Every finding on record at The Sanctuary at Tuttle Crossing

Based on record review, hospital record review, law enforcement interview, and facility policy review, the facility failed to ensure Resident #51 was free from abuse.Actual harm occurred to Resident #51 when Resident #21 made physical contact with Resident #51. Resident #51 fell to the ground and sustained a hematoma to the back of his head. Resident #51 was transported to the emergency room, where he was diagnosed with a falx subdural hematoma and a fracture of his C5 and C6 vertebra. This affected one (Resident #51) of three residents reviewed for abuse allegations. The facility census was 49.Findings Include:Resident #51 was admitted to the facility on [DATE]. His diagnoses were Parkinson's disease without dyskinesia, dementia, psychotic disturbance, mood disturbance, anxiety disorder, repeated falls, and major depressive disorder. Resident #21 was admitted to the facility on [DATE]. His diagnoses were bipolar disorder, schizophrenia, unspecified hearing loss, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Review of his MDS assessment, dated [DATE], revealed he was cognitively intact.Review of Resident #51's Minimum Data Set (MDS) assessment, dated [DATE], revealed he was severely cognitively impaired. Resident #51 utilized a walker and wheelchair for mobility. He was independent with rolling left and right, sit to lying, and lying to sitting mobility tasks. He needed set up assistance with sit to stand mobility task and chair to bed transfers.Review of Resident #51's progress note, dated [DATE], revealed staff heard Resident #51 yelling from his room. Resident #51 was found lying on the floor with his head and torso outside of the room and his legs inside the room. Resident #21, Resident #51's roommate, was present in the room and was standing over Resident #51 yelling. A full body assessment was completed on Resident #51 which revealed a small amount of bleeding and a raised area on the resident's scalp, consistent with possible head impact. Resident #51 appeared fearful and confused during the assessment. Physician was notified shortly after the incident on [DATE]. He was contacted by Licensed Practical Nurse (LPN) #215, and the physician gave the order to send Resident #51 to the hospital for evaluation.Review of Resident #21's progress notes, dated [DATE], revealed Resident #21 was witnessed on [DATE] standing in front of Resident #51. Resident #51 was lying on the floor looking fearful. Resident #21 was yelling profanities toward Resident #51 and staff. Resident #21 repeatedly stated, touch me again and next time you won't be able to stand back up. This incident was not witnessed by staff. Resident #21 confirmed he pushed Resident #21 because Resident #21 urinated on the toilet seat. During the morning of [DATE], Resident #21 was sent to the hospital for a psychiatric evaluation. Review of Resident #51 progress notes, dated [DATE] as a late entry, revealed emergency management services transportation was contacted to take Resident #51 to the hospital for evaluation due to a head injury.Review of Resident #51 hospital medical records, dated [DATE], revealed Resident #51 had a computed tomography (CT) scan of the head which showed he had a falx subdural hematoma, which is a small interhemispheric subdural hematoma with in the anterior interhemispheric fissure measuring a couple of millimeters. There was also a fracture identified through bridging anterior osteophyte at C5-C6 extending through the body of C6. Resident #51 expired in the hospital on [DATE] at 8:52 P.M.Review of Resident #51's hospital discharge records, dated [DATE], revealed the discharge diagnoses included cardiorespiratory arrest, acute hypoxic respiratory failure, suspect aspiration with significant oropharyngeal secretions, oropharyngeal dysphagia advanced dementia, acute traumatic fall, acute traumatic C5-C6 osteophyte fracture, and acute traumatic C6 vertebral body fracture. Review of the facility Self-Reported Incident (SRI), dated [DATE], documented staff found Resident #51 lying on the floor and Resident #21 standing close by. Staff stated Resident #21 was swearing loudly and said, touch me again and next time you won't be able to stand back up. Resident #51 was fully assessed and there was a small amount of bleeding and a raised area on his scalp. Resident #51 was sent to the emergency room for assessment.During an interview on [DATE] at 1:55 P.M., the Administrator confirmed it was reported to him via Director of Nursing that Resident #21 had smacked Resident #51 across the face, which knocked him to the ground and caused an injury to the back of Resident #51 head. He confirmed it was reported to him the incident was unwitnessed, but when he interviewed Resident #21, the resident confirmed he smacked Resident #51, which caused him to fall to the ground. The Administrator confirmed Resident #51 was sent to the hospital for evaluation after the incident and was later determined to have a subdural hematoma and a fracture of the C5 and C6 vertebra. He received this information from DON but also received information from Law Enforcement Detective #600 about the extent of Resident #51's injuries and that the police department had received information about the incident and they were investigating it.During an interview on [DATE] at 9:40 A.M. with Director of Nursing confirmed it was reported to her Resident #21 had smacked Resident #51 across the face, which knocked him to the ground and caused an injury to the back of Resident #51's head. She confirmed she received a phone call from Licensed Practical Nurse (LPN) #215 shortly after the incident occurred on [DATE]. She confirmed she was told the incident was unwitnessed. She confirmed Resident #51 was sent to the hospital, and after testing and assessment at the hospital, it was determined that Resident #51 had a subdural hematoma and a fracture of the C5 and C6 vertebra. She confirmed she reported this to the administrator after being informed by the hospital.During an interview on [DATE] at 11:02 AM., Law Enforcement Detective #600 stated he was contacted by Resident #51's family two or three days after Resident #51 expired. He stated he was collecting information to determine if there were any issues with the incident that happened at the facility between Resident #51 and Resident #21.During an interview on [DATE] at 12:30 PM, Licensed Practical Nurse (LPN) #215 stated she was working the hallway in which Resident #51 and Resident #21 lived. She stated she heard a loud noise on the evening of [DATE], went to their room, and found Resident #51 lying on the floor and Resident #21 near him, saying, He always does this. She later found out that Resident #21 said he always does this because he was accusing Resident #51 of urinating on their toilet seat. LPN #215 stated Resident #21 told her he pushed Resident #51 to the ground. She fully assessed Resident #51 and found a laceration to his right arm and a raised, reddened area with a small amount of blood to the back of his head. She got an order from the physician to send Resident #51 to the hospital for further evaluation.During an interview on [DATE] at 12:52 P.M., LPN #225 stated she was working the opposite hallway to where Resident #51 and Resident #21's room was located. She heard a loud noise back their hallway and went toward that area. She found Resident #51 lying halfway in and out of his room, on the floor, and Resident #21 over top of Resident #51, saying, I promise next time, you won't get up. She did not physically assess Resident #51 but was told about the injury to his forearm and the back of his head. Review of facility policy titled Abuse, Neglect, and Exploitation, dated [DATE], revealed it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. This deficiency represents non-compliance investigated regarding complaint number 2709090.

Based on medical record review, staff interview, and facility policy review, the facility failed to report an allegation of abuse in a timely manner. This affected one (Resident #51) of three residents reviewed for abuse. The census was 49.Findings Include: Resident #51 was admitted to the facility on [DATE]. His diagnoses were Parkinson's disease without dyskinesia, dementia, psychotic disturbance, mood disturbance, anxiety disorder, repeated falls, and major depressive disorder. Review of his minimum data set (MDS) assessment, dated 12/02/25, revealed he had a severe cognitive impairment.Review of Resident #51 progress notes, dated 12/13/25, revealed staff heard Resident #51 yelling from his room on 12/12/25. He was found lying on the floor with his head and torso outside of the room and his legs inside the room. Resident #21 (Resident #51 roommate) was present in the room and was standing over Resident #51 yelling. A full body assessment was completed on Resident #51 with the following found: small amount of bleeding and a raised area on the resident's scalp, consistent with possible head impact. Resident #51 appeared fearful and confused during the assessment.Review of Resident #51 progress notes, dated 12/14/25, revealed Resident #51 was still in the hospital.Review of Resident #51 progress notes, dated 12/15/25 (late entry meant to have been documented on 12/13/25), revealed emergency management services transportation was contacted to take Resident #51 to the hospital for evaluation due to a head injury.Review of Facility Reported Incident (FRI) number 268571, dated 12/13/25 at 10:06 A.M., confirmed on 12/12/25 at 8:00 P.M. there was an allegation of physical abuse between Resident #21 and Resident #51. Staff found Resident #51 lying on the floor and Resident #21 standing close by. Staff stated Resident #21 was swearing loudly and said, touch me again and next time you won't be able to stand back up. Resident #51 was fully assess and found a small amount of bleeding and a raised area on his scalp. He was sent to the emergency room for assessment.Interview with Administrator and Director of Nursing (DON) on 01/06/26 at 1:55 P.M. and 01/07/26 at 9:40 A.M. both confirmed they were notified of the incident between Resident #21 and Resident #51 on 12/12/25. They confirmed they were told that when Resident #51 was found on the ground, Resident #21 was standing near/over top him, stating that, I promise next time, you won't get up. Administrator confirmed he interviewed Resident #21, who told him that he smacked Resident #51, which caused him to fall to the ground. Administrator stated he reported the incident the next day because he initially thought it was an unwitnessed fall. DON and Administrator both confirmed they knew Resident #21 had stated he smacked Resident #51, knocking him to the ground, on the night of the incident. Interview with Licensed Practical Nurse (LPN) #215 on 01/07/26 at 12:30 P.M. confirmed she reported the incident between Resident #21 and Resident #51 to the DON shortly after the incident happened on 12/12/25. She confirmed she told the DON that Resident #21 had indicated he was the one that smacked Resident #51 and knocked him to the ground.Review of facility Abuse, Neglect, and Exploitation policy, dated 08/01/25, revealed it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The facility will have written procedures that include: reporting all alleged violations to the administrator, state agency, adult protective services, and to all other required agencies within specified time frames: immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This deficiency represents non-compliance investigated regarding complaint number 2709090.

Based on record reviews, interviews, review of Wound Physician notes, and policy review, the facility failed to ensure pressure ulcer treatment orders were initiated and ordered timely and accurately. This affected three residents (#20, #40, and #50) of three residents reviewed for pressure ulcer care. The facility census was 59. Findings include:1.Review of the medical record for Resident #20 revealed an admission date of 11/06/25 and a transfer to the hospital date of 12/03/25. Diagnoses included but were not limited to wedge compression fracture of thoracic 11 and thoracic 12 vertebra, heart failure, type two diabetes mellitus with diabetic neuropathy, muscle weakness, repeated falls, and cognitive communication deficit. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 indicating the resident was cognitively intact. The resident was assessed to require substantial/maximal assistance with shower/bathing, bed mobility, lying to sitting on the side of the bed, sit to stand, transfers, and required total staff dependence for toilet hygiene as well as sitting to lying. The resident was also assessed to have a stage 3 pressure ulcer on admission. Review of the plan of care dated 11/06/25 for Resident #20 revealed the resident was at risk for/had an actual alteration in skin integrity related to being admitted with impaired skin integrity of a sacral pressure area with an intervention including but not limited to providing treatments as ordered. Review of the Skin Risk assessment dated [DATE] for Resident #20 revealed the resident was at high risk for skin breakdown. Review of the pressure ulcer assessment dated [DATE] for Resident #20 revealed a sacrum stage two pressure ulcer measuring 2 cm (centimeters) by 2 cm by no depth. Review of the physician order dated 11/07/25 for Resident #20 revealed an order for barrier cream to the sacrum, coccyx and peri area twice a day and after each incontinence episode every shift. The order was discontinued on 11/21/25. Review of the Wound Physician #1500 note dated 11/11/25 for Resident #20 revealed a sacrum stage three pressure ulcer measured 2.3 cm by 1.2 cm by 0.2 cm with a treatment order for Hydrocolloid paste (triad) twice a day and as needed. Review of the Wound Physician #1500 note dated 11/18/25 for Resident #20 revealed a sacrum stage three pressure ulcer measured 2.6 cm by 2 cm by 0.2 cm with a treatment order to continue the Hydrocolloid paste (triad) twice a day and as needed. Review of Resident #20's physician order dated 11/21/25 revealed the facility initiated the order (10 days late) for the Hydrocolloid paste to sacrum, coccyx and peri area twice a day and after each incontinence. Interview on 12/16/25 at 2:45 P.M. with the Director of Nursing (DON) revealed the facility had a barrier cream and a Hydrocolloid paste (triad) in house and if they were not ordered correctly, the staff did not know which one to use. The DON verified Resident #20 received the barrier cream treatment from 11/11/25 through 11/21/25 for the sacrum stage three pressure ulcer instead of Hydrocolloid paste (triad) treatment. 2.Review of the medical record for Resident #40 revealed an admission date of 09/21/25 and a transfer to hospital date of 10/12/25. Diagnoses included but were not limited to cervical disc disorder at cervical 5 to cervical 6 with radiculopathy, pressure ulcer of sacral region stage four, type two diabetes mellitus without complications. Review of Resident #40's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. The resident was assessed to require partial/moderate assistance with bed mobility, substantial/maximal assistance with transfers and total dependence on toilet hygiene and shower/bathing. The resident was also assessed to have a stage four pressure ulcer on admission. Review of the plan of care dated 09/22/25 for Resident #40 revealed the resident was at risk for/had an actual alteration in skin integrity related to being admitted with a pressure ulcer to the sacrum with an intervention including, but not limited to, providing treatments per physician's orders. Review of the Skin Risk assessment dated [DATE] for Resident #40 revealed the resident was at high risk for skin breakdown. Review of the pressure ulcer admission assessment dated [DATE] for Resident #40 revealed a sacrum unstageable pressure ulcer measured 4 centimeters (cm) by 6 cm by undetermined depth. Review of the physician order dated 09/22/25 for Resident #40 revealed an order to clean the sacral wound with wound wash, pat dry, cover with foam border dressing and change every three days and as needed. The order was discontinued on 09/25/25. Review of the Wound Physician #1500 note dated 09/23/25 revealed Resident #40 had a sacrum stage four pressure ulcer measured 5.5 cm by 7 cm by 1 cm with a treatment order for Mesalt with a gauze dressing daily and as needed. Review of the physician order dated 09/23/25 for Resident #40 revealed an order for Mesalt with a gauze dressing daily and as needed. Interview on 12/23/25 at 9:44 A.M. with the Director of Nursing (DON) verified Resident #40 had two active orders for the sacrum stage IV pressure ulcer from 09/23/25 through 09/25/25. 3.Review of the medical record for Resident #50 revealed an admission date of 05/18/22. Diagnoses included, but were not limited to, systolic heart failure, chronic kidney disease stage three, peripheral vascular disease and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of the Skin Risk assessment dated [DATE] for Resident #50 revealed the resident was at high risk for skin breakdown. Review of Resident #50's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. The resident was assessed to require total dependence for toilet hygiene, shower/bathing, bed mobility, and transfers. This resident was assessed to be at risk for developing pressure ulcers and to have two stage three pressure ulcers currently. Review of the plan of care, revised 12/02/25, for Resident #50 revealed actual skin alterations related to the sacrum and right ischium pressure ulcers with interventions including, but not limited to, wound treatments per orders. Review of the Wound Physician #1500 note dated 12/02/25 for Resident #50 revealed a sacrum stage three pressure ulcer measured 4.5 centimeters (cm) by 0.6 cm by 0.2 cm and a right ischium stage three pressure ulcer measured 1 cm by 1.7 cm by 0.2 cm with treatments for both to be Hydrocolloid paste (triad) twice a day and as needed. Review of the physician orders dated 12/04/25 for Resident #50 revealed for the sacrum and right ischium stage three pressure ulcers to use Hydrocolloid paste (triad) twice a day and as needed. Interview on 12/23/25 at 9:43 AM with the Director of Nursing (DON) verified Resident #50 did not have a treatment order for the sacrum and right ischium stage three pressure ulcers from 12/02/25 through 12/04/25. Review of the undated facility policy titled Pressure Injury Prevention and Management revealed evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. This deficiency represents non-compliance investigated under Complaint Number 2685037 and Complaint Number 2669759.

Based on observation and staff interview, the facility failed to store, prepare, distribute, and serve food in a safe and sanitary manner. This had the potential to affect all 49 residents residing in the facility. The facility census was 49. Findings include: Observation of the kitchen on 08/14/25 at 9:35 A.M. revealed the freezer temperature was 12 degrees Fahrenheit on the outside thermometer and 9 degrees Fahrenheit on the inside thermometer. Further observations revealed the freezer had built-up chunks of ice on the floor with pieces of pasta embedded in the ice and a chunk of hair stuck to the ice on the floor. The walk-in refrigerator, when opened, had a strong mildew odor and an unknown black substance along the entire length of the side and back walls. A pool of water had accumulated in the glass surrounding the lightbulb, which was slowly dripping onto the floor, causing the floor to be wet and the refrigerator felt very humid. The ceiling of the refrigerator had dust buildup in front of the fan. Interview on 08/14/25 at 9:44 A.M. with Kitchen Staff #192 confirmed all the above findings. Interview on 08/14/25 at 9:50 A.M. with Dietary Manager #152 confirmed the findings and stated she had no cleaning logs for the kitchen. Observation of the kitchen on 08/14/25 at 11:29 A.M. revealed additional concerns, including an unknown black substance behind the dishwashing sink, dirt buildup around the entrance door, black buildup behind and under the trash can by the handwashing sink, and dirt accumulation on floors and walls in corners and behind shelving. Interview on 08/14/25 at 11:35 A.M. with Dietary Manager #152 confirmed the above findings. Observation on 08/14/25 at 11:47 A.M. with Kitchen Staff #173 revealed food tray temperatures at the end of the 200 hall as follows: chicken 119 degrees Fahrenheit, vegetables 128 degrees Fahrenheit, and stuffing 137 degrees Fahrenheit. When tasted, the food was warm but not hot. Interview on 08/14/25 at 12:01 P.M. with Kitchen Staff #173 confirmed that the food was not hot and holding temperatures were below the 135 degrees Fahrenheit mark. The facility confirmed all 49 residents receive meals from the kitchen. This deficiency represents non-compliance investigated under Complaint Number 2577530.

Based on observation, staff interview, review of a facility sanitation audit, review of a service log and quote, and review of a facility policy, the facility failed to store frozen foods at the appropriate temperatures to prevent spoilage. This had the potential to affect all 57 residents residing in the facility who received food from the facility kitchen. The facility identified one resident (Resident #117) who did not eat food from the kitchen. The census was 58. Findings include: Observation of the walk-in freezer on 05/12/25 at 8:43 A.M. revealed the freezer temperature was registering at 18 degrees Fahrenheit (F). The internal thermometer was observed to have ice build up on the internal workings of the thermometer and it was unable to be read. The door frame's seal was iced over and there was ice observed on the floor of the freezer. A thick layer of ice and frost was observed to on all three shelves and over the contents of the freezer. Further observation revealed some of the food items in the freezer were two ten-pound boxes of sausage patties, ten six-ounce bags of diced chicken, two boxes of twelve 32-ounce bags of crinkle cut carrots, 64-ounces of frozen corn, a box of spiral fries, a box of snap peas, one box of lasagna, one lasagna tray outside of the original box, and two 20-pound logs of ground beef. Interview with [NAME] #172 on 05/12/25 at 8:43 A.M. confirmed the presence of the icy door frame, the icy food contents inside the walk-in freezer, and the temperature of the walk-in freezer was 18 degrees F. [NAME] #172 was unable to answer what the correct temperature of the freezer should be. Interview with Dietary Supervisor #190 on 05/12/25 at 8:49 A.M. revealed the freezer had recently been serviced, but the door seal was unable to be replaced yet. Observation of the walk-in freezer on 05/12/25 at 9:33 A.M. revealed the temperature of the freezer was 10 degrees F. Interview with [NAME] #172 on 05/12/25 at 9:33 A.M. confirmed the freezer temperature was 10 degrees F. Observation of the walk-in freezer on 05/13/25 at 9:19 A.M. revealed the freezer temperature was 10 degrees F. Interview with Dietary Supervisor #190 on 05/13/25 at 9:19 A.M. confirmed the freezer temperature was 10 degrees F. Observation on 05/13/25 at 9:28 A.M. revealed the freezer temperature was observed to be 12 degrees F. Interview with [NAME] #170 on 05/13/25 at 9:31 A.M. confirmed the freezer temperature was 12 degrees F, and revealed he would not want the freezer to be at a temperature any higher than three (3) degrees F. He stated the freezer had been recently serviced, but the door frame still needed to be fixed. Interview with the Administrator on 05/13/25 at 9:38 A.M. confirmed the walk-in freezer temperature was 12 degrees F. Observation of the walk-in freezer temperature on 05/14/25 at 9:55 A.M. revealed internal temperature was 7 degrees F. Interview with [NAME] #172 on 05/14/25 at 9:56 A.M. revealed the chicken and vegetables from the freezer were served to the residents on 05/14/25 for lunch. Interview on 05/14/25 at 9:57 A.M. with [NAME] #170 revealed the facility received a quote for a new freezer seal as of 05/13/25. He stated the freezer was unable to close properly because of the layer of ice build up around the door frame. Interview with the Administrator on 05/14/25 revealed the facility would have someone out to give another quote on the freezer seal on 05/19/25. Observation of the walk-in freezer temperature on 05/14/25 at 11:30 A.M. revealed the ambient internal temperature of the freezer was 20 degrees F. The external thermometer gauge also revealed the temperature of the walk-in freezer was 20 degrees F. Interview with [NAME] #170 on 05/14/25 at 11:30 A.M. confirmed the temperature of the walk-in freezer was 20 degrees F. Interview with Dietitian #179 on 05/14/25 at 1:42 P.M. revealed the facility was keeping logs on the freezer temperatures. She stated there was a previous internal sanitation audit where some issues in the freezer had been identified. Review of a Food and Sanitation Audit, dated 04/30/25, and authored by Dietitian #197, revealed the foods in the freezer were not frozen solid and/or there were signs of freezer burn. Interview with Dietitian #197 on 05/14/25 at 4:59 P.M. revealed he noticed the food in the walk-in freezer on 04/29/25 was noticeably frosty. He stated he noticed a problem with the gasket seal. Review of a service log dated 05/09/25 revealed the door to the freezer was not closing and that it was, iced up on frame. The gasket was noted to be damaged and the kick plate and frame were damaged. Review of a service quote dated 05/13/25 revealed the walk-in freezer has a bad door frame, gasket, heater, and kick plate. Review of a facility policy titled, Monitoring of Cooler/Freezer Temperature, dated 2025, revealed all frozen storage must be maintained at or zero degrees Fahrenheit (F) [sic]. If temperatures are about 10 degrees F, the supervisor will be notified immediately for corrective action. The unit will be repaired as soon as possible. If the problem cannot be corrected within two hours, all food items will be relocated to another unit that can hold foods in an acceptable temperature range.

Based on observation, review of medical records, staff interview, and review of the Centers for Disease Control and Prevention (CDC) webpage, the facility failed to ensure residents with wounds were maintained on enhanced barrier precautions with appropriate orders, care plans, signage, and personal protective equipment in place when providing direct cares. This affected four (#21, #25, #46, and #111) of seven residents reviewed for infection control precautions. The census was 58. Findings include: 1. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive and dementia. Review of Resident #21's care plan dated 05/09/24 revealed she was at risk of infection related to diagnoses with an intervention to monitor for a skin infection. Review of Resident #21's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with severe cognitive impairment and had one unstageable pressure ulcer (obscured full-thickness skin and tissue loss) that was not present upon admission. Review of Resident #21's physician orders revealed the resident had a wound on her left heal as of 03/11/25 and there were treatment orders in place. Observation of Resident #21's room on 05/12/25 at 10:08 A.M. revealed there was not any enhanced barrier precautions (EBP) signage nor personal protective equipment (PPE) outside of Resident #21's room. Interview with Licensed Practical Nurse (LPN) #141 on 05/12/25 at 10:11 A.M. confirmed Resident #21 was not under EBPs and PPE was not readily available outside of her room. Interview with the Director of Nursing (DON) on 05/15/25 at 2:10 P.M. revealed EBPs were necessary for residents with chronic wounds. 2. Review of Resident #25's medical record revealed he was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, congestive heart failure, atrial fibrillation, diabetes mellitus, encephalopathy, and morbid obesity. Review of Resident #25's care plan, dated 02/24/25, revealed no care plan for enhanced barrier precautions. Review of Resident #25's MDS assessment, dated 04/19/25, revealed the resident was cognitively intact and had a stage three pressure ulcer (full-thickness skin loss). Review of Resident # 25's physician's orders, dated 05/08/25, revealed a wound care order to cleanse the right heel with normal saline, pat dry, cover with calcium alginate, and cover with gauze island with border every day shift. Further review revealed no orders indicated for enhanced barrier precautions. Review of Resident #25's wound evaluation and management summary, dated 05/12/25, revealed he had a stage three pressure ulcer to his right heel. Observation on 05/12/25 at 12:45 P.M. revealed Resident #25 did not have any EBPs signage or PPE located outside the resident's room. Interview on 05/12/25 at 12:47 P.M. with Registered Nurse (RN) #149 confirmed Resident #25 had an open wound and there were no EBPs signage or PPE in place. 3. Review of Resident # 46's medical record revealed she was admitted on [DATE] with diagnoses that included major depressive disorder, stage four pressure ulcer of the sacral region, osteomyelitis of the sacral region, and heart failure. Review of Resident #46's MDS assessment dated , 04/14/25, revealed the resident was cognitively intact and had a stage four pressure ulcer (full-thickness skin and tissue loss). Review of Resident #46's wound evaluation and management summary, dated 05/12/25, revealed she has a stage four pressure ulcer to her sacrum. Review of Resident #46's care plan, dated 01/07/25, revealed no care plan for EBP. Review of Resident #46's physician's orders, dated 04/18/25, revealed a wound care order to cleanse the sacrum with normal saline, pat dry, place calcium alginate with sliver to the wound bed, and cover with gauze island with border every day shift. Interview on 05/12/25 at 12:47 PM with RN #149 confirmed Resident #46 had an open wound and there was no orders of care plan for EBPs. Interview on 05/15/25 at 2:10 P.M. with the DON confirmed EBPs are necessary for resident with urinary catheters, percutaneous endoscopic gastrostomy (PEG) tubes, intravenous (IV) sites, or chronic wounds. 4. Review of Resident #111's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery and presence of vascular implants and grafts. Review of Resident #111's admission assessment dated [DATE] revealed he had a left trochanter skin alteration and a wound vacuum (vac) in place. Review of Resident #111's physician orders from May 2025 revealed he had a left hip wound and a wound vac ordered as a treatment intervention. Observation of Resident #111's room on 05/14/25 at 5:00 P.M. and on 05/15/25 at 8:57 A.M. revealed there were no EBPs signage nor PPE outside of Resident #21's room. Interview with LPN #130 on 05/14/25 at 5:03 P.M. confirmed there was no EBPs signage and no readily available PPE outside of Resident #111's room. LPN #130 revealed there was PPE available in the cabinets at the nursing station and they would need to obtain another plastic bin to store some in near his room. Review of the CDC webpage at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, dated 04/02/24, revealed EBPs expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care including any skin opening requiring a dressing. When implementing contact precautions or EBPs, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves). For EBPs, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Also, make PPE, including gowns and gloves, available immediately outside of the resident room.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to honor a resident's choice for bathing opportunities. This affect one (#117) of one residents reviewed for choices. The census was 58. Findings include: Review of the medical record for Resident #117 revealed an admission date of 04/22/25. Diagnoses included cerebral infarction, acute respiratory failure with hypoxia, dysphasia, and paralysis on both sides. Further review of the medical record revealed the resident had no cognitive deficits, required a two person assist with transferring out of bed, could sit in a wheelchair, and required a one person assist for activities of daily living. Interview on 05/13/25 at 10:27 A.M. with Resident #117 revealed the resident was upset due to not receiving showers or offered a bed bath. The resident confirmed she did not get routine showers two times a week and was not offered a bed bath in between shower days. Also, Resident #117 stated the staff would not do her hair because it was very long and she had to wait for her sister to visit to comb and braid her hair. Review of the skin monitoring and shower review sheets for Resident #117 revealed she had a shower on 04/25/25, 04/29/25, 05/02/25, and 05/09/25. The facility was unable to provide documentation from Resident #117's task section of the electronic medical record to confirm if more showers or any bed baths were given. Interview on 05/14/25 at 2:00 P.M. with the Director of Nursing (DON) and Regional Nurse #196 confirmed each resident was to be offered a shower at least two times a week and a bed bath daily. The DON and Regional Nurse #196 believed Resident #117 could be in a wheelchair, therefore, she should be getting a shower two times a week. The DON reviewed the resident's shower sheets and verified from 04/22/25 to 05/15/25 Resident #117 only received four showers with her first shower occurring on 04/25/25. Review of the undated facility policy titled, Bed Baths, revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Review of the undated facility policy titled, Resident Showers, revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided with showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedules as per facility policy.

Based on medical record review and staff interview, the facility failed to provide residents with Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) document when therapy services were ending and the resident had skilled days remaining. This affected one (#158) of three residents reviewed for beneficiary notices. The facility census was 58. Findings include: Review of Resident #158's medical record revealed an admission date of 01/22/25. Diagnoses included anemia, atrial fibrillation, and hypertension. Review of the medical record for Resident #158 revealed the resident received therapy services which were set to end on 02/16/25 due to admission to hospice services. At the time of therapy services ending, Resident #158 was noted to still have skilled benefit days remaining. There was no evidence of the facility providing a Resident #158 with a SNF-ABN. Interview on 05/14/25 at 4:38 P.M. with Business Office Manager #186 verified Resident #158 should have received an SNF-ABN and did not.

Based on observation, resident and staff interview, and medical record review, the facility failed to provide application of splinting devices as recommended by therapy and failed to ensure physician orders were in placed for use of the devices. This affected one (#35) of two residents reviewed for range of motion. The facility census was 58. Findings include: Review of Resident #35's medical record revealed she was most recently admitted on [DATE] with diagnoses that included anoxic brain damage, metabolic encephalopathy, quadriplegia, and anxiety. Review of Resident #35's Minimum Data Set (MDS) assessment, dated 3/31/25, revealed her cognition was severely impaired and she was dependent on staff for mobility, transfers, and eating. Review of Resident #35's occupational therapy discharge summary notes, dated 04/24/24, revealed discharge recommendations for Resident #35 to remain in the facility with donning (putting on) resting hand splints overnight with three to four times during the day in 30-minute increments and a splinting schedule was in place. Review of Resident #35's physical therapy note, dated 06/28/24, revealed a physical therapy assistant (PTA) educated and observed Resident #35's certified nurse aide (CNA) remove bilateral knee braces and bilateral ankle/foot braces. The PTA also verbally informed Resident #35's nurse of the removal of the braces and positioning with pillows. Review of Resident #35's physical therapy Discharge summary, dated [DATE], revealed discharge recommendations for Resident #35 to be up in a chair with bilateral lower extremity splints for four to five hours. Review of Resident #35's physicians orders, dated May 2025, revealed no indication of an order for bilateral hand splints, bilateral knee braces, or bilateral ankle/foot braces. Observation on 05/13/25 at 10:24 A.M. revealed Resident #35 up out of bed in a Broda chair (specialty chair to aid in positioning) with no splints in place. Observation on 05/14/25 at 9:50 A.M. revealed Resident #35 in bed with no splints in place. Observation on 05/14/25 at 10:00 A.M. revealed multiple splints in a box on the floor in Resident #35's room. Interview on 05/14/25 at 9:00 A.M. with Physical Therapist (PT) #194 revealed Resident #35 had been in and out of the facility since her admission and he believed therapy recommended bilateral knee, bilateral ankle/foot splints, and bilateral wrist/hand/elbow splints sometime in the Summer of 2024. Interview on 05/14/25 at 11:02 A.M. with Licensed Practical Nurse (LPN) #146 confirmed Resident #35 was not wearing her splints and they were in the box on the floor. LPN #146 also stated Resident #35 always refused her splints and LPN #146 stated the resident did not have a current order for splints to be applied. Interview on 05/14/25 at 11:04 A.M. with Resident #35 revealed she would wear her splints if offered. Interview on 05/14/25 at 11:10 A.M. with PT #194 revealed when therapy recommends a device or equipment for a resident, therapy educates and works with staff on usage of the device or equipment and any parameters or schedules of use are verbally given to the nurse. Interview on 05/14/25 at 3:01 P.M. with Registered Nurse (RN) #153 revealed Resident #35 did not use splints and the order possibly got missed with Resident #35 going out to the hospital multiple times since admission. Interview on 5/15/25 at 2:05 P.M. with the Director of Nursing (DON) revealed therapy notified nursing in morning meetings with any recommendations for splinting and schedules for use. Nursing should put in a doctor's order and communicate with the direct care staff on how and when to use it.

Based on observation, staff interview, and review of a user guide, the facility failed to ensure residents who required transfer assistance using a mechanical lift were provided with adequate assistance to prevent accidents. This affected two (#22 and #107) of two residents observed for safe transfers. The facility census was 58. Findings include: 1. Observation on 05/13/25 at 2:47 P.M. revealed Certified Nurse Aide (CNA) #149 pushing Resident #22 in her wheelchair followed by pulling a mechanical (Hoyer) lift being her. CNA #149 was observed taking Resident #22 and the Hoyer lift into the resident's room and closed the door. Continued observation revealed a short time later another staff member came to Resident #22's door and asked if CNA #149 was finished with the Hoyer lift and CNA #149 responded she was finished. Continued observation revealed CNA #149 opened Resident #22's room door where Resident #22 could be seen laying in bed. Interview on 05/13/25 at 3:00 P.M. with CNA #149 confirmed she used the Hoyer lift by herself to transfer Resident #22 from her wheelchair to the bed and confirmed there needed to be two staff members present when the procedure was completed. 2. Observation on 05/13/25 at 3:07 P.M. revealed CNA #198 exited Resident #107's room with a Hoyer lift and no other staff members were observed. Resident #107 was observed sitting in her wheelchair at that time. Interview on 05/13/25 at 3:10 P.M. with CNA #198 revealed she used the Hoyer by herself to transfer Resident #107 to her bed to complete care, and then used the Hoyer lift to transfer the resident back into her wheelchair. CNA #198 stated it was safe and permitted to use a Hoyer lift with one staff member and it made it very easy to move residents. Interview on 05/14/25 at 1:19 P.M. with the Director of Nursing (DON confirmed Hoyer lift transfer of residents with only one staff member completing the transfer was not permitted. Review of the undated Patient Lift Safety Guide revealed that most lifts require two or more caregivers to safely operate lift and handle the resident.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure physician orders were followed for residents who received nutritional tube feedings. This affected one (#117) of one residents reviewed for tube feedings. The census was 58. Findings include: Review of the medical record for Resident #117 revealed an admission date of 4/22/25. Diagnoses included cerebral infarction, acute respiratory failure with hypoxia, dysphasia, and paralysis on both sides. Further review of the medical record revealed the resident had no cognitive deficits, required a two person assist with transferring out of bed, could sit in a wheelchair, and required a one person assist for activities of daily living. Interview on 05/13/25 at 10:34 A.M. with Resident #117 revealed when she arrived at the facility she missed two nutritional feedings. The resident stated she was very familiar with her regimen and was upset because no one would explain to her why she did not receive her nutritional feeding. Review of Resident #117's physician orders for April 2025 revealed on 04/22/25 the resident was ordered the nutritional supplement Nutren 2.0 complete liquid nutrition 250 milliliter (mL) bolus five times daily from 04/23/25 to 04/29/25. Review of Resident #117 dietician progress notes dated 04/30/25 revealed Resident #177 and her family requested continuous nutritional feedings and an order was received for Nutren 2.0 55 milliliters per hour (mL/hr) continuous with 60 mL water flushes. Review of Resident #117's medication administration record for 04/01/25 to 04/30/25 revealed on 04/23/25 Resident #17 did not receive her enteral feedings scheduled at 8:00 A.M., 11:00 A.M., and 12:00 P.M.; however, she did receive her feedings at 5:00 P.M. and 9:00 P.M. Interview with the Director of Nursing (DON) 05/14/25 and 6:08 P.M. revealed the facility had a problem with Resident #117's tube feeding pump and verified Resident #117 did not received nutritional feedings as ordered on 04/23/25 at 8:00 A.M., 11:00 A.M., and 12:00 P.M. Review of the undated facility policy titled, Nutritional Management, revealed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. The facility did not have a policy on following physician's orders.

Based on medical record review, staff interviews, and facility policy review, the facility failed to conduct a medication regimen reviews at least monthly. This affected two (#28 and #32) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 01/24/21. Diagnoses include senile degeneration of the brain, major depressive disorder, anxiety disorder, hypertension, hyperlipidemia, hypothyroidism, and sleep apnea. Review of Resident #28's physician orders revealed the resident received antipsychotic, antidepressant, antianxiety, and opioid medications. Review of the pharmacy records revealed no documentation of the pharmacist reviewing Resident #28's medication regimen in February 2025. Additional review of the consultant pharmacist's medication regimen recommendation to the physician did not include a monthly review or recommendations for Resident #28 in February 2025. Interview with the Director of Nursing (DON) on 05/14/25 at 5:45 P.M. confirmed no other documentation was available to indicate Resident #28's medication regimen was reviewed for the month of February 2025.2. Review of Resident # 32's medical record revealed he was admitted on [DATE] with diagnoses that included intracerebral hemorrhage, schizoaffective disorder, anxiety, and hypertension. Review of Resident #32's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/25, revealed Resident #32 was severely cognitively impaired and received an antipsychotic and antidepressant medication daily. Review of Resident #32's physician's orders, dated 05/15/25, revealed orders for the antipsychotic olanzapine 2.5 milligrams (mg) by mouth at bedtime, and the antidepressant medications trazodone 25 mg by mouth at bedtime and sertraline 50 mg by mouth one time a day. Review of the pharmacy progress notes did not include documentation the pharmacist reviewed Resident #32's medications for June 2024 and February 2025. Review of the consultant pharmacist medication regimen review reports, dated from May 2024 to May 2025, did not include monthly reviews or recommendations for Resident #32's medication regimen for June 2024 and February 2025. Interview with the DON on 05/14/25 at 5:45 P.M. confirmed there was no other documentation available to indicate Resident #32's medication regimen was reviewed for the months of June 2024 and February 2025. Review of the facility policy titled, Medication Regimen Review, revealed the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart.

Based on observation, medical record review, staff interview, review of a user guide, review of manufacturer instructions, and facility policy review, the facility failed to prime an insulin pen needle prior to selecting the ordered dose and administering the medication to a resident and failed to administer antibiotic and anticoagulant medications as ordered which resulted in significant medication errors. This affected three (#26, #44, and #113) of eight residents reviewed for medication administration. The facility census was 58. Findings include: 1. Review of Resident #113's medical record revealed a most recent admission date of 04/24/25. Diagnoses included infection following a surgical procedure, hypertension, muscle weakness, and diabetes mellitus type II. Review of Resident #113's physician orders revealed an order dated 04/24/25 for the resident to received Humalog insulin 12 units subcutaneously (SQ) before meals. Observation of medication administration on 05/15/25 at 2:44 P.M. revealed Registered Nurse (RN) #198 identified the order for Resident #113 to receive Humalog 12 units SQ to be administered at that time. RN #198 proceeded to obtain the resident's insulin dispensing pen, applied the injection needle to the pen, and turned the dosage dial to 12 units. RN #198 then proceeded to administer the insulin to Resident #113. Interview on 05/15/25 at 2:46 P.M. with RN #198 verified she did not prime Resident #113's insulin pen prior to selecting the ordered dose and believed the pen did not need primed. Review of an undated user guide titled, Safety Pen Needles, revealed to perform a priming test if recommended by the pen injector device manufacturer. A drop of liquid should appear on the needle tip visible through the viewing window. Review of the manufacturer instructions, revised 07/2023, revealed priming the insulin pen removes air from the needle and insulin cartridge that may collect during normal use and ensure the pen is working correctly. If the pen is not primed before each dose the recipient may get too little or too much insulin. 2. Review of the medical record for Resident #26 revealed an initial admission date of 05/10/23 with a re-entry date of 12/25/23. Diagnoses included acute embolism and thrombosis of the left upper extremities veins, repeated falls, and presence of a left artificial hip joint. The resident was discharged on 05/12/25. Review of Resident #26's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition for daily decision making abilities as well as experiencing disorganized thinking. Review of the progress note date 01/25/25 indicated Resident #26 received care at the local hospital due to a recent fall. It was found Resident #26 tested positive for influenza type A and had a urinary tract infection. Review of the physician orders and medication administration record (MAR) for Resident #26 revealed the ordered antibiotic Keflex 500 milligrams (mg) to give one tablet twice a day was not administered for the evening shift on 01/25/25 nor was it administered during the morning shift on 01/26/25 per the order and schedule. Review of the list of medications available in the facility's emergency medication box revealed there were five (5) tablets of Keflex 250 mg available. Interview on 05/14/25 at 1:21 P.M. with the Director of Nursing (DON) revealed the facility's emergency medication box was a storage of medication that was available at the facility for nursing staff to use when a resident had a medication ordered and the medication was not yet delivered from the facility. The DON confirmed Resident #26's Keflex was available and confirmed the two missed doses of the antibiotic on 01/25/25 and 01/26/25. 3. Review of the medical record for Resident #44 revealed an admission date of 10/05/24. Diagnoses included cerebral infarction, peripheral vascular disease, and hypertension. Review of Resident #44's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition for daily decision making abilities. Review of physician orders for Resident #44 revealed a order for an anticoagulant medication rivaroxaban (Xarelto) oral tablet 2.5 mg to give one tablet every 12 hours for atrial fibrillation with meals. Further review revealed the administration times were scheduled for 7:00 A.M. and 7:00 P.M. Review of the MAR for February 2025 revealed Resident #44's Xarelto was not administered on 02/28/25 for the 7:00 A.M. shift. Review of the MAR for March 2025 revealed Resident #44's Xarelto was not administered on 03/01/25 on the 7:00 P.M. shift, on 03/07/25 for the 7:00 A.M. and 7:00 P.M. shifts, and not given on 03/14/25 for the 7:00 P.M. shift. Review of the MAR for May 2025 revealed Resident #44's Xarelto was not administered on 05/09/25 for the 7:00 A.M. and 7:00 P.M. shifts. Interview on 05/14/25 at 4:41 P.M. with the DON revealed the facility served dinner around 5:30 P.M. The DON confirmed Resident #44's order for Xarelto was to be administered with meals and the 7:00 P.M. dose would not have been administered early enough to be with the last meal of the day. Further interview with the DON also confirmed Resident #44's missed doses of Xarelto in February, March, and May 2025 as listed above. Review of the undated facility policy titled, Medication Administration, revealed to ensure the six rights of medication administration are followed including right dose, right documentation, and right time.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure resident who agreed to receive dental services was provided with the services in a timely manner. This affected one (#43) of one residents reviewed for dental services. The facility census was 58. Findings include: Review of the medical record for Resident #43 revealed an admission date of 04/29/24. Diagnoses included cerebral infarction, alcohol dependence, intellectual disabilities, and hypertension. Review of the plan of care dated 04/29/24, and revised 05/09/24, revealed Resident #43 had the potential for oral dental health problems related to his own teeth. Interventions included to coordinate arrangements for dental care, transportation as needed as ordered, dental consultation and follow-up as ordered, monitor and report to the medical director any signs or symptoms or complaint of oral pain, monitor the resident for any signs or symptoms of chewing/swallowing difficulties, weight loss, fever, congestion, and report to the medical director, monitor for any oral problems, and provide oral care at least every day and more frequently as needed. Review of the facility document for ancillary services revealed Resident #43 was made aware of services available to him on 12/30/24 at which time he had signed the documented indicated he wished to receive those services including dental care. Review of Resident #43's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition for daily decision making abilities. Resident #43 was noted to have his natural teeth and was independent for oral care. Interview on 05/12/25 at 10:30 A.M. with Resident #43 revealed he had not seen a dentist since he had been in the facility and had been asking to see one. Interview on 05/15/25 at 2:30 P.M. with Human Resources (HR) #148 confirmed Resident #43 had a signed document indicating he wished to received ancillary services which had not been properly filed in his record. HR #148 stated typically when it was almost time for the dentist to come to the facility, the social worker would go around to each resident who elected to receive the service to see if they would like to be seen. HR #148 confirmed since Resident #43's paperwork was not properly filed, no one was aware Resident #43 wanted to see the dentist and confirmed he had not been seen.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure documentation of a resident discharging from the facility against medical advice (AMA) was documented in the medical record. This affected one (#54) of three residents reviewed for discharges. The facility census was 58. Findings include: Review of the medical record for Resident #58 revealed an admission date of 02/11/25 and a discharge date of 02/15/25. Diagnoses included chronic heart failure, muscle weakness, and chronic kidney disease. Review of Resident #58's nursing progress note dated 02/15/25 at 2:53 P.M. revealed a nurse was notified by a nurse aide that Resident #58 left with wife without signing out at the nurses' station in the red book, and notifying the nurse. The nurse saw the wife walk past the nurse's station to the resident's room. The resident's wife did not say anything to the nurse about taking the resident. The nurse was assisting another resident before being notified by the nurse aide that the resident left. The nurse aide indicated she went to go look for Resident #58 because she noticed he was no longer in his room. The nurse aide indicated when she caught up to the resident and his wife, she asked if the resident was going to be gone for the day and if he was coming back. The nurse aide said if the resident was leaving, he needed to sign out at the nurses' station in the red book. Resident #58's wife said she would be right in and signed the resident out in the book at the front desk with the time 2:15 P.M. Resident #58's wife also put home in the book as well. The Medical Director and Director of Nursing (DON) were notified of the situation. Interview on 05/14/25 at 11:52 A.M. with Resident #58's wife revealed she took the resident home on [DATE] and had no plan on bringing him back. Resident #58's wife claimed she did not feel the resident was receiving the care he needed while in the facility and he was begging her to take him home so she did. Resident #58's denied receiving any calls from the facility related to her husbands status. Interview on 05/15/2025 at 3:00 P.M. with Business Office Manager #186 confirmed Resident #58's medical record did not have information documented related to him leaving the facility AMA. Review of the undated transfer and discharge policy (including AMA) revealed documentation of this (AMA) notification should be entered in the nurses' notes by the nurse department. The social services designee should document any discussion held with the resident/family in the social services progress notes, if present.

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure resident call systems functioned appropriately. This affected one (#9) of two residents reviewed for call lights. The facility census was 58. Findings include: Review of the medical record for Resident #9 revealed an admission date of [DATE]. Medical diagnoses included metabolic encephalopathy, generalized anxiety disorder, delusional disorder, obstructive sleep apnea, chronic pain, epilepsy, and obesity. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was assessed with intact cognition. Observation on [DATE] at 9:03 A.M. revealed Resident #9's call light button did not activate when the resident pushed the button. Resident #9 attempted to press the call light button several times without success. Further observation outside the resident's room revealed a nurse passing medications was notified and indicated she would assist Resident #9 with the call light system. Observation and interview on [DATE] at 9:28 A.M. revealed Resident #9's call light system continued to malfunction. Resident #9 stated the call light was still not fixed. Observation revealed Resident #9 pushed the call light button multiple times and the call light did not activate. Interview on [DATE] at 9:41 A.M. with Licensed Practical Nurse (LPN) #146 confirmed Resident #9's call light was not working when she attempted to push button at the resident's bedside. LPN #146 stated she would notify maintenance and the Administrator of Resident #9's malfunctioning call light. Interview with the Administrator on [DATE] at 10:41 A.M. confirmed Resident #9's call light system was broken. The Administrator stated Resident #9 would be offered a bedside bell or room change at that time. Review of facility policy titled, Call Lights: Accessibility and Timely Response, dated 2024, revealed staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. Examples include to replace the call light, provide a bell or whistle, increase frequency of rounding, room changes, etc. This deficiency represents non-compliance investigated under Complaint Number OH00165633.

Based on observation and staff interview, the facility failed to maintain a shower room in a clean and sanitary manner. This affected three (Residents #181, #195, and #208) of three residents reviewed for clean environment and had the potential to effect 34 residents who used the shower room on the 200 hall. The facility censes was 49. Findings include: Observation on 09/23/24 at 1:00 P.M. of the 200 hall shower room revealed the floor had a large amount of black, stained areas, nearly covering the entire floor. The floor appeared to be a poured coating. The area directly surrounding the center floor drain was loose. When stepped on, water would bubble from underneath it. A small area of tile on the half wall dividing the two shower areas, had a portion of tile missing. The area was approximately three inches long and one inch wide. Interview on 09/23/24 at 1:30 P.M. with the Administrator revealed the facility has begun to locate contractors to get estimates to have the shower fixed, but have nothing definite yet. Interview on 09/23/24 at 1:10 P.M. with State tested Nurse Aide (STNA) #302 revealed the 200-hall shower was a mess. The floors are stained and loose and some residents refuse to enter to room because it was a mess. Interview on 09/23/24 at 1:15 P.M. with Licensed Practical Nurse (LPN) #301 revealed some of the residents refuse to use the shower room on the 200-hall related to the condition of the room. The floor was stained and loose and a small piece of the tile was missing. Interview on 09/23/24 at 1:30 P.M. with Resident #181 revealed the shower room was disgusting. The floor was filthy and the room stinks. Interview on 09/23/24 at 1:40 P.M. with Resident #195 revealed the 200-hall shower room is nasty and refuses to use the shower room until the facility fixes it. Interview on 09/23/24 at 1:45 P.M. with Resident #208 revealed they refuse to use the shower room in the 200-hall because it was filthy and stinks. This deficiency represents non-compliance investigated under Complaint Number OH00158140.

Based on staff interview, observation, record review, and facility policy review, the facility failed to maintain infection control procedures to prevent the development of infections when staff failed to wash or sanitize their hands before a dressing change and after gloves changes during a dressing change. This affected one (Resident #32) of three Residents reviewed for wounds. The facility census was 50. Findings include: Record review of Resident #32 revealed an admitted [DATE] with pertinent diagnoses of: type two diabetes mellitus with other skin complications, paraplegia, muscular dystrophy, obstructive sleep apnea, need for assistance with personal care, non pressure chronic ulcer of left and right foot, atherosclerotic heart disease of native coronary artery, hypertension, spinal stenosis, disorder of kidney and ureter, hyperlipidemia, cardiac arrhythmia, hypothyroidism, anemia, peripheral vascular disease, chronic kidney disease, and chronic pain syndrome. Review of the 02/25/24 admission Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and uses a wheelchair to aid in mobility. The resident requires supervision or touching assistance for rolling left and right, and partial moderate assistance for sit to lying and lying to sitting on side of bed. The resident was coded as having diabetic foot ulcers Review of a Physician Order dated 03/06/24 revealed to cleanse right outer foot (pinky side) with Normal saline, pat dry, apply calcium alginate, cover with gauze island with border every day shift for wound care. Observation on 03/07/24 at 12:56 P.M. revealed Licensed Practical Nurse (LPN) #11 gathered the supplies for the wound change including calcium alginate, border gauze, wound cleanser, and four by four gauze. LPN #11 put on gloves, but did not wash her hands or use alcohol based hand rub for her hands. LPN #11 removed Resident #32 soiled dressing on the right outer foot, she then removed her soiled gloves, and put on new gloves but she did not wash or use alcohol based hand rub for her hands. LPN #11 used wound cleanser and gauze to clean the wound and she removed her gloves and put on clean gloves but did not wash hands or use hand sanitizer. LPN #11 placed calcium alginate and the wound dressing. Interview with LPN #11 on 03/07/24 at 1:08 P.M. verified she did not wash her hands or use alcohol based hand rub prior to starting Resident #32 dressing change or after removing gloves during the dressing change. Review of the undated facility Hand Hygiene policy revealed the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. This is an incidental finding investigated under Complaint Number OH00150978.

Based on observations, staff interview and policy review, the facility failed to maintain the kitchen in a sanitary condition. This had the potential to affect all 52 residents residing in the facility. The census was 52. Findings include: Tour of the kitchen 12/16/23 at 11:30 A.M. through 12:47 P.M. revealed the following concerns: 1. The ice machine had brown streaks running from the screws onto the white plastic in each corner of the ice machine making up the chute. 2. The fronts of the stainless steel appliances were dirty, smeared, sticky, with dry debris which included the top surfaces of the oven, salad bar, refrigerators, and dishwasher. 3. There was no evidence of the facility recorded food temperatures for breakfast, lunch and supper tray line between 09/01/23 and the lunch meal of 12/13/23. 4. There was no evidence of the facility recorded refrigerator and freezer temperatures to ensure acceptable refrigeration temperatures were maintained since 09/01/23. 5. The walk in refrigerator had a white liquid pooled on the floor. There were two mugs on a shelf with liquid that were uncovered and unidentifiable. 6. Observation of the lunch tray line at 11:50 A.M. revealed Cook #70 left the tray line, went to the salad bar, opened the lid with the handle using his right gloved hand, grabbed shredded cheese into his gloved hand, opened the cabinet door below with his left gloved hand, took a bag of shredded lettuce from the refrigerated cabinet and went back to the trayline. Cook #70 put the shredded cheese on the sandwich, opened the bag of lettuce, reached in the bag with his right gloved hand and took out lettuce. He placed the lettuce on the sandwich all without changing his gloves that touched the handles of the salad bar roll top and underneath cabinet. 7. Observation of the tray line at 11:56 A.M. revealed Cook #70 left the tray line, opened the door to the dry goods pantry using his gloved right hand, returned with a bag of sandwich buns, opened it and retrieved a bun with his right gloved hand without changing his glove that he used to open the pantry door. 8. Observation of the walk in freezer revealed bags of hamburger patties, chocolate chip cookies, oatmeal raisin cookies, and fish fillet were all in bags that had been left open to the air after some of the contents were removed. 9. There was no evidence of dishwasher temperatures was monitored or recorded since 09/01/23. 10. Observation of the dishwasher cycle revealed the dishwasher rinse cycle reached 180 degrees Fahrenheit (F) on the third cycle. The dishwasher wash cycle never reached 150 degrees F after watching seven cycles. On the fifth cycle the temperature reached 148 degrees F. The temperature dropped on the sixth cycle to 146 degrees F and on the seventh cycle the temperature dropped to 140 degrees F. Interview 12/15/23 at 12:47 P.M. with Dietary Manager (DM) #71 revealed his first day was 12/13/23. DM #71 verified there was no evidence of recording of food temperatures, dishwasher temperatures, refrigerator and freezer temperatures. DM #71 verified the ice machine had brown streaks running from the screws in the chute. DM #71 started to record food temperatures on 12/13/23. DM #71 verified the stainless appliances were dirty, and the Cook broke sanitation when he left the tray line, opened the salad prep and the dry goods door without changing gloves. DM #71 verified they had unsealed bags of food in the walk in freezer. DM #71 further verified the dishwasher temperatures did not reach minimum requirements. DM #71 revealed the dishwasher maintenance repairmen were at the facility the prior day because maintenance noticed the temperatures did not meet requirement. The facility confirmed all 52 residents receive their meals from the facility kitchen. Review of the Maintaining a Sanitary Tray Line policy revised 02/23 included wash hands before and after wearing or changing gloves. Change gloves when activities are changed, or when the type of food being handled is change, or when leaving the work station. Review of the Monitoring of Cooler/Freezer Temperature revise 02/23 included it is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. Temperatures will be checked an logged at least twice per day by designated personnel. Logs will be changed out and filed each month. Review of the Record of Food Temperatures policy revised 02/23 included food temperatures will be checked on all items prepared in the dietary department. Hot foods will be held at 135 degrees Fahrenheit or greater. Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log. Review of the Dishwasher Temperature policy revised 02/23 included the wash temperature shall be 150-165 degrees Fahrenheit. The final rinse temperature shall be 180 degrees Fahrenheit shall be 180 degrees or above, but not to exceed 194 degrees for stationary rack single temperature machine. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to develop and implement appropriate interventions for a resident with dementia. This affected one (#16) of three residents reviewed for dementia care. The facility census was 53. Findings include: Review of Resident #16's medical record revealed an admitted [DATE]. Diagnoses included bipolar disorder, vascular dementia, depression, dysphasia, and vitamin deficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired and was rarely, if ever, understood. Resident #16 required extensive assistance with bed mobility, limited assistance with transfers, and supervision for walking in the hallways. Review of the plan of care dated 09/11/23 revealed Resident #16 had impaired cognition and wandering behaviors. Interventions included assess risk factors, family conferences to discuss residents attempts to leave, involve in activities of choice, redirect as needed and stop sign at frequented exits. The plan of care plan did not address interventions related to Resident #16 wandering into other resident rooms and sleeping in their chairs and beds. Review of nursing progress notes from 08/01/23 to 10/23/23 revealed Resident #16 regularly wandered the unit and could usually be redirected. Interview on 10/23/23 at 11:30 A.M. with Resident #14 revealed Resident #16 constantly wandered into resident rooms and would sleep in other resident's chairs and beds. Interview on 10/23/23 at 11:45 A.M. with Resident #7 revealed Resident #16 wandered the secured unit and would enter other resident's rooms and sleep in their bed and chair. While Resident #7 had a velcro stop sign across her door, she stated the sign did not discourage Resident #16 from wandering into her room. Interviews on 10/23/23 from 4:21 P.M. to 4:30 P.M. with State tested Nursing Aide (STNA) #66 and Licensed Practical Nurse (LPN) #99 revealed they were unaware Resident #16 wandered into other resident rooms, believed the resident only wandered in the common areas, and were unaware of any interventions to address Resident #16's wandering. Interview on 10/23/23 at 4:30 P.M. with LPN #95 revealed Resident #16 wandered into other resident rooms, but was usually easily redirected. LPN #95 stated staff attempted to monitor Resident #16, but the resident's wandering was constant. Observations from 9:50 A.M. to 4:50 P.M. revealed Resident #16 had wandered constantly throughout the day and went into residents rooms on several occasions, requiring staff redirection. Resident #16 was not engaged in activities and would be directed to sit on her own in the common area, where she would remain for 30 to 45 seconds before getting up and wandering again. No activities were observed on the unit until approximately 4:00 P.M. Interview on 10/23/23 at 4:55 P.M. with the Director of Nursing (DON) and Corporate Nurse (CN) #100 revealed Resident #16 had known wandering behaviors and stated the resident had plan of care interventions related to going in other resident rooms. Upon review of the plan of care, the DON acknowledged an entry related to wandering into other resident rooms was not entered until today (10/23/23). The DON and CN #100 revealed Resident #16 had interventions in place for staff redirection and activity involvement to decrease wandering and confirmed the activities were scarce on the secured unit. CN #100 verified there were no activities offered to potentially engage Resident #16 and decrease wandering behavior until approximately 4:00 P.M. CN #100 and the DON verified, while they were uncertain Resident #16 would participate in activities, more opportunities should be offered to engage the resident. This deficiency represents non-compliance investigated under Complaint Number OH00146837.

Based on record review, staff interview, surgeon office interview, and review of the facility policy, the facility failed to routinely monitor a resident's surgical wound, notify the physician or surgeon's office of the deteriorating surgical wound, and failed to timely implement a physician order to start a skin treatment. Actual Harm occurred to Resident #55 when her lower back incision went without treatment for at least five days after the Nurse Practitioner noted drainage and slough present in the wound bed with mild dehiscence. Resident #55 subsequently went to the hospital and received treatment to the infected wound. This affected one (Resident #55) of three residents reviewed for non-pressure related skin conditions. The facility identified five residents with skin breakdown that were not pressure related currently at the facility. The facility census was 50. Finding include: Review of Resident #55's medical record revealed an admitted [DATE]. Resident #55 was discharged to the hospital on 11/30/22 and returned to the facility on [DATE]. Diagnoses included spinal stenosis lumbar, surgical aftercare following surgery on the nervous system, acquired absence of the upper limb, obesity, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact. Resident #55 required for extensive two-person physical assistance for bed mobility, dressing, and toilet use. Resident #55 was total dependent on staff for bathing. Review of the hospital discharge paperwork dated 11/22/22 revealed Resident #55 had an incision on her back and the treatment was to keep open to air (OTA). It was clean, dry, and intact on 11/22/22. Review of the initial risk assessment dated [DATE] revealed Resident #55 was at risk for skin breakdown. Review of the initial skin assessment dated [DATE] revealed Resident #55 had a wound abrasion to her abdominal folds and under both breasts. The wound incision to the lower lumbar spine with 32 intact staples, wound was well approximated, dry, intact, and had no odor. Lower back incision was to be left OTA per physician's order. Review of the physician orders dated 11/23/22 revealed Resident #55 had orders for the lower back surgical incision to be left OTA twice daily. Review of the plan of care dated on 11/23/22 revealed Resident #55 was at risk for alteration in skin integrity related to surgical area present on back and under pannus (occurs when extra skin and fat deposits hang from the stomach or belly area of the abdomen) moisture associated skin damage (MASD). Interventions included analgesia as ordered, body check weekly, encourage, and assist with turning and repositioning, give medication as ordered, keep skin clean and dry, maintain pressure reducing mattress, pressure reducing chair and cushion, aid with activity of daily living, and provide skin care as needed. Review of the Weekly Nursing Note dated 11/28/22 revealed the surgical midback had staples, it was slightly red and there was no odor or drainage. The nurse cleansed it with normal saline (NS) and left it OTA. Bilateral excoriation was noted under her bilateral breasts, and it was washed and dried as physician ordered. Review of the progress note dated 11/29/22 stated the Nurse Practitioner (NP) and physician stated no scrubbing or saline to surgical back incision and send Resident #55 to the emergency room (ER) if pain increases or signs and symptoms of infection present. Review of the progress note dated 11/30/22 Resident #55 had a new stage one pressure ulcer to the coccyx. A new physician order was obtained to apply barrier cream as needed and every two hours repositioning encouraged. Resident #55 was notified and verbalized understanding. Subsequently, the progress notes on 11/30/22 at 3:53 P.M. stated Resident #55 was sent to the emergency room (ER). There were no further details on why Resident #55 was sent to the ER. Review of the hospital notes dated 12/01/22 revealed there were no orders for any skin treatments or skin concerns. The staples for the lower back surgical incision were removed. Review of the progress note dated 12/01/22 at 12:16 P.M. stated Resident #55 returned to the facility at around 12:00 P.M. from the local hospital where she had staples removed to the lower back incision. Review of the admission note dated 12/01/22 at 1:24 P.M. stated Resident #55 was alert and arousable. Resident #55 was oriented to person, place, and time. No negative findings on musculoskeletal exam. There was no description of the lower back incision, or any skin concern noted related to Resident #55's bilateral breasts. Review of the treatment administration records for December 2022 revealed the physician orders dated 11/23/22 were resumed for Resident #55. The treatments included for the surgery incision to the lower back incision be left OTA twice daily. Review of the progress note dated 12/02/22 at 9:16 P.M. stated Resident #55 had no negative skin issues noted. Review of the progress note dated 12/05/22 revealed the surgeon's office was contacted regarding treatment for Resident #55's lower back incision. On 12/06/22, the progress note stated the nurse called the surgeon's office to follow up on the treatment order for the lower back incision. The progress notes on 12/05/22 and 12/06/22 did not include any type of description of the lower back incision and did not discuss the reason a treatment was needed. Review of Nurse Practitioner (NP) #654's progress note dated 12/06/22 revealed NP #654 saw Resident #55 due to incisional care concern. Nursing consulted with the surgeon and the surgeon wanted pictures to be sent to his office. The facility was to contact NP #654 if unable to get a return call from the surgeon. NP #654 described the lumbar incision to be pink with scant drainage, slough present in the wound bed with mild dehiscence, no warmth or edema. Nursing reported they contacted the surgeon's office twice on 12/05/22 and the surgeon office responded with requesting picture of the incision. Additional review of the facility's documents revealed there was no evidence a picture was sent to the surgeon's office. Review of the physician note dated 12/07/22 revealed Resident #55 was seen by the physician which included a yeast infection below the breast. The recommendation was to continue with Interdry to control moisture and will order Miconazole powder twice daily for 14 days. There was no evidence this physician order for Miconazole powder twice daily for 14 days was implemented until five days later 12/12/22. There was no mention of the lower back incision in the physician note. Further review of Resident #55's medical record from 12/07/22 to 12/12/22 revealed there was no documentation of any measurements to the lower back incision, no documentation of any concerns related to the lower back incision, and no documentation related to notifying NP #654, the surgeon's office nor Resident #55's primary care physician at the facility. Review of the progress note dated 12/12/22 at 8:10 A.M. documented by LPN #302 stated there was a new order for miconazole Nitrate Powder 2% to be applied to under the breasts topically two times a day for fungal infection for 14 days. On 12/12/22, it was noted after Resident #55's physician office visit, the physician sent Resident #55 to the hospital and did not return to the facility. Review of the hospital skin assessment dated on 12/12/22 at 5:39 P.M. stated Resident #55 was admitted to the hospital with wounds under both breasts, coccyx and had a surgical incision on her back that was also a wound. Review of the hospital's Nursing Wound Consult Evaluation dated 12/13/22 revealed the bilateral breast were pink, white, moist, with dry maroon, and yellow crusts. There were moderate amounts of serosanguinous drainage, but no odor. Etiology consistent with moisture related intertriginous dermatitis. The lumbar surgical incision had 100% yellow slough. Moderate amounts of tan creamy drainage, with no odor. Peri-wound skin red and intact. Cleansed with Anasept skin and wound cleanser. Gently packed the wound with dry Mesalt ribbon. Recommend the Mesalt packing for mechanical debridement. Measurement for the dehisced lumbar surgery site was 11 centimeters (cm.) in length by 2.0 cm wide by 1.0 cm in depth, that had moderate drainage, yellow, and tan in color. Interview on 12/28/22 at 5:17 P.M. with the Director of Nursing (DON) verified the facility did not complete weekly skin checks on Resident #55. The DON stated she was off work for COVID-19 and while she was gone, no skin assessments were done. Interview on 01/05/22 at 2:00 P.M. with Registered Nurse (RN) #302 stated she did work with Resident #55 and remembered when she was assessing her lower back incision. RN #302 could not the date she found this. RN #302 stated she did reach out to the surgeon's office more than four times to get orders to treat the lower back incision. RN #302 stated she had spoken to a nurse over the phone and would not give new orders at this time. RN #302 stated the nurse stated the surgeon would see her on her next appointment. RN #302 never heard back, and then tried to call again to get a response. RN #302 stated she notified NP #654 who stated to keep trying to get ahold of the surgeon. RN #302 also notified the Assistant Director of Nursing (ADON) #228 of her concern of the incision to the lower back incision. RN #302 stated the incision was looking infected, it was not closing like it should be and it was dehiscing. RN #302 stated she spoke to on call physician of the surgeon's office who wanted to see a picture of Resident #55's lower lumbar surgery site by picture through email. RN #302 stated she did not send the email but thought ADON #228 was supposed to do it. Telephone interview on 01/05/22 at 1:59 P.M. with NP #654 stated Resident #55's incision looked infected. NP #654 stated the doctor wanted her to send a picture to the surgeon. NP #654 stated it was dehiscing but Resident #55 did not need to be sent to the ER for the concern. NP #654 verified after 12/06/22, the facility did not contact her regarding Resident #55's incision and did not notify her the facility was unable to contact the surgeon's office. Telephone interview on 01/05/22 at 3:45 P.M. with the Surgeon's Nurse Practitioner (SNP) #707 revealed the facility notified the office that Resident #55 needed a physician order for a treatment to the back incision. SNP #600 stated the surgeon's office faxed the order to the facility on [DATE] to keep the incision left OTA. SNP #600 stated the surgeon's office did not receive any type of notification either through telephone call, fax, or email that Resident #55's surgical back incision had deteriorated. SNP #600 stated they were only asked for a treatment order and the facility did not notify the surgeon's office of any concerns. Interview with Regional Corporate Nurse #800 on 01/05/22 at 4:00 P.M. verified the facility had no records of communications to the NP #654, the surgeon's office, or the primary physician at the facility to notify them Resident #55's back incision had deteriorated. Regional Corporate Nurse #800 verified there was no evidence NP #654 was updated after 12/06/22 when the NP requested to be notified if the facility was unable to be contact the surgeon's office. Regional Corporate Nurse #800 verified the physician note dated 12/07/22 stated there would be an order for Miconazole powder twice daily for 14 days and there was no evidence this was initiated until five days later 12/12/22. Regional Corporate Nurse #800 verified nursing did not document any concerns related to Resident #55's lower back incision. An attempt to interview ADON #228 during the investigation was unsuccessful. Review of the facility's policy titled Wound Treatment Management, dated 2022, revealed the wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modification include lack of progression towards healing, change in the characteristics of the wound, and changes in the resident's goals and preferences, such as the end-of-life or in accordance with his or her rights. This deficiency represents non-compliance investigated under Complaint Number OH00138420.

Based on closed medical record review, review of medical transport records, review of hospital practitioner documentation, review of an emergency room history and physical, review of a hospital discharge summary, review of a facility self-reported incident, review of witness statements, and interviews with facility staff, the facility failed to hold anticoagulants when Resident #57 had indications of bleeding and failed to attempt to contact to alternate practitioners when the physician was not able to be reached. This resulted in Immediate Jeopardy on 02/25/22 at 4:30 A.M. when Resident #57 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57's physician was unable to be reached and no attempts were made to reach the Certified Nurse Practitioner (CNP) #131. Licensed Practical Nurse (LPN) #103 administered Resident #57's morning medications including [MEDICATION(S)], [MEDICATION(S)], and Aspirin, and Resident #57 began bleeding again around an hour and a half later. Transportation was called and Resident #57 was transported to the hospital. At the hospital, Resident #57 was found to have hemorrhagic shock with a suspected lower [CONDITION(S)] and subsequently passed away on 02/25/22. This affected one resident (#57) out of three residents (#10, #54, and #57) reviewed for anticoagulant medication usage. The facility identified 13 residents (#10, #14, #15, #19, #22, #33, #38, #46 #47, #52, #54, #55, #76) on anticoagulants. The census was 55. On 03/31/22 at 4:25 P.M., the Administrator was notified Immediate Jeopardy began on 02/25/22 at 4:30 A.M. when Resident #57 was noted to have bloody stool, the physician was unable to be reached and no attempts were made to reach an alternate practitioner. Resident #57 was administered [MEDICATION(S)] (anticoagulant medication), [MEDICATION(S)] (antiplatelet medication), and Aspirin around 10:00 A.M. on 02/25/22 prior to speaking to a practitioner and began bleeding again around an hour and a half later. Resident #57 was transported to the hospital and found to have hemorrhagic shock with a suspected lower [CONDITION(S)]. Resident #57 subsequently passed away in the hospital on 02/25/22. The Immediate Jeopardy was removed on 04/01/22 when the facility implemented the following corrective actions: · On 04/01/22, a Quality Assurance and Performance Improvement (QAPI) meeting was held with the medical director and interdisciplinary team to discuss alleged deficient practices and plan of action. The Administrator initiated a QAPI meeting to gather and process information from the audits and monitoring process. Findings were to be reported to the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months. · On 04/01/22, the Director of Nursing (DON) conducted and completed an audit of all residents for change in condition and found no unaddressed concerns or concerns related to timely notification to the physician. All residents will be audited for change of condition and timely notification daily by the Director of Nursing or designee for four weeks, then three to five times a week for four weeks, and then monthly for three months. Audits are to be reviewed in the monthly Quality Assurance meeting to determine the need for further monitoring. · On 04/01/22, the DON conducted and completed an audit of all residents and identified 13 residents receiving anticoagulation therapy. Orders were added to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . All new and existing residents with orders for anticoagulant therapy will be audited daily by the Director of Nursing or designee for four weeks, then three to five times a week for four weeks, and then monthly for three months. Audits will be reviewed in the monthly Quality Assurance Meeting to determine the need for further monitoring. · On 04/01/22, the policy titled Medication Monitoring- Monitoring of Medication Administration was revised by the Corporate Clinical Consultant to include the following: Any resident receiving anticoagulation therapy was to have an order set added to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . · On 04/01/22, the DON educated all nurses on when to hold anticoagulants. Any new nurses or agency nurse hired after this date will receive education on this process upon hire. · On 04/01/22, the DON educated all nurses on change of condition, timely notification to the physician and/or CNP, and who to contact when the physician is unavailable. Any new nurses or agency nurse hired after this date will receive education on this process upon hire. · Interview on 04/04/22 between 10:40 A.M. and 10:50 A.M. with Agency LPN #150, Registered Nurse (RN) #145, and LPN #147, revealed staff were knowledgeable of the facility policies related to anticoagulant administration and contacting a physician or alternate practitioner. Although the Immediate Jeopardy was removed on 04/01/22, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #57's medical record revealed Resident #57 was admitted to the facility on [DATE]. Resident #57 discharged to the hospital on 02/25/22 where she subsequently passed away. Resident #57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's plan of care dated 02/02/22 revealed Resident #57 was at risk for adverse medication reactions related to medication use, including Aspirin 81 milligrams (mg) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #57 had intact cognition. Resident #57 received an anticoagulant five days during the lookback period. Review of Resident #57's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57 received [MEDICATION(S)] on the morning of 02/25/22. Resident #57 was to be administered [MEDICATION(S)] one time a day in the morning, Resident #57 received [MEDICATION(S)] on the morning of 02/25/22. Resident #57 was to receive Aspirin 81 mg one time a day in morning, Resident #57 received Aspirin 81 mg in the morning on 02/25/22. Resident #57 was to receive Aspirin 325 mg in the morning, Resident #57 received Aspirin 325 mg in the morning on 02/25/22. Review of Resident #57's progress note dated 02/25/22 at 4:41 A.M. revealed during peri-care an aide and LPN #115 noted Resident #57 had blood in her stool. Resident #57 declined to be sent to the hospital and the family was unable to be reached. Review of Resident #57's progress note dated 02/25/22 at 12:28 P.M. revealed Resident #57 had blood in her stool that morning at 4:30 A.M. The primary care physician and family were aware of the situation and Resident #57's family agreed to send Resident #57 to the hospital for evaluation, transportation would be taking Resident #57 to the hospital in two hours. The primary care physician ordered some of her medications to be put on hold to prevent further bleeding. Review of the Medical Transportation Patient Care Record dated 02/25/22, revealed the paramedics were notified at 1:12 P.M. of the need for transportation for Resident #57. The paramedics arrived to pick up Resident #57 at 1:40 P.M. and noted Resident #57 was alert to herself. Nursing staff reported Resident #57 had a rectal bleed since 4:00 A.M., they additionally reported Resident #57 had been becoming increasingly confused and less talkative. The nursing staff reported Resident #57 was given her morning medications which included [MEDICATION(S)] and Aspirin at 8:00 A.M. The paramedics departed the facility with Resident #57 at 1:46 P.M. and arrived to the hospital at 1:55 P.M. Review of the emergency room provider notes dated 02/25/22, revealed Resident #57 admitted to the emergency room alert to time and not location. The paramedics reported Resident #57 was found to have a rectal bleed around 4:00 A.M. that morning and received her medications at 8:00 A.M. including [MEDICATION(S)], Aspirin, and [MEDICATION(S)]. Resident #57 was pale with visible hematochezia (bloody) stool between her legs and on her rectum. She was found to be hypotensive with a low blood pressure of 74/38 millimeters of mercury (mmHg). Resident #57 and her family indicated they did not want extensive measures and comfort care was started. On 02/25/22 at 8:56 P.M., it was noted that Resident #57 had passed away with her family on the way to the hospital. Review of the hospital history and physical assessment and plan dated 02/25/22, revealed Resident #57 had hemorrhagic shock with suspected lower [CONDITION(S)]. Resident #57 had additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57 was actively hemorrhaging and dying. The note revealed DVT prophylaxis was contraindicated due to a [CONDITION(S)]. Resident #57 was to be admitted for end-of-life care as the family elected not to pursue aggressive measures. Review of the hospital discharge summary dated 03/01/22 revealed Resident #57 passed away on 02/25/22. Resident #57's discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Self-Reported Incident (SRI) dated 03/04/22, revealed there was an allegation of neglect related to Resident #57. The narrative summary revealed on 03/04/22, the ombudsman had notified the administrator of a care concern that took place on 02/25/22. The hospital emergency room had notified the ombudsman of the concern. Resident #57 was sent to the emergency roiagnom on [DATE] from the facility. Resident #57 was found to have blood in her stool by facility staff at 4:30 A.M. The staff notified the physician and DON and attempted to send Resident #57 to the hospital, however, she refused. At 5:00 A.M., the nurse recorded that Resident #57's vitals were stable. At shift change, the oncoming nurse was updated on Resident #57's condition. The day shift nurses assessed Resident #57 prior to administering the prescribed medicine at 7:30 A.M. and noted Resident #57 was no longer bleeding. Later at 12:20 P.M., the nurse noted Resident #57 was bleeding and was able to convince Resident #57 and her family that Resident #57 should be sent to the hospital. The facility was notified on 02/26/22 that Resident #57 had passed away in the hospital. The physician stated Resident #57 was on blood thinners to prevent another stroke and was admitted to the facility after having symptoms consistent with recent [CONDITION(S)]. The facility determined the allegation was unsubstantiated as the evidence showed the facility acted appropriately. The DON reeducated the nurses on proper shift change information. Review of the undated SRI witness statement from LPN #115, revealed on the morning of 02/25/22, LPN #115 assisted with peri-care for Resident #57 and noted blood mixed with her bowel movement. Resident #57 declined to be sent to the hospital and LPN #115 did an assessment of Resident #57's vital signs and pain level. LPN #115 attempted to reach Resident #57's power of attorney (POA) twice and was unable to. LPN #115 attempted to reach Physician #107 and received no response. LPN #115 contacted the DON, informed her of the situation and Resident #57's code status. The DON told her to continue to monitor Resident #57 and attempt to reach the physician. LPN #115 texted the physician and waited for a response. During her last round prior to shift change, she reported no change in Resident #57's condition. Review of the undated SRI witness statement from LPN #103, revealed she was notified of Resident #57's concerns by the night nurse. LPN #103 assessed Resident #57 and noted her vital signs were stable and Resident #57 was no longer bleeding. LPN #103 administered Resident #57's medications. LPN #103 reported later Resident #57 began bleeding while Physician #107 was in the building. Physician #107 ordered Resident #57's blood thinners to be discontinued and a lab draw. The bleeding continued and Resident #57 and her son were convinced to go to the hospital for evaluation. Interview on 03/30/22 at 11:25 A.M. with LPN #115, revealed she was the nurse working when Resident #57 initially presented with bloody stools. LPN #115 reported Resident #57 had a medium amount of blood in her stools but was not bleeding from her rectum. She stated Resident #57 declined to go to the hospital and she was unable to reach her POA. LPN #115 reported she had been unable to reach Resident #57's physician prior to the end of her shift. LPN #115 reported Physician #107 was the only practitioner she attempted to reach as he was the on-call physician. LPN #115 reported Resident #57 had no additional stools prior to shift change. LPN #115 stated anticoagulants should be held based on resident symptoms and orders. Interview on 03/30/22 at 11:31 A.M. and 5:16 P.M. with LPN #103, revealed she was told about the blood in Resident #57's stool during shift change. LPN #103 reported she attempted to contact Physician #107 twice prior to medication administration and was unsuccessful. LPN #103 reported she assessed Resident #57 prior to medication administration and Resident #57 had not been bleeding at that time, however, she reported Resident #57 had not had a bowel movement during her shift. LPN #103 reported she provided Resident #57's medications as ordered around 10:00 A.M. including Aspirin, [MEDICATION(S)], and [MEDICATION(S)]. LPN #103 reported around an hour or two later, Resident #57 had a bowel movement with blood and the bleeding increased rapidly. LPN #103 reported at that time, she was able to get ahold of the physician who put a hold on her anticoagulants. She reported initially Resident #57's family wanted to keep her in the facility. However, LPN #103 stated she was able to convince them Resident #57 required evaluation only the hospital could provide. Interview on 03/30/22 at 1:30 P.M. with Physician #107, revealed he was always reachable by phone, but staff could call the CNP (CNP #131) if needed. Physician #107 was unsure why he was unable to be reached on the morning of 02/25/22. Physician #107 reported administration of Resident #57's [MEDICATION(S)], [MEDICATION(S)], and Aspirin was up to the nurse's discretion at that time. Physician #107 stated the nurse needed to weigh the risks of bleeding with the risk of a stroke. Physician #107 confirmed he was reached after Resident #57 had begun bleeding again and the family had not wanted her sent out, so he put a hold on Resident #57's [MEDICATION(S)], Aspirin and [MEDICATION(S)], and ordered a blood panel. Interview on 03/30/22 at 1:40 P.M. and on 03/31/22 at 10:16 A.M. with the DON revealed administration of Resident #57's anticoagulant medications on 02/25/22 was up to the nurse's judgement. The DON stated calling alternate practitioners was also based on nursing judgement however, the nurse could have called CNP #131 when Physician #107 could not be reached. Interview on 04/04/22 at 12:44 P.M. with the Administrator revealed Resident #57's medications had to have been administered around 7:30 A.M. to 8:00 A.M. on 02/25/22, as the physician was in the building by 10:00 A.M. and the medications were administered prior to the physician arriving in the building. This deficiency substantiates Complaint Number OH 144.

Based on observations, interviews with staff and resident representative, medical record review, review of the facility's investigation report, and review of the hospital records, the facility failed to ensure a resident was provided a safe transfer with a Hoyer mechanical lift and bed mobility during Activities of Daily Living. This resulted in Actual Harm when Resident #5 sustained a bump on the left forehead with bruising and a large hematoma to the face, when resident's head and face were suspected to be rolled into the wall during care or when the resident was transferred in a Hoyer lift with only one staff member. In addition, staff failed to report when bruising was first noticed to begin investigation and treatment. This affected one (Resident #5) of three residents reviewed for accidents and hazards. The facility census was 50. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included cerebral infarction, sleep apnea, depression, and cerebral infarct. Review of the plan of care, dated 06/08/21, revealed Resident #5 was at risk of skin alteration in skin integrity with interventions including to assess for pain and provide treatment according to physician orders, notify the physician and family of changes as needed and provide skin care as needed. The care plan revealed the resident has impaired cognition due to dementia with interventions including administer medications as ordered, ask yes or no questions to determine resident needs, communicate with family and caregivers regarding needs and capabilities, and discuss concerns about confusion with resident's family members. Review of the annual Minimum Data Set (MDS) assessment, dated 06/21/21, revealed Resident #5 had mild cognitive impairment and required extensive assistance of two staff members and was totally dependent for transfers with use of a Hoyer. The resident was always incontinent of bowel and bladder. The resident has skin tears but no other wounds. Review of the progress notes, dated 07/22/21 by the Director of Nursing (DON), revealed the nurse was alerted to the resident having a hematoma to her left forehead, nursing assessment completed, family requested the resident go to the hospital for evaluation, the hospice nurse and nurse practitioner were made aware of the injury. Subsequent progress notes on 07/22/21 revealed the residents' daughter contacted the facility to inform the staff the resident was being kept at the hospital overnight for evaluation. On 07/22/21, the progress notes by the DON revealed the facility's investigation revealed a plastic object at the end of the light string seemed consistent with the resident being rolled toward the wall while providing care and bumped her head on the piece of plastic resulting in injury. The progress note, dated 07/23/21, revealed the resident returned to the facility on [DATE] and the nurse completed an assessment. The assessment revealed the resident had dark colored bruising around the left eye and discoloration across the forehead. On 07/24/21, the DON documented the resident had increased bruising that was not present when she transported to the Emergency Department. The new bruising was noted around the nose, right side of forehead, left eye, and left side of the face extending to the left neck. The DON noted the resident was on Aspirin 81 milligrams (mg.) daily which may lead to increased bruising. Review of the hospital discharge summary, dated 07/23/21, revealed the resident was status post unwitnessed fall. The resident had a left forehead hematoma, left elbow skin tear and left lower extremity skin tears. The residents' daughter stated there was no way the resident fell on her own because she was dependent on staff for bed mobility and transfers. No clear signs of chronic abuse including injuries in various stages although it was challenging to discern signs of abuse given the resident's deteriorated skin condition. The family wished for no further treatment and for the resident to be sent back to the nursing home as soon as possible. Review of the facility's incident investigation revealed there were no staff who knew how the resident sustained a hematoma and bruising above her left eye. State tested Nursing Aide (STNA) #65 received disciplinary action to use two staff for Hoyer transfers, to pay attention to the resident's placements during care, and notify the nurse immediately if any issues arise. Interview on 08/11/21 at 1:00 P.M. with Resident #5's family member (FM) #60 revealed the residents' daughter was at bedside around 10:00 A.M. on 07/22/21 when she noticed a bump on the resident's head at her hairline. The daughter informed the nurse and an aide of the concern and they came to the bedside and agreed the resident had a bump on her forehead at the hairline and bruising on her face but denied knowledge of what happened. FM #60 revealed they had spoken with the facility's Administrator and the DON regarding concerns and were informed that an investigation would be completed. FM #60 revealed after the investigation was completed, the family was informed the facility believed the resident was rolled by staff hitting her head on the wall and was nicked by a piece of plastic that was hanging from a light cord which caused the bump and cut on her head. FM revealed DON interviewed staff and no one confessed to rolling the resident into the wall, but one STNA was given a reprimand. Observation on 08/11/21 at 1:46 P.M. of Resident #5's injuries included a bruised left cheek bone that was reddish purple in color with scattered yellow and brown healing bruises above her eye and on her cheek below the bone. Resident also had a bump slightly smaller than a ping pong ball above her left eye near the hairline. Interview on 08/11/21 at 1:48 P.M. with the DON revealed the DON was first notified of a concern on 07/22/21 when Licensed Practical Nurse (LPN) #64 and STNA #65 informed her of the daughter's observation regarding the bump on Resident #5's head. DON revealed she spoke with the LPN and STNA and neither staff revealed knowledge of how the bump or bruising occurred. LPN informed the DON that she saw the bruising earlier when she was doing medication pass but revealed that she thought it looked like an older bruise and did not say anything to other staff or DON at that time. The DON revealed that she spoke with resident's family and informed them that an investigation would be completed to find out how the bruise occurred, but the initial thought was that it could have been an injury from a Hoyer transfer. The DON revealed the resident's family requested for the resident to be transferred to the hospital due to having a head injury. The DON revealed that while Resident #5 was in the hospital, the DON completed the facility's investigation. The DON revealed she laid in the resident's bed to see from the resident's viewpoints what could have caused the injuries. The DON revealed she found a bell-shaped piece of plastic hanging from the over the bed light string. The DON revealed that it was believed resident's head and face were rolled into the wall during care and therefore into the piece of plastic leading to a cut and bump on the forehead. The DON revealed that during her investigation, she spoke with the Assistant Director of Nursing (ADON), LPN, and STNA who worked night shift on 07/21/21 as well as LPN and STNA that worked day shift on 07/22/21. Night shift staff revealed no knowledge of incident or injury. Day shift STNA #65 denied any knowledge of incident or injury but was given a write up disciplinary action for not alerting staff to the injury and DON's assumption that STNA #65 was involved in rolling the resident's head into the wall. Interview on 08/12/21 at 9:50 A.M. with STNA #66 revealed she was assisting other residents and was asked to assist in a Hoyer transfer for Resident #5 around 7:00 A.M. to 7:30 A.M. on 07/22/21. STNA revealed that when she entered Resident #5's room, STNA #65 had already completed all care and just required the second staff for the Hoyer transfer. STNA #66 did not observe the hematoma or bruising on the resident's head and face. Interview on 08/12/21 at 1:15 P.M. with LPN #64 revealed she was called in for a shift the morning of 07/22/21 and arrived around 8:00 to 8:30 A.M. LPN revealed upon entrance to Resident #5's room, she noticed bruising and a bump on her head and face. LPN revealed she did not report the bruising or bump as she thought they were old injuries. When resident's daughter had arrived for her scheduled visit, daughter came out to the nursing station to ask about the bruises and bump on the resident's head. LPN verified with the residents' daughter that she was unaware of what caused the bruise to her face. LPN revealed that she spoke with the STNA and asked about the resident's injuries. LPN revealed the STNA would not answer her questions. Both the STNA and LPN went to get the DON and inform her of the injuries and the DON took over care of the resident while LPN caught up on getting morning medications passed. This deficiency substantiates Complaint Number OH 558.