Every finding on record at Woodlands Health and Rehab Center

Based on record review, hospital/emergency department documentation, facility policy review, and staff interviews, the facility failed to ensure staff verified Resident #2's documented allergy (to the COVID-19 vaccine) prior to administering the vaccine. The facility also failed to provide timely clinical assessment and medical intervention after the vaccine was administered. This affected one resident (Resident #2) of five residents reviewed for vaccinations.On 11/07/25 at 12:10 P.M., staff administered a COVID 19 vaccination to Resident #2 despite the vaccine being listed as an allergy in the resident's medical record. No immediate assessment or monitoring was completed following administration of the contraindicated vaccine. The resident did not receive a clinical assessment until 11/07/25 at 10:50 P.M., when she was noted to be in respiratory distress with abnormal and unstable vital signs, including: heart rate of 140 beats per minute (normal 60-100), pulse oximetry of 84% on two liters per minute of oxygen (normal 95-100%), respiratory rate of 25 breaths per minute (normal 12-20), and a blood pressure unable to be obtained. Due to the delayed recognition and response to the adverse reaction, Resident #2 required transfer to the emergency department on 11/07/25 and was subsequently admitted for diagnoses including altered mental status, encephalopathy, and acute hypoxic respiratory failure. The resident was treated for anaphylaxis and hospitalized until 11/11/25. Findings include:Review of Resident #2's medical record revealed an admission date of 12/15/11 and a re-entry date of 11/11/25. Resident #2's diagnoses included end stage renal disease, dependence on renal dialysis, type 2 diabetes, heart disease, chronic obstructive pulmonary disease (lung disease), heart failure, reduced mobility, and need for assistance with personal care. Review of Resident #2's allergy list revealed she was allergic to the Pfizer mRNA, BNT 162b2, LNP-S, COVID-19 vaccine with reactions of altered mental status and anaphylaxis dated 04/12/24 and Moderna mRNA-1273, LNP-S, COVID-19 vaccine with reactions of altered mental status dated 04/12/24.Review of the guardianship papers dated 05/06/25 revealed a (court-appointed) guardian was appointed for Resident #2 due to being assessed as incompetent to make her own decisions. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact, did not reject care, was dependent on staff for toileting hygiene, required maximal assistance for bathing, required maximal assistance for personal hygiene, required moderate assistance for transferring, required dialysis, and had a legal guardian.Review of the dialysis communication form dated 11/07/25 at 11:00 A.M. revealed Resident #2's final vital signs from the dialysis center prior to returning to the facility included a pulse of 79 beats per minute (bpm), respirations of 17 breaths per minute, and a blood pressure of 130/53 millimeters of mercury (mm/hg).Review of the physician orders revealed an order (dated 11/07/25) for a single dose of Mnexspike 2025-2026 COVID vaccine syringe ten micrograms (mcg) per 2 tenths of a milliliter (ml) intramuscular.Review of the COVID-19 vaccine administration report revealed consent was obtained from the guardian, education was provided to the guardian, the guardian was educated by a Registered Nurse (RN), and Resident #2 received the Moderna mNEXSPIKE COVID-19 vaccine on 11/07/25 at 12:10 P.M. in the left deltoid (shoulder muscle), prior to the RN assessing/screening whether the vaccine was contraindicated due to allergies.Review of the progress notes from 11/07/25 to 11/11/25 in the electronic medical record (EMR) revealed the absence of documentation that an assessment had been performed on Resident #2 after she was administered the COVID vaccine nor was it was identified she received a vaccine that was listed as an allergy. Record review revealed no evidence of physician notification of the incident at the time of the vaccine administration. Review of the evaluation screen in the EMR from 11/07/25 to 11/11/25 revealed the absence of documentation Resident #2 was assessed after it was identified she received a vaccine that was listed as an allergy. Review of the vital signs flow sheet from 11/07/25 revealed the absence of documentation of vital sign monitoring performed on Resident #2 after she received a vaccine that was listed as an allergy. Review of the nurse's note dated 11/08/25 at 8:51 A.M. and authored by Licensed Practical Nurse (LPN) #301 revealed at 11/07/25 at 10:50 P.M. Resident #2 verbalized to a Certified Nursing Assistant (CNA) that she wasn't feeling well. LPN #301 found the resident panicked, short of breath, and sweating heavily. Resident #2 verbalized she had received the COVID-19 vaccination earlier in the day. Resident #2's vital signs at that time included a heart rate of 140 bpm (tachycardic), a pulse oximetry reading of 84% (low) with two liters per minute (lpm) of oxygen, respirations of 25 breaths per minute and blood pressure that was unable to be obtained. LPN #301 called 911 and the resident was transported to the emergency room and a provider was notified. Review of the Optum (a company through United Health Care that assists with coordinating care of its participating members in the long-term care setting, which uses Physician Assistants, Nurse Practitioners, and Registered Nurse's) notes from 11/08/25 to 11/11/25 revealed they were notified after Resident #2 was sent to the hospital. Review of the Emergency Department (ED) provider note dated 11/08/25 at 4:55 A.M. revealed Resident #2 was admitted to the hospital due to altered mental status. Resident #2 required oxygen at four lpm due to not maintaining sufficient oxygen saturation on two lpm of oxygen. Upon arrival to the ED the resident was treated for anaphylaxis for concerns of possible reaction (to the COVID-19 vaccine she had received).Review of the hospital internal medicine history and physical notes dated 11/08/25 at 6:58 A.M. revealed Resident #2 was admitted with encephalopathy and respiratory failure, both of which could have been caused by an allergic response noted by the physician.Review of the witness statement dated 11/11/25 at 1:06 P.M. by LPN # 301 to Regional Director of Clinical Services (RDCS) #380 revealed on 11/07/25 Resident #2 was administered a COVID-19 vaccine and the resident verbalized to a CNA she wasn't feeling well. LPN #301 found Resident #2 short of breath, shaking, and sweating heavily. Resident #2's vital signs included a heart rate of 140 bpm, a pulse oximetry reading of 84% with two lpm of oxygen, respiration of 25 breaths per minute and a blood pressure that was unable to be obtained. LPN #301 called 911 and sent the resident to the Emergency Room. LPN #301 noted Resident #2 was alert and oriented but had developmental disabilities and a guardian. A review of the nurse's note on 11/11/25 at 2:45 P.M. revealed Resident #2 returned to the facility and was at her baseline.Review of the undated facility investigation summary revealed Assistant Director of Nursing (ADON) #391 obtained consent from the legal guardian of Resident #2 for the COVID-19 vaccine, informed Infection Prevention Registered Nurse (IP RN) #381 consent was obtained and the vaccine could be administered, ADON #391 entered the order into the EMR and was alerted to the allergy, IP RN #381 was then notified immediately but had already given the vaccination.Review of a witness statement from ADON #391 dated 11/11/25 at 2:35 P.M. revealed she obtained verbal consent for the COVID-19 vaccination from the guardian, entered the order for the vaccine administration into the EMR, after the order was entered the EMR alerted about the allergy, and then IP RN #381 was notified immediately. Review of the facility document titled Teachable Moment, dated 11/11/25 revealed ADON #391 was taught to have IP RN #381 obtain consent for vaccines prior to administration to review allergies.An interview on 04/01/26 at 11:55 A.M. with Divisional Director Clinical Education (DDCE) #379 revealed all consents for vaccines were done in the EMR and the facility does not use a paper consent. An interview on 04/02/26 at 9:05 A.M. with the Director of Nursing (DON) and Administrator revealed the facility did not have a policy for verbal consent of a vaccine. An interview on 04/06/26 at 10:10 A.M. with the DON revealed she would expect a resident to be assessed after receiving a vaccine that was listed as an allergy. The DON verified there wasn't documentation Resident #2 was assessed after receiving the COVID-19 vaccine. An interview on 04/06/26 at 10:21 A.M. with RDCS #380 verified the facility did not have documentation of an assessment being performed on Resident #2 after the vaccine administration nor did Optum assess the resident on 11/07/25.Review of the facility policy titled General Dose Preparation and Medication Administration dated 01/01/22 revealed the facility was to comply with applicable law and the State Operations Manual when administering medications, prior to medication administration staff were to take all measure required by facility policy, and staff were to check for allergies prior to administration.Review of the facility policy titled Resident Change in Condition Policy, dated 06/02/25 revealed staff would recognize and respond to a change in resident condition, staff were to communicate when the change in condition started, staff were to assess the resident including vital signs prior to notifying the provider, and the physician/provider was to be notified of an incident involving the resident or a reaction to medications or treatments.This deficiency represents non-compliance investigated under Complaint Number 2673838.

Based on observation, interview, record review and review of the facility policy, the facility failed to follow their legionella water management plan and practice appropriate hand hygiene during medication administration and wound care. This affected two residents (Residents #8 and #100) observed for infection control and had the potential to affect all 79 residents in the facility. Findings include:1. Review of the facility's water management plan (WMP), dated 04/12/19 identified the ice machine as a risk factor. Control measures were listed as cleaning and disinfecting the ice machine based on equipment manufacturer's instructions. Change filter and clean if installed. Make sure to schedule and document all cleanings. Corrective actions were listed as if cleaning schedule was missed, remove unit from service and clean according to manufacturer's instructions If a legionella-positive sample was found outside of control limits, more frequent samples may be required as part of the review of the system operation in order to establish the source of the contamination and determine when the system was back within control limits as specified in the WMP. Review of facility legionella documentation revealed an analytical report containing results from facility water samples taken on 03/10/25. The first floor ice machine had two colony-forming units (CFU)/milliLiter (mL) of legionella detected. Further review of the analytical report defined the theoretical detection unit for legionella as one CFU/mL. No other areas of the facility were identified to have legionella detected from the provided samples. Review of a legionella flush-out form dated 03/25/25 listed the dedicated area(s) of the first floor ice machine and the beauty shop and contained spaces for seven days (filled out 03/26/25 through 04/03/25) and checkboxes for five steps. The instructions read: 1) for the next seven days, flush all available water outlets in the site for 10 minutes per day on hot and another 10 minutes per day on cold. 2. In addition, adjust shower head temperature knob to provide warm water in order to ensure that both hot and cold water and being flushed and run for five minutes. 3. Remove sink aerators, clean and disinfect upon initiating flush out. 4. On the hot water side, test and document any hot water storage tanks, a sink closest to the hot water storage tank and a sink farthest away from the hot water storage tank for temperature (verify below 120 degrees Fahrenheit), free chlorine and total chlorine. 5. Document all flushing activities and testing results and place them into your site Water Management Plan binder. 6. Retest the same outlets within seven days of the final day of flushing. 7. If subsequent legionella water testing comes back as detected, repeat steps one through five and contact corporate for guidance. The sheet was signed off by Environmental Services Director (ESD) #305. No additional testing information or follow-up since 04/03/25 was noted in the facility's legionella documentation. Interview on 04/06/26 at 10:43 A.M. with the Director of Nursing (DON) and Divisional Director of Clinical Education (DDCE)/Registered Nurse (RN) #379 revealed ice machines were out of service after the positive legionella results in March 2025 as the facility was renovating their dining rooms. DDCE/RN #379 confirmed the only area in the facility with a positive legionella result was the first floor ice machine and stated follow-up testing was completed in August 2025. DDCE/RN #379 stated the beauty shop was added to the flush-out protocol as it was an area that had tested positive for legionella in the past. Both the DON and DDCE/RN #379 confirmed there had been no cases of Legionnaire's disease in the facility corresponding with the infection control logs reviewed from January 2025 through March 2026. Follow-up interview on 04/06/26 at 1:11 P.M. with DDCE/RN #379 verified the facility could not locate any evidence of re-testing after the positive legionella result and subsequent flush-out procedure. DDCE/RN #379 shared the facility had not completed their 2026 legionella testing as of the time of the interview as the company had not yet sent them the specimen cups for testing. Interview on 04/06/26 at 1:18 P.M. with ESD #306 revealed she did not recall the positive legionella result from March 2025 and did not recall any further corrective actions taken by the facility after the seven days of flush-out protocol ending 04/03/25. ESD #306 stated the ice machines were disconnected, drained and covered and not in service during the dining room renovations that went on until August or September 2025. ESD #306 verified she could not recall completing any re-testing in the facility after the positive legionella result in March 2025. Review of the facility policy, Legionella Assessment and Prevention Program, revised 01/10/25 revealed if positive results from water testing are received, abatement to mitigate will take place according to source and species. The facility will document the steps taken to mitigate the source and then re-test to ensure the water is free of bacterial growth. [NAME] Healthcare Group policy requires testing to be performed annually at four water sources in the building. These sources should include one resident room sink faucet, one resident showerhead, ice machine and one kitchen sink faucet. These areas should be the furthest location(s) from the water source. Samples should be collected by someone on the assessment team according to the instructions on the test kit. These samples are then mailed to a qualified water testing form. 2. A review of Resident #8's clinical record revealed an admission date of 06/18/22 with diagnoses including congestive heart failure, atrial fibrillation (heart arrhythmia), atherosclerotic heart disease, anemia, high blood pressure and cholesterol, chronic kidney disease, polyneuropathy, diabetes mellitus, osteoarthritis, gout, restless leg syndrome, benign enlarged prostate and cognitive communication deficit. A review of Resident #8's dated 02/16/26 physician orders indicated to cleanse the sacrum and right gluteus pressure ulcer area with Dakin's solution, dry, apply pink polymem to wound bed and cover with foam dressing once a day. An observation of Licensed Practical Nurse (LPN) #304 on 03/31/26 at 4:52 P.M. perform Resident #8's wound treatment revealed a failure to perform hand hygiene to prevent cross contamination of germs. LPN #304 gathered the supplies needed and sanitized the over-the-bed table and placed the supplies on the over-the-bed table. LPN #304 performed hand hygiene and donned a pair of gloves and removed the soiled wound treatment from Resident #8's sacrum and right buttock area. The wound dressing was saturated with serosanguinous fluid and LPN #304 discarded the soiled dressing in the waste receptacle. LPN #304 removed her soiled gloves and performed hand hygiene and donned another set of gloves. LPN #304 proceeded to perform the wound treatment task following infection control standards. Upon completion of the wound treatment LPN #304 removed her soiled gloves and did not perform hand hygiene. LPN #304 then proceeded to touch various items in Resident #8's room including the bed remote, adjusting the bed and Resident #8's bed linens and other surfaces in Resident #8's room. An interview with LPN #304 on 03/31/26 at 5:19 P.M. verified she had not performed hand hygiene after she removed her gloves upon completing the wound treatment task and proceeded to touch various items in Resident #8's room. A review of the facility policy titled Clean Dressing Change Policy effective 03/10/24 indicated the procedure included for the staff to 1. Perform hand hygiene.2. Introduce self to patient/resident.3. Confirm patient/resident ID. 4. Explain procedure to patient/resident, offer bathroom, analgesia.5. Ensure privacy. 6. Set up clean field using a barrier, towel, chux etc. 7. Position patient to visualize area to be dressed.8. Perform hand hygiene.9. [NAME] clean gloves. 10. Check any dressing present, remove and wrap in gloves as you take gloves off, discard in trash bag. 11. Assess wound (if you need to touch the area perform hand hygiene and don new clean gloves).12. Perform hand hygiene.13. Prepare supplies on field including any cleansing solution.14. [NAME] clean gloves.15. Cleanse with ordered solution or normal saline soaked gauze pads. 16. Remove gloves and discard.17. Perform hand hygiene and don clean gloves.18. Apply new dressing[s) as ordered.19. Assist patient/resident back to comfortable position.20. Remove and discard gloves.21. Perform hand hygiene.22. Document procedure and update findings.23. Notify provider if necessary. 3. A review of Resident #100's clinical record revealed an admission date of 03/25/26 with diagnoses including fractured right humerous, Parkinson's disease, mood and psychotic disturbance, atrial fibrillation (heart arrhythmia), hypothyroidism, high blood pressure and cholesterol, lymphedema, gastroesophageal reflux disease, and cognitive communication deficit. A review of Resident #100's physician order dated 03/01/26 to 03/31/26 indicated to administer the following medications orally between 7:30 A.M. 11:30 A.M.: -Allopurinol 300 milligrams (mg) -Citalopram 10 mg -Ferrous sulfate 325 mg -Metoprolol extended release 25 mg -Mirabegron extended release 25 mg -Spironolactone 25 mg -Eliquis 5 mg -Omeprazole 25 mg and to administer Xidra eye drops, one drop each eye between 7:30 A.M. and 11:30 A.M. An observation on 03/31/25 at 8:07 A.M. of LPN #322 administer medications to Resident #100 revealed a failure to perform hand hygiene. LPN #322 approached the medication cart and used hand sanitizer and started to dispense the above listed medications. LPN #322 found one medication (Omeprazole 20 mg tablet) was not in the medication cart and she would need to obtain the medication from the central supply room. LPN #322 locked the medication cart and pushed the button for the elevator. LPN #322 moved the housekeeping cart out of her way when entering the elevator and ushed the buttons in the elevator. LPN exited the elevator and walked to the central supply room and obtained the Omeprazole medication. LPN then used the elevator to travel back to the medication cart and continued to dispense Resident #100's medications in a medication cup without performing hand hygiene before resuming the task. LPN #322 the proceeded to administer Resident #100's oral medications. An interview with LPN #322 on 03/31/26 at 8:21 A.M. confirmed should have performed hand hygiene prior to resuming dispensing and administering Resident #100's medications. A review of the facility policy titled Hand Hygiene Policy effective 09/01/11 indicated hand hygiene was the most important component for preventing the spread of infection. The procedure indicated to perform hand hygiene for the following clinical indications.: -Immediately before touching a resident. -Before performing an aseptic task. -Before moving from a soiled body site to a clean body site. -After touching a resident or resident's immediate environment. -After contact with blood, body fluids, or contaminated surfaces. -Immediately after glove removal.

Based on record review, review of Self-Reported Incident (SRI), and interview the facility failed to notify the Board of Nursing of a licensed nurse's failure to perform their job duties. This affected 24 residents (Resident #6, #12, #15, #17, #24, #36, #39, #43, #52, #54, #56, #57, #59, #61, #66, #70, #82, #87, #88, #104, #105, #106, #107, #108) who resided on the second floor of the facility. The facility census was 79.Findings include:A review of the SRI tracking number 267429 revealed on 11/10/25 during the evening shift from 7:00 P.M. to 7:30 A.M. 24 residents (Resident #6, #12, #15, #17, #24, #36, #39, #43, #52, #54, #56, #57, #59, #61, #66, #70, #82, #87, #88, #104, #105, #106, #107, #108) who resided on the second floor of the facility did not receive their evening medications. The Former Interim Administrator and Regional Director of Clinical Services (RDCS) Nurse #380 received a text message from the night shift nurse stating that she was concerned because the 24 residents listed above did not receive their bedtime medications on 11/10/25. There was a nurse who called off for their shift from 7:00 P.M. to 7:30 A.M. on 11/10/25. The Former Director of Nursing (DON) #389 and Infection Control Preventionist Registered Nurse (IP) #381 were covering the shift from 7:00 P.M. to 7:30 A.M. There was miscommunication, and IP #381 did not understand he would be responsible for the medication administration since he was covering the whole shift. The DON arrived during the morning hours at approximately 3:00 A.M. on 11/11/25 and proceeded to document a late entry indicating the evening medications for the above listed 24 residents were administered on 11/10/25 between 7:00 P.M. and 11:30 P.M. The DON thought IP #381 was unable to sign off the medications due to the inability to access the electronic system and made the decision to document the medications were administered. The medical director and residents' responsible parties were notified of the above findings.A review of the 24 residents' clinical record listed above revealed the Medication Administration Record (MAR) dated 11/01/25 to 11/31/25 had documentation that the Former DON #389 had documented the medications scheduled on 11/10/27 from 7:00 P.M. to 11:30 P.M. were administered for each of the 24 residents.The facility implemented an action plan to ensure all licensed nursing staff understood the process of medication administration. All licensed nursing staff were re-trained on the facility's policy and procedure for medication administration. Regional Director of Clinical Services (RDCS) #380 and Current Administrator conducted daily audits of the residents' clinical records to ensure medications were administered as ordered by the physician at the time scheduled from 11/11/2025 to 12/31/2025. All residents were assessed and no negative outcomes were identified. An interview with IP #381on 03/31/26 at 2:16 P.M. revealed he hadn't been trained to administer medications in the facility. IP #381 stated he was a Registered Nurse (RN) and agreed the expectation of his job duties included administration of medications. IP #381 stated he was assigned to provide care to 24 residents on the second floor of the facility during the evening hours on 11/10/25 from 10:30 P.M. until approximately 3:00 A.M. when the former DON took over the assignment. IP #381 indicated he did not ask the other two licensed nurses to assist him to ensure the residents received their medications as ordered by the physician. IP #381 stated he did administer one Acetaminophen tablet to a resident but was unable to remember which resident he had administered the Acetaminophen medication tablet and had not documented the administration in the resident's clinical record. IP #381 stated he was unable to recall if the other two nurses working the 7:00 P.M. to 7:30 A.M. were aware he was unable to administer medications to the residents. IP #381 stated he had informed the former DON he would not be able to administer medications to the residents he was assigned to care for prior to arriving at the facility. IP #381 stated the facility did not initiate disciplinary process for the failure to administer medications to the residents he was assigned to care for on 11/10/25 from approximately 10:30 P.M. to approximately 3:00 A.M. on 11/11/25. IP #381 stated he should not have been responsible to perform nursing duties when assigned to care for the residents on 11/10/25.An interview on 03/31/26 at 2:54 P.M. with RN #383 and at 5:22 P.M. with Licensed Practical Nurse (LPN) #301 revealed they were aware the medications for the residents assigned to IP #381 were not administered on 11/10/25 from 7:00 P.M. to 11:30 P.M. Both nurses stated they had offered to assist IP #381 to ensure the residents received their medications as ordered. Both nurses stated IP #381 adamantly refused to administer medications to the resident and refused their assistance to ensure the residents received their medications as ordered. Both nurses stated they were informed IP #381 would be assisting in caring for the residents on the second-floor memory care unit assignment and was expected to arrive at approximately 8:30 P.M. on 11/10/25. Both nurses stated IP #381 did not arrive until approximately 10:30 P.M. on 11/10/25. Both nurses stated they offered to teach IP #381 how to use the system and assist him with administering medications. IP #381 refused. The nurses stated the residents were upset and didn't understand what was happening or why they were not receiving their evening medications. LPN #301 stated IP #381 sat in the nursing station and did not help answer call lights or other tasks while he was present in the facility on 11/10/25 and 11/11/15. LPN #301 stated she notified the Former DON #390 that the medications were not administered during the evening shift from 7:00 P.M. to 11:30 P.M. on 11/10/25. Both nurses were upset that IP #381 was not disciplined or held accountable for failure to administer the medications to the residents on his assignment.An attempt to interview Former DON on 03/31/26 at 10:00 A.M., 2:10 P.M. and on 04/01/26 at 1:00 P.M. were unsuccessful. Voice mail messages were left with a request to return the phone call with phone contact information provided. Former DON #390 did not return the phone calls during the annual survey. An interview with RDCS #380 on 04/01/26 at 1:45 P.M. verified the above findings and agreed there was no documentation found to indicate the Board of Nursing was notified regarding IP #381's failure to perform RN job duties regarding medication administration.A review of the facility's Administrator job duties revealed the position summary included the Administrator was to lead, direct and manage the overall operation of the community in accordance with policies, procedures and current federal, local and state standards, guidelines and regulations that govern the community. The Administrator responsibility included to organize, develop and direct resources to maintain the highest degree of quality of care for each resident at all times. The Administrator essential functions included:-Ensure all employees in licensed positions have an active license for the position in which they were hired to perform.-Ensure understanding of all state regulations related to the licensed positions, including waivers, job duties, changes in regulations, temporary permits/licenses, compact state license etc.-Report any known or suspected allegations of abuse, neglect and/or misappropriation in accordance to state guidelines and conducts investigations related to same.

Based on record review and interview the facility failed to ensure accurate and complete documentation in Resident #50's clinical record. This affected one (Resident #50) out of four residents observed for medication administration. The facility census was 79. Findings include:A review of Resident #50's clinical record revealed an admission date of 03/22/25 with diagnoses including chronic kidney disease, atherosclerotic heart disease, cerebral vascular disease with cerebral infarction (stroke), gastroesophageal reflux disease, diabetes mellitus, high blood pressure and cholesterol, and hypothyroidism. During medication administration on 03/31/26 at 8:10 A.M. Resident #50's son approached Licensed Practical Nurse (LPN) #322 and informed her Resident #50 had vomited her medications into a napkin. LPN #322 stated she would check on Resident #50. A review of Resident #50's clinical record dated 03/01/26 to 03/31/26 revealed no documentation that Resident #50 had an incident when she vomited her medications and no documentation the Certified Nurse Practitioner #392 or provider were notified. An interview with LPN #337 on 04/01/26 at 7:17 A.M. revealed she had assessed Resident #50 after she completed the morning medication administration on 03/31/26 and found no negative findings. LPN #322 stated she informed Certified Nurse Practitioner (CNP) #392 that Resident #50 had vomited her medications but had not documented the notification in Resident #50's clinical record. LPN #322 verified there was no documentation in Resident #50's clinical record of the vomiting incident. LPN #337 stated Resident #50 often had reflux and would often have trouble swallowing food and medications due to her swallowing issues. LPN #322 stated CNP #392 was present on the nursing unit at the time she was notified of Resident #50's vomiting her medication episode. LPN #322 stated CNP #392 had assessed Resident #50 but also verified there was no documentation that CNP #392 had assessed Resident #50 after the incident in Resident #50's clinical record. An interview with CNP #392 on 04/02/26 at 10:51 A.M. verified she was notified by LPN #337 that Resident #50 had vomited her undissolved medications in a napkin on 03/31/26. CNP #392 stated this was a common recurrence for Resident #50. CNP #392 stated she had assessed Resident #50 after the incident and found no negative outcome and no signs of aspiration. CNP #337 confirmed she had not documented the incident in Resident #50's clinical record at the time she was notified or after she had assessed Resident #50.An interview with Regional Director of Clinical Service (RDCS) #380 on 04/06/25 at 11:45 A.M. revealed the facility did not have a policy or guidelines for providing documentation in the residents' clinical record. RDCS #380 confirmed the expectation was the staff would provide documentation in the residents' clinical according to standards of practice.

Based on observation, interview, record review, and policy review the facility failed to ensure the call light was within reach for one resident (Resident #9). This affected one of eight residents reviewed for call lights. Findings include: Review of the medical record for Resident #9 revealed an admission date of 09/26/2023 with diagnoses that included stroke, Type 2 diabetes mellitus, heart disease, heart failure, contracture (a shortening or stiffening of muscles, tendons, or skin that limits joint movement) of right hand, contracture of the thigh, contracture of the lower leg, and functional quadriplegia (inability to move the limbs and body from the neck down). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively impaired, did not reject care, dependent on staff for all activities of daily living, and was incontinent of bowel and bladder. Review of the care plan revealed Resident #9 was at risk for falls related to impaired communication and impaired mobility dated 03/22/26. Interventions included keep the call light in reach and keep frequently used items in reach. An observation on 03/30/26 at 10:44 A.M. revealed the call light on the outside of the bed mobility rail, out of reach for Resident #9. An observation on 03/3126 at 12:19 P.M. revealed the call light on the outside of the bed mobility rail, out of reach for Resident #9. An observation on 03/31/26 at 3:34 P.M. revealed the call light on the outside of the bed mobility rail, out of reach for Resident #9. An interview on 03/31/26 at 3:40 P.M. with Licensed Practical Nurse (LPN) # 322 revealed Resident #9 has use of his left arm and can use the call light with his left arm. LPN #322 verified the call light was out of reach for Resident #9. Review of the facility policy titled Call Light Resident Communication System Policy, dated 12/04/25 revealed staff were to ensure the call light was within easy reach if the resident was confined to the bed.

Based on observation, record review and interview the facility failed to ensure the medication error rate was less than five percent (%). This affected two (Resident #6, #50) out of four residents observed for medication administration. The facility had three errors out of 28 opportunities for a medication error rate of 10.7%.The facility census was 79.Findings include:1.A review of Resident #6's clinical record revealed an admission date of 04/25/25 with diagnoses including atherosclerotic heart disease, compression fracture of multiple thoracic vertebra and ribs, Alzheimer's dementia, high blood pressure and cholesterol, anemia, anxiety, insomnia, gastroesophageal reflux disease and medical conditions including muscle weakness, abnormal gait and mobility, and trouble swallowing.A review of Resident #6's physician orders dated 03/01/26 to 03/31/26 revealed to administer the following medications orally between 7:30 A.M. and 11:30 A.M.:-Aspirin 81 milligrams (mg)-Metoprolol extended release 50 mg (hold for systolic blood pressure less than 100 and diastolic blood pressure less than 60)An observation on 03/30/26 at 8:38 A.M. of Licensed Practical Nurse (LPN) #337 administer medications to Resident #6 revealed a medication administration error. LPN #337 obtained the above listed medications and entered Resident #6's room. LPN #337 obtained Resident #6's blood pressure which measured 104/75 millimeters of mercury (mmHg) with heart rate 87 beats per minute. LPN stated she was not going to administer Resident #6 the Metoprolol medication because Resident #6's systolic blood pressure was too low. LPN #337 indicated the physician had written a parameter to hold the Metoprolol medication if Resident #6's systolic blood pressure measured less than 114 mmHg. LPN discarded the Metoprolol 25 mg extended release tablet and administered Resident #6 the Aspirin 81 mg medication orally.An interview with LPN #337 on 03/30/26 at 8:47 A.M. verified the above findings and stated she had misread the physician order and agreed the Metoprolol 25 mg extended release tablet should have been administered.2. A review of Resident #50's clinical record revealed an admission date of 03/22/25 with diagnoses including chronic kidney disease, cerebral infarction (stroke), diabetes mellitus, high blood pressure and cholesterol, atherosclerotic heart disease, hypothyroidism, gastroesophageal reflux disease, and osteomyelitis of vertebra with low back pain.A review of Resident #50's physician orders dated 03/01/26 to 03/31/26 indicated to administer the following medications orally between 7:30 A.M. and 11:30 A.M.:-Atenolol 25 mg (hold for systolic blood pressure less than 110 mmHg or heart rate less than 60 beats per minute-Vitamin D3 25 micrograms (mcg)-Duloxetine 30 mg delayed release tablet-Ferrous Sulfate 325 mg-MiraLAX (polyethylene glycol 3350 powder) 17 gm -Sodium Chloride 1 gram (gm)-Pantoprazole 40 mg granules packetAn observation of Registered Nurse (RN) #363 on 03/31/26 at 7:48 A.M. administer the above listed medications revealed two medication errors were observed. RN #363 obtained Resident #50's blood pressure which measured 159/76 mmHg. RN #363 crushed the tablet medications and mixed with a spoonful of applesauce. RN #363 measured the MiraLax powder up to the inner lining of the cap and was stopped prior to mixing the powder in water. After surveyor intervention, RN #363 read the instructions on the MiraLAX plastic bottle container and revealed the 17 gm dose of MiraLAX powder was measured to the top of the plastic bottle cap. RN #363 confirmed he did not measure the MiraLAX dosage correctly. LPN #363 proceeded to administer the above listed medications except RN #363 administered 50 mg of the Atenolol medication instead of the 25 mg dosage ordered by the physician. On 03/31/25 at 12:03 P.M. LPN #363 checked the physician order and agreed he had administered the incorrect dosage (50 mg) of the Atenolol medication instead of the Atenolol 25 mg dosage ordered.A review of the facility policy titled General Dose Preparation and Medication Administration revised 11/15/24 indicated to only prepare medications to one resident at a time using the three-way-check by comparing the medication to the medication administration record and the prescription label. During medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following:-Verify resident identification per facility policy.-Staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record.-Position resident properly if necessary.-Administer medication within the timeframes specified by the facility policy or manufacturer's information.-Ensure the resident consumed the medication.-Document the administration on the medication administration record.

Based on record review, interview and review of the facility policy, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected three residents (#6, #12 and #66) of five residents reviewed for unnecessary medications. Facility census was 79.Findings include: 1. Review of Resident #12's medical record revealed an admission date of 01/08/24 and diagnoses including Parkinson's disease, hypertension, depression, vitamin D deficiency, anxiety and dementia with behavioral disturbance. Review of Resident #12's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had moderate cognitive impairment and received antipsychotic, antianxiety, antidepressant, opioid and antiplatelet medications. Review of Resident #12's physician's orders included orders dated 01/12/26 for Venlafaxine (antidepressant medication) extended release 150 milligrams (mg) daily which was discontinued on 01/12/26 then was reordered on 01/12/26 for the same dosage and formulation. Resident #12 was also ordered Lorazepam (antianxiety medication) per an order dated 07/02/25 for 0.5 mg three times daily and this order was discontinued on 02/19/26. Review of a pharmacy medication recommendation dated 08/15/25 revealed Resident #12 had multiple antidepressants concomitantly including Mirtazapine 15 mg before bed, Trazodone 50 mg before bed and Venlafaxine extended release 150 mg daily. The recommendation requested to reduce the Venlafaxine to 50 mg daily. The physician's response area was blank and not signed. Review of a pharmacy medication recommendation dated 10/07/25 revealed Resident #12 had multiple antidepressants concomitantly including Mirtazapine 15 milligrams mg before bed, Trazodone 50 mg before bed and Venlafaxine extended release 150 mg daily. The recommendation requested to reduce the Venlafaxine to 50 mg daily. The physician's response area was blank and not signed. Review of a pharmacy medication recommendation dated 11/11/25 revealed Resident #12 had received Lorazepam 0.5 mg three times daily since July 2025 for anxiety. The recommendation requested to attempt a GDR unless clinically contraindicated. The physician's response area was blank and not signed. Review of a pharmacy medication recommendation dated 02/10/26 revealed Resident #12 had received Lorazepam 0.5 mg three times daily since July 2025 for anxiety. The recommendation requested to attempt a GDR unless clinically contraindicated. The physician accepted the recommendation with the following modification of Lorazepam 0.25 mg twice a day and Lorazepam 0.5 mg before bed and signed the recommendation on 02/18/26. Review of psychiatry notes dated 07/09/25, 08/13/25, 09/24/25, 10/22/25, 11/19/25, 12/17/25, 01/21/26, 02/18/26 and 03/18/26 did not indicate to proceed with completing a GDR on Resident #12's medications nor document that a GDR was contraindicated. Interview on 04/01/26 at 2:41 P.M. with Medical Director (MD) #369 revealed regarding pharmacy reviews it depended on whichever medical professional was present to review them. MD #369 stated GDR requests went to him or Certified Nurse Practitioner (CNP) #382. MD #369 was shown Resident #12's blank pharmacy recommendation forms from 08/15/25, 10/07/25 and 11/11/25 and could not speak to these documents. Phone interview on 04/01/26 at 3:01 P.M. with CNP #382 revealed she did help with GDRs but they could also be given to MD #369. CNP #382 stated she did not always get them and the psychiatry nurse practitioner (CNP #299) got some of the medication reviews and would put the need for a GDR in her progress notes. Interviews on 04/01/26 at 4:24 P.M. and 4:39 P.M. with Divisional Director of Clinical Education (DDCE)/Registered Nurse (RN) #379 verified the GDR for Resident #12's Lorazepam was not completed timely, as it was addressed three months after the original request. DDCE/RN #379 also confirmed there was no evidence a GDR for Resident #12's Venlafaxine was attempted or documented as contraindicated. 2. Review of Resident #66's medical record revealed an admission date of 07/14/24 and diagnoses including dementia with other behavioral disturbance, Alzheimer's disease with late onset, hypertension, generalized anxiety disorder, depression and dysphagia. Review of Resident #66's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #66 had moderate cognitive impairment and received antianxiety and antidepressant medications. Review of Resident #66's physician's orders revealed Resident #66 had an order dated 03/20/25 for Buspirone (antianxiety medication) tablets 5 mg for anxiety every eight hours (three times a day) which was discontinued on 10/15/25, then reordered on 10/15/25 for same dosage and timing and then discontinued on 10/16/25. The Buspirone was again reordered on 10/16/25 for the same dosage and timing and discontinued on 12/03/25 when the dosage was increased to 10 mg (two tablets) three times a day. Review of a pharmacy recommendation dated 09/03/25 revealed Resident #66 had received Buspirone 5 mg every eight hours for as-needed anxiety since March 2025. The recommendation requested to attempt a GDR unless clinically contraindicated. The physician's response area was blank and not signed. Review of psychiatry notes dated 08/13/25, 09/10/25, 10/08/25, 12/03/25, 01/07/26 and 03/04/26 did not indicate to proceed with completing a GDR on Resident #66's medications nor document that a GDR was contraindicated. Interview on 04/01/26 at 2:41 P.M. with MD #369 revealed regarding pharmacy reviews it depended on whichever medical professional was present to review them. MD #369 stated GDR requests went to him or CNP #382. Phone interview on 04/01/26 at 3:01 P.M. with CNP #382 revealed she did help with GDRs but they could also be given to MD #369. CNP #382 stated she did not always get them and CNP #299 got some of the medication reviews and would put the need for a GDR in her progress notes. Interviews on 04/01/26 at 4:01 P.M. and 4:54 P.M. with DDCE/RN #379 verified there was no evidence a GDR for Resident #66's Buspirone was attempted or documented as contraindicated. DDCE/RN #379 stated she could not speak to the discontinuation and reordering of Resident #66's Buspirone at the same dosage, timing and formulation noted on 10/15/25 and 10/16/25. 3. Review of the medical record for Resident #6 revealed an admission date of 04/24/25. Diagnoses included atherosclerotic heart disease, repeated falls, multiple fractures of left and right ribs, and wedge compression fracture of T9-T10 vertebra. Review of the quarterly MDS 3.0 dated 03/02/26 revealed Resident #6 was cognitively impaired. Review of the pharmacy consultation report dated 10/16/25 revealed a recommendation to attempt a gradual dose reduction (GDR), unless clinically contraindicated, for Mirtazapine, an antidepressant, 30 milligrams (mg) used for insomnia since April 2025. The form was not marked or signed by physician or certified nurse practitioner. Review of the Medication Administration Records for October 2025, November 2025, December 2025, January 2025 and 02/01/26 through 02/12/26 revealed Resident #6 continued to be administered Mirtazapine 30 mg. Interview on 04/02/26 at 11:02 A.M. with Director of Nursing revealed the facility did not address the 10/16/25 pharmacy recommendation for Resident #6 until 02/12/26 after a second recommendation was sent on 02/10/25. Review of the facility policy, Medication Regimen Review, revised 06/01/24, revealed the consultant pharmacist will provide the residents' MRRs to facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations. Facility should encourage physician/prescriber or or other responsible parties receiving the MRR and the DON to act upon the recommendations contained in the MRR. For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept or act upon the recommendations contained in the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what if any action has been taken to address it. If the attending/provider has decided to make no change in the medication, the rationale should be documented in the resident's health record. Facility should alert the medical director where MRRs are not addressed by the attending physician in a timely manner. The attending physician should address the consultant pharmacist's recommendations no later than their next scheduled visit to the facility to assess the resident.

Based on interview, record review, and policy review the facility failed to ensure Resident #2 was assessed upon return to the facility after dialysis. This affected one resident (Resident #2) out of one reviewed for dialysis. Findings include:Review of Resident #2's medical record revealed an admission date of 12/15/11 and a re-entry date of 11/11/25. Resident #2's diagnoses included end stage renal disease, dependence on renal dialysis, type 2 diabetes, heart disease, chronic obstructive pulmonary disease (lung disease), heart failure, reduced mobility, and need for assistance with personal care.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact, did not reject care, was dependent on staff for toileting hygiene, required maximal assistance for bathing and dressing, required moderate assistance for transferring to a chair, required dialysis, and had a legal guardian.Review of the physician orders revealed an order dated 03/19/24 for Resident #2 to receive dialysis three times a week every Monday, Wednesday, and Friday. The physician orders were absent for an order to assess Resident #2's vital signs on return to the facility from dialysis. Review of the vital sign flow sheet from 03/01/26 to 03/31/26 revealed the absence of post dialysis vital signs documented on 03/02/26, 03/04/26, 03/06/26, 03/09/26, 03/11/26, 03/13/26, 03/16/26, 03/18/26, 03/20/26, 03/23/26, 03/25/26, and 03/27/26.Review of the progress notes from 03/01/26 to 03/31/26 revealed the absence of post dialysis vital sign documentation or resident refusals. An interview on 03/31/26 at 3:40 P.M. with Licensed Practical Nurse (LPN) #322 revealed when a resident returned from dialysis staff were to check vital signs, document in the vital sign flow sheet, and sometimes Resident #2 will refuse vital signs. An interview on 04/06/26 at 2:24 P.M. with Divisional Director of Clinical Education #379 verified Resident #2 was not properly assessed after dialysis.Review of the facility policy titled Hemodialysis Care Policy, dated 07/02/25 revealed that facility would provide competent care to residents that required dialysis.Review of the facility policy titled Resident Change in Condition Policy, dated 06/02/25 revealed the facility would intervene in the event a change in condition occurred, the nurse was to identify when a change in condition occurred, change in condition was to be reported as soon as identified, and that information relevant to a change in condition included vital signs, and when the change in condition occurred.

Based on observation, interview, record review, and policy review the facility failed to ensure oxygen equipment was changed per physician order and stored appropriately. This affected two residents (Resident #35 and Resident #49) of two residents reviewed for respiratory care. The census was 79. Findings include:1. Resident #35 was admitted to the facility on [DATE] with re-entry on 02/17/26 with diagnoses that included orthopedic aftercare following surgical amputation, osteomyelitis (a bone infection) of the left tibia and fibula, stroke, acquired absence of left leg below the knee, chronic kidney disease, need for assistance with personal care, and acute respiratory failure.Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was moderately cognitively impaired, did not reject care, required maximal assistance with activities of daily living, was occasionally incontinent of bladder, and was frequently incontinent of bowel.Review of the care plan revealed Resident #35 had an altered pulmonary status related to a left lung mass with a goal to not exhibit signs of respiratory distress dated 01/22/26 with interventions that included monitoring signs and symptoms of distress and monitor oxygen saturation, and provide medications as ordered. Review of discontinued physician orders revealed an order dated 01/12/26 and discontinued on 01/28/26 for oxygen via nasal cannula as needed to maintain a oxygen saturation greater than 92%, an order dated 01/12/26 and discontinued on 01/28/26 to clean the oxygen concentrator, the filter, and change the oxygen tubing every seven days, and an order dated 02/17/25 and discontinued on 03/30/26 for albuterol sulfate (a medication used to relax the airway muscle increasing airflow to the lungs) two and a half milligrams (mg) per three milliliters (ml) administer three ml's via inhalation every six hours as needed.Review of the Medication Administration Record (MAR) from 01/12/26 to 01/31/26 revealed the last documented time Resident #35's oxygen tubing was changed occurred on 01/27/26.An observation on 03/30/26 at 9:30 A.M. revealed the following: oxygen tubing without a date; the oxygen tubing was laid directly on the resident's bed side stand not covered while not in use; a undated nebulizer mask (a device that converts liquid medication into a mist, allowing it to be inhaled into the lungs) and tubing laid directly on the resident's bedside stand and not covered while not in use; and the nebulizer medication reservoir appeared to have a brown crusty residue on the inside where the medication is dispensed into. An interview on 03/30/26 at 9:13 A.M. with Licensed Practical Nurse (LPN) #322 revealed oxygen tubing was to be dated, changed every week, stored in a bag while not in use, nebulizers were to be changed every week, were to be dated, and were to be in a bag while not in use. An interview with LPN #322 on 03/30/26 at 3:19 P.M. verified the above findings. Review of the facility policy titled Oxygen Administration Policy, dated 06/23/25 revealed oxygen, nasal cannula or mask were to be stored in a plastic bag while not in use, changed weekly, and documented in the electronic medical record (EMR). Review of the facility policy titled Nebulizer Administration Policy, dated 07/29/25 revealed empty nebulizer equipment was to be emptied, rinsed with sterile water/saline, allowed to air dray, the mask wiped with an alcohol wipe, stored in a plastic bag while not in use, changed weekly, and documented in the EMR. 2. Review of the medical record for Resident #49 revealed they were admitted to the facility on [DATE] with diagnoses that included heart disease, dementia, chronic bronchitis (an inflammation of the lining of the bronchial tubes which carry air to and from the lungs), muscle weakness, depression, and need for assistance with personal care. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired, did not reject care, and required moderate assistance for most activities of daily living. Review of the care plan revealed Resident #49 required oxygen related to end of life care with a goal for an blood oxygen saturation greater than 90% dated 02/11/26 with interventions that included oxygen via nasal cannula and change tubing weekly and shortness of breath related to chronic bronchitis with a goal to not exhibit respiratory distress dated 02/11/26 with an intervention to provide respiratory treatments as ordered.Review of the physician orders revealed an order for ipratropium-albuterol (a combination medication used to relax airway muscle and improve breathing in people with lung condition) one half mg ipratropium and three mg albuterol per three ml administer three mg via inhalation every six hours as needed dated 01/27/26, an order for oxygen via nasal cannula at two to four liters per minute as needed dated 01/27/26, and an order to clean the oxygen concentrator, filter, and change the tubing weekly dated 01/27/26.Review of the MAR's from 01/01/26 to 03/31/26 revealed the absence of documentation that concentrator was cleaned, the oxygen tubing was changed, or the nebulizer equipment was changed. An observation 0n 03/30/26 at 9:31 A.M. revealed Resident #43 was lying in bed using the oxygen concentrator with a nasal cannula inserted in his nostrils, the date on the tubing was 03/16/26, the nebulizer mask and tubing were undated, and the nebulizer mask and tubing were laid on the bed side stand uncovered, and the nebulizer mask was hanging off the bed side stand touching the back part of the stand.An interview on 03/30/26 at 9:13 A.M. with Licensed Practical Nurse (LPN) #322 revealed oxygen tubing was to be dated, changed every week, stored in a bag while not in use, nebulizers were to be changed every week, were to be dated, and were to be in a bag while not in use. An interview with LPN #322 on 03/30/26 at 3:19 P.M. verified the above findings. An interview on 03/30/26 at 2:52 P.M. with Divisional Director Clinical Education #379 revealed it was not facility policy to date oxygen equipment.Review of the facility policy titled Oxygen Administration Policy, dated 06/23/25 revealed oxygen, nasal cannula or mask were to be stored in a plastic bag while not in use, changed weekly, and documented in the electronic medical record (EMR). Review of the facility policy titled Nebulizer Administration Policy, dated 07/29/25 revealed empty nebulizer equipment was to be emptied, rinsed with sterile water/saline, allowed to air dray, the mask wiped with an alcohol wipe, stored in a plastic bag while not in use, changed weekly, and documented in the EMR.

Based on record review and interview the facility failed to ensure treatment was in place to properly manage Resident #98's diabetic needs. This affected one resident (Resident #98) out of two residents reviewed for insulin administration. The facility census was 79. Findings include:A review of Resident #98's clinical record revealed an admission date of 03/27/26 with diagnoses including intracranial hemorrhage, hemiplegia affecting the right dominant side with trouble speaking and swallowing, convulsions, non-ST elevated heart attack, heart failure, atherosclerotic heart disease, diabetes mellitus, cirrhosis of liver, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and urinary retention.A review of Resident #98's hospital record revealed Resident #98 was admitted to the hospital following a collapse at work and was found to have a non-ST elevated myocardial infarction (heart attack). Heparin medication (anticoagulant medication used to prevent clot formation) was administered intravenously and Resident #98 started to experience signs of a stroke with trouble speaking and right sided flaccidity. The Heparin medication was stopped, and a stroke alert was called. Multiple areas in Resident #98's hospital record revealed Resident #98 had a diagnosis of diabetes mellitus and received both long and short acting insulin (Lantus 10 unit subcutaneously daily and HumaLog 0 to 8 units before meals and at bedtime) along with blood glucose monitoring before meals and at bedtime during his stay in the hospital. A review of Resident #98's Medication Administration Record dated 03/01/26 to 03/31/26 indicated he did not have blood sugar monitoring or insulin administration until 03/30/26 (three days after admission to the facility).An interview on 04/02/26 at 11:21 A.M. with Resident #98's son revealed he was very upset about his father's (Resident #98) care in the facility. Resident #98's son stated his father should be receiving insulin medication and blood sugar monitoring before meals and at bedtime. Resident #98's son was told the facility was monitoring his blood glucose levels but when he personally checked Resident #98's blood sugar it was greater than 300 mg/dL. Resident #98's son felt the facility was not listening to the family and should be following the orders from the hospital.Interviews with Registered Nurse (RN) #309 and RN #341 on 04/02/26 between 11:00 A.M. and 12:00 P.M. revealed they were assigned to care for Resident #98 over the past weekend. Both nurses stated there was no order to administer insulin to Resident #98 and they were not obtaining blood glucose levels before meals and at bedtime. Both nurses indicated they had no knowledge of Resident #98's family's request for blood glucose monitoring or insulin administration.An interview on 04/01/26 at 3:00 P.M. with Certified Nurse Practitioner (CNP) #382 revealed she personally assessed Resident #98 after his admission to the facility on Monday on 03/30/26. CNP #382 stated she was unaware of the family's request to have blood glucose monitoring before meals and at bedtime. CNP #282 stated Resident #98 did not have a diagnosis of diabetes mellitus and typically do not check blood sugars unless a resident has a diagnosis of diabetes mellitus. After review of Resident #98's hospital record CNP #382 confirmed Resident #98 did have a diagnosis of diabetes mellitus. CNP #382 indicated an order was entered on 03/30/26 to obtain fasting blood sugar before meals and at bedtime and an order for Lantus 100 units per milliliter to administer 3 units at bedtime. CNP #382 agreed the hospital record indicated he was receiving long and short acting insulin during his hospitalization. CNP #382 verified Resident #98 did not have an order to receive insulin to treat his diagnosis of diabetes mellitus until 03/30/26.

Based on interview, record review, and policy review the facility failed to provide individualized activities to meet Resident #9's interests. This affected one resident (Resident #9) out of one resident reviewed for activities. Findings include:Review of Resident #9's medical record revealed an admission date of 09/26/2023 with diagnoses that included stroke, Type 2 diabetes mellitus, heart disease, heart failure, contracture (a shortening or stiffening of muscles, tendons, or skin that limits joint movement) of right hand, contracture of the thigh, contracture of the lower leg, and functional quadriplegia (inability to move the limbs and body from the neck down). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively impaired, did not reject care, dependent on staff for all activities of daily living, and was incontinent of bowel and bladder.Review of Resident #9's annual Activities Observation dated 12/09/25 revealed it was somewhat important to listen music he liked, it was somewhat important to participate in his favorite activities, he preferred one to one activities, his preferred activities were music, tv, family visits, and one to one visits, and he was a DJ prior to admission. Review of the quarterly Activities Observation dated 03/06/26 revealed Resident #9's favorite activities were one to one visits, music, tv, and family visits. Review of the care plan revealed Resident #9 had impaired daily decision making with a goal to function in a structured routine environment dated 03/22/26. Interventions included offer activities that recreate past experiences and offer programs using retained long term memory. Review of the activities log from 12/01/25 to 12/31/25 revealed the activities that were provided for Resident #9 were a movie on 12/20/25, 12/23/25, 12/24/25, 12/26/25, 12/29/25, 12/30/25, and 12/31/25. Review of the activities log from 01/01/26 to 01/31/26 revealed the activities that were provided for Resident #9 were a movie on 01/06/26, a movie on 01/07/26, a one to one visit on 01/07/27, a movie on 01/08/26, a movie on 01/09/26, a movie on 01/10/26, a movie on 01/12/26, a movie on 01/13/26, a movie on 01/16/26, a movie on 01/17/26, a movie on 01/18/26, a movie on 01/20/26, a movie on 01/21/26, a movie on 01/22/26, a movie on 01/23/26, a movie on 01/26/26, a movie on 01/27/26, a movie on 01/28/26, and a movie on 01/31/26.Review of the activities log from 02/01/26 to 02/28/26 revealed the activities that were provided for Resident #9 were a movie on 02/01/26, a movie on 02/03/26, a movie on 02/05/26, a movie on 02/08/26, a movie on 02/09/26, a movie on 02/10/26, a one to one visit on 02/10/26, a movie on 02/13/26, a celebration on 02/13/26, a movie on 02/17/26, a one to one visit on 02/17/26, a movie on 02/18/26, a movie on 02/20/26, a movie on 02/24/26, a movie on 02/25/26, a movie on 02/27/26, and a movie on 02/28/26.Review of the activities log from 03/01/26 to 03/31/26 revealed the activities that were provided for Resident #9 were a movie on 03/01/26, a movie on 03/04/26, a movie on 03/05/26, a movie on 03/06/26, a movie on 03/08/26, a movie on 03/09/26, a one to one visit on 03/09/26, a movie on 03/10/26, a movie on 03/13/26, a movie on 03/14/26, a movie on 03/15/26, a movie on 03/17/26, a movie on 03/19/26, a one to one visit on 03/19/26, a movie on 03/20/26, a movie on 03/21/26, a movie on 03/23/26, a movie on 03/24/26, a one to one visit on 03/24/26, a movie on 03/26/26, a movie on 03/28/26, a movie on 03/29/26, a movie on 03/31/26, and a one to one visit on 03/31/26.An interview on 04/02/26 at 12:28 P.M. with Resident #9's family revealed music was important to him, when she visits music is normally not playing on the stereo next to the resident's bed, and the resident did not have the ability to turn music on or off. An interview on 04/02/26 at 2:53 P.M. with Activities Director #342 revealed one-to-one activities were generally fifteen minutes, occurred two to three times per week, were assessed annually, and were tracked through activity logs. Activity Director #352 noted they were familiar with Resident #9, he was not always able to make his needs known, and the resident was a DJ before admission. An interview on 04/02/26 at 4:20 P.M. with Activities Director #342 revealed movies on the activity log are considered a one-to-one activity, staff would sit with the resident for the duration of the one-to-one visit and verified the activity logs were correct to not include meeting the interest of Resident #9.Review of the facility policy titled Life Enrichment Programming Policy', dated 03/31/25 revealed the facility would provide an activity program based on comprehensive assessments and care plans, it would meet the interests and abilities of the resident, and previous positive lifestyles would be included.

Based on interview and record review the facility failed to provide showers according to resident preferences. This affected two residents (Resident #9 and Resident #35) out of four residents sampled for activities of daily living. Findings include:1.Review of Resident #9's medical record revealed an admission date of 09/26/2023 with diagnoses that included stroke, type 2 diabetes mellitus, heart disease, heart failure, contracture (a shortening or stiffening of muscles, tendons, or skin that limits joint movement) of right hand, contracture of the thigh, contracture of the lower leg, and functional quadriplegia (inability to move the limbs and body from the neck down). Review of Resident #9's Activities Observation dated 12/09/25 revealed it was very important to choose between a tub bath, shower, bed bath, or sponge bath.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed it was very important to choose between a tub bath, shower, bed bath, or sponge bath. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 was cognitively impaired, did not reject care, was dependent on staff for all activities of daily living, and was incontinent of bowel and bladder.Review of the care plan revealed Resident #9 had a self-care deficit due to a stroke with a goal to have needs met by staff dated 03/22/26 with interventions that included bathing assistance of two and hygiene assistance of two. Review of the physician orders revealed an order dated 02/11/26 for Resident #9 to receive a shower two times a week on Wednesday and Saturday.Review of the electronic medical record (EMR) shower sign off from 01/03/26 to 02/01/26 revealed Resident #9 received a shower on 01/04/26, 01/15/26, 01/22/26, 01/24/26, 01/28/26, 01/29/26, 01/30/26 and 01/31/26.Review of the EMR shower sign off from 02/01/26 to 02/28/26 revealed Resident #9 received a shower on 02/11/26, 02/14/26, 02/18/25, 02/21/25, 02/25/26 and 02/28/26. Review of the EMR shower sign off from 03/01/26 to 03/31/26 revealed Resident #9 was showered on 03/04/26, 03/07/26, 03/11/26, 03/14/26, 03/18/26, 03/21/26, 03/25/26, and 03/28/26.Review of the paper showers sheets from 01/15/26 to 03/29/26 revealed Resident #9 received a bed bath on 01/15/26, a bed bath 01/24/26, a bed bath on 01/29/26, a bed bath on 01/31/26, a bed bath on 02/05/26, a bed bath on 02/07/26, a bed bath on 02/14/26, a bed bath on 02/18/26, on 02/22/26 the method of bathing wasn't documented, a bed bath on 02/25/26, a bed bath on 03/04/26, a bed bath on 03/07/26, a bed bath on 03/14/26, a bed bath on 03/18/26, a bed bath on 03/21/26, and a bed bath on 03/29/26. An interview on 04/02/26 at 12:56 P.M. with Licensed Practical Nurse (LPN) #335 revealed showers are documented on paper sheets and the nurse reviews the shower sheet once completed. An interview on 04/02/26 at 1:18 P.M. with Certified Nursing Assistant (CNA) #353 revealed showers are documented on paper shower sheets and the nurse on the floor had to sign them afterwards.An interview on 04/02/26 at 4:05 P.M. with the Director of Nursing (DON) verified the above findings of the resident's preference to receive showers with multiple bed baths given instead.2. Resident #35 was admitted to the facility on [DATE] with re-entry on 02/17/26 with diagnoses that included orthopedic aftercare following surgical amputation, osteomyelitis (a bone infection) of the left tibia and fibula, stroke, acquired absence of left leg below the knee, chronic kidney disease, need for assistance with personal care, and acute respiratory failure.Review of the admission Observation dated 01/12/26 at 7:09 P.M. revealed Resident #35 preferred a shower and preferred bathing three times a week. Review of the care plan revealed Resident #35 had a self-care deficit related to weakness and debility with a goal to improve their level of function dated 01/22/26. Interventions included to provide assistance with activities of daily living and to report deterioration to the physician.Review of the five-day MDS 3.0 assessment dated [DATE] revealed Resident #35 was moderately cognitively impaired, did not reject care, required maximal assistance with activities of daily living, was occasionally incontinent of bladder, and was frequently incontinent of bowel. Review of the physician orders revealed an order dated 01/28/26 for showers twice a week on Wednesday and Saturday which was discontinued on 02/025/26 and an order for showers twice a week on Tuesday and Friday dated 02/18/26. Review of the EMR shower sign off from 01/28/26 to 01/31/26 revealed Resident #35 received a shower on 01/28/26 and 01/31/26.Review of the EMR shower sign off from 02/01/26 to 02/28/26 revealed Resident #35 received a shower on 02/04/26, the resident was then hospitalized from [DATE] until 02/17/26, and then received showers on 02/20/26, 02/24/26, and 02/27/26. Review of the EMR shower sign off from 03/01/26 to 03/31/26 revealed Resident #35 received a shower on 03/03/26, 03/06/26, 03/10/26, 03/13/26, 03/17/26, 03/20/26, 03/24/26, and 03/27/26. Review of the paper showers sheets from 01/21/26 to 03/27/26 revealed Resident #35 received a bed bath on 01/21/26, a bed bath on 01/24/26, refused bathing on 01/28/26, the method of bathing wasn't documented on 02/20/26, the method of bathing wasn't documented on 02/22/26, the method of bathing wasn't documented on 02/24/26, on 02/27/26 received a shower, on 03/03/26 received a shower, the method of bathing wasn't documented on 03/06/26, the method of bathing wasn't documented on 03/10/26, on 03/17/26 received a shower, the method of bathing wasn't documented on 03/20/26, the method of bathing wasn't documented on 03/24/26, and received a shower on 03/27/26. An interview on 03/30/36 at 9:01 A.M. with Resident #35 revealed he doesn't always get showers on his scheduled shower days.An interview on 04/02/26 at 12:56 P.M. with Licensed Practical Nurse (LPN) #335 revealed showers are documented on paper sheets and the nurse reviews the shower sheet once completed. An interview on 04/02/26 at 1:18 P.M. with Certified Nursing Assistant (CNA) #353 revealed showers are documented on paper shower sheets and the nurse on the floor had to sign them afterwards.An interview on 04/02/26 at 4:05 P.M. with the Director of Nursing (DON) verified the above findings of the resident not being bathed three times a week as scheduled.This deficiency represents non-compliance investigated under Complaint Number 2667505.

Based on closed record review and interview, the facility failed to ensure Resident #94's discharge summary was signed, verifying receipt of discharge instructions. This affected one resident (Resident #94) of three reviewed for discharge process.Review of the closed medical record for Resident #94 revealed an admission date of 09/20/25 and a discharge date of 10/04/25. Diagnoses included foreign body in respiratory track, dysphagia, hypertension and anxiety.Review of the discharge Minimum Data Set 3.0 dated 10/04/26 revealed he was cognitively intact and required set-up to moderate assistance with activities of daily living.Review of the Discharge summary dated [DATE] revealed no evidence the resident or family member signed the discharge summary acknowledging wound care instructions as the form indicated a signature should be obtained.Interview on 04/01/26 at 10:13 A.M. with Registered Nurse (RN) #317 verified she did not obtain a signature on Resident #94's discharge summary.Interview on 04/01/26 at 1:39 P.M. with Divisional Director of Clinical Education revealed the facility audited discharge summaries after reviewing complaint involving Resident #94. She stated they discovered nurses were not obtaining signatures from residents or responsible parties on discharge summaries.This deficiency represents non-compliance investigated under Complaint Number 2667505.

Based on observation, record review and interview the facility failed to ensure Resident #8's care plan was revised to indicate an accurate right buttock wound classification and failed to ensure Resident #50's care plan included individualized interventions to address her diagnosis of gastroesophageal reflux disease This affected one resident (Resident #8) out of three residents reviewed for pressure ulcers and one resident (Resident #50) out of four residents reviewed for medication administration. The facility census was 79.Findings include: 1.A review of Resident #8's clinical record revealed an admission date of 06/18/22 with diagnoses including congestive heart failure, atrial fibrillation (heart arrhythmia), atherosclerotic heart disease, anemia, high blood pressure and cholesterol, chronic kidney disease, polyneuropathy, diabetes mellitus, osteoarthritis, gout, restless leg syndrome, benign enlarged prostate and cognitive communication deficit.A review of Resident #8's plan of care initiated on 05/12/25 and edited on 01/09/26 indicated an alteration in skin integrity related to a surgical wound on the right buttocks. A review of Resident #8's wound assessment dated [DATE] indicated the right buttock wound was a pressure ulcer measuring 2.5 centimeters (cm) long by 2.5 cm wide with no depth measured. The right buttock wound was a stage III pressure ulcer which was originally identified on 05/08/25 and was surgically repaired and the classification was changed to a surgical wound but was still a pressure ulcer.An observation of Resident #8's wound treatment completed by Licensed Practical Nurse (LPN) #304 revealed Resident #8 had a pressure ulcer located on the sacrum and right buttock area. The right buttock area was approximately the size of a quarter and approximately one centimeter (cm) deep with red wound bed and no yellow slough or necrosis. Resident #8's surrounding skin was scarred and very red.An interview with Resident #8 on 03/31/26 at 4:28 P.M. revealed he had chronic pressure ulcers located on his buttock and sacral areas which had healed and re-opened several times over the past several years. Resident #8 stated he used a wheelchair and was unable to ambulate and staff assisted him with turning and repositioning to offload the wound areas. Resident #8 stated he had surgical repair of the right buttock pressure ulcer wound in the past but the pressure ulcer did not fully heal.An interview with Wound Registered Nurse (WRN) #309 on 04/01/26 at 8:19 A.M. verified the documentation on Resident #8's care plan had incorrect right buttock wound classification. WRN #309 stated the wound should be classified as a pressure ulcer instead of a surgical wound. WRN #309 agreed Resident #8's plan of care needed revised to indicate a pressure ulcer instead of a surgical wound.2. A review of Resident #50's clinical record revealed an admission date of 03/22/25 with diagnoses including chronic kidney disease, atherosclerotic heart disease, cerebral vascular disease with cerebral infarction (stroke), gastroesophageal reflux disease (GERD), diabetes mellitus, high blood pressure and cholesterol, and hypothyroidism.During medication administration on 03/31/26 at 8:10 A.M. Resident #50's son approached Licensed Practical Nurse #322 and informed her Resident #50 had vomited her medications into a napkin. LPN #322 stated she would check on Resident #50.A review of Resident #50's clinical record revealed no care plan was developed to address Resident #50's diagnosis of GERD. A care plan was initiated to address an increased risk for nutrition/hydration risk related to GERD and other diagnoses, but no specific interventions were initiated to address her reflux/vomiting of medications and risk for aspiration.An interview with LPN #337 on 04/01/26 at 7:17 A.M. revealed she had assessed Resident #50 after she completed the morning medication administration on 03/31/26 and found no negative findings. LPN #322 stated she informed Certified Nurse Practitioner (CNP) #392 that Resident #50 had vomited her medications but had not documented the notification in Resident #50's clinical record. LPN #322 verified there was no documentation in Resident #50's clinical record of the vomiting incident. LPN #337 stated Resident #50 often had reflux and would often have trouble swallowing food and medications due to her swallowing issues. LPN #322 stated CNP #392 was present on the nursing unit at the time she was notified of Resident #50's vomiting her medication episode. LPN #322 stated CNP #392 had assessed Resident #50 but also verified there was no documentation that CNP #392 had assessed Resident #50 after the incident in Resident #50's clinical record.An interview with CNP #392 on 04/02/26 at 10:51 A.M. verified she was notified by LPN #337 that Resident #50 had vomited her undissolved medications in a napkin on 03/31/26. CNP #392 stated this was a common recurrence for Resident #50. CNP #392 stated she had assessed Resident #50 after the incident and found no negative outcome and no signs of aspiration. CNP #337 agreed she had not documented the incident in Resident #50's clinical record at the time she was notified or after she had assessed Resident #50.An interview with Regional Director of Clinical Service (RDCS) on 04/06/25 at 11:45 A.M. verified the above findings and agreed Resident #50's care plan did not had a care plan initiated to address her care needs regarding the diagnosis of GERD and individualized interventions were implemented to address Resident #50's risk of aspiration and reflux/vomiting her undissolved medications.This deficiency represents non-compliance investigated under Complaint Number 2688522.

Based on record review, observation, interview and facility policy review, the facility did not ensure Foley catheter drainage bags were covered in a dignified manner. This affected one (Resident #66) out of three residents reviewed for dignity and had the potential to affect two additional (Residents #29 and #38) identified by the facility as having a Foley catheter. The facility census was 77. Findings include: Review of the medical record for Resident #66 revealed an admission date of 06/18/22. Diagnoses included irregular heartbeat, retention of urine, heart failure, high blood pressure and kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. He was independent for eating, required setup help for oral and personal hygiene and was dependent upon staff for toileting, showering and dressing. Review of the care plan dated 05/14/25 revealed Resident #66 required an indwelling urinary (Foley) catheter. Interventions included measuring intake and output, keeping the tubing and parts of the drainage system off the floor, storing the collection bag inside a protective dignity pouch and avoiding lying on top of the tubing. Observation and interview on 06/23/25 at 9:55 A.M. with Resident #66 revealed he did have a Foley catheter in use. No privacy cover was observed on his catheter drainage bag. Interview at the time of the observation with Certified Nurse Aide (CNA) #201 confirmed catheter drainage bags should be covered with a privacy bag, and Resident #66 did not have a privacy bag on his catheter drainage bag. Review of the undated facility policy Resident Rights revealed the resident had the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. This deficiency is an incidental finding identified during the complaint investigation.

Based on observation, record review, interview and facility policy review, the facility failed to ensure fall interventions were in place and falls were thoroughly investigated. This affected two (Residents #40 and #66) of three residents reviewed for falls. The facility census was 77. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 08/08/23. Diagnoses included hypertension, dementia, muscle weakness, chronic obstructive pulmonary disease (COPD) and epilepsy. Review of the fall risk assessment dated [DATE] revealed Resident #40 was a high risk for falls. Review of the care plan dated 02/20/24 revealed Resident #40 was at risk for falls. Interventions included placing the bed against the wall, ensuring the area was free of clutter, ensuring she was wearing proper footwear, and showing her glasses were being used, ensuring common items were within reach and her call light was within reach. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. She required set up and clean up help for eating and oral hygiene, substantial or maximum assistance for personal hygiene and was dependent on staff for toileting, showering and dressing. Review of the nursing note dated 06/16/25 at 3:05 A.M. revealed Resident #40 was found in her bedroom on the floor. Resident #40 was complaining of back, neck, head and pelvic pain. Vital signs were obtained while emergency medical transportation (EMT) services were called. Vital signs were within normal limits. Resident #40 had some confusion and delayed response, she could not confirm if she hit her head. She also could not explain how she rolled out of bed and onto the floor. The right-side handrail was noted to be up on the bed. The nurse asked if she was trying to sit up on the bed to which she replied, yes. EMTs arrived and the resident was taken to the local emergency department for examination, the doctor, nurse on call on, the administrator and family were notified. Review of the facility fall investigation dated 06/16/25 revealed Resident #40 rolled out of bed and complained of back, head, neck and pelvic pain. Resident #40 was not wearing footwear at the time of the fall. Vitals signs were blood pressure 120/87, pulse 72, temperature 96.5 degrees and respirations 18. Resident #40 reported a pain level of five on one to 10 scale, 10 being the worst. The investigation did not reveal any evidence if Resident #40's bed was against the wall, if her call light was in reach, or if the area was free of clutter. Interview on 06/23/25 at 3:05 P.M. with Certified Nurse Aide (CNA) #206 revealed she heard yelling from Resident #40's room and when she went to check on her, she was on the floor. She revealed she had just helped change the resident approximately 15 minutes before the fall, but she could not confirm if the residents' call light was in reach at the time of the fall, she reported Resident #40 had been more confused prior to the fall. Review of hospital discharge paperwork dated 06/16/25 revealed no negative findings on the CT scans or X-rays for Resident #40; she was discharged home. 2. Review of the medical record for Resident #66 revealed an admission date of 06/18/22. Diagnoses included irregular heartbeat, retention of urine, heart failure, high blood pressure and kidney disease. Review of the fall risk assessment dated [DATE] revealed Resident #66 was a moderate risk for falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #66 was cognitively intact. He was independent for eating, required setup help for oral and personal hygiene and was dependent on staff for toileting, showering and dressing. Review of the care plan dated 04/04/24 revealed Resident #66 was at risk for falls. Interventions included nonskid strips at bedside, toileting assistance as needed, ensuring his reaching device (a long-handled assistive device to help grasp, pick-up, or retrieve objects) was in use, ensuring the floor was clear of glare, liquids and foreign objects and proper, well-maintained footwear. Review of the physician's orders for 05/21/25 revealed an order to encourage Resident #66 to use his reacher when picking up items, nonskid strips to the bedside and bathroom floor and a Call, Don't Fall sign. Observation and interview on 06/23/25 at 2:33 P.M. with Resident #66 revealed he had a reacher, but it was at home. A reaching device was observed in front of the residents' television, at the end of the resident's bed, against the wall. Interview with CNA #201 confirmed the reacher was nowhere near Resident #66 and should be near him to help prevent the risk of falls. Review of the facility policy titled Fall Prevention and Management Policy, dated 08/06/24, revealed a fall was defined as unintentionally coming to rest on the ground, floor or other lower level. Fall risk assessments would be completed at admission, quarterly and as needed, and individualized interventions would be implemented based on those assessments and care planned accordingly. This deficiency represents noncompliance investigated under Complaint Number OH00166245.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident (SRI) review, facility investigation review, interview and facility policy review, the facility failed to ensure residents were free from potential abuse by failing to immediately suspend a staff member after an allegation of staff-to-resident abuse. This affected one (Resident #63) of three residents reviewed for abuse and had the potential to affect all 77 residents in the facility. Findings include: Review of the medical record for Resident #63 revealed an admission date of 03/21/23. Diagnoses included a history of stroke affecting the left, dominant side, hypertension, chronic kidney disease, glaucoma, left eye blindness, osteoarthritis, diabetes and dementia. Review of the quarterly Minimum Data Set (MDS) assessment data 05/06/25 revealed Resident #63 was severely cognitively impaired. He required setup help for eating, partial to moderate assistance for oral hygiene, substantial to maximal assistance for personal hygiene and was dependent on staff for toileting, showering and dressing. Review of the facility SRI tracking number 258295 revealed on 03/15/25 at 11:10 A.M., Housekeeper #214 reported she witnessed Certified Nurse Aide (CNA) #213 physically abused resident #63. Review of the facility investigation revealed Housekeeper #214 witnessed Resident #63 telling CNA #213 he did not want deodorant on. CNA #213 forcefully took his arm and put the deodorant on anyway. Resident #63 called CNA #213 a derogatory name and swatted her away. She revealed she witnessed CNA #213 spray Resident #63 in the face with deodorant and immediately went to the nurse to report her findings. The investigation further revealed Licensed Practical Nurse (LPN) #215 continued passing medications for approximately five to ten minutes prior to addressing Housekeeper #214's concern. CNA #213 reported Resident #63 had been agitated with care and did not want CNA #213 to apply deodorant to his right arm; therefore, she respected the resident's wishes and left his room. She denied forcing the resident to use deodorant or spraying him in the face intentionally. The Administrator spoke with LPN #215 at approximately 5:30 P.M. and was told Housekeeper #214 saw CNA #213 spray Resident #63 in the face with deodorant. LPN #215 confirmed she did not immediately assess Resident #63 and waited approximately ten minutes to do so. At the time of the assessment, the resident did not look like he was in distress, nor did there appear to be any injury to his eyes. The former Director of Nursing (DON) was called at 12:41 P.M. and instructed LPN #215 to switch CNA #213's assignment. The former DON did not suspend CNA #213 upon learning of the alleged abuse. LPN #215 was suspended at 6:45 P.M. Housekeeper #214 was suspended at 6:55 P.M. for not immediately ensuring the resident's safety. The investigation included resident assessments, resident interviews, staff interviews and medical record reviews. Resident #63 was interviewed and assessed as part of the investigation, and his electronic medical record was reviewed. A head-to-toe assessment was completed, and no negative effects to the resident were noted. The allegation of abuse was unsubstantiated. Review of the care plan dated 03/19/25 revealed Resident #63 was resistive to care. Interventions included stopping and reapproaching later, maintaining a calm environment and approach to the resident, allowing the resident to choose options and actively involving the resident in his care. Resident #63 also had a self-care performance deficit. Interventions included encouraging the resident to participate in oral hygiene, only using roll on deodorant and monitoring for pain or intolerance training self-care. Interview on 06/24/25 at 11:41 A.M. with the Administrator revealed CNA #213 was suspended on 03/15/25 at 5:34 P.M. He confirmed she should have been suspended immediately upon learning of the suspected allegation of abuse. Review of the facility policy titled Ohio Resident Abuse Policy, dated 07/11/24, revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. If abuse was suspected, staff would immediately report the concern to their direct supervisor and not leave the resident unattended unless it was necessary to summon assistance. If a staff member was suspected of abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property, the facility would immediately remove the staff member from the resident care areas and that staff would remain under direct supervision until a written statement was complete or law enforcement arrived, if applicable. The accused staff member would be removed from the facility and schedule pending the outcome of the investigation. The deficient practice was corrected on 03/16/25 when the facility implemented the following corrective actions: • Upon discovery on 03/15/25, CNA #213, former DON, Housekeeper #214, and LPN #215 were suspended by the Administrator. • Resident #63 was assessed head-to-toe by a licensed nurse. • Resident #63's physician and family were notified of the incident. • An SRI was reported (there was a delay in the EIDC system working). • The Administrator began interviewing the staff in question. • Resident #63 was assessed for psychosocial decline, none noted. • All staff were educated on the abuse policy by 03/16/25 by the Administrator or designee. • The SRI investigation was completed by the Administrator and the acting DON on 03/18/25 with no negative findings. • The Administrator worked with Corporate Human Resources and provided one on one education and discipline, if applicable, CNA #213, former DON, Housekeeper #214 , and LPN #215 • To monitor and maintain ongoing compliance, the Administrator or designee will monitor for any accusations or signs and symptoms of abuse to determine if the facility followed the abuse policy three times a week for four weeks and then monthly times two months. • The results of the audits will be forwarded to the facility quality assurance and performance improvement (QAPI) committee for further review and recommendations. This deficiency is an incidental finding identified during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to ensure misappropriation of medications for Resident #80. This affected one (Resident #80) of three reviewed for abuse and had the potential to affect all 77 residents residing in the facility. Findings include: Review of the medical record for Resident #80 revealed an admission date of 04/26/25 and a discharge date of 05/31/25. Diagnoses included hypertension, right femur fracture, repeated falls, diabetes, difficulty walking and need for assistance with personal care. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was cognitively intact. She was independent for eating, required supervision for oral hygiene, partial to moderate assistance for personal hygiene and was totally dependent on staff for toileting and showering. She had major surgery to repair her leg. Review of the physician's orders for April 2025 revealed an order for Tramadol (an opioid pain reliever) 50 milligrams (mg) every six hours as needed (prn). Review of the care plan dated 04/29/25 revealed Resident #80 had complaints of pain due to a right femur fracture. Interventions included assessing the effects of pain on the resident, evaluating the effectiveness and pain management interventions, eliminating environmental stimuli, administering medications and monitoring the effectiveness, and positioning for comfort with physical support as necessary. Review of SRI tracking number 259767 dated 04/27/25 revealed Registered Nurse (RN) #200 received a phone call on 04/27/25 at approximately 7:30 P.M. from RN #207 who reported the facility count sheet was off by one pill of Tramadol for Resident #80. RN #207 revealed she questioned the nurse who was finishing her shift, RN #209, about the missing Tramadol and was told she pulled the medication but it was too soon to administer it therefore, she put it in her pocket and when it was time to administer the medication she could not find it. Shortly after that time, RN #209 was asked to assist an unidentified certified nurse aide (CNA) in providing care to another resident. When she returned to the medication cart, she reported she had found the missing Tramadol for Resident #80 and had disposed of it appropriately. By the time RN #200 arrived at the facility to investigate and question RN #209, RN #209 had clocked out and left the facility. RN #200 reached out to RN #209 via text message and asked her to return to the facility to discuss the incident. RN #209 replied she would not be returning to the facility and had terminated her employment. Review of the facility investigation, dated 04/27/25, revealed the investigation included resident assessments, resident interviews, staff interviews, medical record reviews, narcotic record reviews, and staff drug screen reviews. RN #209 refused to cooperate with the investigation, and the incident was reported to the Ohio Board of Nursing. The investigation included a search of the facility sharps containers, where RN #209 reportedly discarded the Tramadol, and no discarded medication was located. Resident #80 was interviewed as part of the investigation and her electronic medical record was reviewed. A head-to-toe assessment was completed to include a pain assessment, and no negative effects to Resident #80 were noted. The allegation of misappropriation of narcotic medications was inconclusive. Interview on 06/24/25 at 11:41 A.M. with the Administrator confirmed Resident #80's medication had been misappropriated. Review of the facility policy titled Ohio Resident Abuse Policy, dated 07/11/24, revealed the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The definition of misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, or mistreatment of resident by a court of law; had a finding of abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property reported into a state nurse aide registry, or had a disciplinary action taken against a professional license by a state licensure body as a result of a finding of abuse, neglect, or mistreatment of residents or a finding of misappropriation of property. The deficient practice was corrected on 05/02/25 when the facility implemented the following corrective actions: • Resident #80 was assessed for pain and reported none at the time of the interview. • Nurses on duty at the time of the incident were asked to submit a urine test for drug screening. • On 04/28/25 an e-mail was sent to Pharmacist #210 informing her of the discrepancy and requesting a pharmacy representative to conduct a comprehensive narcotic audit of the facility. • RN #200 conducted an audit of each medication cart as well as the narcotic count sheets and no other discrepancies were noted. • One 05/02/25, a quality assurance and performance improvement (QAPI) meeting was held with the medical director present to discuss the incident. • The former Director of Nursing (DON) and RN #202 conducted audits of the narcotic accountability records, concluding on 04/28/25. • Residents who received narcotic medications were interviewed by the former DON and none reported concerns with receiving medications. • All nursing staff were re-educated by RN #202 regarding medication administration and documentation, concluding on 04/30/25. • Ongoing compliance with medication administration and documentation was conducted for four nurses per week for four weeks. Results were submitted to the QAPI committee for further review and recommendations. • RN #200 conducted weekly audits of as needed narcotic administration records ensuring all doses were signed and documented in the electronic medical record for four weeks. The results of the audits were submitted to the QAPI committee for further review and recommendations. This deficiency is an incidental finding identified during the complaint investigation.

Based on record review, interview and facility policy review, the facility failed to make the appropriate notifications when Resident #79 removed his Foley catheter. This affected one (Resident #79) of three reviewed for dignity concerns. The facility census was 77. Findings include: Review of the medical record for Resident #79 revealed an admission date of 05/01/25 and a discharge date of 05/21/25. Diagnoses included dementia, failure to thrive, repeated falls, diabetes and prostate cancer. Review of the comprehensive Minimum [NAME] Set (MDS) assessment dated [DATE] revealed Resident #79 was severely cognitively impaired. He required supervision for eating, oral and personal hygiene and substantial or maximum assistance for toileting and showering. Review of the physician's orders for May 2025 revealed Resident #79 had an order to change his indwelling urinary (Foley) catheter once a day and as needed. Review of the care plan dated 05/05/25 revealed Resident #79 had an indwelling urinary catheter. Interventions included freedom from infection and urethral trauma, measuring intake and output, avoiding the tubing or any part of the drainage system from touching the floor, storing the collection bag inside a protective dignity pouch and avoiding obstructions in the drainage. Review of the nursing note dated 05/16/25 at 2:33 A.M. revealed Registered Nurse (RN) #207 was walking down the hallway when she noticed Resident #79 standing in his room. Upon entering the room, she noticed blood on the floor and the resident's Foley catheter was not in place. The Foley was noted to be intact with the balloon intact as well. The resident was assisted with a shower, and the Foley catheter was reinserted with no complaints of pain from the resident. Interview on 06/24/25 at 6:40 A.M. with RN #207 confirmed she walked by Resident #79's room and noticed he was standing near his roommate's bed with some blood on the floor. She revealed his Foley catheter had been removed, she assisted him in getting a shower and replaced the Foley catheter. She confirmed she did not notify the residents physician or family of the incident, and this was typically something that should be done when such an incident occurred. Review of the facility policy titled Resident Change in Condition Policy, dated 06/27/24, revealed a significant change of condition was a decline in a resident's status that would not normally resolve itself without intervention by staff, impacts more than one area of the resident's health status and or requires review or revision to the care plan. The physician and family or responsible party would be notified in the event of an accident or injury revolving the resident, the discovery of an injury, reaction to medication or treatment, a significant change to the residents of physical, emotional or mental condition or need to alter the resident's medical treatment including a change in provider orders. This deficiency represents noncompliance investigated under Complaint Number OH00166245.

Based on record review, interview and facility policy review, the facility failed to ensure advance directive orders were consistent across electronic and paper medical records. This affected two residents (#5 and #29) out of 24 resident records reviewed. Facility census was 84. Findings include: 1. Review of Resident #5's medical record revealed an admitted [DATE] and diagnoses including depression, peripheral vascular disease, cerebral aneurysm, aphasia, dysphagia, anxiety and dementia. Review of Resident #5's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had cognitive impairment, was dependent on toileting and required substantial/maximal assistance for bathing. Review of Resident #5's electronic medical record revealed she had an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA). Review of Resident #5's paper medical record revealed there was an advance directive of DNRCCA on file dated [DATE] as well as a full measures advance directive dated [DATE]. Interview on [DATE] at 8:12 A.M. with the Director of Nursing (DON) confirmed there were advance directives of full code and DNRCCA for Resident #5 in her paper chart and should not have been as this was conflicting information. The DON indicated in the event of a code, staff were to check both the electronic and paper charts for advance directives prior to proceeding with cardiopulmonary resuscitation (CPR) as indicated. 2. Review of Resident #29's medical record revealed an admitted [DATE] and diagnoses including dementia, suicidal ideations, hypertension, depression, anxiety, chronic kidney disease and muscle weakness. Review of Resident #29's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #29 had severe cognitive impairment, required supervision for eating and was dependent on staff for toileting. Review of Resident #29's electronic medical record revealed she had an advance directive of Do Not Resuscitate Comfort Care (DNRCC). Review of Resident #29's paper medical record revealed there was an advance directive of DNRCC on file dated [DATE] as well as a full measures advance directive dated [DATE]. Interview on [DATE] at 8:12 A.M. with the DON confirmed there were advance directives of full code and DNRCC for Resident #29 in her paper chart and should not have been as this was conflicting information. The DON indicated in the event of a code, staff were to check both the electronic and paper charts for advance directives prior to proceeding with CPR as indicated. Review of the facility policy, Advance Directives Protocol, no date revealed the clinical chart will identify any chosen advance directives including any applicable forms such as Do Not Resuscitate (DNR) forms. Advance directives will be reviewed at minimum annually according to MDS schedule. Utilize Advanced Directive audit tool to maintain current advance directive status readily available for review.

Based on closed record review, hospital record review, facility policy review and interview the facility failed to provide adequate supervision and assistance to prevent a fall with injury for Resident #80. Following the fall, the facility failed to complete a comprehensive assessment, provide ongoing monitoring and physician notification to ensure the resident received timely medical treatment. Actual Harm occurred on 11/25/23 at 5:45 P.M. when Resident #80, who was cognitively impaired, at high risk for falls and with a history of recent falls, sustained a fall from the wheelchair in the lounge area following dinner, resulting in a left hip fracture. At the time of the fall, the facility identified the resident had wanted to go to bed and attempted to stand from the wheelchair independently (no staff were with the resident at the time of the incident). Staff failed to comprehensively assess the resident at the time of the fall and on 11/26/23 between 10:00 A.M. and 12:00 P.M. the resident's daughter requested the resident be transferred to the hospital due to increased pain. The resident was subsequently diagnosed with a left hip fracture requiring surgical intervention. This affected one resident (#80) of four residents reviewed for falls. The census was 76. Findings include: Review of the closed medical record for Resident #80 revealed an admitted [DATE]. On 11/26/23 the resident was discharged to the hospital. Resident #80 had diagnoses including repeated falls, type two diabetes mellitus, hypertension, weakness, cognitive communication deficit and fracture of rib on left side. Review of the physician's orders for November 2023 revealed an order for two (staff) to assist for all transfers, bed in low position, bell to wheelchair, encourage to be in common areas (initiated following falls that occurred on 11/21/23) and mat to side of bed. A fall risk assessment, dated 11/24/23 revealed the resident was at high risk for falls. Review of the Minimum Data Set (MDS) assessment, dated 11/26/23, revealed the resident had impaired cognition with a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Review of a nurse's notes dated 11/25/23 at 6:19 P.M. revealed the nurse was passing medications when she heard a loud boom. Nursing assistants were collecting trays near resident when the resident fell . The resident was observed laying on his left side. The resident's vital signs were obtained, blood pressure was elevated at 183/104. The note indicated the resident indicated he was ready to lay down in bed and was assisted by two staff back into his wheelchair. The resident was assessed to have redness to the left shoulder with no other visible injuries noted. The resident was toileted and then put to bed. The nursing note documented, will continue to monitor. The next nursing note entry, dated 11/26/23 at 12:17 P.M. revealed Immediate discharge notice. bed hold notice and care plan sent with pt to hospital. Record review revealed the resident had been transferred to the emergency roiagnom on [DATE] at 12:00 P.M. The note indicated daughter in facility and updated on plan (for STAT x-ray orders to both extremities), daughter wished for resident to be sent outpatient to emergency room . The nursing note, dated 11/26/23 at 1:38 P.M. revealed Resident #80 presented with pain to the left upper and left lower extremities. The physician ordered an x-ray to both extremities STAT or to send the resident to the emergency room (ER) if not able to obtain STAT testing. The note indicated the resident's daughter was in the facility and wished for the resident to go to the ER. Review of a facility Post Fall Huddle (PFH) Form revealed Resident #80 sustained a fall on 11/25/23 at 5:45 P.M. When asked what he was trying to do, go to? What happened? The resident said he was trying to go to bed. The root cause of the fall documented on the form revealed the fall occurred because the resident was ready to lay down. A statement from the nursing assistant who witnessed the fall on 11/25/23 revealed the resident was sitting a wheelchair in the television room doorway in front of the nurse's station (so staff could see him better). The resident was highly confused. While staff were gathering up supper trays from resident rooms and loading them into the caddy, this nursing assistant saw Resident #80 stand up from his wheelchair; he very quickly stumbled fell on his side on the floor landed on his shoulder and leg. The statement indicated the nursing assistant was not fast enough to catch him. The nursing assistant notified the nurse and then they sat the resident up on his butt on the floor. The resident was lifted with a gait belt onto his wheelchair and then assisted him to bed. Interview on 12/04/23 from 10:03 A.M. to 12:15 P.M. with Certified Nurse Practitioner (CNP) #216, Licensed Practical Nurse (LPN) #212, Certified Occupational Therapy Assistant (COTA) # 218, Physical Therapy Assistant #215, Registered Nurse (RN) #220 and State tested Nursing Assistant (STNA) #205 revealed when a resident fell they got the nurse to do an assessment prior to moving the resident from the floor. CNP #216 stated she was not notified about Resident #80's fall because she did not work that weekend. Interview on 12/04/23 at 12:16 P.M. with STNA #250 revealed she took care of Resident #80 on 11/25/23 and 11/26/23. She stated (on 11/25/23) she had heard a commotion while she was in another resident's room. By the time she came out, another STNA and nurse were with Resident #80. She did not assist at that time. She stated it was the end of her shift. She stated the next morning, on 11/26/23, she went to change the resident around 8:00 A.M. and he screamed during care. She noted the resident had a bruise on his left arm. She got the agency nurse, LPN #211, who assessed the resident's arm and leg. LPN #211 told STNA #250 not to move the resident until she called the doctor. STNA #250 stated she saw the resident's daughter in the building she thought between 10:00 A.M. to 11:00 A.M. and the daughter spoke to nurse. The daughter requested the resident be sent out to the hospital. Interview on 12/04/23 at 3:53 P.M. with the Director of Nursing (DON) revealed she was on-call the weekend of the incident and received no phone calls on 11/25/23 related to a resident fall. She questioned her Assistant Director of Nursing (ADON) who also stated she did not received any phone calls. The facility identified at the time of the resident's fall, Agency LPN #210 did not notify her, the on-coming staff, the resident's daughter or the physician of the resident's fall on 11/25/23. Interview on 12/04/23 at 4:13 P.M. with LPN #207 revealed she came on duty the following shift on 11/25/23 and had not been notified or made aware of the resident sustaining a fall on this date. Interview on 12/04/23 at 4:18 P.M. with Registered Nurse (RN) #211 revealed she heard someone yelling when she got to the nursing station on 11/26/23. She stated Resident #80 had a history of yelling out at night and was aware he had been originally admitted with diagnosis of rib fracture. She was looking at his pain medications when Resident #80 stated he needed a medic. RN #211 reviewed the resident's progress notes which was when she discovered he had sustained a fall the prior day. She assessed him then called the physician obtaining orders for STAT x-rays or to send the resident to ER. The daughter arrived during this time period and was informed of the fall at that time. Interview on 12/04/23 at 4:53 P.M. with STNA #202 revealed she was not made aware on 11/25/23 of the resident's fall that had occurred on day shift. Interview on 12/04/23 at 5:02 P.M. with the DON revealed she would have expected the nurse to do a head-to-toe assessment every shift for 72 hours following the fall. The DON verified there was no assessment completed on 11/25/23 from 7:00 P.M. to 7:00 A.M. because staff were unaware the resident had sustained a fall. Review of the hospital record for Resident #80 for his stay from 11/26/23 through 12/01/23 revealed he was admitted from the emergency department on 11/26/23 and diagnosed with a left hip fracture. The resident underwent an intramedullary nailing for the left hip on 11/28/23 and was stable to be discharged to a nursing home on 12/01/23. Review of facility policy titled Fall Prevention and Management Policy, dated 12/09/19, revealed the facility will assess residents at admission, quarterly, after a fall and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00148736.

Based on interviews, record review and review of the facility Self-Reported Incident, the facility failed to ensure Resident #36's left heel wound was assessed and treated timely. Actual Harm occurred on 10/19/22 when the facility failed to comprehensively assess Resident #36's left heel wound, notify the physician, and implement timely would care, resulting in the resident developing an unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) pressure ulcer to the left heel. This affected one resident (Resident #36) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #36 was admitted on [DATE] with diagnoses including diabetes mellitus, muscle weakness, vascular dementia, anxiety and delusional disorders. Review of the weekly skin evaluations for Resident #36 revealed there were no formal skin evaluations of her skin from 10/08/22 through 10/28/22. Review of the shower sheet (which included a skin evaluation) for 10/16/22 for Resident #36 revealed she had no skin issues. On 10/19/22, the shower sheet stated there was a bandage to the left heel which Registered Nurse (RN) #202 and State tested Nurse Aide (STNA) #209 had signed. There were no shower sheets provided by the facility for any dates between 10/19/22 and 10/28/22. Review of Resident #36's medical record revealed no evidence Resident #36's left heel was assessed or treated from 10/19/22 through 10/27/22. Review of Resident #36's physician order dated 10/28/22 revealed staff were to cleanse the left heel with wound cleanser, pat dry and apply nickel thick layer of Santyl (ointment used to help the healing of ulcers) to the wound bed, apply calcium alginate (absorbent wound cover), abdominal pad (ABD) and kerlix (cling like wrapping) every night shift and as needed. There were no physician's orders for left heel treatments dated from 10/19/22 through 10/27/22 noted in her medical record. Review of the Self-Reported Incident dated 10/28/22, revealed the facility substantiated neglect after their investigation verified RN #202 did not assess Resident #36 on 10/19/22 after being updated that there was a band-aid to the left heel. Review of the staff statement, undated, from RN #202, verified she was notified of a band-aid on 10/19/22 by an STNA but did not remove the band-aid to see the area on Resident #36's left heel. Review of the staff statement, undated, from STNA #209, verified she notified the nurse of a band-aid on Resident #36's left heel on 10/19/22. She stated the nurse told her not to unwrap it and she would look at it later. Review of the nursing progress note dated 10/29/22 at 8:50 A.M. revealed Resident #36 had an unstageable wound to her left heel measuring 2.5 centimeters (cm) in length x 2.0 cm in width with an undetermined depth. It stated the area was in-house acquired. There was no documentation dated from 10/19/22 through 10/28/22 related to the left heel. Review of the weekly wound assessments dated from 10/29/22 through 12/27/22, revealed Resident #36's left heel was an unstageable pressure ulcer identified on 10/28/22. The measurements were 2.5 cm in length x 2.0 cm in width x an undetermined depth. There was noted improvement weekly and the wound was changed to a stage three pressure ulcer on 11/29/22 due to being able to visualize the wound bed. On 12/27/22, the measurements were 1.2 cm in length x 0.8 cm in width and 0.2 cm in depth. Interview on 12/28/22 at 1:29 P.M. with the Director of Nursing (DON), verified there was a delay in treatment for Resident #36's left heel. She stated on 10/19/22 a STNA took the shower sheet to the nurse and updated the nurse on a bandage to Resident #36's left heel. She stated RN #202 signed the sheet but never evaluated the area. She stated on 10/28/22 the area was brought to the attention of the previous DON who evaluated Resident #36's heel and immediately updated the physician. She verified on 10/28/22 it was an unstageable pressure ulcer to the left heel. Observation on 12/29/22 at 9:09 A.M. with RN #207 and RN #208 of Resident #36's left heel stage three pressure ulcer, revealed the dressing to be intact, clean, and dry. The dressing was dated 12/28/22. There was no drainage on the dressing. Measurements of the wound were obtained and showed improvement since 12/27/22. Review of facility policy titled Pressure Injury Prevention and Treatment, revised 09/18/20, revealed it was the facility policy that new pressure injuries would not develop unless the individual's clinical condition demonstrates that they were unavoidable. Residents would be assessed for pressure injury risk with significant change of condition. Wounds identified would be assessed initially to include, location and stage; size; exudate; pain; wound bed description; appearance of surrounding tissue; and evidence of infection. Pressure injuries identified would be documented and orders obtained from providers for treatment. At least weekly, an evaluation of the pressure ulcer/pressure injury would be documented. The facility would notify the family/resident representative and the provider of any newly acquired or worsening pressure injuries and any changes in treatment. This deficiency represents non-compliance investigated under Complaint Number OH00138263.