Every finding on record at The Laurels of Kettering

Based on record review, interviews, review of Google Maps, and policy review, the facility failed to document in the medical record when a resident was identified to have left the facility property unsupervised. This affected one (#51) of three residents reviewed for elopement. The facility census was 82. Finding include: Medical record review for Resident #51 revealed he was admitted to the facility on [DATE]. Diagnoses included cognitive deficit, old myocardial infarction, anemia, depression, hypertensive heart disease, cerebral infarction, aphasia, insomnia, mood disorder, and adjustment disorder.Review of the legal guardian paperwork revealed the court found by clean and convincing evidence Resident #51 was incompetent and assigned a guardian effective 04/22/25.Review of the MDS assessment, dated 01/12/26, revealed Resident #51 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 2.Review of the current care plans for Resident #51 revealed at the top of the care plan was a special instruction box that revealed Resident #51 had a guardian. The staff were directed to not allow Resident #51 to leave without permission from the guardian. A care plan, dated 05/15/25, revealed the resident required for twenty-four hour care related to cognition. The interventions listed included to observe for risk/desire to elope.Review of the Risk for Elopement assessment, dated 03/31/26 at 3:56 P.M., revealed Resident #51 was identified to be at risk for elopement. The assessment revealed Resident #51 was mobile with a device.Interview on 04/20/26 at 12:30 P.M. Resident #51 stated he went down the hill in front of the facility and then down the street with no staff members present. Resident #51 revealed the staff at the facility was upset with him when they found out and told him he was not permitted to go outside of the facility unattended. Resident #51 also stated the staff told him he was not permitted to go down the hill and into the street outside of the facility. Resident #51 stated he left the facility grounds last week on another day, but could not say what day it was. Resident #51 stated if he could get out of the facility he would.Interview on 04/20/26 at 12:48 P.M. the Director of Nursing (DON) stated Resident #51 had an incident occur on 04/16/26 around 6:00 P.M. The DON stated she did not feel it was an elopement because she feels he has an inaccurate BIMS score due to his aphasia.Continued review of Resident #51's medical record revealed no documentation regarding the resident leaving the facility property on 04/16/26.Interview on 04/20/26 at 1:19 P.M. Social Service Director (SSD) #284 stated Resident #51 was found outside the facility on 04/16/26 around 6:00 P.M. SSD #284 revealed the DON called the facility and reported Resident #51 was observed at [NAME] Park down the street from facility, past [NAME] Park Pond. SSD #284 confirmed she joined the search and found Resident #51 near the road at the end of the facility's long sidewalk on the left side of the facility property. SSD #284 confirmed Resident #51 refused to go inside the facilityReview of Google Maps revealed [NAME] Park is 0.6 miles from the facility.Interview on 04/20/26 at 1:45 P.M. Licensed Practical Nurse (LPN) #158 stated she was Resident #51's nurse when he was found down the street from the facility on 04/16/26 around 6:00 P.M. LPN #158 state she was not sure how far he got from the facility. LPN #158 confirmed Resident #51 sat at the end of the property outside, near the road, and refused to enter the facility. LPN #158 stated the DON advised her not to report anything inside Resident #158's chart regarding the elopement because the DON did not consider it an elopement. LPN #158 confirmed when she saw Resident #51 on 04/16/26 he was sitting at the base of the hill on the left side of the facility next to the road.Interview on 04/20/26 at 5:03 P.M. Unit Manager (UM) #92 revealed she received a call from the DON on 04/16/26 around 6:00 P.M. UM #92 revealed the DON reported she saw Resident #51 down the street on [NAME] Park Road. (The main road in front of the facility drive) UM #92 reported by the time she got to Resident #51 he was at the end of the sidewalk at the top of the hill on the left side of the facility property near the street. UM #92 revealed Resident #51 refused to come into the facility. UM #92 confirmed she heard the DON advise LPN #158 not to document about Resident #51 being found outside the facility near the road.Review of the facility policy titled Elopement Policy, dated 05/01/22, confirmed it is the policy of the facility to prevent the elopement of guests from the facility. An elopement occurs when a resident who needs supervision leaves a safe area without authorization or necessary supervision to do so. If an employee observes a guest attempt to leave the facility they should complete an incident report and review the current elopement risk and re-evaluate if needed. If a guest leaves the facility, upon return the Director of Nursing (DON) should complete and file an incident report and make appropriate notations in the resident's medical record.This was an incidental example of non-compliance discovered during the complaint investigation.

Based on interview, record review and policy review, the facility failed to meet the needs of residents with regard to the timeliness of reporting stat and critical laboratory (lab) results and have a lab policy. This affected two Residents (#85 and #87) of three residents reviewed for labs.Findings include:1. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE] and discharged on 04/03/26. Diagnoses included anemia, vesicointestinal fistula, spinal stenosis, congenital kyphosis, and chronic obstructive pulmonary disease. Review of provider orders for Resident #85 dated 03/20/26 revealed Protime (PT)/ International Normalized Ratio (INR) on Monday and Thursday. Review of physician orders for Resident #85 dated 03/31/26 revealed warfarin at bedtime every Tuesday, Thursday, and Saturday for treating/preventing blood clots, contact doctor with PT/INR results.Review of PT/INR results dated 04/02/26 for revealed PT 70.4 (high abnormal results) and INR 7.0 (abnormal critical high results). The record had no evidence the physician was notified of the elevated PT/INR levels on 04/20/26.Interview on 04/21/26 at 12:08 P.M. with Medical Director #302 confirmed the critical PT/INR result for Resident #85 was not called to her on 04/02/26. MD #302 confirmed she knew of the result the next day.Interview on 04/21/26 at 1:52 P.M. with the Unit Manager (UM) #92 revealed critical laboratory tests (labs) are to be called to resident's provider and obtain new orders. UM #92 revealed the PT/INR result for Resident #85 results were available but she did not see it until the next morning. UM #92 also confirmed the nurses are instructed to look at labs in the system.Interview on 04/21/26 at 2:23 P.M. with Registered Nurse (RN) #102 revealed they were not aware of the PT/INR result for Resident #85 until 04/21/26.Interview on 04/22/26 at 8:36 A.M. Client Representative (CR) #300 with the facility's lab services American Health Associates, revealed the PT/INR lab drawn on 04/02/26 for Resident #85 with a critical result was called to the facility on [DATE] at 11:36 A.M. CR #300 stated there was only one person working that night so that representative was unable to call right away. CR #300 revealed the PT/INR result was released on 04/02/26 at 6:30 P.M. into the lab system and confirmed the nurses at the facility had access at that time. CR #300 stated their system faxes results however the fax did not go through and failed two times. Review of the American Health Associates (AHA) contract with the facility, dated 08/11/21, revealed critical lab results will be phoned to the facility when they are available. 2. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] and discharged on 04/07/26. Diagnoses included hypoosmolality and hyponatremia, morbid obesity, single subsegmental thrombotic pulmonary embolism without acute cor pulmonale, and hypertension.Review of the medical record revealed Resident #87 had physician orders dated 03/19/26 for PT/INR weekly due to use of coumadin. Review of the medical record revealed Resident #87 had physician orders dated 03/19/26 for a PT/INR STAT for elevated lab levels. Review of the STAT PT/INR results dated 03/20/26 at 4:00 P.M. revealed a PT of 31.9 and an INR of 3.1. There was no documentation the lab test was called to the facility by AHA labs.Review of Resident #87's progress note dated 03/21/2026 at 1:53 P.M. revealed the PT/INR results were reviewed by the nurse and the physician notified. Interview on 04/22/26 at 1:46 P.M. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #93 revealed critical and STAT labs results usually are called from the lab, but the facility nurses should be looking to see if the labs are in the system. The DON and ADON #93 confirmed the lab didn't call the STAT labs to the facility and the nurse didn't review the lab tests until almost 22 hours after they were available. Review of the AHA contract with the facility, dated 08/11/21, revealed laboratory STAT testing will be reported within five hours. STAT results will be phoned to the facility when they are available. This was an incidental example of non-compliance discovered during the complaint investigation.

Based on interview, record review and policy review, the facility failed to follow physician orders for non-pharmaceutical pain interventions for one (#86) of four residents reviewed for pain management. The facility census was 82.Findings include-Review of the medical record revealed Resident #86 was admitted to the facility on [DATE] and discharged on 03/30/26. Diagnoses included polyarthritis, anxiety disorder, pain in unspecified shoulder, hypertension, and diastolic heart failure.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had moderately impaired cognition, was independent with eating and toileting, and required supervision with bathing. Review of the care plan for Resident #86, dated 03/11/26, revealed the resident was at risk for pain and/or has acute pain related to left shoulder replacement,and chronic pain related to polyarthritis. Interventions included to notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain.Review of the provider orders dated 03/11/26 revealed pain-non-pharmacological interventions: massage, meditation, relaxation, positioning, ice therapy on 20 minutes every hour, diversional activity, guided imagery, rest, and social interaction.Review of the pain level summary for Resident #86 from admission to discharge revealed out of 163 times the resident was checked for pain only 11 times did the resident have a pain level at zero. Review of the Medication Administration Records (MAR) for Resident #86 revealed no non-pharmacological interventions were provided to Resident #86 from admission to discharge. Interview on 04/21/26 at 1:12 P.M. with the Physician Assistant (PA) #301revealed non-pharmacological interventions should be completed or offered to residents with pain.Interview on 04/21/26 at 1:26 P.M. with Licensed Practical Nurse (LPN) #114 verified non-pharmacological interventions were not done for Resident #86 when pain was reported.Interview on 04/21/26 at 1:52 P.M. with the Unit Manager #92 confirmed the non-pharmacological interventions were not offered for Resident #86 when pain was reported.Interview on 04/22/26 at 1:46 P.M. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #93 revealed Resident #86 had repeated and almost constant complaints about pain and non-pharmacological interventions should have been offered and they were not. Review of the policy titled Pain Management, dated 03/05/25, revealed the staff will implement the care plan, monitor the residents, and administer therapeutic interventions for pain.This deficiency represents non-compliance investigated under Master Complaint Number 2987791 and Complaint Number 2986526.

Based on record review, interviews, review of Google Maps, and policy review, the facility failed to ensure a resident with directions from legal guardians not to leave the facility and residents with cognitive impairment did not leave the facility property unsupervised. This affected two (#51 and #84) of three residents reviewed for elopements. The facility census was 82. Findings include:1.Medical record review for Resident #84 revealed he was admitted to the facility on [DATE] and discharged to a hospice facility on 04/04/26. Diagnoses included malignant neoplasm of overlapping cites in the brain, hypertension, bipolar disorder, and cerebral edema.Review of the hospital referral for Resident #84, dated 03/26/26, revealed a diagnosis of brain mass, large left posterior frontal lobe and temporal lobe mass, vasogenic edema, and acute encephalopathy. Neurocognitive and functional assessments revealed persistent cognitive deficits, including impaired executive function, memory, and expressive/receptive language, with a St. [NAME] University Memory Score (SLUMS) score consistent with dementia.Review of the Nursing Comprehensive Evaluation dated 03/27/26 revealed under the area of elopement the resident was mobile with a device, had cognitive impairment, and was not identified to be a high risk for elopement.Review of the progress notes for Resident #84, dated 03/30/26 at 7:26 P.M., revealed the resident left the facility this evening and decided to walk outside the facility. Resident #84 wanted to smoke and get fresh air. Resident #84 returned to the facility with no injuries. A Wanderguard was put in place on Resident #84's right lower leg. Review of the facility Self-Reported Incident (SRI) #2750 for neglect, dated 03/31/26 at 11:39 A.M., revealed the incident was identified on 03/30/26 around 4:52 P.M. and involved an elopement of Resident #84. On 03/30/26 at 4:52 P.M. the facility reported Resident #84 asked Activity Aide (AA) #174 to direct him toward the front door. At 5:30 P.M. Licensed Practical Nurse (LPN) #114 reported Resident #84 missing from the facility. The family of Resident #84 was notified of the missing resident at 5:50 P.M. At 6:00 P.M. LPN #114 contacted the local police department and reported Resident #84 missing. On 03/30/26 at 6:10 P.M. the local police department found Resident #84 approximately 1.6 miles away at a car parts store. The facility assessed Resident #84 upon return and Resident #84 did not have injuries. The facility placed a Wanderguard on Resident #84 and updated the medical record.Continued review of the medical record revealed Resident #84's care plan was updated on 03/31/26 to address exit seeking behavior and wandering. Interview with LPN #114 on 04/21/26 at 10:32 A.M. revealed she was the nurse on 03/30/26 around 4:52 P.M. when Resident #84 eloped from the facility. LPN #114 stated the resident had just returned from a family visit around 4:15 P.M. and Resident #84 made the statement that he wanted to smoke. LPN #114 revealed she met with Resident #84's daughter prior to the elopement on 03/30/26 and Resident #84's daughter revealed Resident #84 had the cognition of a twelve-year-old. LPN #114 stated she observed Resident #84 walk through the unit and go back to his room after his daughter had left. LPN #114 stated she went into Resident #84's room and noted he was not there and questioned other staff where he could be. LPN #114 stated she was concerned because no one knew where the resident was so she did a head count. She notified management Resident #84 was missing on 03/30/26 around 5:00 P.M. LPN #114 revealed the family, physician, and police were called. LPN #114 confirmed the local police located Resident #84 at a car parts store and brought him back to the facility. LPN #114 revealed she assessed Resident #84 and he did not have any injuries. LPN #114 obtained an order for the use of Wanderguard. LPN #114 confirmed Resident #114 had some mild confusion; however, it was hard to tell the extent because his daughter would answer for Resident #84 most of the time.Interview on 04/21/26 at 1:02 P.M. Medical Director (MD) #302 revealed you would have to spend a lot of time with Resident #84 to identify his confusion because Resident #84 would answer questions appropriately.Interview on 04/21/26 at 3:45 P.M. LPN #160 confirmed she was the admission nurse for Resident #84 on 03/27/26. LPN #160 confirmed Resident #84 could answer questions; however, the daughter would take over the conversations. LPN #160 confirmed she marked Resident #84 on her assessment as having cognitive issues based on his hospital paperwork.Interview on 04/21/26 at 4:12 P.M. the Administrator reported Resident #84 had no plan and walked 1.5 miles from the facility and did not know where he was. The Administrator identified this as and elopement.Interview on 04/22/26 at 11:05 P.M. AA #174 revealed on 03/30/26 at 4:52 P.M. Resident #84 walked up to her and look confused. Resident #84 asked AA #174 where the front door was. AA #174 reported she had no idea Resident #84 was a resident at the facility and directed him to the front door. Later that day when AA #174 learned Resident #84 had eloped she confirmed she had directed him to the front door.2. Review of the medical record for Resident #51 revealed he was admitted to the facility on [DATE]. Diagnoses included cognitive deficit, old myocardial infarction, anemia, depression, hypertensive heart disease, cerebral infarction, aphasia, insomnia, mood disorder, and adjustment disorder.Review of the legal guardian paperwork revealed the court found by clean and convincing evidence Resident #51 was incompetent and assigned a guardian effective 04/22/25.Review of the MDS assessment, dated 01/12/26, revealed Resident #51 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 2.Review of the current care plans for Resident #51 revealed at the top of the care plan was a special instruction box that revealed Resident #51 had a guardian. The staff were directed to not allow Resident #51 to leave without permission from the guardian. A care plan, dated 05/15/25, revealed the resident required for twenty-four hour care related to cognition. The interventions listed included to observe for risk/desire to elope.Review of the Risk for Elopement assessment, dated 03/31/26 at 3:56 P.M., revealed Resident #51 was identified to be at risk for elopement. The assessment revealed Resident #51 was mobile with a device.Review of the Risk for Elopement asessment, dated 04/20/26 at 12:30 P.M. revealed Resident #51 was not at risk for elopement. Review of the progress notes for Resident #51, dated 04/20/26 at 12:32 P.M., written by the Director of Nursing (DON), revealed the interdisciplinary team (IDT) met to discuss potential elopement risk. The note documented Resident #51 was alert and oriented. The resident has expressive aphasia and cannot voice what he needs. He will go to the courtyard (secured) when the weather is nice. Resident #51 is able to go out front of the facility and around the facility. Resident is able to leave and return independently. Staff does provide checks when the resident is out front or on the patio.The record contained no documentation Resident #51 had left the facility property unsupervised. Interview on 04/20/26 at 12:30 P.M. Resident #51 stated he went down the hill in front of the facility and then down the street with no staff members present. Resident #51 revealed the staff at the facility was upset with him when they found out and told him he was not permitted to go outside of the facility unattended. Resident #51 also stated the staff told him he was not permitted to go down the hill and into the street outside of the facility. Resident #51 stated he left the facility grounds last week on another day but could not say what day it was. Resident #51 stated if he could get out of the facility he would.Interview on 04/20/26 at 12:48 P.M. the DON stated Resident #51 had an incident occur on 04/16/26 around 6:00 P.M. and she did not feel it was an elopement because he has an inaccurate BIMS score due to his aphasia The DON stated the IDT team voiced concerns related to the safety of Resident #51 and his low BIMS score of 2 after the incident on 04/16/26. The DON stated Social Service Director (SSD) #284 voiced the concern for Resident #51's safety related to his ability to be outside unsupervised due to his low BIMS score and the need for a guardian. The DON stated she thought the guardian was just for his finances. The DON confirmed the IDT team meeting held on 04/20/26 included the unit managers and the Administrator. The IDT team meeting did not include SSD #284. Interview on 04/20/26 at 1:19 P.M. SSD #284 stated Resident #51 was found outside the facility on 04/16/26 around 6:00 P.M. SSD #284 revealed the DON called the facility and reported Resident #51 was observed at [NAME] Park down the street from facility, past [NAME] Park Pond. SSD #284 confirmed she joined the search and found Resident #51 near the road at the end of the facility's long sidewalk on the left side of the facility property. SSD #284 confirmed Resident #51 refused to go inside the facility. SSD #284 stated Resident #51 had a BIMs score of 2 on his last MDS assessment. However, Resident #51 has a current MDS in progress and his current BIMS score was a 1. SSD #284 confirmed Resident #51 had a legal guardian of person on file at the facility.Review of Google Maps revealed [NAME] Park is 0.6 miles from the facility.Interview on 04/20/26 at 1:45 P.M. LPN #158 stated she was Resident #51's nurse when he was found down the street from the facility on 04/16/26 around 6:00 P.M. LPN #158 state she was not sure how far he got from the facility. LPN #158 stated on this date Resident #51 sat at the end of the property outside, near the road, and refused to enter the facility. LPN #158 stated the DON advised her not to report anything inside Resident #158's chart regarding the elopement because the DON did not consider it an elopement. LPN #158 revealed Resident #51 will usually sit outside the rehabilitation doors in the secured courtyard and she was surprised to learn he was down the street from the facility unattended by staff. LPN #158 confirmed when she saw Resident #51 on 04/16/26 he was sitting next to the road at the base of the hill on the left side of the facility property.Interview on 04/20/26 at 1:59 P.M. Receptionist #210 revealed on the evening of 04/16/26 at 6:00 P.M. the DON called and reported Resident #51 was outside and down the street from the facility. Receptionist #210 reported she observed Resident #51 at the end of sidewalk near the road to the left of the facility property. He refused to come into the facility. Receptionist #210 revealed she told Resident #51 she was not aware he went so far from the property and Resident #51 reported to her he had been even further away than where he was found that day. Receptionist #210 stated because Resident #51 has impaired cognition and a Legal Guardian he was supposed to report to her when he exits the facility. Receptionist #210 revealed Resident #51 was aware of the need to report to her when he goes outside the facility. Receptionist #210 stated on 04/12/26 and 04/19/26 she observed Resident #51 enter the facility and was not aware he had gone outside.Interview on 04/20/26 at 3:48 P.M. Resident #51's Legal Guardian stated the facility failed to notify her of the incident with Resident #51 being outside the facility and down the street on 04/16/26. Resident #51's guardian confirmed she was upset to learn Resident #51 could go outside the facility unsupervised. Resident #51's guardian stated concern over Resident #51's safety with a BIMS score of 2. Interview on 04/20/26 at 5:03 P.M. Unit Manager (UM) #92 revealed she received a call from the DON on 04/16/26 around 6:00 P.M. UM #92 revealed the DON reported she saw Resident #51 down the street on [NAME] Park Road. (The main road in front of the facility driveway) UM #92 reported by the time she got to Resident #51 he was near the street at the end of the sidewalk at the top of the hill on the left side of the facility property. UM #92 revealed Resident #51 refused to come into the facility. UM #92 stated Resident #51 told her he left the faciity on Sunday 04/12/26 and had been even further away than where he was found on 04/16/26. UM #92 revealed Resident #51 would usually go to the secured courtyard to sun bath on the rehabilitation patio. UM #92 confirmed she heard the DON advise LPN #158 not to document about Resident #51 being found outside the facility near the road.Interview on 04/21/26 at 1:29 P.M. Physician Assistant (PA) #301 stated if a resident has a BIMS score of 2 and a legal guardian then the resident should not be outside the facility unsupervised. Observation on 04/22/26 at 2:23 P.M. revealed Resident #51 was seated in his wheelchair up the hill on the left side of the facility property at the end of the walkway near the street.Interview on 04/22/26 at 2:23 P.M. Resident #51 stated he was allowed to sit at the top of the hill near the street as long as he does not cross the sidewalk line. Resident #51 confirmed he has left the facility property but would not tell anyone so that he does not get into trouble.Review of the facility policy titled Elopement Policy, dated 05/01/22, confirmed it is the policy of the facility to prevent the elopement of guests from the facility. An elopement occurs when a resident who needs supervision leaves a safe area without authorization or necessary supervision to do so. If an employee observes a guest attempt to leave the facility they should complete an incident report and review the current elopement risk and re-evaluate if needed. If a guest leaves the facility, upon return the Director of Nursing (DON) should notify the administrator, examine the resident, contact the physician, contact the resident's legal representative and inform them of the incident, complete and file an incident report, make appropriate notations in the resident's medical record, review the current elopement risk and re-evaluate, investigate how the resident exited and make recommendations on safety measures, and update the resident's care plan. This citation represents non-compliance investigated under Master Complaint Number 2987791 and Complaint Number 2985771.

Based on record review, staff interview, and policy review, the facility failed to ensure the baseline care plan included a resident's hearing status and interventions. This affected one (#85) of four residents reviewed for care plans. The facility census was 82.Findings include:Review of the medical record revealed Resident #85 was admitted to the facility on [DATE] and discharged on 04/03/26. Diagnoses included anemia, vesicointestinal fistula, spinal stenosis, congenital kyphosis, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 was cognitively intact and had moderate difficulty with hearing.Review of the Nursing Comprehensive Evaluation dated 03/23/26 revealed Resident #85 had moderate difficulty with hearing.Review of the baseline care plan for Resident #85 revealed no plan of care related to hearing impairment needs or interventions. Interview on 04/22/26 at 1:14 P.M. with Social Service Assistant (SSA) #203 revealed not aware of any hearing issues or impairment for Resident #85.Interview on 04/22/26 at 1:19 P.M. with Social Service Director (SSD) #204 revealed not aware of any hearing issues or impairment for Resident #85.Interview on 04/22/26 at 1:46 P.M. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #93 confirmed if a resident has moderate impairment with hearing it would trigger inclusion in the baseline care plan. Both verified Resident #85's hearing impairment was not addressed in the baseline care plan. The DON confirmed there was no discussion regarding audiology services with Resident #85. Review of the policy titled Care Planning, dated 03/03/25, revealed a baseline care plan will be developed within 48 hours identifying any immediate needs, initial goals and interventions needed to provide effective and person-centered care. This deficiency represents non-compliance investigated under Complaint Number 2978380.

Based on medical record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure and admission [NAME] Data Set (MDS) 3.0 assesment was completed timely for one (#37) of four residents reviewed for MDS assessments. The facility census was 82.Findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, myasthenia gravis without exacerbation, and dysphagia.Review on 04/22/26 at 9:30 A.M of the admission MDS 3.0 assessment in the electronic medical record revealed an assessment reference date of 04/12/26. The MDS assessment was identified as still in process and should be completed by 04/19/26. Sections A, B, H, I J, L, M, N, O, P, S were identified as still in progress and not complete. Section V, the Care Area Assessment (CAA) summary was not completed. The document was identified as unsigned. Interview on 04/22/26 at 11:25 A.M. with MDS Coordinator #94 verified the admission MDS assessment for Resident #37 was not completed and was overdue. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, dated October 2023, revealed an admission assessment must be completed within 14 days, with the admission date considered day one. This was an incidental example of non-compliance discovered during the complaint investigation.

Based on medical record review, interviews, review of Google Maps, and policy review, the facility failed to notify the physician and the Legal Guardian a resident was exiting the facility without supervision and left the facility property unsupervised. This affected one (#51) out of three residents reviewed for elopement. The facility census was 82.Findings include: Medical record review for Resident #51 revealed he was admitted to the facility on [DATE]. Diagnoses included cognitive deficit, old myocardial infarction, anemia, depression, hypertensive heart disease, cerebral infarction, aphasia, insomnia, mood disorder, and adjustment disorder.Review of the legal guardian paperwork revealed the court found by clean and convincing evidence that Resident #51 was incompetent and assigned a guardian effective 04/22/25.Review of the current care plans for Resident #51 revealed at the top of the care plan was a special instruction box that revealed Resident #51 has a guardian. The staff were directed to not allow Resident #51 to leave without permission from the guardian. A care plan, dated 05/15/25, revealed the resident required for twenty-four hour care related to cognition. The interventions listed included to observe for risk/desire to elope.Interview on 04/20/26 at 12:30 P.M. Resident #51 stated he went down the hill in front of the facility and then down the street with no staff members present. Resident #51 revealed the staff at the facility were upset with him when they found out and told him he was not permitted to go outside of the facility unattended. Resident #51 also stated the staff told him he was not permitted to go down the hill and into the street outside of the facility. Resident #51 stated he left the facility grounds last week on another day but could not say what day it was. Interview on 04/20/26 at 1:19 P.M. Social Service Director (SSD) #284 stated Resident #51 was found outside the facility on 04/16/26 around 6:00 P.M. SSD #284 revealed the Director of Nursing (DON) called the facility and reported Resident #51 was observed at [NAME] Park down the street from facility, past [NAME] Park Pond. SSD #284 confirmed she joined the search and found Resident #51 at the end of the facility's long sidewalk near the road, on the left side of the facility property. SSD #284 confirmed Resident #51 refused to go inside the facility. SSD #284 confirmed Resident #51 had a legal guardian of person on file at the facility.Review of Google Maps revealed [NAME] Park is 0.6 miles from the facility.Interview on 04/20/26 at 1:45 P.M. Licensed Practical Nurse (LPN) #158 stated she was Resident #51's nurse when he was found down the street from the facility on 04/16/26 around 6:00 P.M. LPN #158 state she was not sure how far he got from the facility. LPN #158 stated on this date Resident #51 sat at the end of the property outside, near the road, and refused to enter the facility. LPN #158 confirmed when she saw Resident #51 on 04/16/26 he was sitting next to the road at the base of the hill on the left side of the facility property.Interview on 04/20/26 at 1:59 P.M. Receptionist #210 revealed on the evening of 04/16/26 at 6:00 P.M. the DON called and reported Resident #51 was outside and down the street from the facility. Receptionist #210 reported she observed Resident #51 at the end of sidewalk near the road to the left of the facility property. He refused to come into the facility. Receptionist #210 revealed she told Resident #51 she was not aware he went so far from the property and Resident #51 reported to her he had been even further away than where Resident #51 was found that day. Receptionist #210 stated because Resident #51 has impaired cognition and a Legal Guardian he was supposed to report to her when he exits the facility. Receptionist #210 revealed Resident #51 was aware of the need to report to her when he goes outside the facility. Receptionist #210 stated on 04/12/26 and 04/19/26 she observed Resident #51 enter the facility and was not aware he had gone outside.Additional review of the medical record revealed no documentation of Resident #51's physician being notified the resident had left the facility property. There was no notification the Legal Guardian was notified the resident had left the property or was going outside unsupervised.Interview on 04/20/26 at 3:48 P.M. Resident #51's Legal Guardian stated the facility failed to notify her of the incident with Resident #51 being outside the facility and down the street on 04/16/26. Resident #51's guardian confirmed she was upset to learn he could go outside the facility unsupervised.Interview on 04/21/26 at 1:02 P.M. Medical Director (MD) #302 confirmed the facility failed to notify her when Resident #51 was found either down the street or near the street on 04/16/26. Review of the facility policy titled Elopement Policy, dated 05/01/22, revealed it is the policy of the facility to prevent the elopement of guests from the facility. An elopement occurs when a resident who needs supervision leaves a safe area without authorization or necessary supervision to do so. If a guest leaves the facility, upon return the Director of Nursing (DON) should notify the Administrator, examine the resident, contact the physician, and contact the resident's legal representative. This was non-compliance discovered during the complaint investigation for Complaint Number 2987791.

Based on medical record reviews, staff interviews, and policy review, the facility failed to complete comprehensive wound evaluations that included wound measurements or characteristics. This affected two (#09 and #85) residents out of the three residents reviewed for wound cares/services. The facility census was 81.Findings include:1.Review of the medical record for Resident #09 revealed an admission date of 10/20/24 with medical diagnoses of atrial fibrillation, paranoid schizophrenia, and atherosclerotic heart disease (ASHD). Resident #09 readmitted to the facility on [DATE] with diagnosis of displaced intertrochanteric fracture of left femur status post surgical repair.Review of a quarterly Minimum Data Set (MDS) assessment ,dated 01/31/26, revealed Resident #09 had moderate cognitive impairment and was independent with bed mobility and eating and required supervision with toilet hygiene, bathing, and transfers. Review of the Nursing Comprehensive Evaluation dated 03/10/26 revealed Resident #09 had a surgical incision to left lateral leg. The evaluation did not include measurements or wound description. Further review of the medical record revealed weekly skin assessment dated [DATE] which stated Resident #09 had surgical incision to hip, staples in place, and no measurements noted. Review of skin assessment dated [DATE] indicated Resident #09 had surgical incision to hip which was healing and no measurements were noted. Review of skin assessment dated [DATE] revealed Resident #09 had three small incisions to left hip, left medial thigh, and left medial above knee. The assessments stated the left knee incision had two small separate incisions which were measured as a cluster, steri-strips in place to all areas, covered with abdominal pad and secured with tape. The assessment indicated measurements for left lateral knee incision measured 3.4 centimeters (cm) by 0.1 cm, rear left thigh measured 4.5 cm by 0.1 cm, front left lateral knee measured 3.5 cm by 0.1 cm and the rear left trochanter 4.3 cm by 0.1 cm.2. Review of the medical record for Resident #85 revealed an admission date of 03/11/26 with medical diagnoses of left artificial shoulder joint, polyarthritis, hyperlipidemia, hypertension, and ASHD. Review of the medical record revealed Resident #85 discharged on 03/30/26.Review of an admission MDS assessment, dated 03/16/26, revealed Resident #85 was cognitively intact and required supervision with toilet hygiene and independent with bed mobility and transfers. The MDS indicated Resident #85 had a surgical incision. Review a Comprehensive Nursing Evaluation, dated 03/12/26, indicated Resident #85 had left shoulder surgical site with non-removeable dressing in place. The evaluation did not include measurements or a description of the surgical site. Review of a physician order for Resident #85, dated 03/11/26, stated do not remove the clear dressing and to leave in place until follow up appointment. Review of the skin assessment dated [DATE] and 03/29/26 indicated Resident #85 had no skin issues. Review of the skin assessment dated [DATE] indicated Resident #85 had a surgical site to left shoulder but did not indicate measurements or wound description. Interview on 04/02/26 at 9:54 A.M. with Director of Nursing (DON) confirmed Resident #85 admitted with a clear dressing to the surgical site and verified the medical records for Residents #09 and #85 did not contain documentation the facility completed comprehensive wound assessments that included wound measurements or characteristics. Review of the facility policy titled, Skin Management, revised 01/28/26, stated residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The policy stated upon admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record on the nursing comprehensive evaluation. The policy stated residents admitted with any skin impairment would have appropriate interventions implemented to promote healing, a physician's order for treatment, and skin impairment location, measurements, and characteristics documented. The policy continued to state the licensed nurse would initiate documentation in the electronic health record (EHR), which included a description of the skin impairment as followed: in EHR facilities, the licensed nurse would document on the skin issues evaluation any skin issues identified, document weekly until the area was resolved, and photos would be taken unless refused by the resident.This deficiency represents non-compliance investigated under Complaint Number 2966549.

Based on medical record review, staff and physician interviews and review of information from the American Diabetes Association, the facility failed to assess a resident and notify the physician of a residents elevated blood glucose levels. This affected one (#11) or three residents reviewed for blood sugar readings. The facility census was 75. Findings include: Review of medical record for Resident #11 revealed admission date of 12/18/25. Diagnoses include post hemorrhagic stroke, diabetes mellitus type two, congestive heart failure, depression and anemia. Resident #11 was discharged home with home health on 01/13/26. Review of Resident #11's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He was independent with eating and required touching assistance with toileting hygiene, bed mobility and transfers. Review of the physician orders revealed an accu check order before meals and at bedtime with a start date of 01/03/26. Review of the blood glucose results were as follows: 01/10/26 the 9:31 P.M. result was 403 milligrams (mg) per (/) deciliter (dl); on 01/11/26 the 7:30 A.M. result was 195 mg/dl, 11:30 A.M. result was 236 mg/dl, the 4:30 P.M. result was 326 mg/dl 9:00 P.M. was 376 mg/dl; on 01/12/26 7:30 A.M. result was 353 mg/dl, 11:30 A.M was 399 mg/dl, the 4:30 P.M. was 277 mg/dl, the 9:00 P.M. was 373 mg/ml; on 01/13/26 the 7:30 A.M. result was 443 mg/dl and the 11:30 A.M result was 493 mg/dl. Further record review revealed there was no further assessment of REsident #11 regarding the elevated blood sugar readings and there was no notification to the physician. On 03/17/26 at 11:20 A.M. an interview with the Director of Nursing (DON) stated there were no parameters on Resident #11's accu check order on when to notify the physician. The DON verified Resident #11 was not further assessed regarding the elevated blood sugars and the physician was not notified. The DON verified Resident #11 had been discharged prior to addressing the elevated glucose levels. Interview on 03/17/26 at 12:02 P.M. with Physician #120 revealed she had not been informed of elevated blood glucose levels of Resident #11. Physician #120 stated she would expect to be notified for a blood glucose greater than 350 mg/dl. Review of information from the American Diabetes Association at https://diabetes.org/living-with-diabetes/treatment-care/hyperglycemia revealed hyperglycemia is when blood sugar levels are above 240 mg/dl milligrams. Hyperglycemia could be a serious problem if untreated and could lead to ketoacidosis (diabetic coma). Ketoacidosis is life threatening and needs immediate attention. This deficiency represents non-compliance investigated under Complaint Number 2723164.

Based on medical record review, observations, staff interviews, facility policy reviews, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to timely identify a resident's pressure ulcers until they reached an advanced stage. This resulted in Actual Harm to Resident #35, who developed pressure ulcers while in the facility, which were not identified until they had reached an advanced stage. Resident #35 was noted to have a reddened area on 01/14/25, according to shower sheets, but the area was not assessed, and interventions were not implemented until 01/16/25 when the pressure ulcer was identified as an unstageable pressure ulcer (sloughing and/or eschar) to the coccyx. This affected one (#35) of five residents reviewed for pressure ulcers. The facility census was 76. Findings include: Review of the medical record for Resident #35 revealed an admission date of 06/15/24. Diagnoses included heart failure, dementia, delusional disorders, and anxiety disorder. Review of the care plan, dated 02/01/25, revealed Resident #35 had actual impaired skin integrity related to a pressure injury at stage three to the coccyx with excoriation noted to the peri-area. Interventions included: conduct skin assessment weekly, measure area and document characteristics, observe for signs of infection, apply enhanced barrier precautions (EBP), report abnormal findings to the physician, obtain labs as ordered, refer to the dietician as needed, and administer treatments as ordered. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/07/25, revealed Resident #35 had moderate cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require supervision with eating, and was dependent on staff for toileting, bathing, dressing, and transfers. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 01/04/25, revealed Resident #35 was at moderate risk. Review of the bathing task log, dated January 2025, revealed, on 01/14/25, Resident #35 was noted to have a reddened area. There was no further documentation or assessment of the reddened area. Review of a nursing progress note, dated 01/16/25 at 7:20 A.M., revealed Resident #35 had a new area noted to the coccyx with drainage noted. All required parties were notified. Review of the skin and wound evaluation, dated 01/16/25, revealed Resident #35 had an in-house acquired unstageable pressure ulcer to the coccyx, which measured 11.1 centimeters (cm) in length by 5.9 cm in width. Review of the physician order, dated 01/17/25, revealed Resident #35 was ordered a low air loss mattress (LAL) to the bed every shift. Review of the physician orders for Resident #35, dated 01/17/25, revealed orders to cleanse the coccyx with wound cleanser, pat dry, apply zinc oxide cream and cover with bordered gauze every shift. Review of a nursing progress note, dated 01/20/25 at 5:10 P.M., revealed Resident #35 was seen by the in-house wound provider with new orders for treatment to cleanse area with dermal wound cleanser, pat dry, apply impregnated gauze, cover with bordered gauze dressing. Review of the physician progress note, dated 01/23/25, revealed Resident #35 was noted to have a stage three pressure ulcer on coccyx and was being followed by in-house wound care. Review of the physician orders for Resident #35, dated 01/27/25, revealed orders for an oral multivitamin-minerals tablet once a day. Interview on 06/10/25 at 1:03 P.M. with Certified Nursing Assistant (CNA) #399 revealed Resident #35 had an area to her coccyx that she reported to the night shift nurse on 01/14/25. Interview on 06/10/25 at 2:07 P.M. with Registered Nurse (RN) #388 revealed he could not recall if CNA #399 reported any skin concerns regarding Resident #35 on 01/14/25. Interview on 06/11/25 at 8:32 A.M. with Assistant Director of Nursing (ADON) #387 revealed CNA's were expected to report any new skin findings to their nurse immediately. ADON #387 stated the nurse was responsible for assessing the area, completing a nursing progress note, and a change in condition template. All new skin areas, that were noted in the medical record, popped up on the resident's dashboard, which was managed by the interdisciplinary team (IDT) the following day. ADON #387 verified Resident #35's new skin concern was missed. Interview on 06/11/25 with Licensed Practical Nurse (LPN) #304 revealed she noted the area on Resident #35's coccyx on 01/16/25. The area was open with yellow and bloody drainage. LPN #304 could not recall how big the area was at that time. Interview on 06/11/25 at 4:21 P.M. with ADON #387 verified no further assessment, treatments or interventions were put into place for Resident #35 on 01/14/25, when the reddened area was noted. ADON #387 reported a progress note was written and a treatment was initiated on 01/16/25. ADON #387 further explained Resident #35 was at high risk for the development of pressure ulcers due to a previous stage three pressure ulcer on the left heel. Interview on 06/12/25 at 10:02 A.M. with Wound Physician Assistant (WPA) #502 verified Resident #35 presented with an area to the bilateral buttocks, as an unstageable pressure ulcer. WPA #502 stated Resident #35 was incontinent, had a urinary tract infection (UTI), and was dependent on staff for activities of daily living (ADL), which all played a role in the development of the unstageable pressure ulcer. Observation on 06/12/25 at 10:48 A.M. revealed Resident #35's peri wound to the coccyx was reddened and appeared to be the size of a softball. The wound bed was approximately a dime size in width, with no signs of infection or drainage noted. Review of the NPUAP guidelines, dated 2014, at pages 70-71 (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosity, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.

Based on medical record reviews, staff interviews, and policy reviews, the facility failed to complete a discharge summary or recapitulation of a resident's stay, failed to complete a bed hold notice when resident's were transferred to the hospital and failed to notify the Ombudsman of resident's discharges. This affected four (#15, #27, #75, and #134) out of four residents reviewed for discharges. The facility census was 76. Findings include: 1. Review of the medical record for Resident #134 revealed an admission date of 09/12/24 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, hypertensive heart disease, and malignant neoplasm of kidney. Review of the medical record revealed a discharge date of 01/23/25. Review of the medical record for Resident #134 revealed a quarterly Minimum Data Set (MD'S) assessment, dated 12/20/24, which indicated Resident #134 was cognitively intact and was independent with activities of daily living. Review of the medical record for Resident #134 revealed a 72-hour care conference assessment which stated Resident #134 was undecided with discharge plans at this time and was homeless. The assessment stated Resident #134 stated she wanted to stay at the facility until he found housing or got a waiver to go to an Assisted Living. Review of the medical record for Resident #134 revealed a nurses' note, dated 11/25/24 at 12:41 P.M., which stated Resident #126 was issued a 30-day discharge notice due to nonpayment. The note stated Resident #126 verbalized he did not want his money to go to the facility as he had other bills such as storage and phone bill to pay monthly. Review of a Social Service (SS) note dated 01/20/25 at 4:11 P.M. which stated Social Service spoke with Resident #126 in regard to his discharge. The note stated Resident #134 stated he understood he would discharge to a hotel on 01/22/25. The note stated Resident #134 set up his own transportation along with the hotel booking. Review of the nurses' note, dated 01/22/25 at 6:44 P.M., stated Resident #134 discharged with his belongings, a copy of discharge summary, face sheet, and medication list. Review of the nurses' note dated 01/22/25 at 7:19 P.M. stated Resident #134 was unable to leave the facility due to his transportation never showed up and unable to go to the bank to get money for hotel. Further review revealed a Social Service note, dated 01/23/25 at 9:55 A.M. which stated Resident #134 discharged today to a hotel. Review of the medical record revealed a Discharge Notice for Non-payment, dated 11/25/24, which stated Resident #134 was to discharge to another nursing facility due to outstanding balance. Review of the medical record for Resident #134 revealed a Post Discharge Plan and Summary, dated 10/09/24 and signed as completed on 01/31/25. Further review of Resident #134's medical record revealed there was no documentation regarding a recapitulation of the residents stay. Review of the medical record for Resident #134 revealed no documentation to support the Ombudsman's office was notified his discharge. Interview on 06/11/25 at 2:19 A.M. with Registered Nurse (RN) #387 confirmed the facility opens the Post Discharge Plan and Summary assessment upon a new resident admission. RN #387 confirmed Resident #134's assessment was signed after his discharge from the facility on 01/31/25. RN #387 confirmed there was no documented recapitulation of Resident #134's stay at the time of the discharge. 3. Review of medical record for Resident #15 revealed an admission date of 02/12/24 with a discharge date of 05/28/25. Diagnoses included end stage renal disease (ESRD), atrial fibrillation, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require partial assistance with eating, dependent on toileting, bathing, dressing, and transfers. Review of the progress note dated 05/25/25 at 2:02 P.M. revealed Resident #15 was unresponsive, hypertensive, and hypoglycemic and was sent to the hospital for evaluation. Review of the email notification to the Ombudsman dated 06/10/25 revealed all discharges from January through June 2025 were sent on 06/10/25. Interview on 06/11/25 at 8:03 A.M. with the interim Administrator revealed the previous Administrator was notifying the Ombudsman of discharged residents. The interim Administrator revealed there was a miscommunication with herself and social services where the notification to the Ombudsman was not getting completed. 4. Review of the medical record for Resident #75 revealed an admission date of 03/15/25 with a discharge date of 04/04/25. Diagnoses included type II diabetes mellitus (DM II), peripheral vascular disease (PVD), and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require independent with eating, setup with toileting, dependent with bathing, dressing, and transfers. Review of the progress note dated 04/04/25 at 4:33 P.M. revealed Resident #75's daughter called and stated an Uber would transport Resident #75 to the Veterans facility at 5:00 P.M. Resident #75 in agreement. Review of the email notification to the Ombudsman dated 06/10/25 revealed all discharges from January through June 2025 were sent on 06/10/25. Interview on 06/11/25 at 8:03 A.M. with the interim Administrator revealed the previous Administrator was notifying the Ombudsman of discharged residents. The interim Administrator revealed there was a miscommunication with herself and social services where the notification to the Ombudsman was not getting completed. Review of the facility policy titled, Transfer and Discharge, revised 04/22/25, stated the transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility. The policy stated the criteria for transfer/discharge included the resident or representative failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident did not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his/her stay. The policy stated the notice of transfer/discharge must be made by the facility in writing at least 30 days before the resident was transferred or discharged and in a manner they understand. The policy stated exceptions to the 30-day requirement notice which must be made as soon as practicable before transfer or discharge. The policy stated that when an anticipated discharge is scheduled, the post-discharge plan of care and summary are developed prior to his/her discharge. The policy stated Social Services/designee reviews the plan with the resident and, with consent, the resident representative, at least 24 hours prior to discharge or as soon as practicable of the residents' discharge from the facility. When the facility anticipates discharge, a resident must have a discharge summary that includes a recapitulation of the resident's stay that includes, but was not limited to: 1) diagnoses, course of illness/treatment, therapy, and pertinent lab, radiology, and consultation results, 2) final summary of the resident's status, at the time of discharge, that is available for release to authorized personas and agencies, with the consent of the resident or resident representative, 3) reconciliation of all pre-discharged medications with the resident's post-discharge medications (both prescribed and over-the-counter), 4) post discharge plan of care and summary that was developed with the participate of the resident. The post discharge plan of care and summary must indicate where the individual plans to reside, an arrangement that has been made for the residents' follow-up care and any post-discharge medical and non-medical services. The policy also stated the transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility. The transfer or discharge notice must contain the name, address, and telephone number of the office of the State of the Long-Term Care Ombudsman. This deficiency represents non-compliance investigated under Complaint Number OH00162817. 2. Medical record review for Resident #27 revealed she was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, cellulitis of left lower leg, essential primary hypertension, osteoporosis, hyperlipidemia, anemia, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. Resident #27 was dependent on staff for medication administration. She was independent with eating and required supervision with upper body dressing, personal hygiene. Resident #27 required maximum assistance with toilet use, bathing, and lower body dressing. Review of the progress notes for Resident #27 revealed she was discharged to the hospital on [DATE] and returned to the facility on [DATE] following a hospital stay. Nothing related to a bed hold notification was identified in the progress notes. Interview on 06/12/25 at 10:53 A.M. with the Business Office Manager (BOM) #357 confirmed the facility failed to provide Resident #27 a bed hold notice upon discharge to the hospital on [DATE]. Review of the facility policy titled, Bed Hold Policy, dated 02/14/22, confirmed the facility will contact the Resident or Responsible party regarding a bed hold. The facility will document the bed hold offer and the Resident/Responsible Party decision of the bed hold in the Resident's medical record.

Based on review of the medical record, interviews, and policy review, the facility failed to notify the physician for a change in condition. This affected four (#2, #3, #19, and #53) out of four of residents reviewed for a change in condition. The facility census was 76.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers.Review of the medical record for weights for Resident #2 revealed the following:- 02/28/25: 221.1 pounds- 03/01/25: 289.4 pounds- 03/02/25: 289.4 pounds- 03/11/25: 388.2 pounds- 03/18/25: 388.1 pounds- 03/25/25: 387.2 pounds- 03/26/25: 244 pounds- 04/01/25: 285.6 pounds- 04/04/25: 285.5 pounds- 05/05/25: 285.5 pounds- 06/11/25: 237.6 poundsReview of the medical record for Resident #2 since admission revealed weights were inconsistent with no notification to the physician of significant weight loss and weight gain.Interview on 06/11/25 at 9:42 A.M. with Registered Dietician (RD) #500 verified nursing was to notify the physician and complete a progress note after notification. RD #500 reported concerns inconsistencies with weights. RD #500 verified there were no progress notes for Resident #2's significant weight changes to the physician. 2. Medical record review for Resident #03 revealed she admitted to the facility on [DATE]. Her diagnoses included, gastro-esophageal reflux disease (GERD), atrial fibrillation, borderline personality disorder, osteoarthritis of knee, congestive heart failure (CHF), anemia, edema, major depressive disorder, and obstructive sleep apnea. Review of the Minimum Data Set assessment, dated 05/20/25, revealed Resident #03 was cognitively impaired. Resident #03 was dependent on staff for medication administration, and lower body dressing. She was independent with eating, she required set up assistance with oral hygiene, and maximum assistance from staff with toilet use. She required moderate assistance from staff with showers, and personal hygiene. Review of the progress notes, dated 05/21/25, revealed a weight warning it stated weight fluctuations on the daily weight monitor, Resident #03 received a No Added Salt (NAS) diet, regular textures, thin liquids, and 2000 milliliter (ml) fluid restriction. Resident #03 meal intakes are 51% to 100% on the current diet. No recommendations were identified. No notification to the physician was identified. Review of the progress notes, dated 06/06/25, revealed a weight warning of 5.0% in thirty days, the notes stated it was reviewed with the Inter Disciplinary Team (IDT) team, however, no indication of physician or family notification. Review of the physician orders for Resident #03 revealed an order, dated 11/22/24, for daily weight every day shift related to congestive heart failure (CHF). Review of the Treatment Administration Record (TAR) for Resident #03, dated May 2025, and June 2025, revealed the facility failed to obtain a daily weight on 06/04/25, 06/06/25, 06/07/25, and 05/27/25, 05/21/25, 05/05/25. Review of TAR for May 2025, and June 2025 revealed the following weight changes, May 2025, a six-pound (lb.) weight gain on 05/22/25, a 9.6 lb. weight gain on 05/14/25, and a ten lb. weight gain on 05/28/25. June 2025, Resident #03 had a 19.8 lb. weight gain on 06/05/25. Further review of Resident #03's medical record revealed there was no documentation regarding physician notification regarding the resident's weight changes.Interview on 06/10/25 at 9:42 A.M. with Registered Dietician (RD) #500 confirmed the staff is supposed to inform the Nurse Practitioner (NP) of weight gain, loss, or missed weights. RD #500 stated she will email the Director of Nursing (DON) to make sure she saw the weight change. RD #500 confirmed verification of notification to the physician of the weight changes were not identified in the medical chart for Resident #03. RD #500 confirmed the importance of notification to the physician related weight changes to a possible fluid overload. Review of the facility policy titled, Weight Management Policy, dated 09/22/23, the Dietary Manager, Unit Manager, or Registered Dietician are to communicate weight changes to the Inter Disciplinary Team (IDT) team, attending physician, and responsible party. This is to be documented in the medical chart. 3. Record review for Resident #53 revealed she was admitted to the facility on [DATE]. His diagnoses included, hypertensive heart disease, insomnia, schizoaffective disorder, bipolar disorder, panic disorder, anxiety disorder, agoraphobia, dementia, depression, Parkinson's disease, and hypothyroidism.Review of the Minimum Data Set (MDS) for a Significant Change, dated 05/15/25, revealed Resident #53 received Hospice Services. Resident #53 was cognitively impaired. Resident #53 was dependent on staff for medication, administration and personal hygiene. Resident #53 required staff to set up assistance with meals, oral hygiene, and moderate assistance from staff with toilet use. She required maximum assistance from staff with showers and lower body dressing. Review of the progress notes for Resident #53 revealed on 05/08/25 at 12:45 P.M. revealed the Social Worker (SW) #369 contacted the family to inquire about Hospice Services. The family agreed to a hospice consult verses a tube feed for Resident #53 related to significant weight loss. The family stated they would prefer to meet with a Hospice company. On 05/09/25 at 8:07 A.M. Resident #53's family notified the SW #369 that they chose to meet with a Hospice Company on 05/15/25 at 10:00 A.M. No other verification was identified in the progress notes to confirm Resident #53 had signed to receive hospice services or declined hospice services. Review of the Nutritional Care Plan for Resident #53 dated 05/08/25 revealed she was care planned for a need for Hospice Care for comfort care. Interview with the Regional Consultant Specialist (RCS) #402 on 06/10/25 at 10:44 A.M. confirmed the facility completed a Significant Change MDS for Resident # 53 because the facility thought Resident #53 signed with Hospice services when she met with them. However, Resident #53's family declined the services, and the facility failed to accurately document that Resident #53 does not have hospice. RCS #402 confirmed the facility failed to accurately code a MDS assessment. Interview on 06/10/25 at 10:45 A.M. with SW #369 confirmed Resident 5% of 5's family met with Hospice, however, the family determined they did not want to utilize hospice services. Interview on 06/10/25 at 9:42 A.M. with RD #500 confirmed at an IDT team meeting she recommended a hospice consultation for a feeding tube for Resident #53. RD #500 confirmed the facility failed to have a follow up meeting to discuss the fact that Resident #53's family declined hospice services. She confirmed no physician notification of the decline for hospice services was not documented. 4. Review of the medical record for Resident #19 revealed an admission date of 10/30/21 with diagnoses including multiple sclerosis and neuromuscular dysfunction of bladder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for toileting and required partial/moderate assistance with personal hygiene. Review of the medical record revealed Resident #19 had an indwelling urinary catheter. Further review of the medical record revealed Resident #19 had an order for Macrobid (antibiotic) on 06/09/25 for the treatment of a urinary tract infection (UTI). Review of urology progress notes dated 05/21/25, signed 05/29/25, for Resident #19 revealed an order to notify the urology Nurse Practitioner (NP) prior to obtaining urinalysis for suspected UTI, notify the urology NP for assessment/plan and necessity of sample, and to notify urology NP with any changes to urine output. Review of the medical record revealed no evidence of the resident's urology NP being notified of Resident #19's UTI. Further review of the medical record revealed on 06/03/25 the medical director requested Resident #19 follow up with urology. There was no further documentation regarding follow up with urology for Resident #19.Interview on 06/12/25 at 11:49 AM with Licensed Practical Nurse (LPN) #361 confirmed Resident #19's urology NP had not been notified of Resident #19's change of condition. LPN #361 further confirmed that on 06/03/25 the medical director requested Resident #19 follow up with urology but Resident #19 had not been seen by urology. Review of the facility policy titled Notification of Change, dated 02/14/24, revealed the licensed nurse will notify the resident's attending practitioner of changes in the resident status. Additionally, the licensed nurse will document in the resident electronic medical record the notification and the information that was provided, including any additional orders from the practitioner.

Based on review of the medical record, interviews, and policy review, the facility failed to timely implement appropriate interventions to manage a resident's pain. This affected one (#2) of five reviewed for pain management. The facility census was 76. Findings include: Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the care plan dated 02/28/25 revealed Resident #2 was at risk for pain related to decreased mobility, chronic pain, MS, and generalized pain. Interventions included anticipate need for pain relief, notify physician if interventions were unsuccessful, observe and report non-verbal pain, observe and record loss of appetite, and offer non-pharmacological interventions. Review of the physician progress note dated 03/08/25 revealed pain was being managed with Tizanidine, Gabapentin, Baclofen, and Tylenol. Review of the progress note dated 04/01/25 at 5:14 P.M. revealed Resident #2 refused Tylenol because it did not help pain. Review of the progress note dated 04/08/25 at 12:27 A.M. revealed Resident #2 refused Tylenol because it did not work for him. Review of the progress note dated 05/30/25 at 3:33 P.M. revealed Resident #2 refused Tylenol because it did not help with his pain. Review of the progress note dated 06/09/25 at 4:42 P.M. revealed Resident #2 requested an increase in pain medication. Physician was called and received new order for Gabapentin 100 milligrams (mg), give one capsule by mouth three times a day. Interview on 06/09/25 at 12:51 P.M. with Resident #2 revealed he was on Tizanidine 4 milligrams (mg) three times a day (TID), Baclofen 30 mg TID, and Gabapentin 200 mg TID, but the only medication he was currently on was Baclofen 10 mg TID. Resident #2 reported he had told staff he needed those medications for his MS but no one ever followed up. Interview on 06/12/25 at 7:55 A.M. with Assistant Director of Nursing (ADON) #387 verified Resident #2 was supposed to be seen by neurology in May but due to transportation issues, he was not seen. ADON #387 verified a follow-up concerns medications was not completed. Interview on 06/12/25 at 8:50 A.M. with ADON #387 verified the physician had been documenting in his progress notes that Resident #2 was receiving Tizanidine, Gabapentin, Baclofen, and Tylenol, which was incorrect and the inconsistency was not addressed with the physician. ADON #387 confirmed staff did not address the Resident #2's complaints of pain and that Tylenol was ineffective. Review of the facility policy titled, Pain Management, dated 03/05/25 revealed the facility would evaluate and identify residents for pain, determine the type, location, and severity and develop a care plan for pain management. The licensed nurse would communicate any new onset of resident pain or change in resident pain to the physician and to the interdisciplinary team (IDT) through the 24-hour report/dashboard process.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to provide a homelike environment when meal trays were delivered to the residents with plasticware in place of silverware. This affected three Residents (#05, #67, and #129) out of three residents reviewed for home-like environment. The facility census was 76. Findings include: 1. Medical record review for Resident #05 revealed she was admitted to the facility on [DATE]. Her diagnoses included hyperlipidemia, gastro-esophageal reflux disease, spinal stenosis, insomnia, essential hypertension, major depressive disorder, anorexia, anemia, and pruritus. Review of the Minimum Data Set (MDS) assessment, dated 05/12/25, revealed Resident #05 was cognitively intact. Further review of the MDS assessment revealed she was independent with eating. Review of the progress notes for Resident #05, 06/09/25 at 1:02 P.M. revealed Resident #05's daughter notified the staff that Resident #05's teeth were broken while eating pork chops on Sunday. Nurse Practitioner (NP) #510 confirmed the tooth was cracked but no swelling or redness was identified. Interview on 06/09/25 at 11:07 A.M. with Resident #05's daughter who was in the room with Resident #05. Resident #05's daughter stated Resident #05 broke her tooth on Sunday, 06/08/25 during her meal that consisted of pork chops. Resident #05's daughter stated her mother broke her tooth because the facility served the meal with plastic ware and her mother was unable to cut it and Resident #05's tooth was hanging inside her mouth. Interview with Resident #05 on 06/09/25 at 12:03 P.M. with Resident #05 revealed the facility served pork chops on 06/08/25 with plasticware in place of silverware. Resident #05 stated she was unable to cut the pork and had to try and chew it without cutting it. Resident #05 stated she broke her tooth, and her tooth was hanging and loose. Resident #05 stated she told her family but did not tell the facility because they wouldn't do anything about it. Interview and observation with Licensed Practical Nurse (LPN)#310 on 06/09/25 at 12:06 P.M. confirmed Resident #05 has a broken tooth hanging inside her mouth. Interview with dietary aide (DA) #396 on 06/12/25 at 8:16 A.M. confirmed the facility ran out of silver during mealtime on Sunday. DA #396 confirmed the facility had utilized plastic ware in place of silverware because the facility ran out of silverware. Interview with the Dietary Manager (DM) 348 on 06/11/25 at 7:41 A.M. confirmed the facility used plastic ware on Sunday, June 8, 2025. DM #348 confirmed he ordered replacement silverware in March 2025 when the Resident Council President informed him of the concern of the use of plasticware because the facility was short on silverware. DM#348 confirmed the facility does not have enough silverware to serve all the Residents with silverware at this time. DM#348 confirmed the facility served pork loin on Sunday 06/08/25 and the facility ran out of silverware on that date. Review of the facility menu dated Sunday, June 08, 25, confirmed the facility was scheduled to serve Pork Chops with sweet chili glaze, rice pilaf, roasted zucchini, and dinner roll with a pudding. 2. Medical Record review for Resident #67 revealed she was admitted to the facility on [DATE]. Her diagnoses included acute kidney failure, diabetes mellitus (DM), hyperlipidemia, anemia, gastro-esophageal reflux disease (GERD), and osteomyelitis. Review of the MDS assessment, dated 05/13/25, revealed Resident #67 was cognitively intact. Further review of the MDS assessment revealed Resident #67 was independent with eating. Interview on 06/09/25 at 11:04 A.M. with Resident #67 revealed she was upset that she was unable to eat her pork chop on Sunday, 06/08/25 because the facility served her meal with plasticware. Resident #67 stated she was so upset because she couldn't eat her meal, and her roommate (Resident #05) broke a tooth loose while trying to chew a pork chop with a plastic knife and fork. 3. Medical record review for Resident #129 revealed she was admitted to the facility on [DATE]. Her diagnoses included, essential primary hypertension, gastro-esophageal reflux disease (GERD), hyperlipidemia, chronic kidney disease, and ulcerative colitis. Review of the new admission assessment for Resident #129, dated 06/09/25, revealed she was independent with eating. Interview with Resident #129 on 06/09/25 at 11:45 A.M. revealed she arrived at the facility on 06/06/25 and was unhappy to see she was given plasticware on her meal tray. Resident #129 confirmed she had plasticware on her meal tray on Sunday, 06/08/25. Review of the facility, Resident Council Notes, dated 02/19/25 revealed the council ask the facility for more silverware. Review of the facility titled, Resident Rights, dated 05/14/24, confirmed the facility protects and promotes the rights of each resident and have the right to a dignified existence. The staff will assist the Residents in exercising their rights.

Based on record review, staff interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate coded. This affected one (#53) out of three residents reviewed for MDS accuracy. The facility census was 76. Findings include: Record review for Resident #53 revealed she was admitted to the facility on [DATE]. His diagnoses included, hypertensive heart disease, insomnia, schizoaffective disorder, bipolar disorder, panic disorder, anxiety disorder, agoraphobia, dementia, depression, Parkinson's disease, and hypothyroidism. Review of the Minimum Data Set (MDS) for a Significant Change, dated 05/15/25, revealed Resident #53 required Hospice Services. Resident #53 was cognitively impaired. Resident #53 was dependent on staff for medication administration and personal hygiene. Resident #53 required staff set up assistance with meals, oral hygiene, and moderate assistance from staff with toilet use. She required maximum assistance from staff with showers and lower body dressing. Review of the progress notes for Resident #53 revealed on 05/08/25 at 12:45 P.M. revealed the Social Worker (SW) #369 contacted the family to inquire if the family would want to met with a Hospice Company for a consult or a tube feed was recommended by the dietician related to significant weight loss. The family stated they would prefer to meet with a Hospice company. On 05/09/25 at 8:07 A.M. Resident #53's family notified the SW #36 chose to meet with a Hospice Company on 05/15/25 at 10:00 A.M. No other information was documented related to the Hospice order or consult. Review of the Nutritional Care Plan for Resident #53, dated 05/08/25 revealed she was care planned for a need for Hospice Care for comfort care. Interview with the Regional Consultant Specialist (RCS) #402 on 06/10/25 at 10:44 A.M. confirmed the facility completed a Significant Change MDS for Resident #53 because the facility thought Resident #53 signed with Hospice services when she met with them. However, RCS #402 confirmed Resident #53's family declined the services and the facility failed to accurately document that Resident #53 does not have hospice. RCS #402 confirmed the facility failed to accurately code a MDS assessment. Review of the facility policy titled, Accuracy of MDS, dated 02/22/23, confirmed the accuracy of the MDS must be verified to ensure that the Residents strengths, weaknesses, status, and areas of actual decline or risk of decline are addressed to provide quality of care and to develop the individualized plan of care for the resident. Further review of the policy confirmed accuracy is also necessary as the MDS is directly responsible and like the Medicare Prospective Payment System, state Medicaid reimbursement programs.

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure a comprehensive skin assessment was completed upon admission. This affected one (#126) out of six residents reviewed for skin breakdown. The facility census was 76. Findings include: Review of the medical record for Resident #126 revealed an admission date of 06/07/25 with medical diagnoses of cystitis, hypothyroidism, anemia, congestive heart failure, and chronic obstructive pulmonary disease. Review of the medical record for Resident #126 revealed a nursing comprehensive evaluation, dated 06/07/25, which indicated Resident #126 had a surgical incision to her back which measured 20 centimeters (cm) and had 58 staples. Further review of the evaluation revealed Resident #126 had bruising to right and left iliac crests and left antecubital, and a scab to right deltoid. Review of the medical record for Resident #126 revealed a Brief Interview for Mental Status (BIMS), dated 06/09/25, which indicated Resident #126 had moderately impaired cognition. Review of the medical record for Resident #126 revealed a nurses' note, dated 06/09/25 at 3:19 P.M. which stated notified of skin tear observed on right forearm that was present upon admission and measured 3 cm by 1.5 cm. The note stated no treatment was necessary at this time. Observation with interview on 06/09/25 at 3:03 P.M. with Resident #126 revealed a foam dressing located on right forearm which was dated 06/01/25. Resident #126 stated the dressing was applied to her arm at the hospital and wasn't sure what was under the dressing. Interview on 03/09/25 at 3:09 P.M. with Registered Nurse (RN) #358 confirmed the medical record for Resident #126 did not have documentation to support the facility assessed the skin issue to Resident #126's right forearm and that the dressing was dated 06/01/25. RN #358 stated he evaluated Resident #126's right forearm on 06/09/25 and observed a small skin tear to the forearm. RN #358 stated the area was scabbed over and no treatment was required. Review of the policy titled, Skin Management, reviewed 08/14/24, stated the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. The policy stated upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record. The policy stated residents admitted with any skin impairment would have appropriate interventions implemented to promote healing, a physician's order for treatment, and skin impairment location, measurements, and characteristics documented.

Based on record review, observation, resident and staff interviews, and facility policy review, the facility failed to ensure fall interventions were in place as care planned. This affected one (#31) out of one resident reviewed for falls. The facility census was 76.Findings include:Medical record review for Resident #31 revealed she was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, cellulitis of left lower limb, heart failure, essential primary hypertension, hyperlipidemia, and anemia. Review of the Minimum Data Set (MDS) assessment for Resident #31, dated 03/12/25, revealed she was cognitively intact. Resident #31 was dependent on staff for medication administration, oral hygiene, toilet use, bathing, personal hygiene, dressing, and transfers. She required moderate assistance from staff with eating. Resident #31 required the use of a wheelchair for mobility. Review of the, Fall Care Plan, initiated on 05/28/25, for Resident #31 revealed she was care planned to have the following interventions in place to aide the prevention of future falls. On 06/05/25 the facility added parameter mattress to help with positioning, administer medications as ordered, anticipate needs, encourage to head of the bed lowered, encouraged to sleep at a 90 degree angle, encourage Resident #31 to wear nonskid socks, keep bed in the lowest position, encourage toilet use every two to three hours, ensure bolsters on bilateral sides, keep environment safe, lock wheels on wheelchair, provide resident with activities that minimize the potential for falls, Physical therapy and occupational therapy to evaluate as needed, encourage resident to use call light for assistance. Review of Resident #31's progress notes revealed an Inter Disciplinary Team (IDT) noted, 05/29/25 revealed on 03/12/25 at 7:50 P.M. Resident #31 was found on the floor after she attempted to transfer herself. The intervention was to remind the Resident to use call light before Resident #31 transfers from the bed and wear proper footwear. On 03/27/25 at 3:45 A.M. Resident #31 was found on the floor from the bed and no intervention was listed in the progress notes. On 04/02/25 at 2:40 A.M. Resident #31 was found on the floor. The intervention was to add bolster pillows to both sides of the bed. On 04/21/25 at 6:15 A.M. Resident #31 had a fall from bed. Resident #31 rolled out of bed on the left side and the intervention was to lower her head while she was in bed. On 05/28/25 at 2:05 P.M. from in her bed in front of her nightstand. The intervention was to have her bed in the lowest position. Review of the facility reports titled, Fall Investigation, dated 06/04/25 at 21:45 P.M., for Resident #31 revealed she was found on the floor. She was found on her left side and back to her door. Resident #31 stated she falls out of bed when sleeping. The fall intervention was a perimeter mattress. Review of the fall investigation dated 05/28/25 at 2:05 P.M., for Resident #31 revealed she was found on the floor. Resident #31 was observed on her left side of her bed in front of the nightstand. Resident #31 was identified as having non-gripper socks on. Resident #31 had a bruise on her right knee. The intervention was listed as encourage Resident #31 to have her bed in the lowest position to help prevent injuries. Review of the fall investigation dated 04/21/25 at 6:15 P.M., for Resident #31 revealed she was found on the floor and the left side of her head next to the bed and facing the bed. The resident had a golf ball size bump on the top of her head. Resident #31 was determined to have bed height not appropriate. The intervention was listed as head of bed all the way up while patient sleeping, encourage resident to lower head of bed (HOB) when sleeping. Review of the fall investigation dated 03/27/25 at 3:45 P.M. revealed Resident #31 called for assistance and Resident was agitated. Review of the fall investigation revealed the intervention was to encourage toileting every three hours and keep wheels locked bedside. Review of the fall investigation, dated 03/12/25 at 17:50 P.M. revealed Resident # 31 was found on the floor. Resident #31 was unable to give a description of the fall. The intervention was listed to use call light for assistance with transfers and non-skid socks. Interview on 06/09/25 at 4:27 P.M. with Resident #31 revealed she has had about six falls since her admission. Resident #31 stated the falls happen when she is in bed. Resident #31 was observed lying in her bed with no bolsters or parameter mattress. Resident #31 was lying on a regular air mattress. Interview and observation on 06/11/25 at 2:30 P.M. interview with Licensed Practical Nurse (LPN) #385 confirmed Resident #31 should be on a bolstered mattress and is not. Interview on 06/11/25 at 5:05 P.M. with the Director of Nursing (DON) confirmed the fall intervention for Resident #31 was a bolstered mattress. The DON stated she ordered this specialized mattress herself. The DON contacted the representative from the mattress company and the representative from the mattress company explained the mattress had been delivered but the bolsters were not inflated because the company will not inflate the bolsters without a physician order. Interview on 06/11/25 at 5:11 P.M. with the Assistant Director of Nursing (ADON) #12 confirmed Resident #31 did not have bolstered mattress on her bed and that the facility did not have a physician's orders in place for a bolstered mattress. Review of the facility policy titled, Fall Management, dated 09/22/23, confirmed the facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Further review of the policy revealed interventions should be related to the risk factors as well as incorporation of resident choice to help minimize the risk of a fall. The Inter Disciplinary Team (IDT) team will review and modify the plan of care to minimize repeat falls.

3. Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the medical record for weights for Resident #2 revealed the following: - 02/28/25: 221.1 pounds - 03/01/25: 289.4 pounds - 03/02/25: 289.4 pounds - 03/11/25: 388.2 pounds - 03/18/25: 388.1 pounds - 03/25/25: 387.2 pounds - 03/26/25: 244 pounds - 04/01/25: 285.6 pounds - 04/04/25: 285.5 pounds - 05/05/25: 285.5 pounds - 06/11/25: 237.6 pounds Review of the medical record for Resident #2 since admission revealed weights were inconsistent with no notification to the physician of significant weight loss and weight gain. Review of the progress note dated 03/12/25 at 2:04 P.M. revealed Resident #2 had a 99-pound weight gain in one week. Reviewed with IDT. Recommended to recheck weekly weight and continue to follow. Review of the progress note dated 03/21/25 at 4:11 P.M. revealed Resident #2's current weight consistent with previous weight obtained, which was a 99-pound weight gain in two weeks. Reviewed with IDT and questioned difference in scales that were used. Continue to monitor and follow. Review of the progress note dated 04/04/25 at 3:47 P.M. revealed Resident #2 continued with weight fluctuations since admission. Suspected weights of 380 pounds were in error and weight variations were likely different methods to obtain weight. Interview on 06/11/25 at 9:42 A.M. with Registered Dietician (RD) #500 reported concerns inconsistencies with weights. RD #500 stated she had brought this to the facility's attention because of her concerns with not obtaining accurate weights. RD #500 explained the facility was working on fixing this problem and tried calibrating scales and educating staff. RD #500 verified Resident #2 had a significant weight change from May to June, which she would be following up on and making recommendations. Review of the facility policy titled, Weight Management, revised 09/22/23 revealed residents would be monitored for significant weight changes on a regular basis. Residents were expected to maintain acceptable parameters of nutritional status, such as usual body weight and protein levels. Any resident with unintended weight loss/gain would be evaluated by the interdisciplinary team (IDT) and interventions would be implemented to prevent further weight loss/gain. Re-weights were initiated for a five-pound variance if greater than 100 pounds and for a three-pound variance if less than 100 pounds. If a resident's weight was greater than 200 pounds, a re-weight would be done for a weight loss or gain of three percent. Re-weights would be done within 48-72 hours. Based on record review, interview, and facility policy review, the facility failed to adequately monitor weights and/or implement appropriate interventions for residents who experienced significant weight loss. This affected three (03, #53, #2) out of three residents reviewed for nutrition/weight monitoring. The facility census was 76. Findings include: 1. Medical record review for Resident #03 revealed she was admitted to the facility on [DATE]. Her diagnoses included gastro-esophageal reflux disease (GERD), atrial fibrillation, borderline personality disorder, osteoarthritis of knee, congestive heart failure (CHF), anemia, edema, major depressive disorder, and obstructive sleep apnea. Review of the Minimum Data Set (MDS) assessment, dated 05/20/25, revealed Resident #03 was cognitively impaired. Resident #03 was dependent on staff for medication administration, and lower body dressing. She was independent with eating, she required assistance with oral hygiene, and maximum assistance from staff with toilet use. She required moderate assistance from staff with showers, and personal hygiene. Review of the progress notes, dated 05/21/25, revealed a weight warning. It stated weight fluctuations on the daily weight monitor, Resident #03 received a No Added Salt (NAS) diet, regular textures, thin liquids, and 2000 milliliter (ml) fluid restriction. Resident #03 meal intakes are 51% to 100% on the current diet. No recommendations were identified. No notification to the physician was identified. Review of the progress notes, dated 06/06/25, revealed a weight warning of 5.0% in thirty days, the notes stated it was reviewed with the Interdisciplinary Team (IDT) team, however, no indication of physician or family notification. Review of the physician orders for Resident #03 revealed an order, dated 11/22/24, for daily weight every day shift related to congestive heart failure (CHF). Review of the Treatment Administration Record (TAR) for Resident #03, dated May 2025, and June 2025, revealed the facility failed to obtain a daily weight on 06/04/25, 06/06/25, 06/07/25, and 05/27/25, 05/21/25, 05/05/25. Review of TAR for May 2025, and June 2025 revealed the following weight changes, May 2025, a six-pound (lb.) weight gain on 05/22/25, a 9.6 lb. weight gain on 05/14/25, and a ten lb. weight gain on 05/28/25. June 2025, Resident #03 had a 19.8 lb. weight gain on 06/05/25. Interview on 06/10/25 at 9:42 A.M. with Registered Dietician (RD) 500 confirmed the staff is supposed to inform the Nurse Practitioner (NP) of weight gain, loss, or missed weights. RD #500 stated she will email the Director of Nursing (DON) to make sure she saw the weight change for Resident #03. RD #500 confirmed verification of notification to the physician of the weight changes were not identified in the medical chart for Resident #03. RD #500 confirmed the importance of notification to the physician related weight changes to a possible fluid overload. Review of the facility policy titled, Weight Management Policy, dated 09/22/23, the Dietary Manager, Unit Manager, or Registered Dietician are to communicate weight changes to the IDT team, attending physician, and responsible party. This is to be documented in the medical chart. 2. Record review for Resident #53 revealed she was admitted to the facility on [DATE]. His diagnoses included, hypertensive heart disease, insomnia, schizoaffective disorder, bipolar disorder, panic disorder, anxiety disorder, agoraphobia, dementia, depression, Parkinson's disease, and hypothyroidism. Review of the MDS for a Significant Change, dated 05/15/25, revealed Resident #53 received Hospice Services. Resident #53 was cognitively impaired. Resident #53 was dependent on staff for medication, administration and personal hygiene. Resident #53 required staff to set up assistance with meals, oral hygiene, and moderate assistance from staff with toilet use. She required maximum assistance from staff with showers and lower body dressing. Review of the progress notes for Resident #53 revealed on 05/08/25 at 12:45 P.M. revealed the Social Worker (SW) #369 contacted the family to inquire about Hospice Services. The family agreed to a hospice consult verses a tube feed for Resident #53 related to significant weight loss. The family stated they would prefer to meet with a Hospice company. On 05/09/25 at 8:07 A.M. Resident #53's family notified the SW #369 that they chose to meet with a Hospice Company on 05/15/25 at 10:00 A.M. No other verification was identified in the progress notes to confirm Resident #53 had signed with hospice services or declined hospice services. Review of the Nutritional Care Plan for Resident #53 dated 05/08/25 revealed she was care planned for a need for Hospice Care for comfort care. Interview with the Regional Consultant Specialist (RCS) 402 on 06/10/25 at 10:44 A.M. confirmed the facility completed a Significant Change MDS for Resident #53 because the facility thought Resident #53 signed with hospice services when she met with them. However, Resident #53's family declined the services, and the facility failed to accurately document that Resident #53 does not have hospice. RCS #402 confirmed the facility failed to accurately code a MDS assessment as the resident is not receiving hospice services. Interview on 06/10/25 at 10:45 A.M. with SW #369 confirmed Resident #53's family met with hospice, however, the family determined they did not want to utilize hospice services. Interview on 06/10/25 at 9:42 A.M. with RD #500 confirmed at an IDT team meeting she recommended a hospice consultation for a feeding tube for Resident #53. RD #500 confirmed the facility failed to have a follow up meeting to discuss the fact that Resident #53's family declined hospice services. RD #500 confirmed no further nutritional assessments or interventions were implemented when Resident #53's family declined hospice services.

Based on medical record review, staff interview, and policy review, the facility failed to assess a dialysis access site as per facility policy. This affected one (#132) out of one resident reviewed for dialysis. The facility census was 76. Findings include: Review of the medical record for Resident #132 revealed an admission date of 06/03/25 with medical diagnoses of cervical disc degeneration, end stage renal disease (ESRD), dependence on dialysis, hypertension, and diabetes mellitus. Review of the medical record for Resident #132 revealed a nursing comprehensive evaluation, dated 06/03/25, which indicated Resident #132 was alert and oriented to person and place. The evaluation also indicated Resident #132 admitted with a fistula to left forearm. Review of the medical record for Resident #132 revealed no documentation to support the facility had assessed Resident #132's dialysis fistula to his left forearm. Interview on 06/11/25 at 8:30 A.M. with Director of Nursing (DON) confirmed the facility did not have documentation to support Resident #132's fistula to left forearm had been assessed since admission. DON confirmed nursing staff were to assess the fistula daily per the facility policy. Review of the facility policy titled, Hemodialysis, revised 03/05/24 stated residents receiving hemodialysis would be evaluated pre and post treatment and receive necessary interventions. The policy stated the facility completed the appropriate section of the hemodialysis form prior to the resident receiving each dialysis session and again when the resident returns from hemodialysis. The policy also stated the facility is to evaluate the resident daily for dialysis access site and possible complications, for thrill and bruit.

Based on record review, interview, and policy review, the facility failed to provide behavioral health services for Resident #14 who had diagnoses of mental disorders. This affected one (#14) of six residents reviewed for behavior management. The facility census was 76. Findings include: Review of the medical record for Resident #14 revealed an admissions date of 05/07/25 with diagnoses including bipolar disorder, anxiety disorder, recurrent depressive disorder, opioid dependence, and schizoaffective disorder. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #14 was cognitively intact. Review of Resident #14's orders revealed the resident had a physician order on 05/07/25 for a psychiatric evaluation and treatment. Review of the care plan, dated 05/28/25, revealed that Resident #14 had a history of behavior problems. Interventions include administer medications as ordered, reporting abnormal finding to the physician, approach in a calm manner, observe behavior episodes and attempt to determine underlying cause, and consult psychology as needed. Further review of the care plan, dated 05/28/25, revealed that Resident #14 had a history of not following treatment regimen. Interventions include allowing resident to make decisions about the treatment regime to provide sense of control, approaching resident in a calm manner, and praise resident when behaviors are appropriate. Review of Resident #14's nursing progress note, dated 05/09/25, revealed that she refused morning incontinence care. Review of Resident #14's nursing progress note, dated 05/13/25 revealed that she refused incontinence care. Further review revealed that she told aides to not touch her, to get out of her room and leave her alone. Review of Resident #14's social services progress note, dated 05/14/25, revealed that Resident #14 stated she does not have mood or behavior concerns. Further review of the note revealed that the facility has observed Resident #14 showing behaviors including yelling, screaming and refusing care multiple times a day. Review of Resident #14's nursing progress note, dated 05/15/25, revealed that she refused incontinence care in the morning. Review of Resident #14's behavior progress note, dated 05/25/25, revealed she was requesting pain medication prior to the next available dose. Resident #14 verbalized to the nurse and aide that she would report the nurse for not giving her medication. Physician and Director of Nursing were both notified of Resident #14's behavior. Review of Resident #14's behavior progress note, dated 05/25/25, revealed Resident #14 was aggressive to the nurse when delivering as needed pain medication. Resident #14 was educated that medication may only be administer per physicians orders. Resident #14 stated that she should be able to choose when she receives medication. Physician was notified of behaviors. It was noted that two staff members will be present for future interactions to avoid incidents. Review of Resident #14's physical therapy summary note, dated 05/27/25, revealed Resident #14 was screaming loudly the majority of session. Resident #14 was forcing poop out of her rectum on a few occasions as a form of a tantrum. Resident #14 closed fist punched and open hand slapped physical therapist and aide countless times on arms, chest, and abdomen regions. Resident #14 pull her gown up in hallways and was slapping the physical therapists when he tried to comfort her and help recover her dignity by rolling the gown safely back down. Resident #14 also rammed her wheelchair foot pedals and wheelchair into aides shins repetitively when aide was trying to move around her. Resident #14 was noted to be very emotionally and physically abusive throughout entire therapy session. Review of Resident #14's social services progress note, dated 05/27/25, revealed the resident punched therapist and aide in the chest and arms multiple times. Further review of the progress note revealed that Resident #14 refused to take medication. A pink slip was given to Resident #14 and she was sent to the emergency room by ambulance. Review of the pink slip revealed that Resident #14 represents a substantial risk of physical harm to others and would benefit from treatment in a hospital for her mental illness. Review of Resident #14's nursing progress note, dated 05/28/25, revealed she was returned to the facility by stretcher with no signs of distress and was cleared by the psychology doctor. Review of Resident #14's nursing progress note, dated 06/02/25, revealed she was found in her room playing in her bowel movement. The nurse educated Resident #14 to press the call light when she needed changed. Review of Resident #14's nursing progress note, dated 06/12/25, revealed Resident #14 requested her as needed inhaler. When the nurse brought her inhaler, the resident took the inhaler and self administered two puffs. The nurse then requested the inhaler back and Resident #14 refused, took 2 more puffs and stated that she would take as many puffs as she wants. Resident then asked for her as needed pain medication and the nurse informed her that she could not administer the medication for another hour. Resident #14 began yelling at the nurse for refusing to administer the pain medication early. Interview with Administrator on 06/12/25 at 2:48 P.M. verified that Resident #14 has not received psychology evaluation or treatment since receiving the physician order on 05/07/25. Review of the policy titled, Behavior Management, dated 04/20/23, revealed the facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors

Based on medical record review, staff interview, resident interview, and policy review the facility failed to ensure a resident was provided with staff assistance at the bedside after toileting which resulted in a fall with injury. This resulted in actual harm when Resident #34 who required substantial/maximal assistance to transfer for toileting, did not have on gripper socks on her feet and was assisted off the bedside commode, became unsteady on her feet, was sat on the side of her bed, and the certified nursing assistant (CNA) left the resident alone and stepped out of the room to get additional staff assistance. The resident fell on to the floor face first when she was left on the side of the bed by herself resulting in a laceration that required the resident to get three stitches to her face. The affected one (Resident #34) of three residents reviewed for falls. The census was 83. Findings included: Review of the medical for Resident #34 revealed an admitted [DATE], diagnoses included heart failure, peripheral vascular disease, renal failure, diabetes, and septicemia. Review of fall risk assessment dated [DATE] revealed Resident #34 was not at risk for a fall. It revealed the resident had a fear of falling, muscle weakness, decreased lower extremity joint function, and a balance deficit, or gait deficit. The document further revealed the resident had urinary urgency. Review of the care plan dated 08/15/24 revealed the resident was at risk of falling with injury related to decreased mobility. Interventions were to encourage the resident to wear appropriate footwear, keep the resident's floors and environment free of clutter, keep the call light within reach and encourage the resident to use it. Review of Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had functional limitations in range of motion for upper and lower extremities. Functional status was set-up or cleanup for eating, substantial/maximal assistance for toileting and transfers, and Resident #34 was dependent for bed mobility. A toilet transfer was not attempted due to medical condition or safety concerns. Resident #34 was coded as always incontinent of bowel and bladder. Review of the progress note on 10/17/24 at 5:05 P.M. revealed Resident #34 was sitting on the edge of the bed after being taken to the bedside commode by Certified Nursing Assistant (CNA) #84 (who is no longer employed at the facility) and the resident returned to the side of the bed after toileting at the bedside commode. The resident was having a hard time standing and sat on the side of the bed. The CNA left the room to get help, and the resident fell off the bed onto her face. Review of the investigation dated 10/17/24 for Resident #34 revealed the Licensed Practical Nurse (LPN) #142 was sitting at the nursing station charting and she heard a thump followed by moaning. Upon entering the room, the resident was lying in a prone position with a lean to the right side. The resident stated she was sitting on the edge of the bed unassisted and fell forward hitting her face on the floor. The resident hit her head with blood loss, and she was alert and oriented times four (person, place time, and situation). The resident had a visible laceration above her right eye with blood loss. The resident complained of head and facial pain. Vital signs were taken and were within normal limits. An emergency squad was called, and the resident was taken to the hospital. The resident had a gait imbalance and weakness. All the responsible parties were notified. Review of the post fall evaluation dated 10/18/24 revealed Resident #34 had a fall after returning to bed after toileting. The resident lost her balance during the fall and did not have any assistance. The resident was bare footed, no gait assistance devices were present, no call light was on and the resident was continent at the time of the fall. The new intervention was to not leave the resident sitting on the side of the bed unassisted. Review of the statement written by CNA #84 dated 10/17/24 revealed she assisted Resident #34 to the bedside commode and after the resident was done she was having a hard time standing and she sat her on the side of the bed. While the resident was sitting on the side of the bed the CNA stepped out of the room and asked for help and by the time the CNA turned around the resident had fallen. Review of the statement written by LPN #142 dated 10/17/24 revealed she was sitting at the nursing station and CNA #84 came out of the resident's room and asked for help with the resident. The LPN heard a sound of the resident hitting the floor. Upon entering the room, the resident was prone on the floor disrobed from the waist down. The resident complained of head and facial pain and there was a laceration above the right eye that was visible. Review of statement written by LPN #143 dated 10/17/24 revealed she was at the nursing station and the CNA #84 came out of the resident's room and asked if someone could help her with the resident. This nurse heard a loud thump and upon entering the resident's room she was lying prone on the floor with a lean to the right side. The resident complained about head and facial pain. There was a laceration above the right eye. Review of the hospital after visit summary document dated 10/17/24 revealed Resident #34 had a laceration to her right eye. Review of the record of discussion dated 10/17/24 with CNA #84 revealed she was educated on importance of not leaving resident sitting on the side of the bed especially when the resident was fatigued from care. The CNA was also educated on using the call light to ask for assistance prior to leaving the resident. The resident's safety will be maintained, and the resident will only be left in a safe position. The call light will be utilized to ask for assistance. The CNA didn't sign the document. During an interview with LPN #142 on 11/14/24 at 1:44 P.M. revealed she was at the nursing station when CNA #84 came out of Resident #34's room and asked for some help. LPN #142 stated she heard a thump in Resident #34's room. She stated when she got to the room the resident was lying on her side on the floor with a pool of blood on the floor. During an interview with LPN #143 on 11/14/24 at 1:41 P.M. revealed CNA #84 stuck her head out Resident #34's doorway and asked for help. She stated she heard the resident hit the ground. She said the resident was naked from the waist down, lying prone and slightly on her right side. During an interview with Resident #34 on 11/18/24 at 9:05 A.M. revealed she had to go to the bedside commode on 10/17/24 and CNA #84 got the commode and sat it next to the foot of the bed on the right side of the bed. She stated the aide told her to stand up after the resident urinated and defecated and the resident told the aide she wouldn't be able to stand very long, but the aide said she had to put the brief on her and the resident said no I am going to fall. The resident told the aide she wanted to sit on the side of the bed and the aide said no you are going to get feces on the clean linens and the resident told her if you wiped good enough that wouldn't be a problem. The resident believed she sat on the side of the bed and the aide left the room to get help and then she was on the floor without any garments on the lower half of her body. She said they sent her out to the hospital, and she had three stitches above her right eye brow. Review of the fall policy entitled Fall Management dated 09/22/23 revealed the facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. This deficiency represents non-compliance investigated under Complaint Number OH 00159180 and OH00159112.

Based on medical record review, observation, staff interview, review of facility policy and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure residents had appropriate interventions in place to prevent skin breakdown. Actual harm occurred to Resident #52 when the facility did not implement interventions to float the resident's heels when the resident was noted with a red and boggy heel, the resident developed an unavoidable deep tissue injury to the right heel a few days later. This affected one Resident (#52) of two sampled for pressure ulcers. The facility identified two residents with pressure ulcers. The census was 29. Findings include: Review of the medical record revealed Resident #52 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the care planned for skin dated 07/03/17 interventions included nutritional med pass two ounces four times a day. On 07/06/17 an intervention was added for a pressure ulcer relieving surface bed and [MEDICAL CONDITION] Deterrent (TED) hose. On 07/14/17 a new intervention was initiated for skin prep with a protective foam dressing change every three days and as needed. Review of wound evaluation flow sheet dated 07/14/17 revealed a wound was labeled as unable to determine to the right heel. The measurement was 4.0 centimeters (cm) x 6.0 cm with no depth. It was recorded flat and intact without exudate. It was slightly tender to touch with serous and dark scant amount of fluid under the skin. The wound was circular and the margins were smooth, flat, intact and slightly reddened. Review of nurses noted on 07/14/17 untimed revealed the resident was up all day per her preference staff encouraged the resident to elevate her right extremity at intervals. Review of progress skin note written by wound Registered Nurse (WRN) #10 on 07/14/17 revealed Resident #52 was found with a serum and slightly blood tinged, slightly raised blister on her right heel with slight discomfort and two plus [MEDICAL CONDITION] in the right leg post fall at home and hip repair. The note further revealed the resident indicated she had been strictly lying on her back because she thought she wasn't allowed to lie on her side. WRN #10 educated the resident about the hip precautions and instructed the resident she could turn on her side with a pillow in place between her legs. The note further revealed a heels up cushion was provided for the resident to float her heels when she was in bed lying on her back. Review of a colored picture dated 07/14/17 of Resident #52's wound on her right heel revealed it was circular and eschar covered. Review of the comprehensive assessment dated [DATE] revealed the resident was cognitively intact. She was an extensive assistance for all activities of daily living (ADL) with one personal physical assistance and a supervision for eating. She was always continent for bowel and bladder. Interview with Resident #52 on 08/15/17 at 2:52 P.M. revealed she was told she had a pressure ulcer on her heel and it was from lying on her back in the bed. She stated she wasn't educated on turning from side to side and didn't know she could. She stated she noticed her right heel was painful and asked the nurse to take a look at it and that was when it was discovered to be a pressure ulcer. She stated at that time a pillow was provided for her while lying in bed to float her heels, she denied being educated on floating her heels or the use of a pillow before the discovery of the pressure ulcer. Observation of wound dressing change on 08/16/17 at 10:27 A.M. with WRN #10 revealed the right heel wound was noted flat with eschar, circular, and thin heeling from the edges of the wound. There wasn't any exudate noticeable. Interview with the WRN #10 at the time of the observation revealed a few days before the pressure ulcer was found on Resident #52's right heel the residents heel was red and boggy. WRN #10 indicated she was going to keep an eye on the area because most of the time those type of areas will heal themselves. She further indicated at that time she initiated keeping Resident #52's heels off the bed. She further stated on 07/14/17 the wound on the right heal had serous, dark scant amount of fluid under the skin. She stated she put a treatment in place for the pressure ulcer on 07/14/17 and on 07/17/17 the blister had busted open and the wound had eschar. She stated she didn't document the red and boggy heel, the intervention of keeping the heels elevated, or that she educated the resident before 07/14/17 concerning keeping her heels off the bed. WRN stated she initially assessed the area on Resident #52's heel to be a deep tissue injury. She later assessed it as unable to determine, then to a Stage II. She verified the heel was first boggy and red, then a blistered appeared that opened up and there was eschar noted once the blister opened. Review of Skin Breakdown Prevention Protocol revised 02/28/11 revealed reposition residents frequently and use devices that totally reduce pressure on the heels. According to the NPUAP a deep tissue is persistent non-blanchable deep red, maroon or purple discoloration. The area is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatological conditions.