Every finding on record at Twinsburg Post Acute

Based on observation, interview and facility policy review, the facility failed to ensure dependent residents received adequate bathing assistance. This affected one (#29) of three residents reviewed for bathing assistance. The facility census was 64.Findings include:Findings include:Review of Resident #29's medical records revealed an admission date of 07/28/26. Diagnoses included stroke with right sided weakness, dysphagia (difficulty swallowing), contracture of right hand, aphasia (difficulty speaking) and dementia.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had impaired cognition. Resident #29 required maximum assistance with toileting, bathing and moderate assistance with personal hygiene. Review of the care plan dated 06/25/26 revealed Resident #29 had activities of daily living (ADLs) deficits. Interventions included provide assistance with bathing and personal hygiene. Observation on 08/11/26 at 10:07 A.M. with Certified Nursing Assistant (CNA) #322 and CNA #331 revealed Resident #29 was resting in bed and had a strong foul body odor. CNA #322 and CNA #331 proceeded to provide Resident #29 with a bed bath and upon turning Resident #29 on to his left side, the body odor became more pungent. CNA #322 proceeded to use a clean washcloth and a basin of water to wash Resident #29's back. As she was cleaning Resident #29, the white washcloth had a large amount of black debris and she had placed the washcloth into the clean water and the debris changed the water color to black. Further observation revealed Resident #29's bed linens had various large black and brown stains and were odorous as well. Concurrent interview with CNA #322 and CNA #331 confirmed Resident #29's appearance and stated it appeared as if he had not received a bed bath for a while. Resident #29 was not interviewable. Review of facility policy titled, Activities of Daily Living (ADL), revised March 2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADL care independently, including hygiene, bathing and grooming.This deficiency represents non-compliance investigated under Master Complaint Numbers 3135490 and Complaint Number 2999967.

Based on observation, interview and record review, the facility failed to ensure hand splints were applied appropriately and further failed to ensure splints were clean and free of odors. This affected one (#29) of three residents reviewed for assistive devices. The facility census was 64.Findings include:Review of Resident #29's medical records revealed an admission date of 07/28/26. Diagnoses included stroke with right sided weakness, dysphagia (difficulty swallowing), contracture of right hand, aphasia (difficulty speaking) and dementia.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had impaired cognition. Resident #29 required maximum assistance with toileting, bathing and moderate assistance with personal hygiene. Review of the care plan dated 06/25/26 revealed Resident #29 had activities of daily living (ADL) deficits and impaired range of motion with contractures to the right hand. Interventions included to wear a right resting hand orthotic for six to eight hours a day and in the evening as tolerated. Review of the physician orders for August 2026 revealed an order to encourage Resident# 29 to allow staff to place palm protector on the right hand as tolerated in the morning and remove in the evening. Review of the Treatment Administration Record (TAR) from 08/01/26 to 08/12/26 revealed documentation the right hand splint was applied daily, with the exception of 08/02/26 having no documentation and 08/08/26 documented as N, indicating the splint had not been applied. Observation on 08/11/26 at 10:07 A.M. with Certified Nursing Assistant (CNA) #322 and CNA CNA #331 revealed Resident #29 was resting in bed and had a heavily soiled and odorous hand splint that was resting on the top of the resident's right hand. Concurrent interview with CNA #322 and CNA #331 confirmed the right hand splint was heavily soiled and odorous and stated they were unsure how the splint was to be applied or who was responsible for applying it. Resident #29 was not interviewable.Observation on 08/12/26 at 9:07 A.M. revealed a clean hand splint was observed in a basin on Resident #29's bedside table.Observation on 08/12/26 at 2:42 P.M. revealed the hand splint remained in a basin on Resident #29's bedside table. Concurrent interview with CNA #337 verified Resident #29's hand splint was in a basin and not applied to the resident's hand. CNA #337 stated he believed the nurses were to apply the hand splints.

Based on medical record review, review of the facility Self-Reported Incident (SRI) and staff interview, the facility failed to ensure a complete and accurate medical record. This affected one (#26) of three residents reviewed for accuracy of medical records. The facility census was 64. Finding include: Record review for Resident #26 revealed an admission date of 06/11/19 with diagnoses that included: dementia, essential hypertension, dysphagia and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/05/26, revealed Resident #26 was unable to complete the Brief Interview for Mental Status (BIMS) due to rarely being understood. Resident #26 was dependent for all activities of daily living (ADLs). Review of the facility SRI #274370, incident date of 05/10/26, revealed an allegation of sexual abuse involving former Resident #69 and Resident #26. Resident #69 was found by the nurse in Resident #26 room and was observed sitting on her bed with his hands on her shoulders. Resident #69 left the room once the nurse asked him what he was doing in Resident #26's room. The facility conducted an investigation and sexual abuse was unsubstantiated. Further review of Resident #26's medical record revealed no progress notes or assessments regarding the incident. Interview on 08/12/26 at 12:48 P.M. with former employee, Licensed Practical Nurse (LPN) #418, revealed he was asked by Assistant Director of Nursing (ADON ) #304, who at this time of the incident was the Director of Nursing (DON), to write a statement regarding the incident for the SRI. LPN #418 said he asked ADON #304 if he should add a progress note in Resident #26's chart and she told him no. He said that if something had happened to Resident #26 he would have documented in the medical record but since nothing happened, he did not. Interview on 08/13/26 at 9:56 A.M. with ADON #304 revealed skin checks were completed on Resident #26 and Resident #69 which were included in the SRI. ADON #304 confirmed the incident was not documented in Resident #26's medical record and added they usually did not document incidents in the medical record if the facility conducted an investigation. This deficiency represents non-compliance investigated under Complaint Number 2999967.

Based on observation, record review, staff and family interview, review of Geriatric Nursing clinical literature and review of the facility policy, the facility failed to develop and implement a comprehensive, individualized and effective fall management program to decrease Resident #32's risk of falls including a fall with injury. The facility also failed to ensure fall prevention interventions were in place for Resident #30, #32, #50, and #59. This affected four residents (#32, #30, #50, and #59) of five residents reviewed for accidents. The facility census was 53. Actual harm occurred on 01/25/26 when Resident #32, who had moderate cognitive impairment, a history of multiple falls and risk for falls and history of urinary tract infection (UTI) sustained an unwitnessed fall resulting in an orbital fracture. Prior to the fall with injury, between 10/20/25 and 01/22/26 Resident #32 sustained seven falls without evidence of effective interventions being in place to decrease her risk of falls. Between 12/23/25 and 01/25/26, the facility failed to identify a change in the resident's condition (symptoms indicative of a urinary tract infection) without intervention which increased the resident's fall risk and likely contributed to the fall with injury. Findings include: 1. Review of the medical record for Resident #32 revealed an original admission date of 09/09/25 with diagnoses including chronic kidney disease, repeat falls, reduced mobility, rheumatoid arthritis, end stage renal disease, hearing loss, anxiety, obstructive sleep apnea, osteoarthritis of the right knee, and intervertebral disc displacement, lumbar region. Review of the admission note dated 09/09/25 at 9:11 P.M. revealed Resident #32 arrived on the unit at 6:55 P.M. on a stretcher from a medical center. Resident #32 had presented to the emergency room (ER) due to a fall with no broken bones or fractures. Resident #32 was alert and oriented to person, place, time and surroundings and was able to make needs known. Review of the fall risk assessment dated [DATE] revealed Resident #32 as at moderate risk of falls. Review of the care plan initiated 09/10/25 revealed Resident #32 was at risk for injury related to falls due to impaired and reduced mobility, impaired cognition, use of medication that contributes to falls, history of repeated falls prior to admission, and an unsteady gait. Interventions to assist in preventing falls included a call before you fall sign, provide items to self-occupy such as fidget toys or busy board, and keep the bed in the low position. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had moderate cognitive impairment and no behaviors. The assessment revealed the resident required (staff) set up or clean-up assistance for eating and brushing her teeth. She required partial to moderate (staff) assistance toileting hygiene, personal hygiene, showers/bathing, upper body dressing, rolling left and right, sitting to lying, lying to sitting, sitting to standing, and bed to chair and chair to bed transfers. The resident required substantial to maximum (staff) assistance with lower body dressing and putting on/taking off footwear. The assessment revealed the resident was occasionally incontinent of bladder and always continent of bowel. The MDS revealed Resident #32 had a history of falls prior to admission.Review of the physician's progress note dated 09/18/25 included Resident #32 was admitted for skilled nursing and rehab. Resident #32's chief complaint was mobility and activity of daily living (ADL) dysfunction secondary to weakness with decrease in strength, decrease in functional mobility and reduced ability to safely ambulate placing the resident at risk for falls. Review of the nurse's note dated 10/20/25 at 4:40 P.M. revealed the nurse was informed Resident #32 was on the floor. Resident #32 was assisted into the wheelchair, this nurse asked the resident how did you fall? The resident stated I was trying to get out of bed. The call light was explained to Resident #32. No injuries were observed. Record review revealed no evidence this intervention was appropriate or effective based on the resident's cognitive impairment. Review of the post-fall fall risk assessment dated [DATE] revealed Resident #32 was at moderate risk of falls.Review of the Interdisciplinary Team (IDT) note dated 10/21/25 at 3:18 P.M. included a review of the resident's fall from 10/20/25. The new intervention implemented was a call before you fall sign. Review of the nurse's note dated 10/25/25 at 9:55 P.M. included the nurse was notified that Resident #32 was on the floor in the dining room in front of the wheelchair. Resident #32 revealed she wanted to go lay down and when she preceded to stand while chair unlocked it shifted and she slid to floor. Review of the post-fall fall risk assessment dated [DATE] revealed Resident #32 was at moderate risk of falls.Review of the IDT note dated 10/28/25 at 1:41 P.M. revealed the IDT reviewed the incident on 10/25/25. The nursing intervention was that Resident #32 was educated and verbalized understanding. There was no evidence the facility implemented interventions to ensure the resident was assisted to bed per choice.Review of the nurse's note dated 10/29/25 at 2:47 P.M. revealed the nurse was called to Resident #32's bedroom, observing her lying on her right side on the right side of the bed, nose bleeding. This nurse asked the resident what happened, and the resident was slow to respond stating she slid down from bed, she was wearing in house slippers with no gripper. The resident's top lip was bitten on the fall, and Resident #32 was sent to the ER. Review of the nurse's note dated 11/03/25 at 6:58 P.M. revealed Resident #32 arrived back from the hospital visit after being monitored after a fall.Review of re-admission note dated 11/03/25 at 8:26 P.M. revealed Resident #32 was on and antibiotic for a UTI.Review of the fall risk assessment dated [DATE] revealed Resident #32 was at moderate risk of falls.Review of the IDT note dated 11/04/25 at 11:31 A.M. for Resident #32 revealed the intervention implemented was to encourage Resident #32 to not sit on side of bed without assistance. Record review revealed no evidence this intervention was individualized or effective.Review of the physician orders for Resident #32 revealed an order for a call before you fall sign dated 11/04/26. (This was the intervention implemented on 10/20/25).Review of the quarterly MDS 3.0 assessment dated [DATE] assessment revealed Resident #32 had moderate cognitive impairment, no behaviors, required set up or clean up (staff) assistance for eating, brushing her teeth, and personal hygiene. The resident required partial to moderate (staff) assistance with rolling left to right, sitting to lying, lying to sitting, sitting to standing, and bed to chair and chair to bed transfers. She was occasionally incontinent of bladder and always continent of bowel. The MDS included Resident #32 had no falls, which was inaccurate as Resident #32 had falls on 10/20/25, 10/25/25, and 10/29/25. The fall on 10/29/25 resulted in a six-day hospitalization. Review of the progress note dated 11/11/25 at 5:22 P.M. included the nurse was called to Resident #32's bedroom and observed the resident sitting on her buttocks in front of the wheelchair. No injuries were noted and Resident #32 was put back in her wheelchair to have dinner. Review of the IDT note dated 11/11/25 at 6:11 P.M. included a nursing intervention to offer Resident #32 to go bed after dinner. There was no documented evidence of a root cause analysis for the fall.Review of the nurse's note dated 12/01/25 at 9:22 P.M. revealed Resident #32 was on the floor on the side of her bed upon the nurse walking into the room. There was no evidence of fall/safety interventions being initiated following this fall. Review of the post-fall fall risk assessment dated [DATE] revealed Resident #32 was at high risk for falls. Review of Certified Nurse Practitioner (CNP) #350's Acute Visit note dated 12/23/25 (untimed), revealed a chief complaint of lethargy and blood in tissue. Resident #32 had an altered mental status, unspecified, acute, unstable. Resident #32 presented severely lethargic and altered orientation status. Resident #32 was currently alert and oriented to person only, which represented a change from her baseline. Resident #32 also demonstrated delayed responses during clinical assessment and endorses feeling tired. Nursing staff notes significant change in patient's mental status from the baseline. Assessment was completed with the review of recent labs, medications and vital signs. Ordered a urinalysis (UA) with culture and sensitivity (C&S) (collect urine specimen) to evaluate for urinary source of acute delirium/encephalopathy. Notify provider with results when available. Review of the progress note dated 1/20/26 at 10:04 P.M. revealed Resident #32 was observed on the floor next to the bed by staff. Resident was requesting for the heat to be turned down. New intervention was to offer light weight or different material pajamas for comfort. There was no evidence to support how the facility identified these to be adequate and/or effective fall safety interventions. Review of the progress note dated 01/22/26 revealed Resident #32 tried to get up from her wheelchair in her room and slide down to her buttocks at 1:10 P.M. Resident #32 was assisted back to her wheelchair. An x-ray was ordered due to complaints of pain to the resident's lower back. Review of the Laboratory UA with culture and sensitivity report revealed a urine collection date of 01/14/26 (order for specimen testing received on 12/23/25). Received date to lab of 01/14/26 at 6:50 A.M. and a reported date of 01/23/26 at 9:47 A.M. The results were noted to be abnormal and included positive nitrate in the urine. (Nitrite positive urine is a sign of a UTI). Antibiotics to treat UTI's kill the bacteria that cause nitrites in urine). The results met criteria to perform a urine culture. The culture revealed greater than 100, 000 E- Coli, sensitivity was completed and included on the report. There was no documented evidence the physician or CNP were notified. Review of the progress note dated 01/25/26 at 1:02 P.M. revealed Resident #32 was observed on the floor sitting on her buttocks, with a low yell for help. Resident #32's right eye had a very large/hematoma with small cut in the corner of the eye. Resident #32 was alert enough to say it hurt, rating her pain an eight on a pain scale of zero to 10. Review of a progress note dated 01/25/26 at 1:12 P.M. revealed Resident #32 was transported to the emergency room (ER). Review of the progress note dated 01/25/26 at 3:42 P.M. revealed the ER nurse called. Resident #32 had an orbital fracture/right orbital floor fracture and Review of the Medication Administration note dated 01/26/26 at 8:33 A.M. revealed Resident #32 received Oxycodone tablet 5-325 milligrams (mg) (opioid pain medication) for pain. Repositioning, relaxation, distraction and comfort measures were provided and ineffective. The resident's right eye was slightly opened and Resident #32 revealed it hurts today. Review of the IDT note for Resident #32 dated 01/26/26 revealed the resident's daughter noted she was noticing a change in her mother with things she did (i.e. play with the remote control and pulling multiple tissues and rubbing them on her chest then stacking them). She noted she believed if she figured out a phone number, she would continuously call it multiple times or that her mother becomes fixated as she did with the remote to the bed and hit the button and not realizing she had to stop.Interview on 01/29/26 at 4:34 A.M. with Resident #32's daughter/Responsible Party, while a second daughter was on the phone, revealed concerns Resident #32 had several falls within a short amount of time and had increased confusion. The Responsible Party revealed Resident #32 was more confused than ever and continued to have falls and had a severe eye injury. The daughter stated she requested a UA which was ordered but not collected until 01/14/26. The results were reported on 01/23/26 but no treatment was started for the UTI until the daughter went to the facility on [DATE], upset and requested a copy of the results due to her mother's increased confusion. The daughter was given the results which confirmed a UTI and the nurse notified the CNP and treatment with an antibiotic was then initiated. The Responsible Party revealed she spoke to the Director of Nursing (DON) who reported to her this was an oversight and apologized. On 02/09/26 at 1:15 P.M. an attempted interview with CNP #350 was unsuccessful as the CNP refused to speak to the surveyor.On 02/09/26 at 4:10 P.M. an observation with Certified Nursing Assistant (CNA) #205 revealed Resident #32 was lying in bed. Observation revealed and CNA #205 confirmed Resident #32's bed was not in the low position as per the plan of care and there was no call before you fall sign located in the room. Interview on 02/10/26 at 12:45 P.M. with the DON confirmed fall interventions in the care plan should be in place for every resident. Fall investigations were requested for Resident #32 from the DON; however, no investigations were provided for review during the survey. Medical literature recognizes urinary tract infections as a known contributor to increased fall risk in elderly nursing home residents. UTIs in older adults frequently present with atypical symptoms such as weakness, confusion, or functional decline, which can increase the likelihood of falls. Therefore, accepted standards of practice require assessment for underlying causes, including infection, following a resident fall. Sources include [NAME], J., et al., The Relationship of Urinary Tract Infections and Falls in a Nursing Home, Director Journal; Geriatric Nursing clinical literature on UTIs and fall risk in older adults.Review of the undated facility policy titled, Falls and Fall Risk, Managing revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors include incorrect bed height or width and conditions that may contribute to the risk of falls including infection. 2. Record review for Resident #30 revealed an admission date of 10/24/25. Diagnoses included intracranial injury, fracture of base of skull, maxillary fracture, displaced fracture of shaft of left tibia, disorders of autonomic nervous system, difficulty walking, muscle weakness, and traumatic brain injury. Review of the care plan initiated 10/27/25 revealed Resident #30 had potential for injury related to falls due to impaired communication, impaired cognition, impaired safety awareness, and restlessness related to head injury. Interventions included Resident #30 was to have his bed kept in low position, a pillow on the right side to assist with positioning, and mat on the floor beside the bed. Review of the Fall Risk Observation assessment dated [DATE] revealed Resident #30 was at moderate risk for fallsReview of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 was severely cognitively impaired. Resident #30 required partial/moderate assistance with chair/bed to chair transfer. Resident #30 had falls since admission.Observation on 02/09/26 at 9:09 A.M. revealed Resident #30 was lying in bed. A mat was on the floor to left side bed only. A second mat was leaning against the wall. The bed was raised and not in a low position. Observation on 02/09/26 at 9:16 A.M. with LPN #236 confirmed Resident #30 was at risk for falls. Observation revealed Resident #30 was lying in bed. There was one mat on the floor to the left side of the bed, and the second mat was leaning against the wall. LPN #236 confirmed the mat leaning against the wall should be on the floor next to the bed on the right side. LPN #236 also confirmed Resident #30's bed was not in a low position, and Resident #30 did not have a pillow to his right side while in bed as per the plan of care. Review of the undated facility policy titled, Falls and Fall Risk, Managing revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors include incorrect bed height or width and conditions that may contribute to the risk of falls including infection. 3. Record review for Resident #50 revealed an admission date 06/10/24. Diagnoses included displaced posterior arch fracture of first cervical vertebrae, fracture of neck, and Parkinsonism. Review of the fall risk observation /assessment dated [DATE] revealed Resident #50 was high risk for falls.Review of the modification of the quarterly and Medicare five-day MDS 3.0 assessment dated [DATE] revealed Resident #50 was severely cognitively impaired. Resident #50 used a manual wheelchair for mobility and required substantial/maximal assistance for chair/bed to chair transfer. Resident #50 had no fall since admission (inaccurate, fall with major injury 12/31/25). Review of the care plan initiated 01/19/25 revealed Resident #50 was at risk for falls related to impaired cognition, impaired safety awareness, diagnoses of dementia, Menier's, and osteoarthritis, use of medications that contribute to falls, and recent and remote history of falls. On 12/31/25 Resident #50 had a fracture of the cervical spine and returned from the hospital with a c-collar. Fall interventions included to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. Assure the bed is in low position when in bed and place the fall mat to the right side of the bed. Observation on 02/09/26 at 9:42 A.M. revealed Resident #50 was lying in bed. The bed was raised and not in a low position. The fall mat was on the left side of the bed, and the call light was on the floor behind the head of the bed not within reach for the resident. Observation and interview on 02/09/26 at 9:49 A.M. with LPN #263 confirmed Resident #50 was at risk for falls. LPN #263 confirmed Resident #50 was lying in bed. The bed was raised and not in a low position. The fall mat was on the left side of the bed, and the call light was on the floor behind the head of the bed not within reach for the resident. Review of the undated facility policy titled, Falls and Fall Risk, Managing revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors include incorrect bed height or width and conditions that may contribute to the risk of falls including infection. 4. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, COVID-19, dementia with behavioral disturbance, major depressive disorder, gastroesophageal reflux disease (GERD), and hyperlipidemia.Review of the admission MDS 3.0 assessment revealed it was still in progress.Review of the Brief Interview for Mental Status (BIMS) score dated 02/06/26 revealed a score off 00, indicating Resident #59 had severe cognitive impairment.Review of the fall risk assessment dated [DATE] revealed a score of 22 indicating Resident #59 was at high risk for falls.Review of the care plan initiated 02/06/26 revealed Resident #59 was at risk for falls with or without injury related to altered mental status, antipsychotic medication, history of falls, dementia, psychosis, hallucinations, noncompliance with transfers, and attempts to get up on his own. Interventions included bed pillows for positioning when occupied, educate to keep call light within reach when in bed or sitting next to the bed.Observation on 02/10/26 at 9:02 A.M. with CNA #205 confirmed Resident #59 was lying in bed. Resident #59 did not have bed pillows for positioning, and his call light was in his top nightstand drawer with the drawer closed. CNA #205 confirmed the call light was not within Resident #59's reach. Review of the undated facility policy titled, Falls and Fall Risk, Managing revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors include incorrect bed height or width and conditions that may contribute to the risk of falls including infection. This deficiency represents non-compliance for Master Complaint Number 2733495.

Based on record review and interview, the facility failed to obtain a timely urine sample for a physician ordered urinalysis for a resident exhibiting signs and symptoms of a urinary tract infection (UTI). The facility also failed to ensure timely physician notification of the diagnostic results indicating positive findings consistent with a UTI. The failure to promptly initiate diagnostic testing and follow acceptable standards of nursing practice resulted in a delay in identifying and treating the resident's potential infection placing the resident at risk for worsening infection and avoidable decline. This affected one (Resident #32) of three residents reviewed for timely obtaining and reporting physician ordered labs. The facility census was 53.Findings include:Review of the medical record for Resident #32 revealed an original admission date of 09/09/25 with diagnoses including chronic kidney disease and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 11/08/25 revealed Resident #32 had moderate cognitive impairment, no behaviors, required set up or clean up assistance for eating, brushing her teeth, and personal hygiene. She required partial to moderate assistance with bed to chair and chair to bed transfers. She was occasionally incontinent of bladder and always continent of bowel. Review of Certified Nurse Practitioner (CNP) #350's Acute Visit Note for Resident #32 dated 12/23/25, untimed, revealed the chief complaint was lethargy and blood in tissue. Resident #32 had an altered mental status, unspecified, acute, unstable. Resident #32 presented severely lethargic and altered orientation status. Resident #32 was currently alert and oriented to person only, which represented a change from her baseline. Resident #32 also demonstrated delayed responses during clinical assessment and endorsed feeling tired. Nursing staff notes a significant change in patient's mental status from the baseline. An assessment was completed with the review of recent labs, medications and vital signs. Ordered a urinalysis with culture and sensitivity (UA C&S) to evaluate for urinary source of acute delirium/encephalopathy. Notify the provider with results when available.Review of the physician order for Resident #32 revealed an order dated 12/23/25 to collect urine for a UA C&S, discontinue once collected. The order revealed it was discontinued on 01/22/26 due to the urine being obtained on 01/14/26.Review of the Medication Administration Note dated 12/24/25 at 6:28 P.M. for Resident #32 revealed no urine was obtained for the UA; the resident was hydrating. There was no documented evidence that the physician or CNP was notified.Review of the Medication Administration Note dated 12/26/25 at 12:14 A.M. for Resident #32 revealed for the UA, the resident did not want a man to straight cath her. There was no documented evidence that the physician or CNP was notified.Review of the Medication Administration Note dated 12/29/25 at 12:44 P.M. and 2:57 P.M. for Resident #32 revealed for the UA, the resident was incontinent. There was no documented evidence that the physician or CNP was notified.Review of the Medication Administration Note dated 01/02/26 at 3:23 P.M. for Resident #32 revealed for the UA, the lab will not pick up until Monday.There was no documented evidence that the physician or CNP was notified.Review of the Medication Administration Note dated 01/03/26 at 5:26 P.M. for Resident #32 revealed for the UA, urine was collected into brief. There was no documented evidence that the physician or CNP was notified.Review of the Medication Administration Note dated 01/04/25 at 8:18 P.M. for Resident #32 revealed for the UA, this has been completed. There was no documented evidence that the lab picked up the urine sample or that the physician or CNP was notified.Review of the Medication Administration Note dated 01/10/25 at 8:40 P.M. for Resident #32 revealed for the UA, collect urine for UA C&S; unable to collect.There was no documented evidence that the physician or CNP was notified.Review of the physician orders revealed an order dated 01/12/26 for Resident #32 to obtain urine via straight catheter for UA C&S.Review of the Medication Administration Note dated 01/12/25 at 5:23 P.M. for Resident #32 included the CNP was in house today, the nurse placed a new order per CNP for the UA; obtain urine for UA C&S.Review of the Laboratory UA C&S results for Resident #32 revealed a collection date of 01/14/26, a received date (to the lab) of 01/14/26 at 6:50 A.M. and a reported date of 01/23/26 at 9:47 A.M. The report indicated abnormal results including positive nitrate (Nitrite positive urine is a sign of a UTI. Antibiotics to treat UTI's kill the bacteria that cause nitrites in urine). The results met criteria to perform a urine culture. The culture revealed greater than 100,000 E- Coli, sensitivity (an indication of what antibiotic will kill the bacteria growth) was completed and included on the report. Review of the interdisciplinary team (IDT) note for Resident #32 dated 01/26/26 revealed the resident's daughter noted that she was noticing a change in her mother with things she does, example: playing with the remote control and pulling multiple tissues and rubbing them on her chest then stacking them. She noted that she believed that if she figures out a phone number, she will continuously call it multiple times or that her mother becomes fixated as she did with the remote to the bed and hit the button and not realizing she had to stop.Review of the nurse's note for Resident #32 dated 01/28/26 at 4:18 P.M. included Resident #32's daughter requested a copy of the urinalysis results and paperwork. Resident #32's daughter received copies of the following: face sheet, medication list, and UA results.Review of the physician orders for Resident #32 revealed an order dated 01/28/26 for nitrofurantoin monohyd macro capsule (antibiotic) 100 milligrams (mg) by mouth two times a day for a UTI for five days.Interview on 01/29/26 at 4:34 A.M. with Resident #32's daughter/responsible party, while a second daughter was on the phone, revealed Resident #32 had several falls within a short amount of time; she also had increased confusion. The Responsible Party revealed Resident #32 was more confused than ever and requested a UA which was ordered on 12/23/25 but not collected until 01/14/26. The results were reported to the facility on [DATE], but no treatment was started for the UTI until she went to the facility on [DATE], upset, and requested a copy of the results due to her mother's increased confusion. The daughter was given the results which confirmed a UTI and the nurse then notified the CNP, and the treatment with an antibiotic was initiated. The Responsible Party revealed she spoke to the DON who revealed this was an oversight and apologized.Interview on 02/09/26 at 12:11 P.M. with Licensed Practical Nurse (LPN) #263 revealed the facility had three different fax machines (the first floor, the second floor and the main office) that resident lab results were sent to from the lab. There were different nurses working day to day, so if a nurse was not aware the resident was waiting on a result, they did not look for it, so it gets missed, and the physician or CNP was not notified. LPN #263 stated, It's happened to a lot of residents, if the families don't watch and ask about them, then many get missed.Interview on 02/10/26 at 12:45 P.M. with the DON confirmed Resident #32 had a UA C&S ordered on 12/23/25 due to a decline including a change in mental status. The UA was not collected until 01/14/26 (22 days after it was ordered). The DON revealed she was unsure why the UA was not collected until 01/14/26, but at times, the lab person coming to the facility did not take the collected labs with them. The DON confirmed there was no documentation of CNP #350 being notified that the urine was not obtained until 01/14/26. The DON confirmed the UA with the C&S results were reported to the facility on [DATE]. (Usually a urine C&S takes about 24-48 hours for the culture and 48-72 hours for the sensitivity). The C&S results confirmed Resident #32 had an active UTI. The DON confirmed CNP #350 was not notified of the UA C&S results until 01/28/26 (five days after the results returned) and after the daughter requested the results. The DON revealed the facility had three fax machines that lab results were sent to and revealed there were intermittent times the facility did not receive the lab results back. She revealed at times there had been issues with the facility printer and at times there was no service. She revealed it should have been passed on in the nurses' report (shift to shift report) to monitor for the resident's lab results and revealed the nurses did not follow through to monitor for results. She confirmed Resident #32 continued to have increased confusion and on 01/25/26, two days after the lab result returned confirming a positive UTI, Resident #32 had a fall with a fracture. CNP #350 was not notified of the UTI results until the daughter questioned the nurses on 01/28/26 and at that time an antibiotic was ordered. She stated the nurses should have notified CNP #350 when they did not collect the urine after it was ordered on 12/23/25 when Resident #32 was noted to have an acute change in condition, and the nurses should have called the lab to inquire about the results when they did not receive them timely. The DON revealed the facility had no policy regarding labs.This deficiency represents non-compliance investigated under Master Complaint Number 2733495.

Based on record review, medication administration observation, staff interview, insulin pen instruction manual review and facility policy review, the facility failed to ensure medications were administered in accordance with professional standards of practice to maintain a medication error rate of less than five percent (5%). Observation during medication administration revealed two errors were observed of 39 opportunities with a 5.12% error rate. This affected two (Residents #7 and #32) of four residents observed for medication administration. The facility census was 53.Findings include: 1. Review of the medical record for Resident #32 revealed an original admission date of 09/09/25 with diagnoses including chronic kidney disease, reduced mobility, and intervertebral disc displacement, lumbar region.Review of the care plan initiated 09/10/25 revealed Resident #32 was at risk for complications with gastrointestinal system due to constipation. Interventions included to administer medications as ordered.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had moderate cognitive impairment. She required partial to moderate assistance with bed mobility and transfers and was occasionally incontinent of bladder and always continent of bowel. Review of the physician orders for Resident #32 revealed an order for MiraLAX oral powder 17 grams (gm)/scoop, give one scoop by mouth one time a day for constipation dated 01/30/26.Observation on 02/09/26 at 11:23 A.M. of medication administration with Licensed Practical Nurse (LPN) #263 provide medications for Resident #32 revealed MiraLAX was not available. LPN #263 confirmed the MiraLAX was not available and revealed Resident #32 would have it by tomorrow.2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnosis of type II diabetes mellitus.Review of the care plan initiated 04/21/25 revealed Resident #7 had a diagnosis of diabetes and was at risk for complications. Interventions included to administer medications as ordered.Review of the physician orders for Resident #7 revealed an order for insulin lispro injection 100 units per milliliter (ml) inject six units subcutaneously (sq) before meals for diabetes hold if the blood sugar less than 150 with a start date of 11/19/25.Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of two out of 15, indicating severe cognitive impairment. He did not reject care. He was independent with eating, transfers and oral hygiene and required supervision for toileting hygiene and showers.Observation on 02/10/26 at 8:33 A.M. of medication administration with LPN #207 for Resident #7 revealed LPN #207 assessed Resident #7's blood sugar and revealed the blood sugar was 238. Observation revealed LPN #207 removed the insulin pen lispro from the medication cart, placed a needle on the pen then dialed the pen to six units. LPN #207 did not prime the insulin pen prior to dialing the six units to be administered. LPN #207 then approached Resident #7 and administered the insulin sq. Interview on 02/10/26 at 8:51 A.M. with LPN #207 confirmed she did not prime the insulin pen prior to administration. LPN #207 stated, I don't need to prime because we don't want air to get into it, you never prime pens.Review of the undated insulin pen instruction manual titled, Instruction for Use for lispro insulin pens for use guidance revealed to attach a new needle to the pen. Always do a safety test (Priming) before each injection to check your pen and the needle to make sure they are working properly and to make sure you get the correct insulin dose. Select two units by turning the dose selector until the dose pointer is at the two marks, press the injection button all the way in, when insulin is coming out of the needle tip, your pen is working correctly. If no insulin appears, you may need to repeat this step up to three times before seeing insulin. If no insulin comes out after the third time the needle may be blocked. If this happens change the needle and repeat the safety check. After the safety check is complete, select the dose to administer.Review of the facility policy titled, Administering Medications, dated April 2019, revealed medications are administered in a safe and timely manner, and as prescribed.This deficiency represents non-compliance investigated under Master Complaint Number 2733495.

Based on observation of medication administration, interview, record review, review of insulin pen instruction manual and facility policy review, the facility failed to ensure Resident #7 was free from a significant medication error when the resident received an incorrect dose of insulin as ordered by the physician. This affected one (Resident #7) and had the potential to affect four additional (Residents #1, #6, #24, and #60) identified by the facility as also receiving insulin pen injections. The facility census was 53.Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnosis of type II diabetes mellitus.Review of the care plan initiated 04/21/25 revealed Resident #7 had a diagnosis of diabetes and was at risk for complications. Interventions included to administer medications as ordered.Review of the physician orders for Resident #7 revealed an order for insulin lispro injection 100 units per milliliter (ml) inject six units subcutaneously (sq) before meals for diabetes hold if the blood sugar less than 150 with a start date of 11/19/25.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of two out of 15, indicating severe cognitive impairment. He did not reject care. He was independent with eating, transfers and oral hygiene and required supervision for toileting hygiene and showers.Observation on 02/10/26 at 8:33 A.M. of medication administration with Licensed Practical Nurse (LPN) #207 for Resident #7 revealed LPN #207 assessed Resident #7's blood sugar and revealed the blood sugar was 238. Observation revealed LPN #207 removed the insulin pen lispro from the medication cart, placed a needle on the pen then dialed the pen to six units. LPN #207 did not prime the insulin pen prior to dialing the six units to be administered. LPN #207 then approached Resident #7 and administered the insulin sq. Interview on 02/10/26 at 8:51 A.M. with LPN #207 confirmed she did not prime the insulin pen prior to administration. LPN #207 stated, I don't need to prime because we don't want air to get into it, you never prime pens.Review of the undated insulin pen instruction manual titled, Instruction for Use for lispro insulin pens for use guidance revealed to attach a new needle to the pen. Always do a safety test (Priming) before each injection to check your pen and the needle to make sure they are working properly and to make sure you get the correct insulin dose. Select two units by turning the dose selector until the dose pointer is at the two mark, press the injection button all the way in, when insulin is coming out of the needle tip, your pen is working correctly. If no insulin appears, you may need to repeat this step up to three times before seeing insulin. If no insulin comes out after the third time the needle may be blocked. If this happens change the needle and repeat the safety check. After the safety check is complete, select the dose to administer.Review of the facility policy titled, Administering Medications, dated April 2019, revealed medications are administered in a safe and timely manner, and as prescribed.The deficiency represents an incidental finding identified during the complaint investigation.

Based on observation of medication administration, record review, staff interview and facility policy review, the facility failed to ensure accurate documentation of medication administration in accordance with professional standards of practice. This affected one (Resident #32) of four residents reviewed for medication administration. The facility census was 53.Findings include:Review of the medical record for Resident #32 revealed an original admission date of 09/09/25 with diagnoses including chronic kidney disease, reduced mobility, and intervertebral disc displacement, lumbar region.Review of the care plan initiated 09/10/25 revealed Resident #32 was at risk for complications with gastrointestinal system due to constipation. Interventions included to administer medications as ordered.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had moderate cognitive impairment. She required partial to moderate assistance with bed mobility and transfers and was occasionally incontinent of bladder and always continent of bowel. Review of the physician orders for Resident #32 revealed an order for MiraLAX oral powder 17 grams (gm)/scoop, give one scoop by mouth one time a day for constipation dated 01/30/26.Interview on 01/29/26 at 4:34 P.M. with Resident #32's daughter revealed Resident #32 was not getting her medications as she was supposed to, staff were leaving them in her room, not making sure Resident #32 was taking them then would sign the medication administration record (MAR), that they were administered.Observation on 02/09/26 at 11:23 A.M. of medication administration with Licensed Practical Nurse (LPN) #263 provide medications for Resident #32 revealed MiraLAX was not available. LPN #263 confirmed she was still doing the morning medications for Resident #32 and confirmed the MiraLAX was not available. LPN #263 revealed Resident #32 would have it by tomorrow. Observation revealed LPN #263 signed the MAR confirming the MiraLAX was administered for 02/09/26.Record review on 02/10/26 of the MAR for Resident #32 revealed the MiraLAX scheduled to be administered on 02/09/26 at 9:00 A.M. was documented as administered. Record review of the progress notes and the MAR notes revealed no documentation regarding the MiraLAX administration for 02/09/26 or thereafter.Interview on 02/10/26 at 8:57 A.M. with LPN #263 confirmed during the medication administration with the surveyor on 02/09/26, Resident #32's MiraLAX was not available. LPN #263 confirmed Resident #32 did not receive the MiraLAX at all on 02/09/26 and confirmed she signed the MAR on 02/09/26 indicating the MiraLAX was administered. LPN #263 confirmed she never placed a note in Resident #32's medical record indicating the MAR was signed in error. LPN #263 revealed she will put a note in now. Review of the undated facility policy titled, Charting and Documentation revealed all services provided to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Medication administration is documented in the resident's medical record. Documentation in the medical record will be objective, complete, and accurate.This deficiency represents non-compliance investigated under Master Complaint Number 2733495.

Based on medical record review, observation, interview, and policy review, the facility failed to implement a comprehensive, resident centered plan for the prevention and treatment of pressure ulcers for Resident #26 and Resident #48. This affected two residents (Resident #26 and #48) of three residents reviewed for pressure ulcers.Actual harm occurred beginning on 12/08/25 when Resident #26 who was dependent on staff for activities of daily living, had current pressure ulcers and was at risk of developing additional pressure ulcers was found to have a new open wound area to the gluteal/upper thigh. The facility failed to complete a comprehensive wound assessment of the area, failed to provide appropriate/adequate interventions, and failed to ensure the facility wound physician and wound nurse were timely notified of to prevent the deterioration of the of the wound. On 12/15/25 the wound was first assessed to be an unstageable (a full-thickness wound where the actual depth is hidden by dead tissue (slough or eschar) pressure ulcer to the gluteal area which deteriorated and required antibiotics for a wound infection. Findings include:1. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, contracture unspecified joint, pressure ulcer sacral region Stage III (full-thickness skin loss, where fat is visible but bone, tendon, or muscle isn't exposed, creating a deep crater that can have rolled edges (epibole) and slough) and bed confinement status. Additional diagnosis added and dated 12/30/25 to included pressure ulcer left elbow unstageable, pressure ulcer left buttocks unstageable, pressure ulcer left heel unstageable, and pressure ulcer of the right heel unstageable.Review of the admission Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was rarely or never understood. Resident #26 had an indwelling catheter, was always incontinent of bowel and bladder, was dependent (on staff) for eating, toileting hygiene, personal hygiene, bed mobility, chair/bed to chair transfer. The assessment revealed Resident #26 was at risk for pressure ulcers, had unhealed pressure ulcers, one Stage III present upon admission and no other pressure ulcers were present. Resident #26 had a pressure reducing device for the bed and received pressure ulcer injury care.Review of the care plan dated 09/22/25 revealed Resident #26 was at risk for skin breakdown/pressure ulcers related to osteomyelitis, left hemiparesis and diabetes mellitus. Interventions included to administer medication and treatments as ordered, keep skin clean and dry to the extent possible, and enhanced barrier precautions. Review of the care plan and physician orders revealed no documentation of turning or repositioning restrictions. Review of the progress note for Resident #26 dated 12/08/25 at 4:05 P.M. completed by Registered Nurse (RN) #224 revealed during the wound treatment round this nurse observed a new open area on left back of upper thigh and its skin bruise and tear so this nurse put dressing on it so this nurse clean with ns (normal saline) pat it dry and cover it with foam dressing and notified all responsible party.Review of the physician orders, Treatment Administration Records (TAR) and progress notes for Resident #26 revealed no physician order was obtained for care or treatment to Resident #26's new wound documented in the progress note on 12/08/25 to the left back of upper thigh and no further treatment was applied to the wound until 12/11/25.Review of a Skin Issues Note/Form for Resident #26 dated 12/11/25 at 11:08 A.M. completed by Wound Care Licensed Practical Nurse (LPN) #148 revealed Resident #26 had a new wound to the left gluteus. The wound was a pressure ulcer that assessed to be an unstageable pressure ulcer due to slough and or eschar injury present. The wound was acquired in house, identifying an exact date of 12/11/25. The measurements included three centimeters (cm) length by two cm width by (undetermined depth). Slough was 10% with a moderate amount of exudate. The surrounding tissue was excoriated.Review of the physician orders dated 12/11/25 for Resident #26 revealed an order for treatment to the left rear thigh which included to cleanse with normal saline, pat dry, apply calcium alginate with silver to the wound bed only, cover with dry dressing daily and as needed.Review of a Skin issues Note/Form for Resident #26 dated 12/29/25 completed by Wound Care Nurse LPN #148 revealed the left gluteus unstageable pressure injury was deteriorating. The wound bed had 100% slough present, the wound was in-house acquired, had heavy exudate with a faint odor, the surrounding tissue was dark reddish brown, and the dressing had heavy dressing saturation. The wound measured five cm in length by 13 cm in width by 1.7 cm depth.Review of the physician order dated 12/29/25 for Resident #26 revealed new orders for wound treatment to the left gluteus, cleanse with 0.25% Dakins, pat dry, pack wound with Mesalt ribbon, cover with foam dressing daily and as needed. An additional order dated 12/29/25 included Doxycycline Hyclate (antibiotic) oral tablet 100 milligrams (mg) give one tablet by mouth two times a day, prophylactically, for wound infection for 14 days.Interview on 12/29/25 at 11:15 A.M. with Certified Nursing Assistant (CNA) #199 revealed resident rounds which included turning and repositioning, would be done after breakfast, then after lunch and before dinner. CNA #199 revealed rounds including turning and repositioning should be done three times in a 12-hour shift.Interview on 12/29/25 at 11:45 A.M. with Licensed Practical Nurse (LPN) #183 revealed residents should be checked and changed every two hours. However, the LPN revealed residents were not checked, changed, turned and repositioned timely. Observation on 12/29/25 at 1:32 P.M. revealed Resident #26 was lying in bed. Resident #26 was lying on his backside. Resident #26 was difficult to understand. Resident #26 was not observed to have an indwelling catheter.Record review and interview on 12/29/25 at 1:36 P.M. with Wound Care Nurse LPN #148 revealed Resident #26 was admitted to the facility with a Stage III sacral wound. Since admission, Resident #26 developed five additional in-house pressure ulcers, a left elbow in-house unstageable pressure ulcer (found on 12/18/25), a left heel and right heel unstageable in -house pressure ulcers (found on 10/09/25), and a right planter foot unstageable in-house pressure ulcer (with 100% eschar when found on 12/11/25). The LPN indicated the sacral wound had since been improving and all other wounds were stable. On 12/08/25 a pressure ulcer was found on Resident #26's gluteus area. The nurse who identified the area documented the pressure ulcer as a bruise and skin tear but never notified Wound Care Certified Nurse Practitioner (CNP) #238 or the facility wound care nurse, and an order was not obtained to treat or care for the wound until Wound Care Nurse LPN #148 was notified on 12/11/25 (three days later) of the area. Wound Care Nurse LPN #148 revealed at first she thought the wound was due to the resident being wet because he was a heavy wetter and the wound also had excoriation around it, but when Wound Care CNP #238 assessed the wound on 12/11/25, it was determined by Wound Care CNP #238 it was an unstageable pressure ulcer. Wound Care Nurse LPN #148 revealed Resident #26 does not refuse care to the wound team and was never told of him refusing any care. Wound Care Nurse LPN #148 revealed she believed the wound was caused from Resident #26 not getting up out of bed often, being a heavy wetter, and he had been staying in bed to help heal his wounds. Wound Care Nurse LPN #148 revealed Resident #26 was transferred from the second floor (on 12/22/25) where the long term care residents resided down to the first floor where he could be monitored more closely. Resident #26 was ordered an indwelling catheter to be placed 12/29/25. Wound Care Nurse LPN #148 confirmed the date on the Skin Issue Form/Note indicated the date the wound on the left gluteus was found was 12/11/25, Wound Care Nurse LPN #148 confirmed that was an incorrect date because the wound was actually found on 12/08/25. Interview on 12/29/25 at 3:05 P.M. with Certified Nursing Assistant (CNA) #107 revealed she provided care for Resident #26. CNA #107 revealed Resident #26 needed turned by staff, as his mobility was limited; he could not be turned to the left side due to a stroke so he could only be turned on his back or to the right. Resident #26 never refused to be turned but stated staff were limited with positions to turn him.Interview on 12/30/25 at 9:22 A.M. with LPN #191 revealed Resident #26 could turn on either the right or left side, and there were no restrictions. Interview on 12/30/25 at 9:38 A.M. with CNA #161 revealed Resident #26 never refused turning and revealed but only goes toward the left side, he never turns on the right side. Interview on 12/30/25 at 1:24 P.M. with CNP #226 revealed the nurse called her on 12/08/25 to notify her of a new wound on Resident #26. CNP #226 revealed she told the nurse to notify the Wound Care CNP for orders because she was the one who takes care of the residents' wounds. Interview on 12/31/25 between 10:00 A.M. and 3:30 P.M. with Wound Care CNP #238 revealed she had concerns with Resident #26's wound to the left gluteus, the wound worsened and required surgical debridement and due to an infection in the wound, Resident #26 required an oral antibiotic. Wound Care CNP #238 revealed she should be notified of new wounds when they occur and confirmed she was not notified of Resident #26's wound to the left gluteus until 12/11/25.Observation on 12/31/25 at 4:10 P.M. of wound care to Resident #26's left gluteus wound completed by Wound Care Nurse LPN #148 revealed the left gluteus wound had a strong foul odor with drainage visible covering the outside of the dressing. The wound bed was 100% a dark gray color with sloughing. Wound Care Nurse LPN #148 confirmed the wound was tunneling. Resident #26 moaned and yelled out loud intermittently throughout the wound care. A request was made for a wound care prevention policy. The facility provided a policy on wound care but it did not include skin management or prevention. Review of the facility policy titled, Repositioning revised May 2013 revealed repositioning was a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. If an existing ulcer was present, positioning the resident on an existing ulcer should be avoided. Evaluation included does the resident need scheduled position changes? Does the resident need positioning changes more frequently than hourly? Interventions included a turning/repositioning program includes a continuous consistent program for changing the residents position and realigning the body. A program is defined as a resident's approach documented, monitored, and evaluated. Residents who were in bed should be on at least an every-two-hour repositioning schedule. If ineffective, the turning and repositioning frequency would be increased. 2. Record review for Resident #48 revealed an admission date of 10/23/23 with diagnoses including multiple sclerosis, muscle weakness, and paraplegia with lower extremity contractures.Review of the care plan initiated 01/15/24 revealed Resident #48 had increased risk for skin breakdown and pressure ulcer formation due to impaired and reduced mobility. Interventions included to administer treatments as ordered by the physician, offload heals, positioning pillows to lower extremities, and prafo boots to keep heels elevated off the bed per physician orders.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was rarely or never understood. Resident #48 had a pressure ulcer over a bony prominence, was at risk for developing pressure ulcers, had one Stage II (partial thickness loss of skin that exposes the dermis, which is the middle layer of skin. The wound may also appear as a blister or abrasion and is typically tender and painful.) present on admission, entry or reentry, two Stage III ulcers with one of those present on admission/entry or reentry. The assessment revealed Resident #48 had a pressure reducing device to the bed.Observation on 12/29/25 at 11:30 A.M. with Hospice Registered Nurse (RN) #228 revealed Resident #48 was lying in bed. Resident #48's bilateral lower legs were severely contracted, one pressing tightly against the other. Observation revealed nothing was in place to separate the bone on bone contact. Hospice RN #228 confirmed Resident #48 had a wound to the left outer knee that was chronic and being treated. Hospice RN #228 revealed during her assessment, a foam dressing to Resident #48's left inner knee was found that she was unaware of and confirmed the foam dressing to the left inner knee was dated 12/25/25 (four days earlier). Observation with Hospice RN #228 revealed under the foam dressing to the left inner knee was a piece of calcium alginate covering an open wound. Licensed Practical Nurse (LPN) #183 entered and observed the wound. LPN #183 confirmed with Hospice RN #228 the area to the left inner knee was not documented, neither nurse were aware of the wound and the wound had no physician orders for any treatment. Observation with both LPN #183 and Hospice RN #228 revealed under the border dressing was a piece of calcium alginate covering an open wound. RN #228 measured the open wound open area at three centimeters (cm) in length by two cm in width by 0.1 cm in depth with a small amount of serosanguinous drainage. The surrounding tissue was red. Hospice RN #228 revealed the area was red last week but it was not open, they were putting zinc on it, and they told the Wound Care Nurse (LPN #148). Hospice RN #28 confirmed she never obtained an order to treat the area at the time she was putting zinc on it.Review of the medical record for Resident #48 on 12/29/25 at 11:50 P.M. with LPN #183 confirmed there was no assessment, documentation, or physician order for care and treatment for the wound on Resident #48's left inner knee including no order for zinc. Interview and record review on 12/29/25 at 12:00 P.M. with Wound Care Nurse LPN #148 confirmed there was no assessment, documentation, or physician order for care and treatment for the wound on Resident #48's left inner knee. Wound Care Nurse LPN #148 revealed when a resident received hospice services, she did not monitor their wounds, care or treatments and revealed that was up to hospice to do. Wound Care Nurse LPN #148 revealed Hospice RN #228 never told her about the area or zinc being applied. Wound Care Nurse LPN #148 revealed normally if a resident had a wound, she, or the floor nurse did the measurements, the physician or certified nurse practitioner (CNP) would be notified along with the residents responsible party and a risk management form would be completed. Wound Care Nurse LPN #148 revealed they do find sometimes wounds being treated with no documentation or notification.Observation on 12/31/25 at 4:10 P.M. with LPN #239 present revealed Resident #48 did not have pillows to lower extremities or prafo bots on. Resident #48's contracted lower legs were lying directly one on top the other. LPN #239 confirmed the observation at the time.Review of the facility policy titled, Repositioning revised May 2013 revealed repositioning was a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. If an existing ulcer was present, positioning the resident on an existing ulcer should be avoided. Evaluation included does the resident need scheduled position changes? Does the resident need positioning changes more frequently than hourly? Interventions included a turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program was defined as a specific approach documented, monitored, and evaluated. Residents who were in bed should be on at least an every-two-hour repositioning schedule. If ineffective, the turning and repositioning frequency would be increased. The deficiency represents non-compliance investigated under Complaint Number 2607407 and 2701189.

Based on observation, interview, record review and review of the facility policy, the facility failed to provide timely incontinence care for Resident #16 and #20. This affected two residents (Residents #16 and #20) of three resident reviewed for incontinence care. The facility census was 65.Findings include:1. Record review for Resident #16 revealed an admission date of 08/22/25 with diagnosis including dementia, cervicalgia, and muscle weakness. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired. Resident #16 was always incontinent of urine and occasionally incontinent of bowel. Resident #16 used a wheelchair for mobility, was dependent for chair/bed to chair transfer, wheelchair mobility, toilet transfer and for toileting hygiene. Resident #16 had no wounds or skin problems. Resident #16 was on a turning and repositioning program. Review of the care plan dated 09/02/26 revealed Resident #16 had bladder incontinence. Interventions included to offer toileting rounds upon request and as needed and to provide incontinent care upon request and as needed. Observation on 12/29/25 at 9:24 A.M. revealed Resident #16 was in her room sitting in a Geri chair with her eyes closed. Hospice Registered Nurse (RN) #228 revealed the hospice aide finished Resident #16's shower and placed her in the Geri chair earlier that morning. The hospice aide visited with Resident #16 five days a week for 30 minutes to one hour each visit. Observation on 12/29/25 at 10:00 A.M. revealed Resident #16 was still resting quietly in her Geri chair in her room. Interview on 12/29/25 at 10:01 A.M. with Hospice Aide #230 confirmed she showered Resident #16 this morning, and she visited Resident #230 five days a week and also visited several other residents while at the facility. Hospice Aide #230 revealed sometimes when she visited, Resident #16 would be saturated with urine. Observation on 12/29/25 at 10:30 A.M. revealed Resident #16 was located across from the nurses station in her chair, her eyes were open but she did not respond to conversing. Observation on 12/29/25 at 11:35 A.M. revealed Resident #16 was located across from the nurses station in her chair. Observation and interview on 12/29/25 at 1:52. P.M. with Certified Nursing Assistant (CNA) #199 confirmed she was Resident #16's primary CNA. Observation revealed Resident #16 was still located in her chair across from the nurses station in the same area and position as previously observed. CNA #199 confirmed Resident #16 had been there since that morning and confirmed Resident #16 not been checked or changed since hospice did it around 9:00 A.M. Observation on 12/29/25 at 2:00 P.M. of incontinence care for Resident #16 provided by CNA #199 and Licensed Practical Nurse (LPN) #183 revealed Resident #16's brief was saturated. LPN #183 and CNA #199 confirmed Resident #16 had a dressing intact to the buttocks, the surrounding tissue and buttocks coccyx/sacral area was deep red. CNA #199 revealed no one her told her how often she was supposed to check and change her residents but she tried to do it after lunch and after dinner, and Hospice would do Resident #16 in the morning. Interview on 12/29/25 at 3:00 P.M. with MDS RN #223 revealed residents should be checked, changed, and repositioned every two hours as this was standard of care. 2. Record review for Resident #20 revealed an admission date of 07/28/16 with diagnosis including hemiplegia affecting right dominant side, contracture of right hand, right forearm, right upper arm, left forearm, right elbow, and pressure ulcer of sacral region. Review of the quarterly MDS assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired. Resident #20 was always incontinent of bowel and bladder, had impairment on both sides of the upper extremities, used a wheelchair for mobility, was dependent for toileting hygiene, chair/bed to chair transfer, and wheelchair mobility. Review of the care plan dated 01/31/24 revealed Resident #20 had bladder incontinence. Interventions included to check resident if he is continent, offer to assist with toileting, and if he is incontinent, remove wet or soiled clothing/brief, and provide incontinent care Observation on 12/29/25 at 9:36 A.M. of wound care to Resident #20's left sacral wound provided by LPN #148 and RN #206 (Wound Care Certified Nurse Practitioner (CNP) #238 was present) revealed Resident #20's brief was wet with urine. The sheets Resident #20 rested on was peppered in crumbs and what appeared to be flaking skin cells verified by LPN #148. Observation revealed RN #206 turned Resident #20 to his side, unfastened the brief and LPN #148 moved the side of the brief covering the wound, removed the wound dressing then CNP #238 measured the wound. After the measurement was completed, CNP #238 stepped back and LPN #148 completed the wound care treatment then refastened the same soiled brief. LPN #148, RN #206 and CNP #238 then exited the room. RN #206 returned to the nurses station while LPN #148 and CNP #238 returned to the treatment cart and moved the cart to the next resident room. Interview with LPN #148 confirmed they completed care with Resident #20 an confirmed Resident #20's brief was saturated with urine. LPN #148 revealed the aides will do rounds after breakfast and change the resident. Observation revealed LPN #148, CNP #238 nor RN #206 notified any staff Resident #20's brief was saturated with urine. Interview on 12/29/25 at 10:05 A.M. with Certified Nursing Assistant (CNA) #199 confirmed she was Resident #20's primary CNA. When asked by the surveyor when she will be providing incontinence care for Resident #20, CNA #199 revealed she planned on starting care at the top of the hall and she was not sure when she would get to him. Observation on 12/29/25 at 11:00 A.M. of incontinence care for Resident #20 provided by CNA #199 and #107 confirmed Resident #20's bed sheets were still peppered with crumbs and dried skin cells. CNA #199 and #107 confirmed Resident #20's brief was saturated with urine. CNA #199 revealed no one told her he was wet and revealed her shift started at 7:00 A.M. and confirmed this was the first time this shift checking for incontinence and changing Resident #20. CNA #199 revealed he required two people to assist him with turning and stated there was not enough people who will help. Interview on 12/29/25 at 11:45 A.M. with LPN #183 revealed residents were not being changed timely and there were a lot of heavy care residents. Interview on 12/29/25 at 2:51 P.M. with DON and Administrator revealed the DON has always expected staff to assess residents for incontinence care every two hours or as needed. Administrator confirmed there had been family concerns expressed to her regarding residents not receiving timely incontinence care. Review of the facility policy titled, Urinary Continence and Incontinence - Assessment and Management revised August 2022 revealed If a resident does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. A check and change strategy involves checking the residents continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to help protect the skin.This deficiency represents non-compliance identified during the investigation of Complaint Number 2607407, 2703210, and 2649661.

Based on record review, interview and review of the facility policy, the facility failed to maintain the most current and accurate advance directive in the resident record. This affected one resident (#71) of three residents reviewed for death. Facility census was 65.Findings include:Review of Resident #71's closed medical record revealed an admission date of [DATE] and diagnoses including muscle wasting and atrophy, depression, dementia with behavioral disturbance, dysphagia, hypertension and diffuse large B-cell lymphoma within the intra-abdominal lymph nodes. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively impaired.Review of Resident #71's physician's orders revealed an order dated [DATE] for an advance directive for cardiopulmonary resuscitation (CPR) full code and an order dated [DATE] for admission to hospice for diagnose senile degeneration of the brain with a prognosis of six months or less provided disease follows its expected course. No other advance directive orders were noted in Resident #71's medical record.Review of a plan of care dated [DATE] revealed Resident #71 had an advance directive of full code. Listed interventions included advance directive and code status will be honored and advance directive will be in the medical record at all times.Review of hospice documentation faxed to the facility on [DATE] revealed Resident #71 was admitted to hospice services on [DATE] by Hospice Registered Nurse (HRN) #231. Advance directives were discussed before care was initiated on [DATE] with Resident #71's wife and they did not want CPR or other life-sustaining measures if his heart or lungs stopped working. A Do Not Resuscitate (DNR) order was also completed at this time. Further review of a death visit note dated [DATE] at 12:25 P.M. and authored by HRN #228 revealed Resident #71 expired on [DATE] at 12:30 P.M. and CPR was not initiated. The facility had called to report Resident #71 had expired and upon arrival, HRN #228 confirmed Resident #71 was absent of vitals.Review of a progress note dated [DATE] at 12:57 P.M. and authored by Registered Nurse (RN) #225 revealed Resident #71 expired on [DATE] at 12:30 P.M. and hospice, physician and family were made aware and Resident #71 was cleaned.Telephone interview on [DATE] at 8:25 A.M. with RN #225 revealed she was agency staff and could not recall the last time she worked at the facility. RN #225 recalled working on [DATE] but reported it was a last-minute shift and recalled hospice staff (names not provided) had wheeled Resident #71 in his wheelchair to his room and he looked bad, like he was going to go (pass away). RN #225 reported checking Resident #71's vitals and gave him Morphine medication as directed by hospice staff. RN #225 stated staff told her Resident #71 had passed away within the hour she had been at the facility and she spoke with Unit Manager (UM)/Licensed Practical Nurse (LPN) #105 as she had noticed Resident #71 had an advance directive of full code on his Medication Administration Record (MAR). RN #225 recalled UM/LPN #105 told her to don't worry about [the code status] as they [not specified] would take care of it. RN #225 reported if a resident was full code and were found unresponsive then staff should initiate CPR and shared on [DATE] no code was called and CPR was not provided to Resident #71.Interview on [DATE] at 9:05 A.M. with CNA #107 revealed on [DATE], night shift had gotten Resident #71 up for the day and therapy staff had assisted him with his breakfast. Hospice staff including Home Health Aide (HHA) #231 was present and took over, placing Resident #71 in bed and making him comfortable. CNA #107 recalled going in Resident #71's room with his lunch tray around 11:30 A.M. and tried to wake him up but he had already passed away so she reported this to the nurse (name not recalled). CNA #107 did not recall Resident #71's advance directive and confirmed no code was called on [DATE]. Interview on [DATE] at 9:17 A.M. with LPN #183 recalled she had picked up a shift on [DATE] but was not responsible for Resident #71 and did not recall a code being called this date. Interview on [DATE] at 10:30 A.M. with HHA #231 revealed she was present with Resident #71 when he passed away and recalled him looking like he was going to take his last breath in his wheelchair so she and HRN #228 had placed him in the bed, cleaned him and he passed away 30 minutes or so later. Interview on [DATE] at 10:38 A.M. with HRN #228 revealed she was present when Resident #71 passed away on [DATE] and recalled he had been actively dying so this was expected. HRN #228 was asked about Resident #71's advance directive and explained the hospice company would admit residents with a full code advance directive, but during care conferences and over time discussions would be had regarding goals of care and the advance directives often changed. HRN #228 pulled up Resident #71's hospice records during the interview including an advance directive for Do Not Resuscitate Comfort Care (DNR-CC) signed by Resident #71's wife on [DATE]. HRN #228 explained as they had this advance directive, CPR was not to be done thus no code was called on [DATE].Telephone interview on [DATE] at 10:58 A.M. with HRN #231 revealed when a resident signed on hospice services, consents were completed including advance directives and the hospice company would then fax the consent and advance directive to the facility. HRN #231 stated during a hospice admission he had no way to print out an advance directive and he was not the staff responsible to fax these documents to the facility.Telephone interview on [DATE] at 11:16 A.M. with Certified Nurse Practitioner (CNP) #226 revealed she had been notified Resident #71 had signed onto hospice services during [DATE] and reviewed the facility record during the interview which indicated Resident #71 had an advance directive of full code. CNP #226 stated she was surprised to read this as usually when residents signed on hospice, hospice staff could come in, educate the resident and family on advance directives and most of the time an advance directive of Do Not Resuscitate would be put in place. CNP #226 stated hospice staff were responsible for completion of the new advance directive form as the hospice medical director signed off on it and usually hospice would fax these documents to the facility. During the interview CNP #226 confirmed she only could find evidence Resident #71 was to be a full code from the facility's records.During an interview on [DATE] at 12:40 P.M. the Administrator and the Director of Nursing (DON) were made aware of the discrepancies in the facility's documentation regarding Resident #71's advance directive of full code not matching the accurate DNR-CC advance directive documents from the hospice company and did not disagree with these findings.Review of the facility policy, Advance Directives, revised 2021 revealed if the resident representative has executed one or more advance directive(s) copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The director of nursing services (DNS) or designee notifies the attending physicianof advance directives or changes in advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The resident wishes are communicated to the resident's direct care staff and physician by placing the documents in a prominent, accessible location in the medical record.the plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive.This deficiency represents non-compliance identified during the investigation of Complaint Number 2649661.

Based on observation, interview, record review, and review of the facility policy, the facility failed to maintain enhanced barrier precautions (EBP) and handwashing during resident care. This affected three residents (Resident #20, #48 and #26) of three observed for enhanced barrier precautions.Findings include:1.Record review for Resident #20 revealed an admission date of 07/28/16. Diagnosis included hemiplegia affecting right dominant side, contracture of right hand, right forearm, right upper arm, left forearm, right elbow, and pressure ulcer of sacral region. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired. Resident #20 was always incontinent of bowel and bladder, had impairment on both sides of the upper extremities, used a wheelchair for mobility, was dependent for toileting hygiene, chair/bed to chair transfer, and wheelchair mobility. Review of the care plan dated 09/11/25 included Resident #20 required enhanced barrier precautions (EBP) during high contact resident care activities due to the presence of open wounds. Observation on 12/29/25 at 11:00 A.M. of incontinence care for Resident #20 provided by Certified Nursing Assistant (CNA) #199 and #107 confirmed Resident #20's brief was saturated with urine. Observation revealed neither CNA #199 nor #107 wore an isolation gown during the incontinence care provided to Resident #20 and observation revealed both CNA's shirts touched Resident #20 and his linen items while providing the care. Both CNA #199 and #107 confirmed they did not put an isolation gown while providing incontinence care for Resident #107 or while changing the soiled linens. Observation on the entrance door for Resident #20's room revealed a sign which stated EBP, everyone must clean their hands including before entering and when leaving, providers and staff must also wear gloves and a gown for the following high contact resident care activities which included changing linens, providing hygiene, and changing briefs. Interview on 12/29/25 at 2:51 P.M. with DON and Administrator confirmed staff should apply an isolation gown and gloves when providing incontinent care for Resident #20. DON confirmed all the nursing staff floated and assisted with all residents. 2. Record review for Resident #48 revealed an admission date of 10/23/23. Diagnosis included multiple sclerosis, muscle weakness, and paraplegia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #48 was rarely or never understood. Resident #48 had a pressure ulcer over a bony prominence, was at risk for developing pressure ulcers, had one stage two present on admission, entry or reentry, two stage three ulcers with one of those present on admission/entry or reentry. Review of the care plan dated 12/09/25 revealed Resident #48 required EBP due to indwelling medical device, feeding tube, ostomy and open wounds. Interventions included utilize gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high contact interactions include dressing, bathing, showering, transferring, providing hygiene, shaving, changing linens, changing briefs/toileting, device care or use (central lines, urinary catheters, feeding tube, trach, vent, wound care, etc.) Observation on 12/29/25 at 11:30 A.M. of wound care to Resident #48's left knee provided by Hospice Registered Nurse (RN) #228 and Hospice Aide #230 confirmed Resident #48 had an open area to the left knee. LPN #183 entered the room and was present during care. Both Hospice RN #228 and Hospice Aide #230 confirmed neither wore an isolation gown during wound care and confirmed both care for multiple residents residing at the facility. Interview on 12/30/25 at 10:23 A.M. with DON confirmed Hospice staff were expected to follow the facility infection control practiced including donning and doffing PPE. DON revealed Hospice RN #228 and Hospice Aide #230 visited Resident #10, #15, #16, #18, #48 and #55 on 12/29/25. 3. Record review for Resident #26 revealed an admission date of 09/21/25. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, contracture unspecified joint, protein calorie malnutrition, pressure ulcer sacral region stage three, bed confinement status, pressure ulcer left elbow unstageable, pressure ulcer left buttocks unstageable, pressure ulcer left heel unstageable and pressure ulcer of the right heel unstageable. Review of the admission Medicare five-day MDS assessment dated [DATE] revealed Resident #26 was rarely or never understood. Resident #26 had an indwelling catheter, was always incontinent of bowel and bladder, was dependent for eating, toileting hygiene, personal hygiene, bed mobility, chair/bed to chair transfer. Resident #26 was at risk for pressure ulcers, had unhealed pressure ulcers, one stage three present upon admission and no other pressure ulcers were present. Review of the care plan dated 09/28/25 revealed Resident #26 required EBP during high contact resident care activities due to the presence of open wounds and osteomyelitis. Interventions included to utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities (e.g., dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care). Observation on 12/30/25 at 9:22 A.M. of LPN #191 turning and repositioning Resident #26 in bed revealed LPN #191 repositioned Resident #26's four pillows used to position his body and extremities and his linen and blankets without donning an isolation gown. Observation revealed Resident #26 and his linens frequently touched LPN #191's shirt. LPN #191 did not wash her hands prior to providing care or after completing the care and prior to leaving the room. LPN #191 confirmed Resident #26 had an EBP sign on his door entering his room. The sign included everyone must clean their hands including before entering and when leaving the room; wear gloves and gown when transferring. LPN #191 confirmed she did not wash her hands before entering the room or providing care to Resident #26 or after providing care and before exiting the room. LPN #26 also confirmed she never placed an isolation gown on prior to turning and repositioning Resident #26 in bed. Review of the facility policy titled, Handwashing/Hand Hygiene dated October 2023 revealed the facility considers hand hygiene the primary means to prevent the spread of health-care associated infections. Hand hygiene is indicated immediately before touching a resident, and after touching a resident and or the resident's environment. Review of the facility policy titled Enhanced Barrier Precautions dated December 2024 revealed EBP's refer to an infection prevention and control interventions designated to reduce the transmission of multi-drug-resistant organisms (MDRO's) during high contact resident care activities. EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device. Examples of high contact resident care activities requiring the use of gown and gloves for EBP included dressing, bathing, hygiene, changing briefs or toileting, transferring, providing bed mobility, changing linens, device care or wound care.

Based on interview, medical record review, and policy review, the facility failed to ensure Resident #62 was monitored and treated timely for a change in condition after a fall. This affected one resident (Resident #62) of three residents reviewed for falls. The facility census was 65.Findings include:Review of the closed medical record for Resident #62 revealed an admission date of 11/18/25 and a discharge date of 12/22/25. Diagnosis included spinal stenosis cervical region, fusion of spine cervical region, fibromyalgia, muscle weakness, need for assistants with personal care, and lack of coordination.Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 was always incontinent of urine and occasionally incontinent of bowel. Resident #62 used a walker for mobility, required partial/moderate assistants for bed mobility, substantial/maximal assistants for sit to stand and chair/bed to chair transfers. Resident #62 used a manual wheelchair and required substantial/maximal assistants for wheelchair mobility. Resident #62 did not have a fall anytime in the last month prior to admission/entry or reentry. Resident #62 did have one fall since admission with no injury. Resident #62 had surgery involving fusion of spinal bones requiring active skilled nursing facility (SNF) care.Review of the care plan for Resident #62 dated 11/19/25 revealed Resident #62 had a decline in functional abilities and mobility related to recent hospitalization, status post-surgery with diagnosis spinal stenosis with laminectomy (a spine surgery that removes part or all of the lamina, the bony plate on the back of the vertebra) and fusion of cervical spine C-3 - C9. Interventions included nursing to provide skilled nursing services per the physician's orders to improve or maintain patient function. Resident #62 was also at risk for injury related to limitations imposed by medical condition spinal stenosis s/p C3 - C9 laminectomy and fusion requires assistants with mobility. Interventions included to assist resident with mobility as needed related to recent surgical procedures, mobility limitation and pain. Monitor for changes in condition or declines in ability to participate in activities of daily living, decreased strength, increased weakness or changes in cognition, notify physician if occurs.Review of Resident #62's care plan for pain revealed the resident had potential for altered level of comfort due to recent survey, diagnoses spinal stenosis, laminectomy and fusion of C3-C9, and osteoarthritis revealed interventions including but not limited to to assess for non-verbal indicators of pain, assess pain every shift and as indicated, offer nonpharmacological interventions to relieve discomfort or pain, and to position for comfort. Review of the progress note for Resident #62 dated 12/18/25 at 3:40 P.M. completed by Registered Nurse (RN) #109 revealed, Resident was observed on the floor in her bathroom, while trying to use the bathroom without assistance, she was found lying flat on her back, facing upward with her legs stretched out and was trying to sit up, but was unable to do so, her wheel walker was in front of her, resident stated that she was trying to use the bathroom with out any assistance, she also stated that she hit her head on the wall of the bathroom before falling to the floor, Resident was checked for injury, there was no visible injury noted, but she complained of dizziness, nausea and she vomited twice. She was seen by the NP (Nurse Practitioner) who started her neurological check, then put order in for N/S (normal saline) to be started immediately, resident's daughter was notified, with an immediate intervention for resident to be assisted off the floor to her wheel chair, then to her bed by staff.Review of the progress note for Resident #62 dated 12/18/25 at 4:57 P.M. completed by RN #109 revealed following the fall the resident complained of dizziness as well as nausea and vomiting, and the nurse wanted to have the resident sent out to the ER (emergency room), but the NP saw resident after checking her out, and the NP (#226) stated that resident was being treated in-house and she gave the above orders. The resident's family member was notified of the order.Review of the progress note dated 12/18/25 at 6:40 P.M. completed by RN #109 revealed the spinal surgeon office was contacted and stated if there was anything new about the resident the resident should be sent to ER, but they were not here to see what is going on with her at this time, as it should be determined by the facility.Review of Resident #62's medical record, including the Medication Administration Record and Treatment Administration Record revealed no evidence the resident was monitored for pain every shift per her plan of care. The medical record contained no evidence of non-pharmacological interventions used to manage the resident's pain post fall.Review of the progress note dated 12/22/25 at 11:00 A.M. completed by Licensed Practical Nurse (LPN) #113 revealed the resident was transported to the ER for status post fall on 12/18/25, and daughter at bedside notified.Review of the Computed Tomography (CT) scan of Resident #62's cervical spine without IV contrast results, ordered by Physician #240 for Resident #62, dated 12/22/25, with the exam time of 1:05 P.M., revealed the reason for exam was fell hit head, neck dizziness, recent surgical fusion revealed postoperative changes of CT of C6 laminectomies with bilateral posterior screw and rod fixation. Findings concerning for a nonspecific fracture of the left CT facet adjacent to the left C3 screw. There was also possible backing out of hardware at the C3 level. Surgical evaluation suggested. Notification of the findings were made to Physician #240 via phone call on 12/22/25 at 1:41 P.M.Interview on 12/30/25 at 11:37 A.M. with Resident #62's daughter revealed Resident #62 was admitted to the facility after neck surgery. When she was admitted , she wore a neck brace. Resident 62 visited the surgeon after admission who said she was healing well and she could remove the neck brace. Resident #62 then had a fall hitting her head; one of the nurses told her there was back and forth about her going to the hospital, the nurses wanted her to go because she was acting different, but the CNP said no. Resident #62's daughter revealed on 12/22/25 she went in to visit her mom who was complaining of dizziness and neck pain so she (the daughter) over road the CNP and had Resident #62 sent to the hospital ER. Resident #62 had a scan at the hospital, and the doctor came in to speak with her, livid, with a neck brace she applied to Resident #62 neck and stated she had multiple neck fractures. The surgeon did not want to do the surgery, he said she was too fragile but she was lucky she was not paralyzed. Resident #62 revealed to the physician she took herself to the bathroom because she had been calling for assistance, but no one came then she fell hitting her head.Interview on 12/30/25 at 1:24 P.M. with CNP #226 verified she was in the facility on 12/18/25 when Resident #62 fell and hit her head. CNP #226 confirmed she was aware Resident #62 vomited shortly after hitting her head and confirmed this was the first time Resident #62 had vomited since being admitted to the facility, but she had vertigo (dizziness) in the past. CNP #226 revealed she completed a neuro exam which appeared normal, she witnessed Resident #62 vomiting, then she ordered neuro checks to be continued by the nurses per the protocol and ordered Zofran for the nausea and vomiting. CNP #226 revealed she asked Resident #62 if she wanted to go to the hospital and stated, I recommended she stay, but it was up to her and she said no. CNP #226 revealed she had the nurse call the surgeon and they deferred to back to the CNP and revealed when she went to the hospital, it was because the daughter wanted her sent. CNP #226 confirmed she never spoke to the daughter after the fall to discuss the fall or potential risks. CNP #226 revealed after the fall, the staff never reported any changes in Resident #62's condition or she would have sent her out. Interview on 12/30/25 at 1:45 P.M. with RN #109 regarding the fall on 12/18/25 revealed her first instinct was to have Resident #62 sent out, but the NP assessed her and decided not to send her. The NP saw her twice that day. RN #109 revealed the time frames in the progress notes for how the day went was inaccurate because she did not document at the times she completed tasks for Resident #62. RN #109 confirmed she called Resident #62's surgeon two times that day. The first call was before the fall to discuss swelling in Resident #62's hand which the surgeon stated that, the hand swelling, would not be related to the laminectomy. The second call was after the fall, and the surgeon office said if there were any new changes after the fall to send her to the ER. RN #109 confirmed Resident #62 had new changes after the fall and hitting her head. RN #109 confirmed Resident #62 vomited twice directly after the fall and confirmed she never vomited before the fall. RN #109 revealed the CNP assessed Resident #62 and did not want her sent to the hospital she said she saw her and started IV's and ordered labs. No x-rays or scans were ordered. RN #109 revealed there was one additional difference after Resident #109 fell on [DATE] she noticed and stated, after the fall I noticed when she would sit up she complained of pain in the neck but after she layed down she was fine, she did not want pain medications because she did not have pain when lying down. RN #109 confirmed Resident #62 had pain in the neck prior to the fall but reiterated this pain was different because it was only when going from a laying position to a sitting position which she never complained of before the fall and revealed the pain resolved when laying down. Phone interview on 12/30/25 at 2:01 P.M. with LPN #134 revealed Resident #62 had been her patient in the past and revealed she was at the facility when Resident #62 fell (on 12/18/25). LPN #135 revealed Resident #62 fell in the bathroom. After the fall the staff went and got her, (LPN #134) and revealed they (her and two Certified Nursing Assistants (CNA's), tried to help Resident #62 up off the floor. LPN #134 revealed Resident #62 kept complaining of dizziness and she threw up, she threw up quite a few times. LPN #134 revealed she the Unit Manager wanted to send her out and (CNP #226) was going to do what she wanted. LPN #134 revealed RN #109 was Resident #62's primary nurse that day and revealed several times they tried to get Resident #62 off the floor, they had to lay her back down because when they sat her up, she would throw up. The staff went to get the CNP who did neuro checks then they helped and got Resident #62 up off the floor and she (LPN #135) left and went back to her assignment. Record review with Director of Nursing (DON) on 12/30/25 at 2:37 P.M. of the 72 hour Neuro Assessment Flow Sheet initiated 12/18/25 at 11:15 A.M. for Resident #62 revealed neuro checks (which included level of consciousness, extremities - motor and sensory, pupils, and vital signs) were to be completed on day one - every 15 minutes times (x) four, then every thirty minutes x six, then every one hour x four, then every four hours x 4. On day two and three they were to be completed every shift. DON confirmed the neuro assessment was not completed on 12/18/25 at 4:00 P.M., 5:00 P.M. or 6:00 P.M. as ordered. The assessment was done at 3:00 P.M. then not again until 7:00 P.M. (It was supposed to be done every hour). The next assessment was done at 2:00 A.M. DON confirmed the neuro assessments were not completed as ordered. DON confirmed there was no documentation in the medical record of any changes in condition (with exception of vomiting) after the fall. DON confirmed confirmed she was unable to locate any documentation in Resident #62's medical record confirming Resident #62 was monitored for pain every shift while residing at the facility. Phone interview on 12/30/25 at 4:21 P.M. with CNA #133 revealed he frequently worked with Resident #62 before and after the fall on 12/18/25. CNA #133 revealed the only thing really different after the resident fell was when she sat up she would have pain, and when she laid down she was ok. CNA #133 confirmed she never done that before the fall. Review of the facility policy titled, Change in Resident's Condition or Status dated February 2021 revealed our facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and or status. The deficiency represents non-compliance investigated under Complaint Number 2703210 and 2649661.

Based on observation, record review, facility policy review and interview with resident, facility staff, pharmacy staff and nurse practitioner the facility failed to implement a comprehensive and individualized plan of treatment for Resident #20 to ensure the resident was catheterized timely and as ordered for urinary retention and provided timely and necessary treatment for a urinary tract infection (UTI). Actual harm occurred on 07/28/25 when Resident #20 demanded to be transferred to the emergency room for uncontrolled pain. The resident was subsequently treated for urinary retention and a UTI. Prior to the hospitalization, the resident had physician orders to be straight catheterized for urine retention every six hours; however, this was not being completed as ordered. Following the hospital treatment the facility failed to administer Resident #20's oral antibiotics per the physician orders and continued not to straight catheterize as ordered resulting in the need for intravenous medications. This affected one resident (#20) of three residents reviewed for UTIs. The census was 70. Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, UTI, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. The assessment revealed Resident #20 required supervision or touch assistance with toileting hygiene. Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment. Record review revealed the facility had not developed/implemented a plan of care for Resident #20 for the care and treatment for urinary retention or history of urinary tract infections. Review of the physician's orders revealed an order dated 03/31/25 to straight catheterize every six hours for urinary retention four times a day. The procedure was scheduled to be completed at 5:00 A.M., 11:00 A.M., 5:00 P.M. and 11:00 P.M. Review of the progress note for Resident #20 dated 07/21/25 at 2:32 A.M. revealed Licensed Practical Nurse (LPN) #275 documented completed straight catheterization two times with no visible output. The note included the resident was able to urinate on her own and does it every time she was straight catheterized. The note also included this had been a recurrent issue with Resident #20 and her straight catheterization ordered may need to be revised. However, there was no evidence the physician or certified nurse practitioner (CNP) were contacted to report this or discuss the ongoing care needs of the resident related to her urinary status/urinary retention and/or straight catheterization order. A progress note dated 07/27/25 at 10:42 A.M. completed by LPN #511 revealed Resident #20 was to be straight catheterized every six hours for urinary retention. The procedure was not completed; the supplies were pending order. There was no documentation of notification to the physician/CNP the nurse was unable to complete the procedure, and no documentation Resident #20 requested to speak to the CNP on this date (07/27/25) A progress note dated 07/28/25 at 8:44 P.M. completed by Unit Manager (UM) #293 revealed UM #293 was informed by staff the resident placed call to 911 demanding to be sent to the emergency room (ER) related to uncontrolled pain. The note included Resident #20 was assessed by floor nurse, and all vital signs were within normal limits and no other areas of concern noted. Resident #20 continued to demand to go to ER for further evaluation. Call placed to the CNP making the CNP aware and a verbal order was given to transfer Resident #20 to ER for further evaluation. Review of the hospital After Visit Summary dated 07/28/25 revealed the reason for visit was urinary problem. Diagnosis was urinary retention. The summary included: You had an indwelling urinary catheter placed to drain your urine. A basic metabolic panel, complete blood count, urinalysis with microscopic, reflex culture and urine culture were completed. (Results not provided in record). Review of the progress note for Resident #20 dated 07/29/25 at 2:02 A.M. completed by Registered Nurse (RN) #512 revealed Resident #20 returned from the hospital. Resident #20 had a new indwelling urinary catheter 16 French (16fr)/10cc balloon placed by the hospital for urinary retention. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions. Review of the medication administration record from 08/01/25 to 08/06/25 revealed Cipro was to be administered at 9:00 P.M. and 9:00 A.M. for seven days and it was to start on 08/02/25 at 9:00 P.M. On 08/02/25 at 9:00 P.M., the number nine was documented in the timeframe, which indicated to see the nurses' notes. From 08/02/25 through 08/06/25 for the scheduled dose at 9:00 P.M. the boxes all documented a number nine. The MAR indicated Resident #20 received the Cipro on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only (three of 10 doses documented as administered). However, review of the pharmacy delivery manifest with the Director of Nursing (DON) on 08/06/25 revealed Resident #20's Cipro had never been delivered to the facility (indicating the three doses documented as administered were not actually administered to Resident #20). On 08/04/25 an order was obtained to remove indwelling catheter today (08/04/25) and straight catheterize every four to six hours. An order was also provided for Enhanced Barrier Precautions - use gown and gloves for high contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care for any device including trach, central line, tube feeding and catheter. Interview on 08/06/25 at 1:39 P.M. with Resident #20 revealed staff were supposed to straight catheterize her every four to six hours, but they did not do this. Resident #20 stated staff make excuses and tell her she doesn't need to be straight catheterized because she does urinate. Resident #20 stated sometimes she does urinate and sometimes she doesn't. Resident #20 stated staff provide straight catheterization about three times a day, but she was scheduled four times a day. Resident #20 stated the previous Monday (07/28/25) she had chills, back and abdominal pain, she requested to see the CNP, but she never came. That night she was supposed to be catheterized at 11:00 P.M. but the nurse did not come until 3:00 A.M. She requested several times to see the nurse, but she never came. Resident #20 revealed she was shivering and the abdominal pain continued, she was yelling and still no one came. She called the facility, and no one answered the telephone. Resident #20 stated she became nauseous, needed help, so she called 911. She was then taken to the hospital. Resident #20 stated the ER nurses had to clean her up, and they placed a (urinary) catheter and got 700 cubic centimeters (cc) urine return. The ER physician said she was correct to come to the ER as that was too much urine. Resident #20 stated she received an order for Cipro because she had a UTI that was found from her hospital visit. Resident #20 stated her concern was that she was catheterized last this morning between 4:00 A.M. and 4:30 A.M. and staff have not been in yet to do the next one. Interview on 08/06/25 at 3:15 P.M. with LPN #275 revealed she was Resident #20's primary care nurse. LPN #275 stated she has not straight catheterized her at all today (08/06/25) and was not aware of how frequent Resident #20 need to be straight catharized. LPN #275 referred to the physician orders at the time of the interview and confirmed Resident #20 should be straight catheterized every six hours. Observation on 08/06/25 at 3:35 P.M. revealed LPN #275 was walking down the hall. LPN #275 stated Resident #20 was just straight catheterized and got 500 cc of urine out. UM #293 was present and stated LPN #275 went in Resident #20's room at 11:00 A.M. to straight catheterized her and Resident #20 was not in her room so the next catheter would not be due until 5:00 P.M. anyway. Interview on 08/06/25 at 3:40 P.M. with the DON revealed if a resident had treatment due and was not in their room, the nurse would go back when the resident returned to do the treatment. The DON stated Resident #20 had been getting straight catheterized prior to the hospital visit. The hospital placed an indwelling urinary catheter in. The indwelling urinary catheter was discontinued due to Resident #20 did not have the appropriate diagnosis for an indwelling catheter and the straight catheterize order was continued. Review of Resident #20's Medication Administration Record (MAR) with the DON confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Interview on 08/06/25 at 4:32 P.M. with Resident #20 and with the DON present revealed LPN #275 never offered to straight catheterization her today (08/06/25) until a few minutes ago and she got over 500 cc out. Resident #20 stated to the DON she was upset she had not been getting her Cipro like she was supposed to, and it started later than it was supposed to. Interview on 08/06/25 at 4:34 P.M. with LPN #275 with the DON present confirmed she administered Resident #20 her Cipro this morning and the Cipro was prepackaged by the pharmacy in the medication cart. Observation revealed the DON checked the medication cart with Resident #20's prepackaged medications, and confirmed Resident #20 did not have any Cipro present in any of the prepackaged medications or any other location of the medication cart. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. The DON verified LPN #275 documented on the MAR she gave Resident #20 the Cipro from the prepackaged medications this A.M. Interview and observation on 08/07/25 at 10:14 A.M. with Resident #20 revealed the resident was lying in bed crying. Resident #20 stated she hurt, CNP #514 was just in to see her a few minutes ago and gave new orders. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated, the facility never told her that Resident #20 not getting straight catheterized as physician ordered. And when they do straight catheterization, the staff were obtaining more than 250 cc of urine left in the bladder and this was retention. CNP #514 confirmed retention (a condition in which a person is unable to empty their bladder completely) can cause a UTI. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when she went to the ER on [DATE] and showed she had a UTI, that was why the Cipro was ordered. On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration. Interview on 08/07/25 at 10:39 A.M. with the DON and record review of the Pharmacy Communication request received 08/04/25 at 11:54 A.M. revealed the request stated to Please Respond. Medication Cipro had a drug interaction with (medication) tizanidine. Please consider changing the antibiotic to something else or hold all tizanidine while on this antibiotic. The DON revealed she also gets emails from the pharmacy, but the recommendations also come through the fax. The pharmacy also calls the nurses who need to update the physician with the pharmacy information. The DON confirmed the pharmacy recommendation was not completed and revealed any nurse could do it. Interview on 08/07/25 at 11:04 A.M. with LPN #518 confirmed CNP #514 requested a urinalysis be obtained for Resident #20. Observation on 08/07/25 at 11:38 A.M. revealed Licensed Practical Nurse (LPN) #518 and Unit Manager (UM) #350 straight catheterized Resident #20. LPN #518 straight catheterized Resident #20 for a residual of 1,300 cubic centimeters (cc) during the second attempt. Record review and interview on 08/11/25 at 3:00 P.M. with DON confirmed there were no urinalysis results in the medical record for Resident #20 for the urinalysis ordered 08/07/25. The DON confirmed the urine was obtained on 08/07/25 and the urine was never sent to the laboratory. The DON stated she did not know why the urine was never sent and confirmed it should have been obtained and sent per the CNP orders. Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she ordered a urinalysis on 08/07/25 for Resident #20 and revealed she was never notified the urinalysis was not completed as ordered. Review of the facility policy titled, Catheter Care Urinary revised August 2022 revealed the purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician. This deficiency represents non-compliance investigated under Complaint Number 2581344 and Complaint Number 2574277.

Based on record review, facility policy review and interview the facility failed to ensure Resident #2 received adequate, necessary and timely treatment following a fall with major injury. Actual Harm occurred on 05/20/25 when the facility failed to ensure Resident #2 was provided timely and necessary medical intervention/treatment following a fall. Approximately 12.5 hours after the fall occurred, Resident #2's daughter identified the resident was in excruciating pain. The resident was subsequently transported to the hospital where she was diagnosed with a fractured femur (as a result of the fall) requiring surgical repair. This affected one resident (#2) of three residents reviewed for incidents. The facility census was 70. Findings include: Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia and senile degeneration of the brain. A plan of care for Resident #2 dated 06/19/23 revealed the resident tended to wander due to cognitive impairment and restlessness. The care plan also identified Resident #2 would hide in closets, wander into other resident's room, would attempt to use their restroom or lay in their bed and/or would attempt to get on the elevator looking for her ride. Interventions included to provide assistance in locating own room and an additional intervention was noted to provide one on one. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impairment. The assessment revealed Resident #2 had no impairment of the upper or lower extremities, was dependent on staff for toileting hygiene, required substantial/maximal staff assistance with chair/bed to chair transfer and required staff supervision or touching assistance for ambulation. A Nursing - Fall Risk Observation/assessment dated [DATE] revealed Resident #2 was at moderate risk for falls. The assessment revealed Resident #2's vision was highly or severely impaired and Resident #2 ambulated without problem and without devices. Review of an Interdisciplinary Team (IDT) note dated 05/20/25 at 5:21 P.M. completed by Unit Manager (UM) #293 revealed the IDT team reviewed Resident #2's fall which occurred on 05/20/25. Resident #2's daughter notified UM #293 Resident #2 was in bed when she arrived, and she attempted to assist the resident out of bed when the resident screamed in pain. The physician was notified, and a verbal order was given to transfer Resident #2 to the emergency department (ED). Upon investigation, UM #293 was notified from Resident #24 that on 05/20/25 at approximately (blank) Resident #24 witnessed Resident #2 lying on the floor in her room at the foot of her bed attempting to pull herself up from the floor using the footboard. Resident #24 [Resident #36 was the actual witness to Resident #2 falling and this was confirmed with the Administrator on 07/09/25 at 3:29 P.M. The facility incorrectly documented the wrong resident in their fall investigation.] Resident [#36] stated she pulled the call light for help and as Resident #2 stood up the Certified Nursing Assistant (CNA) entered the room and escorted Resident #2 back to her room. Review of Resident #2's medical record revealed there was no documentation or assessment on 05/20/25 during night shift. There were no vital signs obtained or a physical assessment at the time of the resident's fall. There was no documentation of any injuries sustained status post fall including an injury to Resident #2's left arm (the daughter identified a treatment on left arm on 05/20/25). Review of the documentation survey report for 05/20/25 revealed Resident #2 was turned and repositioned each shift, but the report did not state how many times Resident #2 was turned and repositioned or provided incontinence care. An interview on 08/07/25 at 8:45 A.M., with CNA #211 revealed she provided Resident #2 incontinence care once in the morning during her day shift and explained she didn't need to reposition the resident, so she was not aware of any pain or injuries. There were no as needed pain medications administered and no pain assessment completed on 05/20/25. Review of the facility Investigation Report for Resident #2 dated 05/20/25 completed by the Director of Nursing (DON) revealed on 05/20/25, Resident #2 had a witnessed fall with major injury. The report included on 05/20/25 UM #293 revealed Resident #24 reported Resident #2 wandered into her room at 2:30 A.M. Resident #24 yelled out for help and put on her call light when she noticed Resident #2 on the floor. When Resident #2 finally got up, CNA #246 entered the room and took Resident #2 away. CNA #246 reported he escorted Resident #2 back to her room and he did not notice anything unusual. Review of a typed statement completed by the Director of Nursing (DON) dated 05/20/25 revealed CNA #246 reported he answered Resident [#36]'s call light and noticed Resident #2 was in her room. CNA #246 reported he escorted Resident #2 back to her room. CNA #246 reported that he did not notice anything unusual at that time. CNA #246 reported it was not unusual for Resident #2 to wander. The typed report included Resident [#36] reported to UM #293 that she observed Resident #2 lying on the floor at the foot of the bed around 2:30 A.M.; Resident #[#36] reported she yelled out for help and put on her call light when she noticed resident on the floor. Resident [#36] reported Resident #2 was attempting to get up off the floor using the footboard of the bed. Resident [#36] reported when she finally got up, CNA #246 entered the room and took her away. Review of Hospital #401's after visit summary for Resident #2 dated 05/20/25 at 4:42 P.M. revealed Attending Physician #403 the resident had been seen in a freestanding emergency department with no inpatient services. Resident #2 came from the nursing home after an unwitnessed fall overnight last night. Documentation included Resident #2 provided no history here but had significant pain in her left hip when she moved around in bed. Resident #2 was evaluated emergently. X-ray imaging showed a femoral neck fracture. Resident #2 was then transferred to Hospital #402's emergency department for further evaluation and care. Hospital #402's after visit summary for Resident #2 from a hospitalization 05/20/25 to 05/23/25 revealed a principal diagnosis of left displaced femoral neck fracture. The resident underwent surgical intervention; an open treatment of femoral fracture proximal end neck internal fixation or prosthetic replacement (left). Review of a physician progress note dated 07/04/25 completed by Physician #352 revealed Resident #2 fell at the facility on 05/20/25. The resident was found lying on the floor of her room at the foot of the bed attempting to pull herself up by the footboard. A Certified Nursing Assistant (CNA) was able to assist Resident #2 back to bed. When Resident #2's daughter came to the facility to visit, the daughter tried to assist Resident #2 up out of bed, but Resident #2 screamed out in pain with facial grimacing and refused to move. Resident #2 was sent to the emergency department for a workup. The hospital determined Resident #2 suffered a displaced fracture at the base of the neck of the left femur. She underwent left hemiarthroplasty on 05/21/25. Interview on 07/09/25 at 1:41 P.M. with UM #293 revealed on 05/20/25 when UM #293 began in the morning, Resident #2's daughter was already at the facility and said something was wrong with Resident #2. The daughter reported when she moved the resident, Resident #2 yelled. UM #293 went into the room to assess Resident #2, and Resident #2 was lying on her right side in the fetal position. UM #293 turned her on her left side, Resident #2 cried out in pain. UM #293 called the nurse practitioner (NP) who said to transfer the resident to the hospital. Resident #2 was transported to the hospital around 10:00 A.M. Interview on 07/09/25 at 2:30 P.M. with the DON confirmed there was no documentation when Resident #2 left the facility and/or evidence an investigation was completed to determine how Resident #2 had a fractured femur. Interview on 08/06/25 at 2:10 P.M. with Resident #2's daughter who was Resident #2's responsible party, revealed she visited her mom daily in the afternoon and prior to visiting her mom, she would sign in at the front desk on the visitor log. When she arrived, her routine included first taking her mom to the bathroom. The daughter revealed on 05/20/25 when she arrived to visit, Resident #2 was lying in bed. When she attempted to assist her mom, her mom began screaming in pain. Resident #2's daughter reported she went to the nurse and reported her mom was unable to get up and walk and just moving made her scream in pain. Resident #2's daughter reported she insisted her mom be sent to the hospital and reported she thought her mom must have had a fall because there was also a dressing on her left arm dated 05/20/25 (There was no documentation of a dressing). Resident #2's daughter revealed the staff told her later (unable to recall when) that her mom had wandered into someone's room, fell down, broke her hip, walked on it, and then they assisted her back to bed. Resident #2's daughter revealed There was no way my mom could have walked on it, just moving it made her scream in pain. The resident's daughter revealed it was then another 45 minutes to an hour before the facility transferred the resident to the hospital. Review of the sign in visitor log dated 05/20/25 revealed Resident #2's daughter arrived on 05/20/25 at 2:55 P.M. This shows evidence of the time the daughter arrived, she was sent to the hospital after that. A telephone interview on 08/06/25 at 6:33 P.M. with LPN #277 revealed she was Resident #2's primary charge nurse on 05/20/25 during the day shift. LPN #277 revealed she was on her lunch break (did not recall the time) when she received a call from UM #293 indicating Resident 2's daughter was there and Resident #2 was in pain. LPN #277 stated she gave Resident #2 her medications that morning when the resident was in bed. LPN #277 didn't know how CNA #211 changed her, but Resident #2 did not get out of the bed. UM #293 wanted LPN #277 to write a statement saying she fell on her day shift and the LPN refused to write one. LPN #277 revealed Resident #2 did not appear to be in pain that morning, but she did not have to move her. Interview on 08/07/25 at 8:22 A.M. with Resident #36 revealed she recalled a resident coming into her room. Resident #36 stated a female resident fell, didn't know who the female resident was, it had occurred a couple months ago around twilight time, before morning. Resident #36 stated it looked like the resident was dancing, fell, the man picked her up, she walked out, then she didn't know what happened. Resident #36 confirmed when she saw the resident in her room, she turned her call light on and yelled for help. The man that came in was staff. Interview on 08/07/25 at 8:45 A.M. with CNA #211 revealed she was Resident #2's primary CNA on 05/20/25. CNA #211 stated on the morning of 05/20/25, CNA #211 fed Resident #2 in bed. Resident #2 was usually up wandering but did lay down for naps throughout the day. However, Resident #2 did not get up at all on that day. CNA #211 stated she was on lunch break when Resident #2 was transferred to the hospital. CNA #211 stated she changed Resident #2 that morning, and she did not seem like she was in pain, she was lying in a fetal position, which was not her usual as she would wander typically, and was on her side. CNA #211 stated she didn't have to straighten Resident #2's legs out to provide incontinence care. CNA #211 confirmed she provided incontinence care that morning only and confirmed she was Resident #2's primary CNA on that day. CNA #211 revealed Resident #2 didn't scream until her daughter straightened her legs out. Resident #2 did not get up at all that day. CNA #211 stated Resident #2 did usually get up on night shift and walked around during the day but didn't on 05/20/25. Review of the facility policy titled, Change in a Resident's Condition or Status revised February 2021 revealed the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status. The nurse would notify the resident's attending physician or physician on call when there had been a (an) accident or incident involving the resident; discovery of injuries of an unknown source; significant change in the resident's physical/emotional/mental condition. This deficiency represents non-compliance investigated under Complaint Number 2581344. This is an example of continued non-compliance from the survey dated 06/25/25.

Based on observation, record review, review of a facility Self-Reported Incident (SRI) report, facility policy review and interview, the facility failed to provide residents who have wandering and/or sexual aggressive behaviors with adequate supervision. This affected two residents (#1 and #2) and the potential to affect three residents (#23, #41, and #70) who the facility identified to be independently mobile, confused and residing in the same hall as Resident #1. Findings included:Record review for Resident #2 revealed an admission date of 06/11/19 with diagnoses including dementia and senile degeneration of the brain. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status Score (BIMS) of one indicating Resident #2 was severely cognitively impaired. Resident #2 required the use of a wheelchair for mobility and stated Resident #2 did not wander during the review period.A care plan dated 06/11/19 and revised 07/07/25 revealed Resident #2 was at risk for falls due to impaired mobility, impaired balance, unsteady gait at times, fracture of unspecified part of neck of left femur. Interventions included physical therapy to evaluate and treat dated 05/23/25 and to offer the resident to lay in bed after all meals dated 06/06/25. A care plan dated 05/02/23 revealed Resident #2 had potential for impaired vision as evidenced by diagnosis of glaucoma. Interventions included to encourage to wear glasses. A care plan dated 06/19/23 included Resident #2 tended to wander due to cognitive impairment and restlessness. The care plan included Resident #2 may wander into other resident's room, will attempt to use their restroom or lay in their bed. Interventions included aid in locating own room (last revised 04/12/23) and to provide one-on-one as needed (last revised 07/31/25).Review of Resident #2 progress notes and medical record from 01/01/25 through 07/29/25 revealed no written evidence that the resident exhibited any type of sexual behaviors. Review of a facility SRI created 07/06/25 revealed an allegation of sexual abuse involving Resident #1 and #2 was reported to the State Survey Agency. Resident #1 with Resident #1's penis out and Resident #2 sucking on it. Review of a facility Witness Statement dated 07/06/25 (untimed) and signed by Certified Nursing Assistant (CNA) #217 revealed CNA #217 was taking Resident #1's roommate into his room from the dining room. When CNA #217 entered Resident #1's room, Resident #1 was lying in bed with just a shirt on and Resident #2 had her head down near Resident #1's private area. Resident #1 had his hand on her (Resident #2's) arm and head as Resident #2's mouth was on his (Resident #1's) private area. The statement included CNA #217 immediately secured each resident and informed the nurse. Review of a facility Witness Statement dated 07/06/25 (untimed) and signed by Licensed Practical Nurse (LPN) #283 revealed she was called down to the room and saw Resident #1 with his hand over his private part looking shocked. LPN #283 observed CNA #217 attempting to move Resident #2 who was being combative at the time. LPN #283 assisted CNA #217 removing Resident #2 from the room. Observation on 07/08/25 at 9:23 A.M. revealed Resident #2 was eating breakfast in the dining room using her fingers only. An attempt to interview Resident #2, revealed the resident rambled incoherently unrelated to the conversation. An interview with Unit Manager #293 at the time of the observation revealed Resident #2 was unable to answer questions appropriately or make independent decisions. The unit manager revealed Resident #2 had dementia, could walk but also used a wheelchair. Resident #2 had poor vision and ate all her meals in the dining room. Interview on 07/08/25 at 3:51 P.M. with CNA #211 stated Resident #2 can walk, the staff try to keep her in her wheelchair, but she walks. CNA #211 stated when she arrived at work in the morning on 07/06/25, Resident #2 was wandering the hallway, and she used her hands to feel around. CNA #211 denied trying to redirect Resident #2 to sit in a chair or go to her own room on 07/06/25 and the reason provided was that this was her usual behavior. Interview on 07/08/25 between 3:52 P.M. and 4:00 P.M. with CNA #216 and CNA #238 revealed Resident #2 was able to ambulate and frequently wandered in other residents' rooms.Interview on 07/09/25 at 1:10 P.M. with Physical Therapy Assistant (PTA) #501 confirmed she worked with Resident #2 in therapy. PTA #501 revealed Resident #2 was not safe to ambulate independently.Interview with MDS Nurse #510 on 07/31/25 at 12:49 P.M. stated the resident's plan of care interventions were considered active if the intervention was still listed on the care plan after the revision date. MDS Nurse #510 verified Resident #2's care plan stated to provide Resident #2 1:1 supervision. Interview on 08/12/25 at 4:15 P.M. with Administrator revealed the care plan with 1:1 supervision for Resident #2 was from a previous incident and should have been removed, it was no longer active and discontinued out of the care plan today.2. Record review revealed Resident #1 had a re-admission date of 02/17/16 with diagnoses including vascular dementia with unspecified severity without behavioral disturbances, psychotic disturbances, mood disturbances and urinary incontinence. Review of a care plan dated 05/15/23 revealed Resident #1 had a history of inappropriate sexual behavior at times related to cognitive impairment. Interventions included to provide supervision in social gatherings/recreation programs and staff to minimize any close interaction with female residents. An additional care plan initiated 07/19/24 revealed Resident #1 demonstrated socially inappropriate behaviors: inappropriately touching staff. Interventions included psychological counseling for psych/behavior management.Interview on 07/08/25 at 12:22 P.M. with CNA #233 revealed she worked with Resident #1. CNA #233 stated Resident #1 was sexually inappropriate, especially when staff changed him. Resident #1 would grab at staff; CNA #233 stated they tried to re-direct Resident #1, move his hand but he would not listen. Interview with the Administrator on 07/08/25 between 1:35 P.M. and 3:11 P.M. stated the incident occurred in Resident #1's room while he was in bed. During the interview, the Administrator stated Resident #2 was the perpetrator, not Resident #1. However, no additional information was provided as to how this conclusion was reached. Interview on 07/08/25 at 5:07 P.M. with CNA #233 revealed at the end of May (2025), she was cleaning Resident #1's buttocks due to him being incontinent. CNA #233 turned him over on his side and while she was washing him, Resident #1 began masturbating. CNA #233 also reported Resident #1 tries to touch CNA #233 inappropriately. The CNA stated other CNAs had also reported Resident #1's sexual inappropriateness, but the facility had done nothing to address Resident #1's behavior. A telephone interview on 07/09/25 at 9:26 A.M. with CNA #217 revealed on 07/06/25, she was bringing Resident #1's roommate from the dining room to his room. As CNA #217 walked through the door, CNA #217 saw Resident #1 was lying in bed, Resident #1 had Resident #2 by the arm and had his hand on Resident #2's head/back of her neck making it go up and down on his penis. The CNA stated she observed Resident #1 being forceful with Resident #2 and Resident #2 was trying to move to leave, as she was not sexual at all. CNA #217 told Resident #1 to let Resident #2 go, he was still holding her, then he let her go. The CNA stated Resident #2 was blind, but she moved right away from Resident #1 once Resident #1 released his hands from her. CNA #217 stated she yelled, and LPN #283 came into Resident #1's room. Interview on 07/09/25 at 10:07 A.M. with LPN #283 revealed on 07/06/25 in the morning, she was down the hall coming out of a different room when she heard CNA #217 call for her. LPN #283 entered Resident #1's room and saw CNA #217 moving Resident #2 away from Resident #1. Resident #2 was confused. When LPN #283 walked into Resident #1's room, Resident #1 was in bed sitting straight up with a hospital gown on and his hand over his private part. LPN #283 stated Resident #2 would not be forceful with anyone if she walked into a resident room. Interviews on 07/08/25 between 12:48 P.M. and 12:55 P.M. with CNA #238, CNA #216, and Activity Director #203 revealed Resident #1 participated in activities and frequently sat in the dining room. CNA #238, #216 and Activity Director #203 revealed Resident #1 never required supervision. The facility identified Residents #23, #41, and #70 who resided on the same hall as Resident #1 and were independently mobile and had cognitive impairments. This deficiency represents non-compliance investigated under Control Number OH00167346 (1381517). This is an example of continued non-compliance from the survey dated 06/25/25.

Based on observation, interviews with resident, staff and Certified Nurse Practitioner (CNP), record review, review of insulin administration guidelines, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected four (#7, #11, #20, and #68) of six residents reviewed for medication administration. The facility census was 70.Findings included: 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions. Review of the medication administration record from 08/01/25 to 08/06/25 revealed Cipro was to be administered at 9:00 P.M. and 9:00 A.M. for seven days and it was to start on 08/02/25 at 9:00 P.M. On 08/02/25 at 9:00 P.M., the number nine was documented in the timeframe, which indicated to see the nurses' notes. From 08/02/25 through 08/06/25 for the scheduled dose at 9:00 P.M. the boxes all documented a number nine. The MAR indicated Resident #20 received the Cipro on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only (three of 10 doses documented as administered). However, review of the pharmacy delivery manifest with the Director of Nursing (DON) on 08/06/25 revealed Resident #20's Cipro had never been delivered to the facility (indicating the three doses documented as administered were not actually administered to Resident #20). Interview on 08/06/25 at 3:40 P.M. with the Director of Nursing (DON) revealed the DON reviewed Resident #20's Medication Administration Record (MAR) and confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Interview on 08/06/25 at 4:32 P.M. with Resident #20 and with the DON present revealed Resident #20 stated to the DON she was upset she had not been getting her Cipro like she was supposed to, and it started later than it was supposed to. Interview on 08/06/25 at 4:34 P.M. with LPN #275 with the DON present confirmed she administered Resident #20 her Cipro this morning and the Cipro was prepackaged by the pharmacy in the medication cart. Observation revealed the DON checked the medication cart with Resident #20's prepackaged medications, and confirmed Resident #20 did not have any Cipro present in any of the prepackaged medications or any other location of the medication cart. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. The DON verified LPN #275 documented on the MAR she gave Resident #20 the Cipro from the prepackaged medications this A.M. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when she went to the ER on [DATE] and showed she had a UTI, that was why the Cipro was ordered. On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration. 2. Record review for Resident #11 revealed an admission date of 02/02/24. Diagnosis included type two diabetes mellitus (DM) with unspecified complications. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact, and had medically complex conditions including type two DM with unspecified complications. Resident #11 received injections daily. Review of the care plan for Resident #11 dated 01/11/25 revealed Resident #11 required hypoglycemic medication related to diabetes/hyperglycemia. Interventions included to administer medications as ordered. Review of the physician's orders for Resident #11 included Lantus Solostar subcutaneous solution pen-injector 100 units per milliliter (ml) (Insulin Glargine) inject 15 units subcutaneously two times a day for DM type two. Observation on 08/06/25 at 8:31 A.M. of medication administration with Licensed Practical Nurse (LPN) #275 revealed LPN #275 administered Lantus Solostar to Resident #11 via pen injector. LPN #275 did not prime the pen injector prior to dialing up 15 units and administering the insulin. Interview on 08/06/25 at 8:44 A.M. with LPN #275 stated she did not know what priming the insulin pen meant and confirmed she did not prime the insulin pen. Review of the undated pamphlet for Lantus insulin titled Using the Solostar Pen revealed insulin pens contain multiple doses of insulin; a new needle will be used for each injection; insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; Screw the pen needle onto the insulin pen; Dial two units by turning the dose selector clockwise, push the plunger and watch to see that at least one drop appears; then turn the dose selector to ordered dose. 3. Record review for Resident #7 revealed an admission date of 11/11/24. Diagnosis included type two diabetes mellitus (DM) with hyperglycemia and diabetic autonomic polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, and had medically complex conditions, DM and required injections daily. Review of the care plan dated 04/21/25 revealed Resident #7 had a diagnosis of DM and was at risk for complications. Interventions included blood glucose checks as ordered. Report to physician if blood glucose is outside of set parameters. Review of the physician orders for Resident #7 revealed an order dated 08/05/25 for Humalog injection solution inject as per sliding scale. If 71-150 = zero units, 151-200 = two units, 201 - 250 = four units, 251 - 300 = six units, 301 - 350 = eight units, 351 to 400 =10 units subcutaneously three times a day for DM. Inject zero to 10 units subcutaneously with meals per sliding scale. Observation and interview on 08/06/25 at 9:32 A.M. revealed Licensed Practical Nurse (LPN) #275 assessed Resident #7's blood sugar via fingerstick while Resident #7 was lying in bed. The breakfast tray next to Resident #7 was empty and all the food was consumed. Resident #7 confirmed she ate all her breakfast about an hour ago. Resident #7's blood sugar results was 460. LPN #275 confirmed she should have checked the blood sugar before Resident #7 ate her meal and verified she did not because she was on another hall passing medications. Unit Manager (UM) #293 instructed LPN #275 to hold the insulin until CNP was notified. UM #293 called the CNP for insulin orders, told CNP blood sugar results but never told the CNP the results were obtained after Resident #7 ate 100% of breakfast. UM #293 confirmed she never told CNP that the results were obtained after breakfast and stated the CNP knows what time breakfast was. Interview on 08/06/25 at 9:50 A.M. with Certified Nursing Assistant (CNA) #220 revealed she served the breakfast trays to residents on Resident #7's hall at 8:00 A.M. Interview on 08/06/25 at 9:44 A.M. with CNP #514 revealed blood sugars should be check before meals. CNP #514 stated she wants to know the blood sugar before the resident's eat and staff should have let me Resident #7 already ate her breakfast and said that was important information to know. CNP #514 verified UM #293 never notified her Resident #7 ate her breakfast prior to the blood sugar results. CNP 3514 stated she didn't want a hypoglycemic reaction so she needed to know information to give correct orders. 4. Record review for Resident #68 revealed an admission date of 04/10/23. Diagnoses included chronic atrial fibrillation and hypertension (HTN). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was cognitively intact and had hypertension. Review of the physician orders for Resident #68 revealed an order dated 07/28/25 for metoprolol succinate extended release 24 hour 25 milligrams (mg) give one tablet by mouth one time a day for HTN hold for a heart rate of less than 60 beats per minute or a systolic blood pressure of less than 100. The order under status revealed pending order signature. Review of the Medication Administration Record (MAR) for Resident #68 revealed the metoprolol was not administered in July 2025 or 08/01/25 to 08/11/25. Resident #68's last blood pressure documented in the medical record was dated 07/28/25 at 9:54 A.M. and was 140/88. The last pulse documented was 06/03/25 and was 72. Interview with the Director of Nursing (DON) on 08/11/25 at 3:25 P.M. confirmed staff did not monitor Resident #68's blood pressure or pulse and she was also unable to find the documentation for the pulse and blood pressure daily for Resident #68. DON confirmed the medication metoprolol was not administered to Resident #68 per the order. Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she wrote the order on 07/28/25 for Resident #68 to receive metoprolol succinate extended release 25 mg one time a day. CNP #514 revealed the medication should have started after she ordered it and she was never notified by any staff the medication was never initiated. The medication had a dual purpose for the blood pressure and the heart rate so both the heart rate and blood pressure needed monitored prior to medication administration. Review of the facility policy titled Medication Administration dated 11/2017 revealed to administer the medications as ordered; the physician shall be notified of held medications. This deficiency represents non-compliance investigated under Complaint Number 2574277 and Complaint Number 1381508 (OH00167560).

Based on record review and interviews with staff and pharmacy, the facility failed timely respond and act upon the pharmacy's notification regarding irregularity with a new order to start an antibiotic. This affected one (#20) of one resident reviewed for pharmacy services.Findings included: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions. Interview on 08/06/25 at 3:40 P.M. with the Director of Nursing (DON) revealed the DON reviewed Resident #20's Medication Administration Record (MAR) and confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. The DON verified LPN #275 documented on the MAR she gave Resident #20 the Cipro from the prepackaged medications this A.M. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration. Interview on 08/07/25 at 10:39 A.M. with the DON and record review of the Pharmacy Communication request received 08/04/25 at 11:54 A.M. revealed the request stated to Please Respond. Medication Cipro had a drug interaction with (medication) tizanidine. Please consider changing the antibiotic to something else or hold all tizanidine while on this antibiotic. The DON revealed she also gets emails from the pharmacy, but the recommendations also come through the fax. The pharmacy also calls the nurses who need to update the physician with the pharmacy information. The DON confirmed the pharmacy recommendation was not completed and revealed any nurse could do it. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure wound care was completed as per the physician orders for one resident, Resident #57 of three residents reviewed for wound care. The facility census was 70.Findings include:Record review for Resident #57 revealed an admission date of 10/23/23. Diagnoses included multiple sclerosis, sepsis, chronic osteomyelitis, colostomy, neuromuscular disfunction of the bladder, pressure ulcer stage IV (Full thickness loss with exposed bone, tendon or muscle), and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57 had impairment on one side of the upper extremity and both sides of the lower. Resident #57 was dependent on staff for all activities of daily living (ADL). Resident #57 was at risk for pressure ulcers, had one stage IV pressure ulcer and one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). Review of the physician orders for Resident #57 revealed on 05/23/25, an order for the right dorsum foot to cleanse right dorsum foot with Dakin's 0.25% solution, blot dry, apply calcium alginate with silver, ABD and kerlix. Change daily and as needed every day shift for wound management. Observation 07/08/25 at 4:30 P.M. revealed Wound Care Nurse (WCN) #292 and Unit Manager (UM) #293 were going to provide wound care for Resident #57. WCN #292 and UM #293 confirmed the date on the dressing to Resident #57's wound on the right foot was dated 07/06/25 the initials were [Licensed Practical Nurse (LPN) #283]. Observation after removal of the dressing revealed the old dressing had a heavy drainage and foul odor. The tissue surrounding the edges of the wound bed was white/emaciated. The appearance and odor was verified by WCN #292. Record review of the nursing staff assignment sheets and timecards and interview on 07/09/25 at 9:00 A.M. with the Administrator and UM #293 confirmed LPN #283 worked at the facility on 07/06/25. LPN #283 did not work on 07/07/25 or 07/08/25. The Administrator and UM #293 confirmed LPN #283 completed the dressing change on 07/06/25 and the dressing change was not completed again until 07/08/25. Review of the facility's undated policy titled Wound Care revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Dress the wound and mark tape with initials, time, and date and apply to dressing. This deficiency represents non-compliance investigated under Complaint Number OH00167210 (1381513).

Based on resident, family, staff and certified nurse practitioner (CNP) interviews, record review, and review of the facility policy, the facility failed to timely notify the physician/CNP when physician orders were not completed and pharmacy irregularities on a antibiotic and notify a resident's representative of an incident and a room change involving the resident. This affected two (Residents #1 and #20) of three residents reviewed for notification of change. The facility census was 70. 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment.Review of the physician's orders revealed an order dated 03/31/25 to straight catheterize every six hours for urinary retention four times a day. The procedure was scheduled to be completed at 5:00 A.M., 11:00 A.M., 5:00 P.M. and 11:00 P.M.Review of the progress note for Resident #20 dated 07/21/25 at 2:32 A.M. revealed Licensed Practical Nurse (LPN) #275 documented completed straight catheterization two times with no visible output. The note included the resident was able to urinate on her own and does it every time she was straight catheterized. The note also included this had been a recurrent issue with Resident #20 and her straight catheterization ordered may need to be revised. However, there was no evidence the physician or certified nurse practitioner (CNP) were contacted to report this or discuss the ongoing care needs of the resident related to her urinary status/urinary retention and/or straight catheterization order. A progress note dated 07/27/25 at 10:42 A.M. completed by LPN #511 revealed Resident #20 was to be straight catheterized every six hours for urinary retention. The procedure was not completed; the supplies were pending order. There was no documentation of notification to the physician/CNP the nurse was unable to complete the procedure, and no documentation Resident #20 requested to speak to the CNP on this date (07/27/25)A progress note dated 07/28/25 at 8:44 P.M. completed by Unit Manager (UM) #293 revealed UM #293 was informed by staff the resident placed call to 911 demanding to be sent to the emergency room (ER) related to uncontrolled pain. The note included Resident #20 was assessed by floor nurse, and all vital signs were within normal limits and no other areas of concern noted. Resident #20 continued to demand to go to ER for further evaluation. Call placed to the CNP making the CNP aware and a verbal order was given to transfer Resident #20 to ER for further evaluation. Review of the hospital After Visit Summary dated 07/28/25 revealed the reason for visit was urinary problem. Diagnosis was urinary retention. The summary included: You had an indwelling urinary catheter placed to drain your urine. A basic metabolic panel, complete blood count, urinalysis with microscopic, reflex culture and urine culture were completed. (Results not provided in record).Review of the progress note for Resident #20 dated 07/29/25 at 2:02 A.M. completed by Registered Nurse (RN) #512 revealed Resident #20 returned from the hospital. Resident #20 had a new indwelling urinary catheter 16 French (16fr)/10cc balloon placed by the hospital for urinary retention. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days.A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions.Interview on 08/06/25 at 1:39 P.M. with Resident #20 revealed staff were supposed to straight catheterize her every four to six hours, but they did not do this. Resident #20 stated staff make excuses and tell her she doesn't need to be straight catheterized because she does urinate. Resident #20 stated sometimes she does urinate and sometimes she doesn't. Resident #20 stated staff provide straight catheterization about three times a day, but she was scheduled four times a day. Resident #20 stated the previous Monday (07/28/25) she had chills, back and abdominal pain, she requested to see the CNP, but she never came. That night she was supposed to be catheterized at 11:00 P.M. but the nurse did not come until 3:00 A.M. She requested several times to see the nurse, but she never came. Resident #20 revealed she was shivering and the abdominal pain continued, she was yelling and still no one came. She called the facility, and no one answered the telephone. Resident #20 stated she became nauseous, needed help, so she called 911. She was then taken to the hospital. Resident #20 stated the ER nurses had to clean her up, and they placed a (urinary) catheter and got 700 cubic centimeters (cc) urine return. The ER physician said she was correct to come to the ER as that was too much urine. Resident #20 stated she received an order for Cipro because she had a UTI that was found from her hospital visit. Resident #20 stated her concern was that she was catheterized last this morning between 4:00 A.M. and 4:30 A.M. and staff have not been in yet to do the next one.Interview on 08/06/25 at 3:15 P.M. with LPN #275 revealed she was Resident #20's primary care nurse. LPN #275 stated she has not straight catheterized her at all today (08/06/25) and was not aware of how frequent Resident #20 need to be straight catharized. LPN #275 referred to the physician orders at the time of the interview and confirmed Resident #20 should be straight catheterized every six hours. Interview on 08/06/25 at 3:40 P.M. with the Director of Nursing (DON) confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated, the facility never told her that Resident #20 not getting straight catheterized as physician ordered. And when they do straight catheterization, the staff were obtaining more than 250 cc of urine left in the bladder and this was retention. CNP #514 confirmed retention (a condition in which a person is unable to empty their bladder completely) can cause a UTI. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when she went to the ER on [DATE] and showed she had a UTI, that was why the Cipro was ordered.On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration.Interview on 08/07/25 at 10:39 A.M. with the DON and record review of the Pharmacy Communication request received 08/04/25 at 11:54 A.M. revealed the request stated to Please Respond. Medication Cipro had a drug interaction with (medication) tizanidine. Please consider changing the antibiotic to something else or hold all tizanidine while on this antibiotic. The DON revealed she also gets emails from the pharmacy, but the recommendations also come through the fax. The pharmacy also calls the nurses who need to update the physician with the pharmacy information. The DON confirmed the pharmacy recommendation was not completed and revealed any nurse could do it.Interview on 08/07/25 at 11:04 A.M. with LPN #518 confirmed CNP #514 requested a urinalysis be obtained for Resident #20.Record review and interview on 08/11/25 at 3:00 P.M. with DON confirmed there were no urinalysis results in the medical record for Resident #20 for the urinalysis ordered 08/07/25. The DON confirmed the urine was obtained on 08/07/25 and the urine was never sent to the laboratory. The DON stated she did not know why the urine was never sent and confirmed it should have been obtained and sent per the CNP orders.Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she ordered a urinalysis on 08/07/25 for Resident #20 and revealed she was never notified the urinalysis was not completed as ordered. 2. Record review for Resident #1 revealed a re-admission date of 02/17/16. Diagnosis included vascular dementia with unspecified severity without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. Review of the medical record for Resident #1 face sheet revealed Resident #1 had a representative who was his daughter. The face sheet in the electronic medical record did not have a telephone number available for Resident #1's representative. The medical record revealed Resident #1's representative's telephone number was provided in the hospital record. On 09/11/23, a social services progress note documented the resident representative's telephone number. The progress note dated 04/17/25 completed by Unit Manager #293 revealed Resident #1 received new orders and a telephone call was placed to Resident #1's daughter making her aware of the new orders. Review of the facilities Self-Reported Incident (SRI) revealed on 07/06/25 at 10:38 A.M., a SRI was created by Administrator in Training (AIT) #351. The SRI had allegation of sexual abuse involving Resident #1 and it was witnessed by a staff member. Review of the resident census in Resident #1's electronic medical record revealed Resident #1 resided on the second floor in the same room from 12/14/21 through 07/06/25. On 07/026/25, Resident #1 was transferred to a room on the first floor of the facility. Resident #1's medical record did not have any documentation that Resident #1's responsible party was notified of a sexual abuse incident involving Resident #1 and Resident #1's room change on 07/06/25. Interview on 07/08/25 at 11:59 A.M. with Social Service Designee (SSD) #334 revealed she spoke Resident #1's representative on the telephone about two months ago. SSD #334 stated the telephone number was there on Resident #1's face sheet in the medical record and she was unaware of who took the telephone number off the face sheet. SSD #334 confirmed an incident occurred regarding sexual touching and Resident #1's room was changed on 07/06/25. SSD #334 confirmed Resident #1 did not have any documentation of Resident #1's representative being notified of any occurrence on 07/06/25 and SSD #334 confirmed Resident #1 had a representative in place and Resident #1 was not his own person. Telephone interview on 07/08/25 at 12:16 P.M. with Resident #1's representative revealed the facility staff did not contact her for any incident involving Resident #1 on 07/06/25. Resident #1's representative was unaware Resident #1 moved to the first floor on 07/06/25. Resident #1's representative stated she wanted to be notified of any changes involving Resident #1 and stated she was coming straight to the facility to obtain additional information about the incident involving Resident #1 on 07/06/25. Interview on 07/08/25 at 3:11 P.M. with Administrator confirmed Resident #1's representative was never notified of the incident on 07/06/25 due to there was no telephone number for her. Review of the facility policy titled Change in a Resident's Condition or Status revised February 2021 revealed the facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number 2574277 and Complaint Number OH00167210 (138517).

Based on record review and interview, the facility failed to ensure a Nurse Practitioner (NP) or physician was contacted when Resident #8's family requested several times to speak with one of them. No explanation was provided for the family. This affected one (Resident #8) of three residents reviewed for ability to speak with the NP and physician. The census was 70. Findings Include: Review of the medical record for Resident #8 revealed an admission date of 06/10/25. Diagnoses included sepsis, acute respiratory failure, diabetes, dementia, cerebral infarction acute embolism and thrombosis of deep veins of unspecified upper extremity, and acute postprocedural pain. The resident was discharged to the hospital 06/15/25. Review of the Medicare 5-Day Minimum Data Set (MDS) assessment, dated 06/14/25, revealed Resident #8 had severely impaired cognition. Review of the nurse's note, authored by Agency Nurse #211 dated 06/15/25 at 12:54 P.M. revealed the daughter of Resident #8 stated her mom was crying and miserable and she would like to talk to the Nurse Practitioner (NP). The Resident's temperature was 100.1 degrees Fahrenheit (F), Tylenol (pain reliever and fever reducer) was given. Review of the nurse's note, authored by Agency Nurse #211, dated 06/15/25 at 6:38 P.M. revealed the daughter of Resident #8 stated the resident was not herself and something was wrong. The nurse took the residents' vital signs: Temperature 98.6 degrees F, Pulse 78, and Blood Pressure (BP) 172/86. The daughter stated she wanted the nurse to call the NP and asked the NP to call her. She stated the resident was confused but had a urinary tract infection (UTI). The resident had sepsis three times, and the daughter was afraid of the resident had sepsis again. The nurse educated the daughter that confusion was a symptom of a UTI. Review of the nurse's note, authored by Assistant Director of Nursing (ADON) #209, dated 06/15/25 at 10:43 P.M. revealed the daughter of Resident #8 came to the nurse's station and complained that the resident had an elevated temperature, and that she needed to be sent out to the hospital. Vital signs were checked. Temperature was 98.9 degrees F, Pulse 80, BP 170/86, oxygen saturation (SpO2) 96% on room air. A call was placed to the NP on call, and an order was obtained to send resident out to the emergency room (ER) for evaluation. Resident #8 was sent out to the hospital via 911. Review of the Change in Condition evaluation revealed the clinician was notified on 06/15/25 at 8:45 P.M. and order was obtained to send Resident #8 to the hospital. The daughter was present at the facility at the time of the transfer. Review of the Ambulance Run report revealed emergency medical services (EMS) was called on 06/15/25 at 8:59 P.M. Resident #8 left the facility at 9:27 P.M. Comments: The nurse on scene states that the patient was stable and did not need transport, her vital signs were stable, and fever was reduced with Tylenol. Interview on 06/30/35 at 4:25 PM. with the daughter of Resident #8 revealed she had asked several times to have the on-call NP or physician call her. The agency nurse responded aggressively, saying she wasn't the only person that wanted to speak to a NP or doctor, and I'd have to wait my turn. Later in the evening, the resident's daughter told the nurse she felt Resident #8 should be sent to the hospital. Agency Nurse #211 tried to deter the family numerous times, telling them that it wasn't medically necessary for her mother to go to the ER. An interview on 07/01/25 at 12:34 P.M. with Registered Nurse (RN)/ADON #209 revealed as soon as the ADON walked to the hall she heard Resident #8's family talking. The ADON went and asked the nurse what was going on, then went to talk to the family. The family said they wanted the resident sent out; she had experienced a change in mental status and wasn't acting like herself. The ADON told Agency Nurse #211 to call 911 and get Resident #8 sent out right away. ADON #209 revealed the family stated they had previously asked the nurse to send Resident #8 to the hospital. The facility has a NP and physician on call, it was not a problem to get ahold of them on the weekends. Interview on 07/01/25 at 12:01 P.M. the Director of Nursing (DON) and Regional Nurse Manager #201 verified the daughter of Resident #8 had requested to speak with an NP or physician, and there was no documented evidence that the NP or doctor were contacted. This deficiency represents non-compliance investigated under Complaint Number OH00166802.

Based on closed record review and interview, the facility failed to prevent a significant medication error for Resident #50 resulting in an acute change in condition requiring hospitalization . Actual Harm occurred on 05/17/24 when Resident #50, who had diagnoses of heart failure and chronic bilateral lower extremity lymphedema, was transferred to the hospital due to significant shortness of breath after not receiving the physician ordered diuretic medication, Torsemide following his admission to the facility on [DATE]. Findings include: Review of Resident #50's Hospital After Visit Summary form dated 05/15/24 revealed the resident was admitted (to the hospital) for a past medical history of medication non-compliance, heart failure, chronic bilateral lower extremity lymphedema and sarcoidosis. Aggressive diuresis was performed. Medications included Torsemide (diuretic) 20 mg (milligrams) two tablets by mouth twice daily with his last dose administered on 05/15/24 at 10:22 A.M. Review of Resident #50's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. The resident was transferred/discharged to the hospital on 05/17/24 and did not return to the facility. Resident #50 had diagnoses including pulmonary hypertension, lymphedema and obesity. Review of Resident #50's physician orders revealed an order dated 05/15/24 for Torsemide (oral tablet) 20 mg; give two tablets by mouth twice daily for swelling. The resident also had an order (dated 05/16/24) for Albuterol inhalation 108 mcg (micrograms) two puffs orally every four hours as needed for shortness of breath while awake. Review of Resident #50's Pharmacy packing slip dated 05/15/24 revealed the resident's Torsemide medication was not signed for until 05/17/24 by Registered Nurse (RN) #812. Review of Resident #50's Nurse Practitioner (NP) progress note, authored by NP #811 dated 05/16/24 at 11:03 A.M. revealed the resident had cellulitis of the lower extremity and venous ulcer. The resident was discharged (from the hospital) on oral Torsemide 40 mg twice daily and had chronic pain. Review of Resident #50's medication administration records (MAR) and treatment administration records (TAR) from 05/15/24 to 05/17/24 revealed the resident was not administered Torsemide during his stay. In addition, there was no evidence the resident was administered the Albuterol inhaler during his stay. Review of Resident #50's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #50's undated Quality Improvement Tool for Review of Acute Care Transfers form dated 05/17/24 revealed the resident had a change in condition with complaints of increased epigastric pain. The nurse medicated the resident for pain but (the resident) insisted on going to the hospital. The physician was notified. Review of Resident #50's emergency medical service (EMS) squad report dated 05/17/24 revealed at 5:03 A.M. the squad was called to dispatch to the facility, and they arrived at 5:10 A.M. The report revealed Resident #50 had a hard time breathing. Upon squad arrival, the resident was in his room sitting up and could not breathe. The resident stated that the place was trying to kill him. The resident stated the concern had been going on for over an hour. The staff stated the resident had a breathing treatment and it did absolutely nothing for him. The report included the resident's room was 80 degrees, and he was over 600 pounds. The resident was placed on a CPAP machine and transferred to the hospital. Interview on 06/07/24 at 4:37 P.M. with RN #812 revealed Resident #50 was stable when she cared for him on 05/16/24. She stated she did not have medications to give the resident as they were ordered from pharmacy. She stated she removed what she could from the Pyxis starter system but was not able to administer his Torsemide because it was not available. Telephone interview on 06/07/24 at 6:40 P.M. with NP #811 revealed she was aware the resident's medications were on order from the pharmacy, including his Torsemide. Interview on 06/07/24 at 6:45 P.M. with RN #813 revealed she sent Resident #50 to the hospital on 05/17/24 around 1:00 A.M. to 1:30 A.M. for increased complaints of pain. She stated she had completed Resident #50's leg dressing around 12:00 A.M. and mediated the resident for pain with Oxycodone narcotic pain medication at that time. She stated the resident denied complaints of chest pain or shortness of breath. Telephone interview on 06/10/24 at 8:06 A.M. with Resident #50's insurance representative revealed they received a call from the resident's family member who reported the resident went two days without his prescription medication, being told the facility had not received the medication yet. On 05/18/24 the resident was having difficulty breathing, lost consciousness, and was sent to the emergency department. The resident was treated for having fluid on his lungs and was hospitalized . The insurance representative reached out to Resident #50 who further reported not receiving his prescription medication including Torsemide (following his admission to the nursing facility). Resident #50 indicated he would remain at the hospital until a bed became available at a different skilled rehabilitation facility. Telephone interview on 06/10/24 at 9:33 A.M. with Fire Department #815 revealed they were called to the facility for a male resident with complaints of the resident having a hard time breathing. Staff stated a breathing treatment was implemented. The resident's room was approximately 80 degrees. A CPAP was placed on the resident and the resident's oxygen level was at 100%. The resident was transported to the hospital. Review of the Medication Administration policy dated 11/2021 revealed medications should be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Master Complaint Number OH00154196 and Complaint Number OH00154137.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, emergency room documentation, emergency medical services (EMS) run sheet and interviews, the facility failed to prevent significant medication errors when medications prescribed for Resident #35 were administered to Resident #74 in error. This affected one resident (#74) of three residents reviewed for medication administration. The census was 73. Actual harm occurred on 11/03/23 at approximately 7:15 P.M. when Resident #74 was administered medications ordered for Resident #35 which included atorvastatin calcium (lowers cholesterol) 80 mg, insulin glargine (long acting insulin) 27 units, melatonin (for sleep) five mg, senna-docusate sodium (stool softener) 8.6 mg, carvedilol (beta blocker used to treat high blood pressure and heart failure) 25 mg, clonidine (lowers blood pressure) 0.3 mg, docusate sodium (stool softener) 100 mg, hydralazine (vasodilator used to treat high blood pressure) 100 mg, hydroxyzine (antihistamine can be used to treat anxiety) 25 mg and Flomax (for urinary retention) 0.4 mg. Resident #74 was transferred to the hospital and admitted to the Intensive Care Unit (ICU) for risk of hypotension (low blood pressure) and hypoglycemia (low blood sugar) as a result of the medication errors. Review of the hospital emergency room report revealed Resident #74 was hypotensive with a blood pressure of 72/50 millimeters of mercury (mm Hg) and she was bradycardic (with her heart rate averaging in the 40's beats per minute range). The emergency room documentation indicated Resident #74 had a high probability of sudden, clinical deterioration, which required the highest level of physician preparedness to intervene urgently. Findings Include: Review of the closed medical record for Resident #74 revealed an admitted [DATE] and discharge date of [DATE] with diagnoses including unspecified dementia with agitation, atrial fibrillation, anxiety disorder, hypertension, and displaced fracture of the humerus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/03/23, revealed Resident #74 had impaired cognition. Review of the November 2023 Medication Administration Record (MAR) for Resident #74 revealed Resident #74 was ordered atorvastatin calcium (lowers cholesterol) 40 milligrams (mg), ergocalciferol (Vitamin D2) 1.25 mg, ferrous sulfate (iron) 325 mg, furosemide (diuretic) 20 mg, melatonin three mg (for sleep), sertraline (increases levels of serotonin in brain) 50 mg, Depakote 125 mg (anticonvulsant and also used to decrease behaviors), Eliquis (anticoagulant) five mg, and metoprolol (used to treat high blood pressure) 25 mg. Review of the nurse's progress note dated 11/03/23 timed 9:25 P.M. revealed Resident #74 was sent to the hospital, a physician (Resident #74's son) was at the bedside. Resident #74 was awake, alert, and had a blood pressure of 88/50 mm Hg. Review of emergency room progress notes dated 11/04/23 timed 4:03 A.M. revealed Resident #74 was admitted to the ICU for risk of hypotension and hypoglycemia. Resident #74 received another resident's (Resident #35's) medications which included atorvastatin calcium 80 mg, insulin glargine 27 units, melatonin five mg, senna-docusate sodium 8.6 mg, carvedilol 25 mg, clonidine 0.3 mg, docusate sodium 100 mg, hydralazine 100 mg, hydroxyzine 25 mg and Flomax 0.4 mg. Resident #74's blood pressure measured 72/50 mm Hg and the resident's heart rate was averaging 40-49 beats per minute. Resident #74 had a high probability of sudden, clinical deterioration, which required the highest level of physician preparedness to intervene urgently. Review of the November 2023 MAR for Resident #35 revealed Resident #35 was scheduled to receive atorvastatin calcium 80 mg, insulin glargine 27 units, melatonin five mg, senna-docusate sodium 8.6 mg, carvedilol 25 mg, clonidine 0.3 mg, docusate sodium 100 mg, hydralazine 100 mg, hydroxyzine 25 mg and Flomax (for urinary retention) 0.4 mg at 7:00 P.M. Interview on 12/08/23 at 8:41 A.M. with the Administrator revealed an agency nurse administered the wrong medications to Resident #74. The agency nurse contacted the physician, family, and the Director of Nursing (DON). Interview on 12/08/23 at 10:14 A.M. with the Unit Manager, for the unit where Resident #74 resided, revealed she received a call on 11/03/23 at 7:40 P.M. indicating Resident#74 was given the wrong medications. The physician, family and the DON were contacted. The physician ordered staff to monitor Resident #74 every two hours and report any abnormal findings. Resident #74 received the medications at approximately 8:00 P.M. and was sent to the hospital at approximately 9:25 P.M. with a (decreased) blood pressure of 88/50 mm Hg. Interview on 12/18/23 at 8:53 A.M. with Resident #74's son, (who was a physician) revealed he received a call from the facility on the evening of 11/03/23 informing him Resident #74 received another resident's medications. The son went to the facility and was at Resident #74's bedside until EMS arrived. Resident #74 was awake and alert, but he was concerned about her blood glucose levels and blood pressure. The son fed Resident #74 ice cream sandwiches, peanut butter and jelly and cookies to keep her blood glucose level from dropping too low. After a period of time (not sure of exact time) Resident #74 became confused and EMS was called to transport Resident #74 for treatment. Resident #74 was admitted to the hospital and received intravenous infusions to maintain appropriate blood pressure and blood glucose levels. Resident #74 was in the hospital for five days and remained stable throughout the admission. Upon discharge from hospital, she was transferred to another facility. Interview on 12/18/23 at 9:08 A.M. with Registered Nurse (RN) #103 revealed she was administering medications the evening of 11/03/23. RN #103 explained after finishing the administration of medication for another resident, she pulled up Resident #35's MAR on the computer. Resident #74 began to scream loudly, and RN #103 left the medication cart to assess Resident #74 who was very upset and hearing voices. RN #103 took Resident #74's vitals and told her she would give her medications. RN #103 returned to the medication cart, prepared and administered the medications which were on the computer screen to Resident #74, forgetting she had previously pulled up Resident's #35 MAR. Upon returning to the medication cart and looking at the MAR she immediately realized she administered Resident 35's medications to Resident #74. RN #103 contacted the physician at approximately 7:39 P.M. The physician gave an order to obtain vital signs and blood glucose levels every two hours for 12 hours and to report any negative findings. RN #103 contacted the family and the Assistant Director of Nursing (ADON) at approximately 7:45 P.M. Resident #74's son, who was a physician, came in and fed Resident #74 ice cream, cookies and peanut butter and jelly. The DON called at approximately 8:30 P.M. indicating she felt Resident #74 should be sent to the hospital for observations. RN #103 contacted Resident #74's physician at approximately 8:40 P.M. and obtained an order to send Resident #74 to the hospital for observation. Review of physician orders dated 11/03/23 confirmed orders to obtain vital signs and blood glucose levels every two hours for 12 hours and report any negative findings timed 7:36 P.M., and an order to send Resident #74 to the hospital for observation timed 8:40 P.M. Review of the EMS run report dated 11/03/23 revealed EMS was called at 8:46 P.M. and arrived at 8:53 P.M. EMS transported Resident #74 at 9:27 P.M. Resident #74 was alert oriented to person and place (her baseline), her blood pressure was (hypotensive) 80/53 mm Hg, pulse was 76 beats per minute, respirations were 20 breaths per minute, and blood glucose level was 142. The deficient practice was corrected on 11/04/23 when the facility implemented the following corrective actions: On 11/03/23 at 7:24 P.M., RN #103 self-identified incorrect medication given to Resident #74. On 11/03/23 at 7:39 P.M., RN #103 contacted the on-call physician and reported the medication error. The physician gave an order to monitor Resident #74's blood glucose levels every two hours for 12 hours. On 11/03/23 at 7:40 P.M., the ADON was contacted and notified of the medication error. On 11/03/23 at 7:41 P.M., Resident #74's son was notified of the medication error. On 11/03/23 at 8:30 P.M., the DON contacted the facility and requested Resident #74 be sent to the hospital. The DON provided education to RN #103 via phone which included the five rights of medication administration. RN #103 verbalized understanding. On 11/03/23 at 8:40 P.M., RN #103 contacted the physician regarding the DON's request to send Resident #74 to the hospital. The physician provided an order to transfer the resident to the hospital for observation. On 11/03/23 at 8:46 P.M., EMS was contacted and Resident #74 was transferred to the hospital at 9:23 P.M. On 11/04/23 an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the administrator, all department heads and the medical director. The medication policies and procedures were reviewed and determined to be appropriate. A corrective action plan was developed and initiated for medication administration. The meeting was confirmed by review of attendance sign in sheet. On 11/04/23 the DON provided a 60 minute in-service to all staff responsible for medication administration including medication technicians, LPNs, RNs, and working agency staff on the medication administration policy and five rights of medication administration. Attendance of the staff was verified by review of attendance sign in sheet. On 11/04/23, the DON/designee reviewed all residents' MARs for accuracy and potential errors. On 11/04/23 the administrator/designee began weekly audits of medication administration which included observations to determine medications were administered without error and audits of the medication administration staff's knowledge and use of the five rights during medication administration. The weekly audits would continue for four weeks and then monthly for two months. On 11/20/23, the weekly medication administration audits and corrective action plan were reviewed by the facility's Quality Assurance Performance Improvement Committee/interdisciplinary team which deemed the corrective action was effective. Review of the medication audits through 12/18/23 revealed there had been no medication errors after 11/03/23 and staff were knowledgeable of and used the five rights during medication administration. This deficiency represents non-compliance investigated under Complaint Number OH00148304.

Based on record review and interview the facility failed to provide Resident #1 with adequate assistance during care to prevent the resident from falling out of bed and sustaining an injury. Actual harm occurred on 11/10/19 when Resident #1, who required two staff assistance for activity of daily living care, was being provided personal care by one State tested Nursing Assistant, STNA #200. While attempting to provide personal care for Resident #1 by herself, instead of waiting for a second staff member to assist, Resident #1 rolled out of bed and onto the floor sustaining a seven centimeter (cm) by five cm skin tear to her forehead and a four cm by 0.5 cm scratch to her forehead requiring transfer to the hospital. This affected one resident (#1) of three residents reviewed for falls. Findings Include: Closed record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was severely cognitively impaired with limited range of motion of the upper and lower extremities. The assessment revealed the resident required the assistance of two persons for bed mobility, toileting, transfers and personal hygiene. Review of the care plan for Resident #1 revealed the resident was at risk for falls and had deficits in self care. Interventions included extensive assist with personal hygiene with two staff and extensive assist of two with all activities of daily living. Review of the nursing progress note, dated 11/10/19 at 6:33 [NAME]M. revealed Resident #1's assigned STNA, (STNA #200), requested assistance in Resident #1's room from Registered Nurse #100 (RN). Upon entering the room RN #100 noted Resident #1 in the prone position on the floor next to right side of the bed. Head to toe assessment executed by RN #100 revealed swelling and redness Resident #1's left side of face (cheek). A raised area measuring approximately seven cm by five cm with discoloration at the center of the raised area (forehead) was also noted along with a skin tear measuring four cm by 0.5 cm to the left side of Resident #1's forehead. The residents doctor and family were notified and Resident #1 was transferred to a local hospital for evaluation. Review of the facility fall investigation. dated 11/12/19 revealed STNA #200 was providing incontinence care to Resident #1. When STNA #200 rolled Resident #1 towards her her to complete incontinence care Resident #1 slid off the bed falling between the bed and the STNA onto the floor. Review of a statement provided by STNA #200 revealed she had the resident placed on her left side and was attempting to adjust the bedding and clean the mattress with the resident leaning on her for support. Resident #1 then began to slip off the bed and STNA #200 was unable to stop of the momentum of Resident #1 and she fell on to the floor. No other STNA or staff were present in the room assisting with care at the time of incident. Interview with Director of Nursing on 12/19/19 at 10:07 [NAME]M. verified STNA #200 provided care without the assistance of another STNA or staff member on 11/10/19 resulting in a fall with injury. As a result of the incident, the resident was transferred to the emergency room . The resident did not return to the facility. Information obtained during the complaint investigation revealed the resident was hospitalized in the intensive care unit for three days with fluid on her brain and brain damage as a result of the fall in the facility. This deficiency substantiates Complaint Number OH 773.