Every finding on record at The Laurels of Heath

Based on interviews and record review, the facility failed to protect a resident's right to privacy when staff took a picture of the resident without consent. This affected one (Resident #42) of three residents reviewed for privacy. The facility census was 107.Findings include:Review of the medical record for Resident #42 revealed an admission date of 02/15/23 with diagnoses including paraplegia, seizure, severe-protein-calorie malnutrition, hypertensive without heart failure, insomnia, amaurosis fugax, dilated cardiomyopathy, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #42 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. Additionally, the MDS revealed Resident #42 was dependent on staff for all activities of daily living (ADLs) to include showering and bathing. Furthermore, Resident #42 was dependent on staff to move from side to side in bed.Interview on 01/29/26 at 8:16 A.M. with Resident #42 revealed a Certified Nursing Assistant (CNA) took a picture of his naked back without his consent. Interview on 01/29/26 at 1:16 P.M. with CNA #55 revealed staff are not to be on their cell phones in patient care areas and absolutely no taking pictures with their cell phone.Interview on 01/29/26 at 1:17 P.M. with CNA #206 revealed the wound nurse is the only person who should be taking pictures of residents and that is with a facility phone so the pictures can be uploaded for wound measurements.Interview on 01/29/26 at 1:30 P.M. with CNA #336 revealed the facility is serious about resident privacy and staff are not to take pictures of residents at any time. Interview on 01/29/26 at 2:14 P.M. with Licensed Practical Nurse (LPN) #500 revealed she was off the unit on 01/04/26 and when she returned to the unit, CNA #233 showed her a picture of Resident #42's back on CNA #233's personal cell phone. LPN #500 stated she went into Resident #42's room and asked him to see the skin issue on his back from the picture and Resident #42 had asked her what picture and LPN #500 stated she told Resident #42 that CNA #233 had taken a picture of his back and showed it to her. LPN #500 stated Resident #42 told her he did not like the fact CNA #233 had taken a picture of his back without asking him first. Additionally, LPN #500 stated she did not report the picture incident to management.Interview on 01/29/26 at 3:29 P.M. with LPN #15 revealed she was working on 01/04/26. LPN #15 stated CNA #233 came to her and told her she had taken a picture of Resident #42's back and then sent the picture to LPN #500, who sent the picture to Resident #42's mother. LPN #15 stated she immediately notified the Assistant Director of Nursing (ADON), who told her he would let the Director of Nursing (DON) and the Administrator know what occurred. LPN #15 stated she did not talk to Resident #42 on 01/04/26 about the picture. LPN #15 stated that she did talk to Resident #42 on 01/05/26 about the picture and Resident #42 told her he was not happy about CNA #233 taking a picture of his back without his permission. Interview on 01/29/26 at 4:03 P.M. with the ADON revealed a CNA had taken a picture of Resident #42's back and sent it to the nurse on the unit who was supposed to send the picture to the wound nurse but had sent the picture to the resident's parents. The ADON stated Resident #42 was upset because he had a BIMS of 15 and was his own person to make decisions. The ADON stated the cell phone policy is that staff should never have them in direct care areas in the hallways or where residents can see them. Interview on 01/29/26 at 4:19 P.M. with the Administrator revealed she was notified immediately, within two hours of the picture being taken. The Administrator stated she did notify her corporate office immediately. The Administrator stated she did not talk to CNA #233 or Resident #42 about the picture being taken. The Administrator stated the cell phone policy is that staff should not have their cell phones in personal care areas.Interview on 01/29/26 at 4:53 P.M. with Resident #42 revealed he did not know the picture of his naked back had been taken until he received a call from his father who asked him why he would not let the staff take care of him. Resident #42 stated he asked his father what he was talking about and his father texted him the picture of his naked back. Resident #42 stated that was the first time he knew about any picture being taken of his naked back and he was upset. Resident #42 stated that no one asked his permission to take a picture of his naked back.Interview on 01/30/26 at 1:40 P.M. with CNA #233 revealed while giving Resident #42 a bed bath, she took a picture of Resident #42's naked back without his knowledge. Review of the facility policy, Residents Rights, dated 05/14/24 revealed the facility protects and promotes the rights of each resident. The resident has the right to a dignified existence, self-determination, and communication. Facility staff will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights. Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety. These resident rights include privacy and confidentiality.Review of the facility policy, Telephone, Pager, and Electronic Devices, dated 06/01/24 revealed unless specifically designated otherwise, cellular phones, iPods, tablets, MP3 players, pagers, or any other electronic devices are not permitted to be worn or used in any area outside of the designated staff member break room. Although cellular phones are equipped with cameras and video recording, staff members are strictly prohibited from taking any pictures or videos in any resident area of the facility using personal cell phones.Review of the Centers for Medicare and Medicaid Services (CMS),Center for Clinical Standards and Quality/Survey and Certification Group Memorandum, dated 08/05/16 with the subject of, Regarding Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings by Nursing Home Staff, revealed taking photographs or recordings of a resident and/or his/her private space without the resident's, or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality.This deficiency represents non-compliance investigated under Complaint Number 2708290.

Based on record review and interviews, the facility failed to report an allegation of abuse to the State Agency (SA). This affected one (Resident #42) of three residents reviewed for abuse. The facility census was 107. Findings include: Review of the medical record for Resident #42 revealed an admission date of 02/15/23 with diagnoses including paraplegia, seizure, severe-protein-calorie malnutrition, hypertensive without heart failure, insomnia, amaurosis fugax, dilated cardiomyopathy, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #42 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. Additionally, the MDS revealed Resident #42 was dependent on staff for all activities of daily living (ADLs) to include showering and bathing. Furthermore, Resident #42 was dependent on staff to move from side to side in bed.Interview on 01/29/26 at 8:16 A.M. with Resident #42 revealed a Certified Nursing Assistant (CNA) took a picture of his naked back without his consent. Interview on 01/29/26 at 1:16 P.M. with CNA #55 revealed staff are not to be on their cell phones in patient care areas and absolutely no taking pictures with their cell phone.Interview on 01/29/26 at 1:17 P.M. with CNA #206 revealed the wound nurse is the only person who should be taking pictures of residents and that is with a facility phone so the pictures can be uploaded for wound measurements.Interview on 01/29/26 at 1:30 P.M. with CNA #336 revealed the facility is serious about resident privacy and staff are not to take pictures of residents at any time. Interview on 01/29/26 at 2:14 P.M. with Licensed Practical Nurse (LPN) #500 revealed she was off the unit on 01/04/26 and when she returned to the unit, CNA #233 showed her a picture of Resident #42's back on CNA #233's personal cell phone. LPN #500 stated she went into Resident #42's room and asked him to see the skin issue on his back from the picture and Resident #42 had asked her what picture and LPN #500 stated she told Resident #42 that CNA #233 had taken a picture of his back and showed it to her. LPN #500 stated Resident #42 told her he did not like the fact CNA #233 had taken a picture of his back without asking him first. Additionally, LPN #500 stated she did not report the picture incident to management.Interview on 01/29/26 at 3:29 P.M. with LPN #15 revealed she was working on 01/04/26. LPN #15 stated CNA #233 came to her and told her she had taken a picture of Resident #42's back and then sent the picture to LPN #500, who sent the picture to Resident #42's mother. LPN #15 stated she immediately notified the Assistant Director of Nursing (ADON), who told her he would let the Director of Nursing (DON) and the Administrator know what occurred. LPN #15 stated she did not talk to Resident #42 on 01/04/26 about the picture. LPN #15 stated that she did talk to Resident #42 on 01/05/26 about the picture and Resident #42 told her he was not happy about CNA #233 taking a picture of his back without his permission. Interview on 01/29/26 at 4:03 P.M. with the ADON revealed a CNA had taken a picture of Resident #42's back and sent it to the nurse on the unit who was supposed to send the picture to the wound nurse but had sent the picture to the resident's parents. The ADON stated Resident #42 was upset because he had a BIMS of 15 and was his own person to make decisions. The ADON stated the cell phone policy is that staff should never have them in direct care areas in the hallways or where residents can see them. Interview on 01/29/26 at 4:19 P.M. with the Administrator revealed she was notified immediately, within two hours of the picture being taken. The Administrator stated she did notify her corporate office immediately. Interview on 01/29/26 at 4:43 P.M. with the Administrator revealed she could not find a formal investigation and that LPN #15 did the interviews when the incident occurred. The Administrator stated she did not feel there was intent to do harm, so taking the picture of Resident #42's naked back was not abuse. The Administrator stated she did not complete a report to a State Agency. The Administrator stated it was more of HIPAA violation since CNA #233 took the picture of Resident #42's back so that he could get care. Interview on 01/29/26 at 4:53 P.M. with Resident #42 revealed he did not know the picture of his naked back had been taken until he received a call from his father who asked him why he would not let the staff take care of him. Resident #42 stated that he asked his father what he was talking about and his father texted him the picture of his naked back. Resident #42 stated that was the first time he knew about any picture being taken of his naked back and he was upset. Resident #42 stated that no one asked his permission to take a picture of his back. Resident #42 stated that he felt violated when he found out about the picture of his naked back being taken without his consent because he does not know who saw the picture and that he does not want other people to see him in this condition. Interview on 01/30/26 at 1:40 P.M. with CNA #233 revelaed did not ask Resident #42 if she could take a picture of his naked back while she was giving him a shower. CNA #233 stated that she was never suspended and does not know if any investigation occurred. CNA #233 stated that LPN #15 had told her today not to speak with anyone about the picture of Resident #42's back.Review of the facility policy, Abuse Prohibition Policy, dated 10/14/22 stated that allegations of guest/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.Review of the Centers for Medicare and Medicaid Services (CMS), Center for Clinical Standards and Quality/Survey and Certification Group Memorandum dated 08/05/16 with subject of Regarding Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings by Nursing Home Staff, stated that the facility must report all allegations of abuse, provide protections for any resident involved in allegations, conduct a thorough investigation, implement corrective actions to prohibit further abuse, and to report the findings as required. Anytime that the nursing home receives an allegation of abuse, including those involving posting of an unauthorized photograph or recording of a resident on social media, the facility must not only report the alleged violation to the Administrator and other officials, but must also initiate an immediate investigation.

Based on interviews and record review, the facility failed to complete a thorough investigation when informed of staff taking a photo of a resident without consent. This affected one (Resident #42) of three residents reviewed for abuse. The facility census was 107. Findings include:Review of the medical record for Resident #42 revealed an admission date of 02/15/23 with diagnoses including paraplegia, seizure, severe-protein-calorie malnutrition, hypertensive without heart failure, insomnia, amaurosis fugax, dilated cardiomyopathy, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #42 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. Additionally, the MDS revealed Resident #42 was dependent on staff for all activities of daily living (ADLs) to include showering and bathing. Furthermore, Resident #42 was dependent on staff to move from side to side in bed.Interview on 01/29/26 at 8:16 A.M. with Resident #42 revealed a Certified Nursing Assistant (CNA) took a picture of his naked back without his consent. Interview on 01/29/26 at 1:16 P.M. with CNA #55 revealed staff are not to be on their cell phones in patient care areas and absolutely no taking pictures with their cell phone.Interview on 01/29/26 at 1:17 P.M. with CNA #206 revealed the wound nurse is the only person who should be taking pictures of residents and that is with a facility phone so the pictures can be uploaded for wound measurements.Interview on 01/29/26 at 1:30 P.M. with CNA #336 revealed the facility is serious about resident privacy and staff are not to take pictures of residents at any time. Interview on 01/29/26 at 2:14 P.M. with Licensed Practical Nurse (LPN) #500 revealed she was off the unit on 01/04/26 and when she returned to the unit, CNA #233 showed her a picture of Resident #42's back on CNA #233's personal cell phone. LPN #500 stated she went into Resident #42's room and asked him to see the skin issue on his back from the picture and Resident #42 had asked her what picture and LPN #500 stated she told Resident #42 that CNA #233 had taken a picture of his back and showed it to her. LPN #500 stated Resident #42 told her he did not like the fact CNA #233 had taken a picture of his back without asking him first. Additionally, LPN #500 stated she did not report the picture incident to management.Interview on 01/29/26 at 3:29 P.M. with LPN #15 revealed she was working on 01/04/26. LPN #15 stated CNA #233 came to her and told her she had taken a picture of Resident #42's back and then sent the picture to LPN #500, who sent the picture to Resident #42's mother. LPN #15 stated she immediately notified the Assistant Director of Nursing (ADON), who told her he would let the Director of Nursing (DON) and the Administrator know what occurred. LPN #15 stated she did not talk to Resident #42 on 01/04/26 about the picture. LPN #15 stated that she did talk to Resident #42 on 01/05/26 about the picture and Resident #42 told her he was not happy about CNA #233 taking a picture of his back without his permission. Interview on 01/29/26 at 4:03 P.M. with the ADON revealed a CNA had taken a picture of Resident #42's back and sent it to the nurse on the unit who was supposed to send the picture to the wound nurse but had sent the picture to the resident's parents. The ADON stated Resident #42 was upset because he had a BIMS of 15 and was his own person to make decisions. The ADON stated the cell phone policy is that staff should never have them in direct care areas in the hallways or where residents can see them. Interview on 01/29/26 at 4:19 P.M. with the Administrator revealed she was notified immediately, within two hours of the picture being taken. The Administrator stated she did notify her corporate office immediately. The Administrator stated she did not talk to CNA #233 or Resident #42 about the picture being taken. The Administrator stated the cell phone policy is that staff should not have their cell phones in personal care areas.Interview on 01/29/26 at 4:29 P.M. with the Administrator and the ADON verified they did not talk to CNA #233 or LPN #500 about the picture of Resident #42's back and they did not verify that CNA #233 or LPN #500 had deleted the picture of Resident #42's back from their personal cell phones.Interview on 01/29/26 at 4:43 P.M. with the Administrator revealed she could not find a formal investigation and that LPN #15 did the interviews when the incident occurred. The Administrator stated she did not feel there was intent to do harm, so taking the picture of Resident #42's naked back was not abuse. The Administrator stated she did not complete a report to a State Agency. The Administrator stated it was more of HIPAA violation since CNA #233 took the picture of Resident #42's back so that he could get care. Interview on 01/29/26 at 4:53 P.M. with Resident #42 revealed he did not know the picture of his naked back had been taken until he received a call from his father who asked him why he would not let the staff take care of him. Resident #42 stated that he asked his father what he was talking about and his father texted him the picture of his naked back. Resident #42 stated that was the first time he knew about any picture being taken of his naked back and he was upset. Resident #42 stated that no one asked his permission to take a picture of his back. Resident #42 stated that he felt violated when he found out about the picture of his naked back being taken without his consent because he does not know who saw the picture and that he does not want other people to see him in this condition. Interview on 01/30/26 at 1:40 P.M. with CNA #233 revelaed did not ask Resident #42 if she could take a picture of his naked back while she was giving him a shower. CNA #233 stated that she was never suspended and does not know if any investigation occurred. CNA #233 stated that LPN #15 had told her today not to speak with anyone about the picture of Resident #42's back.Review of the facility policy, Abuse Prohibition Policy, dated 10/14/22 stated that allegations of guest/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.Review of the Centers for Medicare and Medicaid Services (CMS), Center for Clinical Standards and Quality/Survey and Certification Group Memorandum dated 08/05/16 with subject of Regarding Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings by Nursing Home Staff, stated that the facility must report all allegations of abuse, provide protections for any resident involved in allegations, conduct a thorough investigation, implement corrective actions to prohibit further abuse, and to report the findings as required. Anytime that the nursing home receives an allegation of abuse, including those involving posting of an unauthorized photograph or recording of a resident on social media, the facility must not only report the alleged violation to the Administrator and other officials, but must also initiate an immediate investigation.

Based on record review, staff interview, and policy review, the facility failed to ensure an allegation of verbal/ emotional abuse was reported to the State survey agency as required. This affected one (Resident #14) of two residents reviewed for abuse. The facility census was 104. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (a condition where the brain did not function properly due to an underlying metabolic disturbance causing cognitive impairment, changes in behaviors, and other neurological symptoms), Bipolar disorder, malignant neoplasm of the uterus, adult failure to thrive, and depression. Review of Resident #14's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any vision or hearing problems and had clear speech. She was able to make herself understood and was able to understand others. She was cognitively intact and was not noted to have any behaviors or rejection of care during the seven days of the assessment period. Review of Resident #14's progress notes revealed a nurse's note dated 10/05/25 at 9:11 A.M. by Licensed Practical Nurse (LPN) #100 that indicated the resident was unresponsive and was having apneic breathing patterns (a temporary cessation of breathing where the body does not inhale or exhale for a period of time). The nurse was unable to get a blood pressure or a recording of the resident's oxygen saturation level. The nurse's progress note did not provide details of any specific assessments that were performed to evaluate the resident's change in condition. The local hospital was called and made a pick-up at 9:15 A.M. Subsequent notes revealed the resident was admitted to the hospital with the diagnoses of sepsis (a life threatening medical emergency caused by the body's overwhelming response to an infection that could lead to tissue damage, organ failure, or death) and an acute kidney injury.Review of the Nursing Daily Schedule for 10/05/25 revealed Certified Nursing Assistant (CNA) #150 was one of two CNA's assigned to work Resident #14's unit when the resident had a change in condition requiring her to be in the emergency room for an evaluation. She was assigned to work day shift from 6:00 A.M. to 6:00 P.M. On 10/28/25 at 10:59 A.M., an interview with CNA #150 confirmed she worked on 10/05/25 when Resident #14 was found unresponsive. She reported the resident was known to go up and down a lot and the resident seemed tired that day. She was also not eating much and was just not herself. She reported she was present when LPN #100 was in Resident #14's room assessing her change in condition. The resident was able to respond verbally, but was not clear in what she was saying. That was somewhat normal for the resident, as she was not always able to make herself clear when speaking. She heard the nurse ask the resident to squeeze his fingers when assessing the resident. She then heard LPN #100 say Oh (saying resident's first name), that was not my fingers. She denied the resident made any acknowledgement to that comment as the resident was out of it. She felt the nurse was insinuating by that comment that the resident had grabbed his penis and not his fingers. She heard that nurse make comments like that in the past. She indicated the comment felt inappropriate to her and made her feel uncomfortable. She was asked if she reported it and confirmed that she had. She reported she told the unit manager (LPN #200) about it. She was given a paper to write out her statement and gave it back to LPN #200, after she completed it. On 10/28/25 at 11:08 A.M., an interview with the facility's Director of Nursing (DON) revealed she was not aware of any incident that had occurred between LPN #100 and Resident #14 on 10/05/25 (where inappropriate comments were made with sexual innuendoes). She denied she had received any witness statements pertaining to any incident occurring on that day and did not recall any concerns being reported by the unit manager on that day. She reported the unit manager was off on 10/28/25, but should be returning to work the following day. She would follow up with the unit manager to see if she had knowledge of any incidents occurring that day. She would also check with the facility's Administrator to see if she had anything on that. On 10/28/25 at 11:30 A.M., the facility's DON came in and reported she spoke to the unit manager about any incidents that occurred on 10/05/25 involving LPN #100 and Resident #14. The DON reported she had been made aware of the situation, but was looking at it more from the perspective of Resident #14's change in condition not being appropriately addressed or her receiving timely care. She thought the CNA's main concern was that the nurse was not addressing the change in condition. She was informed by the surveyor what was being investigated was an inappropriate comment that LPN #100 allegedly made when he was assessing Resident #14 for her change in condition on 10/05/25. She was told LPN #100 was allegedly observed to check Resident #14's hand grasp strength by asking Resident #14 to squeeze his fingers. He then allegedly made an inappropriate comment to the resident telling her that was not his fingers. She acknowledged an aide had reported she was present during that assessment and observed that to occur. She was informed the aide felt what she saw and heard was an inappropriate comment to make and it made her feel uncomfortable. She acknowledged the aide's interpretation of that comment was that the nurse was insinuating the resident was grabbing his penis, instead of his fingers. She was asked if she asked the unit manager about any written statements that the aide was given to fill out regarding the incident that she had witnessed. She reported the unit manager did confirm she gave the aide a witness statement form to fill out. She again denied she had been provided any written statements pertaining to that incident, nor had the Administrator. The DON stated she would have to follow up with the unit manager when she returned to work on 10/29/25 to see what occurred after the written statement was provided by the aide and where it went from there. On 10/28/25 at 1:04 P.M., a follow up interview with CNA #150 confirmed she filled out a written statement on paper that had been given to her by the unit manager regarding the incident she observed on 10/05/25. She was instructed by the unit manager to just leave it in her (unit manager's) office when she completed it, which she did. She reported she put the written statement under a keyboard to the unit manager's computer and then informed the unit manager where she put it. On 10/29/25 at 9:31 A.M., an interview with LPN #200 revealed she was one of four unit managers that worked in the facility. She confirmed she had been made aware of the incident that occurred between LPN #100 and Resident #14 on 10/05/25. She stated an aide came to her (after Resident #14 had been sent to the hospital) and told her she was in the room with Resident #14 when LPN #100 was assessing her. She further confirmed she was told LPN #100 asked the resident to squeeze his fingers, as part of his assessment, and then made a comment about that not being his fingers. She was not able to get a statement from the resident, since she had transferred out of the facility, and did not get a statement from LPN #100. She confirmed CNA #150 was the aide that reported it to her, after the incident occurred. She further confirmed she had CNA #150 provide a written statement on what had occurred. She then reported she contacted the DON and informed her of the situation and the inappropriate comment that was made by LPN #100. She told the DON she was not able to talk to Resident #14, as the resident had been sent out to the hospital. She was asked if the inappropriate comment made could have been considered verbal/ emotional abuse and replied, yes. She felt the comment was inappropriate, if it in fact had been said. She denied LPN #100 was sent home or suspended pending an investigation. She was asked what the DON said to her, after she reported the incident to the DON. She stated the DON told her she would follow up with it. She denied the DON provided any guidance to them to send the nurse home pending an investigation. She was not aware of the facility submitting a self-reporting incident (SRI) to report the allegation of potential verbal/ emotional abuse. On 10/29/25 at 9:46 A.M., an interview with the DON revealed she did not receive the written statement provided by CNA #150 pertaining to the incident between LPN #100 and Resident #14 that occurred on 10/05/25. She denied the Assistant Director of Nursing (ADON) or any other department head had received it by mistake. She checked all the mailboxes and asked around to see if anyone had received it by mistake. She reported no one had received it and she was not able to locate it anywhere. She confirmed she did receive a call from the unit manager regarding the incident that occurred on 10/05/25. The call was received on 10/05/25 at around 3:00 P.M. She reported when the situation was discussed, a lot of the aides did not like working with LPN #100. He would do push ups at the nurses' station and they found him to be weird. She was not sure if the aides were just targeting that nurse because they did not like him. The unit manager told her an aide had reported a situation to her. She thought the main concern was that the aide did not feel like the nurse was responding to a resident's change in condition as he should have. It was then mentioned the nurse made a comment during his assessment of Resident #14, after asking the resident to squeeze his finger. The comment made to the resident by the nurse was that it was not his fingers or hand that the resident was squeezing. She indicated the resident was unresponsive and would not have been affected by that comment. When she heard about the situation, her mind did not go to a possible allegation of verbal/ emotional abuse. She still did not feel what was said was abuse, as it did not meet the definition of abuse, and the resident was not able to understand. Due to the resident's unresponsiveness at the time, she did not feel the resident heard what was said. She confirmed it was an inappropriate comment, if it was said. She acknowledged that it could not be determined whether the resident was able to hear or comprehend the comment made, or not, based on her altered mental status. The comment made was inappropriate and had sexual innuendoes and should have at least been reported and investigated as a potential abuse allegation. She denied the facility investigated or reported that allegation of potential abuse and no SRI had been completed or submitted as required. Review of the facility's abuse Prohibition Policy last revised on 09/09/22 revealed each resident should be free from abuse. Abuse should include freedom from verbal, mental, sexual, or physical abuse. To assure residents were free from abuse, the facility should monitor resident care and treatments on an on-going basis. It was the responsibility of all staff to provide a safe environment for the residents. Staff members should immediately report incidents of abuse and suspected abuse. Abuse could be staff to resident. Abuse meant the willful infliction of injury with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents was irrespective of any mental or physical condition, may cause physical harm, pain, or mental anguish. Willful, as used in the definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse was the use of verbal or non-verbal communication which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation regardless of their age, ability to comprehend or disability. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse included the use of oral communication to residents within hearing distance, regardless of age, ability to comprehend, or disability. Allegations by anyone who became aware of verbal, physical, mental, sexual, or emotional abuse must immediately report it to his/ her Administrator. An incident report and/ or grievance forms per state specific requirements would be completed. A preliminary, on-site investigation would be initiated within 24 hours of any report. If the accused was an employee of the facility, he/ she would be suspended until the investigation had been completed. The staff would report any allegations or suspicions of mistreatment/ abuse to the Administrator and DON immediately. The Administrator would notify any State or Federal agencies of the allegations per State guidelines (two hours if abuse allegation, all others no later than 24 hours).This deficiency represents non-compliance investigated under Complaint Number 2639140.

Based on record review, staff interview, and policy review, the facility failed to ensure an allegation of potential verbal/ emotional abuse was investigated by the facility when reported to management staff. This affected one (Resident #14) of two residents reviewed for abuse. Findings include:Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (a condition where the brain did not function properly due to an underlying metabolic disturbance causing cognitive impairment, changes in behaviors, and other neurological symptoms), Bipolar disorder, malignant neoplasm of the uterus, adult failure to thrive, and depression. Review of Resident #14's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any vision or hearing problems and had clear speech. She was able to make herself understood and was able to understand others. She was cognitively intact and was not noted to have any behaviors or rejection of care during the seven days of the assessment period. Review of Resident #14's progress notes revealed a nurse's note dated 10/05/25 at 9:11 A.M. by Licensed Practical Nurse (LPN) #100 that indicated the resident was unresponsive and was having apneic breathing patterns (a temporary cessation of breathing where the body does not inhale or exhale for a period of time). The nurse was unable to get a blood pressure or a recording of the resident's oxygen saturation level. The nurse's progress note did not provide details of any specific assessments that were performed to evaluate the resident's change in condition. The local hospital was called and made a pick-up at 9:15 A.M. Subsequent notes revealed the resident was admitted to the hospital with the diagnoses of sepsis (a life threatening medical emergency caused by the body's overwhelming response to an infection that could lead to tissue damage, organ failure, or death) and an acute kidney injury.Review of the Nursing Daily Schedule for 10/05/25 revealed Certified Nursing Assistant (CNA) #150 was one of two CNA's assigned to work Resident #14's unit when the resident had a change in condition requiring her to be in the emergency room for an evaluation. She was assigned to work day shift from 6:00 A.M. to 6:00 P.M. On 10/28/25 at 10:59 A.M., an interview with CNA #150 confirmed she worked on 10/05/25 when Resident #14 was found unresponsive. She reported the resident was known to go up and down a lot and the resident seemed tired that day. She was also not eating much and was just not herself. She reported she was present when LPN #100 was in Resident #14's room assessing her change in condition. The resident was able to respond verbally, but was not clear in what she was saying. That was somewhat normal for the resident, as she was not always able to make herself clear when speaking. She heard the nurse ask the resident to squeeze his fingers when assessing the resident. She then heard LPN #100 say Oh (saying resident's first name), that was not my fingers. She denied the resident made any acknowledgement to that comment as the resident was out of it. She felt the nurse was insinuating by that comment that the resident had grabbed his penis and not his fingers. She heard that nurse make comments like that in the past. She indicated the comment felt inappropriate to her and made her feel uncomfortable. She was asked if she reported it and confirmed that she had. She reported she told the unit manager (LPN #200) about it. She was given a paper to write out her statement and gave it back to LPN #200, after she completed it. On 10/28/25 at 11:08 A.M., an interview with the facility's Director of Nursing (DON) revealed she was not aware of any incident that had occurred between LPN #100 and Resident #14 on 10/05/25 (where inappropriate comments were made with sexual innuendoes). She denied she had received any witness statements pertaining to any incident occurring on that day and did not recall any concerns being reported by the unit manager on that day. She reported the unit manager was off on 10/28/25, but should be returning to work the following day. She would follow up with the unit manager to see if she had knowledge of any incidents occurring that day. She would also check with the facility's Administrator to see if she had anything on that. On 10/28/25 at 11:30 A.M., the facility's DON came in and reported she spoke to the unit manager about any incidents that occurred on 10/05/25 involving LPN #100 and Resident #14. The DON reported she had been made aware of the situation, but was looking at it more from the perspective of Resident #14's change in condition not being appropriately addressed or her receiving timely care. She thought the CNA's main concern was that the nurse was not addressing the change in condition. She was informed by the surveyor what was being investigated was an inappropriate comment that LPN #100 allegedly made when he was assessing Resident #14 for her change in condition on 10/05/25. She was told LPN #100 was allegedly observed to check Resident #14's hand grasp strength by asking Resident #14 to squeeze his fingers. He then allegedly made an inappropriate comment to the resident telling her that was not his fingers. She acknowledged an aide had reported she was present during that assessment and observed that to occur. She was informed the aide felt what she saw and heard was an inappropriate comment to make and it made her feel uncomfortable. She acknowledged the aide's interpretation of that comment was that the nurse was insinuating the resident was grabbing his penis, instead of his fingers. She was asked if she asked the unit manager about any written statements that the aide was given to fill out regarding the incident that she had witnessed. She reported the unit manager did confirm she gave the aide a witness statement form to fill out. She again denied she had been provided any written statements pertaining to that incident, nor had the Administrator. The DON stated she would have to follow up with the unit manager when she returned to work on 10/29/25 to see what occurred after the written statement was provided by the aide and where it went from there. On 10/28/25 at 1:04 P.M., a follow up interview with CNA #150 confirmed she filled out a written statement on paper that had been given to her by the unit manager regarding the incident she observed on 10/05/25. She was instructed by the unit manager to just leave it in her (unit manager's) office when she completed it, which she did. She reported she put the written statement under a keyboard to the unit manager's computer and then informed the unit manager where she put it. On 10/29/25 at 9:31 A.M., an interview with LPN #200 revealed she was one of four unit managers that worked in the facility. She confirmed she had been made aware of the incident that occurred between LPN #100 and Resident #14 on 10/05/25. She stated an aide came to her (after Resident #14 had been sent to the hospital) and told her she was in the room with Resident #14 when LPN #100 was assessing her. She further confirmed she was told LPN #100 asked the resident to squeeze his fingers, as part of his assessment, and then made a comment about that not being his fingers. She was not able to get a statement from the resident, since she had transferred out of the facility, and did not get a statement from LPN #100. She confirmed CNA #150 was the aide that reported it to her, after the incident occurred. She further confirmed she had CNA #150 provide a written statement on what had occurred. She then reported she contacted the DON and informed her of the situation and the inappropriate comment that was made by LPN #100. She told the DON she was not able to talk to Resident #14, as the resident had been sent out to the hospital. She was asked if the inappropriate comment made could have been considered verbal/ emotional abuse and replied, yes. She felt the comment was inappropriate, if it in fact had been said. She denied LPN #100 was sent home or suspended pending an investigation. She was asked what the DON said to her, after she reported the incident to the DON. She stated the DON told her she would follow up with it. She denied the DON provided any guidance to them to send the nurse home pending an investigation. She was not aware of the facility submitting a self-reporting incident (SRI) to report the allegation of potential verbal/ emotional abuse. On 10/29/25 at 9:46 A.M., an interview with the DON revealed she did not receive the written statement provided by CNA #150 pertaining to the incident between LPN #100 and Resident #14 that occurred on 10/05/25. She denied the Assistant Director of Nursing (ADON) or any other department head had received it by mistake. She checked all the mailboxes and asked around to see if anyone had received it by mistake. She reported no one had received it and she was not able to locate it anywhere. She confirmed she did receive a call from the unit manager regarding the incident that occurred on 10/05/25. The call was received on 10/05/25 at around 3:00 P.M. She reported when the situation was discussed, a lot of the aides did not like working with LPN #100. He would do push ups at the nurses' station and they found him to be weird. She was not sure if the aides were just targeting that nurse because they did not like him. The unit manager told her an aide had reported a situation to her. She thought the main concern was that the aide did not feel like the nurse was responding to a resident's change in condition as he should have. It was then mentioned the nurse made a comment during his assessment of Resident #14, after asking the resident to squeeze his finger. The comment made to the resident by the nurse was that it was not his fingers or hand that the resident was squeezing. She indicated the resident was unresponsive and would not have been affected by that comment. When she heard about the situation, her mind did not go to a possible allegation of verbal/ emotional abuse. She still did not feel what was said was abuse, as it did not meet the definition of abuse, and the resident was not able to understand. Due to the resident's unresponsiveness at the time, she did not feel the resident heard what was said. She confirmed it was an inappropriate comment, if it was said. She acknowledged that it could not be determined whether the resident was able to hear or comprehend the comment made, or not, based on her altered mental status. The comment made was inappropriate and had sexual innuendoes and should have at least been reported and investigated as a potential abuse allegation. She denied the facility investigated or reported that allegation of potential abuse and no SRI had been completed or submitted as required. Review of the facility's abuse Prohibition Policy last revised on 09/09/22 revealed each resident should be free from abuse. Abuse should include freedom from verbal, mental, sexual, or physical abuse. To assure residents were free from abuse, the facility should monitor resident care and treatments on an on-going basis. It was the responsibility of all staff to provide a safe environment for the residents. Staff members should immediately report incidents of abuse and suspected abuse. Abuse could be staff to resident. Abuse meant the willful infliction of injury with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents was irrespective of any mental or physical condition, may cause physical harm, pain, or mental anguish. Willful, as used in the definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse was the use of verbal or non-verbal communication which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation regardless of their age, ability to comprehend or disability. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse included the use of oral communication to residents within hearing distance, regardless of age, ability to comprehend, or disability. Allegations by anyone who became aware of verbal, physical, mental, sexual, or emotional abuse must immediately report it to his/ her Administrator. An incident report and/ or grievance forms per state specific requirements would be completed. A preliminary, on-site investigation would be initiated within 24 hours of any report. If the accused was an employee of the facility, he/ she would be suspended until the investigation had been completed. The staff would report any allegations or suspicions of mistreatment/ abuse to the Administrator and DON immediately. The Administrator would notify any State or Federal agencies of the allegations per State guidelines (two hours if abuse allegation, all others no later than 24 hours).This deficiency represents non-compliance investigated under Complaint Number 2639140.

Based on closed resident record review, review of a facility medication error report, review of pharmacy labels, staff interview, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one (#105) of three residents reviewed for medication errors. Actual Harm occurred on 09/30/25 for Resident #105, when a nurse crushed and administered an extended release Morphine (narcotic pain medication) tablet to the resident, while also administering double the ordered dose of prescribed Lyrica (anticonvulsant analgesic) to the resident, resulting in the need to administer Narcan (opioid reversal agent) to the resident to reverse the effects of a drug overdose and to be evaluated at the local emergency department (ED), after the overdose occurred. Findings include: Review of Resident #105's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic pain syndrome, opioid dependence, low back pain, Barret's Esophagus (a condition in which the lining of the swallowing tube/ esophagus that connected the mouth to the stomach became damaged by acid reflux causing the lining to thicken, which could result in difficulty swallowing), and adult-onset diabetes mellitus. Review of Resident #105's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not coded as having displayed any behaviors during the 14 days of the assessment period. He was indicated on the MDS as having received scheduled pain medication, but no pain medications had been administered on an as needed (prn) basis. He complained of occasional pain in the past 5 days reporting having had pain that was a three on a 1-10 pain scale that did not affect his sleep or day to day activities. The medication section was coded to reflect he had been given opioid pain medications during the seven day assessment period. Review of Resident #105's care plans revealed he had an active care plan in place for being at risk for pain and known to have chronic pain related to low back pain (LBP), chronic pain syndrome, back pain, wounds right hip, and taking opioids. The care plan was initiated on 03/26/24 and was last revised on 09/19/25. The goal was for the resident to verbalize adequate relief of his pain or the ability to cope with incompletely relieved pain. The interventions included administering medications as ordered, observe for ineffectiveness and side effects of pain medication (confusion. hallucinations etc.), and report abnormal findings to the physician. Review of Resident #105's physician's orders revealed the resident had an order to receive MS Contin (an extended release, opioid medication used for the long-term, around the clock management of severe pain) Extended Release (ER) 15 milligrams (mg) by mouth (po) twice a day for chronic pain. The order originated on 09/26/25 and continued until 10/01/25, when the order was altered to reflect the additional directive to Do Not Crush the medication. The resident also had an order to receive Lyrica (an anti-convulsant medication used to treat nerve pain from various conditions) 150 mg po three times a day for neuropathy pain. That order had recently been re-ordered as of 09/28/25. The physician's orders did not provide any directive allowing staff to crush medications as needed. Review of Resident #105's progress notes revealed the resident was sent out to the hospital on [DATE] for worsening of the pressure ulcer to his coccyx. The wound had an increase in size, an increase in pain, and an increase in purulent drainage with a foul odor. He returned to the facility on [DATE] on intravenous antibiotics and a new order for MS Contin 15 mg po twice a day for pain. He did not return with an order for the use of Lyrica 150 mg po three times a day that had been ordered prior to his transfer to the hospital on [DATE]. Review of a telehealth note dated 09/28/25 at 8:00 A.M. revealed the nurse practitioner was notified by nursing that Resident #105's previously prescribed Lyrica that was ordered at 150 mg po three times a day for neuropathy was not on the hospital's discharge summary upon his return to the facility on [DATE]. The resident was requesting his Lyrica to be re-instated for pain. An order was given for Lyrica 150 mg po three times a day to be given on a scheduled basis with directions to hold for sedation. Review of a nurse's progress note from registered nurse (RN) #100 on 09/30/25 at 4:45 P.M. revealed a nurse had alerted her that Resident #105 had confusion and was showing slight sedation effects. The resident was noted to be oriented to self and place when assessed by RN #100 with the following vital signs: Blood pressure 95/75, pulse 65 beats per minute, respirations at 17/ minute, and a temperature of 98 degrees Fahrenheit. The resident's oxygen level was normal at 95% on room air. The nurse reviewed the resident's medication and reported he received an extra dose of medication (not specified) and his extended-release medication (not specified) was given crushed with his other scheduled medications. The physician's assistant (PA) was notified immediately regarding the resident's current assessment findings and his reported vital signs. A new order was received to administer Narcan ((an opioid antagonist medication used to reverse or reduce the effects of opioids) 4 mg/ 0.1 milliliters (ml) nasal spray x 1 dose. Review of a nurse's progress note by RN #100 dated 09/30/25 at 4:51 P.M. revealed a new order was received to hold Resident #105's evening dose of MS Contin and Lyrica per an order from the PA. Resident #105 was re-assessed, and his blood pressure was 111/67, pulse 67, respirations of 17, and his oxygen level was 97% on room air. The resident was noted to be alert and oriented to person, place, time, and event. His wife that was visiting wanted him to go to ER to be assessed. The PA was notified and gave an order for the resident to be transferred to the ER for an evaluation as requested by the resident's family. It was deemed by the PA to be a non-emergent transport, due to the resident's current orientation, alertness, and ability to eat and drink. It was made known to the PA and the wife that the community's ambulette service could not transport the resident to the hospital for a couple of hours and both were in agreement that the resident did not need transported emergently and could wait for the ambulette to be available for transport. The resident returned to the facility on [DATE] at 2:10 A.M. in stable condition. He was alert and oriented upon his return and aroused/ responded appropriately. He did not return with any new orders. Review of Resident #105's medication administration record (MAR) for September 2025 revealed the resident was scheduled to receive his MS Contin 15 mg ER tablet po twice a day at 8:00 A.M. and 8:00 P.M. He received his dose of MS Contin 15 mg ER the morning of 09/30/25 at 8:00 A.M. He also received his ordered dose of Lyrica 150 mg at 8:00 A.M., as was ordered three times a day. Review of Resident #105's hospital records for his ER visit on 09/30/25 revealed they included an emergency department (ED) note dated 09/30/25 at 8:18 P.M. that indicated the resident's chief complaint was identified as presenting with a drug overdose. He was being evaluated for hallucinations and an altered mental status after receiving a crushed up Morphine ER tablet at the nursing facility according to his wife that accompanied him to the ER. Upon his arrival, the resident reported he was at his baseline and denied any current complaints. He requested to be sent back to the nursing facility at that time. His symptoms were likely due to receiving a crushed extended release Morphine tablet as his symptoms were currently resolved. No medication changes were made as a result of his ER visit. Review of Resident #105's pharmacy label for the MS Contin (Morphine ER) 15 mg tablets revealed the label on a Controlled Drug Receipt/ Record/ Disposition form dated 09/28/25 included instructions to the nurse that read Do Not Crush, Chew, or Split the medication tablet. The label on the blister pack for the MS Contin 15 mg tablets also included the same instructions not to crush, chew, or split the tablets. Review of a Medication and Treatment Incident Report dated 09/30/25 (date of incident/ date discovered/ and date reported) completed by RN #100 revealed Resident #105 was given MS Contin ER oral tablet crushed, despite it being an extended-release tablet. The time of the incident was indicated to be 4:45 P.M. The medication error resulted in the need for medical treatment/ intervention, as the resident was given Narcan x 1. The medication error was determined to be the result of the nurse's failure to follow procedure. The corrective action taken included providing additional training and written counseling. The training provided involved crushable versus non-crushable medication. The nurse involved in the medication error was not identified by name on the incident report. The medication and treatment incident report did not mention anything about the resident receiving an extra dose of any medication, as was indicated in the progress note dated 09/30/25 at 4:45 P.M., only that his MS Contin had been given crushed with his other medications. Review of the nursing schedule for 09/30/25 revealed licensed practical nurse (LPN) #150 was the nurse assigned to work Resident #105's hall at the time the significant medication error occurred on the resident. Certified Nursing Assistant (CNA) #200 was one of three CNA's that was assigned to work Resident #105's hall when the medication error occurred. Review of the employee file for LPN #150 revealed he received a final written warning on 09/30/25, as a result of the significant medication error that he committed on Resident #105. The disciplinary action given with the final warning was for an infraction of work Rule # 20. A description of the reason for the disciplinary action indicated the nurse committed a medication error that resulted in a resident being sent to the ER to be evaluated following the error. Education was provided to the nurse on medications that could not be crushed, i.e. extended release medications. The nurse signed the disciplinary action report on 10/06/25. On 10/16/25 at 1:12 P.M., an interview with LPN #150 via phone confirmed he did work on 09/30/25, when Resident #105's medication error pertaining to his MS Contin and Lyrica occurred. He further confirmed he was the nurse that administered Resident #105's 8:00 A.M. medications to him. He indicated they just added a new medication for Resident #105's pain control, as his pain medication was changed to Morphine ER. He admitted to crushing the MS Contin (Morphine) ER tablet along with all other medications he gave to the resident that morning. He denied he was aware the MS Contin was not to be crushed. That was the first time he had worked with the resident, since the MS Contin had been ordered. He claimed he had interacted with the resident that entire day following the administration of his morning medications. He reported the resident had been having a change in his condition, as his overall health had been declining. He recalled the resident was pointing and speaking to things that were not there. He told the unit manager and documented his findings. He thought it was somewhere between 10:00 A.M. and 11:00 A.M., when that occurred. The unit manager told him she would call the resident's wife. The wife showed up at the facility later that day and was told the resident was having lots of problems. The wife asked if they had crushed the resident's medications. When told that they had, the wife informed him that the resident was receiving MS Contin XR that should not be crushed. He then reported it to the unit manager. He confirmed, after that incident, he was given a written warning, as a result of that significant medication error. He denied there was any instructions provided with the order for the MS Contin that directed them not to crush, when he gave the medication. He had since been educated on what medications could and could not be crushed. On 10/16/25 at 1:43 P.M., an interview with CNA #200 confirmed she was one of the three aides that worked on 09/30/25, when the medication error involving Resident #105 occurred. She was not aware that a medication error had occurred but did interact with the resident that day. She recalled the resident was very tired that day. She helped the nurse (LPN #150) do the resident's wound treatment that day around 3:00 P.M. or 3:30 P.M. She stated the resident was very confused and was not alert that day per his usual self. They also had to help feed him that day, as the resident was spilling food on himself. She too reported the resident's health had been declining and he was on hospice at that time. She recalled being at the nurses' station at the time when the resident's wife came in and was upset with how the resident was. She thought that was around 5:30 P.M. (towards the end of her shift), but then recalled they were passing meal trays around that time, so it could have been anywhere between 4:45 P.M. and 5:30 P.M. On 10/16/25 at 1:49 P.M., an interview with RN #100 revealed she was the unit manager for Resident #105's hall. She described Resident #105's normal mental status as being alert, but he could have some confusion at times. He was oriented to self and place. He was also known to be drowsy at times, due to the medications he took and his overall health status. She reported the nurse (LPN #150) came to her late in the afternoon of 09/30/25, and told her Resident #105 was not feeling good. She went to his room to assess him and found the resident to be drowsy and more confused than normal for him. She came back into her office to call the resident's provider to inform them of the resident's noted change in condition. LPN #150 then returned to her office and informed her that he crushed the resident's MS Contin and gave him too much Lyrica. She was asked to clarify the nurse's note she wrote that was dated 09/30/25 at 4:45 P.M., which indicated the resident received an extra dose of medication, in addition to his extended-release medication being crushed with other scheduled medications. She confirmed Resident #105 was also given double the dose of Lyrica (300 mg) that was ordered for him on 09/30/25 at 8:00 A.M. She confirmed he received 300 mg, when he should have only been given 150 mg as ordered three times a day. She indicated at the time, they had been giving the resident a 100 mg capsule and a 50 mg capsule of Lyrica to equal a total dose of 150 mg. They then received Lyrica 150 mg capsules from their pharmacy. LPN #150 had indicated to her that he gave Resident #105 a 100 mg capsule of Lyrica, a 50 mg capsule of Lyrica, and a 150 mg capsule of Lyrica equaling 300 mg (doubling his ordered dose). She was asked if the resident had been receiving his medications crushed, prior to the incident occurring on 09/30/25. They were giving him his medications whole in pudding, but at some point started crushing some of his medications due to him having some swallowing issues with the larger pills. She had heard other nurses inform the resident in the past that there were certain medications he received that they could not crush. She was not aware of any of the other nurses ever crushing his MS Contin, prior to or after the incident on 09/30/25. She was not aware of the nurse crushing all the resident's medications that morning and believed the resident had a standing order in place that they could crush allowable medications. She later reported that the standing order giving them permission to crush allowable medications had been inadvertently discontinued somewhere along the way and was not part of his current physician's orders. She was asked if extended release or delayed release medications could be crushed and she replied no. If there was a resident with those type of medications ordered that were having trouble swallowing the tablet or capsule, they should reach out to the physician to see about getting other similar medications ordered that could be given in a form the resident was able to safely take. She confirmed they provided education to the nurses following the occurrence of that medication error about being mindful to follow the instructions on medications' labels regarding those medications that could not be crushed. They have since placed a list of medications that should not be crushed on all units accessible to the nurses administering medications. LPN #150 was the one that administered Narcan to Resident #105, after she got the order when calling the provider. She stated within 60 seconds of receiving the Narcan, the resident was talking per his usual. He was alert, drinking, and eating supper. The wife wanted the resident sent to the ER, despite the resident saying he felt fine. They sent him to the ER as requested by the family and as agreed to by the resident. He returned a short time later with no new orders. On 10/16/25 at 2:10 P.M., an interview with facility's Director of Nursing (DON) revealed RN #100 was in the building when the medication error involving Resident #105 on 09/30/25 occurred. She was informed there had been a change in Resident #105's condition, which included confusion. When RN #100 was looking into the resident's change in condition, LPN #150 said Oh my God, I crushed his Morphine. RN #100 had reached out to the resident's provider and got an order for Narcan. Resident #105 had positive results to the Narcan and was back to his baseline. His wife wanted him sent out to the ER anyway. He was found to be at baseline when he was evaluated at the hospital. She confirmed she was the one that completed the medication error report the day after the medication error occurred. She spoke with the unit manager (RN #100), pulled the nurse's documentation, reviewed the progress notes, and talked with the PA, as part of her review. She stated they started crushing Resident #105's medications ever since he had thyroid surgery, but not all of his medications. She was not 100% sure if all his medications had been crushed that morning, or if it was just the MS Contin. She confirmed the MS Contin should not be crushed as it was an extended-release tablet and would result in the resident receiving an immediate dose of Morphine 15 mg instead of it being slowly released over a 12 hour period. Review of the facility's Medication Administration policy revised 10/17/23 revealed resident medications were to be administered in an accurate and safe manner. Medications were to be administered in accordance with written orders of the attending physician. The nurse was to check the Do Not Crush list before crushing medications. If necessary, the nurse was to contact the ordering physician for a change to a different route of administration when the medication could not be crushed. This deficiency represents non-compliance investigated under Complaint Number 2637682.

Based on observation, staff interview, and review of manufacturer guidelines, the facility failed to label Tuberculin (TB) solution (Tubersol) multi-use vials with a date when opened for use. This deficient practice had the potential to affect all 112 residents residing in the facility. The facility census was 112.Findings Include:1. An observation on 09/11/25 at 7:45 A.M. in the medication refrigerator in the Unit Three medication storage room revealed an opened multi-use vial of Tuberculin solution. There was no date on the vial or on the packaging box to reflect when the vial had been opened for use. The vial expiration was 04/2026.An interview on 09/11/25 at 7:47 A.M. with Medication Technician (MT) #339 confirmed the opened vial of Tuberculin solution without a date reflecting when the vial was opened for use. MT #339 stated the vial should be removed from use and discarded.2. An observation on 09/11/25 at 7:55 A.M. in the refrigerator in the Unit Two medication storage room revealed an opened multi-use vial of Tuberculin solution. There was no date on the vial or on the packaging box to reflect when the vial had been opened for use. The vial expiration date was 04/2026.An interview on 09/11/25 at 7:57 A.M. with Unit Manager (UM) #214 confirmed the opened vial of Tuberculin solution did not have a date of when the vial had been opened for use. UM #214 removed the vial from use and discarded it. UM #214 stated all new admissions receive a two-step TB test upon admission to the facility.3. An observation on 09/11/25 at 8:02 A.M. in the refrigerator in Unit One medication storage room revealed an opened multi-use vial of Tuberculin solution. There was no date on the vial or on the packaging box. The vial expiration date was 04/2026.An interview on 09/11/25 at 8:05 A.M. with UM #422 confirmed the opened vial of Tuberculin solution with no date reflecting when the vial had been opened for use. UM #422 removed the vial from use and discarded it.Review of the manufacturer guidelines for Tuberculin solution (Tubersol) dated 10/2021 revealed a vial of Tubersol which has been entered and in use for 30 days should be discarded.

Based on facility infection tracking and monitoring records, and staff interview, the facility failed to properly monitor and address patterns and trends of known infections. This had the potential to affect all 112 residents in the facility. The census was 112. Findings Include:Review of the facility infection control log, dated June 2025, revealed there were two urinary tract infections on one hallway and 12 total skin infections throughout the facility, including three in one unit and three on a separate unit. Review of facility infection control log, dated July 2025, revealed two fungal infections on one unit, two osteomyelitis infections on another unit, three skin infections on a third unit, and two more fungal infections on a fourth unit. Review of facility infection control log, dated August 2025, revealed three urinary tract infections, two of which the organism was extended-spectrum beta-lactamase (ESBL), in one unit, and two respiratory infections in a separate unit. Review of facility infection control logs and documentation, dated June 2025 to August 2025, revealed there was no documentation to support the facility had addressed the above listed infection patterns/trends. There was no documentation to support any staff education and/or monitoring/auditing of care was completed to reduce the likelihood of these infections spreading.Interview with Registered Nurse (RN) #248 on 09/11/25 at 10:58 A.M. confirmed she has not implemented any staff education, monitoring, or auditing of the patterns/trends listed above. She defined a pattern/trend to be two or more of the same infections/infection areas in the same unit. She confirmed there were patterns/trends and they have not addressed it.

Based on observation, staff interview, review of cleaning schedules, and facility policy review, the facility failed to maintain an clean and homelike environment. This deficient practice affected four (#3, #60, #93, and #105) of 112 residents observed for homelike environment. The facility census was 112.Findings Include:An observation on 09/08/25 at 10:30 A.M. revealed Resident #3 lying in bed with the bed covers pulled up to cover lower body. There were several dark brown stains noted on the white window blinds which were in the half-open position.An observation on 09/08/25 at 2:21 P.M. revealed Resident #93's room had cobwebs located in the corners where the wall met the ceiling and in the windowsill. The floor was dirty with noted stains along the baseboard under the heating and cooling unit and under the three-drawer dresser beside the bed. Further observation revealed Resident #93's fitted and flat sheets were noted to be soiled with dark brown stains near the edge of the bed.An observation on 09/08/25 at 2:30 P.M. revealed Resident #105 sitting in his wheelchair completing a puzzle on the empty bed in his room. The wall directly behind the empty bed was noted to be deeply scratched with several areas of exposed dry wall material noted. The scratches appeared to be approximately one-half inch deep and covered the majority of the lower part of the wall.An observation on 09/10/25 at 8:15 A.M. revealed Resident #60's room with the over the bed light fixture, for bed A, to be uncovered exposing the two florescent light bulbs, the light was turned on. There was no bed located under the light fixture. Resident #60's bed was located closest to the window.A review of the housekeeping room cleaning schedules dated 09/08/25 and 09/09/25 revealed Resident #3 and Resident #93's rooms had been marked as being cleaned by the housekeeping staff.An interview on 09/15/25 at 11:52 A.M. with Maintenance Director (MD) #531 confirmed the unclean conditions in Resident #3 and Resident #93's rooms, the exposed dry wall material in Resident #105's room, and the exposed light bulbs in Resident #60's room.Review of the facility's housekeeping services policy, dated 07/08/25, revealed the purpose was to promote a sanitary environment. This deficiency represents non-compliance investigated under Master Complaint Number 2614276 and Complaint Number 2573417.

Based on medical record review, resident interview, and staff interview, the facility failed to allow a resident to choose to eat a diet texture of their preference when the resident's diet was downgraded without appropriate tests or evaluations completed. This affected one (#49) of one residents reviewed for choices. The census was 112. Findings Include:Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses included amyotrophic lateral sclerosis (ALS), congestive heart failure, hypertensive heart failure, type II diabetes, hyperlipidemia, dysphagia, ischemic cardiomyopathy, atherosclerotic heart disease, old myocardial infarction, nicotine dependence, and non-compliance with other medical treatment and regimen. Review of Resident #49's Minimum Data Set (MDS) assessment, dated 07/02/25, revealed he was cognitively intact. Review of Resident #49's After Visit Summary Hospital form, dated 01/04/24, revealed he was admitted to the hospital for teeth extraction and to treat a tooth/mouth infection. He was admitted back to the facility on [DATE]. Further review revealed a recommendation was made from the hospital for Resident #49 to utilize a soft diet of, **** days after the procedure, but the specific number of days were not identified. There was no documentation that the hospital recommended a long-term diet texture downgrade or a downgrade of his nutritional status.Review of Resident #49's progress note, dated 01/09/24, revealed the resident was referred to speech therapy services. The note revealed nursing reported the resident was coughing on thin liquids and eliciting difficulty with whole medications. Speech Language Pathologist (SLP) #102 spoke with the resident who became agitated when given recommendations and education on diet recommendations/swallow strategies. Resident #49 was educated on reducing aspiration with thickened liquids/crushed medications and the resident reported he only coughed because he was sick and wants staff to leave him be. SLP #102 educated the resident that he was at risk for aspiration, pneumonia, and death if diet recommendations and swallow strategies were not followed and the resident continued to aspirate. Resident #49 returned understanding of the information. Resident #49 also recently had teeth pulled and the resident's swallow function continued to decline due to ALS. Resident #49 was educated on prognosis regarding swallowing, given SLP's name, and encouraged to participate. Resident #49 nodded his head acknowledging the clinician.Review of Resident #49's SLP Discharge Summary document, dated 05/20/24, revealed Resident #49's therapy was to be primarily focused on education. Resident #49 asked to complete a modified barium swallow study (MBSS) to establish a baseline. There was no documentation presented in the document that Resident #49 had a MBSS completed to support the downgrade of his diet.Review of Resident #49's current dietary orders revealed the facility ordered the resident to be downgraded to a pureed texture diet. There was no documentation provided to support medical tests or assessments that were completed to warrant the downgrade.Review of Resident #49's clinical progress notes, dated 02/09/24, 02/28/24, 03/27/24, 05/29/24, 08/14/24, 12/27/24, and 05/13/25, confirmed Resident #49 expression of displeasure for having a pureed texture diet order. There was no documentation to support the facility giving him the option to revert back to a regular texture diet order with the understanding the resident understood the risks associated with it.Interview with Resident #49 (through electronic means) on 09/08/25 at 2:00 P.M. and 09/15/25 at 1:23 P.M. confirmed he refused meals in the facility because he did not want to eat pureed texture food. He confirmed the facility had not offered him any other choices or abilities to eat food provided by the facility, unless it was pureed. He confirmed he had to purchase his own food since January 2024, because the facility will not provide food other than food that was pureed.Interview with Dietitian #101 on 09/11/25 at 9:15 A.M. confirmed Resident #49 had a pureed texture diet order. She confirmed the facility did not offer him any food that was not pureed texture.Interview with SLP #102 on 09/15/25 at 2:52 P.M. confirmed he was not able to change Resident #49's diet order back to mechanical soft or regular texture until he had another swallow study done. SLP #102 confirmed the facility was to provide a pureed texture diet.Interview with Licensed Practical Nurse (LPN) #214 on 09/15/25 at 3:24 P.M. confirmed Resident #49 had a pureed texture diet order. She confirmed the facility does not offer Resident #49 food that would not be pureed.This deficiency represents non-compliance investigated with Complaint Number 2586509.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents had an appropriate diagnosis for use of an antipsychotic medication and failed to provide proper justification for not attempting a gradual dose reduction for a resident's psychotropic medication. This affected two (#118 and #4) of six residents reviewed for psychotropic medications. The facility census was 112.Findings include:1. Review of the medical record for Resident #118 revealed an admission date of 09/03/25 with diagnoses including acute and chronic respiratory failure with hypercapnia, interstitial pulmonary disease, type II diabetes mellitus with hyperglycemia, and acute kidney failure.Review of the physician orders for Resident #118 revealed an order dated 09/03/25 for olanzapine (antipsychotic medication) oral tablet five (5) milligram (mg) to be given one time a day at bedtime for anxiety.Interview on 09/10/25 at 2:13 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #311 confirmed Resident #118's diagnosis for olanzapine was not appropriate. Both staff members stated the resident came from the hospital with the medication, and there was no documented diagnosis and they could not give him a diagnosis. The staff members stated the physician reviews the medications upon admission and saw the residents in-house to do a complete assessment. The DON confirmed there was no psychiatric diagnosis Resident #118 had for olanzapine medication.Review of the facility policy titled, Psychotropic Medication Management, effective 09/10/25, revealed residents receiving psychoactive upon admission, those with new psychoactive medication orders will have an informed consent completed. The resident/family must be informed of risks/benefits and black box warnings. Per facility policy if residents are admitted with a psychotropic medication, without a clearly documented indication, the prescribing practitioner and the interdisciplinary team (IDT) should determine if continuing the medication is justified. 2. Review of the medical record for Resident #4 revealed an admission date of 02/06/24. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, depression, bipolar disorder and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/26/25, revealed the Resident #4 had intact cognition. Review of the plan of care dated 02/26/24 revealed Resident #4 was at risk for side effects of medication due to antidepressants, antianxiety, and antipsychotic medication therapy. Interventions included to assess pain and offer treatment as indicated and offer nonpharmacological interventions.Review of physician orders as of 09/15/25 revealed Resident #4 was ordered the antihistamine with sedative and anxiolytic effects hydroxyzine oral tablet 50 milligrams (mg) three times per day for anxiety; the antidepressant trazodone oral Tablet 50 mg for insomnia, and the antianxiety medication buspirone oral tablet 15 mg four times per day for anxiety.Review of pharmacy recommendations dated 11/08/24 for Resident #4 revealed a gradual dose reduction request for hydroxyzine from 50 mg to 25 mg. Review of the physician response dated 11/14/24 revealed the provider denied the request because Resident #4 had scheduled surgery and he was having trouble sleeping.Review of pharmacy recommendations dated 12/09/24 for Resident #4 revealed a gradual dose reduction request for hydroxyzine 50 mg to 25 mg. Review of the physician response revealed the provider denied the request because Resident #4 had shoulder pain.During an interview on 09/11/25 at 9:29 A.M. with Certified Nurse Practitioner #301 stated she had not received a request from the pharmacy team to decrease Resident #4's dose of hydroxyzine since December 2024.Review of the facility policy titled, Psychotropic Medication Management, dated 09/10/25, revealed a gradual dose reduction must be attempted in two separate quarters unless clinically contraindicated.

Based on medical record review, observation, and staff interview, the facility failed to provide assistance with personal hygiene for a resident who was dependent for care. This deficient practice affected one (#63) of eight residents reviewed for activities of daily living. The census was 112.Findings Include:Review of the medical record for Resident #63 revealed an admission date of 07/11/23 with diagnoses including but not limited to heart disease, depression, seizures, and intellectual disabilities. Review of Resident #63 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of seven out possible 15, and required moderate to dependent assistance from staff to complete activities of daily living (ADLs) tasks including personal hygiene and shaving of facial hair.Review of Resident #63's functional ability deficit care plan dated 06/06/24 revealed assistance from staff was required to complete personal hygiene tasks.An observation on 09/08/25 at 10:14 A.M. revealed Resident #63 resting in bed and watching television. Resident #63 had noticeable facial hair on her upper lip and chin area.An observation on 09/09/25 at 8:43 A.M. revealed Resident #63 consuming the breakfast meal. Resident #63 continued to have noticeable facial hair on her upper lip and chin.An interview on 09/09/25 at 3:20 P.M. with Unit Manager (UM) #373 confirmed Resident #63 had noticeable facial hair on upper lip and chin. UM #373 stated the staff should be offering to shave Resident #63 during her shower and as needed when facial hair was noticeable to others. UM #373 further stated Resident #63 does go to activities and will be out in the unit lounge, where she would be seen by peer residents and facility visitors.This deficiency represents non-compliance investigated under Complaint Number 2586509.

Based on observation, medical record review, review of census information, resident interview, and staff interview, the facility failed to provide meaningful activities per resident preference. This affected one (#86) of four residents reviewed for activities. The census was 112.Findings include:Review of Resident #86's medical record revealed an admission date of 02/23/10 with diagnosis including Parkinson's disease with dyskinesia, bipolar disorder, obsessive-compulsive disorder, unspecified psychosis not due to a substance or known physiological condition, suicidal ideations, schizophrenia, and visual and auditory hallucinations. Review of Resident #86 annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident with intact cognition.Review of an activity plan of care created 02/25/20, and revised 09/09/23, revealed Resident #86 preferred to engage in activities independently. He preferred to stay in his room and sleep. He wears a headset to keep out noise, and will walk in the halls in the afternoon and evening.Review of an activities evaluation dated 06/13/25 revealed Resident #86 preferred to do activities independently in his room. He likes to watch television (TV) and movies, spend time outside when the weather was nice, listen to music, and take naps. The resident preferred activities in his room in the afternoon and evenings and one-on-one activity. Further review of Resident #86's activity documentation for the activity of watching TV/movies revealed no evidence of the activity being completed for thirty days.Interview on 09/09/25 at 8:35 A.M. with Resident #86 revealed he had a TV but it came off the wall and they have not put it back up. Observation throughout the survey revealed Resident #86 did not have a TV in his room. Interview on 09/11/25 at 11:20 A.M. with Activities Director (AD) #325 stated the activity staff talk to Resident #86 and tell him what was going on that day in activities. AD #325 stated Resident #86 preferred to stay in his room, liked to be by himself, and he does not want people in his room. AD #325 stated staff have taken things to Resident #86 for him to do, and he throws them back at them. AD #325 confirmed Resident #86 had moved rooms several times and did not have a TV in his new room. Review of Resident #86's census details revealed his last room move was in April 2025.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to implement splint/brace program for a resident with bilateral hand contractures. This deficient practice affected one (#47) of two residents reviewed for positioning and mobility. The facility census was 112.Findings Include:Review of the medical record for Resident #47 revealed an initial admission date 02/08/23 and a re-admission date 03/14/23. Diagnoses included but were not limited to bipolar disorder, anxiety, depression, suicidal behavior, and contractures.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of two out of possible 15. Resident #47 was dependent on staff for care, bathing, and transfers. Resident #47 was able to feed self, but preferred staff to assist with eating.Review of Resident #47's nutritional care plan dated 02/09/23 revealed Resident #47 was at risk for malnutrition related to refusals of meals and assistance with eating. Further review revealed a skin care plan dated 02/08/23 indicating Resident #47 was at risk for impaired skin related to contractures, incontinence, and dependent on wheelchair for mobility.Review of Resident #47's occupational therapy (OT) Discharge summary dated [DATE] revealed Resident #47's tolerated wearing bilateral hand splints for up to two hours. Further review revealed OT recommendations for floor staff to complete passive range of motion (PROM) exercises to the left hand, active range of motion (AROM) exercises to the right hand, splint use, and verbal ques with self-feeding.Review of Resident #47's physician orders dated 09/01/25 to 09/30/25 revealed there were no orders for the use of braces/splints for bilateral hand contractures or any type of restorative program for PROM and AROM exercises to be completed.An observation on 09/08/25 at 3:44 P.M. revealed Resident #47 sleeping in bed lying on her left side. Resident #47's bilateral hands were visible, with the left hand and fingers curled into the palm of the hand and the right hand and fingers flat with the fingers hyperextended upwards. There were no splints visible in the room.An interview on 09/15/25 at 10:17 A.M. with Therapy Director (TD) #550 revealed Resident #47 was discharged from OT services on 01/13/25. OT staff completed education with restorative staff on splint use and PROM/AROM exercises for Resident #47. OT did not write the orders or complete the evaluation for the implementation of a splint and ROM restorative program for Resident #47. TD #550 stated Resident #47 did have custom bilateral hand splints in her room and they had been used during OT services.An interview on 09/15/25 at 10:25 A.M. with Assistant Director of Nursing (ADON) #311 confirmed Resident #47 did not have a restorative program implemented for PROM and AROM exercises and for bilateral use of hand splints. ADON #311 stated there had not been an evaluation completed or a restorative program order written by the OT for the nursing restorative staff to complete and/or follow.Review of the facility's brace and splint Program policy, dated 04/05/24, revealed properly used splints and braces can enhance mobility, correct alignment and protect specific extremity while maintaining skin integrity and circulation, and avoiding other possible adverse effects of the device. The purpose of the brace and splint program is to achieve the highest level of independence possible.

Based on record review, review of fall investigations, staff interview, and facility policy review, the facility failed to implement appropriate interventions and properly address repeated non-compliance with interventions to prevent resident falls. This deficient practice affected one (#14) of four residents reviewed for falls and accidents. The facility census was 112.Findings Include:Review of the medical record for the Resident #14 revealed an admission date of 06/12/06. Diagnoses included dementia, diabetes, anxiety disorder, and glaucoma.Review of Resident #14's quarterly Minimum Data Set (MDS) assessment, dated 07/17/25, revealed the resident had impaired cognition. Review of the plan of care dated 07/31/25 revealed Resident #14 was at risk for fall related injury and falls due to a history of falls and his requirements for assistance with activities of daily living (ADLs). Interventions included to keep the resident's call light within reach so he can call for assistance with transferring and to wear non-skid footwear when he was not in bed. Review of the plan of care dated 07/31/25 also revealed Resident #14 chose not to follow fall interventions. Interventions included praising Resident #14 when his behavior was appropriate.Review of the nurses notes from 01/01/25 to 09/15/25 revealed Resident #14 had unwitnessed falls on 01/27/25, 02/10/25, 03/16/25, 04/22/25, 05/03/25, 05/28/25, 06/16/25, 07/01/25, 07/16/25, 07/08/25, 07/30/25, 08/30/25, and 09/08/25.Review of the fall investigations dated 01/28/25, 05/05/25, 05/28/25, and 07/07/25 completed by the interdisciplinary team (IDT) revealed Resident #14 slipped on his bedroom floor because the resident was not wearing non-skid footwear. He was educated to wear non-skid footwear anytime he was out of bed.Review of the fall investigations dated 07/31/25 and 09/02/25 by the IDT revealed Resident #14 slipped while transferring, but the fall investigation did not mention if the resident was wearing non-slip footwear.During an interview on 09/11/25 at 11:15 A.M. with Unit Manager (UM) #204 confirmed Resident #14 had been educated numerous times about wearing non-slip footwear when out of bed, but he was non-compliant. She was not able to provide any interventions for his non-compliance.During an interview on 09/11/25 at 2:14 P.M. with the Director of Nursing (DON) confirmed Resident #14 was non-compliant with his fall interventions. She also acknowledged he had 36 falls in the past two years and confirmed all of the falls occurred since they determined he was non-compliant with the interventions. The DON also acknowledge the interventions were repetitive and not working. She stated the facility will attempt to move the resident's room closer to the nursing station for additional monitoring and will institute more frequent checks on Resident #14 from staff.Review of a facility policy titled, Fall Management, dated 07/08/25, revealed the facility will review all resident falls within 24 to 72 hours at the stand-up/clinic-ops meeting to evaluate/investigate the circumstances and probable cause for the fall, review/modify the plan of care to minimize repeat falls.

Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to properly assess a resident prior to making a diet order change, and failed to properly, accurately, and timely obtain resident weights and notify the physician of weight changes as ordered. This affected three (#49, #2, and #9) of eight residents reviewed for nutrition. The census was 112. Findings Include:1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses included amyotrophic lateral sclerosis (ALS), congestive heart failure, hypertensive heart failure, type II diabetes, hyperlipidemia, dysphagia, ischemic cardiomyopathy, atherosclerotic heart disease, old myocardial infarction, nicotine dependence, and non-compliance with other medical treatment and regimen. Review of Resident #49's Minimum Data Set (MDS) assessment, dated 07/02/25, revealed he was cognitively intact. Review of Resident #49's After Visit Summary Hospital form, dated 01/04/24, revealed he was admitted to the hospital for teeth extraction and to treat a tooth/mouth infection. He was admitted back to the facility on [DATE]. Further review revealed a recommendation was made from the hospital for Resident #49 to utilize a soft diet of, **** days after the procedure, but the specific number of days were not identified. There was no documentation that the hospital recommended a long-term diet texture downgrade or a downgrade of his nutritional status. Review of Resident #49's progress note, dated 01/09/24, revealed the resident was referred to speech therapy services. The note revealed nursing reported the resident was coughing on thin liquids and eliciting difficulty with whole medications. Speech Language Pathologist (SLP) #102 spoke with the resident who became agitated when given recommendations and education on diet recommendations/swallow strategies. Resident #49 was educated on reducing aspiration with thickened liquids/crushed medications and the resident reported he only coughed because he was sick and wants staff to leave him be. SLP #102 educated the resident that he was at risk for aspiration, pneumonia, and death if diet recommendations and swallow strategies were not followed and the resident continued to aspirate. Resident #49 returned understanding of the information. Resident #49 also recently had teeth pulled and the resident's swallow function continued to decline due to ALS. Resident #49 was educated on prognosis regarding swallowing, given SLP's name, and encouraged to participate. Resident #49 nodded his head acknowledging the clinician Review of Resident #49's nutritional orders, dated 01/22/24, revealed on that date, the facility changed his diet texture order from regular texture to pureed texture. Review of Resident #49 progress notes, dated 02/09/24, 02/28/24, 03/27/24, 05/29/24, 08/14/24, 12/27/24, and 05/13/25, revealed documentation to support Resident #49 was refusing meals at the facility due to the facility only offering meals with a pureed texture diet. There was no documentation to support a risk agreement/consent form was offered to Resident #49 to accept acknowledgement and responsibility for defying SLP recommendation/order for a pureed texture diet, which was not the diet texture he wanted. Review of Resident #49's SLP Discharge Summary document, dated 05/20/24, revealed Resident #49's therapy was to be primarily focused on education. Resident #49 asked to complete a modified barium swallow study (MBSS) to establish a baseline. There was no documentation presented in the document that Resident #49 had a MBSS completed to support the downgrade of his diet. Review of Resident #49 nutritional assessments, dated 07/08/24 and 07/03/25, revealed the resident was educated on risks of aspiration but continued to be non-compliant with diet texture. There was no documentation to support a medical assessment had been completed to confirm the resident medically needed to change his diet texture to puree. Review of Resident #49's medication administration records (MAR), dated July 2025 to September 2025, revealed multiple days in which Resident #49 refused his medications. But, when he did take his medications, they were whole pills with no modifications, including oxycodone, Baclofen, Lasix, and Senna. There were no orders for his medication to be crushed and there was no documentation to support the facility crushed his medications prior to giving them to him. Interview with Resident #49 on 09/08/25 at 2:00 P.M. and 09/15/25 at 1:23 P.M. confirmed he does not want to eat a pureed texture diet. He confirmed he had never received a swallow study or medical assessment to determine if he needed a pureed texture diet. He confirmed he has refused to have one because he has not shown signs that he needs to have an assessment completed or that he was having trouble swallowing. He orders his own food to be delivered and eats it with no issues. He confirmed he had never been given the opportunity to sign a risk agreement, understanding that he knows the risks of eating a regular texture diet. He stated the facility only offered food that was pureed, which he refuses, and so he does not get any food from the facility. Interview with Dietitian #101 on 09/11/25 at 9:15 A.M. stated she was under the impression Resident #49 had a video swallow study completed at the hospital in January 2024, and when he came back, he was placed on a pureed texture diet. She was unaware of any risk assessment or consent to go against orders being offered to Resident #49 so that he could eat a regular texture diet. Interview with SLP #102 on 09/15/25 at 2:52 P.M. revealed Resident #49's diet order was downgraded to puree on 01/22/24. He confirmed nursing staff told him Resident #49 was having trouble swallowing thin liquids and his medications; which was around the same time he was positive for pneumonia. So, for the resident's safety, his diet order was downgraded. When asked if his diet order should have been upgraded after he was clear of pneumonia, SLP #102 stated he could not do that because Resident #49 would have to perform a swallow study to ensure his safety with a regular texture diet. Because Resident #49 continued to refuse to have the swallow study, he was not permitted to upgrade his diet texture, even though Resident #49 does not want a pureed texture diet order. Interview with Licensed Practical Nurse (LPN) #214 on 09/15/25 at 3:24 P.M. confirmed Resident #49 had a pureed diet texture order. She also confirmed when Resident #49 agreed to take his medication, it was given to him with thin liquids and the pills were whole. She confirmed typically, a resident who was on a pureed texture diet, would have their medications offered/administered crushed. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included cystitis, osteoarthritis, obesity, atrial fibrillation, obstructive sleep apnea, chronic respiratory failure, hyperlipidemia, bipolar disorder, hypertension, fibromyalgia, chronic kidney disease, difficulty walking, muscle weakness, insomnia, and depression. Review of Resident #2's MDS assessment, dated 08/15/25, revealed the resident was cognitively intact. Review of Resident #2's weights, dated 08/11/25 to 09/11/25, revealed the initial weight taken on 08/11/25 was 275 pounds. Further review revealed that weight was scratched out as being inaccurate on 08/28/25. The resident's next weight was taken on 08/22/25 (334 pounds) and was more than seven days after the initial (inaccurate) weight was taken. Review of Resident #2's nutritional assessment, dated 08/14/25, confirmed there could be a discrepancy between the resident's last hospital weight and her initial facility weight. Further review revealed the facility would like to monitor the resident's weekly weights, which was not taken until 11 days after the initial weight was taken. Interview with Dietitian #101 on 09/11/25 at 9:12 A.M. confirmed the initial weight for Resident #2 of 275 pounds was suspected to be inaccurate, which was why she asked for a new weight to be taken on 08/14/25. She confirmed she expected to have all weights accurate, so she can do her job correctly/accurately. She stated she figured Resident #2's weight was inaccurate based on her hospital weight at the time of hospital discharge, and the significant difference between that and the initial weight taken from the facility. She would have the expectation that nursing staff would review any new admission resident hospital weight to determine if an initial weight was accurate or not. Interview with Assistant Director of Nursing (ADON) #311 on 09/11/25 at 3:13 P.M. confirmed if re-weights are asked to be taken, they should be done within 72 hours of the request. He confirmed there were 11 days between Resident #2 initial (inaccurate) weight and her next weight, which was taken on 08/22/25. 3. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. His diagnoses included encephalopathy, end stage renal disease, muscle weakness, difficulty in walking, congestive heart failure, type II diabetes, anemia, anxiety disorder, insomnia, major depressive disorder, idiopathic peripheral autonomic neuropathy, hyperlipidemia, and hypertension. Review of Resident #9's MDS assessment, dated 07/15/25, revealed he was cognitively intact.Review of Resident #9's current physician orders revealed he had an order for daily weights to be taken. Also, the facility was to notify the physician if there was a greater than three pound weight gain in over two days. Review of Resident #9's weights, dated 07/02/25 to 09/11/25, revealed there were no weights documented on 07/14/25, 07/15/25, 09/04/25, and 09/05/25. Review of Resident #9's weights, dated 07/02/25 to 09/11/25, revealed the following weight gains of greater than three pounds over two days were not reported to the physician as ordered: from 08/21/25 (197.8 pounds) to 08/23/25 (202 pounds), 08/17/25 (193.4 pounds) to 08/19/25 (196.5 pounds), 08/07/25 (197.5 pounds) to 08/09/25 (201.2 pounds), 08/04/25 (195.2 pounds) to 08/06/25 (200.1 pounds), 07/16/25 (192.8 pounds) to 07/18/25 (196 pounds), 07/10/25 (185.2 pounds) to 07/12/25 (194.4 pounds), and 07/04/25 (187.4 pounds) to 07/06/25 (193.7 pounds). Interview with ADON #311 on 09/11/25 at 3:11 P.M. confirmed the facility could not find evidence the physician or nurse practitioner was notified as ordered for Resident #9's weight gains on the above dates. Also, he confirmed they could not find any documents of weights obtained on 07/14/25, 07/15/25, 09/04/25, and 09/05/25 where the weights were missing from the record. Review of the facility weight management policy, dated 07/30/25, revealed residents will be monitored for significant weight changes on a regular basis. This deficiency represents non-compliance investigated under Complaint Number 2573417.

Based on medical record review, resident interview, and staff interview, the facility failed to provide/offer timely dental services to residents as needed. This affected two (#49 and #6) of four residents reviewed for dental services. The census was 112. Findings Include:1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses included amyotrophic lateral sclerosis (ALS), congestive heart failure, hypertensive heart failure, type II diabetes, hyperlipidemia, dysphagia, ischemic cardiomyopathy, atherosclerotic heart disease, old myocardial infarction, nicotine dependence, and non-compliance with other medical treatment and regimen. Review of Resident #49's Minimum Data Set (MDS) assessment, dated 07/02/25, revealed he was cognitively intact.Review of Resident #49's dental progress notes, dated 01/19/24, confirmed Resident #24 was edentulous from a medical procedure that occurred earlier in the month at the hospital. The note also revealed they would complete impressions for dentures on the next visit. Review of Resident #49's progress notes, dated 11/14/24, revealed the facility received a new order to cancel the resident's dental appointment due to an insurance issue. Resident #49 was made aware and did not wish to have anyone else updated. Review of Resident #49's progress notes, dated 01/19/24 to 09/11/25, revealed no other dental appointments were attempted to be discussed or scheduled. Review of Resident #49's current care plan revealed a focus area related to being at risk for infection, pain, chewing issues, and bleeding in the oral cavity. Resident #49 had all of his natural teeth removed and had no dentures. Interventions for this care plan included to coordinate arrangements for dental care, dental consultation as needed, dental follow up as ordered, and observe/document/report to the physician as needed related to signs/symptoms of oral/dental problems needing attention. Interview with Resident #49 on 09/08/25 at 2:00 P.M. and 09/15/25 at 1:23 P.M. confirmed he did not have dentures. He confirmed it made it a little more challenging to eat his food, but he still can do it. He confirmed he wanted dentures, and the facility had not talked to him and/or attempted to schedule a dental appointment for his dentures. Interview with Assistant Director of Nursing (ADON) #311 on 09/15/25 at 2:16 P.M. confirmed the only dental note the facility had about an appointment for Resident #49's dental needs was the one provided from 11/14/24. ADON #311 confirmed they have no other evidence to support that denture impressions and/or dental appointments were discussed with Resident #49.2. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of six. The resident was assessed to require assistance with self-care activities.Review of the care plan dated 08/19/25 revealed Resident #6 was at risk for infection, pain, and chewing issues due to her being dependent on the facility staff for oral care. Interventions included staff observation of the resident for oral/dental issues and for staff to make dental appointments as needed.During an interview with Resident #6 on 09/08/25 at 2:44 P.M., Resident #6 confirmed she lost her dentures at an unknown time and the facility had not assisted her with a replacement.During an interview with the Director of Nursing (DON) on 09/09/25 at 4:25 P.M. she verified Resident #6 has not been seen by a dentist since 01/19/24, and was not aware the resident's dentures were missing. She added that Resident #6 would be seen on-site by a dentist on 09/30/25.

Based on medical record review and staff interview, the facility failed to implement restorative programs following completion of therapy services as recommended. This affected one (#11) of two residents reviewed for therapy services. The facility census was 112. Findings Include:Review of Resident #11's medical record revealed an initial admission date of 08/19/24 with a re-admission date 05/24/25. Diagnoses including but were not limited to orthopedic care, fracture of the left femur, high blood pressure, spinal stenosis, and dementia.Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15, and was independent with ambulation, transfers, and personal hygiene. Resident #11 had a history of falls.Review of Resident #11's progress notes dated 05/19/25 at 8:16 A.M. revealed Resident #11 reported to the day shift nurse during morning medication administration that Resident #11 slipped on water on the floor in his room and fell on his left knee during the night. Further review revealed Resident #11 was assessed by Licensed Practical Nurse (LPN) #327 with swelling and pain to left knee was noted. LPN #327 notified the physician and received an order to send Resident #11 to the hospital for further evaluation and treatment.Review of Resident #11's facility fall investigation dated 05/19/25 revealed Resident #11 reported to the day shift nurse (LPN #327) he slipped on water and fell on his left knee. Resident #11 had been carrying a wash basin of water to the bathroom to dump in the sink. Resident #11's neighbor was in the bathroom at the time and closed the door to Resident #11's room causing Resident #11 to drop the basin of water on the floor, and causing Resident #11 to slip and fall on left knee. As a result of the incident the facility recommended therapy evaluations for both physical therapy (PT) and occupational therapy (OT) upon readmission to the facility.Review of Resident #11's PT evaluation and Discharge summary dated [DATE] to 06/23/25 revealed Resident #11 reached maximum potential for ambulation and was discharged from PT services with a restorative program recommendation for ambulation. Further review revealed an ambulation restorative program was implemented on 05/29/25, with daily participation by Resident #11 noted.Review of Resident #11's OT evaluation and Discharge summary dated [DATE] to 06/23/25 revealed Resident #11 reached maximum potential for activities of daily living (ADLs) tasks and was discharged from OT services with an ADLs restorative program recommended. Further review revealed Resident #11 did not have an ADLs restorative program implemented for ADLs tasks.An interview on 09/11/25 at 1:36 P.M. with Restorative Aid (RA) #527 revealed Resident #11 participated in the ambulation restorative program on a daily basis. RA #527 stated Resident #11 has never had an ADLs restorative program to complete.An interview on 09/11/25 at 2:36 P.M. with Therapy Director #550 revealed there was an ADLs restorative program recommended following Resident #11's discharge from OT services on 06/23/25. The program was for ADLs tasks including personal hygiene, dressing, and grooming.An interview on 09/11/25 at 2:56 P.M. with Assistant Director of Nursing (ADON) #311 confirmed Resident #11 did not have an ADLs restorative program implemented. ADON #311 stated when OT wrote the recommended ADLs program and completed the recommended evaluation for the ADLs program on 06/26/25, the evaluation was not locked until 07/02/25 by OT. ADON #311 stated he did not review the list of completed/locked evaluations after implementing Resident #11's ambulation restorative program.

Based on observation, resident and staff interview, review of pest control records, and facility policy review, the facility failed to maintain an effective pest control program. This deficient practice affected three (#3, #52, and #93) of 112 residents observed for environment and pest control. The facility census was 112.Findings Include:An observation on 09/08/25 at 10:15 A.M. revealed Resident #105 sitting at edge of the bed looking out the window. There were multiple house flies noted on the windowsill and bed covers.An observation on 09/08/25 at 11:25 A.M. revealed Resident #52 sitting in a wheelchair in her room awaiting lunch meal service. There were several house flies observed in the room. Resident #52 would occasionally swat at one house fly as it flew around her face.An observation on 09/08/25 at 2:21 P.M. revealed Resident #3 resting in bed with the bed covers pulled up to his chest area. There were multiple house flies on the bed covers and windowsill.An observation on 09/09/25 at 11:00 A.M. revealed Resident #3 sitting up in bed with the bed covers pulled up to cover his lower body. There were multiple flies on the bed covers and flying around Resident #3's face.An interview on 09/09/25 at 11:05 A.M. with Resident #3 revealed there were always flies in his room and he does not like the flies being in his room.An interview on 09/09/25 at 2:00 P.M. with Certified Nurse Aide (CNA) #343 confirmed there are flies throughout the facility, especially in Resident #3's and Resident #105's rooms. CNA #343 stated sometimes there was a pest control company that came to the facility.Review of the facility's pest control visit summary dated 03/25/25 to 09/08/25 revealed the facility was treated for fly activity in the kitchen and in several resident rooms. Further review revealed the pest control company noted the contributing factor for fly activity was poor sanitation in resident bathrooms and recommended cleaning and sanitize the bathrooms of urine and fecal matter on a regular basis.Review of the facility's pest control policy dated 03/05/25 revealed the purpose was to provide an environment free of pests. The facility will have a pest control contract that provides frequent treatment of the environment for pests. It will allow for additional visits when a problem is detected. Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly.

Based on observation, and interview, the facility failed to maintain toilet rails, thresholds, walls, floors and dressers. This affected six (Resident's #2, #3, #4, #5 #8, and #9) of 117 residents in the facility.Findings include:Observations 07/09/25 between 9:33 A.M. and 10:27 A.M. revealed:- Resident #3's bathroom toilet had handrails attached to the bolts that held the toilet seat on the toilet. The rails moved when touched. The right railed moved approximately six inches and the left rail four inches. The toilet water was a milky pink color. The bathroom had an incontinence odor. The door frames entering the room and bathroom were scraped heavily with the paint off. The sink bowl was dirty a rusty color. There were seven broken tiles on the bathroom walls.- The community shower room between three and four the handrails attached to the toilet moved two to four inches when touched. There was molding off the wall between on the right exiting the shower. The linoleum type tile blocks at the threshold of the bathroom door were broken off on the hall side.- Resident #2's bathroom had rails attached to the toilet. The rails moved several inches when held onto making a jiggle motion. There were six tiles off the bathroom wall. Two tiles behind the toilet and four at the shower room were off the wall. Resident #2 did not use the [NAME] and [NAME] bathroom but Resident's #8 and #9 in the adjoining room utilized the bathroom.- Resident #4's floor was sticky. You could hear shoes sticking on floor when walking in the room. A urinal was on the floor. There were three puddles of liquid on the floor in front of the recliner he was sitting in at the time. The rails on his toilet were very loose moving approximately six inches on the left when jiggled and six on the right. The bath tub was blacked on the front quarter. There was black grout around 12 of the wall tiles around the tub, - Resident #5's rails on her toilet were loose moving approximately three inches when jiggled. The doorframe into the bathroom had the paint scrapped off. All four of her dresser drawers were damaged with the facing damaged. Interview 07/09/25 at 9:58 A.M. with Registered Nurse (RN) #83 verified Resident #4's sticky bedroom floor, liquid on the floor, loose toilet rails, and blacked bath tub and grout.Interview 07/09/25 at 10:10 A.M. with Licensed Practical Nurse (LPN) #15 verified the unstable toilet seat rails, toilet bowl water, damaged door frames, broken tiles, dirty sink and odor in Resident #3 room. LPN #15 verified the loose toilet rails in the community shower room, the molding off the wall and damaged floor. LPN #15 verified Resident #2's loose toilet rails, and missing wall tiles affecting Resident's #8 and #9. Interview 07/09/27 at 10:27 A.M. with Certified Nurse Aide #118 verified the toilet rails were loose on Resident #5 toilet, damaged dresser drawers and damaged door frames.The deficiency represents non-compliance investigated under Master Complaint Number OH00167350 (133320) and Complaint Numbers OH00166976 (1330318), OH00166863 (1330317) and OH00166783 (1330314).

Intakes: OH00142128, OH00142229, OH00142360, OH00142708, OH00142737 Based on record review, facility policy review, and staff and resident interview, the facility failed to implement adequate skin risk interventions for Resident #96 to prevent the development of pressure ulcers. Actual harm occurred on 12/09/22 when Resident #96, who was ventilator dependent, at high risk for pressure ulcer development and dependent on staff for turning and repositioning developed an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to left elbow. Resident #96 also developed a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to the back of the head that deteriorated to a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer. The facility failed to provide evidence of necessary and adequate pressure reducing/relieving interventions being in place to prevent the development of the pressure ulcers. This affected one resident (#96) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #96 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis, anoxic brain damage, protein-calorie malnutrition, and quadriplegia. Review of the undated Kardex information for State tested Nursing Assistants (STNA) revealed Resident #96 was to be provided two persons assistance to reposition frequently and as needed. A Braden scale assessment, dated 11/09/22 revealed Resident #96 was high risk for the development of pressure ulcers. Review of a plan of care, dated 11/09/22 revealed Resident #96 was at risk for impaired skin integrity/pressure injury. Interventions included Braden scale per protocol, weekly head to toe skin assessments, cue to reposition self as needed, encourage to float heels while in bed, follow facility policies/protocols for the prevention/treatment of impaired skin integrity, observe skin with showers/care, provide two assistance to reposition frequently and as needed, and turn/reposition resident as needed. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #96 was not cognitively intact. The assessment revealed Resident #96 required total dependence from two staff for bed mobility and transfers and total dependence from one staff for dressing. No behaviors were documented on the MDS. A Skin and Wound evaluation dated 12/09/22 revealed Resident #96 developed an unstageable pressure ulcer to left elbow on 12/09/22. There was 40% granulation (a type of connective tissue that forms on a wound during healing) and 60% eschar with moderate serosanguineous (blood and serous fluid) exudate. Additional care included nutrition supplementation, repositioning device, turning/repositioning program, and treatment as ordered. Wound nurse practitioner and dietician were notified. An order was received on 12/10/22 to cleanse Resident #96's left elbow with wound cleanser then apply hydrogel with alginate silver (highly absorbent, antimicrobial dressing) and cover with Optifoam every day shift. Following the development of the unstageable pressure ulcer, on 12/13/22, Resident #96 was ordered an air mattress to the bed on 12/13/22. A Skin and Wound evaluation dated 02/10/23 revealed the unstageable to Resident #96's left elbow was now classified as a Stage III pressure ulcer. The MDS 3.0 assessment, dated 03/30/23 revealed Resident #96 was cognitively intact and required total dependence of two staff for bed mobility and transfer. The assessment revealed Resident #96 required total dependence from one staff for dressing. No behaviors were documented on the MDS. Review of an ADL care statement for routine standard of care from 11/09/22 to 03/30/23 revealed turning and repositioning was not documented every day on every shift. A Braden scale assessment dated [DATE] revealed Resident #96 was high risk for the development of pressure ulcers. A Skin and Wound evaluation dated 04/05/23 revealed Resident #96 developed a Stage II pressure ulcer to the back of the head. The pressure ulcer measured 0.9 cm long, 1.9 cm wide, and 0.1 cm deep. There was 100% granulation with a light amount of serosanguineous drainage. A nursing note, dated 04/06/23 at 8:03 A.M. revealed Resident #96 had open area to back of head. The doctor and wound nurse were notified and a treatment was implemented. A neck pillow was put in place as an intervention to relieve the pressure to the back of Resident #96's head A plan of care dated 04/07/23 revealed Resident #96 was at risk for impaired skin integrity/pressure injury related to immobility and quadriplegic. On 04/07/23, the plan of care was updated to reveal Resident #96 chose not to allow neck pillow to be used. Interventions included Braden scale, cue to reposition self as needed, provide two assist to reposition frequently and as needed. A Skin and Wound evaluation dated 04/21/23 revealed the Stage II to back of Resident #96's head was now classified as an unstageable pressure ulcer. A Skin and Wound evaluation dated 05/05/23 revealed the unstageable pressure ulcer to Resident #96's head was now a Stage III pressure ulcer that measured 2.6 cm long, 2.5 cm wide, and 0.1 cm deep. A Skin and Wound evaluation dated 05/05/23 revealed Resident #96 had a Stage III pressure ulcer to left elbow from 12/09/22 that measured 1.1 cm long, 1.4 cm wide, and 0.2 cm deep with 100% granulation. There was a light amount of serosanguineous exudate. On 05/09/23 at 2:18 P.M. during an interview with Resident #96, the resident revealed he could not turn and reposition himself and that staff did not turn or reposition him. The resident stated he would not refuse being turned and repositioned. On 05/09/23 at 2:23 P.M. interview with State tested Nursing Assistant (STNA) #254 revealed Resident #96's elbows were put on pillows but Resident #96 did not like to be turned. STNA #254 stated it was hard to position residents on their side when they were ventilator dependent (like Resident #96) as this placed limitations to repositioning. Interview on 05/09/23 at 3:58 P.M. with Wound Certified Nurse Practitioner (CNP) #340 revealed Resident #96 refused the neck pillow frequently. Resident #96 did allow dressing changes to be done by tilting his head forward while sitting up in bed. A foam dressing and pillows were also put in place to relieve pressure to his elbows. The pressure ulcer to head was classified as a Stage II because it was difficult to see. As the wound got bigger the resident's hair fell out and it was easier to see the wound which had 50% slough (yellow/white necrotic tissue), so it was assessed to be unstageable. CNP #340 revealed there was a lot of weight on the resident's head and Resident #96 was unable to move his head independently. During the interview, CNP #340 also revealed the resident had the area to the elbow for awhile and it was difficult to get the area to heal. CNP #340 believed the resident allowed pillows under elbows and stated the resident was unable to move his arms at all. CNP #340 was unsure if Resident #96 refused to be turned or repositioned. Interview on 05/09/23 at 4:15 P.M. with Physician #344 revealed the physician was aware Resident #96 had pressure ulcers but let the Wound CNP do the treatments and monitor the wound. Interview on 05/10/23 at 12:46 P.M. with the Director of Nursing (DON) verified an air mattress was implemented until 12/13/22 following the development of the unstageable pressure ulcer. The DON verified Resident #96 refused the neck pillow to keep his head off of the bed but no other intervention(s) had been put in place to alleviate pressure to the back of the head area. The DON also verified documentation by STNA staff for ADL care that included turning and repositioning was not documented every shift and every day to indicate the care had been provided to decrease the resident's risk of pressure ulcer development from 11/09/22 to 03/30/23. Review of facility policy titled Skin Management, dated 07/14/21, revealed a Braden Scale assessment would be completed upon admission/re-admission, weekly for four weeks, quarterly, and with a significant change of status to determine the risk of pressure injury development. Appropriate preventative measures would be implemented identified at risk and the interventions documented in the care plain. The interdisciplinary team (IDT) considered whether the resident exhibited conditions or was receiving treatments that might place the resident at higher risk of developing pressure injury or complicate their treatment. Such conditions may include: impaired/decreased mobility and decreased functional ability, co-morbid conditions, impaired, diffuse or localized blood flow, and refusal of some aspect of care and/or treatment. The licensed nurse would document preventative measures on the care plan/Kardex. A Resident At Risk meeting would be conducted at least monthly by IDT. During the meeting, the IDT would evaluate resident skin changes, review treatment modalities, interventions and would make recommendations as needed. Care plans and Kardex would be updated accordingly. Residents reviewed for skin alterations include newly developed vascular, diabetic/neuropathic and pressure injuries, any pressure or non-pressure area that has shown no signs of healing within a two week time frame, and new admissions/readmissions with skin conditions (pressure, non-pressure, arterial, venous insufficiency, diabetic neuropathic, surgical sites, rashes, dermatologic conditions, skin tears, etc). A system audit of the Skin Management Guideline would be conducted by the DON/designee to ensure ongoing compliance in all areas. Results would be reported to the QAPI committee for trending, analyzing, and recommendations. This deficiency represents non-compliance investigated under Complaint Number OH00142708, OH00142229, and OH00142128.

Based on review of a closed medical record, a police report, incident report log, the facility Missing Guest policy and procedure and staff interview the facility failed to provide adequate supervision for one resident (Resident #89) to prevent an elopement from the facility. This resulted in Immediate Jeopardy on 05/04/19 at approximately 6:30 P.M. when Resident #89, who was assessed to have moderate cognitive impairment, was at risk for elopement and exhibited exit seeking behaviors, was found approximately 0.3 miles from the facility at a local store without staff knowledge. The likelihood of actual harm or death occurred when the facility was notified by an unidentified community member that Resident #89 was walking with a shuffling gait, unsupervised down busy roadways wearing socks with no shoes. This affected one of four residents reviewed for elopement In addition, a deficiency practice that did not rise to the level of Immediate Jeopardy was identified when the facility failed to ensure residents (#17, #54 and #60) who smoked were not permitted to maintain possession of smoking materials in the facility to prevent potential accidents/fire related to smoking. This affected three of three residents reviewed for smoking. The facility census was 127. On 05/21/19 at 4:50 P.M., the Corporate Administrator, Director of Nursing (DON) and Corporate Nurse #619 were notified Immediate Jeopardy began on 05/04/19 at approximately 6:30 P.M. when the facility received a phone call from an unidentified community member alerting them of a resident (identified to be Resident #89) walking along the side of the road. The incident was subsequently reported to the police department at 6:37 P.M. by the same unidentified community member. A second call to the police department was made at 6:45 P.M., by security staff from the local store the resident had walked to. Resident #89 was subsequently returned to the nursing facility. The Immediate Jeopardy was removed on 05/21/19 when the facility implemented the following corrective actions: · On 05/04/19 at 6:45 P.M. Resident #89 returned to the facility. A wander guard (a monitoring device that is placed on an extremity to alert the facility when a resident attempts to exit) was implemented and the resident was placed on every 15-minute checks. · On 05/04/19 at 9:00 P.M. Licensed Practical Nurse (LPN) #109 checked every door in the facility. All locks and alarms were noted to function appropriately. · On 05/05/19 and 05/06/19 the Administrator/designee began education to staff regarding the facility Missing Guest policy and procedure. · On 05/09/19 the DON updated Resident #89's plan of care to include the resident was at risk for elopement. · On 05/17/19 Resident #89 was discharged from the facility to another long term care facility with a specialized secured memory care unit. · On 05/21/19 training for all staff was completed related to the Missing Guest policy and procedure, Incident Reporting Policy and responding to door alarms. The facility educated 131 staff and identified eight staff members who had not received the education would be educated prior to the start of their next scheduled shift by the DON/designee. On 05/21/19 additional education for all staff nurses was completed on the above policies plus proper documentation on accidents/incidents and putting interventions in place for residents at high risk for elopement. · Beginning 05/21/19 a plan for all new hires to be educated on the Missing Resident Policy during general orientation was implemented. · On 05/21/19 LPNs #27, #124, #131 and #132 completed Elopement Risk Assessments for all residents. Three residents (Resident #15, #21 and #35) of the 124 assessed were identified to be at high risk for elopement. These three residents care plans were reviewed. The facility Resident Elopement Binder was updated. · On 05/21/19 Regional Director of Operations #169 educated Maintenance Director #63 related to completing Missing Resident Drills including the need to conduct the drill at odd hours and on all three shifts quarterly. · On 05/21/19 at 6:22 P.M. 36 staff, including three dietary staff members, eight state tested nursing assistants (STNAs), nine nurses, six therapists, three housekeeping staff, two laundry staff, two maintenance staff and three office personnel participated in a Missing Resident Drill. On 05/22/19 at 7:06 A.M. 32 staff, including 12 nurses, four housekeeping staff, 12 STNAs, two therapists, and two laundry personnel participated in a Missing Resident Drill. Both drills were conducted by Maintenance Director #63. · On 05/21/19 Maintenance Director (MD) #63 and/or designee validated door alarms were functioning properly. A plan to continue to check all Secure Care Doors per facility policy was implemented to be done on an ongoing basis for an indefinite period of time. · Beginning on 05/21/19 a plan was made for all new admissions to be reviewed at the clinical operations meeting to ensure completion of an Elopement Risk Assessment and to ensure interventions were in place and a plan of care was developed. All Unit managers, the DON, Administrator, Social Service staff and Rehabilitation staff were to attend these meetings which would be on-going for an indefinite time period. The results of the meetings would be reported in the monthly Quality Assurance Meeting. · On 05/22/19 between 4:43 P.M. and 4:51 P.M. interviews with STNAs #56, #157, #67, #142, #65 and Respiratory Therapist #61 revealed they were knowledgeable of the facility Missing Person policy and procedure and the measures to take in the event a resident was missing. All of the staff interviewed verified they had received additional training related to elopement and the facility Missing Person policy. Although the Immediate Jeopardy was removed on 05/21/19 the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) related to the identified concerns related to smoking and as the facility was continuing with staff in-services and was in the process of monitoring staff and exit doors to ensure compliance and determine if further action was required. Findings Include: 1. Review of Resident #89's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #89 had moderate cognitive impairment, required extensive assistance of two or more staff for transfers, dressing, toilet use, personal hygiene and bathing. Record review revealed a Risk for Elopement assessment, dated 04/24/19 which indicated the resident had no risk. Review of a nursing progress note, dated 04/26/19 at 1:54 P.M. revealed Resident #89 was wandering in and out of peer's rooms. Review of a nursing progress note, dated 04/27/19 at 1:50 P.M. revealed Resident #89 was exit seeking during the shift and redirection was unsuccessful. Resident #89 was agitated toward staff with attempts of redirection, yelling at staff You robbed me! You took my car! Review of a nursing progress note, dated 04/28/19 at 10:40 P.M. revealed Resident #89 was noted to be exit seeking and redirection was successful. Record review revealed on 05/01/19 a Risk for Elopement assessment was completed which assessed Resident #89 to be at risk (for elopement). Record review revealed no plan of care or interventions were initiated at this time related to the resident's risk for elopement. There was no corresponding nursing progress note completed on 05/01/19 related to the resident's risk for elopement. Review of the Facility Incident Report Log documented on 05/04/19 at 6:30 P.M. Resident #89 eloped from the facility to the parking lot. The immediate intervention listed on the log was for every 15-minute checks and a wander guard device to be implemented. Review of a nursing progress note, dated 05/04/19 at 8:05 P.M. revealed Registered Nurse (RN) #142 was notified at 6:30 P.M. an unidentified staff member had received a phone call from a community member about a guest walking off the facility property. The note documented RN #142 and LPN #47 were able to retrieve Resident #89 at 6:35 P.M. and lead him back to the facility without incident at 6:45 P.M. Resident #89 returned to his room in a calm positive mood. The note indicated the facility Administrator, DON, and Resident #89's brother were notified. A wander bracelet was ordered and applied and checked for function and 15-minute checks were initiated at this time. Review of the facility incident report dated 05/04/19 at 6:30 P.M. revealed Resident #89 eloped and had no injury. Immediate interventions to prevent recurrence was to place a watch mate (wander guard) to the left ankle and conduct every 15-minutes checks on the resident. The report was completed by LPN #77. Record review revealed a police report, dated 05/04/19 at 6:37 P.M. indicated a community member reported a white male wearing dark sweat pants, a tan hoodie sweatshirt, socks and no shoes was walking along the side of the road shuffling his feet. At 6:45 P.M. the local store called and advised they had a resident from the nursing facility at their store with two nurses present. The resident was refusing to get in the nurse's vehicle at that time. Record review revealed a plan of care was initiated on 05/09/19 (five days following the elopement incident) which indicated Resident #89 was at risk for exit seeking and/or wandering due to disorientation to place, history of attempts to leave the facility unattended, impaired safety awareness and wandering aimlessly. Interventions were to provide structured activities, toileting, walking, inside and outside with supervision. Apply wander guard and check for placement, function and expiration date per facility protocol. Approach in a slow calm manner and redirect away from exit doors as needed. Distract him when wandering into inappropriate areas by offering pleasant diversions. Identify pattern of wandering, is it purposeful, aimless, or escapist? Is resident looking for something? Is it a manifestation of pain? Does it indicate the need for exercise? Record review revealed Resident #89 was discharged from the facility on 05/17/19 to another long-term care facility with a secured memory care unit. On 05/21/19 at 3:02 P.M. telephone interview with RN #142 revealed a resident (identified to be Resident #89) had gotten out of the facility, and, should have probably had a wander-guard. RN #142 revealed Resident #89 had a history of [REDACTED]. RN #142 revealed on 05/04/19 around 6:00 P.M., LPN #77 informed him Resident #89 was missing from the facility. RN #142 stated he did not know where LPN #77 had found Resident #89, but he brought Resident #89 back inside from the facility parking lot and he was in his room by 6:15 P.M. On 05/21/19 at 3:15 P.M. telephone interview with LPN #77 revealed she received a phone call from a female community member who informed her she thought there was a resident outside. LPN #77 stated she immediately informed RN #142 who began a head count of residents and noticed Resident #89 was missing. LPN #77 stated she then got in her car and began driving around to look for Resident #89 and found him at a local store. LPN #77 stated Resident #89 was trying to get into the store and would not get in her car so she called RN #142, the DON and the Administrator. LPN #77 revealed at that time, the store security staff called the local police department. The local police arrived and were able to get Resident #89 into RN #142's vehicle. LPN #77 revealed once the resident returned to the facility, he was placed on every 15-minute checks and he was assessed. LPN #77 revealed Resident #89 was wearing only socks and his socks and a foot bandage were soaking wet. Resident #89 had a foot wound infected [MEDICAL CONDITION] for which he was receiving treatment at the facility. LPN #77 revealed the resident's foot dressings were changed and no additional injuries were noted. On 05/22/19 at 8:13 A.M. during a telephone interview with Resident #89's brother he revealed he was not exactly sure what happened because the facility did not go into much detail with him regarding the elopement. Resident #89's brother stated, They just told us they found him out wandering in the parking lot, they told me on another occasion he was trying to leave the facility. Resident #89's brother stated the facility recommended the resident transfer to a secured dementia unit. On 05/22/19 at 8:37 A.M. interview with LPN #47 revealed her supervisor, RN #142 informed her on 05/04/19 (no time was given) Resident #89 was not in the building. LPN #47 stated RN #142 and LPN #77 went in their personal vehicles to look for Resident #89. LPN #47 stated Resident #89 was located at (local store) and was brought back to the facility. LPN #47 stated she notified the family that Resident #89 had gotten off the facility property. LPN #47 stated Resident #89 was put on 15-minute checks and a watch mate was placed on him so that exit doors would alarm if he left again. She was unaware if the police were involved. Review of global positioning system (GPS) data revealed the distance to the local store where Resident #89 was found is approximately 0.3 miles from the facility. The area does not have sidewalks and has a high traffic area with busy roadways because it is located around a shopping mall area. On 05/21/19 at 5:10 P.M. interview with the DON verified Resident #89, who had moderate cognitive impairment and was at risk for elopement, left the facility unsupervised on 05/04/19. During the interview, the DON indicated she was not aware Resident #89 had walked from the facility to the local store without staff knowledge. The DON stated she was only aware the resident had left the facility and thought he was found by staff in the facility parking lot. The DON verified the resident's medical record did not reflect the actual circumstances of the elopement including the location at which Resident #89 was found on 05/04/19. Review of the facility Missing Guest policy and procedure, dated 09/2017 revealed the policy and procedure would be implemented if a guest was presumed to have left the facility unaccompanied or missing from his/her usual location. Upon discovering a guest was missing, staff should verify the last time the guest was seen. Also verify the guest had not been signed out or discharged . The employee who identified a guest was missing must immediately notify all working staff of the missing guest policy by announcing on the public address system code Code White, Unit___ or___Wing. Repeat twice. All available staff would then report to their nurses' stations. The Charge Nurse of the missing guest would notify the charge nurse of each nurses' station of the name of the missing guest and implement the action plan checklist. The Nursing Supervisor or Charge Nurse would assign appropriate staff to look for the guest. All interior areas of the building including closets, guest bathrooms, under beds, behind furniture, and shower rooms will be searched. Facility grounds including outdoor buildings would be searched. 2. A review of Resident #17's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment, dated 02/17/19 revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. It further revealed Resident #17 required two staff assistance for transfers and supervision with locomotion via electric wheelchair. A review of the smoking assessment, dated 04/12/19 revealed Resident #17 had quit smoking and there was no direct observation evaluation for the residents smoking. The care plan, dated 03/06/19 revealed no care plan for smoking. An interview on 05/19/19 at 4:27 P.M. with Resident #17 revealed she had possession of a lighter on her, but wasn't sure if she was allowed to. The resident would not show the surveyor the lighter at the time of the interview. An observation on 05/21/19 at 1:00 P.M. of Resident #17 revealed she was outside smoking with her left hand, which was shaking. She was observed having another resident put out the cigarette for her in the ash tray. No staff were outside with the residents while they smoked. An interview on 05/22/19 at 2:34 PM with the Director of Nursing (DON) confirmed the resident currently smokes. She further revealed the resident did quit smoking back in (MONTH) 2019, but also verified the current smoking assessment wasn't accurate, as well as the absence of a smoking care plan. A review of the policy titled, Guest Smoking, dated (MONTH) (YEAR) revealed all lighters, matches, cigarettes, pipes and liquid smoking products were to be kept at the nurse's station for all smokers regardless of how they have been assessed for supervision. 3. A review of Resident #54's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the smoking assessment, dated 11/19/18 revealed Resident #54 was able to smoke unsupervised and always returned smoking material to nurse staff. A care plan, dated 11/20/18 revealed Resident #54 wished to smoke while in the facility. Interventions included to keep cigarettes at the nurses station and the resident will comply with the facility smoking policy. The MDS 3.0 assessment, dated 04/03/19 revealed a BIMS score of 13 indicating intact cognition. It further revealed Resident #54 required supervision for transfers and locomotion via electric wheelchair. An observation and interview on 05/19/19 at 12:52 P.M. with Resident #54 confirmed half a pack of cigarettes, removed from the container, lined up on his sink countertop. A review of the policy titled Guest Smoking, dated (MONTH) (YEAR) revealed all lighters, matches, cigarettes, pipes and liquid smoking products were to be kept at the nurses station for all smokers regardless of how they have been assessed for supervision. 4. A review of the medical record for Resident #60 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS 3.0 assessment, dated 04/04/19 revealed Resident #60 had intact cognition. A Guest Smoking Assessment was signed on 11/20/18. An interview and observation of Resident #60 on 05/19/19 at 11:31 A.M. revealed a lighter was in the resident's room. LPN #47 confirmed the presence of the lighter at the time of the observation. A review of the policy titled Guest Smoking, dated (MONTH) (YEAR) revealed all lighters, matches, cigarettes, pipes and liquid smoking products were to be kept at the nurse's station for all smokers regardless of how they have been assessed for supervision. This deficiency substantiates Complaint Number OH 345.

Based on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to implement appropriate interventions to prevent pressure ulcers for Resident #64. Actual harm occurred when Resident #64, who is dependent on two staff for bed mobility, developed three Suspected Deep Tissue Injuries (SDTI) on his heels and ankle when the facility failed to implement an individualized turning and repositioning program and failed to elevate his heels to provide pressure relief. A SDTI is a purple or maroon area of discolored intact skin due to damage of underlying soft tissue from prolonged pressure. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This affected one of three residents reviewed for pressure ulcers. Findings include: Review of Resident #64's medical record revealed an original admission date of [DATE] with the latest re-admission on 04/22/18. Admitting [DIAGNOSES REDACTED]. Review of the Braden Scale for predicting pressure ulcers dated 04/12/18 revealed a score of 13, indicating Resident #64 was at a high risk for skin breakdown. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had unclear speech, rarely/never understands others, sometimes made himself understood, had long and short-term memory loss and had severe cognitive impairment. The MDS indicated Resident #64 was dependent on two staff members for bed mobility, transfers and toilet use, had an indwelling urinary catheter, was always incontinent of bowel, was at risk for skin breakdown and had no current skin breakdown. The MDS indicated the facility implemented a pressure reducing device to his bed/chair and application of nonsurgical dressings, however he was not placed on a turning/repositioning program. Record review revealed Resident #64 was found with three SDTI's which developed in house on 04/17/18. The wound tracking for each pressure ulcer/SDTI were as follows: Review of the weekly pressure ulcer skin grids from 04/17/18 to 05/22/18 for the left heel revealed the ulcer was discovered on 04/17/18 and was acquired in-house. The facility classified the wound as a SDTI measuring 5.7 centimeters (cm) by 5.0 cm. The wound was described as an area maroon-purple in color with intact skin. Resident #64 was sent to the hospital on [DATE] and was readmitted on [DATE]. The readmission skin assessment dated [DATE] revealed the SDTI to the left heel measured 9.0 cm by 8.0 cm and remained a purple-maroon color with intact skin. The 05/01/18 weekly pressure skin grid for the left heel revealed the SDTI measured 0.6 cm by 0.6 cm, was maroon-purple in color and the skin remained intact. Review of the weekly pressure skin grid dated 05/08/18 revealed the SDTI was unchanged in size or description from 05/01/18. Review of the 05/15/18 weekly pressure skin grids revealed the STDI measured 0.5 cm by 0.5 cm was purple-maroon in color with intact skin. Review of the weekly pressure skin grid dated 05/22/18 revealed the left heel SDTI was resolved. Review of the weekly pressure grids from 04/17/18 to 07/03/18 for the right heel revealed the pressure ulcer was discovered on 04/17/18 and was acquired in-house. The facility classified the area as a SDTI measuring 4.2 cm by 4.2 cm. The wound was described as maroon-purple in color with intact skin. Resident #64 was sent to the hospital on [DATE] and was readmitted on [DATE]. Review of the readmission skin assessment dated [DATE] revealed the SDTI to the right heel measured 7.0 cm by 6.0 cm and remained a purple-maroon color with intact skin. Review of the 05/01/18 weekly pressure skin grid for the right heel revealed the SDTI measured 6.0 cm by 5.4 cm and was described as a red fluid filled blister. Review of the weekly pressure skin grid dated 05/08/18 revealed the SDTI was 6.0 cm by 5.2 cm and was purple-maroon in color. Review of the 05/15/18 weekly pressure skin grids revealed the STDI measured 4.8 cm by 5.6 cm and was light reddish-tan in color. Review of the weekly pressure skin grid dated 05/22/18 revealed the SDTI measured 4.0 cm by 4.0 cm and was purple-maroon in color with intact skin. Review of the 05/29/18 weekly pressure skin grid dated 05/29/18, 06/05/18 and 06/19/18 revealed the wound was unchanged from the assessment completed on 05/22/18. Review of the 06/21/18 weekly pressure skin grid revealed the SDTI measured 4.0 cm by 3.9 cm and was dark brown-black in color. Review of the 06/26/18 weekly pressure skin grid revealed the SDTI measured 2.4 cm by 3.1 cm and was covered with dark brown eschar (thickened tan, brown or black dead, devitalized tissue). Review of the most current weekly skin assessment dated [DATE] revealed the wound was now classified as an unstageable pressure ulcer (an ulcer with full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured with slough, which is a yellowish, tan, greenish stringy devitalized tissue, or eschar) and measured 2.2 cm by 3.0 cm and was covered with black/brown eschar. Review of the weekly pressure grids from 04/17/18 to 07/03/18 for the left ankle revealed the wound was discovered on 04/17/18 and was acquired in-house. The facility classified the wound as a SDTI measuring 2.6 cm by 2.6 cm. The wound was described as a maroon-purple area color with intact skin. Resident #64 was sent to the hospital on [DATE] and was readmitted on [DATE]. Further review of the readmission skin assessment dated [DATE] revealed on the SDTI to his left ankle measured 3.0 cm by 3.0 cm and remained a purple-maroon color with intact skin. Review of the 05/01/18 weekly pressure skin grid for the right heel revealed the SDTI measured 2.8 cm by 2.4 cm and was described as purple-maroon in color. Review of the weekly pressure skin grid dated 05/08/18 revealed the SDTI was 2.8 cm by 2.4 cm and was described as purple-maroon in color. Review of the 05/15/18 weekly pressure skin grids revealed the STDI measured 2.2 cm by 2.4 cm was purple-maroon in color. Review of the weekly pressure skin grid dated 05/22/18 revealed the SDTI measured 2.2 cm by 2.4 cm and was purple-maroon in color with intact skin. Review of the weekly pressure skin grid dated 05/29/18 revealed the wound was now classified as a Stage III pressure ulcer, a full thickness loss of tissue in which fat tissue is visible and may contain slough and/or eschar, tunneling or undermining, measuring 2.0 cm by 1.9 cm by 0.1 cm with the wound bed being covered with slough. Review of the 06/05/18 weekly pressure skin grid revealed the wound measured 2.0 by 1.9 by 0.1 cm and remained covered with slough. Review of the 06/05/18 weekly pressure skin grid revealed the wound measured 2.0 by 1.9 by 0.1 cm and was red in color. Review of the 06/19/18 weekly pressure skin grid revealed the wound measured 2.0 by 1.9 by 0.1 cm and was red in color. Review of the 06/21/18 weekly pressure skin grid revealed the wound was now classified as unstageable measuring 1.0 cm by 1.2 cm and was covered with slough. Review of the 06/26/18 weekly pressure skin grid revealed the ulcer was unstageable and measured 1.0 cm by 1.2 cm and was covered with dark brown eschar. Review of the most current weekly skin assessment dated [DATE] revealed the wound was now classified as an unstageable and measured 0.8 cm by 0.8 cm and was covered with slough. Review of the plan of care dated 04/25/18 revealed Resident #64 had an alteration in elimination as evidenced by pressure ulcers present on his right heel and left ankle. The facility implemented interventions after the development of the SDTI's for nurses to assess the areas for size, color, and drainage weekly and as needed, assess the condition of skin/dressing as needed, assist him to turn and reposition as needed, body check weekly and as needed, elevate heels in bed as tolerated/needed, maintain alternating pressure reduction air mattress to bed and check function every shift. There were no specific directions to staff as to the frequency of turning and repositioning, the need to elevate his heels off the bed surface on a regular basis to relieve pressure, or what staff were to use to elevate his heels. Review of the Treatment Administration Record (TAR) from (MONTH) (YEAR) to (MONTH) (YEAR) revealed the facility implemented a specialty air mattress to his bed on 04/26/18, nine days after the SDTI's were identified. On 06/21/18 at 11:20 A.M., Licensed Practical Nurse (LPN) #208 was observed to provide the treatment to Resident #64's pressure ulcers. LPN #208 removed the soiled dressing from his left ankle. The pressure ulcer measured 1.2 cm by 1.0 cm and was more than 30% covered with slough. She said the wound had more slough than before and she would notify the physician for possible treatment changes. She cleansed the wound with normal saline, applied Marathon (a liquid skin protectant that forms a barrier film to provide protection for at risk or damaged skin) around the boarder of the pressure ulcer and covered the wound with a [MEDICATION NAME] dressing, a highly absorbent foam dressing. She washed her hands and donned a clean pair of gloves. She removed the soiled dressing and washed her hands and donned a clean pair of gloves. The right heal was dark purple in color and the edges of the wound were beginning to pull away. The wound measured 4.0 cm by 4.0 cm. She cleansed the wound with normal saline (NS), applied Marathon to the boarder and covered with an [MEDICATION NAME] dressing. She said she would update the physician on this wound also and would now classify this wound as an unstageable pressure ulcer. On 07/05/18 at 12:25 P.M. interview with LPN #208 revealed the resident had a heel elevator which cradled the resident's calves. She said he would kick it out of place so it was discontinued. She said he did better with the pillows and was more likely to keep them in place. LPN #208 denied the use of any other interventions but pillows to relieve heel pressure. Review of Resident #64's nursing progress notes from 04/01/18 to 04/17/18 failed to indicate he was noncompliant with heel elevation or that he removed any sort of heel elevator or pillows from under his feet/legs. Review of the current plan of care revealed no issues or information indicating Resident #64 was non-compliant with pressure relieving interventions, including having his heels elevated off the bed surface or being turned and repositioned. Review of the resident's physician's orders [REDACTED]. elevated either with pillows or a heel elevator and no orders for staff to turn and reposition Resident #64 on any specific turn schedule or frequency. On 07/05/18 at 2:30 P.M. interview with the Director of Nursing (DON) verified the facility had not attempted any interventions to float Resident #64's heels/feet other than the pillows. On 07/06/18 at 10:50 A.M. interview with the DON verified the facility had no documentation that Resident #64 removed the heel elevator or pillows from under his heels. Review of the facility's Skin Assessment policy and procedure dated 09/17 revealed it is the policy of the facility to prevent the development of pressure ulcers in a resident who is admitted without pressure ulcers. This policy indicated resident response to preventative efforts would be monitored and evaluated and approaches would be revised as appropriate. This deficiency substantiates Complaint Number OH 576.