Every finding on record at Wexner Heritage House

Based on medical record review, hospital document review, interview, and facility policy and procedure review, the facility failed to ensure laboratory testing and timely follow-up was completed to diagnose and treat a urinary tract infection (UTI).Actual harm occurred beginning on 12/10/25 when Resident #94 exhibited signs/symptoms of a UTI (burning) without evidence of adequate intervention. On 12/11/25 a plan for a urine culture (due to complaints of burning on urination and elevated temperature) was noted; however, the facility failed to send the urine specimen to the laboratory. On 12/16/25 (five days later) the facility recognized the urinalysis was not completed, and a urine specimen was obtained for testing. However, the results of the urinalysis were not available on 12/17/25 before Resident #94 became unresponsive, was intubated, and was transferred to the hospital where the resident was diagnosed with acute respiratory failure, septic shock likely due to bacteria in the urine, and a UTI. This affected one resident (#94) of one resident reviewed for UTIs. The census was 85. Review of the medical record for Resident #94 revealed the resident was admitted to the facility on [DATE] with diagnoses including legal blindness, traumatic subarachnoid hemorrhage, repeated falls, and muscle weakness. Review of Resident #94's physician's orders revealed an order dated 12/06/25 to record Foley (urinary catheter) output every shift. Review of a plan of care dated 12/08/25 revealed Resident #94 was prone to alterations in bladder function related to urine retention and urinary incontinence. Interventions included to monitor urine for color, clarity, foul odor, changes in level of consciousness, obtain urine specimens as ordered, and notify the physician/certified nurse practitioner (CNP) and family of significant changes in condition.Review of Resident #94's nursing progress notes revealed on 12/10/25 at 5:55 P.M., the resident complained of burning from his penis area and Foley catheter and CNP (#1001) was notified for possible urinalysis and culture and sensitivity. Further review of the progress note revealed the CNP reviewed the resident's medical record and saw the resident stated he had urinary retention with new orders to remove the Foley catheter, encourage the resident to void, perform bladder scans and if the resident had (urinary) retention more than 300 (milliliters) to perform a straight catheterization. CNP #1001 also ordered Pyridium, a medication to treat pain or burning, increased urination, and increased urge to urinate, but did not order any laboratory testing as the note revealed the resident had a current urinalysis completed in the hospital. Review of the December 2025 medication administration record (MAR) revealed Resident #94's Foley catheter was removed on 12/10/25 at 5:46 P.M. Further review of the December 2025 MAR revealed the resident's urinary voiding was monitored every four hours daily between 12/10/25 and 12/16/25 with no expended periods of no voiding documented.Review of Resident #94's nursing progress note revealed on 12/11/25, the resident was seen by the CNP for elevated temperature and burning on urination. The assessment and plan revealed to obtain a urinalysis with culture and sensitivity and encourage fluids and hygiene. It was noted the resident was in the hospital between 12/01/25 and 12/05/25, and on 12/03/25 a urine culture in the hospital was negative. A complete blood count (CBC) laboratory test dated 12/11/25 revealed the resident had an elevated white blood cell (WBC) count (indicative of possible infection). Review of a nursing progress note dated 12/11/25 at 11:26 A.M. revealed Resident #94 had a low-grade temperature and also had a low-grade temperature from the previous shift. The note revealed the resident continued to have bouts of confusion and the CNP ordered a urinalysis with culture and sensitivity.However, review of Resident #94's physician's orders revealed no actual physician order for the urinalysis or culture and sensitivity were written on this date. Review of a nursing progress note dated 12/11/25 at 5:48 P.M. revealed Resident #94's WBC laboratory value was elevated, and urine was obtained and awaiting pick up. Further review of the progress notes revealed no evidence the resident's urine sample was picked up for testing.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require self-care assistance.Review of a physician's order dated 12/16/25 at 6:15 P.M. revealed Resident #94 was ordered a urinalysis and culture and sensitivity as a one-time order.Review of Resident #94's December 2025 medication administration record (MAR) revealed the resident's urine was obtained for a urinalysis and culture and sensitivity on 12/16/25 at 10:49 P.M.Review of a laboratory values document revealed Resident #94 had a urine sample collected on 12/17/25 at 12:00 A.M., it was received on 12/17/25 at 5:54 A.M., and reported on 12/17/25 at 11:01 P.M. Resident #94's urine was noted to be extra turbid, was positive for blood, leukocytes, nitrates, WBC, mucous, WBC clumps, and had moderate bacteria present. The urine culture was pending at the time of the laboratory report. The facility received a subsequent facsimile (fax) document which indicated the resident had Escherichia coli (E. coli) in his urine. Review of a nursing progress note dated 12/17/25 at 2:52 A.M. revealed Resident #94 was walked to the bathroom with (nurse) aides, and once the resident was in the bathroom, he went unresponsive on the toilet. A sternal rub was completed by the nurse and was not successful and abnormal abdominal breathing with noted with a weak radial pulse. Emergency medical services (EMS) were contacted, and Resident #94 was transferred to the hospital.Review of a hospital document dated 12/17/25 revealed Resident #94 arrived at the hospital with unresponsiveness and was intubated by EMS staff in the field. Assessment of Resident #94 in the emergency room (ER) revealed the resident had acute respiratory failure with significant encephalopathy; however, there was question for aspiration pneumonia. The resident was noted with shock related to unclear etiology though UTI was likely and potential aspiration pneumonia. The resident had pyuria (pus in the urine) and positive leukocytes on urinalysis and symptoms of painful urination prior to hospitalization. The resident was also noted with lactic acidosis related to severe shock and elevated troponin. Review of a hospital document dated 12/21/25 revealed Resident #94 was extubated on 12/20/25. On imaging, Resident #94's acute respiratory failure was ruled out to be caused by clinically significant pulmonary embolism but may have a component of aspiration pneumonia. The resident was assessed with septic shock in nature due to E. coli bacteremia, with a likely urinary source. The resident had a UTI with E. coli bacteremia and leukocytosis was improving. The resident was also assessed with elevated troponin level, lactic acidosis, acute kidney injury, and elevated sodium levels, all which received treatment. Resident #94's acute metabolic encephalopathy was found with unclear etiology; however, there was suspicion for dementia not previously diagnosed. The resident remained hospitalized as of 12/22/25. Interview with Licensed Practical Nurse (LPN) Unit Manager (UM) #141 on 12/18/25 at 10:46 A.M. revealed Resident #94's urine specimen was obtained on 12/11/25; however, she was not able to recall which member of the nursing staff obtained the specimen. She revealed she was told by the laboratory that they never received Resident #94's urine specimen, she also indicated the specimen was also never recovered at the facility and there were no laboratory results available for the urine specimen from 12/11/25.Interview on 12/18/25 at 2:49 P.M. with CNP #1001 revealed her intention was, after assessing Resident #94 on 12/11/25, to wait and see if removing the resident's indwelling urinary catheter resolved the discomfort rather than potentially ordering an unnecessary urine specimen and laboratory testing. CNP #1001 revealed she expected laboratory specimens be obtained within 48 hours of the order. CNP #1001 stated she never got the results of Resident #94's urinalysis and on 12/15/25 she inquired with LPM UM #141 about the resident's urine sample. CNP #1001 revealed a delay in obtaining results of Resident #94's urinalysis and expressed concerns about the delay in diagnosis and treatment of Resident #94's UTI.Review of the facility's procedure titled, Laboratory Services and Reporting, dated 04/2022, revealed the facility was responsible for obtaining laboratory services when ordered by a medical practitioner. The facility was directly responsible for the timeliness of the applicable services.Review of a facility policy titled, Infection Surveillance Policy, dated 03/10/25, revealed registered nurses (RNs) and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff. Examples included a resident develops signs and symptoms of an infection or a microbiology test is ordered.

Based on observation, staff interview, and facility policy, the facility failed to ensure the dishwasher and three compartment sink was in a working order. Additionally, the facility failed to maintain the kitchen in a sanitary manner and store and prepare foods in a sanitary manner. This had the potential to affect 83 out of 85 residents residing in the facility with two residents on a nothing by mouth (NPO) diet. the facility census was 85.During observation of the kitchen area on 12/15/25 at approximately 9:40 A.M. with Regional Dietary Manager (RDM) #601, upon entering the kitchen and performing hand hygiene, the surveyor observed the paper towel dispenser at the handwashing sink was broken and nonfunctional. RDM #601 confirmed at 9:40 A.M. that the dispenser had been broken for awhile and that maintenance had not repaired it. The surveyor was required to obtain napkins from a back storage area to dry hands.During the same observation, the surveyor observed the front kitchen area near the dishwasher and noted a large strip of broken and missing floor tile, as well as a dishwasher that was leaking water onto the floor. A large puddle of standing water was present in the dishwashing area. RDM #601 confirmed at 9:44 A.M. that the dishwasher had been experiencing issues since approximately September 2025 and had not yet been replaced. Observation on 12/15/25 at 9:48 A.M., of the walk-in refrigerator revealed multiple food items that were expired, deteriorated, or improperly labeled, including cilantro past its use-by date of 12/06/25, wilted spring mix lettuce with a use-by date of 12/06/25, coleslaw dated 12/10/25, [NAME] dated 12/08/25, prepped carrots dated 12/06/25, cabbage received 10/13/25, green onions dated 12/13/25, asparagus cut and prepped dated 12/10/25 and dehydrated, two large boxes of assorted lettuce with no open or use-by dates, washed broccoli dated 12/13/25, cucumbers dated 12/09/25, celery dated 12/13/25 containing a container of dark sauce, spring mix lettuce dated 12/10/25, bell peppers dated 12/10/25, parsnips expired 11/13/25, fresh herbs dated 12/13/25, green beans dated 12/10/25, additional asparagus dated 12/13/25, carrots dated 12/10/25, and a degraded box of watermelon with yellow/brown fruit and no date. Two large containers of cornflakes and one container of Cheerios were observed stored under a prep table without any open or use-by dates. RDM #601 confirmed at the time of the observations the above items.At 10:02 A.M. on 12/15/25, observation of the freezer revealed a large amount of ice buildup on the floor, creating a slip hazard and potential for thawing of frozen food items.On 12/17/25 at 2:56 P.M., the surveyor again observed the handwashing sink and noted the paper towel dispenser remained broken and there was no trash receptacle available for disposal of paper towels. The only available trash cans required lifting lids to discard waste. This was confirmed by Assistant Dietary Manager (ADM) #550.During further observation on 12/17/25 at approximately 3:08 P.M., the surveyor observed extensive dirt and grease buildup on exhaust fans above food preparation areas, food splatter and residue on walls behind the stove, heavily soiled hood vents, and an ice machine with rust and calcified water dripping from a screw into the ice storage area, along with a black substance visible inside the ice bin. These observations were confirmed with ADM #550.On 12/17/25, the surveyor observed the dishwasher in operation and noted it only reached 170 degrees Fahrenheit, below expected sanitizing temperatures of 180. The dishwasher continued to leak water, resulting in pooled water and white calcified residue on the floor. At 4:35 P.M., pooled water remained beneath the dishwasher and had not been removed. The ADM #550 stated the water should be mopped after each meal and confirmed the dishwasher had not been used since lunch and the water had not been mopped.On 12/18/25 at 11:51 A.M., ADM #550 stated they switched to the three compartment sink to clean all dishes due to the dishwasher not working properly. Testing of the three-compartment sink sanitizing solution revealed sanitizer levels of 50 parts per million (PPM), below the required 200 PPM, per ADM #550. ADM #550 confirmed that dishes used throughout the day had been washed using this sanitizer concentration. The sink was drained and refilled; however, at 12:00 P.M., sanitizer levels remained at 100 PPM, still below required levels, and the sink was drained again.Review of sanitization logs revealed no documented sanitizer level monitoring after the morning of 12/17/25, with lunch and dinner entries missing, and no sanitizer levels documented for 12/18/25. At 12:50 P.M., ADM #550 confirmed sanitizer levels should be 200 PPM, while logs reflected readings as high as 400 PPM and 500 PPM on prior dates, indicating inconsistent and inaccurate monitoring.During observation of the service line on 12/18/25 at 12:02 P.M., the surveyor observed multiple hand hygiene and glove use failures by [NAME] #602. [NAME] #602 grabbed the glove dispenser while already wearing gloves, then handled meal tickets and tray racks without changing gloves or performing hand hygiene. The cook was observed handling multiple food items, including fish, potato chips, and vegetables, repeatedly with the same gloves after contacting non-food-contact surfaces such as tray racks and meal tickets. [NAME] #602 also grabbed a hot dog bun from an opened bag using the same gloves and then used a tong to place the bun on the tray without changing gloves. Additionally, [NAME] #602 used gloves to handle cleaning rags to wipe down surfaces immediately prior to handling the fish, then placed the fish on trays with the same gloves, and subsequently used those same gloves to move potato chips and reposition vegetables on the trays. At no point did the cook perform hand hygiene or change gloves between touching surfaces and food items. [NAME] #602 confirmed all above details at the time of the observations. Interview on 12/18/25 at 11:24 A.M., ADM #550 confirmed that a trash can was added near the handwashing sink and cleaning behind the stove was completed after surveyor identification of concerns. The dishwasher remained nonfunctional, and the facility had transitioned to handwashing dishes due to equipment failure.Interview on 12/18/25 at 11:48 A.M. with Maintenance Director (MD) #901, revealed that the freezer had icicles approximately eight inches long due to being left open over time, allowing heat from the kitchen to cause condensation and subsequent ice buildup that had not been cleaned for an extended period. MD #901 confirmed that the dishwasher was broken and leaking, and repairs had been delayed, contributing to ongoing concerns.Interview on 12/17/25 at 3:42 P.M. with Maintenance #900, revealed that freezer doors were being left open improperly, causing water accumulation that refroze into blocks and icicles, and that staff were not following proper procedures. Maintenance #900 also confirmed that the dishwasher was broken, leaking, and not consistently reaching proper sanitization temperatures, with repairs delayed and temporary measures in place.Review of the facility policy titled Food Storage, dated 06/24 storage areas are sequenced, neat, clean, organized and kept at proper temperature. All food products should be correctly labeled with the receive date for product rotation and for the freezer, specifically, all ice build up should be removed from surfaces.

Based on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure Mantoux Tuberculosis (TB) testing and annual assessments were completed in a timely manner which had the potential to affect all 85 residents residing in the facility. Additionally, the facility failed to ensure oxygen tubing was replaced after the nasal cannula fell on the ground for Resident #105, and failed to ensure Enhanced Barrier Precautions (EBP) were followed during medication administration via a gastrostomy feeding tube for Resident #44. The facility census was 85.1. Review of the personnel file for Licensed Practical Nurse (LPN) #141 revealed a hire date of 07/08/25, however, there was no documentation verifying whether the staff actually began providing resident care on or after this date. Review of the initial first step for the Mantoux Tuberculosis (TB) test was administered on 07/08/25 but was not read until 07/10/25, occurring after the staff member's date of hire Review of the personnel file for LPN #350 revealed a hire date of 05/16/25, however, there was no documentation verifying whether the staff actually began providing resident care on or after this date. Review of the initial first step for the Mantoux Tuberculosis (TB) test was administered on 05/16/25 but was not read until 05/18/25, occurring after the staff member's date of hire Interview on 12/22/25 at 9:26 A.M. with Human Resource Manager #905 confirmed that she could not verify the start of care date was prior to LPN #141 and #350's date of hire and that the first reading for the initial TB test was prior to their date of hire. Review of the personnel file for LPN #112 revealed a date of hire date of 04/09/24. Review of the personnel file for LPN #112 revealed there was no evidence that an annual TB questionnaire was completed at the time of the survey. Review of the personnel Certified Nursing Assistant (CNA) #125 revealed a date of hire date of 10/23/18. Review of the personnel file for CNA #125 revealed the most recent annual TB questionnaire was completed on 02/08/24 with no evidence a more recent questionnaire had been completed. Review of the personnel file for CNA #309 revealed a date of hire date of 08/15/17. Review of the personnel file for CNA #309 revealed the most recent annual TB questionnaire was completed on 01/31/24 with no evidence a more recent questionnaire had been completed. Review of the personnel file for CNA #315 revealed a date of hire date of 05/19/21. Review of the personnel file for CNA #315 revealed the most recent annual TB questionnaire was completed on 02/02/24 with no evidence a more recent questionnaire had been completed. Interview on 12/22/25 at 9:26 A.M. with Human Resource Manager #905 confirmed the above personnel did not have an annual TB questionnaire completed timely. Review of the TB control plan and TB risk assessment revealed the facility will test for tuberculosis infections on hire and annually. 2. Review of the medical record for Resident #105 revealed an admission date of 12/16/25 with diagnoses including acute posthemorrhagic anemia, gastrointestinal hemorrhage, acute respiratory failure with hypoxia, and acute pulmonary edema. Review of orders revealed continuous oxygen via nasal cannula at three liters per minute every shift related to chronic obstructive pulmonary disease, initiated on 12/17/25. Review of the care plan revealed no indication of oxygen use. Observation on 12/18/25 at 1:20 P.M. revealed CNA #910 passing meal trays when she accidentally kicked the resident's oxygen tubing, which became wrapped around her leg and was dragged across the floor. At the time, the nasal cannula was not on the resident. CNA #910 handed the oxygen tubing to the resident's daughter. The nasal cannula was then placed back on the resident without being cleaned or sanitized. Interview on 12/18/25 at 1:30 P.M. with CNA #910 confirmed that the nasal cannula was placed back on Resident #105 without cleaning or changing after being dragged across the floor. She acknowledged that she did not explain to the resident or daughter that the tubing should have been replaced due to contamination. She also confirmed that the tubing should have been replaced and that the resident uses continuous oxygen at this time. 3. Review of the medical record for Resident #44 revealed admission date 05/18/16 with diagnoses including but not limited to anoxic brain damage, contractures of bilateral elbows, wrists, hands, and knees, tracheostomy dependent and percutaneous endoscopic gastrostomy (PEG tube for feeding) dependent. A review of Resident #44 physician orders dated 12/01/25 to 12/31/25 revealed an order dated 04/21/25 for Baclofen tablet 20 milligrams (mg) give one tablet via PEG tube three times a day for muscle spasm and an order dated 04/22/25 Resident is on Enhanced Barrier Precautions (EBP), EBP are required with high contact resident activities. An observation on 12/17/25 at 1:19 P.M. revealed on the wall outside Resident #44's room an EBP notification sign. Further observation revealed Licensed Practical Nurse (LPN) #206 preparing the medication Baclofen for administration. LPN #206 completed the preparation, sanitized hands and entered Resident #44's room. LPN #206 washed hands and put on gloves. LPN #209 then flushed Resident #44's PEG tube and checked for placement of the PEG tube. LPN #206 continued to administrate the medication Baclofen via the PEG tube, completed the administration, removed gloves and washed hands. LPN #209 did not place personal protective equipment (PPE) gown prior to the PEG tube flush and administration of medication for Resident #44. An interview on 12/17/25 at 1:30 P.M. with LPN #209 confirmed when LPN #209 administered Resident #44's medication via the PEG tube and did not put a PPE gown on prior to working with Resident #44's PEG tube and administering medication via the PEG tube. Review of the Enhanced Barrier Precautions (EBP) notification sign revealed providers, and staff must also wear gloves and a gown for the following including device care or use central line, urinary catheter, feeding tube, tracheostomy. Review of the facility's policy titled Isolation Precautions revised 06/2021 revealed enhanced barrier precautions are used in conjunction with standard precautions and expand the use of PPE to donning of gown and glove during high-contact care activities that could expose healthcare worker hands/clothing to Multi-Drug-Resistant Organisms (MDRO).

Based on observations, record review, interviews, and policy review, the facility failed to follow physician orders related to obtaining daily weights. This affected Resident #01 and #10 out of five residents ordered to receive daily weights. Additionally, the facility failed to ensure that physician orders for double portions were followed, which affected Resident #18. The facility also failed to obtain a timely self-medication administration assessment for Resident #01 who was receiving tube feeding. The facility census was 85. 1. Review of the medical record for Resident #18 revealed an admission date of 06/03/25 with diagnoses of metabolic encephalopathy, type one diabetes mellitus, cognitive communication deficit, gastroesophageal reflux disease (GERD), and obesity. Review of quarterly Minimum Data Set (MDS) 3.0 assessment completed 12/08/25 revealed Resident #18 is cognitively intact, independent with eating, and has not had a weight gain or loss in the past month. Review of care plan dated 06/10/25 revealed Resident #18 has a nutritional problem or potential related to type one diabetes mellitus, hypertension, hyperlipidemia, GERD, urinary tract infection, seizures, long-term insulin use, transient ischemic attack, and history of falls. Resident also has vitamin D and B12 deficiency and requires double portions with meals. Staff interventions include providing and serving diet as ordered. Review of nutrition/dietary note dated 11/06/25 revealed updated diet order to reflect double portions and request daily sugar-free ice cream with dinner. Doubling portions was intended to aid in desired weight maintenance. Review of physician order dated 11/06/25 revealed Resident #18 was to receive a certified kosher diet, regular texture, regular/thin consistency with double portions. Review of meal ticket dated 12/18/25 for breakfast service for Resident #18 revealed regular diet with thin liquids. The resident was served cranberry juice, one half cup oatmeal, two hard-boiled eggs, orange cranberry muffin, four-ounce fresh fruit cup, eight ounces milk, and six ounces coffee. Review of meal ticket dated 12/18/25 for lunch service for Resident #18 revealed regular diet with thin liquids. The resident was served three ounces crunchy baked fish, one half cup house-made chips, four ounces coleslaw, one half cup banana pudding, six ounces coffee, and eight ounces water. Observation on 12/18/25 at 8:13 A.M. of Resident #18 breakfast tray confirmed he did not receive double portions as required. Resident #18 confirmed his meal tray ticket did not include the double portion requirement. Observation on 12/18/25 at 12:29 P.M. of Resident #18 lunch tray confirmed he did not receive double portions as required. He voiced needing additional food for lunch and dinner service and confirmed his meal tray ticket did not include the double portion requirement. Interview and observation on 12/18/25 at 12:31 P.M. with Certified Nursing Assistant (CNA) #309 and Registered Nurse (RN) #360 confirmed Resident #18 meal ticket did not include the double portion requirement and the resident did not receive double portion sizing for lunch service. CNA #309 and RN #360 denied knowledge the resident was to receive double portions but confirmed physician orders were present in the record for the requirement. Interview on 12/18/25 at 12:33 P.M. with Licensed Practical Nurse #350 confirmed current physician order for Resident #18 to receive double portions during meal times. Review of therapeutic diets policy dated 11/2016 revealed a tray identification system is established to ensure each resident receives their diet as ordered. 2. Review of the medical record for Resident #01 revealed an admission date of 09/07/20 with a re-entry date of 01/17/23 and diagnoses of malignant neoplasm of the base of the tongue, laceration without foreign body of the scalp (subsequent encounter), extended spectrum beta-lactamase resistance, and bacteremia. Review of the quarterly MDS assessment completed on 11/06/25 revealed Resident #01 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, no mood or behavioral concerns, and independence with activities of daily living, including eating. The MDS indicated the resident had a feeding tube, consumed a mechanically altered diet, and reported no weight gain or loss since the prior assessment. Review of physician orders dated 04/04/25 through 11/20/25 revealed Resident #01 was ordered enteral nutrition via gastrostomy tube, including TwoCal HN bolus feedings. Orders included an enteral feeding regimen every four hours (six times daily) that was discontinued on 11/20/25, and a revised order initiated on 11/20/25 at 9:00 P.M. for TwoCal HN, one carton (237 mL) via gastrostomy tube five times daily with prescribed water flushes. Review of physician orders also revealed multiple orders to obtain weights and re-weigh the resident when weight changes of five pounds or greater occurred, including re-weigh orders dated 08/05/25, 09/11/25, 09/17/25, 10/07/25, and 11/03/25, each requiring completion within one day to confirm accuracy. A physician order dated 08/11/25 required weekly weights every Monday for monitoring. Review of the care plan initiated on 01/04/21 and revised most recently on 11/19/25 revealed Resident #01 required tube feeding via gastrostomy tube related to dysphagia and inconsistent oral intake and was permitted to self-administer bolus feedings and medications through the gastrostomy tube. Review of assessments revealed a self-administration medication assessment was completed on 02/02/24, with no evidence of a subsequent reassessment completed thereafter, despite the resident continuing to self-administer medications and enteral feedings. Review of dietary progress notes dated 11/26/25 documented a current body weight of 130.8 pounds on 11/24/25, reflecting a 17.2-pound (11.6 percent) weight loss from 148.0 pounds recorded on 11/03/25. Dietary documentation recommended daily weights for five days to establish accurate weight status; however, review of the medical record revealed daily weights were not completed as recommended. Review of dietary documentation dated 12/12/25 revealed continued significant weight loss over 30 days, with a decrease from 148.0 pounds to 134.2 pounds, representing a nine percent loss. Dietary documentation dated 12/17/25 revealed discrepant weights obtained on 12/15/25, including 143.4 pounds and 134.4 pounds, and requested additional weekly weights to verify accuracy. Review of documented weights revealed Resident #01 weighed 143.4 pounds on 12/15/25 and 134.3 pounds on 12/19/25, reflecting a 9.1-pound (approximately 6.3 percent) weight loss in four days. Review of the medical record revealed no re-weigh was completed until 12/22/25 to confirm the significant weight change, despite physician orders requiring confirmation re-weighs within one day when weight changes of five pounds or greater occurred. Interview on 12/22/25 at 11:19 A.M. with the Director of Nursing (DON) confirmed the re-weigh completed on 12/22/25 was not timely. The DON confirmed the facility policy required confirmation re-weighs when a resident experienced a significant weight change of a 5 pound weight loss/gain. The DON further confirmed the re-weigh ordered for 09/18/25 was not completed and acknowledged dietary recommendations for daily weights following the significant weight loss identified on 11/24/25 were not completed. The DON also confirmed self-administration medication assessments should be completed at least annually and acknowledged Resident #01's self-administration medication assessment had not been completed timely. Review of the facility policy titled, Self-Administration of Medications, dated 12/01, revealed residents who wish to self-administer medications may be subject to periodic assessment for appropriateness by the interdisciplinary team (IDT) based on changes to the residents medical and decision-making status. Nursing staff will check the resident at each administration time to ensure that the medication was self-administered and indicate self-administration was monitored on a medication administration record (MAR) maintained by the nursing staff. 3. Review of the medical record for Resident #10 revealed an admission date of 05/10/22 with diagnoses including encephalopathy, acute kidney failure, Dieulafoy lesion of the intestine, and hypotension. Review of the quarterly MDS assessment completed on 11/10/25 revealed Resident #10 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS indicated the resident experienced weight loss within the last six months. The assessment further reflected extensive dependence for activities of daily living, use of a wheelchair for mobility, and reliance on staff for eating set-up and personal care. Review of documented weights revealed Resident #10 experienced a clinically significant and sustained weight decline beginning in June 2025. Review of weights dated 06/10/25 reflected a weight of 138.6 pounds. Subsequent weights dated 09/09/25 reflected a weight of 128.9 pounds, demonstrating a 9.7 pound weight loss over approximately three months. Review of documented weights further revealed continued weight decline following September 2025. Weights dated 11/08/25 reflected a weight of 124.9 pounds, and weights dated 12/16/25 reflected a weight of 116.8 pounds. This represented a total weight loss of approximately 21.6 pounds from June 2025 to December 2025, equating to an approximate 15.6 percent loss over six months. Review of weights also revealed a one-month weight loss from 123.0 pounds on 11/15/25 to 116.8 pounds on 12/16/25, reflecting a 6.2-pound (approximately five percent) loss, and a three-month weight loss from 128.9 pounds on 09/13/25 to 116.8 pounds on 12/16/25, reflecting a 12.1-pound (approximately 9.4 percent) loss. Review of nutrition and dietary documentation dated 07/16/25, 07/23/25, 08/19/25, and 09/19/25 reflected ongoing identification of nutrition risk and continued provision of Nepro oral nutritional supplement three times daily related to weight loss and dialysis needs. Review of dietary documentation dated 09/19/25 identified declining dry weights and low laboratory values but did not reflect any adjustment to the nutritional supplement regimen or physician orders despite the clinically significant weight loss identified by September 2025. Review of physician orders revealed Nepro oral nutritional supplement was ordered three times daily beginning on 07/15/25 and remained unchanged until 12/11/25. Review of the medical record revealed no changes to nutritional supplement orders or calorie provision were implemented between July 2025 and December 2025, despite ongoing documented weight loss and repeated triggers for significant weight loss during that period. Review of nutrition assessments revealed no comprehensive nutrition assessment was completed after 09/11/24, despite the resident experiencing multiple episodes of significant weight loss between June 2025 and December 2025. Review of the Medication Administration Record for November 2025 revealed Nepro eight ounces by mouth three times daily for weight loss was administered with zero percent intake documented on multiple occasions, including administration at 8:00 A.M. on 11/16/25, 11/18/25, and 11/22/25; at 2:00 P.M. on 11/14/25, 11/18/25, 11/21/25, and 11/23/25; and at 9:00 P.M. on 11/14/25, 11/18/25, 11/20/25, and 11/24/25. Review of the medical record revealed no documented adjustment to the nutrition plan or physician orders during this period of non-consumption. Review of physician orders dated 12/10/25 revealed a change in oral nutritional supplement from Nepro to Glucerna three times daily, indicating the first documented adjustment to supplement orders since July 2025. Interview on 12/17/25 at 4:16 P.M. with Dietician #500 confirmed dietary services transitioned to the facility on [DATE]. Dietician #500 confirmed the resident was being followed weekly with weights and dialysis coordination and stated the resident's weight had stabilized in the three weeks prior to the interview. The Dietician #500 confirmed that no changes to nutritional supplements or physician orders occurred between July 2025 and December 2025 despite ongoing weight decline and triggers for significant weight loss identified in September 2025. Interview on 12/18/25 at 2:43 P.M. with Resident #10 revealed the resident stated he did not like Nepro or Glucerna supplements and expressed dissatisfaction with facility food, which he believed contributed to his weight loss. The resident stated he preferred not to continue losing weight. Review of the facility policy titled, Weight Change Policy, dated 08/25, revealed a significant weight loss is identified as 5% in one month, 7.5% in three months, or 10% loss in six months. Additionally, stated recheck weights are to be obtained for a 5-pound (five) loss or gain if resident weighs over 100 pounds. A 5-pound gain or loss on a resident weighing 100 pounds or more will be reported to the dietitian and the physician. The dietitian or the registered dietetic technician will review the weight changes and make recommendations to the neighborhood nurse for follow-up with the physician as needed. Weekly weights, weight every 3 days, or as needed will be done as ordered and recorded in Point Click Care (PCC).

Based on observation, resident interview, staff interview, and facility policy, the facility failed to ensure foods were at a palatable temperature. This had the potential to affect 83 out of 85 residents in the facility with two residents receiving a nothing by mouth (NPO) diet. The facility census was 85. During interview on 12/16/2025 at 2:12 P.M., Resident #30, stated that the food was terrible, arrived cold, and lacked flavor. Review of additional interviews conducted during the survey revealed that multiple residents reported concerns regarding food being served cold.During observation related to tray service on 12/18/2025, a test tray was not observed on the meal cart at 1:18 P.M. Staff stated that the test tray was not present because it had been left in the kitchen. At 1:23 P.M., staff confirmed that the test tray had been sitting in the kitchen for approximately 15 minutes after being prepared and was not placed on the meal cart prior to service. The temperatures of the lunch items were around 60-80 degrees Fahrenheit (F) and the items were not tasted at that point.During a breakfast meal pass observation on 12/22/2025 from 8:27 A.M. to 8:45 A.M., temperatures of plated food items were obtained. Pancakes were measured at 107 degrees F, sausage at 108 degrees F, and oatmeal at 133 degrees F. At 8:45 A.M., Dietary Assistant Manager #550 was interviewed at the time of the observation and confirmed that the pancakes and sausage were cold, stating that he would not want to eat those items cold for breakfast.Review of the facility policy titled, Food Temperatures, dated in 2023, revealed all hot food items must be cooked to appropriate internal temperatures and held and served at a temperature of at least 135 degrees F, with required cooking temperatures reached and maintained in accordance with regulations, laws, and standardized recipes; hot food items may not fall below 135 degrees F after cooking unless they are intended to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F for a minimum of 15 seconds prior to serving, and caution must be taken to avoid serving food and liquids at temperatures that could cause burns. All cold food items must be stored at a temperature of 41 degrees F or below. Food temperatures should be taken periodically to ensure hot foods remain above 135 degrees F and cold foods remain below 41 degrees F during holding, plating, and until food leaves the service area. Foods should be transported as quickly as possible to maintain required temperatures, and when transportation time is extensive, appropriate methods such as hot or cold carts, pellet systems, or insulated plate bases and domes must be used. Foods sent to units for distribution, including meals, snacks, nourishments, and oral supplements, must be transported and delivered to unit storage areas in a manner that maintains cold foods at or below 41 degrees F and hot foods at or above 135 degrees F, and unit refrigerators must be monitored to ensure temperatures maintain foods at or below 41 degrees F.

Based on observation and staff interview, the facility failed to ensure purred foods were at the appropriate consistency which had the potential to affect Residents #1, #2, #96, #53, #64 who received a pureed diet. The facility census was 85. During observation on 12/18/2025 at 11:26 A.M., the surveyor observed the pureed food preparation process with [NAME] #600. The surveyor observed the fish item intended for residents on a pureed diet and noted the consistency was stringy and not smooth. The fish was described as having separable strands when processed with broth, and the surveyor observed that the texture was not appropriate for residents prescribed a pureed diet. [NAME] #600 stated she was attempting to remove the fish item from the pureed menu due to it not pureeing correctly and further stated that residents did not like the consistency and confirmed the consistency was not correct, however, she confirmed that the item would continue to be served.Review from the International Dysphagia Diet Standardization Initiative (IDDSI), Level 4 foods, which are considered pureed, must be smooth with no lumps, hold their shape on a spoon, and require no chewing to swallow. Pureed foods also must not be stringy or require tongue manipulation to break apart, as these characteristics increase the risk of choking or aspiration. Pureed food should be tested before service to ensure it meets these criteria and is safe for residents with swallowing difficulties to consume.

Based on medical record review, interview and facility policy review, the facility failed to complete a baseline abnormal involuntary movement scale (AIMS) scale for one resident (#12) who was admitted on psychotic medication. This affected one resident (#12) of five residents reviewed for unnecessary medications. The facility census was 85. Review of the medical record for Resident #12 revealed an initial admission date of 08/22/25 with the diagnoses including but not limited to bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive and intra-abdominal and pelvic swelling, mass and lump.Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had indicators of depression and displayed no behaviors including rejection of care. The assessment indicated the resident received antipsychotic, antidepressant, opioid and anticonvulsant. The resident received antipsychotic medications on a routine basis and a gradual dose reduction (GDR) was not attempted and the physician had not documented the GDR was contraindicated. Review of the plan of care dated 08/22/25 revealed the resident used psychotropic medications. Interventions included administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift, consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly, discuss with physician, family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given, monitor/document/report as needed any adverse reactions of psychotropic medications. Review of the resident's physician's orders for December 2025 identified an order dated 11/02/25 for Abilify 10 milligrams (mg) to be given by mouth daily for bipolar disorder. Review of the medical record revealed no AIMS scale completed on admission. Further review revealed the first AIMS completed was on 11/24/25 by the facility contracted psychiatric company. On 12/18/2025 9:42 A.M., interview with Director of Nursing (DON) verified no baseline AIMS was completed on admission. Review of the facility policy titled, Antipsychotic/Psychotropic Drugs, last revised on 03/25 revealed antipsychotic/psychotropic drug therapy shall be used only when it is necessary to treat a specific condition. An AIMS test will be completed every six months at minimum.

Based on observation, medical record review, interview and facility policy review, the facility failed to ensure routine shaving was provided for Resident #12, who was dependent on staff. This affected one resident (#12) of five residents reviewed for activities of daily living (ADL). The facility census was 85. Review of the medical record for Resident #12 revealed an initial admission date of 08/22/25 with the diagnoses including but not limited to bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive and intra-abdominal and pelvic swelling, mass and lump.Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had indicators of depression and displayed no behaviors including rejection of care. The assessment indicated the resident was dependent on staff for bathing and personal hygiene. Review of the plan of care dated 08/22/25 revealed the resident was prone to ADL/functional deficits related to acute on chronic health conditions. Resident requires assistance with ADL's related to bipolar disorder, catatonic disorder, dementia, malnutrition, hypertension, hypothyroidism, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, adult failure to thrive, cardiac pacemaker and intra-abdominal/pelvis swelling/mass. Interventions included assist with daily bathing, hygiene, dressing and grooming cares resident is unable to complete independently as needed daily, maintain call light within reach, encourage use for assistance answering promptly daily, Occupational and Physical Therapy to evaluate and treat as ordered, set up, assist as needed with oral care every am, after meals and at bedtime per resident personal preference and shower bathe per residents personal preference. On 12/17/25 at 8:30 A.M., observation of Resident #12 revealed she had long chin hairs.On 12/17/25 at 3:35 P.M., observation of the resident revealed the resident was resting quietly in bed and she continued to have long chin hair. On 12/17/2025 at 3:39 P.M., an interview with Certified Nursing Assistant (CNA) #372 verified the resident had a scheduled shower this date and the resident's long chin hair was not shaved. The CNA revealed she just didn't have time to shave the resident's chin hair.Review of the facility policy titled, Shaving a Resident, dated 01/05/03 revealed residents are to be shaved on shower days and as needed.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to label oxygen tubing for Resident #09, #14, and #44. This affected three of five residents reviewed for respiratory care. The census was 85. 1. Record review of Resident #09's medical record revealed an admission date of 12/31/24. Diagnoses include chronic obstructive pulmonary disease, heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive heart disease with heart failure, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, and type II diabetes mellitus with diabetic neuropathy. Review of Resident #09's Minimum Data Set 3.0 (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately impaired cognition and that Resident #09 required oxygen therapy. Review of Resident #09's care plan dated 12/02/25 revealed Resident #09 is prone to cardio-pulmonary complications related to acute on chronic health conditions with a goal for Resident #09 to be free from cardio-pulmonary complications through goal date and interventions include, administer oxygen therapy as ordered, and change oxygen tubing weekly. Review of Resident #09's physician orders revealed an order for oxygen at two liters via nasal cannula to maintain oxygen saturation above 92 percent. Observation on 12/15/25 at 4:01 P.M. of Resident #09's room revealed Resident #09's nasal cannula tubing was not labeled and was stuck under her bedside table. Interview on 12/15/25 at 4:06 P.M. with Licensed Practical Nurse (LPN) #280 confirmed Resident #09's nasal cannula tubing was not labeled. 2. Record review for Resident #14's medical record revealed an admission date of 09/21/22. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unsteadiness on feet, dependence on supplemental oxygen, chronic respiratory failure with hypercapnia, atherosclerosis heart disease of native coronary artery with unspecified angina, paroxysmal atrial fibrillation, contracture right hand and elbow, chronic obstructive pulmonary disease (COPD), need for assistance with personal care, muscle weakness, and essential (primary) hypertension. Review of Resident #14's Minimum Data Set 3.0 (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08, indicating Resident #14 had moderate cognitive impairment. Resident #14 required oxygen therapy. Review of Resident #14's care plan dated 11/24/25 revealed Resident #14 is prone to cardio-pulmonary complications related to acute on chronic health conditions with a goal for Resident #14 to be free from cardio-pulmonary complications through goal date and interventions include, administer oxygen therapy as ordered, and change oxygen tubing weekly and change nebulizer tubing weekly when is use. Review of Resident #14's physician orders revealed an oxygen order for 2.5 liters via nasal cannula to maintain oxygen saturation between 88 and 92 percent. Due to COPD , notify the provider if oxygen saturation is less than 92%. Order for oxygen tubing to be changed every seven days (every night shift every Saturday). Observation on 12/15/25 at 12:50 P.M. revealed Resident #14's uncovered nebulizer mask on top of night stand. Observation on 12/15/25 at 4:05 P.M. revealed Resident #14's uncovered nebulizer mask on top of night stand and unlabeled nasal cannula tubing. Interview on 12/15/25 at 4:05 P.M. with LPN #280 confirmed Resident #14's nebulizer mask should be in a bag when not in use and nasal cannula tubing should be labeled. 3. Review of Resident #44's medical record revealed admission date 05/18/16 with diagnoses including but not limited to anoxic brain damage, respiratory failure and tracheostomy dependent. Review of Resident #44's physician orders dated 12/01/25 to 12/31/25 revealed an order dated 04/22/25 for supplemental oxygen six liters (L) via tracheostomy mask with humidified air. Further review revealed no physician orders for oxygen tubing to be changed. An observation on 12/16/25 at 9:45 A.M. revealed Resident #44's oxygen concentrator located in the bathroom and set at six L of oxygen with oxygen tubing attached to the concentrator. The oxygen tubing went from the concentrator across the room to the humidifier for the tracheostomy mask. There was no date on the oxygen tubing to reflect when the tubing had been recently changed. An interview on 12/16/25 at 9:55 A.M. with Unit Manager (UM) #350 verified there were no dates on the oxygen tubing to reflect being recently changed. UM #350 also verified Resident #44 did not have physician orders for the oxygen tubing to be regularly changed. Review of the facility's policy titled, Oxygen Therapy and Storage, effective date 09/2025, the purpose is to establish policies and procedures to store and administer oxygen safely.

Based on observation, interview, and facility policy review the facility failed to maintain safe and comfortable temperatures in Resident #36's room. This affected one (#36) of three residents reviewed for environment. The census was 85. Review of Resident #36's medical record revealed an admission date of 12/03/24. Diagnoses include type II diabetes mellitus with other specified complication, morbid obesity, unsteadiness on feet, need for assistance with personal care, lymphedema, essential (primary) hypertension, muscle weakness, chronic pain syndrome, bilateral primary osteoarthritis of hip, low back pain, and left bundle branch block.Review of Resident #36's Minimum Data Set 3.0 (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.Observation on 12/15/25 at 2:20 P. M of Yazz 4 hallway revealed Certified Nursing Assistant (CNA) wearing winter coat in hallway.Observation on 12/15/25 at 2:24 P.M. reveals maintenance in Resident #36's room regarding heater.Interview on 12/15/25 at 2:35 P.M. with Resident #36 revealed her heater had stopped working and she needed extra blankets to keep warm. Resident #36's stated they moved some items off of the heater near the window sill. Observation on 12/15/25 at 2:36 P.M. reveals thermostat reading room as 69 degrees Fahrenheit (F) with heat set at 80 degrees F.Review of the facility's work order log confirmed a work order labeled as high priority dated 12/15/25 at 1:56 P.M. stating the issue as heat not working in Resident #36's room with notes stating checked heat, verified it works, changed and order was closed at 2:26 P.M.Observation on 12/15/25 at 3:39 P.M. reveals thermostat reading as 69 degrees F in Resident #36's room.Observation on 12/15/25 at 4:30 P.M. reveals thermostat reading as 69 degrees F in Resident #36's room.Interview on 12/16/25 at 8:40 A.M. with CNA #257 confirmed Resident #36's thermostat in room was reading at 69 degrees F.Interview on 12/16/25 at 8:41 A.M. with Licensed Practical Nurse (LPN) #280 confirmed they will place an expedited work order for maintenance regarding Resident #36's heat.Review of the facility's work order log confirmed a work order labeled as a high priority on 12/16/25 at 8:42 A.M. stating heat not working in Resident #36's room.Interview on 12/16/25 at 9:27 A.M with Maintenance Member #110 confirmed the temperature range using an infrared thermometer in different locations in Resident #36's room ranged from 65 to 67 degrees Fahrenheit. Maintenance Member #110 stated housekeeping would be coming to assist Resident #36 with clearing armoire (dresser) to move it away from heater to allow for better airflow. Maintenance Member #110 confirmed Resident #36 should have been temporarily moved to another room if the heater was not working properly overnight.Interview on 12/16/25 at 10:12 A.M. with Maintenance Member #109 revealed Resident #36's window was cracked therefore preventing the room from heating up and they also changed the thermostat in the room.Observation on 12/16/25 at 1:47 P.M. revealed Resident #36's thermostat in room reading 71 degrees F.Interview on 12/16/25 at 1:47 P.M. with Resident #36 confirmed the temperature in the room felt warmer and was comfortable with the thermostat reading at 71 degrees F.Observation on 12/16/25 at 4:37 P.M. revealed Resident #36's thermostat reading at 72 degrees F.Observation on 12/17/25 at 9:50 A.M. revealed Resident #36's thermostat reading at 71 degrees F.Interview on 12/18/25 at 10:51 A.M. with Unit Manager #350 confirms she was not aware of Resident #36's room being cold and would've temporarily moved Resident #36 to another room if they were unable to fix the heater.Review of the facility's policy titled, Extreme Heat/Extreme Cold Policy effective date 04/2025, confirms the facility will provide as comfortable environment as possible for our residents and staff by monitoring temperatures in all areas of the building. In the event of temperatures (i.e. 71 degrees Fahrenheit or below) in resident rooms, these residents will be moved to another area or room that has heat.

Based record review, staff interview and review of facility policy, the facility failed to ensure physician ordered daily weights were collected timely, this affected one (#54) of residents reviewed for physician orders. The facility census was 85.Review of the medical record for Resident #54 revealed an admission date of 11/18/25 with diagnoses of hypocalcemia, cognitive communication deficit, atrial fibrillation, muscle weakness, chronic combined systolic and diastolic heart failure, hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery with angina, hyperlipidemia, and pulmonary embolism.Review of admission Minimum Data Set assessment dated [DATE] revealed Resident #54 is cognitively intact, has active heart and circulation diagnoses of atrial fibrillation, coronary artery disease, heart failure, and hypertension, and is currently taking an antiplatelet and anticoagulant.Review of care plan dated 11/24/25 revealed the resident has a nutritional problem or potential related to cognitive communication deficit, atrial fibrillation, chronic heart failure, heart disease, hyperlipidemia, and weight gain prior to admission. Interventions include obtaining and monitoring weight per policy.Review of physician order dated 11/21/25 revealed instructions to obtain daily weights and notify physician or nurse practitioner for an increase of three pounds or more in one day for chronic heart failure.Review of weight summaries revealed Resident #54 weighed 235.9 pounds (lbs.) on 11/18/25, 233 lbs. on 12/08/25, and 217 lbs. on 12/16/25. Review of progress notes dated 11/21/25, 12/09/25, and 12/16/25 revealed Resident #54 was to resume home regimen except for Lasix due to soft blood pressure, monitor weight changes, weigh daily, and notify nurse practitioner or physician of weight gain of three pounds or more in one day.Review of daily weight task from 11/22/25 through 12/22/25 revealed weights were obtained on 12/16/25 and 12/18/25 with Resident #54 weighing 217 lbs.Review of nutritional assessment dated [DATE] revealed Resident #54 typical weight is between 213 and 215 lbs. The resident had recent history of weight gain related to eating more and a sedentary lifestyle, with a plan to provide diet as ordered and monitor weights and intake per protocol.Review of Treatment Administration Record (TAR) and Medication Administration Record (MAR) for November 2025 and December 2025 revealed no recorded daily weights.Interview conducted on 12/18/25 at 2:45 P.M. with the Director of Nursing (DON) confirmed Resident #54 had an order for daily weights in place since 11/22/25 and daily weights had not been obtained as ordered. The DON stated the physician order was placed incorrectly and triggered as a no documentation order, therefore a prompt to complete daily weights was not initiated. The DON confirmed only three weights were taken during Resident #54's admission.Interview conducted on 12/18/25 at 3:01 P.M. with the Administrator confirmed physician-ordered daily weights for Resident #54 were not obtained as ordered.Interview conducted on 12/18/25 at 3:34 P.M. with Licensed Practical Nurse Unit Director #141 confirmed she were unaware Resident #54 had a physician order for daily weights related to chronic heart failure therefore they were not completed.Interview conducted on 12/18/25 at 4:08 P.M. with Dietician #500 denied concerns regarding weight loss or signs and symptoms of poor fluid management. Dietician #500 stated they spoke with Resident #54 and attributed the weight loss to increased activity and improved food quality intake, and noted the resident expressed interest in losing more weight.Review of physician order policy dated 10/31/21 revealed the nurse who takes the physician order will be responsible for executing the order or providing a safe hand-off to the next nurse, which includes MAR/TAR updates and notifying internal staff of changes or updates.

Based on record review, interview and policy review the facility failed to ensure physician parameters were appropriately followed. This affected three (#04, #08, and #75) of six residents selected for medication regimen review. The facility census was 85. 1. Record review of Resident #04 revealed an admission date of 10/31/25 and readmission of 11/25/25. Diagnoses included but are not limited to osteomyelitis of vertebra, discitis, low back pain, complication of internal fixation device of vertebrae, bipolar disorder, Post Traumatic Stress Disorder (PTSD), depression, gout and chronic pain. Further review of Resident #04 record revealed an order for Hydrocodone-acetaminophen oral tablet 5-325 milligrams (mg), start date 11/25/25, with direction to give two tablets by mouth every four hours as needed for pain, and a second order for Hydrocodone-acetaminophen oral table 5-325 mg, with a start date of 11/25/25, with directions to give one tablet by mouth every four hours as needed for pain. Interview with Licensed Practical Nurse (LPN) #158 on 12/22/25 at 11:04 A.M. confirmed Resident #04 had two active orders for Hydrocodone and reported Resident #04 is given one tab for a pain between four and six, using a 0 (no pain) to 10 (worst pain) pain scale and two tabs for pain between seven and 10. LPN #158 confirmed Resident #04's medication administration record (MAR) does not have parameters listed for when Resident #04 is to receive one tab versus two tabs and was unable to provide documentation of an existing pain scale parameter. LPN #158 confirmed Resident #04 has been receiving either one or two tabs of Hydrocodone for varying pain levels between 0 to 10 on the pain scale. Interview with Unit Manager (UM) #177 on 12/22/25 at 2:02 P.M. confirmed Resident #04 had two orders for Hydrocodone and parameters were not listed on the MAR. Further interview with UM #177 on 12/22/25 at 2:30 P.M. revealed the nurses were administering one or two tabs of Hydrocodone based off of their own assessment of the resident and confirmed there was no documentation of these assessments or how the assessments were completed. UM #177 confirmed a pain scale should be present for the medication and documenting the resident's refusal or preference of a lower dose. Additional interview with UM #177 12/22/25 at 3:30 P.M. revealed Resident #04 controlled substance record for Hydrocodone had pain parameters of one tablet for pain between four and six and two tablets for pain between seven and 10 orally every four hours as needed for pain. UM #117 confirmed the nurses were not consistently following the parameters of the Hydrocodone listed on the controlled substance record. 2. Record review of Resident #08 revealed an admission date of 06/13/19 and readmission of 03/14/24. Diagnoses included but are not limited to dementia, schizoaffective disorder, congestive heart failure, tachycardia, bi-polar disorder, hypertensive heart disease with heart failure, anxiety disorder, unspecified atrial fibrillation, long QT syndrome, left bundle-branch block, orthostatic hypotension, major depressive disorder, Alzheimer's disease, other specified peripheral vascular diseases, atherosclerosis of coronary artery bypass grafts, and presence of aortocoronary bypass graft. Further review of Resident #08 record revealed an order for Hydrochlorothiazide oral tablet 12.5 mg, start date 06/24/25, with further details to give one tablet by mouth one time a day for hypertension and to hold if systolic blood pressure is less than equal to 100 or if heart rate is less than or equal to 60. Record for Resident #08 also revealed an order for Metoprolol Succinate extended release (ER) 24-hour 50 mg, start date 06/23/25, with further details to give one tablet by mouth one time a day for hypertension ad to hold is systolic blood pressure is below 110 or heart rate is below 60. Review of Resident #08's medication administration record (MAR) from September 2025 to December 2025 revealed Hydrochlorothiazide administered with the following blood pressure (BP) and/or heart rate (HR) values; 12/01/25 HR 56, 12/03/25 HR 58, 11/04/25 HR 57, 11/05/25 HR 60, 11/25/25 HR 59, 10/04/25 HR 54, 10/11/25 HR 54, 10/19/25 HR 57, 10/20/25 HR 57, and 09/07/25 HR 60. Further review of Resident #08's MAR from September 2025 to December 2025 revealed Metoprolol Succinate ER administered with the following blood pressure and/or HR values; 12/01/25 HR 56, 12/03/25 HR 58, 11/25/25 HR 59, 11/29/25 HR 54, 10/11/25 HR 54, 10/14/25 BP with systolic value of 108, 10/19/25 HR 57, and 10/20/25 HR 57. Interview with Unit Manager (UM) #350 12/18/25 at 12:20 P.M. revealed the nurses are instructed to hold medications when the residents' blood pressure and/or heart rate are outside of doctor ordered parameters. UM #350 further confirmed if the medication is held there should be documentation of the doctor being notified and any further direction from the doctor if applicable. UM #350 also revealed if the doctor instructed to still administer the medication there should be documentation. UM #350 confirmed per doctor parameters Resident #08 should not have received the Hydrochlorothiazide on 12/01/25, 12/03/25, 11/04/25, 11/05/25, 11/25/25, 10/04/25, 10/11/25, 10/19/25, 10/20/25, and 09/07/25 and confirmed there was no documentation of doctor notification. UM #350 further confirmed per doctor parameters Resident #08 should not have received the Metoprolol Succinate ER on [DATE], 12/03/25, 11/25/25, 11/29/25, 10/11/25, 10/14/25, 10/19/25, and 10/20/25. 3. Review of the medical record for Resident #75 revealed an admission date of 06/02/2025. Diagnosis included seizures, atrial fibrillation, and hypertension. Review of Resident #75's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed this resident experienced long and short-term memory problems with a severely impaired cognition for daily decision-making abilities Review of Resident #75's currently physician orders revealed an order for Metoprolol tartrate oral tablet 25 mg, give one tablet via gastric feeding tube (PEG) tube twice a day at 8:00 A.M. and 8:00 P.M. for hypertension. Do not administer this medication for systolic blood pressure readings (SBP) less than 110 and/or a heart rate less than 60 beats per minute. Review of the medication administration record for August, September, November, and December 2025 revealed multiple days where Resident #75's pulse or blood pressure was not monitored prior to the administration of the ordered Metoprolol tartrate medication. Continued review revealed Resident #75 had another hypertension medication that was administered at 7:00 A.M. which this residents blood pressure was being checked for but not for the 8:00 P.M. medication administration. Interview on 12/18/2025 at 12:46 P.M. with Unit Director (UD) #350 revealed the nurses are instructed to hold medications when blood pressure and or heart rate are outside of doctor order parameters. UD #350 also confirmed if the medication is held the vital measurements should still be recorded in the MAR for the doctor to review. UD #350 confirmed Resident #75's MAR did not have pulse and blood pressures documented on multiple occasions. Review of the facility's General Dose Preparation and Medication Administration policy, revised 11/25/24, revealed facility staff should document necessary medication administration/treatment information. The policy further revealed facility staff should verify each time a medication is administered that the medication, dose, route, rate, and time for the correct resident, as well as confirming the medication administration record (MAR) reflects the most recent order.

Based on observation, review of manufacturer guidelines, and facility policy review the facility failed to remove expired Tubersol tuberculin solution from circulation. This deficient practice had the potential to affect new resident admissions. The facility census was 85.An observation on [DATE] at 9:51 A.M. revealed in the medication storage refrigerator located at the nurses' desk on the first hallway. Inside the refrigerator was an open half-used vial of Tubersol tuberculin solution not labeled with an open date on the storage box or on the vial. Further observation revealed another open half used vial of Tubersol tuberculin solution with an open date [DATE] located on the vial. Both vials of the Tubersol tuberculin solution had an expiration date of 10/2026.A review of the manufacture guidelines for Tubersol tuberculin solution dated 10/2021 revealed a vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date.A review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals revised [DATE] revealed once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. An interview on [DATE] at 9:30 A.M. with Licensed Practical Nurse (LPN) #194 confirmed the open undated vial of tuberculin solution and the open vial of tuberculin solution dated [DATE] were in the medication storage refrigerator. LPN #194 stated the vials should be dated when opened to use and the vial should only be used for 30 - days and then discarded.

Based on record review, interview, and policy review, the facility failed to ensure physician ordered urine screenings were collected timely, this affected two (Resident #36 and Resident #94) out of six reviewed for physician ordered lab results. The facility census was 85. 1. Review of the medical record for Resident #36 revealed an admission date of 12/03/24 with diagnoses including type two diabetes mellitus, depression, chronic pain syndrome, constipation, anxiety and arthritis.Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 is cognitively intact, dependent on staff for personal hygiene and toilet transfers, and requires substantial to maximal assistance with bed mobility.Review of care plan dated 12/03/25 revealed Resident #36 is prone to alterations in bowel and bladder function related to impaired strength and endurance, generalized weakness, unsteadiness on feet, right femur fracture/surgery, anemia, constipation, and diuretic use. Interventions include assisting with toileting and hygiene, monitoring urine, and obtaining urine specimens as ordered.Review of physician visit summary dated 11/13/25 revealed recent lab work showing leukocytosis with white blood cells at 13.3, with an order to obtain urine analysis and culture and sensitivity, encourage fluids and monitor.Review of physician order dated 11/14/25 revealed straight catheter for urine analysis and culture and sensitivity.Review of progress note dated 11/14/25 at 1:35 P.M. revealed urine analysis was not obtained due to insufficient urine for testing.Review of progress note dated 11/14/25 at 5:50 P.M. revealed urine culture was not obtained.Review of physician order dated 11/17/25 revealed straight catheter for urine analysis and culture and sensitivity.Review of physician order dated 11/18/25 revealed straight catheter for urine analysis and culture and sensitivity.Review of progress note dated 11/18/25 at 12:48 P.M. revealed staff spoke with nurse practitioner about inability to obtain urine for urine analysis and culture and sensitivity and received an order to place catheter until there was enough urine to obtain a specimen.Review of progress note dated 11/18/25 at 6:50 P.M. revealed urine was collected and stored in the unit fridge.Review of physician visit summary dated 11/18/25 revealed follow-up on leukocytosis with pending lab results.Review of lab results revealed specimen collected on 11/19/25.Review of physician visit summary dated 11/21/25 revealed follow-up on labs in context of urinary tract infection, positive result for Klebsiella Pneumoniae sensitivity, and a new order to begin Cipro for seven days.Interview on 12/22/25 at 12:26 P.M. with Licensed Practical Nurse (LPN) Unit Director #141 confirmed she is the active infection control designee, with current expectations for staff to obtain urine specimens the day the order is received from the physician, with a goal to have it in the fridge in the morning after for laboratory services to pick up. LPN Unit Director #141 confirmed the initial request for staff to obtain a urine specimen for Resident #36 was placed on 11/14/25, with two additional requests placed on 11/17/25 and 11/18/25. During this time frame, progress notes documented attempts on 11/14/25 and 11/18/25, however only on 11/8/25 did nursing staff notify the physician and obtain an order for a Foley catheter to collect the necessary amount. LPN Unit Director #141 confirmed no additional attempts were made and nursing staff did not successfully collect the urine sample until day four. 2. Record review for Resident # 94 revealed this resident was admitted to the facility on [DATE] with diagnoses including legal blindness, traumatic subarachnoid hemorrhage, repeated falls, and muscle weakness. At the time of admission, Resident #94 had an indwelling urinary catheter due to a history of urinary retention.Review of the care plan dated 12/08/25 revealed Resident #94 is prone to alterations in bladder function related to urine retention and urinary incontinence. Interventions included obtaining urine specimens as ordered.Review of Resident #94's medical record revealed that on 12/11/2025, the resident developed a low-grade fever and confusion. The resident's complete blood count test that day showed an elevated white blood count of 12.5. Certified Nurse Practitioner (CNP) #1001 ordered a urinalysis and culture, and sensitivity.Review of Resident #94's physician orders did not reveal the urinalysis or culture and sensitivity order.During a subsequent interview with Unit Director #141 12/18/25 at 10:46 A.M, she stated the specimen was obtained on 12/11/25, as ordered. However, she was not able to recall which member of the nursing staff obtained the specimen. She confirmed she was advised by the laboratory that they never received the specimen. She also confirmed the specimen was never recovered at the facility, either.On 12/15/2025, CNP #1001 inquired about the results of Resident #94's urinalysis. At this time, Unit Director #141 learned the ordered urine specimen was missing. CNP# 1001 re-ordered the urinalysis and culture and sensitivity again.Review of the treatment administration record of Resident #94 revealed that the specimens ordered were obtained and sent to the laboratory were completed on the evening of 12/16/2025.During a subsequent interview on 12/18/25 at 2:49 P.M. with CNP #1001, she confirmed her expectation is that an ordered specimen should be completed and sent to the processing laboratory within forty-eight hours of the order being received. She expressed concern about the delay in diagnosis and treatment for Resident #94.Review of physician order policy dated 10/31/21 revealed the nurse who takes the physician order will be responsible for executing the order or providing a safe hand-off to the next nurse, which includes medication administration and treatment administration record updates and notifying internal staff of changes or updates.

Based on medical record review, interview and facility policy review, the facility failed ensure one resident had a physician's order for labs obtained. This affected one resident (#12) of five residents reviewed for unnecessary medications. The facility census was 85.Review of the medical record for Resident #12 revealed an initial admission date of 08/22/25 with the diagnoses including but not limited to bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive and intra-abdominal and pelvic swelling, mass and lump.Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit.Review of the resident's current physician's orders for December 2025 identified orders dated 08/22/25 lipid panel every 12 months and 09/11/15 complete blood count (CBC), complete metabolic panel (CMP), vitamin D level, thyroid stimulating hormone (TSH) and Lamictal level every six months.Review of the resident's laboratory results revealed the facility completed a CBC, CMP, vitamin D level, TSH and Lamictal was completed on 09/05/25, 09/22/25, 09/23/25, 10/09/25, 10/31/25, 11/11/25 and 11/19/25 without a physician's order. Interview on 12/18/2025 9:42 A.M. with the Director of Nursing (DON) verified Resident #12 had unnecessary laboratory testing completed on 09/05/25, 09/22/25, 09/23/25, 10/09/25, 10/31/25, 11/11/25 and 11/19/25 without a physician's order. The DON stated there was an order entry error with how the once every 12 month and once every 6 month lab orders were entered. Review of the facility policy titled, Laboratory Services and Reporting, dated 04/22 revealed the community must provide or obtain laboratory services when ordered by a practitioner in accordance with state law.

Based on record review and interview the facility failed to ensure antibiotic stewardship was followed. This affected one (Resident #36) out of four residents reviewed for antibiotic usage. The facility census was 85. Review of the medical record for Resident #36 revealed an admission date of 12/03/24 with diagnoses of type two diabetes mellitus, depression, chronic pain syndrome, constipation, anxiety and arthritis.Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 is cognitively intact, dependent on staff for personal hygiene and toilet transfers, and requires substantial to maximal assistance with bed mobility.Review of care plan dated 12/03/25 revealed Resident #36 is prone to alterations in bowel and bladder function related to impaired strength and endurance, generalized weakness, unsteadiness on feet, right femur fracture/surgery, anemia, constipation, and diuretic use. Interventions include assisting with toileting and hygiene, monitoring urine, and obtaining urine specimens as ordered.Review of physician visit summary dated 11/13/25 revealed recent lab work showing leukocytosis with white blood cells at 13.3, with an order to obtain urinalysis and culture and sensitivity, encourage fluids and monitor.Review of physician orders dated 11/14/25, 11/17/25 and 11/18/25 revealed straight catheter for urinalysis and culture and sensitivity.Review of progress note dated 11/18/25 at 6:50 P.M. revealed urine was collected and stored in the unit fridge.Review of physician visit summary dated 11/21/25 revealed follow-up on labs in context of urinary tract infection, positive result for Klebsiella Pneumoniae sensitivity, and a new order to begin ciprofloxacin (Fluoroquinolones) for seven days.Review of physician order dated 11/21/25 and end date of 11/22/25 revealed ciprofloxacin oral tablet 500 milligrams (mg) give one tablet by mouth twice daily for urinary tract infection.Review of medication administration record for 11/21/25 and 11/22/25 revealed Resident #36 received a total of two doses one on 11/21/25 at 9:00 P.M. and 11/22/25 at 9:00 A.M.Review of laboratory results reported 11/22/25 revealed growth of Klebsiella pneumoniae (1) at 50-60,000 colony-forming units per millilitre (CFU/mL) and Escherichia coli (2) 50-60,000 CFU/mL. Review of sensitivity revealed Ciprofloxacin for bacteria 1 noted as susceptible; however, for bacteria 2 noted as resistant. Nitrofurantoin was noted as susceptible for both organisms. Review of physician order dated 11/22/25 through 11/27/25 revealed Macrobid (nitrofurantoin) 100 mg oral capsule was ordered by mouth twice daily for urinary tract infection (UTI).Review of medication administration record for 11/22/25 through 11/27/25 revealed Resident #36 received all doses of antibiotic with the first administration on 11/22/25 at 9:00 P.M. and last dose on 11/27/25 at 9:00 A.M.Interview on 12/22/25 at 12:26 P.M. with Licensed Practical Nurse (LPN) Unit Director #141 confirmed she is the current active infection preventionist in-house. She confirmed ciprofloxacin was initiated prior to receiving the full culture and sensitivity back, acknowledged that E. coli was resistant to ciprofloxacin, and confirmed the culture results were below the threshold for antibiotic initiation. She denied any abnormal vital signs or symptoms on infection while waiting for the results to come back, history of UTI with sepsis or current infectious disease or urology consult.Review of the McGeer criteria infection surveillance checklist dated 11/21/25 revealed that Resident #36 did not meet the criteria for urinary tract infection. The resident exhibited none of the required clinical signs or symptoms (such as acute dysuria, fever, leukocytosis, suprapubic pain, hematuria, or new/worsening urinary symptoms) and did not meet any microbiological criteria (no qualifying urine culture results) as defined by the McGeer surveillance definitions. Despite this, ciprofloxacin was initiated prior to full culture and sensitivity results, which is inconsistent with antibiotic stewardship principles.Review of antibiotic stewardship policy dated 05/29/25 revealed the antibiotic stewardship team are involved in antibiotic selection, dosing and monitoring for selected agents, and promote best practices reflecting CMS quality improvement recommendations and CDC guidelines regarding use of appropriate antibiotics.

Based on medical record review, and staff interview this facility failed to ensure prescribed splint orders were transcribed and implemented correctly. This affected one (Resident #75) of the two residents reviewed for splints. The facility census was 85. Review of the medical record for Resident #75 revealed an admission date of 06/02/2025. Diagnoses included cerebral palsy, contracture of the right and left hand, and muscle weakness. Review of Resident #75's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed this resident experienced long and short-term memory problems with a severely impaired cognition for daily decision-making abilities. Review of the plan of care dated 07/07/25 revealed Resident #75 was at risk for or prone to the development of contractures. Interventions included to provide Resident #75 with gentle range of motion (ROM) to affected joint as tolerated when proving daily care, application of a Royan Hand Brace apply brace to right hand in the morning, take off at night every day and night shift for contracture of right hand. Review of Resident #75's physician orders revealed an order to apply a right-hand palm protector as tolerated to prevent skin integrity issues one time only for right hand tightness for 12 months. Ordered on 07/08/2025. Review of the nursing progress note dated 07/07/2025 created by Licensed Practical Nurse (LPN) #317 revealed, new order for a right-hand brace due to contractures. Interview on 12/18/2025 at 1:00 P.M. with Director of Therapy #902 revealed this resident had orders for two different splints, a palm protector to the right hand as tolerated daily for 12 months along with the splint that is to be on during the day and off at night. He confirmed the order had been written incorrectly when it said to apply a right-hand palm protector as tolerated to prevent skin integrity issues one time only for right hand tightness for 12 months. order date of 07/08/2025. Claimed that he planned to go into the system and fix the order now to daily as tolerated for 12 months.

Based on medical record review, observation, staff interview and policy review, the facility failed to implement interventions to prevent resident falls for Residents #20 and #94. This effected two of three residents reviewed for falls with injuries. The facility census was 85.1. Review of the medical of Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of osteoarthritis, muscle weakness, and history of falls. The resident's care plan dated 12/08/25 indicated she was at increased risk for falls. Interventions included maintaining the call light within reach.A review of the fall incident on 09/26/25 revealed the resident was found on the floor face down in her room between 4:00 A.M and 5:00 A.M. The nursing assessment noted injuries including a laceration to the left lower leg, edema to the head and eye, and pain upon touch. The resident was sent to the emergency room for evaluation and returned later that day with sutures to the left lower leg. After the fall, the interdisciplinary team met and decided to update the resident's care plan with new interventions included maintaining the bed in the lowest position.An interview on 12/18/25 at 4:15 P.M. with Licensed Practical Nurse, (LPN) #388, who completed the fall report, revealed when Resident #20 was found, she explained she was reaching for her call light on the floor and rolled out of the bed. Observation on 12/18/25 at 4:37 P.M. revealed the bed was not in the lowest position. LPN #388 confirmed this and immediately lowered the bed.A review of the Interdisciplinary Team (IDT) note dated 09/29/25 confirmed the care plan was updated following the fall, and interventions included maintaining the bed in the lowest position.A review of the facility's falls policy revised on 04/01/25 revealed all safety interventions must be immediately implemented after a fall occurs.2. Review of the medical record of Resident #94 revealed he was admitted to the facility on [DATE] with diagnoses of traumatic subarachnoid hemorrhage, muscle weakness, depression, and legal blindness.Review of Resident #20's care plan dated 12/08/2025 indicated he was at increased risk for falls related to impaired strength and endurance, visual impairment, cognitive impairment, use of psychotropic and opioid medications, and history of falls. Interventions included maintaining the call light within reach and providing staff assistance with mobility and transfers.A review of the fall incident, which occurred 12/05/2025, revealed the resident was found on the floor after attempting to get up to use the bathroom. The nursing assessment noted the resident stated he hit his head, but no new bruises were observed. The resident had a pre-existing hematoma on the left side of his head. An interview on 12/17/2025 at 4:30 P.M. with the Resident #20's family member revealed she informed staff at the time of Resident #20's admission and orientation that the resident was blind and could not see his call light. She affirmed he was likely trying to get to the restroom when he fell.An interview on 12/18/2025 at 10:46 A.M. with the Unit Manager revealed the intervention to move the resident closer to the nurses' station was not implemented until 11/08/25. She acknowledged that in his first room, which was in the second to furthest position from the nurses' station, staff would have had difficulty hearing him if he called them. She confirmed that she was not aware of staff implementing any additional interventions to ensure the resident could properly use his call light to call for staff assistance.A review of the facility's falls policy revised on 04/01/2025 revealed a fall risk assessment will be completed on admission, in consideration of a resident's medications, vision and activities of daily living functional status.

Based on observation, interview, medical record review, and facility policy review the facility failed to maintain infection control practices by failing to perform hand hygiene during meal tray service. This affected three of three (Resident #39, #40 and #43) residents observed during meal service. This had the potential to affect all thirteen residents residing on the Yass 2 unit. The facility census was 76.Findings include: 1. Record review of Resident #39's medical record revealed an admission date of 02/07/24. Diagnoses include unspecified dementia, Type II Diabetes Mellitus with chronic kidney disease, Crohn's disease, colostomy status, chronic kidney disease stage III, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic heart failure, repeated falls and cognitive communicative deficit.Review of Resident #39's Minimum Data Set 3.0 dated 08/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.Observation on 10/29/25 at 12:15 P.M. revealed during tray service certified nursing assistant (CNA) #100 entered Resident #39's room and assisted with raising the head of the bed (HOB) and then assisted with the meal tray set up and left room without performing hand hygiene. CNA #100 was then observed to open and reach into the meal delivery cart for another tray. A blue hand sanitizer bottle was observed located on top of the meal deliver cart. Interview on 10/29/25 at 12:37 P.M. with CNA #100 verified they had not used hand hygiene during lunch tray pass.2. Record review of Resident # 43's medical record revealed an admission date of 05/04/25. Diagnoses include unspecified mild dementia, unilateral primary arthritis right knee, chronic kidney disease stage III, Type II Diabetes Mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease stage I through IV, peripheral vascular disease, gastro-esophageal reflux disease without esophagitis, and history of falling.Review of Resident #43's Minimum Data Set 3.0 dated 09/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had cognitive impairment. Observation on 10/29/25 at 12:20 P.M. revealed CNA #100 did not perform hang hygiene prior to entering Resident #43's room and assisting with raising the HOB and meal tray set up. CNA # 100 left Resident #43's room without performing hand hygiene.Interview on 10/29/25 at 12:37 P.M. with CNA #100 verified they had not used hand hygiene during lunch tray pass. 3. Record review of Resident #40's medical record revealed an admission date of 02/29/24. Diagnoses include unspecified dementia, left hand contracture, hypertensive heart and chronic kidney disease with heart failure and stage I through IV chronic kidney disease, history of falling, orthostatic hypotension, essential primary hypertension, cerebral ischemia, and cognitive communicative deficit.Review of Resident #40's Minimum Data Set 3.0 dated 10/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 03 indicating the resident had severe cognitive impairment.Observation on 10/29/25 at 12:27 P.M. revealed STNA #100 remove a clear plastic bag with linen from a chair to sit near Resident #40 in the dining room and did not perform hand hygiene prior to performing meal tray set up for Resident #39 and feeding the resident.Interview on 10/29/25 at 12:37 P.M. with CNA #100 verified they had not used hand hygiene during lunch tray pass.Review of the facilities Infection Control policy dated 11/28/16 and revised 03/25 verified it is the policy of the community to establish guidelines to follow to facilitate maintaining a safe, sanitary and comfortable environment; to proactively prevent and manage transmission of diseases and infections; to identify, reduce, control or prevent the risks of acquiring and transmitting infections among residents, employees, volunteers, visitors and other. The policy also states hand hygiene policies will be followed by all employees.

Based on medical record review, observation, staff interview and facility policy review, the facility failed to complete incontinence care appropriately. This affected one resident (Resident #33) observed for incontinence care. The facility census was 76.Findings include:Review of Resident #51's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included severe protein malnutrition, peripheral vascular disease (PVD), acute kidney disease (AKD) and history of falling. Review of the quarterly minimum data set (MDS) assessment revealed her cognition was severely impaired. She required supervision or touching assistance for eating, was dependent on oral hygiene, toileting, bathing/showering, dressing, personal hygiene and turning and repositioning. Resident #51 was always incontinent of bowel and bladder. No falls and no pressure areas were coded on the MDS. On 10/29/25 at 10:35 A.M. observation of incontinence care provided to Resident #51 revealed certified nursing assistant (CNA) #137 washed her hands and put on gloves, and after washing and rinsing the vaginal area and creases CNA #137 put a clean adult brief on Resident #51. Resident #51 did not have her vaginal area dried after being washed and did not have her buttocks, rectal, and coccyx area cleansed during the incontinent care by CNA #137. Interview with CNA #137 on 10/29/25 at 10:47 A.M. verified she had not dried the resident or washed the buttocks, rectal or coccyx area during incontinent care. Review of the facility policy and procedure Incontinence Care Male and Female Residents dated 08/13/21 revealed after washing and rinsing dries the genital area moving from front to back with dry cloth towel/washcloth. Turns to the side then washes the rectal area moving from front to back using a clean area of the washcloth for each stroke. Rinse and dry the rectal area. This deficiency represents non-compliance investigated under Complaint Number 2652939.

Based on closed record review, hospital record review, policy review and interview the facility failed to implement a comprehensive, resident centered plan for the prevention and treatment of pressure ulcers.Actual Harm occurred on 09/03/25 when Resident #86, who had resided in the facility less than 30 days, was cognitively impaired and required staff assistance with activities of daily living, was assessed to have an unstageable pressure ulcer to the sacrum with necrosis requiring debridement. Resident #86 had been admitted to the facility on [DATE] with a skin alteration to the coccyx that the facility failed to complete a comprehensive wound assessment of, failed to provide appropriate/adequate interventions for and failed to ensure the facility wound physician and wound nurse were timely notified of to prevent the deterioration of the alteration to an unstageable pressure ulcer. This affected one resident (#86) of three residents reviewed for pressure ulcers. Findings include: Review of the closed medical record revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including acute osteomyelitis left ankle and foot, anorexia, sepsis due to methicillin-resistant Staphylococcus aureus (MRSA), aftercare following surgical amputation, type 2 diabetes mellitus, peripheral vascular disease, congestive heart failure, atrial fibrillation, osteoarthritis of the knee, dementia, irritant contact dermatitis, and open wound on left foot. Resident #86 was discharged from the facility on 09/03/25 to the hospital and did not return to the facility following the hospitalization. Review of the hospital record dated 08/24/25 revealed the resident was being discharged to the facility and had Moisture Associated Skin Damage (MASD), skin inflammation caused by prolonged exposure to moisture, leading to skin breakdown and irritation, present to the buttocks with Triad cream (sterile, zinc-oxide base, hydrophilic paste to create a moist environment that aids autolytic debridement) ordered for treatment. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 had severe cognitive impairment. The assessment revealed Resident #86 required maximal (staff) assistance with bed mobility. The MDS also revealed Resident #86 was always incontinent of bowel and bladder. The initial assessment completed did not indicate the resident was admitted to the facility with any type of skin alterations. A care plan dated 08/24/25 revealed Resident #86 was at risk for skin breakdown and development of pressure injury. The care plan included Resident #86 had a left foot wound related to partial second metatarsal amputation, moisture associated skin damage (MASD), and redness under both breasts. Interventions included assisting with turning and repositioning every two hours and as needed, assisting with maintaining skin clean and dry daily, monitoring for MASD/redness and left foot wound for signs and symptoms of infection every shift, completing treatments as ordered, weekly skin assessments as scheduled, and the wound physician/nurse to evaluate and treat as ordered. Record review revealed no documented evidence staff were encouraging or providing turning and repositioning every two hours. In addition, there was no evidence Resident #86 was noncompliant with care or interventions. A physician order dated 08/24/25 revealed Resident #86 was ordered Triad paste to buttocks for incontinence every day and night shift. The resident also had an order for HydraGuard (moisture barrier) to be applied every shift after incontinent episodes for prevention. Review of the treatment administration record (TAR) revealed the treatments were completed per orders.A Braden Scale for Predicting Pressure Sore Risk dated 08/24/25 revealed Resident #86 scored a 14 out of a possible 18 which indicated Resident #86 was at moderate risk for pressure ulcer development. A skin and wound evaluation dated 08/24/25 at 12:01 P.M. included Resident #86 had an unstageable pressure wound to the coccyx. The evaluation noted the wound was present upon admission and measured 9.4 centimeters (cm) long and 0.94 cm wide. The author of the assessment did not sign the document or provide a description of the coccyx wound. A black and white photo dated 08/24/25 was provided for the surveyor from the medical record. No unstageable wound could be identified to the resident's coccyx or buttocks. The quality of the photograph did not support the said stage of the wound.An admission Screener dated 08/24/25 at 3:25 P.M., completed by LPN #200, revealed Resident #86 had an open area to the coccyx. There was no description or staging of the wound despite the document having an anatomical drawing, descriptions of wound staging and areas to document wound measurements. Review of hospital documentation and the facility skin assessments (MDS, skin and wound evaluation, admission screener) for this area were inconsistent at the time of admission, noting the resident had MASD, an open area and an unstageable pressure ulcer to the sacrum. No additional documentation or evidence was provided by the facility to support a comprehensive and accurate assessment, including description and staging of the ulcer was completed. A physician order dated 08/26/25 revealed Resident #86 was ordered Triad paste to be applied to the resident's sacrum for MASD every day and night shift. This order was changed to reflect MASD and not incontinence from the original order dated 08/24/25. The treatment administration record (TAR) revealed Registered Nurse (RN) #200 signed a skin assessment was completed on 08/29/25. Review of the medical record revealed no documentation of the skin assessment and no evidence wound photographs were taken on this date.A physician order dated 09/02/25 revealed Resident #86 was ordered an alternating air mattress for pressure relief. No nutrition interventions were implemented despite the residents increased energy demands with a healing surgical wound and skin alteration to her coccyx. There was no documentation of the wound at this time.Review of the nursing progress notes dated 08/24/25 through 09/02/25 (prior to the wound physician's visit on 09/03/25) revealed no comprehensive documentation of the resident's wound to her coccyx or buttocks, no documentation of the resident's compliance or noncompliance with pressure relieving interventions or evidence any pressure relieving interventions were added except the air mattress (which was ordered on 09/02/25). An initial wound evaluation by Wound Physician #301 dated 09/03/25 revealed Resident #86 had an unstageable wound to the sacrum with necrosis. The wound measured six cm long by 9.5 cm wide with 0.2 cm depth. There was moderate serous exudate with 40-percent thick adherent necrotic tissue and 30-percent slough. The wound was debrided to remove necrotic tissue and establish the margins of viable tissue. A new order was received for Mesalt (a sodium chloride dressing to stimulate the cleansing of discharging wounds) and gauze bordered dressing to be applied to the wound daily and as needed if saturated, soiled, or dislodged. Recommendations included to off-load the wound, reposition per facility protocol, and a low air loss mattress. An interview on 10/21/25 at 10:29 A.M. with Wound Physician #301 revealed he saw all residents with any skin concerns including MASD, open areas, skin tears or pressure ulcers weekly, in the facility. The physician denied being aware or informed of any type of skin impairment/pressure ulcer for Resident #86 prior to 09/03/25. Wound Physician #301 revealed he assessed the resident's pressure ulcer on 09/03/25 and noted it to be unstageable with the measurements noted above (prior to the ulcer being debrided). The physician revealed he had been in the facility on 08/27/25 but had not been informed Resident #86 had any skin impairment on her buttock/sacrum at that time. The physician indicated it was unclear the type of wound that was present (prior to the resident being seen on 09/03/25) given the inconsistencies with the facility skin assessments but stated the resident should have been evaluated by him when the skin alteration/pressure ulcer to the coccyx was first identified as to not delay treatment and to ensure adequate interventions were in place. On 10/20/25 at 3:58 P.M., interview with the Director of Nursing (DON) verified RN #200 stated she completed the weekly skin assessment on 08/29/25 but failed to take wound photos or document the description, including measurements and staging, of the wound. During an interview on 10/21/25 at 10:51 A.M. the Director of Nursing (DON) revealed there was confusion over the type of area Resident #86 had to her buttock/sacrum/coccyx. The DON verified staff labeled the alteration as MASD, an open area, and an unstageable pressure. The DON verified neither MDS assessment or care plan reflected the resident had an unstageable pressure ulcer to the coccyx/sacrum upon admission. The DON also revealed the facility wound nurse was not notified of the resident's skin alteration on admission and expectation is for the wound nurse to be notified. The DON stated the discrepancies in the resident's wound assessment affected the facility's ability to determine if the resident needed additional intervention, care and assessment from the facility wound nurse or assessment from the facility consulting wound doctor. The DON verified RN #200 worked with the resident and felt the RN did assess the resident but failed to document the resident's wound assessment or take photographs per the facility policy/procedures. On 10/21/25 at 12:13 P.M. Administrator indicated the resident's MDS assessment was updated to reflect Resident #86 was admitted with an unstageable pressure ulcer (despite there being no documented evidence the resident had an unstageable pressure ulcer on admission according to the assessments provided).An interview on 10/23/25 at 9:25 A.M. RN/Wound Nurse #204 revealed the floor nurses take pictures of the wounds and should do measurements and a description of the wound. RN/Wound Nurse #204 verified LPN #200 only documented the measurements and did not document slough or any other description of the wound. RN/Wound #204 stated any skin concerns should have a wound consult order put in. This order would identify the resident needed to be seen by the facility wound nurse and the outside wound doctor. The nurse verified the resident's pressure ulcer declined from admission on [DATE] to 09/02/25 when she evaluated the wound and implemented the air mattress. The wound nurse did not have any documentation of the wound on 09/02/25 to provide. The wound nurse stated the Wound Doctor should have seen the resident's wound when he visited on 08/27/25 and she should have been notified of the resident's skin alteration on admission.An interview on 10/23/25 at 11:19 A.M. LPN #200 stated pictures were taken of any skin open areas, but LPN #200 does not think she would have staged a wound. LPN #200 could not recall any specific details about Resident #86 but verified she would have taken a picture if there was an open area but could not recall any other details about the resident's wound and verified she did not document an assessment of the resident's skin to provide her additional details. Wound Care Treatment Guidelines dated 03/31/22 revealed a weekly assessment should be done on all wounds requiring treatment. This should include measurements and a description. Documentation of the treatment should be done immediately after the treatment. This deficiency represents non-compliance investigated under Complaint Number 2609622.

Based on observation, record review, review of wound notes, facility policy review and interview, the facility failed to assess, monitor, and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers and failed to ensure adequate interventions were in place to prevent new pressure injuries for Resident #61. Additionally, the facility failed to comprehensively assess, monitor and implement a treatment for Resident #80's unstageable (full-thickness skin and muscle loss, with slough or eschar obstructing the wound bed making it impossible to determine the true depth of the ulcer.) pressure ulcer on admission to the facility for more than two days. Actual harm occurred on 11/02/24 when Resident #61 who utilized a wheelchair and was dependent on staff for bed mobility developed an unstageable pressure ulcer to the left heel as a result of propelling himself in his wheelchair with no shoes on and/or no off-loading of the left heel while in bed. The facility failed to implement comprehensive and individualized interventions to prevent the development of the pressure ulcer and failed to properly assess, monitor, or implement skin interventions for the unstageable pressure injury until 11/07/24. This affected two residents (#61 and #80) of three residents reviewed for pressure ulcers. The facility census was 72. Findings Include: 1. Review of the medical record for Resident #61 revealed an initial admission date of 09/28/24 with diagnoses including chronic obstructive pulmonary disease, nicotine dependence, pressure induced deep tissue damage to left heel, dysphagia (difficulty swallowing), hypertension, retention of urine, history of traumatic brain injury, and constipation. Review of the resident's admit/readmit screener dated 09/28/24 revealed the resident was admitted to the facility with no skin issues. Review of the resident's Braden scale dated 09/28/24 revealed the resident was at risk for skin breakdown. Review of the plan of care dated 09/30/24 and last revised on 05/20/25 revealed the resident had a potential for development of pressure injuries and other skin impairment related to acute on chronic health conditions, impaired strength and endurance, generalized weakness, lack of coordination, debility, recent acute kidney infection, anemia, history of right radial fracture and right hip fracture/surgery, anticoagulant injections, potential edema to right lower extremity and had a pressure injury to his left heel. Interventions included administer treatments/preventative measures as ordered, monitor for side effects and effectiveness, notify physician with any concerns, assist/encourage resident to turn/reposition as needed, as ordered/tolerated, monitor areas of skin impairment for signs/symptoms of infections, notify physician as needed, assist with maintaining skin clean and dry daily, provide local care to areas of skin impairment as ordered, Dietician will evaluate nutritional status and make recommendations as needed, encourage good food and fluid intake as needed to promote nutritional status, encourage, assist as needed/ tolerated to float heels when in bed daily, monitor skin with daily cares for redness, blisters, dark discolorations, skin pep to heels as ordered, the resident has increased risk of bruising related to anticoagulant use. Monitor/Document/Report all new instances of bruising, weekly skin assessment as scheduled and wound physician/nurse will evaluate and treat as ordered. On 11/07/24, Prevalon boots as ordered were added. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident was at risk for skin breakdown and had no unhealed pressure ulcers. The assessment indicated the facility implemented a pressure-reducing device to the bed/chair and application of ointments/medication other than to feet. Review of the progress note dated 11/02/24 at 7:31 P.M. revealed a certified nursing assistant (CNA) notified the nurse the resident had a dark painful mark on his left heel. The nurse observed what appeared to be an 8.0 centimeter (cm) unstageable pressure area with intact skin. Management and the resident's power of attorney (POA) were notified of the area. Review of the weekly skin and wound evaluation dated 11/02/24 revealed the resident was found to have an unstageable pressure ulcer to his left heel that was not present on admission. The wound measured 4.2 centimeters (cm) by 2.8 cm with slough and/or eschar present. The assessment had no description of the wound. Review of the medical record revealed no treatment or intervention implemented for the unstageable pressure injury to the resident's left heel. Further review revealed no documented evidence the resident's physician was made aware of the unstageable DTI to the resident's left heel at the time of discovery. Review of the weekly wound physician note dated 11/06/24 revealed the unstageable wound to the resident left heel measured 4.2 cm by 6.2 cm with no exudate and described as an intact purple/maroon discoloration. The treatment to paint with betadine daily was implemented. Review of the late entry progress note dated 11/07/24 at 8:05 A.M. revealed the resident was noted to have a deep purple bruise to the left heel upon a skin assessment. The resident was unaware of how the bruise occurred. The note indicated wound physician was to follow. Intervention of Prevalon boots to both heels was implemented. The family as well as the physician were made aware of the area. Review of the residents' November 2024 Treatment Administration Record (TAR) revealed on 11/07/24 the treatment of paint left heel with betadine daily for wound care was initiated. Review of the late entry interdisciplinary team (IDT) progress note dated 11/08/24 at 9:49 A.M. revealed the team met and discussed the area to the resident's left heel and the intervention of Prevalon boots in place when in bed was appropriate. Weekly wound physician assessments were completed on 11/13/24, 11/20/24, 11/27/24, 12/04/24, 12/11/24, 12/18/24, 12/25/24, 12/30/24, 01/08/25, 01/15/25, 01/22/25, 01/29/25, 02/05/25, 02/12/25, 02/19/25, 02/26/25, 03/05/25, 03/12/25, 03/19/25 and 03/26/25 which included measurements of the ulcer each week and status of the ulcer (i.e. improving and/or at goal). Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors including rejection of care. The assessment indicated the resident was at risk for skin breakdown and had one unstageable pressure ulcer not present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care and applications of ointments/medications other than to feet. Weekly wound physician assessments were completed on 04/02/25 and 04/09/25 with wound measurements included. Review of the weekly wound physician progress note dated 04/16/25 revealed the unstageable pressure ulcer to the resident's left heel measured 1.8 cm by 2.4 cm and described as 100% adherent thick devitalized necrotic tissue with a moderate amount of serous exudate. The facility determined the wound had improved (although there was the presence of 100% adherent thick devitalized necrotic tissue and a moderate amount of serous exudate which had not been present during the previous weeks assessments). The treatment was changed to cleanse the wound apply Mesalt and cover with gauze island with border dressing daily and as needed if saturated, soiled or dislodged at this time. Weekly wound physician assessments were completed on 04/23/25 (1.4 cm by 0.2 cm and described as 30% thick adherent devitalized necrotic tissue, 20% slough, 30% granulation tissue and 20% dermis, subcutaneous or tendon with a moderate amount of serous exudate) and 04/30/25 (1.3 cm by 2.3 by 0.2 cm and described as 20% thick adherent devitalized necrotic tissue, 20% slough, 40% granulation tissue and 20% dermis, subcutaneous or tendon with a moderate amount of serous exudate). Review of the weekly wound physician progress note dated 05/07/25 revealed the unstageable pressure ulcer to the resident's left heel measured 0.9 cm by 1.4 cm by 0.2 cm and described as 100% granulation tissue with a moderate amount of serous exudate. The facility determined the wound had improved. Weekly wound physician assessments were completed on 05/14/25, 05/21/25, 05/28/25 and 06/04/25 with measurements and the status of the ulcer documented. Review of the resident's monthly physician orders for June 2025 revealed the following orders: an order dated 09/28/24 to assist resident to float heels as tolerated every shift for prevention, assist resident to turn and reposition every two hours as tolerated every shift for prevention and skin prep to bilateral heels every shift. On 11/07/24 Prevalon boots were ordered to be worn to bilateral feet when in bed. On 02/24/25 an order was initiated to complete skin and wound total body assessment weekly on Wednesday day shift. On 04/03/25 an order was received for active liquid protein 30 milliliters (ml) in eight ounces of water or juice for wound healing. On 04/16/25 an order was obtained to monitor left heel for signs/symptoms of infection every shift. On 05/17/25 an order was obtained for skin and wound picture due every day shift on Wednesday until healed and on 05/19/25 a treatment order was obtained to cleanse left heel with wound cleanser, pat dry, apply Mesalt and cover with island dressing daily and as needed for saturation or dislodgement. On 06/05/25 at 11:15 A.M., an interview with Licensed Practical Nurse (LPN) #146 revealed Resident #61 was admitted to the skilled unit (on 09/28/24) and developed the pressure injury (to the left heel) while on the skilled unit. The LPN revealed the resident was then transferred to the long-term care unit located on the first floor with the pressure injury on 10/24/24: however, in report she was told the resident preferred to position his foot with the area of the wound on the bed which resulted in the pressure injury. On 06/05/25 at 2:20 P.M., an observation of LPN #146 provided the physician ordered treatment to the unstageable pressure injury to the resident's left heel. Observation of the wound revealed the wound was the size of a nickel with a pink wound bed and beige edges. The LPN provided the treatment as ordered. On 06/05/25 at 9:25 A.M., an interview with the Director of Nursing (DON) revealed the facility determined the DTI to the resident's left heel was caused by the resident using his feet to propel himself in his wheelchair. Further interview revealed the DON was unsure why the pressure injury was not found until it was an unstageable DTI when the facility nurses had been documenting they were applying skin prep to his bilateral heels every shift (from admission [DATE] through 11/02/24). On 06/05/25 at 3:00 P.M., an interview with the DON verified the unstageable DTI to Resident #61's left heel was first identified on 11/02/24 and a comprehensive assessment, monitoring or treatment was not completed until 11/06/24 when the facility contracted wound physician assessed the wound and implemented offloading interventions and treatment. 2. Review of the closed medical record for Resident #80 revealed an initial admission date of 05/10/25 with diagnoses including metabolic encephalopathy, palliative care, congestive heart failure (CHF), atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease or end stage renal disease, anemia, dysphagia, open wound right lower leg, anxiety disorder, gastrostomy status, tracheostomy status, acute respiratory failure with hypoxia, constipation, diabetes mellitus, end state renal disease, acquired absence of left foot, and insomnia. Review of the hospital Discharge summary dated [DATE] revealed the resident had an unstageable pressure ulcer to his sacrum and right heel. Review of the admit/readmit screener dated 05/10/25 revealed the resident was admitted to the facility from a specialty select hospital and was dependent on staff for all activities of daily living (ADL). The assessment indicated the resident had no skin issues on admission. Review of the Braden scale dated 05/10/25 revealed the resident was at very high risk for skin breakdown. Review of the plan of care dated 05/12/25 revealed the resident was at risk for skin breakdown and development of pressure injury. Interventions included assist with maintaining skin clean and dry daily, dietician will evaluate nutritional status and make recommendations as needed, encourage good food and fluids intake as needed to promote nutritional status, encourage, assist as needed/tolerated to float heels when in bed daily, monitor skin with daily cares for redness, blisters, dark discoloration, skin prep to heels as ordered, weekly skin assessment as scheduled and wound physician/nurse will evaluate and treat as needed. Review of the resident's physician orders identified orders dated 05/12/25 to cleanse coccyx wound with wound cleanser, pat dry, apply Opti foam border dressing daily, cleanse mid pretibial right cellulitis with wound cleanser, pat dry, cover with non-adherent dressing and wrap with gauze daily, cleanse sacrum with wound cleanser, pat dry, apply Mesalt to wound bed, cover with gauze island dressing daily, assist resident to float heels as tolerated every shift for prevention, alternating air mattress every shift, no fitted sheets, one flat sheet and draw sheet only on air mattress, assist resident to turn and reposition every two hours as tolerated and HydraGuard Moisture Barrier apply topically to peri area and bilateral buttocks every shift and after each incontinence episode. Review of the progress note dated 05/16/25 at 2:10 P.M. revealed the hospice nurse provided skin care to the buttocks and right lower extremity. Review of the skin and wound evaluation dated 05/16/25 which was in progress revealed the resident had an unstageable pressure ulcer to the right heel that was present on admission to the facility. The wound measured 2.7 centimeters (cm) by 1.0 cm. The assessment had no description of the wound. Review of the medical record revealed no documented evidence the resident's unstageable pressure ulcers were comprehensively assessed. Review of the resident's May 2025 Treatment Administration Record (TAR) revealed the resident had no documented treatment to wounds until 05/12/25, two days after the resident's admission to the facility. On 06/05/25 at 3:00 P.M., an interview with the DON verified the unstageable pressure ulcer to the resident's sacrum and right heel were not comprehensively assessed and a treatment was not implemented until 05/12/25 two days after the resident's admission. Review of the facility policy titled, Wound Skin Program, implemented on 03/30/12 and last revised 05/28/25 revealed all residents would be evaluated for specific level of risk for decreased skin integrity on admission and readmission using the Braden Scale. Re-assessment would be done quarterly or whenever the resident shows evidence of significant clinical change or development of an ulcer. The skin team would assess, measure and document all pressure ulcers. A signed physician's order regarding wound treatment must be kept on the resident's chart. The order must be specific and if applicable the order should also have a stop date. The wound nurse/designee would be responsible for the initial assessment of any wound using the Skin and Wound Evaluation form. The physician/nurse practitioner (NP), family, wound care nurse would be notified of new areas. Initial documentation would include specific description of the wound and pertinent history, co-morbidities, nutrition, continence and other contributing factor information. This deficiency represents non-compliance investigated under Complaint Number OH00165908 and Complaint Number OH00165299.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of the facility Medical Appointment and Transportation policy and procedure and interview with facility staff and Bystander #910 the facility failed to provide adequate supervision to Resident #24, who was assessed to have cognitive impairment, delusional disorder and was dependent on staff activities of daily living, following an appointment outside the facility on [DATE] at 1:00 P.M. Resident #24 did not timely return to the facility and his whereabouts were unknown for an extended period of time. This resulted in Immediate Jeopardy and the potential for serious harm, injury or death on [DATE] when facility staff failed to timely identify Resident #24 had not returned from the appointment or investigate his whereabouts, after being transported by a contracted transportation company, until the resident was found on [DATE] at approximately 9:45 P.M. after dark, approximately 0.2 miles from the facility in a driveway of a neighboring private residence. This affected one resident (#24) of three residents reviewed for outside medical appointments. The facility census was 74. On [DATE] at 3:20 P.M. the Interim Director of Nursing (DON), Chief Operations Officer #940, Registered Nurse Unit Manager (RN) #206 and Licensed Practical Nurse Unit Manager (LPN) #200 were notified Immediate Jeopardy began on [DATE] at 12:00 P.M. when Resident #24, who required 24 hour supervision and care was last seen in the facility, leaving for an outside medical appointment (scheduled for 1:00 P.M.) with a contracted transportation company and failed to return to the facility. Facility staff failed to timely inquire or investigate the resident's whereabouts when the resident failed to return to the facility. The facility had no knowledge of Resident #24's whereabouts until [DATE] at approximately 9:45 P.M. when they were contacted by the local police the resident had been located approximately 0.2 miles from the facility in a driveway of a neighboring residence. The resident was assessed by local fire department staff and then subsequently returned to the facility. The Immediate Jeopardy was removed and subsequently corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 9:45 P.M. Resident #24 was returned to the facility by local fire department who also assessed the resident. Upon return to the facility, Resident #24 was assessed by LPN #209. · On [DATE] at approximately 2:47 A.M. Resident #24's physician was notified of the incident by LPN #209. No new orders were obtained at that time. · On [DATE] at approximately 9:00 A.M. a Quality Assurance Performance Improvement meeting was held with the Interdisciplinary Team to discuss process enhancement related to this incident. Meeting attendees included the Administrator, Chief Operations Officer #940, Chief Human Resources Officer #930, Registered Nurse Unit Manager (RN) #206 and Licensed Practical Nurse Unit Manager (LPN) #200. · On [DATE] RN #206 filed a complaint against the contracted transportation company who provided transportation for Resident #24 on [DATE] to and from the medical appointment. This transportation company was also excluded from providing transportation services for residents in the facility effective immediately. As of [DATE] no additional information was available related to the status of the complaint filed against the company. · On [DATE] the Interdisciplinary Administration Team revised the facility Medical Appointment and Transportation policy and procedure to include that residents with a Brief Interview for Mental Status (BIMS) score of 12 or less (moderate to severe cognitive impairment), must be escorted to all appointments by facility staff. Additionally, the policy was updated to include if a resident had been out of the facility for more than four hours or had not returned to the facility by 4:30 P.M., the floor nurse assigned to the resident would follow up with the physician's office and transportation company to determine the residents location. The new written policy was finalized on [DATE] and distributed to all nursing units with a plan implemented for education to continue for newly hired staff. · On [DATE] Infection Preventionist Outcomes Manger #211 and the DON/Designee initiated education for all licensed nursing staff regarding the updated transportation protocol. Education was completed on [DATE]. Review of the Transportation/Appointment Protocol education sheets revealed 26 nursing staff signatures were included on the education. · On [DATE] the DON/designee initiated education for all nursing staff related to the facility abuse/neglect policy and procedure. Education, including abuse and neglect quizzes were completed for all staff by [DATE]. Review of the staff education sign in sheet for abuse dated [DATE] verified the completion of all staff education. · On [DATE] the DON/designee initiated daily audits to ensure residents returned from scheduled appointments. A plan for the daily audits to continue for four weeks and then as needed was implemented. The facility provided evidence of completed Resident Transportation Audit forms from [DATE] through [DATE]. · On [DATE] LPN #215, the nurse assigned to care for Resident #24 on [DATE] was terminated for failure to timely follow up on Resident #24's location after he left for the appointment and did not return to the facility. The Administrator also reported the LPN to the Ohio Board of Nursing related to the incident. · On [DATE] at 8:38 A.M. and 8:47 A.M. interviews with RN #203 and LPN #204 respectively, revealed a new procedure was implemented following the incident with Resident #24 (on [DATE]). Both nurses were knowledgeable of the need to follow up with the physicians' offices if a resident had been out of the facility for an appointment for more than four hours. If the provider's office revealed the resident had left, the nurse would follow up with the transportation company to locate the resident. · Additional interviews from [DATE] through [DATE] with LPN #202, #200 and #210 and State tested Nursing Assistant (STNA) #302, #303 and #304 revealed these staff were knowledgeable of the facility abuse/neglect and updated transportation procedures. · Between [DATE] and [DATE] no additional concerns related to transportation for any residents were identified. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including [CONDITION(S)] of left ankle and foot, diabetes mellitus, delusional disorder, [CONDITION(S)], [CONDITION(S)], sleep apnea, chronic kidney disease and heart failure. Record review revealed the resident had a pacemaker. The plan of care dated [DATE] revealed Resident #24 had impaired cognitive function/dementia or impaired through processes related to short term memory loss. Resident #24 was noted at times to be inappropriate with female staff and easily redirected. Interventions included to ask yes or no questions to determine needs, communicate with resident and family regarding needs and provide opportunities for resident and family to participate in care. The plan of care dated [DATE] revealed Resident #24 was prone to activities of daily living deficits related to acute and chronic health conditions, overall weakness and debility, total incontinence of bowel and bladder, marked impaired mobility (non-ambulatory) and obesity. The resident required 24-hour care and supervision. Interventions included the use of a mechanical (Hoyer) lift with two staff for transfers, assistance of one to two staff with daily bathing, hygiene, dressing and grooming as resident was unable to complete independently, maintain call light within reach, and shower/bathe per resident's personal preference. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #24 had impaired cognition with no behaviors. The assessment revealed the resident required extensive assistance of two staff for bed mobility and transfers and was dependent on staff for dressing, toileting and hygiene. The resident was non-ambulatory and required assistance of one staff for wheelchair mobility. Review of a nursing progress note, dated [DATE] at 10:18 P.M. and authored by LPN #209 revealed Resident #24 was returned to the facility via local fire department at 9:45 P.M. The resident was assessed and noted to be alert and oriented to person and place with periods of confusion. Resident #24 was unable to give a description of what happened. The resident was assessed by the nurse and offered dinner and fluids. The resident's blood sugar was noted to be 152 at the time of his return. Record review revealed on [DATE] the facility submitted a Self-Reported Incident (SRI), tracking number 4, related to an allegation of neglect/mistreatment involving Resident #24. The SRI revealed Resident #24 had an appointment with an outside physician on [DATE] and had not returned to the facility in anticipated amount of time. The facility nurse supervisor was contacted by the police department during the evening and notified the resident was at a residence near-by the facility. The police brought the resident to the facility that evening. The resident was unable to provide meaningful information due to delusional disorder. At the time the SRI was submitted the facility indicated the investigation was currently ongoing with the leadership of the transportation company as to the reason the resident was not brought back to the facility after his physician appointment. The facility substantiated the allegation of neglect. Review of the medical record did not reveal a physician order or any progress notes regarding any type of medical appointment scheduled for Resident #24 on [DATE]. Review of a facility investigation interview dated [DATE] and conducted by RN #206 with the responding police officer (Officer #920) revealed he was the responding officer called to the community (private) residence where Resident #24 was found. Officer #920 reported being called to the residence which was approximately 0.2 miles away from the facility by the homeowner's daughter. The report revealed the resident was unable answer questions but had an appointment packet on him (which identified the nursing home). The officer called the facility and spoke with a nurse. The resident was evaluated by local medics and then returned to the facility via the local fire department. Review of a telephone interview dated [DATE] and conducted by RN #206 with LPN #215 revealed LPN #215 confirmed she worked on [DATE] and was aware Resident #24 had a doctor's appointment scheduled at 1:00 P.M. that day. LPN #215 reported she wheeled Resident #24 downstairs in his wheelchair and outside to the waiting transportation vehicle. LPN #215 verified the STNA on duty asked her where Resident #24's appointment was and what it was for, that afternoon, and she responded she did not know. The LPN confirmed she did not [MEDICATION(S)] to find out the whereabouts of Resident #24 after he left for the appointment. LPN #215 reported she called the day shift nurse supervisor (LPN #210) at approximately 6:00 P.M. on [DATE]. LPN #215 reported the supervisor instructed her to call Resident #24's daughter to inquire about the resident's whereabouts. The interview further revealed LPN #215 did not want to worry Resident #24's daughter and she did not call her. LPN #215 then passed the information on, that Resident #24 had not returned from his daytime appointment, to the night shift nurse who relieved her at 7:00 P.M. On [DATE] at 12:04 P.M. interview with LPN #200 revealed she was the unit manager on the unit where Resident #24 resided. The LPN revealed it was her understanding on [DATE] the resident had convinced the transportation company to drop him off at his old residence (close by the facility) following his appointment, rather than the facility. The LPN further revealed the resident was confused and manipulative at times and stated the resident should not have been sent to the appointment without staff to accompany him. On [DATE] at 2:01 P.M. interview with Nursing Facility Coordinator #401 revealed transportation was scheduled for Resident #24 by the facility and the resident's insurance for a third-party provider. The Coordinator revealed there was a form that should be completed for each instance of resident transportation, that specified if the resident should be accompanied by staff or could go to appointments without supervision. The Coordinator revealed if a resident was alert and oriented, they could go to appointments on their own, but otherwise staff should accompany them. The Coordinator revealed the form was not filled out for Resident #24 and this appointment, because the facility received the appointment reminder from the physician's office in the mail, on letterhead, and that same letterhead appointment reminder was used to write the transportation information on, rather than start a whole new form. On [DATE] at 4:51 P.M. interview with RN #206 revealed the RN believed the facility policy was unclear regarding residents being escorted to appointments by staff. RN #206 revealed Resident #24's family usually met him at his appointments but did not this time. RN #206 further revealed Resident #24 probably should have been escorted to his appointment by staff. RN #206 confirmed the resident was cognitively impaired and often confused. RN #206 confirmed the facility did not know the resident's whereabouts after he left for the appointment until after dark at approximately 9:34 P.M. on [DATE] and that proper steps were not taken to obtain the details of the resident's whereabouts earlier in the day and to ensure his safety. On [DATE] at 12:43 P.M. telephone interview with the manager of the transportation company (Transport #900) confirmed they provided transportation for Resident #24 to his doctor's appointment on [DATE]. Transport #900 indicated the resident had been dropped off in the facility parking lot at the resident's request. Transport #900 revealed the resident was very insistent and demanded to be let out in the parking lot, near a car he stated was his, rather than at the front entrance. Transport #900 revealed the facility later informed them the resident did not make it back to the facility. On [DATE] at 9:34 A.M. telephone interview with Practice Administrator #990 for the Heart and Vascular Clinic revealed Resident #24 had a doctor's appointment scheduled at the clinic for 1:00 P.M. on [DATE]. Practice Administrator #990 further revealed Resident #24 was checked in at 12:21 P.M. for arrival to the clinic and checked out at 12:58 P.M. The Practice Administrator did not have any further details regarding the visit or transportation for the resident. On [DATE] at 10:51 A.M. interview with STNA #303 revealed she was the STNA on shift and caring for Resident #24 on [DATE]. The STNA revealed she cares for Resident #24 regularly, and that he required assistance of two staff for Hoyer transfers and was not able to wheel himself in his wheelchair. STNA #303 revealed she had assisted the resident to get ready for the appointment on [DATE] and was informed transportation had arrived to pick him up. STNA #303 revealed LPN #215 offered to wheel the resident downstairs to the transportation van. STNA #303 revealed she started wondering where the resident was around 2:00 P.M. stating he was usually back from appointments within a couple of hours. STNA #303 revealed she asked LPN #215 what the resident's appointment was for and where it was, and the LPN responded she did not know. STNA #303 revealed she informed LPN #215 again around 3:00 P.M. the resident had not returned and that she was becoming worried about him. The STNA reported she verbalized her fears to LPN #215 who was the nurse on duty, several more times and the LPN responded passively and did not take any action that the STNA was aware of. STNA #303 revealed she reported the failure of the resident's return from his doctor appointment to the third shift aide (STNA #304) at the 6:00 P.M. shift change. On [DATE] at 11:46 A.M. interview with LPN #210 revealed she was the nursing supervisor on duty for day shift on [DATE]. LPN #210 revealed she received a call at approximately 6:00 P.M. from LPN #215 stating Resident #24 had not returned from his doctor appointment. LPN #210 instructed LPN #215 to call the transportation company to find out where the resident was. Attempts to interview LPN #215 during the survey investigation were unsuccessful as the LPN could not be reached and was no longer employed by the facility. On [DATE] at 11:25 A.M. interview with the Administrator revealed she did not receive any calls or notification of Resident #24 missing on [DATE] until approximately 9:00 P.M. The Administrator revealed LPN #208, who was the night shift nurse supervisor called her and informed her Resident #24 had not returned from when he left the facility at 12:00 P.M. that day and the resident's whereabouts were currently unknown. The Administrator revealed she was on the phone with LPN #208 when the police called the facility and informed the nurse the resident had been found. On [DATE] at 11:55 A.M. telephone interview with Bystander #910 revealed she had found a gentleman (later identified to be Resident #24) on [DATE] at approximately 8:45 P.M. Bystander #910 revealed she was checking on her parent's house because they were out of town and when she pulled into the driveway, the resident was outside sitting in a wheelchair in the driveway of her parents' home. Bystander #910 revealed Resident #24 was unable to answer her questions and stated it quickly became clear he was confused so she called the police. Bystander #910 reported the police responded quickly and found an appointment packet the resident had on his person which identified he resided at the nursing home. On [DATE] at 7:43 A.M. interview with LPN #208 verified she was the night shift nurse supervisor on [DATE]. LPN #208 verified she received a call from the night shift nurse at approximately 9:00 P.M. reporting Resident #24 had not returned to the facility following his doctor appointment much earlier that day and the resident's whereabouts had been unknown for approximately nine hours. LPN #208 reported she immediately logged into the electronic medical record to obtain the resident's family contact information and that was when her phone rang, and it was the police, reporting they had found Resident #24. Review of the facility policy titled Medical Appointment and Transportation, dated [DATE] and in place at the time of Resident #24's appointment on [DATE] revealed the policy did not address follow up for a resident in the event of the resident not returning to the facility timely. Review of the revised facility policy titled Medical Appointment and Transportation, dated [DATE] revealed residents would be escorted by staff person or designee, to appointment if the resident had a BIMS score of 12 or less, or if the family was unable to attend the appointment. The policy further revealed if the resident had been out of the facility on the appointment for more than four hours or had not returned from the scheduled appointment by 4:30 P.M., the residents nurse would follow up with the physician's office and transportation to obtain the resident's location. Additionally, the nurse shall then report any concerns to the supervisor on duty, Unit Manager or Director of Nursing for any follow up action. This deficiency substantiates Complaint Number OH 750.

Based on observation, medical record review, review of the facility's policy Wound and Skin Program, staff interview, and resident interview, the facility failed to provide care to prevent the development of pressure sores and provide care and treatment to promote healing of pressure sores causing harm to three (#126, #200 and #300) of six residents reviewed for pressure sores. The facility identified 14 residents with pressure sores. Resident #126 developed a stage III pressure sore (full thickness tissue loss) on 10/18/12 after admission to the facility. The pressure sore was not discovered until a stage III sore developed which progressed to 90 % necrosis by 10/23/12. Resident #126 developed an additional two stage III pressure sores on 11/05/12. The pressure sores were discovered by the facility at stage III pressure. Resident #200 developed a pressure sore after admission to the facility. The pressure sore was not discovered until a stage III pressure sore had developed. Resident #300 developed a pressure sore after admission to the facility. The pressure sore was discovered at stage III when it measured 10 centimeters (cm) by 2 cm with 70% slough Findings include: 1. Review of the clinical record for Resident #126 revealed admission to the facility on [DATE] with diagnoses including [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the wound management physician visit note dated 10/24/12 revealed a note which indicated other than a significant truncal obesity she had no other significant wound healing risk factors other than her diminished muscle strength and inability to ambulate. The report indicated the resident developed increasing bilateral lower extremity [MEDICAL CONDITION], not [MEDICAL CONDITION], with no etiology for this [MEDICAL CONDITION]. The resident was not diabetic. Review of the Minimum Data Set (MDS) assessment completed at admission on 06/27/12 revealed Resident #126 had no pressure areas. Review of the Quarterly MDS assessment completed on 09/17/12 revealed the resident had no pressure areas or venous/arterial ulcers. The resident's cognition score of 13 indicated a reliable interview could be completed. While the notes in Resident #126's medical record indicated the resident was non-compliant with turns and repositioning, the MDS assessments completed on 06/27/12 and 09/17/12 revealed the resident did not reject care. There was no documentation of rejection of care until the resident started having skin issues. Review of the assessments also indicated the resident was dependent for bed mobility, bathing, dressing and incontinence care. Review of the plan of care (no date) for altered skin integrity revealed the resident was at risk due to impaired mobility, diabetes (which she had no [DIAGNOSES REDACTED]. Interventions included the resident was to be assisted with turns every two hours, nutrition, incontinence care, monitor skin folds, elevate heels while in bed, provide pressure relief mattress, pressure relief cushion in the chair, and skin checks weekly. Review of the facility policy, Wound and Skin Program (dated 06/18/12), revealed a Stage III pressure ulcer was described as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle were not exposed. Slough may be present but does not obscure the depth of tissue loss. It indicated a stage III pressure ulcer could include undermining and tunneling. The description given for unstageable was full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and or eschar (tan, brown or black) in the wound bed. The policy revealed until enough slough and or eschar was removed to expose the base of the wound, the true depth, and therefore stage, could not be determined. The protocol, per facility policy, directed staff to provide the following to a Stage III pressure sore: off load area and a pressure redistribution air mattress. The definition of eschar per rule was described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that had lost its usual physical properties & biological activity. Eschar could be loose or firmly adhered to the wound. Slough is necrotic/vascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy (at times). A stage III pressure ulcer was defined as one with full thickness tissue loss. Subcutaneous fat could be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss and it may include undermining or tunneling. A stage IV pressure ulcer was defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and it often included undermining and tunneling. Review of the physician's order dated 09/28/12 revealed skin prep applied to both heels every shift. Review of the physician's orders for Resident #126 revealed the initial treatment to the right heel began on 10/18/12. The description of the right heel pressure sore (which developed in the facility) by the wound team note on 10/18/12 described the area to the right heel as a 2.5 cm by 2.7 cm by 0.1 cm area. The tissue was brown/red in color with scant amount of serous drainage noted. This was the initial finding of the pressure area. The second assessment by the wound team on 10/23/12 described the right heel (plantar) to measure 5.2 cm by 5.2 cm by 0.1 cm deep with 10 % granulation and 90% eschar. The report indicated the resident had a negative pulse to the right foot. Resident #126 was referred to the wound clinic and an initial appointment was completed on 10/24/12 six days later. Review of the description upon assessment of the pressure sores from the wound clinic revealed the right plantar heel area was acquired on 07/02/12 (there was no indication in nursing documentation to indicate treatment to the area until 10/18/12). The description of the area was a measurement of 6 cm. by 6 cm. by 0.2 cm. deep on the right plantar heel. The pressure sore was staged as unstageable with necrotic tissue. The tissue description was described as 76-100% adherent slough, 26-50% moist yellow slough, dry black eschar 26-50% and 26-50% moist eschar. The note indicated this was not normal tissue for this resident. The note indicated the area was warm to touch with a normal pulse. The report indicated good capillary refill and good 3-4+ palpable dorsalis pedis and posterior tibial pulses ( pulses in the feet) bilaterally. Review of the physician's orders from the wound clinic on 10/24/12 for Resident #126 revealed an order for [REDACTED]. The physician ordered keep weight off affected area at all times, turn every 2 hours while in bed, shift weight every 15 minutes while sitting, limit time up in the chair, and rest on sides. The orders included to wear heel guards to keep pressure off heels while in bed or in a chair and please use Lenard Splint to right foot/heel at all times when up and Prevalon boots to both feet/heels at all times when in bed. The physician ordered to continue the use of the speciality bed with alternating air mattress.. Further assessment by the wound team of Resident #126 revealed the team changed the description of the wound from pressure to venous and negative lower extremity pulses. However, the notes from the wound physician disagreed with this finding on 10/24/12 and identified the areas as pressure ulcers and good pulses in bilateral feet at 3-4+. The assessment completed by the wound management team on 10/30/12 indicated the area to the right heel measured 5.0 cm by 4.9 cm and 0.1 cm deep, 10% granulation and 90% eschar. The assessment on 11/06/12 indicated the area measured 4.9 cm by 2.7 cm and 0.1 cm deep with 25% granulation and 75% eschar. Review of the treatment record for Resident #126 for October 24-31 revealed the Lenard Splint to the right foot was circled. There was no explanation on the record why the splint was not provided as ordered. Review of the November 2012 treatment record revealed the Lenard Splint was provided beginning on 11/01/12. The treatment record indicated an air mattress to the bed, not an alternating pressure mattress from October 24 through November 11. A second visit to the wound clinic on 11/08/12 revealed the pressure sore to the right plantar heel measured 5.6 cm by 5.2 cm by 0.2 cm deep. The tissue was described as necrotic tissue, unstageable with a moderate sero-sanguineous, tan drainage with a mild odor. The note identified the right heel pressure as 25-50% dry black eschar and 26-50% moist black eschar with 1-25% granulation. Observation of Resident #126 on 11/10/12 at 9:45 A.M. revealed the speciality mattress provided was set on the static pressure setting. The resident was up in a wheelchair which did have a pressure cushion in the seat. The resident had the Lenard Splint to the right foot. A second observation of the speciality mattress on 11/11/12 at 7:30 A.M. while the resident was asleep in bed revealed the pressure setting was set at static pressure. The selection on the speciality mattress had a setting of alternating pressure but was not used. The resident had no boots on the feet. The feet were elevated off the bed by a pillow but the heels were on the pillow, not floated as ordered. Interview of Resident #126 on 11/10/12 at 9:45 A.M. revealed she did not refuse to turn and reposition and was dependent on staff to do this for her. The resident was asked if the mattress changed air pressure and the resident replied no. The resident stressed during the interview she had no skin problems prior to coming to the facility. A second interview of the resident on 11/11/12 at 7:30 A.M. again stressed no problem with her skin before she came to the facility. Further review of the medical record for Resident #126 revealed on 11/05/12 two new pressure areas developed to the right and left ischial folds. The pressure areas were not identified until a stage III pressure sores had developed. The wound documentation dated 11/06/12 noted the area to the right ischial fold to be a stage III, measuring 2 cm by 6 cm with 0.1 cm deep. The tissue was described as 60% granulation and 40% eschar. The left ischial fold was described as stage III measuring 3.5 cm by 5 cm and 0.1 cm deep with the tissue 60% granulation and 40% eschar. Again, the report indicated the resident was non-compliant with no evidence until the skin issue presented as the resident being non-compliant. The physician visit to the wound clinic on 10/24/12 included an order for [REDACTED]. No open areas were noted to the ischial folds during the visit on 10/24/12. The resident had a urinary catheter to prevent skin breakdown and was dependent on staff to provide bathing, incontinence care and perineal care. The resident was incontinent of bowel and relied on staff for incontinence care. The areas to the right and left ischial folds were not discovered until they were stage III and necrosis was present. The resident was not provided with the alternating pressure mattress as ordered. The resident was referred to the wound clinic on 11/08/12 for assessment. Documentation from the physician identified the two new pressure sores to the right and left ischial folds. as pressure sores. The ischial pressure sore to the left was measured 7.5 cm by 4 cm by 0.1 cm and assessed as stage III. The right ischial pressure sore was identified as stage III and measured 3 cm by 1 cm by 0.1 cm. Both areas were identified with yellow slough tissue. Both areas were identified as having signs and symptoms of infection. The report listed no odor noted from the ischial pressure sores. Interview of the Acting Director of Nursing (ADON) on 11/10/12 at 2:00 P.M. verified the pressure area to the right heel of Resident #126 occurred in house. The ADON verified the pressure area was not discovered until a stage III pressure sore on 10/18/12 and advanced to 90% necrotic unstageable pressure sore by 10/23/12. The ADON verified the Lenard splint to the right foot as ordered on [DATE] was not provided as ordered on [DATE] until 11/01/12 and the physician was not notified for an alternative device. The ADON placed a call to the Unit Manager during the interview. The Unit Manager told the ADON the splint was not available until 11/01/12. The ADON verified the wound clinic physician ordered an alternating air pressure mattress on 10/24/12 but the mattress the facility provided to Resident #126 was set on a static pressure setting. The ADON verified this resident was dependent for positioning. The ADON verified the resident was incontinent and required daily care for incontinence care and bathing. The ADON verified Resident #126 developed an additional two in house pressure sores discovered at a stage III level with necrotic tissue on 11/05/12 of the right and left ischial folds. The treatment to all pressure areas was observed for Resident #126 on 11/11/12. Observation of treatment from 7:45 A.M. to 8:45 A.M. on 11/11/12 by Licensed Practical Nurse (LPN) #20 revealed the area to the right heel plantar was black hard necrotic tissue measuring 2 cm by 4 cm with the outer area of the necrosis open pink/yellow tissue with a moderate amount of drainage. The back of the heel of the right foot was measured separately and measured 1 cm by 2.5 cm. The area was black necrotic hard tissue. The areas to the right plantar heel and the back of the heel were unstageable. Observation of the right ischial fold pressure sore dressing change revealed the area was a pink/red tissue measuring 6 cm by 1 cm by 0.1 cm depth, stage III. Observation of the treatment to the left gluteal fold revealed a foul odor and a large amount of tan drainage. The tissue was gray in color with black necrotic tissue in the center. The area measured 6 cm by 4 cm and 0.1 cm deep. The black necrotic area measured 1 cm by 1 cm. The area was identified as a stage III. The treatment was completed as ordered by the physician. Breaks in infection control was noted during the treatments provided. This was verified by LPN #20 on 11/11/12 at 8:45 A.M. 2. Review of the closed medical record for Resident #200 revealed the resident was admitted to the facility on [DATE] with diagnoses including after care for joint replacement, hypertension, diabetes, anxiety and depression. Review of the minimum data set assessment completed 09/27/12 revealed the resident did not reject care and required maximum assist of one for transfer and bed mobility. The resident required maximum assist of one for bathing, was frequently incontinent of urine and occasionally incontinent of bowel. The assessment indicated the resident was admitted with one pressure area at a stage III measuring 2.7 by 3.0 cm with slough tissue. Review of the Braden scale assessment dated [DATE] revealed a score of 17 which indicated the resident was less than moderate risk for pressure. Review of the admission assessment dated [DATE] listed a red area to the coccyx, open. There were no measurements or further description. Review of the physician's orders on admission and the hospital discharge record revealed no mention of an open area to the coccyx. There were no orders to indicate treatment to the coccyx at the time of admission. Review of the nurses progress notes from the time of admission to 09/28/12 revealed no mention of a pressure area to the coccyx. A note dated 09/28/12 at 7:30 P.M. revealed the resident had [MEDICAL CONDITION] with loose stools and the resident was dependent for incontinence care. Review of dietary notes revealed the initial assessment was completed on 09/25/12. Under the skin section documentation identified the surgical area to the knee with no reference to a pressure area on the coccyx. The check box of pressure ulcer was not checked. The check box for surgical wound was checked with reference to the right knee. Review of the treatment record for Resident #200 revealed no treatment provided to the coccyx area until 9/28/12. Review of the nurse progress note dated 09/28/12 at 11:00 P.M. revealed discovery of two open areas noted at the coccyx sacral area. The smallest measured 0.5 cm x 0.5 cm and 0.1 cm deep. The larger area measured 1.5 cm by 3.0 cm by 0.1 cm wound bed pink/red. The note indicated a standing order initiated to provide remedy repair cream per protocol. A physician's order was initiated on 09/28/12 for treatment to the coccyx. An initial nursing assessment of impaired skin condition was completed on 09/28/12 identifying two open areas on the coccyx with the same measurements as documented in the nurse progress note. Review of an initial wound documentation form indicated 09/28/12 as the date of origination to the pressure area on the coccyx. The body of the note identified the pressure area as a stage III pressure ulcer to the coccyx with the measurement of 2.7 cm by 3.0 cm. The date at the top of the assessment was changed to indicate the pressure area originated on 09/20/12 by obliteration of the 09/28/12 date. The date at the bottom of the assessment continued to reference the date of the report was 09/28/12. The 09/28/12 assessment had an entry dated 09/29/12 that identified the pressure area was one area not two separate areas. Review of the Physician's order written on 09/29/12 revealed an order change to the coccyx to clean with dermal wound cleanser, pat dry, apply Santyl ointment, cover with allevyn dressing and change daily. Review of the weekly wound documentation for Resident #200 revealed an assessment completed on 09/25/12 with the measurement of 2.3 cm by 3.0 cm stage III (same description as noted in the 09/28/12 discovery of the coccyx decubitus). The dressing change indicated the treatment included Santyl with Allevyn was used, this was not ordered until 09/29/12. There was no documentation of treatment on the treatment record to indicate a daily dressing was started on 09/25/12. Review of the facility policy for Charting Guidelines: Correction of Documentation Errors (dated 01/07/03) revealed it was illegal to deliberately erase or obliterate any notations made into the medical record as it invalidated the entire entry. The legal method of correcting a documentation error in a medical record was described in the procedure: Draw a single line through each line of the error or inaccurate material taking care not to obliterate what was previously written. Write the word error, indicate why the error occurred, enter the correct information, date and sign/initial the correction. The questionable situations were to have the correction witnessed by a colleague. The Acting Director of Nursing (ADON) was interviewed on 11/10/12 at 11:07 A.M. with review of the discrepancies in the medical record of Resident #200. The ADON verified the entry made of the wound assessment on 09/25/12 was completed by her. The ADON was unable to explain why the treatment documented completed on 09/25/12 and measurements matched the information on the initial wound documentation completed on 09/28/12 and 09/29/12. The ADON was unable to explain the physician's order given on 09/29/12 was documented as provided on 09/25/12. The ADON verified she was the person that altered the date of the initial wound documentation date of origination from 9/28/12 to 9/20/12 by obliteration. The ADON verified there was no treatment record for the pressure area of the coccyx from 09/25/12 until 9/28/12. Review of all information in the record indicated this pressure ulcer was discovered on 09/28/12 at a stage III, was developed in house, and was not present at time of admission to the facility. On 11/11/12 at 11:20 A.M., the Senior Vice President of Operations requested to review discrepancies in the medical record of Resident #200. The above information was reviewed with review of all documents referenced above. At 1:50 P.M., the facility Administrator and the Senior Vice President of Operations stated an investigation was in progress. A statement was given indicating the facility did not condone documentation that was not complete, accurate, and timely. Interview of the facility Administrator on 11/13/12 at 7:15 A.M. revealed the investigation of altered documentation continued. A hand writing person was being brought into the investigation. The nurse who completed the initial admission assessment had stated that was not her handwriting which added the documentation to the admission assessment of Resident #200 identifying a red open area to the coccyx. 3. Review of the clinical record for Resident #300 revealed admission to the facility on [DATE] with diagnoses including post surgical care with an abdominal incision, Diabetes II, [MEDICAL CONDITION] and hypertension. Review of the admission nursing assessment completed on 10/04/12 revealed no pressure areas noted to any body surface. The Braden score completed on 10/04/12 revealed a score of 20 and the resident was not at risk for pressure. Review of the admission orders [REDACTED]. Review of hospital discharge records revealed no evidence of pressure sore care. The documentation review of skin assessment at the hospital on [DATE] and 10/04/12 revealed no impairment of skin. No minimum data set assessment information was available due to the short stay in the facility. Review of nursing progress notes completed on 10/04/12 and 10/05/12 revealed no reference to pressure sores for Resident #300. Review of the nurse progress note dated 10/06/12 at 1:30 P.M. revealed an open area noted to the coccyx measuring 10 cm by 2 cm with 70% slough noted to the wound bed and 30% pink tissue surrounding the sloughing area. The note indicated a treatment of [REDACTED]. Review of the physician's orders for Resident #300 revealed an order written [REDACTED]. A progress note dated 10/09/12 at 7:00 A.M. revealed a dressing change to the coccyx area. The resident complained of severe pain at the site. The wound bed was described with slough and foul odor. Review of the Initial Wound Documentation for Resident #300 revealed the date of origination of the stage III pressure sore was 10/06/12. The assessment was not completed until 10/09/12. The resident was admitted [DATE]. The resident was noted to have a stage III wound on the coccyx measuring 12.2 cm by 3.0 cm with a 0.1 cm depth. Staff noted slough, mild odor, and a scant amount of tan drainage. The wound was noted to have an unstageable wound which surrounded the coccyx wound measuring 18.0 cm by 13 cm with no depth. The area was described as dark purple and hard to touch. The weekly wound documentation also dated 10/09/12 revealed the same information. Additional physician's orders for Resident #300 to prevent further decline of the stage III pressure area were not initiated until 10/09/12 to provide a Roho cushion to the wheelchair, turn every two hours while in bed, skin prep to bilateral heels every shift, and float heels while in bed. Also, on 10/09/12 an order was obtained to provide an air mattress to the bed. Review of the facility policy Wound and Skin Program (dated 06/18/12 ) revealed a stage III pressure ulcer was described as 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. It indicated a stage III pressure ulcer could include undermining and tunneling. The description given for unstageable was 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. The policy revealed until enough slough and or eschar was removed to expose the base of the wound, the true depth, and therefore, stage, could not be determined. The protocol per facility policy directed staff to provide the following to a stage III pressure sore: off load area and a pressure redistribution air mattress. This was not provided until three days after the identification of the stage III pressure sore to Resident #300. Resident #300 had a scheduled follow up visit with the Ohio Health physician on 10/11/12. Notes from the follow up visit documented the resident left the Ohio Health care hospital on [DATE] to the nursing facility and returned for a scheduled follow up visit on 10/11/12 with an infected intergluteal cleft wound and dehydration. The admission note on 10/11/12 with reference to the pressure sore as painful, foul smelling 7 cm x 1 cm intergluteal cleft wound with 5 cm radius of peripheral induration and dehydration with a need to discuss debridement. The resident was readmitted to the hospital for treatment and did not return to the facility. Interview of the Acting Director of Nursing on 11/11/12 at 1:10 P.M. verified the development of a stage III pressure area three days after admission to the facility. The ADON verified admission records revealed no pressure areas were identified and the resident was not identified at risk for pressure upon admission to the facility on [DATE]. This deficiency substantiates complaint number OH 869.