Every finding on record at Wyandot County Skilled Nursing and Rehabilitation

Based on medical record review, resident and staff interviews, and policy review, the facility failed to follow physician orders regarding Resident #9's indwelling urinary catheter by not flushing the catheter as ordered and failed to notify the resident's nephrologist in a timely manner of a positive urine culture result dated 07/19/26. This resulted in Actual Harm on 07/19/26 when although Medical Director #600 was notified on 07/19/26, the nephrologist, who had specifically ordered the urine and culture and required notification of the results, was never contacted. Medical Director #600 did not initiate treatment and deferred back to the nephrologist, causing additional delay in treatment. From 07/21/26 to 07/23/26, Resident #9 experienced zero to minimal urinary output, and the catheter was not flushed for two of those days, contributing to worsening urinary retention. On 07/23/26, the resident was sent to the emergency room (ER) with urinary retention, excruciating pain, and burning in the urethra when urine leaked into her brief. The ER recommended that an antibiotic (ATB) be started the same day (07/23/26), but the facility did not initiate the antibiotic until 07/24/26, resulting in an additional delay in treatment. This affected one (#9) of one resident review for indwelling catheters. The facility census was 76.Findings include:Review of the medical record for Resident #9 revealed an admission date of 08/06/25. Diagnoses included dementia and obstructive and reflux uropathy.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment and had an indwelling catheter in place.Review of Resident #9's physician order's revealed orders dated 08/06/25 for suprapubic catheter care every shift and as needed and to flush the catheter with normal saline as ordered every 24 hours.The physician's order dated 07/16/26 revealed an order for urinalysis with culture and to send results to Resident #9's nephrologist's office.Review of Resident #9's urinalysis with culture results dated 07/19/26 revealed the final results were positive for a Urinary Tract Infection (UTI) with greater than 100,000 proteus mirabilis. The urine culture revealed a handwritten note by the facility physician which stated to send the results to Resident #9's nephrologist.Review of Resident #9's nursing note dated 07/19/26 at 12:38 P.M. revealed Medical Director #600 was notified of urine and culture results obtained for Resident #9's nephrologist. There was no evidence that the nephrologist office was notified of Resident #9's positive results for a UTI. There were no new orders to treat the UTI.Review of the nursing note dated 07/20/26 at 2:39 P.M. revealed Resident #9 was incontinent of urine and had 200 milliliters (ml) of urine in drainage bag suprapubic catheter. Resident #9 verbalized frequent bladder spasms and the catheter was flushed. The Nurse Practitioner from the nephrologist office was notified.Review of Resident #9's urinary output revealed on 07/21/26 at 6:00 A.M., there was zero cubic centimeter (cc) output, at 2:00 P.M. there was 150 cc output, and at 11:00 P.M. there was 19 cc output. The urinary output documentation revealed on 07/22/26 at 6:00 A.M. was 10 cc output, 2:00 P.M. was 50 cc output, and at 11:00 P.M. was five cc output. The urinary output on 07/23/26 was zero cc at 6:00 A.M. and 2:00 P.M.The nursing note dated 07/23/26 at 1:45 P.M. revealed a call was made to the Nurse Practitioner's (NP) office to update Resident #9 had no urinary output in catheter and Resident #9 had soaked briefs. Resident #9 complained of pain and spasms. The note continued to document the facility nurse requested an antibiotic for urinalysis results, and a message was left for the NP.The nursing notes dated 07/23/26 at 2:00 P.M. revealed the nurse attempted two times to reposition and flush the catheter and was unable to flush or aspirate. The note indicated repositioning the catheter was ineffective and there was no output in the catheter.The nursing notes dated 07/23/26 at 2:40 P.M. revealed Resident #9 was sent to the ER.Review of the medical record did not have any documentation to support Resident #9's nephrologist was notified of urine culture results from 07/19/26 to 07/23/26 nor were there any physician orders to treat the UTI prior to Resident #9 being sent to the ER.Review of Resident #9's July 2026 Treatment Administration Record (TAR) revealed documentation to support the facility staff flushed Resident #9's suprapubic catheter on 07/20/26. There was no documentation to support the facility staff flushed the suprapubic catheter on 07/21/26 or 07/22/26.Review of the ER note dated 07/23/26 revealed Resident #9 was seen for catheter issues and abdominal pain. The ER notes indicated Resident #9 had complained of urinary retention, low abdominal pain, and burning in her urethra when urine leaked into her brief. Resident #9 rated her pain a 10 on a pain scale ranging from zero (no pain) and ten (most severe pain). Resident #9 was diagnosed with a UTI at the facility but had not started an ATB yet. The ER note documented Resident #9 was observed with 22 milliliters (ml) of urine in the catheter bag and a new catheter was placed with urine output. Upon discharge, there were orders to start levofloxacin (antibiotic) 250 milligram (mg) by mouth daily for UTI for three days with a start date of 07/23/26 and end date of 07/26/26.There was a physician order dated 07/24/26 for levofloxacin (ATB) 250 milligram (mg) by mouth daily for UTI for three days.Interview on 08/10/26 at 10:04 A.M. with Resident #9 revealed her suprapubic catheter was blocked for several days before staff finally sent her to the hospital. Resident #9 stated the catheter was changed at the hospital and returned to the facility with a new order for an antibiotic.Interview on 08/12/26 at 12:57 P.M. with the Director of Nursing (DON) confirmed Resident #9 had very low to no urine output on 07/21/26, 07/22/26, and 07/23/26 and that the expectation would have been for staff to flush the suprapubic catheter every 24 hours until received urine return or to notify the physician of lack of urine output. The DON confirmed the facility staff had not flushed the catheter on 07/21/26 or 07/22/26. The DON stated the staff attempted to flush the catheter on 07/23/26 but had no success with urine output and Resident #9 was sent out to the hospital to have the catheter changed. The DON confirmed the facility had not notified the nephrologist according to physician orders and the direction from Medical Director #600 when Resident #9's urine and culture results were positive for a UTI on 07/19/26. The DON confirmed Resident #9 was sent to the ER on [DATE] for urinary retention, bladder spasms, and pain. The DON confirmed Resident #9 returned from the ER on [DATE] with an order for an antibiotic for UTI. The DON stated the nephrologist does not allow the facility's physician to provide orders for Resident #9's suprapubic catheter.Review of the facility's undated policy titled Diagnostic Testing Services, revealed the facility was to provide appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its resident's and in accordance with State and Federal guidelines. The policy stated qualified nursing personnel would receive and review the diagnostic test reports and communicate the results to the ordering physician within 24 hours of receipt unless the report results fall outside of clinical reference ranges and require immediate attention at which time the physician would be notified.

Based on review of the medical record, review of the Legionella plan and policy, review of the tuberculosis plan, observation, review of the infection logs, staff interviews and review of facility policies, the facility failed to ensure they had a Legionella plan with control measures and metrics, failed to maintain a tuberculosis risk assessment, failed to ensure an accurate infection surveillance log was maintained, and failed to ensure Resident #63 who had several open wounds was placed in enhanced barrier precautions. This affected Residents #4, #63, and #65,and had the potential to affect all 76 residents residing in the facility. Findings include: 1. Review of the facility's Legionella Water Management Program Policy (undated) revealed the facility was committed to prevention, detection and control of water contaminants including Legionella. The program shall include identification of situations that an lead to Legionella growth, specific measures used to control the introduction and spread of Legionella, the control limits/parameters that were acceptable, and a plan for when control limits were not met or control measures were not effective. Review of the policy for Water Testing (undated) revealed water shall be tested on ce monthly for proper chlorine levels and if measures were not met corrective actions would be taken. If results were low, the maintenance supervisor shall contact the city water supervisor to determine the cause. Review of the chlorine water testing logs revealed the acceptable level should be maintained from 0.5 to 1.0. 19 areas were measured each month and found results were consistently out of the acceptable ranges. This included 18 of 19 were found out of range in 01/2026, 17 of 19 were found out of range in 02/2026, 19 of 19 were found out of range in 03/2026, 19 of 19 were found out of range in 04/2026, 19 of 19 were found out of range in 05/2026, 19 of 19 were found out of range in 06/2026, 18 of 19 were found out of range in 07/2026. The documentation included no evidence of identification and acknowledgement of out of range Legionella tests and no documentation of steps taken. Review of the water temperature log revealed water temperatures ranged from 101 to 118 degrees Fahrenheit (F) in 2025 and ranged from 100 to 125 degrees F in 2026. The log and documentation did not report what was the acceptable range for the water temperatures. Interviews on 08/11/26 at 10:50 A.M. with Maintenance Staff #101 and #143 reported the facility had a Legionella program but were unaware of a plan with specific measures and metrics (ranges for the data). They confirmed the do chlorine checks and water temperature checks monthly. They reported they had no documentation of additional measures such as cleaning the ice machine and flushing inactive areas. 2. Review of the facility's documentation revealed no evidence of a tuberculosis (TB) risk assessment being completed or maintained and updated annually. Interview on 08/11/26 at 4:00 P.M. with the Administrator confirmed she was aware of what the TB risk assessment documentation was and would check with staff about providing documentation. Interview on 08/12/26 at 8:59 A.M. with the Director of Nursing (DON) revealed she was not aware what the TB risk assessment was and reported she reached out to the health department for them to send the information for the DON to provide for the survey. The DON confirmed the facility did not maintain a TB risk assessment. Interview on 08/12/26 at 12:50 P.M. with Infection Preventionist #198 and DON revealed they wrote down data provided from the local health department this date (08/12/26) and provided it. The DON confirmed she was aware of a risk assessment document provided by the Centers for Disease Control and Prevention (CDC) and confirmed the document they provided was missing majority of the information and included the statistics. 3. Review of the medical record for Resident #4 revealed an admission date of 08/22/25. Review of the progress note dated 07/29/26 revealed a left eye was swollen, red, and draining. The physician was notified and an order for eye drops was requested. The progress note dated 07/30/26 revealed the physician ordered an antibiotic eye ointment drops for conjunctivitis in both eyes. Review of physician orders dated 07/30/26 to 08/06/26 for Polymyxin B-Trimethoprim Ophthalmic solution 10000-0.1 unit/ml with instructions to give one drop in both eyes. Review of the antibiotic tracking logs revealed no entry was made for Resident #4 having conjunctivitis or any eye infections and their was no mention of antibiotic eye drops. Interview on 08/13/26 at 12:59 P.M. with the Infection Preventionist #198 confirmed the Resident #4's eye infection and antibiotic were not documented on the infection tracking log. She acknowledged all infections should be thoroughly documented and tracked for possibly trends and patterns. 4. Review of the medical record for Resident #65 revealed an admission date of 03/16/24. Diagnoses included excessive skin and diabetes mellitus type two. Review of the hospital Discharge summary dated [DATE] revealed Resident #65 was seen for a panniculectomy surgical site infection and started on antibiotics. Review of the progress note dated 07/31/26 revealed Resident #65 returned to the facility from the hospital and was diagnosed with panniculectomy dehisced with infection. Review of the Mcgreer's assessment (undated) revealed the resident had a wound infection. Review of the physician orders dated 07/31/26 to 08/10/26 for Amoxicillin-pot Clavulanate (antibiotic) oral tablet 500-125 milligrams (mg) with instructions to give one tablet twice daily. Review of the antibiotic tracking logs revealed no entry was made for Resident #65 having a wound or skin infection and their was no mention of any antibiotic. Interview on 08/12/26 at 2:50 P.M. with the Infection Preventionist #198 confirmed the Resident #65 had a wound infection and went out to the hospital and was started on IV antibiotics. She confirmed the infection and antibiotic were not documented on the infection tracking log. She acknowledged all infections should be thoroughly documented and tracked for possibly trends and patterns. Review of the facility policy titled Infection Surveillance dated 2025 revealed the facility shall have a system of infection surveillance to monitor the adherence to the recommended infection prevention and control practices and reduce infections and prevent the spread of infections. The facility shall maintain documentation related to infections such as symptoms, infection site, location, lab reports or organism, and medication reviews. 5. Review of medical record for Resident #63 revealed an admission date of 05/20/26. Diagnoses included lymphedema, cellulitis of right lower limb, and peripheral vascular disease. Review of the current physician orders revealed to cleanse left lower leg wounds with normal saline (NS) pat dry apply xeroform ABD Kerlix and ACE bandage until healed daily and cleanse right lower extremity wounds with Vashe apply gentamycin 0.1 percent (%) ointment to wound bed cover with alginate ABD and wrap with Kerlix until healed daily. Review of the wound culture of right lower leg wound dated 07/28/26 revealed Pseudomonas aeruginosa light growth. Culture also yielded light growth of Staphylococcus species (coagulase negative) and gram-positive bacilli consistent with Corynebacterium species. Observation and interview on 08/10/26 at 11:08 A.M. revealed Resident #63 stated she had open wounds on her legs. Observation of the resident's room and door revealed no Enhanced Barrier Precautions (EBP) signage noted. Interview on 08/10/26 at 3:37 P.M. with Licensed Practical Nurse (LPN) #105 revealed Resident #63 was not on EBP. LPN #105 verified there was no signage on the door for EBP. LPN #105 stated the resident should be in EBP for the open wounds on her legs and that the Infection Control Nurse was the one who determines who was on EBP. LPN #105 verified there was no physician order or care plan for EBP for Resident #63. LPN #105 verified the resident admitted with the wounds and was not in EBP. Review of the undated policy titled Enhanced Barrier Precautions revealed an order for EBP will be obtained for residents with any of the following: wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices even if the resident is not known to be infected or colonized with a Multi-drug-resistant organisms (MDRO), infection or colonization with a Center for Disease Control (CDC) targeted MDRO when contact precautions do not otherwise apply. MRDOs for which EBP applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by the CDC but can also include other epidemiologically important MDROs. Important MDROs may include but are not limited to: methicillin-resistant staphylococcus aureus (MRSA), ESBL- producing enterobacterales, vancomycin resistant enterococci (VRE), multidrug resistant pseudomonas aeruginosa, and drug-resistant streptococcus pneumoniae. EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on medical record review, review of the resident account balances, staff interview, and policy review, the facility failed to provide a spend down notice when the resident reached $200 less than and/or exceeded the Supplemental Security Income (SSI) resource limit for one person. This affected two residents (#6 and #22) of two residents reviewed for spend down notices. The facility census was 76.Findings include:1. Review of Resident #6's medical record revealed an admission date of 04/30/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severely impaired cognition.Review of the letter of guardianship dated 04/02/04 revealed Resident #6 had a guardian and the guardian was responsible for person only and was not the guardian for Resident #6's estate.Review of Resident #6's payor source revealed Resident #6 was on Medicare A with Next Gen Medicaid.Review of the resident funds and account balance list revealed Resident #6 had $2,655.01 in his account.The facility was unable to provide a spend down notice form for Resident #6.Interview on 08/11/26 at 1:23 P.M. with Business Office Manager (BOM) #136 verified a spend down notice had not been given to Resident #6. BOM #136 stated she was aware a spend down notice was supposed to be given and stated she will usually get with the residents and buy them something to keep them under the $2,000-dollar limit as the facility does not provide the spend down notice forms.Interview on 08/12/26 at 4:47 P.M. with the Administrator stated she was unaware of Medicare or Medicaid being denied for Resident #6 due to having too much money in their accounts. 2. Review of Resident #22's medical record revealed an admission date of 01/05/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had severely impaired cognition.Review of Resident 22's payor source revealed Resident #22 was on a Medicare Advantage plan with Medicaid.Review of the resident funds and account balance list revealed Resident #22 had $1,979.15 in her account.The facility was unable to provide a spend down notice form for Resident #22.Interview on 08/11/26 at 1:23 P.M. with Business Office Manager (BOM) #136 verified a spend down notice had not been given to Resident #22. BOM #136 stated she was aware a spend down notice was supposed to be given and stated she will usually get with the residents and buy them something to keep them under the $2,000-dollar limit as the facility does not provide the spend down notice forms.Interview on 08/12/26 at 4:47 P.M. with the Administrator stated she was unaware of Medicare or Medicaid being denied for Resident #22 due to having too much money in their accounts. Review of the facility policy titled Resident Personal Funds with a revised date of June 2019 revealed the facility must notify each resident that received Medicaid benefits when the amount in the residents account reached 200 dollars less than the Supplemental Security Income (SSI) resource limit for one person.

Based on review of the medical record and staff interview, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness and adverse effects/side effects. This affected one (#13) of two residents reviewed for unnecessary psychotropic medications. The facility census was 76.Findings include:Review of Resident #13's medical record revealed an admission date of 05/29/25. Diagnoses included vascular dementia and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderately impaired cognition and required the use of antipsychotic, antianxiety, and antidepressant medications.Review of the care plan dated 07/10/26 revealed Resident #13 required antidepressant and antipsychotic medications related to dementia. Interventions included to administer antidepressant medications as ordered by the physician and to monitor and document side effects and effectiveness every shift.Review of Resident #13's physician orders dated 08/13/26 revealed an order for Escitalopram Oxalate 10 milligrams (mg) daily for major depressive disorder, Lorazepam 0.5 mg every four hours as needed for anxiety, agitation, and restlessness, and Risperidone 0.5 mg two times daily for dementia with psychotic disturbance.Review of Resident #13's medical record including Treatment Administration Records (TAR) dated 06/01/26 through 07/31/26 revealed no documentation the staff were monitoring for effectiveness, side effects, and adverse effects of the psychotropic medications. Interview on 08/13/26 at 8:36 A.M. with the Director of Nursing (DON) verified there was no documentation for Resident #13 that the nursing staff had been monitoring the psychotropic medications for effectiveness, side effects and adverse effects. The DON stated the facility did not have a policy regarding the monitoring of psychotropic medications for effectiveness, side effects, and adverse effects.

Based on record review, observation, interview, and policy review, the facility failed to ensure a baseline care plan included a resident's physician orders for oxygen administration and a fluid restriction. This affected one (#86) of three residents reviewed for baseline care plans. The facility census was 76.Findings include:Review of the medical record for Resident #86 revealed an admission date of 08/05/26. Diagnoses included acute respiratory failure with hypoxia, hypotension, disorder of kidney and ureter, urinary tract infection, and hydronephrosis.Review of the physician orders revealed fluid restriction intake record 2,000 milliliters (mls) per day, two-gram (gm), no added salt, special list diet fluid restriction 2000 ml per day, change oxygen tubing and canister (if applicable) sign and date new tubing prior to placement every Saturday, check oxygen saturation every shift, and apply oxygen 2-3 liters (l) via nasal cannula (NC) for saturations less than 90 percent (%) for shortness of breath as needed.Review of the baseline care plan dated 08/05/26 revealed no care plan for fluid restriction or oxygen. No oxygen therapy was marked on the care plan. No mention of fluid restriction under the dietary/nutritional status or added to the diet order in the baseline care plan.Observation on 08/10/26 at 8:38 A.M. revealed Resident #86's oxygen was set on two liters and was receiving oxygen via NC. Interview on 08/12/26 at 1:43 P.M. with Licensed Practical Nurse (LPN) #109 verified there was no care plan for oxygen therapy or fluid restriction. LPN #109 stated the unit managers were the ones who wrote the care plans.Review of the undated policy titled Baseline Care Plan revealed the baseline care plan will include the minimum healthcare information necessary to properly care for a resident including but not limited to: initial goals based on admission orders, physician orders, and dietary orders.

Based on record review, observation, interview, and policy review, the facility failed to ensure comprehensive care plan included all aspects of resident care. This affected two (#2 and #69) of twelve residents reviewed for care plans. The facility census was 76.Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 11/24/24. Diagnoses included type two diabetes with diabetic neuropathy. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment. Review of the physician orders dated 06/03/26 revealed to apply hand splint after breakfast daily switching hands every other day, and send hand splint cover to laundry once weekly and as needed. Review of the care plan dated 06/09/26 revealed no care plan mentioning any concern regarding bilateral hand splints and/or potential risk for contractures. Observation and interview on 08/10/26 at 9:00 A.M. with Resident #2 revealed the resident stated he was to wear the blue hand braces for at least an hour a day. Resident #2 raised his right hand which had slight contractures to his fingers. Resident #2 stated the splints were to keep his fingers open. Interview on 08/12/26 at 2:12 P.M. with the Director of Nursing (DON) verified there was no care plan for contractures or splints for Resident #2. 2. Review of the medical record for Resident #69 revealed an admission date of 10/15/24. Diagnoses included hypertensive heart disease and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively intact. Review of the physician orders revealed an order dated 07/19/26 to admit Resident #69 to Hospice services. Review of Resident #69's care plans revealed no documentation to support the facility had developed a comprehensive person-centered care plan to address Hospice services. Interview on 08/11/26 at 2:06 P.M. with Unit Manager #198 confirmed Resident #69 did not have documentation to support the facility developed a comprehensive person-centered care plan for Hospice. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 dated October 2025 pages four to eight stated the comprehensive care plan included measurable objectives, time frames, and must describe the service.

Based on record review, observation, interview, and policy review the facility failed to ensure care plans were updated regarding a resident's indwelling urinary catheter. This affected one (#2) of 12 residents reviewed for care plans. The facility census was 76.Findings include:Review of the medical record for Resident #2 revealed an admission date of 11/24/2.4 Diagnoses included acute pyelonephritis, urinary tract infection, and urgency of urination.Review of the physician orders dated 03/04/26 revealed to prompt to void every two hours after indwelling urinary catheter was removed with post void residual (PVR) after each void and send results with the resident to follow up appointment (03/05/26) and remove indwelling urinary catheter Thursday morning (03/05/26) at 7:00 A.M. per urology appointment at 2:00 P.M. on 03/05/26.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment and did not have an indwelling urinary catheter. Review of the care conference note held on 06/03/26 revealed the resident was frequently incontinent.Review of the current care plan dated 06/09/26 revealed Resident #2's plan was not updated to reflect the resident did not have an indwelling urinary catheter. The current care plan revealed the resident still had a indwelling urinary catheter and interventions in place for the care of it.Observation and interview on 08/10/26 at 9:00 A.M. with Resident #2 revealed the resident stated he did not have a indwelling urinary catheter. Resident #2 stated he wears a brief and was incontinent. There was no indwelling urinary catheter bag or tube observed hanging on his wheelchair.Interview on 08/12/26 at 2:12 P.M. with the Director of Nursing (DON) verified Resident #2 did not have a indwelling urinary catheter any longer and verified Resident #2's care plan was not updated reflecting this. The DON stated the unit managers were the ones who update the care plans and the care plans were updated on care conference dates. The DON verified Resident #2 had a care conference on 06/03/26 and the indwelling urinary catheter was discontinued on 03/05/26 and the care plan was not updated.Review of the undated policy titled Comprehensive Care Plans revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on medical record review, staff interview, and policy review, the facility failed to complete appropriate wound care assessments and failed to timely implement the physician ordered wound treatment. This affected one (#36) of three residents reviewed for wound care and services. The facility census was 76.Findings include:Review of the medical record for Resident #36 revealed an admission date of 09/05/25. Diagnoses included Parkinson's disease, hypothyroidism, heart failure and atrial fibrillation.Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/22/26, revealed Resident #36 was cognitively intact and no skin issues noted.Review of Resident #36's wound assessment dated [DATE] revealed a new bruise to right shin which measured 3.68 centimeters (cm) in length by 5.95 cm in width with no depth. The Wound Nurse Practitioner (WNP) notes dated 07/30/26 revealed the hematoma to Resident #36's right shin worsened and measured 17 cm in length by 16 cm. in width with no depth. The hematoma had started to drain coagulated blood and the WNP recommended for Resident #36 to be transferred to the emergency room for incision and drainage of hematoma because Resident #36 was on Coumadin (anticoagulant) and risk of bleeding was too high.Review of Resident #36's hospital discharge orders revealed Resident #36 underwent an incision and drainage to right lower extremity (RLE) on 07/31/26. The discharge orders included an order for wet to dry dressing to RLE daily.Review of Resident #36's wound assessment revealed upon readmission on [DATE], Resident #36 had an abscess to right shin. No measurements or description of the wound were noted in the wound assessment. Review of Resident #36's physician orders revealed an order dated 08/07/26 to cleanse the area to the RLE with saline then pack with saline soaked gauze, cover with abdomen (ABD) pad and wrap with kerlix/stretch gauze daily until healed.Review of the nursing notes dated 08/10/26 revealed the nurse changed dressing to the right calf so Physician Assistant could observe the wound. The dressing was removed which had minimal drainage tan color on the dressing, no odor noted, and wound bed was beefy red with some dark areas on the border. The nurse reapplied soaked saline dressing, then abdominal pad and kerlix.There was no documentation in the medical record from 08/07/26 to 08/10/26 to support the facility had measured Resident #36's wound to the RLE since readmission.Review of Resident #36's August 2026 Treatment Administration Record (TAR) revealed no documentation to support the facility initiated a treatment to the RLE until 08/11/26. Interview on 08/11/26 at 4:20 P.M. with the Director of Nursing (DON) confirmed there were no wound measurements on Resident #36's RLE wound upon re-admission on [DATE] through 08/10/26. The DON also confirmed the facility did initiate Resident #36's treatments to the RLE leg wound as physician ordered on 08/07/26.Review of the facility's undated policy titled Pressure Injury Prevention and Management revealed the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Licensed nurses would conduct a full body skin assessment on all residents upon admission/readmission, weekly and after any newly identified pressure injury. The findings would be documented in the medical record and should include types of wounds, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics, and treatment and interventions implemented.

Based on record review, staff interview, and policy review the facility failed ensure nursing was aware of how much fluids they could provide on each shift to a resident who was on a fluid restriction and ensure nursing followed the physician order. This affected one (#86) of one resident reviewed for fluid restriction.Findings include:Review of the medical record for Resident #86 revealed an admission date of 08/05/26. Diagnoses included acute respiratory failure with hypoxia, hypotension, disorder of kidney and ureter, and hydronephrosis.Review of the current physician orders revealed Resident #86 was on a 2,000 milliliters (ml) fluid restriction. There was no break down of fluids for nursing each shift.Review of the baseline care plan dated 08/05/26 revealed there no care plan for fluid restriction.Review of the fluid restriction breakdown at the nurse's station taped to the wall revealed that 1,080 milliliters (ml) from dietary: breakfast 480 ml, lunch 360 ml and dinner 240 ml and 960 ml/day from nursing. There was no breakdown for how much fluids each shift could give from nursing.Review of the treatment administration record (TAR) for August 2026 revealed the following fluid amounts given by nursing: 08/07/26 720 ml day shift and 100 ml night shift for a total of 820 ml; 08/08/26 920 ml day shift and 120 ml night shift for a total of 1,040 ml;08/10/26 1,200 ml day shift and 120 ml night shift for a total of 1,320 ml; and 08/11/26 1,200 ml day shift and 120 ml night shift for a total of 1,320 ml.Interview on 08/12/26 at 1:43 P.M. with Licensed Practical Nurse (LPN) #109 verified Resident #86 was on a fluid restriction. LPN #109 verified there was no breakdown for the fluid restriction for each nursing shift in the physician order. LPN #109 stated they had a posted note that had how much was being sent from dietary and how much nursing could give. LPN #109 verified the note posted did not have a breakdown of how much fluids each shift nursing could give the resident.Review of the undated policy titled Fluid Restriction revealed the nurse will obtain and verify the physician's order for fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department and will be recorded on the medication record or other format as per facility protocol.

Based on medical record review, review of Resident #6's funds transaction history, observation, staff interviews, and policy review, the facility failed to ensure Resident #6's funds were not misappropriated. This affected one (#6) of four residents reviewed for misappropriation. The facility census was 76. Findings include:Review of Resident #6's medical record revealed an admission date of 04/30/24. Diagnoses included chronic combined systolic and diastolic congestive heart failure, mild intellectual disabilities, and adult failure to thrive. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severely impaired cognition and required substantial or maximal assistance for sitting to standing and chair to bed and bed to chair transfers. Resident #6 required a feeding tube and required the use of oxygen therapy. Review of Resident #6's letter of guardianship dated 04/02/04 revealed Resident #6 had a guardian. The guardian was responsible for person only and was not the guardian for Resident #6's estate. Review of Resident #6's authorization to manage funds form revealed the form was signed by Resident #6's guardian on 05/01/24 and the form stated I do hereby request that my personal funds be held, safeguarded, managed, and accounted for by this Health Center. Review of Resident #6's payer source revealed Resident #6 was on Medicare A with Next Gen Medicaid. Review of the resident funds and account balance list revealed Resident #6 had $2,655.01 in his account. Review of Resident #6's transaction history revealed the following items to be purchased:-On 12/30/24, therapy items for Resident #6 were purchased for $543.74. -On 03/31/25, pants, shirts, and bed sheets were purchased for $214.06. -On 04/10/25, a superman shirt from Amazon was purchased for $19.99. -On 04/16/25, a universal charger was purchased for $420.-On 07/07/25, an otoscope from Direct Supply was purchased for $509. -On 12/12/25, an Amazon purchase was made for $16.48. -On 01/23/26, a transfer lift stand was purchased for $850. -On 01/23/26, a ten-liter oxygen concentrator was purchased for $1,375.-On 02/24/26, a Life Vac Home Kit was purchased for $375.11. -On 03/30/26, an iPad cover, clothes, and toothbrush were purchased for $238.11. Review of the receipts provided by the facility revealed the facility did not have a receipt for the following items:-Therapy items for $543.74. -An Amazon purchase for $16.48. -Pants, shirts, and bed sheets for $214.06.-A superman shirt from Amazon for $19.99.Review of the purchased items revealed the following items could not be located in the facility:-Therapy items-Universal chargerObservation on 08/11/26 at 2:01 P.M. revealed Resident #6's room did not have an oxygen concentrator, sit to stand or [NAME] steady lift, or life vac to be present in the room. Observation on 08/11/26 at 2:02 P.M. revealed Resident #6 was sitting in his wheelchair in the living room of the C-hall. Resident #6 had his tube feeding running. No life vac or oxygen concentrator was noted to be on Resident #6's person. No sit to stand lifts were noted in the hallway of the C-hall. One sit to stand lift was noted to be in the C-hall spa room. Interview on 08/11/26 at 2:10 P.M. with Certified Nurse Aide (CNA) #113 revealed the Life Vacs in the facility were not put into place because of Resident #6, they were implemented for the general facility after another resident had choked. Furthermore, Resident #6 would transfer using the sit to stand or would stand and pivot, depending on how strong his legs were that day. CNA #113 verified Resident #6 did not have his own oxygen concentrator, therapy items, life vacs, or sit to stand lifts and that he used the facility provided ones. Interview on 08/11/26 at 2:20 P.M. with Registered Nurse (RN) #170 revealed Resident #6 required two staff to assist in transfers or a sit to stand lift for transfers. RN #170 stated no residents had their own sit to stand lifts and all residents used the facility owned lifts. RN #170 verified Resident #6's diet order was nothing by mouth (NPO). RN #170 verified another resident in the facility had choked and that was the reason the facility bought life vacs and had them all around the facility. RN #170 stated Resident #6 would sometimes wear oxygen at night time but was on room air during the day. RN #170 stated Resident #6 would use a facility owned oxygen concentrator and was unaware of him having his own oxygen concentrator. RN #170 also verified Resident #6 did not have his own otoscope and all residents used the one otoscope that the facility had. Interview on 08/11/26 at 3:10 P.M. with RN #184 verified the facility had one otoscope. RN #184 was unaware where the otoscope came from or when it was purchased. RN #184 verified the otoscope was used for all residents in the facility and was being stored in the B-hall nurses station. RN #184 verified no resident had their own sit to stand lift and all residents used the facility owned lifts. RN #184 verified Medicaid residents would use the oxygen concentrators stored at the end of B-hall and no resident had their own oxygen concentrator that she was aware of. RN #184 verified the facility had a choking incident for another resident and due to the choking incident, life vacs were implemented in the facility. RN #184 verified Resident #6 was NPO and had a tube feeding and in general, would not need a life vac. Observation and concurrent interview on 08/11/26 at 3:26 P.M. with RN #170 verified the oxygen concentrator in Resident #6's room was a five-liter oxygen concentrator. Interview on 08/11/26 at 3:38 P.M. with the Director of Rehab (DOR) #201 revealed the purchase for therapy equipment for $543.74 was for a Nu Step bike for Resident #6. DOR #201 stated the Nu Step was in an area Resident #6 had access to and he would attempt to self-transfer onto the Nu Step. For Resident #6's safety, the facility had to place the Nu Step into the therapy room and keep the door locked if staff were not present. Interview on 08/11/26 at 4:03 P.M. with the Administrator revealed the purchases on Resident #6's account were from when Former Administrator #900 was employed at the facility. The Administrator verified five life vacs for one resident does not make sense and the life vacs were purchased due to another residents choking episode. The Administrator stated she was unaware of why Resident #6 was charged for therapy equipment, the life vacs, the sit to stand lift, the oxygen concentrator, and for the otoscope. When read the definition of misappropriation and asked if this situation was misappropriation, the Administrator stated I don't know how else you would look at it. Interview on 08/11/26 at 4:17 P.M. with the Business Office Manager (BOM) #136 revealed Previous Administrator #900 would order the items for Resident #6 and she would pay for the items out of Resident #6's account. BOM #136 stated she thought the therapy equipment was for bands and weights as a Nu Step bike would be much more than $543.74. BOM #136 was unaware of what the universal charger was or where it could be found in the facility. When asked if she was concerned about the purchases to Resident #6's account, BOM #136 stated yes and no, Resident #6's guardian is generous and said in the past if the nursing home needs something and Resident #6 can benefit from it, it was okay to buy it. Interview on 08/12/26 at 9:39 A.M. with an Institutional Care Pharmacy (ICP) representative revealed that the oxygen concentrator that was charged to Resident #6's account was facility owned and was not attached to any resident account in their system. Furthermore, the ICP representative stated the oxygen concentrator was purchased on 01/22/26 as a backup for the facility oxygen concentrators and it was facility owned. Interview on 08/12/26 at 1:48 P.M. with RN #170 revealed Resident #6 could communicate his wants and needs through pointing and some single words. Furthermore, Resident #6 could not request for anything to be bought for him such as an oxygen concentrator, life vacs, therapy equipment, clothes, shoes, or any other items. Interview on 08/12/26 at 2:09 P.M. with CNA #113 verified Resident #6 could ask for simple things like the bathroom or the bird room, but communicated most of his needs through pointing and gestures. CNA #113 verified Resident #6 would not be able to request for specific items such as an otoscope, a oxygen concentrator, or therapy items to be bought for him. Interview on 08/12/26 at 2:18 P.M. with CNA #132 revealed Resident #6 could ask for certain things such as his iPad by pointing to it. CNA #132 verified Resident #6 would not be able to ask for specific items such as an otoscope, a oxygen concentrator, or therapy items to be bought for him. CNA #132 stated Resident #6 enjoyed the therapy equipment in the facility. CNA #132 stated she had worked at the facility for the past four years and the facility had never gotten a new sit to stand. CNA #132 stated they had a couple new [NAME] steady lifts which she would never use for Resident #6 but in the time she had worked there, the facility had never bought a new sit to stand. Interview on 08/12/26 at 2:34 P.M. with the DOR #201 verified she was unaware of what the charge for therapy items of $543.74 was for. DOR #201 stated it could have possibly been a part of the payment for a Nu Step but she was unaware of what that money actually was used for. Observation on 08/13/26 at 8:36 A.M. of the facility revealed five life vacs to be hanging around the facility. One life vac on the A, B and C hall, one life vac on the crash cart, and one life vac on the wall beside the door in the cafe. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property with a last reviewed date of 04/27/26 revealed misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview, and policy review, the facility failed to maintain the ventilation hood system in a sanitary condition. This had the potential to affect all residents in the facility. The facility census was 64. Findings include: Observation on 12/04/24 at 9:43 A.M. revealed the metal louvres in the hood system were covered in a thick coat of dust and debris. The hood system is directly above the flat top grill, burners, steamer, and convection oven. Interview on 12/04/24 at 09:43 A.M. with Dietary Manager #119 confirmed the vents need to be cleaned. Review of the undated, General Sanitation of Kitchen, policy revealed the hood system is not part of the daily cleaning schedule.

Based on medical record review, interviews, and policy review, the facility failed to ensure advanced directives were accurate. This affected two (Resident #18 and Resident #32) out of three residents reviewed for advanced directives. The census was 64. Findings include: 1. Review of the medical record for Resident #18 revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, type two diabetes mellitus, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had a Brief Interview for Mental Status (BIMS) assessment score of 13, indicating intact cognitive function. Resident #18 was dependent for toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene. Review of Resident #18's facesheet revealed the advance directive was listed as full code. Review of Resident #18's care plan revealed Resident #18's code status was full code. The date initiated and date created for code status was 10/17/22. Review of the multi-disciplinary care conference form dated 01/23/24 revealed Resident #18 was listed as Do No Resuscitate-Comfort Care Arrest (DNR-CCA). Review of the multi-disciplinary care conference form dated 04/15/24 revealed Resident #18 was listed as DNR-CCA. Review of the multi-disciplinary care conference form dated 07/19/24 revealed Resident #18 was listed as full code. Review of the multi-disciplinary care conference form dated 10/11/24 revealed Resident #18 was listed as full code. Review of Resident #18's hard medical chart revealed a DNR order form for Resident #18 signed by a physician on 01/18/24. Resident #18 was listed as DNR-CCA There was also a large green page in the front of the chart that said DNR-CC Arrest. Interview on 12/04/24 at 10:43 A.M. with Licensed Practical Nurse (LPN) #132 confirmed Resident 18's advance directive was DNR-CCA. LPN #132 revealed Resident #18's advance directive was not updated in the Point Click Care (PCC) system. Interview on 12/04/24 at 11:05 A.M. with the Director of Nursing (DON) revealed a staff member would look up a resident's advance directive in the hard chart and PCC. The DON confirmed that Resident #18's advance directive was incorrect in PCC and the advance directive should match in the hard chart, PCC, and care plan. The DON revealed Resident #18's code status was DNR-CCA. Review of the, Advance Directive, policy dated 01/03/18 stated, DNR orders will be honored per established protocols and documented in the resident's care plan. 34745 2. Review of medical record for Resident #20 revealed an admitted [DATE]. The resident was admitted with diagnoses including weakness, anemia, abnormal of gait and mobility, spinal stenosis, history of venous thrombosis and embolism. Review of the DNR form dated 04/06/24 revealed the Power of Attorney (POA) signed for the resident's code status to be DNR- Comfort Care (CC). Review of the face sheet for Resident #20 revealed a code status of DNR-CCA. Review of the care conferences for 06/12/24 and 09/12/24 revealed the code status was DNR-CCA. Interview with the DON on 12/05/24 2:00 PM. verified Resident #20's DNR form which was signed by the POA indicated the resident's code status to be DNR-CC, however PCC and care conferences both had the code status as DNR-CCA. The DON verified this was inaccurate information in both areas.

2. Review of medical record for Resident #20 revealed an admitted [DATE]. The resident was admitted with diagnoses including weakness, anemia, spinal stenosis, and history of venous thrombosis and embolism. The MDS assessment dated [DATE] revealed Resident #20 had intact cognition. The resident was a substantial to maximal assist for mobility. Review of the care plan revealed goals and interventions in place for anticoagulant therapy. Interventions included, observe and inform resident of signs or symptoms of bleeding tell him to inform staff of any such symptoms: black tarry stools, abnormal bleeding, administer coumadin as ordered, obtain labs and other diagnostic tests as ordered and report results, and notify physician as condition warrants. A review of the progress notes dated 12/03/24 at 6:45 A.M. revealed a CNA came and got this nurse to check on the resident related to being unconscious on the toilet after being transferred to the toilet on the sit-to-stand. The resident's vital signs were a follows: blood pressure of 84 systolic 58 diastolic and the skin noted to be pale. When asked how he felt, the resident stated, I have had two migraines. When asked how he was feeling now, the resident stated sick. After finishing on the toilet, the resident was assisted back to bed and made comfortable, call light within reach. The note was absent of notification to the physician. A progress note dated 12/03/24 at 10:46 A.M., revealed at 9:00 A.M. the resident was alert and able to eat this morning 100% and took all his fluids. The nurse had held morning blood pressure medications due to low blood pressure this morning and due to the resident passing out on toilet. The resident was in bed throughout the morning and slept after breakfast. At 10:15 A.M. the blood pressure was 81 systolic 50 diastolic, oxygen (02) saturation was 82 percent (%) on room air (RA), and the resident had a pale color. Applied O2 at two liters saturations up to 84 %. Increased to three liters saturation up to 89% and 90%. He was weak and does agree to go to hospital. Updated his daughter she also agreed to have him sent. The Certified Nurse Practitioner (CNP) aware of spell this morning and now low blood pressure and low O2 saturation. Note order to send to emergency room (ER) for evaluation. 911 called. At 10:40 A.M. squad arrived . At 10:45 A.M., the resident was transported out to ER. Report called to ER. Review of the text message sent, which was given to the surveyor by the MDS Nurse #155, revealed the CNP was sent on 12/03/24 at 10:22 A.M. which included Resident #20 had another episode of passing out on toilet. The resident had a blood pressure of 85 systolic 58 diastolic and held morning blood pressure. The resident still week and blood pressure was now 81 systolic 50 diastolic shallow respirations O2 saturation 84%. Now up to 89%. The resident was alert and talking. Resident said he will go to hospital if needed. The resident is not getting enough fluids by mouth or food. Interview with MDS Nurse #155 on 12/05/24 at 11:20 A.M. revealed the CNP was not notified of the change in condition with low blood pressure, unconsciousness, and blood pressure medication being held for Resident #20 at 6:00 A.M. until the 10:22 A.M. which at the time the CNP stated to send out to ER. 35031 Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was notified when two residents (#07 and #20) experienced a change of condition. This affected two (#07 and #20) of 18 residents reviewed for changes in condition. The facility census was 64. Findings include: 1. Review of the medical record of Resident #7 revealed an admitted [DATE]. Diagnoses include vascular dementia, glaucoma, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired and required substantial/maximal assistance with transfers. The assessment further indicated one fall with minor injury. Review of the progress note dated 07/20/24 at 8:44 A.M., documented by Licensed Practical Nurse (LPN) #132, revealed Certified Nurse Assistant (CNA) reported Resident #07 was not responding as per her norm during morning care. LPN #132 documented having assessed Resident #07 and noted audible wheezing. LPN #132 called to Resident #07 and received no response. Resident #07 responded with What when a sternal rub was performed. Resident #07 did not respond to requests of hand grasp or eye opening. Resident #07's pupils were round and sluggish to light. Blood pressure, oxygen saturation temperature, and pulse (vital signs) were all within normal limits. LPN #132 documented having called the responsible party and left a message, but not the physician. Review of a second note at 12:04 P.M., documented by LPN #132, revealed Resident #07 was awake and responded Ok but could not form coherent sentences. Vital signs were within normal limits and Resident #07 refused lunch. LPN #132 documented the responsible party had not returned a phone call at that time. Still no documentation of physician notification. Review of a third note at 7:34 P.M. documented by LPN #132 revealed Resident #07 was back to baseline, alert and speaking coherently. Interview on 12/04/24 at 1:29 P.M. with LPN #132 revealed she was uncertain whether she had notified the doctor about the change of cognition for Resident #07.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure accuracy of insulin injection by priming the insulin pen prior to dialing up dose of insulin. This resulted in a significant medication error. This affected one resident (#01) of two reviewed for medications pass. The census was 64. Findings include: Review of the physician orders for Resident #01 revealed an order dated 05/16/24 for Novolog flexPen relion subcutaneous solution pen-injector 100 unit per milliter (ml) (Insulin Aspart) to inject as per sliding scale: if 0 to 150 to give 0 units; 151 to 200 to give 2 units; 201 to 250 to give 4 units; 251 to 300 to give 6 units; 301 to 350 to give 8 units; 351 to 400 to give 10 units; 401 to 500 to give 15 units, subcutaneously three times a day. An order for NovoLOG flexpen relion subcutaneous solution pen-injector 100 unit per ml (Insulin Aspart) to Inject 15 unit subcutaneously three times a day. Observation of Licensed Practical Nurse (LPN) #132 revealed LPN #132 performed glucometer test for Resident #01, which was 158. The nurse then prepared the insulin injection. LPN #132 cleaned the Novolog flexpen with alcohol pad, then opened the needle and placed on flex pen. LPN #132 drew up 17 units of insulin. There was not a prime of two units into the needle. LPN #132 gave the resident the insulin in the left abdomen and held for the appropriate amount of time. Interview with LPN #132 on 12/04/24 at 8:13 A.M. verified the flexpen was not primed prior to dialing up the 17 units. Review of the policy dated 2021, Insulin Pen Policy, revealed it is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. To prime the the insulin pen, dial up two units by turning the dose selector clockwise, with the needle pointing up, push the plunger, and watch to see at least one drop of insulin appears on the tip of the needle. Then to set the insulin dose, turn the dose selector to ordered dose.

Based on observation, staff interview, medical record review, review of hospital documentation, review of fall investigations, and policy review, the facility failed to ensure fall interventions were care planned and appropriately implemented to prevent falls. This resulted in actual harm for Resident #40 on 11/10/23 when she sustained a fall, was sent to the hospital, and was found to have a right non-displaced pubic superior fracture and left minimally displaced inferior pubic fracture (pelvic fractures). The fracture was deemed non-operable and Resident #40 was returned to the facility on [DATE]. This affected one (#40) of one resident reviewed for falls. The facility census was 72. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE]. Medical diagnoses included chronic pain, osteoarthritis, insomnia, and repeated falls. Review of Resident #40's significant change in status Minimum Data Set (MDS) assessment, dated 11/22/23, revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating the resident was assessed with severely impaired cognition. Resident #40 was not noted to have any behaviors or wandering. Resident #40 was noted to be in moderate pain and sustained one fall with no injury and one fall with major injury since the prior assessment. Review of Resident #40's plan of care, initiated on 09/08/21 and revised on 11/28/23, revealed Resident #40 to be at risk for falls due to confusion, deconditioning, and not aware of safety needs. An intervention dated 09/12/22 revealed to ensure Resident #40 was wearing appropriate non-skid footwear when ambulating or mobilizing in wheelchair. Additional fall interventions were added to Resident #40's care plan on 11/16/23 following a fall with major injury on 11/10/23. The care plan indicated Resident #40 was sent to the emergency room for evaluation and treatment. There were no new interventions placed or added to the care plan upon the resident's return to the facility on [DATE]. On 11/15/23, following a fall dated 11/14/23, an approach was added to Resident #40's care plan for frequent checks and a bed alarm. On 11/28/23, following a fall dated 11/27/23, an approach was added to Resident #40's care plan to not leave Resident #40 unattended while toileting. Review of the fall investigation report dated 11/10/23 at 6:29 A.M. revealed Resident #40 was observed on the floor next to her bed with her eyes open. Resident #40 indicated she was attempting to go to the bathroom and must have slipped or lost her balance. When staff assisted Resident #40 up off the floor, Resident #40 cried out in pain, grabbed her left leg, and staff returned her to a seated position. The provider was updated and gave an order to send Resident #40 to the hospital for evaluation and treatment. The investigation report identified predisposing situation factors to include Resident #40 ambulating without assistance and wearing improper footwear. There was no indication Resident #40 was wearing appropriate non-skid footwear or that staff had assisted with providing appropriate non-skid footwear. The fall investigation report identified an intervention for Resident #40 to use slipper socks at all times when transferring. Review of the hospital after visit summary dated 11/10/23 revealed a computed tomography (CT) scan was performed at the hospital and revealed a right non-displaced pubic superior fracture and left minimally displaced inferior pubic fracture. The fall was deemed non-operable, and Resident #40 was returned to the facility on [DATE]. Review of Resident #40's physician's orders revealed an order dated 11/11/23 to check the chair and bed alarm to be sure it was on and working twice daily. Nurses were to document the alarm was on and in good working order at 8:00 A.M. and 8:00 P.M. beginning on 11/11/23. Review of a fall investigation report dated 11/14/23 at 6:30 A.M. revealed Resident #40 was observed lying on the floor by day shift staff members entering the unit upon arrival for their shift. Resident #40 was confused and unaware of what had happened. Staff statements in the fall investigation report identified Resident #40's bed was in the low position, the call light was on the bed, and a bed alarm was on the bed but not sounding. Staff statements further revealed there were concerns about staff members turning the alarm to the off position. Resident #40 was found to be in continued pain related to the prior left pelvic injury but had no new injuries. The fall investigation report listed frequent checks and a pressure alarm as new interventions. Review of a fall investigation report dated 11/27/23 at 5:03 P.M. revealed Resident #40 was observed lying on the floor on her back in front of the toilet. The fall was witnessed by a nurse aide when the nurse aide left Resident #40 behind a privacy curtain while using the toilet. Resident #40 sustained a skin tear to her left elbow during the fall. The fall investigation report listed staff to stay beside the resident during toileting for safety as a new intervention. Observation of Resident #40 on 12/20/23 at 7:41 A.M. revealed her seated in a manual wheelchair being propelled down the hallway by a State tested Nurse Aide (STNA) #121. On Resident #40's wheelchair was a cordless pressure alarm. Resident #40 was wearing non-skid shoes. An interview on 12/20/23 at 7:48 A.M. with STNA #121 verified she just toileted Resident #40 and stayed at her side for safety. STNA #121 was familiar with Resident #40's fall interventions. When asked how often Resident #40 was checked and toileted, STNA #121 stated every two to three hours or as needed. STNA #121 verified Resident #40 was confused, rarely remembered to push her own call light, and would likely not think to apply her own footwear. STNA #121 stated changes are communicated verbally by the nurses when needed. An interview on 12/20/23 at 09:40 A.M. with STNA #125 identified Resident #40 to be at risk for falls and had fall interventions which included a chair and bed alarm, a low bed, and non-skid footwear. When asked how often Resident #40 was checked and toileted, STNA #125 stated every few hours. STNA #125 stated nurses communicated changes, and they may also be in the electronic health record (EHR). An interview on 12/20/23 at 11:07 A.M. with Licensed Practical Nurse (LPN) #119 identified Resident #40 to be cognitively impaired. LPN #119 stated Resident #40's alarm was cordless and sounded at the nurse's station. LPN #119 verified the control to turn the alarm on and off was at the nurse's station and intermittently there had been problems with staff turning off Resident #40's alarm. LPN #119 stated nurses communicate changes to things like interventions through verbal report and was not sure the STNAs had access to the care plan, but they did have access to the Kardex within the HER which identified specifics about the resident's care. LPN #119 verified fall interventions of a pressure alarm to bed and chair, non-skid footwear, frequent checks, and not to leave the resident alone while toileting were not items included in Resident #40's Kardex. An interview on 12/21/23 at 9:25 A.M. with Registered Nurse Unit Manager (RN UM) #126 discussed Resident #40's prior falls and subsequent interventions. RN UM #126 identified Resident #40 was severely cognitively impaired and verified she had a care planned intervention since 09/12/22 for non-skid footwear. RN UM #126 stated Resident #40 did not have the cognition to think to call for help in advance or apply her own shoes, and she should have had nonskid socks in place at night. RN UM #126 verified Resident #40 had the bed alarm ordered following the fall on 11/10/23, but it was not care planned or listed as an intervention until after the fall on 11/14/23. RN UM #126 was unable to identify or quantify how frequently Resident #40 should be checked or how that information was communicated to staff. RN UM #126 further verified that due to the frequent falls Resident #40 sustained, she should not have been left unattended in the bathroom, even for a moment. RN UM #126 was unsure if staff utilized the Kardex function in the HER, but it should be updated and available as a reference. RN UM #126 verified no fall interventions were listed on the Kardex. Review of the fall prevention program policy, revised 03/06/20, revealed each resident will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each resident should be provided with interventions that address unique risk factors which include medications, psychological, cognitive status, or a recent change in functional status. The policy further identified that interventions will be monitored for effectiveness and the plan of care will be revised as needed.

Based on observation, review of medical records, review of facility SARS-CoV-2 (COVID-19) tracking documentation, review of Centers for Disease Control and Prevention (CDC) guidelines, staff interview, and policy review, the facility failed to timely identify and test residents and staff with signs or symptoms of COVID-19 or exposed to COVID-19. Additionally, the facility failed to ensure staff were appropriately wearing personal protective equipment. This had the potential to affect all 72 residents residing in the facility. The facility census was 72. Findings include 1. Review of the medical record revealed Resident #33 had an admitted [DATE]. Diagnoses included hypertension, cerebrovascular disease and hyperlipidemia. Further review of the census data revealed the resident resided on C-Hall in the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required limited assistance of one staff for bed mobility, transfers, and ambulation and the extensive assistance of one staff for toileting. Review of a nursing note dated 10/31/23 at 1:30 P.M. revealed the resident was sent to the hospital for critical laboratory values. Review of COVID-19 monitoring documentation revealed the resident tested positive for COVID-19 on 10/31/23 at the hospital. Further review of the COVID-19 monitoring documentation revealed only one other resident (Resident #33's roommate) was tested for COVID-19. No staff on C-hall were tested for COVID-19. 2. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type tow, hypertension, chronic kidney disease and chronic diastolic heart failure. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. The resident required substantial or maximal assistance for bed mobility and partial or moderate assistance for transfers and ambulation. Review of a nursing note dated 11/01/23 at 7:58 A.M. revealed Resident #3's roommate testing positive for COVID-19 in the hospital. Resident #3 was tested and was negative for COVID-19 on day one and day three after exposure. There was no documentation the resident was tested again on day five after exposure. 3. Review of the medical record for Resident #71 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, sepsis, cachexia, hypertension, and anemia. Further review of the census data revealed Resident #71 resided on A-Hall and had no roommate. Review of the admission MDS assessment dated [DATE] revealed the resident had impaired cognition. The resident required partial or moderate assistance for toileting hygiene, bed mobility, transfers, and ambulation. Review of a progress note dated 11/02/23 at 11:47 A.M. revealed Resident #71 was sent to the emergency room for a low oxygen saturation level. The resident was admitted to the hospital and was positive for COVID-19. Review of the COVID-19 monitoring documentation revealed no other residents or staff on A-Hall were tested for COVID-19 following Resident #71's positive COVID-19 test. 4. Review of the medical record for Resident #4 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, hypertension, osteoarthritis and convulsions. Further review of the census data revealed the resident resided on B-Hall. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 had intact cognition. The resident was dependent on staff for bed mobility, transfers, and toileting hygiene. Review of a nursing note dated 12/03/23 at 9:14 A.M. revealed the resident was positive for COVID-19. Review of the COVID-19 monitoring documentation revealed Resident #4's family member was positive for COVID-19. Further review of the documentation revealed Resident #4's roommate was tested for COVID-19 and was also positive. No other residents or staff on B-Hall were tested for COVID-19. 5. Review of the medical record for Resident #64 revealed an admitted [DATE]. Diagnoses included chronic pain syndrome, hypertension, and urinary retention. Further review of census data revealed the resident resided on A-Hall in a private room. Review of the admission MDS assessment dated [DATE] revealed Resident #64 had intact cognition. The resident was dependent on staff for toileting hygiene, transfers, and ambulation. The resident required substantial or maximal assistance for bed mobility. Review of a nursing note dated 12/06/23 at 3:23 P.M. revealed Resident #64 tested positive for COVID-19. Review of the COVID-19 monitoring documentation revealed no other residents or staff were tested . 6. Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included acute respiratory failure, rhabdomyolysis, and hypothyroidism. Further review of the census data revealed the resident resided on A-Hall in a private room. Review of the admission MDS assessment dated [DATE] revealed Resident #66 had impaired cognition. The resident required substantial or maximal assistance with toileting hygiene and bed mobility. The resident required partial moderate assistance with transfers and ambulation. Review of a nursing note dated 12/11/23 at 7:38 A.M. revealed the resident had temperatures of 99.8 degrees Fahrenheit (F), 102.4 degrees F, and then 98.9 degrees F. Resident #66 also complained of a scratchy throat. The resident was administered the pain medication or fever reducing medication Tylenol. There was no documentation the physician was notified and there was no order for COVID-19 testing. Review of a nursing note dated 12/12/23 at 10:54 A.M. revealed Resident #66 was positive for COVID-19. The physician was aware. No other residents or staff on A-hall were tested for COVID-19. Review of the COVID-19 monitoring documentation revealed three employees working on B-Hall later tested positive for COVID-19 at local providers outside the facility. State tested Nurse Aide (STNA) #191 developed signs and symptoms of COVID-19 on 12/04/23 and tested positive for COVID-19 on 12/05/23. STNA #191 last worked on 12/03/23 in B-Hall. STNA #181 developed signs and symptoms of COVID-19 on 12/05/23 and tested positive for COVID-19 on 12/05/23. STNA #181 last worked on 12/03/23 in B-Hall. STNA #280 developed signs and symptoms of COVID-19 on 12/07/23 and tested positive on 12/10/23. STNA #280 worked on B-Hall on 12/06/23 and C-Hall on 12/07/23 and 12/08/23. Licensed Practical Nurse (LPN) #107 developed signs and symptoms of COVID-19 on 12/01/23 and tested positive for COVID-19 on 12/04/23. LPN #107 worked on the A-Hall on 12/01/23 and C-hall on 12/03/23. Continued review of the COVID-19 monitoring documentation revealed no other residents or staff were tested for COVID-19. Interviews on 12/19/23 beginning at 1:33 P.M. and on 12/20/23 beginning at 7:19 A.M., with Infection Preventionist (IP) #110 stated no resident testing was completed for residents exposed to staff who tested positive for COVID-19. IP #110 also revealed no staff testing was completed for staff exposed to other staff and residents positive for COVID-19. IP #110 revealed the staff she interviewed indicated they had spent less than 15 minutes with each resident at one time and therefore were not close contacts and testing was not required. IP #110 later revealed she was unaware a close contact was considered direct contact of more than 15 minutes during a 24-hour period and verified close contacts were not tested . IP #110 verified Resident #3 had exposure to his roommate who tested positive for COVID-19 and was not tested on day five after exposure per CDC guidelines. IP #100 revealed staff were not reporting when they had signs and symptoms of COVID-19. IP #110 verified STNA #181, STNA #191, LPN #108, and STNA #280 tested positive for COVID-19 had worked on all three halls in the facility. Review of the policy titled, COVID-19 Testing, revealed employees would test for COVID-19, depending on current CMS (Centers for Medicare and Medicaid) guidelines. If an employee was symptomatic or exposed, they were responsible for testing prior to starting their next scheduled shift. The employee was responsible for locating the infection control manager or nurse to obtain a COVID-19 test, upon entering the facility. Residents may be tested for COVID-19, according to current CMS guidelines with a doctor's order. Residents would not be routinely tested unless symptomatic, leave regularly, or a positive COVID-19 staff, or resident was suspected/confirmed. A suspected or confirmed COVID-19 staff or resident may require all or specific staff and residents to test per CMS and CDC guidance. Review of the CDC's Infection Control Guidance, updated 05/08/23, revealed anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic patients with close contact with someone with SARS-CoV-2 should have a series of three viral tests for SARS-CoV-2 infections. Testing is recommended immediately and if negative again 48 hours after first negative test and if negative, again 48 hours after the second negative test. This would typically be at day one (1), day three (3) and day five (5). Review of the CDC's guidance for Potential Exposure at Work, updated 09/23/22, revealed a close contact was an exposure of 15 minutes or more was considered prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period. 47990 7. An observation and interview on 12/18/23 at 9:54 A.M. revealed signage outside of Resident #66's room to indicate he was on droplet and contact precautions. Unit Manager Registered Nurse (UM RN) #126 stated Resident #66 had contact and droplet isolation precaution in place related to active COVID-19 infection. An observation on 12/18/23 at 11:22 A.M. revealed STNA #158 applied personal protective equipment (PPE) which included a gown, gloves, and eye protection. STNA #158 placed an N-95 respirator mask overtop of her surgical mask and entered Resident #66's room to deliver his lunch tray. Upon exiting the room, STNA #158 was observed to have taken off her N-95 respirator mask in the room. STNA #158 used the hand sanitizer outside of the room on the PPE cart and was not observed to change her surgical mask. An interview on 12/18/23 at 11:31 A.M. with STNA #158 verified she did not change her surgical mask upon exiting Resident #66's isolation room. STNA #158 stated she did not know she was supposed to and stated she always wore an N-95 respirator mask overtop of a surgical mask when caring for COVID-19 patients. STNA #158 recalled having training on applying and PPE, but could not recall the specifics. She further stated she rarely worked on the hallway on which residents with COVID-19 usually reside. 8. Observation of STNA #115 on 12/19/23 at 9:10 A.M. revealed the staff was observed to put on gown, gloves, an N-95 face mask, and entered Resident #7's bedroom. Continued observation revealed the staff member exited the room with the PPE still on and carrying the finished breakfast meal tray. Resident #7's room was recessed approximately five feet from the main hallway and the meal tray cart was in the main hallway next to the recessed part of the hall. STNA #115 walked to the meal tray cart which was parked in the main hallway and placed the resident's meal tray on the cart with the other resident's meal trays. STNA #115 then returned to the resident's room, removed and discarded her gown and gloves, performed hand hygiene with alcohol-based hand rub, and exited the room wearing the N-95 mask. STNA #115 walked across the hall and down to the communal shower room and washed her hands with soap and water. STNA #115 then walked to the next room on the hallway, the soiled utility room, and discarded her N-95 face mask and put on a surgical mask. Interview with STNA #115 on 12/19/23 at 9:13 A.M. confirmed she exited the resident's wearing her PPE and placed his breakfast tray on the meal tray cart that was in the hallway outside his room. STNA#115 confirmed she received training on how to put on and remove PPE at the facility, but did not remember when that occurred. An interview on 12/21/23 at 2:48 P.M. with IP #110 verified staff members should not wear N95 face masks overtop of surgical masks, and masks should be changed when leaving isolation rooms. IP #110 additionally verified all staff, in all departments, should have on a surgical mask in resident care areas.

Based on medical resident interview, staff interview, and policy review, the facility failed to ensure an accurate and thorough baseline care plan was completed. This affected one (#222) of one resident reviewed for dialysis. The facility census was 72. Findings include: Review of the medical record for Resident #222 revealed an admitted [DATE]. Medical diagnoses included stage five chronic kidney disease, anemia in chronic kidney disease, and dependence on renal dialysis. Review of the Minimum Data Set (MDS) admission assessment, dated 12/12/23, revealed Resident #222 had moderately impaired cognition. Resident #222 was assessed to receive oxygen therapy on a continuous basis and required dialysis. Review of the baseline care plan, dated 12/08/23, revealed Resident #222 required set up assistance with eating, and one person physical assistance with hygiene, toileting, dressing, and bathing. The section regarding medical conditions, including the question if Resident #222 required dialysis, was left blank. The baseline care plan stated to refer to the current physician's orders listed on the medication administration record (MAR) and treatment administration record (TAR). The baseline care plan summary revealed a brief narrative indicating Resident #222 required dialysis three times weekly. The baseline care plan narrative indicated Resident #222 had a fistula (vascular access through which hemodialysis is provided) to the right lower extremity (RLE). The diet order section on the baseline care plan was left blank, as were the sections asking for any dietary preferences or dietary risks. An interview on 12/21/23 at 8:52 A.M. with Registered Nurse Unit Manager (RN UM) #126 verified the baseline care plan listed Resident #222's dialysis vascular access in the wrong extremity and did not have the information from physician orders including Resident #222's dietary order. Review of the baseline care plan policy, dated 2023, revealed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to dietary orders. Any special needs, such as for dialysis, shall be initiated and included in the baseline care plan.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure the residents' care plans were updated timely. This affected two (#41 and #42) of 16 residents reviewed for care plans. The census was 72. Findings include 1. Review of the medical record revealed Resident #41 had an admitted [DATE]. Diagnoses included atrial fibrillation, hypertension, venous insufficiency, hypothyroidism, chronic kidney disease stage three, hyperlipidemia, spinal stenosis, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had intact cognition. The resident was frequently incontinent of urine and was dependent for toileting, hygiene, and transfers. Review of a handwritten order dated 12/08/23 located in Resident #41's hard chart revealed to maintain urinary catheter until follow up in two to three weeks. Review of the physician orders in the electronic medical record revealed no orders regarding the urinary catheter. Review of the resident's plan of care revealed the care plan had not been updated to include the use of the indwelling urinary catheter. Interview on 12/19/23 at 1:04 P.M., the Director of Nursing (DON) verified Resident #41's plan of care had not been updated to include the use of an indwelling urinary catheter. The DON revealed the unit manager was responsible for ensuring the care plans were updated. 48568 47990 2. Review of the medical record for Resident #42 revealed an admitted [DATE]. Medical diagnoses included adult failure to thrive, depression, dementia, and senile degeneration of the brain. Resident #42 was admitted to hospice services at the facility on 11/27/23 with a primary diagnosis of adult failure to thrive. Review of Resident #42's MDS assessment, dated 12/01/23, revealed Resident #42 to have moderately impaired cognition. Resident #42 was noted to have shortness of breath while lying flat. Resident #42 was coded as having received oxygen therapy while a resident. Review of Resident #42's physician order, dated 11/26/23, revealed oxygen was ordered at two to five liters per minute as needed (PRN) to keep oxygen saturation levels greater than 90 percent (%). Review of Resident #42's care plan revealed no indication or notation that he received supplemental oxygen while a resident of the facility. An observation on 12/18/23 at 3:58 P.M. revealed Resident #42 seated up in recliner in his room and had supplemental oxygen applied per nasal cannula. An interview on 12/20/23 at 8:59 A.M. with Registered Nurse Unit Manager (RN UM) #126 verified Resident #42's care plan contained no indication that supplemental oxygen was part of his care needs. Review of the policy titled, Comprehensive Care Plans, dated 2023, revealed no guidelines for revising the plan of care when the resident had a change of condition. Review of the oxygen administration policy, dated 2020, revealed oxygen is administered under orders of a physician, except in cases of an emergency. The policy identified the resident's care plan shall identify the type of oxygen delivery system, when to administer (continuous or intermittent), equipment setting for prescribed flow rates, monitoring of oxygen orders, and monitoring for complications associated with the use of oxygen.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a valid level one Pre-Admission Screen and Resident Review (PASRR) was completed timely under a hospital exemption. This affected one (#66) of one resident reviewed for PASRR. The facility census was 72. Findings include: Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE] from a hospital. Diagnoses included acute respiratory failure with hypoxia, weakness, hypothyroidism, and hyperlipidemia. Review of Resident #66's PASRR records revealed a hospital exemption from preadmission screening notification dated 11/11/23. Interview on 12/19/23 at 12:26 P.M. with the Administrator confirmed the hospital exemption was the only PASRR available for Resident #66. Record review on 12/20/23 showed a PASRR available for Resident #66. The PASRR was dated on 12/19/23 and showed submitter information was Social Services Director #108. Interview on 12/21/23 at 11:06 A.M. with Social Services Director #108 verified that Resident #66 PASRR was not completed within 30 days of his hospital exemption. Review of the facility policy titled, Resident Assessment - Coordination with PASRR Program, dated 2023, revealed exemptions to the pre-admission screening program, dependent on State requirements, include those individuals who are readmitted directly from a hospital, and are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. If a resident was not screened due to an exemption above and the resident remains in the facility longer than 30 days the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate State-designated authority for Level II PASRR evaluation and determination.

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure resident personal property was protected from loss and reports of missing were followed up on. This affected one (#61) of one resident reviewed for missing items. The facility census was 72. Findings include: Review of Resident #61's medical record revealed an admitted [DATE]. Medical diagnoses included cerebral infarction (stroke), muscle weakness, and difficulty in walking. Review of Resident #61's admission Minimum Data Set (MDS) assessment, dated 09/15/23, revealed the resident was assessed with intact cognition. Resident #61 was noted to have frequent pain in the five days prior to the MDS assessment. Additionally, Resident #61 was coded to have had difficulty sleeping and had limited her day-to-day activities due to pain. Review of Resident #61's care plan, dated 09/20/23, revealed Resident #61 had acute and chronic pain related to cardiovascular accident, age, and recent hospitalization . A back brace was not listed on the care plan as an intervention to assist with pain management. Review of Resident #61's interdisciplinary progress notes revealed a note dated 10/11/23 at 10:37 A.M. which indicated Resident #61 experienced severe back pain when up working with therapy. The progress note indicated Resident #61's pain was rated a seven or above on a one to ten scale, and Resident #61 was breathing heavy and sweating, and Resident #61's doctor was notified of the pain. Review of a subsequent progress note dated 10/11/23 at 2:57 P.M. revealed the doctor responded with new orders changing pain and muscle spasm medications, ordered a back brace as needed, and referred Resident #61 to pain management. Review of Resident #61's physician's orders, dated 10/11/23, revealed an order to apply a back brace as needed (PRN) for muscle spasms and support. An interview on 12/18/23 at 11:02 A.M. with Resident #61 revealed her back brace went missing approximately one month ago, she believed on a Friday. Resident #61 stated she mentioned to everyone who took care of her and therapy, and she heard no communication from anyone regarding a replacement of the missing brace. Resident #61 had the box for the back brace still in her room. Observation of the box at that time revealed a BraceUP brand back brace, model number B671011 in black, size three x-large. The box was empty. An interview on 12/18/23 at 11:58 A.M. with State tested Nurse Aide (STNA) #166 revealed she recalled Resident #61 previously having a back brace. She heard it got lost, but had no knowledge of what happened to it. STNA #166 stated she did not report it or fill out a missing item slip as she figured someone else had. An interview on 12/19/23 at 2:17 P.M. with Social Service Director (SSD) #108 revealed she kept a missing item log for the facility and staff who received a report of a missing item are to initiate a form on bright orange paper, which began the search for the missing item. SSD #108 stated resident rooms, laundry areas, and a facility search would be initiated. SSD #108 confirmed she had received no missing item forms for Resident #61 since the resident was admitted to the facility. An interview on 12/19/23 at 2:20 P.M. with SSD #108 and Laundry Staff (LS) #179 in the laundry room revealed she had knowledge of Resident #61's back brace going missing a few weeks ago. LS #179 stated a therapist entered the laundry room searching for the back brace and it was unable to be located. LS #179 stated neither she nor the therapist initiated a missing item form. LS #179 stated instead she wrote Resident #61's name, room number, and back brace on an index card and hung it on the bulletin board in the laundry room near where laundry was folded. LS #179 stated she believed the brace was still missing. An interview on 12/19/23 at 2:25 P.M. with SSD #108 and Physician Therapy Assistant (PTA) #210 in the therapy gym revealed she had knowledge of Resident #61's brace going missing weeks ago. PTA #210 stated the brace was provided for Resident #61's comfort and was purchased by the facility online with no prescription needed. PTA #210 stated she did not believe anyone in therapy initiated a missing item report and did not believe the item was found. An interview on 12/19/23 at 2:30 P.M. with SSD #108 and Resident #61 revealed Resident #61 reported the missing back brace for approximately one month. SSD #108 stated she would initiate a missing item report, and would follow up with Resident #61. SSD #108 verified the missing item report should have been initiated by the first staff member whom Resident #61 reported the missing back brace to. Review of the policy for lost or broken items, dated 06/19/23, revealed it is the responsibility of any staff member to complete the lost or broken items form when a resident advises the staff member that something is lost or broken. The procedure involves filling out a Lost or Broken Item form, witness form, involving the Social Service Director or Administrator in the search and process, searching common areas, and following up with social services if the items are recovered or unable to be located. The facility will work with residents who have a lost or broken item, but the facility's not responsible for the replacement of lost or broken items.

Based on record review, staff interview and review of facility policy, the facility failed to ensure adequate supervision was provided for one resident during personal care. This resulted in actual harm when Resident #11 fell off the toilet and sustained a nasal fracture. This affected one (#11) of three residents who were reviewed for falls. The facility census was 63. Findings include: Review of Resident #11's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident to have severe cognitive impairment. The resident's functional status indicated she required a two person physical assist with transfer and was identified as using a trunk restraint when in the chair. Review of Resident #11's physician order [REDACTED]. Review of Resident #11's restraint evaluation dated 12/28/15, revealed the resident had been assessed for the use of the comfort commode. Review of Resident #11's care plan revealed the resident may use the comfort commode as needed while on the toilet. Review of Resident #11's nurse's note dated 01/15/16, revealed the resident was in the bathroom with a state tested nursing assistant (STNA). The STNA had placed Resident #11 on the toilet without the comfort commode system in place. The STNA left Resident #11 on the toilet and went to turn off a pressure alarm. The resident fell on the floor and was bleeding from her nose. Resident #11 was assessed and sent to the hospital. Review of Resident #11's fall investigation dated 01/15/16, revealed the resident could use the comfort commode as needed while on the toilet and it was not being utilized at the time the resident fell and hit her face. Review of Resident #11's emergency room visit notes dated 01/15/16, revealed the resident sustained [REDACTED]. Interview on 02/08/16 at 1:50 P.M. with Registered Nurse (RN) #2, verified on 01/15/16, Resident #11 had been in the bathroom without the comfort commode in place when she fell . RN #2 reported Resident #11 sustained a non-displaced fracture of her nose. Review of the undated facility policy titled, Fall Prevention Policy, revealed the facility will identify residents at risk for falls and implement a fall prevention program to reduce the risk of falls and injury.

Based on medical record review, observation, staff interview, resident interview, and review of facility policies for physician notification and refusals, the facility failed to implement the following measures to aide in the healing of a non pressure wound: failed to notify the physician of a change in the wound status to assess for a new treatment, failed to notify the physician the resident was refusing ordered protein supplements to aid in wound healing, failed to provide the protein supplements as ordered, and failed to implement an ordered pressure reducing device to promote wound healing. This resulted in actual harm to Resident #79 when a non pressure wound developed necrotic tissue, increased in size by developing significant depth, and developed multiple areas of deep tunneling. The facility identified one resident with a non pressure wound. The facility census was 74. Findings include: Review of Resident #79's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission "Skin Condition Report," dated 06/09/14, revealed there was an area on the resident's lower back, above the coccyx, measuring 20 centimeters (cm) by 8 cm. Review of the "Wound Documentation" sheet dated 06/09/14, revealed the resident was admitted with a wound to the lumbar area of her back, measuring 20 cm by 8 cm. The wound was described as red with serous drainage. Review of the physician orders [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 06/15/14, indicated the resident was alert and oriented. Resident #79 required limited assistance of one staff member for bed mobility and transfers. Review of the plan of care initiated on 06/20/14, indicated the resident had an alteration in skin integrity due to an abrasion to the spine, secondary to a fall at home. The goal was to promote healing to the abrasion area. Interventions included the use a pressure relieving mattress. The plan of care was updated on 07/07/14 with an intervention to consult a wound specialist for treatment to lumbar area. On 07/15/14 the plan of care was updated with the intervention of placing a low air loss mattress to the resident's bed to off load the pressure on the residents back. Review of the wound documentation sheet dated 06/18/14, indicated the area measured 18 cm by 7 cm. The area was covered with slough (necrotic tissue separated from living tissue), a layer of dead tissue, and a small amount of drainage. The treatment remained the same. Review of the wound documentation sheet dated 06/25/14, indicated new growth was forming in the wound, with a small amount of serous drainage present. The treatment to the wound remained unchanged. Review of the wound documentation sheet dated 07/02/14, indicated the wound on the resident's back measured 16 cm by 3.6 cm and was 0.1 cm deep, with 50% of the wound bed covered with dark colored and gray slough. The wound had drainage with a foul odor. The treatment remained unchanged. Review of the medical record found the physician was not notified when the wound on the resident's back had worsened with dark slough and malodorous drainage. Review of nurses' note dated 07/07/14 at 10:20 A.M., documented the attending physician was updated on the resident's wound. The facility received a physician's telephone order from the resident's attending physician to obtain a wound consultation at the wound clinic. Review of the wound documentation sheet dated 07/16/14, documented the resident had been assessed by the wound care specialist on 07/15/14 for a non healing wound to her back. The wound resulted from a fall at home when the resident fell in the bathtub, scraping her back on the faucet. The wound specialist ordered a a low air loss mattress to be placed on the residents bed, to help off load the pressure on the residents back. A protein supplement twice a day to help promote healing was also ordered. Review of wound specialist physician progress notes [REDACTED]. The progress notes document off loading was a critical part of this resident's wound management and the facility will continue to use a low air loss mattress to help keep pressure off the Resident #79's back and the non healing wound. The treatment was to continue with the use of a [DEVICE] to the wound Review of the wound specialist physician progress notes [REDACTED]. The progress note indicated off loading pressure was a critical part of the wound management. The continued use of a low air loss mattress to help keep pressure off the resident's back was recommended. The treatment of [REDACTED]. The note documented the patient and appropriate others were educated on the need for compliance with the treatment plan. The physician asked the facility to notify the wound specialist if there was any impediment to compliance so the specialist could assist the facility in meeting the resident's care needs. During an interview on 09/10/14 at 10:30 A.M., Licensed Practical Nurse (LPN) #22 verified she had measured the wound on 07/02/14 and noted it to be increasing in size with a foul odor. She stated she notified the nursing staff working on the resident's unit. LPN #22 verified she did not notify the physician and stated she was unsure as to the reason for the delay in physician notification. Observation of Resident #79 on 09/10/14 at 9:00 A.M., revealed Resident #79 to be lying in bed on back with the head of bed elevated. The low loss air mattress on bed was in the off position. Upon touching the mattress it was flat and not inflated. At this time Resident #79 stated, "I do not think this mattress works." Additional observations on 09/10/14 at 9:45 A.M. and 1:35 P.M. noted the mattress remained deflated. Observation of the wound on 09/10/14 at 1:35 P.M., with Registered Nurse (RN) #23 and LPN #22, occurred during the dressing change to the area. The back wound measured 12 cm by 3 cm and was 3.6 cm. deep. Tunneling of the wound was observed at 3 o'clock, 5-6 o'clock, and 11 o'clock. The tunnel at 3 o'clock measured 5.2 cm in length. The tunnel at 11 o'clock measured 3.7 cm deep and the tunnel at 5-6 o'clock measured 2.8 cm. The wound bed had scattered areas of slough throughout the wound, with an increased in the amount of slough at the 3 o'clock position. There was light redness surrounding the open area. Observation on 09/10/14 at 2:00 P.M. found LPN #22 and RN #23, to complete the dressing change and leave the resident's room. The low air loss mattress remained off. Observation of the resident on 09/10/14 at 3:00 P.M.,with State tested Nursing Assistant (STNA) #24 verified the residents low air loss mattress was off. She stated it must have been off earlier when she was in the room and she did not notice it. When STNA # 24 turned on the low air loss mattress it began to inflate and the resident stated, "I don't think this mattress is working." Review of the "Dietary Progress Notes" dated 08/23/14, documented the resident had a non healing wound to her back and was at high nutritional risk due to weight loss and poor oral intakes. The progress note stated the resident drinks, Juven (a protein supplement) mixed in 7-up and also received a liquid nutritional supplement daily at noon. The notes indicated Resident #79 consumed all of the supplement, most of the time. The dietician's recommended increasing the liquid nutritional supplement to three times a day. Review of a physician telephone order, from the attending physician, dated 08/25/14, approved the dietician's recommendation to increase the liquid nutritional supplement to three times a day due to weight loss and poor oral intakes. Review of the July 2014, Medication Administration Record [REDACTED]. Review of the August 2014 MAR, revealed the resident refused the Juven 14 of the 62 times offered. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the September 2014 MAR, revealed the resident refused 6 of the 18 Juven supplements offered. The liquid nutritional supplement was offered only once a day, at lunch. The resident refused the supplement eight of nine days the supplement was offered. Interview with RN #20 on 09/10/14 at 10:45 A.M., verified the physician was not notified the resident's wound had gotten worse until 07/07/14. She also verified the resident had not been provided the liquid nutritional supplement three times a day since the order was received on 08/25/14. The RN stated liquid nutritional supplement had not been transcribed to the MAR indicated [REDACTED]. Interview with LPN #25 on 09/10/14 at 11:45 A.M., revealed Resident #79 used to take her Juven supplement in orange juice but she had gotten tired of the orange juice. LPN #25 stated she put it in tomato juice on that day. She stated she was unaware the resident takes the protein supplement with 7-Up. During an telephone interview with Dietician #21 on 09/11/14 at 10:30 A.M., she verified nursing had not notified her of the residents frequent refusals of the Juven and liquid nutritional supplement since her visit on 08/23/14. She stated she assessed the resident's weight and nutritional status once a month and was aware the resident had a non healing wound to her back. The dietician indicated she had no communication with the wound specialist concerning the residents nutritional status, her poor intakes, and her refusals of nutritional supplements. Review of the undated facility policy titled "Resident Change in Condition Physician/Family Notification," revealed the facility was to notify the attending physician with any significant change in the resident's condition. Review of the undated facility policy titled "Refusal Policy," revealed the physician was to be notified of the refusal of medications/ treatments on three consecutive days.