Every finding on record at Advanced Healthcare Center

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to document evidence of care conferences conducted with residents at required intervals. This affected two (#1 and #2) of three residents reviewed for care conferences. The facility census was 72.Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 07/22/22. Diagnoses included gastroesophageal reflux disease (GERD), anxiety, depression, bipolar disorder, schizoaffective disorder, and muscle weakness.Review of the most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a moderate cognitive impairment. The resident did not reject care and did not wander.Review of Resident #1's medical record revealed quarterly MDS assessments were completed on 01/31/26 and 05/03/26, and an annual MDS assessment was completed on 06/28/26. Further review of Resident #1's record revealed documentation of care conferences on 05/29/26 and 06/29/26. No additional care conference documentation was available in Resident #1's record.Interview on 07/21/26 at 9:13 A.M. with Resident #1 revealed the resident did not recall having regular care conference meetings to discuss his plan of care.Interview on 07/21/26 at 5:52 P.M. with the Director of Nursing (DON) confirmed no additional care conference documentation was available for Resident #1.2. Review of the medical record for Resident #2 revealed an admission date of 06/29/20. Diagnoses included asthma, migraine, anxiety, hypertension, and need for assistance with personal care.Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #2 was cognitively intact, did not reject care, and did not wander.Review of Resident #2's medical record revealed a quarterly MDS assessment was completed on 01/24/26, an annual MDS assessment was completed on 04/06/26, and a quarterly MDS assessment was completed on 06/24/26. Further review of Resident #2's record revealed no documentation of care conferences during the time period of 01/01/26 through 07/20/26.Interview on 07/21/26 at 8:35 A.M. with Resident #2 revealed the resident did not have regular care conferences or meetings to discuss his plan of care.Interview on 07/21/26 at 5:52 P.M. with the DON confirmed no additional care conference documentation was available for Resident #2. The DON stated there was no evidence contained in the medical record to support Resident #2 had a care conference at all in 2026 as of 07/21/26.Review of the undated facility policy titled, Clinical Protocol: Care Conferences in Long-Term Care, revealed quarterly care conferences would be held at least every 90 days and a summary would be documented in the medical record.This deficiency represents an incidental finding discovered during the course of this complaint investigation.

Based on closed medical record review, staff interview and review of the facility policy, the facility failed to ensure timely notification for a change in condition for a resident who was cognitively impaired and had a Power of Attorney (POA) for medical decisions. This affected one resident (#12) of three residents reviewed for timely notification. The facility census was 74.Findings include:Review of the closed medical record for Resident #12 revealed an admission date of 07/31/25. Diagnoses included mild intellectual disability, adjustment disorder, dementia, and diabetes mellitus Type II. Resident #12 had a POA to make healthcare decisions. The resident discharged to another facility on 05/08/26.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was moderately cognitively intact and had no skin conditions. Review of the nursing progress note dated 05/04/26 at 6:39 P.M. revealed Resident #12 complained of pain in the lower back and upon assessment, a wound was discovered. The nurse conducted a telehealth visit with the on-call provider and orders were obtained to cleanse and dress the wound, with instructions to have wound care follow-up. Further review revealed no evidence the resident's POA was notified at the time of discovery of the wound on Resident #12's back. Further review of the nursing progress notes from 05/04/26 through 05/06/26 revealed no evidence Resident #12's POA was notified of the wound on his back. Review of the medical Nurse Practitioner's (NP) progress noted dated 05/06/26 revealed Resident #12 was seen for an acute visit/change in status for a new skin integrity wound found on the posterior lumbar back (lower back area). Resident #12 was noted to be a poor historian and the onset and clinical information was difficult to obtain from him. The NP discussed with the wound care NP, who stated she saw the wound on evaluation today and it was noted to have a significantly indurated swelling with a white center. At the time of the wound NP's visit, she did not do a sharp debridement. The NP documented the wound as a lower back abscess that measured 2.8 by (x) 2.8 centimeters (cm) with a firm, protrusive/swollen center with sloth and healthy tissue in a marble like appearance. The NP documented that, per chart review and previous documentation, it apparently started as a boil earlier in the week and the NP was not made aware of it on Monday (05/04/26). Orders included antibiotics, referral for a surgical consult, laboratory testing, and to cleanse the wound with wound cleanser, pat dry, and apply honey hydrogel to the base of the wound every Monday, Wednesday, and Friday. The note stated the NP encouraged and answered multiple questions to perceived satisfaction from the resident, staff, and/or family; however, the note did not indicate any specific contact with Resident #12's family/POA. Interview on 06/02/26 at 4:10 P.M. with the Director of Nursing (DON) verified the facility had no evidence Resident #12's POA was notified of the abscess on the resident's back. The DON stated the facility had some issues in the past contacting the POA and the POA would call back days later. Further interview with the DON confirmed that the previous nursing notes, dated 04/23/26, documented attempts to contact the POA; however, on 05/04/26, when the abscess was discovered on Resident #12's back, there was no evidence the facility attempted to contact the POA. The DON verified the facility had no evidence the POA was notified of the abscess at the time of discovery.A follow-up interview on 06/02/26 at 4:49 P.M. with the DON revealed she attempted to find an incident report for a new skin issue for Resident #12, that may have documented POA notification, but a hand written incident report was not able to be found.Observation on 06/02/25 at approximately 5:10 P.M. revealed the Administrator and the DON discussing timely notification to Resident #12's POA regarding the abscess to his lower back. The DON stated to the Administrator, It probably wasn't timely, but it happened (meaning the notification occurred). The Administrator and DON stated there was documentation of difficulty getting in touch with the POA in the past and the POA did not return calls right away. The DON verified there was not a documented attempt to contact the POA at the time of discovery of the wound on Resident #12's lower back.Review of the facility policy titled, Change in a Resident's Condition or Status, revised May 2024, revealed the facility would promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Unless otherwise instructed by the resident, a nurse would notify the resident's representative when there was a significant change in the residents physical, mental, or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number 3019109.

Based on observation, staff interview, and policy review, the facility failed to maintain a reach in refrigerator at a safe temperature, failed to date and label food items, and failed to maintain a sanitary environment. This had the potential to affect all residents in the facility receiving food from the kitchen, except for Resident's #11, #30, #76, #88, and #89 who were identified by the facility as not receiving food by mouth. The facility census was 83.Findings include:On initial tour of kitchen on 01/26/26 from 6:10 P.M. until 6:26 P.M. revealed at 6:10 P.M. the reach in refrigerator located approximately three feet across from steam table had both doors propped open by serving carts, inside the refrigerator were 15 cups of grape juice, five cups of cranberry juice, 11 cups of orange juice, 26 cups of lemonade, six cups of milk, and 18 cups of an unidentified liquid, all cups were labeled but contained no dates. The inside thermometer for the refrigerator was reading 58 degrees Fahrenheit (F). Interview with Dietary Aide #337 at the time of the observation revealed that the doors were propped open to make it easier to access the prepared cups of juice being placed on the resident's meal trays. Dietary Aide #337 confirmed the various cups of liquids should have been dated to indicated when they were prepared.Continued observation on 6:21 P.M. revealed a resident's meal tray which had been eaten from was sitting on top of a smaller reach in cooler located next to the service door. Interview on 01/26/26 at 6:21 P.M. with Dietary Aide #337 confirmed the tray containing partially eaten food was placed on the reach in cooler after being brought into the kitchen from the dining room.Continued observation of the walk in cooler at 6:26 P.M. revealed two open containers of pudding, one open container of sour cream, and one open container of chicken salad all without labels indicating the dates opened. Also observed in the walk in cooler was a package of opened and undated tortillas on the right side second shelf. Interview on 01/26/26 at 6:26 P.M. with [NAME] #339 confirmed the items listed did not have labels indicating when they were opened.Review of policy titled Food Storage: Cold Foods, with a revised date of 02/2023, revealed that all perishable foods will be maintained at a temperature of 41 degrees F, or below and that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.Review of policy titled Environment with a revision date of 06/2025, revealed that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure narcotic medications were administered and maintained in a secured manner. This affected four (#64, #72, #93, and #94) of 18 residents receiving narcotic medications residing on the 400 unit. The facility census was 83. Findings include: Observation on 01/26/26 at 6:52 P.M. noted Licensed Practical Nurse (LPN) #370 and LPN #316 conducting a shift change narcotic medication and controlled substance inventory for the 400 unit medication cart. LPN #316 was observed to be removing narcotic medication cards from the 400 unit medication cart and counting the number of medications (tablets, contents) on each card and reporting the count to LPN #370. LPN #370 was observed reviewing the controlled substance inventory log for each narcotic and controlled substance contained in the 400 unit medication cart to verify with the count reported. Thirty-nine narcotic medication cards were contained in the locked narcotics drawer in the 400 unit medication cartInterview with LPN #316 at the time of the observation verified he was assuming care of the residents on the 400 unit for the 6:30 P.M. until 7:00 A.M. shift on 01/26/26. Interview with LPN #370 revealed she was finishing her shift and had been assigned to provide care to the residents on the 400 unit from 6:30 A.M. until 7:00 P.M. Continued observation noted LPN #319 removed Resident #64's medication card containing 17 Hydrocodone-acetaminophen 10-325 milligrams (mg). LPN #370 stated the controlled substance inventory log for the Hydrocodone-acetaminophen 10-325 mg noted 18 tablets. LPN #319 removed a second medication card for Resident #63 with 47 tablets of Clonazepam 0.5 mg. LPN #370 stated the controlled substance inventory log displayed a current inventory of 48 tablets. Interview with LPN #370 at the time revealed she had given the medications to Resident #64 during the shift, but did not sign the medications out as administered on the controlled substance log.Continued observation revealed LPN #319 removed Resident #72's medication card containing a physical count of 19 oxycodone 5 mg tablets. LPN #370 stated the count on the controlled substance log log stated there should be 20 tablets remaining. LPN #319 then removed a medication card containing Resident #93's oxycodone 15 mg tablets, the physical count was 18 tablets. LPN #370 reported the count on the controlled substance log was 19. Further observation revealed LPN #319 remove Resident #94's Pregabalin 150 mg medication card from the cart, there was a physical count of 54 tablets. LPN #370 reported 55 tablets were currently listed in the inventory on the controlled substance log.On 01/26/26 at 7:05 P.M. interview with LPN #370 revealed she had administered the narcotic medications to the specified residents (#72, #93 and #94) during the shift however, she was extremely busy and did not record the medications as administered on the controlled substance log at the time of the administration. LPN #370 and LPN #319 verified narcotics and controlled substances are to be signed out on the controlled substance log at the time of administration. Interview on 01/26/26 at 9:20 P.M. with the Director of Nursing verified narcotic medications are to be signed out on the Medication Administration Record and on the Controlled Substance Log at the time of administration immediately after they are removed from the medication cart. According to undated Medication Administration policy, narcotics will be signed out when administered.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure fall prevention interventions were implemented and fall occurrences were thoroughly investigated. This affected one (#4) of one resident reviewed for fall incidents and related interventions. The facility census was 83.Findings include:Review of the medical record revealed Resident #4 admitted to the facility on [DATE], diagnoses included atrial fibrillation, bipolar disorder, schizoaffective disorder, major depressive disorder, anxiety disorder, left and right knee contractures. According to the most current Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 with moderately impaired cognition, lower extremity range of motion impairment on one side, a dependency on staff for the completion of activities of daily living, and transfers. Resident #4 was incontinent of bowel and bladder, had no skin breakdown, was at risk for pressure ulcer development, and was receiving an anticoagulant, opioids, and anticonvulsant medications. On 08/09/25 a nursing plan of care was developed to address Resident #4's history of falling, the plan of care was revised on 12/04/25. Interventions included to ensure anti-tippers are in correct position on the wheelchair, to ensure the resident was wearing appropriate non-skid footwear, encourage the resident to call for help with transfers, to encourage the resident and staff to keep the wheelchair close to the side of the bed, and for non-skid strips on the floor next to bed. Review of the medical record revealed on 12/09/25 a fall follow-up assessment was completed from a fall sustained on 12/03/25. Intervention included for the the care plan updated. On 12/25/25 a fall risk assessment was completed and scored the resident at risk of falling. The assessment noted Resident #4 had previously sustained falls within the past two to six months. Review of nursing progress note dated 12/25/25 at 1:00 A.M. revealed Resident #4 was observed sitting on the floor, on his buttocks next to his bed. Resident #4 stated he was crawling on the floor to get in his wheelchair. Resident #4 denied hitting his head, had no complaints of pain or discomfort, and exhibited no signs or symptoms of distress. Resident #4 had a blood pressure of 112/72 , and a heart rate of 72. The resident was educated on the importance of using the call light and waiting for assistance. Resident #4 was assisted off the floor by two staff members and placed in the wheelchair. Review of the facility occurrence report dated 12/25/25 and timed 1:00 A.M. noted Resident #4 sustained a fall during a transfer in the resident's room. The occurrence report contained no documentation of what fall interventions were in place at the time of the fall, how long the resident had been on the floor, or any potential witnesses or resident specific interventions implemented to address fall incident.Interview on 01/29/26 at 12:45 P.M. with the Director of Nursing (DON) verified the nursing progress note, and the facility occurrence report for Resident #4's fall on 12/25/25 contained no documentation of what fall interventions were in place at the time of the fall, or the reason why the resident attempted to self transfer. Additionally, the DON verified the fall investigation was not thorough as the the missing information was not requested, no witness statements regarding the fall were obtained and there was not a review of current interventions care planned for to ensure the interventions had been effectively implemented. Observation on 01/28/26 at 6:12 A.M. Resident #4 was noted in bed with his eyes closed. The resident's head of the bed elevated, bilateral grab bars were in place, and the resident's specialized wheelchair was located at foot of bed. Both sides of the bed were open to the room, no non-skid strips were in place on the floor to the right side of the bed. At 8:58 A.M. Resident #4 was seated on the right side of the bed, with feet to floor.According to updated facility fall prevention policy, fall investigations are to include asking the resident what they were doing when they fell, identify if there were any witnesses to the fall and if so, obtain a written witness statement of what they saw. The interdisciplinary team (IDT) is to review all information from a fall at the next daily clinical meeting and discuss the fall to include potential causes, interventions in place at time of the fall to determine if they were effective, and review of the resident's care to identify if interventions were appropriate or if new interventions should be added.

Based on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure vision services were provided timely. This affected one (#3) of two residents reviewed for vision services. The facility census was 83. Findings include: Review of the medical record for Resident #3 revealed an admission date of 09/22/25. Diagnoses included hemiplegia and hemiparesis, chronic obstructive pulmonary disease, hypertension, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Further review of the MDS assessment revealed the resident had no corrective lenses. Review of a request for services form dated 09/24/25 revealed the resident had requested to be seen for eye care. Review of the vision provider schedule dated 10/27/25 revealed the provider was in the facility and Resident #3 was not seen by the provider. Review of the progress notes dated 09/25/25 through 01/28/26 revealed no documentation the resident had been provided eye care services as requested. Interview on 01/26/26 at 8:52 P.M., Resident #3 revealed she had requested to see the eye doctor a while ago and had not seen the provider.Interview on 01/28/25 at 9:02 A.M., Social Service Designee (SSD) #404 revealed the eye care provider was last in the facility on 10/27/25 and had not seen Resident #3. SSD #404 verified Resident #3 had not been provided with vision services since her admission to the facility. SSD #404 revealed the facility changed providers at the end of 12/2025 and the new provider also had not been in the building yet to provide vision services for the residents. Review of the undated facility policy Social Services, revealed social services would help and support residents in addressing concrete service needs including referrals for eye care, dental care, podiatry, and durable medical equipment.

Based on observation, and staff interview the facility failed to ensure resident rooms were clean and equipment was adequately maintained. This affected three (#11, #37, and #30) of 24 residents reviewed for environmental services, The facility census was 83. Findings include:1. Observation on 01/26/26 at 6:42 P.M. revealed an area of Resident #37's wall with gouges in the drywall and exposed drywall underlayment behind the head of the bed. The area measured approximately five foot by five foot. Additional observation on 01/28/26 at 6:15 A.M. noted the wall located to the right of Resident #37's bed with a liquid appearing splatter debris covering the wall and to the right of the bed a maroon mat on the floor with the same debris. On 01/28/2026 at 8:15 A.M. observation with Maintenance Director #319 of Resident #37's room verified the gouges in the wall behind Resident #37's head of the bed. On 01/28/2026 at 8:21 A.M. observation with the Director of Environmental Services (ES) #499 verified the debris on the wall and next to Resident #37's bed. ES #499 stated resident has a behavior of spitting. ES #499 was unable to indicate the most recent time the wall or floor matt were cleaned. 2. Observation on 01/28/2026 at 8:41 A.M. noted Resident #11's room wall to the left of the bed with gouges in the drywall and white unpainted drywall patches. The area measured approximately five foot by three foot. On 01/28/26 at 8:43 A.M. interview with the Maintenance Director #319 verified the gouges and unpainted patches to the wall inside Resident #11's room. 3. Observation on 01/27/26 at 10:55 A.M. revealed a tube feeding pump mounted on a pole next to Resident #30's bed, the legs of the pole had a puddle of fresh tube feeding on the legs along with older dried tube feeding covering the legs of the pole. Under the pole on the floor there was a small puddle, approximately two inches in diameter of tube feeding. Interview on 01/27/26 at 11:02 A.M. with the Director of Risk Management #500 verified the tube feeding on the legs of the pole and floor.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure one resident's indwelling urinary catheter was maintained in a sanitary manner. This affected one (#37) of three residents reviewed for indwelling urinary catheters. The facility census was 83. Findings include: Review of the medical record for Resident #37 revealed an admission date of 09/23/25, diagnoses included metabolic encephalopathy, severe protein calorie malnutrition, benign prostatic hyperplasia, obstructive and reflux uropathy, hydronephrosis, hypertension, dementia, myocardial infarction, and resistance to Vancomycin. According to the most current Minimum Data Set (MDS) assessment dated [DATE], Resident #37 had severely impaired cognition, had physical and verbal behavioral symptoms one to three days, rejected care one to three days, was dependent on staff for the completion of activities of daily living including transfers and bed mobility, utilized an indwelling urinary catheter, was incontinent of bowel, and was at risk for pressure ulcer development with no current skin breakdown. On 09/25/25 a plan of care was implemented and on 11/28/25 the plan of care was revised to address Resident #37's indwelling urinary catheter due to obstructive uropathy and benign prostatic hypertrophy. Interventions included to position the catheter bag and tubing below the level of the bladder, to provide privacy bag, and to secure the drainage catheter to the resident's leg with securement device. Review of a physician order dated 10/31/25 revealed a urinary indwelling catheter was to placed to continuous drainage. On 01/14/26 a physician order was written for the administration of Levofloxacin (antibiotic) 750 milligrams (mg) each morning due to a urinary tract infection of bacteremia. Observation on 01/26/26 at 6:42 P.M. Resident #37 was in bed with the indwelling urinary catheter drainage bag laying on the floor under the bed.Observation on 01/26/26 at 9:15 P.M. the indwelling urinary catheter drainage bag was observed to remain on the floor under Resident #37's bed. Interview on 01/26/26 at 9:16 P.M. with Certified Nurse Aide (CNA) #398 stated Resident #37 was in contact isolation due to an infection in his urine (methicillin resistant staphylococcus aureus). CNA #398 also verified the indwelling urinary catheter drainage bag was laying on the floor under the bed and stated the drainage bag should be secured to the bed frame. Observation on 01/27/26 at 3:09 P.M. Resident #37 was in bed with the indwelling urinary catheter drainage bag laying on the floor next to the bed.Observation on 01/29/26 at 6:05 A.M. Resident #37 observed in bed with the indwelling urinary catheter drainage bag on end of bed at the level of his bladder.On 01/29/26 at 6:08 A.M. interview with CNA #398 verified the urinary catheter bag was not below the level of Resident #37's bladder and it should be to prevent the backflow of urine into the resident's bladder.On 01/29/26 at 10:34 A.M. interview with Registered Nurse #342 verified the facility indwelling urinary catheter policy included for staff to ensure the collection bag is not on the floor, was draining properly and secured to the bed, below the level of the bladder so there is no reflux of urine back into the bladder. Review of the undated facility policy titled Catheter Care stated staff are to ensure the drainage collection bag is not on the floor, urine is draining properly, and the urinary drainage bag secured below the level of the resident's bladder to prevent reflux of urine back to the bladder. This deficiency represents non-compliance investigated under Complaint Number 2715485.

Based on observation, medical record review, resident and staff interview and facility policy, the facility failed to thoroughly investigate an allegation of staff to resident physical abuse. This affected one (#3) of seven residents reviewed for staff to resident care and treatment in a facility census of 87. Findings include:Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with chronic obstructive pulmonary disease, type 2 diabetes mellitus, cerebral infarction, hypertension, congestive heart failure, major depressive disorder, chronic viral hepatitis C, anxiety disorder, systemic lupus erythematosus, alcohol abuse, opioid abuse, and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, no recorded behaviors, and required substantial to maximal assistance with activities of daily living. The medical record contained no documentation of Resident #3 making any allegation of abuse from a staff member. On 07/09/25 at 8:15 A.M. interview with Administrator and Director of Nursing (DON) revealed Resident #3's responsible party had made an allegation of staff to resident abuse. Resident #3's responsible party was unable to articulate when or what alleged incident took place until 07/08/25. The DON stated an alleged nurse resigned on date of alleged event of 07/05/25 in the early morning during the 6:00 P.M. to 6:00 A.M. shift. On 07/09/25 at 8:58 A.M. interview with Resident #3 revealed she was hit with bed controller in the chest by a nurse aide. Resident #3 was unable to stated the date or provide any additional information. Telephone interview on 07/09/25 at 12:23 P.M. with the alleged nurse, Licensed Practical Nurse (LPN) #200, revealed she assumed care of Resident #3 on 07/04/25 at 6:30 P.M. and was scheduled to work until the morning of 07/05/25 at 7:00 A.M. Between 11:30 P.M. and 12:00 A.M. LPN #200 went to administer medications to Resident #3. Resident #3 requested the medications crushed. LPN #200 proceeded to crush the medications, placed them in applesauce, and returned to Resident #3's bedside. LPN #200 obtained the electric bed controller from Resident #3's chest, raised the head of the bed, and placed the controlled next to the resident on the mattress. Resident #3 then became agitated and started yelling LPN #200 had hit her in the chest with the bed remote. LPN #200 attempted to calm Resident #3 and denied hitting her. Resident #3 continued yelling and Certified Nurse Aide (CNA) #400 entered the room. Once CNA #400 entered the room LPN #200 left the room and contacted her supervisor ( Registered Nurse (RN) #201) via telephone and reported Resident #3 was accusing her of hitting her and this was an allegation of physical abuse. LPN #200 informed RN #201 she was leaving the facility and turned her medication cart keys over to LPN #202. At approximately 12:30 A.M. Resident #3's son came to the facility and proceeded to Resident #3's room. Resident #3's son then approached LPN #200 at the nurses station and began cursing and threatening LPN #200. LPN #200 turned over care of her residents to LPN #202 until RN #201 reported to the facility. LPN #200 proceeded to leave the facility at 1:00 A.M. LPN #200 stated she did not provide a statement regarding the incident or document the incident in Resident #3's medical record. Interview on 07/10/25 at 5:15 A.M. with CNA #400 revealed she was assigned to Resident #3's care on 07/04/25. She was walking down the hall when she heard yelling coming from Resident #3's room. CNA #400 went to check on the resident. Upon entering the room LPN #200 was standing outside the room and told CNA #400 Resident #3 was alleging she hit her with the bed remote. Resident #3 was yelling out and LPN #200 stated she was leaving the facility due to the allegation or physical abuse. CNA#400 provided Resident #3 with incontinence care and observed no potential injury and exited the room. Following care LPN #200 was observed at her medication cart and told CNA #400 she had notified the supervisor RN and she was leaving due to the allegation of physical abuse. Approximately 10 minutes later RN #201 was observed counting the medication cart and assuming care to the residents on the hall. LPN #200 proceeded to leave the facility. CNA #400 stated she did not provide a statement following the incident. On 07/10/25 at 5:19 A.M. interview with CNA #401 revealed on 07/04/25 she was working in a resident room on the 400 Hall and came out seeing LPN #200 packing her bag at the nursing station. LPN #200 was stating she would not be coming back to the facility. LPN #200 stated Resident #3 alleged LPN #200 had hit the resident with the bed remote. RN #201 had assumed care of her residents. On 07/10/25 at 5:46 A.M. interview with RN #201 revealed on 07/05/25 at 12:37 A.M. she received a phone call from LPN #200 stating Resident #3 accused her of throwing a bed remote at her and LPN #200 was reporting the alleged incident to her supervisor. RN #201 stated she phoned the DON immediately after speaking with LPN #200. RN #201 told the DON Resident #3 alleged LPN #200 threw the bed remote and hit her in the face. RN #201 took another phone call and returned a phone call to the DON at 12:45 A.M. on 07/05/25. RN #201 informed the DON LPN #200 was going to leave and RN #201 was going in to assume care. Approximately 20-25 minutes later RN #201 reported to the facility and LPN #200 had left. RN #201 spoke with Resident #3 who stated the remote hit her in the leg. No marks were identified on Resident #3's face and no pain was stated from the resident. RN #201 stated she did not assess Resident #3 for potential injury and did not attempt to take statements from potential witnesses. Interview on 07/10/25 at 6:28 A.M. with the DON revealed she was not informed until 07/08/25 Resident #3 had reported alleged physical abuse. On 07/05/25 she was informed by RN #201 that Resident #3 reported her remote was thrown on the bed and not the resident had been struck with the bed remote in the chest. The DON confirmed no documentation was contained in Resident #3's medical record regarding the incident and no physical assessment to identify possible injury was completed. Furthermore, no witness statements had been obtained regarding the incident until 07/08/25 when Resident #3's representative alleged Resident #3 was struck by the bed remote in the chest.Review of facility policy titled Abuse, Neglect, and Misappropriation revealed an employee who is alleged or accused of being party to abuse, neglect, misappropriation of property will be immediately removed from the area (s) of resident care, interviewed by facility leadership for a written statement and not left alone. After completing the statement(s) the employee will be asked to vacate the facility until further investigation of the incident is completed. Each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect to misappropriation of funds will be identified and reported to the supervisor and investigated timely. The supervisor or designee will notify the Director of Nursing and Executive Director (Administrator) of the incident or allegation immediately. The Executive Director will direct the investigation. Documentation of the facts and findings will be completed in each resident medical record. Statements will be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. By the fifth day, the alleged abuse investigation form is completed and reviewed for completeness and accuracy by the Executive Director or designee and submitted to the state. This citation represents non-compliance discovered during the investigation of Complaint Number OH00167551/ iQIES Complaint Number 1326898.

Based on observation, medical record review, staff and resident interview, review of Self Reported Incidents, and review of facility policy, the facility failed to immediately report an allegation of staff to resident physical abuse immediately to the administrator. This affected one (#3) of seven residents reviewed for staff to resident care and treatment in a facility census of 87. Findings include:Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with chronic obstructive pulmonary disease, type 2 diabetes mellitus, cerebral infarction, hypertension, congestive heart failure, major depressive disorder, chronic viral hepatitis C, anxiety disorder, systemic lupus erythematosus, alcohol abuse, opioid abuse, and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, no recorded behaviors, and required substantial to maximal assistance with activities of daily living.On 07/09/25 at 8:15 A.M. interview with Administrator and Director of Nursing (DON) revealed Resident #3's responsible party had made an allegation of staff to resident abuse. Resident #3's responsible party was unable to articulate when or what alleged incident took place until 07/08/25. The DON stated an alleged nurse resigned on date of alleged event of 07/05/25 in the early morning during the 6:00 P.M. to 6:00 A.M. shift. On 07/09/25 at 8:58 A.M. interview with Resident #3 revealed she was hit with bed controller in the chest by a nurse aide. Resident #3 was unable to stated the date or provide any additional information. Telephone interview on 07/09/25 at 12:23 P.M. with the alleged nurse, Licensed Practical Nurse (LPN) #200, revealed she assumed care of Resident #3 on 07/04/25 at 6:30 P.M. and was scheduled to work until the morning of 07/05/25 at 7:00 A.M. Between 11:30 P.M. and 12:00 A.M. LPN #200 went to administer medications to Resident #3. Resident #3 requested the medications crushed. LPN #200 proceeded to crush the medications, placed them in applesauce, and returned to Resident #3's bedside. LPN #200 obtained the electric bed controller from Resident #3's chest, raised the head of the bed, and placed the controlled next to the resident on the mattress. Resident #3 then became agitated and started yelling LPN #200 had hit her in the chest with the bed remote. LPN #200 attempted to calm Resident #3 and denied hitting her. Resident #3 continued yelling and Certified Nurse Aide (CNA) #400 entered the room. Once CNA #400 entered the room LPN #200 left the room and contacted her supervisor ( Registered Nurse (RN) #201) via telephone and reported Resident #3 was accusing her of hitting her and this was an allegation of physical abuse. LPN #200 informed RN #201 she was leaving the facility and turned her medication cart keys over to LPN #202. At approximately 12:30 A.M. Resident #3's son came to the facility and proceeded to Resident #3's room. Resident #3's son then approached LPN #200 at the nurses station and began cursing and threatening LPN #200. LPN #200 turned over care of her residents to LPN #202 until RN #201 reported to the facility. Interview on 07/10/25 at 5:15 A.M. with CNA #400 revealed she was assigned to Resident #3's care on 07/04/25. She was walking down the hall when she heard yelling coming from Resident #3's room. CNA #400 went to check on the resident. Upon entering the room LPN #200 was standing outside the room and told CNA #400 Resident #3 was alleging she hit her with the bed remote. Resident #3 was yelling out and LPN #200 stated she was leaving the facility due to the allegation or physical abuse. CNA#400 provided Resident #3 with incontinence care and observed no potential injury and exited the room. Following care LPN #200 was observed at her medication cart and told CNA #400 she had notified the supervisor RN and she was leaving due to the allegation of physical abuse. Approximately 10 minutes later RN #201 was observed counting the medication cart and assuming care to the residents on the hall. LPN #200 proceeded to leave the facility. On 07/10/25 at 5:19 A.M. interview with CNA #401 revealed on 07/04/25 she was working in a resident room on the 400 Hall and came out seeing LPN #200 packing her bag at the nursing station. LPN #200 was stating she would not be coming back to the facility. LPN #200 stated Resident #3 alleged LPN #200 had hit the resident with the bed remote. RN #201 had assumed care of her residents. On 07/10/25 at 5:46 A.M. interview with RN #201 revealed on 07/05/25 at 12:37 A.M. she received a phone call from LPN #200 stating Resident #3 accused her of throwing a bed remote at her and LPN #200 was reporting the alleged incident to her supervisor. RN #201 stated she phoned the DON immediately after speaking with LPN #200. RN #201 told the DON Resident #3 alleged LPN #200 threw the bed remote and hit her in the face. RN #201 took another phone call and returned a phone call to the DON at 12:45 A.M. on 07/05/25. RN #201 informed the DON LPN #200 was going to leave and RN #201 was going in to assume care. Approximately 20-25 minutes later RN #201 reported to the facility and LPN #200 had left. RN #201 spoke with Resident #3 who stated the remote hit her in the leg. No marks were identified on Resident #3's face and no pain was stated from the resident. Interview on 07/10/25 at 6:28 A.M. with the DON revealed she was not informed until 07/08/25 Resident #3 had reported alleged physical abuse. On 07/05/25 she was informed by RN #201 that Resident #3 reported her remote was thrown on the bed and not the resident had been struck with the bed remote in the chest. The DON confirmed no documentation was contained in Resident #3's medical record regarding the incident and no physical assessment to identify possible injury was completed. Furthermore, no witness statements had been obtained regarding the incident until 07/08/25 when Resident #3's representative alleged Resident #3 was struck by the bed remote in the chest.Review of the facility Self Reported Incidents revealed on 07/08/25 the facility reported the allegations of staff to resident abuse toward Resident #3 to the State Survey Agency. Review of facility policy titled Abuse, Neglect, and Misappropriation revealed each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect to misappropriation of funds will be identified and reported to the supervisor and investigated timely. The supervisor or designee will notify the Director of Nursing and Executive Director (Administrator) of the incident or allegation immediately. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Executive Director/designee of the facility. For alleged violations of alleged abuse the facility must report to the state survey agency immediately, but no more than two hours after the allegation is made. This citation represents non-compliance discovered during the investigation of Complaint Number OH00167551/ iQIES Complaint Number 1326898.

Based on medical record review, staff interview, and review of facility policy, the facility failed to administer a diuretic and insulin as ordered within a specified time frame for one (#3) out of seven patients reviewed in a census of 87. Findings include: Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with chronic obstructive pulmonary disease, type 2 diabetes mellitus, cerebral infarction, hypertension, congestive heart failure, major depressive disorder, chronic viral hepatitis C, anxiety disorder, systemic lupus erythematosus, alcohol abuse, opioid abuse, and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, no recorded behaviors, and required substantial to maximal assistance with activities of daily living.Review of the medication administration record and physician orders revealed orders for diuretic hydralazine 100 milligram (mg) tablet three times daily at 8:00 A.M., 2:00 P.M. and 10:00 P.M. and Insulin Aspart Flexpen sliding scale- blood sugar (bs) 151-200 give (=) 3 units, bs 201-250= 6 units, 251-300= 9 units, 301-350= 12 units, 351-400= 15 units, 401-450= 20 units, call physician (MD) if bs above 400 or below 70, administer subcutaneous before meals and at bedtime scheduled 7:00 A.M., 11:00 A.M., 4:00 P.M., and 9:00 P.M.Review of medication administration audit report revealed the hydralazine 100 mg and Insulin Aspart Flexpen three (3) units were scheduled for 07/04/25 at 9:00 P.M. The medications were not administered until 07/05/25 at 12:28 A.M.Telephone interview on 07/09/25 at 12:22 P.M. with Licensed Practical Nurse (LPN) #200 verified she was assigned to administer medications to Resident #3 on 07/04/25 evening (P.M.). Resident #3 was sleeping and the medications were not administered within prescribed timeframes. LPN #200 verified the physician was not notified of the medications being given outside of prescribed timeframes and no entry was made in the medical record indicating the reason the medications were provided late. Review of facility policy titled Medication Administration revealed medications will be administered within the time frame of one hour before up to one hour after ordered time. Medications that are refused or withheld or not given will be documented. Critical medications that are refused including insulin or anticoagulants will be followed up with physician contact. Documentation of medications will follow accepted standards of nursing practice. On 07/10/25 at 8:34 A.M. interview with the Director of Nursing confirmed Resident #3's medications were documented to be administered outside of prescribed time frames. No documentation was contained in the medical record indicating a reason for late medication administration. This deficiency represents non-compliance investigated under Complaint Number OH00167398/ iQIES Complaint Number 1326898.

Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided timely. This affected one (#85) of three residents reviewed for incontinence care. The facility census was 83. Findings include: Review of the medical record for Resident #85 revealed an admission date of 07/13/20. Diagnoses included osteoporosis, urinary incontinence, hypertension, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting. Review of the care plan last revised 01/28/25 revealed the resident had urinary and bowel incontinence related to weakness, difficulty ambulating, and cognitive deficits. Interventions included the use of incontinence briefs and incontinence care as needed. Review of the task documentation for toileting dated 05/27/25 revealed no documentation the resident had been provided incontinence care from 6:30 A.M. through 12:00 P.M. Observations on 05/27/25 at 9:13 A.M. revealed Resident #85 was sitting in the common area in a wheelchair near the nurses' station watching television. Interview on 05/27/25 at 9:17 A.M., Resident #85 revealed her incontinence brief had been changed earlier in the morning. Resident #85 revealed the staff were not checking her for incontinence during the day. Observations on 05/27/25 at 9:17 A.M., 10:01 A.M., 10:40 A.M., and 11:14 A.M., revealed the resident remained in her wheelchair in the common area in front of the television. There were no observations of staff offering to provide the resident incontinence care. Observation on 05/27/25 at 11:32 A.M., revealed Resident #85 remained in the common area in her wheelchair. There were odors of urine and stool present. Interview at 11:32 A.M. Resident #85 revealed staff had not offered to change her incontinence brief. Further observations at 11:45 A.M. and 11:59 A.M. revealed the resident remained in the common area with signs of incontinence. Interview on 05/28/25 at 11:59 A.M., Licensed Practical Nurse (LPN) #202 revealed the resident's nursing assistant was completing incontinence care rounds and had not gotten to Resident #85 yet. Observation on 05/28/25 at 12:00 P.M. revealed Certified Nursing Assistant (CNA) #404 pushed the resident in her wheelchair down to her room. CNA #404 and CNA #232 transferred the resident to the bed using the standup lift. Further observation revealed a puddle of liquid with a urine odor in the resident's wheelchair on the seat cushion. Continued observations revealed the resident's pants were wet and had a strong urine odor. CNA #404 and CNA #232 provided incontinence care. The resident's incontinence brief was heavily saturated with urine and a small amount of stool. Further observation revealed the resident had no skin breakdown. Interview on 05/27/25 at 12:01 P.M., CNA #404 revealed her shift began at 10:30 A.M. and was not aware when Resident #85 had last received incontinence care as the prior shift nursing assistance had not let her know. CNA #404 and CNA #232 verified there was a puddle of liquid on the cushion in the resident's wheelchair. CNA #404 and CNA #232 verified the resident's pants were wet with a strong urine odor. CNA #404 and CNA #232 verified the resident had been incontinent of urine and stool and the resident's brief was heavily saturated with urine. CNA #404 and CNA #232 verified incontinence care should be provided every two hours. Interview on 05/28/25 at 2:34 P.M., the Director of Nursing (DON) revealed as a general rule incontinence care would be provided every two hours or per resident preference. Review of the undated facility policy Routine Resident Care, revealed routine daily care including incontinence care would be provided. This deficiency represents non-compliance investigated under Master Complaint Number OH00165598.

Based on medical record review, review of facility investigations, staff interview, and review of the facility policy the facility failed to ensure medications were administered to the correct resident. This affected one resident (#89) reviewed for medication errors. The facility census was 92. Findings include: Review of the medical record for Resident #89 revealed an admitted [DATE] with diagnoses of follow-up for joint replacement surgery, depression, anxiety, alcohol abuse, and cocaine abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #89 revealed he was cognitively intact and he was not ordered any opioid medication (narcotic pain medication). Review of the current physician orders for April 2025 for Resident #89 revealed no orders for Gabapentin (medication used for nerve pain), Doxycycline (antibiotic), Metoprolol (used to treat high blood pressure), Norco (narcotic (opioid) pain medication), and Oxycodone (narcotic (opioid) pain medication. Review of the listed drug allergies for Resident #89 revealed he had an allergy to Aspirin only. Review of the care plan revised 02/14 for Resident #89 revealed the resident had substance use disorder history of smoking, marijuana, cocaine abuse and alcohol abuse and he now uses his past experiences to help share with others in rehabilitation. Review of the nursing progress notes for Resident #89 dated 01/31/25 revealed he was administered medication in error the following medications: Gabapentin 100 milligrams (mg), Doxycycline 100 mg, Metropolol 25 mg, and Norco 5/325 mg. Interview on 03/31/25 at 10:39 A.M. with Resident #89 stated he was involved in two medication errors where he received medication that was not prescribed to him. Review of the internal investigation for the medication error dated 01/31/25 for Resident #89 revealed Licensed Practical Nurse (LPN) #378 prepared medication for administration and administered the medication to the wrong resident. Phone interview on 04/02/25 at 4:01 P.M. with LPN #378 stated she was working on 01/31/25 and was passing her medications when there were many different events happening with residents requesting to go out to smoke, Certified Nursing Assistants (CNA) reporting different items to her and two residents with the same name. LPN #378 amidst the distractions she prepared medications for administration and delivered the medication to the wrong resident, Resident #89. LPN #378 further stated Resident #89 requested some Tylenol and she returned to the medication cart and discovered the medication she prepared was for a different resident based on the computer screen that she was working on and then returned to Resident #89 and he had already taken the medication she delivered to him. Review of the nursing progress notes for Resident #89 dated 03/27/25 revealed he was administered medication in error, Resident #89 was administered Oxycodone five milligrams. Review of the internal investigation for the medication error dated 03/27/25 for Resident #89 revealed LPN #309 prepared medication for administration and administered the medication to the wrong resident. Phone interview on 04/02/25 at 4:32 P.M. with LPN #309 stated she was working on 03/27/25 and was overwhelmed with distractions with a new resident and her family with anxiety and a resident that was sent out by ambulance and she began her medication administration late. LPN #309 stated during her medication administration she misread the room and administered medication to the wrong resident. LPN #309 further stated she administered Oxycodone five milligrams, two pills, a medication for acid reflux and upon entering the room for Resident #89 he requested Tylenol and she returned to the medication cart, obtained the Tylenol and then returned to Resident #89 and administered the medication. LPN #309 stated Resident #89 inquired about the medication, she explained the medication he was receiving and LPN #309 then stated Resident #89 shrugged his shoulders and took the medication. LPN #309 then stated Resident #89 then reported to her immediately after taking the medication those aren't my pills. LPN #309 stated she returned to the medication cart and discovered she administered the wrong medication to the wrong resident. Interview on 03/31/25 at 5:10 P.M. with the Director of Nursing (DON) identified only one resident with medication errors in the past three months was Resident #89. Review of the incident and accident log for past three months revealed there was only one resident with medication errors, Resident #89. Review of the facility policy titled Medication Administration, undated revealed general procedure for medication administration include observation of the five rights in giving medication, the right resident, the right time, the right medication, the right dose, and the right route. Full attention should be given during preparation of medications avoiding distractions is important for infection prevention and reducing errors. This deficiency represents non-compliance investigated under Complaint Number OH00162741.

Based on review of public social media videos, resident interviews, staff interviews, review of the employee handbook, review of staff schedules, and review of facility policy, the facility failed to ensure residents' right to privacy was honored when State tested Nurse Aide (STNA) #100 video recorded conversations and interactions with staff and residents (including during personal care) in resident rooms, in common areas, discussed resident care needs and described a resident's malodorous wounds using profanity, while posting the videos to social media and not in accordance with facility policy. This affected four (#13, #31, #62, and #73) of four residents reviewed for privacy and confidentiality. The facility census was 81. Findings Include: Review of STNA #100's public social media account revealed three live recorded videos (meaning the video was posted to the social media page as the video was being recorded) taken at the facility involving residents in the privacy of their home. The live recorded videos were dated 12/22/23, 12/25/23 and 12/30/23, with each video lasting between 10 and 16 minutes. Review of the video posted on 12/25/23 revealed STNA #100 speaking with Resident #31. In the video, STNA #100 called Resident #31 by first name and the back of the resident's head was visible on the video. STNA #100 made a comment to Resident #31 about his roommate and an incident that occurred with the roommate the previous night that had nothing to do with the care needs and/or provision of care for Resident #31. Further review revealed STNA #100 describing having to provide care for Resident #73's buttocks (expletive used in the video) wound, adding the wound was malodorous and foul-smelling. Review of the video posted on 12/30/23 revealed STNA #100 discussed care to be provided to Residents #62 and #73, identifying each resident by first name. In addition, the 12/30/23 video revealed STNA #100 entered Resident #13's room. The video went black, but the audio continued to record and STNA #100 and an unknown staff person assisted Resident #13 with personal care. Resident #13 was called by first name and could be heard interacting with the staff during care. The video dated 12/22/23 was deleted prior to being able to fully view the recording. Interview on 01/09/24 at 9:45 A.M. with the Administrator and the Director of Nursing (DON) verified the videos were taken inside the facility. Each denied knowledge of the videos prior to the interview. The Administrator and DON confirmed the residents named in the videos were facility residents and identified STNA #100 as facility staff. Additionally, the DON verified Resident #73 had a wound, as discussed in the 12/25/23 video. A follow-up interview on 01/09/24 at approximately 11:10 A.M. with the Administrator confirmed the facility was the residents' home and they should expect privacy within their home, which included not being recorded. Interviews on 01/09/24 at 2:23 P.M. with Resident #13 and at 2:45 P.M. with Resident #31 revealed each resident denied knowledge of being recorded. Interview on 01/09/24 at 3:55 P.M. with Resident #73 revealed no knowledge of care needs being discussed on a recorded video (wound care discussed in video dated 12/25/23). Resident #73 indicated he would not be agreeable to having any personal information recorded. Review of the staff schedules verified STNA #100 was scheduled to work on 12/22/23, 12/25/23 and 12/30/23. Review of the Employee Handbook, revised July 2015, verified the facility takes no position on the employee's decision to start or maintain a blog or participate in other social networking activities; however, it is the right and duty of the facility to protect itself from unauthorized disclosure of information. In addition, employees may not use their personal cell phones in work areas. The use of cameras (unless job related and approved by the executive director), camera phones, iPods, mp3 players or other electronic devices is not permitted during work hours. Review of the facility policy titled Ohio Abuse, Neglect and Misappropriation, revised 09/20/22, revealed unauthorized disclosure of resident photographs or images could be mental, physical, or sexual abuse depending on how the images were used. Review of the facility policy titled Unauthorized Disclosure of Resident Images, revised 10/25/22, revealed the facility provided resident centered care that inhibited employees from taking photos and/or distributing photographs in any fashion including but not limited to posting on social media sites or videos that demean or humiliate a resident. This deficiency represents non-compliance investigated under Complaint Number OH00149669.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions for use, resulting in a medication error rate above five percent (%). A total of 10 medication errors were observed out of 43 opportunities for a medication administration error rate of 23.26%. This affected four (Residents #16, #52, #1, #53) of six residents observed during medication administration. The facility census was 81. Findings include: 1. Review of Resident #16's medical record revealed a physician order dated 11/17/23 for Hydrocodone-Acetaminophen (pain medication) 5-325 milligrams (mg) one tablet four times a day for pain scheduled 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M. An order dated 06/22/23 for as needed (PRN) Acetaminophen 325 mg two tablets every six hours for pain. Observation on 12/12/23 at 7:17 A.M. noted Licensed Practical Nurse (LPN) #121 obtained Resident #16's medications from the medication cart and proceeded to administer to the resident. Observation noted Resident #16 to complain of left leg pain with facial grimacing. LPN #121 obtained a pain rating of 8 from the resident. LPN #121 returned to the medication cart and stated Resident #16 had a current physician order for Hydrocodone-Acetaminophen 5-325 milligrams (mg), however the medication was not available since the previous day and LPN #121 was unable to access the facility in-house supply due to lack of knowledge. At 7:28 A.M., LPN #121 obtained PRN Acetaminophen 325 mg two tablets and returned to Resident #16's room and administered the two tablets. 2. Review of Resident #52's medical record noted a physician order dated 11/26/22 for levetiracetam oral solution 100 mg/milliliters (ml) give 7.5 ml two times daily for seizures. Prescribed times at 8:00 A.M. and 6:00 P.M. Observation on 12/12/23 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #191 obtaining Resident #52's medications from the medication cart. Medications included levetiracetam oral solution. LPN #52 poured 7.5 milliliters (ml) of solution into a medication cup and proceeded to Resident #52's room. At 9:28 A.M. LPN #191 provided the medication to Resident #52 (approximately an hour and a half late). 3. Review of Resident #53's medical record noted the following physician orders: 12/10/23 Oxycontin extended release 12 Hour Abuse-Deterrent 40 mg two times daily for pain at 9:00 A.M. and 6:00 P.M. 12/06/23 Baclofen 10 mg four times a day for contracture prescribed times 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M. 06/15/23 Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 MCG/ACT one puff inhale four times a day for chronic obstructive pulmonary disease prescribed at 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M., 12/10/23 Ativan 0.5 mg every morning (AM) and bedtime (HS) for anxiety 06/16/23 Fluticasone-Salmeterol inhalation aerosol powder breath activated 500-50 mcg/act one inhale every morning and at bedtime for chronic obstructive pulmonary disease given AM and HS 07/19/23 Lyrica 100 mg three times daily for neuropathy at AM, afternoon, and HS 2/06/23 Baclofen 10 mg four times daily for contractures at 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M. Observation on 12/12/23 at 12:10 P.M. noted Resident #53 in bed stating he had not received his morning (AM) medications, including pain medication. Resident #53 did not describe his level of pain at the time. Interview on 12/12/23 at 12:12 P.M. with LPN #191 confirmed Resident #53 had not received morning medications. LPN #191 proceeded to obtain Resident #53's medications from the medication cart. Medications included the following: Oxycontin extended release 12 Hour Abuse-Deterrent 40 mg, Baclofen 10 mg, Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 mcg/act, Ativan 0.5 mg, and Fluticasone-Salmeterol inhalation aerosol powder breath activated 500-50 mcg/act. At 12:22 P.M. LPN #191 proceeded to administer the AM medications to the resident and confirmed the medications were provided outside of prescribed time frames. Review of facility's undated Medication Administration policy noted medications are to be administered as prescribed by the provider. Medications will be administered within the time frame of one hour before and up to one hour after time ordered. Always follow manufacturer guidelines for specific medication use. Inhalers direct rinsing mouth after steroid inhaler. Review of Liberalized Medication Administration undated timeframe's as follows: AM starting at 6:00 A.M. and may extend to 11:00 A.M., Afternoon starting at 12:00 P.M. and may extend to 3:00 P.M., PM starting at 4:00 P.M. and may extend to 7:00 P.M. Any medication ordered by the physician for a specific time will be given at that specific time.

Based on observation, medical record review, resident interview, family interview, staff interview, review of the facility contingency box medication list, and review of facility policy, the facility failed to ensure medications were available from the pharmacy for timely administration. In addition, the facility failed to secure available medications from the contingency box for administration when resident's medications were unavailable from the pharmacy. This affected five (#2, #68, #284, #285, #287) of nine residents reviewed for medication administration. The facility census was 81. Findings included: 1. Review of Resident #2's medical record revealed an admitted [DATE]. Diagnoses included pancreatic cancer, antiphospholipid syndrome, fibromyalgia, breast cancer, thrombocytopenia, and hemiplegia/hemiparesis following a cerebral vascular accident. Review the admission Minimum Data Set (MDS) assessment, dated 11/24/23, revealed Resident #2 had intact cognition. The resident was independent for activities of daily living (ADLs), but required setup or clean-up assistance with eating. Review of Resident #2's most recent care plan revealed she was at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use. Interventions included to provide anticoagulant/antiplatelet medication per medical providers order. Review of Resident #2's physician order dated 11/17/23 revealed abatacept subcutaneous solution (anti-inflammatory) auto-injector 125 MG/ML (Abatacept) was to be subcutaneously injected in the morning every seven days for inflammation. Review of Resident #2's Medication Administration Record (MAR) for November 2023 revealed on 11/18/23 and 11/25/23, abatacept subcutaneous solution administration was documented as 9, indicating to see nurses notes. Review of Resident #2's physician order dated 11/17/23 revealed linaclotide (treatment of irritable bowel) oral capsule 145 micrograms (mcg) was ordered. Directions were to give one capsule by mouth every morning for digestive aide. Review of Resident #2's November 2023 MAR revealed linaclotide was documented 9 on 11/18/23 and 11/19/23, which indicated to see nurses notes. Review of Resident #2's physician order dated 11/17/23 revealed Pregabalin (anticonvulsant) oral capsule 75 mg was to be administered every morning and bedtime for health maintenance. The medication was to begin on 11/18/23. Review of Resident #2's November 2023 MAR revealed it was documented as 9 on 11/18/23 for both doses. Review of the nursing progress notes from 11/17/23 through 11/19/23 revealed no information related to the reason Resident #2's medications were not administered. Review of the contingency box (c-box - in house available medication) list revealed Pregabalin was available for nursing staff to pull for administration to Resident #2. There was no evidence Pregabalin was pulled from the c-box for administration. Interview on 12/11/23 at 2:48 P.M. with Resident #2 revealed the resident failed to receive medications for two days after she was admitted . 2. Review of Resident #68's medical record revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), and atrial fibrillation. Review of the quarterly MDS assessment, dated 10/01/23, revealed Resident #68 required maximum assist for all ADLS, except eating, which she was independent. Review of Resident #68's medical record revealed a physician's order dated 06/13/23 for Apixaban (anticoagulant) five mg tablet to be administered every morning and bedtime for atrial fibrillation. Additionally, Resident #68 had an order for Diclofenac sodium gel (nonsteroidal anti-inflammatory) external gel 1% to be applied topically to the bilateral knees three times a day for pain. Review of Resident #68's MAR for December 2023 revealed Apixaban and Diclofenac sodium gel had no documentation for administration on 12/10/23 and 12/11/23, evening doses. Review of Resident #68's progress notes, from 12/10/23 and 12/11/23, revealed the notes were silent for a reason Apixaban and Diclofenac sodium gel were not administered. 3. Review of Resident #284's medical record revealed an admitted [DATE]. Diagnoses included lung cancer metastasized to the bone marrow and bones, kyphosis, anemia, chronic obstructive pulmonary disease, diabetes mellitus, acute respiratory failure, and spine fusion. Review of the MDS revealed it was in process. Review of Resident #284's care plan revealed the resident had complaints of acute and chronic pain due to a T-5 fracture, spinal fusion, and lung cancer with metastasized to the bone and bone marrow. Interventions included to provide medication per orders and monitor for side effects and effectiveness of the medication. Review of Resident #284's physician orders, dated 12/04/23, revealed the following orders: Mirtazapine (antidepressant) oral tablet 30 mg to be given by mouth at bedtime for depression, Montelukast sodium (anti-inflammatory) tablet 10 mg to be administered by mouth at bedtime for allergies, Budesonide-Formoterol Furnarate inhalation aerosol (controls asthma and improves lung function) 160-4.5 microgram (mcg) two puffs inhaled orally every morning and bedtime for wheezing, and Lantus (antidiabetic) SoloStar 100 units per milliliter (ml) solution pen-injector, inject 10 units subcutaneously at bedtime for diabetes mellitus. Review of Resident #284's MAR for December 2023 revealed on 12/10/23, there was no documentation of administration of the bedtime doses of Mirtazapine, Montelukast sodium, Budesonide-Formoterol Furnarate, and Lantus. Review of Resident #284's nursing progress notes for 12/10/23 revealed the record was silent as to why the medications were not administered. Review of the c-box medication list revealed Lantus and Mirtazapine were available for nursing staff to pull for administration to Resident #284. Further review revealed no evidence the medication was pulled for Resident #284. 4. Review of Resident #285's medical record revealed an admitted [DATE]. Diagnoses included right femur fracture, multiple sclerosis (MS), asthma, coronary artery disease, lymphedema, and peripheral autonomic disease. Review of Resident #285's MDS revealed it was in process. Review of Resident #285's care plan revealed no mention of pain control or medication administration. Review of Resident #285's physician orders, dated 12/08/23, revealed the resident had the following medication orders: atorvastatin calcium (anticonvulsant) oral tablet 40 mg one time daily at bedtime for hyperlipidemia; calcium carb-cholecalciferol (calcium supplement) oral tablet 600-5 mg/mcg every morning for a supplement; lisinopril (antihypertensive) oral tablet 40 mg every morning for hypertension; metoprolol tartrate (antihypertensive) oral tablet 25 mg to be administered every morning for hypertension; omega-3 oral capsule (Omega-3 Fatty Acids) one by mouth every morning for a supplement; polyethylene glycol 3350 powder 17 grams (gm) by mouth in the morning for constipation; aspirin oral tablet chewable 81 mg to be administered every morning for prophylactic; carbarazepine (anticonvulsant) oral tablet 100 mg every morning and bedtime for convulsions; fluticasone-salmeterol (corticosteroid) inhalation aerosol powder breath activated 250-50 mcg per actuation to be inhaled every morning and at bedtime for shortness of breath and wheezing; glycerin-hypromellose-peg (artificial tears) 400 ophthalmic solution 0.2-0.2-1 % one drop in both eyes every morning and bedtime for dry eyes; levetiracetam oral tablet(anticonvulsant) 500 mg every morning and bedtime for convulsions; senna-docusate sodium (stool softner) tablet 8.6-50 mg every morning and bedtime for constipation; gabapentin (anticonvulsant) oral capsule 300 mg three times a day for health maintenance; and hydrcodone-acetaminophen (opioid pain medication) tablet 5-325 mg one tablet every eight hours as needed for pain rated over six out of 10 for 14 days. Review of Resident #285's MAR for December 2023 revealed the following: On 12/08/23, there was no documentation for atorvastatin administration. On 12/09/23, calcium carb-cholecalciferol was documented as 9, which indicated to see nurses notes. On 12/09/23, lisinopril was documented as 9. On 12/09/23, metoprolol tartrate was documented as 9. On 12/09/23, omega-3 was documented as 9. On 12/09/23, polyethylene glycol 3350 powder was documented as 9. On 12/08/23, there was no documentation for aspirin administration. On 12/09/23, aspirin was documented as 9. On 12/08/23 and 12/09/23, carbarazepine was documented 9. On 12/08/23, the evening dose of fluticasone-salmeterol was silent for any administration documentation. The 12/09/23 morning dose was documented as 9. On 12/08/23 and 12/09/23, glycerin-promellose-peg ophthalmic solution, the MAR was silent for any documentation related to administration. On 12/08/23, levetiracetam administration was blank for the bedtime dose. On 12/09/23, 9 was documented for the morning dose. The 12/08/23 bedtime dose and 12/09/23 morning dose were both absent of documentation of senna-docusate sodium administration. On 12/08/23, gabapentin evening dose was absent for documentation of administration. On 12/09/23, both the morning and afternoon doses were documented as 9. Review of nursing progress notes from 12/08/23 through 12/09/23 revealed no information related to the reason Resident #285 did not receive medications as ordered. Review of the c-box medication list revealed atorvastatin calcium, lisinopril, metoprolol tartrate, gabapentin, senna docusate, and levetiracetam were available for nursing staff to removed from the c-box for administration. There was no evidence nursing staff pulled the medications for administration to Resident #285. Interview on 12/11/23 at 10:32 A.M. with Resident #285 and her family revealed the resident failed to receive her medications for several days after admission. The resident stated she brought her medication with her from her previous facility so there should have been no reason they were not administered. Interview on 12/14/23 at 7:00 A.M. with Licensed Practical Nurse (LPN) #180 verified Resident #258 was admitted with their own medications but was unaware of why those were not started on admission. 5. Review of Resident #287's medical record revealed an admitted [DATE]. Diagnoses included basal cell carcinoma of the scalp and neck, myasthenia gravis, diabetes mellitus, acute respiratory failure. adult failure to thrive, and osteomyelitis. Review of the MDS assessment revealed it was in process. Review of Resident #287's care plan revealed the resident had complaints of acute/chronic pain. Interventions were to follow physician orders for complaint of pain. Review of current physician orders revealed Resident #287 had the following medication orders: gabapentin 100 mg three times a day for health maintenance/neuropathy; Ketonconazole external cream (antifungal) 2% topically daily for a rash until 12/23/23; Lovenox (enoxaparin - anticoagulant) injection 40 mg/ml every 24 hours for circulation; pyridostigmine bromide (treatment for underactive bladder) tablet 60 mg, one and one half tablets every four hours for health maintenance; morphine sulfate ER (opioid) 15 mg twice daily for pain; and Bactrim DS (antibiotic) 800-160 mg Monday, Wednesday and Friday for prophylaxis. Review of the MAR for December 2023 revealed the following: The afternoon dose on 12/08/23 and the morning and afternoon doses on 12/09/23 of gabapentin were silent for administration documentation. On 12/08/23, the MAR reflected no documentation related to the administration of Bactrim. On 12/08/23, pyridostigmine bromide administration was documented as 9 at 1:00 A.M. and 5:00 A.M. and the 1:00 P.M. and 5:00 P.M. doses had no documentation related to administration. Additionally, the 12/10/23 8:00 P.M. dose and the 12/11/23 12:00 A.M. and 4:00 A.M. doses revealed no documentation of administration. On 12/09/23, no documentation was present for Ketonconazole administration. On 12/10/23, enoxaparin injection was documented as 9. Morphine Sulfate was documented as 9 for the morning and evening doses on 12/10/23 and the 12/11/23 morning dose. Further review of nursing progress notes from 12/08/23 through 12/11/23 revealed no documentation related to the reason Resident #287 did not receive medications as ordered. Interview on 12/13/23 at 11:30 A.M. with Registered Nurse (RN) #178 revealed it usually took one to two days to receive ordered medications from their pharmacy, which was located out of town. Interview on 12/14/23 at 6:58 A.M. with Licensed Practical Nurse (LPN) #180 revealed it took one to two days to receive medications from the pharmacy when a resident was admitted . She was unaware of why the medications were not pulled from the back-up contingent box when available and needed. Interview on 12/14/23 at 9:00 A.M. with the Director of Nursing (DON) revealed, upon admission on 12/08/23, Resident #285 had all ordered medications with her. The DON confirmed the MAR indicated Resident #285's medications were not administered as ordered and she was unaware of why the medications were not administered. Additionally, the DON verified Residents #2, #68, #284 and #287 did not receive medications as ordered. The DON stated it generally took one to two days for medications to arrive from the pharmacy once ordered. While some of the missed medications were available in the facility's c-box, the DON confirmed nursing staff did not pull medications, as available, to administer to Residents #2, #68, #284 and #287. Review of the facility policy titled Medication Administration, undated, revealed the facility will proved resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure signage and Personal Protective Equipment (PPE) were posted and available to a COVID-19 positive room. This affected one (Resident #17) of one resident observed for isolation. Additionally, the facility failed to ensure staff took off used PPE and practiced hand hygiene when exiting a COVID-19 positive room. This affected two (Residents #38 and #40) of two residents observed in contact with the staff member. The facility census was 81. Findings include: 1. Review of Resident #17's medical record revealed an admitted [DATE]. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease, nicotine dependence, and COVID-19. Resident #17's COVID-19 diagnosis was added 12/08/23. Review of Resident #17's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #17 was cognitively intact. Resident #17 required set up only for activities of daily living. Resident #17 displayed no behaviors during the review period. Review of Resident #17's care plan revised 12/08/23 revealed the resident was on droplet isolation due to positive COVID-19 test results on 12/08/23. Interventions were to include arranging supplies and equipment in resident's room, implement droplet isolation precautions, and explain purpose or isolation precautions necessary to resident and family. Review of Resident #17's physician orders revealed an order dated 12/08/23 for Contact/Droplet Precautions every shift for COVID-19. Observation on 12/11/23 at 9:34 A.M. of Resident #17's room found red tape along the top and left side of the door. No PPE was available and no signage was posted indicating Resident #17 was on droplet isolation precautions. Interview on 12/11/23 at 9:37 A.M. with Licensed Practical Nurse (LPN) #121 revealed she was not sure if Resident #17 was still considered positive. She verified there was no signage or PPE outside his room. LPN #121 stated the COVID-19 positive residents typically had signs and PPE available. Interview on 12/11/23 at 9:39 A.M. with State tested Nursing Assistant (STNA) #172 revealed he double checked with the unit manager and verified Resident #17 was still on isolation precautions for COVID-19. Review of the facility policy titled, Criteria for COVID-19 Requirements, revised 05/11/23 revealed appropriate signage was to be placed on or around the resident's room door, full PPE was required when entering the room which was to include N95 mask, eye protection, gown and gloves. Full PPE should be located at or near the entrance of the resident's room. 44070 2. Observation 12/11/23 at 1:33 P.M. revealed the food cart arrived to the 300 hall and staff began passing trays to residents. Business Office Manager (BOM) #183 was observed to put on PPE and entered a COVID positive room with two residents inside (#38 and #40). The STNA passed the trays one at a time to the BOM while she was wearing the PPE (N-95, gown, gloves, and faceshield) in the room. A resident declined his food and requested a sandwhich from the kitchen so BOM informed the STNA who left to go to the kitchen. While waiting, BOM #193 stood in the doorway conversing with staff who walked by including an additional aide, maintenance staff, and a nurse. After several minutes of standing in the doorway, BOM #193 exited the room and removed the faceshield, gown and gloves while keeping the exposed/soiled N-95 on and also did not preform hand hygiene after exiting the room. BOM walked through the hallway by numerous residents at the nurses station, residents sitting in the hallway and sitting by the front desk/lobby area. BOM #183 then walked back to her office where she interacted with staff. Interview on 12/11/23 at 1:41 P.M. with BOM #183 confirmed she did not properly remove and dispose of a dirty N-95 mask and did not preform hand hygiene. She revealed she was hot and did not even think about it. BOM #183 reported she was supposed to removed the dirty N-95 mask when exiting the room and place a clean mask on while being in the halways and common spaces. Review of the policy titled, Criteria for COVID-19 Requirements, dated 05/11/23 revealed full PPE was required when entering a residents room including N-95 mask, eye protection, gown and gloves. The PPE should be discarded before exiting the residents room. This deficiency represents non-compliance investigated under Complaint Number OH00148942.

Based on observation, medical records review, staff interview and review of facility policy, the facility failed to timely notify the physician of a malfunctioning catheter. This affected one (#53) of one residents reviewed for catheter care. The facility census was 81. Findings include: Review of Resident #53's medical record revealed an admitted [DATE]. Diagnoses included osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, sacral region, venous insufficiency, type II diabetes mellitus, COPD, schizoaffective disorder, chronic pain, contracture left hip, right hip, left knee, major depression, and anxiety disorder. Review of the MDS assessment, dated 11/11/23, Resident #53 was cognitively intact. dependent on staff for activities of daily living (ADLs), including bed mobility, had an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and one in-house acquired pressure ulcer. Review of the plan of care, revised 07/12/23, revealed Resident #53 had a supra pubic indwelling catheter related to impaired skin integrity, obstruction uropathy, and benign prostatic hypertrophy. Interventions included change catheter per medical provider order, and as needed (PRN), enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, and providing care to urinary catheter, observe /record/report to physician (MD) signs or symptoms (s/sx) of urinary tract infection (UTI), observe for s/sx of discomfort on urination and frequency, position catheter bag and tubing below the level of the bladder and provide privacy bag, secure catheter to the leg with security device, provide catheter care every shift and PRN, and notify medical provider if urine is of abnormal color, consistency, or odor. Observation on 12/13/23 at 6:10 A.M., with Licensed Practical Nurse (LPN) #124, revealed Resident #53 in bed. Entry to the room revealed a pervasive odor. Further observation revealed Resident #53 was heavily soiled with liquid stool and urine and the resident's gown was soiled to middle chest. Continued observation on 12/13/23 at 6:12 A.M. revealed LPN #101 and State tested Nurse Aide (STNA) #112 obtain supplies and proceeded to provide incontinence care to Resident #53, including a bed bath, clothing change and bed linen change. Throughout the observation, Resident #53's urinary indwelling supra-pubic catheter was noted to be leaking from the stoma, with a soiled dressing removed by LPN #101. Additionally, LPN #101 removed a heavily soiled adult incontinence brief and the urinary catheter drainage collection bag was empty. Interview on 12/13/23 at 6:32 A.M. with STNA #112 confirmed she was responsible for Resident #53's care during the night shift, from 10:30 P.M. until 6:30 A.M. STNA #112 stated Resident #53 was last checked at 5:00 A.M. and refused incontinence care or repositioning the entire shift. STNA #112 stated she notified LPN #176 the urinary catheter drainage collection bag was not collecting urine. Interview on 12/13/23 at 6:36 A.M. with LPN #176 revealed she was responsible for Resident #53's care from 6:30 P.M. until 7:00 A.M. LPN #176 verified she was aware Resident #53's urinary catheter drainage collection bag was not collecting urine at the beginning of the shift and she was going to notify the on-coming day shift nurse for further intervention. Review of facility policy titled Notification of Change in Condition, undated, revealed the facility must consult with the resident's physician when there is a change requiring such notification, including circumstances requiring the need to alter treatment, or implement new treatment.

Based on observation, resident interview, staff interview, and facility policy review revealed the facility failed to ensure residents lighting was in working condition and within reach. This affected one (#287) of one residents reviewed for accommodation of needs. The facility census was 81. Findings include: Review of Resident #287's medical record revealed an admitted [DATE]. Diagnosis included basal cell carcinoma of the scalp and neck, myasthenia gravis, diabetes mellitus, acute respiratory failure, adult failure to thrive, and osteomyelitis. Review of the Minimum Data Set (MDS) revealed it was in process. Review of Resident #287's care plan revealed the resident had complaints of acute/chronic pain. Interventions were to follow physician orders for complaint of pain. Observation on 12/11/23 at 3:24 P.M. revealed Resident #287 was lying in bed in a brightly lit room. The resident was unable to reach the wall switches to be able to control the ceiling light nor the overhead bed light. Observation of the bedside lamp revealed it was out of reach and did not contain a light bulb. Interview with Resident #287 on 12/11/23 at 3:25 P.M. revealed he was unable to reach the lights and had to call for assistance to shut off or turn on the lights. Often times he had to sleep with the lights in the on position. Interview on 12/11/23 at 3:27 P.M. with Maintenance Technician (MT) #187 verified Resident #287 was unable to reach the light switches for the overhead bed light, ceiling lights, or bedside lamp. Additionally, MT #187 confirmed the bedside lamp did not have a light bulb. Review of the facility policy titled Resident Rights, undated, revealed it was the policy of the facility to provide a resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident.

Based on observation, medical record review, staff interview, resident interview, review of the air mattress user manual, and review of facility policy, the facility failed to ensure interventions were consistently implemented to promote skin integrity. This affected one (#53) of three residents reviewed for pressure ulcers. The facility census 81. Findings include: Resident #53 admitted to the facility on [DATE] with the diagnoses including osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, and sacral region, venous insufficiency, type II diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, chronic pain, contracture left hip, right hip, and left knee, major depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 11/11/23, revealed Resident #53 was cognitively intact, dependent on staff for activities of daily living (ADLs), had an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and had one in-house acquired pressure ulcer. Review of the plan of care, revised 11/09/23, revealed Resident #53 had impaired skin integrity and was at risk for altered skin integrity due to immobility, poor nutrition, poor vascularity, and pressure ulcers. Interventions included administer medications as ordered, monitor for side effects and effectiveness, administer treatments as ordered by medical provider, ankle lift pillows as tolerated, apply appropriate pressure reducing appliances, apply barrier creams post incontinent episodes, complete skin at risk assessment upon admission/readmission, quarterly, and as needed, complete weekly skin checks, educate resident/resident representative on need for turning and repositioning, enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to wound care for skin openings that require a dressing, ensure residents are turned and repositioned, evaluate existing wound daily for changes (redness, edema, drainage, pain, foul odor), keep gerichair close to resident room and encourage use up to daily as tolerated, monitor meal intake, monitor vital signs, notify resident/resident representative, medical provider of any decline in wound healing, nutritional consult on admission, quarterly, and as needed (PRN), offer dietary supplements per medical provider's orders, provide diet as ordered, and provide peri-care as needed to avoid skin breakdown due to incontinence. Review of a physician order dated 11/10/23 revealed Resident #53 was ordered an Alternating Pressure Mattress (APM) to the bed and to check placement, function, and settings according to manufacturer instructions. Additional review of the plan of care, revised 11/13/23, revealed Resident #53 had a behavior problem related to diagnoses of schizophrenia, anxiety, depression, panic disorder, loss of independence, nursing home admission, pain, and psychosocial issues. Resident #53 smoked in his room, refused to have sheets changed, refused to have wound dressing changed, refused to have nails trimmed, scratched self, digs at back side with his nails, throws food trays on the floor and/or at staff, scratched staff when providing care, combative with cares that are being given, refused to turn and reposition, put hands in stool, preferred to wear gowns, refused respiratory medications, refused to get up out of bed, and refused to off load heels. Interventions included administer medications as ordered, educate resident and resident representative to medication effectiveness and side effects, approach, speak in calm manor, encourage active support by family/resident representatives, encourage resident to express feelings, encourage to maintain as much independence and control/decision making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, and attempt to determine underlying causes, observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs, and praise any indication of progress in behaviors. Review of a weight, dated 12/06/23 and located in the electronic medical record, revealed Resident #53 weighed 127.2 pounds (lbs). Observation on 12/13/23 at 6:10 A.M. with Licensed Practical Nurse (LPN) #124 revealed Resident #53 in bed. Upon entrance to the room, a pervasive odor was noted. Resident #53 was heavily soiled with liquid stool and urine. Continued observation revealed Resident #53's hospital gown was soiled to middle chest. An air mattress was in use to the bed, with the low pressure indicator light flashing. The air mattress weight was set at 260 pounds. Observation on 12/13/23 at 6:12 A.M. revealed LPN #101 and State tested Nurse Aide (STNA) #112 obtained supplies and proceeded to provide incontinence care to Resident #53, including a bed bath, clothing change and bed linen change. Resident #53 was noted to have food debris under him, a heavily soiled adult incontinence brief, and a stage IV pressure ulcer dressing heavily soiled and dislodged, with wound packing dangling from the wound. Interview on 12/13/23 at 6:32 A.M. with STNA #112 revealed she was responsible for providing care to Resident #53 during the night shift, from 10:30 P.M. to 6:30 A.M. STNA #53 revealed the resident was last checked at 5:00 A.M. and refused incontinence care and repositioning during the entire shift. STNA #112 stated she notified LPN #176 and no additional interventions or strategies had been attempted to address the resident's incontinence or repositioning needs. Interview on 12/13/23 at 6:36 A.M. with LPN #176 confirmed she had been assigned to Resident #53's care during the night shift, between 6:30 P.M. and 7:00 A.M. LPN #176 stated she was unaware Resident #53 would not allow incontinence care or repositioning throughout the shift. LPN #176 indicated Resident #53 would respond to her regarding turning, repositioning and incontinence care; however, LPN #176 denied being informed of the refusals or the need for intervention. Interview on 12/13/23 at 7:35 A.M. with wound specialist, Certified Nurse Practitioner (CNP) #1, during treatment observation, revealed Resident #53 had multiple pressure ulcers. CNP #1 stated Resident #53 frequently refused treatments and repositioning. The resident had been given education and encouragement to comply with wound treatment. CNP #1 stated Resident #53 agreed to having wounds treated once daily instead of twice daily. Further observation with CNP #1 and LPNs #101, and #124, during pressure ulcer wound evaluation, noted the following wounds: right hip pressure Stage IV measuring 6.8 centimeters (cm) long x 5 cm wide x 0.4 cm deep; right heel pressure Stage IV measuring 6.9 cm x 7 cm x 0.2 cm; sacrum pressure Stage IV measuring 4.5 cm x 4.9 cm x 1.9 cm; left hip pressure Stage IV measuring 0.4 cm x 0.8 cm x 0.1 cm; right medial lower leg pressure Stage IV measuring 13 cm x 6.7 cm x 0.4 cm; left hip distal pressure Stage IV measuring 8 cm x 5.9 cm x 1.2 cm; and left lateral foot pressure Stage IV measuring 1.5 cm x 1.4 cm x 0.2 cm. The bed air mattress was observed to be flashing low pressure and the weight setting was at 260 lbs. Additional observations on 12/13/23 at 11:39 A.M. and 3:20 P.M. revealed Resident #53 in bed with the air mattress control indicator light flashing low pressure and the weight setting at 260 pounds. Resident #53 was positioned on his back and lying in hole in the mattress, with limited support. Concurrent interview with Resident #53 confirmed he felt like he was sinking into the mattress and this was not comfortable. Interview on 12/13/23 at 3:27 P.M. with LPN #101, unit manager, revealed the facility did not have access to the air mattress instructions for use due to being supplied by the hospice agency. The facility was contacting the hospice agency for access to the instruction manual. Review of alternating air mattress user manual noted the manual should be used for initial set up of the system and for reference purposes. Further review revealed to turn the pressure adjust knob to set a comfortable level by using the weight scale as a guide. The low pressure indicator notes a visible indicator (yellow or red) and warns the pressure is below a preset or user-defined level. The visible alarm indicator will continue to flash until the air pressure issue was corrected. Once corrected, the alarm function will automatically reset. Interview on 12/13/23 at 3:24 P.M. with LPN #153 revealed she was unaware Resident #53 air mattress was not set at the proper weight setting and unaware the air mattress was flashing low pressure since assuming the shift. Review of facility policy titled Skin Care and Wound Management Overview, undated, revealed the policy was to prevent skin impairment and promote healing of existing wounds. Additionally, a plan of care would be developed with individualized interventions to address risk factors, risk factors and interventions would be communicated to the care giving team, and evaluate for consistent implementation of interventions and effectiveness at clinical meeting.

Based on observations, medical record review, family and staff interviews, and review of facility policies, the facility failed to provide pain management to a resident experiencing pain. Actual Harm occurred when Resident #35, with a history of chronic pain, experienced pain as evident by moaning, grunting, and thrashing head on pillow throughout wound care every time one of his lower extremities was moved and grimacing and gritting teeth as range of motion was completed on lower legs. No pharmacological or non pharmacological interventions were offered to alleviate the pain. This affected one (#35) of five residents reviewed for pain. The facility census was 57. Findings include: Review of Resident #35's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 did have a [CONDITION(S)] and gastrostomy (feeding) tube. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderate cognitive impairment with unclear speech with resident usually understood. Resident #35 required extensive assistance of two staff for bed mobility and was dependent upon staff for the completion of activities of daily living. The resident was incontinent of bowel and had a catheter in place for bladder and was at risk for pressure ulcer development, with deep tissue injury to the left heel present on admission. Resident #35 experienced constant pain, with a score of seven out of ten, with ten being the highest severity level of pain. Review of the care plan dated 04/22/22 revealed Resident #35 had complaints of chronic pain related to [CONDITION(S)] and wounds. Goals included Resident #35's ability to communicate pain relief with interventions that included non-medication interventions, medications as ordered, monitoring of pain every shift, and physician notification of ineffective interventions. Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Two additional orders dated 07/08/22, were for [MEDICATION(S)]-acetaminophen 10-325 mg, half a tablet per feeding tube every six hours as needed for moderate pain (not defined) and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pain scores for the month of August 2022 for Resident #35 revealed a zero level of pain on day shift and the following pain scores on the night shift of five out ten on 08/03/22, seven out of ten on 08/04/22, five out of ten on 08/05/22, eight out of ten on 08/08/22, seven out of ten on 08/09/22, seven out of ten on 08/13/22, one out of ten on 08/18/22 and two out of ten on 08/22/22. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #53 at 1:26 A.M. on 08/03/22, at 11:32 P.M. on 08/05/22 and at 9:00 P.M. on 08/09/22. There was no other pain medications documented as being provided. Review of treatment record for Resident #35 for the month of August 2022 was silent for non-medication interventions being attempted for pain management. Interview on 08/23/22 at 9:31 A.M., with Resident #35's Family Member revealed concerns related to the constant pain experienced by Resident #35 and the inability of Resident #35 to participate in therapy and activities of daily living due to pain. Observation on 08/23/22 at 10:44 A.M., revealed Resident #35 moaning, grunting, and thrashing head on pillow throughout wound care every time one of his lower extremities was moved. Observation on 08/23/22 at 3:00 P.M., revealed Resident #35 grimacing and gritting teeth as range of motion was completed on lower legs. Interview on 08/23/22 at 4:45 P.M., with the Director of Nursing verified the pain medication had not been administered to Resident #35 when pain was experienced and further verified there is no documentation of other interventions and or resident refusals of pain medication. The Director of Nursing stated care is often not provided to Resident #35 due to the refusal of care related to pain. Interview on 08/24/22 at 9:07 A.M.,with Registered Nurse (RN) #130 revealed RN #130 was unable to define mild, moderate, or severe pain. Interview on 08/24/22 at 12:13 P.M., with the Director of Therapy Services #140 revealed Resident #35 had plateau with therapy and often refused and did not actively participate due to pain. Review of the policy titled Pain Management and Assessments updated 07/25/18, indicated based on the comprehensive assessment of the resident, the facility must ensure that residents receive treatment and care related to pain. This deficiency is based on incidental findings discovered during the course of this complaint investigation and is an example of the continued non compliance from the survey dated 07/19/22.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure recommended interventions were implemented to prevent skin breakdown. Actual harm occurred when Resident #49 was discovered with an in-house acquired deep tissue injury to the right heel. This affected one (#49) of three residents reviewed for skin breakdown in a facility census of 57. Findings include: Medical record review revealed Resident #49 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed the resident had severe cognitive impairment. Resident #49 required extensive assistance of two staff for bed mobility and was dependent upon staff for the completion of activities of daily living. The resident was incontinent of bowel and bladder and was at risk for pressure ulcer development, with three stage II pressure ulcers present on admission. Further review of the medical record revealed on 06/20/22 the resident was assessed to be at high risk for skin breakdown. On 06/20/22, the physician ordered the resident to be placed on a pressure reducing/relieving mattress. Review of the care plan dated 06/21/22 revealed Resident #49 was at risk for skin breakdown down due to chronic kidney disease, limited mobility, and bedfast. Resident #49 had stage II pressure ulcers to the right buttock, right gluteal fold, and sacrum. The goal indicated Resident #49 would have no further skin breakdown. Interventions included, administer medications as ordered, monitor for side effects and effectiveness, administer treatments as ordered by medical provider, apply barrier creams post incontinent episodes, complete skin at risk assessment upon admission/readmission, quarterly, and as needed, complete weekly skin checks, ensure residents are turned and repositioned, and provide peri-care as needed to avoid skin breakdown due to incontinence. Further review of the medical record revealed no wound descriptions or measurements were completed for the resident until 06/22/22 (two days after admission), when the resident was evaluated by Wound Certified Nurse Practitioner (NP) #01. Wounds were described as follows: stage II pressure ulcer to the right buttock measured 0.46 centimeters (cm) long by (x) 0.62 cm wide x 0.10 cm deep, stage II pressure ulcer to the right buttock fold measured 1.40 cm long x 0.97 cm wide x 0.10 cm deep, and stage II pressure ulcer to the sacrum measured 0.61 cm long x 0.58 cm wide x 0.10 cm deep. Wound Certified NP #01 recommended the following interventions: pressure reduction/offloading to include ensure compliance with turning, elevate legs regularly, wedge/foam cushion for offloading, and mattress overlay. There was no documentation of any wounds to the resident's feet/heels. On 06/27/22, the resident was reassessed to be at low risk for skin breakdown. On 07/04/22, the resident was reassessed to be at high risk for skin breakdown. No additional pressure relieving interventions were implemented. Review of Wound Certified NP #01 documentation revealed measurements and evaluation of the three wounds to the right buttock fold, right buttock, and sacrum, were completed on 07/01/22 and 07/06/22. Wound Certified NP #01 continued to recommend pressure reduction/offloading to include ensure compliance with turning, elevate legs regularly, wedge/foam cushion for offloading, and mattress overlay. There was no documentation contained in the medical record indicating the interventions were implemented as requested by Wound Certified NP #01. Observation on 07/11/22 at 11:38 A.M. noted Resident #49 in bed with a standard facility pressure relief mattress (not an overlay as recommended). The resident was positioned on her back with both heels resting on the surface of the mattress and a pillow at the foot of the bed. Observation on 07/12/22 at 11:49 A.M. revealed Resident #49 was positioned on her back, in bed with heels resting on the surface of the mattress with no pressure relief to her feet or legs, nor were the resident's legs elevated. At 1:25 P.M. the resident remained positioned on her back with heels resting on the mattress and legs not elevated. Observation on 07/12/22 at 2:14 P.M. of State tested Nurse Aide (STNA) #308 and Licensed Practical Nurse (LPN) #334 providing incontinence care to Resident #49 revealed the resident was incontinent of a moderate amount of urine. STNA #308 completed incontinence care and LPN #334 indicated the three pressure ulcers appeared to be healed. Following incontinence care, Surveyor requested LPN #334 remove the resident's socks. Observation of the right heel revealed a deep tissue injury. The wound measured 3.0 cm long x 2.0 cm wide with an unstageable depth. Wound characteristics were with distinct edges, pink and reddened wound bed. Staff were unaware the heel wound existed prior to this observation. Interview on 07/12/22 2:28 P.M. LPN #334 verified no overlay mattress was in place and the resident's heels were not consistently elevated. Interview 07/12/22 at 2:40 P.M. the Director of Nursing (DON) verified Resident #49 was assessed at low risk for skin breakdown on 06/27/22, despite having skin breakdown upon admission. Additionally, the DON verified no initial wound measurements were obtained and no additional interventions were implemented, other than the mattress, which was provided by hospice on admission. Observation 0n 07/13/22 at 12:20 P.M. with Wound Certified NP #01 and LPN #334 present revealed the resident's wounds to the sacrum, right buttock, and right buttock fold were healed. Wound Certified NP #01 noted the right heel wound and obtained measurements of 2.10 cm x 2.11 with no depth. Wound Certified NP #01 described the wound as a pressure ulcer/suspected deep tissue injury. Interview with Wound Certified NP #01 at the time of observation, confirmed she was not informed of ordered interventions not being implemented, this included an overlay type pressure/air mattress, heel elevation, and positioning wedge/cushion. Review of the facility's skin care and wound management policy, effective 07/01/16, revealed staff were to verify appropriate pressure redistribution devices/support surfaces were in place as indicated. Staff were to monitor residents' skin in contact with adaptive equipment for areas of pressure. Implementation of prevention strategies to decrease the potential for developing pressure ulcers. In addition, complete an admission observation tool to identify areas of skin impairment and pre-existing signs. This deficiency substantiates Complaint Number OH 613.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to obtain treatments for pressure ulcers upon admission, failed to implement pressure reducing interventions, and failed to provide ongoing monitoring and assessment of pressure ulcers. This resulted in actual harm when one resident (#1) developed two avoidable in-house Stage II pressure ulcers to the buttocks, did not have ongoing monitoring of current pressure ulcers, and did not have a treatment provided to existing pressure ulcers for six days following admission. This deficient practice affected one (#1) of three residents reviewed for skin breakdown. The facility identified two residents with current pressure ulcers. The facility census was 52. Findings include; Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital ostomy and wound charting dated 08/18/21 and 08/19/21 documented the resident with two stage II pressure ulcers to the right buttocks. The pressure ulcers were described as shallow, pink/red, open with no yellow. Wound care was listed with the application of a foam dressing. Review of the facility admission initial evaluation, dated 08/19/21, the resident was chairfast with limited mobility, was dependent on staff for bed mobility and toileting, utlized a wheelchair for locomotion, and was incontinent of bowel and bladder. The resident admitted with a pressure ulcer to the right buttock, a right big toe amputation, and gangrene to both feet. No wound descriptions, measurements, or treatments were documented. Additionally, the residents admission initial evaluation identified the resident to be at potential risk for skin breakdown and no interventions were documented to be put into place on the assessment. Review of a care plan implemented on 08/20/21 and revised on 08/30/21, identified the resident having impaired skin integrity or at risk for altered skin integrity related to peripheral vacular disease, diabetes mellitus type II, gangrene to current wounds, cardiac impairments, and end stage renal disease with hemodialysis as evidenced by right great toe amputation with wound on admission, left toe gangrene on admission, and two pressure ulcers to the right buttock on admission. Interventions initiated on 08/20/21 included: Administer treatments as ordered by medical provider; Apply barrier creams post incontinent episodes, Complete skin at risk assessment upon admission / readmission, quarterly, and as needed; Complete Weekly Skin checks; Ensure resident is turned and repositioned; and Physical Therapy(PT)/Occupational Therapy (OT ) evaluation and treatment as needed for positioning and wound care. The plan of care did not address any pressure relieving interventions or devices. Review of the physician orders revealed no ordered treatments to the resident's pressure ulcers on the right buttocks upon admission. On 08/25/21 a treatment was ordered for the two pressure ulcers on Resident #1's right buttocks. The treatment included: Cleanse the buttocks with wound cleanser pat dry then apply a large foam dressing or sacral dressing every three days and as needed (PRN). The record had no documentation of an assessment of the two Stage II pressure ulcers. Review of the treatment administration record (TAR) for August 2021 revealed weekly skin assessments were to be completed every Tuesday. The TAR has no documentation a weekly skin assessment was completed on Tuesday 08/24/21. Observation on 08/30/21 at 11:30 A.M. noted Resident #1 seated in a wheelchair at the bedside. No pressure reducing seat cushion was applied to the seat of the wheelchair. Interview on 08/30/21 at 11:45 A.M., State tested Nurse Aide (STNA) #100 and STNA #101 verified no pressure reducing seat cushion was present on Resident #1's wheelchair seat. The STNAs stated the resident is transported to and from a hemodialysis center three days a week in the wheelchair and no seat cushion had been observed in use. Interview on 08/31/21 at 9:55 A.M., the Administrator verified Resident #1 was admitted to the facility with two stage II pressure ulcers to the right buttock. The Administrator confirmed the record lacked documentation a treatment was applied to the resident's buttock pressure ulcers until 08/25/21 and there were no wound measurements completed. Observation and interview on 08/31/21 at 12:05 P.M. with Interim Director of Nursing (IDON) #2 and Divisional Registered Nurse (DRN) #1 verified no assessments of Resident #1's right buttock pressure ulcers had been completed. Further interview with DRN #1 noted the residents pressure ulcers were measured on this day and two additional Stage II pressure ulcers were discovered to Resident #1's buttocks. Interview on 08/31/21 at 12:10 P.M. interview with IDON #2 verified Resident #1 did not have a pressure reducing cushion in use while in the wheelchair and additional pressure ulcers were identified to the resident's buttocks that were not previously identified. Observation on 08/31/21 at 1:10 P.M. with IDON #2 and DRN #1 noted the DRN#1 to remove Resident #1's dressing to the buttocks. Resident #1 was observed to have three Stage II pressure ulcers present on his right buttock and one Stage II pressure ulcer present on his left buttock. DRN #1 proceeded to obtain measurements of the pressure ulcers to the buttocks. The new left buttock was a Stage II pressure ulcer measuring 0.8 centimeters (cm) wide by 1.0 cm long with no depth. The right buttock wound #1, which was present upon admission, was identified as a Stage II pressure ulcer measuring 1.0 cm wide by 0.5 cm long by 0.5 cm deep, The right buttock wound #2, which was present upon admission, was identified as a Stage II pressure ulcer measuring 1.5 cm wide by 0.7 cm long by 0.5 cm deep. The new pressure ulcer to the right buttock, wound #3, was identified as a Stage II pressure ulcer measuring 1.0 cm wide by 0.5 cm long by 0.5 cm deep. Review of body/skin check documentation dated 08/31/21 documented the above measurements. All buttock wounds were noted to be pink with no drainage or odor. Review of the facility policy titled Skin Care & Wound Management, effective 07/01/16, revealed Stage II pressure ulcers (wounds) are assessed weekly. Determine the treatment protocol most appropriate to the resident need. Obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Document wound measurements and characteristics on the Skin Grid Pressure no less than weekly. Verify prevention interventions are in place. Review effectiveness of treatment plan every two (2) weeks and revise as needed. This deficiency substantiates Complaint Number OH 247.

Based on medical record review, interviews with facility staff and the physician group, review of the medication reference information, and review of the facility policy for medication administration, the facility failed to ensure residents were free from significant medication errors when one resident (#64) was given scheduled insulin five hours past the scheduled administration time. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #64 when the resident received long acting and short acting insulin past the scheduled administration time, became hypoglycemic (low blood sugar) requiring intervention from the nursing staff, and experienced [MEDICAL CONDITION] requiring lifesaving measures. This affected one resident (#64) of five reviewed for insulin medication. Additionally, two residents (#25 and #36) were placed at potential risk for harm, that did not rise to the level of Immediate Jeopardy, by failure of the facility to ensure insulin medication was administered at the ordered scheduled time. The facility census was 61. On [DATE] at 4:12 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 1:19 A.M. when agency Licensed Practical Nurse (LPN) #88 administered insulin to Resident #64, five hours past the scheduled administration time, without notifying the physician. This resulted in the resident becoming hypoglycemic, requiring interventions by the nursing staff. On [DATE], Resident #64 was found at 1:19 A.M. with a blood sugar of 170 milligrams per deciliter (mg/dL). At 4:19 A.M., Resident #64 had a blood sugar of 72 mg/dL and was given a yogurt with four sugar packets. At 4:50 A.M., the resident had a blood sugar of 52 mg/dL and was given apple juice with five sugar packets and a [MEDICATION NAME] injection. At 5:05 A.M., the resident had a blood sugar of 46 mg/dL. At 5:15 A.M., the resident was found unresponsive and cardio-pulmonary resuscitation (CPR) was initiated by the nursing staff. On [DATE] at 6:05 A.M., Emergency Medical Service (EMS) staff pronounced the death of the resident. The Immediate Jeopardy was removed on [DATE], when the facility audited all resident ' s medical records with physician orders for insulin and educated all licensed nursing staff on the timeliness of insulin administration and notification to the physician was critical when insulin was late, and the facility implemented the following corrective actions: · On [DATE], agency LPN #88 was placed on a do not return list for Advanced Healthcare. LPN #90 was educated on the completion of tasks including medication administration and giving report to on-coming nurses. · On [DATE], the DON and Corporate Nurse (CN) #135 audited all resident ' s medical records with physician orders for insulin and specifically residents (#05, #22, #25, #29, #30, #36, #48, #50, and #59) who had nighttime insulin orders. The audit included a review of administration of insulin per the physician order. The DON and CN #135 found seven residents (#05, #22, #25, #29, #30, #36, and #48) who were given their nighttime insulin outside of the scheduled administration time between [DATE] and [DATE]. · On [DATE], the DON and designee started education of all facility and agency licensed nursing staff on medication administration with emphasis on insulin administration and notification to physician when changes were necessary to the current order. Education was completed with all licensed staff on [DATE]. This education will be provided for contingency staff (PRN) or agency prior to their next scheduled shift. The facility will continually educate newly hired licensed nursing staff and new agency nurses who are scheduled during their orientation. · On [DATE], a Quality Assurance Performance Improvement (QAPI) meeting was held. Attendees included the Administrator, DON, CN #135, and Human Resources Director (HRD) #145. They discussed the insulin and set up an audit schedule and notification process. · On [DATE] at 10:30 A.M., the Medical Director was notified of Immediate Jeopardy concerns. · On [DATE], the DON and or designee will continue to audit residents with physician orders for nighttime insulin to ensure insulin was given per order, five times a week for four weeks. Results of the audits will be presented in the daily stand up and monthly QAPI meeting for review and recommendation. The QAPI committee will determine when compliance is achieved. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] revealed the resident demonstrated disorganized thinking, disorientation, short term memory loss, and was severely cognitively impaired. Review of the baseline care plan dated [DATE] revealed the resident had diabetes. Interventions included administer insulin injections per physician orders, obtain blood sugars per physician orders, observe the resident for [DIAGNOSES REDACTED], and reporting any abnormal findings to the medical provider. Additionally, the care plan indicated the resident was on [MEDICAL TREATMENT] therapy on Tuesday, Thursday, and Saturday with a chair time of 6:00 A.M. Interventions for this care planned concern included administering medications per the medical providers orders and observing the resident for side effects and effectiveness. Review of the admission physician orders revealed the resident was ordered [MEDICATION NAME] Insulin (short acting insulin) to be given per the following sliding scale: if the blood sugar level was below 60 mg/dL contact the physician, if the blood sugar level was 150 mg/dL to 199 mg/dL administer two units of insulin, 200 mg/dL to 249 mg/dL administer three units of insulin, 250 mg/dL to 299 mg/dL administer four units of insulin, 300 mg/dL to 349 mg/dL administer five units of insulin, 350 mg/dL to 500 mg/dL administer six units of insulin, if the blood sugar was greater than 400 mg/dL notify the physician, to be administered subcutaneously before meals and at bedtime. Additionally, the physician orders revealed the resident was to have [MEDICATION NAME] Insulin (long acting insulin) 12 units, injected subcutaneously daily at bedtime for Diabetes Mellitus. Review of the Medication Administration Record [REDACTED].M., 11:00 A.M., 4:00 P.M., and 8:00 P.M., except on days of [MEDICAL TREATMENT] the morning insulin was scheduled earlier. The residents [MEDICATION NAME] Insulin was scheduled for administration daily at 8:00 P.M. Further review of the MAR indicated [REDACTED].M. on [DATE]. There was no documentation the [MEDICATION NAME] was given at the 8:00 P.M. hour on [DATE]. Further review revealed the resident received 12 units of [MEDICATION NAME] Insulin at 1:19 A.M. on [DATE]. There was no documentation the [MEDICATION NAME] was given at the 8:00 P.M. hour on [DATE] as ordered. Review of the documented blood sugars dated [DATE] and [DATE] revealed the following blood sugars: on [DATE] at 5:14 P.M., 129 mg/dL, on [DATE] at 1:19 A.M., 170 mg/dL, on [DATE] at 4:19 A.M., 72 mg/dL, on [DATE] at 4:50 A.M., 52 mg/dL, and on [DATE] at 5:05 A.M., 46 mg/dL. Review of the nurse progress notes dated [DATE] indicated LPN #88 arrived at 11:30 P.M. and had not received report from the outgoing nurse. LPN #88 was only told by the outgoing nurse about one side of the hallway having received their medication and the way the residents took their medication was on the report sheet. LPN #88 completed the bedtime medication pass on Resident #64, took his blood sugar, and administered insulin. Further review of the progress note revealed LPN #88 began the morning medication pass for the resident at 4:15 A.M. LPN #88 obtained the residents blood sugar and found a reading of 72 mg/dL. The resident was given yogurt with four sugar packets at the time of the reading. At 4:50 A.M., LPN #88 rechecked the residents blood sugar a second time and found it was 52 mg/dL. The resident received a [MEDICATION NAME] injection and an apple juice with five sugars. The resident consumed 80 percent of the apple juice. At 5:05 A.M., LPN #88 rechecked the residents blood sugar a third time and found a reading of 46 mg/dL. LPN #88 asked State tested Nursing Assistant (STNA) #105 to stay with the resident and went to the 100-hall to ask for help from LPN #110. The note further indicated LPN #110 went to the resident ' s bedside while LPN #88 called 911 at 5:15 A.M. LPN #88 then went back to the resident ' s bedside and LPN #110 reported she was unable to find a pulse. LPN #88 had documented she felt a faint pulse, but vital signs could not be obtained so she initiated Cardio-Pulmonary Resuscitation (CPR). Per the note, EMS arrived at 5:26 A.M. and took over the CPR until the resident was pronounced deceased at 6:05 A.M. Interview on [DATE] at 3:41 P.M., LPN #88 verified she had given Resident #64 his scheduled [MEDICATION NAME] Insulin and two units of [MEDICATION NAME] Insulin at the documented time of 1:19 A.M. She stated when she arrived to work around 11:30 P.M. on [DATE], she was not given a proper report from LPN #90, who had not finished passing bedtime medications for one side of the hallway. LPN #88 stated she had to finish the medications that were due and not passed by LPN #90 prior to her leaving. LPN #88 verified the physician was not contacted regarding the insulin she administered late at 1:19 A.M. Interview on [DATE] at 11:16 A.M., Nurse Practitioner (NP) #120 revealed she was part of the provider team caring for Resident #64. NP #120 verified the physician service was not made aware Resident #64 was given insulin late outside of the scheduled time on [DATE]. NP #120 stated if a resident ' s insulin was that far past the scheduled time, she would have recommended the staff hold the insulin, check a blood sugar on the resident and report the findings to her prior to administering any insulin. NP #120 stated that giving insulin late into the night could be dangerous because if the resident had not eaten anything it could cause the blood sugar to drop to an unsafe level. NP #120 also stated the physician service has had issues in the past with staff in the facility not reporting changes to medication times. Interview on [DATE] at 1:45 P.M., LPN #90 revealed she was the second shift nurse who cared for Resident #64 on [DATE]. She revealed she was asked to stay over from day shift for a few hours until her relief nurse came in. LPN #90 stated she was under the impression relief would be coming sooner than when she did so she put off the evening medication pass expecting that it would be completed by the relieving nurse. LPN #90 stated she was helping other staff during that time, got behind, and when the estimated time of the relief nurse kept being pushed back, she started the medication pass on her assigned hall late. LPN #90 stated she was able to get half the residents on the hall done prior to the relief nurse arriving. LPN #90 stated she told the relief nurse residents still needed their bedtime medications passed prior to leaving. Interview on [DATE] at 2:40 P.M., House Physician (HP) #130 revealed he was the primary physician caring for Resident #64. HP #130 verified the physician service was never notified insulin was going to be given late for Resident #64. HP #130 stated giving insulin outside of the desired schedule should warrant notifying the physician. HP #130 stated in the case of Resident #64, he would have recommended to hold any insulin until a blood sugar was obtained and reported to him. Review of the medication reference information (https://reference.medscape.com/drug/[MEDICATION NAME]-insulin-detemir- 2#10) for [MEDICATION NAME]revealed the absorption onset time for [MEDICATION NAME] is three to four hours. Review of the medication reference information for [MEDICATION NAME](https://reference.medscape.com/drug/fiasp-[MEDICATION NAME]-insulin-[MEDICATION NAME]- 1#10) revealed the peak effect of [MEDICATION NAME] is achieved in one to three hours. Review of the policy titled Medication Administration last revised [DATE] revealed facility staff will observe the five rights when giving medication including the right resident, the right time, the right medicine, the right dose, and the right route. Additionally, medications will be administered within the time frame of one hour before or up to one hour after the time ordered. Medications that are refused, withheld, or not given will be documented and critical medications such as insulin will be followed up with contact to the physician. 2) Review of the medical record revealed Resident #25 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the care plan last revised on [DATE] revealed the resident had diabetes. Interventions included administering long acting and short acting insulin medication per the physician orders. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired and was receiving insulin injections. Review of the physician orders dated February 2021 revealed orders for [MEDICATION NAME] (long acting insulin) 60 units every morning and at bedtime. Review of the Medication Administration Record [REDACTED].M. Review of the time stamps for administration revealed on [DATE], LPN #90 administered the residents [MEDICATION NAME] at 11:29 P.M. Review of the nurse progress notes dated [DATE] revealed no evidence the physician was contacted regarding the late administration of insulin. Review of the recorded blood sugars dated from [DATE] to [DATE] revealed the resident had not experienced any abnormalities related to the late insulin administration. Interview on [DATE] at 1:45 P.M., LPN #90 confirmed she had administered insulin late as she thought she would be relieved sooner. When her relief had not shown up, she began administering medications. She was relieved at approximately 11:30 P.M., and half of the hallway was still in need of their medications. She made her relief aware of who still needed their medications. Interview on [DATE] at 2:04 P.M., CN #135 verified Resident #25 received insulin late, outside of the scheduled timeframe, and without physician notification. CN #135 confirmed that she found this late administration while auditing residents with insulin orders and that the physician and family of the resident were contacted regarding the incident. 3) Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment and received insulin injections. Review of the care plan revised on [DATE] revealed the resident had diabetes. Interventions included administering insulin as ordered. Review of the physician orders dated February 2021 revealed orders for Humalog (a fast acting insulin) insulin injections based on a sliding scale coverage: if the blood sugar was 150 mg/dL to 200 mg/dL give two units of insulin; 201mg/dL to 250 mg/dL give four units; 251 mg/dL to 300 mg/dL give six units; 301mg/dl to 350 mg/dL give eight units; 351 mg/dL to 400 mg/dL give 10 units; 401 mg/dL to 450 mg/dL give12 units and notify physician of blood sugar less than 60 mg/dL and greater than 400 mg/dL. Inject subcutaneously before meals and at bedtime. Additional orders included [MEDICATION NAME], 47 units daily at bedtime. Review of the MAR indicated [REDACTED].M. each night. [MEDICATION NAME] was scheduled to be administered at 8:00 P.M. each night. Further review of the time stamps in the MAR indicated [REDACTED].M. on [DATE]. There was no documentation of insulin administered on [DATE] at the 8:00 P.M. or 9:00 P.M. hour. Review of the nurse progress notes dated [DATE] and [DATE] revealed no evidence the physician was contacted regarding the late administration of insulin. Review of the recorded blood sugars on [DATE] and [DATE] revealed the resident had not experienced any abnormalities because of the late administration. Interview on [DATE] at 1:45 P.M., LPN #90 confirmed she had not administered medications on time including insulins as she thought she would be relieved sooner. She was relieved at approximately 11:30 P.M., and half of the hallway was still in need of their medications. She made her relief aware who still needed their medications. Interview on [DATE] at 2:04 P.M., CN #135 verified Resident #36 received insulin late, outside of the scheduled timeframe, and without physician notification. CN #135 confirmed that she found this late administration while auditing residents with insulin orders and that the physician and family of the resident were contacted regarding the incident. Review of policy titled Medication Administration last revised [DATE] revealed facility staff will observe the five rights when giving medication including the right resident, the right time, the right medicine, the right dose, and the right route. Additionally, medications will be administered within the time frame of one hour before or up to one hour after the time ordered. Medications that are refused, withheld, or not given will be documented and critical medications such as insulin will be followed up with contact to the physician. This deficiency substantiates Master Complaint Number OH 203.

Based on medical record review, staff interview, observation of the facility emergency crash carts, review of the emergency crash cart supply check list, review of the facility policy for Cardio-Pulmonary Resuscitation (CPR), and review of the recommended technique for providing CPR, the facility failed to adequately monitor the emergency crash cart supplies, ensuring a CPR backboard was available. Additionally, the facility staff failed to provide adequate life saving measures for one resident (#64) who was in [MEDICAL CONDITION] and had a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #64 when CPR was performed by staff on the resident while the resident remained in the bed, on a surface (mattress) that lessened the overall quality of chest compressions. On [DATE] at 4:12 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 5:15 A.M. when emergency supplies were not available, specifically a CPR backboard, to staff who had performed CPR on Resident #64. Additionally, the Administrator and the DON were notified the staff failed to provide adequate life saving measures for Resident #64 when they continued emergency chest compressions while the resident remained on his mattress, lessening the quality of the chest compressions. After nine-one-one was called and Emergency Medical Services (EMS) arrived at 5:26 A.M., EMS staff moved the resident to the floor and took over CPR until the resident was pronounced deceased at 6:05 A.M. The Immediate Jeopardy was removed on [DATE], when the facility audited the emergency crash carts and replaced missing items such as the backboard and educated all licensed nursing staff on the importance of completing CPR on a firm surface and, the facility implemented the following corrective actions: · On [DATE], agency Licensed Practical Nurse (LPN) #88 who performed CPR has been placed on the do not return list for the facility. LPN #110, the second nurse who performed CPR, was through the agency and will not return to the facility. · On [DATE] at 2:00 P.M., all facility crash carts were audited by Corporate Nurse (CN) #135 and the missing backboard was replaced. The supply list was reviewed, and all items were on the cart. There were extra items found on the crash carts which were not needed and were removed from the cart after the updated audit sheet was put into place. Daily audit sheets on the carts were replaced with up to date audit sheets. · On [DATE], the DON began education for all licensed nursing staff regarding performing CPR on a patient, the location of the crash carts, supplies that should be in the crash cart, and the 100 hall nurse was responsible for checking the carts nightly. As of [DATE], all licensed staff were educated. As needed (PRN) and agency licensed nurses who had not worked, will not be permitted to return until education is completed. The facility will continually educate newly hired licensed nursing staff and new agency nurses during their orientation. · On [DATE], the DON and CN #135 reviewed the closed record for Resident #63 who was the last code to ensure CPR was performed appropriately. The code was reviewed at the time of the incident and again on [DATE]. There were no identified findings during the reviews of the record. · On [DATE] at 5:00 P.M., the Administrator completed an audit of all resident medical records to ensure current code status was accurate. This audit revealed two residents with discrepancies, and they were corrected. · On [DATE], the DON or designee began auditing the facility crash carts to ensure they are checked nightly and all emergency supplies are available. This monitoring will be completed five times a week for four weeks. · On [DATE], a Quality Assurance Performance Improvement (QAPI) meeting was held. Those in attendance included the Administrator, the DON, CN #135, and Human Resources Director (HRD) #145. Results of all audits and mock codes will be presented to daily stand up and monthly QAPI for review and recommendation. · On [DATE] at 10:30 A.M., the facility Medical Director was notified of the Immediate Jeopardy concern. · On [DATE], the DON or designee will complete mock codes twice weekly with State tested Nursing Assistants (STNA)s, LPNs, and Registered Nurses (RN)s for four weeks. · The DON will review any future codes to ensure the quality of CPR performed on the resident was appropriate. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] revealed the resident demonstrated disorganized thinking, disorientation, short term memory loss, and was severely cognitively impaired. Review of the physician orders dated [DATE] revealed the resident had a Full Code status in place. Review of the baseline care plan dated [DATE] revealed the resident had chosen to be a Full Code. Interventions included contacting the physician should the resident choose to change code status and initiate CPR as indicated. Review of the nurse progress notes dated [DATE] revealed LPN #88 began the morning medication pass for Resident #64 at 4:15 A.M. LPN #88 took the residents blood sugar and found a reading of 72 milligrams per deciliter (mg/dL). Resident #64 was given yogurt with four sugar packets. At 4:50 A.M., LPN #88 re-checked the residents blood sugar and found a reading of 52 mg/dL. The resident received a [MEDICATION NAME] injection and an apple juice with five sugars. The resident consumed 80% of the apple juice. At 5:05 A.M., LPN #88 re-checked the residents blood sugar and found a reading of 46 mg/dL. LPN #88 asked State tested Nursing Assistant (STNA) #105 to stay with the resident and went to the 100-hall to ask for help from LPN #110. The progress note indicated LPN #110 went to the resident's bedside while LPN #88 called 911 at 5:15 A.M. The progress note indicated LPN #88 then went back to Resident #64's bedside and LPN #110 reported she could not find a pulse. LPN #88 documented she felt a faint pulse, but vital signs could not be obtained so she initiated CPR with the resident in his bed. The progress note documented LPN #110 left and retrieved the emergency crash cart. Once the crash cart arrived, the staff noted there was no CPR backboard on the crash cart. LPN #88 and LPN #110 continued CPR, switching back and forth with chest compressions. STNA #105 was directed to go get help from the other nurse on a different unit (LPN #100). When LPN #100 arrived at the residents' room, she noted there was not a CPR board being used and went back to check the second crash cart to find a backboard. Per the note, while LPN #100 went to go look for the backboard, Emergency Medical Services (EMS) arrived at 5:26 A.M. The EMS staff moved the resident to the floor and took over CPR until the resident was pronounced deceased at 6:05 A.M. Observation and interview on [DATE] at 11:07 A.M. with the Administrator and CN #135 of the facility's two crash carts revealed each cart had supply checklists located on top of the cart. The supply checklists on each cart had no documentation the cart and/or supplies had been checked. Both checklists were reviewed during the observation with the Administrator and CN #135 and several items were noted missing from each of the crash carts. Emergency crash cart number one was observed missing a CPR backboard, an oxygen tank, and three nasal airways. Emergency crash cart number two was observed missing a nasal cannula, an adult blood pressure cuff, alcohol wipes, a suction tip applicator, and three nasal airways. At the bottom of the supply checklists the following statement was written; Ensure that all equipment is working and the O2 tank is full. Return form to the DON office at the end of each month. CN #135 verified the supplies missing from the carts. CN #135 revealed she believed night shift nursing staff were supposed to check the emergency crash carts and should fill out the supply checklists every shift. Interview on [DATE] at 1:42 P.M., STNA #105 revealed she was the aide assigned to Resident #64 on the shift he expired. STNA #105 stated on the morning of [DATE], she completed care on the resident around 4:45 A.M. and the resident was still alert and complaining he was cold. STNA #105 stated she provided the resident additional blankets and moved on to the rest of her hall assignment. STNA #105 stated at some point after her last care time, the resident stopped breathing and the nurses (LPN #88 and LPN #110) started performing CPR. STNA #105 stated she observed the nurses looking for the CPR board on the emergency crash cart in the residents' room and were not able to locate it. STNA #105 stated she heard the nurses in the room saying that they need a CPR board and they couldn't find one. STNA #105 stated she was instructed to find the other nurse from a different unit for help. STNA #105 stated once she alerted the nurse (LPN #100) from the other unit, she went to the front door to make sure the EMS staff could get into the building. Interview on [DATE] at 1:55 P.M., LPN #110 revealed LPN #88 approached her around 5:00 A.M. for assistance, stating Resident #64 was not responding. LPN #110 stated they grabbed the emergency crash cart, went to the residents' room, and assessed the resident together. LPN #110 stated her observation at the time was the resident was not responding, she could not see the chest rise, the resident was cold, and she was unable to find a pulse. LPN #110 stated LPN #88 began CPR with the resident in the bed and then asked for the CPR backboard from the emergency crash cart. LPN #110 confirmed there was no backboard on the emergency crash cart, and they continued providing CPR with the resident in the bed. LPN #110 estimated approximately 10 minutes of CPR was performed with the resident in his bed prior to EMS arrival. Interview on [DATE] at 2:32 P.M., CN #135 revealed the supply checklists found on the cart were outdated and the company had newer checklists which were never put in place. Interview on [DATE] at 3:41 P.M., LPN #88 revealed she was the nurse caring for Resident #64 on the morning he expired. LPN #88 revealed around 4:00 A.M. she began having issues with the residents' blood sugar dropping. LPN #88 stated around 5:05 A.M. the resident stopped responding but appeared to still be breathing. LPN #88 stated she had STNA #105 stay with the resident as she went to find agency LPN #110 for help. LPN #88 stated she called 911 around 5:15 A.M. and went back to Resident #64 with LPN #110 and they assessed him together. LPN #88 stated she felt a weak and thready pulse, LPN #110 expressed she could not find a pulse, the residents' pulse oximetry was not registering, and they could not see a chest rise. LPN #88 revealed she began CPR on the resident while he was still in his bed and asked LPN #110 to find the backboard from the emergency crash cart to put underneath the resident. LPN #88 stated there was no backboard on the cart they brought into the room, so she directed the aide to go find the other nurse for help. LPN #88 stated when LPN #100 arrived in the room and saw what was happening, she went back down the hall to find a backboard. LPN #88 estimated approximately 10 minutes of CPR was performed with the resident in his bed prior to EMS arrival. Interview on [DATE] at 4:07 P.M., the Administrator revealed the facility had no policy or procedure outlining who was supposed to check the emergency crash cart supplies and how often the checks were performed. Interview on [DATE] at 8:00 A.M., LPN #100 revealed she was approached by an aide on [DATE] between 5:00 A.M. and 5:30 A.M. who told her the nurses on the other unit needed her help. LPN #100 stated when she arrived to Resident #64's room she observed CPR being performed by LPN #88 on the resident. LPN #100 stated she noted the emergency crash cart was in the room; however, there was no CPR backboard being used. LPN #100 stated she told the nurses in the room the resident either needed to be placed on the ground or a backboard needed to be placed beneath the resident. LPN #100 stated one of the nurses told her there was no CPR backboard on the cart. LPN #100 stated she left the room at that time to go check the other emergency crash cart for a backboard. LPN #100 verified when she left the room the staff members continued to perform CPR with the resident in the bed. LPN #100 stated by the time she arrived at the room where the other emergency crash cart was located, she saw the EMS staff coming down the hallway and allowed them to take over. Review of recommendations for CPR technique (https://emedicine.medscape.com/article/ 81-overview) revealed CPR is most easily and effectively performed on a hard surface, which allows for effective compression of the sternum. Delivery of CPR on a mattress or other soft material is generally less effective. Review of the policy titled Cardio-Pulmonary Resuscitation/CPR Nursing Standard revised [DATE] revealed CPR includes external heart massage using chest compressions and clearing of the airway including oxygen delivery to restore or maintain cardiopulmonary function until a higher level of care is assessed. The policy states the facility will honor resident advance directives and regulatory compliance for requests that CPR be performed if cardiac or respiratory activity ceases. This deficiency substantiates Complaint Number OH 740.

Based on observations, review of a Self-Reported Incident (SRI), review of the facility investigation and witness statements, review of a closed and open medical records, review of maintenance reports, review of alarm company reports, review of electrical sound equipment reports, review of the facility policy on mechanical ventilation overview checks and staff interviews, the facility failed to ensure necessary life-sustaining respiratory services were provided and maintained by completing daily respiratory assessments and treatments and obtaining current physician orders for the mechanical ventilator settings in accordance with facility policy for one (#01) resident. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #01 when the ventilator was found in the off position, and had gone unnoticed by any of the facility staff. Consequently, Resident #01 was found unresponsive, cold, white and without respirations and had expired. This affected one (#01) of three residents reviewed for respiratory services. Additionally, two residents (#02 and #03) were placed at potential risk for harm, that did not rise to the level of Immediate Jeopardy, by failure of the facility to ensure daily respiratory assessments were provided and documented in the medical record. The facility identified nine current residents who utilize a mechanical ventilator for life-sustaining respiratory services. The facility census was 65. On [DATE] at 2:29 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 10:15 A.M., when Resident #01 was found unresponsive and cool to the touch by State tested Nurse Aide (STNA) #100 and her ventilator was turned off. STNA #100 notified Licensed Practical Nurse (LPN) #120 of Resident #01's condition and LPN #120 then went to check on Resident #01. At approximately 10:30 A.M., Resident #01 was observed to be cold and very white, had no pulse and the mechanical ventilator was found in the off position. LPN #120 with LPN #300 confirmed together Resident #01 was pulseless and without respirations at 10:35 A.M. The Immediate Jeopardy was removed on [DATE] at 6:30 A.M., when the facility implemented the following corrective actions: · On [DATE] at 10:35 A.M., the facility began investigations into the ventilator being found in the off position for Resident #01. · On [DATE] between 10:40 A.M. and 10:50 A.M., the DON and Director of Respiratory Therapy (DRT) #97, performed an audit of the additional residents on a mechanical ventilator. The residents were assessed for their respiratory status, ensuring physician's orders were in place and they matched the ventilator settings, and the ventilator was in the on position. · On [DATE] at 11:00 A.M., Minimum Data Set (MDS) Nurse #55 began interviews with all direct care staff of Resident #01. · On [DATE] at 11:15 A.M., facility Respiratory Therapists (RT) began hourly audits to monitor residents on a ventilator for ventilator settings. · On [DATE] at 2:00 P.M., the emergency generators were checked for proper function by Maintenance Director (MD) #234 with no concerns. · On [DATE] at 2:00 P.M. to 3:00 P.M., the local sound equipment company came in to inspect the function of the call light system and alarms. No negative findings were identified. · On [DATE] beginning at 3:00 P.M., education was provided by the DON for all STNA's and nurses stating that STNA's cannot silence ventilator alarms or touch a ventilator at any time. · On [DATE] at 4:00 P.M., the facility called the police and a report was made. Police came to the building and took statements. · On [DATE] at 6:30 P.M., RT #130 was removed from providing direct patient care. · On [DATE], the alarm company provided the alarm record for Resident #01 with no relevant findings. · On [DATE], the Administrator, DON, and DRT #97 began re-education of the facility's Licensed Practical Nurses, Registered Nurses, State tested Nurse Aides, and Nursing Management on the use of a Ventilator and maintaining the ventilator in an on position, that physicians orders must be obtained for the use of the ventilator and the Respiratory Therapist must complete respiratory assessments and care of a patient on a ventilator and document daily. The education concluded on [DATE] at 6:30 A.M. · On [DATE], the facility Respiratory Therapist or designee will monitor residents on a ventilator hourly. The audits will continue for eight weeks and then every shift for eight weeks and on-going thereafter. Results of the audits will be reviewed in the Quality Assurance Performance Improvement (QAPI) committee meetings for 90 days. · On [DATE], DRT #97 provided education to RT #130 on the ventilator and that it will not be turned off during [MEDICAL CONDITION] care, inner cannula change or [MEDICAL CONDITION] change. · On [DATE], DRT #97 provided education to all RTs on the ventilator and that it will not be turned off during [MEDICAL CONDITION] care, inner cannula change or [MEDICAL CONDITION] change. · On [DATE], all facility rooms were inspected for emergency electrical components completed by MD #234 including the emergency electrical outlets, light switches, lights and call light, check enunciation light, cord and check for proper operation of the nurse call ringing back to the nurse station for the beds and restrooms for every resident room and there were no concerns identified. · On [DATE] at 2:02 P.M. to 2:44 P.M., observations with DRT #97 verified all residents had their ventilators on per physician's orders. · On [DATE] at 4:49 P.M., interview with RT #130 revealed he was terminated by Chief Executive Officer (CEO) #200 and the Human Resource person on [DATE] for violating policy and incorrect use of Personal Protective Equipment (PPE). RT #130 stated he was told the policy violation was related to turning off a ventilator. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #01 revealed an admission date of [DATE], a re-admission date of [DATE] and date of death on [DATE]. [DIAGNOSES REDACTED]. Resident #01's code status was Do Not Resuscitate-Comfort Care (DNR-CC). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was assessed as requiring oxygen therapy, suctioning, [MEDICAL CONDITION] care and utilizing a ventilator or respirator. Resident #01 was rarely or never understood and there was no cognitive assessment completed. She was assessed as requiring extensive total dependence on staff for all her Activities of Daily Living (ADLs). She was incontinent of bowel and bladder and reliant on tube feeding for nutrition. Review of Resident #01's Plan of Care (POC) revealed she had a [MEDICAL CONDITION] (trach) related to impaired breathing mechanics, [DIAGNOSES REDACTED]. The goal was for Resident #01 to have clear and equal breath sounds bilaterally and no signs/symptoms of infection. Interventions included to ensure [MEDICAL CONDITION] are secured at all times, give humidified oxygen as prescribed, monitor/document for restlessness, agitation, confusion, increased or decreased heart rate, monitor/document level of consciousness, mental status, and lethargy as needed, monitor/document respiratory rate, depth and quality. Check and document every shift/as ordered and suction as necessary. Review of the physician orders revealed prior to Resident #01's hospital stay from [DATE] to [DATE], she had ventilator settings as follows: Assist Control (AC) 12/ Tidal Volume (TV) 450/ Positive End-Expiratory Pressure (PEEP) 5/ oxygen zero to four liters to maintain greater than or equal to 92% pulse oxygenation. The order was dated [DATE] and discontinued [DATE]. Review of the discharge orders from the hospital dated [DATE] revealed there was no orders for the ventilator settings. Review of the monthly physician orders for [DATE] revealed Resident #01 had no current ventilator setting orders after her return to the facility on [DATE] until her death on [DATE]. Review of the Daily Respiratory Assessments for Resident #01 from [DATE] to [DATE] revealed there were only two assessments completed for July dated [DATE] and [DATE] by a respiratory therapist. Review of Resident #01's nursing progress notes revealed on [DATE] at 10:35 A.M., the resident had no pulse, and this was verified by two nurses. Her physician was notified and gave orders to remove the ventilator. Review of the SRI dated [DATE], revealed Resident #01 passed away on [DATE], when she was found by STNA #100. Resident #01's ventilator was found turned off. The facility conducted interviews immediately with staff on the resident's hall. The allegation of abuse, neglect or misappropriation was not suspected and was unsubstantiated by the facility due to the evidence was inconclusive. Review of STNA #100's typed witness statement dated [DATE], revealed STNA #100 last observed Resident #01 around 9:00 A.M., breakfast time. STNA #100 stated Resident #01 looked like her normal self and there were no alarms going off in her room. There were no other issues noted. The statement was signed at the bottom by STNA #100. Review of STNA #110's typed witness statement dated [DATE], revealed STNA #110 last observed Resident #01 around 8:30 A.M. and stated Resident #01 looked like her normal self. There were no alarms going off in her room and no other alarms going off in the hallway or other rooms. The statement was signed at the bottom by STNA #110. Review of LPN #120's typed witness statement dated [DATE], revealed this nurse was notified by RT #130, LPN #120 and STNA #100 of vital signs ceasing at 10:35 A.M. with two witnesses confirming. STNA #100 entered the resident's room at approximately 10:35 A.M. to perform personal care. Patient was found unresponsive and ventilator off. RT #130 reported that with assessment of the ventilator, ventilator battery was fully charged and was plugged into red outlet per policy. DRT #97 notified. Administrator notified. There was no signature on the statement. This was the statement provided by the DON which the DON identified as LPN #120's statement. Review of RT #130's typed witness statement dated [DATE], revealed the ventilator was manually turned off for Resident #01. The ventilator event log showed the ventilator was turned off at 8:13 A.M. RT #130 was with another patient at that time. When RT #130 went into the room, he observed the ventilator was off. Resident #01 was observed with the inner cannula (a tube inserted through [MEDICAL CONDITION] the neck to assist with respiratory treatment) disconnected but not out of the patient. RT #130 found the ventilator off around 10:25 A.M. When RT #130 received report the morning of [DATE], Resident #01 was reported as having coffee ground emesis. The night shift had a washcloth around [MEDICAL CONDITION] absorb the emesis. There was a yellow post-it note attached at the bottom of the statement with a hand-written notation RT completed care at 7:55 A.M. There was no signature on the document by RT #130. Interview on [DATE] at 9:11 A.M. with the Administrator verified she was notified on [DATE] at 10:35 A.M., that Resident #01 was found unresponsive with no heartbeat and the ventilator was turned off. The incident investigation was started immediately. Resident #01 was last seen by LPN #120 at 10:05 A.M. and appeared her normal self. Resident #01 was found by STNA #100 at 10:35 A.M., and the ventilator was turned off. The ventilator was plugged into the red emergency outlet as required and had a full battery charge. No problems were found with the equipment, the electrical system or the alarm system. There were no alarms sounding. The Administrator denied there had been anyone in the room between 10:05 A.M. and 10:35 A.M. The Administrator stated to turn off the vent involved a two-step process, including manually pushing a button then verify on a screen prompt to ensure you want to power off. The facility could not determine who could have or how the ventilator was turned off. Interview on [DATE] at 11:45 A.M. with the Administrator revealed RT #130 was an employee of the hospital who was contracted to provide the respiratory service for the facility. RT #130 was suspended pending investigation by CEO #200 of the hospital because he was working on both Sunday [DATE] and Tuesday [DATE], when there were problems with the ventilators. Interview on [DATE] at 1:01 P.M. with STNA #100 verified she was Resident #01's aide on [DATE]. She was in and out of her room a couple times that morning. She stated Resident #01 was in her normal state that day and denied any problems with the ventilator, that she was aware of. STNA #100 stated she was in the room around 8:00 A.M. and RT #130 was also in the room providing care to the two residents in the room. STNA #100 did not complete Resident #01's morning care at that time. She left the room so RT #130 could do the respiratory care. STNA #100 verified she thought around 10:00 to 10:15 A.M., she found Resident #01 unresponsive. Resident #01 didn't look right and when STNA #100 touched her, she was cool to the touch. She immediately notified LPN #120. When she and the nurse returned to the room, LPN #120 checked her pulse and noted Resident #01 was gone. LPN #120 looked at the screen and observed the ventilator was off. The nurse stated Oh, my God and left to speak to the Administrator. Observation on [DATE] at 2:02 P.M. to 2:44 P.M. with DRT #97 revealed DRT #97 demonstrated how to manually turn off a ventilator. DRT #97 indicated when the ventilator was turned on, it showed a green indicator light, confirming the equipment was on and the power source was working. DRT #97 then demonstrated the two-step procedure for powering off the ventilator. DRT #97 manually pushed the on/off button which initiated a message on the information screen: power off? and the option to choose either yes or no. DRT #97 verified the yes button must be selected to complete the two-step power-off procedure and the ventilator does not alarm when turned off but emits a single beep. DRT #97 demonstrated if the ventilator had any other type of power failure, an audible alarm and the alarm display screen in the hall would both activate. Observations with DRT #97 verified all current residents on ventilators had the correct ventilator settings and were on as required. Interview on [DATE] at 3:26 P.M. with LPN #120 verified she was the nurse providing care to Resident #01 on [DATE]. LPN #120 stated she observed Resident #01 at around 10:00 A.M. when she poked her head into the room to ask the roommate if her pain medication had been effective. Resident #01 appeared to be fine at that time. She did not notice anything out of the ordinary at that time. She was not able to see Resident #01's ventilator though, as it was behind the privacy curtain and there were no alarms sounding. LPN #120 had not noted any alarms for Resident #01 at all that day. STNA #100 informed her at around 10:30 A.M., Resident #01 was unresponsive. LPN #120 went to the room with STNA #100 and found Resident #01 was cold and very white, had no pulse and the ventilator was off. LPN #120 left the room to get another nurse and LPN #300 and RT #130 both returned to the room with her. LPN #300 verified with her there were no vital signs for Resident #01. LPN #120 stated she asked RT #130 why the ventilator was off. RT #130 stated he did not know. LPN #120, LPN #300 and RT #130 all went to talk to the DON. LPN #120 added Resident #01's inner cannula was out of the [MEDICAL CONDITION], and did not think it was all the way out, but stated it was not all the way in. LPN #120 stated this would normally cause the ventilator to alarm, but, again, there were no alarms noted. LPN #120 stated during morning report, she was informed Resident #01 had a small emesis on third shift. Resident #01 did not have any emesis on first shift. Resident #01 was clean and free of emesis when LPN #120 took over care. Interview on [DATE] at 6:38 P.M. with RT #130 verified he was caring for Resident #01 on [DATE]. RT #130 stated he did [MEDICAL CONDITION], ventilator checks, cleaning of the trach, including removing and replacing the inner cannula. RT #130 stated he was in Resident #01's room completing care on [DATE] at 7:55 A.M. RT #130 denied there were any concerns with Resident #01 at the time he provided care. RT #130 stated during morning report, he was told Resident #01 had had coffee ground emesis around [MEDICAL CONDITION] on third shift. He did not recall if there was any emesis when he [MEDICAL CONDITION]. There was a washcloth around [MEDICAL CONDITION] he completed care and he removed the washcloth when he changed [MEDICAL CONDITION] and provided other care. RT #130 denied there were any audible alarms sounding but the alarm display noted to check circuit. RT #130 stated he was not able specifically to recall the specific details. However, typically he would check the circuit, checking connections and ensure everything was working correctly, then he suctions the resident regarding the check circuit alarm. RT #130 verified he completed suctioning for Resident #01. After completing care, RT #130 stated, to his recollection, the ventilator was running, and he ensured everything was working before leaving the room. At no time did RT #130 deny or confirm he turned the ventilator off. He did not see Resident #01 again prior to her death. RT #130 was busy providing respiratory care for all the residents on the 300-hall by himself that day. RT #130 stated he was preparing to see another resident when he noticed other staff at Resident #01's room. He went in to check and noticed the ventilator was off. RT #130 verified he did later receive a call from CEO #200 informing him he was suspended pending investigation. Interview on [DATE] at 11:31 A.M. with STNA #110 via phone call, verified she worked on [DATE] on the ventilator unit. She denied she provided care to Resident #01. She denied hearing any alarms for Resident #01. STNA #110 stated STNA #100 had delivered a breakfast tray to Resident #03 (Resident #01's roommate) around 8:30 A.M. The room curtain was not pulled and both residents could be seen. She stated she could see Resident #01 from the hall and RT #130 was the only person she observed go into the room. Interview on [DATE] at 4:49 P.M. with RT #130 verified he was told 8:13 A.M. was the time Resident #01's ventilator was turned off and this information had been provided by DRT #97 after he read the event log on the ventilator. RT #130 verified Resident #01 did have an inner cannula change that morning. RT #130 could not recall if he turned the ventilator off to complete the cannula change. He denied any intention to turn the ventilator off and leave it off or to cause any harm of any kind. RT #130 stated he was terminated by the hospital CEO #200 and the Human Resource Person #300 on Sunday, [DATE]. The termination was for violating the ventilator policy and incorrect use of Personal Protective Equipment (PPE). RT #130 stated he was told the policy violation was related to turning off a ventilator. RT #130 stated to his recollection, he did not turn the ventilator off while providing care to Resident #01 on [DATE]. Interview on [DATE] at 1:54 P.M. with DRT #97 verified he was RT #130's boss and they were both employed by the hospital and provided respiratory care service to the facility residents. He verified RT #130 was the RT for Resident #01 on [DATE]. DRT #97 verified RT #0130 came to him immediately on [DATE] around 10:30 to 11:00 A.M., after finding Resident #01 deceased and her ventilator turned off, to report the incident to him. RT #130 denied knowing what happened. RT #130 stated when he arrived into Resident #01's room the ventilator was turned off. They walked from the hospital side directly to Resident #01's room. Resident #01 was still in her bed, still connected to the ventilator. DRT #97 looked to see if the ventilator was plugged in and it was. DRT #97 stated he did not touch anything. Everything appeared correct. Alarm cables were connected correctly. The ventilator was off. The green indicator light was on, indicating there was no electric power problem. Under the direction of and along with Regional Director of Respiratory Therapy (RDRT) #500, DRT #97 stated he pulled the event log on Resident #01's ventilator after her death on [DATE]. When they arrived at the room, (DRT #97 was unsure of the exact time) the ventilator appeared to be appropriately connected to the red wall outlet and appeared to be in working order. They went to menu and selected the event log and scrolled through the events showing on the machine. The log showed it had powered down and to his understanding, it indicated that it had been manually shut down. The log did not indicate any mechanical failures. The date and times were noted for each event, but DRT #97 did not recall the exact date or time noted for the shut-down. After reviewing the log, they shut the machine down again. Interview on [DATE] at 3:01 P.M. with the DON and Corporate Nurse #93, both verified there were no current physician orders for the ventilator settings on [DATE] for Resident #01. Both verified the ventilator orders had expired on [DATE] and were never renewed upon Resident #01's return to the facility on [DATE]. Interview on [DATE] at 12:24 P.M. with DRT #97 revealed the only time the ventilator should be turned off was if the ventilator was discontinued or when weaning a patient off the ventilator. DRT #97 verified there would not be any reason for anyone to turn off the ventilator during routine care for a ventilator dependent resident. DRT #97 verified Resident #01 was ventilator dependent to sustain life. DRT #97 verified there was no daily assessments documented for Resident #01 by the RT. Review of Resident #01's monthly physician orders for [DATE] revealed an order dated [DATE] to change 8 disposable cannula tube (dct) one time a day; an ordered dated [DATE] [MEDICAL CONDITION] every shift and discontinued [DATE]; and an order dated [DATE] to [MEDICAL CONDITION] 8 dct Shirley every day and night shift. Review of the Medication Administration Record [REDACTED] On [DATE] and [DATE], there was no documentation of the order for change 8 dct (inner cannula) one time a day as being completed. On [DATE] and [DATE] for the first shift, there was no documentation of the order [MEDICAL CONDITION] every shift as being completed. On [DATE] and [DATE] for the first shift, and on [DATE] for the second shift, there was no documentation of the order for change [MEDICAL CONDITION] 8 dct Shirley every day and night shift ordered as being completed. Review of the Daily Respiratory Assessments for Resident #01 from [DATE] to [DATE] revealed there were only two assessments completed for July dated [DATE] and [DATE] by a respiratory therapist. Interview on [DATE] at 3:01 P.M. with the DON verified the missing signatures on the MAR/TAR, indicating the tasks were not completed on the noted dates. 2. Review of the medical record for Resident #02 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident #02 was ventilator dependent since admission. Review of the Daily Respiratory Assessments for Resident #02 from [DATE] to [DATE] revealed there were only three assessments completed for July dated [DATE], [DATE] and [DATE]. 3. Review of the medical record for Resident #03 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #03 used the ventilator at night and as needed in the daytime. Review of the Daily Respiratory Assessments for Resident #03 from [DATE] to [DATE] revealed there were only three assessments completed for July dated [DATE], [DATE] and [DATE]. Interview on [DATE] at 3:50 P.M. with the Administrator verified there were multiple missing Daily Respiratory Assessments for Resident #01, Resident #02 and Resident #03 from [DATE] to [DATE]. The Administrator verified the above noted assessments were the only assessments on the resident's medical records. She also verified missing MAR/TAR signatures and stated the facility has an on-going issue with it. The Administrator stated the Respiratory Therapists do a lot of documentation on paper, but it does not make it to the chart. They do not document in the computer and the facility has been dealing with the problem for a long time. Review of the facility policy titled Mechanical Ventilator Overview dated [DATE] revealed it is the policy of this facility to provide for safe, effective and resident-specific care for those residents who are either on mechanical ventilation or on the respiratory unit and are at-risk for mechanical ventilation. The respiratory care department is responsible for the set-up, management and monitoring of the ventilator. Initiate ventilator support, the physician's order must include the following: a. Mode of ventilation b. Assist Control c. Synchronized Intermittent Mandatory Ventilation (SIMV) d. Pressure Support (P. Supp) e. Pressure Control (PCV+) f. Bi Level Ventilation g. Set rate h. Tidal volume or Inspiratory Pressures i. Fraction of Inspired Oxygen (FiO2) j. PEEP or [MEDICAL CONDITION] k. Pressure Support l. Auto Flow (only) To maintain accurate and meaningful flow sheets, to ensure proper alarm function, and to assess proper ventilator function, ventilator changes will be performed by licensed respiratory therapy personnel. The therapist is to document changes on the flow sheet. Review of the facility policy titled Mechanical Ventilator Check dated [DATE] revealed it is the policy of the facility to provide resident ventilator maintenance/monitoring, as ordered by resident's physician. Resident-ventilator maintenance/monitoring is a documented evaluation of a mechanical ventilator and of the resident's response to mechanical ventilatory support. This procedure is often referred to as a ventilator check. a. Evaluate and document the resident's response to mechanical ventilation at the time that the check is performed b. Ensure the proper operation of the mechanical ventilator and document it c. Verify and document that the ventilator is functioning and is properly connected to the resident d. Verify and document that the appropriate alarms are activated e. Verify and document that inspired oxygen concentration is measured with every change in FiO2 f. Verify and document that inspired gas is properly heated and humidified g. Verify and document that ventilator settings comply with physician orders All data relevant to the resident-ventilator maintenance/monitoring must be recorded on the appropriate facility form(s) at the time of performance and be included as an official part of the resident's medical record. This deficiency substantiates Complaint Number OH 323.

Based on medical record review, review of hospital records, staff and resident interviews, the facility failed to ensure a resident was provided with appropriate care and treatment regarding bowel movements. This resulted in actual harm when the resident went 10 days without a bowel movement and required hospitalization . This affected one resident (#41) of three residents reviewed for constipation. The facility census was 82. Findings include: Review of Resident #41's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #41's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Resident #41 was frequently incontinent of bowel and bladder. Resident #41 was not on a toileting program at the time of the review. Review of Resident #41's State tested Nursing Assistant (STNA) tracking of bowel movements for the last 30 days revealed Resident #41 went from 06/24/19 through 07/03/19 (10 days) without a bowel movement. Review of Resident #41's hospital record revealed the resident arrived at the emergency roiagnom on [DATE] at 11:42 P.M., and was complaining of abdominal pain, difficulty with bowel movements, vomiting, and dehydration. Resident #41 was diagnosed with [REDACTED]. Resident #41 was treated with Saline 500 milliliters (ml) intravenously (IV) infused over one hour. The resident was also treated with four milligrams (mg) dose of [MEDICATION NAME] (for nausea) through the IV. The report indicated Resident #41 had a bowel movement that evening and was returned to the facility on [DATE]. Interview on 07/08/19 at 10:27 A.M. with Resident #41 revealed she was in pain from not being able to go to the bathroom before she went to the hospital on [DATE]. Resident #41 said she was packed full of stool and couldn't get anything to come out. She said she had been vomiting and a friend took her to the hospital because she was hurting so bad. Resident #41 stated the facility would not do anything about it. Interview on 07/09/19 at 11:08 A.M. with STNA #133 revealed the resident's bowel movements were tracked. The STNA stated she was not aware the resident went 10 days without a bowel movement, therefore nursing was not notified. Interview on 07/09/19 at 1:20 P.M. with the Director of Nursing (DON) revealed there was no bowel protocol or policy or procedure in place. She further confirmed the STNA's documentation revealed Resident #41 went 10 days without a bowel movement. Interview on 07/09/19 at 3:48 P.M. with Licensed Practical Nurse (LPN) #175 verified there was no official bowel protocol; however, the standard practice was to offer prune juice or Milk of Magnesia (MOM) after three days of no bowel movements and if that was not effective in 24 hours to provide a suppository. LPN #175 confirmed Resident #41 had not been provided a suppository as she was unaware the resident went 10 days without a bowel movement.

Based on medical record review, observation, staff interview, review of facility policy and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to monitor a residents skin with the use of a medical device that was implemented as a nursing intervention. This resulted in actual harm when Resident #179 obtained an avoidable facility acquired unstageable pressure ulcer to the left lower leg. This affected one (#179) of five residents who were reviewed for pressure ulcers The facility identified one Resident (#179) with an facility acquired pressure ulcer. The facility census was 84. Findings Include: Review of Resident #179's medical record revealed an admission date of [DATE], discharged [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #179's quarterly minimum data set ((MDS) dated [DATE] revealed the resident was cognitively impaired and at risk for pressure ulcers. Review of Resident #179's current comprehensive care plan revealed the resident had a potential for pressure ulcers related to decreased mobility. Interventions included administer treatments as ordered, monitor effectiveness and assess and monitor wound healing. Review of Resident #179's nurse's note dated 04/25/18 revealed a HeelZup Therapeutic pillow (cushion used to aid and prevent heel pressure ulcers) was utilized replacing the pillows to off load the heels. (This was implemented as a nursing intervention). Review of Resident #179's nurse's note dated 05/06/18 revealed an open blister was discovered on the resident's left rear calf and appeared to be from the heel floating (HeelZup) device. The device was removed and appropriate parties were notified. Further review of Resident #179's pressure wound documentation revealed on 05/06/18 the left lower leg (rear) wound measured 8 centimeter (cm) in length (L) by 7.9 cm in width (W) by 0.1 cm in depth (D) and was documented as unstageable. On 05/13/18 the left lower leg wound measured 4.8 cm L by 2 cm W by 0.2 cm D. On 05/22/18 the wound measured 5 cm L by 2.2 cm W by 0.3 cm D and was unstageable. On 05/29/18 the left lower leg wound measured 6 cm L by 2.6 cm W by 0.2 cm D and was documented as a Stage 3. Review of Resident #179's monthly physician orders dated (MONTH) (YEAR) revealed an order on 05/06/18 to cleanse the left rear calf with normal saline and apply foam dressing three times per week. On 06/12/18 an order for [REDACTED]. Further review of the treatment administration record (TAR) revealed no monitoring of the skin that rested on the HeelZup pillow. Review of Resident #179's Skin Grid Pressure dated 06/12/18 revealed an unstageable pressure ulcer in house acquired to left lower leg (rear) measured 6 cm L by 2.2 cm W by 0.9 cm D with a date of onset as 05/06/18 Observation on 06/20/18 at 1:20 P.M. of Resident #179's wound care revealed Licensed Practical Nurse (LPN) #200 completed wound care to the resident's left posterior lower leg. The wound bed was deep, red and oblong in shape. The old dressing revealed a small amount of tan drainage. The treatment was completed per the physician's orders. Interview on 06/21/18 at 11:30 A.M. with LPN #201 stated Resident #179's pressure ulcer to his left leg was acquired in house and was caused by a device (HeelZup) that was used to elevate the resident's heels off the bed. Interview on 06/21/18 at 1:51 P.M. with the Director of Nursing (DON) stated a HeelZup pillow was put in place to protect Resident #179's heels. The DON further stated the HeelZup pillow was removed after the wound was discovered. There was no physician's order for the HeelZup pillow as it was implemented as a nursing intervention. Telephone interview on 06/21/18 at 2:15 P.M. with Certified Nurse Practioner (CNP) #400 stated Resident #179's pressure wound was an acquired in house and worsened from a Stage 2 on 05/08/18 to a Stage 3 on 05/29/18. CNP #400 stated the pressure wound was related to a medical device (HeelZup) used to elevate the heels off the bed. Review of the facility policy titled Skin Care & Wound Management Overview dated 07/01/16 revealed the interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition contributing to it. Review of information from the NPUAP revealed a Stage 2 pressure ulcer is partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough and may also present as an intact or open/ruptured serum-filled blister. An Unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further review revealed the develop a plan of care is based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. The NPUAP advises to assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters (hips), elbows and beneath medical devices.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of Self-Reported Incidents, staff interviews, resident interviews, and review of facility policy, the facility failed to follow their policy to prevent resident to resident abuse for one (#1) of three residents reviewed for abuse. Actual harm occurred when Resident #2 struck Resident #1 causing a laceration to the face and facial bruising. Resident #1 required an assessment in the emergency room and sutures to close the laceration. The facility census was 88. Findings include: Review of the medical record for the Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/03/17, revealed Resident #1 had impaired cognition. The resident required extensive assistance of one staff for bed mobility, transfers, and ambulation. Review of the nurse progress notes dated 12/11/17 at 1:10 A.M. documented the Director of Nursing (DON) received a call from the facility staff reporting Resident #1 was physically struck in the face by his roommate for an unknown reason. Staff intervened and separated the residents. Resident #1 cannot provide a statement. Resident #1 was assessed and had a cut to his face. Emergency transport and the police were notified and the resident was transferred to the hospital. The physician and resident's family were notified. Review of the nurse progress notes dated 12/11/17 and timed at 2:42 A.M. revealed State tested Nurse Aid (STNA) #3 reported the nurse needed to come back to the floor for an emergency. The STNA reported she heard Resident #1 yelling, went to see what the problem was, and then heard movement in the room. When she got to the room she found Resident #2 on top of Resident #1 hitting him. The STNA stated she had to pull Resident #2 off of Resident #1, moved him to the floor, and went to get the nurse. The nurse and two other nurses arrived to investigate. They separated the residents and assessed Resident #1. The families and physician were notified with orders to transport both residents to the emergency room (ER) for evaluation. Review of the physician progress notes [REDACTED].M. revealed Resident #1 was attacked by his roommate the prior day in the early morning. Resident #1 went to ER with a large left sided facial laceration with bruising. Sutures were placed and the resident returned. Resident #1's room was changed. Review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 11/10/17, revealed the resident had impaired cognition. Review of the current plan of care revealed Resident #2 was resistive to care at times related to dementia. He could be combative at times with staff. Review of the nurse progress notes dated 12/11/17 at 1:05 A.M. revealed the DON received a call from the facility that Resident #2 physically attacked his roommate causing a facial injury. Resident #2 stated he was attacked first. The police were called and a report was filed. Resident #2 was sent to the ER for a psychiatric evaluation. Review of the nurse progress notes dated 12/11/17 and timed at 2:42 A.M. revealed STNA #3 reported the nurse needed to come back to the floor for an emergency. The STNA reported she heard Resident #1 yelling, went to see what the problem was, and then heard movement in the room. When she got to the room she found Resident #2 on top of Resident #1 hitting him. The STNA stated she had to pull Resident #2 off of Resident #1, moved him to the floor, and went to get the nurse. The nurse and two other nurses arrived to investigate. They separated the residents and assessed Resident #1. The families and physician were notified with orders to transport both residents to the emergency room (ER) for evaluation. The ER was advised Resident #2 needed a psychiatric evaluation. Review of the nurse note dated 12/11/17 at 8:02 A.M. revealed the Interdisciplinary Team (IDT) reviewed the occurrence of early morning hours. Resident #2 was assessed at the ER both medically and psychologically and indicated no assessment findings warranted admission. Resident #2 returned to the facility and one on one supervision continued. Resident #2 was now stating he was sorry for his actions and wanted to apologize to the resident and management. Review of the psychiatric progress note dated 12/11/17 at 10:41 A.M. revealed Resident #2 had hit another resident. Resident #2 stated it was because the other patient had lunged at him, so he backhanded him. Resident #2 indicated he had a past history of aggressiveness. The note indicated the psychologist was recommending Resident #2 have an emergency psychiatric facility admission. Review of Self-Reported Incident (SRI) # 9 dated 12/11/17 revealed an incident occurred between Residents #1 and Resident #2 on 12/11/7 at 12:55 A.M. The investigation revealed STNA #3's statement indicated she heard a commotion and responded to the residents' room when she discovered the altercation. She had to physically separate the two residents and went to obtain the nurse. The facility unsubstantiated physical abuse. Review of SRI # 5 dated 12/23/16 revealed Resident #2 has struck the hand of Resident #13, who was his roommate at the time. Resident #2 had been upset because Resident #13 was talking. Interview on 12/27/17 at 9:40 A.M., the DON verified Resident #2 attacked Resident #1 for an unknown reason on 12/11/17. DON verified Resident #1 was sent to the ER for a facial laceration which required stitches. DON stated Resident #2 stated during the investigation Resident #1 had lunged at him, however Resident #1 was not physically able to get up without assistance. Review of the facility policy titled Abuse and Neglect, revised 09/02/16, defined abuse as willful infliction of injury resulting in physical harm. Physical abuse was identified to include hitting. Willful was defined to indicate the individual acted deliberately, not that the individual intended to inflict harm. The intent of the policy was to prevent abuse of residents. As a result of the incident the facility implemented the following corrective actions to correct the deficient practice by 12/26/17. · On 12/11/17 at 12:55 A.M. STNA #3 responded, separated the residents, and obtained the nurse. Assessments of each resident was completed by the nurses on duty. · On 12/11/17 at 1:05 A.M. the DON, the local police, the physician, both resident families, and the emergency transport was notified. Resident #2 was placed on one-on-one supervision. · On 12/11/17 at 1:10 A.M. Resident #1 and Resident #2 were transported to the ER. At approximately 5:00 A.M. Resident #2 returned and was placed one-on-one supervision. · On 12/11/17 at approximately 9:30 A.M. Resident #1 returned to the facility and was moved to a new room. · On 12/11/17 at 9:51 A.M. the psychologist assessed Resident #2 and completed the application for admission for a psychiatric evaluation. By 12:00 P.M. Resident #2's daughter was contacted regarding the potential need for the resident to be transferred to a different long term care facility. Facilities were contacted for possible referrals. · On 12/11/17 Residents were assessed for roommate compatibility and behavior risks. Those residents who had a Brief Interview for Mental Status (BIMS) above a score of eight (indicating intact cognition) were interviewed about abuse. Those residents with a BIMS of seven or below had skin sweeps performed. One resident (#14) was identified as a behavioral risk with no immediate concerns addressed by the resident. No other residents were found to be at risk for physically aggressive behaviors. · On 12/11/17 all staff were in-serviced on the identifying resident behaviors which place them at risk for compatibility, identifying roommate incompatibility, identifying changes in dementia residents, and observation of causes of changes in residents by the Staff Development Professional #22. Those not present in the facility were contacted by phone the same day. · On 12/12/17 at 5:35 P.M. Resident #2 was discharged to a psychiatric hospital. · On 12/13/17 Licensed Social Worker (LSW) #100 spoke with the Social Worker at the psychiatric hospital and provided them a list of facilities that may accept the resident upon discharge. · On 12/15/17 an ad hoc Quality Assurance meeting was held. An audit tool was put in place to weekly monitor resident behaviors and roommate compatibility. · On 12/19/17 and 12/26/17 the DON conducted the weekly audits and no immediate concerns were identified. · On 12/27/17 interviews between 3:32 P.M. and 3:38 P.M. with STNA #2, STNA #4, and Licensed Practical Nurse #5 revealed they were aware of the abuse policy, how to react to a catastrophic event, how to react during a resident to resident altercation, and how to react to resident changes. · Interviews on 12/27/17 between 3:27 P.M. and 3:35 P.M. with Resident #10, Resident #11, and Resident #12 revealed no concerns with the behaviors of other residents. · Review of six additional SRIs revealed no concerns with the investigations. This deficiency substantiates Complaint Number OH 209.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of Self-Reported Incidents, staff interviews, resident interviews, and review of facility policy, the facility failed to prevent resident to resident abuse for one (#1) of three residents reviewed for abuse. Actual harm occurred when Resident #2 struck Resident #1 causing a laceration to the face and facial bruising. Resident #1 required an assessment in the emergency room and sutures to close the laceration. The facility census was 88. Findings include: Review of the medical record for the Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/03/17, revealed Resident #1 had impaired cognition. The resident required extensive assistance of one staff for bed mobility, transfers, and ambulation. Review of the nurse progress notes dated 12/11/17 at 1:10 A.M. documented the Director of Nursing (DON) received a call from the facility staff reporting Resident #1 was physically struck in the face by his roommate for an unknown reason. Staff intervened and separated the residents. Resident #1 cannot provide a statement. Resident #1 was assessed and had a cut to his face. Emergency transport and the police were notified and the resident was transferred to the hospital. The physician and resident's family were notified. Review of the nurse progress notes dated 12/11/17 and timed at 2:42 A.M. revealed State tested Nurse Aid (STNA) #3 reported the nurse needed to come back to the floor for an emergency. The STNA reported she heard Resident #1 yelling, went to see what the problem was, and then heard movement in the room. When she got to the room she found Resident #2 on top of Resident #1 hitting him. The STNA stated she had to pull Resident #2 off of Resident #1, moved him to the floor, and went to get the nurse. The nurse and two other nurses arrived to investigate. They separated the residents and assessed Resident #1. The families and physician were notified with orders to transport both residents to the emergency room (ER) for evaluation. Review of the physician progress notes [REDACTED].M. revealed Resident #1 was attacked by his roommate the prior day in the early morning. Resident #1 went to ER with a large left sided facial laceration with bruising. Sutures were placed and the resident returned. Resident #1's room was changed. Review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 11/10/17, revealed the resident had impaired cognition. Review of the current plan of care revealed Resident #2 was resistive to care at times related to dementia. He could be combative at times with staff. Review of the nurse progress notes dated 12/11/17 at 1:05 A.M. revealed the DON received a call from the facility that Resident #2 physically attacked his roommate causing a facial injury. Resident #2 stated he was attacked first. The police were called and a report was filed. Resident #2 was sent to the ER for a psychiatric evaluation. Review of the nurse progress notes dated 12/11/17 and timed at 2:42 A.M. revealed STNA #3 reported the nurse needed to come back to the floor for an emergency. The STNA reported she heard Resident #1 yelling, went to see what the problem was, and then heard movement in the room. When she got to the room she found Resident #2 on top of Resident #1 hitting him. The STNA stated she had to pull Resident #2 off of Resident #1, moved him to the floor, and went to get the nurse. The nurse and two other nurses arrived to investigate. They separated the residents and assessed Resident #1. The families and physician were notified with orders to transport both residents to the emergency room (ER) for evaluation. The ER was advised Resident #2 needed a psychiatric evaluation. Review of the nurse note dated 12/11/17 at 8:02 A.M. revealed the Interdisciplinary Team (IDT) reviewed the occurrence of early morning hours. Resident #2 was assessed at the ER both medically and psychologically and indicated no assessment findings warranted admission. Resident #2 returned to the facility and one on one supervision continued. Resident #2 was now stating he was sorry for his actions and wanted to apologize to the resident and management. Review of the psychiatric progress note dated 12/11/17 at 10:41 A.M. revealed Resident #2 had hit another resident. Resident #2 stated it was because the other patient had lunged at him, so he backhanded him. Resident #2 indicated he had a past history of aggressiveness. The note indicated the psychologist was recommending Resident #2 have an emergency psychiatric facility admission. Review of Self-Reported Incident (SRI) # 9 dated 12/11/17 revealed an incident occurred between Residents #1 and Resident #2 on 12/11/7 at 12:55 A.M. The investigation revealed STNA #3's statement indicated she heard a commotion and responded to the residents' room when she discovered the altercation. She had to physically separate the two residents and went to obtain the nurse. The facility unsubstantiated physical abuse. Review of SRI # 5 dated 12/23/16 revealed Resident #2 has struck the hand of Resident #13, who was his roommate at the time. Resident #2 had been upset because Resident #13 was talking. Interview on 12/27/17 at 9:40 A.M., the DON verified Resident #2 attacked Resident #1 for an unknown reason on 12/11/17. DON verified Resident #1 was sent to the ER for a facial laceration which required stitches. DON stated Resident #2 stated during the investigation Resident #1 had lunged at him, however Resident #1 was not physically able to get up without assistance. Review of the facility policy titled Abuse and Neglect, revised 09/02/16, defined abuse as willful infliction of injury resulting in physical harm. Physical abuse was identified to include hitting. Willful was defined to indicate the individual acted deliberately, not that the individual intended to inflict harm. The intent of the policy was to prevent abuse of residents. As a result of the incident the facility implemented the following corrective actions to correct the deficient practice by 12/26/17. · On 12/11/17 at 12:55 A.M. STNA #3 responded, separated the residents, and obtained the nurse. Assessments of each resident was completed by the nurses on duty. · On 12/11/17 at 1:05 A.M. the DON, the local police, the physician, both resident families, and the emergency transport was notified. Resident #2 was placed on one-on-one supervision. · On 12/11/17 at 1:10 A.M. Resident #1 and Resident #2 were transported to the ER. At approximately 5:00 A.M. Resident #2 returned and was placed one-on-one supervision. · On 12/11/17 at approximately 9:30 A.M. Resident #1 returned to the facility and was moved to a new room. · On 12/11/17 at 9:51 A.M. the psychologist assessed Resident #2 and completed the application for admission for a psychiatric evaluation. By 12:00 P.M. Resident #2's daughter was contacted regarding the potential need for the resident to be transferred to a different long term care facility. Facilities were contacted for possible referrals. · On 12/11/17 Residents were assessed for roommate compatibility and behavior risks. Those residents who had a Brief Interview for Mental Status (BIMS) above a score of eight (indicating intact cognition) were interviewed about abuse. Those residents with a BIMS of seven or below had skin sweeps performed. One resident (#14) was identified as a behavioral risk with no immediate concerns addressed by the resident. No other residents were found to be at risk for physically aggressive behaviors. · On 12/11/17 all staff were in-serviced on the identifying resident behaviors which place them at risk for compatibility, identifying roommate incompatibility, identifying changes in dementia residents, and observation of causes of changes in residents by the Staff Development Professional #22. Those not present in the facility were contacted by phone the same day. · On 12/12/17 at 5:35 P.M. Resident #2 was discharged to a psychiatric hospital. · On 12/13/17 Licensed Social Worker (LSW) #100 spoke with the Social Worker at the psychiatric hospital and provided them a list of facilities that may accept the resident upon discharge. · On 12/15/17 an ad hoc Quality Assurance meeting was held. An audit tool was put in place to weekly monitor resident behaviors and roommate compatibility. · ON 12/19/17 and 12/26/17 the DON conducted the weekly audits and no immediate concerns were identified. · On 12/27/17 interviews between 3:32 P.M. and 3:38 P.M. with STNA #2, STNA #4, and Licensed Practical Nurse #5 revealed they were aware of the abuse policy, how to react to a catastrophic event, and how to react during a resident to resident altercation. · Interviews on 12/27/17 between 3:27 P.M. and 3:35 P.M. with Resident #10, Resident #11, and Resident #12 revealed no concerns with the behaviors of other residents. · Review of six additional SRIs revealed no concerns with the investigations. This deficiency substantiates Complaint Number OH 209.

Based on observation, medical record review, staff interview, and review of facility policy, it was determined the facility failed to implement physician ordered interventions to prevent the development of pressure ulcers and/or promote healing of pressure ulcers. This resulted in actual harm for Resident #79 who developed one Stage II pressure ulcer on the right lower extremity, one Stage II pressure ulcer on the left lower extremity, one Stage I pressure ulcer on the left heel and one unstageable pressure ulcer to the right heel. This affected one (#79) of two residents reviewed for pressure ulcers of a total of ten residents identified by the facility with pressure ulcers. The total facility census was 80. Findings include: Review of Resident #79's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] reflected numerous risks for developing pressure ulcers including requiring total care, always incontinent, bedfast, and receiving Hospice services. The assessment noted the development of a new pressure ulcer on 06/15/12. All previous assessments revealed the resident's skin was intact. Review of Resident #79's Admission Nursing Skin assessment dated [DATE] revealed redness to the groin area and discoloration bilaterally in lower legs. Review of the Braden Scale Pressure Ulcer Risk Records dated 08/31/11, 11/03/12, 02/01/12, 04/20/12 and 06/15/12 revealed scores of 11-12 (12 or less indicating Resident #79 was at high risk for the development of pressure ulcers. Review of the Nursing Skin assessment dated [DATE] revealed the resident's right heel was discovered to have a black area with eschar that measured 3.5 centimeters (cm) by 4.5 cm. Review of the resident's plan of care, dated 06/15/12, regarding the pressure ulcers included interventions for bilateral heels to be floated and propped with pillows to avoid any direct pressure. The resident was also to be turned every two hours. Review of Resident #79's "Hospice Nursing Comprehensive Update Weekly Visit Notes" completed two times a week revealed Hospice uses the Norton Skin Assessment to determine the resident's risk for pressure ulcers. Resident #79 consistently scored an 8 on the assessments (13 or under indicated there was a high risk for pressure ulcers). Review of Resident #79's Hospice Nursing Notes dated 06/12/12 revealed a note indicating there was a new order for the wound care nurse to evaluate Resident #79's right heel. It noted the right heel had a large black scab and the need to keep the heels off the bed with pillows. Review of Resident #79's "Skin Grid Pressure Ulcer Record" dated 06/15/12 revealed a pressure ulcer to the right heel was discovered. The pressure ulcer was staged as "unstageable" and measured 3.5 cm by 4.5 cm with eschar and an undetermined depth. The facility's "Pressure Ulcer Record" defines eschar as dead tissue that is usually hard, black, brown or tan in color and may appear scab-like. It is usually firmly adherent to the base of the wound and often the sides or edges of the wound. Further review of Resident #79's "Skin Grid Pressure Ulcer Record" dated 06/19/12 revealed the presence of a pressure ulcer to the right lower extremity, on the shin. It was identified as Stage II pressure ulcer that measured 1.0 cm by 1.5 cm by 0.3 cm. There was also a Stage II pressure ulcer found on the left lateral lower extremity, on the outer side of the lower leg. The area measured 3.0 cm by 0.5 cm by 0.2 cm. Review of Resident #79's monthly physician orders [REDACTED]. the wheelchair (ordered 03/09/11). Review of physician telephone orders revealed multiple new orders regarding pressure ulcer prevention and treatment, including an order on 06/13/12 for the wound nurse to re-evaluate and treat Resident #79's right heel pressure ulcer. On 06/15/12, the physician ordered to turn the resident every two hours, elevate heels on a pillow with no pressure on the heels, and apply heel boot protectors. On 06/20/12, treatments were ordered for the resident's right heel, right lower extremity and left lower extremity pressure ulcers. The order again instructed to keep the resident's heels completely off pressure until heel boots arrive from Hospice. The physician order [REDACTED]. On 06/26/12, Resident #79 was seen for the first time by the "Wound Management Service from Northeast Surgical Wound Care". At the time of that visit, the resident's pressure ulcers were as follows; -Wound #1- the right heel had an onset date of 06/15/12, measured 3.0 cm by 4.0 cm and was identified as unstageable pressure ulcer. -Wound #2 - the right lower extremity had an onset date of 06/19/12, measured 0.70 cm by 1.0 cm by 0.10 cm and was identified as a Stage III pressure ulcer. -Wound #3 - the left lower extremity had an onset date of 06/19/12, measured 2.6 cm by 0.50 cm by 0.50 cm and was identified as a Stage III pressure ulcer. -Wound #4- the left heel had an onset date of 06/26/12, measured 2.0 cm by 1.2 cm and was identified as a Stage I pressure ulcer. Observation of Resident #79's pressure ulcers on 06/28/12 at approximately 1:00 P.M., with Assistant Director of Nursing #2, were consistent with the above measurements. Additional observations were made of Resident #79 on all four days of the survey and included the following dates and times; on 06/25/12 at 2:12 P.M., on 06/25/12 at 3:43 P.M., on 06/26/12 at 7:38 A.M., on 06/26/12 at 9:08 A.M., on 06/26/12 at 11:10 A.M., on 06/26/12 at 12:46 P.M., on 06/26/12 at 3:08 P.M., on 06/26/12 at 4:52 P.M., on 06/27/12 at 8:46 A.M., on 06/27/12 at 9:46 A.M., on 06/27/12 at 10:48 A.M., on 06/27/12 at 12:43 P.M., on 06/27/12 at 2:19 P.M., on 06/27/12 at 3:47 P.M., on 06/28/12 at 7:34 A.M., on 06/28/12 at 9:32 A.M., and on 06/28/12 at 12:39 P.M. At the time of all the aforementioned observations, Resident #79's bilateral heels were resting either directly on the bed or directly on the pillow. Although the resident's position varied slightly from the left side to the right side, Resident #79 remained on his back with pressure directly on his buttocks at the time of each observation. Interviews with State tested Nurse Aide (STNA) #35 on 06/28/12 at 1:02 P.M. and with Licensed Practical Nurse (LPN) #37 on 06/28/12 at 1:22 P.M. and LPN #36 at 4:45 P.M. on 06/28/12, verified Resident #79 should have his bilateral heels floated and they should never be resting directly on the bed or on a pillow. They each verified the heels were resting directly on the pillow and that although there was a slight change of position, Resident #79 was positioned consistently on his buttocks. They further verified Resident #79 developed a new pressure ulcer on 06/26/12, during the survey period. Review of the facility's policy entitled "Wound/Skin Guidelines" dated 10/01/10 indicated each facility shall implement a pressure ulcer prevention program which shall include: appropriate and timely determination of pressure ulcer risk, appropriate determination of medical history with regard to skin integrity, timely skin evaluation, and implementation of pressure prevention interventions. Interventions included pressure reducing mattress, heel protectors or elevating of heels from the bed, application of positioning pillows, and turning and repositioning.