Every finding on record at Warren Nursing & Rehab

Based on observation, closed medical record review, review of the facility water management plan and maintenance logs, review of the Centers for Disease Control and Prevention (CDC) guidance related to legionella, review of infection control tracking, and interviews with staff and representatives from the Local Health Department (LHD), the facility failed to develop, implement and follow a comprehensive and effective infection control/water management plan and remediation program to prevent the risk of legionella growth and spread in the water supply. This resulted in Immediate Jeopardy and the potential for serious life threatening harm, negative health outcomes, and/or death beginning on [DATE] when Resident #76, who was bed ridden, had chronic lung disease, was dependent on a mechanical ventilator to breath, and had not left the facility for over 14 days prior to hospitalization, became unresponsive and in respiratory distress requiring emergency transfer to the hospital where she was diagnosed with septic shock, pneumonia and subsequently tested positive (on [DATE]) for legionella pneumophila Ag bacteria in her urine (a rapid urine antigen test used to diagnose Legionnaire's disease, a severe form of pneumonia caused by legionella bacteria) and expired in the hospital on [DATE]. The facility's failure to develop, implement and follow a comprehensive and effective infection control/water management plan and remediation program to mitigate the growth of legionella affected one resident (#76) and placed all 72 current residents in the facility at risk of developing serious life-threatening illness and/or death from Legionnaire's disease.In addition, a concern that did not rise to the level of Immediate Jeopardy was identified when the facility failed to maintain proper infection control practices to prevent the spread of infection. Respiratory Therapist (RT) #364 was observed providing suctioning and tracheostomy care to Resident #18, who was in contact isolation for Clostridium Difficile (C Diff) infection (an infectious and highly contagious diarrhea) without wearing proper personal protective equipment (PPE). This affected Resident #18 and had the potential to affect 11 additional residents (#1, #2, #10, #11, #22, #25, #38, #42, #58, #62, and #65) who resided on the Aspen unit. The facility census was 72.On [DATE] at 2:25 P.M. the Administrator, Director of Nursing ( DON) , Regional Director of Operations (RDO) #801, [NAME] President of Clinical Services (VPCS) #802, and Regional Director of Clinical Services (RDCS) #803 were notified Immediate Jeopardy began on [DATE] when Resident #76 was transferred to the hospital due to respiratory distress and subsequently tested positive for Legionella. Resident #76 expired in the hospital on [DATE]. The facility failed to develop and implement an effective water management program to address areas of water stagnation, plumbing schematics and comprehensive assessment of the physical plant with lack of control measures and remediation/investigation therefore exposing risk of legionella growth and spread to the residents in the facility.The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions:- On [DATE] at 10:42 A.M. Registered Nurse (RN) #431 was contacted by the Local Health Department for notification that Resident #76, who had resided on the Aspen unit in the facility, tested positive for Legionella while at the hospital and expired at the hospital. RN #431 immediately notified the Medical Director, Administrator, Director of Nursing (DON) and Infection Control Physician. - On [DATE] at approximately 11:00 A.M. the Administrator, DON, Assistant Director of Nursing (ADON) and Human Resources instructed via electronic and in-person huddles for staff to avoid unflushed/restricted water and to use alternative (bottled or approved) water and ice. - On [DATE] at approximately 11:30 A.M. the Administrator, Maintenance Director #368 and Dietary Director #317 implemented bottled water for all drinking and cooking. - On [DATE] at 11:30 A.M. the use of ice machines, showers, whirlpool tub, hoppers were restricted on the Aspen unit and on the Birch, Dogwood, Crabapple units only bed baths with provided wipes were permitted as use of showers was restricted. - Between [DATE] and [DATE] the Administrator, DON, ADON and Human Resources provided staff education to six of six RNs, 18 of 27 Licensed Practical Nurses (LPN), 37of 52 certified nursing assistants (CNA), 10 of 10 Housekeepers, five of five Activity staff, seven of seven Respiratory Therapists (RT) , and agency staff including one RN, 21 LPNs, and 31 CNAs. The education included the Centers for Disease Control Legionella signs and symptoms, transmission, surveillance/detection, and the facility's water management program. Education was completed by [DATE]. For any staff not on the schedule due to leave or other reasons, education would be provided prior to start of next shift. - On [DATE] by 3:00 P.M. the DON and Registered Nurse (RN) #350 assessed all current residents for signs/symptoms of legionella infection (cough with phlegm, chest pain, fever, chills, and shortness of breath).- On [DATE] 500 gallons of water was delivered to the facility by commercial provider. - On [DATE] bags of ice were delivered by commercial provider. - On [DATE] at approximately 11:30 A.M. use of ice machine, sinks, showers, whirlpool tub, and hoppers were restricted on the remaining units of Birch, Crabapple, Dogwood and Somerset. - On [DATE] at approximately 12:30 P.M. a phone call was held with the local health department and Ohio Department of Health Bureau of Environmental and Radiation Protection for guidance on (legionella) mitigation and testing. - On [DATE] at 5:00 P.M. six portable handwashing sinks were delivered and stationed on Aspen unit. - On [DATE] by approximately 6:00 P.M. signage was posted by VPCS #806, RDCS #803, the DON, ADON and Respiratory Therapy Director instructing staff to avoid unflushed/restricted water and to use alternative (bottled/approved) water. - On [DATE] ServPro performed professional attic cleaning on the Aspen unit including debris removal, HEPA vacuuming, antimicrobial treatment, stain/odor blocking sealant application, air/surface testing, removal of wet insulation, ceiling repair below the attic and vent pipe repair within the Aspen unit Hallway/Attic area between rooms 503, 508, 502, 509, 510 and 501. - On [DATE] at approximately 10:30 A.M. a phone call meeting was held with a legionella consultant to review the facility water management plan.- On [DATE] at 7:00 P.M. 16 portable handwashing stations were delivered and stationed throughout the facility. - On [DATE] the Maintenance Supervisor (MS) #368 installed 10 legionella prevention filters on the Aspen unit (in the shower room, medication room and rooms 501, 502, 503, 504, 505, 506, 507, 509, 510, 515, 516, 517, 518 and 519). - On [DATE] at 4:37 P.M. Regional Director of Operation completed Somerset unit water flush which included full flushing of all pipes, bathrooms, sinks, hoppers and dialysis den. Documentation was submitted to the Administrator. - On [DATE] at 5:00 P.M. an Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Medical Director, VPCS, RDO, RDCS, Administrator, DON, MDS, Housekeeping, MS #368, Human Resources, RN #431 and the ADON for QAPI tracking including weekly flushing compliance, audit outcomes, symptom surveillance, environmental concerns, legionella water management program review and risk assessment analysis review. - On [DATE] MS #368 installed additional legionella prevention filters to two hand sinks in dialysis, one hand sink in the therapy gym, one hand sink in the first floor public rest room, one hand sink in laundry and six sinks in the kitchen, one sink in the Birch, Dogwood, Crabapple medication rooms, one sink in the first floor dining room, one sink in the Dogwood shower room and the Crabapple room sinks in rooms 710, 716 and 718.- On [DATE] at 6:00 P.M. the RDO re-educated MS #368 on weekly flushing, documentation rules, proper procedures (15 minutes run time, full toilet flush/hopper flush) and reporting/escalation steps. - On [DATE] the RDO contacted an additional Legionella Consultant #901 for mitigation support. - On [DATE] Legionella Consultant #901 performed water testing of 25 samples collected across Aspen, Birch, Crabapple, Dogwood and Somerset units. - The facility implemented a plan for clinical monitoring beginning [DATE] by the DON/ADON or designee to review resident documentation weekly for four weeks for symptoms such as temperature, pulse, respirations, blood pressure, oxygen level, lung sounds, cough and phlegm, chest pain, fever/chills, shortness of breath. - The facility implemented a plan for environmental monitoring by the Administrator or designee beginning [DATE] to review flushing logs weekly for four weeks and monthly thereafter. - The facility implemented a plan for enhanced surveillance by the DON/ADON beginning [DATE] to include a 20 day enhanced respiratory illness monitoring and immediate reporting of suspected cases. - The facility implemented a plan for the water management program beginning [DATE] to be on-going and include daily monitoring of temperature, disinfectant levels, flushing logs, legionella filters for placement and function twice a day and monthly Water Management Plan meetings until investigation closed. Although the Immediate Jeopardy was removed on [DATE] the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include:1. Review of the closed medical record for Resident #76 revealed an admission date of [DATE] with diagnoses including myotonic muscular dystrophy, chronic obstructive pulmonary disease, morbid obesity with alveolar hypoventilation, cardiomyopathy, congestive heart failure, atrial fibrillation, tracheostomy, chronic kidney disease, and dependence of respirator ventilator status. Resident #76 was discharged from the facility on [DATE] to the hospital where she expired on [DATE].Review of the plan of care for Resident #76, date revised [DATE], revealed the resident was a full code, was dependent on mechanical ventilation with a tracheostomy and had a self-care deficit related to myotonic muscular dystrophy, history of cerebral vascular accident, chronic respiratory failure with vent/trach dependence, impaired mobility, and morbid obesity. Interventions included provide full resuscitative measures, monitor/document respiratory rate depth, quality every shift/as ordered, oxygen settings as ordered, suction as necessary, transfer with two assist mechanical lifts, set-up assist for eating, and assist with activities of daily living.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had intact cognition, required (staff) set-up and clean-up assistance for eating, was totally dependent on staff for oral hygiene, toileting, bathing, dressing, bed mobility and transferring. Resident #76 was incontinent of bowel and bladder, had respiratory failure with a tracheostomy and required mechanical ventilation.Review of a nursing note, dated [DATE] at 1:40 P.M. and authored by Licensed Practical Nurse (LPN) #379 revealed at approximately 11:50 A.M. the Certified Nursing Assistant (CNA) responded to Resident #76's call light and noticed Resident #76 appeared cyanotic (bluish discoloration of skin, lips, nails due to lack of oxygen). The CNA immediately called the nurse to the room. Upon entering the room, immediately assessed the resident and her oxygen saturation was 45 percent (normal 90-100%). The nurse promptly suctioned the resident and began bagging. The residents' oxygen saturation improved to 100 percent. Resident #76 was placed back on the ventilator; however, her oxygen saturation began to drop. Another nurse on duty contacted the emergency medical team (EMT) for emergency transport. Bagging continued until EMT arrived and assumed care. The supervisor on call, physician and family was notified.Review of the Transfer Form dated [DATE] at 1:46 P.M. and completed by LPN # 828 revealed Resident #76 was sent to the hospital on [DATE] at 12:00 P.M. from the Aspen unit due to unresponsiveness. The transfer was an unplanned transfer.Review of the Change in Condition Evaluation, dated [DATE] at 1:57 P.M. completed by LPN #828 revealed Resident #76 was short of breath, and unresponsive (which began on [DATE]). Blood pressure was 152/90 (hypertensive). Respirations were greater than 26 per minute, 93 percent oxygen saturation by the vent. Resident #76 was a full code. Shortness of breath was an abrupt change, and oxygen dropped to 35 (%), skin became discolored with a bluish tone. Resident then became unresponsive. No abnormal labs to report. Reported to primary care clinical on [DATE] at 12:11 P.M. Review of the Change in Condition Evaluation dated [DATE] at 7:38 P.M. authored by Registered Nurse (RN) #399 revealed Resident #76 had a respiratory infection, shortness of breath, tired/weak/confused/drowsy. Blood pressure was 108/71, pulse was 104, pulse oximetry was 88 percent. Physical assessment revealed increased confusion, weakness, shortness of breath, and difficult to arouse. Nursing observation included Resident #76 recent arrival back into the facility from the hospital, SpO2 (peripheral capillary oxygen saturation) dropped, arterial blood gas (ABGs) were drawn by Respiratory Therapy (RT). Family was at bedside and made aware resident returned from the hospital with diagnosis of pneumonia. Family aware physician wanted Resident #76 sent back to the hospital because she should have been admitted . Resident #76 had an abrupt change in mental status abnormal ABGs, oxygen levels dropped, with increased respiration and low SpO2.Review of a nursing note, dated [DATE] at 7:40 P.M., authored by RN #399 revealed Resident #76 returned from the hospital. Resident #76 oxygen desaturated down to 84. Oxygen was turned up to 10 liters. SpO2 went to 91 then down to 87. ABGs were drawn with poor results. Paperwork from the hospital stated Resident #76 had pneumonia. Pulmonary doctor was consulted and stated to send Resident #76 back to the hospital. 911 was called.Review of assessment titled Discharge to Hospital Form, dated [DATE] at 8:07 P.M. revealed report was called in to the hospital at 10:19 P.M.Review of the Respiratory Therapy Note dated [DATE] at 8:12 P.M., revealed Resident #76 was re-admitted to the facility when the RT arrived for shift. After the paramedics left, nursing performed an assessment and discovered Resident #76 had a SpO2 of 82 percent. Pulse oximeters were attempted on multiple fingers with no variations. The RT decided to increase oxygen to 10 milliliters per minute. Resident #76's oxygen increased to 85 percent. Resident #76 oxygen saturations increased to 87 percent but then Resident #76 became lethargic. ABGs were drawn from the right radial artery with no complications. Physician was called with results and was notified of the situation. Physician said to send Resident #76 to the hospital to have her admitted .Review of the hospital records for Resident #76 dated [DATE] revealed a chief complaint of low pulse oximeter readings. The principal problems listed included septic shock, morbid obesity, sepsis due to pneumonia, acute on chronic respiratory failure with hypoxia and hypercapnia, shortness of breath, and sepsis with acute hypoxic respiratory failure. Urine legionella antigen was collected on [DATE] and the results were positive for Legionella Pneumophilla Ag in the urine (reference range negative). Discharge diagnoses included intractable ventricular tachycardia, septic shock due to ventilator associated pneumonia resulting in acute on chronic hypoxia/hypercapnic respiratory failure, acute renal insufficiency. Resident #76 expired at the hospital on [DATE] at 8:17 A.M.Review of a facility map revealed Resident #76 had resided on the second floor of the facility on the Aspen unit (the ventilator unit). On the first floor of the facility was an unoccupied, former resident unit identified as Somerset (which was noted by the facility Maintenance Supervisor as closed down after it was affected by a flooding of water in the facility in [DATE]).Review of the Legionella Water Management Program, updated [DATE], revealed it was the policy of the facility to establish water management plans for reducing the risk of legionella and other opportunistic pathogens in the facility's water supply. The facility must designate a team responsible for overseeing the water management program who have expertise in infection control, facility management and maintenance as well as outside consultants if needed. The water management program should be under ongoing review to account for changes in the facility's water systems. Hot water temperatures should be continuously monitored and maintained at 140 degrees Fahrenheit (F) or higher to prevent legionella growth, however, to avoid scalding should be delivered at 120 degrees F. Water flow should be controlled to prevent stagnation. Water systems should be regularly flushed especially in low use areas such as unused faucets, showers or sections of plumbing. Regular cleaning and maintenance of cooling towers and HVAC systems should be inspected, cleaned and disinfected regularly to prevent legionella growth. There was no evidence in this document that it had been revised or updated to reflect control measures in place for the Somerset unit after the flood and closing down the unit in [DATE]. There was no written description of how the facility water was supplied, heated, stored, recirculated, mixed or moved between floors.Review of a facility document titled Logbook Documentation Task Name: Testing and Monitoring of Water Management Plan for Legionella, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], completed by Former Maintenance Director #821 revealed multiple locations in the facility were given a pass rating, however, there were no specifications listed to explain what was evaluated. There were no additional documents with this title after [DATE].Review of a facility document titled Water Management Risk Assessment and Analysis dated [DATE], revealed the water management team (the Administrator, Medical Director, Director of Nursing, Infection Preventionist and Maintenance Director) was responsible for oversight and consultation regarding potential risks exposure prevention and training. The team would develop and maintain a hazard analysis and critical control point plan. The facility administrator and Director of Nursing were responsible for buildings where water systems are present and were responsible for ensuring components of the legionella exposure control plan are developed and current and providing applicable employee training where there is a potential risk of legionella being present. Incoming water was from the city of [NAME]. There was no written description of how the facility water was supplied, heated, stored, recirculated, mixed or moved between floors. Under Facility Control Procedures it was noted the water management plan (WMP) was developed to reduce the risk for legionella growing and spreading to the facility population at higher risk for Legionnaires disease. The facility had chosen control measures as followed: pipework with lack of water flow or stagnation can cause risk for bacterial growth. Weekly flushing of water through all faucets in resident rooms, eye wash stations, and beauty shop, this task will be added to housekeepers to be completed Monday or Tuesday each week and consisting of flushing each faucet for three minutes and showers. Also flush all toilets at least once a week. The hot water system boiler temperature would be set to 140 degrees F and hot water holding tanks at 140 degrees F and facility staff would record the water temperature weekly. Supervision to review documentation by Thursday each week to ensure compliance and if not being done the task would be scheduled to be done by Friday. There was no standardized form attached for recording consistent measures to review or who was responsible to review for remediation. Review of a facility document titled Legionella/Hand Water, dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], completed by Maintenance Supervisor (MS) #368 revealed multiple locations in the facility were given a pass rating, however, there were no specifications listed to explain what was evaluated. Review of a facility provided document Metiri Analytical Group (previously known as CWM Environmental Cleveland, LLC) Analytical Report, date reported [DATE], revealed on [DATE] eight water samples were taken from the Birch unit bathing facility, Birch unit room [ROOM NUMBER], the Aspen unit nurses station, Aspen unit bathroom, Dogwood bathroom, Dogwood bathing facility, Crabapple bathroom and Crabapple bathing facility. The result was less than 0.100 Most Probably Number per milliliter (MPN/ml) for legionella pneumophila group. There were no samples taken from the Somerset unit. Review of email correspondence dated [DATE] at 1:33 P.M. authored by Environmental Specialist (ES) #813 revealed ES #813 was contacting the local health department (LHD) of [NAME] City to provide guidance on a legionella case positive at the facility, as it was in the LHD jurisdiction. The case was considered a presumptive healthcare associated case, so ES #813 asked the facility to follow the Center for Disease Control (CDC) guidance for a full investigation and to set up a call to go over the following steps on [DATE] at 12:30 P.M. with the facility: Contact a Legionella consultant to assist with installing filters, assisting with sample collection, conducting a facility assessment, and water systems. Please see the attached list of active consultants in Ohio. Implement water-use restrictions throughout the facility using point-of-use filters (0.2 microns). ODH recommends using filters graded for at least 60 days during the investigations. Filters should be installed within two to three days after receipt of this email. Working with their consultant, they may either install these filters on all fixtures in the building or on key locations and restrict water access everywhere else. Communicate to staff and residents about water restrictions and post signage near each fixture with a filter for people to contact maintenance staff if a filter is damaged or removed. CDC provides communication resources on their website. Conduct a new risk assessment of the facility, it is recommended to complete a CDC Legionella Environmental Assessment Form (LEAF). Send the completed assessment form to ODH and the local health district when done. Create a Legionella sampling plan for their facility. These will be considered pre-remediation samples and will follow CDC guidance for samples collected during an investigation. Samples should be a combination of flush (bulk water) and first draws/swabs (see CDC sampling guidance). Water samples should be collected in 1L bottles and sent to a CDC ELITE Certified Laboratory. Make sure samples are evenly distributed and include all water sources in each of the case rooms. Buildings with multiple floors should have at least two sample locations on each floor. Buildings with risers should assure there is at least one point of use sampling location on each riser. Many consultants are familiar with ODH sample expectations. Send the sampling plan to ODH with locations marked on a facility map prior to sample collection. Videos and additional sampling resources are found on the CDC webpage. After samples are collected, implement any identified corrections to the potable water system to prevent water stagnation and/or improve water flow. Remediate/treat the facility's water system following the guidance of their consultant. Collect a set of samples at the same locations as the previous set 72-hours after remediation. These will be considered post-remediation samples. Collect additional sets every two weeks until the facility has two consecutive negative sample sets. The facility should revise their water management program based on ODH and local health district recommendations. Their consultant may help with this. We tend to return WMPs within 3-4 weeks of receipt. Review of a facility document provided by the Director of Nursing (DON) on [DATE] revealed a single page document with one typed line that stated all residents have been assessed on [DATE] with no signs of respiratory distress noted. The documentation was signed by the DON. There were no resident names or clinical indicators of what the assessments consisted of on the document. Review of the facility document tilted Water Temperature Log dated [DATE] to[DATE] revealed water temperatures were taken at the same time on four separate resident units but did not specify if the temperatures were taken from the holding tanks or faucets. Review of the Centers for Disease Control (CDC) website (https://www.cdc.gov/investigate-legionella/php/healthcare-resources/control-measures.html) dated [DATE] titled Implementing Control Measures In Healthcare Facilities , revealed examples of immediate control measures included until the investigation is completed avoid creating aerosols by avoiding exposure to hydrotherapy tubs, avoiding use of water from sink/tub faucets in patient rooms, restrict showers(use sponge baths), and limit consumption of non-sterile ice for anyone at risk of aspiration or who has swallowing difficulties. Review of the document titled Q Laboratories Legionella Sample Submission Form, dated [DATE] revealed Legionella Consultant (LC) #811 collected 26 samples from the facility with results reported [DATE]. The ISO legionella results were none detected.Review of the document titled Q Laboratories Final Report, dated [DATE], revealed ISO legionella results were none detected.An interview on [DATE] at 9:18 A.M. with Maintenance Supervisor (MS) #368 revealed the local health department was to call in today at 2:00 P.M. with instructions regarding a resident who tested positive for Legionella. The facility tested the water for legionella on [DATE] and it tested negative and retested on [DATE] because the resident tested positive for legionella.An interview on [DATE] at 9:20 A.M. with the Administrator revealed according to the Center for Disease Control guidelines the facility could wash hands and give bed baths with faucet water with no filters. The Administrator stated because Resident #76's urine tested positive for legionella it could be a false positive. The Administrator verified the health department notified the facility on [DATE] that Resident #76 had tested positive for legionella in the urine.An interview with MS #368 on [DATE] at 9:45 A.M. revealed the facility was using bottled water for drinking and using tap water for the laundry, cooking and the dish machine. MS #368 stated no residents had showers since [DATE], and the DON was to educate nursing staff on resident protocol. Observation on [DATE] at 9:50 A.M. with MS #368 of Resident #76's room revealed the sink still had running water, and the staff had an air mattress on the floor that was in the process of filling for another resident. MS #368 verified the room should not be in-use; however, no signs were posted to not use the room and stated no one was in the room and staff should know not to use the sink.Observation on [DATE] at 9:50 A.M. to 10:30 A.M. with MS #368 revealed no signage was posted at the nurse's stations or anywhere on the Birch, Dogwood, Crabapple or Aspen units to alert staff to not use water from the sink faucets. MS #368 stated the nurses were to use a water pitcher to wash hands with water brought in instead of water from the faucets. Observation on [DATE] at 10:00 A.M. with MS #368 present during the observation revealed the attic area above Resident #76's room presented with moldy drywall, a dead animal carcass, an open white pipe dripping water, wet and moldy insulation and signs of standing water on the floor of the attic. There were also signs of water damage on the ceiling. MS #368 verified the findings at the time of the observation.An interview on [DATE] at 10:25 A.M. with LPN #380 revealed nurses were approved to wash hands in the sinks and use the water from the sinks for resident care because it did not cause an aerosol.An interview on [DATE] at 10:30 A.M. with LPN #319 revealed the nurses were told it was okay to wash hands in the sinks of resident's rooms and the water bottles were to be used for resident drinking water.An interview on [DATE] at 11:12 A.M. with Epidemiologist #804 from the local health department revealed the department was notified by the local hospital on [DATE] that a resident (Resident #76) died in the hospital who tested positive for legionella. The local health department notified the Ohio Department of Health (ODH) Environmental Health unit on [DATE] and awaited direction from ODH Environmental Health prior to contacting the facility. The facility was contacted on [DATE] with an urgent message to have the infection control nurse call the local health department but no call was received from the facility. On [DATE] Epidemiologist #804 called the facility again and was able to speak with Infection Control Nurse #431 to notify the facility a resident from their facility tested positive for legionella in the hospital and expired in the hospital. Epidemiologist #804 asked the facility if Resident #76 had left the building 14 days prior to admission to the hospital on [DATE]. The facility reported Resident #76 had not left the facility 14 days prior to the hospital admission. Epidemiologist #804 stated she would call back to set up a meeting on the next steps the facility was to abide by which was scheduled for 2:00 P.M. on [DATE]. Epidemiologist #804 stated the facility would be instructed to hire a legionella consultant and a list would be provided.On [DATE] at 1:20 P.M., observation during the facility tour revealed a large ceiling stain near Resident #76's room in the hallway on the Aspen unit by the exit sign and a black substance around the pipes in the hallway. Interview with the MS #368 at the time of the observation revealed the stain was from a roof leak about a month ago. When asked if water got inside the air duct work he stated, yes, but we had a company come replace the duct work.An observation was conducted on [DATE] at 1:24 P.M. of the attic on the even room number side of the Aspen unit to inspect the stained area. Observation revealed duct work was not replaced, a plastic drain pipe was disconnected, wet insulation removed from the duct work was left in the area, and signs of what appeared to be water stains and mold on drywall. Observation also revealed a decomposed rodent resembling an opossum outside of Resident #76's room in the ceiling. Photographs were taken at the time of the observation by the life safety surveyor and verified by MS #368. MS #368 stated the air flow from the attic ran into Resident #76's room. An interview and observation were conducted on [DATE] at 2:06 P.M. with MS #368 of the Somerset unit. MS #368 stated the Somerset unit had been flooded by creek water back in [DATE] and had not been in use for some time. When asked about stagnant water lines/deadlines on the unit, MS #368 stated the water is shut off. Observation of water faucets in the mop closet and the shower room at 2:10 P.M. on the Somerset Unit, revealed the water was still turned on to that part of the building. MS #368 verified the taps and pipes were not being flushed on that unit. MS #368 verified there were no other log books of documentation to review regarding testing and monitoring for the water management plan. A request for water flushing logs was made at this time and MS #368 stated there were no logs to prove flushing was being done on the Somerset unit. Despite his prior statement that the water to the [TRUNCATED]

Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent and/or promote pressure ulcer healing. The facility failed to ensure pressure-relieving equipment was functioning as intended, failed to ensure nutritional interventions were initiated, and failed to ensure treatments were implemented and maintained as ordered to prevent the development and/or worsening of pressure ulcers for Residents #10, #11, #25, #27, #44, and #58. Actual Harm occurred beginning on 11/19/25 when Resident #10 who was severely cognitively impaired and at high risk for pressure ulcer development with a history of pressure ulcers developed a deep tissue injury (DTI)/unstageable (full thickness tissue loss) pressure ulcer to the thoracic spine (mid-back) as a result of a malfunctioning low air loss (LAL) mattress. Actual Harm occurred on 12/09/25 when Resident #27 who was severely cognitively impaired and at high risk for pressure ulcer development was found to have an unstageable pressure ulcer to the right ischium. The facility failed to provide evidence the resident was being adequately monitored and/or provided necessary intervention to prevent the ulcer from first being found as an unstageable pressure ulcer. This affected six residents (#10, #11, #25, #27, #44, and #58) of 15 residents reviewed for pressure ulcers. The facility census was 72.Findings include:1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, chronic congestive heart failure, necrotizing fasciitis, moderate protein calorie malnutrition, dysphasia, dependence on a respiratory ventilator, acute pulmonary edema, tracheostomy status, and pressure ulcer of other site Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the coccyx. Review of the resident's physician orders revealed a diet order for the resident to receive nothing by mouth (NPO). The resident had an order for enteral tube feed with Nepro at 40 milliliters (ml) per hour for 20 hours a day (high-protein nutritional supplement). An order (dated 10/30/25 for a low air loss (LAL) mattress, monitor function inflation every shift. An order to cleanse coccyx with full strength Dakin's (antimicrobial cleanser), apply full strength Dakin's on a four by four gauze cover with abdominal (ABD) pad and do not tape every shift, in-house dialysis Monday through Friday, an order for ProStat (a protein supplement for wound healing) 30 milliliters daily dated 07/22/25 and discontinued 10/10/25, an order for liquid protein three times a day dated 12/17/25 and an order for enhanced barrier precautions (EBP). Review of the care plan dated 11/03/25 revealed Resident #10 had a documented pressure ulcer (ulcer to the coccyx). Interventions included monitoring bony prominences for redness, monitoring nutritional status, providing wound treatments as ordered and referring to a specialized practitioner for wound management. The care plan further revealed Resident #10 had the potential for impairment of skin integrity related to impaired mobility and current pressure injury to the coccyx. Interventions included encouraging Resident #10 to turn and reposition every two hours and a low air loss mattress. The mattress was to be monitored for function and inflation every shift. Additional interventions included notifying the dietitian of altered skin integrity and ensuring adequate nutrition related to wound and skin needs. Additionally, the care plan revealed Resident #10 had the potential for alteration of nutrition. Interventions included providing and serving supplements as ordered. A dietary note dated 11/09/25 authored by Registered Dietitian/ Licensed Dietician (RD/LD) #820 revealed a recommendation for Prostat to tube feeding three times a day for low albumin (a protein made in the body that supports tissue repair and maintains fluid balance) as recommended by the dialysis provider. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of five out of 15, indicating Resident #10 had severe cognitive impairment. The MDS also revealed one Stage IV pressure area and no unstageable wounds. The assessment included a pressure-reducing device was in use. Review of the Braden Scale assessment dated [DATE] revealed a score of 11 indicating the resident was at high risk for pressure ulcer development. A review of wound notes authored by Certified Nurse Practitioner (CNP) #830 revealed the following: - On 11/19/25, CNP #830 saw Resident #10 for a chronic Stage IV wound of the coccyx and was to evaluate a new thoracic spine wound. Assessment of the thoracic spine wound revealed deep tissue injury (DTI) (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.) The area on the thoracic spine measured 2.5 centimeters (cm) by 3.0 cm. The thoracic spine wound was defined as facility acquired. CNP #830 further described the area as a new pressure ulcer to the thoracic spine due to LAL bed malfunction. Orders included maintenance to fix the LAL mattress. - On 11/26/25, CNP #830 evaluated the wound to the thoracic spine. The wound was defined as an acute unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) with obscured full thickness skin and tissue loss. Measurements were documented as 6.0 cm by 4.0 cm. CNP #830 documented the wound as deteriorating. Interventions included maintenance to fix or replace the LAL mattress. - On 12/03/25, CNP #830 evaluated the wound to the thoracic spine. The wound was defined as an acute unstageable pressure injury with obscured full thickness skin and tissue loss. Measurements were documented 6.0 cm by 4.5 cm. CNP #830 documented the wound as deteriorating. Interventions included maintenance to fix or replace the LAL mattress. - On 12/10/25 CNP #830 evaluated the wound to the thoracic spine. The wound was defined as an acute unstageable pressure injury with obscured full thickness skin and tissue loss. Measurements were documented as 6.0 cm by 5.5 cm. CNP #830 documented the wound as deteriorating. Interventions included maintenance to fix or replace the LAL mattress. - On 12/17/25, CNP #830 evaluated the wound to the thoracic spine. Measurements were documented as 5.5 cm by 5.5 cm. There was no change noted to the wound progression. Interventions included maintenance to fix or replace the LAL mattress. A review of TELLS log (a computer system to notify and log repairs needed to the facility) dated 10/01/25 through 11/28/25 revealed on 11/19/25 the air mattress for Resident #10 was reported as having low pressure. The bed was documented as repaired on 11/19/25 at 12:42 P.M. On 12/16/25 at 12:01 P.M. an interview with CNP #830 revealed Resident #10 developed an unstageable pressure ulcer to the thoracic spine. CNP #830 stated the unstageable pressure ulcer was a direct result of the LAL mattress not functioning. CNP #830 revealed multiple work orders had been placed to fix the mattress. On 12/17/25 at 7:56 A.M. an observation of wound care for Resident #10 with CNP #830 and Registered Nurse (RN) #431 who was identified as the facility wound nurse revealed the LAL mattress had a yellow blinking light that read low pressure, an alarm for malfunction was not sounding. CNP #830 stated the mattress was still not fixed and does not alarm for malfunction. RN #431 stated, I don't know what it is going to take to get things fixed around here. On 12/17/25 at 10:32 A.M. an interview with Maintenance Supervisor (MS) #368 revealed the maintenance department utilized the TELLS system for identification of issues or things that needed to be repaired. MS #368 revealed LAL mattresses were the responsibility of maintenance staff to repair. MS #368 revealed Resident #10's bed was fixed but could not recall the exact repair to the mattress. In addition, MS #368 revealed he was unaware of any issues since the bed was repaired on 11/19/25. MS #368 stated there was no system in place to routinely check air mattresses. MS #368 stated when a repair was done to an air mattress, he would check it after 30 minutes and if the mattress stayed inflated, he would mark it off as repaired. On 12/17/25 at 1:25 P.M. an interview with RN #431 revealed air mattresses were stocked in the facility. RN #431 stated Dietary Manager (DM) #317 maintained the stockroom and does the ordering for the facility. RN #431 stated DM #317 was notified through TEAMS (a computer/phone way of communicating) of needs for LAL mattresses. RN #431 stated she put the needed repairs for the LAL mattress for Resident #10 in the TEAMS system and put in for a new mattress for Resident #10 on this date (12/17/25). RN #431 further stated MS #368 had access to the TEAMS system. On 12/18/25 at 5:00 P.M. an interview with DM #317 revealed staff would tell her if something needed fixed or ordered. DM #317 stated if something needed fixed, she just fixed it. DM #317 stated she had fixed the mattress for Resident #10 by replacing the pump two times (dates not provided). On 12/23/25 at 10:03 A.M. an interview with RD/LD #820 revealed the protein supplement for Resident #10 was discontinued for Resident #10 after a hospitalization in October of 2025. RD/LD #820 further stated a recommendation for a protein supplement three times a day was received from the dialysis dietitian due to the resident having a low albumin level. RD/LD #820 stated she forwarded the recommendation to Assistant Director of Nursing (ADON) #350 to obtain an order from the physician. RD/LD #820 stated the recommendation for protein supplement resumption and increase was forwarded via paper and email on 11/09/25 and 12/04/25 to ADON #350. On 12/23/25 at 11:44 A.M. an interview with ADON #350 revealed the dietitian was to notify the physician of any needed orders. ADON #350 further stated she had no recollection of protein recommendations for Resident #10. ADON #350 also stated the dietitian was not present during weekly meetings to discuss weights, wounds or recommendations. A review of the undated policy titled Pressure Ulcer Prevention Intervention revealed the purpose of this protocol is to implement preventative skin measures for all residents based on the levels and areas of risk to include moisture, nutrition, activity, mobility, mental status, psychosocial status, and general physical condition. When the interdisciplinary team is considering interventions, facility policy, standard of practice, and resident goals, all should be reviewed and considered prior to the implementation. Interventions for preventative skin care include interventions for nutrition. These interventions include consulting a registered dietitian as needed. It is recommended that when a resident is nutritionally at risk and a pressure ulcer risk the resident is offered a minimum of 30 to 35 calories per kilogram body weight per day and 1.25 kilograms of protein per day. For the residents with nutritional risk and pressure ulcer risk it is recommended to offer a high protein mixed oral nutritional supplement or tube feeding in addition to the usual diet. Interventions for residents at high risk include providing the resident with a mattress meeting the criteria for Group One if the resident does not show any sign of skin breakdown or has evidence of Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; it's color may differ from the surrounding area.) or uncomplicated Stage II wound (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister). Provide residents with a mattress that meets the criteria for group two if the resident has multiple Stage II wounds or uncomplicated Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) and Stage IV wounds. Provide the resident with a mattress that meets the criteria for group three if the resident has a multiple or complicated Stage IV or unstageable pressure wounds. Group two mattresses include a LAL mattress. 2. Review of the closed medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, aphasia, diabetes mellitus type II, dysphasia, contracture of muscle of the right lower leg and left lower leg and vascular syndromes of the brain. Resident #27 expired on 12/27/25. Review of the resident's physician orders revealed the resident's diet order was NPO and the resident had an order for enteral tube feed of Glucerna 1.5 at 45 ml per hour continuous (nutritional supplement). Review of the care plan dated 12/04/25 revealed Resident #27 had the potential for alteration in nutrition and hydration related to cerebral infarction. Interventions included administering tube feeding as ordered. The care plan further revealed Resident #27 was at risk for pressure injuries related to decreased mobility, incontinence, and cerebral vascular accident. Interventions included administering treatments as ordered and monitoring for effectiveness, avoiding prolonged skin contact, making referrals as needed to the dietitian, and following facility policies and protocols for prevention and treatment of skin breakdown. Review of a quarterly nutrition note dated 12/07/25 and authored by RD/LD #820 revealed no recommendations for protein intake. The note included there were no skin concerns noted. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 00, indicating Resident #27 had severe cognitive impairment/resident rarely understood. Review of the wound grid dated 12/09/25 revealed Resident #27 had a facility acquired pressure area to the right ischium that was unstageable that was first identified on 12/09/25. There was no documented evidence that the dietitian was notified of the unstageable pressure ulcer or information as to why/how the wound developed or why it was first identified as an unstageable pressure ulcer. Review of the physician's orders revealed an order dated 12/09/25 to cleanse Resident #27's right ischium with normal saline and apply Santyl (debriding ointment) and cover with a silicone dressing every day shift and as needed. There were no orders for a protein supplement for wound healing. Review of the wound note dated 12/16/25 revealed Resident #27 continued to have an unstageable wound to the right ischium. On 12/23/25 at 10:03 A.M. an interview with RD/LD #820 revealed she saw and reviewed residents with wounds every two weeks. RD/LD #820 verified the lack of protein orders for Resident #27 following the identification of the unstageable pressure ulcer to promote wound healing. RD/LD #820 stated she was in the facility every Saturday, and there was a paper print out of wounds for her to review. RD/LD #820 further stated when she was in facility on 12/19/25, there was no paper print out of wounds for her to review. RD/LD #820 stated she was not notified until today (12/23/25) of the wound for Resident #27. On 12/31/25 at 11:43 A.M. an interview with RN #431 who was identified as the wound care nurse revealed she did not have computer access to print off wound reports for the dietitian. RN #431 stated RN #418 printed off wound reports and gave them to the dietitian. RN #431 stated she had no way of tracking if reports were given to the dietitian. RN #431 stated she was not part of weekly meetings to track wounds as they are conducted during wound rounds. During the investigation, the facility failed to provide evidence the resident was being adequately monitored and/or provided necessary intervention to prevent the ulcer from first being found as an unstageable pressure ulcer. A review of the undated policy titled Pressure Ulcer Prevention Intervention revealed the purpose of this protocol is to implement preventative skin measures for all residents based on the levels and areas of risk to include moisture, nutrition, activity, mobility, mental status, psychosocial status, and general physical condition. When the interdisciplinary team is considering interventions, facility policy, standard of practice, and resident goals, all should be reviewed and considered prior to the implementation. Interventions for preventative skin care include interventions for nutrition. These interventions include consulting a registered dietitian as needed. It is recommended that when a resident is nutritionally at risk and a pressure ulcer risk the resident is offered a minimum of 30 to 35 calories per kilogram body weight per day and 1.25 kilograms of protein per day. For the residents with nutritional risk and pressure ulcer risk it is recommended to offer a high protein mixed oral nutritional supplement or tube feeding in addition to the usual diet. Interventions for residents at high risk include providing the resident with a mattress meeting the criteria for Group One if the resident does not show any sign of skin breakdown or has evidence of Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; it's color may differ from the surrounding area.) or uncomplicated Stage II wound (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister). Provide residents with a mattress that meets the criteria for group two if the resident has multiple Stage II wounds or uncomplicated Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) and Stage IV wounds. Provide the resident with a mattress that meets the criteria for group three if the resident has a multiple or complicated Stage IV or unstageable pressure wounds. Group two mattresses include a LAL mattress. 3. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acquired absence of the left leg above the knee, acquired absence of the right leg above the knee, gangrene, idiopathic aseptic necrosis of bilateral hands, diabetes mellitus type II, peripheral vascular disease, acute kidney failure, and moderate protein calorie malnutrition. Review of the resident's physician orders revealed an order for Med Pass (a supplement for wound healing) 120 ml two times daily. The resident also had a treatment order to cleanse coccyx with normal saline, apply Santyl, and cover with silicone dressing every night shift and as needed and a pressure reducing mattress. Review of the care plan dated 11/11/25 revealed Resident #44 had an impairment of skin integrity. Interventions included a LAL mattress. Review of the five-day MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15, indicating Resident #44 was cognitively intact. The MDS also revealed a Stage IV pressure area and a pressure reducing mattress. A review of wound care notes revealed a LAL mattress was ordered on 12/02/25 for Resident #44. On 12/16/25 at 10:15 A.M. an observation of wound care for Resident #44 revealed a LAL mattress with a low-pressure light blinking and a beeping sound coming from the air pump inflating the mattress. Resident #44 was noted to be sunk into the middle of the mattress. CNP #820 verified the bed malfunction and the position of Resident #44 at the time of the observation. Resident #44 stated the mattress had been alarming for about 30 minutes or so. CNP #820 stated the bed needed fixed, and mattress malfunction was an issue in the facility. A review of the undated policy titled Pressure Ulcer Prevention Intervention revealed the purpose of this protocol is to implement preventative skin measures for all residents based on the levels and areas of risk to include moisture, nutrition, activity, mobility, mental status, psychosocial status, and general physical condition. When the interdisciplinary team is considering interventions, facility policy, standard of practice, and resident goals, all should be reviewed and considered prior to the implementation. Interventions for preventative skin care include interventions for nutrition. These interventions include consulting a registered dietitian as needed. It is recommended that when a resident is nutritionally at risk and a pressure ulcer risk the resident is offered a minimum of 30 to 35 calories per kilogram body weight per day and 1.25 kilograms of protein per day. For the residents with nutritional risk and pressure ulcer risk it is recommended to offer a high protein mixed oral nutritional supplement or tube feeding in addition to the usual diet. Interventions for residents at high risk include providing the resident with a mattress meeting the criteria for Group One if the resident does not show any sign of skin breakdown or has evidence of Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; it's color may differ from the surrounding area.) or uncomplicated Stage II wound (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister). Provide residents with a mattress that meets the criteria for group two if the resident has multiple Stage II wounds or uncomplicated Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) and Stage IV wounds. Provide the resident with a mattress that meets the criteria for group three if the resident has a multiple or complicated Stage IV or unstageable pressure wounds. Group two mattresses include a LAL mattress. 4. Review of Resident #25's medical record revealed an admission date of 04/18/25 with diagnoses including chronic respiratory failure with ventilator dependence, tracheostomy, gastronomy, traumatic subdural hemorrhage, anxiety, type II diabetes mellitus, chronic congestive heart failure, enterocolitis, cystitis, hypotension, hypotension, neuromuscular bladder, dysphagia, gastroesophageal reflux disease, high blood pressure, multiple fractures of ribs, and fractured neck, and clavicle, thoracic aorta injury, aneurysm of ascending aorta and iliac artery, atrial fibrillation (irregular heart rate), pulmonary embolism and venous thrombosis, and dysphagia. A review of Resident #25's record revealed Resident #25 was transferred to the hospital on [DATE] and admitted with diagnoses including septic shock, acute cystitis and atrial fibrillation. Resident #27 returned to the facility on [DATE]. The nursing admission assessment progress note dated 10/27/25 indicated the presence of unstageable pressure ulcers located on the sacrum, right lower leg and ankle. A review of Resident #25's nutrition assessment dated [DATE] revealed Resident #25 had dysphagia and was unable to eat orally and tube feeding was implemented. The assessment indicated that Jevity 1.5 solution (high-protein, fiber-fortified liquid formula) was continuously administered via pump at 40 ml per hour with 30 ml water flushes every four hours. Nutritional supplements were not provided. The nutrition assessment revealed Resident #25 did not have a pressure ulcer at the time the assessment was completed. Resident #25's nursing progress note dated 10/28/25 indicated pressure ulcers located on the sacrum, and two separate areas on the right lower leg. The sacral pressure ulcer was classified as unstageable measuring 8.0 cm long by 9.8 cm wide by 0.2 cm deep, the right lower calf pressure ulcer measuring 2.0 cm long by 2.0 cm wide by 0.1 cm deep and the right mid-calf pressure ulcer measured 4.0 cm long by 2.5 cm wide by 0.1 cm deep. The progress note indicated Resident #25 would be seen on the next wound rounds. A review of the nutrition assessment dated [DATE] revealed a recommendation to increase the Jevity 1.5 tube feeding solution infusion rate to 60 ml per hour. A review of the physician order dated 11/19/25 revealed an order to increase the Jevity 1.5 tube feeding solution rate to 60 ml per hour. An interview with RD #816 on 12/18/25 at 10:42 A.M. verified the recommendation to the have the tube feeding rate increased was not ordered until 11/19/25. She stated she had sent an email to ADON #350 to inform her of the recommendation and had placed a written document to inform ADON #350 of the request to have Resident #25's tube feeding rate increased. RD #815 verified the above findings during the interview. 5. A review of Resident #11's medical record revealed an admission date of 10/20/25 with diagnoses including acute duodenal ulcer with perforation, acute kidney failure, acute pulmonary edema, acute respiratory failure with ventilator dependence, anemia, alcohol dependence, candidiasis of skin and nails, cerebral ischemia, cardiac arrest, emphysema, gastroesophageal reflux disease, hypovolemic chock, hypoxic ischemic encephalopathy, idiopathic aseptic necrosis of left femur, pulmonary embolism, pneumonia, sepsis, type II diabetes mellitus, and osteoarthritis. The resident had an unstageable pressure ulcer located on the sacrum on admission. A review of Resident #11's nutrition assessment completed on 11/18/25 indicated a recommendation for liquid protein 30 ml daily to promote wound healing. A review of Resident #11's physician order dated 12/02/25 to administer 30 ml of liquid protein via gastronomy tube once a day in the morning and to start on 12/03/25. A review of Resident #11's medical record revealed the presence of an unstageable pressure ulcer located on the sacrum upon admission [DATE]). The most recent wound assessment dated [DATE] indicated the unstageable sacral pressure ulcer measured 4.0 cm long by 3.0 cm wide by 0.3 cm deep with serosanguinous drainage, yellow slough, and black eschar present. The wound had remained unchanged. Interview on 12/17/25 at 11:15 A.M. with Director of Clinical Services #816 revealed a dietitian was to assess a new admission within seven days of admission if a resident was high risk such as a tube feeding, pressure ulcer to see if resident was meeting their estimated needs. The dietitian was to complete the new care plan within 14 days of admission. The dietitian was also expected to assess high risk residents monthly instead of quarterly. The facility Corporate Dietitian #817 provided the consulting dietitian corporate standards for calculations and intervention specific for the facility. An interview with RD #816 on 12/18/25 revealed she had recommended a liquid protein supplement be administered to Resident #11 on 11/18/25 and verified the recommendation was not implemented until 12/03/25. RD #816 stated the expectation was the facility should implement the dietician's recommendation within 24 to 48 hours after notification was sent to the facility. RD #816 stated she sent an email to ADON #350 and placed a written notification of the recommendation to add the liquid protein supplement to Resident #11's tube feeding once a day to promote wound healing under ADON #350's door. A review of the undated facility's policy titled Pressure Ulcer Prevention, Intervention indicated the purpose of the protocol was to implement preventative skin measures for all residents based on the levels and areas of risk to include moisture, nutrition, activity, mobility, mental status, psychosocial status, and general physical condition. When the Interdisciplinary Team is considering interventions, facility policy, standard of practice, and resident goals/preferences/advanced directives should be reviewed and considered prior to implementation. The residents' skin will be assessed and monitored on a routine basis as is outlined in the skin assessment protocols. Preventative measures will be implemented in accordance with the residents' assessed risk level and for development of skin integrity impairment and risk factors that may enhance the residents' ability to develop skin integrity impairment. Interventions included assessing nutritional risk and address with the Registered Dietician as needed. Maintain or improve nutrition and hydration, when indicated. Interventions for nutrition include: -Monitor hydration status and increase hydration, as needed. -Consult the Registered Dietician, as needed. -If the resident who is well-nourished develops an inadequate dietary intake of protein or calories, a nutritional assessment should be completed by the [NAME] to determine the factors compromising the intake. Interventions will be implemented based upon the [NAME] assessment and interdisciplinary team review. -It is recommended that when a resident is nutritionally at risk and pressure ulcer risk, the resident is offered a minimum of 30-35 kilocalorie per kilogram (kg) body weight per day, with 1.25-1.5 gram/kg/day protein and 1milliliter (ml of fluid intake per kcal per day). -For the residents with nutritional risk and pressure ulcer risk, it is recommended to offer a high-protein mixed oral nutritional supplement and/or tube feeding, in addition to the usual diet. -Administer oral nutritional supplements and/or tube feeding in between in regular meals to avoid reduction of normal food and fluid intake during regular mealtimes 6. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, brain stem stroke syndrome, osteomyelitis of vertebra, cervical region, neuromuscular dysfunction of bladder, other seizures, pseudomonas, resistance to vancomycin, local infection of the skin and subcutaneous tissue, klebsiella pneumoniae, extended spectrum beta lactamase, methicillin resistant staphylococcus aureus infection, supraventricular tachycardia, dependence on respirator [ventilator] status, muscle weakness, dysphagia, major depressive disorder, acute embolism and thrombosis of left internal jugular vein, gastrostomy status, generalized anxiety disorder, tracheostomy status, quadriplegia, chronic viral hepatitis c and nonrheumatic mitral (valve) prolapse. Review of Resident #58's care plan dated 10/25/25 revealed the resident had impairment of skin integrity due bowel and bladder incontinence, impaired mobility, quadriplegia, activities of daily living (ADL) dependence, altered nutritional status and had pressure injuries to the coccyx and bilateral heels. Interventions included wound treatment as ordered, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #58's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15, indicatin

Based on medical record review, review of hospital records, interviews and review of facility policy, the facility failed to provide timely care and services to treat Resident #38's urinary tract infection (UTI).Actual harm occurred on 10/13/25 when Resident #38, who had a history of UTI and had been stating she felt like she had UTI symptoms of frequent urination and burning a couple days prior, was ordered a urine analysis (UA) test by Nurse Practitioner (NP) #842 to assess for UTI and that order was not entered into the physician orders until 10/15/25 by Licensed Practical Nurse (LPN) #341. On 10/16/25 Resident #16 was hospitalized prior to completion of the UA test, and Resident #38 was diagnosed at the hospital with altered mental status, acute UTI, bacteremia (bacteria in the blood) and acute kidney injury and was treated with intravenous (IV) antibiotics for the infection. Resident #38 remained in the hospital for treatment until returning to the facility on [DATE] where IV antibiotics were continued for treatment. This affected one resident (Resident #38) of three residents reviewed for urinary tract infections. The facility census was 72.Review of Resident #38's medical record revealed an admission date of 10/06/25 with diagnoses including need for assistance with personal care, neuromuscular dysfunction of bladder, urinary tract infection, tracheostomy, morbid obesity, ventilator dependence, and type two diabetes.Review of Resident #38's progress notes dated 10/13/25 at 2:18 P.M. by Licensed Practical Nurse (LPN) #341 revealed the resident reported she believed she had a UTI stating it started a couple of days ago, but this is the worst it felt. Resident #38 complained of frequent urination and burning. The process of obtaining a UA (urine analysis) was explained to the resident by LPN #321 and the Nurse Practitioner (NP #842) and resident agreed to the UA. A new order was obtained for a UA and labs. Resident #38 did ask if they could treat the UTI without obtaining the UA and the NP stated no and again the resident agreed to the UA.Further review of the medical record revealed there was no UA collected on 10/13/25 for Resident #38. Review of Resident #38's physician orders dated October 2025 revealed the order to obtain a UA C&S (culture and sensitivity) was not entered until 10/15/25 at 5:33 P.M. by LPN #341 and not on 10/13/25 when ordered by NP #842.Review of Resident #38's care plan dated 10/14/25 revealed the resident had bowel and bladder incontinence and was at risk for urinary tract infection (UTI). Interventions included staff to clean peri-area with each incontinence episode, check and change per protocol and as required for incontinence, monitor and document for signs and symptoms of UTI including pain, burning, blood tinged urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. There was nothing in the care plan to indicate Resident #38 refused to have urinalysis tests when needed.Review of Nurse Practitioner (NP) #842's progress note date 10/15/25 revealed Resident #38 was seen again on 10/15/25 for complaints of dysuria (painful or uncomfortable urination) and was agreeable to urinalysis and again ordered a UA. Additionally, under the section of their note titled Assessments and Plans NP #842 noted on 10/13/25 resident complained of dysuria and a UA with culture and sensitivity (UA C&S) was ordered, on 10/14/25 UA C&S was encouraged again, and finally on 10/15/25 UA C&S reordered.Review of the Respiratory Therapist (RT) #364 progress note on 10/15/25 at 6:06 P.M. revealed the RT, two nurses and a Certified Nursing Assistant (CNA) entered the resident's room to obtain the UA. During the process of obtaining the UA, the resident's pulse ox dropped to 69 percent and heart rate dropped to 51. The RT increased the resident's oxygen to 16 liters and a peep (positive end expiratory pressure) of eight and turned the resident's fan on. Resident #38's vital signs improved.Review of LPN #379's progress note dated 10/15/25 at 6:20 P.M. revealed Resident #38 was noted to have altered mental status, an assessment was completed and vital signs were within normal limits, the physician was notified and gave additional orders for a UA to be completed and to continue to monitor.Review of LPN #379's progress note dated 10/16/25 at 7:22 A.M. the nurse documented a Change in Condition related to altered mental status, vital signs noted at blood pressure (bp) 152/74, pulse 103, respiratory rate (RR) 28, temperature 98.7 degrees Fahrenheit (F), pulse oxygen 97 percent and was vent dependent, physician was notified and gave orders again to obtain a UA and to send the resident to the emergency room.Review of Resident #38's hospital documentation dated 10/16/25 revealed Resident #38 was sent to the Emergency Department (ED) and admitted for Altered Mental Status (AMS), acute UTI, bacteremia, and acute kidney injury. Resident #38 was treated with broad spectrum antibiotics and was hospitalized from [DATE] to 10/24/25 when they returned to the facility and continued intravenous (IV) antibiotics for UTI.Review of Resident #38's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Resident #38 required substantial to maximal assistance with eating and was dependent on staff for all other Activities of Daily Living (ALDs) including incontinence care, showering, dressing, personal hygiene, and bed mobility.An interview on 12/11/25 at 12:37 P.M. with Resident #38 revealed she did not feel staff took her complaints of UTI symptoms seriously in October when she complained of pain, burning and frequent urination. Resident #38 stated she had been telling the nurse for at least two days about the pain in her bladder before the NP came in to see her. Resident #38 stated she had a history of UTIs and knew what they felt like. She stated she had questions about how they would obtain the UA C&S and was agreeable to it, but the facility staff did not get it right away and waited multiple days to get it. Resident #38 stated she continued to complain of pain, burning and frequent urination the whole time. Resident #38 confirmed the NP saw her twice before she went to the hospital. Resident #38 was upset because she ended up in the hospital and felt if they had gotten the UA C&S when first ordered she would not have ended up in the hospital and would not have been as sick as she was.Two attempts were made on 12/11/25 at 1:45 P.M. and on 12/22/25 at 4:05 P.M. to contact NP #842 with no return calls received.Interview on 12/22/25 at 3:40 P.M. with LPN #341 revealed they confirmed Resident #38 complained of burning and frequent urination on 10/13/25 and that the NP was into see the resident and ordered a UA C&S but did not obtain it and did not enter it into the physician orders. LPN #341 Could not give a reason why they did not obtain the UA C&S or why they did not enter it into the physician orders on 10/13/25.Interview on 12/22/25 at 3:52 P.M. with LPN #379 revealed they obtained the UA C&S on 10/15/25 at 6:06 P.M. with the assistance of the RT, another nurse and a CNA. However, they did not send the UA to the lab due to the resident going out to the hospital for altered mental status and that Resident #38 was admitted for a UTI, acute kidney injury and sepsis. When asked why the facility staff did not obtain the UA C&S when originally ordered on 10/13/25 they could not give a reason.An interview on 12/22/25 at 4:15 P.M. with the Director of Nursing (DON) verified Resident #38 was ordered a UA C&S on 10/13/25 by NP #842 which was not entered as an order nor collected from Resident #38 until 10/15/25. The DON confirmed the urine was collected on 10/15/25 and was to be sent out to the lab for testing on the morning of 10/16/25 but when the lab showed Resident #38 had been sent to the hospital that morning, so the urine was not carried through to the lab. Review of facility policy titled Urinary Continence and Incontinence-Assessment and Management last revised September 2024 revealed identification of urinary tract infections will follow relevant clinical guidelines. The policy did not identify the relevant clinical guidelines in the policy.This deficiency represents noncompliance investigated under Complaint Number 2687759.

Based on personnel record review, interview and document review, the facility failed to ensure complete orientation of 14 newly hired Certified Nursing Assistants. This had the potential to affect all residents residing in the facility. The facility census was 72.Findings include:On 12/18/25 at 2:33 P.M. a review of personnel files was conducted with Human Resource Director (HRD) #443.A review of the personnel file for Certified Nurse Assistant (CNA) #436 revealed a date of hire (DOH) of 09/09/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #450 revealed a DOH of 10/23/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #440 revealed a DOH of 09/18/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #439 revealed a DOH of 09/09/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #457 revealed a DOH of 11/11/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #437 revealed a DOH of 09/02/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #438 revealed a DOH of 09/02/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #453 revealed a DOH of 11/11/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #455 revealed a DOH of 11/11/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #454 revealed a DOH of 11/11/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #408 revealed a DOH of 02/25/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #411 revealed a DOH of 06/10/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #416 revealed a DOH of 04/01/25. There was no completed clinical nursing assistant orientation form within the personnel file.A review of the personnel file for CNA #388 revealed a DOH of 05/05/25. There was no completed clinical nursing assistant orientation form within the personnel file.HRD #443 verified the lack of clinical nursing assistant orientation forms in the personnel files for CNAs #436, #450, #440, #439, #457, #437, #438, #453, #455, #454, #408, #411, #416, #388 at the time of the personnel file reviews.A review of the document titled Job Description: State Tested Nursing Assistant updated May 2025 revealed The CNA is responsible for the delivery of nursing care to residents, monitoring their stability and well-being. The document further stated that the CNA is responsible for demonstrating knowledge and adhering to all Residents Rights.A review of the undated document titled New Employee Orientation Agenda - Day 2 (STNA ONLY) revealed an expectation that the orientation checklist must be returned to the Staff Development Coordinator before taking an individual assignment.

Based on observation, record review, staff interviews and review of facility policy, the facility failed to maintain a safe, functional, sanitary and comfortable environment. This had the potential to affect all 72 residents.Findings include:An observation on 11/20/25 at 1:20 P.M. with Maintenance Supervisor (MS) #368 revealed a large ceiling stain near resident room [ROOM NUMBER] on the Aspen unit. Interview with MS #368 at the time of the observation revealed the stain was from a roof leak about a month ago. When asked if water got inside the air duct work he stated yes, and stated the facility had a company come replace the duct work. Continued observation at 1:22 P.M. with MS #368 inside of room [ROOM NUMBER] revealed a large amount of lint and signs of mold in the ceiling vent. MS #368 verified the findings at the time of the observation. An observation was conducted on 11/20/25 at 1:24 P.M. of the attic on the even room number side of the Aspen unit to inspect the stained area. Observation revealed duct work was not replaced, a plastic drain pipe was disconnected, wet insulation removed from the duct work was left in the area, and signs of what appeared to be water stains and mold on drywall. Observation also revealed a decomposed rodent resembling an opossum outside of room [ROOM NUMBER] in the ceiling. Photographs were taken at the time of the observation by the life safety surveyor and verified by MS #368. MS #368 stated the air flow from the attic ran into room [ROOM NUMBER]. Observations were conducted on 11/24/25 with MS #368 of the Aspen unit and Crabapple unit revealing on the Aspen unit two holes had been drilled through the ceiling wooden sofit into the attic and on the Crabapple unit two holes had been drilled through the ceiling wooden sofit into the attic. All of the holes presented as drain holes from the attic floor out to the air of each unit. MS #368 verified the finding at the time of the observation.Observation on 11/25/25 at 10:05 A.M. with the Administrator of the Somerset Unit revealed tile had fallen off the wall exposing a black substance in the grout in the Somerset utility room. There was standing water in the utility sink with black biofilm around the perimeter of the utility tub, and there was a pervasive musty smell in the hall of the unit. Also in the utility room, a vent fan had a build-up of black substance in the vent fan. The findings were verified by the Administrator at the time of the observation. Interview on 11/26/25 at 11:44 A.M. with Respiratory Therapist #364 revealed she heard a rodent, estimated for the last month, in the attic and informed administration. Observation on 11/26/25 at 12:27 P.M. of room [ROOM NUMBER] bathroom revealed a plastic wash basin was underneath the bathroom sink with water leaking from the sink. Licensed Practical Nurse (LPN) #319 was present during the observation and confirmed the finding. An interview on 11/26/25 at 2:20 P.M. with Respiratory Therapist (RT) #364 revealed in July 2025 there was a leak in the ceiling outside in the 500 hallway outside of room [ROOM NUMBER]. RT #364 said water was dripping down from the ceiling and buckets were placed in the hallway to catch the water that was dripping onto the floor. RT #364 reported that the ceiling was painted over on 11/23/25 to cover up the water stains. An observation on 12/01/25 at 9:03 A.M. of the facility in-house dialysis unit revealed there were multiple broken pieces of flooring in the hallway upon entrance into the dialysis unit by the door. Dialysis RN #841 revealed the facility was responsibile for upkeep of the physical repairs of the unit and had been waiting on the contractor to come back and fix the floor.An interview with the Administrator on 12/01/25 at 9:20 A.M. revealed the facility had been trying to reach out to the floor contractor but had not been able to reach them. The Administrator stated she was unable to provide any documented evidence of attempts to contact the contractor for repairs. Observation on 12/08/25 at 9:40 A.M. through 10:12 A.M. with MS #368 revealed evidence of animal nests in the facility attic. MS #368 verified the finding at the time of the observation. Observation on 12/08/25 at 10:57 A.M. with MS #368 revealed the first floor office of the facilitys' Infection Preventionist had a ceiling with over half the ceiling heavily covered in dark brown staining indicative of water infiltration from prior roof leaks. The staining went from the perimeter of the bricked wall, to the window and to the center of the ceiling where the ceiling light was mounted. An observation was conducted on 12/09/25 at 11:55 A.M. upon entering the facility dialysis unit revealed 17 chipped and cracked gray floor panels measuring approximately 30 inches long by five inches wide each were either lifting around the edges and/or ends or had large missing pieces exposing subfloor. The dialysis unit also had a foul, biological-waste odor consistent with drain back-up.An interview on 12/09/25 at 12:03 P.M. with Dialysis RN #841 verified the chipped and cracked floor panels and revealed the floor panels were never installed correctly since installed and after the flood back in June the tiles lifting and cracking from the floor got worse. RN #841 revealed she was concerned of it being a trip hazard, has been asking for months for it to get fixed and it has still not been fixed. RN #841 stated the flood water was in the common area out side of dialysis and was several inches deep and it flowed in under the entry door to dialysis which afffected those tiles. RN #841 also stated the foul odor on the unit was the resident body waste that was going into the drains from the multiple dialysis machines which went under the floors to the outside. RN #841 said a company had come out several times to clean the drains but the odor will not go away. RN #841 stated a dialysis unit should not have an odor of body waste. Interview on 12/11/25 at 12:11 P.M. with Restoration Contractor (RC) #845 revealed his company provided the water mitigation after the facility flooded in June 2025. RC #845 revealed he spoke with the facility about the flooring in the dialysis unit after the flood and that water had gone underneath the floor in the dialysis unit. RC #845 stated he recommended the facility close the dialysis unit to properly restore the unit and the facility told him they could not close the unit. RC #845 stated the facility told him that a flooring company would be coming the following Monday to replace the floor.Observation on 12/15/25 at 10:26 A.M. revealed the bottom half of room [ROOM NUMBER] entrance door was covered by thin plastic door protector than had separated from the door and was hanging loose exposing a sharp corner sticking out into the doorway entrance. Inside the room hung a privacy curtain separating the two beds in the room. On the privacy curtain was an approximate three feet by two feet area of dark purplish brown staining of either dried blood or feces. Certified Nurse Assistant (CNA) #404 was present during the observation and verified the findings. CNA #404 stated the plastic door protector kept coming off because the resident's wheelchairs get stuck on the door cover going in and out of the room. CNA #404 verified a resident could get injured on the loose sharp corner of the plastic door protector hanging off the door. Observation on 12/18/2025 at 11:41 A.M. of room [ROOM NUMBER] revealed the plastic door protector was now attached to the door with duct tape and the privacy curtain was cleaned and replaced.Observation and interview on 12/29/2025 at 2:47 P.M. with Unit Manager (UM) #846 of room [ROOM NUMBER] door protector revealed the duct tape had come unstuck and the door protector was not attached to the door. UM#846 stated she would put in another work order.Observation on 12/31/2025 at 11:08 A.M. of room [ROOM NUMBER] door protector revealed the door protector was now secured to the door with screws.Review of facility policy titled Quality of Life Homelike Environment, date revised May 2017, revealed facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment.This deficiency represents non-compliance investigated under Complaint Numbers 2683142, 2687759, 2674189, 2684242, and 2688137.

Based on interviews, review of employee personnel files, and review of facility infection surveillance including infection control logs and maps, the facility failed to ensure the Infection Preventionist acquired their Infection Prevention Certificate prior to assuming the role as Infection Preventionist and failed to complete accurate infection control logs and maps. This had the potential to affect all residents in the facility. The facility census was 72.Findings include:Review of the Infection Preventionist (IP) Registered Nurse (RN) #431 employee file revealed a hire date of 06/30/25 with roles indicated as the Infection Preventionist and Wound Care Nurse. Review of IP RN #431's Infection Preventionist certificate revealed they received their certificate on 08/30/25. Review of the facility infection control logs and surveillance map dated October 2025 revealed Resident #25's Clostridium Difficile (C-diff) infection dated 10/14/25 was not documented on either the log or map. Review of the facility infection control logs and surveillance map dated November 2025 revealed Resident #64's C-diff infection dated 11/26/25, and Resident #62's Candida Auris infection dated 11/16/25, and urinary tract infection (UTI) dated 11/27/25 were not documented on either the log or map. An interview on 12/30/25 at 4:30 P.M. with IP RN #431 revealed she was hired at the facility with a start date of 06/30/25 as the Infection Preventionist and Wound Care Nurse. IP RN #431 stated she completed the Infection Preventionist Training Course from 08/24/25 to 08/30/25, received the certificate on 08/30/25 and had no previous formal training on infection prevention prior to this date. IP RN #431 stated the previous Infection Preventionist (RN #340) trained her for two weeks then took a position on the floor and had no further oversite as of 07/21/25. IP RN #431 stated her training was watching RN #340 for one week, then for the second week completing the tasks she watched RN #340 complete the week prior. When asked where the December 2025 infection control log and surveillance was map, she stated it was incomplete and would not be ready for review until 01/01/26. When asked why, she stated she did not keep a running log of infections for the month because she waited until the end of the month to compile the data and completed the surveillance maps. IP RN #431 confirmed the infection control logs from October 2025, and November 2025 were incomplete and did not have all the infections for the facility listed on them including infections for Residents #25, #62 and #64. The December 2025 infection control log was not made available to the surveyor for review until 12/31/25 at 2:00 P.M when IP RN #431 provided it to the survey team. IP RN #431 did not provide a surveillance map for review for December 2025. An interview on 12/31/25 at 11:10 A.M. with the Infectious Disease (ID) Physician #809 revealed he stated the facility had a severe problem with infection control at the facility related to the number of severe opportunistic infection rates. An interview on 12/31/25 at 11:15 A.M. with RN #340 revealed she personally did not review any infection logs, maps, or documents related to the Infection Preventionist roll since she took a position on the floor as of 07/21/25. Review of the facility policy titled Policies and Practices-Infection Control, last revised October 2018, revealed the objectives of the infection control policies were to: Prevent, detect, investigate, and control infections in the facility Establish guidelines for implementing isolation precautions, including Transmission-based precautions Review of the facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, last revised July 2025, revealed as part of the facility Antibiotic stewardship program all clinical infections treated with antibiotics will undergo review by the Infection Preventionist or designee and be documented on facility approved surveillance tracking forms. This deficient practice represents noncompliance investigated under Complaint Number 2655919.

Based on observation, interview and facility policy review, the facility failed to maintain a sanitary garbage storage area. This had the potential to affect all residents. The facility census was 72.Findings include: Observation on 12/10/25 at 8:19 A.M. of the dumpsters revealed one large trash bag torn open and on the ground to the left of the dumpsters. There were two large trash bags on the ground between the two dumpsters with trash including used gloves, straws, and plastic silverware lying on the ground.Interview on 12/10/25 at 8:25 A.M. with the Administrator verified the trash bags and trash on the ground around the dumpster area.Review of the facility policy tilted Food-Related Garbage and Refuse Disposal, dated October 2022, revealed storage areas would be kept clean at all times and would not constitute a nuisance, and outside dumpsters would be free of surrounding litter.

Based on record review, interview and review of facility policy, the facility failed to ensure resident consent or declinations were obtained for COVID-19 vaccinations. This affected five residents (Resident #5, #20, #25, #29, and #38) of seven residents reviewed for vaccinations. The facility census was 72.Findings include: 1. Review of Resident #5's medical record revealed an admission date of 03/30/20. Diagnoses included Major Depressive Disorder (MDD), bipolar disorder, hypertension, congestive heart failure and chronic kidney disease stage III.Review of Resident #5's COVID-19 vaccination consent form dated 09/17/25 revealed the resident consented to the vaccination.Review of Resident #5's Medication Administration Record (MAR) dated September 2025 revealed the resident was not administered the COVID-19 vaccination.2. Review of Resident #20's medical record revealed an admission date of 08/27/25. Diagnoses included acute on chronic respiratory failure, end stage renal disease, acute on chronic congestive heart failure, history or sepsis, and COVID-19.Further review of Resident #20's medical record including physician orders, MARs, and progress notes revealed there was no consent or declination present for COVID-19 vaccination.3. Review of Resident #25's medical record revealed and admission date of 04/18/25. Diagnoses included chronic respiratory failure with hypoxia, hypertension, tracheostomy status, gastrostomy status, and traumatic subdural hemorrhage.Further review of Resident #25's medical record including physician orders, MARs and progress notes revealed there was no consent or declination present for COVID-19 vaccination.4. Review of Resident #29's medical record revealed an admission date of 12/09/25. Diagnosis included dependence on renal dialysis, end stage renal disease, chronic obstructive pulmonary disease, and pulmonary hypertension.Further review of Resident #29's medical record revealed there was no consent or declination present for the COVID-19 vaccination present.5. Review of Resident #38's medical record revealed an admission date of 10/06/25. Diagnosis included type II diabetes, major depressive disorder, hypertension, tracheostomy status, ventilator dependency, acute pulmonary edema and acute on chronic respiratory failure with hypoxia.Further review of Resident #38's medical record including physician orders, MARs, and progress notes revealed there was no consent or declination present for the COVID-19 vaccination.Interview on 12/31/25 at 12:36 P.M. with Infection Prevention (IP) Registered Nurse (RN) #431 revealed Resident #5 consented to receive the COVID-19 vaccination but it was not administered. IP RN #341 confirmed there were no consent or declinations available for Resident #20, #25, #29, and #38. IP RN #431 stated she was not sure why Resident #5 did not receive the vaccination after consenting to it.Review of facility policy titled Coronavirus Disease (COVID-19)-Vaccination of Residents, last revised November 2021 revealed staff were to offer all residents the COVID-19 vaccination and staff were to document consent or declination of the vaccine and if administered staff were to document the date of vaccination, lot number, expiration date, person administering the vaccine and the site of administration in the resident medical record.

Based on record review, interview and review of facility policy, the facility failed to ensure resident consents or declinations were obtained for influenza and pneumococcal vaccines, and the facility failed to document site of administration, lot number, and expiration dates for administered vaccines. This affected five residents (Resident #5, #20, #25, #29, and #38) of seven residents reviewed for vaccinations. The facility census was 72.Findings include:1. Review of Resident #5's medical record revealed an admission date of 03/30/20. Diagnoses included Major Depressive Disorder (MDD), bipolar disorder, hypertension, congestive heart failure and chronic kidney disease stage III.Review of Resident #5's influenza and pneumococcal vaccination consent form dated 09/17/25 revealed the resident consented to both vaccinations.Review of Resident #5's Medication Administration Record (MAR) dated September 2025 revealed the resident received her influenza vaccination on 09/23/25 and she received her pneumococcal vaccination on 09/24/25; however, there was no required documentation such as lot number, expiration date, and site of administration.2. Review of Resident #20's medical record revealed an admission date of 08/27/25. Diagnoses included acute on chronic respiratory failure, end stage renal disease, acute on chronic congestive heart failure, history or sepsis, and COVID-19.Further review of Resident #20's medical record including physician orders, MARs, and progress notes revealed there was no consent or declination present for the influenza or pneumococcal vaccines.3. Review of Resident #25's medical record revealed an admission date of 04/18/25. Diagnoses included chronic respiratory failure with hypoxia, hypertension, tracheostomy status, gastrostomy status, and traumatic subdural hemorrhage.Review of Resident #25's pneumococcal vaccination consent form dated 04/28/25 revealed the resident consented for the vaccine. Infection Preventionist (IP) Registered Nurse (RN) #431 was unable to provide surveyor with influenza vaccination consent or declination form.Further review of Resident #25's medical record including physician orders, MARs and progress notes revealed there was documentation present Resident #25 received their pneumococcal vaccination in April 2025, but there was no documentation of the administration site, lot number or expiration date. Additionally, there was no documentation present related to consent or declination of influenza vaccination.4. Review of Resident #29's medical record revealed an admission date of 12/09/25. Diagnoses included dependence on renal dialysis, end stage renal disease, chronic obstructive pulmonary disease, and pulmonary hypertension.Further review of Resident #29's medical record revealed the resident received the pneumococcal vaccination on 05/07/25. There was no consent or declination present for the influenza vaccination.5. Review of Resident #38's medical record revealed an admission date of 10/06/25. Diagnoses included type II diabetes, major depressive disorder, hypertension, tracheostomy status, ventilator dependency, acute pulmonary edema and acute on chronic respiratory failure with hypoxia.Further review of Resident #38's medical record including physician orders, MARs, and progress notes revealed there was no consent or declination present for the influenza or pneumococcal vaccines.An interview on 12/31/25 at 12:36 P.M. with IP RN #431 confirmed when staff give the influenza or pneumococcal vaccination they are to document administration site, lot number and expiration date. IP RN #431 stated vaccinations are not to be given without signed consent. IP RN #431 confirmed Resident #5 was given her influenza vaccination on 09/23/25 and she received her pneumococcal vaccination on 09/24/25; however, there was no required documentation such as lot number, expiration date, and site of administration. IP RN #431 confirmed there was no consent or declination present for the influenza or pneumococcal vaccines for Resident #20. IP RN #431 was unable to provide surveyor with influenza vaccination consent or declination form for Resident #25 nor was there documentation of administration site, lot number, or expiration date for Resident #25's pneumococcal vaccination. IP RN #431 confirmed for Resident #29 there was no consent or declination present for the influenza vaccination. Finally, IP RN #431 confirmed there was no consent or declination available for Resident #38.Review of the facility policy titled Influenza Vaccine, last revised October 2019 revealed all residents will be offered the influenza vaccine annually and staff were to ensure there was a signed consent or declination for the vaccine and if administered staff were to document the date of vaccination, lot number, expiration date, person administering the vaccine and the site of administration in the resident medical record.Review of facility policy titled Pneumococcal Vaccine, last revised October 2019, revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Staff were to ensure there was a signed consent or declination for the vaccine and if administered staff were to document the date of vaccination, lot number, expiration date, person administering the vaccine and the site of administration in the resident medical record.

Based on observation and interview, the facility did not serve food in a manner consistent with professional standards for food service safety. This had the potential to affect 35 residents (#3, #8, #9,#12, #13, #14, #16, #19, #23, #26, #28, #29, #30, #31, #32, #33, #34, #35, #37, #38, #44, #47, #48, #49, #51, #50, #55, #56, #57, #63, #64, #65, #66, #83, and #84) receiving meals from the second floor kitchenette out of 57 residents who received meals from the facility. The facility identified 15 residents (Resident #90, #18, #21, #22, #25, #27, #02, #10, #41, #42, #11, #58, #01, #62, #67) who did not eat by mouth (NPO). The facility census was 72.Findings include:An observation was conducted on 12/18/25 at 5:00 P.M. of the evening meal service on the second floor and revealed an open to air food transport cart was being pushed off the elevator towards the kitchenette near the common areas dining room. On the cart were three full trays of mini pizza that were not covered during transport. An interview on 12/18/25 at 5:05 P.M. with Dietary Manager (DM) #317 verified the uncovered trays of pizza were transported uncovered from the kitchen on the first floor, up the elevator and to the second floor dining room for the resident meal service. DM #317 verified the pizza should have been covered during transport. This deficiency represents non-compliance investigated under Complaint Number 2687759.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure sugar-free condiments were available in accordance with the planned consistent carbohydrate, limited concentrated sweets menu. This had the potential to affect 10 residents (Resident #17, #29, #32, #34, #36, #03, #05, #65, #68, #71) the facility identified as having a physician order for consistent carbohydrate, low concentrated sweets diet of 57 residents who received meals from the facility kitchen. The facility identified 15 residents (Resident #90, #18, #21, #22, #25, #27, #02, #10, #41, #42, #11, #58, #01, #62, #67) who did not eat by mouth (NPO). The facility census was 72.Findings include: An interview on 12/17/25 at 1:30 P.M. with Licensed Practical Nurse (LPN) #316 revealed LPN #316 had a concern about resident blood sugars with the residents with diabetes. LPN #316 stated diabetic residents used to receive sugar-free condiments but recently did not receive sugar-free syrup or sugar-free jelly any more on the meal trays and instead were being served regular jelly and regular syrup which had alot of sugar in it for diabetics. An observation on 12/17/25 at 3:00 P.M. of the dry kitchen storage area and general kitchen environment revealed there was no sugar-free syrup or sugar-free jelly available for resident use.An interview on 12/17/25 at 3:10 P.M. with Diet Manager (DM) #317 verified residents were to receive sugar-free syrup and sugar-free jelly according to the Consistent Carbohydrate Diet Spreadsheet for the facility. DM #317 verified there was none in the kitchen because none had been ordered. An interview on 12/22/25 at 8:25 A.M. with Dietitian #820 revealed she was to inspect the kitchen monthly but was not sure if the facility had appropriate consistent carbohydrate food items according the to facility spreadsheets. She stated if a resident was on a consistent carbohydrate diet the facility should have available sugar-free condiments for residents because sugar-free condiments were in alignment with the consistent carbohydrate diet.Review of facility Diet Spreadsheet Day 26, Thursday, revealed a CCHO ( Consistent Carbohydrate diet) LCS ( Limited Concentrated Sweets) diet indicated at breakfast diet syrup was to be served with the waffle as well as bacon, unsweetened cereal, juice, milk and margarine. Review of facility Diet Spreadsheet Day 17, Tuesday, CCHO (LCS) diet indicated diet syrup was to be served with a blueberry pancake, sausage link, unsweetened cereal and margarine. Review of facility Diet Spreadsheet Day 31, Tuesday, the CCHO (LCS) diet indicated diet jelly was to be served with a bagel, cream cheese, sausage links, mixed fruit cup and unsweetened cereal and milk. Review of the facility Diet Spreadsheet Day 25, Wednesday, revealed the CCHO (LCS) diet indicated diet jelly was to be served with a breakfast bowl, toast, margarine, unsweetened cereal, juice and milk.Review of facility policy titled CCHO Diet (LCS) (Consistent Carbohydrate) Limited Concentrated Sweets dated year 2022, revealed the CCHO diet followed a regular diet with smaller portions of regular desserts, and utilized sugar substitutes, diet jelly and diet syrup.

Based on observation, record review and interview, the facility failed to remove expired wound and tracheostomy care supplies and enteral feeding formula from storage to prevent usage and failed to securely store medications for Residents #30 and #51. This affected two residents (#30 and #51) and had the potential to affect all 72 residents residing in the facility.Findings include:1. Observation on [DATE] at 11:04 A.M. of Resident #51 revealed the resident was lying in bed. On the overbed table was a clear medication administration cup with four tablets of varying size and one capsule. Interview at the time of the observation with Resident #51 revealed she was not sure how long the pills had been there. Interview at the time of the observation with Licensed Practical Nurse (LPN) #380 verified the pills and capsule inside the medication cup were left on the resident's bedside table. The nurse stated he did not leave the pills at the bedside and believed they were from the previous shift.Review of the medical record for Resident #51 revealed an admission date of [DATE]. Significant diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity, dependence on a respirator, major depressive disorder, anxiety disorder, tracheostomy status, and post-traumatic stress disorder. Physician orders effective [DATE] included bupropion 150 milligrams (mg) by mouth in the morning for depression, buspirone 10 mg, one tablet by mouth twice daily for anxiety, venlafaxine 150 mg, one capsule by mouth twice daily for depression, trazodone 50 mg, one tablet by mouth at bedtime for insomnia, and xanax 1 mg, one tablet three times daily for anxiety. There was no evidence in the medical record to indicate Resident #51 self-administered medications. Review of the admission Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #51 had no cognitive impairment.2. Observation on [DATE] at 8:45 A.M. of Resident #30 revealed the resident was lying in bed. On the bedside table was a plastic medication administration cup with one small white tablet. Interview at the time of the observation with Resident #30 revealed she thought it was her blood pressure pill and could not recall how long the medication had been there. Interview at the time of the observation with Registered Nurse (RN) #418 verified the small white tablet was left at the resident's bedside.Review of the medical record for Resident #30 revealed an admission date of [DATE]. Significant diagnoses included urinary tract infection, need for assistance with personal care, weakness, morbid obesity, bipolar disorder, and anxiety disorder. Physician orders effective [DATE] included labetalol 100 mg, one tablet by mouth every eight hours for hypertension. There was no evidence in the medical record to indicate Resident #30 self-administered medications.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had no cognitive impairment.3. Observation on [DATE] at 2:27 P.M. of the medication storage room located on the Dogwood Unit revealed two tracheostomy care kits with expiration dates of [DATE], six tracheostomy care kits with expiration dates of [DATE], and three collagen dressings (wound dressings to promote healing) with expiration dates of [DATE]. Interview at the time of the observation with Registered Nurse (RN) #431 and the Director of Nursing (DON) verified the expired items were stored for usage.Observation on [DATE] at 2:50 P.M. of the medication storage room located on the Aspen Unit revealed five eight-ounce cartons of enteral feeding formula with expiration dates of [DATE], one case of enteral feeding formula with expiration dates of [DATE], and one case of four-gram fiber packets (a dietary supplement) with expiration dates of [DATE]. Interview at the time of the observation with RN #431 and the DON verified the expired items were stored for usage.Review of the facility policy entitled, Storage of Medication, dated [DATE] revealed the facility stored all drugs and biologicals in a safe, secure and orderly manner. All discontinued, outdated or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed. Review of the facility policy entitled, Administering Medication, dated [DATE] revealed medications were administered in a safe and timely manner as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary team had determined that they have the decision-making capacity to do so. This deficiency represents non-compliance investigated under Complaint Number 2668507.

Based on record reviews, interviews, review of the dialysis agreement and facility policy review, the facility failed to maintain shared communication and collaboration with the dialysis clinic regarding dialysis care and services. This affected six residents (#02, #21, #29, #44, #63, and #67) of eight residents reviewed for dialysis and had the potential to affect six additional residents (#17, #90, #33, #10, #62, #71) identified by the facility as also receiving dialysis. The facility census was 72.Findings include: 1. Review of the medical record revealed Resident #02 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, dependence on a ventilator, dysphagia, pulmonary hypertension, end stage renal disease, dependence on renal dialysis, and gastrostomy. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #02 had a Brief Interview of Mental Status (BIMS) score of two out of 15, indicating severe cognitive impairment. Resident #02 was dependent on staff for oral care, and to transfers from bed to chair. The resident also required feeding tube, oxygen therapy, suctioning, tracheostomy care, invasive mechanical ventilation, and dialysis. Review of the Treatment Administration Record (TAR) dated December 2025, revealed Resident #02 attended dialysis on 12/01/25, 12/02/25, 12/03/25, 12/04/25, 12/05/25, 12/08/25, 12/09/25, 12/10/25, 12/11/25, 12/12/25, and 12/15/25. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/01/25, revealed the facility failed to report Resident #02's vital signs that included temperature, pulse, respiration, blood pressure, and weight prior to dialysis. The facility failed to report if labs were drawn and if Resident #02 had signs and symptoms of an infection. The facility failed to have a nurse sign the pre-dialysis hand off report. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/02/25, revealed the facility failed to report Resident #02's vital signs that included temperature, pulse, respiration, blood pressure and weight. The facility failed to report any medical problems since last dialysis, and if labs were drawn. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/03/25, revealed the facility failed to report Resident #02's vital signs that included temperature, pulse, respiration, blood pressure, and weights prior to dialysis. The facility also failed to report if any new medication was provided prior to last dialysis, lab draws, and if Resident #02 had signs or symptoms of infection. The facility also failed to obtain a nurse signature for the pre-dialysis portion of the communication report. Review of the facility document titled Dialysis Hand Off Communication Report dated 12/04/25 revealed the facility failed to report Resident #02's vitals that included temperature, pulse, respiration, blood pressure, and weight prior to dialysis. The facility also failed to report any medical problems since last dialysis, any lab draws, and if Resident #02 had signs and symptoms of an infection. The facility failed to have a nurse sign the pre-dialysis hand off report. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/05/25, revealed the facility failed to report Resident #02's temperature, pulse, respiration, blood pressure and weight vitals prior to dialysis treatment and failed to obtain a nurse signature on the Pre-Dialysis Hand Off Communication Report. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/09/25, revealed the facility failed to notify the dialysis clinic if Resident #02 had any signs and symptoms of an infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/10/25, revealed the facility failed to notify the dialysis clinic if any new medication was started since last dialysis, any medical problems since last dialysis, if labs were drawn and if Resident #02 had signs and symptoms of an infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/11/25, revealed Resident #02's pre-dialysis weight was missing. 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia, disorder of phosphorus metabolism, and dependence on renal dialysis. Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 had moderate cognitive status with a BIMS score of 08 out of 15, indicating moderate cognitive impairment. Resident #21 was dependent on staff to transfer from bed to chair and required a feeding tube for nutrition. Resident #21 was on dialysis. Review of the TAR dated December 2025, revealed Resident #21 attended dialysis 12/01/25, 12/02/25, 12/03/25, 12/04/25, 12/05/25, 12/08/25, 12/09/25, 12/10/25, 12/11/25, and 12/12/25. Review of the undated facility document titled Dialysis Hand Off Communication Report revealed the facility failed to state Resident #21's code status, vaccine status, mental status, allergies, vitals that included temperature, pulse, respiration, blood pressure and weight prior to dialysis. The facility also failed to report Resident #21's current diet and fluid restriction, compliance with diet and fluids, any new medication since last dialysis, if labs were drawn, condition of access site prior to leaving for dialysis and if Resident #21 had signs and symptoms of infection. The facility also failed to obtain a nurse signature on the pre-dialysis communication form. The facility also failed to obtain a nurse signature on the return to facility following dialysis section regarding condition of access site, if the catheter dressing was dry and intact, if signs and symptoms of infection and failed to sign the return date and time Resident #21 returned from dialysis. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/02/25, revealed the facility failed to notify the dialysis clinic of Resident #21's pre-dialysis weight, current diet and fluid restriction, compliance with diet and fluids, if any new medications were provided since last dialysis, any medical problems since last dialysis treatment, if labs were drawn since last dialysis treatment, the location and condition of the access site prior to leaving for dialysis and if Resident #21 had signs and symptoms of infection. The facility also failed to obtain a nurse signature and the date and time on the return to facility following dialysis and failed to indicate the condition of the access site, if the catheter dressing was dry and intact, or if resident had signs and symptoms of an infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/03/25, revealed the facility failed to report Resident #21's code status, vaccination status, mental status, vital signs that included temperature, pulse, respiration, blood pressure, and weight prior to dialysis. The facility failed to notify the dialysis clinic of Resident #21's current diet and fluid restriction, compliance with diet and fluids, any new medication since last dialysis, any medical problems since last dialysis, any lab draws, the condition of the access site, and if any sign and symptoms of an infection. The facility failed to obtain a nurse signature on the pre-dialysis communication form. The facility also failed to obtain a nurse signature and the date and time Resident #21 returned from dialysis to the facility or document the condition of the access site, if the catheter dressing was dry and intact, or any sign and symptoms of infection. Review of the facility document titled Dialysis Hand Off Communication Report dated 12/04/25 revealed the facility failed to notify the dialysis unit of Resident #21's code status, vaccination status, mental status, vitals, current diet and fluid restrictions, compliance with diet and fluids, any new medications since last dialysis, new medical problems since last dialysis, any lab draws since last dialysis, condition of access site and any signs and symptoms of an infection. The facility also failed to obtain a nurse signature on the pre-dialysis communication report. The facility also failed to have a nurse signature and the date and time of Resident #21's return to the facility following dialysis or document the condition of the access site, if the catheter dressing was dry and intact, any signs and symptoms of infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/05/25, revealed the facility failed to communicate Resident #21's code status, vaccination status, mental status, vitals, current diet and fluid restriction, compliance to diet and fluids, any new medication, new medical problems or new lab draws since last dialysis treatment. The facility failed to assess the condition of the access site, and for signs and symptoms of infection. The facility did not obtain a nurse signature on the pre-dialysis communication report. The facility also failed to have a nurse sign and date the time of on Resident #21's returned to facility following dialysis and failed to assess the access site, document if the catheter dressing was dry and intact, or if resident had any sign and symptoms of an infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/12/25, revealed the facility failed to notify the dialysis clinic of Resident #21's code status, mental status and weight prior to dialysis. The facility also failed to have a nurse signature with the date and time on Resident #21's return to the facility following dialysis. The facility failed to assess the access site, the catheter dressing, and signs and symptoms of infection after dialysis. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/11/25, revealed the facility failed to inform the dialysis clinic of Resident #21's weight prior to dialysis and failed to document the time of return of facility following dialysis and the status of the access site, the catheter dressing and if Resident #21 had signs and symptoms of infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/10/25, revealed the facility failed to have a nurse signature and date and time of Resident #21's return to the facility from dialysis and the condition of the access site, catheter dressing, and if Resident #21 had signs and symptoms of an infection. 3. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage five, hyperkalemia, diabetes mellitus, hypertension and anemia. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #63 had intact cognition, needed substantial assistance to transfer from bed to chair, was on a therapeutic diet, and was receiving dialysis. Review of the TAR dated December 2025, revealed Resident #63 attended dialysis on 12/01/25, 12/02/25, 12/03/25, 12/04/25, 12/05/25, 12/08/25, 12/09/25, 12/10/25, 12/11/25, and 12/12/25. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/01/25, revealed the facility failed to have a nurse signature for the pre-dialysis communication form and inform the dialysis clinic of Resident #63's code status, vaccine status, mental status, vital signs, current diet and fluid restriction, compliance to diet and fluids, any new medication, new medical problems, or new lab draws prior to last dialysis treatment. The facility failed to document the condition of the access site and if Resident #63 had signs and symptoms of infection. The facility also failed to have a nurse signature and the date and time Resident #63 returned to the facility following dialysis, the condition of the access site, the condition of the catheter dressing, and if Resident #63 had any signs or symptoms of infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/02/25, revealed the facility failed to communicate prior to dialysis Resident #63's weight, current diet and fluid restriction, compliance with diet and fluids, any new medication, new medical problems, or new lab draws since last dialysis treatment. The facility failed to communicate if Resident #63 had any signs or symptoms of infection prior to dialysis. The facility failed to have a nurse signature with date and time of Resident #63's return to facility following dialysis and the condition of the dialysis site, catheter dressing, and if Resident #63 had signs and symptoms of infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated by the dialysis clinic as 12/03/25, revealed the facility failed to obtain a nurse signature prior to dialysis and communicate Resident #63's code status, vaccine status, mental status, vital signs, current diet and fluid restrictions, compliance with diet and fluids, any new medication, new medical problems, new lab draws since last dialysis treatment. The facility failed to communicate the condition of the access site, and if Resident #63 had signs and symptoms of an infection. The facility failed to obtain a nurse signature, date and time of Resident #63's return to the facility from dialysis and the condition of the access site, condition of the catheter dressing, and if Resident #63 had signs and symptoms of an infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/04/25, revealed the facility failed to obtain a nurse signature prior to leaving for dialysis and communicate to the dialysis clinic Resident #63's code status, vaccine status, mental status, vital signs, current diet and fluid restriction, compliance to diet and fluid restriction, any new medication, labs or medical condition since last dialysis treatment. The facility failed to communicate the condition of the access site, and if Resident #63 had signs and symptoms of an infection. The facility failed to obtain a nurse signature, date and time Resident 63 returned to the facility from dialysis and failed to assess the access site, catheter dressing, and if Resident #63 had signs and symptoms of an infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/05/25, revealed the facility failed to obtain a nurse signature prior to Resident #63 leaving for dialysis and failed to communicate to the dialysis unit Resident #63's code status, vaccine status, mental status, allergies, vital signs, current diet and fluid restriction, compliance with diet and fluid restriction, any new medication, new labs or medical condition since last dialysis treatment. The facility failed to communicate the condition of the access site and if Resident #63 had signs and symptoms of an infection. The facility failed to obtain a nurse signature and date and time Resident #63 returned to the unit from dialysis and the status of the access site, the catheter dressing, and if Resident #63 had signs and symptoms of an infection. Review of the facility document titled Dialysis Hand Off Communication Report, dated 12/12/25, revealed the facility failed to communicate Resident 63's weight prior to dialysis, current diet and fluid restriction, compliance to diet and fluid restriction, any new medication, new labs or new medical condition since last dialysis treatment. The facility failed to obtain a nurse signature of the date and time Resident #63 returned to the from dialysis and the condition of the access site, the condition of the catheter dressing, and if Resident #63 had signs and symptoms of an infection. Interview on 12/11/25 at 4:36 P.M. with Licensed Practical Nurse (LPN) #844 revealed the night nurse was to fill out the Dialysis Communication Report if a resident left early in the morning for dialysis. LPN #844 also stated when a resident returned to the unit the nurse on duty was to receive the hand off communication report and was to sign the report. The dialysis hand off reports were to be reviewed by the Director of Nursing (DON). Review of the facility document titled Long Term Care Facility Renal Dialysis Coordination Agreement, dated 10/19/20, section Six: Communication, revealed emergency and non-emergency changes in dialysis residents would be communicated in writing. The long-term facility would notify the dialysis facility in writing when a resident refused or demonstrated noncompliance with medical management related to renal replacement therapy such as diet, fluid restriction and medications. 4. A review of the medical record for Resident #29 revealed a date of admission of 12/09/25. Significant diagnoses included end stage renal disease, other complications of kidney transplant, and dependence on renal dialysis. Significant orders included dialysis in-house with Dialyze Direct, Monday through Friday. There were no orders for pre and post dialysis assessments to be completed. Review of the annual MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. The MDS also revealed Resident #29 received dialysis. Review of the care plan dated 10/22/25 revealed Resident #29 had end stage renal disease requiring hemodialysis with history of kidney transplant. Interventions included coordinating with dialysis regarding labs, diet, weight, and medication as necessary. Dialysis in house with Dialyze Direct Monday through Friday with chair time varying. Interventions also included monitoring for change in mental status, monitoring for signs and symptoms of infection, and monitoring for signs and symptoms of hypovolemia or hypervolemia (dangerously low or high volume of blood or extracellular fluids in the body). A review of a facility documents titled; Dialysis Handoff Communication Reports for Resident #29 dated 12/02/25, 12/04/25, 12/05/25 and 12/11/25 revealed the facility failed to report Resident #29's vital signs that included temperature, pulse, respiration, blood pressure, and weight pre and post dialysis. The facility failed to report if labs were drawn and if Resident #29 had signs and symptoms of an infection. The facility failed to have a nurse sign the pre-dialysis and post-dialysis hand off reports. 5. A review of the medical record for Resident #44 revealed a date of admission of 11/11/25. Significant diagnoses included acute kidney failure. Significant orders included dialysis in-house with Dialyze Direct, Monday through Friday. There were no orders for pre and post dialysis assessments to be completed. Review of the care plan dated 11/11/25 revealed Resident #44 had the care need of dialysis Monday through Friday in-house. There was nothing in the care plan regarding pre and post dialysis assessments. There was nothing within the care plan indicating communication with dialysis regarding monitoring for a change in mental status, monitoring for signs and symptoms of infection, and monitoring for signs and symptoms of hypovolemia or hypervolemia. Review of the Medicare five-day MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. The MDS also revealed Resident #44 received dialysis. A review of a facility documents titled Dialysis Handoff Communication Reports for Resident #44 revealed the following: - 12/01/25: No vital signs that included temperature, pulse, respiration, blood pressure, and weight prior to dialysis. There was no post dialysis assessment completed by the facility. - 12/02/25: No pre or post dialysis assessments completed. The sections of the form were blank. - 12/03/25: No vital signs that included temperature, pulse, respiration, blood pressure, and weight prior to dialysis. There was no post dialysis assessment completed by the facility. - 12/04/25: No pre or post dialysis assessments completed. The sections of the form were blank. - 12/05/25: No vital signs that included temperature, pulse, respiration, blood pressure, and weight prior to dialysis. There was no post dialysis assessment completed by the facility. - 12/08/25: There was no post dialysis assessment completed by the facility. - 12/10/25: No vital signs that included temperature, pulse, respiration, blood pressure, and weight prior to dialysis. There was no post dialysis assessment completed by the facility. - 12/11/25: No vital signs that included temperature, pulse, respiration, blood pressure, and weight prior to dialysis. There was no post dialysis assessment completed by the facility. 6. A review of the medical record for Resident #67 revealed a date of admission of 05/28/25. Significant diagnoses included end stage renal disease. Significant orders included dialysis in-house with Dialyze Direct, Monday through Friday. There were no orders for pre and post dialysis assessments to be completed. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 00, indicating the resident had severe cognitive deficit or the resident was not understood. The MDS also indicated Resident #67 received dialysis. Review of the care plan dated 12/29/25 revealed Resident #67 had a care need of dialysis. Interventions included dialysis Monday through Friday. There was nothing within the care plan indicating communication with dialysis regarding monitoring for a change in mental status, monitoring for signs and symptoms of infection, and monitoring for signs and symptoms of hypovolemia or hypervolemia. A review of a facility documents titled Dialysis Handoff Communication Reports for Resident # 67 revealed the following: - 12/01/25: No pre or post dialysis assessments completed. The sections of the form were blank. - 12/02/25: No post dialysis assessment. The section of the form was blank. - 12/03/25: No pre or post dialysis assessments completed. The sections of the form were blank. - 12/04/25: No pre or post dialysis assessments completed. The sections of the form were blank. - 12/05/25: No pre or post dialysis assessments completed. The sections of the form were blank. On 12/10/25 at 4:00 P.M. an interview with Dialysis Registered Nurse (DRN) #841 revealed the facility was to complete pre and post dialysis assessments on the communication document. DRN #844 further stated most often the pre and post dialysis assessments are blank for those residents' receiving dialysis. On 12/15/25 at 2:40 P.M. an interview with DON verified the lack of pre and post dialysis pre and assessments for Residents #02, #21, #29, #44, #63 and #67. The DON also verified no physician orders for pre and post dialysis assessments or care plan interventions for Residents #02, #21, #29, #44, #63 and #67. A review of the policy titled End Stage Renal Disease, Care of a Resident with, dated 09/24, revealed residents with end-stage renal disease will be cared for according to currently recognized standards of care. The policy further stated staff caring for residents with end-stage renal disease, including residents receiving dialysis care shall assess data that is to be gathered about the residents' condition on a daily or per shift basis, review signs and symptoms of worsening condition or complications of end stage renal disease, and monitor care of grafts and fistulas. This deficient practice represents noncompliance investigated under Complaint Number 2687759.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nutritional recommendations were implemented in a timely manner for Residents #11, #21, and #25. Additionally, the facility failed to meet estimated energy needs for Resident #2 who was dependent on enteral (tube) feeding for nutrition. Additionally, the facility failed to evaluate Resident #33 (who was identified to be a high nutritional risk) on a monthly basis. The facility identified 15 current residents who required enteral feeding. This affected five residents (#2, #11, #21, #25, and #33) of 13 residents reviewed for nutrition. The facility census was 72. Findings include: 1. Review of Resident #25's medical record revealed an admission date of 04/18/25 with diagnoses including chronic respiratory failure with ventilator dependence, tracheostomy, gastrostomy status, traumatic subdural hemorrhage, anxiety, type 2 diabetes mellitus, chronic congestive heart failure, enterocolitis, cystitis, hypotension, hypotension, neuromuscular bladder, dysphagia, gastroesophageal reflux disease, high blood pressure, multiple fractures of ribs, and fractured neck, and clavicle, thoracic aorta injury, aneurysm of ascending aorta and iliac artery, atrial fibrillation (irregular heart rate), pulmonary embolism and venous thrombosis, and dysphagia. Review of Resident #25's clinical record revealed Resident #25 was sent to the hospital on [DATE] and admitted with diagnoses including septic shock, acute cystitis and atrial fibrillation. Resident #27 returned to the facility on [DATE]. The nursing admission assessment progress note dated 10/27/25 indicated the presence of unstageable pressure ulcers located on the sacrum, right lower leg and ankle. Review of Resident #25's nutrition assessment dated [DATE] revealed Resident #25 had dysphagia, was unable to eat orally, and tube feedings were implemented. The assessment indicated that Jevity 1.5 cal (tube feeding solution indicating 1.5 calories is provided per milliliter) solution was continuously administered via an enteral feeding pump at 40 milliliters (ml) per hour with 30 ml water flushes every four hours. The assessment indicated additional nutritional supplements were not provided. The nutrition assessment revealed Resident #25 did not have a pressure ulcer at the time the assessment was completed. A review of the nutrition assessment dated [DATE] revealed a recommendation to increase the Jevity 1.5 cal tube feeding solution infusion rate to 60 ml per hour. A review of the physician order dated 11/19/25 revealed an order to increase the Jevity 1.5 tube feeding solution rate to 60 ml per hour. An interview with Registered Dietitian (RD) #816 on 12/18/25 at 10:42 A.M. verified the recommendation to the have Resident #25's tube feeding rate increased was not ordered until 11/19/25. RD #816 stated she had sent an email to Assistant Director of Nursing (ADON) #350 to inform her of the recommendation and had placed a written document to inform the ADON #350 of the request to have Resident #25's tube feeding rate increased. RD #816 verified the above findings during the interview. 2. Review of Resident #11's clinical record revealed an admission date of 10/20/25 with diagnoses including acute duodenal ulcer with perforation, acute kidney failure, acute pulmonary edema, acute respiratory failure with ventilator dependence, anemia, alcohol dependence, candidiasis of skin and nails, cerebral ischemia, cardiac arrest, emphysema, gastroesophageal reflux disease, hypovolemic chock, hypoxic ischemic encephalopathy, idiopathic aseptic necrosis of left femur, pulmonary embolism, pneumonia, sepsis, type 2 diabetes mellitus, and osteoarthritis. Review of Resident #11's nutrition assessment completed on 11/18/25 indicated a recommendation for liquid protein supplement 30 ml daily to promote wound healing. Review of Resident #11's physician order dated 12/02/25 stated to administer 30 ml of liquid protein via gastrostomy tube once a day in the morning and would start on 12/03/25. Interview on 12/17/25 at 11:15 A.M. with RD #816 revealed a dietitian was to assess a new admission within seven days of admission if a resident was high risk, such as if a resident required tube feeding or had a pressure ulcer, to see if the resident was meeting their estimated needs. The dietitian was to complete the new care plan within 14 days of admission. The dietitian was also expected to assess high risk residents on a monthly basis instead of quarterly. The facility's Corporate Dietitian #817 provided the consulting dietitian corporate standards for calculations and intervention specific for the facility. An interview with RD #816 on 12/18/25 revealed she had recommended a liquid protein supplement be administered to Resident #11 on 11/18/25 and verified the recommendation was not implemented until 12/03/25. RD #816 stated the expectation was the facility should implement the dietitian's recommendation within 24 to 48 hours after notification was sent to the facility. RD #816 stated she sent an email to ADON #350 and placed a written notification of the recommendation to add the liquid protein supplement to Resident #11's tube feeding once a day to promote wound healing under the ADON #350's door. 3. Resident #2 was admitted to the facility on [DATE]. Medical diagnoses included chronic respiratory failure, dependence on ventilator, muscle weakness, difficulty swallowing, end stage renal disease, dependence of renal dialysis, tracheostomy, gastrostomy status, and nutritional deficiency. Resident #2 was noted to weigh 122.8 pounds (lbs) upon admission to the facility on [DATE]. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #2 had severely impaired cognition with a Brief Interview of Mental Status score of 07. Resident #2 did not reject care and did not attempt to eat. Resident #2 was dependent on staff to transfer from bed to chair. Resident #2 required enteral feeds which provided 51 percent (%)or more of the total daily calories. Resident #2 was on oxygen therapy, suctioning, tracheostomy care, invasive mechanical ventilator, and dialysis. Review of the plan of care dated 12/05/25, revealed Resident #2 required a tube feeding related to difficulty swallowing, other nutrition risk included end stage renal disease with dialysis thus needing Nepro tube feeding, wound care , and undesired significant weight loss. The goal was for Resident #2 to maintain a stable weight. Interventions included collaborating with the dialysis dietitian, monitor for tube dislodgement, obtain labs, dietitian to evaluate quarterly and as needed, monitor calorie intake, estimated needs, and make recommendations for changes to tube feeding as needed, Review of the admission Nutrition assessment dated [DATE] at 8:35 P.M. written by Dietitian #820 revealed Resident #2 was assessed for pressure ulcer, enteral feedings, and dialysis. Resident #2 received no food by mouth. The goal was to have a stable current weight. Resident #2 was ordered Nepro at 35 ml per hour for 20 hours daily to provide 1260 calories and 56 grams of protein. Estimated energy needs consisted of 1500 to 1700 calories and about 55 grams of protein. Resident #2 was noted to have an Unstageable coccyx wound on admission. ProSource protein supplement was added daily and a recommendation to run Nepro continuous (24 hours per day) at 35 ml per hour to provide 1512 calories and 68 grams protein was made. Review of a weight change note dated 11/18/25 written by Dietitian #820 revealed Resident #2 was at risk for malnutrition as evidenced by current body weight on 11/17/25 was 114.8 pounds. The comparison weight was 122.6 pounds on 11/13/25 which indicated a 6.4% weight loss in four days. The note indicated Resident #2's tube feeding was adjusted to meet estimated energy needs. Review of the physician order start date of 11/18/25 end date of 12/05/25 revealed Resident #2 was to receive enteral feeding with Nepro at 40 ml per hour for 20 hours. Review of Dietary Note dated 12/04/25 written by Dietitian #820 revealed Resident #2 was on Nepro at 40 ml per hour to provide 1620 calories and 73 grams protein. ProSource protein supplement was provided for altered skin. Resident #2 had high estimated energy needs due to weight loss and wound care. Nepro provided the estimated energy needs per order on 11/18/25. Review of a weight change note dated 12/05/25 written by Dietitian #820 revealed Resident #2 had a 5.7 % weight loss in one month and a 6.6 % weight loss in 18 days. Review of physician orders dated 12/05/25 revealed Resident #2's enteral feed order was increased to Nepro at 45 ml per hour for 20 hours per day. Review of Resident #2's weights revealed on 12/05/25 the resident weighed 108.2 pounds. Review of facility document titled Wounds for 12/01/25 to 12/17/25 revealed on 12/03/25 Resident #2 had an unstageable pressure ulcer on the coccyx and on 12/10/25 the unstageable coccyx pressure ulcer was resolved. Observation on 12/22/25 at 3:30 P.M. revealed Resident #2 was in her reclining chair adjacent to her bed in her room. Inspection of the tube feeding setup revealed the feeding pump was not powered on, the tube feeding monitor display was not lit, there was no display of rate, volume, or status indicators to indicate the tube feeding pump was in use. There were no audible alarms or alerts present at the time of observation. Observation for 12/22/25 at 3:45 P.M. with Licensed Practical Nurse (LPN) #424 verified the tubing connection and flow was not on by a manual check of the feeding pump and stated the tube feeding had not been restarted since Resident #2 came back from dialysis at noon. LPN #424 stated Resident #2 had dialysis earlier in the day and does not receive enteral feeding during dialysis treatments. Interview on 12/23/25 at 10:14 A.M. with Dietitian #820 revealed Nepro at 45 ml per hour was needed to meet the resident's estimated energy needs. Based on the resident's nutrition assessment on 11/18/25, Resident #2 was at risk for malnutrition, therefore the tube feeding rate was increased because the original rate was not meeting the resident's estimated energy needs and had resulted in Resident #2 having a weight loss. Dietitian #820 stated the facility did not notify her of significant weight changes or which resident needed monitored. If a resident had a significant weight change, Dietitian #820 would notify ADON #350. ADON #350 then was to notify the DON if there was a significant weight change. If there was a significant weight change, the facility was expected to reweigh the resident. Dietitian #820 stated she did not attend risk meetings regarding weight changes in the facility. 4. Resident #21 was admitted to the facility on [DATE]. Medical diagnosis included sepsis (systemic infection), moderate protein calorie malnutrition, urinary tract infection, end stage renal disease needing dialysis, diabetes, encephalopathy (disorder of the brain) acute respiratory failure, cerebral infarction, dependence on renal dialysis and dysphagia (difficulty swallowing). Review of Resident #21's physician orders revealed an order dated 08/08/25 for Vital Advanced Formula (AF), an enteral feeding solution. Vital AF was to be administered at a rate of 45 ml per hour for a duration of 20 hours daily. Review of an admission Nutrition assessment dated [DATE] at 4:47 P.M. authored by Dietitian #819 revealed Resident #21 needed enteral feeding and dialysis. Resident #21 was ordered to have nothing by mouth and the majority of nutrition was through tube feedings. The goal was for Resident #21 to maintain a stable weight and ensure estimated energy needs consisting of 1682 calories and 67 grams of protein were provided. Resident #21 had an existing diagnosis of protein calorie malnutrition. Current tube feeding order was Vital AF at 45 ml per hour that provided 1296 calories and 81 grams of protein. Dietitian #819 was to follow weight and tube feeding acceptance because the ordered tube feeding was less than calculated estimated nutrition needs. Review of Resident #21's weights revealed on 09/02/25, the resident weighed 143.9 pounds. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #21 had a BIMS score of 8 indicating moderately impaired cognition. Resident #21 did not display physical or verbal behaviors and did not reject care. Resident #21 did not attempt to eat, was dependent on activities of daily living (ADLs). Resident #21 required extensive assistance to roll left and right in bed and to sit on the side of the bed. Resident #21 was dependent on staff to stand, and transfer from bed to chair. Resident #21 needed a feeding tube for nutrition that provided 51% or more of total calories and 501 cubic centimeters (equivalent to milliliters) of fluids per day. Resident #21 additionally required dialysis treatments. Continued review of Resident #21's weights revealed on 11/05/25 the resident weighed 140.8 pounds. Review of the plan of care dated 12/03/25 revealed Resident #21 had the potential for alteration in nutrition and hydration related to sepsis, encephalopathy, gastroenteritis, cerebral infarction, type two diabetes, dysphagia, end stage renal disease with hemodialysis, nothing by mouth need for tube feeding. Goal was no significant weight change with edema, demonstrate adequate hydration, and tolerate dialysis treatments. Interventions included administer medication, collaborate with dialysis dietitian on plan of care, dialysis treatments per order, monitor dialysis site for bleeding, monitor for dehydration, monitor for fluid overload and notify physician, monitor of difficulty swallowing, monitor of signs and symptoms of malnutrition such as muscle wasting, significant weight loss, obtain labs and monitor, provide nothing by mouth. Review of Resident #21's weights revealed on 12/05/25, the resident weighed 124.1 pounds. On 12/18/25, Resident #21 weighed 124.7 pounds. Review of a weight change note dated 12/05/25 at 10:19 P.M. written by Dietitian #820 revealed Resident #21 had a one- and three-month weight loss. Current tube feeding order of Vital AF at 45 ml per hour for 20 hours provided 1080 calories, and 67.5 grams protein. Resident #21 had an 11.86 percent weight loss in one month and 13.76 weight loss in three months. Due to the weight loss, the RD requested to increase Vital AF tube feeding to 65 ml per hour for 20 hours to provide 1300 calories, and 97 grams of protein. Review of a dietary note dated 12/20/25 written by Dietitian #820 revealed Resident #21 was out of the facility from 12/15/25 to 12/17/25. Current tube feeding order was Vital AF at 45 ml per hour for 20 hours. Dietitian #820 requested a reweight. Resident #21's estimated calorie needs were 1500 calories and 56 grams of protein. The resident's tube feeding of Vital AF at 45 ml per hour was providing 1080 calories and 67.5 grams of protein. Dietitian #820 requested Vital AF to increase to 65 ml per hour for 20 hours. Review of physician orders start dated 12/20/25 revealed Resident #21 had an enteral feed order for Vital AF at 65 ml per hour for 20 hours per day. Interview on 12/18/25 at 12:25 with ADON #350 revealed all reweighs of a resident were done immediately if a significant weight change occurred. The reweight was documented in the electronic medical record. She stated the facility did not have a risk meeting regarding weights since October 2025 when the previous Director of Nursing quit. Interview on 12/23/25 at 10:14 A.M. with Dietitian #820 verified a request was made on 12/05/25 to increase Resident #21's tube feeding rate, but was not implemented until 12/20/25 when a second request was made. Dietitian #820 verified Resident #21 had a significant weight loss because the original tube feeding rate did not meet the resident's estimated energy needs. Dietitian #820 stated it was not protocol for the dietitian to call the physician regarding nutrition recommendations, but ADON #350 was notified by email of nutrition recommendations and was to make the request to the physician and then write the order. Dietitian #820 verified she made a recommendation on 12/05/25 for the tube feeding rate to be increased but the rate was not increased until 12/20/25 per physician orders, 15 days later. Dietitian #820 also verified Resident #21 was not care planned to be on a weight loss program. Interview on 12/23/25 at 4:00 P.M. with ADON #350 revealed she received Dietitian #820's email requesting Resident #21's tube feeding rate to be increased but assumed Dietitian #820 was to call the physician for approval and notify the family of the order change. Interview on 12/24/25 at 12:30 P.M. with the Director of Nursing verified the facility did not have weight or risk meetings since she started and assumed the dietitian was to call the physician and family regarding order changes because that was done in her previous facility. Interview on 12/24/25 at 12:31 P.M. with The Administrator revealed the facility had not approached the Medical Director if Dietitian #820 could have order writing privileges in the facility. Interview on 12/30/25 at 10:56 A.M. with Corporate Dietitian #817 revealed the dietitian or nurse could notify the physician to increase the tube feeding rate. If the dietitian contacted the physician the dietitian was to communicate with nursing staff. The current dietitian in the facility did not have order writing privileges. The facility was not able to produce a policy and procedure regarding nutrition recommendations and Dietitian order writing privileges. 5. Resident #33 was admitted to the facility on [DATE]. Medical diagnosis included end stage renal disease, congestive heart failure, type two diabetes, absence of left knee, morbid obesity, and dependence on dialysis. Review of physician orders start date 04/07/23 revealed the facility was to monitor Resident #33's weight monthly and an order dated 10/01/24 for a regular diet with an 1800 ml daily fluid restriction. Review of Nutrition Plan of Care revision date 10/09/24 written by Facility Corporate Dietitian #817 revealed Resident #33 had nutrition problems related to end stage renal disease on dialysis, history of swallowing difficulties, history of significant weight fluctuations, body mass index above desired range and fluid restriction. Goal was to have nutritionally pertinent labs. Interventions included administer medication, collaborate with Dialyze direct dietitian on plan of care. Resident was on dialysis but on a therapeutic renal diet restrictions based on labs. Diet recommendations as needed, fluid restriction per physician order, night snack, monitor weights, monitor for signs of dysphagia, obtain labs as ordered, provide diet as ordered, monitor intake, and the facility dietitian was to evaluate and make diet change recommendations. Review of Resident #33's nutritional assessments revealed an annual assessment was completed on 10/22/24, and the next nutrition assessment was completed 12 months later on 10/22/25. Continued review of Resident #33's electronic medical record revealed a monthly nutrition note was documented on 02/21/25, 03/19/25, 04/11/25, 05/19/25, 05/28/25 and 07/21/25. No monthly nutrition note was documented again until 10/14/25 when the quarterly nutrition assessment was due, followed by monthly nutrition notes on 11/09/25, and 12/04/25. Review of the MDS 3.0 Discharge Assessment Return Anticipated dated 10/13/25 revealed Resident #33 short- and long-term memory was okay. Resident #33 did not reject care and needed assistance for eating, maximal assistance for oral hygiene. Resident #33 was dependent on staff to roll left and right in bed, and transfer from the bed to a chair. Resident #33 was on a therapeutic diet and received dialysis. Review of facility census records revealed Resident #33 was actively admitted in the facility until 10/13/25 when Resident #33 was admitted to a local hospital. Resident #33 returned to the facility on [DATE]. Review of Resident #33's recorded weights revealed on 11/05/25 the resident weighed 278.0 pounds and on 12/04/25 the resident weighed 250.0 pounds. Review of a weight change note dated 12/04/25 written by Dietitian #820 revealed weight loss was desired, intake was ok, and the resident tolerated their ordered diet. Interview on 12/17/25 at 9:36 A.M. with RD #816 revealed dietitians were to evaluate residents who were deemed high risk, such as residents who required dialysis or tube feedings, on a monthly basis instead of quarterly. Interview on 12/17/25 at 1:59 P.M. with MDS Nurse #418 revealed the dietitian had access to update nutrition plan of cares and was expected to update nutrition plan of care if a new intervention or goal was put in place. Interview on 12/23/25 at 10:14 A.M. with Dietitian #820 revealed Resident #33 was considered a high nutrition risk resident because he received hemodialysis and recommended to follow Resident #33's nutrition status monthly instead of quarterly. Dietitian #820 verified Resident #33 had a significant weight loss and was not care planned to be on a weight loss program. Dietitian #820 stated all residents were to be weighed monthly. Dietitian #820 also verified Resident #33 was not assessed by a dietitian or had a nutrition note between 07/21/25 and 10/14/25. Interview on 12/30/25 at 10:08 A.M. with Facility Corporate Dietitian #817 verified that a dietitian did not assess Resident #33 or have a nutrition note from the dates of 07/21/25 to 10/14/25 and Resident #33 was not care planned to be on a weight loss program. Review of facility policy Weight Management Guidelines undated, revealed weights should be recorded in the medical record by a qualified nutrition professional. If a weight loss was clinically desired from usual body weight range a care plan should reflect this. If a resident has a significant weight loss or gain, a report should be given to the Director of Nursing and reviewed in Risk Meeting. Nursing should notify the physician and family of significant weight loss.

Based on observation, interviews, record review, and review of maintenance documents and facility policy, the facility failed to maintain adequate room temperatures in the common area/dining room and resident rooms. This affected six residents (#15, #34, #48, #50, #52 and #69), and had the potential to affect 26 residents (#5, #6, #7, #8, #16, #23, #24, #26, #32, #36, #39, #43, #46, #47, #48, #51, #53, #56, #57, #59, #60, #66, #68, #69, #70 and #93) who used the common area/dining room . The facility census was 72.Findings include:Interview on 11/26/25 at 8:10 A.M. with Resident #15 complained the common area was so cold last week he had to stay in his room because his room was warmer.Interview on 11/26/25 at 8:15 A.M. with Certified Nurse Assistant (CNA) #840 stated the building was so cold last week, the residents refused to receive showers.Interview on 11/26/25 at 8:25 A.M. with Resident #48 complained the common area was so cold he had to eat lunch in his room and did not like to feel that cold.Interview on 11/26/25 at 8:26 A.M. with Registered Nurse (RN) #431 verified Resident #48 preferred to eat in the common area and liked to be out of his room to participate with others.Interview on 11/26/25 at 9:04 A.M. with Regional Director of Operations (RDO) #802 revealed nursing staff had contacted him because the thermostat read 67 degrees Fahrenheit (F).Observation on 12/01/25 at 9:25 A.M. of the second-floor common area revealed the thermostat read 68 degrees (F) and the air handler which conditions and circulates air read 64 degrees (F). Interview with Housekeeper #331 at the time of the observation verified the temperature readings and stated no staff were able to change the thermostats in the common area/dining room. The prior weekend was so cold in the facility, she had to wear extra clothing and complained how cold the facility was over the holiday weekend.Interview on 12/01/25 at 9:30 A.M. with Resident #50 who was sitting in the second-floor dining room with a blanket on complained the dining room was too cold to be comfortable.Interview on 12/01/25 at 9:40 A.M. with Resident #52 complained that over the prior weekend her room was so cold she had to sleep with three blankets on.Interview on 12/01/25 at 3:14 P.M. with Maintenance Supervisor (MS) #368 verified the upstairs dining room/common area was cold in the mornings. He stated the air handler needed reset.Observation on 12/02/25 from 9:30 A.M. to 10:11 A.M. with RDO #802 of room temperatures using the facility's handheld digital thermometer which tests ambient air temperatures revealed Resident #69's room was at 69 degrees (F). Interview at the time of the observation with RDO #802 verified the finding, and stated the facility was heated by a roof top unit that blew into each resident's room.Observation on 12/16/25 at 9:35 A.M. during medication pass observation of Resident #34's room who complained the room was always cold revealed an unnamed maintenance staff member took an ambient temperature using a handheld digital thermometer which resulted in a reading of Resident #34's room as 67 degrees (F), then repeated was 66.9 degrees (F), and finally was 67.3 degrees (F). Resident #34 was provided with an additional blanket.Interview on 12/16/25 at 11:00 A.M. with the Administrator verified the heat was out in the building and was notified at 5 A.M. on that day (not specified). The Administrator stated maintenance came in that morning and discovered a breaker was down.Review of a maintenance document from a heating company dated 11/09/25 revealed the heat exchanger needed replaced, and it was recommended a new inducer and burners be replaced.Review of a maintenance document from a heating company dated 11/20/25 revealed all heating units on-site seemed to operate with incorrect gas pressure settings. The gas pressure was adjusted on the three units that were part of the scheduled service, but the remaining units on-site still required gas pressure adjustments, and must be set up to ensure proper combustion, efficient heating performance, and compliance with equipment standards.Review of the facility policy entitled, Temperature Extremes, dated February 2025 revealed the temperature throughout the facility would be maintained between 71 and 81 degrees (F). Any temperature outside of the range required specific interventions to avoid potential negative impact on the residents' well-being.This deficiency represents non-compliance investigated under Complaint Number 2687759, Complaint Number 2674189, Complaint Number 2684242, Complaint Number 2679591, Complaint Number 2688137, Complaint Number 2672693, Complaint Number 2647699 and Complaint Number 2614520.

Based on observation, record review, interview and policy review the facility failed to ensure residents were assisted with activities of daily living including hair, nail and oral care. This affected three residents (Resident #30, #31 and #51) of 12 residents reviewed for activities of daily living. The census was 72.Findings include: 1. A review of the medical record for Resident #30 revealed a date of admission of 08/08/25. Significant diagnoses included urinary tract infection, need for assistance with personal care, and morbid obesity. Review of a care plan dated 08/08/25 revealed Resident #30 had a self-care deficit related to morbid obesity. Interventions included assisting with activities of daily living as needed.Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating intact cognition.Review of bathing documentation revealed no concerns. Staff were using bathing wipes during the facility water emergency (legionella) and had shower caps available for resident use. On 12/08/25 at 9:00 A.M. an observation of Resident #30 revealed them to be in bed. Resident #30 was noted to have oily hair that was uncombed and visible dirt noted under their fingernails.On 12/10/25 at 8:45 A.M. an observation of Resident #30 revealed their hair to be oily and their fingernails were dirty under the nails. Resident #30 stated their hair had not been washed for several weeks.On 12/10/25 at 9:00 A.M. Registered Nurse (RN) #418 verified the oily hair and dirty fingernails for Resident #30. The RN provided no additional information during the interview.On 12/30/25 at 3:00 P.M. an interview with Regional Director of Clinical Services (RDCS) #803 revealed the facility always has shampoo caps (a cap that is single use, premoistened with shampoo designed for waterless hair washing). RDCS #803 further stated the shampoo caps are stocked on each residential unit and in the supply room that all staff have the code for. An observation of the supply room at the time of the interview revealed approximately one-half case of shampoo caps. 2. A review of the medical record for Resident #31 revealed a date of admission of 09/05/25. Significant diagnoses included diabetes mellitus type two with foot ulcer, nonpressure chronic ulcer of the right foot, and need for assistance with personal care. Review of a care plan dated 09/05/25 revealed Resident #31 had a self-care deficit related to diabetes with foot wounds. Interventions included assistance with activities of daily living as needed.Review of a Medicare five-day minimum data set (MDS) assessment dated [DATE] revealed a BIMS of 14 out of a possible score of 15, indicating intact cognition. The MDS also revealed Resident #31 was a partial to moderate assistance for bathing.On 12/08/25 at 9:00 A.M. an observation of Resident #31 revealed them to be in a wheelchair. Resident #31 was noted to have oily hair that was not combed and visible dirt under their fingernails.On 12/10/25 at 8:45 A.M. an observation of Resident #31 revealed their hair to be oily and uncombed. Their fingernails were noted to be dirty. Resident #31 stated their hair had not been washed for at least two weeks. This was due to a water emergency in the facility.Review of bathing documentation revealed no concerns. Staff were using bathing wipes during the facility water emergency (legionella) and had shower caps available for resident use. On 12/10/25 at 9:00 A.M. Registered Nurse (RN) #418 verified the resident's oily and uncombed hair and dirty fingernails for Resident #31.On 12/30/25 at 3:00 P.M. an interview with Regional Director of Clinical Services (RDCS) #803 revealed the facility always has shampoo caps (a cap that is single use, premoistened with shampoo designed for waterless hair washing). RDCS #803 further stated the shampoo caps are stocked on each residential unit and in the supply room that all staff have the code for. An observation of the supply room at the time of the interview revealed approximately one-half case of shampoo caps. 3. A review of medical records for Resident #51 revealed a date of admission of 10/17/25. Significant diagnoses included chronic respiratory failure with hypoxia, morbid obesity due to excess calories, and need for assistance with personal care. Review of a care plan dated 10/17/25 revealed Resident #51 had a self-care deficit related to chronic respiratory failure and morbid obesity. Interventions included assistance with activities of daily living as needed.Review of the admission MDS assessment dated [DATE] revealed a BIMS of 15, indicating intact cognition. The MDS further revealed Resident #51 was a set up for oral care and dependent for all other activities of daily living. On 12/04/25 at 11:02 A.M. an observation of Resident #51 revealed them to be in bed. Resident #51 was tearful and stated they had just got a shower but their teeth had not been brushed since admission despite having oral care items available in their bathroom. Resident #51 was noted to have visible dirt under their fingernails. Licensed Practical Nurse #380 verified the dirt under Resident #51's fingernails at the time of the observation.On 12/16/25 at 3:00 P.M. observation and interview with Resident #51 revealed their teeth had still not been brushed. There was no toothbrush observed on Resident #51's bedside table. Resident #51 stated to look in the bathroom, and you will see my toothbrush that needs charged. One toothbrush that had dry bristles without signs of use was noted in the battery-operated toothbrush holder and two new toothbrushes were noted to be in a clear plastic, unopened covering. There was an unopened tube of toothpaste also observed. Social Worker Designee #351 verified the findings at the time of the observation.A review of the policy titled Activities of Daily Living (ADL), Supporting dated 03/24 revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided to residents who are unable to carry out activities of daily living independently with the consent of the resident and in accordance with the plan of care.This deficiency represents noncompliance investigated under Complaint Numbers 2687759, 2684242, 2641584, and 2655919.

Based on observation, record review, interview, and review of facility policy, the facility failed to have call lights within reach for Resident #41, #50 and #56. This affected three residents ( #41, #50 and #56) of 72 residents observed for call lights. The facility census was 72. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 09/22/23 with diagnoses including chronic respiratory failure and nontraumatic intercerebral hemorrhage. There were no physician orders regarding call lights.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #41 had severe cognitive impairment and impairment bilaterally to the upper and lower extremities. Resident #41 was dependent for all activities of daily living (ADL).Review of the care plan dated 12/17/25 revealed Resident #41 had a potential for falls related to limited mobility and post cerebral vascular accident. Interventions included ensure call light was available to resident's unaffected side. The care plan also revealed Resident #41 to have a communication problem related to being nonverbal and does not respond to verbal or tactile stimulation. Interventions included for the call light to be in reach.On 12/04/25 at 11:23 A.M. Resident #41 was observed to be lying in their bed. The call light was noted to be wrapped around the over bed light that was approximately five feet over the head of Resident #41and completely out of her reach. Licensed Practical Nurse (LPN) #380 was present during the observation and verified the findings. 2. Review of medical records for Resident #50 revealed an admission date of 02/05/21 with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD) and diabetes mellitus type two. There were no physician orders regarding call light use.Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 was cognitively intact.Review of the care plan dated 08/06/25 revealed Resident #50 was at risk for falls related to COPD. Interventions included be sure the resident's call light and personal items were within reach and encourage the resident to use the light for assistance as needed. On 12/04/25 at 10:37 A.M. an observation of Resident #50 revealed them to be lying in bed. The call light was noted to be wrapped around the overbed light that was located across the room. LPN #380 verified the location of the call light being out of reach for Resident #50 at the time of the observation. 3. Review of the medical record for Resident #56 revealed a date of admission as 05/12/17 with diagnoses including unqualified visual loss of both eyes and expressive language disorder. There were no physician orders regarding call light use.Review of the annual MDS assessment dated [DATE] revealed Resident #56 was cognitively intact.Review of the care plan dated 10/22/25 revealed Resident #56 had the potential for falls related to blindness. Interventions included encourage resident to use the call light for assistance and maintain the call light within reach.On 12/03/25 at 1:51 P.M. an observation of Resident #56 revealed them to be lying in bed. The call light was wrapped around the overbed light approximately five feet over the head of the resident. Certified Nurse Aide #311 verified the call light placement at the time of the observation.A review of the facility policy titled Answering Call Lights, undated, revealed when leaving the room be sure the call light is placed within the resident reach.

Based on record review, staff interviews and facility policy review the facility failed to ensure resident advanced directives (code status) were accurate. This affected one resident (#6) of 53 residents reviewed for the annual survey. The facility census was 72.Findings include: Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnosis that included: major depressive disorder, dementia, intracranial injury, essential hypertension, anxiety disorder, occlusion and stenosis of unspecified cerebral artery, alcohol dependence and unspecified psychosis. Record review revealed Resident #6 had an advanced directive order dated 05/07/20 for Full Code status (all life sustaining measures in the event of a cardiac or respiratory arrest).Review of a care plan dated 03/19/25 revealed the resident was a full code. Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #6 Care Conference Note dated 11/18/25 revealed the resident's mother requested resident's code status be changed from a Full Code to a Do Not Resuscitate Comfort Care (DNRCC) (no life saving measures in the event of cardiac or respiratory arrest). Interview on 12/4/25 at 1:23 P.M. with Resident #6's mother confirmed she wanted the resident's code status changed to a DNRCC.Interview on 12/11/25 at 2:38 P.M. with Director of Social Services (DSS) #351 revealed Resident #6's last care conference was completed on 11/18/25 with DSS #351 and the nurse unit manager. DSS #351 revealed she was unable to change code status and the nurse unit manager was supposed to get the order updated and signed by the resident's nurse practitioner. DSS #351 stated she would follow-up to ensure the order was updated.Interview on 12/15/2025 at 1:16 P.M. with Licensed Practical Nurse (LPN) #316 verified Resident #6's advanced directive status was changed to DNRCC and the DNRCC form was on the nurse's desk this morning (12/15/25) and was signed by the physician. LPN #316 stated the updated form was provided to the secretary to scan into Resident #6's medical record.Review of facility Advance Director Policy with a revised date of December 2016 revealed:13. The Interdisciplinary Team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident.14. The Director of Nursing Services or designee will notify the Attending Physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care.

Based on record review, interview and policy review the facility failed to ensure they notified the emergency contact of a resident's change in condition. This affected one resident (Resident #38) of one resident reviewed for notification of change. The facility census was 72.Findings include: Review of Resident #38's medical record revealed an admission date of 10/06/25 and a discharge date to the hospital on [DATE]. Diagnosis included acute on chronic respiratory failure, ventilator dependent, neurogenic bladder, urinary tract infection, hypertension, and tracheostomy status.Review of Resident #38's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, required substantial to maximal assistance with eating, and was dependent on staff for all other Activities of Daily Living (ADLs) including oral hygiene, toileting hygiene, showers, incontinence care, dressing, and bed mobility.Review of progress notes dated 12/19/25 at 2:58 P.M. revealed Resident #38 was experiencing a change in condition including bleeding with suctioning, blood in urine and vital signs documented as temperature 102.1 degrees Fahrenheit (F), respiratory rate 31 breaths per minute, pulse oximetry 66 percent. Resident was removed from the ventilator and manually bagged on 15 liters of oxygen by the respiratory therapist who suctioned for moderate amounts of brown bloody secretions. The resident was noted to have dried blood on front of teeth but refused oral care by the Respiratory Therapist and Certified Nursing Assistant (CNA). Physician was notified and order given to send to the Emergency room. Resident was admitted to the hospital.Review of Change in Condition assessment dated [DATE] and authored by the Director of Nursing (DON) revealed Resident #38's family was not notified of the hospital transfer.Review of Progress note dated 12/25/25 at 11:00 A.M. revealed the resident's husband showed up to the facility to visit and found the resident was not there and was unaware of this. DON notified at this this time of husband's concerns.Interview on 12/29/25 at 4:45 P.M. with Resident #38's husband revealed he arrived to the facility on [DATE] to visit his wife and was extremely upset when he found out his wife was not in her room. He stated he went to the nurse and found she had been sent to the hospital on [DATE] and admitted to the hospital. He stated he was extremely upset he was not notified the resident was sent to the ER and admitted to the hospital on [DATE] to the Intensive Care Unit (ICU) and was not doing well.Interview on 12/30/25 at 4:15 P.M. with the DON revealed she confirmed she was contacted on 12/25/25 by the nurse on duty and notified of Resident #38's husband was at the facility and was upset no one called and notified him of Resident 38's change in condition and stated he should have been called as he was listed as emergency contact number one and the resident was not able to make decisions on her care at the time of transfer due to altered mental status and emergent situation.Review of facility policy titled Change in a Resident's Condition or Status, last revised May 2024, revealed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and or status.

Based on interview, record review, and facility policy review, the facility failed to develop and implement comprehensive care plans for residents. This affected three residents (#13, #14, and #19) of three residents reviewed for comprehensive care plan implementation. The facility census was 72.Findings include:1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia, adult failure to thrive, homelessness, mood disorder, glaucoma, Guillain-Barre syndrome, obstructive sleep apnea, and panic disorder. Review of Resident #19's Minimum Data Set (MDS) 3.0 dated 10/26/25 revealed a BIMS score 15, indicating intact cognition. The MDS also revealed Resident #19 required set-up/supervision with all Activities of Daily Living and Mobility. The MDS also indicated the resident showed little interest or pleasure in doing things almost daily. Further review of Resident #19's Medical Record revealed on 11/11/25, the Resident signed a consent to receive mental health day program treatment which consisted of daily group therapy, as well as additional individual therapeutic behavioral support, psychiatric medication management, individual psychotherapy and family psychotherapy. Review of Resident #19's undated care plan revealed the resident was at risk for social isolation due to anxiety, depression, and stated little pleasure or interest in doing things. Goals included the resident would maintain social relationships with staff and peers as evidenced by initiating social encounters daily through next review and interventions included allowing the resident to express feelings and desires, a calendar in the resident's room, inviting the resident to structured activities while respecting her right to refuse, praising involvement in activities, providing encouragement, providing supplies and assistance as needed for self-directed pursuits and reporting signs of isolation. Resident #19's care plan included no focus areas, goals, or interventions related to a mental health program. Review of Resident #19's current physician orders revealed orders for Buspirone HCl Oral Tablet 15 MG (Buspirone HCl) Give 15 mg by mouth two times a day for anxiety, Duloxetine HCl Oral Capsule Delayed Release Sprinkle 60 MG (Duloxetine HCl) Give 60 mg by mouth in the morning for Depression and Divalproex Sodium Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 125 mg by mouth every 8 hours for mood. An interview with MDS Nurse #418 on 12/17/25 at 1:52 P.M. confirmed Resident #19's care plan did not contain any focus areas, goals, or interventions related to a mental health day program. 2. Review of Resident #13's medical record revealed the resident was admitted on [DATE] with diagnoses of acute kidney failure, dehydration, anemia, osteoarthritis, chronic pain, hypertension, hyperlipidemia, major depressive disorder, moderate protein-calorie malnutrition, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, muscle weakness, and need for assistance with personal care. Review of Resident #13's MDS assessment dated [DATE] revealed a BIMS score of 14, indicating intact cognition. Review of the MDS also revealed Resident #13 required set-up with oral care and eating, maximum assistance with dressing and bathing and was dependent on staff for toileting, was verbally inappropriate toward staff at times and reported feeling down or depressed less than daily. Interview with Resident #13 on 12/11/25 at 12:37 P.M. indicated he was alert and oriented, pleasant, and talkative and stated he hoped to go home soon to help take care of his ex-wife. During the interview, the resident also indicated no staff member had discussed discharge planning with him. Interview with the Social Services Designee (SSD) #351 on 12/15/25 4:46 P.M. revealed she was aware of resident's hope to discharge home with his ex-wife after rehab but stated discharge to the community was not appropriate at the time, as the resident was unable to care for himself. SSD #351 further stated she did not have a part in creating the comprehensive care plan and was not responsible to care plan psychosocial needs or interventions for residents. Interview with MDS Nurse #418 on 12/17/25 at 1:52 P.M. revealed she was responsible for creating the entire care plan except for dietary and activities needs. She stated she takes into consideration admission paperwork, hospital paperwork, doctor's orders, and stated she would expect to see self-care needs, skin integrity, resident care needs, isolation precautions, dialysis, pain and discharge planning needs addressed in the comprehensive care plan. MDS Nurse #418 verified that discharge plans were not included in Resident #13's comprehensive care plan. Review of the Social Service Designee's job description dated and acknowledged on 07/14/25 revealed it was the responsibility of the Social Service Designee to participate in discharge planning, develop and implement social care plans and resident assessments and to assist in developing a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident and the goals to be accomplished for each problem/need identified relating to mood, behavior, psychosocial wellbeing, discharge status, code status and smoking, if applicable and to review and revise care plans and assessments as necessary, at a minimum quarterly. 3. A review of medical records for Resident #14 revealed the date of admission as 02/06/25. Significant diagnoses included post-traumatic stress disorder (PTSD). Significant orders included haloperidol ( an antipsychotic medication) 10 milligrams at bedtime for PTSD. A quarterly MDS assessment dated [DATE] revealed a BIMS of 15 (cognitively intact). The MDS also revealed PTSD as an active diagnosis and the use of antipsychotic medication. A Trauma Evaluation assessment dated [DATE] revealed Resident #14 had a history of physical and sexual abuse. Triggers were listed as talking about the past. A Care Plan dated 11/17/25 revealed Resident #14 had a self-care deficit related to PTSD. There were no triggers care planned that may impede self-care. Further review of the care plan revealed an update on 12/10/25. Resident #14 had a history of trauma with potential for re-traumatization related to past history of historical trauma and PTSD. There were no triggers listed in the care plan. A psychiatric nurse practitioner note dated 11/12/25 revealed Resident #14 to have PTSD. There were no triggers listed in the note. On 12/10/25 at 9:14 A.M., an interview with Certified Nurse Aide (CNA) #439 revealed she was unaware Resident #14 had PTSD or of any triggers that may upset him. On 12/10/25 at 2:40 P.M., an interview with SSD #351 revealed the care plan For Resident #14 had been updated to indicate PTSD on 12/10/25 and it was based on Resident #14's trauma assessment. SSD #351 verified the Trauma assessment dated [DATE] had triggers listed on it that were not addressed. SSD #351 stated Resident #14 just got his voice back after having a tracheostomy so she could not know what potential triggers were. Review of the facility's policy titled Care Planning – Interdisciplinary Team revised September 2013 stated the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, record review, interview and facility policy review, the facility failed to assess wounds and obtain appropriate treatment orders upon re-admission from the hospital, failed to ensure wound care supplies were available, and/or failed to complete pressure ulcer treatments as ordered by the physician for Residents #60, #7, and #79. Actual Harm occurred on 04/11/24 when Resident #60, who was severely cogntively impaired, dependent on staff for all activities of daily living, at risk for pressure ulcer development and had a history of pressure ulcers, was found per Wound Physician #675 to have an unstageable (full-thickness pressure ulcer in which the base was obscured by slough and/ or eschar (dead skin) pressure ulcer to the left sacrum. The facility failed to ensure systems and interventions were in place to prevent the development of the pressure ulcer and to identify the pressure ulcer prior to it being identified as an unstageable ulcer. In addition, staff failed to consistently assess, and complete treatments as ordered resulting a deterioration of the left sacral wound and Resident #60 being transferred to the hospital, per family request, on 04/19/24 and admitted with a diagnosis of osteomyelitis to the left sacral pressure ulcer. This affected three residents (#60, #7, and #79) of four residents reviewed for pressure ulcers. The facility identified 12 residents (#1, #2, #7, #17, #19, #20, #43, #49, #57, #60, #77, and #79) with pressure ulcers. The facility census was 78. Findings include: 1. Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses including anemia, spastic quadriplegic cerebral palsy, intellectual disabilities, pressure ulcer of the sacral region, severe protein calorie malnutrition, and epilepsy. Review of the admission Minimum Data Set (MDS) assessment completed on 03/12/24 revealed Resident #60 had severely impaired cognition, was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. The MDS further revealed Resident #60 had one Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) to the sacral region and one Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to the right posterior thigh present on admission. Review of Wound Physician #675's progress note dated 03/28/24 revealed the Stage II pressure ulcer to Resident #60's left buttock was resolved and the Stage III pressure ulcer to Resident #60's right posterior thigh continued to improve and would be reassessed in seven days by the wound physician. There were no other wounds identified at the time of this assessment. A physician order dated 04/05/24 for wound care to the Stage III pressure ulcer of the right posterior thigh was also present with the following instructions: cleanse with normal saline (NS) or wound cleanser, apply collagen powder mixed with hydrogel, and cover with a dry dressing daily, on day shift. A prior order for the Stage III pressure ulcer of the right posterior thigh was in place from 03/08/24 through 04/04/24 and included cleansing the area with NS or wound cleanser, applying a collagen sheet, and covering with a dry dressing daily on day shift. Review of the treatment administration record (TAR) for April 2024 revealed no evidence the ordered wound care to the Stage III pressure ulcer of Resident #60's right posterior thigh was completed on 04/01/24, 04/03/24, 04/04/24, 04/05/24, or 04/10/24. Review of Wound Physician #675 's progress note dated 04/11/24 revealed an initial evaluation of an unstageable pressure ulcer of Resident #60's left sacrum. (The resident had a previously healed Stage II pressure ulcer on the lower left buttock, identified on admission which healed on 03/28/24. This was not the same area according to Wound Nurse Licensed Practical Nurse (LPN) #553. The new wound measured 5.0 centimeters (cm) by 5.0 cm by 0.3 cm with light serous exudate,100% devitalized necrotic tissue. A new order was written to cleanse with NS, apply Santyl (ointment used to remove damaged tissue) and ComfiTel dressing (silicone dressing that adheres gently to the skin, but not to wounds) daily. Review of the April 2024 TAR revealed no evidence the ordered wound care to the new pressure ulcer on the left buttock/sacral area was completed per physician orders on 04/14/24 or 04/17/24. Further review of the electronic TAR notes revealed wound care was unable to be completed per physician orders on 04/17/24 due to Santyl ointment being unavailable. Review of the TAR for April 2024 revealed no evidence the ordered wound care to the Stage III pressure ulcer of Resident #60's right posterior thigh was completed on 04/14/24 or 04/17/24. Review of Wound Physician #675's progress note dated 04/18/24 revealed the pressure ulcer on Resident #60's left sacrum was exacerbated due to multifactorial and measured 7.5 cm by 6.4 cm by 1.2 cm with moderate serous exudate. Further review revealed a surgical excisional debridement of the wound where 14.4 cm of devitalized tissue, necrotic periosteum bone and slough were removed, revealing itself to be a stage four pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) Review of this note revealed inconsistencies with the wound being described twice as exacerbated and once as not a wound deterioration. Review of a progress note dated 04/19/24 revealed Resident #60's guardian and representative wanted to see the resident's pressure ulcer/wound then requested Resident #60 be sent to the hospital after wound observation. Review of the hospital admission progress notes dated 04/19/24 revealed Resident #60 had a sacral decubitus ulcer with erosive changes of the lower sacrum and coccyx consistent with osteomyelitis and a small developing abscess anterior to the sacrococcygeal junction, confirmed by computed tomography (CT) scan of Resident #60's pelvis. Review of the hospital discharge instructions also revealed the sacral wound was to be dressed with a wet to dry Kerlix dressing, covered with a dry dressing at a minimum of daily and when saturated or soiled. The resident was readmitted to the facility on [DATE]. Review of the progress notes, skilled nursing assessments and skin and wound evaluations revealed no documented evidence Resident #60's wound was re-assessed after she returned to the facility from the hospital on 04/26/24. Review of the April 2024 TAR revealed the 04/11/24 pre-hospital treatment of cleanse left buttock (which was the left sacrum wound identified on 04/11/24 per Wound Care LPN #553) with NS or wound cleanser, and Santyl and cover with border gauze was documented as completed on 04/27/24 and 04/28/24. However, there were not appropriate orders for treatment to the recently debrided left sacrum pressure ulcer until Monday, 04/29/24, when assessed by wound care. Review of the nursing progress note dated 04/28/24 stated called clinical phone to advise how to change coccyx (sacral) wound that was debrided in the hospital. Was advised to use calcium alginate dressing and a foam covering until wound care can assess Monday morning, 04/29/24. No new order was written, and there was no documented evidence that the recommended treatment was applied on 04/28/24. Review of the physician orders revealed an order dated 04/29/24 for a wet to dry dressing with instructions to cleanse Resident #60's sacral wound with NS, pack with saline moistened gauze, and cover with an abdominal (ABD) pad every night shift and as needed if it becomes soiled. Review of the orders also revealed an order dated 04/12/24 to cleanse the area to Resident #60's left buttock with NS or wound cleanser, apply Santyl, and cover with a bordered dressing daily. There were no updated sacral wound care orders in Resident #60's physician orders from her re-admission to the facility on [DATE] until 04/29/24. Review of the April 2024 TAR revealed no evidence the wound care to the pressure ulcer/wound on the left buttock/sacral area was completed per physician orders on 04/29/24. Observation of Resident #60's wound care on 04/30/24 from 12:05 P.M. to 12:20 P.M. being performed by Wound Care LPN #553 revealed the old dressing to sacral wound was saturated with pale yellowish to light brown tinged drainage with the written date of the last dressing change faded. At the time of the observation, LPN #533 stated the date looked to be 04/30 and said it may have been changed by the night shift. The wound measured 9.8 cm by 6.6 cm by 0.2 cm with no tunneling and wound care was performed per physician orders at the time of the observation. Interview on 04/30/24 at 12:25 P.M. with Wound Care LPN #553 confirmed Resident #60's wound had shown signs of deterioration and was a Stage IV pressure wound. Prior to being hospitalized on [DATE]. Wound Physician #675 did not change wound care orders, despite change in appearance and size of the wound, and that was not typically what she experienced working with other more seasoned wound care physicians who would alter treatments if wounds regressed or did not show adequate signs of improvement. During the interview, LPN #553 confirmed the wound care treatment to which she was referring did not get changed by Wound Physician #675 after his assessment on 04/18/24 was for the left sacral wound, despite the order stating, left buttock, and that the wound to the lower left buttock was healed on 03/28/24. Interview on 04/30/24 at 4:10 P.M. with State tested Nurse Aide (STNA) #660 revealed she reported concerns to staff nurses that Resident #60's pressure ulcer/wound looked like it was getting bigger before she went to the hospital on 04/19/24. LPN #660 further reported Resident #60 was found without a dressing over her pressure wounds on several occasions, which she also said she reported to the nurses on duty who did not always do anything about it. Interview on 04/30/24 at 4:15 P.M. with STNA #562 revealed she had reported the lack of dressings covering Resident #60's pressure ulcer/wound several times and was concerned it was getting bigger and worsening. She further stated she became so concerned she stayed after her shift on 04/17/24 until Resident #60's wound was cleaned, and a new dressing was applied. During this interview, STNA #562 reported the nurse on the unit verbalized she did not know what to do with the wound, so STNA #562 went to another unit and asked that nurse to come look at Resident #60's wound. Per STNA #562, the nurse from the Dogwood unit assessed the wound, sent a photo of the wound to the DON, and provided wound treatment per DON instructions. The STNA informed the surveyor that she wrote a statement on 04/17/24 and one other date, which she could not recall, and placed it in the DON's mailbox. Interview on 05/01/24 at 8:15 A.M. with STNA #644 revealed she reported a concern with a foul odor coming from Resident #60's covered pressure ulcer/wounds within a few days before she was sent to the hospital on 04/19/24, but she was unable to confirm to whom she reported or on what date. Interview on 05/01/24 at 9:00 A.M. with the Director of Nursing (DON) revealed wounds had been challenging since she took the job two months ago. She reported the previous wound care nurse was no longer in the facility and the facility had a new one that started two weeks ago. The DON also reported the previous wound care physician who came to the facility weekly was let go due to documenting wounds were improving when they were not and not changing wound care orders when something did not work. She revealed a new physician was starting in the facility on Friday, 05/03/24, and a whole skin assessment of every resident was going to be completed. During an interview on 05/01/24 at 11:00 A.M, the surveyor informed the DON interviews with STNAs revealed concerns with wound care and the worsening of Resident #60's pressure ulcer/wound prior to her hospitalization on [DATE], and a note with those concerns was placed in her mailbox by an STNA on 04/17/24. In addition, the DON was informed there were no updated sacral wound care orders in Resident #60's physician orders from her re-admission to the facility on [DATE] until 04/29/24 and no documented evidence wound care was completed as ordered. The DON nodded her head with an up and down motion (reflecting agreement with the information shared). During this interview, the DON denied ever receiving written statements from any STNA regarding concerns related to worsening of the resident's wound, wound care not being performed, or nurses not reapplying dressings to Resident #60's sacral pressure ulcer when informed by the STNAs the dressing was missing. Review of the undated policy titled Pressure Ulcer Prevention Intervention revealed treatments should be administered as ordered and evaluated for effectiveness. 44810 2. Review of the medical record for Resident #79 revealed an admitted [DATE]. Diagnoses included myelodysplastic syndrome, type two diabetes mellitus, and hypertension. Review of the admission MDS assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment. Resident #79 required partial/moderate assistance for eating; substantial maximal assistance for oral hygiene and personal hygiene; and dependent for toileting, shower/bathing, upper body dressing, lower body dressing, and putting on and taking off footwear. Resident #79 had two unstageable pressure ulcers in the wound bed present on admission and was at risk for developing pressure ulcers. Review of the care plan dated 02/15/24 revealed Resident #79 had a pressure ulcer. Interventions included to change the dressing per physician's order and to follow the facility policies/protocols for the prevention/treatment of skin breakdown. Review of the physician's order for Resident #79 dated 04/04/24 revealed an order to clean open area on sacrum with normal saline, apply black foam to wound bed and apply collagen sheet to cover skin on right buttocks and cover with wound vac film and apply wound vac to 125mmhg continuous. Change every Tuesday, Thursday, and Saturday. Review of the TAR for Resident #79 revealed his wound vac was not changed on 04/17/24 because no wound vac supplies were available. Review of the nursing progress note dated 04/17/24 at 6:05 A.M. revealed Resident #79's wound vac dressing was not changed because the wound vac supplies were not available. Review of the nursing progress note dated 04/18/24 revealed a note that Resident #79's wound vac was not changed because the wound vac supplies were not available. Telephone interview on 04/29/24 at 2:47 P.M. with Wound Vac Representative #669 confirmed she was the representative for the facility. She reported the facility keeps an extra stock of wound vac supplies and an extra wound vac on reserve for when one breaks or malfunctions. She also confirmed that the only supplies that were delivered to the facility were on 03/22/24 with five foam dressing kits and five canisters and 04/18/24 with nine foam dressing kits and eight cannisters. Wound Vac Representative #669 reported when wound vacs were delivered, they just contain the vac and not the dressing kits and the canisters because the facility stocks them. She also reported that the wound vac foam dressing kits are only a one-time use. Wound Vac Representative #669 also reported that the facility had never called to state they had run out of supplies, and she was their only representative and they are very good at keeping those items stocked. She reported she has never received a phone call that they ran out. Interview on 04/30/24 at 10:39 A.M. with Wound Care Nurse LPN #553 revealed that she has been the wound care nurse for two weeks. She reported that wound vac supplies were ordered from the supplier. She confirmed that wound vac supplies were in the building when she started on 04/15/24, and they did get another shipment. She reported staff let her know when they run out of supplies and there are extra in the medication rooms. She reported that were also extra supplies in the clinical manager's office. She stated not a single nurse had talked to her about wound vac supplies since she started. She reported that if the nurse was unable to change a wound vac dressing due to being out of supplies and there was not an as needed order in place the physician should be notified. Interview on 04/30/24 at 2:30 P.M. with the DON reported she did not have documentation that the wound vac dressing was changed and verified that the nurses documented wound care supplies were not available for Resident #79 on 04/17/24, and 04/18/24. The DON reported that the facility does not have a policy on wound vacs or the supplies. Interview on 05/01/24 at 9:00 A.M. with the DON revealed wounds have been challenging since she took the job two months ago. She reported the previous wound care nurse was no longer in the facility, and the facility had a new one start two weeks ago. The DON also reported the previous wound care physician who came to the facility weekly was let go due to documenting wounds were improving when they were not and not changing wound care orders when something did not work. She revealed a new physician was starting in the facility on Friday, 05/03/24, and a whole skin assessment of every resident was going to be completed. Review of the undated facility policy pressure ulcer prevention intervention revealed the resident's skin will be assessed and monitored on a routine basis as is outlined skin assessment protocols. 3. Review of the medical record for Resident #7 revealed an admitted [DATE]. Resident #7 was in the hospital from 04/20/24 to 04/26/24. Diagnoses included human immunodeficiency virus, sepsis, tracheostomy status, stage four pressure ulcer of the sacral region, and psychoactive substance abuse uncomplicated. Review of the admission assessment dated [DATE] revealed Resident #7 had a 10.0 cm length by 10.0 cm width by 6.0 cm depth Stage IV pressure ulcer to his coccyx. Review of the admission MDS assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. Resident #7 was dependent for oral hygiene, toileting, showering, dressing upper body, dressing lower body, and putting on and taking off footwear. Resident #7 had one unhealed Stage IV pressure ulcer. Review of the care plan dated 04/16/24 revealed Resident #7 had a potential for impaired skin integrity. Interventions included to keep skin clean and dry and changing the dressings as ordered by the physician. Review of the nursing progress note dated 04/20/24 revealed at 6:22 A.M. Resident #7 was found with his tracheostomy tube pulled out. The DON, the physician, and Resident #7's mother were notified, and he was sent to the hospital for further treatment. Review of nursing progress note dated 04/26/24 revealed Resident #7 returned from the hospital at 2:45 P.M. He was assessed and the wounds to his right hip and coccyx had clean and dry dressings. Resident #7 was situated in bed and made comfortable. Review of the hospital discharge paperwork for Resident #7 dated 04/26/24 revealed no documentation regarding his right hip wound. Review of the nursing reassessment dated [DATE] revealed that Resident #7 had a pressure injury to his coccyx and right hip. No other documentation was available. Review of the physician's order dated 04/28/24 revealed an order to not apply a brief to Resident #7 until groin and bilateral inner thighs heal. Review of physician's order dated 04/30/24 revealed an order to clean Resident #7's coccyx wound with [NAME] (cleansing agent) and apply wet to dry dressing daily and as needed. The facility may use normal saline until the [NAME] was available. On 04/29/24 at 9:01 A.M. Resident #7 was observed lying in bed. Observation on 05/01/24 at 7:45 A.M. of wound care for Resident #7 with Wound Care Nurse LPN #553 and STNA #636 revealed Resident #7's inner thighs and scrotal were macerated and red. Trace marks of barrier cream were observed on the areas. The resident's coccyx dressing was saturated and beginning to peel off. An old dressing was dated 04/30/24. The dressing was saturated with serous drainage with no odor. The coccyx wound base and small areas of bowel movement in the wound bed. The edges were dry, and no areas of necrosis were observed. Wound Care Nurse LPN #553 cleansed the wound with normal saline and the wound bed appeared to have a small amount of slough, and the rest of the wound bed was beefy red. Wound Care Nurse LPN #553 then applied a wet to dry dressing. After the wound care was completed a foam boarder dressing was discovered on Resident #7's right hip. Wound Care Nurse LPN #553 reported she did not know why that dressing was there. STNA #636 confirmed Resident #7 returned from the hospital with it. STNA #636 exited the room and Wound Care Nurse #553 then removed the dressing to the right hip. The dressing had no date and time marked on it. An area of pressure was observed to his right hip. There was moderate serous drainage to the dressing and the base was beefy red. No odors were observed. Wound Care Nurse #553 reported she was not made aware of this area and confirmed there were no treatments in place for it (from readmission from the hospital on 04/26/24). Review of the undated facility policy pressure ulcer prevention intervention revealed the resident's skin will be assessed and monitored on a routine basis as is outlined skin assessment protocols. This deficiency represents non-compliance investigated under Master Complaint Number OH00153218 and Complaint Number OH00153238 and is an example of continued non-compliance from the survey completed on 04/11/24.

Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, ensure timely and accurate assessments were completed, ensure treatments were completed as ordered and/or to ensure staff were knowledgeable of care planned interventions for Resident #76 and Resident #82. Actual Harm occurred on 02/22/24 when Resident #82 who required substantial to maximum staff assistance with bed mobility and was totally dependent on staff with transfers and toileting was found per Wound Physician #703 progress note to have an unstageable (full-thickness pressure ulcer in which the base was obscured by slough and/ or eschar (dead skin) pressure ulcer to his right buttock and an unstageable deep tissue pressure ulcer to his left heel (this was the first time these two areas were documented per the medical record) eight days after admission. The facility failed to provide evidence of effective interventions being in place prior to the development or evidence the pressure ulcers were identified before being found as unstageable pressure ulcers. This affected two residents (#76 and #82) of four residents reviewed for pressure ulcers. The facility identified 13 residents (#8, #19, #44, #46, #70, #76, #82, #83, #70, #187, #192, #287, #288) with pressure ulcers. Findings include: 1.Review of the medical record for Resident #82 revealed an admitted [DATE] with diagnoses including myelodysplastic syndrome (disorder of the blood cell formation in the bone marrow), diabetes, hypertension, and osteoarthritis. Review of the Admission/ Readmission Packet- V2 dated 02/14/24 and completed by Licensed Practical Nurse (LPN) #838 revealed Resident #82 was alert and oriented times three, communicated verbally with clear speech. The skin assessment was completed on admission that noted he had a left elbow abrasion, scabbed over area to left outer forearm, left great toe joint under nail was red and swollen, and bilateral upper extremities were edematous. The assessment revealed an intact clear blister to the sacrum area that measured 2.0 centimeters (cm) in length, 2.0 cm in width, and 0.5 cm in depth, open area 2.0 cm in length by 2.0 cm in width and a blister 4.5 cm in length and 1.5 cm in width. There were no pressure areas noted to the right buttock and/ or left heel noted on admission. Review of the Kardex for Resident #82 revealed he did not have one in place from date of admission, 02/14/24, to the date it was brought to the attention of the Director of Nursing (DON), 04/03/24, including no documented evidence of interventions in place to prevent pressure ulcers/ skin impairment. Review of the baseline care plan dated 02/14/24 for Resident #82 revealed Resident #82 had an activities of self-care performance deficit. Interventions included the resident was totally dependent on staff for repositioning and transfers. He utilized a mechanical lift for transfers. (However, this baseline care plan was not provided until 04/03/24 as the DON did not know where to locate it when first requested on 04/02/24). Review of the baseline care plan (dated 02/14/24) for Resident #82 revealed Resident #82 had a potential for pressure ulcer development. Interventions included turning and repositioning every two hours or more often as needed, bed flat as possible to reduce shear, assess, record, and monitor wound healing, and moisturizer to his skin. (However, this baseline care plan was not provided until 04/03/24 as the DON did not know where to locate it when first requested on 04/02/24). The Braden Scale for Predicting Pressure Ulcer Risk was completed and noted Resident #82 to be at risk (for pressure ulcer development) as his sensory perception was limited, he was very moist, he was bedfast, he had limited mobility, and he had a problem with friction and shear. Review of the physician's orders for February 2024 through April 2024 revealed on 02/15/24 there was an order to cleanse the open area to resident's sacrum with normal saline, apply collagen sheet (encourages cell proliferation, angiogenesis, and collagen deposition to the wound bed) and dressing every night shift Monday, Wednesday, and Friday. Review of an Initial Wound Evaluation and Management Summary dated 02/22/24 and completed by Wound Physician #703 revealed Resident #82 had an unstageable pressure ulcer to his sacrum that measured 6.0 cm in length, 4.0 cm in width and 0.2 cm in depth and contained 40 percent thick adherent necrotic tissue. He had an unstageable pressure ulcer to his right buttock that measured 12.0 cm in length, 13.0 cm in width, and 0.2 cm in depth and contained 50 percent thick adherent necrotic tissue. He ordered leptospermum honey (MediHoney) applied three times per week and cover with composite dressing (provides bacterial barrier, absorption, and adhesion) to his right buttock. The note also revealed Resident 382 had an unstageable deep tissue injury to his left heel that measured 2.4 cm in length, 2.0 cm in width and depth unable to be determined. The heel was purple/ maroon in color. On 02/23/24 Resident #82 was ordered a treatment to his left heel to cleanse with normal saline, apply betadine (topical antiseptic), pad, and protect with abdominal pad and wrap with Kerlix gauze. On 02/23/24 he was also ordered a pressure relieving boot to his left heel (after the deep tissue pressure injury was identified). On 02/27/24 there was an order to cleanse the open area on the resident's sacrum and right buttock with normal saline, apply Medihoney (supports the removal of necrotic tissue and aides in wound healing) and dressing every night shift (this was the first date referenced for a treatment to his right buttock). Review of the comprehensive care plan dated 03/07/24 revealed Resident #82 had impaired skin impairment related to bowel and bladder incontinence, diabetes, impaired mobility, and pressure injury present. Interventions included assisting with hygiene and general skin care, consulting with the wound physician, pressure reducing mattress to bed, and educating the resident on need to reposition to side. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition. The assessment revealed the resident was dependent on staff assist for toileting, sitting to lying, lying to sitting, and transfers. He required substantial to maximum assistance of staff to roll to the left and right. On 03/21/24 the treatment order to the resident's sacrum and right buttock changed to cleanse open area on sacrum and right buttock with normal saline, apply black foam to wound bed and cover with wound vac at 125 millimeters of mercury (mmHg) to continuous suction and change every Tuesday, Thursday, and Saturday. Review of the Wound Evaluation and Management Summary dated 03/21/24 and completed by Wound Physician #703 revealed Resident #82's pressure wound to his sacrum was now a Stage IV (full thickness skin loss) that measured 7.2 cm in length, 5.0 cm in width, and 3.3 cm in depth. The wound bed contained 60 percent granulating tissue, 30 percent necrotic tissue, and 10 percent slough. His right buttock pressure ulcer was now classified as a Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) pressure ulcer that measured 8.8 cm in length, 7.4 cm in width, and 0.2 cm in depth with 40 percent necrotic tissue. His left heel continued to be an unstageable deep tissue injury that measured 2.0 cm in length, 1.5cm in width, and depth was unable to be measured. The area continued to remain intact with purple/ maroon discoloration. Interview on 04/01/24 at 1:44 P.M. with LPN/ Infection Control Preventionist #970 revealed she also followed all the wounds at the facility. She revealed the first date she saw Resident #82's wounds were on 02/22/24 on Wound Physician #703's initial wound evaluation as she completed rounds with him. She verified on the resident's admission assessment dated [DATE], LPN #838 had documented Resident #82 had an intact clear blister to his sacrum area that measured 2.0 cm in length, 2.0 cm in width, and a depth of 0.5 cm, an open area measuring 2.0 cm in length by 2.0 cm in width and another blister 4.5 cm in length and 1.5 cm in width. She revealed how the areas were documented and it appeared all three were on his sacrum. There were no pressure areas noted to the right buttock and/or left heel noted on admission. She verified the first documentation that Resident #82 had a pressure area to his right buttock was when Wound Physician #703 had consulted on 02/22/24 and the area was documented as unstageable. She also verified the first time Resident #82 had any documentation regarding his deep tissue pressure injury to his left heel was also on 02/22/24, and it was also found unstageable. Interview on 04/02/24 at 9:05 A.M. with the DON revealed she was unable to locate a baseline care plan for Resident #82 regarding prevention of pressure ulcers and interventions. She verified the first care plan regarding interventions was on his comprehensive care plan on 03/07/24. Observation on 04/02/24 at 10:45 A.M. of wound care completed by LPN/ Infection Control Preventionist #970, LPN #845 and State tested Nursing Assistant (STNA) #927 revealed Resident #82 continued to have the pressure ulcer to his sacrum that contained approximately 80 percent yellow slough and 10 percent eschar, pressure wound to his right buttock that was described as beefy red containing yellow slough, and a deep tissue pressure injury to his left heel that was approximately a quarter in size and covered in hard eschar. The treatments were completed as ordered. Interview on 04/03/24 at 11:25 A.M. with the DON revealed she did not realize that when asked previously where Resident #82's baseline care plan was as she stated there was an area in the electronic medical record that a person reviewing had to go under the trigger button to view. She verified she was not familiar with this since she was hired as she had not been shown that on orientation; therefore, had not been educating the nurses on the location of where to find the baseline care plan. Interview on 04/03/24 at 12:00 P.M. with LPN #854 (currently assigned to Resident #82) revealed she had worked at the facility since November 2023 and was not familiar with how to locate a baseline care plan in the electronic record. She was unable to show this surveyor where Resident #82's baseline care plan including his interventions to prevent pressure ulcers, except in the comprehensive care plan dated 03/07/24. Interview on 04/03/24 at 12:08 P.M. with STNA #940 (currently assigned to Resident #82) revealed she had worked for approximately four years at the facility. She revealed she was not aware how to access any care plans but revealed she utilized the Kardex for each resident regarding interventions related to their care. STNA #940 showed this surveyor how she looked up each resident's Kardex in the electronic record and verified Resident #82 did not have a Kardex in place; so therefore, was not aware what interventions he had in place regarding prevention of pressure ulcers. Interview on 04/03/24 at 1:40 P.M. with the DON verified the STNA's utilized the Kardex to know what interventions to follow especially in relation to the prevention of pressure ulcers. She verified Resident #82 did not have a Kardex in place. Interview on 04/03/24 at 12:13 P.M. with Registered Nurse (RN) #902 revealed she did not know where to locate the baseline care plans and/ or interventions for a resident newly admitted . Review of the undated facility policy labeled, Pressure Ulcer Prevention and Risk Identification revealed the facility would assess each resident for risk of pressure ulcer development in an effort to establish measures to prevent the development of pressure ulcers within the facility or to prevent further decline of already existing pressure ulcer. The policy revealed preventative measures would be implemented based upon the residents assessed need and risk score. The nurse would perform a head-to-toe assessment on admission and every seven days thereafter to identify any new skin areas and document in the medical record. 2. Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including cerebral infarction, acute kidney failure, pressure ulcer of his sacral region, and tracheostomy. Review of the Admission/ Readmission Packet-V2 dated 02/06/24 completed by LPN #704 revealed a skin assessment was completed on admission, and Resident #76 had a stage four pressure ulcer to his coccyx that measured 10.0 cm in length, 6.0 cm in width and 6.0 cm in depth. There were no other skin impairment issues noted including on his right ear. On admission, a Braden Scale for Predicting Pressure Sore Risk was also completed, and he was at risk due to limited sensory perceptions, he was occasionally moist, he was chairfast, he was completely immobile, and he had a problem with friction and shear. Review of baseline care plan dated 02/06/24 revealed Resident #76 had potential for impairment of skin integrity. Interventions included moisture barrier after each incontinent episode, floating heels while in bed, encouraging turning and repositioning in bed every two hours, and checking and changing every two to three hours. Review of the Kardex dated 02/06/24 to 04/03/24 revealed Resident #76 only had interventions related to safety regarding seizure precautions. He did not have any interventions on his Kardex regarding the prevention of pressure ulcers for the STNAs to follow. Review of Wound Physician #703's progress note dated 02/08/24 revealed Resident #76 had a Stage II (partial thickness loss of dermis) pressure ulcer to the right ear that measured 3.3 cm in length, 0.5 cm in width and 0.1 cm in depth. He also had a Stage IV pressure ulcer to his sacrum that measured 9.0 cm in length, 6.5 cm in width and 2.9 cm in depth with 10 percent necrotic tissue and 10 percent slough. Review of Medicare five-day Minimum Data Set, dated dated dated [DATE] revealed Resident #76 was rarely and/ or never understood. He was dependent on staff for activities of daily living including bed mobility, toileting, and transfers. Review of March 2024 Treatment Administration Record (TAR) revealed Resident #76 had an order to cleanse the right ear with normal saline and apply collagen paste and band-aid every night shift on Tuesday, Thursday, and Saturday. The TAR had blanks on 03/09/24 and 03/12/24 indicating the treatment was not completed as ordered. He also had an order to cleanse his sacrum wound with normal saline, apply oil emulsion into wound bed over bone, apply black foam, and wound vac as 125 mmHg continuously every Tuesday, Thursday, and Saturday. The TAR was blank on 03/09/24, 03/12/24, and 03/26/24 indicating the treatments were not completed as ordered on these dates. Review of the comprehensive care plan dated 03/03/24 revealed Resident #76 had the potential for impairment of skin integrity related to incontinence, impaired mobility, and pressure injury that was present. Interventions included assisting with hygiene and general care, keeping skin clean and dry, consulting wound physician, pressure reducing mattress, and treatment as ordered. Review of Wound Physician #703 progress note dated 03/28/24 revealed Resident #76 continued to have a Stage II pressure ulcer to his right ear that measured 1.0 cm in length, 0.4 cm in width and the depth was not measurable as it had dried exudate (scab). He also continued to have a Stage IV pressure ulcer to his sacrum that measured 7.8 cm in length, 9.0 cm in width and 3.3 cm in depth as the wound bed contained 20 percent necrotic tissue and 10 percent slough. Interview on 04/03/24 at 10:33 A.M. with the DON verified there were blanks on the March 2024 TAR indicating the treatment was not completed as ordered. She revealed she was unable to locate a baseline care plan for Resident #76 regarding prevention of pressure ulcers and interventions until his comprehensive care plan on 03/03/24. Interview on 04/03/24 at 11:25 A.M. with the DON revealed she did not realize that when asked previously where Resident #76's baseline care plan was as she stated there was an area in the electronic medical record that a person reviewing had to go under the trigger button to view. She verified she was not familiar with this since she was hired as she had not been shown that on orientation; therefore, had not been educating the nurses on the location of where to find the baseline care plan. Observation of the wound to Resident #76's right ear on 04/03/24 at 11:22 A.M. with RN #902 revealed Resident #76's ear lobe was described as a scabbed area to the center of the wound with brownish/ white tissue surrounding the scabbed area with drainage. Upon observation, the resident was completely dependent on staff to reposition his head to the side to observe the wound. Interview on 04/03/24 at 12:13 P.M. with RN #902 (assigned to Resident #76) revealed she did not know where to locate the baseline care plans and/ or interventions for a resident newly admitted , only the comprehensive care plan. Interview on 04/03/24 at 12:15 P.M. with STNA #939 and #963 (assigned to Resident #76) revealed they did not know where to locate the baseline care plans. They utilized the Kardex to know how to care for a resident and what interventions they had. They showed this surveyor Resident #76's Kardex which only had interventions regarding seizure precautions. There were no interventions regarding prevention of pressure ulcers. Interview on 04/03/24 at 1:41 P.M. with the DON verified the Kardex for Resident #76 that the STNA's utilize for care/ interventions only had interventions for seizures and nothing regarding pressure ulcer prevention and/ or management. Review of the undated facility policy labeled, Pressure Ulcer Prevention and Risk Identification revealed the facility would assess each resident for risk of pressure ulcer development in an effort to establish measures to prevent the development of pressure ulcers within the facility or to prevent further decline of already existing pressure ulcer. The policy revealed preventative measures would be implemented based upon the residents assessed need and risk score. The nurse would perform a head-to-toe assessment on admission and every seven days thereafter to identify any new skin areas and document in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00151709.

Based on observation, record review, staff interview, review of the facility incident reports, review of witness statements, review of archived weather reports, review of the Procedure Guidelines Missing Resident policy and procedure and review of staff in-services for elopement, the facility failed to provide adequate supervision for a resident residing on the secured dementia unit. This resulted in Immediate Jeopardy for one resident (Resident #9) who exited from the facility unsupervised and was found walking outside in a back parking lot in the snow dressed in street clothes without a jacket or shoes. This affected one of seven residents reviewed identified at risk for elopement. The facility identified 48 residents residing on the secured units. The facility census was 126. On 02/24/16 at 10:19 A.M. the Executive Director (ED) and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/16/16 at approximately 8:30 A.M. when Resident #9, who was assessed to exhibit wandering behavior and confusion, exited from the facility on a cold snowy day without staff knowledge. Resident #9 was observed in the dining room eating his breakfast between 8:00 A.M. and 8:30 A.M., and then ambulated back to the Willows unit of the facility unsupervised. Resident #9 exited the building through an alarmed exit door on the secured unit. The alarm sounded, but was not heard by staff. Resident #9 was found by Physical Therapy Assistant (PTA) #15 at approximately 8:45 A.M. in the back parking lot of the facility. PTA #15 found Resident #9 in the snow without a jacket and wearing socks without shoes. The Immediate Jeopardy was removed on 02/24/16 at 10:30 P.M. when the facility implemented the following corrective actions: · On 02/16/16 at 8:45 A.M. PTA #15 brought Resident #9 into the facility at which time Resident #9 was assessed and fifteen minute checks were put into place. · On 02/16/16 at 9:15 A.M. the DON reviewed current nursing assignments on the unit and modifications were implemented to ensure a staff member remained on the unit to observe resident activities. · On 02/17/16 at 7:00 A.M. the maintenance department staff assessed all door alarms to ensure they were working appropriately. · On 02/17/16 at 12:00 P.M. all resident care plans and care cards (cards used by the state tested nurse aides (STNAs) to direct care) were reviewed by the DON. The elopement notebook was reviewed and updated by the DON to ensure accuracy. · Between 02/16/16 and 02/24/16 there was no evidence any resident had successfully eloped from the facility. · Random observations on 02/23/16, 02/24/16 and 02/25/16 revealed at least one nursing staff member on the secured units. No residents were observed attempting to exit the building. · On 02/24/16 at 6:00 P.M. an additional alarm was added to alert staff the doors on the Willow unit had been opened. · On 02/24/16 at 7:13 P.M. Registered Nurse (RN) #29 began conducting random rounds across all shifts for four weeks to ensure staff assignment process was being followed. The staff assignment process included a staff member would be on each unit during meal times. · On 02/24/16 at 7:13 P.M. the facility began implementing missing persons and door alarm drills that were to be conducted on each shift for one week. · On 02/24/16 at 8:00 P.M. the DON and RN #29 completed a review of all current residents previously identified as being at risk of elopement and modified their plan of care and the care cards. · All current residents had elopement risk assessments completed on 02/24/16 by LPN #33 and RN #30. No new residents were identified as being at risk for elopements. · On 02/24/16 at 8:00 P.M. the Willows unit nurse was designated to be in charge of managing staff assignments when emergencies arose including inclement weather to ensure appropriate staff was available to meet the residents' needs. The nurse was to notify the CEO and/or DON of staffing needs or concerns. · On 02/24/16 at 10:30 P.M. the DON, RN #12 and RN #29 completed training of 48 STNAs, 26 Licensed Practical Nurses (LPN)s, and five RNs on the process for missing person/elopement incident, alarm response, staff assignment to unit, process for leaving unit for breaks etc., and door modification with additional alarm. Per the DON all staff not educated on 02/24/16 will be educated prior to working. As of 02/26/16 there were 22 staff members who had not received the training. · The following staff were interviewed on 02/26/16 between 9:43 A.M. and 10:22 A.M. and were aware of the process for missing person/elopement incident, alarm response, staff assignment to unit, process for leaving unit for breaks, and door modification with additional alarm: STNA #35, LPN #36, LPN #11, STNA #37, LPN #38, STNA #26, STNA #19, and STNA #25. Although the Immediate Jeopardy was removed when the facility implemented corrective actions, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as not all the staff have been educated and trained on the new procedures and there has not been adequate monitoring completed. Findings Include: Review of Resident #9 ' s closed medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9 ' s quarterly elopement risk assessment dated [DATE] revealed Resident #9 was at risk for elopement. The assessment indicated Resident #9 was cognitively impaired, independently mobile, had poor decision making skills, and wandered, oblivious to safety needs. Review of the elopement risk assessments dated 02/09/16 and 02/16/16 revealed Resident #9 was at risk for elopements. Review of Resident #9 ' s Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #9 had impaired decision making skills and required supervision. Review of the functional status revealed Resident #9 required extensive assistance of one person physical assistance for locomotion on and off the unit. Review of the plan of care revised 02/12/16 revealed Resident #9 was at risk of injury secondary to elopement and/or wandering; Resident #9 had impaired cognition and was unaware of safety needs. Resident #9 ' s goals included he would be able to wander safely within his environment per review period. Resident #9 would be maintained on the secure unit and stay in view as much as possible on the secured unit. Interventions included one to one to allow resident to vent feelings, family conferences, discuss resident attempts to leave facility and to follow facility elopement procedures if the resident wandered. The plan of care was updated twice on 02/16/16 to include every fifteen minute surveillance. Review of the current physician's order [REDACTED]. to alert staff of attempt to transfer unassisted; check placement and function every shift. Review of Resident #9 ' s nurse ' s notes revealed on 02/16/16 at 3:50 P.M., a nurse ' s note written by LPN #17, revealed at 8:45 A.M. on 02/16/16 Resident #9 was observed exit seeking. The note indicated the resident exited to the parking lot with a walker and was redirected by staff without incident. Resident #9 stated he was looking for his car. Fifteen minute checks and surveillance was implemented to monitor Resident #9. On 02/16/16 at 3:52 P.M., a nurse ' s note written by LPN #17 revealed at 9:15 A.M. on 02/16/16 Resident #9 exited out the door to the parking lot while staff was feeding another resident. The resident stated he was looking for his car. Resident #9 was redirected without incident and restorative staff took the resident to an activity upstairs in the facility. Review of the facility nursing assessment dated [DATE] at 8:45 A.M. and written by LPN #17 revealed Resident #9 was exit seeking. Resident #9 believed his car was in the parking lot. The assessment revealed Resident #9 exited out the door to the parking lot. The resident complained of needing to find his car. No injury was noted; the resident was returned to the unit. Resident #9 ' s temperature was 96.9 degrees, respirations were 18, pulse was 76 and blood pressure was 132/76. The physician and family were notified between 8:45 A.M. and 9:00 A.M. Fifteen minute surveillance was implemented and the plan of care was initiated. Review of the investigation dated 02/16/16 at 9:15 A.M. and written by LPN #17 revealed Resident #9 exited out the door while staff on the wing was feeding another resident. A therapist (PTA #15) witnessed Resident #9 in the parking lot and redirected him back into the facility without incident. Resident #9 again stated he was looking for his car. The restorative staff took him upstairs for an activity event with effect. There was no injury. The vital signs were noted as blood pressure 134/76, respiratory rate 18, pulse 76, and temperature was 97 degrees. The physician was notified at 9:30 A.M. and the family was notified at 4:00 P.M. The resident continued on every 15 minute surveillance. Review of STNA #19 ' s written statement dated 02/16/16 revealed on 02/16/16 all residents were taken into the dining room including Resident #9. Resident #9 was sitting at the table waiting to get his breakfast. STNA #19 was serving trays and next thing I knew therapy had him saying that he was outside. STNA #19 stated Resident #9 was taken back to the unit, his socks were changed and a nurse (not identified) assessed Resident #9. The statement revealed Resident #9 had gone out the exit to the parking lot. The statement did not indicate the time the resident was seen last or the time the resident was brought in by therapy. The statement did not indicate if any alarms were heard going off or if the door alarm was sounding. Review of the archived weather conditions report revealed for 02/16/16 at 8:45 A.M. indicated there was light snow noted, the temperature was 32 degrees Fahrenheit and winds were 16 miles per hour. Review of the report indicated on 02/16/16 the average accumulation of snow was 6.6 inches for the town the facility was located within. Review of the witness statement dated 02/16/16 and written by LPN #17 revealed she was passing medications in the dining room at the time of the elopement. The statement did not indicate if any alarms were heard going off or if the door alarm was sounding. Review of the witness statement dated 02/16/16 by PTA #15 revealed PTA #15 was ambulating a different resident down the hallway when he and Certified Occupational Therapy Assistant (COTA) #16 saw Resident #9 outside. Resident #9 was walking toward the door from the rear parking lot. PTA #15 and COTA #16 assisted Resident #9 inside and an unidentified nurse was notified. Resident #9 was found outside without shoes. The statement indicated fifteen minutes later PTA #15 was ambulating another resident down the hallway and heard COTA #20 say Resident #9 ' s outside again. PTA #15 ran outside to get Resident #9. Resident #9 was ambulating with two forward walkers stacked together and was wearing slippers. RN #21 saw PTA #15 assisting Resident #9 and opened the door to let the resident in. Review of the witness statement by COTA #20 dated 02/16/16 revealed COTA #20 was walking another (unidentified) resident back to his room when COTA #20 saw Resident #9 walking with his forward walker through the snow in the back parking lot. PTA #15 was nearby and assisted Resident #9 inside the building. The statement indicated nursing (unidentified) was notified. The statement indicated fifteen minutes after the first incident; COTA #20 saw Resident #9 again walking outside on the back side walk. PTA #15 ran to get Resident #9 back inside. Nursing (unidentified) was notified. Review of the witness statement dated 02/24/16 at 3:45 P.M. and written by STNA #23 revealed STNA #23 arrived at work at 8:06 A.M. on 02/16/16. The statement revealed when she arrived at work, she was sent to work the Willows unit. Resident #9 was in bed fully dressed at approximately 8:15 A.M. STNA #19 asked STNA #23 to go to the dining room and STNA #19 would stay on the unit. STNA #23 went to the dining room and Resident #9 was brought to the dining room at 8:30 A.M. STNA #23 stated Resident #9 ate breakfast and then left around 8:45 A.M. Interview on 02/23/16 at 9:11 A.M. with STNA #19 revealed on 02/16/16 Resident #9 got out in the snow. STNA #19 stated she was the only one on the Willows unit at the time, and was in the dining room. STNA #19 indicated she did not know Resident #9 left the dining area and could not hear the alarm sounding. STNA #19 indicated Resident #9 exited out the door on the left side of the unit. STNA #19 stated PTA #15 saw him outside and brought him in. STNA #19 was unable to give time frames for when Resident #9 was last observed in the dining area. STNA #19 stated Resident #9 was fully dressed but had no shoes on and only socks. Interview on 02/23/16 at 9:27 A.M. with PTA #15 revealed she was ambulating another resident and she and COTA #20 happened to look out the window and saw Resident #9 outside by the door. PTA #15 indicated Resident #9 left out a door on the Willows unit. PTA #15 revealed the incident happened around breakfast time but she was unable to tell what time it was. PTA #15 stated Resident #9 ' s socks were absolutely soaking wet. PTA #15 stated Resident #9 did not have a jacket or shoes on. PTA #15 revealed the resident was not cold to the touch and she did not know how long he was outside. PTA #15 verified 02/16/16 was the day they got 10 inches of snow. Interview on 02/23/16 at 10:33 A.M. with RN #21 revealed Resident #9 exited the building from the exit door closest to the Somerset unit on 02/16/16. RN #21 stated she thought a staff member (unidentified) visualized Resident #9 walking and someone (unidentified) went out and got Resident #9. RN #21 stated she was not there when Resident #9 first eloped from the facility. RN #21 verified it was cold and snowy out on 02/16/16. Interview and observation on 02/24/16 at 11:00 A.M. with the DON and RN #29 revealed the alarm for the Willows exterior doors was heard faintly in the dining area. The double door located in the hallway from the secured units dining area to the Willows unit was open during the observation. The DON and RN #29 confirmed this observation. RN #29 indicated there should have been a staff member on the unit the day Resident #9 exited the building. Interview on 02/24/16 at 12:05 P.M. with the DON verified the ability to hear the alarm was not investigated prior to this date. Re-interview on 02/24/16 at 12:38 P.M. with RN #21 revealed she was not there for the first elopement. RN #21 stated she was there the second time Resident #9 exited the building and she noticed Resident #9 had on a long sleeve shirt, long pants, slippers and no jacket. RN #21 verified she did not document this information. RN #21 stated the alarm sounded and verified that information was also not documented. RN #21 stated the alarm had to be shut off by a key and the nurses had the keys to shut the alarm off. RN #21 stated she did not know if the staff was able to hear the alarm when Resident #9 exited the building. RN #21 stated Resident #9 was able to walk through the secured unit independently but needed supervision off the unit. Interview on 02/24/16 at 1:12 P.M. with COTA #20 revealed she was providing assistance to another resident on the day Resident #9 eloped from the facility. COTA #20 stated it was between 8:00 A.M. and 9:00 A.M. and she looked out the right side windows in the walkway and observed Resident #9 outside. COTA #20 stated PTA #15 was in the hallway also. COTA #20 went to the door to get Resident #9. COTA #20 stated Resident #9 was pushing his walker in the snow on the path that had been plowed. Resident #9 was half way from the first exit door on the Willows unit and the door into the Somerset unit when first observed. COTA #20 stated Resident#9 was almost to the Somerset walkway unit doors by the time they were able to get the door open to get outside and get the resident. COTA #20 stated she did not see him exit the building nor did she know how long he was outside. COTA #20 stated he was wearing blue jeans a denim long sleeve shirt and tube socks. Resident #9 did not have a coat or shoes on. COTA #20 stated she did not hear the door alarming when Resident #9 was observed outside the building. Re-interview on 02/24/16 at 1:36 P.M. with STNA #19 revealed she could not exactly tell the surveyor the time frame of last seeing Resident #9 in the secured dining room but it would have been between 8:00 A.M. and 8:30 A.M. when she was still passing breakfast trays. STNA #19 stated PTA #15 came in and asked her if she knew Resident #9 was outside. STNA #19 stated the documented 8:45 A.M. time frame would probably be about right for when Resident #9 returned to the facility. STNA #19 confirmed there was no facility staff on the Willows unit when Resident #9 exited the exterior door closest to the Somerset unit. STNA #19 indicated the alarm for the door was sounding during Resident #9 ' s first exit from the facility but was not heard at her location in the dining room because the radio was on, the television was on, and there was commotion in the dining room. STNA #19 said at the time Resident #9 exited the building she and one other aide were in the secured unit and STNA #23 was back and forth on the Birch unit getting people up and to the dining area. Re-interview on 02/24/16 at 2:45 P.M. with PTA #15 revealed one of the doors (the right side of the double doors) in between the Willows unit and the secured unit dining room was open when she brought Resident #9 back on the unit. There was no staff on the unit when PTA #15 arrived on the unit with Resident #9 after finding him outside. PTA #15 stated the alarm for the Willows unit exterior door closest to the Somerset unit was alarming. PTA #15 stated the alarm was able to be heard but was very low. PTA #15 stated LPN #17 arrived to the unit shortly after PTA #15 and began to assess the resident. Interview on 02/24/16 at 3:49 P.M. with STNA #23 revealed she came in late around 8:00 A.M. on 02/16/16. STNA #23 stated LPN #24 instructed her to report to the Willows unit because she was needed there instead of on her assigned unit (Somerset) STNA #23 stated she arrived at the Willows unit and she was with STNA #19. She stated most of the residents on that unit were up at that time. STNA #23 stated she visualized Resident #9 in bed after she arrived on the unit. STNA #23 stated she went to the dining room. STNA #23 stated she saw Resident #9 in the dining room while she was assisting a resident at his table. STNA #23 stated she saw Resident #9 at 8:30 A.M. or later in the secured dining area. STNA #23 stated she did not see the resident getting up or leaving the dining room so she did not know the exact time he left the dining area. STNA #23 stated she did not hear the alarm the first time Resident #9 exited the building. STNA #23 stated that she was assigned to the Willows unit but did float over to the Birch unit when STNA #25 needed help with residents who required two staff for assistance. Interview on 02/24/16 at 4:30 P.M. with LPN #24 revealed on 02/16/16 whatever nurse had the keys for the Willows unit communicated they needed another STNA for that unit. LPN #24 stated when STNA #23 arrived at the facility she told her to go to the Willows unit. LPN #24 revealed she did not hear the door alarm when Resident #9 exited the building. Interview on 02/25/16 at 7:16 A.M. with STNA #25 revealed she was at the facility on 02/16/16 the day Resident #9 exited the building; however, she did not know anything about it until she was informed by STNA #19. STNA #25 did not hear the alarm when Resident #9 exited the building. STNA #25 stated she was on the Birch unit that day and STNA #19 was on the Willows unit. STNA #25 indicated they were on the units alone but there may have been a STNA that floated. Interview on 02/25/16 at 7:24 A.M. with LPN #17 revealed the first time Resident #9 exited the building therapy brought the resident back in. LPN #17 denied hearing the alarm but indicated she knew Resident #9 was on the unit and thought STNA #19 was on the unit. LPN #17 stated she was in the dining room passing medications when Resident #9 exited the building. LPN #17 indicated Resident #9 ambulated independently with the walker and was quick. Interview on 02/25/16 at 9:55 A.M. with the DON revealed prior to Resident #9 ' s exit seeking behavior on 02/16/16 they did not require a nursing staff member to be on the unit during dining. The DON stated that they did implement this after Resident #9 displayed the exit seeking behavior. Observation on 02/23/16 at 12:30 P.M. revealed Resident #9 seated in the dining area with walker in reach. Resident #9 was seated on a dining room chair and there were no signs or symptoms of any injuries. Interview on 02/25/16 at 8:55 A.M. was attempted with Resident #9 but Resident #9 was unable to give any relevant information and was noted to be confused and asking if he was home yet. Review of the facility ' s Procedure Guidelines- Missing Resident policy and procedure dated December, 2010 indicated to ensure missing residents were located quickly. The procedure revealed upon return of the resident to the facility, the charge nurse or director of nursing would complete an incident report detailing the incident in its entirety. The procedure indicated to document the incident in the resident ' s chart. Documentation should be objective, concise and reflect the actual facts as they relate to the incident including but not limited to times and details of when the resident was last seen, staff actions and status of how when and where the resident was found. The procedure indicated to review and revise/update the care plan to reflect the incident and modify approaches to prevent recurrence. This deficiency was cited as an incidental finding to Complaint Number OH 618.

Based on closed record review, observation, and interview the facility failed to ensure one resident (Resident #135) received timely care and services following two falls with injury. Actual harm occurred when Resident #135 incurred a fall on 11/30/15 at 12:50 A.M. and experienced pain to the right side and right side weakness and then was found at 10:30 A.M. on the floor in a fetal position with complaints of pain to the right hip. There was no indication of safety precautions following the first fall or of pain management following either fall. In addition the facility failed to identify a bruised area for one resident (Resident #29) who was receiving anti-coagulant therapy. This affected two of five residents reviewed. The facility census was 126. Findings include: 1. Review of Resident #135's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #135's Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #135 was severely cognitively impaired. Resident #135 required limited assistance of two staff for bed mobility and was able to walk in room and corridor with supervision of one person physical assistance. Review of Resident #135's nurse ' s notes dated 11/30/15 at 12:50 A.M. revealed the nurse was called to the unit by an unidentified state tested nurse aide (STNA) and Resident #135 was found on the floor in her room beside her bed. The note indicated Resident #135's right lower extremity was weaker than the left lower extremity and the resident had complaints of pain with pressure on the right leg. Review of the physician orders [REDACTED]. Review of the nursing assessment for Resident #135 dated 11/30/15 at 10:30 A.M. revealed an unidentified nurse was alerted by the physical therapy assistant that Resident #135 was lying on the floor in the dining room. Resident #135 was found on the right side in the fetal position. Resident #135 was not wearing shoes and stated they were uncomfortable. An assessment was completed and indicated Resident #135 complained of pain to the right hip. Review of nurse's notes and Medication Administration Record [REDACTED]. There was no further physician orders [REDACTED].#135 remaining on bed rest or new orders related to pain. Review of the Medication Administration Record [REDACTED].M. at which time she was given two tablets of 325 mg of Tylenol. Review of Resident #135's radiology report signed on 11/30/15 at 4:22 P.M. revealed a repeat x-ray was suggested to determine if fracture was present. Review of Resident #135's radiology report signed on 12/01/15 at 11:39 A.M. revealed a suspect right [MEDICAL CONDITION] and highly recommended repeating to confirm. Resident #135 was ordered to be sent to the hospital. Review of the physician orders [REDACTED].#135 to the emergency room status [REDACTED]. Review of the census form revealed Resident #135 was discharged from the facility to the hospital on [DATE] at 3:28 P.M. Interview on 02/29/16 at 11:24 A.M. with Licensed Practical Nurse (LPN) #11 revealed Resident #135 did fall and break her hip. LPN #11 stated Resident #135 was in pain but could not remember if she did anything or gave anything for pain. LPN #11 confirmed Resident #135 did have signs of a potential [MEDICAL CONDITION] following the fall on 11/30/15 at 1:00 A.M. and fell again at 10:30 A.M. with continued signs and symptoms of a [MEDICAL CONDITION]. LPN #11 stated the facility did not like sending residents to the hospital and they wanted to get the x-ray's back prior to sending Resident #135 to the hospital for treatment for [REDACTED].#11 indicated after the second fall on 11/30/15 at 10:30 A.M. Resident #135 did remain in bed because she did not feel well enough to get up. Interview on 02/29/16 at 12:24 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #12 confirmed Resident #135 was not given anything for pain until 11/30/15 at 5:50 P.M. following both falls on 11/30/15. The DON confirmed there was evidence of pain documented in the nursing notes and assessments on 11/30/15 at 12:50 A.M. and 11/30/15 at 10:30 A.M. The DON confirmed Resident #135 did not have any orders related to bed rest or new interventions for pain management. The DON confirmed Resident #135's x-ray was not read until 11/30/15 at 4:22 P.M. and the repeat x-ray was not read until 12/01/15 at 11:39 A.M. The DON confirmed Resident #135 was transferred to the hospital for treatment of [REDACTED].M. 2. Review of Resident #29's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's MDS dated [DATE] revealed Resident #29 was severely cognitively impaired. Resident #29 required supervision for bed mobility, walk in room, and walk in the corridor. Review of Resident #29's current physician orders [REDACTED].#29 received [MEDICATION NAME] five milligrams nightly. Review of Resident #29's plan of care revised on 12/07/15 revealed the resident was at risk for abnormal bleeding or hemorrhage related to use of an anticoagulant. Review of the plan of care revealed to monitor and report to the physician any signs or symptoms of abnormal bleeding. Review of Resident #29's nurse's notes from February of 2016 revealed no evidence of bruising. Review of Resident #29's weekly skin assessment dated [DATE] revealed no skin issues were present. Review of Resident #29's weekly summary dated 02/22/16 revealed no indication of any bruises. Observation on 02/22/16 at 10:16 A.M. revealed Resident #29 in the lounge area on the Birch unit. The resident rolled up his sleeve and stated look at this. A purple/green discoloration was noted to Resident #29's right elbow area including part of the upper dorsal forearm. Resident #29 was asked how the discoloration got there and he stated I don't know. Interview on 02/23/16 at 8:42 A.M. with STNA #25 revealed she was unaware Resident #29 had any bruises or skin issues. Interview on 02/23/16 at 8:45 A.M. with LPN #27 revealed she was unaware of any bruising or skin conditions for Resident #29. Observation with LPN #27 on 02/23/16 at 8:50 A.M. revealed Resident #29 had a purple and green discoloration on the outer aspect of the right elbow and upper forearm area. LPN #27 indicated the area was bruised. LPN #27 confirmed Resident #29 received [MEDICATION NAME] and indicated it may have been obtained during a blood draw. Resident #29 stated they drew blood from, and pointed to the antecubital area that was not observed to be bruise. LPN #27 confirmed the observation. Interview on 02/23/16 at 1:40 P.M. with the DON confirmed there was no documented evidence of Resident #29 ' s bruise. This deficiency substantiates Master Complaint OH 838, Complaint OH 618 and Complaint OH 742.

Based on record review, review of facility self reported incidents and interview the facility failed to maintain a safe environment evidenced by obstructing the pathway of Resident #32 with a mechanical lift resulting in a fall with a significant injury and hospitalization . This affected one of three residents reviewed for facility self reported incidents. Findings include: Resident #32 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. The care plan for Resident #32 indicated he required the sit-to-stand lift with one to two staff for transfers. The care plan dated 06/16/09 indicated Resident #32 had altered thought processes, could not make himself understood and required extensive assist to total dependence for activities of daily living. Care plans revised on 04/20/11 indicated he had a significant decline and was easily agitated, not easily redirected and he was at risk for falls due to dementia, weakness, impaired balance and a history of falls. The facility completed a Self Reported Incident, (SRI), on 06/01/11 due to a complaint from Resident #32's durable power of attorney (DPOA) regarding a fall Resident #32 sustained on 05/29/11 at 5:22 A.M. The SRI indicated State tested Nursing Assistant (STNA) #5 was in the room assisting Resident #32's roommate and using the sit-to-stand lift. STNA #5 moved the lift aside and was adjusting it when Resident #32 was attempting to get up from bed, got out of bed, attempted to walk and fell , tripping on the sit-to-stand lift. The facility investigation stated Resident #32 hit his head on the nightstand, approximately five feet away across the room, and fell face down on the floor. Resident #32 was sent to the emergency room and due to increased concerns with the Cat Scan of his head, he was life-flighted to a larger hospital for further evaluation. The hospital documentation indicated the head laceration was 2.6 centimeters (cm) by 7.6 cm long and there was a large right periorbital hematoma. There were "acute fractures of the right nasal bone" and the right posterior bone is lightly angulated. Nurse's notes revealed Resident #32 returned to the facility on [DATE] at 8:31 P.M. Resident #32 had a laceration on the top of his head running north to south and had 11 staples to close the laceration. His right eye was completely swollen shut and a 2.5 cm laceration was noted from the inner corner of his right eye onto his left cheek and a laceration about 0.5 cm under his left nostril. The investigation revealed a witness statement from STNA #3. STNA #3 questioned why the alarm had not been sounding to alert staff Resident #32 was attempting to get up unassisted. STNA #5 indicated she had turned the alarm off and told Resident #32 to sit down. STNA #3 told STNA #5 you have to stop what you are doing and go to Resident #32. The roommate was already safely sitting in his chair. Interview with the director of nursing (DON) on 08/08/11 at 9:00 A.M. confirmed that the facility substantiated this allegation and terminated STNA #5. The DON indicated STNA #5 turned off Resident #32's alarms and did not properly prevent him from getting up unassisted and per her statement, made no attempt to prevent or lessen the fall. This was an incidental finding identified during the investigation of Master Complaint Number OH 849 and Complaint Number OH 746.