Altercare Cambridge Inc.

Based on observation, review of the facility policy, and interview with the staff, the facility failed to ensure the facility was cleaning the floors in the residents' rooms and hallways with a disinfectant. This had the potential to affect all 47 residents in the facility. The facility census was 47.Findings include:Observation of the gallon container of orange neutral cleaner on 12/23/25 at 9:30 A.M. with Environmental Service Coordinator #313 revealed there was no documentation on the bottle indicating it was a disinfectant. On 12/23/25 at 9:33 A.M. an interview with Environmental Service Coordinator #313 confirmed the facility used bleach wipes for the hard surfaces in the room and an orange neutral cleaner on the floors in the resident rooms. Review of the product properties guide on the website revealed the orange neutral cleaner was not a disinfectant. Further review of the ingredients revealed no disinfectant ingredients; the main ingredient was sodium cocoamphoacetate which was a coconut oil surfactant used in shampoos and soaps. Review of the United States Environmental Protection Agency website for approved disinfectants revealed the orange neutral cleaner was not listed as an approved disinfectant. Review of the facility policy titled, Environmental Service, dated 07/01/25 revealed it was the facility policy to maintain the resident's environment in a clean and sanitary condition. The floors would be dust mopped then mopped with a disinfectant solution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the medical record, review of the facility policy, and interview with staff the facility failed to ensure as needed psychotropic medications were not used beyond 14 days without rationale. This affected two residents (#1, #51) reviewed for unnecessary medications. Findings include:1.Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included sepsis, pneumonia, dysphagia, end stage renal disease, chronic respiratory failure with hypoxia, congestive heart failure, hypertension, rheumatoid arthritis, macular degeneration, vitamin D deficiency, exocrine pancreatic insufficiency, depression, hypertensive heart, chronic kidney disease, osteoarthritis, and atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition, had no behaviors, and was not on any antipsychotic medications. Review of the December 2025 physician's orders revealed Resident #1 had an order for lorazepam (benzodiazepine used to treat anxiety) 0.5 milligram twice daily for anxiety as needed dated 11/20/25 with no rationale. Review of the Note to the Attending Physician (pharmacy recommendation) dated 12/10/25 revealed Resident #1 was currently receiving lorazepam 0.5mg twice daily as needed for longer than 14 days. If the medication was needed to be extended please document the rationale for the extended period in the medical record and indicate a specific duration. The note was signed by the nurse practitioner on 12/22/25. On 12/22/25 at 2:43 P.M. an interview with the Director of Nursing )DON) verified Resident #1 was receiving lorazepam for longer than 14 days without a stop date or rationale. Review of the facility policy titled, Psychoactive Medication, dated 05/01/25 revealed it was the policy of the facility to utilize psychoactive medication therapy to assist a resident to reach his/her highest practicable level of well-being. The facility would limit psychoactive medication use to circumstances in which the resident had a medical diagnoses and/or symptoms that warrant the use of therapeutic psychoactive medication. As needed orders for psychotropic drugs were limited to 14 days. If the practitioner believed that it was appropriate for the as needed order to be extended beyond 14 days he or she should document their rationale in the resident's medical record and indicate the duration of the as needed order. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, streptococcal infection, contusion of left thigh, dysphagia, cognitive communication deficit, congestive heart failure, urinary tract infection, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, atherosclerotic heart disease, hypothyroidism, depression, hyperlipidemia, hypertension, panic disorder anxiety disorder, goiter, fracture of right pubis, and low back pain. Review of the December 2025 Physician's orders revealed Resident #51 had an order for lorazepam 0.5 milligrams every four hours as needed for terminal restlessness dated 12/01/25. Resident #51 was not receiving hospice services. On 12/22/25 at 2:43 P.M. an interview with the Director of Nursing verified Resident #51 was on lorazepam for longer than 14 days without a stop date or rationale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, self-reported incident (SRI) review, facility investigation review, facility policy review, and interview, the facility failed to complete a thorough investigation following an allegation of abuse. This affected one (#55) of one resident reviewed for abuse. The facility census was 47.Findings include: Review of the Self-Reported Incident (SRI) #267738 submitted to the Ohio Department of Health (ODH) on 11/19/25 revealed an investigation was initiated by the facility for an allegation of physical abuse. The SRI revealed Resident #55 was discharged to the hospital on [DATE] following a non-SRI related critical lab finding. Resident #55's daughter contacted the facility on 11/19/25 to report the resident had bruising on her right hip and possibly small bruises on her back. There was no alleged perpetrator. Staff were interviewed and it was revealed that over the weekend 11/15-11/16/25 staff had attempted to utilize a mechanical lift known as a sit-to-stand to safely transfer the resident. Staff stated Resident #55 demonstrated a noticeable right-side lean during this time and had to be highly encouraged to keep her feet in place. Staff stated the resident had rubbed her right hip area against device on multiple occasions and leaned in the back support brace with most of her body weight. The night shift nurse and aide noticed a small quarter-sized reddened/pink area located on the right hip while providing care on the night of 11/17/25. On the morning of 11/18/25 preceding the resident's transfer to the hospital, the certified nurse aide (CNA) notified the nurse on duty of the area as well, however, before she could be examined, she was sent to the hospital. At no time did the resident voice concerns of pain or issues with the area. It was reported by staff that the resident demonstrated a right-side lean multiple times while transferring, causing the resident's hip to come into contact with the assistive device. The resident also put her full weight into the supportive sling that was wrapped around her back which is the most likely explanation for the alleged bruising. The facility unsubstantiated the allegation of abuse. Review of the medical record for Resident #55 revealed an admission date of 09/24/25 with diagnoses including infection following a procedure surgical site, cellulitis of left lower limb, muscle weakness, dysphagia, cognitive communication deficit, repeated falls, fracture of left femur, acute respiratory failure with hypoxia, anemia, and anxiety. Review of the Minimum Data Set (MDS) 3.0 revealed the resident was severely cognitively impaired and required physical assistance from staff with activities of daily living (ADLs). Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #334, Certified Nursing Assistant (CNA) #303 and CNA #358's witness statements did not indicate dates or times of the referenced incident in their statements; CNA #358's witness statement (conducted via phone by the Director of Nursing) did not contain her last name or title; there was no witness statement obtained from CNA #367 who was identified by the DON as one of the two staff present during Resident #55's sit-to-stand incident; and no physical assessments for abuse were conducted of non-interviewable residents. Interview on 12/29/25 at 9:51 A.M. with the Director of Nursing (DON) confirmed the investigation of SRI #267738 did not contain witness statements for LPN #334 and CNA (#303 and #358) with a date of the incident referenced in the statements; and CNA #358's witness statement (conducted via phone by the Director of Nursing) did not contain her last name or title. The DON further confirmed there was no witness statement obtained from CNA #363 who was present during the identified incident which resulted in Resident #55's injury; and there were no observations or physical assessments for abuse of non-interviewable residents. Interview on 12/29/25 at 10:55 A.M with the Administrator confirmed the investigation for SRI #267738 did not contain witness statements with complete names and titles of all staff interviewed and dates of the information referenced in the witness statements. The Administrator further confirmed there was no evidence or documentation of non-interviewable residents having been physically assessed for abuse. Reviewed facility policy, Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation, undated, revealed the facility will not tolerate abuse, neglect, misappropriation of resident property or exploitation of its residents. Once the Administrator and ODH are notified, an investigation of the allegation or suspicion will be conducted. Investigation protocol: interview the resident, the accused, and all witnesses. Witnesses generally include anyone who witnessed or heard the incident; came in close contact with the resident the day of the incident; and employees who worked closely with the accused employee and/or alleged victim the day of the incident. Obtain written statements from the resident, if possible, the accused, and each witness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the medical record, review of the notification of bed hold forms, review of the facility policy, and interview with the staff, the facility failed to ensure a resident was notified in writing the amount of the bed hold routine daily charge. This affected two residents (#1, #51) of three residents reviewed for bed hold notices. Findings include:1.Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included sepsis, pneumonia, dysphagia, end stage renal disease, chronic respiratory failure with hypoxia, congestive heart failure, hypertension, rheumatoid arthritis, macular degeneration, Vitamin D deficiency, exocrine pancreatic insufficiency, depression, hypertensive heart, chronic kidney disease, osteoarthritis, and atrial fibrillation. Review of the progress note dated 10/26/25 at 12:02 P.M. revealed Resident #1 was sent to the emergency room for left lower lobe consolidation collapse. Review of the Notification of Bed Hold Days form dated 10/27/25 revealed the notice did not specify the amount it would cost the resident per day. On 12/24/25 at 10:36 AM an interview with the Administrator revealed he had been doing the bed hold notices and did not indicate the daily per diem charge on the bed hold notices Review of the facility policy titled, Bed Hold Days, dated 10/21 revealed the facility would provide to the resident and the resident representative at the time of the transfer of a resident for hospitalization or therapeutic leave, a written notice which specified the duration of the bed hold policy. 2.Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, streptococcal infection, contusion of left thigh, dysphagia, cognitive communication deficit, congestive heart failure, urinary tract infection, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, atherosclerotic heart disease, hypothyroidism, depression, hyperlipidemia, hypertension, panic disorder anxiety disorder, goiter, fracture of right pubis, and low back pain. Review of the Progress Note dated 11/07/25 at 8:48 P.M. revealed the physician was notified of Resident #51's laboratory results and gave the order to send the resident to the emergency room for evaluation. Review of the Notification of Bed Hold Days dated 11/07/25 revealed the notice did not specify the amount it would cost the resident per day. Review of the Progress note dated 11/10/25 at 12:39 P.M. revealed Resident #51 was lethargic and confused. The Nurse Practitioner was notified and gave an order for the resident to go to the emergency room for evaluation. Review of the Notification of Bed Hold Days form dated 11/10/25 revealed the notice did not specify the amount it would cost the resident per day.Review of the Progress note dated 11/26/25 at 1:39 P.M. revealed the power of attorney for Resident #51 was in the facility and wanted the resident sent to the emergency room due to her change in condition. Review of the Notification of Bed Hold Days dated 11/26/25 revealed the notice did not specify the amount it would cost the resident per day. On 12/24/25 at 10:36 AM an interview with the Administrator revealed he had been doing the bed hold notices and did not indicate the daily per diem charge on the bed hold notices. Review of the facility policy titled, Bed Hold Days, dated 10/21 revealed the facility would provide to the resident and the resident representative at the time of the transfer of a resident for hospitalization or therapeutic leave, a written notice which specified the duration of the bed hold policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide a person-centered, comprehensive care plan, developed and implemented to meet the preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This affected two residents (#37, #48) of five residents reviewed for care plans. The facility census was 47.Findings include:1. Review of the medical record for Resident #37 revealed she was admitted to the facility on [DATE]. Diagnoses included osteomyelitis; muscle weakness; need for assistance with personal care; methicillin resistant staphylococcus aureus; bacteremia; noncompliance with other medical treatment and regimen; Type 2 diabetes mellitus with diabetic polyneuropathy; depression; chronic obstructive pulmonary disease; anxiety disorder; hyperlipidemia; hypokalemia; anemia; acute kidney failure; hyperglycemia; and gastroesophageal reflux disease without esophagitis. Review of a Minimum Data Set (MDS) version 3.0, dated 11/18/25, for Resident #37 revealed a Brief Interview for Mental Status (BIMS) assessment score of 12 on a 0-15 scale. A score of 12 would indicate moderate problems with thinking and memory. The resident was to be non-weight bearing on the right foot, and required assistance with activities of daily living. Review of a care plan for Resident #37, dated 12/18/25, indicated the resident had an infection related to osteomyelitis of the right ankle. Interventions included providing medications as ordered. The care plan revealed the resident had a wound vacuum (or wound vac, a device which used negative pressure to accelerate wound healing and improve outcomes), which she frequently changed the rate on as a concern for healing of the chronic wound. There was a problem listed on care plan for behavioral symptoms. This problem included non-adherence to care/services which included noncompliance with changing settings on a wound vac, pulling tubes out of the wound vac, blaming the cat for changing the wound vac settings, noncompliance with keeping clothes on, constantly picking at wound vac dressing, yelling and cussing on phone and crawling around on the floor. Interventions for this included obtaining a psychological consult as needed and providing alternatives to refusals of care. Further review of the care plan for Resident #37 failed to reveal a problem statement or interventions for care and maintenance of a peripherally inserted central catheter (PICC). It also failed to reveal a problem for behavioral concerns regarding illegal drug use or mental health concerns. On 12/22/25 at 12:28 P.M., an observation of Resident #37 revealed a PICC line inserted into her right arm. The resident did not have a wound vac in place. This was confirmed by Registered Nurse (RN) #314 on 12/23/25 at 3:30 P.M. On 12/23/25 at 3:30 P.M., an interview with Registered Nurse (RN) #314 revealed the resident was no longer receiving intravenous antibiotics, however she still had a PICC line, which had been used for lab work and kept in place until the resident went to the Infectious Disease practitioner to see if she would require further intravenous antibiotics. She confirmed there had been no orders to discontinue use or care of PICC line. She further confirmed the resident no longer had orders for use of a wound vac. She reported the resident had been caught a few times with drug paraphernalia, and other smoking implements in her room, and was very disruptive to the entire hall. Review of a progress note, dated 12/13/25 at 7:30 A.M., was entered into Resident #37's chart on 12/15/25 at 1:58 P.M. The note indicated the staff found three pipes with an unknown substance in them wrapped in tissue in the resident's recliner. The resident was noted to appear under the influence of drugs or over medicated. The police were called and took the pipes and a report was filed. This was confirmed by Registered Nurse (RN) #336 on 12/24/25 at 10:48 A.M. An interview with RN #336 on 12/24/25 at 10:48 A.M., revealed Resident #37 had brought what they believed to be drugs into the facility or would sit with significant other across the street from the facility for long periods of time, smoking and possibly using other drugs. The facility had drug tested her and these tests came back positive. Because of this, her pain medications had been adjusted to non-narcotic pain medications. An interview with Registered Nurse (RN) #400 on 12/29/25 at 1:00 P.M. revealed Resident #37 had a care plan which did not address PICC line maintenance, drug use, or other behavioral issues which could be detrimental to her health and well-being. She also confirmed the care plan continued to list a wound vac as a problem, however the wound vac had been discontinued. 2. Review of medical record for Resident #48 revealed she was admitted on [DATE]. She had diagnoses of metabolic encephalopathy, sepsis, muscle weakness, acute on chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, hypothyroidism, unspecified bilateral hearing loss, anemia, and depression. Review of a Minimum Data Set (MDS) version 3.0 for Resident #48 dated 11/05/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 on a 0-15 scale. A score of ten indicated moderate problems with thinking and memory. Review of a care plan dated 12/22/25 revealed Resident #48 had an alteration in hearing but did not wear any hearing aides. There was no evidence in the review of the care plan to address Hospice or palliative care for the resident. Review of the medical record for Resident #48 failed to reveal an order for Palliative Care to begin. The first progress note from palliative care was noted on 01/02/25 and continued through 12/05/25. An interview with Registered Nurse (RN) #400 on 12/29/25 at 1:00 P.M. revealed Resident #48 was active with a Palliative Care agency. She confirmed the resident's record did not have orders or care plan for Palliative care. Review of a facility policy, dated 05/01/25, titled Care Planning-Comprehensive, revealed the facility's interdisciplinary team was responsible for care planning. The team would develop an individualized, comprehensive plan for each resident. Per the policy, care plans were to be updated as a resident condition changed. These plans were reviewed quarterly or when a significant change in condition in which a Minimal Data Set (MDS) assessment was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, Self-Reported Incident (SRI) review, facility policy review, and interviews, the facility failed to timely identify and address a resident's change in condition following a mechanical lift transfer. This affected one resident (#55) of three residents reviewed for hospitalizations. The facility census was 47. Actual harm occurred on 11/16/25 when Resident #55, who was severely cognitively impaired and required staff assistance for activities of daily living, slammed her body down into a sit-to-stand (mechanical lift) device on her right side and back due to an episode of increased weakness. The facility staff failed to notify the resident's medical provider of the change in condition including the episode of weakness and slamming of the right side of her body and back down into the sit-to-stand device. The resident was assessed at the time with no injuries noted. Following the initial assessment, there was no documented evidence of ongoing monitoring of the resident's right side and back for bruising or injury. The resident was admitted to the hospital on [DATE] (two days later) with diagnoses including traumatic hematoma of the right gluteal region, acute kidney injury likely due to hypovolemia as a result of extravasation (the accidental leakage of fluid from a blood vessel into surrounding tissue) of blood into the tissue, acute blood loss anemia, and severe anemia as a result of the sit-to-stand incident on 11/16/25. Findings include: Closed record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including infection following a procedure surgical site, cellulitis of left lower limb, dementia, anemia, muscle weakness, dysphagia, cognitive communication deficit, repeated falls, fracture of left femur, and acute respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) 3.0 revealed Resident #55 was severely cognitively impaired and required physical assistance from staff with activities of daily living (ADLs) and substantial/maximal assistance with sit-to-stand and chair/bed-to-chair transfer. Review of the care plan dated 10/21/25, revealed Resident #55 had anemia and was at risk for fatigue, weakness, and confusion. Interventions included observing the resident for the following signs and symptoms associated with anemia: pale skin, fatigue, shortness of breath, headaches, insomnia, dizziness, leg cramping, increased heartbeat and altered blood values such as low hemoglobin. Further review of the care plan revealed the resident was at risk for falls/injury related to confusion, history of falls, and incontinence of bowel and urine. Interventions included with device use, to observe for potential mental and physical side effects such as lethargy, mood changes, mobility changes, skin integrity changes, and toileting changes; and to report side effects to the physician or nurse practitioner (NP). Review of a facility Self-Reported Incident (SRI) tracking number 267738 submitted to the Ohio Department of Health (ODH) on 11/19/25 revealed an investigation was initiated by the facility following an allegation of possible physical abuse. The SRI revealed Resident #55 was discharged to the hospital on [DATE] following a non-SRI related critical lab finding. Resident #55's daughter contacted the facility on 11/19/25 to report the resident had bruising on her right hip and possibly small bruises on her back. There was no alleged perpetrator. Staff were interviewed and it was revealed that over the weekend, 11/15-11/16/25, staff had attempted to utilize a mechanical lift known as a sit-to-stand to safely transfer the resident. Staff stated Resident #55 demonstrated a noticeable right-side lean during this time and had to be highly encouraged to keep her feet in place. Staff stated the resident had rubbed her right hip area against the device on multiple occasions and leaned in the back support brace with most of her body weight. The night shift nurse and aide noticed a small quarter-sized reddened/pink area located on the right hip while providing care on the night of 11/17/25. On the morning of 11/18/25 preceding the resident's transfer to the hospital, the certified nursing assistant (CNA) notified the nurse on duty of the area as well, however, before she could be examined, the resident was sent to the hospital. The SRI included at no time did the resident voice concerns of pain or issues with the area. It was reported by staff that the resident demonstrated a right-side lean multiple times while transferring, causing the resident's hip to come into contact with the assistive device. The resident also put her full weight into the supportive sling that was wrapped around her back, which is the most likely explanation for the alleged bruising. The facility unsubstantiated the allegation of abuse. Review of a nursing progress note, 11/16/25 at 12:31 P.M., (authored by Licensed Practical Nurse (LPN) #318) revealed she was alerted by the CNA that Resident #55 appeared weak while utilizing the sit-to-stand device. Respirations were even and unlabored with respiratory rate of 18, pulse was 88, blood pressure was 124/75, oxygen saturation was 87% on room air. The resident was alert and oriented to self and surroundings and did mention to her spouse while visiting that she fell and was running around the facility all night, which she did not. She was easily reoriented and able to answer questions and express needs. She stated she just feels tired today. Review of a Treatment Administration Record (TAR), dated November 2025, revealed routine daily vital signs were ordered twice daily, on each shift. On 11/16/25 between 7:00 A.M. and 7:00 P.M., Resident #55's oxygen saturation level was 87%. Further review revealed the preceding daily oxygen saturation levels were between 94%-99%. There was no evidence documented in the medical record of physician notification of the change/abnormally low oxygen saturation level. Review of a nursing progress note dated 11/18/25 at 11:23 P.M., (authored by the Director of Nursing (DON) and recorded as a late entry on 11/24/25 at 10:39 A.M.) revealed per licensed practical nurse (LPN) interview, Resident #55 slammed her body down into sit-to-stand on her right side and her back during an episode of weakness. There were no noted injuries. The resident was safely transferred into bed and assessed thoroughly with no major obvious and/or findings. Upon documentation review it was noted that night shift LPN observed new bruising to the right hip area on 11/17/25. The area was identified as a clustered, small area of newer looking discoloration to the right side of hip area through the night by both CNA and LPN per completed pink man form. The area is consistent per interview with staff of resident bumping off sit-to-stand on Sunday evening. Further review of the medical record revealed no documentation of Resident #55 slamming into the sit-to-stand on 11/16/25 until 11/18/25 (recorded as late entry on 11/24/25 at 10:39 A.M.) when a nursing progress note was entered by the DON. Review did not reveal a nursing progress note regarding the newly identified bruising to the right hip on 11/17/25, described as a clustered small area of newer looking discoloration to the right side of hip area, as referenced in the 11/18/25 nursing progress note authored by the DON. Review of the Illustration of Documentation and Measurements of Skin Areas (Pink Man Form), dated 11/17/25, revealed a small circle drawn on the posterior right hip area. There was no documentation of measurements. Review of Resident #55's laboratory results collected on 11/17/25 revealed an abnormally low hemoglobin level of 6.9 grams per deciliter (g/dL) (normal range 11.7-15.8 g/dL). The Nurse Practitioner (NP) was notified on 11/18/25 and gave the order for the resident to be transferred to the emergency department (ED). Review of Resident #55's preceding hemoglobin levels were 9.2 g/dL on 10/31/25; 9.0 g/dL on 10/13/25; and 8.8 g/dL on 10/10/25. Review of Resident #55's hospital records revealed she arrived at the emergency department on 11/18/25 at 9:14 A.M. with diagnoses of acute blood loss, severe anemia, traumatic hematoma of hip, and acute kidney injury. The resident was found to have a hemoglobin of six (6) and was transfused with one unit of packed red blood cells. Her hemoglobin the next morning was 7.2 and therefore she was scheduled for two more units of packed red blood cells. The record noted a repeat computed tomography (CT) scan of the pelvis would be completed to assess for any further worsening of the hematoma, which may warrant a transfer for angiogram and embolization if indicated. The plan was to transfuse to maintain hemoglobin above 8 and monitor hemoglobin and hematocrit every six hours. Surgery would be involved if there is no improvement after the transfusions, and/or the resident may be transferred out to have angiography for subsequent embolization if there was a persistent bleed. Acute kidney injury was noted to be likely due to hypovolemia as a result of the extravasation of blood into the tissue. The hospital record noted would avoid all nephrotoxins and maintain patient on intravenous (IV) fluid hydration to get off the blood transfusion and would be repeating labs in the morning to assess for correction of the renal function. The patient has Alzheimer's dementia and is disoriented with her surroundings. The hospital records revealed fall precautions would be maintained. Interview on 12/29/25 at 2:01 P.M. with Resident #55's daughter (Family Member #401) confirmed her mother had sustained traumatic bruising (in November 2025) to her entire right buttock area requiring the transfusion of three units of blood. The resident subsequently had fluid overload and was transferred to a Columbus area hospital to receive a higher level of care and received diuretics and treatment for congestive heart failure likely caused from the blood transfusions. The resident did not require surgical intervention. Interview on 12/23/25 at 4:33 P.M. with the DON revealed she first became aware of an issue after Resident #55's daughter called her on 11/19/25. The resident had been transferred to the hospital on [DATE] due to a very low hemoglobin level. Resident #55's daughter reported her mom had a large, bruised area to the right buttock and back. After interviews with staff, the DON concluded during an episode of weakness on 11/16/25 while being transferred with a sit-to-stand, Resident #55 sustained an injury/bruising. The DON stated following this incident, a Sara Steady Sit-to-Stand was utilized to transfer the resident due to increased weakness. The DON confirmed following the incident on 11/16/25 which was identified as the root cause of the resident's injury, there was no evidence of ongoing monitoring of the resident's right side or back, nor physician notification of the episode of weakness/incident. The DON revealed she believed a small bruise was initially identified on night shift, 11/17/25, but there was no evidence of physician notification. The DON further confirmed the facility did not investigate the resident's allegation made on 11/16/25 of a fall the night before as documented in the nursing progress note. Interview on 12/23/25 at 12:31 P.M. with Nurse Practitioner (NP) #400 revealed she did not recall being notified at the time of the incident on 11/16/25 when Resident #55 had an episode of weakness and slammed into the sit-to-stand; however, she was notified of the incident later in the week when the resident had an episode of weakness/pallor and slurred speech. NP #400 stated at this time she ordered lab work including a hemoglobin level to be obtained. Interview with Licensed Practical Nurse (LPN) #318 on 12/23/25 at 5:08 P.M. revealed she was notified by CNA #363 that Resident #55 was weak during a transfer with a sit-to-stand and fell against the device bumping her right side. The LPN revealed the resident's vital signs were stable other than her oxygen saturation which was 87% on room air. LPN #318 stated Resident #55 did not complain of pain or injury. LPN #318 confirmed she did not notify the physician of the incident or of the low oxygen saturation level of 87%. LPN #318 stated she believed she rechecked the oxygen saturation level later and it had come up, however, she did not document this reading. Review of the facility's policy titled, Change in the Residents Condition or Status, dated 05/01/25, revealed it was the facility's policy to ensure the resident's attending physician and the resident's authorized representative or interested family member were notified of changes in the resident's physical, mental, or psychosocial status. The nurses would immediately notify the resident, consult with the resident's attending physician, on-call physician, nurse practitioner, physician assistant, or clinical nurse specialist and notify resident's authorized representative when there was an accident or incident involving the resident, which resulted in an injury and had the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status. Procedure for documentation of changes in the medical record: the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status (e.g. assessment, appropriate notifications, interventions, and responses).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital record review, policy review and interview, the facility failed to implement a comprehensive and individualized pressure ulcer program to timely identify, treat and/or prevent a decline of pressure ulcers. This affected two residents (Resident #42 and #07) of three residents reviewed for pressure ulcers. Actual Harm occurred on 12/06/25 when Resident #42, who had been identified at risk for pressure ulcer development and required maximum staff assistance for bed mobility, returned from the hospital with a red and blanchable area to his (unidentified) buttock without evidence of a comprehensive skin assessment or implementation of pressure relieving interventions or wound treatment to prevent decline in the pressure ulcer. On 12/11/25, a skin assessment identified a new Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) pressure ulcer to the coccyx without implementation of pressure relieving intervention until 12/15/25 (a low air loss mattress). Findings include: 1. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including muscle weakness, polymyalgia rheumatica, atrial fibrillation, heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, chronic ulcer of lower leg, venous insufficiency, hypothyroidism, type 2 Diabetes Mellitus, malnutrition and cognitive communication deficit. Review of Resident #42's Minimum Data Set (MDS) assessment completed on 10/21/25 revealed a Brief Interview for Mental Status score of 14 out of a possible 15 points, indicating the resident had intact cognition. The resident used a walker for mobility. Resident #42 was dependent on staff for toileting, lower body dressing, and transfers. He required substantial/ maximal (staff) assistance for bed mobility, including rolling in bed, showering, and dressing. The resident was frequently incontinent with bowel and bladder. Under Section M for skin conditions it was noted the resident had unhealed pressure ulcers/injuries. The resident required pressure reducing devices for bed, applications of ointments/ medications other than to the feet and dressings applied to the feet. The resident had one unstageable deep tissue injury noted on the assessment. Review of the resident's care plan dated 10/21/25 revealed Resident #42 has a pressure injury to his left heel with shearing and friction concerns, and poor sensory perception. The goal developed was for the resident's wound to show progressive signs of healing by target date of 01/21/26. Interventions included continuing with preventative care plan (there was no preventative care plan located as part of the medical record) measures to prevent further skin breakdown, nutritional status assessments as needed, observe wound for any redness, warmth, drainage, odor, and report to physician as needed. Further review of the medical record revealed the resident was admitted to the hospital on [DATE] with a diagnosis of weakness. The resident returned to the facility on [DATE]. Review of the hospital records revealed no mention of wounds to the resident's coccyx or buttocks. Chronic wounds to the right extremity and left heel were noted.Further review of Resident #42's medical record revealed a progress note authored by Licensed Practical Nurse (LPN) #344 on 12/06/25 at 4:04 P.M. and edited on 12/07/25 at 11:23 A.M. which documented the resident returned to the facility from the hospital. Assistant Director of Nursing (ADON) was made aware of the resident's arrival at the facility. Skin assessment completed upon arrival and noted resident had an area to his upper right shin and left heel (previously identified before hospitalization) and redness to his (unidentified) buttock but was blanchable with scattered bruising to all his body from recent hospital stay. The progress note revealed to See wound grids for noted areas (however, there were no skin grids completed by LPN #344 for the buttock). There was no mention of additional wounds to the buttocks or coccyx.Further review of the medical record revealed no documentation of physician notification related to the resident's red, blanchable area to his coccyx or buttocks. In addition, there was also no notification in the on-call physician notification notebook (kept at the nurses' station).Further review of the medical record revealed no evidence of any risk for pressure ulcer development care plan or mention of the resident's pressure ulcers/injuries to his buttocks or coccyx.Review of weekly skin checks for Resident #42 revealed a skin check completed on 12/11/25 by LPN #344 stating a new area to the coccyx was identified. Assistant Director of Nursing (ADON) notified. No additional assessment was provided.Review of Resident #42 orders revealed an order dated 12/11/25 to cleanse the sacrum with soap/water, pat dry, apply Triad Paste (a zinc oxide based, sterile, hydrophilic wound dressing used for mild to moderate exudate (drainage) that creates a moist wound environment that facilitates natural debridement and protects the skin, especially in areas difficult to apply a dressing) twice a day (BID) and as needed (PRN) every shift.Review of Resident #42's wound management detail report revealed an assessment created and completed by the ADON on 12/13/25 and made a late entry for 12/06/25 (a seven day delay) revealed a wound to the sacrum measuring 4.2 centimeters (cm) in length, 5 cm in width, 0.1 cm in depth., Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (pockets or narrow passages under the skin)). Review of Wound Care Physician #404s progress note dated 12/11/25 revealed a stage III pressure wound to the sacrum, full thickness, measuring 8.5 cm by (x) 9 cm x 0.2 cm. Open ulceration area of 45.9 cm squared, light serous drainage, no pain, no signs of infection.Review of Resident #42's wound management detail report revealed an assessment created and completed by ADON on 12/13/25 and made a late entry for 12/11/25 (three-day delay) revealed a wound to the sacrum measuring 8.5 cm in length, 9 cm in width, 0.2 cm in depth., Stage III.Review of the Treatment Administration Record (TAR) for December 2025 revealed the Triad Paste treatment was initiated on 12/11/25.Review of Resident #42 orders revealed an order placed on 12/15/25 for a low air loss mattress, check functioning each shift three times a day (TID).Review of the December 2025 TAR revealed the low air loss mattress was implemented on 12/15/25.Review of Resident #42's wound management detail report revealed an assessment created and completed by ADON on 12/18/25 revealed a wound to the sacrum measuring 0.5 cm in length, 1.2 cm in width, 0.2 cm in depth., Stage III. The wound had light, clear drainage with pink, well defined wound edges. Review of Resident #42's record revealed no documentation of the resident refusing interventions including weight shifts, turning and repositioning, or treatments.Observation of wound care on 12/23/25 at 3:02 P.M. with ADON and Registered Nurse #403 revealed Resident #42 had an open area to his right buttock measuring 7.5 cm in length and 2.5 cm in width. The wound had no drainage and the wound bed was pink. The ADON stated that the wound had moved down further (the wound increased in size) since last Thursday (12/18/25). The ADON cleansed the area with soap and warm water, patted dry, and applied Triad Paste. Interview with the resident revealed he was unable to recall how long he had the pressure wound but he was currently getting treatment to the wound. The resident provided no additional information. Interview with Registered Nurse #314 on 12/24/25 at 7:36 A.M. revealed when a resident returns from the hospital, whether it's an admission or re-admission, it is always treated like an admission. First the nurse checks their medications, gets a second nurse to check off the medications, contacts the provider, asks the resident questions and completes a head-to-toe assessment which includes a skin assessment. Everything the nurse does was to be documented such as assessments of new wounds, skin changes even if it's bruising from Intravenous catheters (IV's), everything was documented. Skin assessments when a resident was admitted or returned can be found in the body of the admission note, which was in the progress notes. Any new skin abnormalities were measured, and a wound grid was created. If a resident's skin was red and blanchable, they would initiate interventions immediately to prevent it from deteriorating and opening. Wound rounds were completed once a week; the nurse should assess skin changes and document them. Wounds may be assessed more frequently, depending on the order, severity, changes in the wound, etc With any new skin issues, you are to notify the physician. If there was a new skin issue, for example red and blanchable but not open, med one (on-call physician notification) would be notified. Immediate interventions were initiated such as Triad paste and border foam dressing. Skin interventions to prevent new or worsening areas begin on admission, and/or readmission.Interview with Wound Care Physician #404 on 12/24/25 at 10:03 A.M. revealed. Wound Care Physician #404 sees patients at the facility on Fridays and takes measurements but he was not aware of any open areas to the resident's skin until 12/11/25. Wound Care Physician #404 stated he recommended a low air loss mattress for Resident #42 on 12/11/25 because one was not already in place. Further interview revealed he was unsure of the resident's additional pressure prevention interventions but due to the resident already having one pressure ulcer and a wound to his leg, in addition to the resident's impaired mobility, he would have expected the resident to have had interventions in place.Interview on 12/24/25 at 12:46 P.M. with the ADON revealed she was responsible for overseeing pain management, restorative nursing services, wounds, and bowel and bladder incontinence. If a resident had (skin) redness, depending on where the redness was located, the resident should have preventatives (interventions) like extra protective cream (EPC) or a foam dressing, floating their heels, pressure reduction (devices) or Triad paste. The ADON further stated the treatment would depend on the location of the pressure area and the resident's mobility patterns (requiring staff assistance) with pressure and diabetic wounds being referred to the wound physician (Wound Care Physician #404).Further interview revealed Resident #42 was a re-admission and the admitting nurse completed a skin assessment, and she (the ADON) did a follow up skin assessment to the admission skin assessment. The ADON stated Resident #42 returned to the facility on [DATE] (Saturday) but she was not working that day and did not assess the wound until 12/08/25. The ADON verified the wound assessment for this wound was created by the ADON on 12/13/25 but back dated to reflect it was completed on 12/06/25, however, the ADON did not work on 12/06/25. The ADON did not provide additional information as to why the assessment was incorrectly dated 12/06/25 or why it was not consistent with LPN #344's findings (the hospital record also did not indicate the resident had any pressure ulcers or injuries to his coccyx or buttocks at the time of discharge back to the facility). The ADON shared the resident had two areas on his buttock that were red and open and she documented the areas were a Stage II (please note, the ADON did not identify the resident had two areas on his buttock and identified the area as a Stage III on the initial assessment). Wound Care Physician #404 evaluated the resident on 12/11/25 and determined the wound to the resident's sacrum was a Stage III. The ADON confirmed she only had her paper wound documentation for 12/08/25 that was for her personal tracking and not part of the resident's medical record. The ADON also confirmed there were no treatments ordered until the resident was seen by the wound physician on 12/11/25 despite her knowledge of the wound on 12/08/25 because she knew the physician would give orders when he visited on 12/11/25. The ADON verified she did not enter the order for the low air loss mattress that the wound physician ordered on 12/11/25 because she forgot and said looking back she should have gotten orders to start treatment to the resident's wound before the wound physician visited and per the documentation, the resident's wound declined without evidence of appropriate treatment and timely interventions.Interview on 12/24/25 at 1:03 P.M. with Regional Nurse #400 and #403 verified there were no interventions ordered or implemented until 12/11/25 for Resident #42's altered skin integrity. The Regional Nurses verified two skin grids were dated 12/06/25, one for the red and blanchable area and one for the Stage III pressure ulcer/injury to the sacral/coccyx area.Interview on 12/24/25 at 1:10 P.M. with the Director of Nursing (DON) confirmed Wound Care Physician #404 recommended a low air loss mattress on 12/11/25 for Resident #42; however there was no documentation or evidence the resident received the low air loss mattress until 12/15/25.Four unsuccessful interview attempts were made to contact LPN #344 by phone during the time of the survey from 12/22/25 through 12/24/25. Review of facility policy titled pressure injuries: assessment, prevention, and treatment revised 5/01/25 revealed it was the facilities policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. A pressure injury risk assessment would be completed upon admission, quarterly, annually, and with significant change period skin would be assessed routinely for the presence of developing pressure injuries and documented on the nursing skin tool. Interventions for prevention based on risk factors can include checking the residents for incontinence at least every two hours, cleaning the skin when soiled, using a moisture barrier, encouraging residents to shift weight every 15 minutes while sitting in a chair, use the pressure redistribution mattress, and use pillows or wedges and other devices for positioning. A Stage 3 pressure injury was defined as a full thickness skin loss in which adipose is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough or eschar may be visible. The depth of the tissue damage varies by anatomical location, areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and or bone are not exposed if slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. For provisions orders treat the wound per physician orders, protect the wound, manage drainage, promote A moist wound healing, and manage pain.2. Record review revealed Resident #07 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left side, flaccid hemiplegia affecting left side, muscle weakness, abnormal posture, muscle wasting, diabetes mellitus, insomnia, hyperlipidemia, anxiety, vascular dementia, wheelchair dependent, bipolar disorder, contracture of left lower extremity and left upper extremity, and vascular dementia. Review of resident #07 quarterly Minimum Data Set (MDS) completed 10/28/25 revealed a BIMS score of 05, indicating severe cognitive impairment. The resident used a wheelchair and was dependent of staff for activities of daily living. The resident was also identified at risk for pressure ulcer development and required a pressure relieving device to the bed and chair.Review of Resident #07 skin tool completed on 12/20/25 completed by Registered Nurse #309 revealed the resident had no new areas of concern. Review of the resident's medical record revealed no current wound care orders.On 12/23/25 at 2:12 P.M. incontinence care was observed being performed on Resident #07 with the assistance of Regional Registered Nurse (RN) #403. Observation revealed scattered areas on Resident #07 bilateral buttock with scabbing, open areas, and blanchable tissues. All areas confirmed by Regional RN #403 on 12/23/24 at 2:15 P.M.Interview on 12/24/25 at 1:03 P.M. with Regional Nurse #400 and #403 confirmed Resident #07 had areas of impaired skin integrity that were not timely identified by staff resulting in delayed treatment to the wounds.Review of facility policy titled change in resident condition or status revised on 05/01/25 revealed it was policy to ensure the resident's attending physician, representative were notified of changes in the residence physical, mental, or psychosocial status. Nurses would immediately notify the resident, consult with resident's attending physician, or on call physician, nurse practitioner when there is a significant change in the residence physical, mental, or psychosocial status such as a deterioration health, mental, or echo social status and either life threatening condition or clinical complications. Documentation of changes in the medical record include the nurses recording in the resident's medical record information relative to changes in the resident's medical or mental condition or status such as assessments, appropriate notification, interventions, and response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure medications were properly stored. This affected one resident (#27) of one resident reviewed for medication storage. The facility census was 47.Findings include:Review of the medical record for Resident #27, revealed an admission date of 08/19/21. Diagnoses included: spinal stenosis, lumbar region without neurogenic claudication, Alzheimer's disease, dementia and major depressive disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14. Observation on 12/22/25 at 10:23 A.M. revealed a medicine cup containing four pills on Resident #27's bedside table. Resident #27 stated she does not know how long they have been there.Review of the physician orders revealed Resident #27 did not have an order to self-administer medications or for medications to be left at bedside.Interview on 12/22/25 at 10:25 A.M. with Licensed Practical Nurse (LPN) # 361 revealed she administered Resident #27's medications, confirmed she left the medications on the bedside table and further confirmed Resident #27 does not have an order for self-administration or for medications to be left at bedside.Review of facility policy titled, Medication Storage in the Facility dated May 2020, revealed medications are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self reported incident review, and interview the facility failed to ensure the incident log was complete and accurate for a resident fall and failed to ensure a resident's medical record was complete. This affected one resident (#55) of two residents reviewed for accidents. The facility census was 47.Findings include:Review of the medical record for Resident #55 revealed an admission date of 09/24/25. Diagnoses included infection following a procedure surgical site, cellulitis of left lower limb, muscle weakness, dysphagia, cognitive communication deficit, repeated falls, fracture of left femur, acute respiratory failure with hypoxia, anemia, and anxiety. Review of a Minimum Data Set (MDS) version 3.0, dated 10/13/25, revealed a Basic Interview for Mental Status (BIMS) of seven on a 0-15 scale. A BIMS score of seven would indicate severe problems with thinking and memory. It also indicated the resident needed assistance with all activities of daily living (ADLs).Review of a Care Plan, dated 10/21/25, revealed Resident #55 had anemia and was at risk for fatigue, weakness, and confusion. Interventions included observing the resident for the following signs and symptoms associated with anemia: pale skin, fatigue, shortness of breath, headaches, insomnia, dizziness, leg cramping, increased heartbeat and altered blood values such as low hemoglobin. Further review of the Care Plan revealed the resident was at risk for falls/injury related to confusion, history of falls, and incontinence of bowel and urine. Interventions included with device use, to observe for potential mental and physical side effects such as lethargy, mood changes, mobility changes, skin integrity changes, and toileting changes; and to report side effects to the physician or nurse practitioner (NP).Review of Self-Reported Incident (SRI) #267738 submitted to the Ohio Department of Health (ODH) on 11/19/25 revealed an investigation was initiated by the facility following an allegation of possible physical abuse. The SRI revealed Resident #55 was discharged to the hospital on [DATE] following a non-SRI related critical lab finding. Resident #55's daughter contacted the facility on 11/19/25 to report the resident had bruising on her right hip and possibly small bruises on her back. There was no alleged perpetrator. Staff were interviewed and it was revealed that over the weekend, 11/15-11/16/25, staff had attempted to utilize a mechanical lift known as a sit-to-stand to safely transfer the resident. Staff stated Resident #55 demonstrated a noticeable right-side lean during this time and had to be highly encouraged to keep her feet in place. Staff stated the resident had rubbed her right hip area against device on multiple occasions and leaned in the back support brace with most of her body weight. The night shift nurse and aide noticed a small quarter-sized reddened/pink area located on the right hip while providing care on the night of 11/17/25. On the morning of 11/18/25 preceding the resident's transfer to the hospital, the certified nursing assistant (CNA) notified the nurse on duty of the area as well, however, before she could be examined, the resident was sent to the hospital. At no time did the resident voice concerns of pain or issues with the area. It was reported by staff that the resident demonstrated a right-side lean multiple times while transferring, causing the resident's hip to come into contact with the assistive device. The resident also put her full weight into the supportive sling that was wrapped around her back, which is the most likely explanation for the alleged bruising. The facility unsubstantiated the allegation of abuse.Review of a nursing progress note, dated 11/16/25 at 12:31 P.M., (authored by Licensed Practical Nurse (LPN) #318) revealed she was alerted by CNA that Resident #55 appeared weak while utilizing the sit-to-stand device. Respirations were even and unlabored with respiratory rate of 18, pulse was 88, blood pressure was 124/75, oxygen saturation was 87% on room air. The resident was alert and oriented to self and surroundings and did mention to her spouse while visiting that she fell and was running around the facility all night, which she did not. She was easily reoriented and able to answer questions and express needs. She stated she just feels tired today. Review of a progress note for Resident #55, dated 11/17/25 at 12:55 P.M. revealed a nurse was called to Resident #55's bathroom. Upon entering bathroom, resident was noted to be sitting on the toilet. Face noted to be pale but resident alert. Speech noted to be slurred at this time but appropriate responses. Staff assist resident off the toilet and to her wheelchair. Noted that resident had a large formed BM in the toilet. Noted that once in wheelchair, resident regained color to her face and was alert and oriented and stated that she felt better. Able to carry a conversation with this nurse. Noted that when this nurse left the room resident was eating a donut prior to going to her appointment. Husband at bedside. Call light and fluids within reach. The resident record failed to reveal communication with the resident's primary care provider regarding a change in her condition. This was confirmed by Nurse Practitioner (NP) #401 on 12/23/25 at 5:02 P.M.An Interview on 12/23/25 at 5:02 P.M. with NP #401 confirmed she did not recall being notified of incident on 11/17/25, but was notified later in the week when the resident had an episode of weakness/pallor and slurred speech at which time she ordered a hemoglobin level to be checked. Review of a progress note for Resident #55, dated 11/18/25 at 11:23 A.M., revealed a note from IDT (interdisciplinary team). This note was noted to actually be documented on 11/24/25 at 10:39 A.M. as a late entry. The note indicated on chart review it had been found the night shift LPN (Licensed Practical Nurse) noted new bruising to the right hip area on 11/17/25 , which had been identified as a clustered small area of newer looking discoloration to right side hip area through the night by both STNA (state tested nurse assistant) and LPN per completed pink man form, area is consistent per interview with staff with resident bumping off sit to stand on Sunday evening. Per LPN interview when resident during a weak episode slammed body down into sit to stand on right side and her back, at the time of incident there were no noted injuries per interview with staff resident was educated after incident and safely transferred into bed and assessed thoroughly with no major obvious and/or finding's. Review of the facility incident and accident log failed to reveal an incident regarding Resident #55 on 11/16/25. This was confirmed by the Director of Nursing (DON) on 12/29/25 at 9:51 A.M. On 12/29/25 at 9:51 A.M., an interview with the Director of Nursing (DON) confirmed the nursing progress notes failed to contain documentation of 11/16/25 transfer incident and incidents of ongoing weakness. The DON confirmed the incident and accident log did not reflect the incident on 11/16/25 regarding Resident #55.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received timely pain management. This affected one (Resident #50) of three residents reviewed for pain management. The census was 48. Findings include: Record review revealed Resident #50 admitted to the facility on [DATE] with diagnoses including anemia, hypertension, thyroid atrophy, hypomagnesemia, anxiety, and femur fracture with surgical intervention.Review of Resident #50 admission Minimum Data Set (MDS) section C for cognition revealed a Brief Interview for Mental Status Score of 15, indicating Resident #50 was cognitively intact.Review of MDS section J for health conditions revealed Resident #50 was receiving a scheduled pain medication regimen, and received as needed (PRN) pain medication.Review of Resident #50 care plan completed on 06/11/25 revealed Resident #50 has a left hip surgical wound. Goals include resident will have controlled pain and a level of comfort maintained daily. Interventions include to administer pain medications per physicians orders, remind the resident that reporting pain early may improve effectiveness of pain medication, try non medication relief measures such as repositioning pillows, pad, support, diversion, and observe and report if resident is experiencing breakthrough pain with current medication.Review of Resident #50 orders revealed an order starting 06/19/25 and ending on 06/23/25 for Oxycodone tablet 5 milligrams (mg) orally (PO) every four hours (q.4h) PRN.Review of grievance filed by Resident #50 on 06/23/25 with the Director of Nursing (DON) revealed Resident #50 wanted her pain medications more frequently.Review of event statement form completed on 06/24/25 by physical therapy assistant (PTA) #999 revealed Resident #50 had reported to her on the night of 06/22/25 into 06/23/25 she had waiting six hours for pain medicationReview of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was a six and a half hour time without medication from 1:13 P.M. until 7:47 P.M. and an eight and a half hour time from 7:47 P.M. until 5:21 A.M. on 06/23/25.Review of Resident #50 Medication Administration Record (MAR) for June of 2025 revealed Oxycodone 5mg PO q.4h PRN administered on 06/22/25 at 12:32 A.M., 4:28 A.M., 9:09 A.M., 1:13 P.M., and 7:47 P.M Resident #50 pain medication was given q.4h until 1:13 P.M. when there was a six and a half hour time between doses.Review of Resident #50 progress notes revealed a note dated 06/22/25 at 8:00 P.M. authored by assistant director of nursing (ADON) stating certified nurse ' s aides (CNA ' s) alerted this nurse that resident was upset, upon entering room Resident #50 demanded a pain pill stating it was due several hours ago. Let the resident know she was just then due to be able to get her PRN dose.Review of Resident #50 Narcotic log, MAR, and progress notes revealed they were due for their PRN dose on 06/22/25 at 5:13 P.M., not 8:00 P.M Review of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was a six and a half hour time without medication from 1:13 P.M. until 7:47 P.M Record review revealed no documentation of non-pharmacological pain interventions attempted or implemented to address Resident #50 pain between the hours of 1:13 P.M. 7:47 P.M. on 06/22/25.Review of Resident #50 June 2025 MAR revealed Oxycodone 5mg PO q.4h PRN was given on 06/22/25 at 7:47 P.M. and was not administer again until eight and a half hours later on 06/23/25 at 9 and a half hours later at 5:21 A.M.Review of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was an eight and a half hour time without pain medication from 7:47 P.M. until 5:21 A.M. on 06/23/25. After this time Resident #50 began receiving her pain medication every four hours as previous until discontinuation of the order. Record review revealed no documentation of non pharmacological pain interventions attempted or implemented to address Resident #50 pain between the hours of 7:13 P.M. on 06/22/25 and 5:21 A.M. on 06/23/25. Interview on 08/25/25 at 9:25 A.M. with certified nursing assistant (CNA) #888 revealed staff was telling Resident #50 her pain medication was due every eight hours however Resident #50 pain medication was due every four hours at that time. CNA #888 stated on 06/22/25 on night shift into 06/23/25 Resident #50 was upset because she had asked for pain medication several hours prior and still had not received any.Interview on 08/26/25 at 8:41 A.M. with ADON revealed Resident #50 wanted pain medication on 06/22/25, stated Resident #50 is very consistent with timing of her pain medication and knows when they are due.Interview on 08/26/25 at 12:36 P.M. with Resident #50 revealed on 06/22/25 on night shift she had requested pain medication, she had fell and broke something and had surgery on a couple weeks prior so she had been in a lot of pain. Resident #50 stated she requested the pain medication on night shift on 06/22/25, she waited several hours and no one brought her pain medication. Their pain continued to get worse as she waited and it got pretty bad due to how long they had been waiting. Resident #50 stated it was not until early morning sometime on 06/23/25 that she received her pain medication.Interview on 08/26/25 at 12:40 P.M. with ADON revealed on 06/22/25 at 8:00 P.M. she authored a note which stated Resident #50 pain medication was just then due. ADON confirmed on 06/22/25 Resident #50 pain medication was actually due at 5:13 P.M. approximately three hours prior to the resident being told it was due. ADON stated she did not get to the building until about 7:00 P.M. on 06/22/25. ADON confirmed after Resident #50 received pain medication from her on 06/22/25 at 7:47 P.M. Resident #50 did not receive pain medication again until 06/23/25 at 5:21 A.M., ADON stated she was not on the floor the entire night shift of 06/22/25. ADON stated Resident #50 was very on top of her pain medication, she always knew when it was due, and she took it right when it was due.Interview on 08/26/25 at 12:55 P.M. with PTA #999 revealed PTA #999 was assisting Resident #50 with therapy on 06/24/25 when Resident #50 had stated on the night of 06/22/25 into 06/23/25 she requested pain medication and had been waiting a long time, at least six hours. PTA #999 stated she immediately went to administration and filed a statement reporting what she had been told by resident #50.Review of Facility policy named Pain Medication Administration revised 05/21/25 revealed It is the facilities policy to administer pain medications in accordance with professional standards of practice. Review the residence care plan to assess for any special needs of the resident. The residents ' experience of pain is highly individual and subjective. Pain is whatever the resident says it is. Intense pain can result from even minor procedures or surgery. Not attempt nonpharmacological interventions as per the residence plan of care prior to administering pharmacological interventions if possible. Administer as needed pain medication as ordered.This deficiency represents non-compliance investigated under Complaint Numbers 2568688, 1274323, 1274309, and 1274308.

Based on review of the job descriptions, review of the employee handbook, review of a self-reported incident investigation, review of timed stamped and dated photographs, review of the facility assessment, review of time sheets, interviews, policy review, and review of the Nurse Practice Act, the facility failed to ensure care and services were provided within acceptable standards of quality when Licensed Practical Nurse (LPN) #133 was observed pre-pouring resident medications and also observed sleeping multiple times throughout the shift. This had the potential to affect the residents residing on the Rodeo Unit where LPN #133 was working. The facility census was 48.1. Review of Licensed Practical Nurse (LPN) #133's timecard dated 11/06/25 and 11/07/24 revealed LPN #133 clocked in at 11:54 P.M. on 11/06/25 and clocked out at 6:12 P.M. on 11/07/24. The LPN worked 17.75 hours.Review of photographs dated 11/07/24 at 4:33 A.M., revealed LPN #133 standing in front of medication cart with the card drawer open. There were approximately nine medication cups with several loose pills in the cups and five clear cups set up in a line with no medications in them yet were on top of the medication cart. Interview on 08/25/26 at 9:25 A.M., with Certified Nursing Assistant (CNA) #888 confirmed LPN #133 pre-pouring medication and groups medication administration times (morning and afternoon medication times) together so she only has one medication pass. Residents will question their medication and LPN #133 would tell residents the medication was correct and just take them. Administration staff were aware, and several staff had reported LPN #133, but nothing was addressed and the nurse continued to pre-pour medications. Interview on 08/25/25 at 1:06 P.M., with LPN #133 and the Director of Nursing (DON) revealed LPN #133 confirmed she was the nurse in the photo dated 11/07/24 at 4:33 A.M. pre-pouring medications for administration. The LPN reported she had occasionally pre-poured medication to get a jump start on the day. The DON reported she was not aware the LPN was pre-pouring medications and staff should not be pre-pouring medications (for a later administration). Review of LPN #133's job description dated 09/19/23 revealed the LPN would administer scheduled medications to residents in a timely manner, ensuring proper and correct dosages were given. Properly record administration on the Medication Administration Records (MAR). Follows the facility's policy and procedures for administrating medications.Review of the facility's policy titled Medication Administration-General Guideline dated 05/2020 revealed when medications are administered by mobile cart the cart is taken to the resident location and administered at the time they are prepared. Medication is not pre-poured either in advance of the medication pass or for more than one resident at a time. 2. Review of a photograph of a Facebook post dated 06/23/25 revealed Resident #50 had posted two pictures of LPN #133 asleep on the couch in the common area. The post indicated this was the dayshift nurse (nurses name posted) at (facility's name posted) sleeping on night shift at 3:30 A.M. The nurse picks up all the hours, now we know how she does it. Feel sorry for the residents that need help, like me. I have been waiting for my pain medication for almost six hours. Review of pictures/videos dated 06/23/25 at 1:38 A.M., 1:45 A.M. and 4:03 A.M., revealed LPN #133 on the couch in the common area, asleep. Review of Self-Reported Incident (SRI) Tracking Number 261941, dated 06/23/25, revealed Resident #50 alleges she went too long without pain medication. Review of the investigation revealed a statement authored by Registered Nurse (RN) #152 that indicated on 06/22/25 into 06/23/25 she had walked over to the other unit approximately midnight to get medication and asked the Assistant Director of Nursing (ADON) for the medication room keys. The ADON stated she had given the keys to LPN #133. RN #152 went to ask LPN #133 for the medication keys, and she was observed on the couch in the day area covered up with a blanket, sleeping. RN #152 woke her up and she stated she didn't have the keys and went back to sleep. RN #152 told the ADON that LPN #133 stated she didn't have the keys. The ADON stated LPN #133 had the keys and they just had counted the narcotic drawer. RN #152 stated she returned to her unit and thought she would get the medication she needed later. The lab technician came over at approximately 3:30 A.M. and asked if there were labs on the other unit due to there being no log and the nurse was asleep, and she could not wake her. Both CNAs were present during the conversation. RN #152 had gone back to LPN #133's unit at 5:30 A.M. to get medication out of the medication room and LPN #133 had asked if lab had been there. LPN #133 reported she was unable to print the labs off the computer. RN #152 told LPN #133 she could have called her over and she could have printed them. LPN #133 stated I'm allowed to take a break. RN #152 returned to her unit. Review of a statement authored by Physical Therapist (PT) #999 dated 06/24/25 revealed Resident #50 had reported to PT #999 that LPN #133 had been sleeping for six hours, and she had to wait on her pain medication. Review of a statement authored by the Administrator via phone with CNA #503 on 06/25/25 at 12:14 P.M., revealed CNA #503 was called over to the 200 unit by CNA #888 to help with resident care around 3:00 A.M., on 06/23/25 and she had seen LPN #133 on the couch. CNA #503 returned to her unit. Sometime around 3:30 A.M. the lab tech reported to CNA #503 and #888 she saw someone sleeping on the couch and a resident was taking pictures. Review of CNA #144's statement dated 06/25/25 revealed the CNA had come in early around 1:30 A.M., the RN went over to the other unit to get some medication and reported she couldn't get LPN #133 up and the CNA had asked for help to pull a couple resident up because she couldn't get the LPN awake. Around 3:00 A.M., the lab tech asked if there were any labs because the nurse was asleep and she could not wake her up and there was a resident on the unit taking pictures. The CNA went back over to see what was going on. Review of LPN #133's timecard revealed the LPN worked 18.0 hours on 06/19/25, 12.75 hours on 06/20/25, 17.58 hours on 06/21/25, 11.75 hours on 06/22/25, 10.0 hours on 06/23/25.Interview on 08/25/25 at 1:06 P.M., with LPN #133 and the Director of Nursing (DON) revealed LPN #133 confirmed she was the nurse in the photos dated 06/23/25 at 1:38 A.M., 1:45 A.M. and 4:03 A.M. LPN #133 reported she took her break from 3:30 A.M. to 4:00 A.M. LPN #133 reported staff don't lock out for their 30-minute break. The time clock just asked if you took a break when you clock out and you enter yes or no. Interview on 08/26/25 at 6:43 A.M., with Licensed Practical Nurse (LPN) #148 revealed about four or five months ago she had observed LPN #133 sleeping on the unit. Interview on 08/26/25 at 12:06 P.M., with Assisting Director of Nursing (ADON) #131 confirmed LPN #133 had worked over 16 hours on 06/19/25 and 06/21/25.Interview on 08/25/25 at 1:33 P.M., with the DON, revealed staff don't always communicate with administration changes in schedule but LPN #133 picks up a lot of shifts. There was one other incident 7-8 months ago staff had reported LPN #133 sleeping, however she was not able to verify, nor did she document the incident or investigation. After the incident in June staff are not permitted to work over 16 hours. The DON confirmed LPN #133 had worked several 16-hour shifts in the last few days. The DON confirmed several staff had resigned due to the incident in June. Interview on 08/28/27 at 2:11 P.M., with Registered Nurse (RN) #600 revealed LPN #133 had been reported numerous times to Administration staff for sleeping, not administering medication as ordered, and not assessing residents. The DON and ADON tolerate her behavior because LPN #133 comes into work, so they don't have to. Review of the facility assessment undated revealed the average daily census was 47.3. The facility provides care and services to individuals with certain medical and cognitive disabilities. The facility care team reviews all referrals prior to admission to determine needed staff, equipment and supply resources to care for the potential admission. The facility's daily staffing was based on the resident's population and acuity taking into consideration staffing needs for each resident unit and shift.Review of LPN #133 job description dated 09/19/23 revealed the LPN would ensure quality resident care. Review of the Nurse Practice Act revealed it does not address employment matters, such as work schedules, nor does it establish limits on the number of hours a licensee may practice within a given period of time. However, nurses must be knowledgeable of the standards of nursing practice in Rule 4723-4-03, OAC (related to RN practice), and Rule 4723-4-04, OAC (related to LPN practice). These rules require RNs and LPNs to demonstrate competence and accountability in all areas of practice in which the nurse is engaged, which includes but is not limited to 1) consistent performance of all aspects of nursing care; and 2) appropriate recognition, referral or consultation and intervention when a complication arises. In addition, all nurses are required to maintain a safe environment for the patient. Rule 4723-4-06(H), OAC. Working under conditions of fatigue may not be safe for the nurse or the patient. A nurse who fails to demonstrate competence or does not provide consistent performance within his or her nursing practice as a result of excessive work hours, or for any other reason, will not have met standards of safe practice. This deficiency represents non-compliance investigated under Complaint Numbers 2568688, 1274323, 1274309, and 1274308.

Based on observation, BIPA (Benefits Improvement and Protection Act) Report review, daily census report review, and interview, the facility failed to post accurate nurse staffing information as required. This had the potential to affect all 49 residents residing within the facility.
Findings include:
On 12/30/24 at 9:07 A.M., observation of the reception area revealed a BIPA Report dated 12/30/24 indicating the current census was 46. At 9:09 A.M., an interview with the Administrator stated he would need to double-check the census as the BIPA Report could change due to, he received this report from the corporate office. The Administrator stated the BIPA report currently posted had been printed out on 12/27/24 to cover through the weekend, including this one. BIPA Report postings were observed at the reception desk and both nursing stations.
On 12/30/24 at 4:15 P.M. observation of the posted BIPA Reports dated 12/30/24 at two nursing stations and the reception area revealed the facility census was 46.
Review of the Daily Census Report dated 12/30/24 revealed the facility census was 49.
On 12/31/24 at 7:30 A.M., observation of the reception area revealed the posted BIPA Report was dated 12/30/24 with a census of 46. On 12/31/24 at 7:30 A.M., interview with Receptionist #215 verified the above posting.
On 12/31/24 at 9:05 A.M., the interview with the Administrator verified the facility census on 12/30/24 was 49 and the BIPA Reports posted did not accurately reflect the daily census.
This deficiency is an incidental finding investigated under Complaint Number OH00160178.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to maintain resident dignity for Resident #100. This affected one resident (#100) of three sampled residents. The facility census was 49.
Findings include:
Medical record review revealed Resident #100 was admitted to the facility on [DATE] with a history of urinary tract infections and discharged to the hospital on [DATE]. The resident returned to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, dementia, prostate cancer, obstructive uropathy, and an indwelling urinary catheter.
Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was cognitively intact for daily decision-making and utilized an indwelling urinary catheter.
Review of the Physician Orders dated 12/30/24 revealed Resident #100 was ordered a suprapubic catheter to straight drainage.
On 12/30/24 at 9:19 A.M., observation revealed Resident #100 and Resident #83 were sitting in wheelchairs in the lobby/TV area across from the nursing station. The resident's indwelling urinary catheter tubing was observed lying on the floor without a barrier under the resident's wheelchair. Yellow urine was observed in the uncovered collection drainage bag. Assistant Director of Nursing (ADON) #200 verified the above at the time of the observation and stated the drainage bag should be covered.
Review of the policy titled Resident Rights, revised October 2016, revealed employees shall treat all residents with kindness, respect, and dignity.
This deficiency is an incidental finding investigated under Complaint Number OH00160178.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) document accurately reflected medications and a psychiatric hospitalization. This affected one (Resident #37) of four residents reviewed for PASRR documents. The census was 46.
Findings Include:
Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, Alzheimer's disease, major depressive disorder, delusional disorder, dementia with psychotic disturbance, and panic disorder.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/19/24, revealed the resident was severely cognitively impaired and received an anti-anxiety medication.
Review of Resident #37's PASRR document, dated 08/26/24, revealed under Section E, no anti-anxiety medication. Review of the resident's physician orders, dated 03/29/24, revealed the order for Xanax 0.5 milligrams (mg) to be administered three times per day. Review of the medication administration record (MAR), dated August 2024, revealed the resident received this medication as ordered. Further review of the PASRR document under Section E, incorrectly indicated the resident had not been hospitalized for inpatient psychiatry. Review of Resident #37's medical record revealed the resident was hospitalized on [DATE] due to increased confusion, paranoia, believing he was breaking up a prostitution ring, making sexual comments to staff, delusions, grandiosity, and having trouble sleeping.
During interview on 09/03/24 at 4:41 P.M., Social Services Designee (SSD) #194 confirmed Resident #37's PASRR document was not accurate and did not indicate the use of an anti-anxiety medication nor the inpatient psychiatric hospitalization on 03/11/24.

Based on observation, medical record review and staff interview, the facility failed to follow appropriate transmission based precautions for a resident on contact precautions. The affected one (Resident #253) of two residents identified on transmission based precautions. The facility census was 46.
Findings include:
Review of Resident #253's medical record revealed an admission date of 08/30/24 with diagnoses that included enterocolitis due to clostridium difficile, sepsis, pneumonia and chronic obstructive pulmonary disease. Physician's orders upon admission indicated Resident #253 required contact transmission based precautions and resident to remain in his room related to signs of symptoms of a highly transmissible disease or epidemiologically significant pathogen.
Observation on 09/04/24 at 2:20 P.M. revealed Activity Coordinator (AC) #192 in Resident #253's room. A sign was posted on Resident #253's door frame indicating he was on contact precautions and a cart containing personal protective supplies was noted below the sign and outside the resident's room door. AC #192 was sitting on the edge of Resident #253's bed and was wearing a protective gown and gloves. The gown was tied twice in the back but was open with approximately a three to four inch opening with AC #192's pants contacting the linens of Resident #253's bed. Resident #253 was observed sitting in a recliner next to the bed. Resident #253 was observed in the bed earlier in the day.
On 09/04/24 at 2:22 P.M. interview with AC #192 indicated she was completing an activity assessment for Resident #253. She verified the resident had contact precautions in place for C-Diff and should not have been sitting on the residents bed with her personal clothing exposed and contacting the bed linens.
On 09/04/24 at 2:40 P.M. AC #192 indicated she changed into new nursing scrubs after informing the Director of Nursing and Administrator of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a meal ticket, observation, resident interview, staff interview, and policy review, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding a resident's hemodialysis treatments. They also failed to ensure the medical record accurately reflected the resident's current order for a fluid restriction and staff were knowledgeable about the resident's need for a fluid restriction as ordered for end stage renal disease. This affected one (Resident #19) of one resident reviewed for dialysis.
Findings include:
1 a.) Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, dependence on renal dialysis, pulmonary hypertension, and congestive heart failure.
Review of Resident #19's physician's orders revealed the resident had an order for dialysis treatments every Monday, Wednesday, and Friday. The order originated on 08/19/23.
Review of Resident #19's active care plans revealed she had a care plan in place for an alteration in renal function, as the resident was receiving renal dialysis. The care plan was initiated on 06/28/23 and indicated the facility was to encourage the dialysis center to forward dialysis treatment notes to the facility.
Review of Resident #19's medical record revealed it was absent for most of the dialysis visit notes for the resident's dialysis treatments she received in the past 30 days. Out of the 14 times the resident was sent out of the facility for a dialysis treatment, 13 of those visits did not have a dialysis visit note to indicate what the resident's pre-weight and dry weight (weight after dialysis) were, what her vital signs were, what medications she had been given, and how the resident tolerated the dialysis treatment during each visit.
On 09/03/24 at 2:22 P.M. an interview with Resident #19 revealed she did not believe the facility was sending her to the dialysis center with any paperwork. She also denied the dialysis center had sent her back to the facility with any dialysis visit notes. She did not feel the facility and the dialysis center were communicating as well as they should.
On 09/04/24 at 3:02 P.M., an interview with LPN #133 revealed the facility's nurses completed dialysis observation assessments on Resident #19 before and after she had her dialysis treatments. She denied those dialysis observation forms that were completed were sent with the resident to dialysis. She further denied the resident was sent back to the facility with any dialysis visit notes. Any communication made between the dialysis center and the facility would be done by the dialysis center calling them. She indicated they may get a call from the dialysis center on occasion, if there was a new order or a change in the resident's condition. She denied the facility would know what the resident's weights and vital signs were pre and post-dialysis. They would also not know what medications the resident received while at dialysis, or how she tolerated the treatment.
On 09/05/24 at 10:10 A.M., findings were verified by the Director of Nursing (DON) and RN #220 that Resident #19's electronic medical record (EMR) did not show evidence of consistent and adequate communication occurring between the facility and the resident's dialysis center. They acknowledged the dialysis center was not sending a dialysis visit note for the resident that let them know what the resident's pre-weight and dry weight was when the resident received hemodialysis. There was also no communication of any medications that may have been administered to the resident or how she tolerated the dialysis treatment while there. They acknowledged their policy and the resident's plan of care indicated the facility was to receive a dialysis visit note from the dialysis center when the resident received her treatments three days a week.
The facility's dialysis policy updated 2024 was reviewed and revealed it was the policy of the facility that all residents utilizing renal dialysis receive comprehensive interdisciplinary monitoring to ensure resident safety and support of dialysis services. The dialysis center would send reports from the resident's dialysis treatments to the facility after each visit.
1 b.) Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease (ESRD), dependence on renal dialysis, pulmonary hypertension, and congestive heart failure.
Review of Resident #19's physician's orders revealed the resident had an order in place for a 1,500 milliliter (ml)/ day fluid restriction with directions for dietary to provide 1,000 ml and nursing to provide 500 ml to equal the 1,500 ml/ day. The 500 ml allotted to nursing was further broke down to 250 ml on the day shift and 250 ml on the night shift. The order had been in place since 04/26/24.
Review of Resident #19's active care plans revealed the resident had a care plan in place for an alteration in renal function, as the resident was receiving renal dialysis for ESRD. The care plan was initiated on 06/28/23 and indicated the resident was on a 1,200 ml/ day fluid restriction with nursing and dietary dividing fluids with meals and daily care including medication passes. The care plan intervention was not consistent with what was specified in the physician's orders. That intervention for the 1,200 ml/ day fluid restriction had been in place since 06/28/23.
Further review of Resident #19's care plans revealed she had another care plan in place for being at risk for altered nutrition related to ESRD and being on hemodialysis. That care plan indicated the resident was on a 1,500 ml/ day fluid restriction, which was not consistent with what was indicated on the alteration in renal function care plan. The care plan for the resident's risk for altered nutrition was last revised on 08/15/24.
Review of Resident #19's meal ticket for 09/05/24 revealed the resident was identified as being on a 1,200 ml fluid restriction. It did not break it down on the meal ticket to specify how much fluid the resident should be given for each meal.
On 09/03/24 at 2:22 P.M. an observation of Resident #19 noted her to be in her room. She was noted to have a can of pop in her room and a full Styrofoam cup of water. The resident was not sure if she was on a fluid restriction or not for her dialysis.
On 09/05/24 at 8:06 A.M., an interview with State Tested Nursing Assistant (STNA) #144 revealed she was not aware of Resident #19 being on a fluid restriction. She indicated they gave the resident the same amount of water in her Styrofoam cup as the other residents received. She indicated the resident usually did not drink all of what was given to her in her Styrofoam cup and thought she only drank about 240 ml from it. She usually did drink what they sent on her meal trays. She then indicated, since the resident was on dialysis, she likely was on a fluid restriction, as most of them were. She did not know what amount of fluids the resident could have, if she was on a fluid restriction. She felt the resident probably drank what she was able to, but did not know for sure, as they did not know what she drank when out of the facility with her family.
On 09/05/24 at 10:10 A.M., findings were verified by the DON and RN #220 that Resident #19's care plans, physician's orders, and meal ticket were unclear on the amount of the fluid restriction the resident was to be on. They acknowledged the discrepancy in the amount of fluids that the resident could have as documented on her two care plans, physician's orders, and meal ticket. They confirmed the resident's current order was for a 1,500 ml/ day fluid restriction and the care plans and meal ticket should all reflect such. They further acknowledged the STNA interviewed, who was caring for Resident #19, was unaware she was on a fluid restriction and was providing the resident water in a Styrofoam cup just like they did with all the other residents.

Based on observation, resident interview, record review, policy review and staff interview, the facility failed to ensure oxygen tubing was changed weekly and documented as administered in the medical record. This affected one (Resident #8) of two residents reviewed for supplemental oxygen use. The facility census was 46.
Findings include:
Observations of Resident #8 on 09/03/24 at 9:26 A.M. revealed the resident lying in bed. Supplemental oxygen was supplied by an oxygen concentrator (machine that separates nitrogen from atmospheric air delivering 95% pure oxygen) via a nasal cannula. No evidence of any date to the tubing and nasal cannula was observed. Additional observations of Resident #8 on 09/03/24 at 3:58 P.M., 09/04/24 at 7:38 A.M. and 09/04/24 at 12:05 P.M. revealed supplemental oxygen in use by Resident #8 with no date on the tubing. Observation on 09/05/24 at 9:50 A.M. revealed Resident #8 sitting in her recliner and supplemental oxygen lying on her bed with the tubing undated.
Interview with Resident #8 on 09/05/24 at 9:50 A.M. revealed that she uses the supplemental oxygen when in bed every day. She could not recall when the oxygen tubing was replaced.
Review of Resident #8's medical record revealed an admission date of 01/15/24 with diagnoses that included chronic obstructive pulmonary disease, Parkinson's disease and cerebrovascular accident. Further review of the medical record including Minimum Data Set (MDS) 3.0 significant change assessment with a reference date of 08/09/24 indicated Resident #8 had an independent and intact cognition level and used supplemental oxygen therapy.
Physician's orders for Resident #8 indicated on 08/03/24 an order for two liters of supplemental oxygen as needed for a blood oxygen saturation level lower than 89%. No order was found related to replacing the oxygen tubing routinely.
Progress notes revealed as needed supplemental oxygen was utilized by Resident #8 on
08/03/24, 08/05/24, 08/06/24, 08/07/24, 08/11/24, 08/12/24, 08/18/24, 08/20/24, 08/24/24, 08/25/24, 08/26/24, 08/27/24, 08/30/24 and 09/02/24. An additional progress note dated 08/11/24 indicated Resident #8 uses the supplemental oxygen every night while sleeping. No evidence of changing the oxygen tubing was found in the progress notes.
Review of the Medication Administration Record (MAR) revealed documentation of supplemental oxygen administered as ordered on 08/03/24, 08/05/24, 08/17/24 and 09/01/24. No evidence of changing oxygen tubing was found on the MAR.
On 09/03/24 at 3:20 P.M. interview with Licensed Practical Nurse (LPN) #133 indicated residents on supplemental oxygen therapy have tubing changed weekly on Fridays by a contracted oxygen supply company.
On 09/05/24 at 9:55 A.M. interview with the Director of Nursing verified Resident #8's oxygen tubing and nasal cannula were not dated and unknown when last replaced. The DON also verified supplemental oxygen use was not consistently documented as administered on the MAR.
Review of the facility policy titled Respiratory Treatment Oxygen dated 05/19/21 indicated to change oxygen tubing, nasal cannula every seven days.

Based on observations, interview with staff, and review of facility policy the facility failed to ensure staff preformed proper hand hygiene during medication administration. This affected two resident ( Resident #34 and #45) out of four observed for medication administration. The facility census was 49.
Findings included:
Observation on 04/16/24 at 7:27 A.M. revealed Registered Nurse #110 administered medication to Resident #39 then proceeded to return to the medication cart without washing her hands and prepared medication for Resident #34.
At 7:33 A.M. RN #110 administered those medication to Resident #34. She then returned to the medication cart without washing her hands.
At 7:45 A.M. RN #110 prepared and administered medications for Resident #45 without washing her hands prior however she did wash her hands after she administered the medication.
On 04/16/24 at 7:50 A.M. an interview with RN #110 revealed she had not washed her hands after administering medication to Resident #39, before and after administering medication to Resident #34 and prior to administration of medication to Resident #44.
Review of the hand washing policy titled, Hand washing/Hand hygiene, dated 11/20 revealed it was the facility policy to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that would aide in the prevention of the transmission of infections. Hands were to be washed before preparing or handling medications.
Review of the facility policy titled, Medication Administration, dated 05/20 revealed the person administering medication adheres to food hand hygiene which included washing hands thoroughly per policy, before beginning a medication pass, prior to handling any medications, and after coming into direct contact with a resident.
This deficiency represents noncompliance as an incidental finding identified during the investigation of Complaint Number OH00152284.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , review of the medical record and interview with the staff the facility failed to ensure that private identifiable medical information for Resident #10 was not visible on the computer screen and left unattended by staff. This affected one resident ( Resident #40) of four residents observed for medication administration. The facility census was 49.
Findings included:
Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included muscle weakness, chronic obstructive pulmonary disease, diabetes, hypertension, rheumatoid arthritis, major depressive disorder, anxiety disorder, respiratory failure, polyneuropathy, glaucoma, vitamin D deficiency, congestive heart failure, low back pain, irritable bowel syndrome, ulcerative colitis, diverticulitis, intervertebral disc degeneration, chronic pain syndrome, and adult failure to thrive.
Observation on 04/16/24 at 7:22 A.M. revealed the facility medication cart was sitting outside room [ROOM NUMBER] with resident information for Resident #40 up on the screen unattended and where any passerby could view the information.
On 04/16/24 at 7:25 A.M. an interview with Registered Nurse #110 came out of the room [ROOM NUMBER] and verified she had left Resident #40's private health information up on her computer screen while she went into the resident's room.
Review of the undated facility policy titled, HIPAA, revealed protected health information may not be used or disclosed for reasons other than treatment, payment, or health care operations without resident authorization. Do not leave written documents with resident health information in a location that could be seen by unauthorized individuals and keep unattended medical records behind the nurse's station.
This deficiency represents noncompliance identified as an incidental finding during the investigation of Complaint Number OH00152284.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record and interview with staff the facility failed to ensure medications were not left unattended on top of the medication cart and failed to ensure the medication cart was locked while unattended. This had the potential to affect three residents ( Resident #33, #41, and #43) out of 21 who were cognitively impaired and independently mobile on the Rodeo Unit. The facility census was 49.
Findings included:
Observation on 04/16/24 at 7:22 A.M. revealed the facility medication cart was sitting outside room [ROOM NUMBER] unlocked and with a plastic medicine cup with 12 tablets in it on the top of the cart. The medication in the medication cup was for Resident #40 and contained; one tablet of aspirin (analgesic) 81 mg, one tablet of Buspar (anti-anxiety) 15 mg, one tablet of Carafate (gastrointestinal agent) 1 gram, one tablet of vitamin D 3 ( vitamin) 5000 units, one tablet of Dicyclomine (anti-cholinergic) 20 mg, one tablet of Duloxetine (anti-depressant) 60 mg, one tablet of Hydroxychloroquine (immune-suppressant) 200 mg, one tablet of Lasix (diuretic) 20 mg, one tablet of Leflunomide (immunosuppressant) 20 mg, one tablet of Lyrica (pain medication) 75 mg, one tablet of Pantoprazole heartburn medication) 40 mg, and one tablet of Sulfasalazine (amino acid) 500 mg.
On 04/16/24 at 7:25 A.M. an interview with Registered Nurse #110 came out of the room [ROOM NUMBER] and verified she had left the cart unlocked and left medication unattended on the top of her medication cart. She stated the resident wanted to take the medication after she ate.
Review of the facility policy titled, Medication Administration, dated 05/20 revealed during medication administration the medication cart was to be kept closed and locked when out of sight of the medication nurse or aide. No medication was to be kept on top of the cart . In addition, privacy was to be maintained for all resident information when not in use.
This deficiency identified noncompliance as an incidental finding during the investigation of Complaint Number OH00152284.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility investigation, review of operating instructions of an enteral feeding pump, resident interview, and staff interview, the facility failed to ensure a resident received an enteral tube feeding at the rate ordered by the physician and staff adequately monitored the flow rate of the enteral feeding when assessing the resident for complications associated with his peg tube. This affected one resident (#15) of one resident reviewed for enteral tube feedings.
Findings include:
A review of Resident #15's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dysphagia and gastrostomy status.
A review of Resident #15's physician's orders revealed he had an order to receive an enteral feeding (nutritional supplement that was provided through a feeding tube directly into the stomach that was surgically placed through the abdominal wall) of Isosource 1.5 cal at 55 milliliters/ hour (ml/ hr) on a continuous basis. The order was initiated on 01/15/24 upon the resident's admission into the facility.
A review of Resident #15's progress notes noted a nurse's note dated 01/15/24 at 11:36 P.M. by Registered Nurse (RN) #100 revealed the resident utilized his call light for nurse assistance at approximately 6:45 P.M. complaining of bleeding at his peg tube insertion site. His peg tube was indicated to have recently been inserted on 01/13/24. The infusion pump was indicated to be operational and running continuous tube feeding. At approximately 9:00 P.M., the resident had been assessed and found to have fully saturated another dressing around his peg tube insertion site. After replacing the dressing, the resident began to complain of intense nausea and exhibited pale skin and diaphoresis (moist skin). Due to the nausea, the nurse clamped the peg tube continuous feeding and noticed the continuous infusion pump had been set to dispense 295 ml/ hr as opposed to the resident's prescribed 55 mL/hr of tube feed. The resident was suspected as having received 295 mL/hr since his arrival to the facility at around 3:00 P.M. when the tube feed was initiated by the previous shift nurse. The resident's abdomen was noted to be distended and the resident began dry heaving into a wash basin. Due to excessive bleeding of surgical site, nausea and vomiting, abdominal distention, and gross over feeding of the resident, the nurse immediately called an ambulance to transport the resident to the emergency room (ER) for an evaluation. The facility's Director of Nursing (DON) was indicated to have been notified.
A review of Resident #15's ER report revealed the resident was seen in the ER on [DATE] at 10:34 P.M. The ER notes indicated the resident was sent by the nursing facility following a recent placement of a peg tube and the nursing facility was reportedly infusing the tube feeding at an accelerated rate. He had bleeding at his peg tube insertion site and abdominal complaints. He had complaints of nausea, while in the ER, and his abdomen was soft, non-tender, and round. He had bowel sounds present. His peg tube was not found to have had any drainage when checked in the ER. He was discharged back to the nursing facility.
A review of a nurse's progress note dated 01/16/24 at 12:26 A.M. by RN #100 revealed Resident #15 arrived back to facility with no new orders from the ER. The nurse contacted the on-call physicians service and received an order to hold the resident's tube feeding for the duration of the shift and continue to monitor for bleeding. They were to notify the in-house provider in the morning for further orders. The resident was assessed by the facility's nurse practitioner and gave orders to resume his enteral tube feeding at 55 ml/ hour on a continuous basis as was previously ordered when the resident had no further complaints of nausea.
A review of Resident #15's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he did not have any communication issues and was cognitively intact. He was not known to display any behaviors and was not known to reject care.
A review of Resident #15's care plans revealed the resident had a feeding tube and received tube feeding as his primary source of nutrition related to dysphagia. The care plan was initiated on 01/18/24. The care plan specified he was to receive Isosource 1.5 at 55 ml/ hour. The goal included the resident would tolerate tube feeding and be free from signs and symptoms of gastrointestinal distress. The interventions included the need to administer the tube feeding per the physician's orders.
A review of the facility's investigation into the incident that occurred on 01/15/24 pertaining to Resident #15's enteral feeding revealed statements were obtained by the DON from RN #100, RN #140, and LPN #125. The statement from RN #100 obtained on 01/15/24 revealed the nurse had called the DON at 1:00 A.M. and notified her that at some point Resident #15's enteral feeding pump had started running at 295 ml/ hour. The nurse informed the DON that she had sent the resident to the ER due to nausea, vomiting, abdominal distention and other acute findings. He returned to the facility shortly after with no new orders. The nurse then contacted the facility's on-call physician's service and received an order to keep the resident NPO (nothing by mouth) and nothing by peg tube until he was evaluated by the facility's nurse practitioner (NP). She asked the nurse to provide her with some images of the enteral feeding pump via phone so she could see the settings and the amount that had been infused. She asked the nurse if she had received in report when the resident had been hooked up to the enteral feeding pump and was told by the nurse that she had not been made aware. Images of the enteral feeding pump that was sent to the DON as requested showed the pump settings read 295 ml/ hour and 290 ml volume infused. The nurse did state at some point before sending the resident out that she cleared the volume infused and she was unable to recall the amount that was listed when she cleared the pump. She also was not able to recall how much was left in the enteral feeding bag before discarding it after the resident was sent to the hospital. The nurse was unable to confirm if the 290 ml volume infused was the total volume he received while in the facility or not, as the nurse believed she may have cleared the enteral feeding pump, but could not be sure she did.
The statement obtained from RN #140 by the DON on 01/16/24 revealed Resident #15 was set up with his tube feeding as ordered sometime around 5:30 P.M. to 5:45 P.M. She reported she was the one who had set up the enteral feeding pump system as ordered, but was unable to recall just exactly what the order was. She was able to recall that it was 50 something and that he also had water flush orders. She recalled his peg tube site had been bleeding slightly since his admission, but was not able to provide any more information than that.
A statement obtained from LPN #125 by the DON on 01/16/24 confirmed Resident #15's enteral tube feeding was set up as ordered around 5:30 P.M. to 5:45 P. M by RN #140, who was in training with her. She too recalled the peg tube site had been bleeding slightly since his admission, but did not notice an increase in the amount of bleeding or any complaints of nausea or vomiting. She was unable to recall much more about the incident than that.
The facility's investigation did include the image of Resident #15's enteral feeding pump that had been sent to the DON by RN #100. The image showed the infusion rate was set at 295 ml/ hr and the volume delivered was indicated to be 290 ml. The image was a Xerox copy and had a hand written note on it that indicated it had been sent from RN #100.
A review of the operator instructions for EntraFlo Nutrition Delivery System from Medline revealed there were directions on how to modify pump settings. The operating instructions for changing the rate or dose limit indicated the person making changes had to press run/ pause to stop the pump before being able to make any changes. They then had to select new flow/ infusion rate by pressing + or - buttons on the face of the pump. They then had to select new dose limit by pressing set dose limit and then press the + or - button within the next three seconds. They could press reset to clear volume delivered if desired and then press the run/ pause button to restart the pump.
On 01/31/24 at 2:08 P.M., an interview with State Tested Nursing Assistant (STNA) #200 revealed she had worked the afternoon shift on 01/15/24 when Resident #15 was admitted . She was assigned to his unit and assisted him with care. She recalled being in his room around 6:00 P.M. to assist the resident with changing his gown as he had blood on it due to bleeding around his peg tube site. She notified RN #100, who intervened and assisted the resident with changing his dressing around the peg tube site. She was in his room again around 8:30 P.M. when the resident was complaining of feeling sick. She described him as being pale and was having difficulty keeping his eyes open. She reported the resident's complaints to RN #100 again and RN #100 had her go to the resident's room to see what his enteral feeding pump was running at. She remembered the pump read 295 on the left side of the pump and had a one on the right side of it. She was not sure what the numbers meant but relayed it back to RN #100, who was checking to see what the pump should have been set at. RN #100 commented that the enteral feeding pump was running six times the amount that the resident should have been getting. The nurse then checked the resident and sent him out to the hospital after she was unable to reach the resident's family. She was not able to give any specific times when things occurred after the 8:30 P.M. time she mentioned, but stated the resident was still in the facility when her shift ended at 10:00 P.M. She had not talked to the DON or any other administrative staff as part of the facility's investigation into the incident.
On 01/31/24 at 5:05 P.M., an interview with Resident #15 revealed he did not recall much about what occurred on 01/15/24 as he indicated he was a little out of it after his transfer from Columbus. He did recall there being an issue with the amount of enteral feeding he received but thought it was from the hospital he came from infusing it at a higher rate than he should have received. He was not aware that the enteral feeding was not set up until after he arrived at the facility. He was asked if it would have been possible that he may have changed the settings on the pump by pushing the buttons on the front of it. He denied that he knew anything at all about the pump and would not know how to even work it.
On 01/31/24 at 5:15 P.M., an interview with the DON confirmed there had been a problem with Resident #15's enteral tube feeding on 01/15/24. She had been notified of the issue by RN #100 on 01/16/24 around 1:00 A.M. She investigated it like a medication error and it was difficult for her to ascertain exactly what happened. From what she could determine, Resident #15's enteral feeding was set up by the day shift nurses (RN #140 and LPN #125)They claimed they had set it up and it was running as ordered at the time their shift had ended around 6:00 P.M. RN #100 reported she had found the enteral feeding pump infusing at 295 ml/ hour instead of the 55 ml/ hr it was ordered at. RN #100 was not able to say how long it had infused at that rate as she did not look at the pump early in her shift when she was assessing the resident when it was reported he had bleeding from his peg tube site. It was not until after 8:30 P.M. that RN #100 had found the pump infusing at 295 ml/ hour. RN #100 was also not able to tell her how much had been infused since it had been initiated as the nurse was unsure if she had cleared the infused volume amount when responding to the pump's sounding alarm. The nurse had told her that she did not touch the pump but then stated she may have reset the infused volume, which would have required her to touch the pump. The nurse was also unable to tell her what the amount was that was remaining in the enteral feeding bag when she had discarded it after the resident had went to the hospital and the feeding was put on hold. She indicated RN #100 was worked up about the resident's bleeding he was having from his peg tube site. She felt the nurse was not responding to the situation in the manner she should have as she did not check to see what rate the feeding was being infused at when she was in the room assessing the problems with his peg tube site. She confirmed she had the nurse take a picture of the pump to send her to show what the infusion rate was set at. She confirmed it was reading 295 ml/ hr, more than what was ordered for the resident to receive. The nurse was telling her that over a 1,000 ml of enteral feeding had been infused but she told the nurse that would not have been possible unless she added more to the enteral feeding bag, which the nurse did not. She suspected the resident received about the approximate amount he should have based on the volume infused amount that was showing considering the flow rate and what time the other nurses reported the feeding had been initiated. She was not able to determine how long the resident received the accelerated amount of enteral tube feeding that was showing on the pump. As a result of that incident, she changed the way in which the nurses took report at shift change. They were now required to do a standing report in the room of any resident on an enteral feeding to verify the amount infusing was what was ordered by the physician. She also had RN #100 do a competency to ensure she knew how to properly operate the enteral feeding pump.
This deficiency represents non-compliance investigated under Complaint Number OH00150213.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure flu and pneumococcal vaccinations were offered. This affected one resident (Resident #19) of five residents reviewed for vaccines.
Findings include:
Review of Resident #19's medical record revealed a 06/27/21 admission date with diagnoses including peripheral vascular disease, diabetes, and anemia.
Review of Resident #19's 05/31/22 annual MDS revealed the resident was independent for daily decision making, required extensive assist of one for bed mobility, transfer, toileting, personal hygiene and did not walk. The resident received ointment to areas other than feet.
Review of Resident #19's Preventative Health Care included the resident had a flu vaccine prior to admission [DATE]. There was no evidence the facility offered a flu vaccine after the 06/27/21 admission. The facility had no information for Resident #19 on a past history of receiving the pneumococcal vaccine. There was no evidence the facility offered a pneumococcal vaccine when admitted .
On 08/09/22 at 9:55 A.M. during interview, the Administrator affirmed the facility could not locate a consent for acceptance or decline of the flu or pneumonia vaccine for Resident #19 since admission.
Review of the facility's Influenza protocol (dated 11/2019) included the facility will offer an annual flu vaccine to the residents and staff between October and March of each year. The facility shall provide pertinent information about the significant risk and benefits of the vaccines to the staff, residents and residents authorized representatives. We will utilize the Vaccine Authorization Form and it will be filed in our medical records. All residents will be offered the flu vaccine annually. Current vaccine information given to the resident or authorized representation and acknowledgment of receipt completed annually. If residents have declined in prior years continue to offer the flu vaccine annually.
Review of the facility's Pneumococcal vaccine policy (updated in 2022) revealed all residents will be offered pneumococcal vaccine to aid in preventing pneumococcal infections. Prior to admission residents will be assessed for eligibility to receive the pneumococcal vaccine PCV15, PCV20 and the pneumococcal PPSV23. Before receiving the pneumococcal vaccination the resident or authorized representative shall receive information, education regarding the benefit of an potential side effects of the pneumococcal vaccine. Residents and authorized representatives have the right to refuse the vaccine. If refused appropriate entries will be documented in the resident medical records indicating the date of refusal of the pneumococcal vaccine. If the resident or authorized representative refuses upon admission the facility will offer the vaccine on an annual basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to have fall interventions in place. This affected three residents (#5, #10 and #28) of four residents reviewed for falls.
Findings include:
1. Review of Resident #10's medical record revealed a 09/18/21 admission with diagnoses including metabolic encephalopathy, syncope and collapse, acute respiratory disease, muscle weakness, difficulty in walking, muscle wasting and atrophy, Type 2 diabetes mellitus with hyperglycemia, cardiac arrhythmia's, hypertension, Vitamin D deficiency, hypocalcemia, benign prostatic hyperplasia, emphysema, major depressive disorder, anxiety disorder, diverticulosis of intestine, and irritable bowel syndrome.
The resident had a 10/12/21 risk for fall plan of care related to behaviors, history of falls, medications including anxiolytic's, antidepressants, antihypertensive's, and diabetes. Interventions included on 02/14/22 to place a sign in room to remind to get assistance with footwear, 06/12/22 to place a sign in the bathroom to ask for assistance with transfers, and 07/16/22 to place sign in room to use call light for assistance with transfers.
Review of the medical record for Resident #10 revealed falls on 10/29/21, 01/03/22, 01/23/22, 02/01/22, 02/13/22, 02/19/22, 03/21/22, 04/06/22 (resulting in a fractured elbow), 06/12/22, and 07/16/22.
Review of the 05/03/22 quarterly MDS revealed the resident was independent for daily decision making, required extensive assist of two for bed mobility and transfer, supervision of two to walk in room, did not walk in corridor, and had one fall with major injury and one fall with no injury since the last assessment.
Resident #10 was moved to a private room [ROOM NUMBER]/22/22 after testing positive for COVID-19.
Observation 08/02/22 at 10:26 A.M. revealed Resident #10 did not have any signage in his room or bathroom related to fall safety measures. Observation of Resident #10's prior room revealed a sign to ring for call light, and please ask a staff member to help you with footwear. The bathroom did not have a sign related to safety.
Interview 08/02/22 at 3:27 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #45 verified there was no signage in the room with Resident #10 after he was moved to a private room as care planned.
2. Review of Resident #28's medical record revealed a 12/28/21 admission with diagnoses including intestinal obstruction, intestinal bypass and anastomosis status, Muscle weakness, Abnormal posture, need for assistance with personal care, chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, paroxysmal atrial fibrillation, anemia, unspecified, dysphagia oral phase, emphysema, mild intermittent asthma with status asthmatics, hyperlipidemia, hypothyroidism, vitamin D deficiency, vitamin B deficiency, major depressive disorder, generalized anxiety disorder, anorexia, osteoarthritis, osteoporosis, dementia without behavioral disturbance, hypokalemia, and Gastro-esophageal reflux disease.
Review of Resident #28's 10/26/21 Risk for Falls/Injury related to history of falls, incontinence of bowel and urine, anxiolytic, antidepressant, antihistamine, antihypertensive, laxative and narcotic medications plan of care revealed the 06/08/22 intervention to place a sign as a reminder to ask for assistance was not included as an intervention on the plan of care.
Review of the 06/08/22 Fall with Injury Event included Resident #28 was out of bed ambulating without assistance, fell and fractured her wrist. The immediate safety approach was to place sign as a reminder to ask for assistance.
Review of the 06/14/22 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making, had little interest or pleasure in doing things, feeling down, depressed, hopeless, feeling tired with little energy, poor appetite, hallucinations. Resident #28 required extensive assist of one for bed mobility, transfers, dressing, personal hygiene, limited assist of one for walking in room, and extensive assist of two for toilet. The resident had one fall with major injury since last assessment. The resident was on antidepressant, antianxiety, and opiod medications. The resident was at risk for pressure ulcers and had a skin tear. She utilized pressure reducing devices for bed and chair, application of non surgical dressing and application of ointments and medications.
Observation 08/01/22 at 2:56 P.M. of Resident #28's room revealed no signage related to safety posted.
On 08/03/22 at 8:31 A.M. interview with Resident #28 revealed someone put a sign up in her room that morning to please ask for assistance. Observation revealed a sign in the room and bathroom to ask for assistance.
Interview 08/03/22 at 11:03 A.M. with Registered Nurse (RN) #45 revealed the facility started a quality assurance and performance improvement plan (QAPI) 08/02/22 after the surveyors found fall interventions not in place. They identified the signage in the room which was the intervention for the 06/08/22 fall was not on the plan of care. The intervention was added to the plan of care 08/03/22. She did not know who put the signs up. The signs were not there on 08/01/22 and the resident said the signs were hung that morning.
Review of the facility's Fall Investigation policy dated 06/03/19 included an immediate safety intervention will be implemented. A Change in Plan of Care Communication Form will be initiated.
3. A review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included seizure disorder, congestive heart failure, history of a stroke with hemiparesis (weakness) and hemiplegia (paralysis) affecting the right dominant side, dementia with behavioral disturbances, muscle weakness, abnormalities of gait and mobility, difficulty walking, unsteadiness on feet, need for assistance with personal care, abnormal posture and repeated falls.
A review of Resident #5's quarterly Minimum Data Set (MDS) assessment completed on 04/19/22 revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not known to have any behaviors but was known to reject care one to three days of the seven day assessment period. He required an extensive assist of two for bed mobility, transfers, dressing and toilet use. Balance issues were noted during transitions and walking and he was only able to stabilize himself with staff assistance. He was not indicated to have had any falls since his admission or prior assessment and was not known to have any falls prior to his admission.
A review of Resident #5's care plans revealed he had a care plan for being at risk for falls related to behaviors, confusion, history of falls, incontinence, impaired gait stability and medications that increased the risk of falls. The care plan was initiated on 07/25/22. Interventions to prevent the falls from occurring included providing therapy as per plan, encouraging the resident to use call lights for transfers/ ambulation assistance, identifying non-compliance with safety issues and report to the physician as needed, and observe the resident in his room for safety needs when passing the room and re-directing for safety as needed. The resident also had a care plan for behaviors that included non-adherent with care/ services. He displayed behaviors of self transferring and was non-compliant with allowing assistance from staff.
A review of Resident #5's fall events revealed he had had nine falls in the past four months with two falls occurring in April, four falls in May and three falls in June 2022. His last fall was on 06/18/22. All falls were the result of unassisted transfers. He did not sustain any major injuries as a result of those falls. Two of the falls (05/07/22 and 06/18/22) revealed immediate safety approaches taken after the fall included the use of non-skid strips to the floor. With the fall on 05/07/22, non-skid strips were to be added to the floor by his bed. With the fall on 06/18/22, non-skid strips were to be applied to the floor in front of the toilet in his bathroom.
On 08/02/22 at 3:10 P.M., an observation of Resident #5's room revealed he did not have any non-skid strips applied to the floor by his bed or in front of the toilet in his bathroom. Findings were verified by Registered Nurse (RN) #37.
On 08/02/22 at 3:12 P.M., an interview with RN #37 revealed Resident #5 used to reside on the 200 hall before he was moved to his current room on the 100 hall. He was moved to the 100 hall during the facility's Covid-19 outbreak following his exposure to someone with Covid-19.
Further review of Resident #5's medical record confirmed he had been moved from room [ROOM NUMBER]-1 to his current room on the 100 hall on 07/24/22. His fall prevention interventions for the use of non-skid strips to the floor by the bed and on the floor in front of the toilet was not carried over to his new room when he was moved on 07/24/22. His at risk for falls care plan was not revised to reflect the addition of non-skid strips to his floor as a fall prevention intervention following the falls that occurred on 05/07/22 and 06/18/22.
On 08/03/22 at 12:00 P.M., an interview with RN #45 confirmed the resident's fall prevention interventions were to include the use of non-skid strips to the floor by the bed and in front of the toilet. She acknowledged he did not have any non-skid strips on his floor by the bed or in front of his toilet in his current room. She confirmed the use of the non-skid strips were added as fall prevention interventions following the falls occurring on 05/07/22 and 06/18/22. She also confirmed the resident did have a recent room change and those fall prevention interventions for the use of non-skid strips did not get carried over to his new room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure pressure ulcers were adequately assessed to identify the correct staging of the pressure ulcer, failed to ensure a laboratory test and supplements recommended by the wound physician were implemented for wound healing, and a resident identified as being at risk for pressure ulcers had appropriate skin prevention interventions in place to help reduce the risk of pressure ulcers from developing. This affected two (Resident #35 and #93) of three residents reviewed for pressure ulcers.
Findings include:
1. A review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included a fracture of the right femur at the femoral neck, a history of a stroke with hemiparesis and hemiplegia of the right dominant side, muscle weakness, and difficulty walking. The resident was admitted to the facility with a stage II pressure ulcer (a pressure ulcer that presents as a shallow open crater or a fluid filled blister) on her coccyx.
A review of a wound grid observation dated 06/24/22 revealed Resident #35 was indicated to have a stage II pressure ulcer on her coccyx that measured 3 centimeters (cm) x 3 cm with a depth unable to be determined. A description of the wound surface revealed there was a dark area to the coccyx that was not open. The wound was assessed by Licensed Practical Nurse (LPN) #13.
A subsequent assessment of the coccyx wound was completed on 06/27/22 that indicated the wound had been resolved/ healed.
A review of a wound grid observation dated 07/14/22 revealed Resident #35 was again noted to have a stage II pressure ulcer to her coccyx that originated on that date. The wound measurements were 1.4 cm x 2 cm x 0.1 cm. The wound surface description indicated the wound bed had 75% slough (dead tissue that is found in a full thickness wound and usually a cream or yellow color) and 25% eschar (necrotic tissue that is dryer than slough and tan, brown or black in color) despite a depth of 0.1 cm being recorded for the pressure ulcer.
A wound grid observation dated 07/18/22 revealed Resident #35's pressure ulcer to her coccyx was assessed as being a stage III pressure ulcer (full thickness skin loss in which adipose tissue was visible in the ulcer and granulation tissue and rolled wound edges were often present; if slough or eschar obscured the extent of tissue loss, that was an unstageable pressure ulcer). The pressure ulcer measured 1.4 cm x 1.6 cm with a depth not able to be determined. The wound bed was indicated to have been covered with 50% slough. Subsequent assessments of the resident's pressure ulcer on her coccyx completed on 07/25/22 and 08/01/22 continued to classify the wound as a stage III pressure ulcer despite no depth being able to be recorded. Those assessments indicated the wound surface had 20% slough present.
A review of an initial wound evaluation and management summary revealed Resident #35 was seen by a wound physician on 07/25/22. The wound physician recommended the resident have a pre-albumin level (a blood test that measures protein levels in your blood to determine malnutrition and the need for protein supplementation) drawn, and to receive a multivitamin (MVI) once daily, Vitamin C 500 milligrams (mg) twice a day, and Zinc Sulfate 220 mg by mouth once daily for 14 days.
A review of Resident #35's physician's orders revealed no evidence of the resident being placed on a MVI, Vitamin C or Zinc Sulfate as recommended by the wound physician on 07/25/22 to help promote wound healing. The medical record also provided no documented evidence of the resident's pre-albumin level being checked as recommended by the wound physician.
A review of Resident #35's medication administration record (MAR) for July and August 2022 confirmed there was no evidence of the resident receiving a MVI, Vitamin C or Zinc Sulfate x 14 days as recommended by the wound physician that evaluated her pressure ulcer on 07/25/22. Findings were verified by the Director of Nursing (DON).
On 08/04/22 at 2:45 P.M., an interview with the DON revealed the facility's wound nurse was not working that day. She was asked to review Resident #35's wound grid observations for her pressure ulcer to the coccyx from 06/24/22- 06/27/22 and 07/14/22 to present. She confirmed the resident's pressure ulcer that she had upon admission did resolve and re-opened on 07/14/22. She acknowledged the pressure ulcer was not adequately assessed on 06/24/22, when it was classified as a stage II pressure ulcer. She confirmed the wound surface description indicated there was a dark area to the coccyx that was not open. She stated based on that, the pressure ulcer should have been classified as a suspected deep tissue injury and not a stage II pressure ulcer. She then acknowledged the wound assessment dated [DATE] was not accurate as the pressure was classified as a stage II pressure ulcer with a depth of 0.1 cm. while the wound surface description indicated there was 75% slough and 25% eschar present. She agreed, based on the description of the wound bed, the pressure ulcer should have been considered an unstageable pressure ulcer at that time. She was then asked about the assessment completed on 07/18/22 that identified the wound as a stage III pressure ulcer with a depth of the wound not able to be determined. The wound surface was indicated to have been filled with 50% slough. She acknowledged, if the wound bed was covered with 50% slough and a depth was not able to be determined, the wound should have still been classified as an unstageable pressure ulcer. The assessment on 07/25/22 considered the wound to be a stage III pressure ulcer that had 20% slough and 80% epithelization. The depth of the wound was indicated not to be able to be determined. She agreed based on the wound assessment the wound should have been assessed as an unstageable pressure ulcer due to the 20% slough present causing them not to be able to determine the depth of the wound bed. She confirmed she was the nurse who assessed the resident's wound on 07/25/22. The wound physician had looked at it and she only documented what he was reporting. She confirmed, with where the 20% slough was located in the wound bed, they were not able to determine the full depth of the wound. Based on that, she stated it should have been an unstageable pressure ulcer. They could not determine if it was a stage III or stage IV pressure ulcer under the area covered by slough as they could not tell if adipose tissue was present or if bone, tendon, or muscle could be seen. The DON also confirmed the recommendation made by the wound physician (when he visited on 07/25/22) was not carried through with. A pre-albumin level had not been checked and the resident was not started on those medications recommended to help promote wound healing.
On 08/04/22 at 4:30 P.M., an interview with Registered Nurse (RN) #45 revealed the facility's DON usually made rounds with the visiting wound physician. She stated the physician would have informed her of any recommendations made as a result of his visit. She reported the wound physician did not share those recommendations verbally with the DON. The recommendations were included on his visit report that they would have received the same day. A nurse should have recognized those recommendations were made in that report and should have written them as orders to be carried out.
2. A review of Resident #93's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Parkinson's disease, dementia, peripheral vascular disease (PVD) and muscle weakness.
A review of Resident #93's admission assessment completed 07/20/22 revealed a Braden risk assessment was completed as part of the assessment and identified him as being at risk for pressure ulcers. Risk factors included his skin occasionally being moist from exposure to urine, being chair fast, having very limited mobility, and the potential for friction and shearing. He was also known to have PVD and edema. He had calluses at the time of his admission but was not noted to have any known pressure ulcers present upon admission.
A review of Resident #93's admission Minimum Data Set (MDS) assessment completed on 07/27/22 revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors nor was he known to reject care. He required an extensive assist of two for bed mobility, transfers and ambulation in her room. He was identified as being at risk for pressure ulcers but did not have any unhealed pressure ulcers at the time the assessment was completed. Skin and ulcer treatments indicated to have been implemented was the use of pressure reduction devices for his bed and chair.
A review of Resident #93's care plans revealed he had a care plan in place for being at risk for skin breakdown related to impaired mobility, impaired cognition, PVD, and friction/ shearing concerns. The goal was for him not to develop skin breakdown. The interventions included the use of a pressure re-distribution cushion. The care plan and the use of the pressure reduction cushion was initiated on 08/02/22.
On 08/01/22 at 3:01 P.M., an observation of Resident #93 noted him to be sitting up in his wheelchair in his room. He was a little restless in his chair and reported his buttocks was sore. He was not noted to have a cushion under him while sitting in the wheelchair.
On 08/02/22 at 1:35 P.M. and again on 08/03/22 at 10:44 A.M., observations of Resident #93 noted him to again be sitting up in his wheelchair in his room without any pressure reduction cushions in place under his buttocks. He continued to report his buttocks were sore.
On 08/08/22 at 4:07 P.M., an interview with Licensed Practical Nurse (LPN) #13 revealed she did not consider Resident #93 to be at risk for pressure ulcers despite his Braden risk assessment identifying him as being at risk. She denied he had any current pressure ulcers and was known to get up and moved around. She reported the resident had the use of a pressure reduction cushion when up in his wheelchair. She confirmed he was either in bed or up in his wheelchair when she was there.
On 08/08/22 at 4:10 P.M., an interview with State Tested Nursing Assistant (STNA) #11 revealed she usually seen Resident #93 up in his wheelchair in the afternoons when she was there. She denied he was ever on a pressure reduction cushion when she seen him up in his wheelchair. They did offer to put a pillow behind his back but he usually declined.
On 08/08/22 at 4:15 P.M., Registered Nurse (RN) #37 was asked to assess Resident #93's buttocks due to him complaining of it being sore when he was sitting up in his wheelchair. She observed his bilateral inner buttocks to be reddened but was still blanchable. She confirmed the resident was considered to be at risk for pressure ulcers. He was known to go back and forth between his bed and wheelchair. She was not aware of the resident was supposed to have a pressure reduction cushion under his buttocks when up in his wheelchair as part of his skin prevention interventions. She verified he did not have a pressure reduction cushion present in his wheelchair or anywhere else in his room. She acknowledged his at risk for pressure ulcer care plan did include the use of a pressure reduction cushion to his chair. She questioned why that was on his care plan as one of his skin prevention intervention even though he was considered to be at risk for the development of pressure ulcers, sat up in his wheelchair during the day and had limited mobility. She stated the facility's offsite MDS nurse added that to his care plan but she did not know why. She acknowledged the resident verbalized his buttocks were sore when sitting in his wheelchair and the pressure reduction cushion would be beneficial for added padding.

Based on observation, record review and interview, the facility failed to ensure timely intervention for constipation and assessment and treatment orders for a leg wound. This affected three (Resident's #16, #19 and #28) of 15 residents reviewed.
Findings include:
1. Review of Resident #16's medical record revealed a 10/29/21 admission with diagnoses including cachexia, hypertension, hypothyroidism, gastro-esophageal reflux disease, vitamin D deficiency, osteoarthritis, diverticulitis, slow transit constipation, mild protein calorie malnutrition, and altered mental status.
Review of a 11/19/21 plan of care for constipation related to medications and decreased mobility included the resident will have a soft formed bowel movement at least every three days. Interventions included to administer medications as ordered and observe for bowel movement every three days.
Review of the 05/16/22 Significant Change MDS revealed the resident was moderately impaired for daily decision making, extensive assist of two for bed mobility, transfer, did not walk, extensive assist of one for dressing, toilet use, personal hygiene, and totally dependent of one for bathing. The resident was on hospice care.
Interview 08/01/22 at 3:24 P.M. with Resident #16 included she has been having constipation issues since arrival and doesn't go very often. She would like to sit on toilet but they said I can't since I can't stand on one leg.
Review of the physician orders included as needed orders dated 11/21/21 for Milk of Magnesia, a laxative, 400 milligrams (mg)/5 milliliter (ml) give 30 ml oral once a day as needed for constipation, Miralax, a laxative, 17 Grams (GM) daily as needed for constipation was ordered 05/11/22, a 06/06/22 order for Bisacodyl, a laxative, delayed release delayed release (DR)/enteric coated (EC) 5 milligrams (mg)/ give 10 mg daily as needed for constipation and a 06/29/22 order for Bisacodyl 10 milligram (mg) suppository rectally give daily as needed for constipation.
Review of the Point of Care bowel movement record and progress notes revealed the resident had a large bowel movement on 06/07/22. There was no evidence of another bowel movement until 06/20/22, 13 days later, when the resident had a small bowel movement.
Review of the as needed medications revealed as needed medication for constipation was not administered when the resident went 13 days without a bowel movement (06/07/22-06/20/22).
There was not a bowel movement documented between 06/20/22 and 06/30/22. On 06/20/22 the resident had a small bowel movement. On the seventh day of no bowel movement 06/27/22 the resident received Bisacodyl 5 mg tablet without result. On 06/29/22 Bisacodyl 5 mg was administered. The resident had a small bowel movement 06/30/22 resulting in three bowel movements in the 23 day period. The resident had a small bowel movement 07/29/22. There was no evidence of a bowel movement between 07/29/22 and 08/05/22. On 08/03/22, the fifth day without a bowel movement, Bisacodyl was administered without effect.
Interview 08/03/22 at 5:29 P.M. with Registered Nurse (RN) #45 revealed the facility does not have a bowel protocol. The nurses were to call the physician if an intervention was needed but they did not have a policy on what day without a bowel movement the doctor was to be called.
Interview 08/04/22 at 2:30 P.M. with RN #45 revealed she did not find any documentation of the resident having a bowel movement on days that were not documented in the bowel movement record. She verified there was no evidence in the seven, 10 and 13 days without a bowel movement of intervention on the fourth day. RN #45 included the expectation would be to intervene after three days without a bowel movement.
2. Review of Resident #19's medical record revealed a 06/27/21 admission date with diagnoses including peripheral vascular disease, diabetes, and anemia.
Review of the 05/31/22 annual MDS revealed the resident was independent for daily decision making, required extensive assist of one for bed mobility, transfer, toileting, personal hygiene and did not walk. The resident received ointment to areas other than feet.
Observation 08/01/22 at 11:31 A.M. with Resident #19 revealed the resident had an undated dressing to left shin. Observation of Resident #19 on 08/02/22 at 2:01 P.M. revealed an open area to her left shin without a dressing.
Review of Resident #19's record revealed there was not an order for a dressing to the left shin. There was not an assessment of the wound to the left shin.
Interview on 08/02/22 at 2:03 P.M. with State Tested Nurse Aides (STNA) #1 and #46 revealed the resident was dressed when they arrived. They said she did not have a dressing on her shin this morning.
Interview on 08/02/22 at 2:05 P.M. with RN #43 verified there was an open area on the resident's left shin without a dressing. She said she did not know about it.
Review of the progress notes revealed on 08/02/22 at 3:09 P.M. the state nurse pointed out an open area on the left shin of Resident #19. The area was covered with a dry clean dressing and a message left for the nurse practitioner.
On 08/02/22 the facility obtained an order to cleanse left shin with normal saline, pat dry, apply xeroform gauze and secure with dry dressing daily and as needed for loose or soiled dressing.
A plan of care was initiated 08/02/22 for a diabetic ulcer to left shin.
Review of a 08/04/22 progress note included a venous ulcer to left anterior shin. No signs of infection. No edema. Vascular staining to bilateral lower extremities. Wound margins are irregular. Fibrinous tissue noted to wound bed. Wound periphery intact with minimal localized erythema. No warmth. No drainage. Continue wound care as ordered. An albumin and pre-albumin ordered.
Interview 08/04/22 at 11:42 A.M. with RN #45 verified Resident #19's record had no mention of a wound area on the shin or dressing application. RN #45 does not know who put a bandage on without documenting the area or getting a dressing order.
3. Review of Resident #28's medical record revealed a 12/28/21 readmission with diagnoses including intestinal obstruction, intestinal bypass and anastomosis status, muscle weakness, abnormal posture, need for assistance with personal care, chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, paroxysmal atrial fibrillation, anemia, unspecified, dysphagia oral phase, emphysema, mild intermittent asthma with status asthmatics, hyperlipidemia, hypothyroidism, vitamin D deficiency, vitamin B deficiency, major depressive disorder, generalized anxiety disorder, anorexia, osteoarthritis, osteoporosis, dementia without behavioral disturbance, hypokalemia, and gastro-esophageal reflux disease.
Review of a 10/26/21 plan of care for constipation related to medications and decreased mobility included the resident will have a soft formed bowel movement at least every three days. Interventions included to administer medications as ordered and observe for bowel movement every three days.
Review of the 06/14/22 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making, had little interest or pleasure in doing things, feeling down, depressed, hopeless, feeling tired with little energy, poor appetite, hallucinations, extensive assist of one for bed mobility, transfers, dressing, personal hygiene, limited assist of one for walking in room, and extensive assist of two for toilet. The resident had one fall with major injury since last assessment. The resident was on antidepressant, antianxiety, and opiod medications. The resident was at risk for pressure ulcers and had a skin tear. She utilized pressure reducing devices for bed and chair, application of non surgical dressing and application of ointments and medications.
Review of the physician orders included orders dated 01/07/22 for Senna Plus, a stool softener, 8.5/50 mg twice a day for chronic constipation, 02/03/23 for Colace, a stool softener, 100 mg twice a day for constipation and a 05/05/22 order for Bisacodyl a laxative, delayed release delayed release (DR)/enteric coated (EC) 5 milligrams (mg) daily as needed for constipation.
Review of the Point of Care bowel movement record and progress notes revealed the resident a large bowel movement on 06/07/22. There was no evidence of another bowel movement until 06/13/22, six days later, when the resident had a small bowel movement. Review of the as needed medications revealed as needed medication for constipation was not administered when the resident went six days without a bowel movement.
Email notification on 08/09/22 at 9:18 A.M. with the Administrator provided no evidence of a bowel movement or as needed medication for constipation between 06/07/22 and 06/13/22. There was no evidence of intervention after three days without a bowel movement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #28's medical record revealed a 12/28/21 admission with diagnoses including intestinal obstruction, intestinal bypass and anastomosis status, Muscle weakness, Abnormal posture, need for assistance with personal care, Chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, paroxysmal atrial fibrillation, anemia, unspecified, dysphagia oral phase, emphysema, mild intermittent asthma with status asthmatics, hyperlipidemia, hypothyroidism, vitamin D deficiency, vitamin B deficiency, major depressive disorder, generalized anxiety disorder, anorexia, osteoarthritis, osteoporosis, dementia without behavioral disturbance, hypokalemia, and Gastro-esophageal reflux disease.
Review of the 10/26/21 Risk for Falls/Injury related to history of falls, incontinence of bowel and urine, anxiolytic, antidepressant, antihistamine, antihypertensive, laxative and narcotic medications plan of care revealed the 06/08/22 intervention to place a sign as a reminder to ask for assistance was not included as an intervention on the plan of care.
Review of the 06/08/22 Fall with Injury Event included the resident was out of bed ambulating without assistance, fell and fractured her wrist. The immediate safety approach was to place sign as a reminder to ask for assistance.
Review of the 06/14/22 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making, had little interest or pleasure in doing things, feeling down, depressed, hopeless, feeling tired with little energy, poor appetite, hallucinations, extensive assist of one for bed mobility, transfers, dressing, personal hygiene, limited assist of one for walking in room, and extensive assist of two for toilet. The resident had one fall with major injury since last assessment. The resident was on antidepressant, antianxiety, and opiod medications. The resident was at risk for pressure ulcers and had a skin tear. She utilized pressure reducing devices for bed and chair, application of non surgical dressing and application of ointments and medications.
On 08/03/22 the intervention sign in room to remind resident to ask for assistance was added to the plan of care.
Interview 08/03/22 at 11:03 A.M. with Registered Nurse (RN) #45 revealed the facility started a quality assurance and performance improvement plan (QAPI) 08/02/22 after the surveyors found fall interventions not in place. They identified Resident #28's signage in the room which was the intervention for the 06/08/22 fall was not on the plan of care. It was added 08/03/22.
Review of the facility's Fall Investigation policy dated 06/03/19 included an immediate safety intervention will be implemented. A Change in Plan of Care Communication Form will be initiated.
Based on record review, observation, and staff interview, the facility failed to ensure care plans were revised to reflect new fall prevention interventions added after falls occurred. This affected two (Resident #5 and #28) of four residents reviewed for falls.
Findings include:
1. A review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included seizure disorder, congestive heart failure, history of a stroke with hemiparesis (weakness) and hemiplegia (paralysis) affecting the right dominant side, dementia with behavioral disturbances, muscle weakness, abnormalities of gait and mobility, difficulty walking, unsteadiness on feet, need for assistance with personal care, abnormal posture and repeated falls.
A review of Resident #5's quarterly Minimum Data Set (MDS) assessment completed on 04/19/22 revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not known to have any behaviors but was known to reject care one to three days of the seven day assessment period. He required an extensive assist of two for bed mobility, transfers, dressing and toilet use. Balance issues were noted during transitions and walking and he was only able to stabilize himself with staff assistance. He was not indicated to have had any falls since his admission or prior assessment and was not known to have any falls prior to his admission.
A review of Resident #5's care plans revealed he had a care plan for being at risk for falls related to behaviors, confusion, history of falls, incontinence, impaired gait stability and medications that increased the risk of falls. The care plan was initiated on 07/25/22. Interventions to prevent the falls from occurring included providing therapy as per plan, encouraging the resident to use call lights for transfers/ ambulation assistance, identifying non-compliance with safety issues and report to the physician as needed, and observe the resident in his room for safety needs when passing the room and re-directing for safety as needed. The resident also had a care plan for behaviors that included non-adherent with care/ services. He displayed behaviors of self transferring and was non-compliant with allowing assistance from staff.
A review of the resident's fall events revealed he had had nine falls in the past four months with two falls occurring in April, four falls in May and three falls in June 2022. His last fall was on 06/18/22. All falls were the result of unassisted transfers. He did not sustain any major injuries as a result of those falls. Two of the falls (05/07/22 and 06/18/22) revealed immediate safety approaches taken after the fall included the use of non-skid strips to the floor. With the fall on 05/07/22, non-skid strips were to be added to the floor by his bed. With the fall on 06/18/22, non-skid strips were to be applied to the floor in front of the toilet in his bathroom.
On 08/02/22 at 3:10 P.M., an observation of Resident #5's room revealed he did not have any non-skid strips applied to the floor by his bed or in front of the toilet in his bathroom. Findings were verified by Registered Nurse (RN) #37.
On 08/02/22 at 3:12 P.M., an interview with RN #37 revealed Resident #37 used to reside on the 200 hall before he was moved to his current room on the 100 hall. He was moved to the 100 hall during the facility's Covid-19 outbreak following his exposure to someone with Covid-19.
Further review of Resident #5's medical record confirmed he had been moved from room [ROOM NUMBER]-1 to his current room on the 100 hall on 07/24/22. His fall prevention interventions for the use of non-skid strips to the floor by the bed and on the floor in front of the toilet was not carried over to his new room when he was moved on 07/24/22. His at risk for falls care plan was not revised to reflect the addition of non-skid strips to his floor as a fall prevention intervention following the falls that occurred on 05/07/22 and 06/18/22.
On 08/03/22 at 12:00 P.M., an interview with RN #45 confirmed the resident's fall prevention interventions were to include the use of non-skid strips to the floor by the bed and in front of the toilet. She acknowledged he did not have any non-skid strips on his floor by the bed or in front of his toilet in his current room. She confirmed the use of the non-skid strips were added as fall prevention interventions following the falls occurring on 05/07/22 and 06/18/22. She also confirmed the resident did have a recent room change and those fall prevention interventions for the use of non-skid strips did not get carried over to his new room.

Based on record review and staff interview, the facility failed to obtain laboratory testing as ordered to monitor medication use. This affected two Residents (#19 and #31) of five residents reviewed for unnecessary medication.
Findings include:
1. Review of Resident #19's medical record revealed a 06/27/21 admission date with diagnoses including peripheral vascular disease, diabetes, and anemia.
Physician orders included atorvastatin 40 mg daily for high cholesterol and magnesium oxide 400 mg twice a day, both ordered 06/27/21.
Review of a 01/04/22 pharmacy recommendation included to add a lipid panel, Vitamin D level and Magnesium yearly. The recommendation was accepted on 01/06/22 to add the orders to the February, 2022 laboratory draw with the HGBA1C.
Review of the physician orders revealed the order was entered 01/06/22 for a lipid profile, Vitamin D level and Magnesium on the second monday of every 12th month.
Review of the 05/31/22 annual MDS revealed the resident was independent for daily decision making, required extensive assist of one for bed mobility, transfer, toileting, personal hygiene and did not walk. The resident received ointment to areas other than feet. The resident received antianxiety, antidepressant, and insulin medications.
Review of the laboratory reports revealed no evidence of the lipid, Vitamin D and magnesium levels being drawn in February, 2022 per physician accepted pharmacy recommendation.
Review of a 07/28/22 physician progress note included the lipid level was to be monitored for hyperlipidemia.
On 08/08/22 at 5:07 P.M. the Administrator acknowledged the facility had not obtained Resident #19's lipid, magnesium and Vitamin D levels laboratory testing.
2. Review of Resident #31's medical record revealed a 09/05/19 admission with diagnoses including multiple sclerosis, diabetes, hyperlipidemia, anxiety disorder, hypertension, Schizoaffective disorder, and osteoarthritis.
Physician orders included a 06/10/20 order for atorvastatin 10 mg daily for high cholesterol, 07/10/20 order for magnesium oxide 400 mg once a day, and a 10/21/21 lipid profile and magnesium order on the second monday of the 12th month.
Review of Resident #31's 07/12/22 annual MDS revealed the resident was independent for daily decision making, little interest, feels down, trouble sleeping, little energy, poor appetite, hallucinations and delusions, receives scheduled pain medication, and as needed. The resident took antipsychotic, antianxiety, antidepressant, anticoagulant, antibiotic, diuretic, and opiod medications. On 02/08/22 the physician documented gradual dose reduction was clinically contraindicated.
Review of Resident #31's medical record revealed no evidence of the lipid profile or magnesium level testing as ordered.
On 08/10/22 at 9:35 A.M. , during interview the Administrator acknowledged the facility had not obtained the lipid profile and magnesium level as ordered Resident #31.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy and interview, the facility failed to ensure personal protective equipment (PPE) and surfaces were sanitized when leaving isolation rooms, isolation linens and personals were washed in a sanitary manner, and a urinary collection bag was maintained off the floor. This affected Residents #17, #25, #28, #34, and #92. This had the potential to affect all the residents in the facility.
Findings include:
1. Observation 08/01/22 12:05 PM of the lunch meal revealed State Tested Nurse Aide (STNA) #46 gowned, gloved and had an N-95 mask and goggles on when she delivered a tray to Resident #28 (this resident was in quarantine for exposure to COVID-19). Upon exiting the room, STNA #46 removed the PPE, except for goggles. STNA #46 used hand sanitizer and donned another N-95 mask, walked down the hall, and turned right down the hall.
STNA #46 did not sanitize her goggles after leaving the quarantine room.
Interview 08/01/22 at 12:09 P.M. with STNA #46 verified she did not clean her goggles when she exited the quarantine room.
On 08/01/22 at 12:12 P.M. observation revealed STNA #12 exited Resident #34's room (this resident was positive for COVID-19). STNA #12 set her goggles on the isolation bin outside the room, donned a N-95 mask, picked up the goggles, and cleaned them with an alcohol pad. Once STNA #12 donned the goggles, she was leaving the area without cleaning the top of the isolation bin where she had set the potentially contaminated goggles.
On 08/01/22 at 12:15 P.M. interview with STNA #12 verified she did not clean the top of the isolation bin after setting her goggles on it when she exited the room.
On 08/01/22 at 12:17 P.M. observation revealed STNA #46 donned PPE gown, gloves and already had on a N-95 mask and goggles. STNA #46 took a lunch tray into the quarantine room of Residents #17 and #25 (these residents were in quarantine due to being unvaccinated and the facility being in outbreak mode for positive cases). STNA #46 exited the room with PPE doffed and set her goggles on the isolation bin outside the room, donned a N-95 mask, picked up the goggles and cleaned them with an alcohol pad. Once STNA #46 donned the goggles, she was leaving the area without cleaning the top of the isolation bin where she had set the potentially contaminated goggles.
On 08/01/22 at 12:20 P.M. during interview, STNA #46 verified she did not clean the top of the isolation bin after setting her goggles on it when she exited the room.
Review of the facility's Coronavirus (COVID-19) Protocol dated 06/22/22 included eye protection will be cleaned when exiting a residents room when in quarantine/isolation room; recommend supply care givers with two sets of eye protection and paper bags, doff and clean eye protection when exiting the room and place in bag, don the second pair of eye protection, and rotate between the two pieces of eye protection each time exiting a resident room.
2. Observation and interview 08/10/22 at 1:14 P.M. with Laundry Worker #2 included builder break, emulsifier detergent, stainer, cl de-iron, and softener were the products used for washing. Laundry Worker #2 revealed for isolation linen she uses cycle 2/1 (the linens cycle) and isolation personals on cycle 2/3 (no bleach). Observation revealed the Intercon wall sign, indicating which cycle to use for specific types of laundry, indicated cycle 2/7 was to be used for isolation. The first number was the washer program and second number the pump program. Laundry Worker #2 indicated she did not use the cycle 2/7 listed for isolation. She stated she had not been taught to use the cycle.
Interview 08/10/22 at 2:57 P.M. with Intercon Employee #47 revealed cycle 2/7 for isolation had a boat load of chemicals: 4.5 ounces of Break, 1.5 ounces of emulsifier detergent, 4.5 ounces of bleach and 0.8 ounces of both neutralizer and softener. For COVID-19 and isolation much heavier chemicals are used.
The cycle 2/1 was 3.0 ounces of Break which breaks down linens for better suds, 3.0 ounces of detergent, 3.0 ounces of bleach, 1.5 ounces of both neutralizer and softener.
On 08/10/22 at 3:42 P. M . during interview Intercon Employee #47 indicated there were no kill rates for the laundry products with no indication of what they kill.
Review of the facility's water temperature sheet for August of 2022 indicated the water temperature at the riser which feeds the laundry was 120 degrees Fahrenheit.
Interview 08/10/22 at 3:55 P. M with Maintenance #35 revealed the laundry did not have a water temperature booster.
Interview 08/10/22 at 4:59 P.M. with Laundry Worker #2 included she receives the isolation linens and personals from a red bin left outside. The bin is lined with a clear bag. It is filled with individual clear bags of linen or personals. She indicated staff wheel the bins outside instead of through the building and leave it next to the transport van. She periodically looks outside to see if there is a red bin. She indicated the bin would be located 20-30 feet from the door in the parking lot. She did not know of any safety measures to prevent someone from opening the bin outside.
Review of Center for Medicare regulation includes the facility should be using the fabric manufacturer's recommended laundry cycles, water temperatures and chemical detergent products:
- Recommendations for laundry processed in hot water temperatures is 160ºFahrenheit (71ºCelsius) for 25 minutes; and
- For laundry that is not hot water compatible, low temperature washing at 71 to 77 ºF (22-25 ºC) plus a 125-part-per-million (ppm) chlorine bleach rinse has been found to be effective and comparable to high temperature wash cycles.
Review of the facility's Departmental (Environmental Services)-Laundry and Linen policy (updated 11/2020) included it is the facility's policy to provide a process for the safe and clean handling washing and storage of linen. To minimize possible contamination of the environment use individualized red plastic bags when gathering linens from the residents with infections or colonization with multi drug resistant organisms such as methicillin-resistant staphylococcal aureus or vancomycin-resistant enterococci as necessary per Center for Disease Control guidelines including laundry/linen removed from an isolation room. Wash linen in water that is at least 140 degrees Fahrenheit for at least 25 minutes. Sodium hypochlorite, bleach, should be used on all colorfast loads in the amount of at least 1000 mL of a 1% solution for every 100 pounds of linen except in facilities that utilize the ozone system.
3. A review of Resident #92's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic urinary retention and a history of a malignant neoplasm of the kidney status post partial nephrectomy (removal of the kidney).
A review of Resident #92's physician's orders revealed the use of a 16 french indwelling urinary catheter to straight drain for the diagnosis of retention. They were to change the urinary drainage bag on the 15 th of every month and as needed. Urinary output was to be measured three times a day.
A review of Resident #92's Minimum Data Set (MDS) assessments revealed his 5 day/ admission MDS assessment was still in progress. His baseline care plans were established as part of the clinical admission documentation assessment completed on 07/21/22. The section that addressed his genitourinary status revealed the resident was known to have an indwelling urinary catheter. The care plan section of the assessment revealed the use of an internal urinary catheter (Foley). Urinary catheter approaches included the need for staff to keep the urinary drainage bag covered per policy, below the level of his bladder and off the floor.
On 08/01/22 at 4:35 P.M., an observation of Resident #92 revealed he was sitting up in his recliner by the bed. His indwelling urinary catheter drainage bag was noted to be sitting on the floor in between the recliner and the resident's bed.
On 08/02/22 at 2:45 P.M., a follow up observation of Resident #92 noted him to be lying in bed in a supine position. His indwelling urinary catheter's drainage bag was on the right side of the bed towards the window. The drainage bag was noted to be in direct contact with the floor. Findings were verified by Registered Nurse (RN) #37. She was overheard advising Resident #92 that his indwelling urinary catheter's drainage bag could not be touching the floor. She asked the resident if he knew how the drainage bag got on the floor and he denied any knowledge of how it got there. She acknowledged indwelling urinary catheter drainage bags should not be placed on the floor to reduce the risk of urinary tract infections. She secured it up off the floor by hooking it to the resident's bed frame at the end of his bed.
On 08/02/22 at 2:50 P.M., an interview with Resident #92 revealed he did not put himself in bed after being in his recliner as he was unable to do so. He stated he always asked for help when needing to get into and out of his bed. He reported a male staff member had helped him into bed and denied he transferred himself or placed his indwelling urinary catheter's drainage bag directly onto the floor.
A review of the facility's urinary catheter care policy updated November 2019 revealed the staff were instructed to be sure the catheter tubing and drainage bag were kept off the floor.

Based on observation and interview, the facility failed to maintain the kitchen in a sanitary condition. This had the potential to affect all the residents in the facility except Residents #29 and #93 who did not receive nutrition from the kitchen. The facility census was 43.
Findings include:
Initial tour of the kitchen 08/01/22 at 8:45 A.M. revealed the following;
1. The ice machine had brown slimy film on the lip of the shoot. The slimy film wiped off with a paper towel. There was dried white debris around the door seal and lid.
2. In the dry storage, breadcrumbs were opened and not dated.
3. The vents above the range top and grill were dusty. There were grease traps on each side of the vents. The trap on the left had blowing dust stringing out an inch long.
4. The ansel system above the rangetop and griddle had dust going up the piping and on the red spray covers.
5. The lights above the griddle and range cooking surface were dusty.
6. The tops of the convention oven and the steamer were dusty, with a greasy texture and crumbs.
7. The reach in refrigerator had six rusty shelves. The top left shelf was peeling white paint.
Interview 08/01/22 at 9:07 A.M. with Dietary Coordinator #9 verified the dust on the vents, grease trap, lights, convection oven, and steamer. Further interview verified the rusty and peeling shelves in the reach in refrigerator and undated bread crumbs.