Every finding on record at Anderson, The

Based on observation, interview, facility policy review, and Food and Drug Administration (FDA) guidelines review, the facility failed to ensure food was stored and served in a sanitary manner. Specifically, the facility failed to ensure that kitchen equipment was kept clean, prepared food stored in the walk-in cooler was labeled and dated, and staff wore effective hair restraints in the kitchen. This failed practice had the potential to affect all 91 of 92 residents who received meals from the kitchen.Findings include: 1. Observations in the kitchen on 08/11/2025 at 8:44 AM revealed a dirty toaster with built up grime and crumbs on the tray and conveyor belt wheels. A bulk food storage bin containing rice was dirty with a sticky substance on the lid. During an interview on 08/11/2025 at 8:55 AM, the Kitchen Manager (KM) stated they cleaned bulk food storage bins once a week on Mondays or Tuesdays, so they were due to be cleaned. During an observation on 08/12/2025 at 12:31 PM, the bulk food storage containers continued to appear dirty with a sticky substance on the lid. During an interview on 08/12/2025 at 3:50 PM, the KM stated he did rounds in the kitchen to confirm things were clean. The KM stated he knew the toaster was an issue but it had been that way for a long time. The KM stated he would have to disassemble it to try to clean it. During an interview on 08/13/2025 at 11:30 AM, the Administrator (ADM) stated kitchen staff should clean the kitchen daily. During a telephone interview on 08/13/2025 at 12:59 PM, the Registered Dietitian (RD) stated she was at the facility once a week and was also available by phone and email. The RD stated she regularly completed kitchen walk-throughs with the KM to identify concerns. The RD stated she had encouraged the KM to use a cleaning schedule to ensure things were cleaned regularly. The RD stated she had encouraged the KM to dispose of the bulk storage bins because they rarely used them. Review of the facility policy titled Sanitation, reviewed 08/01/2018, revealed the food service area shall be maintained in a clean and sanitary manner by all dietary staff. The policy indicated All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas.2. Observations in the kitchen on 08/11/2025 at 8:45 AM in the walk-in cooler revealed prepared tuna salad with no date or label. A creamy pasta with a label that read Tuesday, but no date or identification of food item. A prepared item that appeared to be chicken salad with a date but no item description. A prepared item with a date but no item description. A container of what appeared to be tomato soup with no date or label. During an interview on 08/11/2025 at 8:49 AM, the Kitchen Manager (KM) stated the creamy pasta was broccoli soup, but then he corrected himself and stated it was macaroni and cheese. The KM confirmed there was no date on the container. The KM stated the another item looked like chicken salad and had a date but verified there was no description of the item. The KM stated another prepared item that was dated appeared to be ham salad but confirmed it did not have a description. The KM verified a container of tomato soup had no date. The KM stated prepared food items should be dated and it was important to date items to ensure they were not serving spoiled food. During a follow-up interview on 08/12/2025 at 3:50 PM, the KM stated he expected all food items to be labeled and dated. During an interview on 08/13/2025 at 11:30 AM, the Administrator (ADM) stated she expected food in the kitchen to be dated and labeled correctly per the facility policy. During a telephone interview on 08/13/2025 at 12:59 PM, the Registered Dietitian (RD) stated all foods prepared in the kitchen should be dated with a prepared-on date and a discard date. Review of the facility policy titled Food Storage, last reviewed by the facility on 08/01/2018, revealed food items removed from original container must be stored in proper containers with a label and date applied.3. Observation in the kitchen on 08/11/2025 at 8:49 AM revealed the KM in the walk-in cooler with a beard and no beard net. The KM continued to tour the kitchen with the surveyor with no beard net covering his facial hair. Observation on 08/12/2025 at 8:26 AM revealed the KM in the dish room with no beard net or cover for facial hair. During an interview on 08/12/2025 at 11:28 AM, the KM stated he had just arrived the morning before when he came into the walk-in cooler so he had not had a chance to put on his beard net yet. The KM stated he did not think he needed to wear a beard restraint in the dish room. The KM stated he thought he only needed to wear a beard restraint when he was handling food.Observation on 08/12/2025 at 12:07 PM revealed the KM standing at the end of the tray line during the lunch meal service. A beard net was around his neck and his facial hair was not covered by the beard restraint. During an interview on 08/12/2025 at 3:50 PM, the KM stated all staff were expected to wear hair nets or hats in the kitchen. The KM stated he thought they only needed to wear the beard restraint around food. During an interview on 08/13/2025 at 10:41 AM, the Director of Nursing (DON) stated staff should be wearing beard restraints in the kitchen and she had already talked to the KM about it. During an interview on 08/13/2025 at 11:30 AM, the Administrator (ADM) stated she expected all kitchen staff to wear beard restraints, and staff knew that. During a telephone interview on 08/13/2025 at 12:59 PM, the Registered Dietitian (RD) stated she expected food service staff to wear beard restraints any time they were preparing food or were near clean dishes or utensils.Review of the facility policy titled Foodservice Workers Hair Coverings, last reviewed by the facility on 08/01/2018, revealed all employees working in food preparation areas, including chefs, cooks, dishwashers, and anyone else handling food or food contact surfaces, are required to wear a hairnet, beard net (if applicable), or other approved hair covering. The hair restraint must fully cover all hair and be clean and free of visible dirt. [NAME] nets must be worn by employees with facial hair. The purpose of this policy is to prevent hair from contaminating food and food contact surfaces.Review of the FDA's 2022 Food Code, revised in 2022, revealed Chapter 2 Management and Personnel included a section titled 2-402 Hair Restraints, which stated FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGE-USE ARTICLES.

Based on record review, review of the admission Agreement, and interview, the facility failed to ensure completion of an admission Agreement for three (#6, #95, and #99) of four sampled residents reviewed for admission agreements.Findings include:Review of the facility admission Agreement, developed 01/14/2020, revealed in the section titled 1 Parties to Contract, included this an Agreement between [Facility Name], nursing home operated by [Corporation Name]. All of the above parties to this contract understand, acknowledge, and agree to all the following terms and conditions without any reservations or exceptions whatsoever, further, the parties acknowledge and agree good and valuable consideration to support each party's obligation. The admission Agreement revealed at Bullet S; The Undersigned: Has read and received the foregoing, certifies the information is correct, and agrees to the terms and conditions of the admission Agreement and addenda material incorporated herein by reference. The admission agreement the resident represents he/she has been verbally advised of and has received the homes basic per diem rate and a schedule of charges for items not covered in the basic per diem and agrees to pay and be liable for any and all health care services at the home. This includes but is not limited to a guarantee of payment for any and all charges not paid by Medicare, Medicaid, and/or other third party payor or in the event that such benefits are or become denied or the Resident is or becomes ineligible for such benefits. Review of the admission record for Resident #6 revealed an admission on [DATE]. The admission record contained no signed admission Agreement. Review of the admission record for Resident #95 revealed an admission on [DATE]. The admission record contained no signed admission Agreement. Review of the admission record for Resident #99 revealed an admission on [DATE]. The admission record contained no signed admission Agreement. The facility was unable to provide documented evidence of signed admission Agreements for Residents #6, #95, or #99.During an interview on 08/13/2025 at 4:19 PM, the admission Director (AD) confirmed they did not have signed admission agreements for Residents #6, #95, and #99. The AD stated the admission agreements should have been signed. The Administrator (ADM) was interviewed on 08/13/2025 at 4:38 PM. The ADM confirmed the facility did not have signed admission agreements for Resident #6, #95, or #99. The ADM further stated it was their expectation for all residents to sign the facility's admission agreement. This citation represents noncompliance discovered during the investigation of Complaint Number 1301534.

Based on closed medical record review, hospital record review, review of information from the Cleveland Clinic regarding hypotension, and interviews, the facility failed to ensure staff identified a change in condition for Resident #22 when the resident experienced hypotension (low blood pressure) and diaphoresis (sweating especially to an unusual degree as a symptom of disease) and failed to notify the physician of the resident's hypotension and diaphoresis resulting in a delay in care and treatment. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm beginning on [DATE] at 3:15 P.M. when Resident #22, who had a history of hypertension (high blood pressure), had a blood pressure of ,d+[DATE] millimeters of mercury (mm/Hg) which was not reported to the physician and no treatment was provided. Resident #22's family member requested the resident be sent to the hospital for evaluation on [DATE] at 7:33 P.M. (four hours after the resident first exhibited a decline in condition) due to the resident's continued hypotension and diaphoresis. Resident #22 was admitted to the hospital on [DATE] with diagnoses of septic shock and encephalopathy and expired at the hospital on [DATE]. This affected one (#22) of four residents reviewed for falls. The facility census was 88. On [DATE] at 11:42 A.M., President #218, Director of Nursing (DON), and Assistant Director of Nursing (ADON) #226 were notified Immediate Jeopardy began on [DATE] at 3:15 P.M. for Resident #22, when staff failed to inform the resident's physician of a change in condition when Resident #22 began to complain of pain, was diaphoretic, and hypotensive thereby delaying care and treatment, until Resident #22's family arrived to the facility and requested the resident be sent to the emergency department for further evaluation. Consequently, Resident #22 was admitted to the hospital with diagnoses of septic shock, hypotension, and hypothermia. The resident expired at the hospital on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 1:15 P.M., the facility will continue with its staff education and monitoring program specifically to ensure that any and all pertinent policies and procedures regarding resident changes in condition to ensure staff are implementing them as directed to prevent the same actions, situations, and/or practices from occurring in the future, by conducting in-service education via the employee communication system which will include all clinical employees. This was completed on [DATE] at 1:15 P.M. and included eight Registered Nurses (RN), 22 Licensed Practical Nurses (LPN) and 35 State tested Nursing Assistants (STNA). Education will be ongoing. On [DATE] at 2:00 P.M., ADON #226 sent out the education notification immediately to alert nursing staff to notify the physician immediately when a change of resident condition occurs. On [DATE] at 2:00 P.M., the DON completed counseling and education with LPN #185 regarding proper documentation and communication with physician regarding resident change in condition. On [DATE] at 2:00 P.M., the facility will continue to ensure there are systems in place to complete ongoing assessments of residents' health status when they experience a change in condition as evidenced by the following: When a resident has a change in condition, if indicated, the nurse may complete a Change of Condition Assessment in Point Click Care; the form is located under the Assessments tab in the resident electronic medical record. The change of condition includes along with any labs, analysis, x-rays, notification with physician date and time along with notification of responsible party date and time. After the completion of the assessment, if indicated, the attending physician will be notified immediately. Change of condition assessment form has been activated and implemented. The facility will continue to ensure that staff notify the attending physician immediately for any potential changes in treatment when a change in condition occurs. This is implemented and effective. Beginning on [DATE] at 2:00 P.M., all 90 residents in the facility will have a head-to-toe assessment and will be assessed for abnormal vital signs, abnormal change in mental status, any skin issues, and complaints of pain by 7:00 P.M. on [DATE]. This will be done by the attending charge nurses. Results will be noted in resident's chart and a progress note will be completed. If there are any signs of change in condition the physician will be notified immediately, and the change of condition assessment will be completed. The facility will continue to both assess and reassess all current residents for potential changes in condition, notification of physician, and any needed revisions to the plan of care to ensure potential issues are appropriately addressed and followed through on. This action was verified by the surveyor with record reviews for Residents #28 and #29. On [DATE] at 2:00 P.M., education will be provided to each nurse 1:1 and the employee will be shown the policy and procedure for the change in condition and the physician of notification. The employee will be shown where to find the change of condition assessment and the information it requires. The employee will demonstrate back showing how to find the assessment and where the policy is located. This education will be completed by the start of each nurse's next shift. This will be completed by ADON #226 for dayshift staff and RN #194 for nightshift staff. On [DATE] at 3:00 P.M., the charting guideline policy was reviewed by the DON and ADON #226 to include changes reflective of electronic charting. Information removed consisted of paper documentation and frequency of monitoring systems. The changes now adhere to our current frequency and monitoring systems and inclusive of the change in condition assessment. On [DATE], interview with LPN #210 at 8:52 A.M., STNA #248 at 8:58 A.M., LPN #214 at 9:00 A.M., LPN #253 at 10:31 A.M., and LPN #282 at 10:36 A.M. revealed the staff had received education and in-service training on change in condition, physician notification, and documentation and were knowledgeable about the facility's procedures and processes. On [DATE] at 9:30 A.M., the facility began implementation of the change in condition assessment information to be reviewed during daily morning clinical meeting. It will begin on this date and time and will be ongoing indefinitely. On [DATE] at 9:30 A.M., the quarterly Quality Assurance and Performance Improvement (QAPI) meeting is scheduled and will take place to include all day shift supervisors, MDS, Director of Therapy, Director of Nursing, Assistant Director of Nursing, Director of Food Services, Director of Environmental Services, Social Services, Activity Director, Medical Director, and the Administrator. During this meeting, we will address the revised policy on change in condition and physician notification. Beginning on [DATE], the DON or designee will perform auditing of any change of condition in the facility. The audit will consist of three random residents, twice a week for four weeks and will be monitored monthly for three months. We will be auditing that a change of condition assessment was completed based off our review in clinical meeting from the 24-hour report. All changes to a resident condition will be communicated with families or power of attorney's when it occurs. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine if further action is required and monitoring to ensure on-going compliance. Findings include: Closed record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic obstructive pulmonary disease, weakness, dementia, and hypertension. Review of the order summary revealed Resident #22 had an order in place for assist of two for bed mobility and Hoyer lift for transfers ([DATE]) and an order for Tylenol oral tablet 325 milligrams (mg) give two tablets by mouth every six hours as needed for pain ([DATE]). Review of a care plan dated [DATE] revealed Resident #22 had an activity of daily living (ADL) self-care performance deficit related to impaired balance and obesity. Interventions included two staff assistance with any care given while resident is in bed ([DATE]), resident is totally dependent on two staff to turn and reposition in bed as necessary ([DATE]), resident is totally dependent on two staff to provide shower ([DATE]), to provide a sponge bath if a shower cannot be tolerated ([DATE]), and resident is totally dependent on two staff for transferring with a mechanical lift ([DATE]). Review of a quarterly Minimum Data Set (MDS) assessment collected on [DATE] revealed Resident #22 had mildly impaired cognitive function, no behaviors, required dependence of staff for care for bathing, toileting, dressing, bed mobility, and transfers. Review of a Morse Fall Scale assessment completed on [DATE] revealed Resident #22 was a moderate risk for falling. Review of the medical record revealed the following vital signs for Resident #22: On [DATE] at 11:19 A.M., blood pressure (BP) was ,d+[DATE] mm/Hg; at 5:16 P.M., BP was ,d+[DATE] mm/Hg. On [DATE] at 10:14 A.M., BP was ,d+[DATE]mm/Hg; at 5:28 P.M., BP was ,d+[DATE] mm/Hg. On [DATE] at 9:34 A.M., BP was ,d+[DATE]; at 11:45 A.M., BP was ,d+[DATE] mm/Hg (prior to the resident's fall). The resident's body temperature was recorded on [DATE] at 6:15 P.M. as 97.6 degrees Fahrenheit (F) (location, forehead). Review of a nursing note dated [DATE] at 11:52 A.M. by Licensed Practical Nurse (LPN) #185 revealed a State tested Nursing Aide (STNA) informed the nurse Resident #22 was rolled out of bed while receiving a bed bath but did not hit her head during the fall. Upon entering the room, Resident #22 was found lying on her back on the floor next to the bed, she was alert and immediately assessed for pain. Resident #22 denied pain but did have abrasions to left index and middle fingers, vital signs were within normal limits, and resident was assisted back into bed with the assistance of four staff and neuro checks were initiated. The nurse called Resident #22's son and made him aware of the situation. Review of a Neurological Check assessment completed on [DATE] at 12:00 P.M. revealed Resident #22's blood pressure was ,d+[DATE] mm/Hg (normal blood pressure is ,d+[DATE] mm/Hg). Review of a Counseling Form completed on [DATE] at 12:15 P.M. by the DON with STNA #130 revealed the seriousness of the situation was explained, STNA #130 stated she attempted completing Resident #22's care by herself because she thought she could do it, and the DON instructed her to clock out and informed her she was terminated. Review of a Neurological Check assessment completed on [DATE] at 12:15 P.M. revealed Resident #22's blood pressure was ,d+[DATE] mm/Hg; an assessment completed at 3:15 P.M. revealed Resident #22's blood pressure was ,d+[DATE] mm/Hg, she was complaining of pain rated at four out of 10 and she was grimacing, withdrawing, or showing other non-verbal signs of pain. Review of a nursing note dated [DATE] at 3:40 P.M. by LPN #185 revealed Resident #22 was having complaints of increased pain to her left knee, the on-call provider was contacted and gave a new order for STAT (immediate) three-view x-ray of left knee. No new orders were received for pain management. There was no evidence the on-call provider was notified of the resident's low blood pressure (,d+[DATE] mm/Hg and ,d+[DATE] mm/Hg). Review of a medication administration record (MAR) for [DATE] revealed Resident #22 did not receive as needed Tylenol per orders when complaining of pain on [DATE]. Review of a Neurological assessment dated [DATE] at 4:15 P.M. revealed Resident #22's blood pressure was ,d+[DATE] mm/Hg; at 5:20 P.M. her blood pressure was ,d+[DATE] mm/Hg and at 6:21 P.M. her blood pressure was ,d+[DATE] mm/Hg. There was no evidence the resident's medical provider was notified. Review of a nursing note dated [DATE] at 7:01 P.M. by LPN #185 revealed Resident #22 had an x-ray completed to her left knee and was awaiting results. Resident #22 was very diaphoretic and stated she was cold. Vital signs were checked, blood glucose was checked, and no abnormalities noted. There was no evidence the resident's medical provider was notified of the resident's condition including the previous low blood pressure readings and diaphoresis. Review of a nursing note dated [DATE] at 7:33 P.M. by LPN #185 revealed Resident #22 was sent out to the hospital at the request of her family for further evaluation related to increased diaphoresis and pain all over. On-call provider was notified and gave the order to send to the emergency room for evaluation. Review of a hospital History and Physical dated [DATE] revealed Resident #22 came to the hospital and presented with septic shock with hypothermia and encephalopathy, a history of extended-spectrum beta-lactamase (ESBL) (an enzyme produced by some bacteria that can make them resistant to certain antibiotics. ESBL producing bacteria are harder to treat and may require complex treatments) and had (urine) cultures pending, acute kidney injury, and elevated troponin levels with a history of coronary artery disease. Resident #22 suffered from a fall while at a nursing facility, afterwards they got her up and she was sweating and did not appear to feel well. During assessment, Resident #22 was confused and unable to answer questions regarding the day, month, year, or date. Review of a critical pulmonology note dated [DATE] revealed Resident #22 admitted to the emergency room after diaphoresis and low blood pressure. Resident #22 had been in her room with multiple blankets on and no air conditioning (at the nursing home). At the hospital her blood pressure continued to drop to ,d+[DATE] mm/Hg and her temperature was 95.4 degrees Fahrenheit. Review of a hospital note dated [DATE] revealed overnight, Resident #22 suffered from respiratory failure (related to aspiration while at the hospital) and worsened hypotension. She was placed on a ventilator. Review of a nursing note dated [DATE] at 11:51 P.M. by LPN #275 revealed Resident #22's son called and notified the facility Resident #22 expired. Interview on [DATE] at 12:51 P.M. with Resident #22's family revealed the evening of [DATE], they came to visit the resident, and she was very sweaty and disoriented. They stated this was abnormal for her and they had to request staff to send her to the hospital. Interview on [DATE] at 1:25 P.M. with the DON confirmed Resident #22 had an order and care plan interventions in place for assist of two which was not followed. Interview on [DATE] at 2:31 P.M. with LPN #185 revealed on [DATE] after she had finished medication pass, the STNA came up the hall and informed her she was giving Resident #22 a bed bath and had rolled her out of the bed. The STNA stated she did not have a second person, and LPN #185 immediately educated the aide. LPN #185 stated she went to Resident #22 to assess her, her vitals were normal, she hadn't hit her head, but the cranial checks were started. LPN #185 stated she had notified the physician and the DON. LPN #185 stated Resident #22 was stable and had no complaints of pain once in bed. As the day progressed, Resident #22 complained of pain and was sweating really bad, so an order was received for an x-ray. After the x-ray was completed, Resident #22's son came in and was concerned so he requested Resident #22 be sent to the hospital for additional evaluation. LPN #185 stated Resident #22 started sweating in the afternoon, after lunch but before dinner. LPN #185 stated that is also when Resident #22 started to have low blood pressure. LPN #185 stated sometimes Resident #22 would have high blood pressure and sometimes it would be low. LPN #185 stated she could not recall how soon after Resident #22 became diaphoretic she contacted the provider, but no new orders were received for pain medication and the as needed Tylenol was not administered. LPN #185 stated low blood pressure was not concerning to her. When asked what diaphoresis and hypotension could be indicators for, LPN #185 stated it could be a sign of sepsis or a bleed. LPN #185 confirmed since Resident #22 had medical health problems and had been rolled out of bed earlier in the day, the hypotension and diaphoresis should have been more concerning. LPN #185 confirmed she did not request to send Resident #22 to the hospital prior to 7:33 P.M. (on [DATE]). LPN #185 stated she had been about to call the provider to update them on Resident #22's status when the family requested the resident to be sent to the hospital. Interview on [DATE] at 4:19 P.M. with the DON revealed the low blood pressure was not concerning because people can have numbers that low and be normal and would not be a reason to send someone to the hospital. The DON stated she could not comment on the combination of hypotension along with diaphoresis because she did not see it in person. The DON stated Resident #22 was always cold and there was nothing abnormal about her symptoms. The DON did confirm nursing notes did not display the resident's medical provider or physician were made aware of the diaphoresis or hypotension until Resident #22's son requested for her to be sent to the hospital. Interview on [DATE] at 9:45 A.M. with Physician's Assistant (PA) #400 (Resident #22's primary care provider) revealed he was made aware either on [DATE] or [DATE] because Resident #22 was a long-term patient and the last time he had seen her was the end of June (2024). PA #400 stated he remembers going to the facility on Wednesday ([DATE]) and he didn't see Resident #22 on point click care (PCC) and when he asked where she was, the facility staff explained to him that she passed away. PA #400 confirmed he was not made aware at the time of the fall on [DATE] due to not being on-call over the weekend of the incident. PA #400 stated a normal blood pressure for Resident #22 ranged from about ,d+[DATE] (systolic)/,d+[DATE] (diastolic). PA #400 confirmed Resident #22's vitals appeared to be stable on [DATE] until about 3:15 P.M. PA #400 revealed due to not being on-call, he was not made aware of the change in condition, but a provider should have been made aware of a change in Resident #22's blood pressure if other symptoms of something were present. Interview on [DATE] at 10:56 A.M. with Nurse Practitioner (NP) #410 (works for the on-call medical provider company that cover the facility on weekends) revealed she was not aware Resident #22 had been rolled out of bed during care provided by one staff member on [DATE]. NP #410 stated after three in the afternoon (on [DATE]), she was called because Resident #22 had fallen out of bed and was complaining of knee pain. NP #410 stated she did order an x-ray. NP #410 confirmed she was not made aware of Resident #22 being diaphoretic or hypotensive. NP #410 stated she could not recall when she was made aware Resident #22 went to the hospital and she did not have access to the system to look. NP #410 stated if she had known during the afternoon phone call, she received regarding Resident #22's pain, that Resident #22 also was diaphoretic and hypotensive, since she was unaware of Resident #22's medical history, she would have sent the resident to the hospital for evaluation. Review of the Cleveland Clinic website (undated) revealed symptoms of low blood pressure include confusion or trouble concentrating and unusual changes in behavior. A low blood pressure is considered to be less than 90 for systolic and less than 60 for diastolic. This deficiency represents non-compliance investigated under Complaint Number OH00156609.

Based on review of the medical record, review of hospital records, and care plan review, observations, and interviews, the facility failed to provide adequate assistance with care resulting in a fall and failed to ensure fall interventions were in place. This affected two residents (#22 and #29) of four residents reviewed for falls. The facility census was 88. Findings include: 1. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic obstructive pulmonary disease, weakness, dementia, and hypertension. Review of a quarterly minimum data set (MDS) collected on 07/26/24 revealed Resident #22 had mildly impaired cognitive function, no behaviors, required dependent care for bathing, toileting, dressing, bed mobility, and transfers. Review of a care plan dated 07/03/24 revealed Resident #22 had an activity of daily living (ADL) self-care performance deficit related to impaired balance and obesity. Interventions included two staff assistance with any care given while resident is in bed (06/23/23), resident is totally dependent on two staff to turn and reposition in bed as necessary (07/15/20), resident is totally dependent on two staff to provide shower (07/15/20), to provide a sponge bath if a shower cannot be tolerated (07/03/20), and resident is totally dependent on two staff for transferring with a mechanical lift (07/15/20). Review of the order summary revealed Resident #22 had an order dated 12/06/23 for assist of two for bed mobility and hoyer lift for transfers. Review of a Morse Fall Scale assessment completed on 08/02/24 revealed Resident #22 was a moderate risk for falling. Review of a nursing note dated 08/03/24 at 11:52 A.M. by Licensed Practical Nurse (LPN) #185 revealed a State tested Nursing Aide (STNA) informed the nurse Resident #22 was rolled out of bed while receiving a bed bath but did not hit her head during the fall. Upon entering the room, Resident #22 was found lying on her back on the floor next to the bed, she was alert and immediately assessment for pain. Resident #22 denied pain but did have abrasions to left index and middle fingers, vital signs were within normal limits, and resident was assisted back into bed with the assistance of four staff and neuro checks were initiated. The nurse called Resident #22's son and made him aware of the situation. Review of a nursing note dated 08/03/24 at 3:40 P.M. by LPN #185 revealed Resident #22 was having complaints of increased pain to her left knee, the on-call provider was contacted and gave a new order for STAT (emergent) three-view x-ray of left knee. Review of a nursing note dated 08/03/24 at 7:01 P.M. by LPN #185 revealed Resident #22 had an x-ray completed to her left knee and was awaiting results. Review of a nursing note dated 08/03/24 at 7:33 P.M. by LPN #185 revealed Resident #22 was sent out to the hospital at the request of her family for further evaluation. The resident's on-call provider was notified and gave the order to send the resident to the emergency room for evaluation. Interview on 08/31/24 at 1:25 P.M. with Director of Nursing (DON) confirmed Resident #22 had an order and care plan interventions in place for assist of two which was not followed. 2. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, history of falls, dementia, and hypertension. Review of an annual MDS completed on 06/12/24 revealed Resident #29's cognition was severely impaired, had no behaviors, and was dependent on staff for bathing, toileting, dressing, bed mobility and transfers. Review of orders dated 12/06/23 revealed Resident #29 should have assist of two for bed mobility and hoyer lift for transfers. Review of a care plan dated 10/13/22 revealed Resident #29 was at risk for falls related to incontinence, psychoactive drug use, and unaware of safety needs. Interventions included but were not limited to bolster in place to mattress (06/12/24), fall mats in place to both sides of the bed (06/12/24), and provide a safe environment (10/13/22). Observation on 08/31/24 at 11:51 A.M. of Resident #29 resting in bed revealed bolsters were not in place to her bed and the floor mats were leaning against the wall across from her bed. Interview on 08/31/24 at 11:59 A.M. with the DON confirmed the fall mats were not in place to both sides of Resident #29's bed nor were the bolsters in place. Review of a policy titled Accident Protocol (dated 02/12/10) revealed the DON will investigate and analyze all accidents to determine any causative factors and any changes in the resident's care plan. This deficiency represents non-compliance investigated under Complaint Number OH00156609.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse. This affected one resident (#44) of one resident reviewed for abuse. The facility census was 88. Findings included: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including schizophrenia, cerebral infarction, and vascular dementia. Review of a Facility Reported Incident (FRI) submitted on 05/15/24 revealed Resident #44 alleged an aide hit her on the hand while in the bathroom and told her she should be able to care for herself. Review of the FRI revealed the allegation was unsubstantiated because staff spoke with Resident #44 who stated the aide was a younger aide and she was really good and was not trying to be mean. Additionally, another staff member who entered the room during the alleged incident was interviewed and stated the incident did not occur. Interview on 08/31/24 at 1:25 P.M. with the Director of Nursing (DON) verified she did not have evidence of an investigation being completed. The DON stated there were no witness statements, additional staff or resident interviews. The DON stated the Administrator completed the investigation via phone but did not document the investigation and there was no staff re-education completed to ensure staff were aware of the abuse policy. Review of a policy titled Abuse (dated 08/01/18) revealed different types of incidents should be investigated, a staff member should be responsible for initial reporting, investigation, and reporting to proper authorities. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00156609.

Based on review of the posted COVID-19 signage regarding personal protective equipment (PPE), observations, review of the facility policies and procedures, staff interviews, and review of the Centers for Disease Control and Prevention guidelines, the facility failed to implement effective and recommended infection control practices including a system to ensure the availabilty and appropriate use of PPE by staff, a system to ensure staff were donning and doffing PPE when required, and ensuring staff were practicing proper hand hygiene to prevent the spread of COVID-19 in the building. This resulted in Immediate Jeopardy and the potential for serious negative health outcomes and/or life-threatening harm when 25 residents (#10, #15, #23, #30, #37, #40, #44, #48, #52, #53, #55, #58, #65, #68, #71, #76, #83, #86, #190, #193, #194, #195, #196, #200 and #240) and 13 staff (Licensed Practical Nurse [LPN] #210, #224, #239, #242, #256, #277, and #291, State tested Nursing Assistant [STNA] #240, #275 and #299, Housekeeper #233, and Certified Occupational Therapist Assistant [COTA] #208 and #288 tested positive for COVID-19 without the aforementioned systems in place to prevent the transmission and spread of COVID-19 to the vulnerable residents in the facility. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 91 residents at potential risk for the likelihood of serious life-threatening harm, negative health complications and/or death. The facility census was 91. On 11/07/23 at 11:36 A.M., the Administrator, Director of Nursing (DON), and Registered Nurse Infection Control Preventionist (RNICP) #235 were notified that Immediate Jeopardy began on 10/31/23 when Resident #65 and LPN #291 tested positive for COVID-19. The facility failed to implement appropriate and recommended infection control practices during a COVID-19 outbreak at the facility including inappropriate donning and doffing of PPE when entering and exiting a COVID-19 isolation room, improper hand hygiene, and ensuring PPE was readily available to staff. Upon entrance to the facility on [DATE], a total of 10 residents had tested positive with five additional positive residents that day within a six-day time frame since 10/31/23. The Immediate Jeopardy was removed on 11/10/23 when the facility implemented the following corrective actions: The facility continued to educate staff on the appropriate use of PPE to include what to wear, when to utilize it, and appropriate hygiene in all COVID-19 positive resident rooms to include Residents #10, #15, #23, #30, #37, #40, #44, #48, #53, #55, #71, #76, #86, and #196. Resident #58 no longer resided at the facility. On 11/07/23, RNICP #235 or designee, immediately started in-servicing all staff via the company messaging system to each staff member. Additionally, in-servicing will continue via in person in-service, telephone in-service, and an in-service will be an sent by email. Education during the in-service included all COVID-19 resident rooms will display a green magnet containing pictures and explanations of what PPE is required. All COVID-19 positive residents require the following: o Location of all appropriate PPE accessible to all staff either on the over the door hanger, central supply or the nurse ' s station. o Transmission based precautions include contact, droplet, and droplet/contact. o Mask N95 only (surgical mask is not acceptable) in COVID-19 positive rooms o Gown - Must be donned prior to entering a room and removed prior to exit in COVID-19 positive rooms o Gloves - Must be donned prior to entering a room and removed prior to exit. o Face Shield or Goggles - Must be donned prior to entering a room and either disposed of or cleaned utilizing a sanitizing wipe found on nurse ' s carts, central supply room, or nurse's stations. o Using hand sanitizer or washing hands prior to entering room and exiting the resident room. o Contact precautions - residents known or suspected to be infected with pathogens transmitted by contact. Employees should wash their hands before and after resident care. Gloves, gowns and dedicated disposable equipment should be used. In our building there will be a yellow magnet displayed outside the residents ' room. All items should be thrown away prior to exiting the room. o Droplet precautions (COVID-19) - patients known or suspected to be infected with pathogens transmitted by respiratory droplets (Coughing, sneezing, or talking). Employees should wash their hands before and after resident care. Mask, eye wear, gown, and gloves should be used. In our building there will be a green magnet displayed outside the residents ' room. All items should be thrown away prior to exiting the room. o Hand Hygiene Technique - Wet hands and wrists thoroughly o Apply soap to hands. o Lather all surfaces of wrists, hands, and fingers producing friction, for at least 20 seconds, keeping hands lower than the elbows and the fingertips down. o Clean fingernails by rubbing fingertips against palms of the opposite hand. o Rinse all surfaces of wrist, hands, and fingers, keeping hands lower than the elbows and the fingertips down. o Use clean dry paper towels/towels to dry all surfaces of fingers, hands, and wrists starting at the fingertips then disposes of paper towels/towels in the waste container in the room. o Using clean dry paper towels/towel to turn of facet then dispose of paper towels/towel into waste container in the room. o Do not touch inside of sink at any time. o Biohazard bags - are no longer required when bagging COVID-19 positive resident ' s trash or other items that need thrown away. Education was completed for all staff on 11/10/23. On 11/07/23, RNICP #235 or designee, began to audit employee adherence to PPE use in COVID-19 rooms at a minimum of five days a week. Five random COVID-19 positive residents (or remaining number if less than five) will be audited each day for five days every week during the outbreak. The IP or designee will be monitoring in the form of an audit to ensure all appropriate PPE is worn correctly by staff in COVID-19 positive rooms. This will include: N95, gown, gloves, faces shield or goggles. Both donning and doffing will be observed. On 11/07/23, RNICP #235 or designee, will be responsible for ensuring the PPE is readily available on each unit twice daily, covering each 12 hour shift, during outbreak. PPE will be readily available to staff either in the over the door hangers, the central supply room, or at the nurse ' s station. PPE will include N95, gown, gloves, faces shield or goggles. The facility will continue to test both residents and staff on Mondays and Thursdays for 14 days following the last positive staff or resident. The facility will also test any resident or staff member that exhibits symptoms to include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body ache, headache, new loss of taste or smell, sore throat and cold like symptoms. Residents will be monitored with a pulse oximeter and temperatures will be taken at least daily for each resident during the COVID-19 outbreak. Observation on 11/08/23 from 11:20 A.M. through 2:00 P.M. revealed the facility staff providing care for residents were wearing correct PPE and performing hand hygiene. All halls had PPE stocked on the doors for access to correct PPE for residents with COVID-19. Interviews on 11/08/23 with Housekeeper #254, LPN #290, LPN #291, and STNA #275 verified they had been educated on COVID-19 isolation precautions, the proper PPE to wear in the room of a resident who was positive for COVID-19, and hand hygiene. Although the Immediate Jeopardy was removed on 11/10/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of an email dated 11/01/23 documented the Administrator notified the local health department that a staff member and three residents were positive for COVID-19. The local health department recommended the following: COVID-19 Close Contact: Someone who was within six feet of an infected person (regardless of masks or personal protective equipment worn) for at least fifteen minutes (total/cumulative time) starting from two days or (48 hours) before the illness onset or (for asymptomatic clients), two days prior to positive specimen collection and through their isolation period. Testing was recommended immediately but no earlier than 24 hours after the exposure. If negative, then 48 hours after the first negative test. If negative, then 48 hours after the second negative test. This will typically be at day one, (where day of exposure was day zero), day three, and day five. If additional cases were identified or if contact tracing was not possible, strong consideration should be given to shifting to the broad-based approach if not already being performed. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every three to seven days until there were no new cases for 14 days. If antigen testing was used, more frequent testing (every three days), should be considered. Observations on 11/06/23 between 8:05 A.M. through 9:15 A.M. revealed residents diagnosed with COVID-19 were spread throughout the facility and the facility did not have a designated COVID-19 unit. During an observation on the 400 Hall on 11/06/23 at 10:09 A.M., STNA #218 came out of Resident #10 and Resident #15 ' s room, who were COVID-19 positive, with a shower chair and linen cart. STNA #218 left the shower chair and linen cart in the hall next to two Hoyer lifts without completing sanitation. During an interview on 11/06/23 at 10:10 A.M., STNA #218 verified she did not sanitize the shower chair or linen cart after being in a COVID-19 positive room and would get to it later. During an observation on the 400 Hall on 11/06/23 at 11:42 A.M., Maintenance Staff (MS) #297 was in Resident #10 and Resident #15 ' s room, who were COVID-19 positive. Maintenance Staff #297 was changing a smoke detector wearing no PPE and the room door was open. During an observation on the 400 Hall on 11/06/23 at 11:45 A.M., MS #211 was in Resident #37 and Resident #86 ' s room, who were COVID-19 positive. MS #211 was changing a smoke detector wearing no PPE and the room door was open. During an interview on 11/06/23 at 11:48 A.M., MS #211 stated he was not aware he was in a COVID-19 positive room, and if he had known he would have worn a gown, mask, and gloves. During an interview on 11/06/23 at 11:50 A.M., MS #297 verified he was not wearing any PPE in the COVID-19 positive room. During an observation of the 400 Hall on 11/06/23 at 1:14 P.M., the rooms of Residents #10, #15, #37, and #86, who were COVID-19 positive, did not have appropriate PPE supplies readily available for use prior to entering the room. There were surgical masks, gowns, and gloves available. No face shields, eye protection or N-95 masks were available. During an observation on 11/06/23 at 1:16 P.M., STNA #218 came out of Resident #30 ' s room, who was COVID-19 positive, wearing a face shield and surgical mask. STNA #218 did not sanitize the face shield or change the surgical mask prior to entering Resident #03, #80, and #141 ' s room, who were not in isolation. During an interview on 11/06/23 at 1:19 P.M., STNA #218 stated she did not change her surgical mask or sanitize her face shield after being in a COVID-19 positive room. During an observation of the 600 Hall on 11/06/23 at 1:38 P.M., Residents #53 and #65, who were COVID-19 positive, did not have appropriate PPE supplies readily available outside their room. There were surgical masks, gowns, and gloves available. No face shields, eye protection or N-95 masks were available. During an observation of the 400 Hall on 11/06/23 at 1:42 P.M., Residents #30, #23 and #55, who were COVID-19 positive, did not have appropriate PPE supplies readily available outside their room. There were surgical masks, gowns, and gloves available. No face shields, eye protection or N-95 masks were available. During an observation on 11/06/23 at 1:45 P.M., Housekeeping Aide (HA) #203 went into the room of Resident #44 to clean the room. HA #203 was wearing only a surgical mask and gloves. HA #203 came out of the room to get the sweeper with her surgical mask below her nose. During an interview on 11/06/23 at the time of observation, HA #203 did not think Resident #44 was positive with Covid-19. She thought it was the room across the hall. HA #203 verified she was not wearing eye protection, a gown or an N-95 mask prior to entering Resident #44 ' s room. During an observation of the 400 Hall on 11/06/23 at 1:48 P.M., STNA #218 went into Resident #30 ' s room, who was COVID-19 positive, wearing a gown, gloves, and a N-95 mask. She was not wearing eye protection. STNA #218 left the room wearing an N-95 mask. During an interview on 11/06/23 at 1:50 P.M., STNA #218 verified she did not wear eye protection, which was on the desk. STNA #218 stated she did not need to change her N-95 mask because most residents on the 400 Hall had COVID-19. During an observation on 11/06/23 at 1:59 P.M., MS #211 and MS #227 entered the room of Resident #71, who was COVID-19 positive. Both MS #211 and MS #227 were wearing surgical masks and did not perform hand hygiene. During an interview on 11/06/23 at 2:02 P.M., MS #227 verified he went into the COVID-19 positive room with only a surgical mask on. MS #211 stated he did not know Resident #71 was positive for COVID-19. MS #211 stated the other resident, who was moved out of the room, had COVID-19. MS #211 verified he did not have eye protection, gown, gloves, or an N-95 mask on when he entered Resident #71 ' s room. MS #211 stated he did not perform hand hygiene in or out of Resident #71 ' s room. During an observation of the 400 Hall on 11/07/23 at 8:50 A.M., STNA #263 answered the call light for Resident #10 and Resident #15 ' s room, who were COVID-19 positive. STNA #263 donned PPE prior to entering the room which included a gown, gloves, and surgical mask. STNA #263 put an N-95 mask over top of the surgical mask. She was not wearing eye protection. During an interview on 11/07/23 at 8:59 A.M., STNA #263 revealed when entering a COVID-19 positive room, she should don a gown, gloves, N-95 mask, and a face shield. STNA #263 reported there were no face shields/eyewear available. She said she doesn ' t work in central supply, so she didn ' t know about the availability of the face shield, so she did not put one on. STNA #263 also reported she wore a surgical mask under the N-95 mask when going into a COVID-19 positive room. During an interview on 11/07/23 at 9:25 A.M., RNICP #235 and the DON stated they test for COVID-19 routinely every Monday and Thursday. RNICP #235 stated they would test anytime if a resident had symptoms. RNICP #235 stated they leave it up to the nurse to perform vitals and nurse assessments if the resident was not feeling well. During an interview on 11/07/23 at 2:03 P.M., the DON and RNICP #235 verified the appropriate PPE supplies were not readily available outside the rooms of residents positive for COVID-19. Review of the facility policy titled COVID-19 Policy revealed the policy of the facility was to follow the guidance of the CDC and Ohio Department Health (ODH) for recommendations related to the treatment and testing of COVID-19. The objective of this policy was to protect our residents and staff while reducing the risk of spreading COVID-19 by abiding by the current ODH and CDC guidelines. Review of the facility policy titled Infection Control Extended Transmission Based and Isolation Precautions, dated 03/15/2019, revealed transmission-based precautions will be used for residents who are documented or suspected to have infections or communicable disease that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. Transmission based isolation precautions are to be used in addition to standard precautions. Review of the CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, May 8, 2023, revealed under Bullet #2 Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection Health Care Professionals (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The facility had 25 residents (#10, #15, #23, #30, #37, #40, #44, #48, #52, #53, #55, #58, #65, #68, #71, #76, #83, #86, #190, #193, #194, #195, #196, #200 and #240) and 13 staff (LPN #210, LPN #224, LPN #239, LPN #242, LPN #256, LPN #277, LPN #291, STNA #240, STNA #275, STNA #299, Housekeeper #233, COTA #208, and COTA #288 test positive for COVID-19. 44412

Based on medical record review, staff interviews, resident interview, review of the facility's fall investigation, and policy review, the facility failed to provide adequate staff assistance to prevent accidents. This resulted in actual harm when Resident #73 was receiving care by one staff, fell out of bed and fractured her left femur. Additionally, the facility failed to ensure Resident #2 received adequate staff assistance during care that resulted in an avoidable fall which resulted in no actual harm with the potential for more than minimal harm. This affected two (#2 and #73) out of four residents reviewed for falls. The facility census was 91. Findings include: 1. Review of the closed medical record for Resident #73 revealed she was admitted to the facility from 08/25/21 to 04/10/23, and from 04/14/23 through 10/30/23. Diagnoses included acute and chronic respiratory failure with hypercapnia, metabolic encephalopathy, peripheral vascular disease, generalized anxiety, pulmonary hypertension, fibromyalgia, hypothyroidism, and other specified disorders of bone density and structure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/02/23, revealed this resident had intact cognition. This resident was assessed to require extensive assistance of two staff for bed mobility and personal hygiene, extensive assistance of one staff for dressing and was totally dependent on two staff for transfer and toilet use. Review of the plan of care, initiated on 08/27/21, revealed the resident had an activities of daily living self-care performance deficit related to impaired balance. Interventions included extensive assistance to dependence by one to two staff to turn and reposition in bed. Review of the progress note dated 10/30/23 revealed Resident #73 was found lying on her left side on the floor. Resident #73 was assessed and no obvious injuries were noted, but the resident reported severe pain in her left knee. Further assessment revealed the resident had severe pain in her left leg. Resident #73 was not moved off the floor until emergency medical services arrived and transferred the resident to a stretcher. Review of the facility's fall investigation, dated 10/30/23, revealed Resident #73 reported My leg went over and I went down on my knees. My face hit on the way down. The investigation also revealed a new intervention of a wide/bariatric bed was in place and the resident was changed to two-person assistance for all bed mobility, including but not limited to turning and repositioning, incontinence care, and activities of daily living. The investigation stated Resident #73's morbid obesity contributed to her inability to maintain balance. The interdisciplinary team note at the conclusion of the investigation revealed Resident #73 was laying on her bed and receiving incontinence care when her left leg pulled her over and caused her to fall off the bed. Resident #73 was still holding onto the side rails and landed on her knees. The facility noted Resident #73 sustained a left femur fracture and educated all staff. Review of the hospital record dated 10/30/23 revealed Resident #73 had a closed bicondylar fracture of the left femur. Review of the facility counseling form for State tested Nursing Assistant (STNA) #216, dated 10/30/23, revealed STNA #216 was providing care to Resident #73 in bed and the resident rolled over too far, which caused her to fall out of bed. The form stated STNA #216 was counseled that the resident needed two-person assistance during care due to her size and bed mobility. Interview on 11/13/23 at 10:40 A.M. with STNA #216 revealed Resident #73's level of assistance fluctuated depending on how well she was moving. STNA #216 stated Resident #73 was moving well on the date of the incident. STNA #216 reported she was providing incontinence care for Resident #73 while she was in bed and lying on her side. STNA #216 expressed it was time for the resident to roll back and her feet went over the bed, which caused her to fall on her knees out of bed while still holding onto the handrails. STNA #216 stated Resident #73 had already let go and was on the floor by the time she made it around the bed. She yelled for help and ran into the hall to find assistance. Interview on 11/13/23 at 3:50 P.M. with the Director of Nursing (DON) revealed it was a gray area when deciding if a resident needed the assistance of one or two staff. The DON stated Resident #73 could move around in bed by herself, but if she needed help to roll then they would use two staff. Interview on 11/14/23 at 1:15 P.M. with the DON revealed Resident #73 could turn herself and turn to her side. The DON stated Resident #73 had a wider mattress but not a bariatric bed at the time of the incident. The DON expressed the aide is unable to assess the number of staff needed for resident assistance. Review of the facility policy titled Falls Prevention, revised 01/20/16, revealed it was the policy of the facility to have a system in place to prevent initial and/or subsequent falls. 2. Review of the medical record for Resident #2 revealed she was admitted [DATE]. Diagnoses included Schmorl's node of lumbar region, cardiomegaly, insomnia, chronic obstructive pulmonary disease, anxiety disorder, plantar fascial fibromatosis, atherosclerotic heart disease, epilepsy, malignant neoplasm of colon, poly osteoarthritis, metabolic encephalopathy, congestive heart failure, type 2 diabetes, hypertension, morbid obesity, sleep apnea, peripheral vascular disease, anemia, chronic kidney disease, and dementia. Review of the MDS assessments, dated 06/09/23 and 08/01/23, revealed the resident had moderate cognitive impairment. She was dependent for completing activities of daily living (ADL's). Review of her Morse Fall Scale dated 06/01/23 revealed she had no previous falls and knew her own limits, but had an impaired gait. Review of her Care Plan dated 10/24/23 revealed she had a self-care performance deficit related to impaired balance and was at risk for falls related to balance problems, incontinence status and the use of psychoactive medication. Review of the progress notes for Resident #2 dated 06/23/23 revealed Resident #2 was getting a bed bath from an aide when she rolled, fell out of bed and landed on her right side on the floor. She was sent to the emergency room (ER) for further evaluation. Review of the hospital records dated 06/23/23 revealed a computed tomography (CT) scan of Resident #2's head and spine revealed no acute fractures or obvious traumatic injuries. Review of the fall investigation dated 06/23/23 revealed Resident #2 was getting a bed bath by an aide when she rolled and fell out of bed on her right side to the floor. Resident #2 was sent to the ER for further evaluation as she was slow to respond to verbal response and it was unclear if she hit her head. No injuries were observed at time of the incident or post incident. The Interdisciplinary Team Note (IDT) note included with the investigation revealed Resident #2 remained on the floor until the squad arrived to transport her to the ER for evaluation. She returned from the hospital without any known injuries. During an interview on 11/13/23 at 12:10 P.M. Resident #2 verified one staff member was assisting her with her bath when she fell . During an interview on 11/14/23 at 1:26 P.M. with the Director of Nursing (DON) she reported at the time of the fall Resident #2 had a geriatric bed, was normally able to assist with care, and normally was able to have one staff person assist with her care. She stated on 06/23/23 when receiving her bed bath one of Resident #2's legs went over the other while she was laying on her side. This caused her to roll over out of the bed. The DON reported Resident #2 was sent directly to the ER for evaluation with no injuries noted. During an interview on 11/14/23 at 2:38 P.M. with STNA #293 she reported she was the only staff assisting Resident #2 with her bed bath. She stated she had finished the bed bath, Resident #2 was still lying on her side, the resident coughed which threw her body forward, and she landed on the floor on her right side. STNA #293 reported Resident #2 stated she was fine but was sent to the emergency room for evaluation as a precaution and was found to have no injuries.

Review of Payroll Based Journal , facility documents, and interview with staff, the facility failed to submit the Payroll Based Journal report in first quarter of 2023. The facility censu was 91. Findings include: Review of the Payroll Based Journal revealed the facilty had not submitted their report for the first quarter of 2023. Interview on 11/14/23 at 2:50 P.M. with Data Service (DS) #266 stated he did submit the Payroll Based Journal report on the first quarter. DS #266 stated he was not sure why it did not go through. Review of an email date 05/17/23 revealed Data Service (DS) #266 had reached out to Centers for Medicare and Medicaid Services (CMS) to fix the data that was that not submitted on 02/09/23. DS #266 stated he was stumped on why it was not submitted with success.

Based on medical record review, staff interviews, and policy review, the facility failed to ensure a resident's medications were administered without error. This affected one resident (#43) of five reviewed for unnecessary medications. The facility census was 91. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included cerebral infarction, left bundle branch block, major depressive disorder, and functional urinary incontinence. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition. Review of the medication error report dated 10/23/23 revealed Resident #43 was administered Lasix 40 milligrams (mg), Coreg 6.25 mg, Tylenol 650 mg, and Colace 100 mg. Licensed Practical Nurse (LPN) #293 reported she confused two residents (#43 and #74). Resident #43 noticed a pill that was different from her usual medications. LPN #293 told Resident #43 that she would check and see when the order was written and what it was. Resident #43 had already consumed the pills at that time. On-call provider was notified at 6:15 P.M. and provided instructions to LPN #293 to monitor blood pressure for 24 hours. Resident #43 was also aware that her output for the night will increase. An order was placed to monitor Resident #43's blood pressure every four hours for 24 hours. Review of the physician order dated 10/23/23 revealed Resident #43 was ordered to have her blood pressure monitored every four hours for 24 hours. Interview on 11/14/23 at 1:35 P.M. with the Director of Nursing (DON) revealed Resident #43 was given Resident #74's medication. The DON reported no adverse reactions occurred. The physician, family, and the resident were notified. Orders were given to monitor blood pressure every four hours for 24 hours. The DON reported LPN #293 was educated and instructed to complete an incident report. Review of the facility policy titled Physician orders, dated 08/18/18 revealed all medications administered to the resident must be ordered by the resident's attending physician. This deficiency is non-compliance discovered during the investigation for Complaint Number OH00148158.

Based on medical record review, observations, and staff interviews, the facility failed to properly date oxygen tubing according to physician orders. This affected one (#20) out of 19 residents reviewed for oxygen therapy. The facility census was 91. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, pulmonary hypertension, major depressive disorder, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 08/23/23, revealed Resident #20 had intact cognition. Review of the physician order dated 09/13/22 revealed Resident #20 was ordered to remove filter from oxygen concentrator, clean and replace every week. Review of the physician order dated 09/13/22 revealed Resident #20 was ordered to change hand held nebulizer tubing monthly and date and initial tubing. Review of the physician order dated 03/13/23 revealed Resident #20 was ordered oxygen at two to three liters via nasal cannula to keep oxygen saturation above 90%. Observation on 11/13/23 at 1:20 P.M. revealed Resident #20 was wearing two liters of oxygen via nasal cannula with no date or initials labeled on the oxygen tubing. Interview on 11/13/23 with the Director of Nursing (DON) verified Resident #20's oxygen tubing was not dated or labeled since the tubing was changed.

Based on record review, staff interview, and policy review, the facility failed to ensure weights were obtained per physician order for one resident (#84) and failed to follow physician orders to notify the physician of weight changes within prescribed parameters for one (#47) resident. This affected two (#47 and #84) out of 21 residents reviewed for physician orders. The facility census was 91. Findings include: 1. Review of the medical record for Resident #84 revealed she was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, supraventricular tachycardia, localized edema, hyperkalemia, heart failure, hypomagnesemia, anxiety disorder, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/06/23, revealed this resident had intact cognition. This resident was assessed to require limited assistance for transfers. Review of the physician orders revealed an order dated 10/10/23 for a daily weight. Review of the Medication Administration Record (MAR) from 10/01/23 through 10/31/23 revealed daily weights were not obtained on 10/13/23 through 10/15/23, 10/17/23, 10/21/23 through 10/22/23, 10/24/23 through 10/26/23, 10/28/23, and 10/30/23. Interview on 11/14/23 at 4:58 P.M. with Unit Manager Licensed Practical Nurse (LPN) #238 confirmed the order was changed to daily weight monitoring for Resident #84. Unit Manager LPN #238 verified there was no documentation of the daily weights on the above dates. Review of the facility policy titled Weight Protocol, 08/20/18, revealed weights would be completed based on clinical judgement and/or physician order. 2. Review of medical record for Resident #47 revealed an admitted [DATE]. Diagnosis included Alzheimer's disease, myocardial infarction, chronic obstructive pulmonary disease, cardiac pacemaker, and atherosclerotic heart disease. Review of the Minimum Data Set assessment, dated 10/15/23, revealed Resident #47 was cognitively intact. Review of physician order dated 09/20/23 for Resident #47 revealed an order for daily weight to be obtained. Notify provider of gain greater than three pounds in a day or five pounds in a week. Review of weights dated 10/15/23 was 231.2 pounds, 10/16/23 was 234.6 pounds, 10/28/23 was 228.6 pounds, and 10/29/23 was 232.4 pounds. There was no evidence the phsician was notified of the weight changes greater than three pounds in a day. Interview on 11/14/23 at 3:55 P.M. with Director of Nursing (DON) verified on 10/16/23 the resident had a 3.4-pound increase,and 10/29/23 there was a 3.8-pound increase. The DON verified no one notified the physician of the weight gain.

Based on record review, staff interview, and policy review, the facility failed to ensure dependent residents received assistance with bathing. This affected two (#78 and #84) out of three residents reviewed for activities of daily living. The facility census was 91. Findings include: 1. Review of the closed medical record for Resident (FR) #78 revealed the following admissions to the facility: 05/23/22 to 06/10/22, 06/21/22 to 12/03/22, 12/03/22 to 06/26/23, 06/30/23 to 07/05/23, 07/15/23 to 07/19/23, 07/22/23 to 07/23/23, 07/25/23 to 10/02/23, 10/04/23 to 10/31/23. Diagnoses included chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, major depressive disorder, generalized anxiety disorder, atherosclerotic heart disease, heart failure, metabolic encephalopathy, cerebral infarction, and emphysema. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 07/31/23, revealed this resident had intact cognition. This resident was assessed to be dependent on staff for bathing. Review of the plan of care initiated on 06/10/22 revealed the resident had an activities of daily living self-care performance deficit related to impaired balance. Interventions included provide sponge bath when a full bath or shower cannot be tolerated. Review of the shower documentation for Resident #78 revealed no documentation related to bathing provided from 09/01/23 through 09/20/23. Interview on 11/14/23 at 11:21 A.M. with Unit Manager Licensed Practical Nurse (LPN) #238 confirmed there was no bathing documentation for Resident #78 from 09/01/23 through 09/20/23. 2. Review of the medical record for Resident #84 revealed she was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, supraventricular tachycardia, localized edema, hyperkalemia, heart failure, hypomagnesemia, anxiety disorder, and hyperlipidemia. Review of the quarterly MDS 3.0 assessment, dated 08/06/23, revealed this resident had intact cognition. This resident was assessed to require one person physical assistance for bathing. Review of the plan of care initiated on 06/15/23 revealed the resident had an activities of daily living self-care performance deficit related to impaired balance, limited mobility, and pain. Interventions included provide a sponge bath when a full bath or shower cannot be tolerated. Interview on 11/07/23 at 2:34 P.M. with Resident #84 revealed she had not received scheduled showers. Review of shower documentation for Resident #84 on 11/14/23 revealed there was no showers documented since 11/02/23. Interview on 11/14/23 at 11:21 A.M. with Unit Manager LPN #238 confirmed there was no shower documentation for Resident #84 since 11/02/23. Review of the facility policy titled Resident Bathing, revised 05/21/14, revealed all residents had the right to choose when and how often they are bathed and/or showered, and all residents would be scheduled for a minimum of two showers per week for general cleanliness and proper hygiene purposes. This deficiency represents non-compliance investigated under Master Complaint Number OH00148336 and Complaint Number OH00148158.

Based on review of the medical record, staff interviews, and policy review, the facility failed to complete care conferences for two residents (#6, #39) and failed to update the care plan for one (#84) of 21 residents reviewed for care conferences. The facility census was 91. Findings include: 1. Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, chronic obstructive pulmonary disease (COPD), generalized anxiety disorder, and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 08/30/23, revealed this resident had intact cognition. Review of the medical record for Resident #39 revealed social services reached out to Resident #39's sister, which was his Power of Attorney (POA), through email and voicemail in attempt to schedule a care conference on 11/04/22, 01/09/23, 04/07/23, 06/13/23, and 09/07/23. Review of the medical record for Resident #39 revealed no care conferences had been completed in the last 12 months. Interview on 11/14/23 at 1:42 P.M. with the Director of Nursing (DON) verified social services had not completed any care conferences with Resident #39, who had intact cognition, for the last 12 months. 2. Review of the medical record for Resident #84 revealed she was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, supraventricular tachycardia, localized edema, hyperkalemia, heart failure, hypomagnesemia, anxiety disorder, and hyperlipidemia. Review of the quarterly MDS 3.0 assessment, dated 08/06/23, revealed this resident had intact cognition. Review of the physician orders revealed an order dated 06/01/23 to obtain weight every Monday, Wednesday, and Friday, which was discontinued on 10/10/23 when a new order was placed for a daily weight. Review of the plan of care initiated on 08/20/23 revealed the resident had congestive heart failure. Interventions included weight monitoring on Monday, Wednesday, and Friday. Interview on 11/15/23 at 11:17 A.M. with the DON confirmed the care plan was not updated to reflect change to daily weight monitoring. 3. Review of the medical record for Resident #6 revealed she was admitted to the facility on [DATE]. Diagnoses included heart failure, anemia, unspecified protein-calorie malnutrition, morbid (severe) obesity due to excess calories, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, acute kidney failure, hypothyroidism, hyperkalemia, anxiety disorder, and major depressive disorder. Review of the quarterly MDS 3.0 assessment, dated 08/31/23, revealed this resident had intact cognition. Interview on 11/07/23 at 2:26 P.M. with Resident #6 revealed she had not had a recent care conference with facility staff. Review of the progress notes from 08/01/23 through 11/13/23 revealed no documentation related to care conferences. Interview on 11/14/23 at 2:48 P.M. with the DON confirmed no documentation related to care conferences conducted for Resident #6. Review of the facility policy titled Care Conferences, revised 2019, revealed care conferences should be held at least quarterly after initial care conference upon admission, with a change in condition, or upon request.

Based on review of the medical record, interviews, and policy review, the facility failed to complete a comprehensive care plan. This affected three (#15, #20, and #84) out of 21 residents reviewed for care plans. The facility census was 91. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus (DM II), COVID-19, chronic kidney disease, stage three, morbid obese, and hypertension. Review of the admission Morse fall risk assessment dated [DATE] revealed Resident #15 was at moderate risk for falls Review of the medical chart revealed Resident #15 had falls on 10/30/23 and 10/31/23. No care plan was initiated to identify the residnet to be at risk for falls and no intervention were put into place to prevent further falls. Interview on 11/14/23 at 10:41 A.M. with Registered Nurse Infection Control Preventionist (RNICP) #235 verified there was no care plan created for Resident #15 related to falls. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, pulmonary hypertension, major depressive disorder, and congestive heart failure. Review of the physician order dated 09/13/22 revealed Resident #20 was ordered to remove filter from oxygen concentrator, clean and replace every week. Review of the physician order dated 09/13/22 revealed Resident #20 was ordered to change hand held nebulizer tubing monthly and date and initial tubing. Review of the physician order dated 03/13/23 revealed Resident #20 was ordered oxygen at 2-3 liters via nasal cannula to keep oxygen saturation above 90%. Review of the medical chart revealed Resident #20 did not have a care plan initiated for oxygen therapy. Interview on 11/14/23 at 10:44 A.M. with RNCIP #235 verified Resident #20 was currently receiving oxygen therapy but did not have a care plan for oxygen therapy. 3. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, supraventricular tachycardia, localized edema, hyperkalemia, heart failure, hypomagnesemia, anxiety disorder, and hyperlipidemia. Review of the active physician orders revealed an order for Eliquis oral tablet 5 milligrams (mg) to be given by mouth two times a day related to heart failure. Review of the plan of care revealed no care plan related to anticoagulant use. Interview on 11/15/23 at 11:17 A.M. with the Director of Nursing (DON) confirmed there was no care plan for anticoagulant use. Review of the facility policy titled Care Planning Interdisciplinary Team, reviewed 08/16/18, revealed the care planning/interdisciplinary team would develop a comprehensive care plan for each resident.

Based on medical record review, resident and staff interview, and review of facility documents for residents rights, the facility failed to honor the choice to not be gotten out of bed to be weighed prior to getting up for the day for one resident (#47) out of 21 residents reviewed for choices. The facility census was 91. Findings Include: Review of medical record for Resident #47 revealed an admitted [DATE]. Diagnosis included Alzheimer's disease, myocardial infarction, chronic obstructive pulmonary disease, cardiac pacemaker, and atherosclerotic heart disease. Review of the Minimum Data Set assessment, dated 10/15/23, revealed Resident #47 was cognitively intact. Resident #47 required two-person physical assist for transfers. Review of plan of care dated 01/27/23 revealed Resident #47 had fluid overload or potential fluid volume overload related to chronic obstructive pulmonary disease, bilateral edema, and dementia. Interventions inncluded monitor fluid overload, notify changes in edema and weight as needed. Review of physician order dated 09/20/23 for Resident #47 revealed an order for daily weight obtained. Notify provider of gain greater than three pounds in a day or five pounds in a week. The time to obtain the weight was listed as 6:00 A.M. Review of progress notes revealed Resident #47 refused morning weights on 09/26/23, 11/03/23, and 11/13/23, with the nurse practitioner notified of the refusal. Review of progress note dated 09/26/23 at 6:20 A.M., documented by Licensed Practical Nurse (LPN) #215, revealed Patient #47 refused daily weight stating It was too early. Review of progress note dated 11/03/23, documented by LPN #226, revealed Resident #47 refused to get up for morning weight. Resident #47 stated she wanted to wait until she got up for the day. Review of medical record for weights revealed the weights that were not obtained on 09/24/23, 09/25/23, 09/29/23, 10/02/23, 10/03/23, 10/04/23, 10/05/23, 10/06/23, 10/07/23, 10/08/23, 10/09/23, 10/13/23, 10/14/23, 10/17/23, 10/18/23, 11/11/23, and 11/12/23. Interview on 11/08/23 at 10:00 A.M. with Resident #47 revealed she was tired of being woke up early in the morning around 5:00 A.M. Resident #47 wanted to be weighed when she got up for the day. Interview on 11/13/23 at 11:00 A.M. with LPN #230 revealed she knew Resident #47 at times refuse her weights. LPN #230 stated she could have the physician change the time of the physician order. Review of the facility document titled The Resident Rights revealed residents had the right to have staff assist in rising and retiring in accordance with their requests.

Based on record reviews, observations, resident interview, staff interviews, review of policies, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to pressure ulcer prevention interventions were in place as ordered by the physician; failed to ensure wound care was performed in a clean and sanitary manner and assess skin regularly for a resident at risk for pressure sores. This affected two (#22 and #90) of three residents reviewed for pressure ulcers. The facility census was 84. Findings include: 1. Review of the medical record for Resident #22 revealed an admitted [DATE], with diagnoses including metabolic encephalopathy, bipolar disorder, malignant neoplasm of left breast, acute kidney failure (AKF), osteoarthritis, and HTN. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 02/28/23 revealed the resident was cognitively intact and required extensive assistance of one to two staff with ADLs. Resident #22 was coded for the presence of an unstageable pressure ulcer which was present upon admission to the facility. Review of the pressure ulcer risk assessment for Resident #22 dated 02/24/23 revealed resident was at risk for the development of pressure ulcers. Review of the care plan for Resident #22 dated 03/07/23 revealed resident had unstageable pressure ulcers to bilateral heels due to decreased mobility and protein malnutrition. Interventions included the following: administer meds as ordered, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the physician, offer frequent repositioning, follow facility policies/protocols for the prevention/treatment of skin breakdown, inform the resident/family/caregivers of any new area of skin breakdown, keep legs up on pillow to float heels off the bed, monitor nutritional status, serve diet as ordered, monitor intake and record, pressure relieving/reducing device on bed/chair. Review of March 2023 monthly physician orders for Resident #22 revealed orders dated 02/24/23, for Prevalon (pressure relief) boots while in bed to bilateral feet and pillows under bilateral lower extremities while in bed to relieve pressure to heels. An order dated 03/14/23, to cleanse pressure ulcer to the right heel with normal saline (NS), pat dry, apply Xeroform gauze and cover with island dressing once daily and as needed. Review of the March 2023, Treatment Administration Record (TAR) for Resident #22 revealed the Prevalon boots were initialed off as applied to resident's feet and the order to float heels was initialed off as completed. Observation on 03/20/23 at 11:16 A.M., of Resident #22 revealed resident was not wearing Prevalon boots and her heels were not floating. Resident #22's heels were resting directly on a pillow. Interview on 03/20/23 at 11:18 A.M., of LPN #150 confirmed Resident #22 was admitted with an unstageable pressure ulcer to the heel, had orders to wear Prevalon boots while in bed and to have her heels floated. LPN #150 further confirmed Resident #22 was not wearing Prevalon boots and there were no boots in her room. LPN #150 confirmed the resident's heels were not floated. Observation on 03/20/23 at 11:27 A.M., of LPN #150 revealed the nurse placed a brand-new pair of Prevalon boots on Resident #22's feet. Resident #22 tolerated the application and said the boots fit appropriately. Interview on 03/20/23 at 11:27 A.M., of LPN #150 confirmed she requested a new pair of boots from central supply to place on the resident because she wanted to comply with the physician's order. Interview on 03/20/23 at 11:31 A.M., of Resident #22 confirmed today was the first time she recalled anyone from the facility applying boots to her foot. Interview on 03/20/23 at 11:40 A.M., with State tested Nursing Assistant (STNA) #175 confirmed she was Resident #22's nurse aide and she did not think the resident had orders for Prevalon boots. STNA #175 confirmed she propped the resident's feet directly on pillows earlier in the morning. Observation of wound care for Resident #22 on 03/20/23 at 11:45 A.M., per LPN #150 revealed the nurse donned gloves in hallway and was not observed washing or sanitizing hands prior to donning gloves. LPN #150 then retrieved wound care supplies from treatment cart while wearing the same gloves. LPN #150 entered the resident's room and prepared for the dressing change, still wearing the same gloves. LPN #150 removed the old dressing which had a golf ball sized amount of reddish-brown exudate on dressing. Resident #22 had a quarter sized open area to her right heel with a red wound bed and moderate amount of serosanguinous drainage noted. LPN #150 cleansed the ulcer with normal saline and gauze and patted the wound bed dry with gauze. LPN #150 applied Xeroform gauze and a new dressing. LPN #150 was wearing the same gloves she had donned in the hallway throughout the dressing change. Interview on 03/20/23 at 12:10 P.M., with LPN #150 confirmed she had washed her hands at approximately 11:30 A.M., in another resident's room. LPN #150 confirmed she donned gloves in the hallway at approximately 11:45 A.M. and wore the same gloves throughout gathering supplies for the dressing change for Resident #22 and throughout the dressing change for Resident #22. Interview on 03/20/23 at 9:20 A.M., with LPN #100 confirmed she had received the physician's order for Resident #22 upon resident's admission on 02/24/23 for resident to wear Prevalon boots in bed and to float heels. LPN #100 confirmed these measures were put in place because resident was admitted with unstageable pressure ulcers to her heels. LPN #100 stated that an order to float heels included the heels being suspended in air, so that there is no pressure on them at all, and heels laying directly on a pillow could not be determined to be floated. LPN #100 stated the following steps should be taken regarding hand hygiene during a clean dressing change: wash hands in resident's room prior to starting the procedure, don gloves, remove old dressing, doff gloves, wash hands, don clean gloves, cleanse wound per order, doff gloves, wash hands, don clean gloves, apply wound treatment and cover with dressing, date and initial the dressing, doff gloves, wash hands. Review of the undated policy titled Prevention of Pressure Ulcers revealed the facility would provide preventative measures to prevent development of pressure ulcers based on resident's identified risk factors. Review of the undated policy titled Infection Control-Standard Precautions revealed staff should wash hands after touching blood, body fluids, secretions, or excretions, and contaminated items, whether gloves are worn. Staff should put on clean gloves just before touching mucous membranes and nonintact skin. Staff should remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Review of the NPUAP guidelines dated 2014 page 115 revealed ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. 2. Review of the medical record for Resident #90 revealed an admitted [DATE], with diagnoses including schizoaffective disorder, diabetes mellitus (DM), dementia with behavioral disturbance, post-traumatic stress disorder (PTSD), peripheral neuropathy, spinal stenosis, protein calorie malnutrition, anxiety disorder, hypertension (HTN), bipolar disorder and a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #90 dated 02/13/23 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Resident was coded for the presence of an unhealed stage III pressure ulcer which was not present upon admission. Review of the pressure ulcer risk assessment for Resident #90 dated 09/07/22 revealed resident was at moderate risk for the development of pressure ulcers. Review of the care plan for Resident #90 dated 10/18/13 revealed resident was at risk for development of pressure ulcers related to incontinence, decreased mobility, and weight loss. Resident had a history of DM which increased her risk for skin breakdown. Interventions included the following: assist resident with changing of soiled pad as needed, encourage adequate nutritional and fluid intake daily, keep skin clean/dry and bed linens clean, dry and as wrinkle-free as possible, monitor bony prominences during care provision for signs and symptoms of skin breakdown including changes in skin color/temp of skin, complaints of tenderness or burning, uneven color appearance, discuss any areas of concern with physician, pressure reduction mattress to bed. Review of the weekly skin check for Resident #90 dated 10/17/22 revealed there were no skin issues noted. Review of the next weekly skin check for Resident #90 dated 11/07/22 revealed resident had a pressure ulcer noted to her sacrum. The note referred the reader to the wound note per the wound Nurse Practitioner (NP) #1, dated 11/08/22, for more details. There were no skin checks dated 10/18/22 to 11/06/22. Review of the nurse progress notes for Resident #90 dated 10/18/22 to 11/06/22 revealed the notes did not include documentation regarding the resident's skin. Review of the wound NP #1 note for Resident #90, dated 11/08/22, revealed resident presented with a stage III pressure ulcer to her sacrum which measured 0.5 centimeters (cm) in length by 0.6 cm in width by 0.1 cm in depth. The wound bed had 25 percent (%) granulation tissue and 75% slough. Interview on 03/21/23 at 9:20 A.M., with Licensed Practical Nurse (LPN) #100 confirmed Resident #90's skin should be assessed weekly by a licensed nurse and documented in the electronic medical record. LPN #100 confirmed Resident #90 had a weekly skin check on 10/17/22 which indicated resident had no skin issues. Resident #90 did not have a skin check from 10/18/22 to 11/06/22. LPN #100 confirmed when staff checked Resident #90's skin again on 11/07/22 resident presented with a stage III pressure ulcer to her sacrum which was 75 % slough to the wound bed. LPN #100 confirmed Resident #90's progress notes dated 10/18/22 to 11/06/22 did not include documentation regarding the resident's skin. Review of the undated policy titled Prevention of Pressure Ulcers revealed nursing staff will be trained to assess residents for risks of developing pressure ulcers. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Numbers OH00140607.

Based on review of facility documents and staff interview, the facility failed to ensure there was a Registered Nurse (RN) physically present in the facility for at least eight consecutive hours daily. This had the potential to affect 84 of 84 residents residing in the facility. The census was 84. Findings include: Review of facility staffing schedule dated 03/19/23, revealed an RN was not scheduled on this date. Interview on 03/20/23 at 2:04 P.M., with the Administrator confirmed the facility did not have an RN working on 03/19/23. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, record review, review of the third shift get up list, and staff interview, the facility failed to ensure a resident was woken up and prepared for the day based on their preference. This affected one resident (#64) out of 12 residents the facility identified as being woken up and assisted on third shift. The facility census was 82. Findings include: Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #64's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #64 required extensive assistance with bed mobility, dressing, eating, personal hygiene, transfers and toilet use. Observation on 08/16/22 at 5:00 A.M. revealed Resident #64 was up in her wheelchair in the east common area. Interview with Resident #64 on 08/16/22 at 5:00 A.M., revealed Resident #64 preferred not to get up before 5:00 A.M. Resident #64 stated she had told the staff she did not want to get up until 8:00 A.M. but they continued to get her up before 5:00 A.M. Interview with Registered Nurse (RN) #03 on 08/16/22 at 5:00 A.M., revealed the facility started to get residents up before 5:00 A.M. because the facility had twelve resident rooms to get up before 7:00 A.M. RN #03 stated she was not sure if the residents that got up prior to 5:00 A.M. preferred to get up that early. RN #03 verified Resident #64 was gotten up prior to 5:00 A.M. Review of the facility's get up list dated 07/29/22 revealed the facility had 12 rooms to get up on night shift at the facility. Resident #64's room number was listed on the night shift get up list. This deficiency substantiates Complaint Number OH 140.

Based on observation, staff interview, and policy review, the facility failed to half consumed meal trays were removed from the common area in a timely manner. This affected two residents (#64 and #76) out of 12 residents reviewed who the facility identified as being third shift get ups. The facility census was 82. Findings include: Observation on 08/16/22 at 5:00 A.M. revealed Resident #64 and Resident #75 was up in their wheelchairs in the east common area. There were five half eaten dinner trays from the night before sitting next to the residents on two tables in the east common area. Interview with Licensed Practical Nurse (LPN) #801 on 08/16/22 at 5:07 A.M., verified there were five half eaten dinner trays from the night before sitting next to Resident #64 and Resident #75 on two tables in the eat common area. Review of the facility policy titled Meal Time Safety undated revealed all trays are to be retrieved within one hour of placement. Removing a tray within one hour reduces the risk of falls and infections. Food should not be left out at room temperature for more than one hour.

Based on record review and interview, the facility failed to report an incident of misappropriation of narcotics to the State Agency. This had the potential to affect Residents #5, #9, #12, #35, #41, #52, #65, and #67. The facility census was 82. Findings include: Review of the Self-Reported Incidents for the facility revealed the misappropriation of narcotics on 06/25/21 was not reported to the State Agency. Review of the undated facility audit of narcotic medications revealed multiple single doses of resident narcotics, [MEDICATION(S)] 50 milligrams (mg), half tablet, [MEDICATION(S)] 15 mg capsule, [MEDICATION(S)] 50 mg tablet, [MEDICATION(S)]/acetaminophen (APAP) 7.5-325 mg tablet, [MEDICATION(S)] 50 mg tablet, [MEDICATION(S)] 0.25 mg tablet, [MEDICATION(S)] 0.5 mg two tablets, [MEDICATION(S)] 15 mg tablet, Oxycodone/APAP 7.5-325 mg tablet, Oxycodone/APAP 7.5-325 mg two tablets from Residents # 5, #9, 12, 35, 41, 52, 65, and #67. Interview on 10/14/21 at 11:31 A.M. with the Administrator revealed the missing medications were replaced by the facility and no residents had been affected. Interview on 11/02/21 at 11:51 A.M. with the Administrator confirmed the facility did not have a copy of an SRI in the facility investigation file or evidence of reporting the misappropriation of narcotic medications. Interview on 11/02/21 at 11:55 A.M. with Licensed Practical Nurse (LPN) #100 revealed she was completing all the reporting paperwork for the misappropriation of narcotics that occurred on 06/25/21 per instructions. LPN #100 stated no electronic reports were filed with the Ohio Department of Health. This deficiency substantiated Complaint Number OH 323.

Based on medical record review, staff interview, and review of the facility investigation, the facility failed to ensure a wheelchair was properly equipped with footrests for the resident to use prior to transporting the resident to an appointment. This resulted in actual harm when staff were assisting Resident #88 with transportation in a wheelchair without footrests, the resident put her foot down during the transportation, twisted her right ankle and subsequently sustained a non-displaced right ankle fracture requiring casting. This affected one (#88) out of three residents reviewed for accidents. Facility census was 84. Findings include: Review of the medical record for Resident #88 revealed an admitted [DATE] and a discharge date from the facility on 07/21/21. Diagnoses included unspecified dementia without behavioral disturbance. Review of Minimum Data Set (MDS) assessment for Resident #88 dated 06/06/21 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with Activities of Daily Living (ADL's). Review of a nurse progress note for Resident #88 dated 06/02/21 per Registered Nurse (RN) #400 revealed the nurse was helping the resident and resident's representative meet transportation staff at the front of facility for the resident to go to the hospital for an appointment. When writer was wheeling resident to the front of the building, the resident put her feet down and twisted her right ankle. Resident's representative rode on the transport vehicle to the outside appointment with the resident and reported when they arrived back at the facility following the appointment that the resident kept putting her feet down while being wheeled throughout transportation to the hospital and getting imaging done. The resident's representative then reported the resident was complaining of pain to her lower extremities. Review of a nurse progress note for Resident #88 dated 06/02/21 timed at 8:45 P.M. revealed the resident was noted with increased pain to right ankle, was unable to perform range of motion due to increased pain and an order for an x-ray to the right ankle was obtained. Review of the nurse progress note for Resident #88 dated 06/03/21 timed at 12:07 A.M. revealed x-ray results showed a right ankle fracture. Resident's representative was notified of the fracture and requested resident be sent to the hospital for evaluation in the morning. Review of the nurse progress note for Resident #88 dated 06/03/21 timed at 9:15 A.M. revealed the resident was sent to the hospital for evaluation of right ankle fracture and right ankle had significant swelling at this time. Review of hospital notes dated 06/03/21 revealed the resident had x-rays taken at the hospital which confirmed right ankle fracture. Further review of hospital notes revealed hospital physician recommended the resident should be non-weightbearing of the right lower extremity at all times and should follow-up with an orthopedic doctor. Review of notes revealed the hospital staff applied a plaster cast to resident's fractured right lower extremity. Review of the nurse progress note for Resident #88 dated 06/03/21 timed at 5:51 P.M. revealed the resident returned to the facility with instructions to be non-weight bearing to right lower extremity and to follow-up with orthopedic surgeon. Review of the care plan for Resident #88 dated 06/03/21 revealed the resident had limited physical mobility related cerebral infarction and [CONDITION(S)]. Foot pedals were removed from the resident's wheelchair for increased independence with locomotion and resident used her feet to propel self in wheelchair. Resident was observed to put her feet down without warning. Interventions included facility would ensure wheelchair pedals should be down during transportation in and out of facility for appointment. Review of the facility investigation regarding the fracture to Resident #88's right ankle dated 06/03/21 revealed staff interview with RN #400 reported that while resident was being propelled in wheelchair on 06/02/21 to go to an appointment, the resident planted her feet down and her right ankle was twisted. Resident's representative was present at this time and resident did not indicate that incident caused pain or warranted assessment. Resident's representative did not seem concerned with the incident or note any pain to resident at that time. Resident #88 then left the facility with transport staff and representative. Resident's representative reported to facility upon return from the appointment that resident had continued to plant feet while being propelled in the wheelchair during the entire appointment. Further review of the investigation revealed resident's representative asked Occupational Therapist (OT) #350 on 06/03/21 to place the foot pedals on resident's wheelchair. OT #350 found the foot pedals and placed them on the wheelchair on 06/03/21 and educated resident representative they should be used for transport in wheelchair only. Review of the investigation summary revealed the resident had an ongoing behavior of planting her feet on the ground while being propelled in her wheelchair and the foot pedals to the wheelchair should be in place for resident transport. Interview on 08/05/21 at 12:37 P.M. with the Director of Nursing (DON) confirmed the foot pedals to Resident #88's wheelchair were not in place at the time of the outside medical appointment on 06/02/21. The DON further confirmed the facility investigation revealed the resident planted her feet on the ground while being propelled in her wheelchair to the transport vehicle on 06/02/21 and twisted her right ankle. The DON confirmed Resident #88 went to the appointment accompanied by her representative who reported while at the appointment Resident #88 continued to plant her feet on the ground while being propelled in the wheelchair. The DON confirmed after returning from the appointment on 06/02/21, Resident #88 had right ankle pain and swelling, and x-ray revealed a fracture. The DON confirmed the facility investigation revealed no falls or other possible etiologies for fracture and facility concluded the fracture occurred sometime on 06/02/21 on the way to or from the appointment or at the appointment related to resident planting her feet on the ground while being propelled in her wheelchair without foot pedals in place. The DON further confirmed Resident #88's care plan was updated to include foot pedals in place for transport in the wheelchair. This deficiency substantiates Complaint Number OH 212.

Based on record review, observation, staff interview and hospital documentation the facility failed to correctly position one resident's right leg onto a geri chair, after a transfer with a mechanical lift. The resident had a physical deficit on his right side and he was unable to position his right leg on his own. His right leg fell into the space between the arm rest and leg rest. This resulted in actual Harm when the resident sustained [REDACTED]. This affected one Resident (#48) of three residents sampled. The facility identified six residents who used geri chairs. The resident census was 82. Resident #48 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #48 did not speak, sometimes he was understood and sometimes he understood others. Resident #48 required the extensive assistance of two staff with bed mobility, dressing and toilet use. He required the extensive assistance of one staff with personal hygiene and was dependent on two staff for transfers. Resident #48 had a range of motion impairment on one side of his upper and lower extremities. Resident #48 had a care plan for his activity of daily living self-care performance deficit related to stroke. Pertinent interventions included the resident was totally dependent on two staff for transferring. Also, the resident required mechanical lift (Hoyer) with two staff assistance for transfers. Review of Physical Therapy (PT) notes dated 06/10/17 documented Resident #48 assisted with repositioning in geri chair to elevate lower extremities due to increase right lower extremity [MEDICAL CONDITION]. Instructed to not sit/lay with forward head due to potential for increase neck pain from prolonged forward flexed positioning Review of investigation dated 07/10/17 at 5:45 A.M. revealed at 5:45 A.M. a third shift aide reported she found the resident in the geri chair with his right lower extremity caught in between the arm rest and leg rest. The resident was trying to remove his lower extremity. Once the aide removed his right lower extremity, a skin tear was found and notified the nurse immediately. The nurse notified the shift supervisor. The area was covered with [MEDICATION NAME], non-adherent pads and loosely wrapped with kling. Elevated right lower extremity with towel. Resident #48 was oriented to person and place. Attempting to dangle legs off of side of geri chair. Review of an incident note dated 07/10/17 at 8:24 A.M. revealed at 5:45 A.M., a 3rd shift aide found the resident in a geri chair with his right lower extremity (RLE) caught in between the arm rest and leg rest. The resident was trying to remove his lower Extremity. Once the aide removed his RLE, a skin tear was found. The aide notified the nurse immediately. Skin tear was noted and measured 15.5 centimeters (cm) by 2.8 cm, wound bed light pink, actively bleeding, skin rolled back, and raised. Raised left side skin tear bouncy and tender when palpated. Surrounding skin pink and intact. Covered area with a dressing with [MEDICATION NAME], non adherent and kling. Vital signs stable, no complaint of pain to RLE at rest, facial grimaces when palpating RLE. Shift supervisor notified the physician. Resident transferred via private ambulance at 6:50 A.M. and transferred to hospital. Power of Attorney (POA) notified at 8:05 A.M. Review of the hospital documentation dated 07/10/17 revealed the final impression was a right leg laceration that was repaired without complications. Patient without evidence of other traumatic injury and will be discharged home with outpatient follow up. Given size of the wound and nursing home location, patient will be started on a course of Keflex (antibiotic). The laceration was 17 cm in length. Review of order note dated 07/10/17 at 11:22 A.M. revealed the resident returned from the hospital emergency room (ER) at 11:11 A.M. with new orders for: Keflex (antibiotic) 500 milligram (mg) by mouth (PO) twice a day (BID) for seven days, [MEDICATION NAME] ([MEDICATION NAME] supplement) one tablet PO every day for seven days, may remove sutures to wound in 10-14 days. Dressing in place to RLE from hospital. Will cleanse site with Normal Saline (NS), pat dry, cover with non-adherent pad and wrap with kling every day until healed. Will remove first dose of antibiotic from the facility supply Review of skin/wound noted dated 07/10/17 at 2:14 P.M. revealed laceration to lateral RLE reapproximated with 37 sutures. Moderate bleeding noted to dressing from hospital. Cleansed with NS, patted dry, covered with two non-adherent pads and wrapped with kling. RLE elevated on pillow. Review of Wound Specialist Progress Note dated 07/14/17 revealed the Nurse Practitioner (NP) documented Resident #48 was being seen for large skin tear to right lower leg that occurred on 07/10/17 and required 37 sutures in the ER. Currently treating with Xeroform. He recently suffered a stroke and he was not able to communicate subjective information. The treatment was to cleanse the wound with saline, apply to wound bed: [MEDICATION NAME], kling daily. Incision looks very good. Continue [MEDICATION NAME] and kling. Keflex 500 mg twice a day till 07/17/17. Will plan to remove sutures next week. Review of Wound Specialist Progress Note dated 07/21/17 documented the sutures were removed and wound looked good. Added Ace for [MEDICAL CONDITION] management and to help wound edges reapproximated. Continue Xeroform, leg elevation and encourage protein for healing. Observation on 07/24/17 at 10:30 A.M. revealed the resident was sleeping in a low bed. An observation was made on 07/24/17 at 10:40 A.M. with State tested Nurse Aide (STNA) #10 and STNA #11 transferring Resident #48. A gauze bandage was noted on the residents' right lower extremity. Resident #48 did not speak; he could understand questions and nodded yes or no. The Hoyer (mechanical lift) pad was positioned under the resident and he was transferred to the geriatric (geri) chair. The geri chair was padded on the interior surface as well as on the bilateral arm rests and under the residents' legs. He was offered a blanket which he declined. A pillow was placed under his legs. Resident #48 was wheeled into the common area. He was asked if he wanted to watch television or look outside the door and he declined both options. When asked if he wanted to sit at the dining room table; he nodded yes. Resident #48 had a pillow under his right leg. On 07/24/17 at 10:55 A.M. Resident #48 was interviewed and asked if he had stitches in his leg. He nodded yes. When asked if his leg fell off the chair; he nodded yes. Resident #48 had a flat affect and appeared comfortable. On 07/24/17 at 11:25 A.M., STNA #12 was interviewed via telephone. STNA #12 said she and STNA #13 were transferring Resident #48 from the bed to the geri chair. STNA #12 said after Resident #48 was in the chair, STNA #13 left the room in a hurry. STNA #12 looked over and noted Resident #48 was pulling on his leg which was caught between the arm and the space where the recliner moved. Resident #48 was tugging on his right leg with his left arm. STNA #12 pulled the cushion over and tried to pull the leg over and upwards. She said Resident #48 had fragile skin and she saw he was bleeding. She said she immediately notified the nurse. STNA #12 said Resident #48 legs were not positioned correctly after he was lowered into the geri chair. She said in the process of sitting him down in the chair, his right immobile leg slid into the open space between the arm rest and the leg rest On 07/24/17 at 11:48 A.M. Resident #48 was observed sitting in his geri chair in the dining/common area. During the observation the Director of Nursing (DON) pointed to a space between the arm rest and the leg rest where Resident #48's leg became stuck. The DON asked Resident #48 if he was trying to get up and he nodded no. On 07/24/17 at 11:54 A.M. the DON said when Resident #48 had the incident, the blue padding was not in the geri chair. The intervention was to add the blue padding which provided very little space where Resident #48's leg could potentially get stuck. The DON indicated the only statement they obtained about the incident was from the nurse's electronic charting. The DON indicated the nurse put enough information in her notes that the facility did not investigate further. Per the note the resident was found sitting in the geri chair. The DON said Resident #48 was dangling his leg off the side, got his leg stuck between the arm and leg rest and he was trying to remove his leg. The STNA approached and saw the skin tear. The DON did not know where this occurred. She assumed he was up in the lounge as it occurred at 5:45 A.M. There had been no prior incidents. She did not know what happened that morning. The DON verified she had not interviewed any of the STNA's who were providing care for Resident #48 on 07/10/17. On 07/24/17 at 12:10 P.M. Resident #48 was observed sitting in the dining room eating his lunch while he sat in the geri chair with his feet on the ground. There were no concerns noted related to his positioning. On 07/24/17 at 12:17 P.M., Licensed Practical Nurse (LPN) #20 was interviewed. LPN #20 said the protocol for any injury was to complete an accident and injury report, read documentation and rely on that unless it was an injury of unknown origin. LPN #20 reviewed the nursing documentation, and indicated Resident #48 was viewed with his leg stuck in the geri chair, he was pulling on his leg and the STNA found him and helped remove his leg. LPN #20 indicated she thought this occurred in the lounge because of the time of the injury, as most of the residents are in the common area at that time. LPN #20 said there were no witnesses to the injury so the resident must have still been in his room. LPN #20 indicated she did not interview any nurse aides after the incident occurred. On 07/24/17 at 3:45 P.M. LPN #21 was interviewed via telephone. LPN #21 provided care for Resident #48 on 07/10/17. LPN #21 said a STNA told her Resident #48's leg was caught in the geri chair and he was trying to pull it out. The nurse verified Resident #48 sustained a laceration to his right leg. This deficiency substantiates Complaint Number OH 391.