Every finding on record at Vancrest of Ada

Based on closed medical record review, review of hospital records, review of the facility submitted Self-Reported Incident (SRI), review of staff and resident statements, resident and staff interview, and review of the facility policy, the facility failed to ensure residents did not develop avoidable, facility acquired, pressure ulcers. This resulted in actual harm for Resident #50 on 10/24/25 when facility staff placed the resident on a bedpan and failed to check on her and remove her from the bedpan for an extended period of time. Consequently, Resident #50 developed a deep tissue injury (DTI - a type of pressure injury that begins in the deeper tissues and is caused by prolonged pressure) on her buttocks. Additionally, upon discovery of the DTI, the facility failed to thoroughly assess and document the DTI. This affected one (#50) of three residents reviewed for pressure ulcers. The facility census was 48.Findings include:Review of the closed medical record for Resident #50 revealed an admission date of 01/08/25. Diagnoses included atrial fibrillation (abnormal heartbeat), diabetes mellitus Type II, congestive heart failure (CHF), chronic kidney disease (CKD) stage three (CKD is measured in stages one through four, stage four requires renal dialysis), liver cirrhosis, peripheral vascular disease (PVD), bilateral (both sides) below the knee amputation (BKA), and altered mental status (AMS). Resident #50 transferred to the hospital on [DATE] due to AMS and was subsequently discharged from the facility on 10/31/25, without returning following her hospitalization.Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/06/25, revealed Resident #50 was cognitively intact, required moderate (staff) assistance with toileting, had occasional bladder incontinence, and had no unhealed pressure ulcers. Review of the care plan, revised September 2025, revealed Resident #50 required one (staff) assistance for toileting and bed mobility and preferred the use of a bedpan for toileting. Review of Nurse Practitioner (NP) #415's visit note, dated 10/24/25 at 10:24 A.M., revealed Resident #50 was acutely seen for lethargy and AMS. Resident #50's roommate (Resident #32) was at the nursing station and reported the resident had been more confused and the nursing staff validated the concern, and reported Resident #50 had been slow to respond. Further review revealed Resident #50 complained of lower abdominal pain, loose stools, fever (although no documented fever), strong concentrated urine, and concern for a urinary tract infection (UTI). Continued review revealed the resident was positive for a change in activity, increased weakness, decreased concentration, and abdominal pain with loose stools. Resident #50 was ill-appearing, despite being alert and oriented to person, place and time. Resident #50 had a labile affect, delayed speech, and somnolence (state of drowsiness or strong desire to fall asleep). The resident stated she did not feel well. The plan for treatment was to encourage fluids, obtain a urine sample, and a suspected UTI with a plan to treat with ceftriaxone (antibiotic) one gram (gm) intramuscularly (IM) for three days. A stat (immediate) complete blood count (CBC - measures values for possible infection) and basic metabolic panel (BMP - measures electrolyte values, this will indicate dehydration or electrolyte imbalance) were to be completed. If no improvement, send to the emergency department (ED) for evaluation and treatment. Review of the October 2025 physician orders revealed on 10/24/25, Resident #50 had orders for four ounces of water every two hours related to UTI, obtain urinalysis (UA) with reflex (test to identify an infection in the urinary system), CBC, BMP, and ceftriaxone sodium injection one gm IM daily for three days. Review of the Weekly Wound and Skin Assessment Documentation, dated 10/24/25, revealed Resident #50 had a new, dark blanchable redness area to the bilateral buttocks. No wound measurements or characteristics were documented.Review of a nursing progress note, dated 10/24/25 at 12:38 P.M. and authored by Licensed Practical Nurse (LPN) #341, revealed Resident #50 had increased confusion, unclear speech, and incontinent episodes. NP #415 was notified, and orders were obtained for treatment. Review of the ED notes, dated 10/25/25, revealed the attending physician documented that Resident #50 had skin breakdown to the bilateral buttocks. The nurse documented that the nursing facility reported Resident #50 was accidentally left on the bedpan overnight on Thursday (10/23/25 into 10/24/25). Further review of the nursing documentation revealed Resident #50 had a large DTI ring circling the buttocks and the DTI portion on the right buttock was blistered. Further review of the 10/25/25 hospital records revealed a photograph showing the resident's right outer buttock, extending down to the gluteal fold (area where the bottom of the buttock and the top of the posterior thigh begins) was deep red, nearly ruddy, in color. The right outer buttock showed an area that was open, with a deep, dark, nearly purple center of the open area. Review of a second photograph revealed an image of the resident's left buttock that showed a dark red area to the outer buttock. The area on Resident #50's right and left buttocks was in the shape of a bedpan. Review of the hospital wound consultation note revealed Resident #50 had a wound to the bilateral buttocks classified as a DTI. The wound was deep red and purple discoloration that extended to the posterior thigh. Further review revealed the DTI to the bilateral buttocks and posterior thigh was the result of prolonged bedpan use as the wound was the shape/impression of a bedpan. No measurements were documented at that time. Review of a follow-up wound consultation note, dated 11/01/25, revealed the wound on Resident #50's right buttock measured 10 centimeters (cm) by 1.5 cm x less than (<) 0.1cm with slough (dead tissue in a wound), fibrin (protein that aids in blood clotting), and eschar (blackened dead tissue) noted to the areas of the wound bed. The left buttock and posterior thigh measured 24 cm x 1.4 cm x < 0.1 cm with non-blanchable intact skin. Review of a facility submitted SRI, initiated on 10/27/25 and completed on 10/31/25, revealed the Administrator was notified by hospital staff that Resident #50 alleged that a staff member left her on bed on a bedpan for an extended period of time during the night of Thursday, 10/23/25, into the early morning of Friday, 10/24/25. The resident's care plan was reviewed, indicating her preference not to be awakened while sleeping and that she would use the call light when assistance was needed. The resident had a Brief Interview of Mental Status (BIMS) score of 15, indicating she was cognitively intact. Clinical documentation revealed the nursing and NP notes from the morning of 10/24/25 reflected the resident was experiencing increased confusion and diarrhea, but there were no reports or observations of pain, emotional distress, or mental anguish during the timeframe referenced. The resident was alert and oriented. During catheterization that morning, the bedpan was removed, and a reddened area was noted. Certified Nursing Assistant (CNA) documentation confirmed routine checks were performed before and after the alleged timeframe referenced by hospital staff, with no record of the resident requesting assistance or complaining about the bedpan after use. The resident's roommate stated CNA #303 provided care around 2:45 A.M. and placed Resident #50 on the bedpan and left the room. The roommate also stated the resident did not use her call light or otherwise request assistance. CNAs interviewed confirmed that the resident typically signaled staff via call light when she wished to be removed from the bedpan, and no such request was made that night. The facility unsubstantiated the allegation of neglect, citing Resident #50 was cognitively intact, did not verbalize complaints prior to her hospitalization, care was provided in accordance with her plan of care, documentation and staff interviews that showed the resident was routinely checked on and showed no signs of pain, mental anguish, or emotional distress, and the facility maintained that there was no evidence the resident was left on the bedpan for an extended period of time prior to her hospitalization.Review of CNA #303's written statement, dated 10/27/25, revealed she arrived for her normal night shift and received report from the previous shift. CNA #303 further stated the call light was engaged for Resident #50's room at approximately 2:00 A.M., she assisted Resident #32 to the bathroom, and Resident #50 did not engage the call light but requested her fan be turned on and did not have any other needs. CNA #303 further stated the call light for Resident #50's room did not come back on for the remainder of the shift. Review of CNA #387's written statement, dated 10/27/25, revealed she arrived for her shift on 10/24/25 (dayshift) and obtained report from the previous shift and was not notified of Resident #50 being on the bedpan. CNA #387's stated she provided breakfast to Resident #50 and the resident had no further needs. At approximately 9:45 A.M. to 10:00 A.M., the nurses notified her that Resident #50 was on the bedpan and had redness on her buttocks from the bedpan. Review of LPN #322's written statement, dated 10/27/25, revealed she assisted a co-worker to obtain a urine sample for Resident #50 (on 10/24/25) when the two nurses noted Resident #50 was on the bedpan. LPN #322 further stated the bedpan was removed from under Resident #50 and there was a dark red, blanchable redness around her buttocks where the bedpan was. LPN #322's statement revealed Resident #50 reported third shift staff put her on the bedpan. Review of LPN #308's written statement, undated, revealed she worked the night shift on 10/23/25. Further review revealed LPN #308 assisted Resident #50 with care at approximately 12:00 P.M. At approximately 4:53 A.M., she administered medication to Resident #32 and Resident #50 requested to be put back to bed. LPN #308 had to re-oriented Resident #50 that she was already in bed. Review of LPN #425's written statement, undated, revealed she was informed by LPN #322 that Resident #50 was left on the bedpan by third shift and had indentation. Review of Resident #32's written statement, undated, revealed she was assisted to the bathroom at approximately 2:30 A.M. to 2:45 A.M. (on 10/24/25) by CNA #303, at which time Resident #50 was also assisted by CNA #303 to use the bedpan. Interview on 11/03/25 at 8:20 A.M. with the Administrator confirmed the facility investigated an allegation of neglect involving Resident #50 being left on a bedpan for an extended period of time but could not pinpoint how long she had actually been left on the bedpan. The Administrator stated the resident was cognitively intact and typically called for assistance, which she did not do that night; however, he acknowledged the resident had a decline that day. The Administrator stated they knew the resident was on the bedpan for longer than they would like. Interview on 11/03/25 at 11:27 A.M. with CNA #387 verified she worked on 10/24/25, started her shift at 6:00 A.M., and was assigned to provide care for Resident #50. CNA #387 stated she did not place Resident #50 on the bedpan at any time during that morning. CNA #387 further stated she received report from the previous shift and it was not reported that the resident was on the bedpan. Interview on 11/03/25 at 11:46 A.M. with CNA #314 verified she worked dayshift on 10/24/25, was assigned to complete resident showers for the day, and she did not place Resident #50 on the bedpan. CNA #314 further stated Resident #50 was due for a shower on 10/24/25 and she refused due to not feeling well. A telephone interview on 11/03/25 at 1:32 P.M. with CNA #319 verified she worked on 10/24/25, her shift started at 6:00 A.M., and she was assigned to the hall Resident #50 resided on. CNA #319 stated she did not put Resident #50 on the bedpan that morning and did not receive in report from the previous shift that the resident was on the bedpan. CNA #319 stated she observed Resident #50's buttocks later during her shift and her bottom was really red on the outer part of the left buttock. A telephone interview on 11/03/25 at 2:02 P.M. with LPN #322 revealed that on 10/24/25, sometime after breakfast, she assisted another nurse (LPN #341) in obtaining a urine sample from Resident #50. When she pulled the covers back from Resident #50, LPN #322 stated she noticed the resident was on the bedpan. LPN #322 further stated that when the bedpan was removed from under Resident #50, there was a dark, deep red ring on the resident's bottom. LPN #322 stated she asked Resident #50 how long she was on the bedpan and the resident did not know she was still on the bedpan, did not know how long she had been on it, and stated that someone from third shift put her on the bedpan. LPN #322 further stated she interviewed the CNAs that were working that morning and both of them denied assisting Resident #50 onto the bedpan from the beginning of their shift (at 6:00 A.M.) and were not aware she was on the bedpan. LPN #322 further stated she reported the incident to LPN #425 and was instructed to monitor the redness. LPN #322 stated she reported to LPN #341, who was assigned to care for the resident, the direction from LPN #425. LPN #322 confirmed she did not complete an assessment of the wound.A follow-up interview on 11/03/25 at 3:04 P.M. with the Administrator revealed the facility unsubstantiated the allegation of neglect because they could not pinpoint the length of time Resident #50 was left on the bedpan. The Administrator stated, because he was not clinical, he could not determine how long was too long to be left on a bedpan, but he confirmed two hours would be too long. Review of the staff statements, NP visit notes, and staff interviews with the Administrator revealed, at a minimum, Resident #50 was on the bedpan from at least 6:00 A.M. on 10/24/25, when day shift staff arrived and reported they did not place the resident on the bedpan, until approximately 10:20 A.M. (nearly 4.5 hours) when the licensed nurses collected the urine sample to complete the UA as ordered by NP #415 due to a change in condition experienced by the resident. The facility was unable to determine which staff placed Resident #50 on the bedpan.A telephone interview on 11/03/25 at 3:52 P.M. with CNA #303 verified she worked the night shift on 10/23/25 (10:00 P.M. on 10/23/25 to 6:00 A.M. on 10/24/25) and was assigned to care for Resident #50. CNA #303 denied she put the resident on the bedpan. CNA #303 stated she responded to the call light for Resident #50's roommate during the shift, but Resident #50 did not have any needs.A telephone interview on 11/04/25 at 9:45 A.M. with LPN #341 revealed she worked on 10/24/25 and discovered Resident #50 on the bedpan when she and another nurse (LPN#322) went to collect a UA for the resident. LPN #341 confirmed Resident #50 was confused that day and could not recall when she was placed on the bedpan or by whom. LPN #341 stated Resident #50 was removed from the bedpan and both sides of her bottom were red. LPN #341 verified she did not document the wound characteristics and did not monitor it throughout her shift.Interview on 11/05/25 at 7:51 A.M. with Resident #32 (roommate of Resident #50) revealed the resident was cognitively intact and able to be interviewed. Resident #32 stated that on 10/23/25 at approximately 2:30 A.M. to 2:45 A.M., she turned on the call light and CNA #303 responded and assisted her to the restroom. Resident #32 further stated that while she was in the bathroom, she could hear CNA #303 and Resident #50 talking and Resident #50 requested to use the bedpan. Resident #32 stated the aides did shift change rounds outside the residents' rooms. She stated she was awake and heard the report from night shift to day shift and she did not hear the night shift aide report that Resident #50 was on the bedpan. Resident #32 stated she was in the room when the day shift nurses took Resident #50 off the bedpan and overheard one of them comment about the bright redness to the resident's bottom. Resident #32 stated Resident #50 had fallen asleep on the bedpan before, but staff had always returned to check on her.Interview on 11/05/25 at 8:12 A.M. with the Director of Nursing (DON) revealed the facility's process for new skin impairments was to file an incident report, obtain measurements of the new skin impairment, make notification (to the physician/family/responsible party/DON), and obtain orders for treatment of the skin impairment. Further interview with the DON verified the facility procedure was not followed when the new skin impairment was identified on Resident #50's buttocks on 10/24/25. The DON stated she was not aware of Resident #50's skin impairment until the Administrator notified her of it on 10/27/25. Interview on 11/05/25 at 8:18 A.M. with NP #420 revealed she had provided wound care for previous wounds that Resident #50 had, and those wounds had resolved. NP #420 confirmed Resident #50 had no unhealed pressure ulcers prior to the new wound identified on 10/24/25. NP #420 reviewed the wound photographs from the hospital and stated a DTI was a type of pressure ulcer and she would have classified the wound on Resident #50's bilateral buttocks as a DTI pressure ulcer as a result of pressure from an object (bedpan). NP #420 confirmed she was not notified of Resident #50's wound and just learned of it during this interview. A telephone interview on 11/05/25 at 10:37 A.M. with LPN #310 revealed she received in report on the morning of 10/25/25 that Resident #50 had been left on the bedpan and had a pressure ring. LPN #310 confirmed she did not monitor or assess the wound during her shift. LPN #310 stated the resident was not doing well and she contacted the physician and received an order to send her to the ED for further evaluation and treatment. LPN #341 stated that when she called in report to the hospital, prior to the resident arriving here, they asked her about any wounds, and she reported the resident's wounds on her bottom from being left on the bedpan. Interview on 11/05/25 at 10:52 A.M. with NP #415 verified Resident #50 was seen on 10/24/25 for an acute illness when the resident's roommate reported to her that Resident #50 had been talking out of her mind and the staff confirmed the resident had not been feeling well. NP #415 further stated Resident #50 was arousable and was able to answer questions, but she was not her usual self and typically they would banter back and forth and this did not occur during the visit. NP #415 stated she ordered further testing and treatment for a suspected UTI. NP #415 stated she would have still been in the facility at the time the DTI was discovered on Resident #50 on 10/24/25 and confirmed she was not notified of the skin impairment and just learned of it during this interview. During a follow-up interview on 11/05/25 at 4:00 P.M. with Resident #32, the resident stated Resident #50's bedpan was usually kept in a bag in the bathroom and while she was using the bathroom (during the early morning of 10/24/25), CNA #303 came and got the bedpan for Resident #50. Review of the facility policy titled, Pressure Ulcer Risk Assessment and Management, revised October 2016, revealed it was the facility policy to assess all residents on admission and regularly thereafter to determine the presence of skin conditions and/or areas of skin compromise, and to identify potential risk factors for their development. The intent was that a resident would not develop pressure areas unless the resident's clinical condition demonstrated that they were unavoidable. Responsibilities of the floor nurse would include obtaining measurements (width, length, and depth), updating the physician, and application of appropriate treatments. Review of the facility policy titled, Skilled Nursing Facility Wound Care Policy, undated, revealed the facility would follow the requirements set forth by the Ohio Department of Health (ODH) and the Centers for Medicare and Medicaid (CMS) Federal Regulations for treatment and services to prevent/heal pressure ulcers to ensure residents were not developing avoidable wounds while in the facility and received appropriate treatment and services for existing wounds. This deficiency represents non-compliance investigated under Complaint Number 2655902.

Based on closed medical record review, staff interview, Nurse Practitioner (NP) interview, and review of facility policy, the facility failed to notify the provider and resident representative of a new skin impairment. This affected one (#50) of one resident reviewed for notification of change. The facility census was 48. Findings include:Review of the closed medical record for Resident #50 revealed an admission date of 01/08/25 and a discharge date of 10/31/25. Diagnoses included atrial fibrillation (abnormal heart beat), diabetes mellitus type II, congestive heart failure (CHF), chronic kidney disease (CKD) stage three (CKD is measured in stages one through four, stage four requires renal dialysis), liver cirrhosis, peripheral vascular disease (PVD), bilateral (both sides) below the knee amputation (BKA), and altered mental status.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact and had no unhealed pressure ulcers.Review of the Weekly Wound and Skin Assessment Documentation dated 10/24/25 Resident #50 revealed a dark blanchable redness to the bilateral buttocks. No measurements or other wound characteristics were documented.Review of the physician orders for October 2025 revealed no new wound orders related to the new skin impairment identified on Resident #50's buttocks on 10/24/25. Review of Resident #50's nursing progress notes revealed no evidence the NP, Wound NP, or responsible party were notified of Resident #50's new skin impairment to her buttocks. Interview on 11/03/25 at 8:18 A.M. with Wound NP #420 confirmed she was not notified of the new skin impairment identified on Resident #50's buttocks on 10/24/25. NP #420 further stated she would typically be notified of new skin impairments for follow-up. Interview on 11/05/25 at 10:52 A.M. with NP #415 confirmed she was not notified of the new skin impairment to the bilateral buttocks of Resident #50. NP #415 further stated she rounded on Resident #50 the morning of 10/24/25 and was still in the facility at the time the facility staff identified the skin impairment. Interview on 11/05/25 at 8:12 A.M. with the Director of Nursing (DON) verified the facility had no evidence the NP or resident representative were notified of the new skin impairment identified on Resident #50's buttocks. 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.

Based on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen environment. This had the potential to affect all 37 residents residing in the facility. The facility census was 51. Findings include: Observation on 02/03/25 beginning at 8:40 A.M. revealed the kitchen floor surrounding the deep fryer had a thick amount of grease as well as both left and right sides of the deep fryer; the handles of the oven had a large amount of dried food substances; the shelf above the range was covered in aluminum foil but black with foods and grease; the two shelves above the steam table had a moderate film of grease build-up; the top of the convection oven had a thick film of black grease; and the ice scoop was stored inside the machine on top of the ice. Interview on 02/03/25 at 9:00 A.M. with [NAME] #110 verified the above findings. Review of the policy titled, Sanitization, dated 11/22, revealed all kitchens and kitchen areas are kept clean and free from debris.

Based on medical record review, review of Medicare beneficiary notice letters, and staff interview, the facility failed to issue Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) to residents. This affected two residents (#24 and #104) of three residents reviewed for Medicare beneficiary notice letters. The census was 51. Findings include: 1. Review of Resident #24's medical record revealed an admitted [DATE]. Diagnoses listed included hemiplegia, type two diabetes mellitus, hypertension, and major depressive disorder. Review of a Notice of Medicare Non-Coverage (NOMNC) dated 10/07/24 revealed Medicare part A services would end on 10/11/24. Further review of Resident #24's medical record revealed he remains in the facility. There was no documentation of a SNFABN being issued to Resident #24 on 10/11/24. 2. Review of Resident #104's closed medical record revealed an admitted [DATE]. Diagnoses listed included atrial fibrillation, type two diabetes mellitus, and muscle weakness. Review of a NOMNC dated 12/16/24 revealed Medicare part A services would end on 12/20/24. Further review of Resident #104's closed medical record revealed she remained in the facility after 12/20/24. There was no documentation of a SNFABN being issued to Resident #104. Resident #104 was discharged from the facility on 01/07/25. During an interview on 02/05/25 at 1:40 P.M. the Administrator confirmed Residents #24 and #104 were not issued SNFABN. The Administrator confirmed both Residents #24 and #104 remained in the facility after Medicare part A services were discontinued and they had not exhausted Medicare part A benefits.

Based on medical record review and staff interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included minimum healthcare information necessary to properly care for the immediate needs for one resident (#259) of one resident reviewed for baseline care plans. The facility census was 51. Findings include: Review of medical record of Resident #259 revealed an admitted [DATE]. Diagnoses included chronic systolic heart failure. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 was cognitively intact. Review of care plan initiated on 01/13/25 revealed the treatment of Tubigrips (compression stockings) and ace wraps was not added to the care plan Review of physician order dated 01/31/25 revealed to apply Tubigrips size G then wrap over the top with ace wraps every A.M. off P.M. Observation on 02/03/25 at 11:02 A.M. and second observation on 02/04/25 at 1:02 P.M. revealed Resident #259 sitting in recliner in resident's room. Tubigrips (compression stockings) in place bilateral without ace wraps. Ace wraps were on the counter in the resident's bathroom. Interview on 02/03/25 at 11:02 A.M. revealed Resident #259 stated he was told by staff he no longer needed ace wraps on his legs. Interview on 02/04/25 at 1:15 P.M. with Licensed Practical Nurse (LPN) #173 verified Resident #259 did not have ace wraps on bilateral and an order was in place. Interview on 01/13/25 at 1:00 P.M. with Assistant Director of Nursing (ADON) #219 revealed the care plan did not address the treatment of tubigrips and ace wraps in the care plan.

Based on observation, record review, and interview, the facility failed to implement a comprehensive care plan to include all aspects of patient care. This affected one (Resident #1) of 16 residents reviewed for comprehensive care plans. The facility census was 51. Findings include: Review of medical record for Resident #1 revealed an admitted [DATE] with diagnoses including but not limited to hemiplegia/hemiparesis following cerebral infarction affecting right dominant side, rheumatoid arthritis, age-related osteoporosis, muscle weakness, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impairment on both sides for upper body movement and lower body movement. Review of current physician orders revealed no orders for splinting or bracing right hand contracture. Review of discharged physician orders revealed Resident #1 to wear right palm protector throughout the day eight to twelve hours, hand hygiene to be completed pre/post application, apply orthotic during A.M. care routine and remove during P.M. care routine prior to bed time from 09/07/23 through 10/02/23. Review of Occupational Therapy (OT) discharge note dated 12/15/23 revealed resident and staff inconsistent with palm protector application despite continued education and importance of use for contracture management. Review of care plan dated 01/03/25 revealed no care plan regarding contracture's. Observation and interview on 02/03/25 at 10:19 A.M. revealed Resident #1 had a significant contracture to right hand. Resident #1 stated she could open it a little bit. Resident #1 stated that the staff sometimes stretch it and she denied wearing any splints or braces to that hand. Observation and interview on 02/05/25 at 3:21 P.M. revealed Resident #1 resting in bed. No splints or palm protector noted in right hand. Resident #1 stated they used to have a palm protector in place but not recently or for awhile now. Interview on 02/05/25 at 3:15 P.M. with Physical Therapist (PT) #221 revealed she was unsure when Resident #1 was last seen for OT. PT #221 verified Resident #1 had a significant contracture to her right hand. PT #221 stated the resident had the contracture when admitted . Interview on 02/06/25 at 10:18 A.M. with MDS #220 verified Resident #1 did not have a care plan for contracture's or Range of Motion (ROM). MDS #220 verified the resident should have a care plan regarding contracture's.

Based on observation, record review, interview, and policy review, the facility failed to provide treatment for contracture's. This affected one (Resident #1) of one reviewed for contracture's. The facility also failed to provide treatments per physician order. This affected one (Resident #259) of one reviewed for treatments. The facility census was 51. Findings include: 1. Review of medical record for Resident #1 revealed an admitted [DATE] with diagnoses including but not limited to hemiplegia/hemiparesis following cerebral infarction affecting right dominant side, rheumatoid arthritis, age-related osteoporosis, muscle weakness, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impairment on both sides for upper body movement and lower body movement. Review of current physician orders revealed no orders for splinting or bracing right hand contracture. Review of discharged physician orders revealed Resident #1 to wear right palm protector throughout the day eight to twelve hours, hand hygiene to be completed pre/post application, apply orthotic during A.M. care routine and remove during P.M. care routine prior to bed time from 09/07/23 through 10/02/23. Review of Occupational Therapy (OT) discharge note dated 12/15/23 revealed resident and staff inconsistent with palm protector application despite continued education and importance of use for contracture management. Review of care plan dated 01/03/25 revealed no care plan regarding contracture's. Observation and interview on 02/03/25 at 10:19 A.M. revealed Resident #1 had a significant contracture to right hand. Resident #1 stated she could open it a little bit. Resident #1 stated that the staff sometimes stretch it and she denied wearing any splints or braces to that hand. Observation and interview on 02/05/25 at 3:21 P.M. revealed Resident #1 resting in bed. No splints or palm protector noted in right hand. Resident #1 stated they used to have a palm protector in place but not recently or for awhile now. Interview on 02/05/25 at 3:15 P.M. with Physical Therapist (PT) #221 revealed she was unsure when Resident #1 was last seen for OT. PT #221 verified Resident #1 had a significant contracture to her right hand. PT #221 stated the resident had the contracture when admitted . Interview on 02/06/25 at 9:10 A.M. with Certified Nursing Assistant (CNA) #210 revealed she did not believe the resident had a splint or palm protector for her hands. CNA #210 looked in the CNA care book revealing no mention of any splint or palm protectors for Resident #1. 51516 2. Review of medical record of Resident #259 revealed an admitted [DATE]. Diagnoses included chronic systolic heart failure. Review of the 5-day MDS assessment dated [DATE] revealed Resident #259 was cognitively intact. Review of physician order dated 01/31/25 revealed to apply Tubigrips size G then wrap over the top with ace wraps every A.M. off P.M Observation on 02/03/25 at 11:02 A.M. and second observation on 02/04/25 at 1:02 P.M. revealed Resident #259 sitting in recliner in resident's room. Tubigrips (compression stockings) in place bilateral without ace wraps. Ace wraps were on the counter in the resident's bathroom. Interview on 02/03/25 at 11:02 A.M. revealed Resident #259 stated he was told by staff he no longer needed ace wraps on his legs any longer. Interview on 02/04/2025 at 1:15 P.M. with Licensed Practical Nurse (LPN) #173 verified Resident #259 did not have ace wraps on bilateral and had an order to place ace wrap bilateral on top of tubigrips daily for edema.

Based on medical record review, observation, and staff interview, the facility failed to ensure an ordered safety intervention was in place for a resident. This affected Resident #21 of four reviewed for accidents. The census was 51. Findings include: Review of Resident #21's medical record revealed an admitted [DATE]. Diagnoses listed include hypertension, psychotic disturbance, and severe dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had severe cognitive impairment. Review of the care plan dated 09/13/23 revealed Resident #21 had an activities of daily living (ADL) self care performance related to her severe dementia. Resident #21 required supervision and cueing for eating. The care plan was updated after 01/17/25 to add an intervention for a Kennedy cup (spill proof cup) was to be used for hot liquids. Review of progress notes revealed on 01/17/25 at 8:30 A.M. Resident #21 reached for her hot chocolate and spilled it on her upper thighs while the Certified Nursing Assistant (CNA) was placing a shirt protector. Redness and a blisters appeared on Resident #21's left thigh. Silvadene (burn treatment cream) was ordered by physician. Review of physician orders revealed an order dated 01/17/25 to use a Kennedy cup for hot liquids. Observation on 02/02/25 at 12:55 P.M. revealed Resident #21 was sitting at a dining room table. Resident #21 had a cup of hot chocolate without lid. The cup was not a Kennedy cup. No staff were currently assisting Resident #21 with her meal or sitting near. Interview with Certified Nurse Aide (CNA) #211 on 02/04/25 at 12:55 P.M. confirmed Resident #21 did not have a Kennedy cup with her hot chocolate. CNA #211 stated that she did not know Resident #21 required a Kennedy cup for her hot drinks. Interview with the Director of Nursing (DON) on 02/04/25 at 1:00 P.M. confirmed Resident #21 had an order for Kennedy cups for hot liquids and that Resident #21 had recently burned herself by spilling hot chocolate.

Based on record review, observation, interview, and policy review the facility failed to ensure oxygen tubing was changed per physician order. This affected three (Residents #7, #22, and #23) of five residents reviewed for oxygen. The facility census was 51. Findings include: 1. Review of medical record for Resident #7 revealed an admitted [DATE] with diagnoses including but not limited to asthma. Review of current physician orders revealed oxygen tubing/equipment to be changed/cleansed weekly. Observation on 02/03/25 at 10:40 A.M. revealed oxygen tubing dated 01/04/25. Interview on 02/03/25 at 10:41 A.M. with Certified Nursing Assistant (CNA #209) verified the oxygen tubing was dated 01/04/25. 2. Review of medical record for Resident #22 revealed an admitted [DATE] with diagnoses including but not limited to personal history of pulmonary embolism, dementia, and atherosclerotic heart disease. Review of current physician orders revealed change oxygen tubing on Thursdays. Observation on 02/03/25 at 9:58 A.M. of oxygen concentrator in the bathroom revealed oxygen tubing was dated 01/16/25. Oxygen running at two liters via nasal cannula. Interview on 02/02/25 at 10:06 A.M. with CNA #209 verified the oxygen tubing was dated 01/16/25. 3. Review of medical record for Resident #23 revealed an admitted [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease. Review of current physician orders revealed oxygen tubing/equipment to be changed/cleansed weekly. Observation on 02/03/25 at 10:13 A.M. revealed oxygen tubing dated 01/24/25. Interview on 02/03/25 at 10:13 A.M. with CAN #181 verified the oxygen tubing was dated 01/24/25. Review of policy titled, Oxygen Therapy-Mask and Cannula, not dated revealed when cannula becomes soiled with secretions, it needs to be changed. 10:00 P.M. - 6:00 A.M. shift changes all oxygen supplies weekly.

Based on medical record review, staff interview, and review of information from Medscape, the facility failed to follow pharmacy recommendation for one resident (#25) of five reviewed for unnecessary medications resulting in an unobserved medication error. The facility census was 51. Findings include. Review of the medical record of Resident #25 revealed an admitted [DATE]. Diagnoses included anemia, gastroesophageal reflux disease, migraines, and angina pectoris. Review of the physician orders dated 07/08/24 revealed orders for Topamax (migraines) 25 milligrams (mg) twice daily, Protonix 40 mg daily, Isosorbide mononitrate extended release 40 mg daily, and ferrous sulfate 325 mg daily. Review of a pharmacy recommendation dated 08/02/24 revealed a recommendation to consider holding or discontinuing the medications if crushing becomes necessary long-term. The document was indicated as agree and signed by the physician. Interview on 02/05/25 at 11:20 A.M. with Licensed Practical Nurse #167 revealed she crushes all of Resident #25's medications as Resident #25 will spit out any whole medications. LPN #167 was unaware the medications should not be crushed. Review of medication information from Medscape at https://www.medscape.com/nurses revealed Protonix is a proton pump inhibitor, Topamax is a anticonvulsant, Isosorbide mononitrate is a nitrate and Ferrous Sulfate is a iron supplement. Further review of Medscape revealed these medications should be swallowed whole and should not be split, crushed, or chewed.

Based on record review, staff interview, policy review and review of medication information from Medscape, the facility failed to ensure a resident was free from unnecessary medications regarding having an adequate indication of use for a long-term antibiotic. This affected one (#40) out of five resident reviewed for antibiotic stewardship. The facility census was 51. Findings include: Review of medical record for Resident #40 revealed an admitted [DATE] with diagnoses of dementia with behavioral symptoms, major depressive disorder, malnutrition, cognitive communication deficit, and anxiety. Resident #40 does not have a diagnosis of chronic urinary tract infections (UTI). Further review of the medical record revealed Resident #40 had a urinalyses with culture on 05/06/24 with Cipro (antibiotic) 250 milligrams (mg) two times a day for seven days ordered on 05/12/24 for UTI. A urinalysis with culture on 06/05/24 with Microbid 10 mg two times a day for seven days ordered on 06/10/24 for UTI. A urinalysis with culture on 06/24/24 with Amoxicillin 500 mg two times a day for five days ordered on 06/28/24 for UTI. Daughter states Resident #40 was on daily Cipro for UTI prophylaxis in the past. Daughter also mentions that Resident #40 typically gets diarrhea when on an antibiotic and request for Resident #40 to be placed on an antibiotic prophylaxis. Cephalexin oral suspension reconstituted 250 mg/5milliliter (ml), 2.5 ml by mouth one time a day, daily for UTI prevention and cranberry 250 mg daily was ordered on 07/02/24. Resident #40 was not diagnosed with a UTI when she was started on cephalexin, she did not have a stop date, and managment team never discussed stopping antibodic with doctor. Interview on 02/06/25 at 2:15 P.M. with Infection Disease Nurse #219 revealed no Time Out Sheet (a form the facility has for the provider to fill out for over use of medication is noticed) on Resident #40. Infection Disease Nurse #219 stated a time out sheet was not needed in Resident #40's case because the family requested her to be placed on the antibiotic. Infection Disease Nurse #219 confirmed cephalexin is not indicated for prolonged use. Review of policy titled, Antibiotic Stewardship, undated, revealed the prescribers will complete antibiotic order including the following elements: drug name, dose, frequncy of administration, duration of treatment including start and stop date or number of days of therapy, route of administration and indications of use. Review of medication information from Medscape at https://reference.medscape.com/drug/keflex-cephalexin-342490 revealed cephalexin is a 1st generation cephalosporin antimicrobial used to treat infections. Further review of Medscape revealed prolonged use of cephalexin is associated with fungal or bacterial superinfection.

Based on observation, Novolog insert, and staff interview, the facility failed to ensure insulin pen was primed resulting in a significant medication error. This affected one resident (#15) of one reviewed for insulin administration. The facility census was 51. Findings include: Review of medical record for Resident #15 revealed an admitted [DATE] with diagnoses including but not limited to urinary tract infection, paroxysmal atrial fibrillation, and type two diabetes without complications. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #15 received insulin injections three days out of seven during look back period. Review of current physician orders revealed Lantus SoloStar pen injector 100 unit/milliliter inject six units subcutaneously (SQ) daily at 8:00 P.M., Novolog FlexPen SQ solution pen injector 100 unit/milliliter inject per sliding scale if 0-150 no insulin, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, 401-500 = 12 units call physician if blood sugar is greater than 400 before meals and at bedtime. Observation on 02/04/25 at 11:01 A.M. of insulin administration for Resident #15 revealed LPN #173 checked the residents blood sugar with a result of 208. LPN #173 checked the sliding scale on the medication administration record (MAR) and revealed the resident was to receive 4 units. LPN #173 removed the residents Novolog FlexPen from the cart, placed a needle on the pen, and proceeded to dial 4 units to the pen. LPN #173 entered the residents room and donned gloves, cleaned area on abdomen with alcohol wipe, removed cap from the needle on the pen and injected the insulin into the resident's abdomen. LPN #173 did not prime the insulin pen with two units prior to dialing up the dose to give to the resident per manufacturer recommendations. Interview on 02/04/25 at 11:08 A.M. with LPN #173 verified she did not prime the insulin pen prior to dialing up the ordered dose. LPN #173 stated she did not know you had to prime the pen every time you used it. Review of package insert for Novolog FlexPen revealed for each injection select a dose of two units, take off the outer needle cap, and the inner needle cap, with the pen pointing up, tap the insulin to move the air bubbles to the top, press the button all the way in and make sure insulin comes out of the needle, repeat up to two more times with the same needle if needed. If insulin does not come out after three times, change the needle and try again. If insulin still does not come out after changing the needle, the pen may be broken.

Based on observation, staff interview, and scoop size chart, the facility failed to follow the menu for pureed diets. This affected three residents (#02, #04, and #35) identified by the facility as receiving a puree diet. The facility census was 51. Findings include: Observation on 02/07/25 at 11:45 A.M. revealed [NAME] #110 serving the meal. [NAME] #110 did not have a spreadsheet to indicate correct portion sizes. [NAME] #110 used a blue handled scoop to portion the pureed chicken onto the plates. Upon questioning the portion amount, [NAME] #110 did not know the amount the scoop provided. [NAME] #00 further did not serve any bread to the three residents. Upon interview with [NAME] #110, she responded the facility does not serve bread to puree diets as it just clumps. Review of the menu for Tuesday revealed the lunch to consist of Italian chicken breast, AuGratin potatoes, cauliflower, dinner roll, and apple cake. Review of the spreadsheet dated 02/04/25 revealed the pureed diet was to receive a number eight scoop (grey-handled, 1/2 cup). The menu further did not have any portion size for the dinner roll. Review of the scoop size chart revealed the blue-handled scoop portioned out one quarter cup of product. The grey-handled scoop would have portioned out one half cup.

Based on observation, interview, and policy review, the facility failed to ensure proper infection control practices during medication pass. This affected two residents (#1 and #15) of four residents reviewed for medication administration. The facility census was 51. Findings include: 1. Review of medical record for Resident #1 revealed an admitted [DATE] with diagnoses including but not limited to methicillin resistant staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere, unspecified open wound of abdominal wall, urinary tract infection, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #1 received intravenous antibiotics (IV ATBs) with IV access. No isolation per MDS. Review of current physician orders revealed change peripherally inserted central catheter (PICC) line dressing every week on Thursday, contact isolation related to MRSA, and vancomycin IV one gram intravenously daily for MRSA. Observation on 02/04/25 at 10:06 A.M. of IV administration for Resident #1 revealed Licensed Practical Nurse (LPN) #101 donned gloves prior to entering room. LPN #101 cleansed PICC port with alcohol pad, flushed IV with 10 milliliters of normal saline, attached the ATB ball to the port and placed the ball into the holder on the back of the wheelchair. LPN #101 cleaned up area and removed gloves and washed hands. Interview on 02/04/25 at 10:15 A.M. with LPN#101 verified she did not don a gown prior to entering the room to a resident in contact isolation for MRSA to hang IV medication through a PICC line. Review of policy titled, Isolation-Categories of Transmission-Based Precautions, revised January 2012 revealed contact isolation used for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis. Gown: wear a disposable gown upon entering the contact precaution room or cubicle. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces. 2. Review of medical record for Resident #15 revealed an admitted [DATE] with diagnoses including but not limited to urinary tract infection, paroxysmal atrial fibrillation, and type two diabetes without complications. Review of the MDS assessment dated [DATE] revealed the resident is cognitively intact. Resident #15 received insulin injections three days out of seven during look back period. Review of current physician orders revealed Lantus SoloStar pen injector 100 unit/milliliter inject six units subcutaneously (SQ) daily at 8:00 P.M., Novolog FlexPen SQ solution pen injector 100 unit/milliliter inject per sliding scale if 0-150 no insulin, 151-200 =2 units, 201-250 =4 units, 251-300 =6 units, 301-350 =8 units, 351-400 =10 units, 401-500 =12 units call physician if blood sugar is greater than 400 before meals and at bedtime. Observation on 02/04/25 at 11:07 A.M. following blood sugar check with glucometer, revealed Licensed Practical Nurse (LPN) #173 placed the glucometer on the medication cart, donned gloves, and cleaned the glucometer with an alcohol pad and placed on a paper towel. LPN #173 removed gloves and sanitized hands. Interview on 02/04/25 at 11:08 A.M. with LPN #173 verified she cleaned the glucometer with an alcohol wipe. LPN #173 verified the facility uses the same glucometer for each resident on the 200 hallway that require blood sugar readings. Review of policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment revised on September 2022 revealed reusable items are cleaned and disinfected or sterilized between residents. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions.

Based on record review, staff interview, policy review, and review of information from Medscape, the facility failed to conduct ongoing review for antibiotic stewardship. This affected one (#40) out of five resident reviewed for antibiotic stewardship. The facility census was 51. Findings include: Review of medical record for Resident #40 revealed an admitted [DATE] with diagnoses of dementia with behavioral symptoms, major depressive disorder, malnutrition, cognitive communication deficit, and anxiety. Resident #40 does not have a diagnosis of chronic urinary tract infections (UTI). Further review of the medical record revealed Resident #40 had a urinalyses with culture on 05/06/24 with Cipro (antibiotic) 250 milligrams (mg) two times a day for seven days ordered on 05/12/24 for UTI. A urinalysis with culture on 06/05/24 with Microbid 10 mg two times a day for seven days ordered on 06/10/24 for UTI. A urinalysis with culture on 06/24/24 with Amoxicillin 500 mg two times a day for five days ordered on 06/28/24 for UTI. Daughter states Resident #40 was on daily Cipro for UTI prophylaxis in the past. Daughter also mentions that Resident #40 typically gets diarrhea when on an antibiotic and request for Resident #40 to be placed on an antibiotic prophylaxis. Cephalexin oral suspension reconstituted 250 mg/5milliliter (ml), 2.5 ml by mouth one time a day, daily for UTI prevention and cranberry 250 mg daily was ordered on 07/02/24. Resident #40 was not diagnosed with a UTI when she was started on cephalexin, she did not have a stop date, and managment team never discussed stopping antibodic with doctor. Interview on 02/06/25 at 2:15 P.M. with Infection Disease Nurse #219 revealed no Time Out Sheet (a form the facility has for the provider to fill out for over use of medication is noticed) on Resident #40. Infection Disease Nurse #219 stated a time out sheet was not needed in Resident #40's case because the family requested her to be placed on the antibiotic. Infection Disease Nurse #219 confirmed cephalexin is not indicated for prolonged use. Review of policy titled, Antibiotic Stewardship, undated, revealed the prescribers will complete antibiotic order including the following elements: drug name, dose, frequncy of administration, duration of treatment including start and stop date or number of days of therapy, route of administration and indications of use. Review of medication information from Medscape at https://reference.medscape.com/drug/keflex-cephalexin-342490 revealed cephalexin is a 1st generation cephalosporin antimicrobial used to treat infections. Further review of Medscape revealed prolonged use of cephalexin is associated with fungal or bacterial superinfection.

Based on review of nursing schedules, review of timecards, staff interview, and policy review, the facility failed to ensure an Registered Nurse (RN) was scheduled for at least eight hours everyday. This had the potential to affect all 54 residents residing in the facility. Findings include: Review of the daily schedule dated 09/01/24 revealed no RN was scheduled. Review of the RN nursing timecards for 09/01/24 revealed no RN worked on 09/01/24. Interview on 09/04/24 at 1:06 P.M. with the Administrator verified the facility had no RN coverage for 09/01/24. Review of the policy titled Staffing, Sufficient and Competent Nursing dated August 2022 revealed a Registered Nurse provides services at least eight hours every 24 hours, seven days a week. Registered Nurses may be scheduled more than eight hours depending on the acuity needs of the resident. This was an incidental finding discovered during the course of the complaint investigation.

Based on staff interview, record review, and review of facility policy, the facility failed to permit a resident to return to the facility following a hospitalization . This affected one (Resident #160) of three residents reviewed for discharge. The facility census was 57. Findings include: Review of the medical record for Resident #160 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included fracture of the left humerus (bone in the arm), a fracture of the left fibula (bone in the lower leg), fracture of the lumbar (back), history of falls, and bradycardia. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 05/26/23, revealed Resident #160 was cognitively intact. Resident #160 required the extensive assistance of two person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the nursing note dated 06/02/23 revealed Resident #160 was being transferred to the hospital due to status post fall. Review of the nursing note dated 06/06/23 at 3:14 P.M. revealed the resident representative was verbally notified of Resident #160's denial of return to the facility due to his care needs. Interview on 07/03/23 at 11:31 A.M. with Regional Administrator (RA) #312 stated a collaborative decision was made with herself and the Administrator that the facility would not take Resident #160 back based on the family being upset. They felt this would have a negative impact on the resident. The trust between the facility and the family had been broken and this would impact the recovery of the resident and felt another facility would be best for the best outcome of the resident and family. Interview on 07/03/23 at 3:30 P.M. with Social Services (SS) #313 stated she communicated with Resident #160's representative notifying of denial of readmission due to unable to meet the resident's care needs. SS #313 also stated she communicated with the local hospital of denial and documented this denial on a log of all referrals she keeps. Telephone interview on 07/03/23 at 4:53 P.M. with the Administrator stated a collaborative decision was made with the RA #312 that Resident #160 was refused re-admission back to facility based on not being able meet the families' expectations, danger to himself in the facility by not using the call light, unsure of behavior, and family dissatisfaction with blaming facility for fall and fracture. The Administrator stated she did not have knowledge if this was documented other than unable to meet the resident's needs on the denial log. The Administrator refused to answer a specific question of if the family was not upset, would Resident #160 be allowed to be readmitted . The Administrator was also asked a specific question of what were the care needs the facility was unable to meet with Resident #160 re-admission considering Resident #160's initial admission was for a fall with fractures and the need for therapy for goals to return to the community. The re-admission for Resident #160 would be for fall with fractures (fall in facility with femur fracture and surgical repair) and need for therapy. The Administrator did not answer the question. Review of the facility policy titled Transfer or Discharge, Facility-Initiated, dated 10/2022, revealed residents who are sent emergently to an acute setting such as a hospital are permitted to return to the facility. If the facility does not permit a resident's return to the facility (i.e., initiated a discharge) based on inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including the notification of appeal rights. This deficiency represents non-compliance investigated under Complaint Number OH 00143555.

Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) 3.0, the facility failed to complete admission Minimum Data Set (MDS) assessments within the required timeframe. This affected four (#208, #209, #212 and #55) out of the four residents reviewed for timely completion of admission MDS assessments. The facility census was 53. Findings include: 1. Review of the medical record for Resident #212 revealed an admitted [DATE] with medical diagnoses of hypotension, atrial fibrillation, status post left hip fracture, and chronic obstructive pulmonary disease. Review of the medical record for Resident #212 revealed an admission nursing assessment dated [DATE] which indicated Resident #212 was cognitively intact and required extensive assist with bed mobility, transfers, toileting, and dressing. Review of the medical record revealed an admission MDS had not been completed. 2. Review of the medical record for Resident #209 revealed an admitted [DATE] with medical diagnoses of altered mental status, acute respiratory failure with hypoxia, dementia, and peripheral vascular disease. Review of the medical record for Resident #209 revealed an admission nursing assessment, dated 04/14/23, which indicated Resident #209 was alert to person only and required extensive assistance with bed mobility, transfers, dressing, and toileting. Review of the medical record for Resident #209 revealed an admission MDS had not been completed. 3. Review of the medical record for Resident #208 revealed an admitted [DATE] with medical diagnoses of arthritis, hyperlipidemia, anxiety, depression, and anemia. Review of the medical record for Resident #208 revealed an admission nursing assessment, dated 05/02/23, which indicated Resident #208 was cognitively intact and required extensive assist for bed mobility, transfers, dressing and toileting. Review of the medical record for Resident #208 revealed an admission MDS had not been completed. 4. Review of the medical record for Resident #55 revealed an admitted [DATE] with medical diagnoses of cardiac arrest, atrial fibrillation, congestive heart failure, diabetes mellitus, and hypertension. Review of the medical record for Resident #55 revealed an admission nursing assessment, dated 04/21/23, indicated Resident #55 was cognitively intact with long term memory loss and required extensive assistance with bed mobility, transfers, toileting and bathing. Review of the medical record for Resident #55 revealed an admission MDS had not been completed. Interview on 05/16/23 with the Director of Nursing (DON) confirmed admission MDS assessments were not completed for Residents #208, #209, #212, and #55. DON stated the facility was training a new MDS nurse and the facility was behind in completing admission MDS assessments timely. Review of the RAI manual revealed an admission comprehensive MDS must be completed on the 14th day of the resident's admission to the facility.

Based on medical record review, observation, staff interview and review of facility of policy, the facility failed to provide care for a resident's intravenous access. This affected one (#15) of one residents reviewed in the sample for IV access. The census was 53. Findings include: Review of Resident #15's medical record revealed an admitted d of 03/24/22. Diagnoses listed included hypertension, major depressive disorder, chronic obstructive pulmonary, type two diabetes mellitus, hyperlipidemia, hypothyroidism, hemiplegia, and hemiparesis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was cognitively intact with brief interview for mental status score (BIMS) of 14 and required extensive assistance for personal hygiene. Review of physician orders revealed an order dated 05/02/23 for may place peripherally inserted central catheter (PICC). Further review of Resident #15's medical record revealed no documentation of her PICC line dressing being changed or being assessed. Observation on 05/16/23 at 2:24 P.M. revealed a PICC line dressing located in Resident #15's right upper arm was dated 05/02/23. During an interview on 05/17/23 at 9:17 A.M. the Director of Nursing (DON) confirmed Resident #15's PICC line dressing had not been changed since the insertion date of 05/02/23. The DON also confirmed the was not any documentation of Resident #15 PICC line being assessed since 05/02/23. Review of the facility's undated policy titled Intravenous Therapy-Preventing Catheter-Related Infections revealed catheter sites should be assessed visually or by palpitation on a daily basis. If residents have any of the following symptoms, remove the dressing the dressing and thoroughly examine the site. Symptoms included tenderness and the insertion site, fever without obvious source, and other signs and symptoms suggesting local or bloodstream infection (BSI). Transparent dressing on short term central venous catheter (CVC) devices should be changed every three to seven days.

Based on medical record review, staff interview, review of Self Reported Incident (SRI) and facility policy, the facility failed to perform a thorough investigation regarding an allegation of sexual abuse. This affected one (#6) out of one SRI's reviewed. The facility identified one SRI in the last six months. Facility census was 48. Findings include: Review of the medical record for Resident #6 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set for Resident #6 dated 10/29/19 revealed she was assessed as being cognitively intact. Her activity of daily living was assessed as needing supervision of one person physical assistance for locomotion on the unit and uses a wheelchair for mobility. Review of the nurses notes for Resident #6 dated 10/31/19 at 4:49 revealed at 11:00 [NAME]M. the resident reported incident involving a male resident that lives in Assisted Living (AL) to State tested Nurse Assistant (STNA). STNA reported incident to nurse and then reported to management. Resident is alert and oriented SRI opened for related allegations. Review of the SRI dated 10/31/19 revealed the incident information of category of allegation or suspicion was for sexual abuse. The alleged or suspected perpetrator was family or visitor with initial source of allegation or suspicion was staff. The SRI involved Resident #6 and a resident who resides in the AL. The summary of the incident revealed the resident of the AL facility, attached to the nursing home, asked to take Resident #6 back to her room from dining room. Resident #6 told him it was okay for him to take her back to her room. Resident #6 alleged, when the two were approaching her room, he stepped in front of her wheelchair and touched her breast. She asked him to stop, he stopped and walked away. After interviewing Resident #6, she verified she feels safe and was not harmed in anyway. She does not have any physical or mental anguish from the incident. The facility asked the resident from AL to only visit the nursing home under supervision. Nursing home staff are aware to redirect him back to the AL. The allegation was unsubstantiated. The investigation included interviews with Resident #6, the resident from AL, Director of Nursing (DON) and STNA whom the Resident #6 had talked to her. The investigation did not include interviews with other female residents who reside in the facility or any staff who may have been working in the facility at the time of the incident. Interview with the Administrator on 02/11/20 at 2:09 P.M. verified he did not interview any residents or staff regarding Resident #6's allegation of sexual abuse. The Administrator stated he only put a message on the message board for the resident from the AL who is to be redirected back to the AL side. There was no interviews of any of the other female residents. Interview on 02/11/20 at 2:36 P.M. with STNA #300 and STNA# 301 revealed they were not aware there was a resident from the AL who had to be supervised when in the nursing home side of the building. Review of the facility's policy Abuse, Neglect, Exploitation, and Misappropriation of Resident Property undated revealed it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Under the section of investigation revealed the investigation protocol is for the person investigating the incident should generally take the following actions included to interview the resident, the accused, and all witnesses. Witness generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents and or family members) and employees who worked closely with the alleged victim the day of the incident. If there are no direct witnesses, then the interviews may be expanded, to cover all employees on the unit or as appropriate the shift.