Every finding on record at Tuscany Gardens

Based on observations and interview with staff, the facility failed to ensure privacy was maintained during medication administration for Residents #21, #52, #77, #84, #85, and #88. This affected six residents (#21, #52, #77, #84, #85, and #88) of 14 observed for medication administration. Findings Include: 1. Review of the medical record for Resident #85 revealed an admission date of 01/05/26 and diagnoses of diabetes, muscle weakness, cognitive communication deficit, need for assistance with personal care, high blood pressure, constipation, and congestive heart failure. Observation of medication administration on 03/13/26 at 11:35 A.M. revealed Registered Nurse #201 prepared medication at the medication cart outside the room of Resident #85. She proceeded to go into the room of Resident #85 without locking the screen of the computer leaving personal health information for Resident #85 in view for anyone to see. The information in view included the residents name, room number, diagnoses and medications. On 03/13/26 at 11:44 A.M. an interview with Registered Nurse #201 verified she had not locked the computer screen to protect Resident #85's personal health information.2. Review of the medical record for Resident #77 revealed an admission date of 10/16/19 and diagnoses of eating disorder, cerebral palsy, acute kidney failure, gastrointestinal hemorrhage, anxiety disorder, constipation, and contact with and suspected exposure to viral communicable diseases. Observation of medication administration on 03/13/26 at 11:42 A.M. revealed Registered Nurse #201 prepared medication at the medication cart outside the room of Resident #77. She proceeded to go into the room of Resident #77 without locking the screen of the computer leaving personal health information for Resident #77 in view for anyone to see. The information in view included the residents name, room number, diagnoses and medications. On 03/13/26 at 11:44 A.M. an interview with Registered Nurse #201 verified she had not locked the computer screen to protect Resident #77's personal health information.3. Review of the medical record for Resident #21 revealed an admission date of 09/27/25 and diagnoses of diabetes, malignant neoplasm of pancreatic duct and kidney, depression, and congestive heart failure. Observation of medication administration on 03/13/26 at 1:34 P.M. revealed Registered Nurse #200 prepared medication at the medication cart outside the room of Resident #21. She proceeded to go into the room of Resident #21 without locking the screen of the computer leaving personal health information for Resident #21 in view for anyone to see. The information in view included the residents name, room number, diagnoses and medications. On 03/13/26 at 2:03 P.M. an interview with Registered Nurse #200 verified she had not locked the computer screen to protect Resident #21's personal health information.4. Review of the medical record for Resident #88 revealed an admission date of 04/15/24 and diagnoses of anxiety, dementia, neuromuscular dysfunction of the bladder, slow transit constipation, and depression.Observation of medication administration on 03/13/26 at 1:38 P.M. revealed Registered Nurse #200 prepared medication at the medication cart outside the room of Resident #88. She proceeded to go into the room of Resident #88 without locking the screen of the computer leaving personal health information for Resident #88 in view for anyone to see. The information in view included the residents name, room number, diagnoses and medications. On 03/13/26 at 2:03 P.M. an interview with Registered Nurse #200 verified she had not locked the computer screen to protect Resident #88's personal health information.5. Review of the medical record for Resident #84 revealed an admission date of 09/01/21 and diagnoses of dementia, urinary tract infection, depression, constipation, and urine retention.Observation of medication administration on 03/13/26 at 1:43 P.M. revealed Registered Nurse #200 prepared medication at the medication cart outside the room of Resident #84. She proceeded to go into the room of Resident #84 without locking the screen of the computer leaving personal health information for Resident #84 in view for anyone to see. The information in view included the residents name, room number, diagnoses and medications. On 03/13/26 at 2:03 P.M. an interview with Registered Nurse #200 verified she had not locked the computer screen to protect Resident #84's personal health information.6. Review of the medical record for Resident #52 revealed an admission date of 02/17/26 and diagnoses of depression, altered mental status, urine retention, high blood pressure, constipation, and congestive heart failure. Observation of medication administration on 03/13/26 at 1:46 P.M. revealed Registered Nurse #200 prepared medication at the medication cart outside the room of Resident #52. She proceeded to go into the room of Resident #52 without locking the screen of the computer leaving personal health information for Resident #52 in view for anyone to see. The information in view included the residents name, room number, diagnoses and medications. On 03/13/26 at 2:03 P.M. an interview with Registered Nurse #200 verified she had not locked the computer screen to protect Resident #52's personal health information.

Based on observation and interview with staff, the facility failed to ensure the medication carts were locked when unattended. This had the potential to affect 9 (#17, #34, #40, #50, #57, #59, #63, #87, and #93) cognitively impaired and independently mobile residents, on the 200 and 300 halls, identified during the survey. Findings Include: 1. Observation of medication administration on 03/13/26 at 11:35 A.M. revealed Registered Nurse #201 prepared medication at the medication cart outside the room of Resident #85. She proceeded to go into the room of Resident #85 without locking the medication cart.On 03/13/26 at 11:44 A.M. an interview with Registered Nurse #201 verified she had not locked the medication cart.2. Observation of medication administration on 03/13/26 at 11:42 A.M. revealed Registered Nurse #201 prepared medication at the medication cart outside the room of Resident #77. She proceeded to go into the room of Resident #77 without locking the medication cart. On 03/13/26 at 11:44 A.M. an interview with Registered Nurse #201 verified she had not locked the medication cart. 3. Observation of medication administration on 03/13/26 at 1:34 P.M. revealed Registered Nurse #200 prepared medication at the medication cart outside the room of Resident #21. She proceeded to go into the room of Resident #21 without locking the medication cart.On 03/13/26 at 2:03 P.M. an interview with Registered Nurse #200 verified she had not locked the medication cart.4. Observation of medication administration on 03/13/26 at 1:38 P.M. revealed Registered Nurse #200 prepared medication at the medication cart outside the room of Resident #88. She proceeded to go into the room of Resident #88 without locking the medication cart. On 03/13/26 at 2:03 P.M. an interview with Registered Nurse #200 verified she had not locked the medication cart. 5. Observation of medication administration on 03/13/26 at 1:43 P.M. revealed Registered Nurse #200 prepared medication at the medication cart outside the room of Resident #84. She proceeded to go into the room of Resident #84 without locking the medication cart.On 03/13/26 at 2:03 P.M. an interview with Registered Nurse #200 verified she had not locked the medication cart. 6. Observation of medication administration on 03/13/26 at 1:46 P.M. revealed Registered Nurse #200 prepared medication at the medication cart outside the room of Resident #52. She proceeded to go into the room of Resident #52 without locking the medication cart. On 03/13/26 at 2:03 P.M. an interview with Registered Nurse #200 verified she had not locked the medication cart.

Based on observations, review of the medical record, review of the Controlled Drug record, and interview with the staff, the facility failed to ensure the Controlled Drug record and the narcotic count were maintained to identify the actual doses of oxycodone/acetaminophen (a controlled narcotic medication) in the facility and failed to ensure staff did not pre-pour narcotic medication prior to administration for Resident #9. This affected one Resident (#9) of 14 observed for medication administration.Findings Include:Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included mood disorder, bipolar disorder, anemia, diabetes, mild cognitive impairment, chronic pain, dementia, insomnia, cataracts, absence of a spleen, and follicular disorder.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #9 had intact cognition.Review of Resident #9's physician orders revealed an order dated 07/18/25 for oxycodone acetaminophen 10/325 milligrams with instructions to administer one tablet four times per day for pain.Review of the Controlled Drug Record-Disposition form on 03/13/26 for the oxycodone-acetaminophen for Resident #9 revealed he should have had 13 tablets of oxycodone-acetaminophen left however the medication card in the narcotic drawer only had 12 tablets left. Observation of medication administration on 03/13/26 at 11:48 A.M. revealed Registered Nurse #201 retrieved an oxycodone acetaminophen 10/325 milligrams out of the locked medication cart for Resident #9. The count remaining on the card was 12 tablets. Registered Nurse #201 proceeded to sign the dose out however the record indicated there should have been 13 doses remaining. The record indicated one tablet was administered, for the future, at 12:00 P.M. on 03/13/26 for 13 tablets and one administered, for the future, at 5:00 P.M. on 03/13/26 for 12 tablets left however both were errored out and initialed by Registered Nurse #201.On 03/13/26 at 11:55 A.M. an interview with Registered Nurse #201 revealed she had wasted a dose of oxycodone acetaminophen earlier in the day and did not have anyone witness or sign for it. A supervisor was called at this time to report the discrepancy.On 03/13/26 at 12:44 P.M. an interview with Regional Clinical Nurse #300 revealed Registered Nurse #201 had not told the surveyor the truth about what had happened to the narcotic. On 03/13/26 at 12:45 P.M. an interview with Registered Nurse #201 revealed she had pre-poured the dose of oxycodone acetaminophen for Resident #8 and it was in the top drawer of the medication cart and she was scared to tell the surveyor the truth. She stated she was trying to get ahead because Fridays were crazy with admissions and the nurse practitioner rounding. She sated she had pre-poured medications and signed them out for the whole shift. She verified she errored them out when she found out she would be observed for medication administration.

Based on observation, review of the medical record, interview, and review of facility policy, the facility failed to maintain proper infection control during administration of tube feed medications for Resident #15. This affected one resident (Resident #15) of 14 observed during medication administration.Findings Include: Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, chronic obstructive pulmonary disease, anemia, hypothyroidism, gastrostomy, major depressive disorder, generalized anxiety disorder, hallucinations, schizoaffective disorder, adult failure to thrive, and dementia.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #15 had severely impaired cognition and had a feeding tube.Observation of tube feed medication administration on 03/13/26 at 9:58 A.M. revealed Licensed Practical Nurse (LPN) #202 went into the room of Resident #15, obtained the graduated container and syringe (the syringe was inside the graduate with no bag or date) off the bedside table, she went into the bathroom and put 500 milliliters (ml) in the graduate and came back out of the bathroom, and set the cup with the medication and syringe directly on the bedside table without placing a barrier down. The table was visibly dirty. She proceeded to administer the medication with the syringe. On 03/13/26 at 10:20 A.M. an interview with Licensed Practical Nurse #202 verified she had set the syringe directly on the visibly dirty bedside table without a barrier.On 03/13/26 at 1:20 P.M. an interview with Regional Clinical Nurse #300 verified Licensed Practical Nurse #202 should have placed a barrier on the bedside table prior to placing the syringe on the table. Review of the facility policy titled, Enteral Tube Medication Administration, dated 06/11/24 revealed it was the practice of the facility to administer medication through an enteral feeding tube as prescribed and in accordance with current clinical standards of practice.

Based on observation, record review, staff interview and facility policy review, the facility failed to change and date oxygen tubing and supplies as ordered and failed to store respiratory equipment in a safe and sanitary manner. This affected four residents (#38, #44, #71, #82) of four residents reviewed for respiratory care. The census was 99.Findings Include:1. Review of the medical record for Resident #44 revealed an initial admission date of 05/02/25 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), pulmonary embolism, congestive heart failure, hypertension, chronic kidney disease, hyperlipidemia, gastro-esophageal reflux disease, osteoarthritis, constipation, hypothyroidism, anxiety disorder and chronic respiratory failure. Review of the plan of care dated 05/12/25 revealed the resident has a respiratory deficiencies or abnormalities of pulmonary function related to COPD, history of respiratory failure and oxygen use. Interventions included administer oxygen as ordered, aerosol treatments as ordered, diagnostic studies as ordered, elevate head of bed as needed, medications as ordered, monitor for signs/symptoms of respiratory function, monitor lung sounds as ordered, monitor oxygen saturation as ordered, Monitor/observe if resident is avoiding lying flat related to shortness of breath or trouble breathing, observe for signs/symptoms of dyspnea, oxygen as ordered, provide inhalers as ordered, respiratory assessment as ordered, respiratory medications as ordered, update Physician with any abnormal or new findings for possible evaluation or further treatment as needed, update resident/family as necessary and vital signs as ordered. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident received oxygen therapy. Review of the resident's monthly physician orders for September 2025 identified orders dated 08/25/25 clean filter on oxygen concentrator every Wednesday on night shift, may use three to four liters of oxygen continuously per nasal cannula to maintain oxygen saturation above 90% every shift, change oxygen tubing/cannula/mask every Wednesday on night shift. Review of the resident's May, June, July, August and September Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documented evidence the resident's nasal cannula or humidifier bottle was changed weekly. On 09/15/25 at 3:03 P.M. observation of the resident revealed the oxygen nasal cannula was not dated and the humidifier bottle was not dated and empty. On 09/15/25 at 3:15 P.M., an interview with Registered Nurse (RN) #582 verified the nasal cannula had no date and no documented evidence the tubing had been changed since admission to the facility. The RN also verified the humidifier bottle had no date and was empty. 2. Review of the medical record for Resident #38 revealed an initial admission date of 01/16/25 with the latest readmission of 08/05/25 with the diagnoses including but not limited to congestive heart failure, diabetes mellitus, hypothyroidism, atrial fibrillation, depression and osteomyelitis of vertebra, lumbar region. Review of the plan of care dated 01/28/25 revealed the resident required oxygen related to congestive heart failure. Interventions included administer oxygen as ordered, change filter on oxygen concentrator per orders, change oxygen tubing, mask and cannula per orders, monitor lung sound as ordered, observe for signs/symptoms of dyspnea and respiratory system observation, monitoring, and data collection of current respiratory deficiencies or abnormalities of pulmonary function, update physician as needed. Review of the resident's quarterly Minimum Data (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident received oxygen therapy. Review of the resident's monthly physician orders for September 2025 identified orders dated 02/05/25 change oxygen tubing/cannula/mask every Wednesday on night shift, change filter on oxygen concentrator weekly every Wednesday on night shift, oxygen at three liters per minute continuous per nasal cannula to maintain saturation above 90% and 04/09/25 check oxygen saturation every shift while on oxygen. On 09/15/25 at 11:21 A.M., observation of the resident revealed the resident's oxygen nasal cannula had no date and the humidifier bottle had no date and was empty. On 09/15/25 at 11:36 A.M., an interview with RN #582 revealed verified the resident's oxygen nasal cannula had no date and the humidifier bottle was not dated and empty. 3.Review of the medical record for Resident # 71, revealed an admission date of 07/21/21. Diagnoses included but were not limited to paralytic syndrome, chronic obstructive pulmonary disease, asthmas, gastroesophageal reflux disease, osteoporosis, pulmonary heart disease, diaphragmatic hernia, allergic rhinitis, dysphagia, peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating the resident had no cognitive deficit. Review of an order dated 08/06/21, revealed Resident #71 required staff to administer Budesonide Suspension 0.25 milligrams (mg)/2 milliliter (mL) 2 ml inhale orally two times a day for asthma via nebulizer. Further review revealed a physician order dated 02/05/25 to change nebulizer tubing, cannula, and mask on night shift every Wednesday. Observation on 09/15/2025 at 11:39 A.M. Resident #71's nebulizer tubing and mask were lying in an open plastic box on a brown paper towel with no visible date on the tubing or mask. Interview on 09/15/25 at 1:37 P.M. with Registered Nurse (RN) #582 confirmed Resident #71's nebulizer mask and tubing were lying in open plastic box on a brown paper towel. Additionally, RN #582 confirmed the tubing was undated, but should be dated and changed every Wednesday night. Interview on 09/17/25 at 09:30 A.M. with RN Manager of Clinical Services #700 stated there is no policy for nebulizers or tubing and no policy on storing and cleaning nebulizer supplies. 4. Review of the medical record revealed Resident #82 was admitted on [DATE]. Diagnoses include chronic obstructive pulmonary disease (COPD), type II diabetes mellitus without complications, chronic systolic (congestive) heart failure, and obstructive sleep apnea. Review of Resident #82's Minimum Data Set (MDS) dated [DATE] states Resident #82 had a BIMS of 15 out of 15, cognitively intact and required use of walker or wheelchair and experienced shortness of breath or trouble breathing when laying flat. Review of Resident #82's care plan dated 09/15/25 revealed Resident #82 has respiratory deficiencies related or abnormalities of pulmonary function related to COPD, orthopnea, and SOB on exertion with the goal of reducing the risk of respiratory complications through target date. Interventions include elevate head of bed (HOB) as needed, oxygen as ordered, respiratory assessment as ordered, respiratory medications as ordered, and respiratory therapy treatments are ordered. Review of Resident #82's care plan dated 09/15/25 revealed Resident #82 is at risk for decreased cardiac output and impaired gas exchange related to disease process with goal of Resident lungs will be clear and no SOB on exertion and resident #82 will show adequate cardiac output. Interventions include oxygen as ordered, rest periods as needed, visual reminder to wear oxygen at all times and monito the effectiveness of interventions. Review of Resident #82's physician orders revealed an order for continuous oxygen at 2-4 L via nasal cannula every shift. Review of Resident #82's physician orders revealed an order to change oxygen tubing/cannula/mask weekly every night shift every Wednesday related to chronic obstructive pulmonary disease. Review of Resident #82's physician orders revealed an order to change nebulizer tubing/mask/cannula weekly every night shift every Wednesday. Review of Resident #82's TAR revealed oxygen tubing was not documented as being changed on 09/03/25. Observation on 09/15/25 at 11:30 A.M. Resident #82 sitting in recliner with oxygen concentrator in use with a undated empty humidifier bottle and no date on oxygen tubing. Observation on 09/15/25 at 11:31 A.M. of Resident #82's bed revealed an uncovered nebulizer mask laying on the bed with the tubing labeled 08/27. Interview on 09/15/25 at 11:30 A.M. with Resident #82. revealed he requires 4L of oxygen Interview on 09/15/25 at 2:00 P.M. with Resident #82 revealed he occasionally requires the use of his nebulizer. Interview on 09/15/25 at 2:05 P.M. with LPN #575 verified the humidifier bottle on Resident #82 was empty, O2 tubing was not dated, and nebulizer mask was uncovered on Resident #82's bed. Review of the facility's policy titled Oxygen Administration revised on 07/30/24 indicates oxygen tubing and mask/cannula may be changed weekly and as needed when in use and nebulizer tubing and delivery devices may be changed as recommended by the manufacturer and as needed when in use. Review of the National Institutes of Heath (NIH) https://www.nhlbi.nih.gov/sites/default/files/publications/How-to-Use-a-Nebulizer-21-HL-8163.pdf publication number 21-HL-8163 titled How to use a nebulizer, dated October 2021stated in between uses to store the nebulizer parts in a dry, clean plastic storage bag. Keep each person's medicine cup, mouthpiece or mask, and tubing in a separate labeled bag to prevent the spread of germs.

Based on observation, staff interview, and facility policy, the facility failed to ensure proper food storage, labeling, and staff hygiene in the kitchen. This had the potential to affect 93 out of 99 residents residing in the facility, with six residents on nothing by mouth (NPO) diets. The facility census was 99.Findings include:Observation on 09/15/25 from 8:28 A.M. to 8:46 A.M. revealed that in the freezer there was open frozen corn on the cob that was undated, and opened frozen carrots that were undated. In the refrigerator, there was an open strawberry yogurt that was undated, open shredded lettuce that was undated, open shredded cheese that was undated, and open shredded mozzarella cheese with an open date of 08/05/25. In the dry storage area, there was opened spaghetti with an unreadable open date and opened orzo that was undated. Additionally, Dietary Personnel #550 and Dietary Personnel #521 were observed to have hats on with exposed hair coming out of the hat from a ponytail that was not contained in the hat or a hair net.Interview on 09/15/25 at 8:46 A.M. with Dietary Manager #599 confirmed the above findings and stated that she instructed all staff to place hair nets on if there was any exposed hair coming outside of the hats being worn.Review of the facility policy titled, Dating and Labeling, stated that all refrigerated, ready-to-eat, time/temperature controlled for safety (TCS) food held refrigerated for more than 24 hours must be date marked, and unmarked or expired foods must be discarded. Additionally, it stated that food must be clearly marked to indicate the date by which the food will be consumed, served, sold, or discarded, with a maximum of 7 days.

Based on observation, medical record review and interview, the facility failed to ensure residents were provided adaptive equipment to promote independence with eating. Additionally, the facility failed to ensure food residents disliked were not served to residents. This affected one resident (#79) of four residents reviewed for nutrition. The facility census was 99.Findings Include:Review of the medical record for Resident #79 revealed an initial admission date of 10/16/19 with the latest readmission of 11/30/24 with the diagnoses including but not limited to cerebral palsy, chronic respiratory failure, chronic pain syndrome, protein calorie malnutrition, anemia, anxiety disorder, gastro-esophageal reflux disease and neuropathy. Review of the plan of care dated 10/25/19 revealed the resident had the potential for alteration in nutrition and hydration related to malnutrition, dysphagia, cerebral palsy, history of gastrointestinal bleed and anxiety. Interventions included adaptive equipment as ordered, honor food preferences as able, medications as ordered, monitor consistency of diet served, obtain food preferences, provide assistance with meals/snacks as necessary, extensive assistance and provide diet as ordered. Review of the resident's meal ticket dated 09/16/25 revealed the resident disliked oatmeal, biscuit and gravy, chocolate, cereal, gravy and watermelon. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident required set-up assistance with eating. The assessment indicated the resident received a mechanically altered diet. Review of the resident's monthly physician orders for September 2025 identified orders dated 11/12/24 regular mechanical soft diet, double handled cups with spout lid, divided plate and left-hand curve utensils. On 09/16/2025 at 8:45 A.M., observation of the resident revealed his meal ticket indicated he did not like gravy however his ground sausage had brown gravy covering it. The resident was trying to use a regular fork due to the left curved utensil was not within reach. The resident was noted to only have one two handled cup on his meal tray. The resident had a glass of water in a regular cup instead of a two handled cup. On 09/16/2025 at 8:50 A.M., interview with Certified Nursing Assistant (CNA) #573 revealed the resident's water is poured into the two handled cup that had cranberry juice once he is done and the left curve utensil was not within the resident's reach to utilize. CNA #573 also verified the sausage was covered in gravy and his meal ticket specified he disliked gravy. On 09/18/2025 at 3:27 P.M., an interview with Dietary Supervisor #599 revealed if the resident disliked gravy, then he shouldn't have it on the ground sausage. She said he worked with speech and that was the recommendation. The Dietary Supervisor verified each fluid should have a lidded two handled cup and the resident should be handed the left curved utensil with set-up.

Based on observation, medical record review, interviews and review of resident meal ticket, the facility failed to meet the nutritional needs of one resident. This affected one resident (#79) of four residents reviewed for nutrition. The facility census was 99.Findings Include:Review of the medical record for Resident #79 revealed an initial admission date of 10/16/19 with the latest readmission of 11/30/24 with the diagnoses including but not limited to cerebral palsy, chronic respiratory failure, chronic pain syndrome, protein calorie malnutrition, anemia, anxiety disorder, gastro-esophageal reflux disease and neuropathy. Review of the plan of care dated 10/25/19 revealed the resident had the potential for alteration in nutrition and hydration related to malnutrition, dysphagia, cerebral palsy, history of gastrointestinal bleed and anxiety. Interventions included adaptive equipment as ordered, honor food preferences as able, medications as ordered, monitor consistency of diet served, obtain food preferences, provide assistance with meals/snacks as necessary, extensive assistance and provide diet as ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident required set-up assistance with eating. The assessment indicated the resident received a mechanically altered diet. Review of the resident's monthly physician orders for September 2025 identified orders dated 11/12/24 regular mechanical soft diet, double handled cups with spout lid, divided plate and left-hand curve utensils. Review of the resident's meal ticket dated 09/16/25 revealed the resident disliked oatmeal, biscuit and gravy, chocolate, cereal, gravy and watermelon. On 09/16/2025 at 8:45 A.M., observation of the resident revealed his meal ticket indicated he did not like gravy however his ground sausage was covered with a brown gravy. Further observation revealed the resident had one pancake and the ground sausage on his plate and the dislike for hot and cold cereal was not replaced to meet the residents' nutritional needs. On 09/16/2025 at 8:50 A.M., an interview with Certified Nursing Assistant (CNA) #573 verified the dietary department had not sent any replacement for the oatmeal not served due to the resident disliking oatmeal and cereal.

Based on observations, medical record review, and staff interview, the facility failed to ensure the call light was positioned within reach of one resident. This affected one (Resident #60) of one resident observed for call light placement. The facility census was 99.Findings include: Review of the medical record for Resident #60 revealed an admission date of 09/04/24. Diagnoses included but not limited to sepsis, atrial fibrillation, paranoid schizophrenia, muscle weakness, need for assistance with personal care, dysphagia, mild cognitive impairment, depression, hypothyroidism, hyperlipidemia, acute respiratory failure, retention of urine, signs and symptoms concerning food and fluid intake, neuromuscular dysfunction of bladder, primary hypertension, abnormalities of gait and mobility.Review of the most recent Minimum Data Set (MDS) assessment, dated 09/03/25, revealed the Resident #60 had moderate cognitive impairment. The resident was assessed to require assistance on staff for all his activities of daily living (ADL). In addition, the resident was identified as having a foley catheter and occasional incontinence of the bowel.Review of Resident #60's plan of care, dated 09/04/24, revealed Resident #60 had a risk for falls. Interventions included ensure call light is within reach. Observation on 09/15/25 at 11:30 A.M. revealed Resident #60 in bed on his right side and the call light was lying on the floor behind his bed.Interview with Registered Nurse (RN) #582 on 09/15/25 at 1:39 P.M. confirmed Resident #60's call light was on the floor behind the resident's bed and not within reach of the resident.Observation on 09/22/25 at 8:43 A.M. revealed Resident #60's call light was on the floor behind the bed and not within easy reach of the resident.Interview on 09/22/25 at 1:08 P.M. with RN Regional Clinical Nurse Manager #700 stated there is no call light policy.

Based on record review and staff interview, the facility failed to ensure the signed advanced directive for Resident #4 was correct. This affected one (Resident #4) out of three residents reviewed for advanced directives. The facility census was 99. Findings include:Review of the medical record for Resident #4 revealed an admission date of 12/13/23 with diagnoses that included unspecified diastolic (congestive) heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease unspecified, and unspecified sequelae of cerebral infarction.Review of the significant change Minimum Data Set (MDS) 3.0 assessment for Resident #4 revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicating impaired cognition. Review of the advanced directive for Resident #4 in the medical record revealed it was dated 12/18/23 for Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) and Do Not Intubate (DNI). In the electronic medical record, the advanced directive was listed as DNRCC, and the orders were for DNRCC.Interview on 09/15/25 at 2:57 P.M. with Licensed Practical Nurse (LPN) #549 revealed Resident #4 had transitioned to hospice on 09/06/25. She confirmed that the signed document in the hard medical record chart was for DNRCC-A, but the order stated DNRCC. LPN #549 could not recall which was the active code and stated she assumed it would be updated but did not know where to find the correct code.Review of the medical record chart on 09/17/25 at 11:58 A.M. for Resident #4 revealed that, after surveyor intervention, a newly signed advanced directive was placed in the hard chart for DNRCC, which now matched the physician orders.Interview on 09/17/25 at 11:58 A.M. with LPN #593 confirmed that the newly signed advanced directive was in the hard chart, but it was not dated by the physician.

Based on record review and interview the facility failed to ensure resident preferences were followed for medication administration. This affected one (Resident #103) out of one resident reviewed for choices. The facility census was 99. Findings include: Review of the medical record for Resident #103 revealed an admission date of 06/19/25 with diagnoses of cerebral infarction, Parkinson's disease, progressive supranuclear ophthalmoplegia, vitamin d deficiency, falls and hypertension. Review of physician order dated 06/20/25 revealed aspirin 81 milligram (mg) chewable oral tablet, given once daily by mouth for preventative, amlodipine besylate 5 mg oral tablet, given once daily for hypertension, magnesium oxide 400 mg oral tablet, given once daily for cramps and spasms, vitamin D3 125 micrograms (mcg) oral capsule, given once daily as a supplement, and propranolol 10 mg oral tablet every eight hours for hypertension. Review of care plan dated 07/01/25 revealed Resident #103 may require assistance with activities of daily living (ADL) interventions include requires assistance with eating, encouraging activity during daily care and participation in performing ADL's. Review of Minimum Data Set (MDS) 3.0 assessment completed 07/02/25 revealed Resident #103 is moderately cognitively impaired. Review of the Medication Administration Record (MAR) from 09/01/25 through 09/22/25 revealed that the following medications were administered daily at 5:00 A.M. as scheduled: aspirin 81 mg, amlodipine besylate 5 mg oral tablet, magnesium oxide 400 mg and vitamin D3 125 mcg. Additionally, propranolol 10 mg tablet given at 6:00 A.M. Interview on 09/16/25 at 7:30 A.M. with the Director of Nursing (DON) and Regional Clinical Nurse #700 confirmed medication times on some units start at 5:00 A.M. and some units 6:00 A.M. Those times are for the medications that need to be given before meals like Synthroid or omeprazole, or if that is the resident's choice. Otherwise residents are not woken for medications that early. Review of blood pressure summary from 09/10/25 through 09/22/25 revealed the resident was woken up on 09/01/25 at 5:10 A.M., on 09/02/25 at 5:02 A.M., on 09/03/25 at 5:07 A.M., on 09/04/25 at 4:44 A.M., on 09/05/25 at 4:52 A.M., on 09/06/25 at 6:24 A.M., on 09/07/25 at 6:13 A.M., on 09/08/25 at 6:12 A.M., on 09/09/25 at 4:56 A.M., 09/10/25 at 4:50 A.M., on 09/11/25 at 6:08 A.M., on 09/12/25 at 5:13 A.M., on 09/13/25 at 2:08 A.M., on 09/14/25 4:33 A.M., on 09/15/25 at 4:38 A.M., 09/17/25 at 6:36 A.M. , 09/18/25 at 4:16 A.M., 09/20/25 at 4:52 A.M., 09/21/25 at 4:48 A.M. and 09/22/25 at 4:43 A.M. Interview on 09/16/25 at 8:22 A.M. with Resident #103 revealed resident complaint that he gets his morning medication daily between 5:00 A.M. and 6:00 A.M , the resident denied any medications which require being taken before or after meal or without other medications. Resident #103 has asked night shift nursing staff why he is getting the medications early, however they just proceed to hand him his medication and do not provide explanation or rationale. Interview on 09/16/25 at 12:06 P.M. with Registered nurse (RN) #507 confirmed some residents are administered medications in the morning due to staffing, and it lessens the burden on day shift since the resident to nurse ratio is high. RN #507 is unaware of Resident #103 complaints of getting his medication in the early morning but would understand why a resident would be unhappy getting woken up early in the morning, and if a resident is to complaint about their medication timing it would be addressed with unit manager or the Director of Nursing. Interview on 09/17/25 at 1:45 P.M. with Resident #103 resident complaint of staff waking him up at 6:00 A.M. for his medication this morning, he claims he likes to sleep in and would prefer to receive his medications after or around breakfast. Interview on 09/17/25 at 11:23 A.M. with Licensed Practical Nurse (LPN) #575 is unaware of any resident complaints of getting medications early in the morning, but would understand if a resident voiced frustration over being woken up during the middle of their sleep to give medication. LPN #575 denied nursing assessment capturing resident preferences pertaining to what time they would prefer medications or when they would like to wake up.

Based on interview ,record review and facility policy, the facility failed to have appropriate diagnosis to support the use of antipsychotic medication for residents and failed to complete labs per pharmacy recommendations and per physician orders. This affected three (Resident #11, Resident #13, and Resident #14) out of five residents reviewed for unnecessary medications. The facility census was 99. Findings include:1.Review of the medical record for Resident #11 revealed an admission date of 03/30/23 with diagnoses of chronic respiratory failure with hypoxia, unspecified psychosis not due to a substance or know physiological condition, insomnia, anxiety and major depressive disorder.Review of care plan dated 03/30/23 revealed resident is at risk for adverse effects related to psychoactive medication use: antipsychotic for psychotic disorder unspecified. Interventions include assess behaviors for which drugs are being given, assess for adverse effects, assess for non-drug approaches to deal with behaviors, give medications as ordered, pharmacy monthly drug review, psychiatric evaluation as needed and reduction in medications when indicated. Review of Quarterly Minimum Data Set (MDS) 3.0 assessment completed 12/27/24 revealed Resident #11 is cognitively intact, has diagnoses of anxiety and depression and is taking antipsychotics. Review of physician order dated 12/31/24 through 02/23/25 revealed perphenazine (antipsychotic) oral tablet four milligrams (mg) by mouth two times a day related to unspecified psychosis not due to a known physiological condition and order type of antipsychotic. Review of physician order dated 02/23/25 through 03/04/25 revealed perphenazine oral tablet four mg by mouth two times a day for major depressive disorder and order type of anti-anxiety. Review of physician order dated 03/11/25 through 06/24/25 revealed perphenazine oral tablet four mg by mouth two times a day related to unspecified psychosis not due to a substance or known physiological concern and order type of standard medication. Review of physician order dated 06/24/25 through 08/15/25 revealed perphenazine oral tablet give two mg give two times a day related to unspecified psychosis not due to a substance or known physiological condition and order type of standard medication. Review of physician order dated 08/15/25 through 08/19/25 revealed perphenazine oral tablet give two mg give two times a day related to unspecified psychosis not due to a substance or known physiological condition and order type of standard medication. Review of physician order dated 08/19/25 through 08/26/25 revealed perphenazine oral tablet give two mg one one time a day for severe nausea and vomiting for seven days and order type of standard medication.Interview conducted on 09/22/25 at 1:01 P.M. with the Director of Nursing confirmed diagnoses of major depressive disorder with auditory hallucinations and unspecified psychosis not due to a substance or known physiological condition were not appropriate diagnoses for usage of perphenazine. The Director of Nursing confirmed the resident does not have a diagnosis of schizophrenia, and the physician order 08/19/25 through 08/26/25 was the only appropriate administration of the medication.Review of Food and Drug Administration label for perphenazine undated revealed indication for medication treatment includes diagnoses of treatment of schizophrenia and for the control of severe nausea and vomiting in adults. Review of unnecessary drugs policy dated 06/27/15 revealed unnecessary drugs are any drug when used in excessive dose; for excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. 2. Review of the medical record for Resident #13 revealed an admission date of 02/18/18 with diagnoses of cerebral atherosclerosis, chronic obstructive pulmonary disease, chronic pain, major depressive disorder, epilepsy, hypertension, schizoaffective disorder bipolar type, dementia, anxiety, anemia, shortness of breath and insomnia. Review of Resident #13 care plan dated 02/21/18 revealed resident is at risk for complications related to diagnosis of seizure disorder interventions include administer medications as ordered. Review of physician order dated 05/21/23 revealed clonazepam (klonopin) 0.125 milligrams give one tablet sublingually for involuntary movements and diagnosis of dementia with behaviors. Review of Quarterly minimum data set (MDS) 3.0 assessment completed 06/27/25 revealed Resident #13 has a memory problem, is severely impaired with making decision regarding tasks of daily life, exhibits inattention, disorganized thinking, has delusions and hallucinations, has physician/verbal behaviors 1-3 days of week. Resident #13 also receives antidepressant, antipsychotic and anticonvulsant. Review of monthly pharmacist medication regimen review dated 05/28/25 revealed clonazepam 0.125 mg three times per day was being evaluated, the resident is noted to have been taking the medication since 2023 where it was last increased. Resident has diagnosis of schizoaffective disorder, bipolar, depression, associated agitation/behaviors, and insomnia for which she is is seen by psychiatric services. Behaviors include kicking, pacing, yelling, cursing, pinching, expressing false beliefs and seeing/hearing things. Resident is due to gradual dose reduction, with physician contraindication of reduction causes target symptoms to return and/or worsen. with physician response as other. Review of psychiatric progress note dated 06/16/25 revealed patient occasionally screams and yells without any apparent reason, with a plan to continue Zoloft (Selective Serotonin Reuptake Inhibitor for depression) 75 mg daily, Lamictal (Anticonvulsant) 100 mg twice daily, Klonopin (Sedative) 0.125 mg daily, Zyprexa (Antipsychotic) 2.5 mg two times daily and trazodone (Antidepressant and Sedative) 75 mg three times daily. Review of psychiatric progress note dated 07/21/25 revealed staff reported resident is doing well, and is being seen for medication management. Plan for medication management to include Zoloft 75 mg daily, Zyprexa 2.5 mg two times daily and trazodone 150 mg three times daily. Review of physician order dated 09/19/25 revealed clonazepam tablet disintegrating 0.125 mg tablet related to epilepsy, unspecified, not intractable, without status epilepticus. Interview conducted on 09/22/25 at 10:10 A.M. with the Director of Nursing confirmed clonazepam was removed from the residents plan during the psychiatric visit on 07/21/25, however the medication continued to be given for diagnosis of involuntary movements and diagnosis dementia with behaviors. However the resident was seen by the facility physician on 09/19/25 where the diagnosis for the medication indication was changed to epilepsy, unspecified, not intractable, without status epilepticus. Review of Food and Drug Administration label for klonopin tablet revealed indication for usage include seizure disorders and panic disorder. 3. Review of the medical record for Resident #14 revealed an admission date of 03/08/24 with diagnoses of anxiety, insomnia, bipolar disorder and depression. Review of care plan dated 03/14/24 revealed Resident #14 experiences alteration in mood and/or behavior interventions include medications as ordered by physician. Review of admission minimum data set (MDS) 3.0 assessment completed 03/22/24 revealed Resident #14 is cognitively intact, has diagnosis of bipolar, exhibits no behaviors or mood concerns. Review of physician order dated 03/08/24 through 07/02/24 revealed lithium carbonate oral capsule 150 milligrams (mg) by mouth for bipolar disorder. Review of physician order dated 07/03/24 through 07/10/25 revealed lithium carbonate extended release oral capsule 300 milligrams (mg) by mouth for bipolar disorder. Review of laboratory results dated [DATE] revealed lithium level obtain with a value of 0.3 mmol/L. Review of physician order revealed obtain lithium level on 02/05/25 one time only for treatment. Review of daily lab draw list dated 02/05/25 revealed Resident #14 was on list lithium level, specimen marked a collected however no site or phlebotomist listed. Review of monthly medication regimen review dated 06/23/25 revealed please consider ordering a lithium level every six months. Review of physician order dated 07/01/25 revealed lithium level every six months. Review of hospital record dated 07/09/25 revealed lithium level obtain with a value of 0.2 mmol/L. Review of physician order dated 07/12/25 revealed lithium carbonate oral capsule 300 mg one capsule by mouth for bipolar. Interview conducted on 09/22/25 at 10:10 A.M. with the Director of Nursing (DON) confirmed Resident #14 lithium levels should have been checked every six months per physician order, the DON confirmed the lithium level requested on 02/05/25 could not be located in the residents medical record and could not confirm it was completed. Additionally the DON confirmed a pharmacy recommendation had been made on 06/23/25, with a follow up physician order on 07/01/25 for the facility to obtain a lithium level, however the lithium level was not obtained and was completed 07/09/25 during pre-operative testing at the local hospital. Review of physician order policy dated 07/14/10 revealed physician orders will be accurately transcribed and initiated, in accordance with professional standards of practice. Review of unnecessary drugs policy dated 06/27/15 revealed unnecessary drugs are any drug when used in excessive dose; for excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued.

Based on interview and medical record review the facility failed to ensure Resident #4 and Resident #99 had accurate Minimum Data Set (MDS) assessments. This affected two (Resident #4 and #99) of 34 medical records reviewed. The facility census was 99.Findings include:1. Review of the medical record for Resident #4 revealed an initial admission date of 12/13/23 with the latest readmission date of 06/22/25 with the diagnoses including but not limited to diabetes mellitus, neuromuscular dysfunction of bladder, hypertension, hyperlipidemia, hypothyroidism, depression, anxiety, congestive heart failure, cerebral infarct, pressure ulcer and chronic obstructive pulmonary disease. Review of the plan of care dated 06/16/25 revealed the resident had an alteration in skin integrity as evidenced by pressure ulcer to left buttocks. Interventions included assess area for size, color, drainage weekly and as needed, assess condition of skin/dressings as needed, assess for pain and provide treatment per physician order, body check weekly and as needed, dietary consult as needed, dietary supplement per order, do not massage boney prominences, elevate heels in bed as tolerated/needed, encourage and assist resident to keep head of bed less than 30 degrees during periods of rest as tolerated, encourage and assist resident to turn and reposition as needed, enhanced barrier precautions, keep linen dry and as wrinkle free as possible, leave depends open when in bed as tolerated, low air loss mattress, notify physician and family of changes as needed, pressure reducing chair cushion as tolerated/needed, provide assistance with ADL and positioning as needed, provide resident/family education on maintaining skin integrity and potential complications as needed, provide skin care as needed and provide treatments as ordered. Review of the resident's Braden scale dated 04/30/25 revealed a score of 18 indicating the resident was at risk for skin breakdown. Review of the progress note dated 06/15/25 at 3:35 P.M. revealed assessing resident's skin and previously identified MASD resolved, but now there is an unstageable (the wound bed cannot be visualized, and hence the pressure ulcer cannot be staged) pressure ulcer present to coccyx. 50% purple and 50% dry brown crust present to wound bed. Review of the resident's weekly pressure skin grid dated 06/15/25 revealed the resident was found to have an unstageable pressure ulcer to the left buttocks measuring 4.0 centimeters (cm) by 4.0 cm. The wound was described as 50% dry brown crust and 50% purple. The facility implemented the intervention to Cleanse wound with normal saline. Pat dry. Apply primary dressing: Triad ointment. Cover with secondary dressing: Bordered adhesive foam dressing. Change every day and as needed. Review of the resident's readmission skin assessment dated [DATE] revealed the resident was readmitted to the facility with a pressure wound to the left buttocks measuring 4.0 cm by 3.5 cm by 0.2 cm. The wound had no staging, description of the wound or if exudate was present. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was at risk for skin breakdown and had one unstable pressure ulcer that was present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressing other than to feet and application of ointments/medications other than to feet. Review of the resident's monthly physician orders for September 2025 identified orders dated 08/17/25 evaluate and assess pressure area with dressing located at left buttocks every shift, 08/24/25 cleanse wound to left buttocks with soap and water, pat dry, apply calcium alginate with silver, cover with bordered adhesive foam dressing every shift and as needed if dressing is soiled or dislodged. On 09/22/25 at 11:20 A.M., interview with the Registered Nurse (RN) #700 verified the resident was readmitted to the facility with the same unstageable pressure ulcer identified on 06/15/25 and the MDS was coded inaccurately to reflect the unstageable pressure ulcer was a newly identified wound. 2. Review of the medical record for Resident #99 revealed an admission date of 06/13/25 with diagnoses including iron deficiency anemia secondary blood loss (chronic), vascular dementia unspecified severity without behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Recorded impairment on one side for upper and lower extremities, setup required for eating, dependent-maximal assistance required for all activities of daily living (ADLs), and no medical equipment was noted. The MDS documented that the resident was not able to ambulate in her wheelchair. Review of the progress note dated 06/19/25 at 10:23 A.M. documented that the resident was alert, sociable, and spending time with family. The note indicated the resident wore glasses, had a wheelchair and walker, and was observed using her wheelchair. The resident engaged in preferred activities including knitting, watching news and westerns, listening to Christian music, and attending church services via iPad. Interview on 09/18/25 at 2:48 P.M. with Resident #99 confirmed she had a wheelchair since admission. Interview on 09/18/25 at 2:58 P.M. with Registered Nurse (RN) #524 confirmed the resident initially had a wheelchair upon admission. During the survey, Resident #99 was observed multiple times in her wheelchair maneuvering throughout the facility, including independently eating in the dining room. Interview on 09/18/25 at 3:03 P.M. with MDS Nurse #515 confirmed the MDS entry indicating the resident did not use a wheelchair was entered in error. Staff had verbally reported the resident did not use a wheelchair, but this was not documented in the chart.

Based on record review and staff interview, the facility failed to ensure timely follow-up for Resident #6's level II Preadmission Screening and Resident Review (PASARR) evaluation. This affected one (Resident #6) out of one resident reviewed for PASARRs. The facility census was 99.Findings include:Review of the medical record for Resident #6 revealed an admission date of 08/05/24 with diagnoses that included paraplegia, hereditary and idiopathic neuropathy, injury of urethra, schizoaffective disorder, and post-traumatic stress disorder.Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #6 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of the medical record chart for Resident #6 revealed the PASARR indicated the need for a level II evaluation, but there was no documented evaluation or attempt in the medical chart for the level II evaluation.Interview on 09/16/25 at 3:35 P.M. with Social Worker (SW) #583 verified that another staff member, not present, initially submitted the PASARR level II evaluation to the Department of Developmental Disabilities ([NAME]) on 03/07/25 and provided the electronic submission.Interview on 09/17/25 at 2:39 P.M. with SW #583 provided follow-up that they submitted to [NAME] via email, after surveyor intervention, on 09/16/25 stating they had called previously for the evaluation but had not received it. SW #583 could not provide any documented evidence that the call took place. After the email was submitted, [NAME] provided the level II evaluation with a date of determination on 04/02/25 and a mailing date of 04/02/25. SW #583 scanned the level II determination on 09/17/25.

Based on record review, resident interview, and staff interview, the facility failed to develop and implement a comprehensive care plan addressing Resident #8's contractures. This affected one (Resident #8) out of nine residents reviewed for activities of daily living. The facility census was 99.Findings include:Review of the medical record chart for Resident #8 revealed an admission date of 01/22/22 with diagnoses that included type II diabetes, dementia, psychotic disturbance, mood disturbance, anxiety, secondary parkinsonism, stiffness of unspecified joint, and schizoaffective disorder.Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating impaired cognition. The assessment documented that the resident had impairments in both upper extremities and was maximally dependent for upper extremity dressing. The resident was also dependent on staff for rolling left and right in bed and required assistance with transfers.Observation on 09/15/25 at 11:26 A.M. of Resident #8 revealed her wrists were contracted with her fingers folded into her palm. Review of the care plan for Resident #8 revealed the only mention of her wrists concerned noncompliance with orthotic orders. There was no documentation addressing the resident's contracture wrists or interventions to maintain range of motion. There were no measurable goals, specific interventions, or monitoring instructions for range-of-motion exercises, hand positioning, or hygiene. The care plan was not updated after occupational therapy discontinued services on 04/10/24, despite ongoing documentation of contractures in progress notes. Staff interviews confirmed they provided care or therapy but did not reference adding this to the care planReview of progress notes revealed that on 04/10/24 at 09:52 A.M., a therapy note documented that the resident refused to wear bilateral hand orthotics, and occupational therapy services were discontinued. On 06/20/25 during a chronic visit with the provider note it detailed the resident had bilateral upper-extremity hand contractures and tremors, and bilateral hand splints applied were documented. On 07/08/25 during a readmission visit, bilateral upper-extremity hand contractures and tremors were again documented with splints applied and skin intact. Post-acute care visits on 07/15/25, 07/18/25, and 07/22/25 continued to document bilateral upper-extremity hand contractures and use of splints, with no additional interventions recorded in the care plan. On 07/29/25 during a post-acute care visit, the right hand was noted as more contracted than the left, with a splint in place and recommendations included supportive care and continued use of splints. Chronic visits on 08/05/25 and 08/22/25 documented upper-extremity hand contractures (right greater than left) and use of splints; no care plan orders or interventions regarding the wrists were present beyond splint application with no observation of splints being used by the resident. Interview on 09/17/25 at 10:54 A.M. with Resident #8 revealed she did not have splints in place and could not recall if splints had ever been used or if therapy would help.Interview on 09/17/25 at 10:59 A.M. with Licensed Practical Nurse (LPN) #593, revealed staff previously attempted to place splints, but the resident removed them. She could not confirm if splints were currently available in the resident's room.Interview on 09/18/25 at 8:54 A.M. with Registered Nurse (RN) #524, revealed the last orders for the resident's palms were in April 2024 due to refusal of the palm guards, and there was no information in the care plan regarding her contractures.

Based on observation, record review, staff interview, and resident interview, the facility failed to provide appropriate Activities of daily living (ADL) care for resident's dependent on staff. This affected two (Residents #8 and #70) out of 9 residents reviewed for ADLs. The facility census was 99. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 01/10/22 with diagnoses including urinary tract infection, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and morbid (severe) obesity due to excess calories. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating impaired cognition. The assessment documented that the resident had impairments on both upper extremities, was dependent on staff for personal care tasks including eating, oral hygiene, toileting, bathing, and dressing, and was dependent for rolling and transfers. Review of the care plan revealed noncompliance with orthotic orders and personal care; however, no care plan interventions addressed the resident's contracture wrists or hygiene needs. Observation on 09/18/25 at 08:56 A.M. revealed the resident's wrists were contracted with fingers folded into the palms. The right palm had redness and fingers were painful when pulled back. The right palm had a foul odor, white residue, redness, and hair removed from the palm. The resident's fingernails on the right hand were approximately half an inch long. Observation confirmed by Registered Nurse (RN) #524. Additionally, observation on 09/18/25 at 11:10 A.M. confirmed that the right fingernail was long, and hair had been removed from the right palm during observation, which was confirmed by Regional Clinical Nurse #700. Review of shower records indicated the resident received a bath the morning of 09/18/25 at 12:26 A.M. and nails were trimmed but the observation showed the fingernail was long in length. Observation on 09/18/25 at 11:10 A.M. revealed hair had been removed from the fingers. The right fingernail was about one-half inch long. The resident stated she liked her fingernails short and requested they be trimmed, and Misty began trimming the nail. The resident stated no one had cleaned her palm after the morning observation. Regional Staff reported that RN #524 changed her statement when they spoke with her and said she did not think the hand was red or had an odor. The surveyor asked regional Nurse #700 to smell the resident's hand but she declined. Regional Nurse #700 stated staff would not document if a resident's hands were cleaned and that refusals should be documented in the chart, but no refusals were noted other than the therapy recommendations. Interview on 09/18/25 at 11:10 A.M. with Resident #8 confirmed that she preferred to have her fingernails short in length and stated she would like to have them cut. 2. Review of the medical record for Resident #70, revealed an admission date of 05/19/23 and re-entry date of 03/03/25. Diagnoses included but were not limited to epilepsy, morbid obesity, mild intellectual disabilities, shortness of breath, pulmonary embolism without acute cor pulmonale (a blood clot in the lung which does not cause sudden, acute heart strain on the right side of the heart), primary hypertension, vitamin D deficiency, traumatic brain injury, dyspnea, chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15. The resident was assessed to be dependent on staff for personal hygiene which included combing hair and shaving. Resident #70 was assessed to require maximum assistance in showering or bathing. Observation on 09/16/2025 at 08:20 A.M. revealed Resident #70 was lying in her bed wearing a t-shirt which had crusted food near the neckline seam of the t-shirt. Resident #70 had worn the t-shirt all day yesterday 09/15/25. Additionally, Resident #70 had several days of black and white colored, bristly, hair growth on chin and upper lip. Interview on 09/16/25 at 08:20 A.M. Resident #70 stated she does not like the hair growing on her chin and upper lip. Resident #70 stated she only gets shaved when she gets her showers. Resident #70 also stated she was not offered a gown or pajamas to sleep in the previous night, so she was still in her t-shirt from the prior day. Interview on 09/16/2025 at 8:28 A.M. with Certified Nursing Assistant (CNA) #573 confirmed Resident #70's t-shirt had dried crusted food on it from the previous day. CNA #573 verified Resident #70 had facial hair and stated it looked like the facial hair growth was three to four days old. CNA #573 confirmed Resident #70 is totally dependent on staff for personal hygiene. Review of shower sheets revealed Resident #70 had a shower on 09/14/25. Requested personal care policy and activities of daily living (ADL) policy and Registered Nurse #700 stated there are no facility policies for personal care or ADLs.

Based on medical record review, hospice record review and interview, the facility failed to ensure hospice information, including the hospice certification and plan of care for certification was up to date and available at the facility. This affected one resident (#44) of one resident reviewed for hospice services. The facility census was 99. Findings Include:Review of the medical record for Resident #44 revealed an initial admission date of [DATE] with the diagnoses including but not limited to chronic obstructive pulmonary disease, pulmonary embolism, congestive heart failure, hypertension, chronic kidney disease, hyperlipidemia, gastro-esophageal reflux disease, osteoarthritis, constipation, hypothyroidism, anxiety disorder and chronic respiratory failure. Review of the plan of care dated [DATE] revealed the resident received hospice services for end stage chronic respiratory failure with hypoxia. Interventions included follow physician's orders and Resident's advanced directives, hospice services as ordered, hospice to collaborate care with facility staff, contact hospice for changes in resident condition, assist with grieving process by allowing resident to express concerns/fears offer supportive but realistic feedback, provide emotional support and comfort measures, oral hygiene frequently, skin inspection during care, medications as ordered, pain assessment as needed, monitor resident for breakthrough pain, provide pain control and pain medications as ordered. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident received hospice services. Review of the resident's monthly physician orders for [DATE] identified orders dated [DATE] to admit to hospice services. Review of the plan of care located in the binder indicated the hospice recertification and plan of care expired on [DATE]. Further review revealed the hospice certification and plan of care was good through [DATE] to [DATE]. Review of the resident's hospice certification and plan of care for certification period [DATE] to [DATE] revealed on [DATE] a verbal order was obtained for recertification on [DATE] with a terminal diagnosis of chronic respiratory failure with hypoxia with a life expectancy of six months or less if the disease runs it's normal progression from Hospice Physician (HP) #705 by Hospice Registered Nurse (HRN) #710. Further review revealed the HP #705 signed the hospice recertification and plan of care on [DATE] when the certification was requested by the surveyor. On [DATE] at 2:50 P.M., an interview with Registered Nurse #700 revealed the resident's hospice service was in the building and reviewed the resident's information and verified the information was up to date. The RN verified the hospice company sent the resident's hospice certification and plan of care on [DATE] after being requested by the surveyor and following the physician's signature. Review of the hospice contract [DATE] revealed hospice shall obtain a written certification of terminal illness for each hospice patient's election period specifying that the hospice patient has a medical prognosis that his or her life expectancy is six months or less is the terminal illness runs its normal course and including specific clinical findings and other documentation supporting a life expectancy of six months or less. The written certification shall be signed and dated by the hospice Medical Director or a physician member of the hospice interdisciplinary group. The hospice shall obtain the written certification no later than two calendar days after hospice patient begins to receive care from hospice and no later than two calendar days after hospice care is initiated in any subsequent benefit period.

Based on observation, medical record review, interview and facility policy review, the facility failed to comprehensively assess pressure ulcers/injury upon admission/readmission to the facility. This affected two residents (#2 and #4) of seven residents reviewed for pressure ulcers. The facility census was 99.Findings include:1. Review of the medical record for Resident #2 revealed an initial admission date of 02/02/24 with the latest readmission date of 06/30/25 with the diagnoses including but not limited to acute myocardial infarction, acute respiratory failure with hypoxia, diabetes mellitus, dysphagia, atrial fibrillation, congestive heart failure, anxiety disorder, depression, sleep apnea, pressure ulcer, sick sinus syndrome, obstructive and reflux uropathy and gastrostomy status. Review of the plan care dated 04/15/25 revealed the resident had an alteration in skin integrity as evidenced by a pressure ulcer to the coccyx. Interventions included assess area for size, color, drainage weekly and as needed, assess condition of skin/dressing as needed, assess for pain and provide treatment per physician order, body check weekly and as needed, dietary supplement per order, dietary consult as needed, do not massage boney prominences, encourage and assist resident to elevate heels when in bed needed/tolerated, encourage and assist resident to turn and reposition as needed, enhanced barrier precautions, keep linen dry and as wrinkle free as possible, maintain pressure reducing mattress, notify the physician and family of changes as needed, pressure reducing chair cushion as tolerated/needed, provide assistance with activities of daily living (ADL) and positioning as needed, provide resident/family education on maintaining skin integrity and potential complications as needed, provide skin care as needed and provide treatments per physician orders. Review of the resident's readmission skin assessment dated [DATE] revealed the resident was readmitted to the facility with a stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) pressure ulcer to her coccyx measuring 4.5 centimeters (cm) by 1.5 cm by 0.3 cm. The assessment had no description of the wound or presence of exudate. The facility implemented the treatment to cleanse the area and apply triad paste to affected area. Review of the resident's weekly pressure skin grids revealed the pressure ulcer was assessed weekly on the following dates, 04/20/25, 04/27/25, 05/04/25, 05/11/25, 05/18/25, 05/25/25, 06/01/25 and 06/08/25. Review of the resident's readmission skin assessment dated [DATE] revealed the resident was readmitted to the facility with a stage III pressure ulcer measuring 8.1 cm by 2.4 cm by 0.3 cm. The assessment had no description of the wound or presence of exudate. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The assessment indicated the resident was at risk for skin breakdown and had one stage III pressure ulcer present on admission. The resident was also coded as having MASD. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressing other than to feet and application of ointments/medications other than to feet. Review of the resident's weekly pressure skin grids revealed the pressure ulcer was assessed weekly on the following dates, 07/06/25, 07/13/25, 07/20/25, 07/27/25, 08/03/25, 08/10/25, 08/17/25, 08/24/25, 08/31/25 and 09/07/25. Review of the most recent weekly pressure skin grid dated 09/14/25 revealed the resident's stage III pressure ulcer to the coccyx measured 0.5 cm by 0.3 cm by 0.1 cm and described as 100% red granulation tissue with the peri wound have moisture associated skin damage. The facility had determined the wound had improved and continued the treatment of cleans wound with normal saline, pat dry and apply triad ointment every shift and as needed. Review of the resident's monthly physician orders for September 2025 identified orders dated 08/03/25 cleanse wound to coccyx with normal saline, pat dry, apply triad ointment, cover with bordered adhesive foam dressing daily and as needed for soiled or dislodged, 08/31/25 evaluate and assess pressure area without a dressing every shift and cleanse fungal dermatitis/MASD to left buttocks with soap and water, pat dry, then apply triad ointment every shift. On 09/22/25 at 11:20 A.M., an interview with the Registered Nurse (RN) #700 revealed the nurse staged the wound the same as prior to her hospitalization as a stage III pressure ulcer and the assessment contains a description of what a stage III pressure ulcer would look like at the top of the assessment. The RN verified the resident had no comprehensive assessment completed upon readmission to the facility of the stage III pressure ulcer. 2. Review of the medical record for Resident #4 revealed an initial admission date of 12/13/23 with the latest readmission date of 06/22/25 with the diagnoses including but not limited to diabetes mellitus, neuromuscular dysfunction of bladder, hypertension, hyperlipidemia, hypothyroidism, depression, anxiety, congestive heart failure, cerebral infarct, pressure ulcer and chronic obstructive pulmonary disease. Review of the plan of care dated 06/16/25 revealed the resident had an alteration in skin integrity as evidenced by pressure ulcer to left buttocks. Interventions included assess area for size, color, drainage weekly and as needed, assess condition of skin/dressings as needed, assess for pain and provide treatment per physician order, body check weekly and as needed, dietary consult as needed, dietary supplement per order, do not massage boney prominences, elevate heels in bed as tolerated/needed, encourage and assist resident to keep head of bed less than 30 degrees during periods of rest as tolerated, encourage and assist resident to turn and reposition as needed, enhanced barrier precautions, keep linen dry and as wrinkle free as possible, leave depends open when in bed as tolerated, low air loss mattress, notify physician and family of changes as needed, pressure reducing chair cushion as tolerated/needed, provide assistance with ADL and positioning as needed, provide resident/family education on maintaining skin integrity and potential complications as needed, provide skin care as needed and provide treatments as ordered. Review of the progress note dated 06/15/25 at 3:35 P.M. revealed while assessing the resident's skin, the previously identified moisture associated skin damage (MASD) resolved, however there was an unstageable pressure ulcer present to the coccyx described as 50% purple and 50% dry brown crust present to wound bed. Review of the resident's weekly pressure skin grid dated 06/15/25 revealed the resident was found to have an unstageable pressure ulcer to the left buttocks measuring 4.0 centimeters (cm) by 4.0 cm. The wound was described as 50% dry brown crust and 50% purple. The wound was assessed by the Certified Nurse Practitioner (CNP) and an autolytic debridement was completed. The facility implemented the intervention to cleanse wound with normal saline, pat dry, apply Triad ointment and cover with a bordered adhesive foam dressing daily and as needed. Review of the resident's readmission skin assessment dated [DATE] revealed the resident was readmitted to the facility with a pressure wound to the left buttocks measuring 4.0 cm by 3.5 cm by 0.2 cm. The wound had no staging, description of the wound or if exudate was present. Review of the resident's weekly pressure skin grid dated 06/29/25 revealed the wound to the left buttocks was now classified as a stage III pressure ulcer measuring 4.0 cm by 3.5 cm by 0.2 cm and described as being 100% red. The facility determined the wound had improved. The facility changed the treatment cleanse wound with normal saline. Pat dry. Apply primary dressing: Triad ointment. Cover with secondary dressing: Bordered adhesive foam dressing. Change every day and as needed. Review of the resident's weekly pressure skin grids dated 07/06/25, 07/13/25, 07/20/25, 07/27/25, 08/03/25, 08/10/25, 08/17/25, 08/24/25, 08/31/25, 09/07/25 were assessed weekly by the CNP. Review of the resident's latest weekly pressure skin grid dated 09/14/25 revealed the stage III pressure ulcer to the left buttocks remained classified as an unstageable and measured 1.5 cm by 1.8 cm and described as 70% yellow and 30% red with a moderate amount of serosanguineous drainage. The facility determined the wound had improved and continued the current treatment. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was at risk for skin breakdown and had one unstable pressure ulcer that was present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressing other than to feet and application of ointments/medications other than to feet. Review of the resident's monthly physician orders for September 2025 identified orders dated 08/17/25 evaluate and assess pressure area with dressing located at left buttocks every shift, 08/24/25 cleanse wound to left buttocks with soap and water, pat dry, apply calcium alginate with silver, cover with bordered adhesive foam dressing every shift and as needed if dressing is soiled or dislodged. On 09/17/2025 at 3:20 P.M., an interview with RN #700 revealed the wound was previously MASD that evolved into a pressure ulcer. She said the resident had a decline, poor intake and was now receiving hospice services. RN #700 verified the lack of a comprehensive assessment to the stage III pressure ulcer. 09/22/25 at 11:20 A.M., interview with the Regional Nurse revealed the nurse staged the wound as a stage III pressure ulcer and the assessment contains a description of what a stage III pressure ulcer would look like at the top of the assessment. The RN verified the resident had no comprehensive assessment completed upon readmission. Review of the facility policy titled, Skin Assessment, last revised 03/15/24 revealed it was the intent of the facility to provide necessary care to prevent the development of pressure injuries unless the resident's clinical condition demonstrates that the development is unavoidable. Areas of altered skin integrity that are present or which develop subsequently to admission are treated according to medical direction and are conscientiously followed. An assessment of a resident's alteration in skin integrity shall be performed and recorded in the resident's medical record at least weekly. Staging of a pressure injury is performed to indicate the characteristics and extent of tissue injury. Licensed nurses may perform a comparative analysis of the pressure injury to a staging chart and document the observation, measurements and comparative analysis, including the stage of the wound.

Based on record review, observation, and staff interview, the facility failed to monitor and provide timely follow-up for Resident #8's bilateral wrist contractures. This affected one (Resident #8) out of two residents reviewed for mobility and range of motion. The facility census was 99.Findings include:Review of the medical record for Resident #8 revealed an admission date of 01/10/22 with diagnoses including type 2 diabetes mellitus without complications, dementia, psychotic disturbance, mood disturbance, anxiety, secondary parkinsonism, stiffness of joint, and schizoaffective disorder.Review of the 5-day Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 09 out of 15, reflecting impaired cognition. The MDS documented dependency on staff for personal care including eating, oral hygiene, toileting, bathing, and dressing, and full or partial dependence for transfers, rolling, and mobility. The resident's care plan did not address management of bilateral wrist contractures or the use of hand orthotics. There were no measurable goals, specific interventions, or monitoring instructions for range-of-motion exercises, hand positioning, or hygiene. The care plan was not updated after occupational therapy discontinued services on 04/10/24, despite ongoing documentation of contractures in progress notes. Review of therapy documentation showed that Occupational Therapy (OT) services were discontinued on 04/10/24 after the resident refused to wear bilateral hand orthotics. The note, dated 04/10/24 at 09:52 A.M., stated, Resident refused to wear bilateral hand orthotics; therefore, OT services discontinued. Voice mail left for Power of Attorney regarding discharge of OT services.Progress notes between April 2024 and June 2025 consistently documented the presence of upper extremity contractures and hand splints during routine provider visits but contained no evidence of active therapy or follow-up. For example, 06/20/25 at 02:35 P.M., Chronic Visit by the Advanced Practice Registered Nurse-Certified Nurse Practitioner (APRN-CNP): upper-extremity hand contractures/tremors; bilateral hand splints applied. Additionally, 07/08/25 at 11:12 A.M., readmission by, APRN-CNP: upper-extremity hand contractures/tremors; bilateral hand splints applied.Interview on 09/17/25 at 10:54 A.M. with Resident #8 revealed no splints were in place. The resident stated she did not think she had splints in the past, could not answer if she thought splints would help, and became non-responsive.Interview on 09/17/25 at 10:59 A.M. with Licensed Practical Nurse (LPN) #593, revealed splints had previously been attempted but she could not recall how long it had been since their last use. She stated therapy had met with the resident initially, but the resident removed the splints when they were placed. She was not sure if there were any splints currently in the resident's room.Interview on 09/17/25 at 04:15 P.M. with Rehabilitation Director #800, revealed a referral for contractures occurred on 06/11/25 and again on 07/07/25. He stated the equipment included bilateral palm guards, which are used only to prevent fingers from digging into palms. He reported that a restorative program existed from January 2023 and that the restorative aide had provided passive range-of-motion services. He stated measurements on 06/11/25 showed left-wrist flexion of 30 degrees and right-wrist flexion of 20 degrees, and on 07/07/25 the left wrist was not measured and the right wrist measured 30 degrees. He added they attempted to bring the resident back for skilled therapy after the July visit, but she only qualified for restorative services.Interview on 09/18/25 at 08:54 A.M. with Registered Nurse (RN) #524, revealed the last orders for palm guards were in April 2024 due to resident refusal and that there was no information in the care plan addressing the resident's contractures.Interview on 09/18/25 at 08:51 A.M. with Restorative Aide #559, revealed she last worked with the resident in 2023, providing range-of-motion services and applying palm guards to the resident's hands.Interview on 09/18/25 at 10:44 A.M. with Regional Rehab director #860, revealed a transitional document from the previous therapy company dated 01/25/25 contained no measurements. She stated that on 03/20/24 it was documented the resident only tolerated a palm protector and refused to wear the orthosis. She confirmed splint refusals in April 2024 and confirmed the next referral was in June 2025. She added there were no original measurements from prior to January 2023 and that the handoff from the previous occupational therapist contained no measurements so it was unable to be determined if there was a decline in the residents mobility. Interview on 09/18/25 at 10:51 A.M. with Occupational Therapist (OT) #850, revealed the NA (not assessed) entry for the left-wrist measurement on 07/07/25 could have been a documentation error. He stated he attempted to locate the resident's wrist splints in the room but found only foam rollers and no palm guards.Review of the medical chart revealed no evidence of monitoring or additional interventions for Resident #8's contracture wrists from April 2024 to June 2025 including any restorative aide intervention.

Based on observations, staff interviews, medical record review to include hospital records, progress notes, and urology notes, and facility policy review, the facility failed to properly and safely maintain urinary catheters to include the timely address of urology recommendations for one resident's suprapubic catheter. This affected two residents (#60 and #81) of six residents reviewed for catheter care. The facility census was 99.Findings include:1.Review of the medical record for Resident #60 revealed an admission date of 09/04/24. Diagnoses included but not limited to sepsis, A-fib, paranoid schizophrenia, muscle weakness, need for assistance with personal care, dysphagia, mild cognitive impairment, depression, hypothyroidism, hyperlipidemia, acute respiratory failure, retention of urine, s/s concerning food and fluid intake, neuromuscular dysfunction of bladder, primary hypertension, abnormalities of gait and mobility. Review of the most recent Minimum Data Set (MDS) assessment, dated 09/03/25, revealed that Resident #60 had a moderate cognitive impairment. The resident was assessed to require assistance from the staff for all his activities of daily living (ADL). In addition, Resident #60 was identified as having a foley catheter and occasional incontinence of the bowel. Review of Resident #60's plan of care, dated 09/04/24, revealed Resident #60 had an alteration in elimination foley catheter for diagnosis of neuromuscular bladder, continent of bowel. Resident #60 had a voiding trial which failed twice with the foley removed on 10/11/24 and the foley placed again on 10/31/24. Resident #60's interventions for the alternation in elimination included enhanced barrier precautions, irrigate foley per order, foley catheter care every shift and as needed (PRN), empty foley catheter bag every shift and prn, secure foley catheter tubing to prevent accidental dislodgement, foley bag in place prn, keep foley catheter bag below the level of the bladder to prevent backflow, determine if removal is possible, monitor of signs and symptoms of a urinary tract infection (UTI) such as elevated temperature, dysuria (pain at urination), flank pain, hematuria, foul smelling urine, report to physician to seek diagnosis and treatment promptly. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed an order with a start date of 11/06/24 and discontinue date of 09/18/25 for a 20 French (FR) indwelling foley catheter with a ten cubic centimeter (cc) balloon to gravity every shift for neurogenic bladder. Resident #60's care plan stated the catheter is a Coude (medical device used for urinary catheterization that features a bent or curved tip to help it navigate past obstructions like an enlarged prostate or urethral strictures, making it easier and less painful for men and women with certain urinary conditions to empty their bladder) catheter. There is no order noted for the Coude catheter and no size for the Coude catheter noted. Further review of the MAR and TAR revealed a current order for acetic acid irrigation solution zero-point twenty-five percent (0.25%) use 30 cc via irrigation every day every shift for foley care with a start date of 01/2/25. Resident #60 has a current order for catheter care every shift every day with a start date of 10/31/24. Additionally, there is a current order to change catheter if signs and symptoms of infection or system leak/compromised as needed with a start date of 09/18/25. Review of hospital records for Resident #60 dated 05/01/25 revealed primary encounter diagnosis as displacement of foley catheter and foley was replaced at the hospital emergency room. Resident #60 was ordered cephalexin (Keflex) 500 milligram (mg) with instructions to take one capsule by mouth four times a day for seven days. Review of hospital records for Resident #60 dated 05/08/25 stated the reason for visit was bloated. The diagnosis for Resident #60 on 05/08/25 was malfunction of foley catheter. The hospital records also stated the foley catheter was not in the appropriate place. The balloon had to be deflated, and the catheter had to be inserted more as there wasn't enough fluid in the foley balloon. Review of hospital records dated 08/26/25 stated Resident #60's catheter was replaced in the emergency room and blood-stained urine in the bag which was mostly from a trauma. No hospital records noted for 07/02/25 hospital visit. Review of a progress note dated 07/02/25 revealed the urologist was called and Resident #60 was sent to the emergency room for his catheter to be replaced as his current catheter wasn't flushing. Review of the Urology notes for Resident #60 dated 06/06/25 indicated the chief complaint as follow up urinary retention. Records show placement of a 16 FR two-way Coude catheter using sterile technique during the 06/06/25 visit. The balloon was inflated with ten cc of fluid. There was immediate return of urine. The bladder was irrigated, revealing proper placement of the catheter and clear yellow urine. Resident #60 had specific patient counseling related to significant ureteral erosion (occurs when prolonged or improper use of an indwelling urinary catheter causes the urethra to wear away, creating a pressure injury that can range from meatus erosion (at the opening) to erosion of the full urethra or surrounding tissues. Risk factors include poor catheter security, prolonged use, and conditions like diabetes or poor mobility.) Resident #60 was recommended to transition to a suprapubic (a drainage tube placed through a small surgical incision in the lower abdomen to drain urine from the bladder when urination is not possible through the urethra) catheter which is a preventative measure against further urethral erosion. The urologist placed a referral for Resident #60 for interventional radiology for the placement of a suprapubic catheter. Review of a urology record for Resident #60 dated 06/23/25 revealed repeated attempts by the urologist to contact the patient and/or nursing staff at the facility as unsuccessful. Review of the urology record for Resident #60 dated 07/08/25 reported contact was made with the patient and one of the nursing staff. The urologist learned at this time that the patient has a power of attorney (POA). The urologist called the POA and explained the suprapubic procedure to the POA and the POA agreed the procedure was reasonable. Resident #60's POA explained there was an issue with Resident #60's insurance which the facility was working on. The urologist noted the staff were to straighten out the insurance issue and to get back with them. Furthermore, the urologist noted the nursing staff and POA were amendable with the above plan. Review of progress note dated 07/02/25 revealed interventional radiology was to call the unit manager on 07/09/25 to schedule the suprapubic catheter placement. No further notes noted regarding the scheduling of the appointment for the suprapubic procedure. Review of progress notes dated 04/21/25 to 09/17/25 which revealed Resident #60 has a cognitive impairment noted multiple times and multiple notifications made to Resident #60's sister when a change in condition occurred or Resident #60 was sent to the hospital. Observations on 09/15/25 at 11:31 A.M. and 1:26 P.M. revealed Resident #60 has a catheter and the catheter bag is hooked to his walker. Interview on 09/15/25 at 11:26 A.M. with Certified Nursing Assistant (CNA) #637 who stated Resident #60's catheter leaked a lot and didn't collect in the bag until he went to the hospital. CNA #637 reported the leaking around the catheter happened for a couple of months. She reported it to the nurse but stated nothing changed until Resident #60 went to the hospital. CNA #637 stated now Resident #60 has a special catheter which can't be changed at the facility, and they don't have the supplies for it. CNA #637 stated Resident #60 would need to go to the hospital for the catheter to be changed. Interview on 09/17/25 at 5:15 P.M. with Licensed Practical Nurse (LPN) #547 stated Resident #60 has had trouble with his catheter because the resident sometimes pulls it out. LPN #547 stated the staff can't put the catheter back in so Resident #60 must go to the hospital to have the catheter replaced if it becomes dislodged. Interview on 09/18/25 at 8:22 A.M. with LPN #534 who stated Resident #60 does have a catheter. LPN #534 stated Resident #60's catheter is a 16Fr 10 milliliter (mL) Coude catheter. LPN #534 stated he is not familiar with a Coude catheter. LPN #534 stated Resident #60 does go to an outside urologist but wasn't sure when the resident had last been seen. Interview on 09/18/2025 at 11:30 A.M. with Regional RN #700 and Director of Nursing (DON) stated the nurses would change the Coude catheter unless Resident #60 is someone who would have to go out to urology. Regional RN #700 stated Resident #60's catheter was flushed before he went to the hospital on [DATE]. Furthermore, Regional RN #700 stated the catheter is not changed unless signs or symptoms of a UTI or system leakage. DON stated she is not sure if the plan is for Resident #60 to get a suprapubic catheter. Interview on 09/22/2025 at 8:17 A.M. Resident #60 stated he doesn't remember how long he has had the catheter. Furthermore, Resident #60 stated he doesn't remember going to the urologist or anyone discussing the suprapubic catheter with him on 09/18/25. Resident #60 stated he thinks he is supposed to go to the hospital if there are issues with his catheter and stated he doesn't pull at his catheter. Interview on 09/22/2025 at 8:43 A.M. interview with RN #631 who acknowledged Resident #60 had an urology appointment earlier in the year and stated she didn't know what happened. RN #631 stated the unit manager, or DON follows up on specialist or doctor's appointments for the residents. RN #631 revealed the unit manager would follow up if a resident needed a procedure or follow up appointment. RN #631 stated she would schedule a procedure if it were needed as she is the unit manager. RN #631 stated Resident #60 is not his own decision maker, that his sister is his decision maker. RN #631 revealed Resident #60's sister would be involved in determining if resident would proceed with the suprapubic procedure. RN #631 stated Resident #60 does have a diagnosis of dementia or cognitive impairment. Interview on 09/22/2025 at 11:00 A.M. with RN #570 confirmed Resident #60's snap secure (device to secure a catheter) is broken and Resident #60's catheter not secured. Furthermore, RN #570 stated Resident #60's catheter could become dislodged from the urethra since the catheter is not secured. Additionally, RN #570 stated if Resident #60 rolls over, the catheter will tug since it is not locked in place. RN #570 stated usually the aides will report that the snap secure is broken, but no one told her today. RN #570 stated Resident #60's sister is his decision maker. RN #570 revealed she calls Resident #60's sister if major things are going on with him or if there is a change in condition. In addition, RN #570 revealed she knows Resident #60 is supposed to have an appointment to get a suprapubic catheter placed but doesn't know when. RN #570 verified the unit manager is the person responsible for making resident appointments and notifying the nurses. Interview on 09/22/2025 at 11:26 A.M. with DON who confirmed the unit managers are the staff who schedule follow up appointments or appointments with specialists after consulting with family representative. Interview on 09/22/2025 at 11:30 A.M. requested policy on physician/appointments for follow up or continuity of care policy and was told by Regional RN #720 that the facility has no policy. 2. Record review of Resident #81's medical record revealed an admission date of 12/05/23. Diagnoses include type II diabetes mellitus with diabetic neuropathy, neuromuscular dysfunction of bladder, and essential hypertension. Review of Resident #81's Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 15 out of 15, cognitively intact. Resident # 81 requires partial/moderate assistance with toileting hygiene, uses a wheelchair, has a neurogenic bladder with an indwelling catheter. Review of Resident #81's physician orders reveal an order to flush catheter with normal saline 60ml daily every day shift for patent catheter with start date of 11/12/2024. Review of Resident #81's care plan dated 08/05/25 revealed Resident #81 has an alteration in elimination related to supra- pubic catheter, neuromuscular dysfunction with a goal Resident #81 will be clean, dry, and odor free. Interventions include irrigations as ordered, empty foley catheter bag every shift and as needed, secure foley catheter tubing to prevent accidental dislodgement, keep foley catheter bag below level of bladder to prevent backflow, and monitor for s/s of UTI: elevated temp, dysuria, flank pain, hematuria, foul smelling urine, report to MD to seek diagnosis and treatment promptly. Review of Resident #81's care plan dated 08/05/25 revealed Resident #81 is at risk for infection related to foley catheter, UTI, and S/P foley catheter change with goals including Resident #81 will remain free of signs and symptoms of infection and will not develop any UTI's. Interventions include monitor for s/s of UTI: foul smelling urine, cloudy urine, sediment, decreased output, labs as ordered, Inform physician or nurse practitioner of abnormal labs. Review of Resident #81's urology notes indicate Resident #81 had a supra-pubic catheter placed 10/07/24. Observation on 09/16/25 at 8:34 A.M. of Resident #81's room revealed a box with an open syringe, a open bottle of acetic acid, and small unopened bottle of normal saline. Record review of Resident #81's physician orders revealed a discontinued order for acetic acid irrigation solution with a discontinuation date of 10/08/24. Interview with on 09/16/25 at 8:40 A.M. with Nurse #534 verified if order for acetic acid was discontinued the bottle should have been thrown away and nurses should use a new syringe each time catheter is flushed. Interview on 09/17/2025 at 2:45 PM with Resident #81 revealed he has frequently told the nurses that the syringe used to flush his supra-pubic catheter should be a new syringe for every flush stating their urologist told them. Observation on 09/18/25 at 9:23 A.M. revealed a open syringe package in box in Resident #81's room. Interview on 09/18/25 at 9:25 A.M. with Nurse #534 verified the open syringe Resident #81's room stating staff will be using the syringe later today to flush the catheter and backtracking and discarding the syringe when questioned about sterility of open package. Review of the facility's policy titled Use of Indwelling Urinary Catheter/Foley Catheters dated 03/07/15 indicated for a resident with an indwelling catheter staff should use appropriate infection control practices regarding hand washing, catheter care, tubing, and the collections bag. Evaluate factors that predispose the resident to the development of urinary incontinence or the use of an indwelling urinary catheter: considerations of complications resulting from the use of an indwelling catheter such as symptoms of blockage, with associated bypassing urine, expulsion of the catheter, pain, discomfort and bleeding. Additionally, the policy stated develop and implement a plan of care that identifies interventions to minimize catheter related injuries, pain, accidental removal and obstruction of urine flow.

Based on record review, hospital record review staff interview and facility policy and procedure review the facility failed to ensure Resident #78 was free from significant medication errors. Actual Harm occurred on 05/18/21 when Resident #78 was administered medication not prescribed for her but rather prescribed for another resident which resulted in the resident becoming unresponsive. The resident required [MEDICATION(S)] (medication used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had [CONDITION(S)] (low blood pressure) which required intravenous (IV) fluids to be administered while she was treated in the hospital for an overdose. Following hospital treatment Resident #78 returned to the facility. This affected one resident (#78) of four residents reviewed for medication administration. Findings include: A review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #78's nurses' progress note revealed a note, dated 05/18/21 at 5:50 A.M. indicating the resident's physician was notified of [MEDICATION(S)] (antianxiety medication), [MEDICATION(S)] (anticonvulsant medication also used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An assessment was completed and was within normal limits, as were her vital signs. A nurse's progress note, dated 05/18/21 at 9:25 A.M. revealed the nurse was alerted Resident #78 was very drowsy and was not able to be aroused easily. The nurse assessed the resident and notified the physician's assistant of the resident's condition. New orders were received for the resident to be sent to the hospital for an evaluation. The resident left the facility at 9:53 A.M. She returned to the facility on [DATE] at 6:10 P.M. A review of a medication incident report dated 05/18/21 revealed Resident #78 received another resident's medications that morning. The medication incident report did not identify whose medications the resident erroneously received nor did it identify the medications that had been given in error. A review of the facility's investigation into the medication error that had occurred on the morning of 05/18/21 revealed there was a medication incident involving Resident #78 and her 5:00 A.M. medications. The investigation determined Resident #78 was given the medications intended for Resident #86. The medications indicated to have been erroneously given to Resident #78 included [MEDICATION(S)] (nonsteroidal anti-[CONDITION(S)] medication), [MEDICATION(S)], [MEDICATION(S)] (muscle relaxant), [MEDICATION(S)], [MEDICATION(S)] (Dopamine promoter used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #86's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M.: [MEDICATION(S)] 5 milligrams (mg), [MEDICATION(S)] 500 mg, [MEDICATION(S)] 50 mg, [MEDICATION(S)] (antiviral medication) 400 mg, [MEDICATION(S)] (Vitamin D3) 2000 units, Vitamin B-12 500 micrograms (mcg), [MEDICATION(S)] (antispasmodic used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 78's hospital records for her emergency room visit on 05/18/21 revealed the resident presented to the emergency room with an unresponsive episode. The records revealed the resident apparently received her neighbor's medication around 5:00 A.M. and was found to be unresponsive. EMS was called and she was given [MEDICATION(S)] which woke her up. IV fluids had been started by EMS prior to her arrival to the emergency room . While in the hospital, the resident was hypotensive with her blood pressure as low as 73 systolic (top number) and 32 diastolic (bottom number) requiring her to receive three liters of IV fluids. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/03/21 at 3:41 P.M. interview with the Director of Nursing (DON) confirmed Resident #78 did receive medications intended for Resident #86 on 05/18/21. The DON revealed the two residents resided in rooms which were right across the hall from one another. The DON revealed she was initially informed Resident #78 only received three medications ([MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]) that were intended for Resident #86. She confirmed, as indicated in her investigation, Resident #78 received more than just the three medications listed in the nurse's progress note. She listed others that had been due to Resident #86 in her investigation report that he would have been scheduled to receive at 5:00 A.M. A review of the facility Medication Administration policy, effective 06/21/17 revealed medications would be administered consistent with accepted standards of practice. The legally authorized or trained person administering the medication was to open the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse was responsible for noting any changes on the eMAR. The nurse was to read the label and compare it to the eMAR before preparing the medication. If a medication was unavailable, the nurse was to contact the pharmacy and document accordingly. This deficiency substantiates Complaint Number OH 385.

Based on observation, record review and interview the facility failed to provide timely pain management and coordinate Hospice services for Resident #224, implement pressure relief interventions for Resident #72 and failed to implement and establish bowel protocol parameters for Resident #18 and #176. Actual harm occurred when Resident #224 experienced moderate to severe pain for 4 1/2 hours without intervention. This affected two residents (Resident #224 and #72) of two residents reviewed for pain and two residents (Resident #18 and #176) of five residents reviewed for unnecessary medication use. Findings include: 1. Medical record review revealed Resident #224 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to Hospice services on 11/13/15. a. Review of the admission pain assessment dated [DATE] revealed the resident had no pain. Review of the Admission Care Plan dated 11/12/15 revealed no interventions for pain. The form was blank. Review of the Care Plan Cover dated 11/12/15 revealed no evidence of pain management or non-pharmacological interventions to reduce/relieve pain. Review of the Medication Administration Record [REDACTED] On 11/16/15 at 12:00 A.M., 6:00 A.M. and 12:00 P.M., the resident received scheduled [MEDICATION NAME] (narcotic pain medication) 2.5 milligrams (mg) for moderate to severe pain. The resident's pain range was zero to three on a scale of one to 10. There was no documented evidence of the location of pain, non-pharmacological interventions or whether the scheduled [MEDICATION NAME] sulfate was effective in relieving the resident's pain On 11/16/15 at 6:00 P.M., the resident received scheduled [MEDICATION NAME] five mg for pain rated three out of 10. Documentation revealed the medication was effective. On 11/16/15 as needed (PRN) [MEDICATION NAME] five mg was administered at 9:35 P.M. and was documented as effective. Review of Resident #224's progress note dated 11/16/15 at 4:20 P.M. revealed Hospice was at the facility and was told that resident was in pain, and staff and family were asking for an increase in the pain medication. The nurse attempted to move the resident and the resident screamed out in pain upon any movement or repositioning. Hospice stated they would call the physician; however, the wrong physician was contacted and the orders could not be accepted. After four and a half hours there was no reply from Hospice and Registered Nurse (RN) #39 called the physician and received new orders to increase [MEDICATION NAME] sulfate to five mg every six hours. On 11/16/15 at 2:18 P.M., observation revealed Resident #224 was grimacing and moaning. The resident's family was in the room and informed Registered Nurse (RN) #39 the resident was still in pain. RN #39 spoke with the family and stated Hospice was notified of the resident's pain but she had not heard back from them. RN #39 explained to the family the resident was starting the process of actively dying and verified the current [MEDICATION NAME] dose was not effective. RN #39 stated if Hospice did not get a new pain medication ordered, she would contact the facility doctor to increase the [MEDICATION NAME] herself. Further review of the Progress Notes revealed the following: On 11/17/15 at 5:34 P.M., family was concerned over the lack Hospice involvement and the difficulty in getting an increase of medications when appropriate. On 11/18/15 at 11:42 A.M., Resident #224 had reached the point of being comfortable with the current dosage of medication and family expressed much appreciation in the current comfort level. Family, Hospice, and nursing all comfortable with resident's orders and moving forward until death occurred. Review of the Management of the Resident in Pain policy revised March 2011 revealed nursing expectations included to implement interventions for all residents in pain and implement protocol for appropriate treatment, evaluate response to interventions, recognize side effects and document assessments, interventions, evaluations and resident care provided accordingly. The expected outcome was for the patient to experience maximal pain relief with minimal side effects. The pain management policy included the assessment of pain was to be completed with admission process to the facility. Assessment of verbal complaints and non-verbal signs or symptoms of pain will be completed. Nonverbal indicators of pain included but not limited to moaning, crying, irritability, and anxiety. The level of pain including intensity of pain if reportable by resident, identify pharmacological and non-pharmacological methods to reduce pain, document assessments, interventions, evaluations and resident care accordingly. Provide medication as ordered and evaluate the resident's response to interventions. Notify the physician if interventions were ineffective. On 11/17/15 at 3:37 P.M., interview with RN #39 verified Hospice was notified of the resident's pain when they were at the facility earlier in the day, however, there had been no new orders received for pain management for four and a half hours. RN #39 verified there was no evidence of a comprehensive pain assessment since admission, and no pain care plan or non-pharmacological interventions had been implemented. On 11/17/15 at 3:43 P.M., interview with the Director of Nursing (DON) verified a comprehensive pain assessment should have been completed when the resident had a change in pain, there was no initial or comprehensive facility or Hospice pain care plan, and verified the resident's Hospice provider did not timely manage Resident #224's pain. The DON stated Resident #224's Hospice provider had no other residents currently within the facility. b. Review of Resident #224's medical record revealed she was admitted to Hospice on 11/13/15. Review of the medical record revealed no documented evidence of Hospice eligibility, plan of care, assessment or progress notes. Review of the Hospice Agreement dated 05/23/14 revealed hospice was to develop, at the time an eligible resident was admitted into the hospice program, a hospice plan of care for the management and palliation of the resident's terminal illness. The hospice plan of care was to be a written document which included a detailed description of the scope and frequency of hospice services, medications and supplies needed to meet the resident's needs. The plan of care was to specify which services and supplies related to the patients terminal illness and therefore will be furnished. The plan of care was to be reviewed and updated as necessary at least every other week. Modifications were to be discussed with the patient/family and provided to the nursing facility. Hospice was to furnish to the nursing facility medical information, the most recent plan of care specific to each hospice patient; the hospice election form and any advanced directives specific to each patient; physician certification and recertification of the terminal illness, names and contact information for hospice personnel involved in the hospice care of each patient, instructions on how to access the on-call system; hospice medication information specific to each patients; and hospice physician and attending physician orders [REDACTED]. The facility was to be provided with the following information specific to each hospice patient residing at the facility including the most recent plan of care, the hospice election form and any advanced directives, the physician certification and recertification of the terminal illness. Hospice was to be notified immediately for a significant change in resident condition, questions related to the resident plan of care, any questions/concerns from family or caregivers related to hospice, when near death, at time of death and new orders. On 11/17/15 at 3:43 P.M., interview with the DON verified there was no documented evidence of a Hospice plan of care, directive for the management of pain, no Hospice progress notes or care plans. On 11/18/15 at 7:25 A.M., interview with the DON stated Resident #224's Hospice provider was not used often at the facility and the Hospice nurse stated all the documentation was electronic and the facility had to call the office to have the assessments and notes from hospice faxed to the facility. The DON stated the facility was having a meeting with the Hospice provider today regarding the above. 2. Medical record review revealed Resident #72 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely impaired for daily decision-making, required extensive assist with bed mobility and transfer, and had no pain. Review of the Pain Rating Data assessment dated [DATE] revealed Resident #72 had chronic pain rated a six out of 10. Review of the physician orders [REDACTED]. Review of Resident #72's medical record revealed no evidence of a pain care plan. On 11/16/15 at 3:13 P.M., observation revealed Resident #72 was sitting in a Broda chair (specialized wheelchair) wearing gripper socks with bilateral heels resting against the foot rest. Resident #72 complained of heel pain rated a three out of 10. Observation revealed the resident's feet and heels were resting directly against the foot rest of the Broda chair, and a pillow and pressure relieving boots were in a chair across the room. On 11/16/15 at 3:15 P.M., interview with State tested Nurse Aide (STNA) #114 verified the resident was not wearing the pressure relieving boots and stated the resident was supposed to wear them to prevent pressure ulcer development. STNA #114 applied the pressure relieving boots to both feet. STNA #114 asked the resident if he was still having pain and the resident said no. 3. Review of the medical record revealed Resident #176 was admitted to the facility on [DATE] with a medical [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. On 06/19/15 [MEDICATION NAME] Tablet 5 milligram (mg.) give one or two tablets as needed for constipation. There were no guidelines to follow as to when to administer the as needed medication, or when to administer one tablet verses two tablets. On 06/19/15 Milk of Magnesia (MOM) 30 milliliters (ml.) every 24 hours as needed for constipation, not to exceed more than three consecutive doses. The facility was to notify the physician if the constipation continued. There were no guidelines to follow as to if the facility was to administer the MOM initially or the [MEDICATION NAME] Tablets first. On 06/19/15 [MEDICATION NAME] Adult Suppository, give one suppository rectally every 24 hours if MOM was not effective. There were no guidelines to follow as to how many days the suppository should be administered or what to do if the suppository was not effective. On 06/19/15 Polyethylene [MEDICATION NAME] Powder 17 grams (gm.), dissolved in eight ounces of fluid, every 24 hours as needed for constipation There were no guidelines if this was to be attempted before of after the MOM, the [MEDICATION NAME] Tablets, or the [MEDICATION NAME] Adult Suppository. Review of the State tested Nurses Aide (STNA) Flow Record for the month of October 2015 revealed Resident #176 did not have a bowel movement from 10/01/15 to 10/03/15 or from 10/08/15 through 10/10/15. Review of the Medication Administration Record [REDACTED]. Review of the plan of care dated 07/02/15, revealed Resident #176 was at risk for constipation with the goal that she was to have a bowel movement at least every three days. The interventions included the facility was to administer the as ordered medication for constipation. On 11/18/15 at 9:39 A.M. interview of the Director of Nursing (DON) revealed the facility did not have a Bowel Protocol Policy, but utilized best practice. The DON stated best practice would be utilized if a resident had not had a bowel movement in three days. If this occurred, the nurses were to start with the use of MOM first, if that was ineffective they would than use [MEDICATION NAME] Tablets, and finally to progress to the use of enemas. The DON stated this was not a policy to follow just best nursing practice. On 11/18/15 at 1:19 P.M. interview with the DON revealed Resident #176 had not had a bowel movement from 10/01/15 through 10/03/15 or from 10/08/15 through 10/10/15 and there was no evidence that the physician ordered as needed medication for constipation was administered to relieve Resident #176's constipation. 4. A review of Resident #18's medical record revealed a current physician order [REDACTED]. An interview on 11/18/15 at 1:47 P.M. with Licensed Practical Nurse (LPN) #104 revealed that if the resident does not have a bowel movement for two full days the nursing staff were to administer the MOM. LPN #104 further stated that if there were no results by the next shift the nursing staff would give a suppository. An interview on 11/18/15 at 1:57 P.M. with a unit manager revealed the nurse should use common sense and if the resident does not have a bowel movement in three days the nurse should administer the MOM. The unit manager further revealed if the resident does not have a bowel movement by that evening the nurse should administer a suppository. On 11/18/15 at 9:39 A.M. interview of the Director of Nursing (DON) confirmed the facility did not have a Bowel Protocol Policy, but utilized best practice. The DON stated best practice would be utilized if a resident had not had a bowel movement in three days. If this occurred, the nurses were to start with the use of MOM first, if that was ineffective they would than use [MEDICATION NAME] Tablets, and finally to progress to the use of enemas. The DON stated this was not a policy to follow just best nursing practice.

Based on record review and staff interview, the facility failed to ensure that a resident who entered the facility without a pressure sore did not acquire one while in the facility. This affected one (Resident #64) of three residents who were reviewed for pressure sores. The facility identified seven residents with pressure sores. Harm occurred to Resident #64 on 03/13/13 when the facility failed to initiate interventions to prevent the deterioration of a pressure ulcer. Findings include: Review of Resident #64's medical record revealed an admission date of [DATE]. Admitting [DIAGNOSES REDACTED]. Review of a pressure ulcer risk assessment completed 02/19/13 revealed the resident had no current pressure ulcers and no history of pressure ulcers. The resident was assessed as limited assist with ambulation, occasionally incontinent of bowel, consumed 75-100% of meals, and had [MEDICAL CONDITION] present. Review of an admission skin assessment revealed no pressure ulcers but indicated the resident had non -pressure areas of bruising to the back of the right hand and left ante-cubical (bend in the inner elbow). Review of the admission minimum data set (MDS) assessment, dated 02/26/13, revealed the resident was rarely/never understood, had a [DIAGNOSES REDACTED]. Resident #64 was assessed as being at risk for developing a pressure sore but had no pressure sores upon admission to the facility. Review of documentation on the skin grid for pressure form, dated 03/05/13, revealed a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister) to the left buttocks. The area was described as open with peeled away skin. The area was red and blanchable. The area measured 9 centimeters (cm) in length, 6.8 cm in width and <0.1 cm in depth. No odor or drainage was noted. The resident was encouraged to allow staff to turn and reposition him frequently. Review of skin assessment dated [DATE] revealed no new areas had been identified. Review of a Nurse Practitioner (NP) wound assessment dated [DATE] revealed a soft deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the left buttocks assessed as nonblanchable with purple hued perimeters and black hyperpigmentation. The NP indicated she suspected a deep tissue injury (DTI). The center of the wound was excoriated, [DIAGNOSES REDACTED]tous with a small amount of serosanguineous drainage measuring 8 cm in length by 6.7 cm in width by 0.1 cm in depth. The NP gave an order to cleanse the areas with normal saline, cover with foam dressing, and change every other day and as needed. Orders were also given to turn the resident side to side when repositioning in bed and contact the physician or NP for decline in skin condition. Review of a physician's orders [REDACTED]. Review of a NP wound assessment dated [DATE] revealed the resident had an unstageable pressure sore (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to the left buttocks. Description of the wound was purulent yellow, tan, green, no odor exudate with necrotic tissue that was loose adherent yellow slough, being dark red and nonblanchable. The area measured 4.8 cm in length by 2.5 cm in width. There was no documentation of the wound's depth. The treatment had been changed to apply santyl with [MEDICATION NAME] every other day and contact the physician or NP for decline in skin condition. Review of the MDS assessment dated [DATE] revealed the resident required extensive assistance of two or more persons for bed mobility, transfers, and toilet use. Review of the NP's wound assessment dated [DATE] revealed an unstageable pressure sore to the left buttocks that measured 4.0 cm in length by 2.3 cm in width. Orders were given to continue with the same treatment. Review of the weekly skin grid for pressure dated 04/17/13 revealed an unstageable pressure sore to the left buttocks that originated on 03/05/13. The pressure sore measured 4 cm in length by 2.3 cm wide by < 0.1 cm deep with a scant amount of purulent drainage. Review of the plan of care for risk for skin breakdown due to limitations in bed mobility and left sided weakness (initiated 02/28/13) revealed interventions to elevate heels off the mattress, inspect skin during routine care, mattress, cushion to the wheelchair, lotion to skin, pillows for positioning, skin assessments weekly and as needed, ted hose to bilateral legs, and treatments as ordered.. The plan of care failed to instruct staff to turn the resident with two plus people. Review of the plan of care for impaired communication related to [MEDICAL CONDITION] (initiated 03/12/13) revealed the resident had periods of confusion and forgetfulness and was not usually able to make needs and concerns known. The plan of care indicated staff must anticipate and meet unspoken needs. Review of the plan of care for ulceration or interference with structural integrity of layers of skin related to a stage two pressure sore to the left buttocks ( initiated 04/25/13) revealed interventions to cleanse the area to the left buttocks with normal saline, pat dry, cover with foam dressing, and change every three days and as needed. Other interventions included monitoring the skin on the treatment sheet and progress record, monitoring for signs and symptoms of infection and notifying the physician. The plan of care did not reflect the change of the stage two pressure sore to a deep tissue injury or unstageable pressure ulcer. Review of the plan of care for self-care/functional decline related to hemorrhagic stroke with left sided weakness failed to describe under interventions that the resident required extensive assistance of two plus staff members for bed mobility and transfers. On 05/08/13 at 12:52 P.M., interview with the director of nursing revealed the plans of care had not been revised to reflect the deterioration of Resident #64's pressure sore or to reflect the amount of staff assistance the resident needed. Review of medication and treatment administration records and state tested nursing assistants flow records for March, April and May 2013 revealed no documentation of application or continued monitoring of the physician ordered air mattress or that the resident was repositioned from side to side. Review of nurses' notes dated 03/11/13 to 04/11/13 revealed no documented evidence the air mattress was initiated or monitored for placement. Review of nurses' notes dated 03/11/13 to 04/11/13 revealed only twelve shifts of documentation that indicated the resident had been turned and repositioned every two hours. Review of nursing assistant flow records for March, April and May 2013 revealed no documented evidence Resident #64 had been repositioned every two hours by two or more staff members or that the air mattress had been put on the resident's bed and monitored. On 05/08/13 at 4:10 P.M., interview with Registered Nurse #10 revealed Resident #64 had acquired a deep tissue injury to his left buttocks while in the facility.

Based on review of the closed clinical record, staff interview and review of the Pain policy and procedure, the facility failed to assess a resident with increased pain, monitor the effectiveness of interventions and provide care when the interventions were not effective causing harm to the resident. This affected one of three residents reviewed for pain (Resident #100). The facility census was 89. Harm occurred to Resident #100 when the facility failed to complete a thorough assessment of a resident's pain and failed to provide intervention resulting in the resident being in severe pain as evidenced by the resident being in such pain she urinated in her bed instead of being taken to the bathroom or using a bedpan because these actions caused so much pain. Findings include: Review of the discharge clinical record for Resident #100 revealed the resident was admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of an x-ray report dated 08/01/12 and faxed to the facility at 6:03 P.M. revealed the resident suffered a complete displaced subcapital right femoral fracture. The physician was notified at 9:44 P.M. Review of the progress notes revealed the resident began experiencing more pain than usual on or about 07/30/12. On 07/30/12 the resident had pain medication changed to a stronger medication. The resident was on [MEDICATION NAME] 50 milligrams scheduled and was changed to [MEDICATION NAME] 5-500 milligrams one tablet every six hours as needed for pain. Review of the progress notes revealed the medications were still ineffective at times and the order was changed to a scheduled dose of [MEDICATION NAME] 5-500 milligrams two tablets three times a day given at 8:00 A.M., 2:00 P.M. and 8:00 P.M. Review of the progress notes dated 07/30/12, 07/31/12 and 08/01/12 revealed though the nurses had called the physician regarding the resident's increased pain, there was no assessment of the hips. The resident was mostly complaining of right hip pain but had complained of left hip on at least two occasions, once to nursing and once to therapy staff. There was no evidence the nurses did a physical assessment to determine the possible cause of the new onset of increased pain. On 07/30/12 at 12:00 P.M., a late entry was created on 08/04/12 (two days after discharge). The note stated the nurse gave [MEDICATION NAME] as needed one tablet for complaints of pain to right hip at this time. Documentation revealed the resident was crying out, grimacing and guarding the right hip and groin. Upon assessment, the resident made no mention of hurting herself. She just said that it hurt. There was no pain assessment completed to assess the resident's pain. On 07/30/12 new orders were obtained to change the [MEDICATION NAME] to a scheduled dose and was increased to two tablets. The note at 2:55 P.M. identified the resident was in bed resting, complained of pain, was crying and guarding left hip. The nurse gave pain medications with little relief noted at this time. There was no pain assessment completed to assess the resident's pain. Progress note at 11:49 P.M. revealed, resident noted to continue to guard right hip, facial grimacing noted, scheduled pain medication given with some noted relief. Review of the Pain Assessment completed on 07/30/12 at 11:53 P.M. revealed the resident's pain score was rated 8/10 on the pain analog scale, 10 being the worst imaginable pain. The pain type was marked right hip throbbing, ache, sore and tender, constant, everything aggravates the pain and pain pills help or alleviate the pain. There was no follow-up pain score to determine the effectiveness of the medication. The next progress note dated 07/31/12 at 5:49 P.M. revealed the resident was in wheelchair resting at this time, complained of pain throughout the shift, scheduled pain medications given with positive results. Review of progress notes dated 08/01/12 at 1:40 P.M. revealed staff stated the resident was refusing to get out of bed and use the restroom or even use a bedpan related to pain. This nurse and an aide attempted to transfer the resident and she yelled out loudly "no, I can not get up and will just pee in my bed". Pain medications administered as ordered. A note at 1:47 P.M. stated the resident had been refusing to get up to go to the restroom or even use the bedpan. The resident stated it was too painful although pain medications had been given as scheduled. The resident stated she had no relief. Staff assisted the resident with all needs. On 08/01/12 at 3:41 P.M., an order was received for x-rays to hips and pelvis. Review of the Pain assessment completed on 08/01/12 at 2:13 P.M. revealed the resident's pain score was rated 8/10, hips, knees and ankles, sharp, ache, tender, cramp, tight were all marked on the pain assessment. Frequency of pain was marked frequent, duration constant, affected sleep, rest, appetite, emotional and can't focus was marked on the assessment. Lying in bed was marked as what helped or alleviated the pain. There was no follow-up pain assessment to determine if the interventions were effective but the progress notes stated there was no relief. There was no evidence the nurse followed up to manage the resident's pain when the resident experienced no relief causing harm to the resident when she was willing to "pee in the bed" due to the pain rather than use the bathroom or even the bedpan. Resident #100 refused to get out of bed and was unable to participate in therapy due to the pain. Review of a note on 08/01/12 at 9:44 P.M. by LPN #11 revealed the hip and pelvis x-ray results (received via fax at 6:03 P.M.), identified a complete displaced subchapter right femoral fracture was noted. The physician was paged to the facility at 9:44 P.M. At 10:29 P.M. the physician returned call to the facility with new order for CT scan of the right hip. Resident was notified and message left for resident's daughter. On 08/01/12 at 10:36 P.M. daughter returned call to the facility concerning new orders. Another late entry for 08/01/12 at 10:37 P.M. stated daughter voiced understanding concerning new order for CT of right hip. Review of progress notes revealed there were no further pain assessments the rest of the day on 08/01/12 or through 08/02/12. On 08/02/12 at 7:45 A.M. when the resident was being transferred to the gurney to leave for an appointment via ambulance to the pain clinic, she screamed out in pain and was not medicated due to an order (dated 08/01/12) to hold pain medication for the appointment. This physician's orders [REDACTED]. There was no evidence this was clarified with the physician to hold the pain medication in light of the [DIAGNOSES REDACTED]. This was verified during interview with Licensed Practical Nurse (LPN) #44 on 10/26/12 at 10:00 AM. Review of a late entry created on 08/03/12 (after resident was discharged ) for 08/01/12 at 4:15 P.M. by LPN #10 charted food and fluids were offered, repositioned, 1:1 given, ice packs applied to bilateral hips, however she stated she did not want them. Tylenol was offered and refused, stated she did not want anymore pain medication. Head to toe assessment completed with lungs clear to auscultation, skin pink, warm and dry, bilateral legs in alignment, no internal or external rotation noted. No bruising or [MEDICAL CONDITION] noted. The resident denied that she had fallen at anytime. Late entry for 08/02/12 at 7:45 A.M. created on 08/03/12 (day after discharge) stated, resident Leave of Absence per ambulance for doctors appointment. When transferring the resident she screamed out in pain. No pain medication given due to orders to hold medication. Review of a note dated 08/02/12 at 5:06 P.M. revealed the resident left the facility at 7:45 A.M. to go to scheduled pain clinic appointment. The nurse reviewed the X-rays report upon arrival that morning that was ordered on [DATE]. The nurse noted the report identified a complete displaced subcapital right femoral fracture was noted. The physician was notified upon receiving X-rays last night and ordered a CT scan. When the doctor came in for rounds on this date the nurse documented she had the doctor review the chart showing him where the resident had no noted dislocations or fractures when she had testing down in the hospital upon going to the hospital for increased pain to the right groin and hip. The note identified the nurse told the physician that "I am pretty sure this is a new fracture" . Resident had no reported falls, injuries or trauma and denied the same to staff when increased pain started. The note identified the physician agreed after comparing the two reports and told the nurse to call the clinic where Resident #100 was and have them send her to the emergency department for an orthopedic evaluation. Review of the Management of the Resident in Pain, Policy and Procedure (dated 10/18/01 revised on 04/02 and 03/11) revealed under the section of Nursing Expectations, 2. Evaluate response to interventions, recognize side effects and adjust according to resident condition, physician order, nursing judgement. 3. Document assessments, interventions, evaluations and resident care provided accordingly. Pain Management Policy Assess level of pain including intensity of pain if reportable by resident on numeric pain scale 0-10, 0= no pain, 10 being the worst pain imaginable. Document assessments, interventions, evaluations, and resident care accordingly, provide medication per physician's orders [REDACTED]. Notify the physician if interventions were ineffective. Interview on 10/26/12 at 9:40 A.M. with Certified Occupational Therapy Assistant (COTA) #35 revealed the resident had complained of pain during both Occupational Therapy (OT)and Physician Therapy (PT) treatments and had become unable to do certain tasks she had been doing prior such as refusing to stand and do lower body tasks. Review of OT notes dated 08/01/12 revealed the resident refused to stand and would scream in pain with right hip and thigh. This was verified with COTA #35 at the time of the review. Interview on 10/26/12 at 2:25 P.M. with LPN #44 confirmed the pain assessments did not include follow-up documentation regarding the effectiveness of the pain medications. LPN #44 identified the assessments should be documented in the nurses notes but confirmed they were not. Interview on 10/26/12 at 8:00 A.M. with the Director of Nursing (DON) verified there was no follow-up as to whether the pain medication administered to Resident #100 was effective and a follow-up pain score was not used. This certification deficiency substantiates Complaint Number OH 730.

Based on observation, record review, policy review and staff interview, review of job description, and review of manufacturer instructions, the facility failed to properly assess residents' risks for the development of pressure ulcers, identify areas of redness on bony prominences as pressure ulcers, initiate skin grids for the assessment and continued monitoring of the pressure ulcers and implement appropriate preventative measures and treatments to prevent the development of /or the deterioration of existing pressure ulcers. This affected five (Residents #43, #48, #79, #168 and #177) of five residents reviewed for pressure ulcers. The facility identified nine residents residing in the facility with pressure ulcers. Of the nine residents identified with pressure ulcers, five of those residents developed the pressure ulcers after admission to the facility. The facility census was 95.This resulted in harm for Resident #79 who had a deterioration in a Stage II pressure ulcer to the coccyx and developed two additional unstageable pressure ulcers after his admission to the facility. This resulted in harm for Resident #168 who was assessed as a moderate risk for pressure ulcers with no interventions implemented and developed two facility acquired pressure ulcers to the right buttocks and the right heel. The right buttocks had resolved but the right heel deteriorated from a Stage II pressure ulcer to an unstageable pressure ulcer. This resulted in harm for Resident #177 who had a deterioration in an unstageable pressure ulcer that had 100% granulation tissue in the wound bed to an unstageable pressure ulcer with necrotic tissue present the following day. Findings include:1. On 02/09/12 at 6:30 P.M., an observation noted Resident #79 lying in bed in a supine position. There were two pillows in place under the resident's lower extremities. The pillows were up around the resident's knees and the heels were pressed into the mattress. The facility's nursing staff was present and assisted with turning the resident to allow the visualization of the resident's pressure ulcers. The left leg was elevated and the sock was removed. The resident grimaced when the sock was taken off and reported the heel was sensitive. There was an unstageable pressure ulcer to her left outer heel. (An unstageable pressure ulcer is defined as a full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). Resident #79's outer heel had a black, irregular shaped raised scab present that was approximately the size of a dime. The entire left heel was pink in color with peeling skin. The outer layer of the skin was off. The resident was then turned on her side to allow for the visualization of her coccyx area. The upper coccyx area had some redness present. Within the reddened area was a small pinpoint open area that had white wound edges. Review of Resident #79's medical record revealed she was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A skin assessment for admit/re-admitted d 12/20/11 revealed there were no pressure ulcers present upon readmission to the facility. The assessment identified non-pressure areas as being present which included documentation of multiple bruises in various locations on her body. There was also a red area documented as present on the resident's coccyx. A pressure ulcer risk assessment completed on 12/20/11 gave the resident a score of 6 based on risk factors identified as part of the assessment's screening questions. The resident's identified risks included requiring limited assistance with ambulation and mobility, being occasionally incontinent, having a nutritional intake between 50-75%, a daily fluid intake of 1,000 to 2,000 milliliters per day and having two [DIAGNOSES REDACTED]. A score of 8 or more indicated the resident was at high risk for pressure ulcers and the prevention protocol should be implemented immediately and documented on the care plan. A quarterly Minimum Data Set (MDS) assessment completed on 12/31/11 revealed the resident had severely impaired cognition. She was also noted to require extensive assist of two for bed mobility and transfers. A weekly skin assessment completed on 01/11/12 included instructions that guided staff to observe the resident's skin condition, including pressure points and heels. The instructions also advised the staff to review documentation of previously reported skin conditions and to complete information for areas in which abnormal skin conditions such as redness, rashes, bruises, ulcers, wounds, burns, or surgical incisions appear. The weekly skin assessment form included a section titled Skin Observation. Under this section the staff was to indicate the reason for the assessment and documentation of any skin conditions noted. It gave a place to indicate if a pressure area or a non-pressure area was noted during the assessment. If a pressure ulcer was present the assessor was to complete a pressure ulcer skin grid for each new area identified. If it was a non-pressure area the assessor was to complete a non-pressure skin grid for each new area identified. The form indicated the reason for the assessment was a weekly skin check and documented a previously identified pressure ulcer was noted during the assessment. Since the form indicated the area noted was a previously identified pressure ulcer there was not a skin grid for pressure area completed at that time. The facility's Point Click computer software program did not include a skin grid assessment of a pressure or a non-pressure area to the coccyx from 12/20/11 until 01/12/12. Pressure ulcer skin grid sheets dated 01/12/12 noted the development of unstageable pressure ulcers to the resident's left heel and left outer heel and a Stage II pressure ulcer to the coccyx. ( A Stage II pressure ulcer is a pressure ulcer with partial thickness loss of dermis presenting as a shallow open ulcer, with a pink wound bed or slough. It may also present as an intact or ruptured serum filled blister). Resident #79's area to the left heel measured 3.1 cm x 3.4 cm. The left outer heel measured 1.2 cm x 1.8 cm. The coccyx wound measured 0.4 cm x 0.4 cm x < 0.1 cm. A pressure ulcer skin grid for the coccyx wound dated 01/19/12 identified the area as still being a Stage II pressure ulcer and included measurements of 0.4 cm x 0.4 cm x 0.4 cm. The wound status, since the last assessment, indicated the wound had improved despite the length and width remaining the same with the depth marked as being deeper. A pressure ulcer skin grid for the left outer heel dated 01/19/12 revealed the pressure ulcer showed improvement despite the area remaining an unstageable pressure ulcer with the same measurements as the previous week. There was no weekly skin grid for the pressure ulcer to the left heel on 01/19/12. A weekly skin grid for pressure ulcers dated 01/25/12 for the Stage II pressure ulcer that was present on the coccyx revealed the area had healed on 01/24/12. The stage of the wound was marked as a suspected deep tissue injury (SDTI) with no record of any measurements and a description of the color as being fleshtone. (A SDTI was defined as a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear). There were no additional pressure ulcer skin grids for the coccyx after the assessment dated [DATE] despite the coccyx area being red and open when observed on 02/09/12. A pressure ulcer skin grid (not dated) for the unstageable pressure ulcer to the left outer heel revealed the wound status showed improvement. The measurements at that time indicated it was 1.2 cm x 1.8 cm with depth unknown which was unchanged from the assessments completed on 01/12/12 and 01/19/12. The left heel was assessed again on 01/25/12 and remained an unstageable pressure ulcer measuring 3.1 cm x 3.4 cm. The assessment indicated the pressure ulcer showed improvement even though the measurements obtained was the same as the measurements collected on 01/12/12. A care plan for the resident's risk for impaired skin integrity was not developed until 02/08/12. The care plan included the presence of a pressure ulcer to the left heel. There was no documentation of a pressure ulcer being present on the resident's coccyx. Review of the facility's policy on Skin: Skin Assessment- Monitoring of Healing Process policy (dated 10/18/01 and revised in November 2006) revealed a qualified nurse was to monitor pressure ulcers daily. A nurse would also assess ulcers at the time of admission, re-admission, at least weekly and with a significant change. After a thorough assessment of the ulcer the clinician should identify the type of the ulcer. The ulcer type should be recorded in the medical record and on appropriate skin grids. Review of a policy for Skin: Skin Assessment and Documentation Guide (dated 07/18/03 and revised in November 2006) indicated a skin grid pressure form should be used when a new pressure area was identified. One form was to be used for each pressure ulcer. The pressure ulcer was to be measured each once a week and as needed for changes in the wound. The measurements and description was to be recorded on the skin grid pressure form. Review of a policy on Skin- Pressures (originated on 10/18/01 and revised in November 2006) revealed the definition of an avoidable pressure ulcer meant the resident developed a pressure ulcer and the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that were consistent with the resident needs, resident goals and recognized standards of practice; monitored and evaluated the impact of the interventions; or revised the interventions as appropriate. Interventions for an identified Stage I pressure ulcer included the use of pressure relieving devices to bed and sitting surfaces. Review of a policy on Skin: Pressure Ulcer Risk Assessment and Prevention (dated 10/18/01 and revised in November 2006) revealed it was the facility's policy that residents admitted to the facility would be assessed for the presence of pressure ulcers or other skin breakdown. Residents would also be assessed for the risk of development of pressure ulcers. Interventions to eliminate or minimize the risk factors would be introduced at the earliest possible time. The facility's goal was to prevent facility acquired pressure ulcers unless the resident's clinical condition demonstrated that they were unavoidable. Preventative measures for mobility and activity deficits for chair bound residents included repositioning at least every hour while up in the chair, have the resident shift her weight every 15 minutes if able while in the chair, use pressure relieving device for seating surfaces, individualize positioning as needed, follow a turning schedule with 30 degree rule, use pillows and increase frequency and supplement turning with small shifts in position. Interview with licensed practical nurse (LPN) #16 on 02/09/12 at 6:20 P.M. confirmed the resident was re-admitted on [DATE] with a red area to the coccyx. LPN #16 verified the re-admission skin assessment completed on 12/20/11 did not identify the reddened area to the coccyx as a pressure ulcer. She confirmed it should have been determined to be a pressure ulcer as the area of redness was over a bony prominence and did not blanch when touched. LPN #16 denied the facility staff completed any additional assessments of that area until 01/12/12 when it was open and determined to be a Stage II pressure ulcer. She acknowledged the weekly skin grids that were completed for the pressure ulcers after 01/12/12 were marked incorrectly as the assessments reflected the pressure ulcers were showing improvement when compared to the previous weeks measurements and showed no change in measurements. LPN #16 also confirmed there was no documentation available that showed a weekly assessment had been completed of the pressure ulcer to the left heel on 01/19/12. LPN #16 verified the only weekly assessment on that area had been done on 01/12/12 and 01/25/12. She reviewed the pressure ulcer risk assessment that was completed for the resident's readmission to the facility on [DATE] and confirmed it was not an accurate assessment. She stated the pressure ulcer risk assessment should have reflected the resident had a pressure ulcer if the red area was properly assessed when she was readmitted . LPN #16 stated the ambulation and mobility section on the assessment was also marked incorrectly as the assessment indicated the resident required limited assistance which was defined as minimal physical assist. She stated the resident should have been marked as being chairfast as she was non-ambulatory most of the time and required assistance with transfers. She reported with the change in those areas the resident's assessment score would have been a nine which would have identified her as a high risk for pressure ulcers. She indicated if Resident #79 would have been initially identified as a high risk for pressure ulcers more preventative interventions would have been implemented and a care plan would have been developed when the resident was first readmitted . LPN #16 indicated with the implementation of additional interventions such as a turn schedule, pressure reduction cushion for use in the wheelchair and the use of pillows to keep the resident's heels elevated the coccyx wound may not have deteriorated and the pressure ulcers to the left heel may not have developed. 2. Medical record review revealed Resident #177 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment (dated 02/06/12) revealed Resident #177 was severely impaired for daily decision making, required total assistance with bed mobility, transfers and personal hygiene. The resident was not at risk for development of pressure ulcers, had no pressure ulcers upon admission, had no infections, and was not on a turning and repositioning program. Review of the Pressure Ulcer Risk Assessment (dated 01/31/12) revealed Resident #177 was at high risk for pressure ulcers. Review of the Admit/Re-admit Skin Assessment (dated 01/30/12) revealed Resident #177 was admitted to the facility with a left heel and coccyx ulcer. Review of Resident #177's admission Skin-Grid Pressure assessment (dated 01/31/12) included an unstageable purple-yellow, fluid filled left heel pressure ulcer that measured 4.0 cm in (l) by 3.5 cm (w). Review of the Nurse Practitioner (NP) Wound Assessments (dated 01/31/12) included the following: -On 01/31/12, an unstageable, left heel pressure ulcer measured 4.0 cm in (l) by 3.5 cm in (w). Skin was intact and dark purple. -On 02/07/12, the left heel skin was not intact and measured 3.8 cm in (l) by 4.2 cm in (w) by 0.1 cm in (d) with 100% granulation tissue. On 02/07/12, the NP ordered to change the treatment of [REDACTED]. Review of the medical record revealed no documented evidence the left heel treatment was transcribed to the resident's treatment record. On 02/08/12 at 4:21 P.M., observation of Resident #177's left heel pressure ulcer revealed the pressure ulcer measured 5.5 cm in (l) by 5.0 cm in (w) by 0.1 cm in (d) with a necrotic area at the superior aspect of the wound that measured 3.5 cm in (l) by 2.0 cm in (w). The periwound revealed hard, rolled edges. The following observations were made of Resident #177: -On 02/08/12 at 9:20 A.M., seated in geri-chair with bilateral heels resting against the foot/leg rest of the gerichair. -On 02/08/12 at 11:05 A.M., seated upright in geri-chair with bilateral feet flat against floor, no pressure relief to feet observed. -On 02/08/12 at 1:30 P.M., positioned in bed on back on a non-specialty mattress. -On 02/09/12 at 9:23 A.M., seated in gerichair in an upright position with feet flat against the floor, no pressure relief to feet observed. Review of the medical record revealed no documented evidence of preventative skin interventions or care plan to prevent the decline or development of avoidable pressure ulcers for Resident #177. Review of the Treatment Administration Record (dated February 2012) revealed no documented evidence the unstageable coccyx pressure ulcer treatment was completed on five of 13 opportunities between 02/01/12 and 02/07/12. Review of the Health Status Progress Note (dated 02/05/12 at 7:00 P.M.), revealed Resident #177's heel pressure ulcer broke open and clear,orange colored drainage was observed. Review of the medical record revealed no documented evidence the physician was notified the change in condition of the resident's pressure ulcer until 02/06/12 at 1:46 P.M. and a new order was obtained. On 02/08/12 at 1:51 P.M., interview with the director of nursing (DON) verified the left heel pressure ulcer had deteriorated and opened without physician notification until the following day. Review of the Change of Condition policy (revised April 2003) revealed the resident, physician and guardian/interested family member was to be notified within 12 hours of any significant changes in the resident's clinical condition that included when a resident was admitted with pressure ulcers, development of new pressure ulcers or a change in the condition of a wound or pressure ulcer. On 02/08/12 at 2:15 P.M., interview with the DON verified the coccyx pressure ulcer treatment was not documented as completed on five of 13 opportunities. The DON also verified the resident was only to be up in chair for 20-40 minutes and the resident was up longer than 40 minutes for therapy. The DON verified the resident's mosaic cushion in his chair provided pressure relief for up to a Stage II pressure ulcer and the resident had an unstageable pressure ulcer to the coccyx. On 02/08/12 at 2:20 P.M., interview with the DON verified the medical record revealed no documented interventions upon admission to prevent the decline or development of additional pressure ulcers, the care plan cover did not have adequate interventions and there was no actual pressure ulcer care plan upon admission. On 02/08/12 at 2:30 P.M., interview with the DON verified the resident's unstageable pressure ulcer to the left heel had declined from 100% granulation to necrotic tissue between 02/07/12 and 02/08/12 and no interventions were implemented. On 02/08/12 at 5:14 P.M., interview with the DON verified Resident #177 did not have a specialty mattress on his bed for unstageable pressure ulcers and the physician was not notified timely of changes in the wounds. On 02/08/12 at 5:14 P.M., interview with the DON verified the facility did not implement preventative interventions to prevent the decline of existing pressure ulcers or the development of new, avoidable pressure ulcers for Resident #177. On 02/08/12 at 5:50 P.M., interview with RN #1 verified the nurse practitioner (NP) #23 ordered a new treatment to Resident #177's left heel pressure ulcer on 02/07/12 to calcium alginate and verified this order was not implemented. RN #1 verified she applied Santyl to the wound on 02/08/12 and the new order was not transcribed. On 02/08/12 at 6:00 P.M., interview with NP #23 verified the resident's left heel wound bed was 100% granulation tissue with no necrosis on 02/07/12. NP #23 verified new orders were written to change the left heel treatment and was unaware the order was not transcribed or implemented. NP #23 stated she had ordered interventions for the resident that included an air mattress, frequent turning and skin prep to bony prominence's. NP #23 stated she was unaware these interventions had not been implemented. On 02/08/12 at 6:20 P.M., interview with RN #1 verified Resident #177 did not have an air mattress as indicated by the CNP, had a Prevent Series pressure relieving mattress 80" Pro mattress that was not approved for an unstageable pressure ulcer. 3. Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment (dated 01/03/12) revealed Resident #168 was independent for daily decision making, required extensive assist with bed mobility and transfers, had range of motion limitations and was at risk for pressure ulcers. Review of the Pressure Ulcer Risk Assessment (dated 12/28/11) revealed Resident #168 was not at high risk for pressure ulcer development. Review of the Admission Skin Assessment (dated 12/28/11) revealed no pressure ulcers. Review of the Weekly Skin Assessments (dated 12/28/11 and 01/05/12) revealed Resident #168 had no pressure ulcers. Review of Resident #168's admission Physician order [REDACTED]. Review of Resident #168's laboratory bloodwork (dated 12/29/11) revealed a [MEDICATION NAME] level of nine (normal 17-34 mg/dL). Review of the Progress Notes dated 01/06/12 (late entry documented on 01/19/12 at 11:04 A.M.) revealed a new area was noted to the resident's buttocks. Review of the medical record revealed no documented assessment or physician notification of the area to the resident's right buttock until assessment by NP on 01/10/12. Review of the Nurse Practioner (NP) Wound Assessment (dated 01/10/12) revealed Resident #168 had a right buttock Stage II pressure ulcer that measured 0.2 centimeters (cm) in length (l) by 0.2 cm in width (w) by 0.1 cm in depth (d). No assessment of the pressure ulcer wound bed or wound characteristics was documented. Review of the physician order [REDACTED]. Review of the TAR (dated January 2012) revealed the right buttock pressure ulcer healed as of 01/17/12. Review of the State tested Nursing Assistant job description (undated) revealed STNA's were to provide routine daily nursing care and services. Review of the Patient Education Information sheet for A+D ointment (dated 02/08/12) revealed used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations. On 02/10/12 at 1:35 P.M., interview with RN #3 verified the STNA's cleansed and applied A&D ointment to skin impairments on the buttocks. RN #3 verified Resident #168's Stage II right buttock pressure ulcer treatment indicated STNA's could complete the treatment. On 02/10/12 at 4:30 P.M., interview with RN #2 verified Resident #168's medical record revealed no documented evidence of a comprehensive assessment or status of the pressure ulcer. RN #2 verified STNA's were not qualified to complete a pressure ulcer treatment, and verified A&D Ointment was not an appropriate treatment for [REDACTED]. Review of the Progress Notes (dated 01/20/12) revealed Resident #168 developed a serum filled intact blister to the right heel. Review of the Skin-Grid Pressure assessments revealed the following regarding Resident #168's facility acquired right heel pressure ulcer: -On 01/20/12, Stage II right heel pressure ulcer measured 4.2 cm in (l) by 3.2 cm in (w). -On 01/23/12, Stage II right heel pressure ulcer measured 4.0 cm in (l) by 3.5 cm (w) with an intact serum filled blister. -On 01/25/12, an unstageable right heel pressure ulcer measured 4.2 cm (l) by 4.6 cm (w) by <0.1 cm depth (d). The heel was dark and mushy, and no change to the treatment was ordered. Review of the medical record revealed no documented evidence interventions were implemented to prevent the development and deterioration of Resident #168's avoidable right heel pressure ulcer. Review of the Monthly Physician order [REDACTED].#168's Stage II right heel pressure ulcer. Review of the Treatment Administration Record (dated February 2012) revealed Resident #168's right heel pressure ulcer was washed with soap and water and skin prep applied between 02/01/12 and 02/06/12. Review of the At Risk for Impaired Skin Integrity care plan (dated 01/10/12) revealed goals (initiated 01/10/12) that included to be free of skin breakdown with interventions that included pressure reduction devices if ordered, skin assessments and treatments as ordered, and repositioning as needed. Review of the Impaired Skin care plan (revised 02/08/12) revealed the resident had impaired mobility and an area to the right heel. An intervention to elevate heels off the bed was added on 02/08/12. Review of the care plan revealed no interventions of pressure relief while the resident was up in the wheelchair. Review of the medical record revealed no documented evidence of interventions implemented after the development of a Stage II right heel pressure ulcer on 01/20/12 until 02/08/12. Review of the Skin Assessment and Documentation Guide policy (revised November 2006) revealed interventions were to be implemented upon admission to prevent skin breakdown and to treat actual breakdown when indicated. The care plan was to be updated as the resident's needs or condition changed. A skin assessment was to be completed by the nurse once a week, physician and family notification, and new orders received were to be documented in the medical record. Measurements were to be completed once a week and as needed for changes in the wound. Measurements and a description of the wound was to be documented on the skin grid pressure form. On 02/09/12 at 2:10 P.M., Resident #168 was observed sitting up in a wheelchair wearing grippy socks with bilateral feet observed to be pressed against the foot pedals with no pressure relief. On 02/10/12 at 12:10 P.M., Resident #168 was observed sitting in her room in a wheelchair. The resident's bilateral heels was observed to be pressed against the foot rest with no pressure relief. On 02/10/12 at 2:14 P.M., observation of Resident #168's superior right heel pressure ulcer dressing change revealed a moderate amount of serosanguineous drainage, no odor. The Stage II pressure ulcer was irregular in shape and measured 4.0 cm in (l) by 4.5 cm in (w) by 0.3 cm in (d). The wound bed was red with 25% yellow slough and two necrotic areas observed. The lateral necrotic area within the wound bed measured 0.4 cm in (l) by 0.4 cm in (w), and the medial necrotic area measured 0.1 cm in (l) by 0.1 cm in (w). The periwound was macerated and pink. A necrotic area was also observed to the superior aspect of the periwound that measured 0.4 cm in (l) by 0.1 cm in (w). On 02/09/12 at 2:10 P.M., interview with STNA #4 verified the resident's feet and heels were pressed against the foot pedals without pressure relief, the resident had a pressure ulcer to the right heel, and the resident preferred to sit up in the wheelchair most of the day. On 02/10/12 at 11:35 A.M., interview with RN #2 verified there was no documented evidence in the medical record Resident #168's risk for pressure ulcer was reassessed after the development of pressure ulcers on 01/06/12 or 01/20/12, no interventions were implemented upon admission due to resident not identified at high risk for pressure ulcer development, no interventions were implemented after the development of the Stage II buttock and Stage II right heel pressure ulcer. RN #2 verified no documented evidence of elevation of heels in bed, and no interventions were implemented to protect the resident's heels when up in the wheelchair. On 02/10/12 at 4:00 P.M., RN #1 verified Resident #168's right heel pressure ulcer had declined and was avoidable. RN #1 verified no interventions had been implemented because the resident was inaccurately assessed at low risk for pressure ulcers. RN #1 verified there were no pressure relieving interventions for the resident's unstageable right heel pressure ulcer when she was up in the wheelchair. On 02/10/12 at 1:45 P.M., interview with RN #2 verified Resident #168's pressure ulcer assessment (dated 01/25/12) was inaccurate and the resident's right heel pressure ulcer had declined, and verified the weekly pressure ulcer assessment was not done weekly. 4. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The resident was [AGE] years old. Documentation in the medical record revealed the resident was non-compliant with care and had a non-compliance plan of care in place. Review of the MDS assessment dated [DATE] revealed the current number of unhealed pressure ulcers was coded as four known but not stageable due to non-removable dressing, coded as two known but not stageable due to coverage of wound bed by slough or eschar, and coded as four suspected deep tissue injury in evolution. The resident currently had unstageable pressure ulcers to her buttocks, right and left heel that were healing. Review of the physician orders [REDACTED]. Review of the TAR revealed a treatment for [REDACTED]. Further review of the TAR revealed Resident #48 was scheduled to receive the Marathon treatment to the bilateral heels on 02/03/12 and 02/05/12. The treatment was circled as not provided. There was documentation on the TAR on 02/05/12 the treatment was not provided due to it was not available. Review of the physician orders [REDACTED]. Review of the TAR revealed the physician order [REDACTED]. Review of the skin risk assessment dated [DATE] revealed Resident #48 was identified as being at high risk for pressure ulcers with a score of 8. On 02/08/12 at 2:20 P.M. observation of the treatment completed by RN # 1 to the left buttock of Resident #48 revealed when RN # 1 removed the adult incontinence brief there was no dressing covering the wound. On 02/09/12 at 9:00 A.M. review of the manufacturer's guidelines for Marathon liquid skin protectant revealed the product naturally wears off over one to three days depending on skin type and activity level, inspect the protectant regularly and if any cracking or flaking appear, apply another layer on top until the area was completely covered once again. 5. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #43 required extensive assistance of two staff in the area of bed mobility, transfers and toilet use. Review of the admission MDS assessment dated [DATE] and admission nursing assessment revealed Resident #43 had no pressure ulcers upon admission. Resident #43 was identified on the MDS as high risk for development of pressure ulcer. Review of pressure ulcer risk assessment dated [DATE] revealed Resident #43 was assessed as a moderate risk (score of 7) for development of pressure ulcers. Review of Pressure Skin Grids revealed Resident #43 developed a facility acquired suspected deep tissue injury to the left heel on 09/07/11. Review of the Pressure Skin Grid dated 09/07/11 revealed a purple area noted to the left heel. Resident #43 complained the heel hurt but the resident refused pain medication. The