Every finding on record at Accord Care Community Orrville LLC

Based on record review, observation and interview, the facility failed to maintain Resident #34's heel protector boots to prevent the development of pressure ulcers and failed to obtain laboratory tests and a wound clinic referral to manage Resident #52's wounds in a timely manner. This affected two residents (#34 and #52) out of three residents reviewed for wound care. The facility census was 57.Findings include:1. A review of Resident #52's clinical record revealed an admission date of 10/23/25 and re-admission date of 11/18/25 with diagnoses including gastrointestinal hemorrhage, nontraumatic subarachnoid hemorrhage, trouble swallowing, diabetes mellitus, high blood pressure, anemia, heart failure, neuromuscular dysfunction of the bladder, sacral pressure ulcer, malnutrition, alcohol abuse, anxiety, depression, gastroesophageal reflux disease, peripheral vascular disease, hydrocephalus disease, aneurysm, cerebrovascular vasospasm, Cushing's disease (rare endocrine disorder where a benign pituitary tumor secretes too much, causing too much adrenocorticotropic hormone, causing the adrenal glands to overproduce the stress hormone cortisol), constipation, obstructive and reflux uropathy.A review of Certified Nurse Practitioner (CNP) #91's progress note dated 11/04/25 indicated she wrote an order to obtain a referral to the wound clinic and to recheck laboratory test for a comprehensive metabolic panel (CMP). On 11/09/25 CNP #91's progress note indicated a referral was made on 11/04/25, and the facility had failed to call the wound clinic for the referral and had not obtained the laboratory test for the CMP as ordered on 11/04/25.Resident #52's wound documentation dated 12/01/25 indicated the presence of an unstageable pressure ulcer (a deep wound where the true depth and extent of tissue damage can't be determined because the base is covered by yellow (slough) or black/brown (eschar) dead tissue) on the sacrum measuring 12.1 centimeters (cm) long by 10.9 cm wide and 1.3 cm deep.An interview with CNP #91 on 12/03/25 at 9:51 A.M. verified the facility had not obtained the wound clinic referral and laboratory tests CNP #91 had ordered on 11/04/25.An interview on 12/03/25 at 3:35 P.M. with Regional Director of Clinical Operations (RDCO) #92 verified the above findings and agreed the staff had failed to draw the CMP laboratory test or submit a referral for the wound clinic to manage Resident #52's wounds.2. Review of the medical record for Resident #34 revealed an admission date of 06/27/23 and a readmission date of 09/05/23. Diagnoses included diabetes mellitus, chronic kidney disease, and polyneuropathy.A review of Resident #34's care plan initiated on 06/30/25 indicated Resident #34 had potential for skin breakdown and required protective/preventative skin care maintenance to both heels. Interventions on the care plan included maintaining heel protector boots while in bed.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/22/25, revealed Resident #34 had moderately impaired cognition and was dependent on staff for activities of daily living (ADL).Review of the physician's orders for December 2025 revealed that Resident #34 was ordered bilateral heel protector boots while in bed as tolerated two times a day.Observation on 12/03/25 at 8:56 A.M. revealed that Resident #34 was lying in bed, her heel protector boots were lying against the wall. Resident #34 stated that her boots should have been on. This was verified by Licensed Practica Nurse (LPN) #56 at time of observation. LPN #56 stated that the boots should have been on Resident #34.This deficiency represents non-compliance investigated under Complaint Number 2667793.

Based on observation, record review and interview, the facility failed to have a restorative program in place to prevent a decline residents' functional abilities and failed to ensure Resident #10's hand splints or rolled washcloths were maintained. This affected one resident (#10) out of three residents reviewed for contractures and had the potential to affect all residents who had therapy services. The facility census was 57.Findings include:A review of Resident #10's clinical record revealed an admission date of 11/21/24 and a readmission date of 04/08/25 with diagnoses including acute/chronic respiratory failure, high heart rate, bipolar disorder, anxiety, depression, obesity, epilepsy, herpes viral infection of urogenital system, chronic migraines, post-traumatic stress disorder, convulsions, persistent vegetative state, quadriplegia, anoxic brain injury, and contractures of the right and left hands.A review of Resident #10's physician order dated 04/08/25 indicated to apply a rolled washcloth to both hands two times a day for contractures.A review of Resident #10's care plan initiated on 03/06/25 and revised on 07/14/25 indicated an alteration in musculoskeletal status related to contractures due to quadriplegia. The goal of the care plan revealed Resident #10 would remain free of injuries or complications through the review date. Interventions on the care plan included applying rolled washcloths to both hands.An observation on 12/02/25 at 2:31 P.M. revealed Resident #10 had contractures of both hands. Resident #10's hands were clenched in a tight-fisted position without splints or rolled washcloths applied. Licensed Practical Nurse (LPN) #81 verified the absence of the splints (washcloths) at the time of the observation.An interview on 12/02/25 at 2:17 P.M. with LPN #90 stated the facility did not have a restorative program system in place to address range of motion exercises and/or restorative therapy recommendations.An interview with Therapy Director (Certified Occupational Therapist (COTA)) #27 on 12/02/25 at 2:31 P.M. stated the therapy department did not provide restorative recommendations for the nursing staff to implement to prevent a decline in a resident's functional ability because the facility did not have a restorative program system in place. COTA #27 agreed the residents who had therapy services were at risk for declining after their therapy services were discontinued because there was no restorative services implemented after discontinuation of the therapy services. COTA #27 stated the facility would have the physician order an evaluation for the need for therapy services when a resident had a decline in their functional abilities.Observation on 12/03/25 at 2:17 P.M. with Assistant Director of Nursing (ADON) #85 verified that Resident #10 was not wearing her splits (washcloths) in her hands. ADON #85 verified the facility did not have a restorative program in place to prevent a decline in a resident's functional ability. This deficiency represents non-compliance investigated under Complaint Number 2661672.

Based on observation and staff interview, the facility failed to maintain a clean, sanitary, and safe environment. This affected three residents (#34, #57, and #36) of three residents reviewed for physical environment and had the potential to affect all 57 residents residing in the facility.Findings include:Observation on 12/03/25 at 8:56 A.M. revealed that Resident #34 was lying in bed, her comforter was dirty, the thermostat had no cover on it. This was verified by Licensed Practical Nurse (LPN) #56 at time of observation.Observation on 12/03/25 at 9:01 A.M. revealed Resident #57 had dirty sheets, the thermostat cover was off, and the strip of molding that belonged on the sink was leaning up against the wall in the bathroom. Resident #57 stated that he did not know how long the cover was missing but the molding for the bathroom sink was a couple of weeks. This was verified on 12/03/25 at 9:09 A.M. by Housekeeping Supervisor (HS) #64.Observation on 12/03/25 at 9:05 A.M. revealed Resident #36 had dirty sheets, and the cover was off the thermostat. This was verified on 12/03/25 at 9:05 A.M. by HS #64.Observation on 12/03/25 at 9:06 A.M. revealed Resident #42 had the strip of molding that belonged on the sink was leaning up against the wall in the bathroom. This was verified on 12/03/25 at 9:07 A.M. by HS #64Interview on 12/03/25 at 9:33 A.M. with Regional Facilities Manager (RFM) #200 revealed that the former maintenance director resigned without working his notice out. RFM #200 stated that he did not know that molding was off the sinks or thermostat covers were missing. This deficiency represents noncompliance investigated under Complaint Numbers 2667793 and 2661672.

Based on record review, interview, and facility policy review, the facility failed to convey Resident #51's personal funds and a final accounting to the resident within 30 days of death. This affected one Resident #51 out of three residents reviewed for resident funds. The facility census was 50.Findings include:Review of Resident #51's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE] when the resident expired in facility. Diagnoses included but were not limited to Alzheimer's Disease, dementia, severe protein-calorie malnutrition, congestive heart failure (CHF), and type 2 diabetes mellitus with diabetic neuropathy.Interview on [DATE] at 7:09 A.M. with Resident #51's spouse reported his wife, Resident #51, passed away on [DATE] and he did not receive the refund check until last week. Resident #51's spouse reported he contacted the Ombudsman who helped assist with the refund.Interview on [DATE] at 10:25 P.M. with [NAME] Office Manger (BOM) #226 confirmed Resident #51's refund check was not refunded timely in 30 days. BOM #226 confirmed the check was not issued until [DATE] sometime. BOM #226 unable to provide explanation as to why it took so long and not refunded timely by 30 days. Interview on [DATE] at 12:45 P.M. with Administrator confirmed Resident #51's refund check was not refunded timely to Resident #51's spouse. Interview on [DATE] at 7:56 A.M. with Ombudsman #268 revealed Resident #51's spouse contacted her on [DATE] for assistance in obtaining the resident's remaining funds. Ombudsman #268 spoke with the Administrator on [DATE] and was told they were working on the issue. Ombudsman #268 reported Resident #51's spouse received the refund check sometime in July of 2025 which was not timely. Review of Resident #51's personal fund account balance and disbursement check revealed on [DATE], $759.00 was issued to Resident #51's spouse.Review of the facility policy, Resident Personal Funds, undated, revealed distribution of funds will be returned no later that thirty (30) days after discharge.This deficiency represents non-compliance investigated under Complaint Number 2565017.

Based on observation, interview, record review and review of the facility policy the facility failed to develop and implement a comprehensive and effective pain management program to ensure Resident' #3's pain was adequately assessed and treated prior to treatments of multiple (vascular) wounds on her bilateral lower extremities. This affected one resident (#3) of three residents reviewed for pain. The facility census was 52. Findings include: Review of Resident #3's medical record revealed an admitted [DATE] with diagnoses including peripheral vascular disease, major depressive disorder, type two diabetes with diabetic peripheral angiopathy without gangrene and heart failure. Review of Resident #3's care plan dated 04/12/21 revealed Resident #3 was at risk for pain related to immobility, peripheral vascular disease and heart failure. The goal developed was for Resident #3 to not have an interruption in normal activities due to pain. Interventions included to administer analgesia per orders; anticipate Resident #3's need for pain relief and respond within a timely manner to any complaint of pain; monitor and record pain characteristics; treatments as ordered. Review of Resident #3's physician orders dated 03/28/24 revealed orders for Tylenol Extra Strength tablet 500 mg (acetaminophen), give two tablets by mouth every eight hours as needed for pain and fever. Reposition, rest, and offer drinks and snacks related to pain. Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] included Resident #3 was cognitively intact. Resident #3 was dependent for toileting hygiene, upper and lower body dressing and personal hygiene. Resident #3 required substantial to maximal assistance for the ability to roll from lying on back to the left and right side and return to lying on back on the bed and the ability to move from sitting on the side of the bed to lying flat in bed. Review of Resident #3's wound notes dated 02/25/25 written by Doctor of Nursing Practice (DNP) #100 revealed the resident was being seen for an initial consult today for bilateral lower extremity wounds noted per nursing staff. Resident #3 had a history of wounds to the affected areas. Resident #3 reported discomfort to the wounds when wound care was completed. Wound one was a new wound of Resident #3's left proximal lower extremity as of 02/25/25 and was in-house acquired. Measurements were length 1.5 cm, width 1.2 cm and depth 0.1 cm. Treatment was cleanse every day and as needed, apply hydrogel, cover with adaptic, followed by non-adherent dressing, wrap with roll gauze and secure with tape. Wound two was a new wound, in-house acquired, of Resident #3's left medial lower extremity. Measurements were length 1.2 cm, width, 1.2 cm and depth 0.1 cm. Treatment was cleanse every day and as needed, apply hydrogel, cover with adaptic, followed by non-adherent dressing, wrap with roll gauze and secure with tape. Wound three was a new wound, in-house acquired of Resident #3's left medial distal lower extremity. Measurements were length 3.0 cm, width 2.8 cm, and depth 0.1 cm. Treatment was cleanse every day and as needed, apply hydrogel, cover with adaptic, followed by non-adherent dressing, wrap with roll gauze and secure with tape. Wound four was a new wound, in-house acquired of Resident #3's left distal lower extremity. Measurements were length 2.5 cm, width 4.5 cm, and depth of 0.1 cm. Treatment was cleanse every day and as needed, apply hydrogel, cover with adaptic, followed by non-adherent dressing, wrap with roll gauze and secure with tape. Wound five was a new wound, in-house acquired, of Resident #3's left lateral lower extremity. Measurements were length 1.0 cm, width 1.0, depth of 0.1 cm. Treatment was cleanse every day and as needed, apply hydrogel, cover with adaptic, followed by non-adherent dressing, wrap with roll gauze and secure with tape. Wound six was a new wound, in-house acquired of Resident #3's left lateral lower extremity. Measurements were length 2.3 cm, width, 1.8 cm, and depth was 0.1 cm. Treatment was cleanse every day and as needed, apply hydrogel, cover with adaptic, followed by non-adherent dressing, wrap with roll gauze and secure with tape. Wound seven was a new wound, in-house acquired of Resident #3's left lateral distal lower extremity. Measurements were length 1.0 cm, width 0.7 cm, depth 0.1 cm. Wound eight was a new wound, in-house acquired of Resident #3's right proximal lower extremity. Measurements were length 2.2 cm, width 1.8 cm and depth 0.1 cm. Wound nine was a new wound, in-house acquired of Resident #3's right medial lower extremity. Measurements were length 2.0 cm, width 2.4 cm, and depth of 0.1 cm. Wound ten was a new wound, in-house acquired of Resident #3's right distal lower extremity. Measurements were 2.7 cm, width 3.2 cm, and depth 0.1 cm. Wound eleven was a new wound of Resident #3's right distal lower extremity. Measurements were length 1.7 cm, 1.5 cm, 0.1 depth. Treatments for wounds seven, eight, nine, ten and eleven were cleanse every day and as needed, apply hydrogel, cover with adaptic, followed by non-adherent dressing, wrap with roll gauze and secure with tape. Wounds one through eleven were full thickness and the etiology was venous stasis. Recommendations were treatment orders per wound grid, consider medicating Resident #3 for pain prior to wound care to ease symptom burden. Review of Resident #3's medical record including progress notes dated 02/26/25 at 4:29 P.M. through 03/01/25 at 4:25 P.M. did not include documented evidence Resident #3 was evaluated/assessed for pain. However, there was no written evidence the resident had complaints of pain during this time period. Review of Resident #3's Medication Administration Audit Report dated 03/03/25 revealed orders to cleanse wounds to right lower extremity and left lower extremity with saline, pat dry, apply hydrogel to wound bed, apply adaptic to wound bed, cover with non-adherent dressing, wrap with Kerlix every night shift for vascular wounds. The report stated the scheduled time for the dressing change was 03/03/25 at 11:00 P.M. but the dressing change was not completed until 03/04/25 at 4:02 A.M. Review of Resident #3's medical record including the Medication Administration Record (MAR) dated 03/04/25 did not reveal Resident #3 was assessed for pain or that Tylenol Extra Strength tablet 500 mg (acetaminophen), give two tablets by mouth every eight hours was administered for pain at or prior to 4:02 A.M. when Resident #3's dressing changes to her right and left lower extremities was completed. Further review revealed Resident #3 was not administered Tylenol for pain until 03/04/25 at 6:54 A.M. for a pain level of five on a zero to ten scale, zero being no pain and ten being the worst pain on this date. Review of Resident #3's Pain assessment dated [DATE] revealed Resident #3 stated she frequently had pain or hurting in the last five days and pain made it hard for her to sleep at night. Over the past five days pain limited Resident #3's day-to-day activities. Resident #3 rated her pain at a five on a scale of zero to ten, zero being no pain and ten being the worst pain. The assessment revealed Resident #3 received Tylenol 500 mg as needed. Repositioning, rest and offer drinks, snacks had been ineffective. Review of Resident #3's wound notes dated 03/04/25 written by DNP #100 revealed Resident #3 had eleven wounds of her bilateral lower extremities. The treatment ordered for wounds one through eleven was cleanse daily and as needed, apply xeroform, followed by non-adherent dressing, wrap with roll gauze and secure with tape. The note also included to consider medicating Resident #3 for pain prior to wound care to ease symptom burden. Review of Resident #3's Medication Administration Audit Report dated 03/05/25 revealed orders to cleanse wounds to left lower extremities and right lower extremities with saline, pat dry, apply xeroform, cover with non-adherent dressing, wrap with Kerlix daily for autolytic debridement every night shift for vascular wounds was scheduled for 11:00 P.M. and was not completed until 03/06/25 at 4:05 A.M. Review of Resident #3's medical record including the MAR dated 03/06/25 did not reveal Resident #3 was assessed for pain or that Tylenol was administered at or prior to Resident #3's right and left lower extremity dressing changes at 4:05 A.M. Tylenol was not administered until 03/06/25 at 9:15 A.M. for pain rated at a level of 8. Review of Resident #3's progress notes dated 03/06/25 at 9:15 A.M. revealed Resident #3 stated that her pain was rated an eight out of 10. The note included Resident #3 was resting in bed at the time. Review of Resident #3's Medication Administration Audit Report dated 03/06/25 revealed orders to cleanse wounds to left lower extremities and right lower extremities with saline, pat dry, apply Xeroform, cover with non-adherent dressing, wrap with Kerlix daily for autolytic debridement every night shift for vascular wounds was scheduled for 11:00 P.M. and was not completed until 03/07/25 at 4:46 A.M. Review of Resident #3's medical recording including the MAR dated 03/07/25 did not reveal Resident #3 was assessed for pain or that Tylenol or other pain medication was administered at or prior to 4:46 A.M. Further review did not reveal Tylenol was administered at any time on 03/07/25. Review of Resident #3's Medication Administration Audit Report dated 03/07/25 revealed orders to cleanse wounds to left lower extremities and right lower extremities with saline, pat dry, apply xeroform, cover with non-adherent dressing, wrap with Kerlix daily for autolytic debridement every night shift for vascular wounds was scheduled for 11:00 P.M. and was not completed until 03/08/25 at 4:23 A.M. Review of Resident #3's medical record including the MAR dated 03/08/25 did not reveal Resident #3 was assessed for pain or that Tylenol or other pain medication was administered at or prior to 4:23 A.M. Further review did not reveal Tylenol was administered at any time on 03/08/25. Review of Resident #3's Medication Administration Audit Report dated 03/08/25 revealed orders to cleanse wounds to left lower extremities and right lower extremities with saline, pat dry, apply xeroform, cover with non-adherent dressing, wrap with Kerlix daily for autolytic debridement every night shift for vascular wounds was scheduled for 11:00 P.M. and was not completed until 03/09/25 at 1:14 A.M. Review of Resident #3's medical recording including the MAR dated 03/09/25 did not reveal Resident #3 was assessed for pain or that Tylenol or other pain medication was administered at or prior to 1:14 A.M. Further review did not reveal Tylenol was administered at any time on 03/09/25. Review of Resident #3's Medication Administration Audit Report dated 03/09/25 revealed orders to cleanse wounds to left lower extremities and right lower extremities with saline, pat dry, apply xeroform, cover with non-adherent dressing, wrap with Kerlix daily for autolytic debridement every night shift for vascular wounds was scheduled for 11:00 P.M. and was not completed until 03/10/25 at 4:10 A.M. Review of Resident #3's medical record including MAR dated 03/10/25 did not reveal Resident #3 was assessed for pain or that Tylenol or other pain medication was administered at or prior to 4:11 A.M. Further review did not reveal Tylenol was administered at any time on 03/10/25. Observation on 03/06/25 at 9:13 A.M. with Licensed Practical Nurse (LPN) #102 revealed she was administering residents their medications. Certified Nursing Assistant (CNA) #103 walked up to LPN #102 and reported that Resident #3 was asking for pain medication. LPN #102 administered two Tylenol 500 mg tablets to Resident #3 for a complaint of pain rated an eight out of 10 pain in her left leg. Interview on 03/06/25 at 3:50 P.M. with Resident #3 revealed sometimes the nurses gave her pain medication timely when she had pain and sometimes they did not. Interview on 03/10/25 at 11:30 A.M. with CNA #104 revealed Resident #3 had complaints that her left leg and knee hurt and she complained and groaned when she was moved while lying in her bed. CNA #104 stated she told the nurse when Resident #3 was in pain. CNA #104 stated the resident's pain medication helped a little bit, but the CNA did not believe the medication took the pain away completely. CNA #104 indicated Resident #3's legs were wrapped and night shift changed the wound dressings. CNA #104 stated Resident #3 was in pain this morning and she told LPN #105. Observation on 03/10/25 at 12:26 P.M. of CNA #104 providing Resident #3's morning care revealed the resident had both lower extremities wrapped in Kerlix and the wounds were unable to be visualized. CNA #104 lowered the head of Resident #3's bed and Resident #3 closed her eyes and laid quietly. CNA #104 stated Resident #3 did not like to move around much because of her pain. Resident #104 confirmed she sometimes did not like to be moved because of the pain in her legs. Interview on 03/10/25 at 4:06 P.M. with Resident #3 revealed her leg wounds hurt when the nurses wrapped and unwrapped her legs and put something on the areas. Resident #3 stated it hurt a lot when the nurses changed the dressings on her legs, she told the nurses it hurt, but most of the time she was not given anything for pain when her leg dressings were changed. Resident #3 stated she had so many wounds on her legs, they hurt and she stated she wondered how she got so many wounds. Interview on 03/10/25 at 4:08 P.M. with LPN #105 revealed Resident #3 often complained of leg pain. However, LPN #105 indicated Resident #3 was quiet and did not like to complain. LPN #105 stated sometimes she felt like she was the only nurse who gave Resident #3 and other residents their pain medication. LPN #105 indicated she thought Resident #3 would do well with a scheduled pain regimen because she was so quiet and did not usually complain. LPN #105 stated she talked to the night shift nurse's about medicating Resident #3 for her pain when they did her dressing changes but she was not sure if they did. Interview on 03/10/25 at 4:30 P.M. with the Administrator and Regional Nurse #106 revealed Resident #3 was cognitively intact and stated they believed the resident could ask for pain medications if she was having pain. Review of the facility policy titled Administering Pain Medications dated 10/2010 included the purpose of the procedure was to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. Review the resident's care plan to assess for any special needs of the resident. The pain management program was based on a facility-wide commitment to resident comfort. Be familiar with the physiologic and behavioral (non-verbal) signs of pain such as verbal expressions such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching the jaw etceteras; behavior such as resisting care, irritability, depression, decreased participation in usual activities; limitations in his or her level of activity due to the presence of pain; guarding, rubbing or favoring a particular part of the body. It was very important to recognize cognitive, cultural, familial, or gender-specific influences on a resident's ability or willingness to verbalize pain. For example some cultures value stoicism and a high threshold for pain which might influence a resident's willingness to report pain or accept pain-relieving interventions. Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief was obtained. This deficiency represents non-compliance investigated under Complaint Number OH00162597.

Based on open and closed medical record review, hospital record review, facility policy review, review of Centers for Disease Control (CDC) guidance and interview, the facility failed to ensure residents were administered the Coronavirus (COVID-19) vaccination after receiving education and consenting to the vaccine. This affected four residents (#6, #29, #30, #43) and had the potential to affect 16 additional residents (#3, #4, #8, #12, #13, #16, #17, #24, #28, #32, #34, #35, #40, #42, #52 and #53) who after receiving education and consented to the COVID-19 vaccine, had not yet received the vaccine. The facility census was 53. Actual harm occurred beginning on 01/28/25 when Resident #30, who consented to receiving the COVID-19 vaccine, but never received the vaccine, tested positive for COVID-19 and was subsequently transferred to the emergency room . The resident returned to the facility on [DATE] with orders for continued treatment associated with COVID-19 and pneumonia. However, on 01/31/25 the resident's condition deteriorated with symptoms including shortness of breath, low oxygen saturation and chest pain resulting in the resident again being transferred to the hospital at which time she was admitted for ongoing care related to COVID-19 and treatment of chronic hypercapnic respiratory failure, tachypnea and meeting the hospital sepsis criteria. The resident did not return to the facility after being transferred to the hospital. Findings include: 1. Review of the facility's infection control log revealed 20 residents, Resident #1, #6, #16, #20, #23, #25, #26, #27, #29, #30, #37, #39, #41, #42, #43, #46, #48, #49, #51, and #54 tested positive for COVID-19 during a facility COVID-19 outbreak between 01/16/25 and 02/02/25. Interview on 02/04/25 at 10:06 A.M. with Regional Clinical Operations Specialist #170 revealed she failed to schedule a COVID-19 clinic or order the COVID-19 vaccinations from the pharmacy (in September-October 2024) for residents including Resident #3, #4, #6, #8, #12, #13, #16, #17, #24, #28, #29, #30, #32, #34, #35, #40, #42, #43, #52 and #53 who had previously requested the COVID-19 vaccination. Interview on 02/05/25 at 10:49 A.M. with the Administrator revealed in October 2024 they had placed orders for some of the residents who desired the COVID-19 vaccine to their pharmacy. It was then decided to cancel the orders and to have a COVID-19 vaccine clinic. However, the clinic was never scheduled due to an unknown reason and the residents who requested the COVID-19 vaccine during this time were not administered the vaccine. The Administrator revealed when the facility identified this error, they tried to order the vaccine in January 2025, but it was unavailable and then the facility was in a COVID-19 outbreak. He reported the facility had ordered vaccines to be sent today (02/05/25). Review of the facility COVID policy Coronavirus Disease (COVID-19)- Infection Prevention and Control Measures dated September 2022 revealed infection prevention and control measures that were implemented to address the SARS-CoV-2 pandemic were incorporated into the facility infection prevention and control plan. These measures included identifying and managing ill residents and staff and encouraging all staff, residents, and visitors to remain up to date with all COVID-19 vaccine doses. Review of the Centers for Disease Control (CDC) guidance titled COVID-19 Vaccination for Long-term Care Residents dated 08/30/24, revealed if you live or work in a long-term care (LTC) setting, you can help protect yourself and the people around you by getting your 2024-2025 COVID-19 vaccine. COVID-19 vaccines are the best way to protect yourself from serious illness, hospitalization , and death caused by COVID-19. Older adults and people with certain health conditions are more likely to get very sick from COVID-19. COVID-19 vaccines can help keep you from getting seriously ill if you do get COVID-19. CDC recommends everyone ages [AGE] years and older, including people who live and work in long term care (LTC) settings, get two doses of a 2024 to 2025 COVID-19 vaccine six months apart. People who are moderately or severely immunocompromised should get at least two doses of 2024 to 2025 COVID-19 vaccine six months apart. They may also get more appropriate doses, beyond two doses at least two months apart, after talking to a healthcare provider. People can self-confirm as moderately or severely immunocompromised. This means they do not need documentation to receive a COVID-19 vaccination they are eligible for. While it is recommended to get 2024 to 2025 COVID-19 vaccine doses six months apart, the minimum time is two months apart, which allows flexibility to get the second dose prior to typical COVID-19 surges, travel, life events, and healthcare visits. 2. Review of the closed medical record for Resident #30 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #30 had diagnoses including acute and chronic respiratory failure with hypoxia, diabetes mellitus type two, and morbid obesity due to excess calories. The medical record indicated the resident was transferred to the hospital on 01/31/25 and was never readmitted to the facility. Continued review revealed no evidence the resident had ever received a COVID-19 vaccination while residing in the facility. Review of Resident #30's Resident COVID-19 Vaccination Voluntary Administration or Declination Acknowledgment form, dated 09/20/24, revealed the resident signed consent indicating she wanted the facility to administer her the COVID-19 vaccination. Review of Resident #30's physician's orders revealed (admission) orders dated 09/20/24 for albuterol sulfate inhalation aerosol solution 108 (90 base) micrograms per actuation (mcg/act) with instructions to give two puffs every four hours as needed for wheezing/shortness of breath and continuous oxygen at two liters per minute via nasal cannula. On 09/21/24 the resident was ordered DuoNeb solution 0.5-2.5 (3) milligram (mg)/3 milliliter (ml) once every four hours as needed for shortness of breath and fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/act twice daily. The physician's orders further revealed the only order for a COVID-19 vaccine was dated 01/25/25, but it was not signed off as completed in the Medication Administration Record or the Treatment Administration Record. Review of Resident #30's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #30's nursing progress note dated 01/27/25 at 10:20 P.M. revealed the resident was short of breath and wheezing. Her blood pressure was 114/67, pulse 63, temperature 97.4, respirations 20 and oxygen level was 86 percent on 3 liters per minute. Her as-needed inhaler and aerosol were given. An oxygen saturation recheck was 92 percent and the resident voiced relief. Review of Resident #30's nursing progress note dated 01/28/2025 at 2:45 P.M. and authored by Licensed Practical Nurse (LPN) #159 revealed the resident's symptoms continued to decline. The Medical Director (MD) ordered chest x-rays to be done. When the results came in it showed right basilar airspace disease. The resident was tested for COVID-19 and was positive. The MD wanted the resident sent to the emergency department. The resident was made aware and agreed. The resident's representative was notified, and an ambulance was called to transport. Review of Resident #30's hospital emergency department (ED) notes from 01/28/25 timed 3:30 P.M. revealed the resident presented to the hospital with respiratory symptoms, she reported she had body aches and a headache for about a week. She tested positive for COVID-19 today. She also had a chest x-ray that showed right basilar airspace disease. Per nursing home records, it did not appear the resident was started on any new medications. Reportedly low oxygen level for her at the nursing home so she was transferred to the ED. Review of the plan revealed the hospital would discharge her home (back to the facility) on antibiotics for COVID-19 and superimposed pneumonia. She was given (the antibiotic) Doxycycline. Review of the resident chest x-ray showed patchy bilateral airspace disease and poor inspiratory effect apparently related to viral or bacterial pneumonia. Review of Resident #30's nursing progress note dated 01/28/2025 at 8:45 P.M. and authored by LPN #137 revealed the resident returned to facility via squad, and she was transferred to her bed via squad and staff. The resident was in good spirits. The resident was noted to be hoarse when speaking. Vital signs included blood pressure was 74/49 (hypotensive), pulse 66, respirations 18, temperature 97.3, and oxygen saturation at 95% with oxygen usage. The resident stated she was going to call her husband as soon as she was situated in her bed and let him know she was back and that no further notification needed to be made. Review of Resident #30's physician's orders dated 01/28/25 revealed an order for the antibiotic, Doxycycline Hyclate Oral Capsule with instructions to give 100 milligrams (mg) by mouth two times a day for pneumonia for 10 days. Review of a 01/29/25 physician's orders revealed an order for Paxlovid (300 mg nirmatrelvir with 100 mg ritonavir) oral tablet therapy pack with instructions to give one tablet by mouth two times a day for COVID-19 for five days. Review of the Medication Administration Record (MAR) for Resident #30 revealed the resident received Doxycycline from 01/29/25 to 01/31/25 and received Paxlovid from 01/30/25 to 01/31/25. Review of Resident #30's nursing progress note dated 01/31/25 at 9:52 A.M. and authored by LPN #109 revealed the resident complained of shortness of breath and pain in her chest when coughing. Pulse oximetry was at 84 to 86 (percent) on oxygen (indicating a low saturation). The resident was very congested, currently on Doxycycline and Paxlovid for COVID-19 and pneumonia. The resident stated she felt she needed to be seen. The physician was updated and instructed to send the resident to the emergency room for evaluation. The resident's husband was aware. Review of Resident #30's progress note dated 01/31/25 at 5:42 P.M. revealed emergency room staff reported the resident was placed on a BiPap (a bilevel positive airway pressure machine providing non-invasive positive pressure ventilation) with six liters per minute oxygen and was being transferred to a different hospital (name provided). The note indicated the Director of Nursing (DON) was updated. Review of Resident #30's hospital emergency department notes dated 01/31/25 at 10:26 P.M. revealed the resident's findings were consistent with likely chronic hypercapnic respiratory failure. The patient continued to test positive for COVID-19. From a clinical perspective, on presentation, the patient was tachypneic and did meet sepsis criteria. However, due to secondary concerns for fluid overload status, full sepsis fluids were not given. The patient was covered with antibiotics for possible pneumonia. Additionally, the patient was COVID-19 positive and showed evidence of acute hypoxia. The patient had been getting breathing treatments and was currently on supplemental oxygen. The patient's comorbidities as well as evidence of hypercapnic respiratory failure secondary to COVID-19 warranted admission. Given the patient's respiratory status, it was felt the patient would best be served by being transferred to the main hospital. Interview on 02/05/25 at 10:49 A.M. with the Administrator verified Resident #30, who had consented to receive a COVID-19 vaccine upon admission (in September 2024), had not been provided the vaccine prior to contracting COVID-19 while residing in the facility. The resident subsequently contracted COVID-19 while residing in the facility (in January 2025) requiring in-patient hospital intervention/treatment. The resident did not return to the facility following her transfer to the hospital on 01/31/25 and was permanently discharged from the facility on 02/03/25. On 02/05/25 at 3:36 P.M. an interview with Compliance Specialist #206 revealed the last update she received was that Resident #30 was being transferred from the emergency room to (hospital name) main campus for treatment. On 02/10/25 at 10:17 A.M., information obtained via email from the Administrator revealed Resident #30 had since been transferred to another facility that was in-network. 3. Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses including end stage renal disease, COVID-19 and shortness of breath. Review of Resident #43's COVID-19 Vaccination Voluntary Administration or Declination Acknowledgment form, dated 10/06/24, revealed the resident signed consent indicating she wanted the facility to administer her the COVID-19 vaccination. Review of Resident #43's physician's orders since admission revealed she was never ordered the COVID-19 vaccine. Review of the current list of residents who requested the COVID-19 vaccine booster, provided by the facility, revealed Resident #43 wanted the booster. Review of the facility infection control log revealed Resident #43 became symptomatic and tested positive for COVID-19 on 01/24/25. Review of Resident #43's record revealed a health status note dated 01/24/25 at 5:36 A.M. revealed upon administration of morning medications, the writer noted the resident to have congestion. The resident also complained of general malaise and itchy ears. Her lungs were clear to auscultation and vital signs were stable. A COVID-19 test was positive, droplet isolation was implemented, the physician was made aware, and dialysis was cancelled for the day. On 02/05/25 at 11:58 A.M. an interview with Resident #43 revealed the resident had requested (and signed consent) to receive COVID-19 vaccinations following her admission to the facility. The resident denied receiving a COVID-19 vaccine/booster during her stay. During the interview, the resident reported she had tested positive for COVID-19 and had symptoms including congestion, malaise and itchy ears. Interview on 02/05/25 at 10:49 A.M. with the Administrator verified Resident #43, who had consented to receive a COVID-19 vaccine in October 2024, was not provided the vaccine and then subsequently tested positive for COVID-19 while residing in the facility (on 01/24/25). 4. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including unspecified dementia, dyspnea and cognitive communication deficit. Review of Resident #29's Covid-19 Vaccination Voluntary Administration or Declination Acknowledgment form, dated 07/23/24, revealed the resident signed consent indicating she wanted the facility to administer her the COVID-19 vaccination. Review of Resident #29's immunization tab in the electronic health record revealed the COVID-19 immunization was pending and dated 10/06/24. Review of Resident #29's physician's orders from July to February 2025 revealed the resident was never ordered the COVID-19 vaccine. Review of the facility infection control log revealed Resident #29 became symptomatic and tested positive for COVID-19 on 02/02/25. Review of Resident #29's record revealed a nurse's note dated 02/02/25 at 11:29 A.M. that included the resident complained to staff that she was not feeling well, and she was having a runny nose. A COVID-19 test was administered which was positive. Isolation protocols were put in place, a message was left for the resident's power of attorney, her temperature was 97.7 degrees Fahrenheit (afebrile), no coughing was noted, and her lungs were clear to auscultation but diminished. Interview on 02/05/25 at 10:49 A.M. with the Administrator verified Resident #29, who had consented to receive a COVID-19 vaccine in July 2024, was not provided the vaccine and then subsequently tested positive for COVID-19 while residing in the facility (on 02/02/25). 5. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses included paraplegia, mild intellectual disabilities and severe vascular dementia. Review of Resident #6's COVID-19 Vaccination Voluntary Administration or Declination Acknowledgment form, dated 07/24/24, revealed the resident's Power of Attorney (POA) signed consent for the resident to be administered the COVID-19 vaccination. Review of Resident #6's physician's orders from July 2024 to February 2025 revealed the resident was never ordered the COVID-19 vaccine. Review of the facility infection control log revealed Resident #6 became symptomatic and tested positive for COVID-19 on 01/28/25. Review of Resident #6's record revealed a nurse's note dated 01/27/25 at 3:08 P.M. that included the resident had a cough and general fatigue. A COVID-19 test revealed the resident was positive for COVID-19. Droplet isolation was initiated, and the physician and resident's representative were notified. Interview on 02/05/25 at 10:49 A.M. with the Administrator verified Resident #6, whose POA had consented to receive a COVID-19 vaccine in July 2024, was not provided the vaccine and then subsequently tested positive for COVID-19 while residing in the facility (on 01/28/25). This deficiency represents non-compliance investigated under Master Complaint Number OH00162253 and Complaint Number OH00162122.

Based on observation, interview, review of employee time punch details, review of staffing schedules, policy review, and review of the facility assessment, the facility failed to ensure there was sufficient staff to provide residents with timely care. This had the potential to affect all 53 residents residing in the facility. Findings include: Review of the staffing schedule for 02/03/25 revealed the facility had three Certified Nursing Assistants (CNA) and two Licensed Practical Nurses (LPN) scheduled for the 6:00 A.M. to 6:00 P.M. day shift, with one additional Registered Nurse (RN) scheduled in training. Prior to the shift beginning, one LPN and two CNAs called off, leaving the facility staffed with only one LPN, one RN in training, and one CNA to provide care to 53 residents. Review of the employee time punch details for 02/03/25 revealed CNA #151 clocked out at 6:00 A.M., CNA #103 clocked out 6:15 A.M., and two agency CNAs clocked out at 5:58 A.M. and 6:01 A.M. There were no CNAs present in the facility until Agency CNA #208 clocked in for her shift on 02/03/25 at 6:45 A.M. Observation on 02/03/25 at 10:37 A.M. revealed the facility was separated into four halls with one hall designated as a locked memory care unit. The linen closet on this unit was noted to be locked. There was no evidence of a kardex, care plan, or an activities of daily living (ADL) book on the unit. The facility had several residents on transmission based precautions and signs were noted in the facility indicating they had a COVID-19 outbreak. Telephone interview on 02/03/25 at 3:52 P.M. with Agency CNA #208 reported she arrived at the facility on 02/03/25 at approximately 6:36 A.M. This was the first time she had worked at the facility. Agency CNA #208 stated, upon arriving for her shift, she walked to the nurse's station and introduced herself. A facility nurse advised her to please report to the memory care unit because they did not have any staff working on that unit. She was told at this time she was the only CNA in the building. She reported to the nurse that she had never worked in the facility before and did not feel comfortable working on the unit by herself. Agency CNA #208 stated she was concerned for her CNA license. She was told by the facility nurse that someone would be coming in soon to assist her. The CNA reported she asked for a report on her patients, but was told the nurse had just arrived and did not have a report to give her. She was told that all the CNAs had left the facility without giving a report or ensuring the next shift had arrived to take over their assignments. Agency CNA# 208 continued that she attempted to find a Kardex or care plan to help assist her with resident care, but she was unable to locate any reference materials. Agency CNA #208 stated when she arrived on the memory care unit around 6:45 A.M., residents were wet, and one resident was covered in bowel movement. She was not provided the code and was unable to access the locked laundry area where clean linens were stored. She reports she used incontinence wipes to clean up the residents the best she could. She stated she had to change one residents incontinence brief while he remained in his recliner due to not having any information on how any of the residents on the unit transferred. Agency CNA #208 continued that at one point, an unnamed dietary staff member brought trays into the memory care unit, but she had no way of knowing how residents transferred, what kind of assistance they needed, or what their diets were. She reported trying to get help on the unit she pushed open the locked door to make it alarm, but no one responded to the alarm for at least 15 minutes. She continued after about 15 minutes she believed someone from therapy responded and helped tell her which residents required assistance with feeding. Agency CNA #208 stated she was not able to provide timely incontinence care nor was able to turn and reposition many of the residents due to being the only one on the unit, having no access to the laundry room, and no care plan information for any of the residents. She went on to say many of the residents were COVID-19 positive, in isolation, and probably needed extra care and services that she was unaware of or unable to provide. Agency CNA #208 stated around 7:45 A.M. a nurse came on the unit. Also, around this time the Administrator arrived at the unit. CNA #208 reported to the Administrator that she did not have the proper supplies to care for the residents on the unit and told him she felt all these residents were unsafe with the staffing levels in the facility. Interview on 02/03/25 at 4:05 P.M. LPN #109 reported she arrived at the facility a little before 6:00 A.M. on 02/03/25. She stated she received a report from an unknown agency nurse. She stated the only people who showed up for work that day was herself and another nurse who was in training. She continued that after getting the shift report she looked around and realized there were no other staff present in the facility except for her and the nurse in training. All of the CNAs scheduled to work did not come in and the night shift CNAs left without coverage. She started around 6:45 A.M., an unnamed Agency CNA arrived at the facility and she asked her to please go to the memory care unit because no one was on the unit. She went on to say she was unable to give her a report or any information regarding the residents on that unit. LPN #109 proceeded to send out a group text to off-duty employees asking for help at the facility. LPN #109 stated, at one point, she thought about calling the paramedics to come into the facility to assist with resident care. She stated that she and the nurse in training were the only staff present to care for all the residents outside of memory care. She stated she answered call lights and provided supervision until 7:30 A.M. when management and additional help arrived. LPN #109 confirmed she felt very unsafe in the situation, and residents went without timely incontinence care and repositioning. She also stated medications were not administered on time that morning. Interview on 02/03/25 at 4:37 P.M. RN #141 stated she arrived to the facility that morning around 5:54 A.M She reported it was supposed to be her third day in training. She attempted to get a report from an unnamed agency nurse, but was told she had to leave. Another nurse was scheduled for work, but she showed up and then left right away. She reported that she still had a report sheet from the Friday before and had to use that. She stated she was not comfortable taking the assignment. She went on to say that around 6:20 A.M. she had realized that all of the night shift CNA had left the facility, and none of the day shift CNAs had reported to work. stated this left the memory care abandoned and only herself and LPN #109 present in the facility to care for all the residents. RN #141 reported an Agency CNA arrived late and was advised to report to the memory care unit since no one was present on that unit. She confirmed she was unable to give her a report or any information about the residents on that unit since this was only her third day working in the facility. RN #141 confirmed the agency aide expressed concerns regarding resident safety. She went on to say due to the lack of staff, the only care she was able to provide until around 7:30 A.M. was answering call lights and maintaining supervision. RN #141 reported the staffing levels were unsafe due to many residents requiring additional assistance related to the COVID-19 outbreak, no shift-to-shift report having been given, she was not fully trained and was unfamiliar with the computer system, and one hospice resident was actively dying. Around 7:30 A.M. to 8:00 A.M., RN #141 reported additional help arrived at the facility. Telephone interview on 02/04/25 at 11:06 A.M. with CNA #103 reported she was one of the CNAs who worked on 02/02/25 from 6:00 P.M. until 02/03/25 at 6:00 A.M. Se reported the facility staffing is not good and sometimes there are only two CNAs scheduled for the entire building. She reported that on 02/03/25, only one CNA showed up for work briefly. She stated she was unable to stay and work due to a previous engagement and left the facility without ensuring proper coverage. She reported she gave a nurse report and then left shortly after 6:00 A.M. Telephone interview on 02/04/25 at 11:19 A.M. CNA #151 reported she worked in the facility on 02/02/25 from 6:00 P.M. until 02/03/25 at 6:00 A.M. She stated there were no CNAs listed on the schedule to come into work on day shift beginning on 02/03/25 at 6:00 A.M. She stated the facility scheduler had been off work sick. She stated when she left in the morning shortly after 6:00 A.M. only one person had come to work. She stated she had written down the last time she changed her residents on a sheet of paper and left it at the nurse's station without giving it to anyone. She verified she left the facility without ensuring adequate coverage due to a previous commitment. Telephone Interview on 02/04/25 at 1:31 P.M. Agency LPN #210 reported she worked in the facility on 02/02/25 from 6:00 P.M. until 02/03/25 at 6:00 A.M. She reported no CNAs showed up for their shift on 02/03/25. She went on to say all four CNAs that were working with her the night before abandoned their shift without a replacement. Agency LPN #210 went on to say when she left in the morning, the only staff present was an LPN and another nurse who was in training. Telephone interview on 02/4/25 at 1:40 P.M. Agency LPN #211 reported she worked in the facility 02/02/25 from 6:00 P.M. until 02/03/25 at 6:00 A.M. She stated on her shift she had two agency CNAs and two facility CNAs. She estimated all four CNAs left the facility by 6:10 A.M., leaving no CNAs in the facility and the memory care unit completely unattended. She stated she gave the report to the oncoming nurse and at 6:45 A.M. an agency CNA arrived at the facility and was sent to the memory care unit since there was no staff members present in the unit. Interview on 02/04/25 at 10:06 A.M. with Regional Clinical Operation Specialist Registered Nurse (RCOSRN) #170 reported she arrived at work on 02/03/25 at 7:30 A.M., got report from the nurses, and immediately began assisting residents on the memory care unit. She confirmed that due to multiple staff call offs, the facility was understaffed that morning. She stated it is the facility policy that CNAs complete a walk through with the oncoming CNAs and give the oncoming shift a detailed report before leaving the facility. She verified a shift-to-shift report was not completed, and night shift CNAs left the facility without ensuring adequate replacements. She verified that the facility's memory care unit was to be staffed 24 hours a day and confirmed that from 6:10 A.M. until 6:45 A.M. there was no coverage on the unit. RCOSRN #170 stated that the facility kept a care plan for each resident in a binder outside of the memory care unit at the main nurse's station, and verified without receiving a report and being oriented to where this information is stored, Agency CNA #208 would not have had access to any resident information. Interview on 02/04/25 at 1:45 P.M. with the Administrator revealed he was aware of the staffing shortage on the morning of 02/03/25. He reported, due to last-minute staff call-offs, the facility was not staffed adequately. He reported that once he was aware of the situation, facility management arrived at the facility. The Administrator estimated management staff arrived by 7:30 A.M. and assisted with resident care. He reported at a very minimum, the facility can operate with three to four CNAs and two nurses. He went on to state a staff member should always be on the memory care unit at all times. He verified the night shift CNAs should have stayed until a proper replacement arrived and a report was given before leaving the facility. He confirmed he would be providing education to the CNAs who left the facility before ensuring a replacement was present. Review of the facility policy, Staffing revised 10/2027 revealed the facility works to provide sufficient members of staff with skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Staffing numbers and skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Review of the Facility Assessment Tool last updated 01/08/25 regarding direct care staff revealed the facility on an ongoing basis will evaluate the current needs/acuity of residents by facility wing/hall and ensure adequate staffing of licensed staff is provided at all times to meet the needs of the residents at any given time including but not limited to ADL needs are being met, residents have adequate supervision, medications are administered timely, per physician orders and blood sugars are properly monitored. Consideration of the completion of daily staffing is needed, facility administration will be notified immediately and engage the assistance of sister facilities, administration, and agencies as appropriate to ensure significant staffing is achieved. This deficiency represents non-compliance investigated under Master Complaint Number OH00162253.

Based on observation, interview, record review and policy review the facility failed to ensure facility staff member donned and doffed the correct personal protective equipment (PPE) when entering and exiting Resident #26's room, who was COVID-19 positive. This had the potential to affect 37 residents (2, #3, #4, #5, #7, #8, #9, #11, #12, #13, #14, #15, #17, #18, #19, #21, #24, #28, #31, #32, #33, #34, #35, #36, #38, #40, #41, #42, #43, #44, #45, #47, #50, #52, #53, #54, and #55) who were not currently infected with COVID-19. The facility census was 53. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included hypertension, insomnia, anxiety disorder, unspecified dementia, and positive for COVID- 19 on 01/31/25. Review of Resident #26 physicians' orders revealed an order dated 01/31/25 for droplet isolation precautions to be maintained due to COVID positive. All meals and services were to be provided in the room every day and night shift for seven days. Review of the facility infection control log revealed Resident #26 became symptomatic and tested positive for COVID-19 on 01/31/25 and was placed on droplet precautions. Further review revealed 20 residents tested positive for COVID-19 during a facility COVID-19 outbreak between 01/16/25 and 02/02/25. Observation on 2/5/25 at 11:20 A.M. revealed Resident #26's door to her room was open. A sign was posted outside of the resident's door stating she was on droplet precautions. A bin full of PPE was noted to be outside of her door. Observation inside of the room revealed Resident #26 was in her bed and Agency Certified Nursing Assistant (CNA) #200 was standing beside her. Maintenance Director #202 was also present in the room using the bed remote for an additional empty bed that was in the resident room. Agency CNA #200 and Maintenance Director #202 were observed to only have surgical masks on. They did not have the required PPE including gloves, N95 respirator mask, gowns, and face shields. They remained in the room until 11:23 A.M. when they both walked out of the room and used hand sanitizer. Interview on 02/05/25 at 11:23 A.M. with both CNA #200 and Maintenance Director #202 confirmed they did not don and doff proper PPE when entering and exiting Resident #26's room. They both verified she was COVID positive and stated they forgot to don the PPE before entering the room. Additionally, Maintenance Director #202 stated he was only in the room for a couple of minutes. Interview on 02/05/25 at 10:54 A.M. The facility's Director of Nursing (DON) confirmed when staff entered a COVID-19 positive room, staff should wear an N95 respirator mask, gown, gloves, and a face shield. Upon leaving the room staff should clean or disregard the face shield, remove the gown, gloves, and N95 mask and wash their hands or use hand sanitizer. Review of the recent facility education completed due to the recent COVID-19 outbreak revealed education for PPE dated 01/07/25, education for cleaning face shields dated 01/07/25, education for Droplet Precautions dated 01/07/25, education titled COVID education dated 01/14/25 had been provided to facility staff. The sign-in sheets revealed STNA #200, and Maintenance Director #202 did not sign that they received the education on any of these topics. Review of the facility's policy, Isolation-Categories of Transmission-Based Precautions revised 10/2022 revealed transmission-based precautions are additional measures used that protect staff, visitors, and other residents from becoming infected. These measures are determined by specific pathogen and how it spreads from person to person. The three types include contact, droplet, and airborne. Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by individual coughing, sneezing talking, or by the performance of procedures such as suctioning. Policy indicated masks are worn when entering the room, gloves, gown, and goggles are worn if there is a risk of spraying respiratory secretions. This deficiency represents non-compliance investigated under Master Complaint Number OH00162253 and Complaint Number OH00162122.

Based on observation, record review, and interview, the facility failed to ensure residents with non-pressure related skin issues were comprehensively assessed in a routine manner. This affected one resident (Resident #10) of three residents reviewed for non-pressure related skin impairment. The facility census was 53. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included pain in the right knee, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus with diabetic neuropathy, and peripheral vascular disease. Review of Resident #10's nurse progress note dated 01/03/25 at 11:19 A.M. revealed staff alerted the nurse that the resident has an open area to right lower extremity. The abrasion was to the resident's right shin noted measuring 3.4 centimeters (cm) in length by 10.5 cm in width and 0.1 cm in depth. Resident #10 stated his left heel went across his leg while he was uncrossing his legs. The resident was encouraged to sit with his legs uncrossed. The medical director was notified, and treatment orders were put in place and initiated. Observation on 02/03/25 at 3:20 P.M. revealed Regional Clinical Operations Specialist Registered Nurse #170 dressed Resident #10's wound. The resident was observed to have two small, open ulcers to his lower right leg. Both areas were cleansed with saline, collagen was applied, and an abdominal pad (absorbent dressing) was placed over the wounds, and wrapped with kerlix (a rolled gauze dressing). Review of Resident #10's wound monitoring records revealed on 01/03/25 the facility assessed the wound and described it as one abrasion measuring 3.2 cm in length by 10.5 cm in width, and 0.2 cm in depth. On 01/16/25, the facility assessed the wound again describing it as one abrasion measuring 4.5 cm in length, by 8.5 cm in width and 0.1 cm in depth. Continued review of the resident chart revealed no further wound monitoring was completed after 01/16/25. Review of Resident #10's outside wound healing center assessment dated [DATE] revealed the center classified the wound as a non-pressure chronic ulcer of the right calf with fat later exposed measuring 8.4 cm in length by 4.4 cm in width, and 0.1 cm in depth. The note states the resident underwent debridement at the outside wound center Review of Resident #10's physicians' order revealed an order dated 01/16/24 for Bactrim DS (an oral antibiotic) 800-160 milligrams (mg) with instructions to give 1 tablet by mouth two times a day for 10 days for wound infection. Interview on 02/05/25 at 1:30 P.M. with Compliance Specialist #206 revealed on 01/03/25, Resident #10 was noted to have an abrasion to his right knee. He was seeing the facilities wound practitioner until 01/16/25 when family requested the resident be seen at an outside wound center. He was also prescribed antibiotics for a wound infection on this date. He was supposed to follow up at the wound center in one week, but due to an acute illness he was unable to go. Compliance Specialist #206 confirmed the facility did not ensure continued wound monitoring was completed after his 01/16/25 wound center visit. This deficiency represents non-compliance investigated under Complaint Numbers OH00161733 and OH00161732.

Based on record review, fall investigation review, interview and policy review, the facility failed to have documented evidence fall prevention interventions were implemented and failed to ensure care plans were updated timely to prevent repeat falls for Resident #56. This affected one resident (#56) of three residents reviewed for falls. The facility census was 55. Findings include: Review of the medical record for Resident #56 revealed and admitted [DATE] and a discharge date of [DATE]. Diagnoses included dementia, diabetes, adult failure to thrive, anxiety, cognitive communication deficit, insomnia, and lack of coordination. Review of the quarterly MDS assessment dated [DATE] revealed Resident #56 was severely cognitively impaired. He required supervision or touch assistance for eating, and partial to moderate assistance from oral hygiene, toileting, showering, dressing, and hygiene. Review of the care plan dated 10/23/23 revealed Resident #56 was at risk for falls due to dementia, medications, and impaired safety awareness. Interventions included elbow protectors to be worn as tolerated, encouraging the resident to use the bathroom upon rising, before and after meals and at bedtime, and providing periods of rest. Review of the physician's orders for November 2024 revealed an order to remind and demonstrate the use of the call light two times a day for Resident #56, which began on 11/20/24. Review of the fall risk assessment dated [DATE] revealed Resident #56 was at a high risk for falls. Review of the fall investigation dated 11/23/24 at 3:00 P.M. revealed Resident #56 was found on the floor and lying on his back in between the beds in his room. Resident #56 did have a bowel movement, and it appeared Resident #56 was rushing to get to the bathroom and fell on his way. No injuries were noted. An intervention was added to assist Resident #56 to the toilet after lunch in between lunch and dinner. The investigation did not include documented evidence of Resident #56's witness statements regarding the event, when Resident #56 was last toileted, and if Resident #56 was wearing elbow protectors and non-skid socks. There was also no documented evidence that the resident's care plan was updated to include assisting the resident to the toilet after lunch and between lunch and dinner. Review of the fall investigation dated 11/25/24 at 1:58 A.M. revealed Resident #56 was observed lying on his back on the floor in his room by the door. He was noted to have visible bruising starting on the right side of his head, right upper arm, right forearm, right elbow and right knee. Resident #56 was incontinent at the time of the fall. He was not able to answer questions appropriately, pupils were pinpoint and non-reactive to light. Vital signs included a BP 142/108, pulse 56, respirations 10, oxygen saturation 73%, and temperature 96.9 degrees F. Resident #56 was last noted to be resting quietly in bed approximately 30 minutes prior to the incident. He was wearing gripper socks on his feet. Resident #56 received oxygen at four liters per minute and his oxygen saturation increased to 97%. A skin and range of motion assessment was unable to occur due to Resident #56 being immobilized for safety until the paramedics arrived. The physician was notified and ordered Resident #56 be sent to the emergency department (ED), Resident #56's responsible party was also notified. There was no documented evidence of whether or not Resident #56 was wearing elbow protectors and when the resident was last toileted. Review of the ED discharge instructions dated 11/25/24 at 2:18 A.M. revealed Resident #56 was treated for a fall, an abrasion to the right arm and a closed head injury. Instructions were to follow up with his primary care physician within two to four days. Interview on 12/09/24 at 2:38 P.M. with Licensed Practical Nurse (LPN) #205 confirmed the facility did not obtain witness statements for the fall investigations for Resident #56. Review of Resident #56's care plan dated 12/09/24 revealed a new intervention which included assistance with toileting between lunch and dinner was added after surveyor intervention. Interview on 12/10/24 at 8:51 A.M. with the Director of Nursing (DON) confirmed the fall investigation for Resident #56 did not include documented evidence that all interventions were in place or when the resident was last toileted prior to the fall. The DON also verified a new intervention which included assistance with toileting between lunch and dinner was not timely added to the resident's care plan after the fall that occurred on 11/23/24. Review of the facility policy titled Falls and Fall Risk, Managing, dated March 2018, revealed the facility would monitor and document a residents' response to interventions intended to reduce falls or risks of falls and reevaluate conditions and interventions as needed. This deficiency represents noncompliance investigated under Master Complaint Number OH00160153.

Based on record review, observation, and interview, the facility did not ensure food was served at palatable temperatures. This had the potential to affect 54 residents that received meals from the facility. One resident (Resident #46) out of 55 residents received nothing by mouth. The facility census was 55. Findings include: Interviews during phase one of the annual survey on 10/21/24 from 8:15 A.M. through 5:00 P.M. with Residents #2, #3, #14, #25, #40, and #159 revealed each had complaints the food was cold and/or not palatable. Observation of tray line on 10/22/24 from 11:00 A.M. trough 11:54 A.M. revealed food was above 165 degrees Fahrenheit (F). A test tray was requested as the last resident's food was plated. The food truck left the kitchen at 11:55 A.M. and arrived at the unit at 11:56 A.M. When the last tray on the truck was delivered on 10/22/24 at 12:00 P.M., the test tray was removed from the food truck and placed on a table where food temperatures were taken. Dietary Manager (DM) #208 took the temperature of the food and stated that the temperature for the chicken thigh was 108 degrees F and the peas were 115 degrees F. DM #208 said the food should be hotter. Upon tasting the food it was tepid. The facility was not able to provide a policy regarding what food temperatures should be at point of service. This deficiency represents non-compliance investigated under Complaint Number OH00158226 and OH00158184.

Based on medical record review, observation, staff interview, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). Two errors occurred within 30 opportunities for an error rate of 6.67%. This affected one (Residents #13) of four residents reviewed for medication administration. and had the potential to affect an additional 13 residents, (Resident #5, #16, #21, #22, #27, #28, #29, #31, #32, #40, #41, #157, and #158) who received insulin injections. The facility census was 55 residents. Findings include: Record review for Resident #13 revealed an admitted [DATE]. Diagnosis included type two diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was moderately cognitively impaired. Resident #13 required set up or clean up assistance with meals and partial moderate assistance with personal hygiene. Resident#13 had a diagnosis of diabetes mellitus. Review of the care plan for Resident #13 dated 12/12/23 revealed Resident #13 was at risk for hypo/hyperglycemic episodes related to insulin dependent diabetes mellitus and required daily and sliding scale insulin. Interventions included to administer insulin as ordered. Review of the physician orders dated 08/28/24 for Resident #13 revealed an order for insulin lispro (one unit dial) 100 units per milliliter (ml) solution pen-injector, inject 20 units subcutaneously (sq) with meals for diabetes mellitus. An additional order dated 06/09/24 included lantus sq solution 100 unit/ml (insulin glargine) inject 40 units sq two times a day for diabetes mellitus. Observation on 10/22/24 at 7:10 A.M. of Licensed Practical Nurse (LPN) #254 preparing the lispro kwikpen 20 units for Resident #13 revealed LPN #254 did not prime the insulin pen injector prior to setting the pen at 20 units. LPN #254 verified she did not prime the insulin pen prior to injecting the medication then continued and injected the lispro insulin. Observation on 10/22/24 at 7:13 A.M. of LPN #254 prepare the lantus solostar 40 units (via insulin pen) for Resident #13 revealed LPN #254 did not prime the insulin pen injector prior to setting the pen at 40 units. LPN #254 verified she did not prime the insulin pen prior to injecting the medication then asked, How do you do that? LPN #254 continued and injected the lantus solostar 40 units without priming the insulin pen. Review of the daily staffing schedule for September/October 2024 revealed LPN #254 worked with residents in all areas of the facility. Interview on 10/22/24 at 11:55 A.M. with the Director of Nursing (DON) confirmed LPN #254 worked in all areas of the facility with all residents. The DON confirmed Resident #5, #16, #21, #22, #27, #28, #29, #31, #32, #40, #41, #157, and #158 also received insulin injections. Review of the manufacturer's guidelines titled, Use of the Insulin Lispro revised July 2023 included for sq use three ml single-patient-use pen included insulin lispro kwikpen was a disposable single-patient use prefilled pen containing 300 units of insulin lispro. More than one dose could be given from the pen. The guidelines indicated to always use a new needle for each injection. Prime before each injection. Priming the pen meant removing the air from the needle and cartridge that could collect during normal use and ensured that the pen was working correctly. If the pen was not primed before each injection, too much or too little insulin could be administered. Review of the manufacturer's guidelines for use of lantus insulin titled Safely and Effectively revised 11/2018 included, Important Administration Instructions. Always perform the safety test (priming) before each injection. Performing the safety test ensured an accurate dose was administered by ensuring the pen and needle worked properly and removed air bubbles. The guidelines indicated to select a dose of two units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. Hold the pen and needle pointing upwards. Tap the insulin reservoir so any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. If no insulin comes out, the needle may be blocked, change the needle and try again. If no insulin comes out after changing the needle, your solostar may be damaged. Do not use this solostar. This deficiency represents non-compliance investigated under Complaint Number OH00158226.

Based on observation, interview, and record review, the facility failed to provide residents with their preferences during meals. This affected four (#3, #8, #16 and #34) of four residents reviewed for food preferences. The facility census was 55. Findings include: 1. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia, adult failure to thrive, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/03/24, revealed the resident had severely impaired cognition. The resident required partial or moderate assistance for activities of daily living (ADLs). Review of the October 2024 physician orders revealed that Resident #3 was ordered a regular diet with no restrictions and double portions. Review of Resident #3's diet ticket revealed that he disliked orange juice. Observation on 10/22/24 at 7:18 A.M. revealed Resident #3 was sitting up in bed and his breakfast tray had an entree of eggs, sausage casserole with toast, Cheerios, milk, and orange juice. Interview on 10/22/24 at 7:27 A.M. with Dietary Manager (DM) 208 confirmed Resident #3 was served orange juice and his diet ticket indicated a dislike of orange juice. 2. Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses to include but not limited to depression, anxiety disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/27/24, revealed the resident had intact cognition and required partial or moderate assistance for activities of daily living. Review of the October 2024 physician orders revealed that Resident #8 was ordered a no added salt diet, regular texture, regular consistency of liquids and give fruit for dessert. Review of Resident #8's diet ticket revealed that she was to get fruit for dessert. Observation and interview on 10/22/24 at 11:52 A.M. revealed that Resident #8's tray was plated and placed in the food cart to be delivered. Resident #8's food tray included a piece of cake and no fruit. This was verified by [NAME] #239 at time of observation. 3. Review of the medical record for Resident #16 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to diabetes mellitus, chronic kidney disease, and chronic pulmonary disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/03/24, revealed the resident had moderately impaired cognition and required substantial or maximal assistance for activities of daily living. Review of the October 2024 physician orders revealed that Resident #16 was ordered a consistent carbohydrate, no added salt diet, regular texture, regular consistency of liquids Review of Resident #16's diet ticket revealed that she wanted eight ounces of milk to drink with her meal. Observation and interview on 10/22/24 at 11:52 A.M. revealed that Resident #16's food was plated and placed on the food cart to be delivered. Further observation revealed there was no milk on Resident #16's meal tray. This was verified by [NAME] #239 at time of observation. 4. Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE] with diagnoses to include but not limited to diffuse traumatic brain injury, convulsions, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/24, revealed the resident had moderately impaired cognition and required supervision for activities of daily living. Review of the October 2024 physician orders revealed that Resident #34 was ordered a regular diet with no restrictions and double portions. Review of Resident #34's diet ticket revealed the resident wanted eight ounces of milk to drink with his meal. Observation and interview on 10/22/24 at 11:52 A.M. revealed that Resident #34's tray was plated and placed into the food cart to be delivered. There was no milk on Resident #34's tray. This was verified by [NAME] #239 at time of observation. Review of the facility policy dated December 2017 titled, Therapeutic Diets, revealed that diets were prescribed in accordance with resident's goals and preferences. This deficiency represents non-compliance investigated under Complaint Number OH00158226 and OH00158184.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure advanced directives were accurate. This affected one (Resident #108) of one resident reviewed for advanced directives. The census was 55. Findings include: Medical record review revealed Resident #108 was admitted to the facility on [DATE]. Diagnoses included dementia, insomnia, and hypertension. A Brief Interview for Mental Status (BIMS) dated [DATE] revealed a score of ,d+[DATE], which indicated Resident #108 was not cognitively intact. Further review of Resident #108's medical records revealed the hard copy chart included conflicting advanced directives. One advanced directive indicated Full Measures, that required all life saving measures be used. A second advanced directive indicated Do Not Resuscitate - Comfort Care (DNR-CC), that specified Cardio Pulmonary Resuscitation (CPR) was not to be initiated in case of cardiac or respiratory arrest. The DNR-CC was signed by the physician and both forms were dated [DATE]. The electronic medical record indicated Resident #108's advanced directive was DNR-CC. Interview with Licensed Practical Nurse (LPN) #227 and the Administrator on [DATE] between 9:40 A.M. and 9:50 A.M. confirmed there were two different advance directives in the hard chart. They revealed in the case of a resident experiencing a cardiac or respiratory arrest, staff would reference and follow the advance directive in the hard chart. They confirmed the advance directive in the electronic record and the hard copy chart should be the same but for Resident #108, they were conflicting. Review of the facility's Advance Directives policy (revised [DATE]) revealed, Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The Interdisciplinary Team will review annually with the resident, and/or her representative, her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument.

Based on interview, record review, and review of the facility policy, the facility failed to timely notify Resident #25's Power of Attorney (POA) of an injury of unknown origin. This affected one (Resident #25) of three residents reviewed for resident representative notification. The facility census was 55. Findings include: Record review for Resident #25 revealed a readmitted [DATE]. Diagnoses included age related physical debility, dementia, cognitive communication deficit, Parkinson's disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was rarely or never understood. Resident #25 had impairment on both sides of the upper and lower extremities. Resident #25 was dependent for eating, oral hygiene, toileting, bathing, personal hygiene, bed mobility, chair/bed, bed to chair transfers, and wheelchair mobility. Review of the progress note for Resident #25 dated 09/22/24 timed at 10:53 A.M. completed by Licensed Practical Nurse (LPN) #275 included upon feeding resident in dining room, this nurse noted a bruised raised area two centimeters (cm) in length by 1.2 cm in width by 0.4 cm with open area in center measuring 0.3 cm by 0.3 cm by 0.0 cm. No drainage or odor noted. Also noted, open area right forehead measuring 0.5 cm by 0.3 cm by 0.0 cm. No drainage or odor noted. Location of injury consistent with contact with Hoyer (mechanical lift) bar during transfer. Review of the progress note for Resident #25 dated 09/22/24 timed at 10:59 A.M. revealed Resident POA aware of bruise noted to center forehead. Observation on 10/21/24 at 12:43 P.M. of Resident #25 revealed Resident #25 was sitting up in the dining room. Further observation revealed a large light purple/bluish colored bruise to the center of the forehead. Resident #25 was non-interviewable. Interview on 10/22/24 at 8:56 A.M. with Resident #25's POA/Emergency contact #1 revealed she worked at the facility as a receptionist. While at work, at some point that morning (09/22/24), POA/Emergency contact #1 went to see her mom, her mom had what looked like a lifted goose egg the size of a golf ball cut in half sticking out of her forehead, it was oval shaped up and down just above the bridge of her nose to the hairline. Resident #25's POA/Emergency Contact #1 revealed, Nobody notified me, I noticed it when I came to work, I asked her nurse what happened, she said I don't know, I fed her at breakfast then noticed it. Interview on 10/23/24 at 8:00 A.M. with Licensed Practical Nurse (LPN) #275 revealed she was not aware of Resident #25's bruise to her forehead until she began assisting Resident #25 in the dining room. LPN #275 confirmed Resident #25's POA/Emergency Contact #1 asked her what happened, she was not notified prior. Interview on 10/24/24 at 11:12 A.M. with State tested Nursing Assistant (STNA) #230 revealed on 09/22/24 she was Resident #25's primary STNA. When she transported Resident #25 to the dining room at around 8:00 A.M. on that day, her and LPN #275 noticed the bruised area on her forehead at that time. Review of the facility policy titled, Change in Resident's Condition or Status revised May 2017 revealed the facility was to promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and or status. This deficiency represents non-compliance investigated under Complaint Number OH00158226.

Based on staff interview, medical record review, review of facility reported incidents (FRI) and review of the facility policy, the facility failed to report an injury of unknown origin to the State agency. This affected one (Resident #25) of two residents reviewed for abuse. The facility census was 55. Findings include: Record review for Resident #25 revealed a readmitted [DATE]. Diagnoses included age related physical debility, dementia, cognitive communication deficit, Parkinson's disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was rarely or never understood. Resident #25 had impairment on both sides of the upper and lower extremities. Resident #25 was dependent for eating, oral hygiene, toileting, bathing, personal hygiene, bed mobility, chair/bed, bed to chair transfers, and wheelchair mobility. Review of the care plan dated 04/01/24 revealed Resident #25 had potential impairment to skin integrity related to incontinence, aspirin use, fragile skin (age related). Interventions included to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of the physician order dated 09/22/24 for Resident #25 revealed to monitor the bruise to center forehead and leave open to air. Review of the progress note for Resident #25 dated 09/22/24 timed at 10:53 A.M. completed by Licensed Practical Nurse (LPN) #275 revealed upon feeding resident in dining room, this nurse noted a bruised raised area two centimeters (cm) in length by 1.2 cm in width by 0.4 cm with open area in center measuring 0.3 cm by 0.3 cm by 0.0 cm. No drainage or odor noted. Also noted, open area right forehead measuring 0.5 cm by 0.3 cm by 0.0 cm. No drainage or odor noted. Location of injury consistent with contact with Hoyer (mechanical lift) bar during transfer. Review of the FRI's from 09/21/24 through 10/21/24 revealed there was no FRI completed for an injury of unknown origin for Resident #25. Observation on 10/21/24 at 12:43 P.M. of Resident #25 revealed Resident #25 was sitting up in the dining room. Resident #25's bilateral arms were partially contracted. A large light purple/bluish/yellow colored bruise located from below the hairline to above the eyebrows in the center of the forehead was observed. Resident #25 was non-verbal and did not respond to conversation. Interview on 10/22/24 at 8:56 A.M. with Resident #25's Power of Attorney (POA)/Emergency contact #1 revealed she worked at the facility as a receptionist. Resident #25's POA revealed when she went to work, at some point that morning (09/22/24), she went to see her mom, her mom had what looked like a lifted goose egg the size of a golf ball cut in half sticking out of her forehead, it was oval shaped up and down just above the bridge of her nose to the hairline. Resident #25's POA/Emergency contact #1 noticed it when she came to work and asked her nurse what happened. The nurse said she did not know, she fed her breakfast then noticed it. Resident #25's POA/Emergency contact #1 revealed she left the faciity on [DATE] at around 3:00 P.M. and Resident #25 had no injuries to her forehead at that time. Resident #25's POA/Emergency contact #1 revealed she still did not know how the injury occurred. Interview on 10/22/24 at 3:09 P.M. with Licensed Practical Nurse (LPN) #291 revealed Resident #25 was unable to turn or reposition herself, or even slightly move side to side without assistance. Interview and observation on 10/22/24 at 4:02 P.M. revealed State tested Nurse Aides (STNAs) #230 and #233 transferring Resident #25 from the bed to the chair. The interview and observation revealed inconsistencies with Resident #25 bumping her head during a Hoyer transfer. STNAs #230 and #233 confirmed Resident #25 was unable to move in bed or in the chair without assistance. Observation revealed Resident #25's bed had two half rails, one located on each side of the upper portion of the bed. Observation while Resident #25 was being repositioned in bed to place the Hoyer pad under her by STNAs #230 and #233 revealed the side rail bars lined up to the same height and shape as the bruise on the forehead. Observation with Director of Nursing (DON) on 10/23/24 at 9:38 A.M. of STNA #216 and #230 transfer Resident #25 with a mechanical lift from her chair to her bed revealed no concerns with the transfer. The DON revealed the bar used to lift Resident #25 might have swung sideways and hit her in the head causing the injury of unknown origin. However, observation revealed inconsistencies to location of the injury if the bar were to start swinging. STNA #230 confirmed two STNAs were required to transfer a resident in and out of bed using a mechanical lift but only one STNA was required to turn and reposition Resident #25 in bed including for incontinence care. Observation with the DON while Resident #25 was in bed verified the side rail top bar was the same height as Resident #25's forehead and shape of the bruise lined up with the siderail. The DON confirmed that the injury could have potentially been caused by a staff member turning Resident #25 in bed and hitting her head on the siderail causing the injury to her forehead. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Revised September 2022 revealed all reports of resident abuse (including injury of unknown origin) neglect, exploitation, or theft/misappropriation of resident property would be reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations would be documented and reported. If resident abuse, including injury of unknown source was suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The Administrator or the individual making the allegation immediately reported his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The Ombudsman; The resident's representative; law enforcement officials; the resident's attending physician and the Medical Director. This deficiency represents non-compliance investigated under Complaint Number OH00158226.

Based on staff interview, medical record review, review of facility investigations, and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown origin for Resident #25. This affected one (Resident #25) of two residents reviewed for abuse. The facility census was 55. Findings include: Record review for Resident #25 revealed a readmitted [DATE]. Diagnoses included age related physical debility, dementia, cognitive communication deficit, Parkinson's disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was rarely or never understood. Resident #25 had impairment on both sides of the upper and lower extremities. Resident #25 was dependent for eating, oral hygiene, toileting, bathing, personal hygiene, bed mobility, chair/bed, bed to chair transfers, and wheelchair mobility. Review of the care plan dated 04/01/24 revealed Resident #25 had potential impairment to skin integrity related to incontinence, aspirin use, fragile skin (age related). Interventions included to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of the physician order dated 09/22/24 for Resident #25 revealed to monitor the bruise to center forehead and leave open to air. Review of the physician order dated 01/30/24 revealed an order for a mechanical lift (Hoyer) for transfer with two assistance. Review of the progress note for Resident #25 dated 09/22/24 at 10:53 A.M. completed by Licensed Practical Nurse (LPN) #275 revealed upon feeding resident in dining room, this nurse noted a bruised raised area two centimeters (cm) in length by 1.2 cm in width by 0.4 cm with open area in center measuring 0.3 cm by 0.3 cm by 0.0 cm. No drainage or odor noted. Also noted, open area right forehead measuring 0.5 cm by 0.3 cm by 0.0 cm. No drainage or odor noted. Location of injury consistent with contact with Hoyer bar during transfer. Review of the daily staffing schedule dated 09/21/24 revealed staff worked 12 hour shifts (6:00 A.M. to 6:00 P.M. and 6:00 P.M. to 6:00 A.M.) On 09/21/24 from 6:00 A.M. to 6:00 P.M. LPN #247, LPN #290, State tested Nursing Assistant (STNA) #225, STNA #243, STNA #248, [NAME] #256 and STNA #257 worked the day shift. On 09/21/24 from 6:00 P.M. to 6:00 A.M. (09/22/24) LPN #238, LPN #274, STNA #207, [NAME] #236, STNA #252, and STNA #259 worked the shift. Review of the daily staffing schedule dated 09/22/24 revealed from 6:00 A.M. to 6:00 P.M. LPN #247, LPN #275, STNA #243, STNA #248, STNA #256, and STNA #258 worked from 6:00 A.M. to 6:00 P.M. Review of the Facility Reported Incidents (FRI) from 09/21/24 through 10/21/24 revealed there were no FRI's completed for and injury of unknown origin for Resident #25. Observation on 10/21/24 at 12:43 P.M. of Resident #25 revealed Resident #25 was sitting up in the dining room. Resident #25's bilateral arms were partially contracted. A large light purple/bluish/yellow colored bruise located from below the hairline to above the eyebrows in the center of the forehead was noted. Resident #25 was non-verbal and did not respond to conversation. Interview on 10/22/24 at 8:56 A.M. with Resident #25's Power of Attorney (POA)/Emergency contact #1 revealed she worked at the facility as a receptionist. When POA/Emergency contact #1 revealed, at some point that morning (09/22/24), she went to see her mom, her mom had what looked like a lifted goose egg the size of a golf ball cut in half sticking out of her forehead, it was oval shaped up and down just above the bridge of her nose to the hairline. Resident #25's POA asked her nurse what happened, she said I don't know, I fed her at breakfast then noticed it. Resident #25's POA/Emergency contact #1 revealed she left the faciity on [DATE] at around 3:00 P.M. and Resident #25 had no injuries to her forehead at that time. Interview on 10/22/24 at 3:09 P.M. with LPN #291 revealed Resident #25 was unable to turn or reposition herself, or even slightly move side to side without assistance. Interview and observation on 10/22/24 at 4:02 P.M. while STNAs #230 and #233 transferred Resident #25 from the bed to the chair revealed inconsistencies with Resident #25 bumping her head during a Hoyer transfer. STNAs #230 and #233 confirmed Resident #25 was unable to move in bed or in the chair without assistance. Observation revealed Resident #25's bed had two half rails, one located on each side of the upper portion of the bed. While Resident #25 was being repositioned in bed to place the Hoyer pad under her by STNAs #230 and #233 revealed the side rail bars lined up to the same height and shape as the bruise on the forehead. Interview on 10/23/24 at 8:00 A.M. with LPN #275 revealed a STNA did not make her aware of the bruise and raised area on Resident #25's forehead prior to going to the dining room for breakfast on 09/22/24. LPN #275 told the DON or Unit Manager #227 (she was unsure which one) about the injury, she did not talk to any other staff about it or initiate an investigation herself as to origin of the injury. LPN #275 thought Unit Manager #227 determined the injury was from the Hoyer. Interview on 10/23/24 at 8:07 A.M. with LPN Unit Manager #227 revealed she did not determine the injury to Resident #25's forehead was from the Hoyer. LPN Unit Manager #227 did not know who made the determination; she did not talk to any staff about it. Interview on 10/23/24 at 8:19 A.M. with the Director of Nursing (DON) revealed one of the aids told her Resident #25 had a bruise on her forehead. The DON looked at the bruise, it was purple dark, so then she looked how Resident #25 transferred. The DON noted the Hoyer bar came close to Resident #25 during the transfer. The DON revealed the daughter said she never saw the Hoyer bar actually touch her mother but it did come close. The DON asked the STNAs on first shift how she transferred, they said with two people. The DON asked if they noticed the Hoyer bar hitting Resident #25 and they said no. The DON educated staff on use of a mechanical lift during transfers. Review of the investigation on 10/23/24 at 9:20 A.M. for the injury to Resident #25's forehead with the DON, completed by the DON revealed two staff members and Resident #25's POA were interviewed regarding how the injury occurred to Resident #25's forehead. The DON confirmed no other staff or residents were interviewed. The DON revealed an inservice with staff was completed on 09/23/24 on mechanical lift transfers. No other education was provided related to prevention of further injuries for Resident #25. Review of the typed first investigation for Resident #25 dated 09/23/24, untimed, completed by the DON revealed, This writer spoke to (STNA #292) who generally works on A hall at night and she stated that she did not know how the bruise got there, Yes, she transferred with a Hoyer lift. Yes the bars might come close to her but we hold them away. I don't remember seeing a bruise. Review of the typed second investigation for Resident #25 dated 09/23/24, untimed, completed by the DON revealed, This writer spoke with (STNA #230) and she stated that she saw a bruise on (Resident #25) forehead and it wasn't there last time she worked. She was unaware of any event that would have caused the bruise. She also stated that the Hoyer bars do come close to her when she transfers. (STNA #230) generally works on A hall. The DON confirmed no other staff were interviewed regarding the bruise. Review of the daily staff schedule revealed STNA #292 did not work on 09/21/24 or 09/22/24. Observation with the DON on 10/23/24 at 9:38 A.M. of STNA #216 and #230 transferring Resident #25 with a mechanical lift from her chair to her bed revealed no concerns with the transfer. The DON indicated the bar used to lift Resident #25 might have swung sideways hitting her in the head. However, observations during the transfer revealed inconsistencies to location of the injury if the bar were to start swinging. STNA #230 confirmed two STNAs were required to transfer a resident in and out of bed using a mechanical lift but and one STNA was required to turn and reposition Resident #25 in bed including for incontinence care. Observation with the DON while Resident #25 was in bed revealed the side rail top bar was the same height as Resident #25's forehead and the shape of the bruise lined up with the siderail. The DON confirmed that the injury could have potentially been caused by a staff member turning Resident #25 in bed and hitting her head on the siderail causing the injury to her forehead. The DON confirmed no staff reported the injury and staff should report an injury at the time it occurred. Interview on 10/24/24 at 11:12 A.M. with STNA #230 confirmed on 09/22/24 she was Resident #25's primary STNA. When she transported Resident #25 to the dining room at around 8:00 A.M. on that day (09/22/24), her and LPN #275 noticed the bruised area on her forehead at that time. STNA #230 revealed the third shift STNA changed and dressed Resident #25 in the mornings then she would get her up for breakfast by 8:00 A.M.; STNA #230 revealed she never turned the lights on while getting her up, that's why she did not see the area prior to taking her to the dining room. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Revised September 2022 revealed all reports of resident abuse (including injury of unknown origin) neglect, exploitation, or theft/misappropriation of resident property were to be reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations were to be documented and reported. If resident abuse, including injury of unknown source was suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The Administrator or the individual making the allegation immediately reported his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The Ombudsman; The resident's representative; law enforcement officials; The resident's attending physician and the Medical Director. All allegations were to be thoroughly investigated. The Administrator initiated the investigations. The individual conducting the investigation as a minimum was to interview staff members on all shifts who had contact with the resident during the period of the alleged incident. Interviews other residents to whom the accused employee provided care and services. The investigation was to be documented completely and thoroughly. This deficiency represents non-compliance investigated under Complaint Number OH00158226.

Based on record review and interview, the facility failed to ensure appropriate treatment was in place for moisture associated dermatitis (MASD) to promote adequate healing. The affected one (Resident #3) of four residents reviewed for skin impairment. Findings include: Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere and diabetes. Resident #3 resided on the secured memory care unit. Review of Resident #3's care plans revealed an intervention dated 08/15/24 to provide incontinence care and apply barrier cream after each incontinent episode. Review of Resident #3's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory impairment and did not have pressure ulcers. Review of Resident #3's physician orders revealed an order to cleanse the intergluteal cleft and bilateral buttocks with soap and water, apply zinc cream two times a day for MASD and as needed after each incontinence was discontinued on 09/21/24 at 10:06 P.M. because the MASD healed. Review of Resident #3's Skin Grid Non-Pressure form dated 09/23/24 revealed the resident had MASD first acquired on 08/18/24 and the area was improving. Resident #3's medical record did not have evidence the zinc MASD treatment was ordered or provided from 09/23/24 to 10/01/24. Review of Resident #3's physician orders revealed an order dated 10/01/24 (discontinued 10/14/24) to cleanse the bilateral buttocks with soap and water, apply zinc cream two times per day and as needed. Review of Resident #3's Skin Grid Non-Pressure form dated 10/14/24 revealed the resident had MASD with a date acquired of 08/18/24. The form indicated the area was improving and continue treatment as ordered. Review of Resident #3's physician orders revealed an order dated 10/14/24 to cleanse the bilateral buttocks/coccyx with soap and water, apply zinc cream two times per day and as needed. Review of Resident #3's medication administration records (MARs) and treatment administration records (TARs) from 08/18/24 to 10/21/24 revealed the ordered treatments were documented as completed. Interview on 10/21/24 at 3:00 P.M. with State tested Nursing Assistant (STNA) #243 confirmed Resident #3 had skin impairment on his bilateral buttocks and she had reported the breakdown to the nurse. Interview on 10/21/24 at 3:17 P.M. with the Director of Nursing (DON) indicated Resident #3 refused care at times and would refuse to be changed at times. The resident would be approached later in order to provide care. The DON indicated Resident #3 had 4-N-1 Skin Protectant barrier cream in place from 09/23/24 to 10/01/24. Observation on 10/22/24 at 9:55 A.M. with STNA #216 and Licensed Practical Nurse (LPN) Unit Manager (UM) #227 of Resident #3's buttocks revealed redness in the intergluteal cleft with some MASD identified. Interview on 10/22/24 at 10:00 A.M. with LPN UM #227 revealed she was made aware Resident #3's physician order for the treatment to the resident's bilateral buttocks and intergluteal cleft was not in the computer on 10/01/24 and placed the treatment in the electronic health record (EHR) for the resident at that time. Interview on 10/23/24 at 10:42 A.M. with Manufacturer Representative #277 revealed the 4-N-1 skin protectant was a light barrier and not a treatment for MASD. He stated it did not cure MASD but was used to prevent further complications related to incontinence. Review of the undated 4-N-1 Wash Cream manufacturer directions (provided by the facility) indicated the product was a no-rinse skin protectant wash cream that was a gentle alternative to soap and water. The cream cleaned, protected, nourished, and restored even the most delicate skin. Fortified with dimethicone, the cream left behind a moisture barrier to nourish and protect the skin. The cream was ideal for frequent cleansing and incontinence care. Review of the Pressure Ulcers/Skin Breakdown Clinical Protocol revised April 2018 indicated the physician would help identify factors contributing or predisposing residents to skin breakdown and would clarify the status of relevant medical issues. This deficiency represents non-compliance investigated under Complaint Number OH00158226.

Based on observation, record review and interview, the facility failed to ensure Resident #15 was provided timely incontinence care. This affected one (Resident #15) of two residents reviewed for incontinence care. Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness, other lack of coordination and schizoaffective disorder. Review of Resident #15's care plans revealed a focus dated 07/09/24 indicating the resident was incontinent of bowel and bladder with interventions including to assess resident for burning, pain and distention, monitor for changes in urinary elimination and provide incontinence care, and apply barrier cream after each incontinent episode. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and was always incontinent of urine and bowel. Review of the undated Nurse Report Sheet for the C hall revealed Resident #15 was to be checked for incontinence and changed. Observation on 10/22/24 at 1:42 P.M. revealed Resident #15 was asleep and sitting in the main common lounge in a wheelchair. A strong odor of urine was in the lounge in the vicinity of Resident #15. The resident had on pants and was sitting on a green chux pad which appeared to have a large urine stain on the pad underneath of the resident. Observation on 10/22/24 at 1:49 P.M. revealed Resident #15 was sitting in the common area. The resident was still sitting on the urine stained chux pad. Observation on 10/22/24 at 2:00 P.M. revealed Medical Records/Activity Director #240 handed Resident #15 a Bingo card for the activity and then walked to other residents. She did not identify the resident had odors or was sitting on a wet chux pad. Interview on 10/22/25 at 2:25 P.M. with State tested Nurse Aide (STNA) #233 revealed Resident #15 was aggressive with her during care and she had last changed the resident after breakfast and before lunch. STNA #233 could not provide an approximate time the incontinence care was provided. Observation on 10/22/24 at 3:05 P.M. revealed STNA #204 completed Resident #15's incontinence care. She confirmed the resident's incontinence brief, pants, chux pad located on the wheelchair and the cushion on the wheelchair were saturated with urine. Review of the Perineal Care policy revised February 2018 indicated the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This deficiency represents non-compliance investigated under Complaint Number OH00158226.

Based on record review, interviews, and facility policy review the facility failed to complete an investigation of an allegation of potential staff-to-resident verbal abuse of Resident #51. This affected one resident (#51) of three residents reviewed for abuse and neglect. The facility census was 58. Findings include: Review of the medical record for the Resident #51 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. Review of the comprehensive Minimum Data Set 3.0 (MDS) assessment, dated 07/03/24, revealed Resident #51 had intact cognition and required substantial assistance for activities of daily living (ADL). Further review of the MDS revealed that Resident #51 was incontinent of bowel and bladder. Review of progress notes from 04/01/24 through 08/12/24 revealed no mention of the incident. Review of the care plan revealed that Resident #51 was verbally sexually inappropriate with staff. There was no care plan that stated Resident #51 made false accusations. Interview on 08/13/24 at 2:05 P.M. with Resident #51 revealed that when State tested Nursing Assistant (STNA) #212 was changing him, he had an erection. Resident #51 stated that STNA #212 stated, You don't get much attention down there. Resident #51 stated that he was at a loss for words. Resident #51 stated that it only happened once, and he didn't feel that it was abuse. Resident #51 stated that he felt safe, and that STNA #212 still takes care of him because he didn't mean it. Review of facility self-reported incidents (SRI) in the Ohio Department of Health's gateway system database revealed no submissions related to the incident. Interview on 08/14/24 at 7:00 A.M. with Scheduler #223 revealed that she started in June 2024 and was told by the Director of Nursing (DON) not to schedule STNA #212 on A Hall, where Resident #51 resided, but did not tell her why. Interview on 08/14/24 at 7:06 A.M. with the DON revealed that through an interview with STNA #212, he stated that he never said that to Resident #51. Resident #51 stated, he didn't want a [expletive] taking care of him to STNA #212. The DON could not produce any documentation that she further investigated the incident. Interview on 08/14/24 at 2:48 P.M. with Regional Director of Operations (RDO) #293 revealed she was interim administrator during the timeframe of the incident between STNA #212 and Resident #51, and she was not aware that an incident occurred. RDO #293 would have investigated the incident to determine if it was a customer service concern or abuse. Review of the facilities Abuse Prevention Policy dated 04/2021 the facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. This deficiency represents noncompliance investigated under Complaint Number OH00156767.

Based on closed and open medical record review, facility policy and procedure review and interview the facility failed to implement effective and individualized pressure ulcer care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to timely implement a pressure ulcer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual Harm occurred on 11/17/21 when Resident #80, who was cognitively impaired and required extensive assistance from staff for bed mobility, transfers and toileting was identified to have skin impairment to the spine and right heel per documentation on a bathing sheet. However, no comprehensive assessments of the areas were completed at that time and no treatments were initiated. The area to the right heel was first assessed on 11/23/21 as a suspected deep tissue injury. From 11/23/21 to 12/08/21 the area was assessed to deteriorate. On 12/01/21 the resident was assessed to have a suspected deep tissue injury to mid back. A treatment was not initiated until 12/06/21 and discontinued on 12/09/21 without evidence the area had healed. The resident was discharged from the facility on 12/12/21 with both pressure ulcers still present. Actual Harm occurred when Resident #13, who was admitted to the facility on [DATE] with a suspected deep tissue injury to the left heel was not provided a treatment to the area until 12/10/21. From 12/08/21 to 12/22/21 the facility identified the pressure ulcer had deteriorated. This affected three residents (#13, #48 and #80) of four residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #80's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to home on 12/12/21. Resident #80 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment, dated 11/15/21 revealed Resident #80 had no skin impairment noted on admission. Review of a Braden scale for predicting pressure ulcer assessment, dated 11/15/21 revealed Resident #80 was at low risk for the development of pressure ulcers. Review of the plan of care, dated 11/15/21 revealed Resident #80 had potential/actual impairment to skin integrity related to fragile skin and poor oral intake. Interventions included an alternating pressure mattress to bed and bilateral heel protector boots at all times. The plan of care was updated on 11/23/21 to reflect the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/17/21 revealed Resident #80, had impaired cognition. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and toilet use. The assessment indicated the resident had no skin impairment. a. Review of bath sheet documentation for Resident #80 dated 11/17/21 and 11/20/21 revealed staff identified an area to the resident's right heel. The area was circled to identify a skin concern. However, there was no corresponding assessment, nursing progress note(s) or treatment order associated with the identification of the area on the bath sheet documentation. Review of a wound nurse practitioner consult note, dated 11/23/21 revealed Resident #80 had a suspected deep tissue injury (DTI) to right heel that measured 1.5 centimeters (cm) long by two cm wide with no depth noted. The note revealed the wound was in-house acquired and was purple-maroon in color. The note indicated a new order was implemented at that time to pad and protect the right heel three times a week and as needed. A physician order, dated 11/23/21 revealed to pad and protect right heel three times per week and as needed. Review of the treatment administration record (TAR) revealed no evidence this treatment was completed as ordered on 11/26/21, 12/06/21 or 12/10/21. Review of a wound nurse practitioner consult note, dated 12/01/21 revealed the suspected DTI to Resident #80's right heel measured one cm in length by 1.2 cm width with no depth noted. Review of a wound nurse practitioner consult note, dated 12/08/21 revealed Resident #80 had a suspected DTI to right heel that measured three cm in length by three cm width. The ulcer was noted to be purple-maroon in color and the note revealed the ulcer was worsening. The note contained no additional information related to how or why the ulcer had worsened as of that time. There were no corresponding nursing progress notes related to the status of the pressure ulcer at that time either. Facility wound documentation, dated 12/08/21 and completed by Licensed Practical Nurse (LPN) #100 who was the facility wound nurse reflected Resident #80 had a DTI to the right heel that measured three cm long by three cm wide. This was the only wound assessment completed by facility staff for this area for Resident #80 during the resident's stay in the facility. Review of the treatment administration record from 11/15/21 to 12/12/21 revealed no evidence the bilateral heel protectors were in place at all times as care planned. On 12/29/21 at 2:26 P.M. during an interview with the Director of Nursing (DON), the DON revealed there was a documentation problem and there were no facility forms to fill out for areas of identified skin impairment except for on the skilled assessments. The DON revealed any skin deviation/issue was to be circled on the bath sheets. The DON revealed it was the State tested Nursing Assistants (STNAs) responsibility to complete the bath sheet and if a nurse also signed the bath sheet it meant an assessment was done. The DON was unable to provide any nursing assessment of the area to the resident's heel from 11/17/21 or 11/20/21. During the interview, the DON verified that although the area was first identified on 11/17/21, there was no documentation of an assessment of the resident's right heel until 11/23/21 by the wound nurse practitioner consultant. The DON was unable to explain why the area of skin impairment was documented on the bath sheet but had no corresponding comprehensive nursing assessment completed at the same time. When asked why/how the pressure ulcer to the right heel developed, the DON was unable to provide any information and indicated she felt the issue was only a documentation issue. The DON was unable to provide any evidence the facility had adequate interventions in place to prevent the development of a DTI to the resident's heel, failed to comprehensively assess the area when first identified and failed to implement a pressure ulcer treatment when the area was first identified. The DON also verified the physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempts to interview the wound nurse practitioner nurse consultant during the complaint investigation were unsuccessful and the consultant was unavailable due to illness. b. Review of bath sheet documentation for Resident #80 dated 11/17/21 and 11/20/21 revealed staff identified an area to the resident's mid back/spine. The area was circled to identify a skin concern. However, there was no corresponding assessment, nursing progress note(s) or treatment order associated with the identification of the area on the bath sheet documentation. Review of a wound nurse practitioner consult note, dated 12/01/21 revealed Resident #80 had a suspected deep tissue injury to midline of back that measured seven cm long and two cm wide. The note revealed the ulcer was in-house acquired. Other than the area being first identified on the bath sheets, dated 11/17/21 and 11/20/21, this was the first assessment with measurements and staging of the wound. On 12/01/21 at 11:27 A.M. a treatment order for the area to the mid-back/spine area was obtained. The order was to apply skin prep to the peri wound discoloration and foam to mid spine every Monday, Wednesday, and Friday. Review of the treatment administration record revealed the treatment was not initiated until 12/06/21 and then was discontinued on 12/09/21. Review of a wound nurse practitioner consult note, dated 12/08/21 revealed Resident #80 had a suspected DTI to the midline spine that measured 5.5 cm long by 2.4 cm wide. A corresponding wound documentation note, completed by LPN #100, also dated 12/08/21 reflected Resident #80 had a DTI to the mid [MEDICATION(S)] spine that measured 5.5 cm long by 2.4 cm wide. On 12/29/21 at 2:26 P.M. interview with the DON verified Resident #80, who was admitted with no pressure ulcers, was identified to have an area of skin breakdown to his mid-back/spine on 11/17/21 during a bath. There was no comprehensive nursing assessment, including a description of the ulcer or staging until 12/01/21 when the wound nurse practitioner consultant assessed the area to be a DTI. The DON verified a treatment order was obtained on 12/01/21, however, the treatment was not initiated until 12/06/21 (five days later). During the interview, the DON revealed she thought possibly the treatment order had been discontinued on 12/09/21 because the resident was supposed to go home on this date. However, the resident was not discharged until 12/12/21. The status of the pressure ulcer to the mid back / spine area was not included on the resident's discharge paperwork. During the interview with the DON, the DON was asked why/how the pressure ulcer to the resident's mid-back/spine developed. The DON was unable to provide any information and indicated she felt the issue was only a documentation issue. The DON was unable to provide any evidence the facility had adequate interventions in place to prevent the development of a DTI to the resident's mid-back/spine, failed to comprehensively assess the area when first identified and failed to implement a pressure ulcer treatment when the area was first identified. On 01/05/22 at 8:50 A.M. telephone interview with Resident #80's family revealed concerns related to the condition of the resident's skin at the time of discharge. The family revealed the resident had a pressure ulcer to the coccyx area that was approximately six inches by six inches with open areas and drainage. The area was red and purple in color. The resident's one heel was covered in what appeared to be a blood blister and there was a small purple area on the other heel. The resident had an area to the back that was five inches by two inches that was opening and draining. The family member revealed home health/hospice assessed the resident and the pressure ulcers following discharge from the facility when the resident returned home. Resident #80 was placed on Hospice services and subsequently passed away. On 01/05/21 at 9:02 A.M. interview with LPN #100 revealed she was the facility wound nurse. During the interview, the LPN revealed she was not sure why treatment orders were not put in place unless it was when she was not working due to taking time off. LPN #100 revealed the floor nurses were supposed to assess/describe what wounds looked like but were not to stage any wounds. LPN #100 was unable to provide any documentation of comprehensive assessments of the above wounds. Attempts to interview the wound nurse practitioner nurse consultant during the complaint investigation were unsuccessful and the consultant was unavailable due to illness. Review of pressure ulcers/skin breakdown-clinical protocol policy and procedure dated March 2014 revealed the staff would examine the skin of a new admission for ulcerations or alterations in skin. The physician would assist the staff to determine etiology and characteristics. Review of the pressure ulcer/injury risk assessment policy and procedure revised July 2017 revealed the following information should be recorded in the resident's medical record utilizing facility forms: type of assessment conducted, date and time and type of skin care provided, the condition of the resident's skin (size and location of any red or tender areas). Review of pressure ulcers/injuries overview revised July 2017 revealed a Stage I pressure ulcer appeared as intact skin with a localized area of non-blanchable redness. A Stage II pressure ulcer appeared as partial-thickness loss of skin with exposed dermis, presenting a shallow open ulcer. This stage should not be used to describe MASD. Deep tissue pressure injury is intact skin with localized are of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. 2. Review of the Resident #13's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] back to long-term care facility where she resided prior to getting COVID-19, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of health status note, dated 12/03/21 at 4:35 A.M. revealed Resident #13 arrived at the facility with skin alterations that included a suspected deep tissue injury (DTI) to the left heel. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed Resident #13's bilateral heels were to be elevated off the bed/chair with pillows under calves. Review of the treatment administration record (TAR) revealed Resident #13's heels were elevated from 12/04/21 to 12/06/21 and then the order was discontinued. There was no corresponding nursing progress note to provide information related to why the order was discontinued on this date. Review of the admission MDS 3.0 assessment, dated 12/06/21 revealed Resident #13 had impaired cognition. The assessment revealed the resident required extensive assistance from two for bed mobility, transfers and toilet use. The assessment also noted the resident had one Stage II pressure ulcer, one unstageable DTI, a skin tear and moisture associated skin damage (MASD) upon admission. Review of the plan of care, dated 12/08/21 revealed Resident #13 had potential/actual skin impairment to left heel related to debility due to COVID-19. Interventions included bilateral heel suspension boots at all times, alternating pressure mattress (APM) to bed and indicated facility protocols were to be followed for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of wound documentation, completed by LPN #100 (the facility wound nurse), dated 12/08/21 revealed Resident #13 had a DTI to left heel that measured 1.5 cm long by two cm wide. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A treatment order was also in place for the left heel to have an abdominal (ABD) gauze pad and Kerlix (woven gauze) wrap every Monday, Wednesday and Friday on day shift. Review of the treatment administration record (TAR) revealed the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a wound nurse practitioner consult note, dated 12/15/21 revealed no information of a DTI to Resident #13's left heel at that time. Review of wound documentation, dated 12/15/21 revealed the wound nurse consultant noted Resident #13 had a Stage II/DTI to the left heel that measured 7 cm long by 6 cm wide. However, this documentation was inaccurately written for Resident #73 in error. On 12/16/21 at 9:22 A.M. interview with LPN #100 verified the wound nurse consultant had mistakenly documented Resident #13's skin impairments under Resident #73's name. Review of the wound nurse consultant note, dated 12/22/21 for Resident #73 (should have been for Resident #13) revealed a Stage II pressure ulcer to left heel that measured 10 cm long by 11 cm wide and was noted to be a blood blister. The wound was assessed to have worsened as of this time. The note failed to contain any additional information about why or how the wound had worsened at that time. On 12/28/21 at 10:34 A.M. interview with the DON verified Resident #13 had been admitted on [DATE] with a suspected DTI to the left heel. However, and there were no measurements or description of the wound at that time. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also verified a treatment was ordered on 12/08/21 but was not put in place until 12/10/21. The DON further verified the wound nurse practitioner had documented Resident #13's skin impairments under the wrong resident. The facility wound nurse documented on 12/08/21, Resident #13 had DTI to left heel that measured 1.5 cm long and 2 cm wide. The facility wound nurse documented on 12/15/21 Resident #13 had a Stage II pressure ulcer to left heel that measured seven cm long by six cm wide. The DON verified the wound consultant documented on 12/22/21 a Stage II pressure ulcer to left heel that measured 10 cm long by 11 cm wide for Resident #73 instead of Resident #13. The DON verified the pressure ulcer to Resident #13's left heel had deteriorated during the resident's stay. During the interview with the DON, the DON was unable to provide any evidence to support timely and adequate interventions and treatments were in place to prevent the deterioration of Resident #13's pressure ulcer to the left heel. On 01/05/21 at 9:02 A.M. interview with LPN #100 revealed she was the facility wound nurse. During the interview, the LPN revealed she was not sure why treatment orders were not put in place unless it was when she was not working due to taking time off. LPN #100 revealed the floor nurses were supposed to assess/describe what wounds looked like but were not to stage any wounds. LPN #100 was unable to provide any documentation of comprehensive assessments of the above wound. 3. Review of Resident #48's medical record revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 assessment, dated 12/15/21 revealed Resident #48 had intact cognition. The assessment revealed the resident required extensive assistance from two for bed mobility, transfers and toilet use. The assessment revealed the resident required assistance from one staff for bathing and personal hygiene. The resident was always incontinent of urine and always continent of bowel. The MDS revealed no skin concerns. Review of health status note, dated 12/17/21 at 6:32 P.M. revealed Resident #48 had an open area to the left upper gluteus that measured 1 cm long by 1.5 cm wide with no depth noted. There were no additional notes or assessments of this area following this note on 12/17/21. On 01/04/21 at 11:21 A.M. interview with the DON revealed the physician had been notified on 12/17/21 of open area to Resident #48's left upper gluteus and gave an order to continue barrier cream. The DON verified there was no other documentation after 12/17/21 about the open area to Resident #48's left upper gluteus. Resident #48 was discharged on [DATE] to the hospital due to an acute change in medical condition and elevated lab values (a high PT/INR). This deficiency substantiates Complaint Number OH 488 and Complaint Number OH 728.

Based on record review and interview, the facility failed to administer pain medications in a timely manner. This resulted in actual harm for one (Resident #200) of five residents review for medication administration. Resident #200 experienced severe pain when pain medication was not provided for approximately 23 hours after admission. The census was 52. Findings include: Review of Resident #200's medical record revealed an admitted [DATE] at 1:15 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge orders dated 08/19/21 revealed Resident #200 was ordered oxycodone (opioid pain medication) 5 milligram (mg) every six hours as needed for pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. on 08/19/21. Review of the nurse admission screener assessment dated [DATE] at 2:41 A.M. revealed Resident #200 rated his pain level 10 out of 10 (a 10 on the pain scale represents the most severe or worst pain you have ever experienced). Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #200 did not receive oxycodone 5 mg until 08/21/21 at 12:30 A.M. Review of the nurse's note dated 08/20/21 at 4:00 A.M. revealed Resident #200 would not let the nurse remove bandage on left femur because the hospital just changed it and it was too painful. Resident #200 asked for pain medications, the resident was told no medications for him at that time. Interview on 08/23/21 at 10:15 A.M. with Resident #200 stated that he was admitted to the facility at 1:15 A.M. after having surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #200 stated he asked for pain medications but was told they could not give him any until the next day because they did not have the medications. Review of the plan of care dated 08/24/21 revealed Resident #200 was at risk for pain related to let hip surgery due to fall with fracture. Interventions included to administer [MEDICATION(S)] as ordered, give 30 minutes before treatments or care, evaluate the effectiveness of pain interventions every shift, compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results. Monitor/record pain characteristics every shift and as needed. Interview on 08/26/21 at 9:07 A.M. with Licensed Practical Nurse (LPN) #545 stated that Resident #200 asked for pain medications upon admission, but the resident could not receive the medications until the orders were put into the system. LPN #545 stated she called the pharmacy several times between 1:30 A.M. and 6:00 A.M. because the resident was asking for [MEDICATION(S)] (antianxiety medication). LPN#545 stated she was in and out of the resident's room throughout the shift and had asked the resident if he was in any pain and Resident #200 stated that he was always in pain. LPN #200 could not state why the oxycodone was not administered as ordered. Interview on 08/26/21 at 9:24 A.M. with the Administrator and Director of Nursing (DON) confirmed Resident #200 was admitted on [DATE] at 1:15 A.M. but neither staff could verify whether staff administered ordered pain medications. The administrator stated the facility had pain medications in the startup box that should have been pulled for Resident #200. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/27/21, revealed Resident #200 had intact cognition.

Based on observation, interview, medical record review and facility policy review, the facility failed to assess and monitor a newly identified alteration in skin integrity, and failed to provide appropriate treatment to prevent the development of an avoidable stage three pressure sore from developing for Resident #2. This resulted in harm when Resident #2 developed a stage three pressure ulcer with [MEDICAL CONDITION] (a deep skin infection)on the distal portion of the right great toe. This affected one of three residents reviewed for pressure ulcers. The facility census was 57. Findings include: Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].#2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was at risk for pressure ulcers. There was no documentation Resident #2 had a pressure ulcer on the assessment. Review of the wound assessment revealed Resident #2 had a stage two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure area to the right great toe occurring 07/31/14 and healing on 09/10/14. Review of Resident #2's nurses notes dated 10/01/14, revealed Resident #2 had a new open area to the tip of the right great toe with moderate amount of bloody discharge noted and the area was open and measured one centimeter (cm)by one cm. There were no further assessments of the wound from 10/01/14 through 10/23/14. Review of the physician orders [REDACTED]. This dressing was to be changed daily. There were no further interventions noted for this area through 10/23/14. Review of the physician progress notes [REDACTED]. The note indicated the wound was a full thickness ulcer on the distal aspect of the right great toe with a large amount of skin slough and an odor noted from the wound. Physician #75's progress note revealed this wound was a non-healing ulcer of the right great toe secondary to pressure from the digital deformity of the right hallux hammertoe with [MEDICAL CONDITION]. Review of the physician communication form dated 10/30/14, revealed Physician #75 was staging this wound as a stage three pressure wound (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss). There were physician notes in Resident #2's medical record through 12/11/14 related to the stage three pressure area to the distal right great toe. However, review of the physician progress notes [REDACTED]. Review of the nursing notes created 01/07/15 at 12:22 P.M., with an effective date of 12/30/14, revealed the dressing to the right great toe was changed. The wound had a moderate amount of serosanguinous drainage on the dressing. The wound bed was beefy red and the measurements of the wound were one centimeter width by 0.8 centimeters length by less than 0.1 centimeters of depth. On 01/05/15 at 1:18 P.M., interview with RN #1 denied Resident #2 currently had a pressure ulcer. Interview on 01/07/15 at 9:40 A.M., with Registered Nurse (RN) #9 indicated the wound on Resident #2's foot was not pressure related. Observation on 01/07/15 at 12:49 P.M., revealed Registered Nurse (RN) #9 obtain and prepare supplies for Resident #2's dressing change. Resident #2's sock was removed with some sanguineous drainage noted on the sock. Resident #2's old dressing dated 01/06/15 was removed by RN #9. Resident #2's right foot displayed a wound to the distal portion or tip of the right great toe that was noted to be red with some slough (unviable tissue) noted in the base of the wound. There was also undermining noted to this wound. Undermining is the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface. There was also a blistered area noted on the dorsal or knuckle portion of the right great toe. Neither area was measured during the observation. Both areas were approximately the size of a dime. RN #9 cleansed her hands and obtained a four inch by four inch piece of gauze and some normal saline. RN #9 first cleansed the wound located on the tip of the right toe with the gauze pad and normal saline. Once this area was cleansed, RN #9 used the same gauze pad to cleanse the wound on the dorsal portion of the right great toe. RN #9 did not change gloves, wash hands or obtain unused clean supplies prior to moving to the second wound. RN #9 confirmed this observation and the potential for cross contamination between the first wound cleansed and the second wound. The dressing was then completed according to the current physician orders. Interview on 01/08/15 at 9:02 A.M., with RN #9 revealed the assessment entered on 01/07/15 was completed on 12/30/14. RN #9 indicated that she had "forgot" to enter the information on the wound the day it was observed. RN #9 revealed the facility staff asked her to enter the information into the computer on 01/07/15. Interview on 01/08/15 at 9:08 A.M., with the Director of Nursing (DON) revealed she had asked RN #9 to enter the information into Resident #2's record on 01/07/15. The DON indicated the wound care nurse thought Resident #2's wound to the distal right great toe was a traumatic injury when found on 10/01/14. The DON confirmed due to the wound nurse thinking the wound was a traumatic injury there were no assessments of the wound or evidence of monitoring the wound from 10/01/14 through 10/23/14. The DON indicated non- pressure areas are not routinely measured. The DON indicated the wound was not healing so Physician #75 was consulted at this time. The DON confirmed the resident's wound was not evaluated as a pressure area and confirmed Resident #2 had a history of [REDACTED]. The DON confirmed the physician staged Resident #2's right great toe wound as a stage three pressure area on 10/23/14. Interview with Licensed Practical Nurse LPN #2 on 01/08/15 at 11:30 A.M., revealed wound assessments for pressure areas are completed weekly. LPN #2 indicated the wound would be staged when found if pressure related. LPN #2 indicated the staff refer to the wound book for guidance on staging pressure ulcers and appropriate treatment. LPN #2 confirmed triple antibiotic ointment covered with a dry clean dressing was not an appropriate treatment for [REDACTED]. Interview on 01/08/15 at 11:47 A.M., with LPN #12 confirmed there was no evidence of interventions other than the triple antibiotic ointment to Resident #2's pressure sore on the right great toe from 10/01/14 through 10/23/14 Interview on 01/08/15 at 1:15 P.M., with Physician #75 revealed Resident #2 was at risk for developing a pressure ulcer due to Resident #2's deformity of the right great toe hallux. Physician #75 indicated Resident #75's right great toe was contracted and was a deformity referred to as a hammer toe. Physician #75 confirmed Resident #2's wound was pressure related and verified his assessment of the wound including the staging of the wound as a stage three pressure ulcer. Physician #75 confirmed Resident #2 presented to his office on 10/23/14 with [MEDICAL CONDITION] of the right great toe. Review of the facilities pressure wound resource revealed the pressure ulcer staging guide. This guide was from the 2007 dated reproduction of the national pressure ulcer advisory panel. This guide revealed a stage three pressure ulcer is full thickness tissue loss. The guide indicated slough may be present but does not obscure the depth or the tissue loss and there may be undermining and tunneling. Review of the treatment guidelines updated 03/11/14, revealed no evidence of triple antibiotic ointment as a standard treatment for [REDACTED].

Based on observations, record review and interviews, the facility failed to monitor the skin condition for one resident (Resident #85), resulting in harm as evidenced by the discovery of a necrotic ulcer and a decline in an existing wound. The facility failed to establish fluid restrictions and administer ordered medications for one resident (Resident #38), who received [MEDICAL TREATMENT] services, and failed to assess continuing complaints of pain following a fall for one resident (Resident #15). This affected one of five identified residents with non-pressure related ulcers, one of one resident reviewed with [MEDICAL TREATMENT] services and one of four residents reviewed for falls. The facility census was 79 residents. Findings include: 1. Resident #85 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE], indicated he was alert and oriented. The skin assessment indicated his left shin had a pink "jungle not"(SIC) measuring 5 centimeters (cm) x 12 cm. There were purple areas that wrapped around the ankles. His skin risk assessment indicated he was a low risk for the development of decubitus ulcers. Interventions included a pressure reduction mattress and cushion, daily skin inspection, management of moisture, turning schedule, protection of heels, management of friction and shear, nutrition, therapy screening, control pain and assess peripheral status. Review of physician's orders [REDACTED]. Interview with the wound nurse, Licensed Practical Nurse (LPN) #16, on 07/11/12 at 4:00 P.M., revealed she was not aware of any ulcer on Resident #85's shins. LPN #16 stated she did not have the information because it was not a pressure sore. Treatment was provided by the unit nurse. On 07/12/12 at 9:42 A.M., observation was made of the treatments to Resident #85's shins by LPN #16. While the LPN was providing treatment to the resident's left shin, the resident complained that the outside of his left foot was sore. LPN #16 removed a non-skid sock from his left foot. A black area was clearly visible over the boney prominence of his left lateral ankle. LPN #16 palpated the side of his foot and surrounding areas asking if he was experiencing pain. The resident denied pain until she directly pressed on the blackened area. He jerked his leg and voiced pain. LPN #16 reported she was not made aware of the area on the ankle. She described the area as a round wound with a dark brown black area surrounded by white edges. The resident stated it had been there for about a month. She stated she would measure the areas after speaking to the physician about the treatment needed. Interview with LPN #16 on 07/16/12 at 11:00 A.M., indicated the nursing assistants had been instructed to inform her of any breaches of skin integrity so that interventions could be immediately put in place to promote healing and prevent decline. On 07/12/12 at 1:46 P.M., LPN #16 reported the left shin ulcer measured 7 centimeters (cm) long x 3 cm wide with less than 0.1 cm deep. This measurement identified worsening of the ulcer between 07/08/12 and 07/12/12. LPN #16 described the left lateral ankle wound as a dry wound bed covered with black eschar. She stated had she been aware of the shin ulcer she would have been monitoring, measuring and adjusting the treatment to prevent it's decline. She confirmed she also was not aware of the left lateral ankle wound. 2. A review of the medical record for Resident #38 revealed a [DIAGNOSES REDACTED]. Further medical record review revealed Resident #38 received [MEDICAL TREATMENT] treatments three times a week (Tuesday, Thursday and Saturday), at an outside facility. A review of the physician orders [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the MAR for June and July, 2012, revealed that Resident #38 did not receive five of eleven 12:00 P.M. scheduled doses of calcium acetate in July, and seventeen of thirty 12:00 P.M. scheduled doses in June. Review of the medical record did not contain evidence of notification to the physician of the missed doses of calcium acetate. On 07/11/12 at 3:50 P.M., an interview with LPN #17, assigned to the care of Resident #38, revealed that the TAR and MAR indicated [REDACTED]. LPN #17 stated Resident #38 was allowed four ounces (120 cc) of fluid per shift, and did not know why the noon calcium acetate was often circled, which indicated not administered on the record. At 4:10 P.M., an interview with LPN #6, who was assigned to Resident #38's care, stated the Resident was allowed ice and she was not sure about fluid. LPN #6 also stated that the noon dose of calcium acetate was not given to Resident #38 on [MEDICAL TREATMENT] days. At 4:16 P.M., an interview with Dietary Manager #18 revealed that dietary used 1320 cc of the fluid restriction with meals and nursing used 120 cc (4 oz.) a day (24 hours), although she was unable to locate the breakdown documentation in Resident #38's medical record. At 4:42 P.M., an interview with the resident care coordinator, Registered Nurse (RN) #9, revealed that missed doses of medications should be reported to the nursing supervisor and the physician. RN #9 also stated that nursing should be aware of the amounts of fluids to provide a resident on fluid restriction. On 07/16/12 at 3:30 P.M., an interview with [MEDICAL TREATMENT] RN #19 revealed that [MEDICAL TREATMENT] residents receiving calcium acetate should take the medication with meals or snacks to reduce phosphorous levels. She stated residents could bring the medication with them to the [MEDICAL TREATMENT] center or take with the meals/snacks provided after [MEDICAL TREATMENT]. 3. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a nursing note dated 06/01/12, timed 11:20 A.M., indicated the resident fell hitting her head. She was assessed and complained of pain to her head, back, and hip. She was sent to the hospital for further assessment. The resident returned from the hospital the same day at 1:05 P.M. She complained of pain approximately twice daily through 06/08/12, and was given pain medication. After the initial assessment on 06/01/12, there was no indication Resident #15 was assessed by the nursing staff for bruises or injuries related to the fall. On 06/08/12, the resident saw an orthopaedic physician. The physician's note indicated the resident had been complaining of pain since the first of the month when apparently she had fallen. She had a bruise to her right wrist and hand, and had pain and tenderness on palpation. An x-ray of her right hand was obtained which showed a fracture to the fifth metacarpal. On 07/16/12 at 1:23 P.M., interview with the director of nursing (DON) confirmed there was no documentation in the nursing notes or bath/skin sheets indicating Resident #15's bruise.

Based on observation, medical record review and interview, the facility failed to ensure Resident #83's skin was monitored for signs and symptoms of skin impairment. This resulted in harm as evidenced by an in house acquired unstageable pressure ulcer. This affected one of three residents reviewed for pressure ulcers. There were six residents in the facility with pressure ulcers. Facility census was 79. Findings include: Medical record review revealed Resident #83 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented Resident #83 had no pressure wounds. A care plan for being at risk for skin breakdown dated 02/22/12, revealed interventions including turn as needed, manage friction and sheer, keep head of bed elevation as low as tolerated, monitor turning and a waffle overlay to bed and chair. A physician order [REDACTED].#83's bed. Nurses notes dated 05/14/12, documented waffle mattress removed. A comprehensive assessment dated [DATE], identified Resident #83 as being at risk for development of pressure ulcers. The assessment indicated the resident did not have a pressure ulcer. Interview with the wound nurse on 07/11/12 at 1:30 P.M., revealed she was called at home on 06/24/12. She was told Resident #83 had a pressure sore located on the right lower buttock that was covered with yellow slough (dead tissue in the process of separating from viable portions of the body). She observed the wound on 06/25/12, and confirmed the wound was covered with a yellow slough. She determined the wound was unstageable. The wound nurse had no knowledge of Resident #83 having any skin impairment to the area prior to the phone call. Since the pressure ulcer was identified, Resident #83 was to be up in a chair for no more than 60 minutes two to three times per day. When in bed he was to be positioned on his sides to promote wound healing. A wound assessment progress report included documentation dated 06/25/12, that the wound measured 2.5 centimeters (cm) x 1.5 cm x 0 cm depth with 85% slough. On 06/28/12, the wound was covered with 100% slough and a wound culture was completed. Review of the culture and sensitivity report dated 06/30/12, revealed a heavy growth of [MEDICAL CONDITION] resistant staph Aureus (a type of staph bacteria that is resistant to certain antibiotics). Physician orders [REDACTED]. Wound care observation on 07/12/12 at 12:55 P.M., revealed the right lower buttock wound measured 2.5 cm x 2.0 cm x 0.1 cm., the wound had a defined border with red edges, the wound bed had tight yellow eschar (dead tissue) with scattered pink areas of budding tissue coming up through the eschar. Interview with the director of nursing and wound nurse on 07/12/12 at 3:00 P.M., revealed the waffle mattress was discontinued because Resident #83 slept in a recliner chair and not in bed. Resident #83 spent all his time in a recliner chair or wheelchair. The only time he was not seated was when he was toileted. He could not be redirected to the bed or off his buttock. Nurses completed weekly skin sweeps on shower days, and state tested nurse aides (STNAs) completed visual assessments daily when providing care. Once Resident #83's unstageable pressure ulcer was identified, all staff were educated regarding the importance of daily skin inspections. The DON said STNAs were documenting they were completing skin checks on each shift; however, if the skin had been checked daily the wound would not have been unstageable at the time of discovery. This type of skin impairment could not have occurred over night. A palliative care consult was completed to assist the facility in implementing interventions to assist in keeping Resident #83 in bed to allow the wound to heal. Interview with the minimum data set (MDS) nurse on 07/12/12 at 3:15 P.M., revealed there was not a care plan related to Resident #83 wanting to be in recliner and not in bed. Resident #83 was identified as high risk for skin breakdown. Had staff completed daily skin assessments when providing care, skin impairment could have been identified at an earlier stage and interventions initiated to prevent ongoing deterioration which required daily wound care, antibiotic therapy and confinement to bed.