Every finding on record at Woods on French Creek Nursing & Rehab Center the

Based on record review, interviews and facility policy review, the facility failed to ensure care plans were developed and updated specifically to the individualized needs of the resident. This affected two residents (Resident #9 and #79) out of 18 residents reviewed for care plans. The facility census was 67.Findings include: 1. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] and discharged on 01/27/26. Review of the admission pressure injury condition report dated 12/16/25 revealed an unstageable dark purple/red area on Resident #79's sacrum. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was admitted with an unstageable pressure ulcer. Review of the non-pressure wound condition report dated 01/26/26 identified Resident #79 had two open wounds to the right mid-thigh, one measuring 1.2 centimeters (cm) length, 0.5 cm width and 0.5 cm depth, and the other measured 0.7 cm length, 0.5 cm width and 0.5 cm length. Review of the care plan initiated 12/17/25 revealed Resident #79 was at risk for developing alteration in skin integrity. Interventions included providing skin assessment, elevating heals, assisting with turning and repositioning, inspecting skin, and notifying the physician of changes. The care plan did not identify Resident #79 had an unstageable wound to the sacrum on admission or the development of two open wounds to the mid-thigh and its subsequent needs or services. Interview on 06/16/26 at 9:47 A.M. with the wound Certified Nurse Partitioner (CNP) #720 stated she was consulted on 01/27/26 for Resident #79's wounds which were previously healed surgical incisions reopened and draining fluid. CNP #720 ordered antibiotics, a wound treatment dressing, and referred the resident to orthopedics for a follow-up evaluation. Interview on 06/16/26 at 1:30 P.M. with Director of Nursing (DON) verified a wound care plan specific to Resident #79's wound care needs and services was not implemented. 2. Review of the medical record for Resident #9 revealed he was admitted to facility on 02/27/26 with diagnoses of encephalopathy, dysphagia, gastrostomy status, and severe protein-calorie malnutrition. Review of the most recent MDS assessment dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) of six which indicated severe cognitive impairment. The resident required substantial assistance for all activities of daily living, had an indwelling urinary catheter and was always incontinent of bowels. Review of progress notes from 02/27/26 through 06/16/26 revealed resident had a gastrostomy tube placed on 03/19/26 at the hospital. Review of the hospital after visit summary dated 03/26/26 revealed discharge instructions to place a single layer of four-by-four gauze under the gastrostomy tube bumper and avoid stacking multiple layers of gauze under it. Review of the care plan updated 05/27/26 revealed no focus area, goals, or interventions related to the presence of a gastrostomy tube, or the care and management of the device. Interview with Administrator and Infection Control Nurse #678 on 06/16/26 at 11:20 A.M. verified Resident #9's care plan did not include any goals and interventions specific to the gastrostomy tube or the care and management of the gastrostomy tube. Review of facility policy titled, Care Conference revised on 03/20/24, revealed the facility's interdisciplinary team shall periodically review the resident's care plan and make necessary revisions based on the goals, preferences, and needs of the resident. This deficiency represents non-compliance investigated under Complaint Number 2705952.

Based on observation, interview, and record review, the facility failed to provide adequate care and treatment for Resident #9's gastrostomy tube. This affected one resident (Resident #9) out of two residents reviewed for enteral feeding. The census was 67.Findings include:Review of the medical record for Resident #9 revealed he was admitted to facility on 02/27/26 with diagnoses of encephalopathy, dysphagia, gastrostomy status, and severe protein-calorie malnutrition.Review of the most recent MDS assessment dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) of six which indicated severe cognitive impairment and required substantial assistance for all activities of daily living. Review of progress notes from 02/27/26 through 06/16/26 revealed resident had a gastrostomy tube (a flexible tube through the abdominal wall into the stomach used for the delivery of liquid and nutrition) placed on 03/19/26 at the hospital.Review of the hospital after visit summary dated 03/26/26 revealed discharge instructions to place a single layer of four-by-four gauze under the gastrostomy tube bumper and avoid stacking multiple layers of gauze under it.Review of the progress notes from 02/27/26 through 06/16/26 revealed Resident #9 was admitted to hospital on [DATE] for a clogged nasogastric feeding tube (a medical tube through the nose directly into the stomach used for temporary feeding). A gastrostomy tube was placed while at the hospital on [DATE] and Resident #9 was discharged back to facility on 03/24/26 with discharge instructions to place a single layer of four-by-four gauze under the gastrostomy bumper and avoid stacking multiple layers of gauze under it. Review of the physician orders, and the medication and treatment administration records since Resident #9's admission revealed no orders or evidence of the care and management of the gastrostomy tube. However, there was an order for daily nocturnal enteral feedings of Isosource 1.5 Cal (a calorically dense nutrition formula) at 60 milliliters (ml) per hour for nine hours.Review of the care plan updated 05/27/26 revealed no focus area, goals, or interventions related to the presence of a gastrostomy tube, or the care and management of the device.Observation on 06/15/26 at 12:00 P.M. of Resident #9's gastrostomy tube with Registered Nurse (RN) #682 during medication administration revealed the resident had a patent gastrostomy tube that was clamped. The gastrostomy stoma site (surgical opening in the skin) was open to air and had some dried crusting around the site. There was no split gauze dressing observed covering the stoma site. Interview at the time of the observation with RN #682 stated Resident #9 has had the gastrostomy tube for a while after a previous hospitalization in March 2026. Resident #9 received nocturnal enteral feedings of Isosource 1.5 Cal at 60 ml per hour for nine hours. Resident #9 was now able to also tolerate a mechanical soft diet but continued to receive the nocturnal enteral feedings for protein-calorie malnutrition. RN #682 confirmed Resident #9 did not have specific orders for the access, care, or management of the gastrostomy tube.Interview with Director of Nursing on 06/15/26 at 12:30 P.M. verified there were no active orders for the access, care, and management of Resident #9's gastrostomy tube, and the care plan did not contain any goals or interventions specific to it.

Based on record review and staff interview, the facility failed to timely act upon pharmacist recommendations to address any medication irregularities in the medical record. This affected one resident (Resident #2) of six residents reviewed for unnecessary medications. The facility census was 67.Findings include:Resident #2 was admitted to the facility on [DATE] with diagnoses that included other seizures, major depressive disorder and type one diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment and required assistance of one staff person for completing her activities of daily living (ADLs). The assessment also noted no verbal or physical behaviors toward staff or others.Review of the physician orders for April 2026 and May 2026 revealed Resident #2 had an order dated 04/23/26 for Haldol (an antipsychotic medication used to treat severe agitation, hallucinations, delusions or other psychotic symptoms) 1 milligram (mg) for anoxic brain damage (a brain injury caused when the brain does not get enough oxygen, which can affect thinking, movement, speech, memory, or consciousness). The order was subsequently discontinued on 06/06/26.Review of the pharmacy recommendation dated 05/13/26 revealed the facility pharmacist noted Resident receives haloperidol 1 mg TID (three times daily). Could we update this antipsychotic order to include an accepted diagnosis for use? Resident #2's primary care physician noted on the recommendation to ask psych. Additional review of Resident #2's medical record revealed no changes to Resident #2's Haldol order or diagnoses.Interview with the Assistant Director of Nursing (ADON) #678 on 06/15/26 at 7:11 A.M. verified the facility did not engage its psychiatrist or another provider regarding Resident #2's pharmacy recommendation from 05/13/26.

Based on record review, staff interview, and review of the Food and Drug Administration (FDA) medication guide, the facility failed to ensure antipsychotic medications had a valid clinically appropriate indication for use. This affected one resident (Resident #2) of six residents reviewed for unnecessary medications. The facility census was 67.Findings include:Resident #2 was admitted to the facility on [DATE] with diagnoses that included other seizures, major depressive disorder, and type one diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 04/20/26, revealed Resident #2 had moderate cognitive impairment and required assistance of one staff person for completing activities of daily living (ADLs). The assessment also noted no verbal or physical behaviors toward staff or others.Review of the physician orders for April 2026 and May 2026 revealed Resident #2 had an order dated 04/23/26 for Haldol, an antipsychotic medication used to treat severe agitation, hallucinations, delusions, or other psychotic symptoms, 1 milligram (mg) for anoxic brain damage, a brain injury caused when the brain does not get enough oxygen, which can affect thinking, movement, speech, memory, or consciousness. The order was subsequently discontinued on 06/06/26.Review of behavior tracking records for April 2026, May 2026, and June 2026 revealed one single instance of crying and another single instance of yelling and screaming. No other behaviors were marked on Resident #2's behavior tracking sheet.Review of the Food and Drug Administration (FDA) medication guide for Haldol revealed Haldol was indicated for use to treat schizophrenia and was indicated for the control of tics and vocal utterances of Tourette's disorder. Review of Resident #2's medical record revealed no diagnoses of schizophrenia or Tourette's disorder. The guide also noted Haldol should be given cautiously to individuals with seizure disorders because Haldol may lower the convulsive threshold.Review of the pharmacy recommendation dated 05/13/26 revealed the facility pharmacist noted, Resident receives haloperidol 1 mg TID (three times daily). Could we update this antipsychotic order to include an accepted diagnosis for use? Resident #2's primary care physician noted on the recommendation to ask psych. No changes to Resident #2's Haldol order were noted in the medical record.Interview with Assistant Director of Nursing (ADON) #678 on 06/15/26 at 7:11 A.M. verified Resident #2's Haldol was administered between 04/23/26 and 06/06/26 without an appropriate diagnosis or indication for use.

Based on observation and staff interview, the facility failed to ensure a safe, clean and sanitary laundry room. This had the potential to affect all the residents residing in the facility. The census was 67.Findings include:Observation on 06/14/26 at 9:52 A.M. of the laundry room with Laundry Aid (LA) #689 revealed in the dirty laundry area there was an empty large laundry cart used to keep dirty laundry. The cart had crumbled up paper towels and debris located at the bottom of the cart. The washer area had a plastic bag of garbage laying on the floor in the middle of the room. The floor in the area had multiple areas of splattered dirt and debris along both sides of the washing machines and throughout the laundry area. There was a window screen sitting under the window that was covered with lint and dirt. Behind the washer was a drain. Next to the drain contained a large pile of an unknown white substance. In the clean laundry area, there was a dryer filled with clothing which had a lint screen that was heavily covered with lint. Under the lint screen contained several large piles of lint. The floor in the clean area had multiple areas of splattered dirt and debris. The dryer filter cleaning log revealed there was no documentation for lint removal on 06/14/26 at 6:00 A.M., 7:00 A.M., 8:00 A.M or 9:00 A.M.Interview at 10:00 A.M. with LA #689 verified the dirty floors and lint in the dryer. LA #689 stated she completed drying two loads of laundry and has not cleaned the lint filters.Interview on 06/14/2026 at 1:01 P.M. with the Director of Environmental Services #637 stated the late shift staff were responsible for cleaning the floors Monday through Friday. Staff were expected to clean lint screens after every load.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRCTED PRIOR TO THIS SURVEY Based on record review, staff interview, resident interview, review of the Emergency Medical Services (EMS) run report, review of the hospital documentation, and facility policy review, the facility failed to timely report a fall, failed to complete a timely and thorough resident assessment, and failed to ensure timely care and treatment after a fall. This resulted in Actual harm on 10/12/25 at 12:00 A.M. when Resident #52 fell out of bed and was assisted back into bed by staff without a thorough assessment. On 10/13/25 at 9:15 A.M., Resident #52 screamed out in pain with care, was thoroughly assessed, complained of bilateral leg pain, had x-rays completed, required EMS transportation to the hospital, and was diagnosed with bilateral femur fractures requiring surgical intervention on 10/14/25. The facility census was 68. Review of Resident #52's medical record revealed an admission date of 06/21/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right non dominant side, type two diabetes mellitus, morbid obesity due to excess calories, dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had moderately impaired cognition. Resident #52 required substantial to maximal assistance for toilet hygiene and showering and was always incontinent of bowel and bladder, required substantial to maximal assistance for bed mobility and was dependent for chair to bed or bed to chair transfers. Review of the care plan dated 06/29/22 revealed Resident #52 was at risk for falls including a concern for falls with injury related to decreased mobility, weakness, unsteadiness, hemiplegia/hemiparesis of the right side, and presence of bilateral artificial knees. Interventions included ensuring the call light is within reach, have commonly used articles within reach, non-skid strips to the exit side of the bed, and encourage the resident to ask for assistance. Review of the fall risk assessment dated [DATE] revealed Resident #52 was at risk for falls. Risk factors identified included Resident #52's need for assistance with elimination, inability to ambulate, inability to move from a seated to a standing position, and unsteadiness requiring staff assistance for stabilization. Review of the progress notes for 10/12/25 revealed nothing regarding the resident putting legs over side of bed or of the fall. Review of the progress note dated 10/13/25 and timed at 12:51 P.M. written by Licensed Practical Nurse (LPN) #165 revealed Resident #52 was complaining of pain to her bilateral legs with movement during care. Upon assessment, Resident #52 stated she had bilateral hip pain that extended to her knees. The nurse practitioner was notified, and new orders were received for stat (immediate) x-rays of bilateral hips and knees. The orders were placed and family was notified via voice message. Review of the progress note dated 10/13/25 at 2:51 P.M. entered by the Assistant Director of Nursing (ADON) indicated Resident #52 had swung both of her legs to the side of the bed and was holding onto the assist bar when she began to slide down. A nearby aide heard her and came to attempt to stop her from sliding but was unable to and assisted the resident to her knees. Additional staff assisted and a mechanical lift was used to get the resident back into bed. The nurse practitioner and family were notified. Review of the progress note dated 10/13/25 at 9:47 P.M. written by Registered Nurse (RN) #187 documented x-ray results were received for Resident #52. The on call physician was notified of the results, and an order was received to send Resident #52 to the emergency department for treatment. The family and Director of Nursing (DON) were notified. Review of the EMS run report dated 10/13/25 revealed they received a call from the facility at 9:24 P.M. requesting assistance with transporting a resident to the hospital. The report indicated upon arrival, they were met by nursing staff who stated Resident #52 had bilateral femur fractures. The staff reported Resident #52 had a fall the previous night, but they could not find a report for the fall. Due to complaints of pain, x-rays were completed and confirmed bilateral femur fractures. Interview with Resident #52 revealed she remembered falling the night before. Resident #52 reported a pain level of a nine out of ten and 50 micrograms (mcg) of fentanyl was administered for pain control. Resident #52 was transported to the Emergency Department (ED) for treatment. Review of the hospital documentation dated 10/13/25 revealed Resident #52 suffered a fracture of the left mid-femoral shaft with lipohemarthrosis (fat and bone escape from bone marrow into the joint space), and a comminuted right distal femur fracture noted above the right knee arthroplasty with the posterior fragment displaced one full width. Resident #52 underwent an open reduction and internal fixation (ORIF) of both legs on 10/14/25. Resident #52 was discharged from the hospital and returned to the facility on [DATE]. Review of the facility fall log revealed Resident #52 suffered a fall; however, the log does not specify the date or time of a fall. Interview on 11/04/25 at 8:34 A.M. with Resident #52 revealed she had one fall while at the facility. Resident #52 stated she was in a lot of pain and needed to be sent to the hospital because she broke her bones. Resident #52 could not recall why she was trying to get out of the bed, who the staff were that assisted her back into bed, or how the fall happened. Interview on 11/04/25 at 12:33 P.M. with Certified Nursing Assistant (CNA) #108 verified she worked hall 400 on 10/12/25. CNA #108 could not recall the exact time of Resident #52's fall but stated the fall had occurred sometime between 12:00 A.M. and 1:00 A.M. CNA #108 stated she heard someone talking and went to see who it was, and upon entering Resident #52's room, Resident #52 was holding onto the bedrail and was coming down out of the side of the bed. CNA #108 stated Resident #52's knees were bent and the resident landed on her knees on two blankets that were lying on the floor next to the bed. CNA #108 denied lowering the resident to the floor, stating she could not get to the resident in time as Resident #52 was already falling from the bed when she entered the room. CNA #108 stated when Resident #52 landed on the floor the residents' legs were straight out in front of her body and the resident was in a sitting position with her back against the side of the bed. CNA #108 stated she lifted the resident away from the bed to make sure the bed was not hurting her back. Once she felt the resident was safe CNA #108 said she left the resident sitting on the floor and went to get help from CNA #159. Prior to coming to Resident #52's room, CNA #159 called RN #109, who was out of the building on break. CNA #159 then went to Resident #52's room to wait for RN #109. CNA #108 stated she felt like it was taking RN #109 too long and because the resident was laying on the cold hard floor, she and CNA #159 decided to use the mechanical lift and transferred Resident #52 back into the bed. CNA #108 stated Resident #52 was not crying but had stated two or three times after the fall that her legs hurt. CNA #108 stated during her 5:00 A.M. rounds, Resident #52 had vomited. CNA #108 stated she reported this to the nurse. Interview on 11/04/25 at 2:05 P.M. with CNA #159 verified she was working hall 500 on 10/12/25. CNA #159 stated that CNA #108 had approached her as she was charting and stated that Resident #52 was trying to climb out of bed and had lowered herself to her knees while holding onto the bed railing. CNA #159 stated she called RN #109 and handed the phone to CNA #108 for her to explain what had happened. After the phone call had ended, CNA #108 and CNA #159 went into Resident #52's room. CNA #159 stated Resident #52 was sitting on the floor with both legs out in front of her. CNA #159 stated Resident #52 stated she was trying to get out of bed to get her medicine. CNA #159 stated Resident #52 was not crying but did complain of knee pain when being transferred back to bed using the mechanical lift. CNA #159 stated when they got Resident #52 back into bed, RN #109 was in the room to assess the resident. CNA #159 stated for falls, they are not to move the resident until the nurse has assessed the resident, but she did not think this incident was a fall since Resident #52 lowered herself to the floor. An additional interview on 11/06/25 at 8:12 A.M. with CNA #108 revealed after Resident #52 had been assisted back into bed after falling, she and CNA #159 cleaned Resident #52 up as she had been incontinent. CNA #108 verified Resident #52 stated her legs hurt during incontinence care. CNA #108 denied letting the nurse know at the time; however, CNA #108 stated she did let the nurse know around 5:00 A.M. that Resident #52 complained of bilateral leg pain and that the resident had vomited. Interview on 11/06/25 at 8:30 A.M. with CNA #300 revealed she worked hall 400 on the dayshift on 10/13/25. CNA #300 stated CNA #108 gave her report but did not report a fall for Resident #52 during the night. CNA #300 stated, at the beginning of her shift she walks around the unit to visualize all of her residents and the morning of 10/13/25, Resident #52 was asleep during her first round at 7:00 A.M., and CNA #300 stated this was not uncommon as Resident #52 usually gets out of bed around 9:15 A.M. CNA #300 stated at approximately 9:15 A.M. on 10/13/25 she went to provide Resident #52 care and when attempting to provide care Resident #52 screamed out in pain and the resident's legs looked swollen. CNA #300 stated she got the nurse immediately. CNA #300 stated LPN #165 was on the phone with a physician regarding another resident at the facility but that LPN #165 stated she would go and see Resident #52 as soon as she was off of the phone. CNA #300 stated after the nurse assessed Resident #52, LPN #165 told her to make the resident a two person assist until further notice, and that LPN #165 had reached out to the physician to obtain orders for x-rays. CNA #300 stated she checked on Resident #52 more frequently and did not move her unless absolutely necessary. Interview on 11/06/25 at 9:01 A.M. with LPN #165 revealed she worked day shift on 10/13/25. LPN #165 stated she usually worked halls 400 and 500 and is very familiar with the residents on those hallways. LPN #165 stated she received report from RN #109 the morning of 10/13/25 and was not told that Resident #52 had suffered a fall. LPN #165 stated Resident #52 was bedbound and never attempted to get out of bed. LPN #165 stated CNA #300 went into Resident #52's room to provide care and when she attempted to provide care, Resident #52 was screaming in pain. LPN #165 said she checked the medical record and progress notes and did not find anything unusual. LPN #165 stated when she assessed Resident #52, the resident would scream in pain any time LPN #165 touched her legs. LPN #165 stated she called the Nurse Practitioner (NP) and obtained an order for stat x-rays, and x-rays were completed around 4:00 P.M. In a follow up interview with CNA #108 on 11/06/25 at 10:19 A.M., CNA #108 revealed she only reported the fall to CNA #159 and RN #109. CNA #108 stated she did not give the aides on the day shift report, therefore the aides on days were not told of the incident. Interview on 11/06/25 at 1:24 P.M. with RN #109 revealed she had worked the night shift on 10/12/25 and worked halls 400 and 500. RN #109 stated she saw Resident #52 at 8:00 P.M. during her medication pass and had not noted any abnormalities with Resident #52. RN #109 stated she went on break around midnight and had been outside for two minutes when she received a call from CNA #159 informing her that Resident #52 had put her legs over the side of the bed. RN #109 stated this was abnormal for Resident #52, so she immediately came into the building and went to Resident #52's room. RN #109 said upon entering the room she saw Resident #52 lying in bed with the mechanical lift pad underneath her, a mechanical lift was in the corner of Resident #52's room, with both CNA #108 and CNA #159 at Resident #52's bedside. RN #109 stated CNA #108 said that Resident #52 had her legs over the side of the bed and was holding onto the railing. RN #109 stated at no point did CNA #108 report that Resident #52 had touched the floor. RN #109 stated she compared Resident #52's knees and looked over her legs and did not see any abnormalities. RN #109 stated she was not aware Resident #52 went to the ground and was not aware that CNA #108 and CNA #159 had picked her up from the floor. RN #109 denied being told by CNA #108 that Resident #52 was complaining of pain or had vomited. Review of the facility policy dated 10/17/16 titled Fall Management revealed when a resident falls they will receive prompt medical attention and immediate needs will be quickly assessed and responded to. When it is necessary for EMS to be contacted, the resident is provided comfort until EMS arrives. In follow up to a fall, appropriate intervention directed by the physician will be implemented and family will be notified, further evaluation of the resident's health condition, the environment, equipment, medication, staff, resident practices, and other factors will be determined by the interdisciplinary care team (IDT) and the care plan updated as appropriate. The IDT will also determine if additional facility wide, resident specific, staff, resident or family education, or any other measures need to be implemented. The deficiency was corrected on 10/14/25 when the facility implemented the following corrective actions: - On 10/13/25, the Medical Director was notified of Resident #52's fall and of the x-ray results of bilateral femur fractures. - On 10/13/25, an ad hoc Quality Assurance meeting was held to discuss incident and action plan, including review of the facilities fall policy. - On 10/13/25, CNA #108 and CNA #159 were immediately reeducated by the Administrator and Director of Nursing (DON) via phone on what is a fall and that a resident is not to be transferred after being found on the floor until the nurse has assessed the resident. - On 10/14/25, RN #109 was immediately reeducated by the Administrator and DON via phone on what is a fall including that being lowered to the floor is considered a fall and requires an incident report and provider notification. - On 10/14/25, skin sweeps were completed on residents who were unable to be interviewed by the DON, and the facility wound nurse for possible injuries related to any change in planes. No injuries were found. - On 10/14/25, all interviewable residents were interviewed by the DON for any falls that were not reported. No unreported falls were discovered. - On 10/14/25, nursing staff were re-educated on fall response protocol including education that residents lowered to the floor is considered a fall as there is a change in plane, the need to complete a head to toe assessment, notification of family and physician, incident report in Point Click Care (PCC), fall risk evaluation, pain assessment, in the progress note - document the fall, complete set of vitals, any injury, physician and family notification, and new implemented intervention. - On 10/14/25, CNAs were educated on falls. Education included staying with the resident, call for the nurse, provide support, comfort, and reassurance to the resident, do not move the resident as the nurse has to assess the resident, and fill out the CNA witness statement. - On 10/14/25, the DON, Assistant Director of Nursing (ADON), and Unit Manager conducted leadership rounds focusing on staff awareness of post-fall procedures. - On 10/14/25, the DON reviewed all previous falls from the 10/01/25 forward were reviewed to ensure timely reporting, notification, documentation, and nurse assessment. - Upon Resident #52's return to the facility on [DATE], the IDT completed a fall risk assessment for Resident #52 and updated the care plan to reflect one fall in the last 30 days. Resident #52 remained a high fall risk with no additional interventions identified. Ongoing monitoring will include:- Weekly leadership rounds focusing on staff awareness of post-fall procedures will occur weekly until compliance is identified. - Starting 10/15/25, the DON or designee will review falls daily for two weeks and then weekly for 30 days to ensure timely reporting, notification, documentation, and nurse assessment. - All audits will be reviewed at Quality Assurance and Performance Improvement (QAPI). This deficiency represents non-compliance investigated under Master Complaint Number 2651423.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRCTED PRIOR TO THIS SURVEY Based on record review, staff interview, resident interview, review of the Emergency Medical Services (EMS) run report, review of the hospital documentation, and facility policy review, the facility failed to timely report a fall, failed to complete a timely and thorough resident assessment, and failed to ensure timely care and treatment after a fall. This resulted in Actual harm on 10/12/25 at 12:00 A.M. when Resident #52 fell out of bed and was assisted back into bed by staff without a thorough assessment. On 10/13/25 at 9:15 A.M., Resident #52 screamed out in pain with care, was thoroughly assessed, complained of bilateral leg pain, had x-rays completed, required EMS transportation to the hospital, and was diagnosed with bilateral femur fractures requiring surgical intervention on 10/14/25. The facility census was 68. Review of Resident #52's medical record revealed an admission date of 06/21/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right non dominant side, type two diabetes mellitus, morbid obesity due to excess calories, dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had moderately impaired cognition. Resident #52 required substantial to maximal assistance for toilet hygiene and showering and was always incontinent of bowel and bladder, required substantial to maximal assistance for bed mobility and was dependent for chair to bed or bed to chair transfers. Review of the care plan dated 06/29/22 revealed Resident #52 was at risk for falls including a concern for falls with injury related to decreased mobility, weakness, unsteadiness, hemiplegia/hemiparesis of the right side, and presence of bilateral artificial knees. Interventions included ensuring the call light is within reach, have commonly used articles within reach, non-skid strips to the exit side of the bed, and encourage the resident to ask for assistance. Review of the fall risk assessment dated [DATE] revealed Resident #52 was at risk for falls. Risk factors identified included Resident #52's need for assistance with elimination, inability to ambulate, inability to move from a seated to a standing position, and unsteadiness requiring staff assistance for stabilization. Review of the progress notes for 10/12/25 revealed nothing regarding the resident putting legs over side of bed or of the fall. Review of the progress note dated 10/13/25 and timed at 12:51 P.M. written by Licensed Practical Nurse (LPN) #165 revealed Resident #52 was complaining of pain to her bilateral legs with movement during care. Upon assessment, Resident #52 stated she had bilateral hip pain that extended to her knees. The nurse practitioner was notified, and new orders were received for stat (immediate) x-rays of bilateral hips and knees. The orders were placed and family was notified via voice message. Review of the progress note dated 10/13/25 at 2:51 P.M. entered by the Assistant Director of Nursing (ADON) indicated Resident #52 had swung both of her legs to the side of the bed and was holding onto the assist bar when she began to slide down. A nearby aide heard her and came to attempt to stop her from sliding but was unable to and assisted the resident to her knees. Additional staff assisted and a mechanical lift was used to get the resident back into bed. The nurse practitioner and family were notified. Review of the progress note dated 10/13/25 at 9:47 P.M. written by Registered Nurse (RN) #187 documented x-ray results were received for Resident #52. The on call physician was notified of the results, and an order was received to send Resident #52 to the emergency department for treatment. The family and Director of Nursing (DON) were notified. Review of the EMS run report dated 10/13/25 revealed they received a call from the facility at 9:24 P.M. requesting assistance with transporting a resident to the hospital. The report indicated upon arrival, they were met by nursing staff who stated Resident #52 had bilateral femur fractures. The staff reported Resident #52 had a fall the previous night, but they could not find a report for the fall. Due to complaints of pain, x-rays were completed and confirmed bilateral femur fractures. Interview with Resident #52 revealed she remembered falling the night before. Resident #52 reported a pain level of a nine out of ten and 50 micrograms (mcg) of fentanyl was administered for pain control. Resident #52 was transported to the Emergency Department (ED) for treatment. Review of the hospital documentation dated 10/13/25 revealed Resident #52 suffered a fracture of the left mid-femoral shaft with lipohemarthrosis (fat and bone escape from bone marrow into the joint space), and a comminuted right distal femur fracture noted above the right knee arthroplasty with the posterior fragment displaced one full width. Resident #52 underwent an open reduction and internal fixation (ORIF) of both legs on 10/14/25. Resident #52 was discharged from the hospital and returned to the facility on [DATE]. Review of the facility fall log revealed Resident #52 suffered a fall; however, the log does not specify the date or time of a fall. Interview on 11/04/25 at 8:34 A.M. with Resident #52 revealed she had one fall while at the facility. Resident #52 stated she was in a lot of pain and needed to be sent to the hospital because she broke her bones. Resident #52 could not recall why she was trying to get out of the bed, who the staff were that assisted her back into bed, or how the fall happened. Interview on 11/04/25 at 12:33 P.M. with Certified Nursing Assistant (CNA) #108 verified she worked hall 400 on 10/12/25. CNA #108 could not recall the exact time of Resident #52's fall but stated the fall had occurred sometime between 12:00 A.M. and 1:00 A.M. CNA #108 stated she heard someone talking and went to see who it was, and upon entering Resident #52's room, Resident #52 was holding onto the bedrail and was coming down out of the side of the bed. CNA #108 stated Resident #52's knees were bent and the resident landed on her knees on two blankets that were lying on the floor next to the bed. CNA #108 denied lowering the resident to the floor, stating she could not get to the resident in time as Resident #52 was already falling from the bed when she entered the room. CNA #108 stated when Resident #52 landed on the floor the residents' legs were straight out in front of her body and the resident was in a sitting position with her back against the side of the bed. CNA #108 stated she lifted the resident away from the bed to make sure the bed was not hurting her back. Once she felt the resident was safe CNA #108 said she left the resident sitting on the floor and went to get help from CNA #159. Prior to coming to Resident #52's room, CNA #159 called RN #109, who was out of the building on break. CNA #159 then went to Resident #52's room to wait for RN #109. CNA #108 stated she felt like it was taking RN #109 too long and because the resident was laying on the cold hard floor, she and CNA #159 decided to use the mechanical lift and transferred Resident #52 back into the bed. CNA #108 stated Resident #52 was not crying but had stated two or three times after the fall that her legs hurt. CNA #108 stated during her 5:00 A.M. rounds, Resident #52 had vomited. CNA #108 stated she reported this to the nurse. Interview on 11/04/25 at 2:05 P.M. with CNA #159 verified she was working hall 500 on 10/12/25. CNA #159 stated that CNA #108 had approached her as she was charting and stated that Resident #52 was trying to climb out of bed and had lowered herself to her knees while holding onto the bed railing. CNA #159 stated she called RN #109 and handed the phone to CNA #108 for her to explain what had happened. After the phone call had ended, CNA #108 and CNA #159 went into Resident #52's room. CNA #159 stated Resident #52 was sitting on the floor with both legs out in front of her. CNA #159 stated Resident #52 stated she was trying to get out of bed to get her medicine. CNA #159 stated Resident #52 was not crying but did complain of knee pain when being transferred back to bed using the mechanical lift. CNA #159 stated when they got Resident #52 back into bed, RN #109 was in the room to assess the resident. CNA #159 stated for falls, they are not to move the resident until the nurse has assessed the resident, but she did not think this incident was a fall since Resident #52 lowered herself to the floor. An additional interview on 11/06/25 at 8:12 A.M. with CNA #108 revealed after Resident #52 had been assisted back into bed after falling, she and CNA #159 cleaned Resident #52 up as she had been incontinent. CNA #108 verified Resident #52 stated her legs hurt during incontinence care. CNA #108 denied letting the nurse know at the time; however, CNA #108 stated she did let the nurse know around 5:00 A.M. that Resident #52 complained of bilateral leg pain and that the resident had vomited. Interview on 11/06/25 at 8:30 A.M. with CNA #300 revealed she worked hall 400 on the dayshift on 10/13/25. CNA #300 stated CNA #108 gave her report but did not report a fall for Resident #52 during the night. CNA #300 stated, at the beginning of her shift she walks around the unit to visualize all of her residents and the morning of 10/13/25, Resident #52 was asleep during her first round at 7:00 A.M., and CNA #300 stated this was not uncommon as Resident #52 usually gets out of bed around 9:15 A.M. CNA #300 stated at approximately 9:15 A.M. on 10/13/25 she went to provide Resident #52 care and when attempting to provide care Resident #52 screamed out in pain and the resident's legs looked swollen. CNA #300 stated she got the nurse immediately. CNA #300 stated LPN #165 was on the phone with a physician regarding another resident at the facility but that LPN #165 stated she would go and see Resident #52 as soon as she was off of the phone. CNA #300 stated after the nurse assessed Resident #52, LPN #165 told her to make the resident a two person assist until further notice, and that LPN #165 had reached out to the physician to obtain orders for x-rays. CNA #300 stated she checked on Resident #52 more frequently and did not move her unless absolutely necessary. Interview on 11/06/25 at 9:01 A.M. with LPN #165 revealed she worked day shift on 10/13/25. LPN #165 stated she usually worked halls 400 and 500 and is very familiar with the residents on those hallways. LPN #165 stated she received report from RN #109 the morning of 10/13/25 and was not told that Resident #52 had suffered a fall. LPN #165 stated Resident #52 was bedbound and never attempted to get out of bed. LPN #165 stated CNA #300 went into Resident #52's room to provide care and when she attempted to provide care, Resident #52 was screaming in pain. LPN #165 said she checked the medical record and progress notes and did not find anything unusual. LPN #165 stated when she assessed Resident #52, the resident would scream in pain any time LPN #165 touched her legs. LPN #165 stated she called the Nurse Practitioner (NP) and obtained an order for stat x-rays, and x-rays were completed around 4:00 P.M. In a follow up interview with CNA #108 on 11/06/25 at 10:19 A.M., CNA #108 revealed she only reported the fall to CNA #159 and RN #109. CNA #108 stated she did not give the aides on the day shift report, therefore the aides on days were not told of the incident. Interview on 11/06/25 at 1:24 P.M. with RN #109 revealed she had worked the night shift on 10/12/25 and worked halls 400 and 500. RN #109 stated she saw Resident #52 at 8:00 P.M. during her medication pass and had not noted any abnormalities with Resident #52. RN #109 stated she went on break around midnight and had been outside for two minutes when she received a call from CNA #159 informing her that Resident #52 had put her legs over the side of the bed. RN #109 stated this was abnormal for Resident #52, so she immediately came into the building and went to Resident #52's room. RN #109 said upon entering the room she saw Resident #52 lying in bed with the mechanical lift pad underneath her, a mechanical lift was in the corner of Resident #52's room, with both CNA #108 and CNA #159 at Resident #52's bedside. RN #109 stated CNA #108 said that Resident #52 had her legs over the side of the bed and was holding onto the railing. RN #109 stated at no point did CNA #108 report that Resident #52 had touched the floor. RN #109 stated she compared Resident #52's knees and looked over her legs and did not see any abnormalities. RN #109 stated she was not aware Resident #52 went to the ground and was not aware that CNA #108 and CNA #159 had picked her up from the floor. RN #109 denied being told by CNA #108 that Resident #52 was complaining of pain or had vomited. Review of the facility policy dated 10/17/16 titled Fall Management revealed when a resident falls they will receive prompt medical attention and immediate needs will be quickly assessed and responded to. When it is necessary for EMS to be contacted, the resident is provided comfort until EMS arrives. In follow up to a fall, appropriate intervention directed by the physician will be implemented and family will be notified, further evaluation of the resident's health condition, the environment, equipment, medication, staff, resident practices, and other factors will be determined by the interdisciplinary care team (IDT) and the care plan updated as appropriate. The IDT will also determine if additional facility wide, resident specific, staff, resident or family education, or any other measures need to be implemented. The deficiency was corrected on 10/14/25 when the facility implemented the following corrective actions: - On 10/13/25, the Medical Director was notified of Resident #52's fall and of the x-ray results of bilateral femur fractures. - On 10/13/25, an ad hoc Quality Assurance meeting was held to discuss incident and action plan, including review of the facilities fall policy. - On 10/13/25, CNA #108 and CNA #159 were immediately reeducated by the Administrator and Director of Nursing (DON) via phone on what is a fall and that a resident is not to be transferred after being found on the floor until the nurse has assessed the resident. - On 10/14/25, RN #109 was immediately reeducated by the Administrator and DON via phone on what is a fall including that being lowered to the floor is considered a fall and requires an incident report and provider notification. - On 10/14/25, skin sweeps were completed on residents who were unable to be interviewed by the DON, and the facility wound nurse for possible injuries related to any change in planes. No injuries were found. - On 10/14/25, all interviewable residents were interviewed by the DON for any falls that were not reported. No unreported falls were discovered. - On 10/14/25, nursing staff were re-educated on fall response protocol including education that residents lowered to the floor is considered a fall as there is a change in plane, the need to complete a head to toe assessment, notification of family and physician, incident report in Point Click Care (PCC), fall risk evaluation, pain assessment, in the progress note - document the fall, complete set of vitals, any injury, physician and family notification, and new implemented intervention. - On 10/14/25, CNAs were educated on falls. Education included staying with the resident, call for the nurse, provide support, comfort, and reassurance to the resident, do not move the resident as the nurse has to assess the resident, and fill out the CNA witness statement. - On 10/14/25, the DON, Assistant Director of Nursing (ADON), and Unit Manager conducted leadership rounds focusing on staff awareness of post-fall procedures. - On 10/14/25, the DON reviewed all previous falls from the 10/01/25 forward were reviewed to ensure timely reporting, notification, documentation, and nurse assessment. - Upon Resident #52's return to the facility on [DATE], the IDT completed a fall risk assessment for Resident #52 and updated the care plan to reflect one fall in the last 30 days. Resident #52 remained a high fall risk with no additional interventions identified. Ongoing monitoring will include:- Weekly leadership rounds focusing on staff awareness of post-fall procedures will occur weekly until compliance is identified. - Starting 10/15/25, the DON or designee will review falls daily for two weeks and then weekly for 30 days to ensure timely reporting, notification, documentation, and nurse assessment. - All audits will be reviewed at Quality Assurance and Performance Improvement (QAPI). This deficiency represents non-compliance investigated under Master Complaint Number 2651423.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident and staff interview, review of x-ray images, review of orthopedic records, review of therapy notes, review of physician notes, and review of facility corrective action, the facility failed to ensure residents who required assistance with transfers were safely transported in their wheelchair to prevent injury. Actual harm occurred to Resident #10 when a dental provider staff member was transporting the resident in his wheelchair and pushed the resident's right foot into a door frame which resulted in excruciating pain and a subsequent distal posterior tibial fracture to the right foot. Resident #10 required orthopedic follow-up appointments, was required to wear a protective boot, and was non-weight bearing to the right foot until the fracture healed. This deficient practice affected one (#10) of three residents reviewed for accidents. The facility census was 70. Findings include: Review of Resident #10's medical record revealed an initial admitted [DATE]. Diagnoses included type II diabetes mellitus, congestive heart failure, chronic kidney disease, and anxiety. Review of the most recent quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 was cognitively intact. The resident utilized a wheelchair and was dependent on staff for mobility. Review of the physical therapy notes dated 06/26/24 revealed Resident #10 was being wheeled into the therapy gym by a dental assistant and the dental assistant ran the resident's right leg rest into the doorframe with the resident indicating he was in severe pain, and he felt like his foot was broken. The resident also stated it felt like when he previously broke the foot on the opposite leg. Nursing was notified and an order to obtain an x-ray was given. Review of the health status progress notes dated 06/26/24 and timed 11:42 A.M. revealed Resident #10 stated the dental assistant ran his right foot into the wall on the way to therapy. The resident was yelling out that the foot was broken. There was no redness, swelling, or warmth noted to the resident's right foot. The physician was notified and ordered an x-ray of the resident's right foot. Review of Resident #10's x-ray results dated 06/26/24 revealed images were taken due to pain and trauma. Further review of the x-ray results revealed an acute distal posterior fibial fracture and mild soft tissue swelling. An x-ray of the right foot also identified a questionable fourth proximal phalanx fracture. A new order was given to consult with orthopedic care. Review of the orthopedic notes dated 06/27/24 revealed Resident #10 was seen for acute right ankle pain, ankle injury, and a closed fracture of the right ankle. The resident was instructed to wear a boot at all times and to remain non-weight bearing at all times. Review of the physician notes dated 07/15/24 revealed Resident #10 had been seen by dental and then his leg was jammed up and ended up having a fracture. The plan for care included as-need pain medication and follow-up with orthopedics. Interview on 03/26/25 at 10:24 A.M. with Resident #10 revealed, on 06/26/24, the resident saw a dentist in an examination room located in the facility. When the resident finished speaking with the dentist, the dental assistant offered to push him to therapy. While pushing the resident, the dental assistant turned her head to say something to another person and ran Resident #10's right foot into the doorframe of the therapy room. Resident #10 stated to the dental assistant that she broke his foot, the dental assistant tried to deny it was broken and then left the resident. Resident #10 stated he had excruciating pain once going back to his room and, ultimately, found out he had broken his right foot. Resident #10 reported having a walking-cast and being non-weight bearing until cleared by a physician. Resident #10 reported after many orthopedic appointments he was cleared to begin putting weight on his foot again. Interview on 03/26/25 at 11:44 A.M. with Registered Nurse (RN) #238 revealed she was working on the day Resident #10's foot was fractured. RN #238 stated a dental assistant had been pushing the resident from the examination room to the therapy room and jammed the resident's foot in the door. RN #238 stated Resident #10 reported excruciating pain, and x-rays were ordered which showed a fractured right foot. Interview on 03/27/25 at 8:43 A.M. with Physical Therapy Assistant (PTA) #382 revealed PTA #382 was scheduled to see Resident #10 on the date of the aforementioned incident (06/26/24). PTA #382 reported the resident had been in the examination room seeing the dentist. Afterwards, the dental assistant was pushing the resident and when she brought him around the corner, PTA #382 heard a thud and Resident #10 said, Ow, and was cursing and saying the dental assistant broke his foot. PTA #382 informed nursing and did not have the resident stand on the foot in case he did have a fracture. PTA #382 stated the resident ended up having a fracture from the incident, so therapy was limited after that due to the resident's non-weight bearing status. Interview on 03/27/25 at 3:04 P.M. with RN #349 revealed he helped with transporting residents to and from dental appointments on a regular basis. RN #349 reported it was common knowledge among staff that vendors were not to be transporting residents to and from appointments. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 06/27/24: On 06/26/24, Resident #10 was immediately assessed and the provider was updated by the Director of Nursing (DON). On 06/26/24, all residents seen by the dentist were interviewed and/or assessed by the facility Administrator and the DON to identify any concerns. No concerns were identified. On 06/26/24, all residents who were seen by the dentist were reviewed by the Administrator and the DON to determine if any special accommodation was needed for dental visits. On 06/26/24, Licensed Social Worker (LSW) #844 was educated by the Administrator that dental staff were to ask facility staff to assist with transporting residents to and from dental visits. On 06/26/24, an ad hoc Quality Assessment and Assurance (QAA) Committee meeting was held with the Administrator and the DON to review the incident investigation, internal action plan, and audit plan. On 06/27/24, dental staff were educated by the DON to ask facility staff to assist with transporting residents to and from dental visits. On 06/27/24, all nursing staff members were educated by the Administrator that dental staff were to ask facility staff to assist in transporting residents to and from dental visits. On 06/27/24, the Administrator initiated audits to observe dental visits to ensure dental staff were asking facility staff to assist with transporting residents to and from dental visits. Negative findings would be addressed immediately with reeducation provided and reported to the QAA Committee for review. The Administrator observed the next two dental visits on 08/21/24 and 01/31/25 with no concerns identified related to dental staff transporting residents. Interviews on 03/27/25 between 2:50 P.M. and 3:24 P.M. with LSW #844 and Certified Nurse Aide (CNA) #498 verified they were provided education regarding transportation of residents to and from dental visits. Staff interviewed possessed appropriate knowledge of the education provided by the facility. This deficiency represents non-compliance investigated under Complaint Number OH00162109.

Based on observation, resident interview, resident representative interview, staff interview, and medical record review, the facility failed to implement and assess for appropriate interventions for a resident at risk for weight loss. This affected one (#2) of two residents reviewed for nutrition. The facility census was 69. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included dementia, rheumatoid arthritis, hypertensive heart disease, chronic pain syndrome, and anemia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was independent with set up for eating and had no significant weight changes. Review of a plan of care dated 10/06/22 revealed Resident #2 was at risk for alteration in nutrition status related to dementia, use of diuretics, decreased mobility, advanced age, and overall decline. Interventions included assistance with meals as needed, two handled cup with lid and straw for drinks, encourage the resident to dine in the dining room, offer meal substitutes when foods are refused, built-up utensils for all meals, and refer to dietitian or therapy as needed. Review of physician's orders revealed Resident #2 was ordered a no added salt diet with regular texture and thin consistency liquids, a two handled cup with lid and straw in drinks, and built-up utensils for all meals. There were no orders for nutritional supplements or snacks. Resident #2 had an order dated 03/15/23 for the diuretic furosemide 20 milligrams by mouth once per day every Wednesday and Friday. Review of documented weights for Resident #2 revealed on 08/04/22 a weight of 170.5 pounds, on 02/03/23 a weight of 158.2 pounds, on 07/02/23 a weight of 165.8 pounds, and on 08/12/23 a weight of 155.5 pounds. Resident #2 had 6.21 percent (%) weight loss in one month. Review of a nutrition risk tool dated 06/20/23 revealed Resident #2 was assessed at moderate risk for nutritional decline. Review of a nutrition assessment dated [DATE] revealed Resident #2 was on a no added salt diet and required two handled cups with lids and straw. There was no note of snacks or nutritional supplements being provided. Resident #2 was documented to eat between 75 % and 100 % of meals. Resident #2's weight was noted to be overall stable with no significant weight change. Resident #2 was noted to have a history of fluid shifts with edema and use of diuretics. There were no indications Resident #2 was assessed for sleeping during meals. There were no changes made to the nutritional plan of care. Review of a physician progress note dated 06/25/23 revealed Resident #2 was seen for a check up on dementia, hypertension, and congestive heart failure. There were no acute symptoms noted during the exam. Medications were reviewed with no new orders. There was no indication Resident #2 was assessed for sleeping during meals. Review of a therapy screen for skilled services assessment dated [DATE] revealed Resident #2 was assessed at baseline and required no therapy services. Review of a nurse practitioner (NP) progress note dated 08/07/23 revealed Resident #2 was assessed for increased itching. The NP noted Resident #2 had stable weights and made no changes to the congestive heart failure plan of care. There was no indication Resident #2 was assessed for sleeping during meals. Review of progress notes from June 2023 through August 2023 revealed no indication of fluid shifts related to edema that may be attributing to weight changes, and revealed no indication Resident #2 was assessed for sleeping during meals. Observation on 08/14/23 at 8:59 A.M. revealed Resident #2 was sitting in a recliner chair in her room with a breakfast meal on tray table in front of her. Observation on 08/14/23 at 10:03 A.M. revealed Resident #2 continued to be sitting in a recliner chair in her room. Resident #2 continued to attempt to feed herself the breakfast meal. Further observation of the tray table revealed a breakfast tray that included two pieces of toast, beverages in two handled cups with lid and straw, and an open yogurt container. On the floor in front of Resident #2 was a spoon and fork. Resident #2 was attempting to put jelly on the toast. Interview with Resident #2 at time of observation revealed she was struggling to get jelly on toast. Resident #2 reported sometimes the staff will help her with meals. Observation on 08/15/23 at 10:14 A.M. revealed Resident #2 was in bed with a breakfast tray in front of her on the tray table. Resident #2 was noted to be sleeping and ate less than half of the breakfast tray. Observation on 08/15/23 at 12:14 P.M. revealed Resident #2 was seen in the dining room sleeping at the table. The lunch meal was delivered to Resident #2 at 12:18 P.M. Resident #2 was noted to continue to sleep at table. Resident #2 was awakened by staff several times from 12:14 P.M. to 12:52 P.M.; however, continued to fall asleep. Resident #2 did not eat the lunch meal; however, did eat dessert when it was placed in front of her. At 12:52 P.M., Registered Nurse (RN) #875 brought Resident #2 back to her room. Observation on 08/15/23 at 12:59 P.M. revealed Resident #2 was sitting in her wheelchair in her room, and on the tray table in front of her was a sandwich cut in half. Resident #2 was observed to fall asleep between bites of sandwich. Interview on 08/15/23 at 2:26 P.M. with RN #875 confirmed Resident #2 slept through the lunch meal, and indicated it was common for Resident #2 to sleep during meals or between bites. Observation on 08/15/23 at 2:33 P.M. revealed Resident #2 continued to sit in her wheelchair in her room, continued sleeping, and on the tray table in front of her was half of a sandwich. Observation on 08/16/23 at 8:09 A.M. revealed Resident #2's breakfast was delivered. Observation on 08/16/23 at 8:38 A.M. revealed Resident #2 was sleeping in a recliner chair with her breakfast sitting in front of her on the tray table. Resident #2 had a two handled cup with a lid and straw. Resident #2's breakfast was untouched. Observation on 08/16/23 at 8:49 A.M. revealed State tested Nurse Aide (STNA) #864 was collecting breakfast trays and entered Resident #2's room. STNA #864 indicated Resident #2 did not eat anything yet and encouraged her to eat. Interview on 08/16/23 at 8:50 A.M. with STNA #864 confirmed Resident #2 slept through the breakfast meal and had not eaten. STNA #864 indicated she attempted to wake Resident #2 up three times already for breakfast. STNA #864 indicated Resident #2 does not use silverware appropriately and typically plays with the silverware or pushes stuff around on the tray with silverware. An interview was attempted on 08/16/23 at 8:53 A.M. with Resident #2; however, Resident #2 was still sleeping. Resident #2 briefly opened her eyes and did not respond to questions. Resident #2 was up in a reclining chair with untouched breakfast in front of her. Observation on 08/16/23 at 8:58 A.M. revealed Resident #2 fell back asleep and had not eaten any items on her tray. Interview on 08/16/23 at 9:06 A.M. with the Director of Nursing (DON) stated Resident #2 had general decline and was likely appropriate for hospice services. The DON indicated Resident #2 was not on any sedative medications that would cause sleeping during meals. Observation on 08/16/23 at 9:11 A.M. with Dietary #911 stated Resident #2's breakfast tray was collected and was untouched. Resident #2's meal intake was confirmed with Dietary #911. Dietary #911 indicated Resident #2 usually liked sweet foods and coffee; however, did not eat the donut or drink coffee on the tray. Interview on 08/16/23 at 9:12 A.M. with Licensed Practical Nurse (LPN) Unit Manager #912 and the DON confirmed Resident #2 was not on any sedative medications and confirmed Resident #2 lost 10.3 pounds in last month per the electronic medical record (EMR). LPN Unit Manager #912 and DON were unable to report if Resident #2 was assessed for sleeping during meals. Interview on 08/16/23 at 9:29 A.M. with Registered Dietitian (RD) #913 confirmed Resident #2 had no orders for nutritional supplements or snacks between meals, and was unaware Resident #2 was sleeping through meals. RD #913 indicated Resident #2's weight loss was not significant (significant weight loss was identified as greater than five percent loss in one month) and confirmed weight change had not yet been assessed. Observation on 08/16/23 at 11:48 A.M. with LPN Unit Manager #912 revealed Resident #2 was on scale in shower room, and Resident #2 was sitting in a wheelchair. The scale indicated the weight was 217.0 pounds and the tag on Resident #2's wheelchair indicated it weighed 59.6 pounds. Resident #2's updated weight was 157.4 pounds and indicated a significant weight loss of 5.06 % over one month. Interview on 08/16/23 at 1:44 P.M. with RN #878 stated Resident #2 ate meals in both the dining room and her room. RN #878 indicated Resident #2 was known to fall asleep during meals. RN #878 confirmed Resident #2 did not have order for snacks or nutritional supplements in the case she did not eat a meal. Interview on 08/16/23 at 4:54 P.M. with Resident #2's daughter stated her mother had declined mentally and she was unaware if Resident #2 slept through meals. Resident #2's daughter indicated, to her knowledge, Resident #2 did not require assistance during meals. Resident #2 indicated it was common for Resident #2 to fall asleep during visits. Review of a facility policy titled, Weight Policy, dated 07/01/04, revealed residents experiencing weight changes would have appropriate measures taken to ensure resident maintains nutritional status. The policy identified significant weight changes were five percent change in 30 days. Interventions could include feeding programs, finger foods, therapy screening, and dietary supplements.

Based on observation, staff interview, medical record review, review of a facility policy, the facility failed to administer medications as ordered. There were three medication errors observed out of 27 opportunities for a medication error rate of 11.1 percent (%). This affected two (#46 and #14) of four residents observed for medication administration. The census was 69. Findings include: 1. Observation of medication administration by Registered Nurse (RN) #878 for Resident #46 on 08/16/23 at 8:21 A.M. revealed one of the medications administered was a stool softener Senna 8.6 milligrams (mg) by mouth. RN #878 did not administer Resident #46 a Senna-docusate sodium combination pill during the procedure. Review of Resident #46's medical record, following administration of medication on 08/16/23, revealed there was no active order for Senna 8.6 mg. There was an active order dated 03/10/23 for a Senna-docusate sodium combination pill with a dosage of 8.6-50 mg to be given twice daily for constipation at 9:00 A.M. and 9:00 P.M. Interview with RN #878 on 08/16/23 at 9:44 A.M. verified the incorrect medication was administered to Resident #46, and stated she made the mistake because orders for the combination pill were usually written as Senna-Plus. 2. Observation of medication administration by RN #878 for Resident #14 on 08/16/23 at 8:32 A.M. revealed one of the medications administered was Senna 8.6 mg. No Senna-docusate sodium combination pill was given during the procedure. Additionally, RN #878 removed five pills of the anti-inflammatory medication dexamethasone two (2) mg, and split one of the five pills in half, and discarded the other half to create a total dose of nine (9) mg. The medications were then placed in a medication cup to be crushed. RN #878 confirmed Resident #14's physician order called for two and one-half tablets of dexamethasone four (4) mg to be given, so the pill was split to make the correct dose. When RN #878 announced she was ready to crush the pills, the surveyor intervened to verify two and one-half tablets of dexamethasone 4 mg would create a total dose of 10 mg, not 9 mg which was what RN #878 had ready for administration. Review of Resident #14's physician orders at that time revealed Resident #14's total dose of dexamethasone was to equal 10 mg. RN #878 then prepared the correct dosage and administered it to the resident. Review of Resident #14's medical record revealed an order dated 03/15/23 for two and one-half tablets of dexamethasone 4 mg creating a total dose of 10 mg to be given daily on Wednesdays and Thursdays at 8:00 A.M Further review of Resident #14's physician orders revealed no active order for Senna 8.6 mg. There was an active order dated 03/13/23 for a Senna-docusate sodium combination pill with a dosage of 8.6-50 mg to be given twice daily for constipation at 8:00 A.M. and 8:00 P.M. Interview with RN #878 on 08/16/23 at 9:44 A.M. confirmed the active order for Resident #14's dexamethasone for two and one-half 4 mg tablets, and confirmed there was no order for Resident #14 to receive Senna 8.6 mg. RN #878 stated she made the mistake because orders for the Senna-docusate sodium combination pill were usually written as Senna-Plus. Review of the medication administration policy, dated 06/21/2017, revealed the medication name, strength, and quantity was to be verified for each medication before giving it to the resident.

Based on observation, staff and resident interviews, medical record review, and review of a facility policy, the facility failed to ensure resident medications were maintained in a safe and secure manner. This affected one (#39) of one residents reviewed for medication storage. The facility census was 69. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included unilateral primary osteoarthritis of the right hip, unspecified pulmonary hypertension, and primary generalized arthritis. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was alert and oriented to person, place, and time and was extensive assist for activities of daily living (ADLs). Review of Resident #23's August 2023 monthly physician orders revealed orders for the diuretic torsemide oral tablet 20 milligrams (mg), the blood pressure medication hydralazine oral tablet 50 mg, the antiemetic medication ondansetron oral tablet four (4) mg, the supplement vitamin D3 oral tablet, the pain medication aspirin 81 mg chewable oral tablet, the antihypertensive medication doxazosin mesylate two (2) mg oral tablet, the supplement potassium chloride extended-release tablet extended release 20 milliequivalents (mEq), the blood pressure medication carvedilol 3.125 mg oral tablet, the stool softener polyethylene glycol 17 gram powder, and the medication for heart failure isosorbide dinitrate 30 mg oral tablet. There were no orders to keep medications at Resident #39's bedside. Observation on 08/14/23 at 8:55 A.M. with Resident #39 revealed the resident had a white tissue on her bed with medication on to of it. Interview with Resident #39 at that time stated she had six to eight pills, but declined allowing the surveyor to count them. Resident #39 declined to name the pills after grabbing the tissue and closing her fist. Interview and observation on 08/14/23 at 8:58 A.M. with State tested Nurse Aide (STNA) #897 confirmed Resident #39's pills were left at bedside and were wrapped up in tissue in her closed fist. Interview on 08/14/23 at 8:59 A.M. with Resident #39 stated she held on to her pills and took them after breakfast. Interview on 08/14/23 at 9:05 A.M. with Licensed Practical Nurse (LPN) #831 confirmed Resident #39 pills were left in her room. LPN #831 stated Resident #39 liked to take her pills after breakfast with her apple sauce or orange juice. Follow-up interview on 08/14/23 at 10:00 A.M. with LPN #831 stated she provided Resident #39 with torsemide 20 mg oral tablet, hydralazine 50 mg oral tablet, vitamin D3 oral tablet, aspirin 81 mg chewable oral tablet, potassium chloride 20 mEq extended-release oral tablet, carvedilol 3.125 mg oral tablet, polyethylene glycol 17 grams powder, and isosorbide dinitrate 30 mg oral tablet. Review of the facility policy titled, Medication Administration, dated 06/21/17, revealed medications would be administered by legally authorized and trained persons in accordance to applicable state, local, and federal laws and consistent with accepted standards of practice. Review of the document revealed that tablets and capsules would be poured into the medication cup while remaining with resident while medication is swallowed. Review of the document also revealed to never leave a medication in a resident room without orders to do so, and to proceed to the next resident after all medications had been administered and documented. Review of the document revealed the facility did not implement the policy.

Based on observation, resident interview, staff interview, medical record review, and review of a meal ticket, the facility failed to provide adaptive eating utensils as ordered and care planned. This affected one (#2) of two residents reviewed for nutrition. The facility census was 69. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included dementia, rheumatoid arthritis, hypertensive heart disease, chronic pain syndrome, and anemia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was independent with set up for eating. Review of a plan of care dated 10/06/22 revealed Resident #2 was at risk for alteration in nutrition status related to dementia, use of diuretics, decreased mobility, advanced age, and overall decline. Interventions included assistance with meals as needed, two handled cup with lid and straw for drinks, encourage the resident to dine in the dining room, offer meal substitutes when foods are refused, built-up utensils for all meals, and refer to dietitian or therapy as needed. Review of physician's orders revealed Resident #2 was ordered a no added salt diet with regular texture and thin consistency liquids, a two handled cup with lid and straw in drinks, and built-up eating utensils for all meals. Observation on 08/14/23 at 8:59 A.M. revealed Resident #2 was sitting in a recliner chair in her room with a breakfast meal on tray table in front of her. Observation on 08/14/23 at 10:03 A.M. revealed Resident #2 continued to be sitting in a recliner chair in her room. Resident #2 continued to attempt feed herself the breakfast meal. Further observation of the tray table revealed a breakfast tray that included two pieces of toast, beverages in two handled cups with lid and straw, and an open yogurt container. On the floor in front of Resident #2 was a spoon and fork. There were no noted built-up eating utensils in the room. Resident #2 was attempting to put jelly on the toast. Interview with Resident #2 at time of observation revealed she was struggling to get jelly on toast. Resident #2 reported sometimes the staff will help her with meals. Observation on 08/16/23 at 8:09 A.M. revealed Resident #2's breakfast was delivered. Observation on 08/16/23 at 8:38 A.M. revealed Resident #2 was sleeping in a recliner chair with her breakfast sitting in front of her on the tray table. Resident #2 had a two handled cup with a lid and straw, but no built-up eating utensils. Resident #2's breakfast was untouched. Observation on 08/16/23 at 8:49 A.M. revealed State tested Nurse Aide (STNA) #864 was collecting breakfast trays and entered Resident #2's room. STNA #864 indicated Resident #2 did not eat anything yet and encouraged her to eat. Interview on 08/16/23 at 8:50 A.M. with STNA #864 confirmed Resident #2 slept through the breakfast meal and had not eaten. STNA #864 confirmed there were no built-up eating utensils on Resident #2's meal tray. STNA #864 indicated she attempted to wake Resident #2 up three times already for breakfast. STNA #864 indicated Resident #2 does not use silverware appropriately and typically plays with the silverware or pushes stuff around on the tray with silverware. Review of Resident #2's paper meal ticket dated 08/16/23 for breakfast meal revealed documentation for built-up eating utensils. Interview on 08/16/23 at 9:12 A.M. with Licensed Practical Nurse (LPN) Unit Manager #912 and the DON confirmed Resident #2 did not have built-up utensils on her meal ticket and there was a physician order in electronic medical record (EMR) for adaptive equipment. Interview on 08/16/23 at 9:29 A.M. with Registered Dietitian (RD) #913 confirmed there was an order in Resident #2's EMR for built-up silverware that was not on the meal tray ticket. Interview on 08/17/23 at 2:10 P.M. with the Administrator stated the order for Resident #2 to have built-up eating utensils did not show up on an order report and was missed during an adaptive equipment audit. The Administrator stated the therapy department indicated the order was likely made in error. The Administrator was unaware why the order was in place from 2019 to 2023 if the order was not needed.

Based on record review, staff interview, interview with Wound Certified Nurse Practitioner (WCNP) #280, review of the hospital Nurse Practitioner documentation, and review of the facility policy, the facility failed to assess, monitor, and clarify Resident #72's skin impairments noted by the physician and the nurse practitioner. Additionally, the facility also failed to clarify treatment orders for the identified skin impairments. This affected one (#72) of three residents reviewed for skin impairments. The facility census was Findings include: Review of the closed medical record for Resident #72 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #72 had intact cognition. Further review of the MDS assessment revealed the resident had no pressure injuries. The assessment also indicated the resident had no venous or arterial ulcers. The resident discharged to the hospital on 04/08/21, and was readmitted to the facility on [DATE]. The resident discharged from the facility again on 05/04/21, with no return. Review of the hospital Nurse Practitioner documentation dated 03/17/21, revealed the resident had end stage [CONDITION(S)], peripheral artery disease with non-healing ulcer on left great toe and was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Also noted was [CONDITION(S)] of the penis. Review of the admission nursing assessment dated [DATE], identified the resident was admitted with no areas of skin impairment. There was no documentation regarding a non-healing ulcer on the left great toe. Review of an pressure ulcer risk assessment dated [DATE], revealed the resident had both moderate and high-risk factors for pressure ulcer development. Review of a physician note dated 03/26/21, noted the resident was missing three toes and had a necrotic lesion on the left great toe. Review of a physician order dated 03/29/21, revealed the resident was ordered a head to toe skin check weekly on Mondays on day shift. Review of the nursing progress notes dated 03/26/21 through 03/30/21, revealed no skin assessment or monitoring documentation of the necrotic lesion on the left great toe. Review of Nurse Practitioner (NP) #300's note dated 03/30/21 at 6:07 P.M., revealed the resident's [CONDITION(S)] was stable per resident and resident's wife. Areas of concern at this time were the tip of the penis and the left great toe. Review of the NP's physical assessment of the resident revealed the penis had white exudate covering the tip which the resident was trying to pull off, and advised not to pull exudate. Tissue underneath was beefy pink and clean, no bleeding. The NP also noted the necrotic tip on the resident's left great toe. Review of NP #300's progress note dated 04/01/21 at 5:58 P.M., revealed the resident had [CONDITION(S)]. The NP noted per the resident and the resident's wife, there was a new area of drainage behind the scrotum. Areas of concern at this time were the tip of the penis and left great toe. The physician noted barrier cream after cleansing the area behind scrotum daily, and wound nurse practitioner to follow. Also reported nursing noticed new open area behind scrotum that was draining small amount of bloody drainage. Further review of the progress note revealed the penis had a white exudate covering the tip which resident was trying to pull off, advised not to pull on exudate. Tissue underneath was beefy pink and clean, no bleeding. Also noted was an open area behind the scrotum which had white tissue draining scant serosanguinous drainage. The resident reported soreness in that area. Continued review of the NP progress note revealed the left foot was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes, pressure ulcer and non-pressure ulcer weekly skin grid assessments dated 03/26/21 through 04/08/21, revealed no weekly assessments or documentation regarding the non-healing ulcer on the left great toe or open area behind the penis. There was no documentation the physician was contacted to clarify the skin impairments noted in the NP progress notes dated 03/30/21 and 04/01/21. Review of the plan of care dated 04/06/21, revealed the resident was at risk for alteration in skin integrity related to decreased mobility, episodes on incontinence, diabetes and end stage [CONDITION(S)]. Interventions included weekly body checks, skin assessments per facility policy, dietary consult as needed and encourage and assist resident to turn and reposition as needed. Further interventions included a pressure reducing mattress, notify family and physician of changes as needed. Also, for Prevalon boots daily at bedtime, and provide skin care as needed. Review of NP #300's progress note dated 04/07/21 at 10:31 A.M., revealed new area of drainage per resident and resident's wife behind scrotum. The NP noted the areas of concern were the tip of penis and necrotic tip on left great toe, wound NP to follow. The NP noted the left great toe with necrotic tip unchanged. The NP noted the resident was followed by vascular surgery. The resident had an angiogram planned for 04/08/21. The NP noted, orders in Prevalon boots daily at bedtime. The NP noted the chronic pain/penile pain was stable on current regiment with adverse effects managed. The resident reported last week nursing noticed new open area behind scrotum which was draining small amount of blood. The NP noted the penis had white exudate covering tip. An open area behind scrotum had white tissue draining scant serosanguinous drainage. The NP noted the necrotic tip of left great toe with no surrounding [CONDITION(S)]. The NP noted the resident's plan of care was discussed with resident and nursing staff. Review of a nurses note dated 04/08/21, revealed the resident was out to an appointment and would not return tonight. Review of the readmission nursing skin assessment dated [DATE], revealed upon return from the hospital, the resident's assessment indicated the resident had a Stage II pressure ulcer to the coccyx. The wound measured four centimeters (cm) in length by three cm in width by zero cm in depth. The wound description noted the skin was pink, red, moist, with a small blister with open skin. No other skin impairments were identified. Review of the nursing progress notes and weekly wound consult note dated 04/13/21 through 04/19/21, revealed no skin impairments in addition to the Stage II pressure injury to the coccyx. Review of NP #300's progress notes dated 04/19/21 and 04/21/21, revealed the NP continued to note the drainage behind the scrotum and the necrotic tip on the left great toe. The NP continued to note wound care was following and the plan of care was discussed with nursing staff. Review of WCNP #280's consult note dated 04/22/21, revealed nursing staff reported a new wound located to the left great toe. The NP noted the diabetic ulcer to the left great toe measured 0.7 cm in length by 1.1 cm in width by zero cm in depth. The tissue was noted as 100% eschar. The surrounding skin was intact with no signs of infection. The wound NP ordered to cleanse the wound with normal saline, pat dry and apply skin prep daily to the wound bed and leave open to air. Review of WCNP #280's consult note dated 04/28/21, revealed the resident was seen for a follow up visit for wound care services. The NP noted the resident had a Stage II pressure area to the coccyx. The wound NP noted the resident had diabetic ulcers to the left heel and the left great toe. The wounds were noted as moderate in severity. The wound had been treated with local dressing changes at the site per nursing. The resident denied any signs of infection. The wound NP noted the coccyx measured 0.4 cm in length by 0.3 cm in width by 0.2 cm visualized depth with 100% pink tissue and a small amount of serosanguinous drainage. The peri-wound was noted as intact with no odor, [CONDITION(S)] or sign of infection. No treatment changes were ordered. The NP noted the area to the left great toe measured 0.7 cm in length by 0.9 cm in depth by zero depth. The tissue was 100% eschar. There was no drainage. The surrounding skin was intact with no redness or signs of infection. The NP noted to cleanse the area with normal saline, pat dry and apply [MEDICATION(S)] to wound bed and leave open to air. The NP noted the wound to the left heel measured 2 cm in length by 2 cm in width by 0.2 cm in depth. The tissue was 100% purple with no drainage. The peri-wound was intact with no redness or signs of infection. The NP ordered to pad and protect with an abdominal pad with Kerlix and to change two times a week and as needed. There was no documentation regarding any other areas of skin impairment. Review of a skin grid non-pressure wound assessment dated [DATE], revealed the resident had a wound on his left great toe acquired on 04/13/21. The area was identified as a diabetic foot ulcer measuring 0.7 cm in length by 0.9 cm in width by zero depth. There was no drainage, no odor and no tunneling. The tip of left great toe was noted as black. A care plan was initiated on 04/29/21, for the alteration in skin integrity as evidenced by diabetic ulcer present at the left great toe and left heel. Additional interventions included to assess area for size, color, drainage as needed, assess condition of dressings as needed, encourage and assist resident to elevate heels off bed and to provide skin care as needed. Interview on 07/21/21 at 3:41 P.M. with Licensed Practical Nurse (LPN) #212, verified there were no physician orders documented for the open area to the scrotum or weekly wound assessments for an open area to the scrotum. LPN #212 stated if the area was there then it should have been monitored and evaluated weekly. LPN #212 stated a treatment would have been put in place per the wound NP. Interview on 07/22/21 at 12:46 P.M. with WCNP #280, revealed a full head to toe was completed during weekly wound assessments. WCNP #280 stated Resident #72 had no open areas behind his scrotum. WCNP #280 stated the facility staff and the resident's NP had not reported any open areas to the scrotum. WCNP #280 also stated the resident and the resident's family had not reported any open areas on the scrotum. Interview on 07/22/21 at 4:06 P.M. with the Director of Nursing (DON), revealed the facility had not monitored the area to the great left toe until 04/22/21. Interview on 07/23/21 at 1:38 P.M. with the Director of Nursing (DON), stated as a team the 24 hour report and 72 hour report should have been reviewed and followed up with the physician and nurse practitioner regarding the skin impairments. The DON stated there was a lack of communication from the health care providers. The DON stated the providers should have entered orders regarding treatments. Review of the facility policy titled, Skin Assessment, revised 09/2017, revealed areas of alteration in skin that were present, or which develop subsequently to admission, were treated according to medical direction and conscientiously followed. On a weekly basis, an assessment of the area(s) would be performed and recorded in the resident's medical record. The resident's response to preventive efforts and treatment interventions was monitored and approaches were revised as appropriate. This deficiency substantiated Complaint Number OH 842.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure peritoneal [CONDITION(S)] was completed for Resident #72 per physician orders. This affected one (#72) of three residents reviewed for facility provided peritoneal [CONDITION(S)] treatment. The facility census was 71. Findings include: Review of the closed medical record for Resident #72 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #72 had intact cognition. Further review of the MDS assessment revealed the resident required limited assistance of one staff member for bed mobility, dressing, and toileting, and required extensive assistance of two staff members for transfers. The resident discharged to the hospital on 04/08/21, and was readmitted to the facility on [DATE]. The resident discharged from the facility again on 05/04/21, with no return. Review of the plan of care dated 03/29/21, revealed Resident #72 received peritoneal [CONDITION(S)]. Interventions included contacting [CONDITION(S)] nurse with any complications or concerns, maintaining communication with [CONDITION(S)] staff and physician, and completing peritoneal [CONDITION(S)] as ordered. Review of physician orders for April 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 6:00 A.M. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/21/21 at 4:05 P.M. with Licensed Practical Nurse (LPN) #212, verified there was no documentation contained in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Signing off Medications or Treatments on Administration Records, revised 08/16/10, revealed all paper and electronic MAR's and Treatment Administration Records (TAR's) would be signed off at the time the medication or treatment was administered by the licensed nurse or professional delivering the service. Review of the facility policy titled, [CONDITION(S)] Management, dated 10/11/18, revealed the facility would assess, monitor for complications and provide adequate intervention in the management of those receiving hemodialysis based on physician orders and the plan of care. This deficiency substantiates Complaint Number OH 842.

Based on record review, staff interview and review of the facility policy, the facility failed to administer medication for Resident #72 per physician orders. This affected one (#72) of three residents reviewed for medication administration. The facility census was 71. Findings include: Review of the closed medical record for Resident #72 revealed an admitted [DATE]. Diagnoses included pulmonary embolism, fracture of shaft of right humerus, fracture of ramus of mandible, fracture of upper end of right humerus, diabetes mellitus Type II, end stage [CONDITION(S)], occlusion and stenosis of bilateral carotid arteries, [CONDITION(S)], depressive disorder, anxiety disorder, [CONDITION(S)], obstructive sleep apnea, difficulty walking, muscle weakness, and dependence on renal [CONDITION(S)]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. Review of physician order dated 03/26/21, revealed the resident was ordered [MEDICATION(S)] five milligrams two times a day by mouth for [CONDITION(S)]. The order was discontinued and a new order dated 03/27/21, revealed to administer [MEDICATION(S)] tablet five milligrams two times a day for [CONDITION(S)]. Hold if systolic blood pressure is greater than 175 when sitting. Review of medication administration records (MAR) dated 03/26/21 through 05/04/21, revealed the resident had not received the medication on 03/27/21 at 5:00 A.M. There was also no documentation the resident had received the medication on 04/04/21 at 5:00 A.M., 04/05/21 at 5:00 A.M. and 04/06/21 at 5:00 A.M. Review of the nursing progress notes dated 03/26/21 through 05/04/21, revealed no documentation the resident had refused the medication. Interview on 07/21/21 at 3:56 P.M. with Licensed Practical Nurse (LPN) #212, verified there was no documentation Resident #72 received the medication [MEDICATION(S)] at 5:00 A.M. on 3/27/21, 04/04/21, 04/05/21 and 04/06/21. Review of the facility policy titled, Medication Administration, dated 06/11/17, revealed medications would be administered by legally-authorized and trained persons in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice. This deficiency substantiates Complaint Number OH 842.

Based on observation, medical record review and staff and resident interview, the facility failed to accommodate residents needs by ensuring call lights were within reach and accessible for Resident #25, #58 and #2[AGE]. This affected three (#25, #58 and #2[AGE]) of 48 residents reviewed for call light placement. Facility census was 68. Findings include: 1. Record review revealed Resident #2[AGE] was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2[AGE] was moderately cognitively impaired and required extensive assistance of activities of daily living. Review of the care plan falls dated 02/12/20 revealed that call light should be within reach. Observation of Resident #2[AGE] on 02/18/20 at 9:36 A.M. revealed Resident #2[AGE] was sitting in a recliner with her legs elevated. When this surveyor asked Resident #2[AGE] if she uses the call light, Resident #2[AGE] stated that she was told to use the call light when she wants to get up, so she doesn't fall. The call light was wrapped around the side rail of the bed located the furthest from the resident. The Administrator on 02/18/20 at 9:37 A.M. verified the call light was not within reach of Resident #2[AGE]. 2. Medical record review revealed Resident #25 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Observation on 02/18/20 at 10:07 A.M. revealed Resident #25 was sitting in his recliner on the right side of the bed. Further observation revealed Resident #25's call light was attached to the left side of the bed and not within the resident's reach. Interview on 02/18/20 at 10:07 A.M. with Licensed Practical Nurse (LPN) #47 verified Resident #25's call light was not within reach. LPN #47 stated Resident #25 required staff assistance for transfers. 3. Review of the medical record for Resident #58 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/20, revealed the resident had impaired cognition. The resident was extensive assistance of one for bed mobility, transfers, and ambulation. Observation on 02/18/20 at 10:23 A.M., of Resident #58 sitting in wheelchair in her/his room with the call light laying across the top of bed and not in reach. Interview on 02/20/20 at 12:21 P.M. with the Director of Nursing (DON) revealed all staff should ensure the resident's call lights were in reach. The DON confirmed Resident #25, #58 and #2[AGE] call lights should be within reach.

Based on medical record review, observation, staff and resident interview and policy review, the facility failed to ensure resident nail care was provided. This affected one (#25) of three residents reviewed for activities of daily living. The facility census was 68. Findings include: Medical record review revealed Resident #25 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Further review of the MDS assessment revealed the resident required limited assistance from one staff member for personal hygiene. Review of the nurses progress notes dated 01/01/20 through 0[DATE] revealed no documentation the resident had refused nail care. Observation on 02/18/20 at 9:56 A.M. revealed Resident #25's fingernails were long with dark debris underneath the nails. Interview on 02/18/20 at 9:56 A.M. with Resident #25 revealed he wanted his fingernails trimmed. Resident #25 revealed staff had not cut his fingernails in a few weeks. Observation on 0[DATE] at 12:45 P.M. revealed Resident #25's nails remained long and untrimmed. Interview on 0[DATE] at 12:47 P.M. with Licensed Practical Nurse (LPN) #47 verified the resident's fingernails had not been trimmed. Interview on 0[DATE] at 3:18 P.M. with the Director of Nursing (DON) revealed the facility had no policy regarding nail care. The DON revealed resident nails should be trimmed on shower days and as needed.

Based on medical record review and resident and staff interviews, the facility failed to provide services to maintain a resident's hearing. This affected one (#37 out of 19 residents sampled for hearing. The facility census was 68. Findings include: Review of Resident #37's medical record identified admission to the facility occurred on 12/26/17. Resident #37 had a medical [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was completely cognitively intact, with a Brief Interview for Mental Status (BI[CONDITION]) score of 15 out of 15. Review of an Audiology visit 09/05/19 identified Resident #37 was alert and oriented time three (person, place and time) was evaluated with an otoscope (device to view ear canal) which identified impacted cerumen (wax) in both ears. The visit report identified hearing tests were not preformed this visit, due to wax in the left ear. Right ear was identified partially blocked. The notes identified refer to Nurse Practitioner (NP) for removal, test post cerumen removed. Review of Resident #37's Medication Administration Record [REDACTED]. The records identified no evidence and or follow up if the wax removal occurred. Review of Resident #37's progress notes from 09/05/19 through 02/18/20 identified no evidence of any follow up regarding Resident #37 ear wax and or hearing testing being completed. Interview with Resident #37 on 02/18/20 at 2:32 P.M. The interview required speaking directly into her left ear, as she identified she was very hard of hearing. Resident #37 identified she has a hard time hearing, is totally deaf in the right ear and is very hard of hearing in the left ear. Resident #37 identified several months ago someone told her she had a bunch of wax in her ears and that someone would come evaluate this and remove it. Resident #37 identified no one has ever followed up with the ear wax concerns. Interview with State tested Nursing Assistant (STNA #91) was conducted on 02/20/20 at 8:43 A.M. STNA #91 confirmed Resident #37 is very hard of hearing and she must speak directly into her left ear to communicate with her. Interview with Licensed Practical Nurse #69 occurred on 02/2020 at 8:51 A.M. The interview confirmed there was no evidence of any follow up for Resident #37 following the Audiology visit on 09/05/19. There is no assessment to identify if the [MEDICATION NAME] was effective and a hearing test to be completed.

Based on observation, medical record review, staff and resident interview, the facility failed to honor resident food preferences. This affected two (#11 and #[AGE]) of 19 sampled residents. The facility census was 68. Finding include 1. Medical record review revealed Resident #11 had an admitted d of 11/09/18. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of an undated diet history and food preference sheet revealed the resident preferred cold cereal, cranberry juice and coffee. Further review revealed the resident disliked chicken breasts, chicken legs, corn, and carrots. Review of the resident's dietary meal ticket dated 02/20/20 revealed all the resident's disliked foods were not included on the dietary meal ticket. The meal ticket indicated the resident disliked bananas, potatoes and orange juice. Observation on 02/20/20 at 8:38 A.M. revealed Resident #11 had a banana and orange juice on her breakfast tray. Interview on 02/20/20 at 8:38 A.M. with Resident #11 revealed she should not have received a banana or orange juice. Resident #11 stated the facility had not been honoring her food likes and dislikes. Interview on 02/20/20 at 8:56 A.M. with the Dietary Manager (DM) #53 verified the resident had received orange juice and a banana on her meal tray. DM #53 verified the resident's meal ticket indicated orange juice and bananas were listed as dislikes on the residents meal ticket. DM #53 revealed the dietary cook and the aide should verify resident meals with the meal tickets. Interview on 02/20/20 at 10:20 A.M. with the Registered Dietician (RD) #54 verified the resident's food preference sheet was undated and most likely completed at admission. RD #54 verified there were no updated food preference sheets in the medical record. RD #54 verified the resident's likes and dislikes from the food preference sheet were not indicated on the resident's dietary meal ticket. RD #54 revealed she was newly employed with the facility, and going forward dietary preferences would be reviewed annually. Further interview with RD #54 revealed the facility had no policy regarding resident food preferences. 2. Review of Resident #[AGE]'s medical record identified admission to the facility occurred on 09/13/19 with medical [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] identified Resident #[AGE] had a BI[CONDITION] score of 15, which identified completely cognitively intact. Review of Resident #[AGE]'s nutritional written plan of care, identified honor food preferences. Review of Resident #[AGE]'s nutritional assessments dated 0[DATE], 01/13/20, 02/18/20 revealed Resident #[AGE] can not tolerate cabbage or fried foods. The assessment identified updated food preferences, however did not list what those preferences were. Interview with Resident #[AGE] occurred on 02/18/20 at 11:33 A.M. Resident #[AGE] was asked if she liked the food and replied the facility does not follow her likes and dislikes preferences and send her multiple items she does not like. Observation of Resident #[AGE]'s meal service and meal ticket occurred on 0[DATE] at 11:53 A.M. The meal ticket was blank in the area that identified Resident #[AGE]'s Food Like/Dislikes. Interview with RD #54 on 02/20/20 at 10:20 A.M. identified the facility staff utilize the meal tickets during services to provide residents food preferences. The interview confirmed she just started at the facility a month ago and confirmed Resident #[AGE]'s meal ticket does not identify any of her preferences.

Based on observation, medical record review and family and staff interviews, the facility failed to ensure a resident was provided with eating equipment to maintain independence with eating. This affected one (#30) out of four residents reviewed for maintaining independence with eating. The facility census was 68. Findings include: Review of Resident #30's medical record identified admission to the facility occurred 09/25/15, following a stroked. Resident #30 had additional medical [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #30 was not interviewable. Review of Resident #30's nutritional assessment dated [DATE] identified he utilizes a sip cup, but there was no documentation regarding any need for bowls to maintain independence. Resident #30 requires a pureed diet with honey thick liquids. The assessment also identified Resident #30 required being fed by staff and there was no evidence the resident was actually able to feed himself. Observation of Resident #30's meal services occurred on 02/18/20 at 12:03 P.M. in the dinning room. Resident #30 was observed to be sitting in a tilt back style wheelchair. Licensed Practical Nurse (LPN) #105 was observed to place a full plate of pureed food on the table for Resident #30, turn his chair away from the table and start spoon feeding the resident. Resident #30 was observed trying to reach the table to turn his chair facing the table, multiple times. LPN #105 was observed to continue to spoon feed the resident. LPN #105 was observed to leave the table and Resident #30 was able to, pull himself around to the table, pick up the bowl and started feeding himself, without issue. Resident #30 was then able to pick up his drink sip cup, independently, and drink. LPN #105 was observed to not allow and or encourage Resident #30 to attempt to feed himself, prior to completing spoon feeding. Interview with Resident #30's family member on 0[DATE] at 12:50 P.M. identified Resident #30 is able to feed himself, most of the time, if the food he receives is placed in bowls. Resident #30 is able to manage eating from the bowl and drinking from a sip cup to maintain independence. Interview with Registered Dietician (RD #54) on 0[DATE] at 1:24 P.M. revealed she is new to the facility and determined Resident #30 has not been evaluated by Occupational therapy or herself regarding his ability to feed himself and possible interventions and assistive devices to make that happen. RD #54 confirmed Resident #30 does not have an order for [REDACTED].#54 confirmed Resident #30 does well eating independently, most of the time when he is provided a bowl with food in it.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observations, medical record review, review of incident investigation, and staff interview, the facility failed to use the required number of staff and the required mechanical lift during a transfer to prevent injury. This resulted in actual harm when one (#56) resident was transferred with assistance of only one staff and did not utilize the mechanical lift, resulting in a laceration to the right leg extending to the muscle, measuring 20 centimeters (cm) by 9 cm, with a skin flap which required surgical intervention. This affected one (#56) of three residents reviewed for assistance with transfers. The facility census was 72. Findings include: Review of Resident #56's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment and required two staff to assist with all transfers. Review of the Transfer and Lift assessment dated [DATE], revealed the resident required physical assistance with transfers of a mechanical Hoyer lift and two-person assistance. Review of progress notes dated 06/25/17, documented Resident #56 sustained a large skin tear to her right lower leg. The skin appeared to be hanging loosely with the wound bed open and bleeding. The bed and chair were inspected to determine the cause of the laceration to her leg. No sharp edges were found sticking out of the bed or the chair. The resident was transferred to the Emergency Department via ambulance. Resident #56 was admitted from the Emergency Department to the Operating Room for surgery to repair the right leg laceration. Review of the Emergency Department documentation dated 06/25/17, revealed Resident #56 was brought in with an extensive, deep (down to the muscle), right lower leg laceration (20 cm by 9 cm) with a large skin flap attached. Resident #56 was admitted to the hospital for surgical repair. Review of the Incident Follow-Up documented on 06/25/17, revealed Resident #56 was being pivoted from her bed to a Broda chair by one staff member. As the resident was being transferred, her right leg caught the edge of the chair causing a skin tear. The nurse was immediately notified and assessed the right lower extremity. Interview on 07/05/17 at 12:05 P.M. with the Administrator and Director of Nursing (DON), revealed the administrative staff had brought the State tested Nurse Aide (STNA) in to demonstrate what had happened as part of the investigation. The STNA demonstrated a one-person pivot lift correctly. They both verified Resident #56 required two staff to transfer her with a mechanical lift. The Administrator and DON verified the STNA transferred the resident without assistance and without the mechanical lift, which resulted in the right leg laceration requiring surgery. Observation on 07/05/17 at 3:43 P.M., revealed Resident #56 was in her room in a chair. There was lamb's wool covering her leg and foot area and the resident was wearing protective booties. Observation on 07/06/17 at 9:18 A.M., revealed Resident #56 was in room in her bed with family present and family requested the resident remain in bed. This deficiency substantiates Complaint Number OH 982.