Every finding on record at Vancrest of Urbana, Inc

Based on medical record review, review of hospital records, staff interview, and review of the facility policy, the facility failed to ensure staff safely transferred residents via mechanical lift. This resulted in Actual Harm to Resident #19 on 06/06/25 when staff transferred the resident into a recliner via Hoyer lift. The Hoyer lift was not wide enough to accommodate Resident #19's recliner and the bar of the lift swung back and struck the resident in the forehead causing bruising and a laceration to her forehead which required an emergency room visit and repair with sutures. This affected one (Resident #19) of three residents reviewed for accidents. The facility also failed to prevent resident falls and failed to thoroughly investigate resident falls. This affected one (Resident #25) of three residents reviewed for falls. The facility census was 61 residents. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 07/29/23 with diagnoses including displaced fracture of base of neck of left femur, contracture of lower leg muscle, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 06/02/25 revealed the resident had severe cognitive impairment, had functional limitations to the bilateral lower extremities, and was dependent on staff assistance with all transfers. Review of the incident report for Resident #19 dated 06/06/25 timed at 9:30 A.M. revealed staff were transferring resident to the recliner when Hoyer legs would not stretch wide enough to accommodate the recliner. Staff continued to use the Hoyer lift to lower the resident into the recliner. As the staff were lowering Resident #19 into the recliner, the Hoyer lift snapped back and hit the resident on the head causing a laceration. Resident #19 was sent to the emergency room (ER). Review of the progress note for Resident #19 date 06/06/25 timed at 10:43 A.M. revealed two Certified Nursing Assistants (CNAs) reported the resident sustained a laceration to the head during a Hoyer lift transfer when the legs of the lift did not stretch wide enough for the recliner causing the lift to snap back resulting in the resident sustaining the laceration as they were lowering the resident into the recliner. Review of the progress note for Resident #19 dated 06/06/25 timed at 1:30 P.M. revealed the resident returned from the ER with a suture to a laceration to the resident's left upper forehead. The resident also had some purple bruising to the forehead. Review of the care plan for Resident #19 updated 06/06/25 revealed the resident sustained a skin tear and a laceration to her head during a Hoyer lift transfer. Interventions included staff should use caution during transfers and bed mobility to prevent striking the resident's arms, legs, and hands against any sharp or hard surface. Review of the hospital records for Resident #19 dated 06/06/25 revealed the resident arrived in the ER with a head injury sustained when staff at the nursing home transported the resident to a recliner via Hoyer lift. Resident sustained a head injury without loss of consciousness when she was struck in the head with a metal pole from the left. Resident #19 had significant bleeding and receives Xarelto (a blood thinner) for treatment of atrial fibrillation. Lidocaine with epinephrine was applied to the injured area and the laceration was repaired with one suture applied. Review of the interdisciplinary team (IDT) investigation of the incident involving Resident #19 dated 06/09/25 revealed two aides assisted the resident to the recliner via Hoyer lift. During the transfer the legs of the Hoyer lift would not extend to the width of the recliner due to the size of the chair. The Hoyer device made contact with resident's head causing a laceration. Resident #19 was sent to the ER and returned with a suture to the laceration to the forehead. Resident #19 typically rested in a geri chair when out of bed but was in the process of getting a new chair from the hospice provider, and the recliner was used instead on 06/06/25. The facility follow up included to not utilize the recliner for Resident #19 because the Hoyer legs could not spread wide enough for the resident to safely transfer and to educate staff on the resident's care plan and appropriate Hoyer usage. Interview on 07/02/25 at 2:00 P.M. with the Director of Nursing (DON) confirmed on 06/06/25 two CNAs transferred Resident #19 to her recliner with a Hoyer that was too small to accommodate the width of the recliner. The DON confirmed staff continued with the transfer even when they became aware the Hoyer lift was not the correct size to complete the transfer. The DON confirmed as the staff lowered Resident #19 into the recliner, the bar of the Hoyer lift swung back and hit the resident in the head. Resident #19 sustained a laceration and bruising to the left forehead which resulted in the resident being sent to the ER for sutures. The DON confirmed the aides involved in the incident for Resident #19 on 06/06/25 were a hospice aide and a facility aide who was no longer employed with the facility. Review of the facility policy titled Activities of Daily Living dated September 2018 revealed staff should follow necessary precautions to ensure the safety of the residents during activities of daily living (ADLs). 2. Review of the medical record for Resident #25 revealed an admission date of 04/05/22 with diagnoses including type two diabetes mellitus, acquired absence of left leg below knee, acquired absence of right leg below knee, and chronic respiratory failure with hypoxia. Review of the progress note for Resident #25 dated 04/12/25 timed at 2:00 A.M. revealed the resident was on the floor laying on his right side between the window wall area and the bed. The bed was locked, and the side rails were up. Resident #25 complained of lower back pain and requested to go to the emergency room. Review of the fall report dated 04/12/25 at 2:00 A.M. revealed the resident was laying on the floor. Resident stated his arm was tired, so he let go of the side rail and then fell to the floor. Further review of the fall report revealed the event was not witnessed and resident did not go to the hospital. Review of the care plan for Resident #25 updated 04/12/25 revealed the resident had an actual fall with minor injury. Interventions included the following: educate resident on safety techniques with positioning and the use of assist bars, and encourage rest breaks when tired. Review of the MDS assessment for Resident #25 dated 05/06/25 revealed the resident was cognitively intact and required substantial assistance with bed mobility. Interview on 07/01/25 at 9:00 A.M. with Resident #25 confirmed he had fallen from his bed in April 2025. Resident #25 confirmed he was not interviewed about the incident, and when CNA #255 came into his room to change him, she shoved him over to the right side of the bed and he fell off the edge of the bed and onto the floor. Interview on 07/07/25 at 10:08 A.M. with Licensed Practical Nurse (LPN) Unit Manager #204 confirmed she documented Resident #25's fall on 04/12/25 in the progress notes, because the agency nurse who was working at the time of the fall didn't document anything about the fall. LPN #204 confirmed the facility did not interview Resident #25 about how the fall occurred. Interview on 07/07/25 at 11:38 A.M. with CNA #255 confirmed on 04/12/25 at approximately 2:00 A.M. she went into Resident #25's room to perform peri-care after trying to get another staff member to assist. CNA #255 confirmed she was not able to get another staff member to assist with Resident #25's peri-care, so she went into his room alone. Interview confirmed she rolled Resident #25 onto his right side, away from her, and the resident rolled out of bed onto the floor. CNA #255 confirmed the fall report was not accurate, and the fall was her fault because she rolled the resident away from her. CNA #25 confirmed the nurse didn't assess the resident or interview him. Interview on 07/07/25 at 2:25 P.M. with the Director of Nursing (DON) confirmed on 04/12/25 Resident #25 fell out of bed during routine care. The DON confirmed the fall investigation report dated 04/12/25 was not complete, and the resident was not interviewed after the fall. Review of the facility policy titled Managing Falls and Fall Risk undated revealed the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. This deficiency represents noncompliance investigated under Complaint Number OH00166581 and Complaint Number OH00164646.

Based on observations, policy review, and staff interview, the facility failed to date dry product when delivered to the facility, failed to discard expired foods, and failed to ensure staff changed gloves after touching surfaces before touching food while preparing food served to the residents. This had the potential to affect all 67 residents who received food from the kitchen. The facility census was 67. Findings include: 1. Observation on [DATE] at 8:20 A.M. of the dry food storage area revealed two bags of spiral noodles with expiration date of [DATE], seven bags of vanilla wafers with one bag open with no date, four bags of yellow cake mix, eight bags of powdered sugar, four bags of brown sugar, and three cans of three bean salad not dated with the date delivered to facility. Interview on [DATE] at 8:26 A.M. with Dietary Aide #27 verified the two bags of spiral noodles were expired. Dietary Aide #27 verified the vanilla wafers, yellow cake mix, powdered sugar, brown sugar, and cans of three been salad were not dated. Dietary Aide #27 stated the vanilla wafers were in a box that was dated yesterday and someone must have taken them from the box. Dietary Aide #27 verified the box with brown sugar, powdered sugar, and three bean salad was not dated as well. Interview on [DATE] at 11:25 A.M. with Dietary Manager (DM) #37 verified the undated brown sugar, powdered sugar, three bean salad, and the expired spiral noodles. DM #37 stated the yellow cake mix was dated however, the date was on the back of the package. DM #37 informed the yellow cake mix bags were inspected front and back and no date was present at the time of the observation. Review of the facility policy titled Food Receiving and Storage, revised [DATE], revealed dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Such foods are rotated using a first in - first out system. 2. Observation on [DATE] at 11:45 A.M. revealed Dietary Aide #22 was preparing a cheeseburger for a resident. Dietary Aide #22 touched the hamburger bun, hamburger, cheese, and spatula with the same gloved hands. Dietary Aide #22 then touched the fryer basket handle, prep table, and tongs before touching the sandwich again with the same gloved hands to move it over to put French fries into the container. Dietary Aide #22 did not change gloves or wash hands throughout the entire process. Interview on [DATE] at 11:55 A.M. with Dietary Aide #22 verified she did not change her gloves between touching surfaces and then touched food. Dietary Aide #22 verified that she was supposed to change gloves.

Based on record review, completion of a test tray, review of resident council notes, observations, and resident and staff interviews, the facility failed to serve palatable meals to the residents. This affected five (Resident #19, #21, #22, #25, and #66) of 17 residents reviewed for dietary services. The facility census was 67. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included congestive heart failure, hypertension, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact. Interview on 04/09/24 at 10:02 A.M. with Resident #19 revealed the food was often cold when she receives it. 2. Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, type two diabetes mellitus, and non-celiac gluten sensitivity. Review of the MDS assessment dated [DATE] revealed Resident #66 was cognitively intact. Interview on 04/11/24 at 9:19 A.M. with Resident #66 stated the chicken and dumplings served for lunch yesterday were dry. Resident #66 stated he did not eat very much of them. Resident #66 stated the problem was that some days the food was good but, on the other days, the food was terrible. 3. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included acute respiratory failure. Review of the MDS assessment dated [DATE] revealed Resident #22 had moderately impaired cognition. Observation and interview on 04/09/24 at 12:35 P.M. with Resident #22's plate of food revealed she had cream dried beef gravy, toast, fruit, corn, and drinks. Resident #22 stated the chip beef gravy was not good. Resident #22 stated it did not look good and was tasteless. Resident #22 stated the food here can be terrible. 4. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and atrial fibrillation. Review of the MDS assessment dated [DATE] revealed she was cognitively intact. Interview on 04/10/24 at 10:00 A.M. with Resident #21 stated her meal yesterday was cold, tasteless, and awful. Resident #21 stated she always gets carbohydrates, and she does not eat any carbohydrates. Subsequent interview on 04/11/24 at 9:50 A.M. with Resident #21 stated the meal yesterday for lunch and dinner was awful. Resident #21 stated she refused the lunch and dinner yesterday. Resident #21 who stated she was offered an alternative but also refused it. 5. Review of the medical record for Resident #25 revealed she was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation and heart failure. Review of the MDS assessment dated [DATE] revealed Resident #25 was cognitively intact. Interview with Resident #25 on 04/09/24 at 1:30 P.M. revealed the facility needed to do something about the food. She revealed the food was usually served cold and very tasteless. She stated she was the Resident Council President and has addressed this multiple times with the administration. Resident #25 revealed nothing has been done about the quality of the food. Observation on 04/10/24 at 1:11 P.M. of test tray revealed one scoop of mashed potatoes, one scoop full of chicken and dumplings, and carrots. Mashed potatoes taste and texture were okay. Chicken and dumplings looked unrecognizable and in a clump on the tray. The dumplings were dry with a heavy texture and chewy. The dumplings tasted like flour. Chicken was tough and flavorless. Carrots were soggy and watered down. Interview on 04/11/24 at 12:43 P.M. with Dietary Manager (DM) #37 stated the chicken and dumplings that were prepared yesterday came frozen. DM #37 stated the dumplings were frozen and the chicken was shredded chicken that comes in frozen and they were cooked separately and then combined. DM #37 stated she believed the cook added cream of chicken soup to the chicken and dumplings. Review of the Resident Council notes for February, March, and April of 2024 revealed the residents expressed concerns regarding the food and menus.

Based on record review, interview, and policy review, the facility failed to ensure residents were given the Notice of Medicate Non-coverage in a timely manner. This affected one (Resident #282) of three residents reviewed for beneficiary notices. The facility census was 67. Findings include: Review of the medical record for Resident #282 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included chronic hepatitis and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #282 had moderate cognitive impairment. Review of the Notice of Medicate Non-coverage (NOMNC) revealed Resident #282's last covered day of Part A services was 10/17/23. The NOMNC was signed by the resident on the same day on 10/17/23. Interview on 04/11/24 at 3:44 P.M. with Business Office Manager (BOM #120) verified Resident #282 did not receive the NOMNC until 10/17/23, which was the last covered day. BOM #120 stated she thought the resident was going to stay here on hospice and family was unsure. BOM #120 verified that regardless of Resident #282 staying past the last covered day, the family and resident should have been notified 48 hours prior to last covered day. Review of the facility's policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised September 2022, revealed if the resident's Medicare part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage is issued to the resident at least two calendar days before benefits end.

Based on record review, staff interview, and policy review, the facility failed to ensure care plans were person-centered to include all areas of concern. This affected three (Resident #14, #50, and #72) of 17 residents reviewed for care plans. The facility census was 67. Findings include: 1. Review of Resident #14's medical record revealed Resident #14 had an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, and age-related physical debility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severely cognitively impaired. Resident #14 was dependent on staff for toileting and was incontinent of bowel and bladder. Review of the plan of care dated 03/18/24 revealed that Resident #14 had no active care plan of incontinence care, wore incontinence briefs, and was dependent on staff for care. Resident #14 was at risk for nutrition and dehydration related to urinary tract infections. Interventions included monitor for signs and symptoms of dehydration, explain importance of adequate urinary output, monitor skin status, and obtain weight as resident allows. Interview on 04/11/24 at 1:38 P.M. with Quality Assurance Nurse (QAN) #122 verified Resident #14's care plan did not include areas to address Resident #14's incontinence care, wore incontinent briefs, and was dependent on staff for care. QAN #122 stated Resident #14 should have had this addressed at the beginning of her stay at the facility. 2. Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, anxiety, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had severe cognitive impairment and received an antidepressant. Review of the care plan dated 04/05/24 revealed the resident did not have an active care plan for psychotropic medications regarding antidepressant medications. Interview with the Director of Nursing on 04/12/24 at 10:15 A.M. confirmed the facility did not have a care plan for the resident's use of psychotropic medications. 3. Review of the medical record for Resident #72 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, chronic kidney disease stage three, major depressive disorder, and adjustment disorder with anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was dependent on staff for toileting and was incontinent of bowel and bladder. Resident #72 had severe cognitive impairment. Review of the care plan dated 02/23/24 revealed no active care plan of incontinence care. Interview on 04/11/24 at 1:24 P.M. with State tested Nursing Assistant (STNA) #69 verified Resident #69 was incontinent of urine. STNA #69 verified the resident wore briefs and received incontinence care from staff. Interview on 04/11/24 at 1:24 P.M. with Quality Assurance Nurse (QAN) #122 verified Resident #72 did not have an active care plan for incontinence care. QAN #122 verified the resident was incontinent since admission into facility and should have a incontinence care plan. Review of the facility's policy titled Care Planning-Interdisciplinary Team, revised March 2022, revealed comprehensive, person-centered care plans are based on resident assessments and developed by and interdisciplinary team.

Based on medical record review, review of the facility policy, review of the guidance from Medscape, and staff interview, the facility failed to ensure a resident had the proper diagnosis for administration of an antipsychotic medication. This affected one (Resident #3) of five residents reviewed for unnecessary medication use. The facility census was 67. Findings include: Review of the medical record for Resident #3 revealed she was admitted to the facility on [DATE] with a diagnosis of delirium due to known physiological condition, Alzheimer's disease, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severe cognitive impairment. Review of Resident #3's physician orders for 04/2024 revealed an order for Zyprexa (antipsychotic) for delirium. Review of Resident #3's diagnoses revealed no schizophrenia or bipolar disorder diagnoses. The only diagnosis listed was delirium due to known psychological condition, but no psychological diagnoses was listed. Interview on 04/12/24 at 8:50 A.M. with the Director of Nursing verified Resident #3 was on Zyprexa for delirium and did not have a diagnoses of schizophrenia or bipolar disorder. Review of the guidance from Medscape at https://reference.medscape.com/drug/zyprexa-relprevv-olanzapine-342979 revealed Zyprexa is an antipsychotic medication commonly used to treat schizophrenia or bipolar disorder. In the geriatric population, Zyprexa is not approved for dementia-related psychosis, because of increased risk of cardiovascular or infection-related mortality. Review of the facility policy titled Antipsychotic Medication Use, dated 07/2022, revealed a resident will only receive antipsychotic medication when necessary to treat a specific condition for which they are indicated and effective.

Based on record review, review of the facility policy, and staff interview, the facility failed to ensure the residents were offered the pneumonia vaccine. This affected three (#19, #20, and #50) of five residents reviewed for pneomococcal immunization. The facility census was 67. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. The medical record revealed Resident #19 had the influenza vaccination on 10/03/23, and there was no evidence the resident was offered the pneumococcal immunization. Interview on 04/11/24 at 3:50 P.M. with the Director of Nursing (DON) confirmed Resident #19 did not get offered the pneumonia vaccination. 2. Review of the medical record for Resident #20 revealed an admitted [DATE]. There was no evidence Resident #20 was offered the pneumococcal immunization or received it in the past prior to admission. Interview on 04/11/24 at 9:50 A.M. with the Director of Nursing (DON) confirmed Resident #20 did not get offered the pneumonia vaccination. 3. Review of the medical record for Resident #50 revealed an admitted [DATE]. There was no evidence Resident #50 was offered the pneumococcal immunization or received it in the past prior to admission. Interview on 04/11/24 at 9:50 A.M. with the Director of Nursing (DON) confirmed Resident #50 did not get offered the pneumonia vaccination. Review of the facility's undated policy titled Pneumococcal Vaccine Policy revealed all residents who were admitted to the facility were to be offered the pneumococcal vaccine. Residents were to have pneumococcal assessment within five working days of resident's admission.

Based on medical record review, staff interview, and review of policy, the facility failed to timely obtain a newly admitted resident's medications. This affected one (#4) of three residents reviewed for medications. The census was 68. Findings include: Review of Resident #4's closed medical record revealed an admitted [DATE] (Sunday). Diagnoses listed included cervical disk disorder with myelopathy, spinal stenosis, osteoarthritis, depression, hypothyroidism, and anxiety. Resident #4 left the facility against medical advice (AMA) on 08/01/23. Review of physician orders revealed an order dated 07/30/23 for levothyroxine sodium tablet 88 micrograms (mcg) give one tablet by mouth at bedtime for hypothyroidism. An order dated 07/31/23 was for methylprednisolone oral therapy pack four milligrams (mg) given one tablet a day for pain and inflammation for seven days. Review of medication administration records (MARs) revealed levothyroxine 88 mcg was not administered on 07/30/23 or 07/31/23 due to not being available. Methylprednisolone oral therapy pack four mg was not administered on 07/31/23 due not being available. Interview on 09/20/23 at 2:05 P.M., with Registered Nurse (RN) #100 stated that normal pharmacy delivery days were on Monday, Wednesday, and Friday. If a resident was admitted on the weekend, Tuesday or Thursday, or after pharmacy deliveries on Monday, Wednesday, and Friday the pharmacy service would call a local pharmacy to obtain resident medications. RN #100 stated Resident #4's levothyroxine sodium tablet should have been available to be administered on 07/30/23 and 07/31/23 and methylprednisolone on 07/31/23 but both medications were not available at the facility. Review of the policy titled Pharmacy Services Overview dated revised April 2019, revealed pharmacy services are available to residents 24 hours a day, seven days a week. Residents should have a sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. This deficiency represents non-compliance investigated under Complaint Number OH00146222.

Based on medical record view, hospital documentation review, staff interview, and review of a facility policy the facility failed to allow a resident to return to the facility after a visit to the emergency room . This affect one (#15) of four residents reviewed for discharge. The census was 71. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, hypertensive heart disease with heart failure, chronic systolic (congestive heart failure), chronic obstructive pulmonary disease, cerebral vascular disease, and depression. Further review of the medical record revealed Resident #15 was sent to the emergency department (ED) on 07/31/23, did not return to the facility, and the facility stopped billing Medicaid for Resident #15 on 07/31/23. Review of Resident #15's facility nursing progress notes on 07/31/23 revealed Licensed Practical Nurse (LPN) #149 returned to the facility at 6:50 P.M. after an incident involving Resident #15. The progress notes further revealed the physician sent an order to the facility indicating to emergency admit (pink slip) Resident #15 to the hospital for a psychiatric evaluation. LPN #149 called the ED and was instructed by ED staff that a formal pink slip had to be completed and signed by the physician and accompany the resident. At 9:00 P.M., the physician sent the completed pink slip form to the facility and emergency medical services (EMS) was called for transport. EMS arrived and Resident #15 refused to go to the hospital with them. Resident #15 took his gown off and urinated on the floor. The EMS staff tried to speak to Resident #15 calmly to have him willingly go with them; however, Resident #15 cursed and threatened the EMS staff. The EMS staff called their supervisor, who arrived at the facility, and EMS staff administered an intramuscular medication to Resident #15, and transferred him to the hospital. Review of the ED physician report dated 07/31/23 at 9:57 P.M. revealed, upon arrival to the ED, Resident #15 had normal vital signs, was in no acute distress, and was cooperative. Resident #15 was under the influence of the dissociate anesthetic medication Ketamine which was given prior to arrival. Resident #15 reported he was drinking alcohol, denied any suicidal or homicidal ideation, and denied intentionally starting a fire. After speaking with the facility staff, Resident #15 was sent to the ED under the suspicion that he intentionally set a fire, but Resident #15 denied the allegation. The application for Resident #15's emergency admission came with the resident to the ED, but it was believed it was not a legal document. Resident #15 was observed for an extended period at which time he reached clinical sobriety. At the time of disposition, Resident #15 was alert and oriented, was not slurring any speech, and was conversing in full sentences. Resident #15 denied any history consistent with acute or life-threatening pathology. Resident #15 expressed he was upset about having to move rooms at the skilled facility, and that he smoked a bunch of cigarettes because he was upset, and threw a cigarette butt in a trash can. Resident #15 stated he felt bad about his actions and would not be smoking in his room anymore. Resident #15 was appropriate for discharge with an estimated arrival for an ambulance to take Resident #15 back to facility at 12:45 A.M on 08/01/23. Review of Resident #15's facility nursing progress note dated 07/31/23 at 10:30 P.M. revealed LPN #149 received a call from the ED reporting Resident #15's pink slip was not valid. The ED nurse explained the ED would monitor Resident #15 and evaluate him after his medication wore off, but there was nothing medically wrong with Resident #15 and he would be returning to the facility. LPN #149 indicated it was not safe for Resident #15 to return to the facility because of a threat to resident and staff safety. LPN #149 indicated she would call the Administrator due to policies and procedures in accepting Resident #15 back to the facility who was pink slipped, and Resident #15 was not to return to the facility. LPN #149 reached out to the Administrator about the phone call she had with the ED staff and left a voicemail for Physician #210 with no return call received. Review of the ED nursing progress notes revealed a discharge report was called into the facility at 1:34 A.M. on 08/10/23 and received by LPN #110. Review of Resident #15's facility nursing progress notes on 08/01/23 at 2:00 A.M. revealed Social Services Designee (SSD) #120 received notification Resident #15 was was returning to the facility, so he called the ED staff and was told the pink slip was invalid, and they felt Resident #15 was cleared to return to the facility. There was no additional documented information in Resident #15's facility medical record about him arriving at the facility after being sent to the hospital on 07/31/23, and the facility instructing the transport personnel to take Resident #15 back to the hospital as the facility would not readmitted the resident to the facility. Review of the ED nursing progress report dated 08/01/23 at 1:44 A.M. revealed a male called from the facility, and identified as the Director of Nursing (DON), and spoke with the ED nurse. The DON wanted to know why Resident #15 was sent back to the facility and why the pink slip was not valid. The DON was accusing Resident #15 of intentionally starting a fire in the bathroom, and he continued to be upset after an explanation was given. Review of Resident #15's ED medical record revealed on 08/01/23 at 2:15 A.M., Resident #15 returned to the hospital and was readmitted . Further review revealed the nursing home refused to accept Resident #15 back into the facility after he was medically cleared, discharged from ED, and report was given to facility nurse before Resident #15 left the ED. At the time of the report, the facility nurse did not refuse to take Resident #15 back. The legal team of the hospital was contacted and decided to have Resident #15 admitted after he was cleared by psychiatry, and will be placed in another nursing facility because the current facility was not willing to accept him back. Review of Resident #15's hospital record on 08/01/23 at 7:39 A.M. revealed a hospital case manager sent clinical documentation to the facility, and at 9:25 A.M. on 08/10/23 the case manager attempted to call the facility's social services designee with no answer. An email was also sent with no response received. At 9:49 A.M. on 08/01/23, the hospital case manager spoke with the facility's Ombudsman about the situation, and at 11:35 A.M. someone from the nursing home stated they should be willing to accept Resident #15 back if they had a bed available. At 11:40 A.M. on 08/01/23, all clinical documentation was sent to the facility, and at 2:54 P.M. the case manager received a call from Ombudsman #399 who explained the facility was refusing to allow Resident #15 to return to the facility. Ombudsman #399 and the case manager continued working on alternative placement in case the facility refused to allow Resident #15 to return. Resident #15 was discharged from the hospital on 08/07/23 to another long-term care facility. Interview on 08/15/23 at 11:00 A.M. with the Administrator and the Director of Nursing (DON) occurred. The Administrator explained on 07/31/23 they were notified Resident #15 was caught smoking in his room and a few minutes later there was a fire in his bathroom waste basket. The residents were evacuated, the fire was put out, and Resident #15 was placed in a private room. Facility staff believed earlier in the day during a leave of absence Resident #15 obtained cigarettes and a lighter, and the facility was a non-smoking facility. Facility staff found an empty bottle of alcohol in his room. Physician #210 was notified of the incident and informed Resident #15 was not acting like himself as he was laughing at staff and residents during the evacuation. Physician #210 ordered to pink slip Resident #15 for an evaluation, and Social Service Designee (SSD) #120 notified a local behavior hospital with no return call. Three hours later, per Physician #210, Resident #15 was sent to the local ED with a pink slip. Interview on 08/15/23 at 11:30 A.M. with Physician #210 stated he did not see Resident #15 on 07/31/23. Physician #210 stated he did not need to as the staff explained the situation, and he verified he ordered Resident #15 be pink-slipped to the hospital. Physician #210 confirmed he received a call from the facility's nurse on 08/01/23 explaining the ED physician called and was sending Resident #15 back to the facility. Physician #210 called the ED and spoke to someone and told the ED staff they could not send Resident #15 back to the facility as he wanted a psychological evaluation completed on Resident #15. Physician #210 reported that he assumed Resident #15 would return to the facility after having a psychological evaluation. Interview on 08/15/23 at 11:30 A.M., with SSD #120, who handles facility admissions, confirmed he was called back into the facility at 6:00 P.M. on 07/31/23 because of a fire. When he spoke to Resident #15 he was belligerent, and not remorseful for his actions or the safety risk caused to facility or residents. SSD #120 confirmed he worked with LPN #149 to obtain a pink slip for Resident #15. SSD #120 confirmed Resident #15 did not return to the facility, and he was told by the Administrator not to follow up on Resident #15 during the day on 08/01/23 for readmission. Interview on 08/15/23 at 11:45 A.M., with LPN #149 confirmed she was called back into the facility on [DATE] at 6:50 P.M. and was working with the SSD #120 to obtain a pink slip to send Resident #15 out for a psychological evaluation. Interview on 08/15/23 at 11:55 A.M., with the Administrator confirmed she instructed the SSD #120 not to contact the ED to find out a status report on Resident #15. The Administrator stated per Physician #210, the ED staff member hung up the phone with Physician #210 while discussing the case around 2:00 A.M. on 08/01/23; therefore, it was no longer their responsibility where Resident #15 was or how he was doing. The Administrator placed a call to Ombudsman #399 and explained the situation and stated they would not take Resident #15 back because he did not have a psychological evaluation done. The Administrator stated Ombudsman #399 told her he would call the hospital to explain the situation, and she did not have to take Resident #15 back to the facility. The Administrator knew nothing about Resident #15 until she received facsimile (fax) documentation from another facility requesting Resident #15's medical records. The Administrator was adamant they never discharged Resident #15 from the facility. A telephone interview was completed on 08/15/23 at 12:15 P.M., with Ombudsman #399 who clarified he did not tell the Administrator not to take Resident #15 back. Ombudsman #399 reported he explained to the Administrator why they would have to take Resident #15 back and the process of issuing a proper 30-day discharge. Interview on 08/16/23 at 9:30 A.M with the Director of Nursing (DON) stated she was new to the facility, and she was not at the facility while a pink slip was being obtained for Resident #15. DON stated she was called in and arrived at the facility and found Resident #15 sitting in the hallway unattended. DON stated she instructed staff to start one-on-one observations while they determine where Resident #15 would be sent. DON stated she observed Resident #15 to be calm and non-threatening. After Resident #15 was transferred out of the facility she left for the night, and she was not contacted when Resident #15 was discharged from the hospital and returned to the facility during the early morning on 08/01/23. DON stated she later found out the Administrator did not allow Resident #15 to come into the building when he was initially discharged from the ED and returned to the facility. DON stated facility staff refused Resident #15 admittance back into the facility. Interview on 08/16/23 at 10:40 A.M., with SSD #120 confirmed Resident #15 was discharged from the ED and was transported to the facility. SSD #120 stated when he arrived facility staff instructed the EMS staff to transport Resident #15 back to the hospital. Interview on 08/16/23 at 3:45 P.M. with the ED Physician #400 confirmed his documentation in Resident #15's hospital medical record, and stated he discharged Resident #15 back to the facility. ED Physician #400 stated the facility sent Resident #15 back to the ED and did not readmit him to the facility. ED Physician #400 stated he spoke to the hospital legal team and was instructed to readmit Resident #15 to the ED in order to find another place for him to be discharged to. Review of the facility's transfer and discharge policy dated November 2017 revealed before a resident was discharged , appropriate notice will be provided to the resident and/or their legal representative. This deficiency represents non-compliance investigated under Complaint Number OH00145095.

Based on medical record review, staff interview, review of emails sent to the State Long-Term Care Ombudsman, and review of a facility policy, the facility failed to notify the Office of the State Long-Term Care Ombudsman when residents were discharged from the facility. This affected two (#15 and #24) of four reviewed for discharge. The facility census was 71. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, hypertensive heart disease with heart failure, chronic systolic (congestive heart failure), chronic obstructive pulmonary disease, cerebral vascular disease, and depression. Further review of the medical record revealed Resident #15 was sent to the hospital on 07/31/23 and was discharged to the hospital on 07/31/23. There was no documentation the Office of the State Long-Term Care Ombudsman was notified. 2. Review of Resident #24's medical record revealed an admitted [DATE]. Diagnosis included displaced fracture of the lateral malleolus of the right tibia. Resident #24 was discharged home on 05/17/23 and return to the facility was not anticipated. There was no documentation the Office of the State Long-Term Care Ombudsman was notified. Review of email documentation sent to the Office of the State Long-Term Care Ombudsman office in May, June and July 2023 regarding resident transfers and discharges from the facility did not include documentation or notification of Resident #15 and Resident #24 being discharged from the facility. Interview on 08/16/23 at 4:15 P.M. with Social Service Designee (SSD) #120 stated he did not notify the Office of the State Long-Term Care Ombudsman when residents are discharged from the facility, including Resident #15 and Resident #24, and it was his understanding the Ombudsman was to be notified for transfers from the facility only. Interview on 08/16/23 at 4:20 P.M., with the Administrator stated it was not facility policy to notify the Office of the State Long-Term Care Ombudsman when residents are discharged from the facility. Review of the facility's transfer and discharge policy dated November 2017 revealed no indication the Ombudsman should be notified when a resident was discharged from the facility.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to provide a discharge summary when residents were discharged from the facility. This affected one (#22) of four residents reviewed for discharge. The census was 71. Findings include: Review of Resident #22's medical record revealed an admitted [DATE]. Diagnoses included transient ischemic attack, cerebral infarction, and bone density and structure disorder. Resident #22 was discharged on [DATE]. Review of Resident #22 medical record revealed there was no discharge summary completed when Resident #22 was discharged on [DATE]. Interview on 08/16/23 at 2:00 P.M. with Social Service Designee (SSD) #120 stated Resident #22 was discharged to an assisted living facility, therefore, Resident #22 did not require a discharge recapitulation of her stay. SSD #120 stated the facility sent documentation by facsimile (fax) to the assisted living facility. Interview on 08/16/23 at 2:05 P.M. with Licensed Practical Nurse (LPN) #149 confirmed Resident #22 did not receive written discharge summary when she was discharged to her home at an assisted living facility, and confirmed the assisted living facility was not part of the nursing home. Review of a blank discharge instruction packet provided by LPN #149 revealed a recapitulation of a resident's stay while receiving services by the facility. Each resident being discharged or their representative were to sign an acknowledgement of receipt of their discharge instructions for care. Review of the facility's transfer and discharge policy dated November 2017 revealed it did not include information related to a discharge summary was to be provided when a resident was discharged to the community.

Based on medical record review and staff interview, the facility failed to have physician visits or progress notes available in resident medical records. This effected three (#15, #18, and #22) of four resident's medical records reviewed for reviewed for discharge. The census was 71. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, hypertensive heart disease with heart failure, chronic systolic (congestive heart failure), chronic obstructive pulmonary disease, cerebral vascular disease, and depression. Further review of the medical record did not have physician progress notes or visit noted available for review. 2. Review of Resident #18's medical record revealed an admitted [DATE]. Diagnoses included chronic gout, hypertension, hyperlipidemia, and chronic kidney disease. Further review of the medical record did not have physician progress notes or visit notes available for review. 3. Review of Resident #22's medical record revealed an admitted [DATE]. Diagnoses included transient ischemic attack, cerebral infarction, and bone density and structure disorder. Further review of the medical record did not have physician progress notes or visit notes available for review. Interview on 8/15/23 at 11:00 A.M. with the Administrator confirmed the Director of Nursing had to contact the physician's office to send the progress notes or visit notes for residents that were seen in order to have the notes for review. The Administrator confirmed she called Resident #15 physician's office to have them facsimile (fax) all his visit notes to the facility. Interview on 08/15/23 at 1:00 P.M., with Social Service Designee #120 revealed physician progress notes for Resident #15 dated 05/08/23, 05/16/27, 05/27/23, 06/16/23 and 06/27/23 were received through the fax machine on 08/15/23. Interview on 08/16/23 at 2:15 P.M. with the Director of Nursing revealed physician visits notes dated 4/10/23, 4/22/23 and 04/27/23 for Resident #15 were received by the facility from the fax machine on 08/16/23. Interview on 08/16/23 at 2:25 P.M. with the Director of Nursing confirmed Resident #18's and Resident #22's physician progress notes were not available in their medical records.

Based on observation, staff interview and policy reviews, the facility failed to store food and maintain food in a safe fashion and and failed to serve food in a hygienic manner. This had the potential to affect 67 of 67 residents who receive food from the kitchen. The total facility census was 67. Findings include: Observation of the reach in refrigerator with Dietary Manager (DM) #113 in the central kitchen on 02/27/23 at 9:40 A.M., revealed turkey lunch meat was in a zipper plastic bag dated 02/20/23 and ham lunch meat was in a zipper plastic bad was dated 02/20/23. At the time of the observation, DM #113 stated the two lunch meats should only be stored in the refrigerator for three days and DM #113 removed the lunch meat zipper bags from the refrigerator so they could not be used. There were two bowls in the reach in refrigerator that had a red liquid in them and the bowls were not dated or labeled. DM #113 verified the bowls should be dated and labeled and removed the bowls. DM #113 stated they were tomato soup. Observation of the lunch meal tray line on 03/01/23 from 12:00 P.M. to 12:35 P.M., observed Cook #79 picked up the egg roll, and place it on the plate with his gloved hand. Then Cook #79 after all food was placed on the plate, the cook would pick up the meal ticket for the specific resident and place it next to the resident plate to be placed in the food cart for distribution to the residents on the floor. Interview on 03/01/23 at 12:30 P.M., with DM #113 confirmed Cook #79 should no touch food items with his gloved hand and then touch non food items to prevent contamination of the food. Interview with the Director of Nursing on 03/01/23 at 12:40 P.M. it was confirmed the facility had not had any outbreak of illness related to food contamination. The DON verified the kitchen staff plating food should not touch food items with the same gloved hand that touches non food items. Review of the policy titled Food Storage dated 2021 revealed leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within seven days or discarded as per the 2017 Federal Food Code. All foods should be covered, labeled and dated and routinely monitored to assure that food (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Review of policy titled Food Preparation and Service dated 2001 revealed food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels. or utensils that are not adequately cleaned. Cross-contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods.

Based on record review, staff interviews and policy review, the facility failed to ensure residents who received psychotropic drugs were provided routine behavior monitoring. This affected four (#2, #3, #8 and # 58) of five residents reviewed for unnecessary medications. The total facility census was 67. Findings include: 1. Review of the Resident #2's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including weakness, hypothyroidism, left knee replacement, depression, anxiety, dementia and cerebral infarction. Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively impaired, wanders daily but had no other behaviors. Resident #2 required limited assist with personal hygiene, supervision for toileting, and dressing and was independent with bed mobility, transfers, and eating. Resident #2 received seven days of antipsychotic and antidepressant medication and six days of antianxiety medication. Review of Resident #2's physician orders revealed the resident had the following medication orders: Trazadone (sedative) 50 milligrams (mg) daily at bedtime as needed for insomnia, ordered on 10/27/22 with end date of indefinite; Buspirone (antianxiety) 15 mg twice a day for anxiety dated 10/27/22; Desvenlafaxine ER (antidepressant) 150 daily for depression dated 10/27/22; Seroquel (antipsychotic) 75 mg daily for Alzheimer's/dementia and Divalproex Sodium (anti seizure) oral tablet delayed release 250 mg daily for behaviors dated 10/27/22. Review of the last two months of behavior monitoring for Resident #2 revealed the resident had evidence of behavior monitoring in the medical record. Interview 03/02/23 at 10:00 A.M., with Licensed Practical Nurse (LPN) #120 revealed the residents on psychoactive medication have daily behavior monitoring under the assessment tab in the electronic medical record. Interview on 03/02/23 at 10:33 A.M., with the Director of Nursing (DON) confirmed the resident had not had behavior monitoring completed at the facility. The DON stated the resident had a history of inpatient psychiatric hospitalization , however, there are no diagnosis other than dementia, Alzheimer or depression in the resident's medical record to support the use of the Seroquel in the care of this resident. The DON verified the resident should have daily behavior monitoring. 2. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including traumatic brain injury, dementia, depression and unspecified psychosis. Review of the quarterly MDS assessments dated 01/19/23 revealed Resident #3 had cognitive impairment, no behaviors, delusions or hallucinations. Resident #3 received seven days of antipsychotic, antidepressant, and opioid medication. Review of Resident #3's physician orders revealed Seroquel (antipsychotic) 12.5 mg twice daily ordered on 05/19/22 and Zoloft (antidepressant) 50 mg at bedtime dated 03/06/18. Review of Resident #3's medical record revealed the resident had evidence of behavior monitoring on the following days during the last two months: 01/01/22, 01/04/22, 01/05/22, 01/06/22, 01/09/22, 01/13/22, 01/14/22, 01/25/22, 01/29/22, 02/05/22, 02/09/22, 02/15/22, 02/17/22, 02/18/22, 02/24/22, 02/26/22, 02/27/22 and 02/28/22 Interview on 03/02/23 at 10:33 A.M., with the DON confirmed the resident had not had routine behavior monitoring completed at the facility. The DON verified the resident should have daily behavior monitoring in the medical record. 3. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including atrial fibrillation, hypertension, anxiety depression and dementia. Review to the annual MDS assessment dated [DATE] revealed the resident is cognitively intact and received seven days of antipsychotic, antidepressant, hypnotic and diuretic medication. Review of Resident #8's physician orders revealed the resident had the following medication orders: Ariprazole (antipsychotic) 0.5 mg at bedtime for major depression dated 09/05/21; Bupropion (antidepressant) 150 mg daily for depression dated 09/07/21; Trazadone (sedative) 50 mg daily for insomnia dated 05/30/22; Xanax (antianxiety) 0.25 mg three times daily for anxiety dated 09/28/22; and Zoloft (antidepressant) 150 mg daily for depression dated 09/05/21 Review of Resident #8's medical record revealed there was no behavior monitoring documented on the following days during the last two months: 01/01,22 01/04/22, 01/06/22, 01/08/22, 01/12/22, 01/13/22, 01/16/22, 01/18/22, 01/22/22, 02/08/22, 02/11/22, 02/15/22, 02/17/22, 02/18/22, 02/20/22, 02/25/22, 02/26/22, and 02/28/22. 01/01,22 01/04/22, 01/06/22, 01/08/22, 01/12/22, 01/13/22, 01/16/22, 01/18/22, and 01/22/22. Interview on 03/02/23 at 5:06 P.M., with the DON confirmed the resident had not had routine behavior monitoring completed at the facility. The DON verified the resident should have daily behavior monitoring in the medical record. 44080 4. Review of record for Resident #58 revealed admitted on 12/13/21, with diagnoses included dementia without behaviors, bipolar disorder, anxiety, and major depressive disorder. Review of MDS assessment dated on 12/21/22, revealed Resident #58 was severely cognitively impaired. Review of Resident #58 physician orders revealed the resident had the following medications orders: Aripiprazole (antipsychotic) 5 mg by mouth at bedtime every day, ordered 02/25/23; Aripiprazole (antipsychotic) 2 mg by mouth at bedtime, ordered 09/30/22, end date on 01/25/23; Citalopram (antidepressant) 5 mg by mouth every day, ordered 12/13/21, end date on 02/09/22; Namenda (dementia) 20 mg by mouth daily, ordered 02/15/23; Donepezil (dementia) 10 mg by mouth at bedtime, ordered 12/13/21; Trazadone (sedative) 50 mg by mouth at bedtime, ordered 12/13/22, end date on 12/01/22 and Trazadone (sedative) 100 mg by mouth at bedtime, ordered 12/01/22. Review of Resident #58 medical record revealed there was no behavior monitoring documented on the following days during the last two months: 01/01/23, 01/06/23, 01/12/23, 01/13/23, 01/16/23, 01/19/23, 01/22/23, 02/08/23, 02/11/23, 02/15/23, 02/17/23, 02/18/23, 02/19/23, 02/26/23, and 03/01/23. Interview on 03/02/23 at 5:06 P.M., with the DON confirmed the resident had not had routine behavior monitoring and should have been completed daily. Review of policy titled Behavioral Assessment, Intervention, and Monitoring dated 2001 last revised March 2019 revealed: The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorder(s) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable. Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents. Residents will have minimal complications associated with the management of altered or impaired behavior. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Under the section of Management: When medications are prescribed for behavioral symptoms, documentation will include: rationale for use; potential underlying causes of the behavior; other approaches and interventions tried prior to the use of antipsychotic medications; potential risks and benefits of medications as discussed with the resident and/or family; specific target behaviors and expected outcomes; dosage; duration; monitoring for efficacy and adverse consequences; and plans (if applicable) for gradual dose reduction.

Based on record review, staff and resident interview, the facility failed to invite and involve a resident and/or their representative in their care planning and conduct care plan meetings. This affected one (#26) of 24 residents reviewed for care planning. The facility census was 67. Findings include: Review of the medical record for Resident #26 revealed admitted [DATE]. The resident was admitted with diagnoses including stroke and hemiplegia of the left dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive two person assistance for bed mobility, one total dependence for transfers, toileting, and supervision for eating. Resident #26's MDS documentation revealed a quarterly MDS assessment was completed on 10/14/22. Review of the progress notes for Resident #26 revealed no documentation of care conferences being held. Upon request the facility provided paperwork for a care conference dated 10/26/23. There was no evidence of an invitation to a care plan meeting. Interview on 02/27/23 at 2:52 P.M., with Resident #26 revealed she or her representative had not had care conference or an invitation. Interview on 03/02/23 at 5:00 P.M., with Social Services Designee #139 verified the last care conference for Resident #26 was on 10/26/23 and no family or resident attended.

Based on record review, staff interviews, and policy review, the facility failed to notify a physician of a fall with a head injury. This affected one (#63) of two reviewed for accidents. The facility census was 67. Findings include: Review of medical record for Resident #63 revealed admitted [DATE]. The resident was admitted with diagnoses including pneumonia, bacteremia, hypertension, atrial fibrillation, depression, and anxiety. The resident remains in the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has intact cognition and required extensive one person assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and supervision for eating. Record review revealed Resident #63 had an unwitnessed fall in the bathroom on 02/28/23. The fall resulted in contusion to the left forehead. Neurological assessments were initiated and were negative. Notification of the fall was written in the provider communication book. Interview on 03/02/23 at 8:44 A.M., with Certified Nurse Practitioner (CNP) #153 revealed she was not informed of Resident #63's fall. She added she created a list which was posted in the provider communication book of examples of when to call the provider and when it was acceptable to leave the information in the communication book. CNP #53 verified a fall with head injury requires a call to the provider. Interview on 03/02/23 at 9:10 A.M., with the Director of Nursing (DON) verified Resident #63 had a fall which resulted in a contusion to her left forehead, and it was the expectation the provider would be notified. The DON also verified there was no documentation CNP #153 had been notified, other than written in the communication book. Review of the policy tilted Fall Policy, dated September 2012, revealed preceding an assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on record review and staff interview, the facility failed to inform a resident/ representative of cost for care and services that they would be responsible for when a payor source would change. This affected two (#7 and #36) of three residents reviewed for beneficiary notification the cost of the skilled service after by Medicare Part A. The total facility census was 67. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE], with Medicare Part A as her payor source. The resident record revealed the resident payor source changed on 02/16/23 to Medicaid and the resident remained in the facility. Resident #7's diagnoses included diabetes, chronic kidney disease, hypertensive heart disease, Parkinson's disease, hyperlipidemia, and depression. Review of Resident #7's quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident was cognitively intact, had no behaviors, and required extensive assist for bed mobility, and personal hygiene, limited assist with transfers, toileting, and dressing and required supervision for eating. The resident received 15 minutes of speech therapy, 245 minutes of occupational therapy and 160 minutes of physical therapy during the review period. Review of the Skilled Nursing Facility/Advanced Beneficiary Notice (SNF/ABN) provided to Resident #7's Power of Attorney (POA) on 02/12/23, revealed the resident was receiving skilled services at the facility through the Medicare Part A benefit starting on 12/30/23 and the skilled benefit through Medicare Part A would end on 02/14/23. Review of Resident #7's SNF/ABN revealed the facility informed the POA the inpatient skilled nursing facility stay would not be paid by Medicare Part A and the resident/POA would be responsible for the following payment related to the resident's continued stay at the facility. Room and board payment of $288.00 a day, eight incontinent supplies per day with no monetary value provided, and six days of oxygen therapy with no monetary value provided. The SNF/ABN did not provide the cost of the skilled services the resident was being cut from for the POA to review and decide if the POA wanted to the resident to continue with the skilled services. Interview on 03/02/23 at 11:18 A.M., with Social Service Designee (SSD) #139 confirmed the cost for the skilled services which were no longer being provided under Medicare Part A for Resident #7 was not provided on the SNF/ABN. 2. Review of Resident #36's medical record revealed the resident was initially admitted to the facility on [DATE], with the most recent re-admitted [DATE], with the payor source of Medicare Part A. The resident record revealed the payor source changed to Medicaid on 01/11/23 and the resident remained in the facility. Resident #36's diagnoses included hypertension, chronic kidney disease, peripheral vascular disease, anemia, and chronic obstructive pulmonary disease. Review of Resident #36's discharge from Medicare Part A, MDS assessment dated [DATE] revealed the resident had received 145 minutes of speech therapy, 2198 minutes of occupational therapy and 1432 minutes of physicial therapy while on Medicare part A services. Review of Resident #36's SNF/ABN revealed the facility informed the resident the inpatient skilled nursing facility stay will not be paid by Medicare part A starting on 01/11/23 and the resident would be responsible for the following payment related to the resident's continued stay at the facility. Room and board payment of $288.00 a day, and eight incontinent supplies per day with no monetary value provided. The SNF/ABN did not provide the cost of the skilled services the resident was being cut from for the resident to review and decide if they wished to continue with the skilled services. Review of Resident #36's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, and required extensive assist for bed mobility, transfers, dressing, toileting, and personal hygiene, and required supervision for eating. Interview on 03/02/23 at 11:18 A.M. with SSD #139 confirmed the cost for the skilled services which were no longer being provided under Medicare Part A for Resident #36 was not provided on the SNF/ABN.

Based upon observation, resident and staff interviews, the facility failed to maintain a environment in good repair. This affected one (#30) of 67 residents reviewed for homelike environment. The facility census was 67. Findings include: Review of medical record for Resident #30 revealed admitted [DATE]. The resident was admitted with diagnoses including stroke, hemiplegia affecting right dominant side. The resident remains in the facility. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had intact cognition and required supervision for eating and extensive assistance for all other activities of daily living. Interview and observation on 02/27/23 at 1:02 P.M., with Resident #30 revealed she was bothered by the chipped paint and dry wall damage beside her bed, which was caused by her recliner hitting the wall. Resident #30 shared the facility moved her bed against the damaged wall after a fall and she would like the wall fixed. Observation of the wall, at the time of the interview, revealed beside Resident #30's bed an area approximately three foot by six inch of scattered gouging of drywall. Interview on 03/02/23 at 8:29 A.M., with Maintenance Director (MD) #73 verified the damaged area to the wall of Resident #30's room. MD #73 acknowledged the room was not homelike and shared the facility was aware of the damage to walls from recliners and would be identifying and fixing those areas.

Based on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a discharge assessment in a timely manner. This affected one (#64) of 24 residents reviewed for assessments. The facility census was 67. Findings include: Review of the closed medical record for Resident #64 revealed admitted [DATE]. The resident was admitted with diagnoses including stroke, diabetes mellitus type two, hypertension and atrial fibrillation. The resident was discharged on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition and required extensive assistance or was totally dependent for her activities of daily living. Review of the MDS assessments in the medical record revealed a discharge assessment was not completed as of 02/28/23. Interview on 03/01/23 at 8:09 A.M., with MDS Nurse #124 verified a discharge MDS was not completed as required for Resident #64. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual v1.17.1R, effective July 15, 2022, revealed a discharge assessment must be completed no later than 14 days after the date of discharge.

Based on record review, observation, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interviews, the facility failed to accurately assess a resident and reflect the accurate assessment on the the Minimum Data Set (MDS) 3.0 assessment. This affected two (#48 and #57) of 24 resident assessments reviewed for accuracy. The total facility census was 67. Findings include: 1. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, rheumatoid arthritis, idiopathic peripheral neuropathy, and palliative care. Review of Resident #48's physician orders revealed the resident started hospice care on 09/27/22 with a terminal diagnosis of Alzheimer's Disease. Resident #48 additionally had a physician order for bilateral palm protectors for four hours daily as tolerated dated 06/27/22. Review Resident #48's care plans revealed the resident had a care plan for activities of daily living with an intervention of bilateral palm protectors for four hours daily dated 07/05/22, and a hospice care care plan in place dated 09/27/22. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 had cognitive impairment, and was dependant on staff for all daily cares. Resident #48 was assessed as not having any functional limitation in range of motion. Section J 1400 was listed as no, indicating the resident did not have a condition or chronic disease that may result in a life expectancy of less that 6 months. and section O 0100 K hospice was not marked. Review of the quarterly MDS assessment dated [DATE], revealed Resident #48 had cognitive impairment, and was dependant on staff for all daily cares. Resident #48 was assessed as not having any functional limitation in range of motion. Section J 1400 was listed as no, indicating the resident did not have a condition or chronic disease that may result in a life expectancy of less that 6 months. and section O 0100 K hospice was not marked. Observation of Resident #48 on 02/27/23 at 2:10 P.M., revealed the resident was sitting in her room in the wheelchair and her hands were closed and her fingers were touching her palms. There was a note above the bed which stated to have palm protectors in place. The resident was asked if she could open her hands and she was unable to straighten her fingers on command. Observation of Resident #48 on 02/28/23 at 8:08 A.M., revealed bilateral palm protectors were in place. Interview on 03/01/23 at approximately 10:25 A.M., with the Director of Nursing (DON) confirmed the resident has bilateral hand contractures and uses palm protectors daily. The DON also confirmed the resident was on hospice services. Interview on 03/01/23 at 3:30 P.M.,with MDS Nurse #124 confirmed Resident #48 was on hospice services but it was not indicated on the quarterly MDS dated [DATE] or on the significant change MDS dated [DATE] and J 1400 was listed as no on both assessments. MDS Nurse #124 stated she reviews the information provided by the nursing staff to complete the MDS assessments. 44080 2. Review of record for Resident #57 revealed admitted on 10/05/21. Diagnoses included palliative care, cerebral infarction, and mild cognitive impairment. Review of Significant Change MDS assessment dated on 11/07/22 revealed Resident #57 was cognitively intact and Section J 1400 was listed as no, indicating the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. and section O 0100 K hospice was not marked. Review of MDS dated on 02/07/23 revealed Resident #57 was cognitively intact and Section J 1400 was listed as no, indicating the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. and section O 0100 K hospice was not marked. Review of Plan of Care dated 02/21/23 revealed Resident #57 had diagnosis of cerebral atherosclerosis and was admitted to hospice. Interventions included one on one visit as needed, allow resident to ventilate feelings, call hospice with any concerns, observer for pain, observe for signs and symptoms of depression and grief, offer reassurance, and see hospice plan of care. Review of physician order dated on 10/28/22 revealed Resident #57 had been admitted to hospice on 10/27/22 with diagnosis of cerebral atherosclerosis. Interview on 03/01/23 at 3:40 P.M., with MDS Nurse #124 confirmed Resident #57 was on hospice services but it was not marked on the quarterly MDS dated [DATE] or on the significant change MDS dated and J 1400 was marked as no on both assessments. MDS Nurse #124 stated she reviews the information provided by the nursing staff to complete the MDS assessments. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual v1.17.1R, effective July 15, 2022, revealed under section G 0400: Functional Limitation in Range of Motion revealed revealed Upper Extremity - includes shoulder, elbow, wrist, and fingers. For each hand, instruct the resident to make a fist and then open the hand. Coding Tips: Do not look at limited ROM in isolation. You must determine if the limited ROM impacts functional ability or places the resident at risk for injury. Under Section J 1400: Prognosis (cont.): Coding Instructions-Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services

Based medical record review, review of an incident report, review of staff statements, staff interview and policy review, the facility failed to ensure Resident #52's fall intervention were implemented to prevent falls in accordance with the resident's care plan. This resulted in actual harm when Resident #52's personal safety alarm was not on, the resident experienced a fall and was subsequently hospitalized related to facial fractures and a subdural hematoma. Additionally, the facility failed to ensure new/different fall interventions were attempted to prevent reoccurrence of falls. This affected two (#44 and #52) out of two residents reviewed falls/accidents. The facility census was 71. Findings include: 1. Review of medical record for Resident #52 revealed an admitted d of 10/21/15 with [DIAGNOSES REDACTED]. Review of fall risk assessment completed 07/16/18 documented Resident #52 as having a fall risk score of 15 making her at high risk for falls. Review of comprehensive care plan documented Resident #52 was at risk for falls related to changes, history of episodes of lethargy, limited mobility, weakness, fatigue, right below the knee [MEDICAL CONDITION], use of antidepressants, incontinence, pain, [MEDICAL CONDITION], and can be impulsive and unaware of satiety needs. Further review documented on 04/01/17 and 11/10/17 documented the resident has had fall due attempting to transfer herself. On 04/17/18 an intervention was in place to have a personal safety alarm while to bed/chair to remind her of the need for assistance and to alert staff of her need of assistance. There lacked any intervention for the resident being none compliant with the use of the personal alarm. Review of discharge return anticipated Minimum Data Set (MDS) assessment date 09/20/18 assessed Resident #52 as being severely cognitively impaired and documented the Resident as having a fall with major injury. She was also documented as requiring extensive assistance for transfers, dressing and personal hygiene. Review of nursing note dated 09/20/18 documented Resident #52 was found laying face down underneath her sink. The resident was seen sitting in her wheel chair in the hallway prior to the fall. The resident at this time had a laceration above right eyebrow and a small cut to inside of right eye from falling on glasses, both were bleeding. Resident had a bruise to her right knuckle and expressed pain to her head and right wrist. Further review documented Resident #52 was transported to the Hospital #1 for evaluation. The hospital updated and reported a fractured right cheek bone and transported Resident #52 to Hospital #2 for further evaluation and treatment. There lacked any documentation of her personal alarm being in place and activated when she fell . Review of incident report dated 09/20/18 documented Resident #52 was found laying face down underneath her sink. The resident was seen sitting in her wheel chair in the hallway prior to the fall. The resident at this time had a laceration above right eyebrow and a small cut to inside of right eye from falling on glasses, both were bleeding. Resident had a bruise to her right knuckle and expressed pain to her head and right wrist. Further review documented Resident #52 was transported to the Hospital #1 for evaluation. The hospital updated and reported a fractured right cheek bone and transported Resident #52 to Hospital #2 for further evaluation and treatment. Further review lacked any documentation if the alarm was in place or activated at the time of the fall. Resident #52 was documented as confused the resident had been notes as leaning forward in wheelchair recently. Review of statement/investigation dated 09/20/18 documented Resident #52 was out in the hall way to go to breakfast and in less than five minute the resident was found on the floor. Further review documented the alarm was attached to the wheel chair and functioning properly. At this time State tested Nurses' Aide (STNA) #315 the alarm was attached to the resident when she was in the hallway. Further review lacked any information or investigation as to how Resident #52 alarm was not in place or sounding at the time of the fall. Review of Hospital #2's continuity of care documented resident was admitted on [DATE] post fall with injuries including a fracture to the right orbital wall, laceration of the right eyebrow and a subdural hematoma. Further review documented she was discharge from the hospital on [DATE] with discharge instructions for post care. On 11/19/18 at 3:54 P.M. interview via telephone with STNA #330 verified the alarm was on Resident #52's chair and it was snapped to her shirt earlier in the morning. She stated when they found Resident #52 face down the alarm was not attached to the resident or sounding. She is not sure how the alarm came off. She stated maybe the clip was loose. She doesn't feel the resident would be able to take it off herself. On 11/19/18 at 4:46 P.M. interview with Licensed Practical Nurse (LPN) #350 verified the resident alarm was not sounding when Resident #52 fell . She stated she is unable to remember if it wasn't clipped to her properly or the alarm was not functioning properly at the time of the fall. She verified she did an incident report and that would reflect her findings at the time of the incident. On 11/20/18 at 2:34 P.M. interview with Assistant Director of Nursing (ADON) verified Resident #52's alarm was functioning properly and the clip was not broken. She further verified she did not further investigate as to why the alarm was not attached to Resident #52 at the time of the fall. She cannot recall doing any formal in servicing/training to ensure clip alarms are placed on the resident properly to ensure proper functioning. Review of policy titled fall risk assessment revised 10/01/14 documented the resident will be assessed at risk for falls and a total score of 10 or greater indicates the resident is at risk for falls. At this time interventions will be established and become part of the resident's documented care plan. Further review documented residents at high risk for falls will have appropriate interventions put into place. 2. Review of Resident #44's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #44's quarterly MDS assessment dated [DATE] identified the resident as being rarely/never understood. It identified the resident as requiring extensive one person assist with bed mobility and extensive one person assist with transfers. Review of Resident #44's medical record and fall investigation identified Resident #44 as having a fall on 09/11/18 at 7:07 P.M. The incident description indicated the nurse was across the hall from the resident room and the resident was lying in bed. The nurse turned around to get into the medications cart and heard a loud noise and the resident was lying prone on the floor next to the bed. A new intervention of staff to follow the resident into his room and help him transfer into bed if he is attempting to do so was implemented. Review of Resident #44's medical record and fall investigation indicated the resident had fallen on 09/16/18 at 3:20 P.M. The incident description indicated that the nurse was called to the resident's room by the aide and the resident was found on his knees beside the bed. There was no evidence that a new fall intervention was implemented or discussed following this fall. Further review of Resident #44's medical record and fall investigation indicated the resident had sustained a fall on 09/26/18 at 12:45 P.M. The incident description indicated the nurse found the resident sitting on the bedroom floor in between the beds. There was no evidence that a new fall intervention was implemented or discussed following this fall. Additional review of Resident #44's medical record and fall investigation indicated the resident had fallen on 10/20/18 at 10:44 A.M. The incident description indicated the nurse heard a noise and found the resident sitting on his buttocks on the floor in the resident's room; the resident was sitting between the wheelchair and the closet. There was no evidence that a new fall intervention was implemented or discussed following this fall. Interview with Registered Nurse (RN) #301 on 11/19/18 at 2:08 P.M. voiced Resident #44 had fallen in his room on 09/11/18 and a new intervention was implemented for staff to follow the resident into his room and help him transfer into bed if he is attempting to do so. She confirmed Resident #44 had fallen in his room again on 09/16/18, 09/26/18 and 10/20/18. She confirmed there were no new fall interventions implemented after these falls and there was no evidence that new fall interventions were discussed.

Based on observation, medical record review, review of the facility matrix, staff and nurse practitioner interviews, review of information from the National Pressure Ulcer Advisory Panel (NPUAP) and review of facility policies, the facility failed to ensure the staff appropriately and timely assessed, notified the physician and implemented an appropriate treatment for [REDACTED]. This resulted in actual harm when Resident #46's untreated skin impairment to the right buttock subsequently worsened with the development of slough (dead cells/tissue) to the wound. This affected one (#46) of three residents reviewed for skin breakdown. The facility identified all residents as at risk for skin impairment. Facility census was 70. Findings include: Review of Resident #46's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of four, indicating severe impairment in cognition. He required extensive assistance with two plus staff members for bed mobility and transfers. He was not admitted with a pressure ulcer but was assessed as at risk for pressure ulcers. He had a pressure reducing mattress. Review of the resident's care plan initiated on 01/02/18 and revised on 01/10/18 revealed the resident had the potential for impairment of skin integrity due to poor tissue integrity and incontinence. Interventions included: assessing the condition of the resident's skin, especially over bony prominences for breakdown, educating the resident on the need to reposition, pressure reducing mattress to bed, notify dietitian of altered skin integrity, measure area per facility protocol. Review of the resident's Braden scale revealed the resident was assessed as a low risk for pressure ulcer on 12/30/17. On 01/06/18, the resident was assessed as being at moderate risk and on 01/24/18 was assessed as being at high risk for pressure ulcer development. Review of the resident's physician's orders [REDACTED]. Document significant findings in progress notes. On 01/17/18, an order was obtained to apply Calazinc cream (barrier cream that protects skin against moisture, itching, minor irritation, and diaper rash caused by wetness, urine and/or stool) to the right inner buttock until area was resolved. There were no additional orders regarding care and/or treatments to the right buttock. Review of the resident's wound progress note dated 01/25/18 revealed the resident was seen for wound evaluation of a chronic arterial wound(s) of the right second toe. There was no mention of any skin impairment of the resident's buttocks. Review of the resident's nursing notes revealed an entry on 01/26/18 at 12:56 P.M. indicating the resident had a small open area on top of his coccyx area and a small open area on the center of his lower back. Barrier cream was applied and treatment completed. There were no measurements, wound descriptions or wound assessment completed/documented. There was no documentation indicating the physician or responsible party were notified and there were no new physician's orders [REDACTED]. Review of the facility matrix roster provided to the survey team on 01/29/18 revealed Resident #46 was not identified as having a facility acquired pressure ulcer. Interview with Licensed Practical Nurse (LPN) #125 on 01/31/18 at 11:01 A.M. revealed she was not aware of an open area to Resident #46's coccyx area. She stated she did not have orders to care for an open area to the coccyx. Further review of Resident #46's weekly nursing skin assessments revealed the first skin assessment after admission was completed on 01/12/18 with no open area to the right buttock noted. The next weekly skin assessment was completed on 01/15/18 and noted the top layer of skin was off the right buttock and the wound bed was bright red measuring 7.0 centimeters (cm) by 2.0 cm. The area was cleansed and patted dry. Calazinc was applied and [MEDICATION NAME] bordered dressing placed over area to protect it from shearing. There was no documentation indicating the doctor or responsible party were notified. The next weekly nursing skin assessment was completed on 01/23/18. Open area was noted to right inner buttock with current treatment noted as Calazinc to buttocks. Review of the resident's Alteration in Skin assessments revealed an assessment dated [DATE] indicated the resident had an open area to the right inner buttock. Open area to the right inner buttock was also documented in the 01/24/18, 01/25/18, and 01/26/18 assessment with no measurement or description of the open area. Observation of Resident #46's wound on 01/31/18 at 3:33 P.M. with the Director of Nursing (DON) revealed an open area to the resident's right inner buttock measuring 0.9 cm by 1.3 cm with yellow slough covering the wound bed. This was the only open area noted. Interview with the DON immediately after the observation revealed the resident had a stage three pressure ulcer (definition from the NPUAP, Stage 3 Pressure Injury: Full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury). She stated she was not previously aware of this skin impairment. Review of a nursing noted dated 01/31/18 at 5:53 P.M. revealed the resident's buttocks and coccyx were examined and a stage three pressure ulcer was noted to the resident's right upper buttocks near his coccyx. The area measured 0.9 cm by 1.3 cm. The wound bed was moist and 100% covered in yellow slough. Peri-wound skin was pink and blanchable. No odor or drainage was present. Continued review of the nursing notes revealed an order was obtained on 01/31/18 at 3:15 P.M. for Santyl (enzymatic deriding ointment) for the resident's wound and the resident was to be seen by the wound nurse practitioner on 02/01/18. The resident's responsible party was notified. Review of the resident's physician's orders [REDACTED]. Interview with the DON on 02/01/18 at 9:33 A.M. verified Resident #46 was noted to have some excoriation to the right buttock on 01/17/18 and a moisture barrier cream was started. She verified the first indication the resident had an open area to the right buttock was on 01/21/18 noted on the alteration in skin assessment. She verified there was no measurement or description of the wound documented and the physician was not notified of a new area of skin impairment until 01/31/18. She further stated Certified Nurse Practitioner (CNP) #100 observed the resident's right buttock the morning of 02/01/18 and stated the area was a stage two pressure ulcer (from the National Pressure Ulcer Advisory Panel, Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) as she could visualize some of the wound bed. The DON stated she was present during the observation and some of the slough was gone, but not all of it. The DON also verified there was no weekly skin assessment completed until 01/12/18, then 01/15/18, and 01/23/18. She verified this was not completed weekly as scheduled. Interview with CNP #100 on 02/01/18 at 11:08 A.M. revealed she initially stated the resident had a pressure ulcer, but after a more thorough review of the resident's chart she noted the resident had experienced increased diarrhea. She stated she felt the resident had a non-pressure area. She stated the wound bed was 90% red/granulation and 10% yellow slough, which she could mostly clean off with wound cleaner. Review of CNP #100's wound care progress note dated 02/01/18 at 11:20 A.M. revealed the resident was seen for wound evaluation of a chronic arterial wound(s) of the right second toe. A new area to the right buttock was noted and described as an acute wound secondary to excoriation due to frequent loose stools. CNP #100 documented the area to the right buttock had been documented as a superficial wound about a week and a half ago. CNP #100 further documented, per report from nursing staff and chart review, the resident had been having loose stools and was tested to rule out [MEDICAL CONDITION] (c. diff). CNP #100 documented the resident had areas of blanchable redness to the bilateral buttocks in addition to the open area to the right buttock. CNP #100 documented the resident continued to have loose stools and the skin to the buttocks area was moist. On exam, the right buttock wound had ointment covering the wound. After cleansing with wound cleanser, the wound bed was described as 90% red and 10% yellow. The wound measurements were documented as 1.0 cm by 1.4 cm by less than 0.1 cm. The resident was not experiencing any pain. [DIAGNOSES REDACTED]. Plan for care for the excoriation of the buttocks, including right buttock open wound was to cleanse with mild soap and water, dry thoroughly, apply Chamosyn (skin barrier ointment) three times daily. Ensure the patient was cleaned and dried after each urinary and stool incontinence episode. Review of a facility policy titled Pressure Ulcer Risk Assessment and Management with a revision date of 10/25/16 revealed it was the policy of the facility to assess all residents on admission and regularly thereafter, to determine the presence of skin condition and/or areas of skin compromise, and to identify potential risk factors for their development. Responsibilities of the floor nurse will include, communication to the wound care nurse/designee, of any areas of skin breakdown for continued follow up, obtaining measurements including width, length, and depth, updating the physician and application of appropriate treatments, and weekly skin assessment. Identification measures included: if open areas were noted the nurse will notify the physician and initiate appropriate treatment orders. Once weekly, during bathing, any reddened or open skin areas will be documented and followed up by nursing staff and documented in the weekly skin assessment. During routine care direct care staff should be noting and reporting any areas of skin compromise to the floor nurse for follow up. Care planning included the nurse initiating an appropriate treatment and follow up when a resident has an open area or is found to be high risk for skin breakdown. The resident will be documented on every shift until healed. Treatment measures included the floor nurse obtaining treatment orders utilizing the wound care protocols established by the facility Quality Assurance committee. Monitoring and documentation measures included the wound care nurse will measure each pressure area weekly, including a description of the wound character and healing process. The section titled Other Skin Conditions indicated areas of excoriation were included. treatment for [REDACTED]. Monitoring of these areas was to be completed weekly. Review of a facility policy titled Notification of Changes in Residents with a revision date of 07/05 revealed the charge nurse will immediately notify the resident, resident's physician and legal representative; family member when there is: a significant change in the resident's physical, mental or psychosocial status or a need to alter treatment significantly. Documentation of the change in condition will include time and person notified.