Every finding on record at Violet Springs Health Campus

Based on record review and interview the facility failed to ensure Resident #86, #88, #91, and #93's medical record reflected their diagnoses and failed to document Resident #91's treatment time accurately. This affected four residents (#86, #88, #91, and #93) of 24 records reviewed. The facility census was 54.Findings include: 1.Review of Resident #86's medical record revealed an admission date of 01/02/26 his face sheet and diagnosis page in the electronic medical record did not indicate his diagnoses. Review of Resident #86's hospital discharge summary 01/02/26 revealed diagnoses including hypertension, dementia, and chronic kidney disease. Interview on 01/14/26 at 9:50 A.M. with the Director of Nursing (DON) verified the resident's medical record was missing their diagnoses. A policy for medical records was requested but not provided. 2. Review of Resident #88's medical record revealed an admission date of 01/05/26 his face sheet and diagnosis page in the electronic medical record did not indicate his diagnoses. Review of Resident #88's hospital history and physical dated 09/16/25 revealed the resident had diagnoses including esophageal adenocarcinoma, coronary artery disease, anxiety, and gastroesophageal reflux disease. Interview on 01/14/26 at 9:50 A.M. with the DON verified the resident's medical record was missing their diagnoses. A policy for medical records was requested but not provided. 3.Review of the electronic medical record for Resident #91 revealed an initial admission date of 01/06/26. Review of the resident's face sheet revealed no diagnoses listed for the resident. Review of the resident's hospital summary revealed the diagnoses including but not limited to hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of left lower extremity, atrial fibrillation and congestive heart failure. On 01/14/26 at 9:50 A.M., interview with the Director of Nursing (DON) verified the resident's electronic medical record had no diagnoses readily available on the medical record. 4. Review of the medical record for Resident #93 revealed an initial admission date of 01/10/26 with the diagnoses including but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, severe morbid obesity. right bundle branch block, bifascicular block, ventricular tachycardia, gout, Parkinson's disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, constipation and prediabetes. Review of the resident's admission observation and data collection dated 01/10/26 revealed the resident was admitted to the facility being alert, with impaired daily decision making. Review of the admission wound documentation of the venous ulcer to the left lower extremity/shin dated 01/10/26 revealed the wound measured 5.0 centimeters (cm) by 6.0 cm. The wound was described as closed/resurfaced tissue with the surrounding tissue being described dark purple or rusty discoloration. The wound was determined to be stable. Review of the admission wound documentation of the venous ulcer to the right lower extremity/shin dated 01/10/26 revealed the wound measured 5.0 cm by 6.0 cm. The wound was described as having no exudate, closed/resurfaced tissue with the surrounding tissue being described dark purple or rusty discoloration. The wound was determined to be stable. Review of the plan of care dated 01/12/26 revealed the resident was at risk for skin breakdown r/t indwelling catheter, bowel incontinence, antiplatelet, morbid obese, vascular ulcers, hypothyroidism. Interventions included avoid shearing skin during positioning, turning and transferring, conduct weekly skin assessment, encourage and assist to turn and reposition for comfort and as needed, float heels as needed and tolerated, keep linens clean and dry, keep resident as clean and dry as possible, minimize skin exposure to moisture, observe feet during care for redness, swelling, or changes in condition and notify physician as needed, pressure reducing cushion to chair, pressure reducing mattress to bed, treatments/preventative treatments as or when ordered, use lifting device as needed for bed mobility and moisture barrier product to perineal as needed. Review of the weekly wound documentation of the venous ulcer to the left lower extremity/shin dated 01/13/26 revealed the wound measured 5.0 centimeters (cm) by 6.0 cm. The wound was described as closed/resurfaced tissue with the surrounding tissue being described dark purple or rusty discoloration. The wound was determined to be improving. Review of the admission wound documentation of the venous ulcer to the right lower extremity/shin dated 01/13/26 revealed the wound measured 5.0 cm by 6.0 cm. The wound was described as having no exudate, closed/resurfaced tissue with the surrounding tissue being described as dark purple or rusty discoloration. The facility determined the wound was improving. Review of the resident's monthly physician orders for January 2026 identified an order dated 01/10/26 to cleanse bilateral lower extremities, pat dry, apply xeroform to open wounds, pad heels and weeping areas with ABD pads, wrap legs from base of toes to just below knees with Kerlix and ace wraps daily and as needed. Review of the resident's January 2026 Treatment Administration Record (TAR) revealed the treatment to the resident's bilateral lower extremities of cleanse, pat dry, apply xeroform to areas, cover with ABD, wrap legs from base of toes to just below knees with kerlix and ace wraps daily was documented as a late entry and documented as completed at 11:00 A.M. instead of the 3:45 P.M. as observed by Licensed Practical Nurse (LPN) #390. On 01/12/26 at 3:45 P.M., interview with LPN #390 revealed she was walking down the hallway and asked if the surveyor wanted to observe the resident's wound care. The LPN was informed a resident interview was being conducted. She verified the resident's twice daily treatment was just now being completed. She also verified the resident had no dressing or ace wraps on his bilateral lower extremities. On 01/13/26 at 3:15 P.M., interview with the Director of Nursing (DON) verified the documented time of 11:00 A.M. was an inaccurate time of administration of the treatment provided at 3:45 P.M. Review of the facility policy titled, Resident Rights Guidelines, last revised 05/11/17 revealed the resident had the right to have their medical record to contain personal and financial information kept confidential.

Based on observation, record review, interviews and facility policy review, the facility failed to ensure three residents (#65, #79 and #93) who were dependent on staff received appropriate grooming. Additionally, the facility failed to ensure one resident (#91) who required assistance from staff received routine bathing. This affected four residents (#65, #79, #91 and #93) of four residents received for activities of daily living (ADL). The facility census was 54.Findings Include: 1. Review of the medical record for Resident #91 revealed an initial admission date of 01/06/26 with the diagnoses including but not limited to hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of left lower extremity, atrial fibrillation and congestive heart failure. Review of the resident's admission life enrichment assessment dated [DATE] revealed it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. The resident indicated she preferred to receive showers. Review of the profile care guide dated 01/08/26 revealed see shower schedule for showers. The resident was to receive showers every Wednesday and Saturday. Review of the resident's shower documentation from 01/09/26 to 01/13/26 revealed the resident was provided a partial bed bath (cleansing only the areas of face, neck, axilla, hands and perineum) was provided on 01/09/26, 01/11/26 and 01/13/26. Further review of the shower documentation revealed the resident had not been provided a shower since admission to the facility on [DATE]. On 01/12/26 at 1:32 P.M. interview with the resident revealed she had not had a shower since admission but would like to have routine bathing. On 01/14/26 at 11:36 A.M., interview with Licensed Practical Nurse (LPN) #396 verified the resident had three partial baths since admission to the facility on [DATE]. The LPN revealed the resident had been in the facility for eight days and should have had two scheduled showers on 01/07/26 and 01/10/26. Review of the facility policy titled, Guidelines for Bathing Preference, dated 05/11/16 revealed the resident shall determine their preference for bathing upon admission, including the day of the week, time of day and type of bathing (tub bath, bed bath or shower). Bathing shall occur at least twice a week unless resident preference states otherwise. 2. Review of the medical record for Resident #93 revealed an initial admission date of 01/10/26 with the diagnoses including but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, severe morbid obesity. right bundle branch block, bifascicular block, ventricular tachycardia, gout, Parkinson's disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, constipation and prediabetes. Review of the resident's admission observation and data collection dated 01/10/26 revealed the resident was admitted to the facility being alert, with impaired daily decision making. Review of the plan of care dated 01/12/26 revealed the resident required staff assistance to complete self-care and mobility functional tasks completely and safely. Interventions included allow resident sufficient time to complete all or parts of task, do not rush resident, encourage resident to do as much as safely possible for self, observe for deterioration in functional abilities and report if occurs, offer facial shaving on shower days as needed or as requested, provide adequate rest periods between activities, provide nail care on shower days and as needed and therapy eval and treat as needed and ordered. On 01/12/26 at 4:05 P.M., observation of Resident #93 revealed the resident observed with several days of facial hair growth. On 01/13/26 at 4:40 P.M., observation of the resident revealed the resident continued to have several days of facial hair growth. On 01/13/26 at 4:42 P.M., interview with Certified Nursing Assistant (CNA) #307 verified the resident's continued to have long facial hair and said she had not tried to shave the resident. The CNA revealed residents are shaved when showers are provided and as needed. On 01/14/26 at 11:29 A.M., observation of the resident revealed he was in activities and his facial hair remained long. On 01/15/26 at 2:16 P.M., interview with the Director of Nursing (DON) revealed the facility had no policy pertaining to shaving. 3. Review of Resident #65's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a complete rotator cuff tear or rupture of the right shoulder, encounter for other orthopedic aftercare, sprain of the ligaments of his cervical spine, displaced fracture of the middle phalanx of the left middle finger, non-displaced transverse fracture of the right patella, Parkinson's disease, tremors, primary osteoarthritis of the bilateral hips, depression, and a history of falls. Review of Resident #65's admission Minimum Data Set (MDS) assessment revealed it was still in process. He did have some of his care plans developed and they included a care plan for needing the assistance with activities of daily living (ADL's) related to having a diagnosis of Parkinson's disease. The care plan was initiated on 12/29/25. The goal was for the resident to maintain his highest level of functional and cognitive status. The interventions included providing him with assistance during ADL care to include but not limited to eating, toileting, bed mobility, transfers, wheelchair mobility, and ambulation. It did not specifically mention assistance with shaving or grooming. Review of Resident #65's shower schedule revealed his assigned shower/ bath days based on his room location was every Tuesday and Friday. His shower/ bath was to be provided on the night shift. Review of Resident #65's shower/ bath documentation revealed he was receiving complete bed baths as his bathing activity on the days he was scheduled to receive them. His last documented complete bed bath was on 01/10/26. On 01/12/26 at 4:48 P.M., an observation of Resident #65 noted him to be lying in bed dressed in a hospital gown. He had a light growth of facial hair and his hair was messy, greasy and did not look like it had been recently washed or combed. An interview with the resident at the time of the observation revealed he liked to be clean shaven. He reported he had not been shaved since Friday, when his brother shaved him, and used to shave daily when at home. He had went three days without shaving. He denied anyone had offered to assist him with combing his hair that day either. On 01/13/26 at 12:38 P.M., an observation of Resident #65 noted him to be up in his wheelchair and in the private dining room for lunch with several other residents that needed assistance from staff with their meals. He was dressed in a hospital gown and had a cervical collar in place. He remained unshaven and his hair remained greasy and uncombed. A staff member (Rehab Director #500) was sitting next to him and conversing with him during his meal. On 01/13/26 at 2:05 P.M., an interview Rehab Director #500 confirmed she was in the private dining room with Resident #65 during the lunch meal. She was working with him and another resident that was seated next to him for meal assistance/ oversight. She reported Resident #65 had a fall that reduced his ability to use his right arm and she was working to improve it's use. She further confirmed the resident had a disheveled appearance, while out in the dining room, as his hair looked greasy and messy like it had not been washed lately. She did not notice that he had not been shaved lately as well. On 01/13/26 at 2:14 P.M., an interview with Resident #65 revealed he still had not been shaved, since his brother shaved him last Friday. He indicated he was likely to get a bath later that night and figured they would offer to shave him, but continued to indicate that it was his preference to be clean shaven, and he shaved daily when at home. He had a light growth of facial hair that was consistent with not being shaved for a few days. He reported his scheduled bath days were Tuesdays or Wednesdays and Fridays. He confirmed three complete bed baths and one partial bed bath had been given as documented since he had been at the facility. He denied he received personal care every morning or night on the days that he was not scheduled to receive a complete bed bath, which was what he preferred. They usually did him in the evenings, but he would have to ask them to do it. They did not just come in and offer that to him without him asking. He reported the nurse working the floor that day was the one that took him out to the private dining room for his lunch meal. He denied that she offered to comb his hair before taking him out there. He questioned if the nurse would have been the one responsible for doing that, but nonetheless, he stated he would have liked to have his hair combed before going out to the private dining room around other residents. On 01/13/26 at 3:35 P.M., an interview with the Director of Nursing (DON) confirmed Resident #65 had not been assisted with the removal of his unwanted facial hair as per his preference. She acknowledged the resident reported he had not been shaved since last Friday and was one who shaved daily when at home. She further acknowledged the resident reported the last time he had been shaved was by his brother. She also confirmed the resident was taken out to the private dining room for his lunch meal earlier that day, without anyone combing his hair before he left his room and put in the private dining room with other residents around. She was informed other staff that were in the private dining room with the resident confirmed his hair was messy/ uncombed and did not look like it had been washed recently. She denied the facility had a policy specific to bathing or other personal hygiene care. 4.Review of Resident #79's medical record revealed an admission date of 09/26/24 with diagnoses to include but not limited to unspecified sequelae of cerebral infarction, dementia, atherosclerotic heat disease, type two diabetes mellitus, vitamin D deficiency, cerebellar stroke syndrome, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted and a staff assessment for mental status was not conducted. Review of Resident #79's behavior revealed no documented refusals or rejection of care. Furthermore, review of Resident #79's functional abilities for self are revealed that Resident #79 is dependent on staff for all activities of daily living (ADLs) to include showering and personal hygiene. Review of the care plan dated 10/15/24 for Resident #79 revealed Resident #79 required staff assistance to complete self-care and mobility functional tasks completely and safety with interventions to include provide nail care on shower days and as needed. Observation on 01/12/26 at 11:09 A.M. of Resident #79 sitting in his room with white dried flakes on his shirt and odor of urine in the room. Licensed Practical Nurse (LPN) #358 verified Resident #79 had white flakes on his shirt and the room smelled of urine at the time of the observation. Observation on 01/12/26 at 1:00 P.M. of Resident #79 sitting in his Broda chair at lunch in the dining room. The Assistant Director of Health Services (ADHS) #338 verified that Resident #79's fingernails were long and had dirt underneath them. Observation on 01/14/26 at 12:42 P.M. of Resident #79 lying in bed trying to eat lunch with cranberry juice stains on his shirt and white blanket covering him. The ADHS #338 verified that Resident #79's shirt still had the cranberry juice stains on it from breakfast and the cranberry stains were on the white blanket at the time of the observation. Review of the job description of for Certified Resident Care Associate dated 10/2009 revealed under personal care functions assist resident with dressing/undressing as necessary, keep resident dry to include change gown, cloth, linen when it becomes wet or soiled assist resident with nail care to include clipping, trimming, and cleaning fingernails, and change bed linens.

Based on observation, medical record review and interviews, the facility failed to ensure one resident (#52) who was utilizing a c-pap machine had a physician's order for the use of the c-pap machine. Additionally, the facility failed to ensure one resident (#93) received oxygen therapy as physician ordered and failed to store nebulizer medication delivery systems appropriately for two residents (#41 and #43). This affected four residents (#41, #43, #52 and #93) of four residents reviewed for respiratory care and treatment. The facility census was 54.Findings Include:1. Review of the medical record for Resident #93 revealed an initial admission date of 01/10/26 with the diagnoses including but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, severe morbid obesity. right bundle branch block, bifascicular block, ventricular tachycardia, gout, Parkinson's disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, constipation and prediabetes. Review of the resident's admission observation and data collection dated 01/10/26 revealed the resident was admitted to the facility being alert, with impaired daily decision making. The assessment indicated the resident was admitted to the facility with oxygen use. Review of the plan of care dated 01/12/26 revealed the resident had a potential for shortness of breath while lying flat related to COPD and acute respiratory failure with hypoxia. Interventions included administer oxygen per physician orders and as needed, elevate head of bed or place in upright position as needed, labs as ordered, medications as physician ordered and therapy evaluation and treatment as needed. Review of the resident's monthly physician orders for January 2026 identified an order dated 01/12/26 for oxygen at three liters per nasal cannula continuously and resident has diagnoses of respiratory failure, monitor for shortness of breath, restlessness, fatigue, rapid breathing, elevated heart rate. Monitor for any negative outcomes such as new or worsening conditions and notify the physician. On 01/12/26 at 10:26 A.M., observation of the resident revealed the resident had no oxygen in place as physician ordered. On 01/12/26 at 12:40 P.M., observation of Resident #93 revealed he was sitting at the nurse's station with no oxygen in place as physician ordered. On 01/12/26 at 3:45 P.M., interview with Licensed Practical Nurse (LPN) #390 verified the resident was not provided oxygen outside of his room while in therapy, dining room and while sitting at the nurse's station. 2. Review of the medical record for Resident #52 revealed an initial admission date of 12/14/25 with the diagnoses including but not limited to noninfective gastroenteritis and colitis, diarrhea, diverticulosis, cerebral ischemia, chronic peripheral venous insufficiency, lymphedema, hypertension, congestive heart failure, Alzheimer's disease, cellulitis of right lower limb, major depressive disorder, anemia, obstructive sleep apnea, hyperlipidemia, hypothyroidism,, bradycardia, right bundle branch block and dementia. Review of the resident's plan of care revealed no care plan addressing the resident's use of a c-pap machine. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was not utilizing a non-invasive mechanical ventilator such as a bi-pap or c-pap machine. Review of the resident's monthly physician orders for January 2026 revealed no current physician orders for the use of the c-pap machine and what settings the machine was to be set. On 01/13/26 at 12:10 P.M., observation of the resident's room revealed a c-pap machine sitting on the resident's nightstand with the mask laying on the stand with no protective covering. On 01/13/26 at 1:25 P.M., Interview with the Director of Nursing (DON) verified the resident had no physician's order for the use of the c-pap machine and the mask was not stored inside a protective covering. 3.Review of the medical record for Resident #41 revealed an admission date of 11/25/25 with e re-entry of 12/01/25 with diagnoses to include but not limited to hypertensive heart disease with heart failure, acute on chronic diastolic heart failure, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, pleural effusion, paroxysmal atrial fibrillation, hyperlipidemia, nonrheumatic mitral insufficiency, unspecified cirrhosis of liver, hypokalemia, anxiety, and type two diabetes mellitus. Review of the admission MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. Review of an order for Resident #41 dated 12/02/25 revealed ipratropium-albuterol solution for nebulization give zero point five milligrams (mg)-three mg (two point five mg base)/three milliliters (mL) amount to administer three mL three times a day Observation on 01/12/26 at 10:59 A.M. of Resident #41's nebulizer face mask uncovered on the nightstand. Licensed Practical Nurse (LPN) #358 verified Resident #41's nebulizer face mask was uncovered on the nightstand at the time of the observation. LPN #358 stated she did not know how nebulizer face masks should be stored. Interview on 01/14/26 at 3:05 P.M. with the Director of Health Services who verified the facility did not have a nebulizer policy. 4.Review of the medical record for Resident #43 revealed an admission date of 07/15/20 with a re-entry date of 03/04/25 with diagnoses to include but not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, morbid (severe) obesity due to excess calories, anxiety disorder, cellulitis of abdominal wall, type two diabetes mellitus with chronic kidney disease stage 3, hypertensive heart disease, and shortness of breath. Review of the quarterly MDS dated [DATE] revealed a BIMS of 12 which indicated moderate cognitive impairment. Review of an order for Resident #43 dated 12/02/25 revealed ipratropium-albuterol solution for nebulization give zero point five mg-three mg (two point five mg base)/three mL amount to administer three mL via nebulizer every six hours as needed. Observation on 01/12/26 at 11:03 A.M. of Resident #43's nebulizer machine with the tubing and facemask uncovered and lying on Resident #43's nightstand. Licensed Practical Nurse (LPN) # 358 verified the nebulizer face mask was uncovered and lying on the nightstand at the time of the observation. Review of the care plan dated 07/16/20 revealed Resident #43 was at risk for shortness of breath while lying flat related to chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease with interventions to include medications as ordered.

Based on medical record review, observations, and interviews, the facility failed to identify, assess, and implement interventions to prevent pressure ulcers for Resident #40, and failed to ensure pressure relieving interventions were in place for Resident #91. This affected two residents (#40 and #91) of the three residents reviewed for pressure ulcers. The facility census was 54.Findings include:1.Review of the medical record for Resident #40 revealed an admission date of 08/26/25 and re-entry date of 11/20/25 with diagnoses to include but not limited to hypertensive heart disease with heart failure, acute on chronic diastolic heart failure, pulmonary fibrosis, chronic obstructive pulmonary disease, hypothyroidism, unspecified fall, laceration without foreign body of right upper arm, urinary tract infection, phlebitis and thrombophlebitis, osteoporosis, and anxiety disorder. Review of the care plan for Resident #40 dated 09/04/25 revealed the resident was at risk for skin breakdown related to dementia, incontinence, and decreased mobility with interventions to include avoid shearing skin during positioning, turning, and transferring, conduct weekly skin assessments by paying particular attention to bony prominences, encourage and assist resident to turn and reposition for comfort and as needed, float heels as needed and as tolerated, observe feet during care for redness, swelling or changes in condition, notify physician as needed, pressure reducing cushion to chair, pressure reducing mattress to bed, and treatments and preventative treatments as or when ordered. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 which indicated moderate cognitive impairment. Review of the behavior noted for Resident #40 revealed no rejection of care which would preclude Resident #40 from achieving goals for health and well-being. Review of the mobility of Resident #40 revealed resident required moderate assistance (helper does less than half the effort) to roll right and left and required substantial assistance (helper does more than half) for all transfers to include chair/bed-to-bed, toilet transfer, and shower transfer. Review of the skin conditions noted for Resident #40 revealed the resident to be at risk for pressure ulcers/injuries and skin problems listed as skin tears. Review of an order dated 11/20/25 for Resident #40 revealed to encourage resident to float heels (heels not touching the bed because a pillow or folded blanket is under the back of the ankle) while in bed as tolerated. There were no documented refusals of care for the month of 11/2025, 12/2025, or 01/2026. Review of an order dated 11/20/25 for Resident #40 revealed to encourage resident to turn and reposition while in bed. There were no documented refusals of care for the month of 11/2025, 12/2025, or 01/2026. Review of an order dated 11/21/25 for Resident #40 revealed weekly skin assessments for Resident #40 to be completed and new treatments and notifications for any new areas noted. There were no documented refusals of care for 11/25/25, 12/2025, and 01/2026. Review of an order dated 11/21/25 for Resident #40 revealed apply skin prep to bilateral heels twice a day for prevention. There were no documented refusals of care for the month of 11/2025, 12/2025, or 01/2026. Review of an order dated 11/21/25 for Resident #40 revealed elevate legs when seated. There were no documented refusals of care for the month of 11/2025, 12/2025, or 01/2026. Review of an order dated 11/23/25 for Resident #40 revealed pressure relieving boots while in bed nightly. There were no documented refusals of care for the month of 11/2025, 12/2025, or 01/2026. Review of the Braden Scale which scores a patient's risk for pressure ulcers from six (severe risk) to 23 (no risk), with lower scores indicating higher risk, based on six factors: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction & Shear. Total scores categorize risk as: 19-23 (No Risk), 15-18 (Mild Risk), 13-14 (Moderate Risk), 10-12 (High Risk), and less than nine (Very High/Severe Risk), guiding preventive interventions like repositioning, skin care, and nutrition support). Review of the Braden Scale dated 12/01/25 for Resident #40 revealed a score of 15 which indicated a mild risk. Review of the Treatment Administration Record (TAR) for Resident #40 revealed an order dated 12/15/25 do not use adhesive bandages on resident skin. There were no refusals of care documented for 12/2025. Review of the TAR for Resident #40 revealed an order dated 12/16/25 observe foam dressing to right heel every shift twice daily and may peel back and view area to monitor if area has opened. There were no refusals of care documented on the 12/2025 TAR. Review of an order for Resident #40 dated 12/16/25 revealed preventative foam dressing to right heel, change every seven days. There were no refusals documented for 12/23/25 and 12/30/25. Review of the Wound Management Detail Report for Resident #40 dated 12/16/25 revealed the right heel was documented as other-redness for wound type. The right heel wound had a length of four centimeters (cm) and width of two cm and comment stated area red no opening. Review of the Wound Management Detail Report for Resident #40 dated 12/23/25 revealed the right heel documented as wound type other-redness with a length of four cm and width of two cm and healing status documented as stable. Review of the Wound Management Detail Report for Resident #40 dated 12/30/25 revealed the right heel documented as wound type other-redness with a length of four cm and width of two cm and healing status documented as improving, area red. Review of the Wound Management Detail Report for Resident #40 dated 01/06/26 revealed the right heel documented as wound type other-redness with a length of three cm and width of three cm and healing status documented as improving, mild red. Review of the Wound Management Detail Report for Resident #40 dated 01/13/26 revealed the right heel documented as wound type as unspecified ulcer with a length of one cm and width of one cm, tissue type closed/resurfaced (meaning skin integrity has been restored either through natural processes or by medical intervention as with staples or sutures). Review of an order dated 01/13/25 for Resident #40 revealed cleanse wound with wound cleanser or normal saline, pat dry, apply skin rep to heel, non-adherent pad, kerlix and secure with ace wrap (stretchy, elastic compression bandage used for supporting injured muscles, joints by reducing swelling and providing gentle pressure) daily or as needed (PRN) until healed. Observation of the Assistant Director of Health Services (ADHS) performing wound care for Resident #40 on 01/14/26 at 3:36 P.M. revealed as Certified Nursing Assistant (CNA) #303 was removing Resident #40's right leg pant, Resident #40 yelled out that her right leg was hurting and bleeding. Resident #40's pants were moved up and the ADHS proceeded to remove the ace wrap and then to cut the kerlix dressing from Resident #40's right leg. Then the ADHS removed the abdominal (ABD) dressing from Resident #40's right heel. Resident #40 was moaning, groaning, and saying her leg hurt the entire time. The ADHS stopped after removing the old bandage and asked Resident #40 if she wanted more pain medicine as she had acetaminophen one hour prior to the dressing removal. Resident #40 said yes and the ADHS brought in as needed Tramadol and told Resident #40 she would be back later to complete the dressing change. Observation of the ADHS performing wound care for Resident #40 on 01/14/26 at 4:38 P.M. revealed the right heel wound was dark red to black in color and it was the size of a penny. The ADHS stated the right heel measured at one point three cm in length and one centimeter in width. The ADHS cleaned the right heel with skin prep, placed a petrolatum-impregnated cellulose acetate mesh to the right heel, covered it with an ABD dressing, covered with gauze and secured with an ace wrap. Observation on 01/15/26 at 8:16 A.M. of Resident #40 sitting in the dining room with her legs down and no pressure relieving boot on her right heel. Observation on 01/15/26 at 8:52 A.M. of Resident #40 sitting in her wheelchair in her room with her legs down with no pressure relieving boot. The ADHS verified that Resident #40's legs were not elevated. Interview on 01/15/26 at 8:52 A.M. with the ADHS who stated Resident #40's right heel was just red last week and now it is black and has worsened. The ADHS stated that Resident #40 is at risk for pressure ulcers/injuries, had weekly skin assessments, and that she is not sure when the pressure injury to Resident #40's right heel happened. The ADHS stated she is not sure if the nurse practitioner (NP) or the physician had seen Resident #40's wound to her right heel as the NP had not observed her changing a dressing or asked to see the wound. The ADHS stated she would recommend Resident #40 to see the wound clinic at this time as all the interventions have failed and her heel is getting worse. The ADHS stated she is not wound certified. Interview on 01/15/26 at 10:59 A.M. with the Director of Health Services (DHS) who stated the facility does not have a wound NP to come in to assess and monitor wounds. The DHS stated she is wound certified. The DHS stated that the ADHS had taken the wound course, but had not re-taken the test, so she is not wound certified. The DHS stated she did not see Resident #40's right heel until 01/13/26. The DHS stated the wound process is for the ADHS to do the initial assessment of any wound, then the ADHS follows the wound weekly until the wound is healed. The DHS stated the NP and physician had probably not seen Resident #40's right heel. The DHS verified that Resident #40 is compliant with care and that interventions were in place to prevent pressure ulcers. The DHS stated she had been following Resident #40's wounds and had seen the right heel as recently as 01/13/26 when the right heel was darker red, turning purple and would be a suspected deep tissue injury (SDTI) (a severe pressure-related wound damaging skin and underlying soft tissues, often starting under intact skin as a bruise-like purple or maroon area, that rapidly deteriorates to reveal significant tissue death-necrosis). Interview on 01/15/26 at 12:49 P.M. with CNA #303 who stated that Resident #40 is up a lot and her legs are down. Additionally, CNA #303 stated she had never seen Resident #40 wearing pressure relieving boots. Interview on 01/15/26 at 12:59 P.M. with Licensed Practical Nurse (LPN) #397 who stated that she does not know if Resident #40's heels were floated when she is in bed. Additionally, LPN #397 stated that the interventions for pressure ulcers/injuries are on the MAR and TAR and the nurses sign off on the orders unless Resident #40 refused care and that she does not remember the CNA's telling her that Resident #40 refused care. Interview on 01/15/26 at 3:04 P.M. with the ADHS who was shown the Pocket Guide to Pressure Ulcers fourth edition and stated that Resident #40's right heel looked like the picture of a stage one pressure ulcer and was blanchable, but that on 01/15/26 Resident #40's right heel looked like the picture illustrating the deep tissue injury (DTI). The ADHS verified that she is not wound certified and had not re-taken the exam. Interview on 01/15/26 at 3:12 O.M. with the DHS who stated that she is aware of the concerns regarding identification, assessment, and documentation of Resident #40's wounds. The DHS stated that an unavoidable pressure ulcer is when you have all the interventions in place and a resident still gets a pressure ulcer. Additionally, the DHS stated that if all the measures are in place and the measures (interventions) are signed off they are being done, then she would not have done anything differently. Furthermore, the DHS stated that the only thing she can think of is that Resident #40 had allergies to adhesives and maybe that caused her skin to breakdown. Interview on 01/15/26 at 4:17 P.M. with the NP for the facility who stated that Resident #40 had bandages on bilateral legs on 01/13/26 but was in the dining room and did not want to return to her room for the NP to exam them. Furthermore, the NP stated that she was not aware that Resident #40 had any pressure ulcers/injuries at this time. Review of the facility policy Guidelines for General Wound and Skin Care dated 12/12/25 revealed the purpose of the policy was to provide measures that will promote and maintain good skin integrity. Additionally, the facility policy Guidelines for General Wound and Skin Care dated 12/12/25 revealed notify wound care nurse/nurse supervisor for all new stage two through four pressure ulcers or if you have any questions. Review of the facility policy Dressing changes dated 12/16/24 revealed follow doctor's recommendations for treatment. Review of the facility policy Pressure/Statis/Arterial/Diabetic Wound Guidelines dated 12/08/25 revealed the purpose of the policy is to provide weekly documentation guidelines of wound measurements and condition. Documentation description of the wound should include length, width, depth, exudates, color, odor, wound margins, surrounding tissue, and tunneling and/or undermining if applicable. Additionally, the facility policy Pressure/Statis/Arterial/Diabetic Wound Guidelines dated 12/08/25 revealed re-assessment/measurement weekly or with significant change in wound noting current treatment, medical interventions provided, and comments as needed in progress notes and wound management or with follow up weekly in wound zoom. 2. Review of the medical record for Resident #91 revealed an initial admission date of 01/06/26 with the diagnoses including but not limited to hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of left lower extremity, atrial fibrillation and congestive heart failure. Review of the admission wound documentation dated 01/06/26 for the Stage II pressure ulcer to the coccyx revealed the wound measured 2.0 cm by 1.5 cm by 0.1 cm and described epithelial tissue with the surrounding tissue being pin. The wound had no exudate and the facility determined the wound was improving. Review of the admission wound documentation dated 01/06/26 for the Stage III pressure ulcer to the left heel revealed the wound measured 1.5 cm by 1.0 cm. The wound was described as closed resurfaced with edges attached to the base and no exudate was present. The surrounding skin was red and blanchable. The facility determined the wound was stable. Review of the resident's admission observation and data collection dated 01/07/26 revealed the resident was admitted to the facility with skin issues and an occurrence progress note was completed. Review of the Braden Scale contained in the admission observation and data collection dated 01/07/26 revealed a score of 15 indicating the resident was at risk for skin breakdown. Review of the progress note dated 01/07/26 at 4:36 A.M. revealed the resident was admitted to the facility with an open area to the coccyx measuring 2.5 centimeters (cm) by 1.5 cm and an open area to the left heel measuring 1.5 cm by 1.0 cm. The resident's skin to the left lower extremity was noted to be discolored. Review of the progress note dated 01/07/26 at 7:24 P.M. revealed the admission reassessment was completed and the resident was found to have a pressure wound on the coccyx and left heel. The right heel was soft and tender. Review of the plan of care dated 01/08/26 revealed the resident had a pressure ulcer to coccyx and left heel on admission. Interventions included administer analgesics per physician orders, assess and record the condition of the skin surrounding the pressure ulcer, encourage fluids unless contraindicated, observe and report sings of infection, observe for the report signs of pain related to pressure ulcer, obtain a dietary consult, pressure reducing cushion to chair, reducing mattress, provide diet, supplements, vitamins and minerals as ordered, treatment per physician order, notify physician if treatment is not effective and weekly skin assessment, measurement and observation of the pressure ulcer and record. Review of the weekly wound documentation dated 01/13/26 for the Stage II pressure ulcer to the coccyx revealed the wound measured 2.0 cm by 1.5 cm by 0.1 cm and described epithelial tissue with the surrounding tissue being pin. The wound had no exudate and the facility determined the wound was improving. Review of the weekly wound documentation dated 01/13/26 for the Stage III pressure ulcer to the left heel revealed the wound measured 1.5 cm by 1.0 cm. The wound was described as closed resurfaced with edges attached to the base and no exudate was present. The surrounding skin was red and blanchable. The facility determined the wound was stable. Review of the resident's monthly physician orders for January 2026 identified orders dated 01/07/26 cleanse wound to coccyx with wound cleanser or normal saline (NS), pat dry, apply skin prep to peri-wound and cover with border dressing daily and as needed for dislodgement or soiled, cleanse wound to left heel with wound cleanser or NS, pat dry, apply skin prep to peri-wound and cover with border dressing three times a week on Monday, Wednesday, Friday and as needed for dislodgement or soiled, apply foam dressing to right heel and change every five days or as needed for soiled, 01/08/26 cleanse bilateral buttocks with soap and water, pat dry, apply house barrier cream twice daily for prevention, cleanse wound under left breast with wound cleanser or NS, pat dry, apply house anti-fungal powder to peri-wound daily and as needed, 01/08/26 staff to use enhance barrier precautions, wearing a gown and gloves at minimum during high-contact care activities and 01/09/26 MedPass 2.0 120 milliliters (ml) twice daily. On 01/12/26 at 1:32 P.M., observation of the resident during the resident interview revealed the resident had street shoes on the left heel with no off-loading to the Stage III pressure ulcer. On 01/13/26 at 12:08 P.M., observation of the resident revealed she was laying in bed with no off-loading to the Stage III pressure ulcer to the left heel. On 01/13/26 at 12:11 P.M., an interview with Licensed Practical Nurse (LPN) #385 verified the resident had no off-loading to the Stage III pressure ulcer of the left heel. Review of the facility policy titled, Guidelines for General Wound and Skin Care, last revised 02/23/23 revealed evaluate the resident for the need for a pressure reduction surface for bed/chair and the need for elbow protectors and/or heel floats/boots.

Based on record review, staff interview, and policy review, the facility failed to ensure psychotropic medications used on an as needed basis (prn) were limited to 14 days, unless the prescribing physician and/ or advanced level provider documented a rationale in the medical record and indicated the duration for the prn order. This affected one resident (#45) of five residents reviewed for unnecessary medications. Findings include:Review of Resident #45's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder. Review of Resident #45's progress notes revealed the resident was seen by the nurse practitioner on 10/29/25 following a hospitalization for a pulmonary embolism. She was also known to have severe Alzheimer's dementia with anxiety, which was a chronic illness, and indicated to be stable. She was receiving Buspirone (an anti-anxiety medication) 10 mg three times a day, Duloxetine (an anti-depressant) 30 mg daily, and Remeron (an anti-depressant) 7.5 mg every night at bed time. No medication adjustments were needed at that time. Further review of Resident #45's nurses' progress notes revealed a nurse's note dated 10/30/25 at 6:43 A.M. that indicated the resident was displaying signs of restlessness and anxiousness throughout the shift. She was noted to be walking towards exit doors and into other resident rooms and redirection attempts were not always successful. She was also walking without her walker and had to be redirected to her walker several times. She was unable to sleep for a long period of time. Review of Resident #45's physician's orders revealed the resident received an order for the use of Xanax (an anti-anxiety medication that was included under the broader category of a psychotropic medication) 0.25 milligrams (mg) twice a day prn. The order was received on 10/30/25 and was an open ended order. That order continued until 12/11/25, when the prn order was resumed on 12/11/25 at the previously prescribed dose and frequency of use. That order remained until 01/05/26, when a new order was received for Xanax 0.25 mg by mouth every 12 hours as needed. That order was an open ended order with no specific duration of use indicated. Further review of Resident #45's medical record revealed she was seen by the nurse practitioner on 11/13/25 at 9:09 A.M in an effort to decrease recidivism to the hospital. The nurse practitioner included the resident's use of Xanax 0.25 mg by mouth (po) twice a day prn as one of the medications the resident received at the time, when listing all the medications the resident was on. There was no documentation in that progress note of the resident displaying any signs related to her anxiety diagnosis and the resident was described as being cooperative during that visit. She again indicated the resident's chronic illness of severe Alzheimer's dementia with anxiety was stable and she listed out the medications (Buspirone, Duloxetine, and Remeron) the resident was currently receiving to manage that condition. She did not add the Xanax that had been started on 10/30/25, as one of the resident's medications being used for the management of her chronic anxiety related to Alzheimer's dementia. There was no documentation from the nurse practitioner providing a rationale as to why the Xanax should be continued, or an indication of the planned duration for it's use. On 01/15/26 at 10:30 A.M., an interview with the facility's Director of Nursing (DON) confirmed Resident #45's Xanax that was ordered prn beginning on 10/30/25 did not include an initial stop date of 14 days as required. She acknowledged there was nothing documented in the resident's medical record from the physician or nurse practitioner providing a rationale as to why the use of the Xanax on a prn basis should be extended or an indication of the planned duration for use. Review of the facility's policy on Psychotropic Medication Use and Gradual Dose Reduction Guidelines revised 03/10/25 revealed the purpose of the guidelines was to ensure every effort was made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation, and monitoring by the interdisciplinary team. Residents should receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support usage. The medical necessity was to be documented in the medical record. PRN orders for psychotropic drugs were limited to 14 days. Except as provided if the attending physician or prescriber believed that it was appropriate for the prn order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the prn order.

Based on observation, interview, record review, and review of facility policy the facility failed to regularly assess and obtain a physician order for a restraint for Resident #8. This affected one resident (#8) of one resident reviewed for restraints. The facility census was 54.Findings include:Review of Resident #8's medical record revealed an admission date of 01/15/21 with diagnoses including epilepsy, unspecified mood disorder, expressive language disorder, unspecified convulsions, and age-related osteoporosis. Review of Resident #8's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. She had a trunk restraint that was used daily.Review of Resident #8's plan of care revised 11/17/25 revealed the resident was requesting a seatbelt to wheelchair, a physical restraint due to unable to independently released when in chair. Interventions included using seatbelt when in motorized wheelchair for safety and positioning and release per resident request, assure the medical record contains documentation of the medical condition justifying the use of restraint, obtain physician order before applying restraint, attempt restraint reduction with goal to discontinue, monitor, document or report any negative outcome, complete a restraint assessment before applying restraint and quarterly thereafter, and obtaining signed consent. Review of Resident #8's medical record information documentation from 01/01/25 to 01/14/26 revealed no restraint assessments.Review of Resident #8's physicians' orders on 01/14/26 revealed no order for a restraint.Interview on 01/14/26 at 9:50 A.M. with the Director of Nursing (DON) verified Resident #8 did not have an order for her restraint and had not been assessed in the last year.Review of the policy 'Guidelines for Restraint/Enabler use' dated 12/17/24, revealed each resident was to have an individualized nursing observation upon admission, quarterly and as needed, that shall address the need for the safety device, the medical symptom for use of the device and identification of whether the device restricts movement or limits the resident from doing something they could previously do. An order was to be obtained that specified the type of restraint or enabler and the reason for use.

Based on record review, observation, interview, and policy review, the facility failed to ensure a resident with non-pressure wounds had wound treatments provided timely as per physician's orders and another resident received treatment to dry, flaky skin from eczema as per physician's orders. This affected two residents (#65 and #93) of four residents reviewed for non-pressure skin conditions. Findings include:1. Review of Resident #65's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a complete rotator cuff tear or rupture of the right shoulder, encounter for other orthopedic aftercare, sprain of the ligaments of his cervical spine, displaced fracture of the middle phalanx of the left middle finger, non-displaced transverse fracture of the right patella, Parkinson's disease, tremors, primary osteoarthritis of the bilateral hips, anxiety disorder, and depression. Review of Resident #65's physician's orders revealed he had orders in place to apply Betamethasone Dipropionate Cream (a potent topical corticosteroid used to relieve inflammation, redness, itching, and swelling from skin conditions like eczema, psoriasis, and dermatitis) 0.05% with directions to administer a thin layer (does not specify where) twice a day. The order originated on 12/30/25 and remained a current treatment. He also had an order for Ketoconazole cream (an anti-fungal medication used to treat various fungal and yeast skin infections like seborrheic dermatitis) 2% (T) twice a day to beard area until resolved. That treatment was initiated on 01/02/26 and continued to be in use. Review of Resident #65's progress notes revealed a nurse's note dated 12/31/25 at 12:09 P.M. that indicated the resident was noted to have a rash on his face that originated on 12/30/25 at 4:17 P.M. The physician was made aware of the rash. Further review of Resident #65's progress notes revealed a nurse's progress note dated 12/31/25 at 7:35 P.M. that indicated a new order was received for Ketoconazole cream with directions to apply to his face twice a day until clear. A nurse's note dated 01/08/26 at 5:56 P.M. revealed a follow up on the resident's face was completed and the area on his face had been resolved. Review of Resident #65's treatment administration record (TAR) for January 2026 revealed the nurses continued to sign off to reflect treatments were being done twice a day to the resident's face applying Ketoconazole cream 2% topically (T) to redness/ flaking skin to beard area. They were also signing off the TAR to reflect the Betamethasone Dipropionate Cream 0.05% was being applied as a thin layer twice a day, but did not specify the location where that cream was being applied. On 01/12/26 at 4:54 P.M., an interview with Resident #65 revealed he continued to have issues with dry skin on face. He stated the staff were supposed to wash his face twice daily and apply a medicated cream to it. He indicated it did not always get done twice a day and was usually just once a day that it was done. He usually had to ask to have the treatment completed as ordered. On 01/13/26 at 5:02 P.M., an interview with Registered Nurse (RN) #377 revealed Resident #65 did have some dry, flaky skin to the beard area of his face when he first came in. She reported his face was looking a lot better now. She was asked about the treatment they were signing off on the TAR for the Betamethasone Dipropionate, since the order was not clear where to apply it. She reported she was not sure where the cream was being applied despite her signing off on the TAR the past two mornings between 6:00 A.M. and 10:00 A.M. indicating the treatment had been completed. She was not able to answer how she was signing off the TAR to reflect the treatment was done, when the order did not specify where to apply the Betamethasone Dipropionate cream. She confirmed she did not apply the cream as ordered that morning despite signing off the TAR to indicate that it was. She did not recall applying it yesterday either despite signing the TAR off showing that she did. She was then asked about the Ketoconazole 2% cream that was also ordered to be applied twice a day. She admitted she did not apply that cream as ordered earlier that day either despite signing off the TAR to reflect that she had. She acknowledged the resident was reporting he was not getting his Ketoconazole cream applied to his face twice a day as ordered and her statements confirmed that as being accurate. 2. Review of the medical record for Resident #93 revealed an initial admission date of 01/10/26 with the diagnoses including but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, severe morbid obesity. right bundle branch block, bifascicular block, ventricular tachycardia, gout, Parkinson's disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, constipation and prediabetes. Review of the resident's admission observation and data collection dated 01/10/26 revealed the resident was admitted to the facility being alert, with impaired daily decision making. Review of the admission wound documentation of the venous ulcer to the left lower extremity/shin dated 01/10/26 revealed the wound measured 5.0 centimeters (cm) by 6.0 cm. The wound was described as closed/resurfaced tissue with the surrounding tissue being described dark purple or rusty discoloration. The wound was determined to be stable. Review of the admission wound documentation of the venous ulcer to the right lower extremity/shin dated 01/10/26 revealed the wound measured 5.0 cm by 6.0 cm. The wound was described as having no exudate, closed/resurfaced tissue with the surrounding tissue being described dark purple or rusty discoloration. The wound was determined to be stable. Review of the plan of care dated 01/12/26 revealed the resident was at risk for skin breakdown r/t indwelling catheter, bowel incontinence, antiplatelet, morbid obese, vascular ulcers, hypothyroidism. Interventions included avoid shearing skin during positioning, turning and transferring, conduct weekly skin assessment, encourage and assist to turn and reposition for comfort and as needed, float heels as needed and tolerated, keep linens clean and dry, keep resident as clean and dry as possible, minimize skin exposure to moisture, observe feet during care for redness, swelling, or changes in condition and notify physician as needed, pressure reducing cushion to chair, pressure reducing mattress to bed, treatments/preventative treatments as or when ordered, use lifting device as needed for bed mobility and moisture barrier product to perineal as needed. Review of the weekly wound documentation of the venous ulcer to the left lower extremity/shin dated 01/13/26 revealed the wound measured 5.0 centimeters (cm) by 6.0 cm. The wound was described as closed/resurfaced tissue with the surrounding tissue being described dark purple or rusty discoloration. The wound was determined to be improving. Review of the admission wound documentation of the venous ulcer to the right lower extremity/shin dated 01/13/26 revealed the wound measured 5.0 cm by 6.0 cm. The wound was described as having no exudate, closed/resurfaced tissue with the surrounding tissue being described as dark purple or rusty discoloration. The facility determined the wound was improving. Review of the resident's monthly physician orders for January 2026 identified orders dated 01/10/26 cleans bilateral lower extremities, pat dry, apply xeroform to open wounds, pad heels and weeping areas with ABD pads, wrap legs from base of toes to just below knees with Kerlix and ace wraps daily and as needed. An order dated 01/12/26 for oxygen at three liters per nasal canula continuously, resident has a diagnosis of respiratory failure, monitor for shortness of breath, restlessness, fatigue, rapid breathing, elevated heart rate. Monitor for any negative outcomes such as new or worsening conditions and notify the physician. Review of the resident's January 2026 Treatment Administration Record (TAR) revealed the treatment to the resident's bilateral lower extremities of cleanse, pat dry, apply xeroform to areas, cover with ABD, wrap legs from base of toes to just below knees with kerlix and ace wraps daily was documented as a late entry and documented as completed at 11:00 A.M. instead of the 3:45 P.M. as observed. Review of the resident's progress note dated 01/10/26 at 7:06 P.M., revealed the resident was admitted to the facility with oxygen at three liters via nasal canula continuously. Head to toe assessment completed with discoloration noted on bilateral lower extremities. On 01/13/26 at 10:26 A.M., observation of Resident #93 revealed the resident was in therapy with no treatment or ace wraps to his legs. On 01/12/26 at 12:40 P.M., observation of Resident #93 revealed he was sitting at the nurse's station with no treatment or ace wraps to his legs. On 01/12/26 at 3:31 P.M., observation of Resident #93 revealed the resident was quiet at bedrest with no treatment or ace wraps to his bilateral lower legs as physician ordered. On 01/12/26 at 3:45 P.M., interview with Licensed Practical Nurse (LPN) #390 revealed she was walking down the hallway and asked if the surveyor wanted to observe the resident's wound care. The LPN was informed a resident interview was being conducted. She verified the resident's twice daily treatment was just now being completed. She also verified the resident had no dressing or ace wraps on his bilateral lower extremities at this time. Review of the facility policy titled, Guidelines for General Wound and Skin Care, last revised 02/23/23 revealed the purpose of the policy was to provide measures that will promote and maintain good skin integrity. Dress chronic wounds using clean technique since all chronic wounds are contaminated.

Based on observation, interview, medical record review, review of activity calendar, and review of policies revealed the facility failed to provide preferred independent activities to Resident #86, and failed to provide evidence Resident #49 and Resident #86 were invited to or attended group activities. This affected two residents (#49 and #86) of two residents reviewed for activities. The facility census was 54. Findings include:1.Review of Resident #49's medical record revealed an admission date of 12/16/25 with diagnoses including unspecified mood disorder, pulmonary fibrosis, hypothyroidism, depression, anxiety, dementia, and hypertension.Review of Resident #49's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition.Review of Resident #49's life enrichment assessment dated [DATE] revealed it was very important for the resident to listen to music (country was her favorite), be around animals, keep up with the news, do things with groups, participate in religious services, and read books, newspapers or magazines. Additionally, it was very important to do her favorite activities which included, bowing, cooking, reading, and coloring.Review of Resident #49's plan of care dated 12/23/25 revealed she may not participate in programming of interest due to my diagnosis of depression. Interests include reading, listening to country music and cooking. Interventions included introducing to other residents, encouraging family and friend support, inviting and assisting to activities, and reviewing campus schedule with resident.Review of Resident #49's activity documentation 12/14/25 to 01/14/26 revealed she had participated in a personal activity of the activity packet nine times, the notes related to this were not specific to the resident and indicated all residents received the activity packet or enjoyed it. She additionally had mindful moments sensory programming on 01/12/26 and a visitor on 01/13/26. There was no evidence she was provided music or other preferred activities. No activities were declined.Observation on 01/12/26 at 10:02 A.M., 1:42 P.M., and 2:25 P.M., on 01/13/26 at 1:30 P.M. and 3:36 P.M., on 01/14/26 at 8:49 A.M., and on 01/15/26 at 8:35 A.M. revealed Resident #49 awake in her recliner with no entertainment.Interview on 01/15/26 at 8:35 A.M. with Resident #49 revealed she loved country music.Interview on 01/15/26 at 8:35 A.M. with Certified Resident Care Associate (CRCA) #324 verified there was no method in Resident #49's room to play country music. She reported the facility had smart speakers that they could use to play music for residents.Interview on 01/15/26 at 10:24 A.M. with Life Enrichment Director #417 revealed activities aides were to ask residents in the morning when they were passing the activity packet if they were interested in the activities for the day. She verified there was no evidence Resident #49 had been offered or was declining group activities. She additionally verified, Resident #49 preferred country music, and they had smart speakers they could provide residents. 2. Review of Resident #86's medical record revealed an admission date of 01/02/26 with no diagnoses listed.Review of Resident #86's hospital Discharge summary dated [DATE] revealed diagnoses including hypertension, dementia, and chronic kidney disease.Review of Resident #86's activity documentation from 01/02/26 to 01/14/26 revealed he had participated in a personal activity of the activity packet six times, the notes related to this were not specific to the resident and indicated all residents received the activity packet or enjoyed it. On 01/13/26 the resident had visitors and a visit from the life enrichment director. No activities were declined.Review of Resident #86's life enrichment assessment dated [DATE] revealed it was very important for the resident to have books, be around pets, keep up with news, and participate in religious services.Review of Resident #86's Brief Interview for Mental Status (BIMS) dated 01/07/26 revealed he had severely impaired cognition.Observation on 01/12/26 at 2:20 P.M., 2:44 P.M., and 3:00 P.M. revealed Resident #86 at a dining room table sleeping. Activities were observed occurring in another area at that time.Interview on 01/15/26 at 10:24 A.M. with Life Enrichment Director #417 revealed activities aides were to ask residents in the morning when they were passing the activity packet if they were interested in the activities for the day. She verified there was no evidence Resident #86 had been offered or was declining group activities. Review of the policy 'Resident Choice' dated April 2025, revealed the residents were to be invited to attend activities and will be provided the opportunity to participate in structured and individual programs. Residents who prefer not to participate in structured programs will be offered alternatives for the meaningful pursuit of leisure interests.

Based on record review, observations, and interviews, the failed to ensure medications were not kept at bedside without orders for Resident #21 and #43. This affected two residents (#21 and #43) of the three residents reviewed for medications. This facility census was 54.Findings include:1. Review of the medical record for Resident #43 revealed an admission date of 07/15/20 with a re-entry date of 03/04/25 with diagnoses to include but not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, morbid (severe) obesity due to excess calories, anxiety disorder, cellulitis of abdominal wall, type two diabetes mellitus with chronic kidney disease stage 3, hypertensive heart disease, and shortness of breath. Review of the quarterly MDS dated [DATE] revealed a BIMS of 12 which indicated moderate cognitive impairment. No current self-administration of medication evaluation was documented for Resident #43. Review of the care plan dated 07/16/20 revealed Resident #43 was at risk for shortness of breath while lying flat related to chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease with interventions to include medications as ordered. Review of an order for Resident #43 dated 03/04/25 Combivent Respimat (ipratropium-albuterol) mist 20-100 micrograms (mcg) amount to administer one puff inhalation every six hours as needed. Observation in Resident #43's room [ROOM NUMBER]/12/26 at 11:03 A.M revealed Combivent Respimat inhaler on Resident #43's bedside table. At the time of the observation, Licensed Practical Nurse (LPN) #358 verified the Combivent Respimat inhaler was on Resident #43's bedside table and stated she did not know if Resident #43 was supposed to have the inhaler at bedside as it had been there since she started. Review of the facility Medication Storage policy dated 11/01/22 revealed medications must not be stored on the floor. Medications must be stored under proper conditions to protect against degradation which includes having an environment that is dry, sanitary, and has appropriate light controls. 2. Review of the medical record for Resident #21 revealed an initial admission date of 12/31/25 with the diagnoses including but not limited to urinary tract infection (UTI), adult failure to thrive, hyperlipidemia, hematuria, severe protein calorie malnutrition, neoplasm of left kidney, non-infective gastroenteritis and colitis, calculus of gallbladder, chronic obstructive pulmonary disease, pleural effusion, acute kidney failure, fracture of upper end of right humerus, elevated white blood cell count, systemic inflammatory response syndrome, encephalopathy, diarrhea, low back pain hypertension and cerebral infarction. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the resident's monthly physician orders for January 2026 identified an order dated 12/31/25 for Fluticasone Propionate spray 50 micrograms (mcg)/actuation with the special instructions to instill two sprays in each nares daily. Review of the medical record revealed no self-administration assessment to determine if the resident was capable of self-administering the medication Flucticasone Propionate spray 50 mcg. On 01/12/26 at 12:21 P.M., observation of Resident #21 revealed a bottle of Flucticasone Propionate spray 50 mcg was observed to be sitting on the resident's bedside table. On 01/12/26 at 12:35 P.M., interview with Licensed Practical Nurse (LPN) #390 verified the medication was stored improperly on the resident's bedside table and should be locked in the medication administration cart. The LPN also verified the resident had no physician order or assessment to self-administer the medication.

Based on record review, observation, and interviews, the facility failed to provide double portions as ordered for Resident #3 and failed to provide adequate meal assistance and hydration for Resident #79. This affected two residents (#3 and #79) of the seven residents reviewed for nutrition. The facility census was 54.Findings include:1. Review of the medical record for Resident #3 revealed an initial admission date of 11/12/25 with the diagnoses including but not limited to metabolic encephalopathy, sepsis due to enterococcus, severe sepsis with septic shock, urinary tract infection, multiple myeloma in remission, severe protein malnutrition, pleural effusion, dry eye syndrome, bariatric surgery status, hypothyroidism, hypotension, anxiety disorder, depression, obstructive sleep apnea, hyperlipidemia, Review of the plan of care dated 11/17/25 revealed the resident required increased caloric, protein, and/or nutrient needs related to presence of impaired skin integrity. Interventions included dietitian to re-evaluate as indicated, encourage fluids, labs as ordered by physician, obtain weight as ordered or as needed, provide diet as ordered, provide supplements, vitamins, and/or minerals as ordered and tube feeding and flush as ordered. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors including rejection of care. The resident's weight was coded at 98 pounds and had a significant weight loss and was not on a prescribed weight loss regimen. Review of the resident's monthly physician orders for January 2026 identified orders dated 11/13/25 Remeron 7.5 milligrams (mg) by mouth at bedtime for appetite stimulant and 12/10/25 MedPass 2.0 120 milliliters (ml) by mouth twice daily. On 01/12/26 at 10:20 A.M., interview with the resident revealed she was supposed to receive double portions at meals however they do not give her the double portions. The resident lifted the lid of her breakfast try and stated she received a cinnamon bagel with cream cheese and two servings of rice Krispies for breakfast and had told them she preferred frosted flakes. Observation of the breakfast tray revealed the resident ate the cereal. On 01/12/26 at 12:51 P.M., observation of the lunch meal revealed the resident was served a bowl of chicken and dumplings soup, a serving of carrots and a serving of Jello. The Executive Director (ED) who served the resident her lunch verified the resident was not served double portions for the lunch meal. The ED verified the resident's meal ticket did not indicate the resident was to receive double portions. 2.Review of Resident #79's medical record revealed an admission date of 09/26/24 with diagnoses to include but not limited to unspecified sequelae of cerebral infarction, dementia, atherosclerotic heat disease, type two diabetes mellitus, vitamin D deficiency, cerebellar stroke syndrome, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted and a staff assessment of mental status was not conducted. Review of Resident #79's behavior revealed no documented refusals or rejection of care. Additionally, review of Resident #79's functional ability for eating required staff to set up his tray or meals. Review of Resident #79's swallowing abilities revealed no deficits. Furthermore, review of Resident #79's functional abilities for self care revealed that Resident #79 is dependent on staff for all activities of daily living (ADLs). Review of the care plan dated 09/30/24 revealed Resident #79 is at risk for malnutrition related to diagnoses, inadequate nutrient/energy intakes, and/or metabolic demands with interventions to include assist with meals as needed, offer alternate food and beverage items as needed, and provided diet, supplements, medications, and adaptive equipment as ordered. Review of the meal percentages from 01/01/26 to 01/14/26 for Resident #79 revealed no morning or bedtime snack given. Observation on 01/12/26 at 12:36 P.M. of Resident #79 who received his tray which was a regular diet consisting of two hot dogs in buns and French fries. Observation on 01/13/26 at 12:39 P.M. of Resident #79 struggling to cut his ham for lunch, his fruit cup was still covered. Observation on 01/13/26 at 12:55 P.M. of Resident #79 in the dining room, trying to cut his ham, glass is empty and fruit is still covered. Observation on 01/13/26 at12:58 P.M. of Resident #79 who is eating his cornbread muffin and his fruit is still covered. Observation on 01/13/26 at 12:05 P.M. of Resident #79 sitting in his Broda chair in the dining room with a Styrofoam cup and tray in front of him with his silverware still rolled in his napkin. Observation on 01/14/26 at 8:34 A.M. of Resident #79 semi-lying in bed with his breakfast tray on the bedside table which was to the side of the bed and not in front of Resident #79. Licensed Practical Nurse (LPN) #330 verified that Resident #79 was semi-lying in bed with his breakfast tray on the bedside table which was to the side of the bed and out of Resident #79's reach. Observation on 01/14/26 at 12:42 P.M. of Resident #79 lying in bed trying to drink water from a glass cup for lunch. The Assistant Director of Health Services (ADHS) # 338 verified that Resident #79 was lying in bed and trying to drink his water. Additionally, the ADHS #338 verified that Resident #79's bedside tray was not in front of him and was out of his reach to properly eat his meal. Observation on 01/14/26 at 2:36 P.M. of Resident #79 in the Mayflower dining area and the resident had no fruit or water available. Observation on 01/14/26 at 3:36 P.M. of Resident #79's water cup on his bedside table which was pushed against the wall and his water cup was out of reach. ADHS #338 verified at the time of the observation that the water cup was out of Resident #79's reach and stated the water cup was empty. Interview on 01/14/26 at 12:22 P.M. with Dietary Services Assistant #368 revealed that the expectation of dining services assistants is unrolling the silverware, serving drinks, and making sure all containers are uncovered. Interview on 01/13/26 at 12:28 P.M. Dietary Services Assistant Director #353 who stated we try to let the residents open their own silverware and food items. If I walk by a few times and see that the resident has not opened their silverware, then I will stop and open the silverware and food items for them. Interview on 01/12/26 at 12:59 P.M. with Resident #79 who stated he did not like hot dogs and the staff didn't offer him anything else. Interview on 01/14/26 at 7:34 A.M. with Certified Nursing Assistant (CNA) #303 who stated that the CNAs give water to the residents who can ask for it. Additionally, CNA #303 stated they do not have a water cart where they pass out water to the residents but must use the styrofoam cups and the CNA's give water to the residents individually. Interview on 01/14/26 at 9:03 A.M. with the ADHS #338 who stated when the resident comes in at admission, we do an assessment for feeding/eating needs and if they need assistance, then they are placed in the private dining room. We reassess residents often to see if the residents need assistance and when we do rounds. We train the CNAs to report if they think the resident needs assistance with meals. ADHS #338 stated the expectation for set-up for meals was to put the tray in front of the residents and if they need something cut up, then the staff is to cut it for the resident. Interview on 01/14/26 at 12:43 P.M. with Dietary Services Assistant #384 who stated that she takes the residents' tray into their room after making sure that the meal ticket is correct. Then she puts the tray on the resident's bedside table, takes off the cover and makes sure the silverware is there, and the meal is ready for the resident to eat. Interview on 01/14/26 at 3:05 P.M. with the DHS who stated there is no facility hydration policy. Interview on 01/14/26 at 4:07 P.M. the DHS who stated that all residents are offered a bedtime snack and not just residents with diabetes. Interview on 01/14/26 at 5:10 P.M. the ADHS #338 verified that Resident #79 can reach for, pick up and drink from a styrofoam cup on his own if the cup is within his reach. Review of the Dining Services Assistant job description undated revealed the dining services assistants are to set up meal trays, food carts, dining room, etc., as instructed. Review of the facility policy Meal Service dated 10/25/25 revealed a nourishing bedtime snack will be provided at bedtime. Additionally, the facility policy Meal Service dated 10/25/25 revealed if an individual is not accepting their food, an appropriate alternate is offered. Substitutions will be offered to residents who consume 75 percent (%) or less. Furthermore, the facility policy Meal Service dated 10/25/25 revealed staff will assist the individual as needed. This deficiency represents non-compliance investigated under Complaint Number 2682505.

Based on observation, interview, and record review the facility failed to provide the appropriate diet texture as ordered for Resident #65 and #67. This affected two residents (#65 and #67) of twelve reviewed for dining. The facility census was 54.Findings include: 1.Review of Resident #67's medical record revealed an admission date of 11/13/25 with diagnoses including fracture of unspecified part of femur, chronic obstructive pulmonary disease, heart failure, anxiety disorder, Parkinson's disease, and unspecified convulsions. Review of Resident #67's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. She received antianxiety medication, antidepressants, anticoagulants, antibiotics, opioids, and anticonvulsants. Review of Resident #67's after visit summary dated 01/12/26 revealed the resident was at moderate risk for aspiration and the diet recommended for the resident was International Dysphagia Diet Standardization Initiative (IDDSI) level six (soft and bite sized) and liquid recommendation was IDDSI level three (moderately thick). Review of Resident #67's physician order dated 01/12/26 revealed an order for a mechanical soft diet with honey or moderately thick liquids. She was to have one on one supervision during eating. Observation on 01/13/26 at 8:20 A.M. revealed Resident #67 eating in her room. Her tray had two pieces of toast and two whole sausage patties on it (about three inches wide). At 8:26 AM observation with Registered Nurse (RN) #392 revealed Resident #67 had one sausage patty remaining. Additionally, she was observed with cups of regular coffee and water that appeared to be a thin consistency. Observation of her tray ticket dated 01/13/26 revealed she was to receive a regular diet with no indication of thickened liquids. Interview on 01/13/26 at 8:26 A.M. with RN #392 verified Resident #67 had not received the appropriate diet or liquids. It did not appear that the kitchen had been updated with the resident's current diet. Review of the Complete IDDSI Framework Detailed definitions 2.0 dated 2019, revealed moderately thick liquids drips slowly in dollops through the prongs of a fork but easily pours from spoon when tilted. Soft and bite sized food was described as being able to be mashed or broken down with pressure from a fork or spoon. Bite sized pieces should be no larger than 1.5 centimeters. For these foods biting is not required but chewing is. The food piece sizes was to minimize choking risk. A policy for mechanically altered diets was requested but not provided 2. Review of Resident #65's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included complete rotator cuff tear or rupture of the right shoulder, encounter for other orthopedic aftercare, sprain of ligaments of cervical spine, displaced fracture of the middle phalanx of the left middle finger, non-displaced transverse fracture of the right patella, Parkinson's disease, tremors, dysphagia (difficulty swallowing), and depression. Review of Resident #65's nutrition admission assessment dated [DATE] at 12:09 P.M. revealed the resident had dysphagia warranting a PEG (percutaneous endoscopic gastrostomy) tube (an artificial opening through the abdominal wall by surgically inserting a tube into the stomach for administering liquid nutritional supplements) placement. The resident was indicated in the assessment to have failed a modified barium swallow (MBS) at the hospital prompting the need for the PEG tube placement. He was NPO (nothing by mouth) at that time and was receiving enteral nutritional support due to his NPO status. The dietitian recommended increasing his tube feeding of Vital AF to 65 milliliters (ml)/ hour to meet his nutritional needs and would reassess as needed. Review of Resident #65's progress notes revealed a nurse's note dated 01/06/26 at 12:24 P.M. that indicated following his swallow study yesterday, the resident's diet order changed to a mechanical soft textured diet with thin liquids. Special instructions added to included 1:1 assist and no bread. Review of Resident #65's monthly physician's orders revealed he had an order in place for a regular diet, mechanical soft texture, and thin liquids. He was to have one on one assist with meals and he was not to receive any bread. On 01/13/26 at 12:38 P.M., a meal observation noted Resident #65 to be eating his lunch meal in the private dining room with several other residents. Resident #65 had a staff member (Rehab Director #500) seated beside him at the table he was at conversing with him during the meal. The resident was noted to have his meat grounded up and also had a sweet potato, green beans, and a dinner roll. He was feeding himself and had a good appetite as he almost had all of his meal consumed when the observation was made. On 01/13/26 at 2:05 P.M., an interview with Rehab Director #500 revealed she was doing a group session with Resident #65 and one other resident, when Resident #65 was observed eating in the private dining room. She had been working with the resident to help him better feed himself. He had a fall prior to his admission and she was working on getting his right arm more functional for eating. She identified the resident as being on a mechanical soft diet. She confirmed the resident was provided what she believed to be grounded up ham, a sweet potato, green beans, and a dinner roll. She was asked if the resident was supposed to receive a dinner roll, since his current diet order showed under special instructions that he was not to receive any bread. She was not aware of the no bread order, but verified the current physician's orders in the facility's computer software system did specify that he was not to receive bread. She would have to follow up with the speech therapist to see if he was not permitted to have bread. She reported the resident ate well for lunch and has shown a good appetite, since they upgraded his diet to allow for food by mouth. She denied she had noted him to have any coughing episodes during the meal. On 01/13/26 at 2:14 P.M., an interview with Resident #65 revealed he did not have any concerns with the meals he received. He felt like he was getting the proper diet based on his mechanical soft diet order. He reported he was given chopped up hamburger for his lunch in place of ham. He verified other items received included a sweet potato, green beans, and a roll. He was asked if he was supposed to be eating bread and replied he thought he could, if it was soft. He was not aware of the order for him not to have any bread. He stated somedays they give it to him and other days they don't. On 01/13/26 at 3:15 P.M., an interview with the facility's Administrator revealed he knew there was an issue with resident's not receiving appropriate diets, as occurred with Resident #65 during his lunch meal. He confirmed Resident #65 was not to receive any bread, but had been given a dinner roll with his meal. He stated the dietary department used a system called meal tracker. The nursing department entered diet orders into MatrixCare and the diet order was be communicated through Meal Tracker. The issue they were having was when a diet order was added to MatrixCare, it would populate an update button for that particular resident in meal tracker. If a dietary staff member did not click on the update button, it would pull the previous diet order in the system when printing out the meal tickets for that particular meal. That was why they were having issues with the resident's not receiving the appropriate updated diet that was in MatrixCare.

Based on observations, medical record review, interviews and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection. This affected two residents (#91 and #93) of 22 sampled residents. The facility census was 54.Findings Include:1. Review of the medical record for Resident #93 revealed an initial admission date of 01/10/26 with the diagnoses including but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, severe morbid obesity. right bundle branch block, bifascicular block, ventricular tachycardia, gout, Parkinson's disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, constipation and prediabetes. Review of the resident's admission observation and data collection dated 01/10/26 revealed the resident was admitted to the facility being alert, with impaired daily decision making. The assessment indicated the resident was admitted to the facility with an indwelling urinary catheter. Review of the plan of care dated 01/12/26 revealed the resident had an indwelling urinary catheter related to urinary retention. Interventions included lab work completed per physician orders, leg strap in place to prevent residents catheter from being pulled out, maintain a closed system with urinary bag below the resident's bladder and cover, observe for any signs of complications such as a urinary tract infection (UTI), observe the tubing and avoid any obstructions, please record resident urinary output and provide assistance with catheter care and change foley catheter per physician orders. Review of the resident's monthly physician orders for January 2026 identified orders dated 01/10/26 catheter care every shift and monitor output every shift. On 01/13/26 at 4:40 P.M., observation of the resident revealed the indwelling urinary catheter bag was laying on the floor of the resident's room. On 01/13/26 at 4:42 P.M., interview with Certified Nursing Assistant (CNA) #307 verified the resident's catheter collection bag as laying on the floor. 2. Review of the medical record for Resident #91 revealed an initial admission date of 01/06/26 with the diagnoses including but not limited to hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of left lower extremity, atrial fibrillation and congestive heart failure. Review of the admission wound documentation dated 01/06/26 for the stage II pressure ulcer to the coccyx revealed the wound measured 2.0 cm by 1.5 cm by 0.1 cm and described epithelial tissue with the surrounding tissue being pink. The wound had no exudate, and the facility determined the wound was improving. Review of the admission wound documentation dated 01/06/26 for the stage III pressure ulcer to the left heel revealed the wound measured 1.5 cm by 1.0 cm. The wound was described as closed resurfaced with edges attached to the base and no exudate was present. The surrounding skin was red and blanchable. The facility determined the wound was stable. Review of the resident's admission observation and data collection dated 01/07/26 revealed the resident was admitted to the facility with skin issues and an occurrence progress note was completed. Review of the Braden Scale contained in the admission observation and data collection dated 01/07/26 revealed a score of 15 indicating the resident was at risk for skin breakdown. Review of the progress note dated 01/07/26 at 4:36 A.M. revealed the resident was admitted to the facility with an open area to the coccyx measuring 2.5 centimeters (cm) by 1.5 cm and an open area to the left heel measuring 1.5 cm by 1.0 cm. The resident's skin to the left lower extremity was noted to be discolored. Review of the progress note dated 01/07/26 at 7:24 P.M. revealed the admission reassessment was completed and the resident was found to have a pressure wound on the coccyx and left heel. The right heel was soft and tender. Review of the plan of care dated 01/08/26 revealed the resident had a pressure ulcer to coccyx and left heel on admission. Interventions included administer analgesics per physician orders, assess and record the condition of the skin surrounding the pressure ulcer, encourage fluids unless contraindicated, observe and report sings of infection, observe for the report signs of pain related to pressure ulcer, obtain a dietary consult, pressure reducing cushion to chair, reducing mattress, provide diet, supplements, vitamins and minerals as ordered, treatment per physician order, notify physician if treatment is not effective and weekly skin assessment, measurement and observation of the pressure ulcer and record. Review of the weekly wound documentation dated 01/13/26 for the stage II pressure ulcer to the coccyx revealed the wound measured 2.0 cm by 1.5 cm by 0.1 cm and described epithelial tissue with the surrounding tissue being pin. The wound had no exudate and the facility determined the wound was improving. Review of the weekly wound documentation dated 01/13/26 for the stage III pressure ulcer to the left heel revealed the wound measured 1.5 cm by 1.0 cm. The wound was described as closed resurfaced with edges attached to the base and no exudate was present. The surrounding skin was red and blanchable. The facility determined the wound was stable. Review of the resident's monthly physician orders for January 2026 identified orders dated 01/07/26 cleanse wound to coccyx with wound cleanser or normal saline (NS), pat dry, apply skin prep to peri-wound and cover with border dressing daily and as needed for dislodgement or soiled, cleanse wound to left heel with wound cleanser or NS, pat dry, apply skin prep to peri-wound and cover with border dressing three times a week on Monday, Wednesday, Friday and as needed for dislodgement or soiled, apply foam dressing to right heel and change every five days or as needed for soiled, 01/08/26 cleanse bilateral buttocks with soap and water, pat dry, apply house barrier cream twice daily for prevention, cleanse wound under left breast with wound cleanser or NS, pat dry, apply house anti-fungal powder to peri-wound daily and as needed and 01/08/26 staff to use enhance barrier precautions, wearing a gown and gloves at minimum during high-contact care activities. On 01/15/26 at 9:55 A.M., observation of Licensed Practical Nurse (LPN) #390 revealed she had the required supplies in a graduate pitcher and placed them on the resident's bedside table. She donned a pair of gloves removed the soiled dressing which consistent of two border foam dressings. The LPN then cleansed the wound with normal saline (NS) and a 2 X 2. She then applied skin prep to the heel and the skin around the wound. The LPN then changed her gloves without washing or sanitizing her hands. The LPN then placed a border gauze over the wound and wrapped with an ace wrap from toes to mid shin. The LPN failed to don personal protection equipment (PPE) as physician ordered for enhanced barrier protection (EBP) during the wound treatment. On 01/15/26 at 10:05 A.M., interview with LPN #390 verified the lack of PPE and the lack of handwashing during treatment administration. Review of the facility policy titled, Dressing Change, dated 05/11/16 revealed the purpose of the policy was to ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize and/or control contamination. The procedure was as follows, place plastic bag or trash can near to dispose the soiled dressing, create a clean field, remove old adhesive with adhesive remover, if necessary, taking care not to get solution into wound wash hands with soap and water, open dressing pack, put on first pair of disposable gloves, remove soiled dressing and discard in plastic bag or trash can, dispose of gloves in plastic bag or trash can, wash hands with soap and water, put on second pair of disposable gloves, follow doctor's recommendation for treatment, apply dressing and secure with tape when done with treatment if necessary, if using scissors make sure it is cleansed with antiseptic after contact with soiled dressing, remove gloves and discard, wash hands with soap and water, assist resident to comfortable position with call light in reach and discard soiled dressings per protocol. Review of the facility policy titled, EBP Standard Operating Procedure, last revised 02/09/17 revealed EBP will be in place during high contact care activities for residents with the following conditions, all residents with chronic wounds, including but not limited to pressure ulcer, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. All residents with indwelling medical devices included but not limited to catheters, central lines, feeding tubes, tracheostomy tubes and those residents known to be infected or colonized with a multidrug resistant organism (MDRO).

Based on observation, interview, and medical record review the facility failed to ensure Resident #49's call light was kept within reach. This affected one resident (#49) of five reviewed for environment. The facility census was 54.Findings include:Observation on 01/12/26 at 10:02 A.M., 1:42 P.M., and 2:25 P.M., on 01/13/26 at 1:30 P.M. and 3:36 P.M., on 01/14/26 at 8:49 A.M., and on 01/15/26 at 8:35 A.M. revealed the resident in her recliner with no call light. The call light was observed near her bed across the room.Interview on 01/15/26 at 8:35 A.M. with Certified Resident Care Associate (CRCA) #324 revealed the resident could use a call light. CRCA #324 verified the resident spent most of her time in the recliner and had no way to call for staff. She reported the facility did not have call light pendants and the regular wall call light did not reach to the recliner. She reported she knew extended cords could be obtained for the call light, but the resident did not have one.Review of Resident #49's medical record revealed an admission date of 12/16/25 with diagnoses including unspecified mood disorder, pulmonary fibrosis, hypothyroidism, depression, anxiety, dementia, and hypertension.Review of Resident #49's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition.Review of Resident #49's plan of care dated 12/18/25 revealed she was at risk for falls related to history of falls, medication side effects, and diagnoses. Interventions included keeping the call light within reach.Review of Resident #49's plan of care dated 12/19/25 revealed the resident was noncompliant with physician orders or plan of care as evidenced by refusing to sleep in bed, instead using her recliner. Interventions included assessing need for guardian, encouraging activity participation, encouraging to participate in decision making, and monitoring ability to give informed consent.Review of Resident #49's progress note dated 12/21/25 at 5:23 A.M. revealed the resident had been in her recliner all night.Review of Resident #49's progress note dated 01/07/26 at 11:11 P.M. revealed the resident was in her recliner.Review of Resident #49's progress note dated 01/12/26 at 6:32 P.M. revealed the resident was in the recliner.Review of Resident #49's progress note dated 01/13/26 revealed the nurse spoke to Resident #49's son who reported the resident found comfort sleeping in a recliner.Review of Resident #49's progress note dated 01/13/26 at 5:38 P.M. revealed the resident was in the recliner.Review of Resident #49's progress note dated 01/14/26 at 3:51 A.M. revealed the resident had been sitting in the recliner for the entirety of the nurses shift.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had two errors out of 30 opportunities for a medication error rate of 6.6%. This affected one resident (#61) of three residents reviewed for medication administration observations. Findings include: On 01/14/26 at 7:55 A.M., an observation of the medication administration pass revealed Licensed Practical Nurse (LPN) #330 was intending to administer the morning medications for Resident #58 that were due between the hours of 6:00 A.M. and 10:00 A.M. LPN #330 had pulled the medications out of the medication administration cart for Resident #58 that included numerous tablets/ capsules for the resident, as well as a Lidocaine 4% patch. She approached the resident that was in the back left corner of the room and informed her that she had her morning medications to give her. The resident was sleeping, but aroused easily when spoken to. LPN #330 informed the resident that she had a Lidocaine patch for her and wanted to apply it to her lower back. The resident questioned the need for the patch and LPN #330 informed her it was for pain. The resident denied she had any pain, but the nurse applied the patch to the resident's right lower back (lumbar region) anyway and informed her it was to keep her from having any pain. The nurse then handed the resident the cup that contained her pills and encouraged her to take them with water. The resident questioned the nurse on where her Preservision Areds tablet was, as it was a red pill, and was not in the cup of pills that had been given to her. LPN #330 then returned to the medication administration cart, where she had the electronic medical administration record (eMAR) pulled up and did not see the order for Preservision Areds. She then realized the medications that she had previously pulled for Resident #58 was not to be given to the resident in the back left corner of the semi-private room and belonged to the resident that was in the front right corner of the room. She realized Resident #61 was the resident in the back left corner of the room that she had erroneously applied the Lidocaine 4% patch to the resident's lower back. She placed the medication cup that contained Resident #58's morning medication in the top drawer of the medication administration cart and then proceeded to pull Resident #61's medications from a pre-packaged packet that included all the pills the resident was to receive at the time. The nurse then re-entered Resident #61's room and approached the resident that was lying in the bed by the door. She called out the resident by name identifying her as the first name of Resident #61, who again, resided in the bed that was located in the back left corner of the room. She realized she was approaching the wrong resident again, this time with Resident #61's medications, and caught herself before giving that resident any medications. She then went to the resident in the back left corner of the room and informed her that she now had her morning medications that were due at the time. She pointed out that the medications included the Preservision Areds that the resident had previously asked for, along with nine other medications given at that time. The resident was reluctant to take them, until she asked the surveyor if those were her medications and if they were safe to take. She was informed they were in a pre-packaged packet that had her name on it. She took the medications as given and continued to voice concern about the nurse trying to give her the wrong medications. She asked what would have happened if it was a resident who was cognitively impaired and did not know enough to question what was being given to them. The nurse apologized to the resident before leaving the room. Review of Resident #61's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dorsalgia (pain anywhere in the back, including the neck, mid-back, and lower back). Review of Resident #61's physician's orders revealed she had an order for Lidocaine 4% patch with directions to apply it topically (T) once a day as needed (prn) for her right ribs. That order had been in place since 09/09/25. She was also noted to have an order to receive Probiotic Formula (Bacillus Coagulans- Inulin) capsule once daily between 6:00 A.M. and 10:00 A.M. The resident was not observed to have been given the Probiotic earlier that morning when all her other morning medications had been administered. Review of Resident #61's eMAR for January 2026 revealed the resident was to receive the Probiotic daily between 6:00 A.M. and 10:00 A.M. LPN #330 had initialed the eMAR to reflect the Probiotic had been given despite observations indicating otherwise. Findings were verified by LPN #330. On 01/14/26 at 9:01 A.M., an interview with LPN #330 confirmed that she had applied a Lidocaine 4% patch (T) to Resident #61's right lower back (lumbar region) that was only ordered on a prn basis. She further confirmed Resident #61 had questioned why the nurse was applying the Lidocaine patch and denied having any pain at the time of administration. She acknowledged the current order for the Lidocaine patch was to apply it to her right rib area prn. She then verified that she did not give Resident #61 her Probiotic that was scheduled to be given between the hours of 6:00 A.M. and 10:00 A.M., with the resident's other morning medications. She confirmed the Probiotic was erroneously omitted. She checked the resident's medications in the medication administration cart and found the Probiotic pre-packaged in the packet containing the resident's bedtime medications. She indicated it was not uncommon for their pharmacy to package medications in the pre-filled packets for the wrong time of day. She indicated the day of the medication administration observation was the first day she had been put out on the floor by herself. She was confused with the layout of the room and how the residents' names were placed on the wall outside the room. She verified the name on the top should be the resident that was by the door and the resident's name on bottom was for the resident furthest from the door. Review of the facility's policy on Medication Administration Preparation and General Guidelines revised November 2018 revealed medications were administered as prescribed in accordance with good nursing principles and practices. The nurse administering the medications was to follow the five rights of medication administration, which included right resident, right drug, right dose, right route, and right time. Medications were to be administered in accordance with written orders of the prescriber. Residents were to be identified before the medication was administered. Methods of identification included checking the photograph attached to the medical record, calling the resident by name (except in residents with cognitive impairment), having the resident verify their last name, and if necessary, verify the resident's identification with other facility personnel.

Based on observation, interview, and medical record review the facility failed to prepare a vegetarian menu in advance and follow the menu for Resident #85. This affected one resident (#85) of five residents reviewed for dining. The facility census was 54.Findings include:Observation on 01/13/26 at 12:00 P.M. revealed Resident #85 received green peas, baked sweet potatoes, and a salad. She did not receive baked ham.Observation on 01/14/26 at 11:50 A.M. revealed Resident #85 received green beans and mashed potatoes from the kitchen. She did not receive chicken or noodles.Interview on 01/14/26 at 11:50 A.M. with Area Director of Food Services #317 verified Resident #85 did not receive the Entree. He reported they had vegetarian options and the always available menu which included meat free options and she should receive one of those.Interview on 01/15/26 at 9:38 A.M. with Resident #85's power of attorney (POA) verified the resident followed a vegetarian diet and she expected the resident to be receiving full meals.Interview on 01/15/26 at 10:00 A.M. with Culinary Support #250 revealed they did not have a vegetarian menu but had some plant-based meats. Culinary Support #250 revealed staff should ask Resident #85 what she wanted and that often when they asked her if she wanted something, she would say no. However, she verified the resident had dementia and might not be able to articulate what she wants and should be receiving an entree.Interview on 01/15/26 at 11:25 A.M. and 1:14 P.M with Director of Clinical Services (DCS) #316 revealed they usually treat vegetarians as a preference, not a menu. DCS #316 verified with Resident #85's dementia she may not be able to reflect her preferences or she may say no to food she might eat if it were in front of her. DCS #316 reported that Resident #85 should have received at least the noodles on 01/14/26 from the chicken and noodles and should receive an entree. DCS #316 reported the kitchen had vegetarian options like cottage cheese or egg salad they could send. He reported at times the daughter would help select her menu and when the daughter wasn't available they should always send available items.Review of Resident #85's medical record revealed an admission date of 01/03/26 with diagnoses unlisted in the medical record.Review of Resident #85's hospital history and physical dated 12/26/25 revealed diagnoses including dementia, right femur fractureReview of Resident #85's Brief Interview for Mental Status (BIMS) dated 01/07/26 revealed she had severely impaired cognition.Review of Resident #85's physician order dated 01/07/26 revealed an order for regular diet, vegetarian.Review of the menu for lunch on 01/13/26 revealed residents were to receive baked glazed ham, review of the lunch menu for 01/14/26 revealed residents were to receive chicken and noodles.A policy or guidance for a vegetarian diet was requested but not received.

Based on medical record review, interviews and facility policy review, the facility failed to ensure one resident (#91) was bathed according to their preference. This affected one resident (#91) of four residents reviewed for activities of daily living (ADL). The facility census was 54.Findings Include:Review of the medical record for Resident #91 revealed an initial admission date of 01/06/26 with the diagnoses including but not limited to hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of left lower extremity, atrial fibrillation and congestive heart failure. Review of the resident's admission life enrichment assessment dated [DATE] revealed it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. The resident indicated she preferred to receive showers. Review of the profile care guide dated 01/08/26 revealed see shower schedule for showers. The resident was to receive showers revery Wednesday and Saturday. Review of the resident's shower documentation from 01/09/26 to 01/13/26 revealed the resident was provided a partial bed bath (cleansing only the areas of face, neck, axilla, hands and perineum) was provided on 01/09/26, 01/11/26 and 01/13/26. Further review of the shower documentation revealed the resident had not been provided a shower since admission to the facility on [DATE]. On 01/12/26 at 1:32 P.M. interview with the resident revealed she had not had a shower since admission but would like to have routine bathing. On 01/14/26 at 11:36 A.M., interview with Licensed Practical Nurse (LPN) #396 verified the resident had three partial baths since admission to the facility on [DATE]. The LPN revealed the resident preferred showers. Review of the facility policy titled, Guidelines for Bathing Preference, dated 05/11/16 revealed the resident shall determine their preference for bathing upon admission, including the day of the week, time of day and type of bathing (tub bath, bed bath or shower). Bathing shall occur at least twice a week unless resident preference states otherwise.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to document and address a resident representative grievance timely. This affected one (Resident #54) of three resident grievances reviewed. The census was 52.Findings Include:Record review for Resident #54 revealed he was admitted to the facility on [DATE]. His diagnoses were peritoneal abscess, sclerosing mesenteritis, other disease of stomach and duodenum, other specified diseases of intestines, syncope and collapse, unspecified severe protein-calorie malnutrition, occlusion and stenosis of bilateral carotid arteries, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, chronic kidney disease, other ventricular tachycardia, atherosclerotic heart disease, hypo-osmolality and hyponatremia, nonrheumatic aortic (valve) stenosis, unspecified right bundle-branch block, old myocardial infarction, and hyperlipidemia. Review of his Brief Interview for Mental Status (BIMS) assessment, dated 09/12/25, revealed he was cognitively intact.Review of Resident #54 medical records found that he was discharged from the facility on 10/02/25 to the hospital for a physician ordered direct admission to deal with on-going medical issues that was outside the scope of care for the facility to manage.Observation on 10/09/25 at approximately 9:15 A.M. revealed a black stand lamp brought to the conference room by the Administrator. The lamp matched the description of a lamp that was alleged to have been stolen from Resident #54 while he was in the facility. The Administrator verified during the observation the lamp belonged to Resident #54 and the facility was still in possession of it. Interview with Plant Operations Director #155 and Administrator on 10/09/25 at 9:50 A.M. and 9:58 A.M. confirmed the facility had Resident #54's lamp in the maintenance office. They confirmed they took it out of his room after it was discovered the family had plugged it into an extension cord, so they removed the extension cord and the lamp from his room. Plant Operations Director #155 stated he told Resident #54 he was taking the lamp out of his room. When asked what Resident #54's response was, he stated, he really didn't have a response. the Administrator confirmed that on 09/30/25, there was a note left on his room door by Resident #54's family, stating they were missing the lamp and would like it back. The Administrator confirmed he was aware the family had made the request, but had not gotten the lamp back to them. He stated he attempted to contact the family with no success. He confirmed he does not have the note the family left, and he confirmed there was no documentation to support he completed a grievance investigation/resident concern form and confirmed there was not a resolution to the grievance.Review of facility Resident Concern Process procedure, dated 12/16/24, revealed the facility will provide an open and customer friendly atmosphere for residents and their families and representatives to voice concerns and problems with their assurance that this concerns will be heard and acted upon. The facility will be committed to the on-going education of their employees on immediately responding to and resolving customer concerns. Enter the concern using the desktop icon labeled Resident Concern Form. All concerns should be entered electronically, however Environmental and Dining departments may use a paper Resident Concern form, submitting to their supervisor who will enter. Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution. Follow up from the department leader will occur within 24-48 hours with resolution entered in the electronic record. The department leader will document the resolution on the concern form using an addendum when needed and will follow up with the person reporting the concern to explain the resolution.

Based on closed medical record review, hospital record review, review of an Emergency Medical Services (EMS) run report, staff interview, and facility policy review, the facility failed to timely and adequately identify an acute change in medical condition resulting in a delay in medical intervention/hospital care for Resident #54 resulting in the resident being found unresponsive and requiring cardiopulmonary resuscitation (CPR). Actual harm occurred beginning during the night shift on [DATE] when staff failed to identify an acute change in Resident #54's condition to ensure timely and adequate medical intervention was provided. At 6:00 A.M. Resident #54 sustained an unwitnessed fall. Resident #54 had an emesis (vomiting) and voiced complaints of not feeling well. The resident did not consume any breakfast and continued vomiting. At approximately 8:00 A.M., Certified Nurse Practitioner (CNP) #521 ordered intravenous (IV) fluids to be given to the resident; however, the IV fluids were not initiated until approximately 4:20 P.M. The resident was assessed to be hypotensive (low blood pressure) at 8:48 A.M. (91/51), 11:57 A.M. (95/62), 1:04 P.M. (90/58), and 4:55 P.M. (92/70). The resident did not consume lunch and continued vomiting at approximately 4:20 P.M. On [DATE] at 5:20 P.M., Resident #54 was found unresponsive and required cardiopulmonary resuscitation (CPR). Emergency Medical Services were called at that time, and the resident was subsequently transported to the emergency room. This affected one resident (#54) of three residents reviewed for change in condition. The facility census was 52. Findings include: Review of Resident #54's closed medical record revealed an admission date [DATE] with diagnoses including acute respiratory failure, congestive heart failure (CHF), high blood pressure, cardiomegaly, atrial fibrillation, and history of hemorrhagic stroke. Record review revealed the resident was admitted for short term rehabilitation (therapy services) following a stroke with a goal to discharge to home. Resident #54 was transferred to the hospital on [DATE] and did not return to the facility. Review of Resident #54's physician (admission) orders revealed an order dated [DATE] for advance directives indicating the resident was a Full Code (a medical directive that instructs healthcare providers to perform all possible life-saving measures in the event of a medical emergency, such as cardiac or respiratory arrest), Torsemide 20 milligrams (mg) (a diuretic medication used to to treat blood pressure, heart, and kidney conditions by increasing elimination of water, sodium, and potassium and resulting in increased urination) twice a day, an order to obtain daily weight related to CHF, and Metoprolol 50 mg (a beta blocker medication used to treat a variety of heart and blood pressure conditions) to be given two times per day. There were no parameters with the orders for the medications to be held. Review of Resident #54's physician orders dated [DATE] revealed orders for 2000 milliliters (ml) fluid restriction for 360 ml (12 ounces (oz) or 1.5 cups) three times per day (per meal) from dietary, 360 ml (12 oz) day shift from nursing, 360 ml (12 oz) evening shift from nursing, and 200 ml (6.8 oz) night shift from nursing to equal 2000 ml, an order dated [DATE] for Zofran (an antiemetic) 4 mg as needed with instructions to give one tablet every six hours as needed for nausea and/or vomiting, and an order dated [DATE] for continuous oxygen at two liters via nasal cannula. There was no documented evidence of an order for an Ensure nutritional drink. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 required (staff) assistance for transfers, ambulation, and personal hygiene tasks and was independent with eating. The MDS revealed the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of Resident #54's physician orders revealed on [DATE] an order was obtained for Torsemide 20 mg with instructions to administer an extra 20 mg dose in the morning if weight gain for two days, as needed and on [DATE] an order was obtained for Torsemide 20 mg with instructions to administer 40 mg daily for CHF. Review of Resident #54's plan of care dated [DATE] revealed Resident #54 had potential for cardiovascular distress related to congestive heart failure, high blood pressure, and arterial fibrillation with interventions including, but not limited to, administer oxygen per physician orders, obtain laboratory testing as ordered and report results to the physician, administer medications as ordered, and observe for signs and symptoms of cardiovascular distress and report as needed. Review of Resident #54's blood pressure vital signs from [DATE] through [DATE] revealed abnormal ranges on [DATE] at 9:38 P.M. (81/55), [DATE] at 8:48 A.M. (96/60), [DATE] at 5:53 P.M. (99/60), [DATE] at 9:12 A.M. (97/61), and [DATE] at 8:09 P.M. (96/58). Review of Resident #54's physician orders dated [DATE] revealed an order was obtained for the diuretic medication, Torsemide 40 milligrams twice a day related to increased daily weight and increased edema. Review of the skilled nursing progress note dated [DATE] revealed Resident #54 was alert and oriented and able to make needs known. Resident #54 had bilateral lower extremity weakness, her lung sounds were clear and regular, with a steady and regular heart rate. There was no edema observed to the resident's lower extremities. Review of Resident #54's laboratory results dated [DATE] revealed abnormal results of blood urea nitrogen (BUN) 25 milligrams per deciliter (mg/dL) (normal levels 6 - 21 mg/dL) (an elevated level could indicate kidney issues or dehydration), white blood count (WBC) 13.42 microliters (uL) (normal levels 3.40 - 10.80 uL) (an elevated value could indicate infection), hemoglobin 10.40 grams per deciliter (g/dL) (normal levels 12.3 - 15.3) and hematocrit 33.4 percent (%) (normal levels 34% - 46.6%), and creatinine 1.6 mg/dL (normal levels 0.5 - 0.9). The resident's sodium 137 milliequivalents per liter (mEq/L) (normal levels 136 - 145) and potassium 3.6 mEq/L (normal levels 3.5 - 5.1) levels were normal. Review of Resident #54's nursing progress note dated [DATE] at 6:00 A.M. revealed the resident was observed lying on the floor on her right side with her feet facing the recliner. Resident #54 attempted to self-transfer from the recliner. Resident #54 was educated on using the call light for assistance with transfers. Review of Resident #54's fall investigation, dated [DATE], revealed the resident attempted to transfer independently, but could not due to having a history of a stroke and the resident required assistance with activities of daily living. The investigation noted that the resident did not strike her head during the fall on [DATE], but that the resident was more confused. did not feel well, and had several episodes of emesis noted during the day. Review of Resident #54's abnormal vital signs dated [DATE] at 7:53 A.M., revealed her pulse was 92 beats per minute (bpm); At 7:56 A.M. her pulse was 70 bpm and her oxygen saturation (SpO2) was 90% on two liters of oxygen via nasal cannula. At 8:48 A.M. her blood pressure was 91/51; And at 8:50 A.M. her blood pressure was 98/60. Review of Resident #54's [DATE] Medication Administration Record (MAR) revealed on [DATE] during the morning medication administration, Resident #54 received the following medications: Folic Acid 1 mg, Jardiance 10 mg, Lantus insulin 22 units, Sennosides-docusate sodium tablet 8.6-50 mg, Metoprolol 50 mg (her blood pressure read 103/71), Miralax 17 grams, potassium chloride 20 milliequivalents (mEq), and Torsemide 40 mg. The exact time of the medication administration was not available for review. Review of Resident #54's meal/fluid intakes from [DATE] revealed Resident #54 ate 76% to 100% of most meals and drank 360 ml of fluids per meal. The meal/fluid intakes for [DATE] revealed the resident did not eat breakfast or lunch and she drank a total of 360 ml of fluids (Ensure nutritional drink). Review of Resident #54's progress note dated [DATE] at 9:57 A.M. authored by CNP #521 revealed Resident #54 was assessed by CNP #521 at 8:00 A.M. related to a vomiting episode the morning of [DATE]. CNP #521 noted Resident #54's recent laboratory results, her WBC and BUN were elevated. CNP #521 ordered a chest x-ray to be obtained and gave an order for sodium chloride 0.9% parenteral solution 500 milliliters (ml) via intravenous route (IV) with instructions for the fluids to be administered 100 ml per hour for kidney protection and potential dehydration related to vomiting and the use of a diuretic medication. Review of Resident #54's abnormal vital signs dated [DATE] at 11:57 A.M. revealed her blood pressure was 95/62 and at 1:04 P.M. her blood pressure was 90/58. Review of Resident #54's evaluation/event form dated [DATE] at 1:12 P.M. authored by Licensed Practical Nurse (LPN) #240 revealed Resident #54 had an episode of vomiting on [DATE] at 8:00 A.M. following the administration of Resident #54's morning medications and after the resident consumed 240 ml of a clear Ensure supplement drink related to Resident #54 not eating the breakfast meal due to not feeling well. LPN #240 notified CNP #521 and requested Resident #54 to be assessed and for the CNP to review the recent laboratory results dated [DATE]. LPN #240 administered Zofran four mg disintegrating tablet with effective results noted. Review of Resident #54's evaluation/event form dated [DATE] at 6:15 P.M. revealed Resident #54 had another vomiting episode on [DATE] at approximately 4:00 P.M. LPN #240 notified CNP #521 of Resident #54's second episode of vomiting and Resident #54's lack of eating breakfast and lunch meals related to not feeling well. There were no new orders received, and Zofran was not recorded as administered following the vomiting episode. Review of Resident #54's physician orders revealed orders dated [DATE] at 4:20 P.M. for sodium chloride 0.9% parental solution 500 milliliters (ml) via IV to be administered 100 ml per hour which had initially been ordered on [DATE] at 8:00 A.M. There was no documented evidence of an order for a urinalysis to be completed. Review of Resident #54's abnormal vital signs dated [DATE] at 4:55 P.M. revealed her blood pressure was 92/70. Review of Resident #54's progress note dated [DATE] at 6:40 P.M. authored by LPN #240 revealed Resident #54's chest x-ray results were pending and sodium chloride 0.9% parental solution 500 milliliters (ml) via IV to be administered 100 ml per hour was initiated. Resident #54 was observed breathing heavily and then stopped breathing. LPN #240 attempted to arouse Resident #54 and checked for vital signs. Resident #54 did not respond, and CPR was initiated. Emergency Medical Services (EMS) were called and arrived at the facility, assessed Resident #54, noted there was a pulse, and EMS then transported Resident #54 to the emergency room. Resident #54's family and CNP #521 were notified. Review of the EMS run report for Resident #54 dated [DATE] at 5:33 P.M. revealed upon arrival to the facility, facility staff were performing CPR, there was a pulse obtained on the resident, and Resident #54 was transported to the hospital. While enroute, Resident #54 required CPR again, with CPR continuing upon arrival to the emergency department. Review of the hospital paperwork for Resident #54 dated [DATE] at 5:50 P.M. revealed Resident #54 arrived at the hospital at 5:47 P.M. with CPR initiated at 5:50 P.M. and continuing until 6:26 P.M. when Resident #54 was pronounced deceased . Review of Resident #54's chest x-ray results, dated [DATE] and fax timed 11:31 P.M. [obtained by the facility after the resident expired], revealed the chest x-ray was ordered due to an elevated WBC count. Cardiomegaly was identified as well as opacities in the right lung bases which may have been due to atelectasis or pneumonia. Following the resident's transfer to the hospital, the facility completed an investigation (due to the resident being found unresponsive and subsequently passing away). The investigation information consisted of a review of the resident's vital signs, witness statements, laboratory results, nurse notes, physician progress notes, and resident demographics. Review of the statement from the Executive Director, dated [DATE], revealed the county Coroner contacted the facility and asked basic questions concerning Resident #54's fall and how the resident was prior to the code. The Coroner stated he had no concerns with the fall contributing to her death. He stated he felt the cause of death was related to the resident's heart issues. He stated he was not looking into it any further and was submitting the death certificate to be signed. Review of the statement from Certified Resident Care Assistant (CRCA) #517, dated [DATE], revealed the CRCA had arrived in the morning and was informed by the night shift nurse that the resident had been passing emesis at night and that she should keep an eye on her. The statement included when the CRCA went in to check on her, the first thing she said was that she wasn't feeling well. The CRCA stated she informed the nurse. About 20 minutes later the resident began vomiting again. The statement indicated the CRCA assisted the resident to get cleaned up and use the bathroom and then the resident rested for a while. The Nurse Practitioner did come to evaluate the resident. The statement also included the resident later woke up and was restless. The CRCA took her to the bathroom and helped her back to the recliner but noted that after some time, she had another blow out of vomit. The CRCA cleaned the resident up and informed the nurse and noted that the resident refused to eat breakfast and lunch. Review of the statement from LPN #240 dated [DATE] revealed Resident #54 had vomited in the morning [indicating on [DATE]] after administering morning medications. When CNP #521 rounded, LPN #240 requested for Resident #54 to be assessed due to her not feeling well. CNP #521 evaluated Resident #54 and ordered a chest X-ray to be obtained and to initiate IV fluids of normal saline. At around 4:00 P.M. Resident #54 vomited again and CNP #521 was notified and requested the IV normal saline to be started and to notify her if the nurse was unable to initiate the IV placement. The IV was placed and normal saline fluid was initiated. LPN #240 then observed Resident #54 breathing heavily and she went to Resident #54 and called her name and Resident #54 was not responding. CPR was started immediately, and EMS was called. CPR continued until EMS arrived. Resident #54 had a pulse at the time EMS transported Resident #54 to the hospital. Review of the statement from Coroner #525 dated [DATE] revealed there were no concerns of Resident #54's fall contributing to her death. The statement included the cause of death was related to Resident #54's heart issues, and no further investigation was required. An interview on [DATE] at 4:34 P.M. with CNP #521 revealed the dayshift nurse had notified her of Resident #54 vomiting and not feeling well. She stated Resident #54 was the first one she saw that day, and the night nurse had notified her of the fall earlier. She stated she ordered a urinalysis culture and sensitivity (UA CS) due to her change in behavior. The wash basin was sitting by the resident's recliner and there was white mucus-looking emesis in the basin. CNP #521 revealed she assessed the resident, and she denied hitting her head, her neurological checks were normal for her, but she complained of her right shoulder hurting from her recent fall, but the more she moved it the better it felt to her. She complained of abdominal nausea and Zofran was ordered to help with that. IV fluids were also ordered due to her being on a large dose of Torsemide and she didn't want the resident to become dehydrated due to the medicine and her not feeling well, and she wanted her kidney function to be maintained as well due to her chronic kidney disease diagnosis. CNP #521 stated she also requested the chest X-ray due to the lab results from the previous week with her WBC's elevated, so she stated she was looking for a source of possible infection. She revealed the orders were not because of the fall, only to address the increased WBC's. CNP #521 stated when Resident #54 was admitted she had increased swelling and had a slight weight increase, but they managed that with medications and she was stable and the morning she assessed the resident [indicating [DATE]], though she did have some increased swelling in her lower legs and the staff had them elevated in the recliner. Interview on [DATE] at 11:15 A.M. with CRCA #517 revealed Resident #54 had vomited two times during the day on [DATE] and was not feeling well. Resident #54 did not eat breakfast and lunch, which was not normal for her. She stated Resident #54 did participate in therapy in the afternoon of [DATE]. Interview on [DATE] at 8:58 A.M. with LPN #214 revealed Resident #54 had fallen at 6:00 A.M. on [DATE] while attempting to transfer from the recliner. Resident #54 did not activate the call light for staff assistance prior to the fall. LPN #214 stated Resident #54 would always use the call light for assistance from staff, so not activating the call light was abnormal behavior for the resident. She stated Resident #54 was at baseline through the night of [DATE] and activated the call light several times for assistance from staff. LPN #214 stated she notified the CNP about the fall and she ordered the UA CS to be collected to check for a urinary tract infection since the resident's behavior was abnormal. She further confirmed the residents low blood pressure readings on [DATE], but also stated the resident often had lower blood pressure readings in the mornings. Interview on [DATE] at 4:34 P.M. with CNP #521 revealed CNP #521 evaluated Resident #54 following the first episode of vomiting at approximately 8:00 A.M. LPN #240 had administered a Zofran 4mg tablet with effective results noted. CNP #251 reviewed Resident #54's laboratory results obtained [DATE] with abnormal findings including an elevated BUN and WBC. CNP #521 ordered for a chest X-ray to be obtained and for IV fluids to be initiated of sodium chloride 0.9% parental solution 500 milliliters (ml) via IV to be administered 100 ml per hour. An interview on [DATE] at 10:02 A.M. with LPN #240 confirmed Resident #54's order for sodium chloride 0.9% parental solution 500 milliliters (ml) via IV to be administered 100 ml per hour was not initiated when initially received from CNP #521 at 8:00 A.M. on [DATE] and was actually initiated at approximately 4:00 P.M. (approximately 8 hours later) following Resident #54's second episode of vomiting. She further stated the urinalysis was not obtained as the resident was incontinent, but the chest X-ray was obtained. An interview on [DATE] at 12:25 P.M. with CNP #521 revealed LPN #240 did not notify CNP #521 the order for the IV fluids was not initiated following the first episode of vomiting as ordered by CNP #521. When LPN #240 notified CNP #521 of Resident #54's second episode of vomiting at approximately 4:00 P.M., CNP #521 requested the order for sodium chloride 0.9% parental solution 500 milliliters (ml) via IV to be administered 100 ml per hour to be initiated immediately. CNP #521 stated the fluids were ordered for kidney protection [not dehydration per the order] so it was acceptable to wait four to six hours to start the IV. She stated she did not feel Resident #54 was having an acute change in condition, but she did feel the resident had something going on due to her labs, but she was addressing it with the UA order and the chest X-ray order. An interview on [DATE] at 1:17 P.M. with the Director of Nursing (DON) revealed the CNP would write the order for the IV fluids and leave it on the nurses desk, but if it was a STAT order (to be completed immediately) then she would verbally tell the nurse and they would initiate the IV immediately or as quickly as possible. She stated her understanding was that Resident #54's IV was not a STAT situation, and that the CNP would have been okay with not starting the IV until they did start it at 4:00 P.M., since it was for kidney protection. An interview on [DATE] at 1:30 P.M. with the Assistant Director of Health Services (ADHS) revealed she would complete the IV initiations sometimes depending on the nurse on the hall. She stated that LPN #240 notified her verbally around 4:00 P.M. on [DATE] and requested Resident #54's IV to be placed after therapy and after the second episode of emesis. She stated she placed the IV in her left hand and it was successful on the first try and there were no issues. She stated if the order was to be placed as soon as possible then the CNP would write a STAT order, but if it was just fluids then she would tell them that it was okay to start it later, up to six hours after the order was received. An interview on [DATE] at 10:32 A.M. with Coroner #525 revealed Coroner #525 initiated an investigation into Resident #54's death due to her having been at the hospital less than 24 hours prior to death. There was no autopsy performed due to Resident #54's death had no suspicious findings upon completion of the investigation. The Coroner released jurisdiction on [DATE] to the facility's medical director. A review of the facility's policy titled Notification of Change in Condition dated [DATE] revealed resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner. This deficiency represents non-compliance investigated under Complaint Number OH00166297.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one resident (Resident #54) out three residents reviewed for falls. The facility census was 52. Findings Include: Review of Resident #54's medical record revealed admission date [DATE] with the following diagnoses including but not limited to acute respiratory failure, congestive heart failure (CHF), cardiomegaly, atrial fibrillation, and history of hemorrhagic stroke. Resident #54 expired on [DATE]. Review of Resident #54's admission fall risk evaluation dated [DATE] revealed Resident #54 was at risk for falling related to poor mobility, history of stroke, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 required assistance from staff for transfers, ambulation, and personal hygiene tasks and the resident had impaired cognition with Brief Interview Mental Status (BIMS) of 9 out of possible 15. Review of Resident #54's post fall evaluations dated [DATE] and [DATE] revealed Resident #54 continued to be at risk for falls. Review of Resident #54's fall care plan dated [DATE] revealed Resident #54 at risk for falls with interventions including providing non-skid footwear, staff to assist resident with transfers, and encourage Resident #54 to assume the standing position slowly. Review of Resident #54's progress note dated [DATE] at 6:00 A.M. authored by Licensed Practical Nurse (LPN) #214 revealed Resident #54 had attempted to self-transfer from the recliner, resulting in Resident #54 being found on the floor beside the recliner. Resident #54 was observed wearing regular socks instead of non-skid socks or shoes. An interview on [DATE] at 8:58 A.M. with LPN #214 confirmed Resident #54 was not wearing non-skid socks or shoes prior to the fall on [DATE] at 6:00 A.M. LPN #214 stated Resident #54 was wearing regular socks at the time of the fall and should have had either shoes or non-skid socks in place instead. Review of the facility's fall management policy dated [DATE] revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. This deficiency represents non-compliance investigated under Complaint Number OH00166297.

Based on employee file review and staff interview, the facility failed to ensure State tested Nursing Assistants (STNAs) received annual performance reviews. This had the potential to affect all residents residing in the facility. The facility census was 46 residents. Findings Include: Review of STNA #139's employee file revealed a date of hire of 05/30/23. STNA #139's file contained a 90-day evaluation dated 11/10/23. STNA #139's file did not include an annual performance appraisal as of 10/17/24. Interview on 10/17/24 at 10:25 A.M. with Business Office Staff (BOS) #136 confirmed there was no annual evaluation present in the employee file for STNA #139. BOS #136 stated they were not required to do evaluations after the 90-day evaluation. Interview on 10/17/24 at 12:00 P.M. with the administrator confirmed there was no annual evaluation in the employee file for STNA #139.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of emergency medical services (EMS) records, review of hospital records, review of video footage, interviews with facility staff, the coroner, law enforcement and restaurant owner, and review of facility policy, the facility failed to ensure Resident #51 was provided a safe environment, adequate supervision and assistance during an outing to prevent a fall down a flight of stairs. This resulted in Immediate Jeopardy when Resident #51, who was assessed to have unspecified dementia/ severe cognitive impairment, was at moderate risk for falls and utilized a motorized wheelchair for mobility entered a restaurant on a facility planned community outing, maneuvered her motorized wheelchair without staff assistance, and then drove the wheelchair down 18 stairs resulting in the resident sustaining numerous injuries/fractures. The resident subsequently passed away as a result of the injuries sustained during the fall. This affected one resident (#51) of seven residents reviewed for accidents/falls. The facility census was 49. On [DATE] at 4:49 P.M., the Administrator, Director of Health Services (DHS), and Regional Clinical Director (RCD) #115 were notified Immediate Jeopardy began on [DATE] at approximately 12:15 P.M., when Resident #51 sustained a fall down a flight of stairs during a facility planned outing at a local restaurant. At the time of the incident, the resident was not provided a safe environment or adequate supervision/assistance while maneuvering her motorized wheelchair without staff assistance and drove her wheelchair down 18 stairs resulting in Resident #51 suffering numerous injuries/fractures. The resident passed away as a result of the incident. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: On [DATE], all residents with motorized wheelchairs had their wheelchairs assessed to determine if there were any functional issues. There were none noted. The facility implemented a plan to assess all motorized wheelchairs at least twice per week for four weeks, and then monthly thereafter to ensure proper functionality. This was completed by Program Director #121. On [DATE], the facility ensured all residents in motorized wheelchairs were following their therapy recommendations prior to leaving the facility for a community outing. The facility implemented a plan for this to be assessed at least twice per week for four weeks, and then monthly thereafter to ensure they are being followed. This was completed by Program Director #121. On [DATE] and [DATE], Program Director #121 assessed all residents who utilized a motorized wheelchair in the facility (Residents #17, #20, and #48) and found no issues with their ability to safely use the wheelchairs. On [DATE], all nurses were educated by the Executive Director and DHS, about the following policies: Change of Condition policy, Notification of Change policy, Guidelines for Therapy Referral, Physician Provider Notification, Responsible Party Notification, Stop and Watch Early Warning Tool, SBAR communication tool, and Falls Management policy. On [DATE], the facility implemented the practice of filling out community activity forms with the following information: Residents attending the activity, staff attending the activity, indicating if a resident was in a wheelchair, resident Brief Interview for Mental Status (BIMS) score, location/address of the activity, and name of contact at the activity to confirm if the location was wheelchair accessible. Also, the facility would also send a State tested Nursing Assistant (STNA) on each outing as well. On [DATE], all life enrichment (activities) staff were educated by Regional Life Enrichment Staff #120 regarding the following policies: Resident BIMS scores, resident care plans and resident profiles (what they mean and where they can be found in the medical records), and the newly implemented community activity forms. On [DATE], all therapy staff were educated by Therapy Director #121 on the following policies: screening/observation process of new/existing residents, and Resident First Profile. On [DATE], the Executive Director reviewed the following policies with no changes needed: fall management policy and resident outings and trips policy. On [DATE], the facility reviewed the medical records for Resident #17, #20, and #48 to ensure their fall risk assessments, BIMS assessment, therapy evaluations (and recommendations if any), resident profile, and care plans were complete and accurate. No issues were found. On [DATE], Therapy Staff #300, Activity Associate #105, Activity Associate #102, STNA #106, STNA #107, and Registered Nurse (RN) #108 were interviewed. They confirmed they had received appropriate educations and trainings consistent with the facility's plan of correction. The facility staff interviewed were knowledgeable regarding the education that was provided to them. Findings include: Review of the closed medical record for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbances, morbid obesity, unspecified convulsions, disorientation, need for assistance with personal care, other lack of coordination, cognitive communication deficit, unsteadiness on feet, dependence on wheelchair, and muscle weakness. Review of Resident #51's plan of care, initiated on [DATE] revealed Resident #51 had significant severe cognitive deficits with further deterioration anticipated due to the intrinsic nature of the disease process. Interventions included to encourage Resident #51 to make simple decisions with limited choices daily, observe cognitive functioning with all hands-on care and contact, and refer significant declines/changes to the physician as needed. A second plan of care, initiated [DATE] revealed Resident #51 had impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduced safety awareness. The long-term goal was for Resident #51 to remain safe and not injure herself, secondary to impaired decision making. Interventions included to determine if decisions made by the resident endanger the resident or others, intervene if necessary; in new situations, provide support and reassure; pay attention to basic needs and provide ADL care as required, provide cues and supervision for decision making, and re-direct Resident #51 when agitated behaviors are present or potential for injury is evident. Additionally, a plan of care initiated [DATE] revealed Resident #51 required staff assistance to complete activities of daily living (ADL) tasks completely and safely related to dementia. Interventions included encourage Resident #51 to do as much as safely possible for self, observe for deterioration in ADL abilities and report if occurs, and therapy evaluation and treat as needed and ordered. Review of the Minimum Data Set 3.0 (MDS) assessment, dated [DATE], revealed Resident #51 had severe cognitive impairment. The assessment revealed Resident #51 was dependent on staff for assistance with transfers, personal hygiene, and bathing/showering. Review of Resident #51's most recent Fall Risk Assessment, dated [DATE], revealed Resident #51 was at moderate risk for falls. Review of Resident #51's progress notes, dated [DATE], revealed the facility documented, Resident noted with fall while on outing. EMS assessed resident. Resident transported to (local hospital) from outing. Daughter and provider updated. There were no other documented progress notes regarding the fall/incident that happened during the community outing on [DATE]. Review of the Emergency Medical Services Patient Care Record, dated [DATE], revealed EMS arrived at the community restaurant on [DATE] at 12:20 P.M. The report indicated Resident #51 was the individual involved and she fell down stairs and steps. Cardiopulmonary Resuscitation (CPR) was started immediately. EMS documented that there was injury and trauma to her airway and her tongue was swollen, which required them to use video to place the breathing tube, which was successful. An intravenous line was placed, and Resident #51 received three, one milligram (mg) doses of epinephrine by the time she reached the hospital. Resident #51 was unresponsive to care and services during the whole time she was in the care of EMS. Injuries noted on the report included open or depressed skull fracture, two or more proximal long bone fractures, and bruising to her lower two abdomen quadrants. Review of the EMS Patient Care Report, dated [DATE], revealed the narrative of the EMS run included the following: EMS was dispatched to a community restaurant for a person (Resident #51) who had fell down the stairs and was not breathing. Local fire department was dispatched also for the manpower. When they arrived at the scene, unknown females met them outside the restaurant and stated, she is dead, she caved her head in, there is nothing you can do. EMS went to where Resident #51 was located and found Resident #51 laying in the prone position at the bottom of the staircase. She was pulseless and apneic (involuntary or temporary pause in breathing). EMS repositioned Resident #51 on the floor and began manual compressions. A cardiac monitor and ventilator were placed to continue life sustaining measures. An initial heart rhythm of asystole (the cessation of electrical and mechanical activity of the heart) was noted. EMS took Resident #51 to the ambulance and transported her to the emergency room . Resuscitation efforts continued the entire time she was in the ambulance as well. Review of Resident #51's hospital records, dated [DATE], revealed on [DATE], she arrived at the emergency room with EMS performing CPR. The EMS personnel stated Resident #51 had a fall in her motorized wheelchair of approximately 25 stairs at the community restaurant, and when they arrived, she was in asystole (at the bottom of the stairs). EMS intubated her, placed an intraosseous IV and gave her epinephrine. Resident #51 had pulseless electrical activity (PEA) without the return of spontaneous circulation. No other information was available at that time. Physical exam of Resident #51 included a large laceration to the left forehead with large hematomas noted, an open fracture of the mid left tibia and fibula, and laceration to the mid right leg. At a later time, the hospital received more information that Resident #51 was seen on the camera at the restaurant and appeared to go headfirst over the staircase in her motorized wheelchair. Interview with Restaurant Owner #207 on [DATE] at 2:35 P.M. revealed she was in the building at the time of the incident with Resident #51. She stated the residents were in the gift shop by themselves. One of the facility staff had taken a couple residents to the dining room, which was out of sight of the gift shop. The other two male facility staff were outside assisting residents into the building, with one of the facility staff opening the front doors to the restaurant/gift shop. One of the male facility staff ran inside the gift shop and ran down the stairs to see if he could help as soon as he heard Resident #51 fell down the stairs. Restaurant Owner #207 indicated EMS was called to assist with the situation. Interview with Activities Associate #102 on [DATE] at 3:15 P.M. revealed Resident #51 was the first resident/wheelchair off the bus. He stated he assisted Resident #51 off the wheelchair lift and walked with her (and others) into the restaurant. He opened both sets of entry doors to allow Resident #51 to maneuver herself into the gift shop of the restaurant. He stated approximately four to six residents were in the restaurant at this time, but he did not know where they all were. He confirmed another female staff (Activities Associate #101) was already in the restaurant with a few residents. He stated when Resident #51 went through the second entry door into the restaurant, he asked her to wait. She continued in her motorized wheelchair without stopping/waiting. Activities Associate #102 then said are you ok to Resident #51 and stated she nodded her head and indicated that she was, so he let her continue while he kept holding the doors. He revealed he did not see Resident #51 fall. When he heard that Resident #51 fell , he stated he was near the doors, so he ran to the stairs and down them to see if he could help. One of the community members at the bottom of the stairs told him that Resident #51 did not have a pulse. He revealed a community member told him that EMS was called. During the interview, Activities Associate #102 revealed he had been employed with the facility for approximately three and a half weeks. He revealed they did not really discuss a plan as to who would take which residents into the facility and where each staff person would be when they got into the restaurant, but they had all gone on activities together before and they kept with the same plan. He was not able to explain/express what the same plan was. Interview with Transportation Associate #103 on [DATE] at 3:35 P.M. revealed he was the bus driver for six of the residents who went to the restaurant on [DATE]. He revealed he was outside of the restaurant when Resident #51 fell . He indicated he does not know where the other two staff were at the time of Resident #51's fall because he was assisting residents off of the bus. Interview with Activity Associate #101 on [DATE] at 3:50 P.M. revealed upon arriving to the restaurant, she entered with three residents. She revealed she went to the dining area of the restaurant with three other residents to pick the table and chairs for the entire group. While she was in the dining area, she was told by a restaurant staff person that one of their residents fell down the stairs. When she got to the gift shop area of the restaurant, Activities Associate #102 was at the bottom of the stairs checking on Resident #51. She revealed she called Life Enrichment Director (LED) #104 immediately after Resident #51's fall to report the incident. She stated when they got off the bus, prior to the fall, she told the two other staff that she would take a couple residents into the restaurant to get the table/chairs set up for all nine residents. She revealed she was in the dining area and did not see Resident #51 fall. Interview with Law Enforcement #206 on [DATE] at 9:11 A.M. revealed he watched the restaurant video of Resident #51 falling down the stairs. He stated it appeared Resident #51 turned near the corner of the stairs and fell straight down the stairs. Review of restaurant security camera video footage on [DATE] at 12:35 P.M. revealed the video was one minute and two seconds in length. The date on the video was [DATE] at approximately 12:23 P.M. and the title of the video was gift shop. Immediately as the video started, Resident #51 could be seen in her motorized wheelchair between the half wall of the stairway to the basement, and the exterior wall of the giftshop/restaurant; not very far from exterior door. Approximately 13 seconds after the video started, Resident #51 could be seen independently maneuvering her motorized wheelchair from the exterior door, to the back/middle section of the gift shop, where the top of the staircase was located. Approximately 19 seconds after the video started, Resident #51 could be seen facing the top of the staircase in her motorized wheelchair. Resident #51 then continued to independently maneuver her motorized wheelchair towards the stairs and proceeded to fall down the stairs with her motorized wheelchair. Resident #51 was then seen rolling down the stairs in her motorized wheelchair. At no point did it appear that Resident #51 stopped her wheelchair prior to falling down the staircase. Approximately four seconds after Resident #51 initially fell , video showed a person (identified to be Activities Associate #102) run from the exterior door to the top of the staircase. Approximately 10 seconds after the initial fall, Activities Associate #102 could be seen going down the stairs. For the other 32 seconds of the video, no other facility staff went into the gift shop area. At the time Resident #51 fell , there were no facility staff observed around Resident #51 to provide supervision/assistance or to ensure the environment was safe for Resident #51 while in the gift shop area. Interview with Coroner #205 on [DATE] at 12:58 P.M. revealed they would be completing an autopsy due to the nature of Resident #51's death. He stated based on the medical evaluation he had completed thus far, Resident #51 had the following injuries: multi-bilateral rib fractures which would have severely hindered Resident #51's breathing, complete dissection of the T11 and T12 thoracic spine, and C1 and C2 fracture with spinal cord traction. He stated he had not made a formal cause of death, but the most likely reason was multiple blunt force trauma accident. Interview with the Administrator on [DATE] at 8:05 A.M. confirmed the sequence of events that Activities Associate #102 reported, due to the information being reported to her in the same manner when she arrived at the restaurant. Activities Associate #102 was opening the door for Resident #51 and asked her to wait; however, she did not wait so Activities Associate #102 asked Resident #51 if she was ok and Resident #51 indicated she was. The Administrator confirmed Activities Associate #101 was in the dining area (The dining area was away from the gift shop area which was where the stairs were located). The Administrator confirmed she saw the restaurant video and there appeared to be no delay or hesitation with Resident #51 from turning right and around the corner of the gift shop and when she fell down the stairs. She stated the facility set staffing levels for community outings based on the level of the needs of the residents and they do not have a set number of staff that go on outings. Interview with Program Director #121 on [DATE] at 8:20 A.M. revealed Resident #51 had continued therapy with her motorized wheelchair for repetition and muscle memory. She revealed Resident #51 could not retain information about her motorized wheelchair or the ability to use it, other than what she had already retained. Resident #51 had maximized the amount of information about her wheelchair and how to use it, which was why they were performing therapy services related to maneuvering the wheelchair and turning it off/on three days per week as repetition. Review of the facility policy titled Resident Outings and Trips policy, dated [DATE], revealed the site chosen for the outing would be checked and reviewed for safety and accessibility. Notification of all proposed outings would be communicated to the Executive Director and Director of Health Services to support staffing ratios during outings. Campus staff to resident ratio would vary according to the type of outing, number of residents/patients, and the mental and physical functioning of the residents/patients. This deficiency represents non-compliance investigated under Complaint Number OH00151548.