through 06/10/19 for lower left leg swelling and possible [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/17/19 revealed Resident #47 had moderate cognitive impairment and required extensive assistance for her activities of daily living (ADL). Her bowel and bladder assessment documented an indwelling urinary catheter. Review of the nursing progress notes dated 06/25/19, revealed Resident #47 was admitted to the hospital with [REDACTED]. Review of the hospital notes dated 06/28/19, for Resident #47 revealed a urology assessment identified a chronic draining wound at the resident's suprapubic tube site and an acute care surgery evaluation identified a left gluteal abscess. A computerized tomography (CT) scan showed a multiloculated hematoma/abscess on the resident's left leg and buttocks. The wound and ostomy nurse identified on 06/28/19, a right groin abscess which measured four centimeters (cm) in length by 0.5 cm with 0.2 cm depth. The hospitalist evaluation dated 06/30/19, diagnosed [MEDICAL CONDITION] secondary to a left gluteal abscess. Further review of the hospital records revealed the resident underwent [REDACTED]. Review of Resident #47's treatment administration record from (MONTH) 2019 revealed no treatment was documented for any area involving the resident's left rear upper thigh area. Interview on 07/18/19 at 12:25 P.M. with Corporate Clinical Coordinator (CCC) #200 and review of the State tested Nurse's Aide (STNA) shower/skin assessment sheets with CCC #200, dated 04/2019 through 06/2019, revealed no skin issues were identified by the STNA. CCC #200 confirmed review of shower sheets. On 07/28/19 at 2:18 P.M. interview with Licensed Practical Nurse (LPN) #250 revealed she remembered Resident #47 having redness under her breasts and abdominal folds. The LPN stated the resident did have a blister on her thigh area but didn't believe any treatment was ordered for the blister. LPN #250 also revealed the resident was alert to person, place and time, but had intermittent confusion. During an interview on 07/18/19 at 4:44 P.M. with CCC #200 and the Administrator, CCC #200 revealed LPN #250 had told her she recalled Resident #47 coming back to the facility on [DATE] and reporting she needed to go to an urgent care to treat the broken boils to her left upper thigh. The LPN told CCC #200, she had not assessed or documented the thigh area at that time. CCC #200 confirmed staff acknowledged excoriation to the resident's abdominal folds on 04/23/19 but had not documented any information related to the left rear thigh area. CCC #200 confirmed no assessments or treatments had been initiated or documented for the resident's rear upper left thigh after the administration of warm compresses were completed in 03/2019. CCC #200 confirmed the resident was hosptalized on [DATE] with a [DIAGNOSES REDACTED]. The resident underwent [REDACTED]. This deficiency substantiates Complaint Number OH 688, Complaint Number OH 418 and Complaint Number OH 376.

Based on medical record review, observation, review of wound clinic progress notes, review of hospice documentation, staff interviews, review of facility policy, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure wound treatments were completed as ordered, and failed to timely identify wounds. This resulted in harm when Resident #3's pressure ulcer had no treatment implemented, and the pressure ulcer worsened to a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed). Additionally Resident #2's pressure ulcers were not being assessed, and treatments for the pressure ulcer were implemented, without a physician's order. This affected two residents (#2 and #3) of three residents with pressure ulcers reviewed. The facility census was 63. Findings include: 1. Medical record review revealed Resident #3 was originally admitted to the faciliy on 03/24/17, and most recently readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's Alteration in Skin Integrity Care Plan dated 04/30/18 included body checks weekly, measure wounds weekly, consult with the wound clinic, per order, and provide treatments, per physician orders. The resident was at risk for skin alteration related to altered sensation, history of skin impairment, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The resident was dependent, or required extensive assistance for all activities of daily living (ADLs) except supervision with eating. The resident was noted with two unstageable pressure ulcers, one Stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling), and one Stage 2 pressure ulcer. Review of wound notes dated 09/04/18 revealed Resident #3 had a wound to the right trochanter (hip/femur) measuring 3 centimeters (cm) x 2.5 cm, x 0.1 cm in depth. The resident was also noted with a wound to the left ischium (hip) measuring 4 cm x 3 cm, x 2.5 cm in depth. Additionally the resident had a wound to the right ischium measuring 1.5 cm x 1.5 cm, x 2.0 cm in depth. Both ischium pressure ulcers were identified as Stage 4 pressure ulcers. Review of Resident #3's admission physician orders, and Treatment Administration Record (TAR) dated 09/04/18 revealed an order to irrigate the left ischium and right ischium Stage 4 pressure ulcers with Dakins solution, pack the wounds with Mesalt, and cover with dry dressing every shift. The order was discontinued on 09/14/18, and the last treatment was completed on 09/13/18. Further review of Resident #3's physician's orders from 09/04/18 through 09/12/18, revealed there was no treatment ordered for the resident's right trochanter Stage 2 pressure ulcer. Review of the wound clinic documentation revealed Resident #3 was seen on 09/11/18 for wounds to the right trochanter. The wound measured 3 cm x 2 cm, x 0.1 cm in depth. The base of the wound was noted with black eschar. The wound was documented as being unstageable. The left ischium measured 3.8 cm x 3.6 cm, x 2.0 cm in depth. The right ischium measured 1.9 cm x 0.9 cm, x 1.0 cm depth. Both of the left and right ischium wounds were documented as Stage 4 pressure ulcers. Review of Resident #3's physician order dated 09/12/18 revealed to cleanse the right trochanter with normal saline, apply Santyl, saline moist gauze, and cover with a dry dressing daily, every night shift. Review of Resident #3's (MONTH) (YEAR) TAR revealed no documentation wound treatments were completed for the resident's right or left ischium Stage 4 pressure ulcer on 09/13/18, 09/24/18, 09/29/18, or 09/30/18. Continued review of Resident #3's medical record and wound clinic documentation revealed no evidence the resident's pressure ulcers were assessed from 09/12/18 through 09/23/18, and from 09/26/18 through 10/14/18. Review of Resident #3's (MONTH) (YEAR) TAR revealed the treatment for [REDACTED]. The left ischium wound treatment was not completed on 10/01, and 10/05/18. Review of Resident #3's physician orders for (MONTH) (YEAR) revealed no treatment was ordered or completed for the pressure ulcer for the residents left ischium. Review of Resident #3's weekly wound record dated 10/15/18 revealed the pressure ulcers had increased in size. The pressure ulcer to the right trochanter now measured 3.6 cm x 3.0 cm x 1.0 in depth. The wound was noted to be unstageable. The resident's left ischium Stage 4 pressure ulcer now measured 6.2 cm x 3.4 cm, x 1.2 depth. The Stage 4 pressure ulcer to the right ischium now measured 2.4 cm x 1.3 cm x 1.0 in depth. Interview on 10/16/18 at 10:27 A.M., with the Director of Nursing (DON) revealed she was not aware Resident #3 had a pressure ulcer to the left ischium. She further revealed the hospice nurse indicted Resident #3 had a dressing to the left ischium for prevention. The DON confirmed there was no weekly monitoring for Resident #3's pressure ulcers. She confirmed there was no treatment for [REDACTED]. The DON also confirmed there was no treatment in place on 09/14/18 and 09/15/18 for the right and/or left ischium. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed the resident had short/long term memory problems, and was severely impaired for decision making. Review of Resident #2's care plan for Impaired Skin integrity dated 08/25/18 revealed the resident had wounds to the bilateral buttocks, bilateral groin, and penile head. Interventions included to measure the areas weekly and record characteristics on the skin log. Interventions were for an air mattress, and to assist as needed to float heels while in bed. Review of Resident #2's admission wound assessment revealed the resident was admitted with pressure ulcers on the right buttock measuring 8.0 cm x 3.0 cm x 0.2 cm in depth. The resident also had a wound to the left buttock measuring 7.5 cm x 4.0 cm x 0.2 cm in depth. Neither pressure ulcer was staged until 09/05/18 when the right buttock wound was identified as unstageable, and the left buttock was identified as a Stage 4 pressure ulcer. Review of weekly wound assessments dated 09/08/18 revealed Resident #2 acquired a pressure ulcer (busted blister) to the left hip. The pressure ulcer was identified as an unstageable pressure ulcer measuring 5.0 cm x 5.4 cm x 0.1 cm in depth. Review of Resident #2's nursing note dated 09/17/18 revealed Resident #2 was admitted to Hospice services. Review of Hospice documentation dated 09/26/18 revealed Resident #2 had a Stage 2 pressure ulcer to the right hip. The resident was also noted with an unstageable pressure ulcer to the right shin, and a deep tissue injury was noted to the left outer heel. Review of Resident #2's (MONTH) (YEAR) TARs revealed no evidence treatments were completed on 09/23/18 or 09/24/18. Further review of the medical record and Hospice documentation revealed there was no evidence of monitoring of Resident #2's wounds from 09/26/18 until 10/10/18. Review of Resident #2's TAR for (MONTH) (YEAR) revealed no documentation of wound treatments to the left groin, right groin, and penile head were completed on 10/05/18 or on 10/12/18. Observation on 10/15/18 at 3:40 P.M., with Licensed Practical Nurse (LPN) #101 revealed the LPN completed treatments to Resident #2's right groin, left groin, and the penile head. Registered Nurse (RN) #203 assisted with the treatments. Resident #2's left boot was removed, and a dressing was noted to the resident's left outer ankle. The dressing was dated 10/09/18. LPN #101 confirmed there was no order for a treatment for [REDACTED]. The dressing was removed by LPN #101. There was a moderate amount of serous sanguineous drainage on the dressing. LPN #101 received an order from the physician to cleanse the left outer ankle, and apply Santyl. Interview on 10/15/18 at 5:10 P.M., with LPN #101 confirmed there was no wound treatment orders for Resident #2's right shin, or left lower leg, however there were dressings on both areas. Interview on 10/15/18 at 5:48 P.M., with the DON confirmed Resident #2 had a dressing on the left outer ankle dated 10/09/18, and there was no physician's order. The DON revealed she was unaware Resident #2 had two additional dressings to his bilateral lower legs dated 10/14/18 with no physician's order. Review of the facility's policy titled, Pressure Ulcer Record, dated (MONTH) 2011, revealed all pressure ulcers would be documented on the pressure ulcer record weekly. One form was to be completed for each site. Record the date and site when first identified. Document in the description the location and appearance of the pressure ulcer. Document the wound stage. Measure the wound in centimeters and record the length, width, and depth. Continue to measure and document on the wound every seven days. Review of information from the NPUAP revealed an unstageable pressure ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. This deficiency substantiates Complaint Number OH 355.