Every finding on record at Arbors at Fairlawn the

Based on record review and interview, the facility failed to ensure Resident #84 did not receive as needed Ativan as a scheduled medication. The facility also failed to ensure that documentation revealed the need for as needed Ativan and what non-pharmacological interventions were attempted prior to administration of Ativan. This affected one (Resident #84) out of 11 residents reviewed for unnecessary medication. The facility census was 81. Findings include:1. Review of the medical record revealed Resident #84 was admitted on [DATE] and discharged on 01/20/26. Resident #84 had diagnoses that included hypertensive heart disease, chronic kidney disease, dementia, benign prostatic hyperplasia, hypertension, urinary incontinence, depression, hyperlipidemia, and atrial fibrillation.Review of the admission orders from hospice revealed Resident #84 was ordered Ativan (antianxiety) 0.5 milligrams (mg) every four hours as needed. Review of the medication administration record (MAR) revealed Resident #84 had Ativan 0.5 mg scheduled every six hours. Resident #84 received six doses of Ativan between 01/15/26 at 8:00 P.M. and 01/16/26 at 8:00 A.M.An interview on 08/03/26 at 12:18 P.M. Director of Nursing (DON) verified Resident #84's Ativan was administered six times as scheduled every four hours on 01/15/26 and 01/16/26. The DON verified the order was for Ativan 0.5 mg as needed every four hours. 2. Review of the medical record revealed Resident #84 was admitted on [DATE] and discharged on 01/20/26. Resident #84 had diagnoses that included hypertensive heart disease, chronic kidney disease, dementia, benign prostatic hyperplasia, hypertension, urinary incontinence, depression, hyperlipidemia, and atrial fibrillation.Review of the admission orders from hospice revealed Resident #84 was ordered Ativan 0.5 mg every four hours as needed. Review of the MAR revealed Resident #84 received Ativan as needed on 01/16/26 at 10:38 P.M., on 01/17/26 at 4:31 P.M. and 8:35 P.M., on 01/18/26 at 2:11 A.M, 6:20 A.M. 1:48 P.M. and 6:14 P.M., on 01/19/26 at 2:21 A.M., 1:42 P.M., and 7:35 P.M. and on 01/20/26 at 12:58 A.M., and 8:34 A.M. The medical record did not reveal documentation of Resident #84 experiencing anxiety and no non-pharmacological interventions were documented. An interview on 08/03/26 at 12:18 P.M. DON verified Resident #84 was administered Ativan as needed without documentation of anxiety and/or any non-pharmacological interventions being attempted prior to the administration of Ativan. This deficiency represents non-compliance investigated under Complaint Numbers 2686109 and 2628195.

Based on observation, interview, and review of validation checklist perineal care (2019), the facility failed to ensure infection control procedures were followed during incontinence care for Resident #3. This affected one (Resident #3) out of one resident observed for incontinence care. The facility census was 81.Findings include:Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, depression, and acute kidney failure.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was cognitively intact. The resident was frequently incontinent of urine and always incontinent of bowel. Resident #3 required substantial to maximal assistance with toileting. An observation on 07/30/26 at 9:32 AM of incontinence care for Resident #3 by Certified Nursing Assistant (CNA) #453 and Assistant Director of Nursing (ADON) #435 revealed CNA #453 washed, rinsed, and dried the front peri area while wearing gloves. CNA #453 used the same gloved hand to pick up a container of powder on nightstand and applied powder to the resident's peri area. CNA #453 and ADON #435 then assisted Resident #3 with turning onto her right side. CNA #453 did not change gloves or do any hand hygiene. CNA #453 washed the residents' buttocks. The resident was having a bowel movement while CNA #453 continued to provide care. CNA #453 used her gloved hand to open a drawer on the nightstand to look for skin barrier cream. CNA #453 then picked up the powder container again to put powder on the resident's buttocks. CNA #453 and ADON #435 verified CNA #453 did not remove or change her gloves after providing incontinence care and then touched other items in the room. Review of the Validation Checklist Perineal Care (2019) revealed to determine if the individual performing perineal care is doing so in accordance with the facility policy. Record observations below. 1. Did staff member complete hand hygiene prior to procedure? 2. Did the staff member don appropriate personal protective equipment as indicated? 3. Did the staff member prevent cross-contamination while providing perineal care?This deficiency represents non-compliance investigated under Master Complaint Number 2972842.

Based on observation, record review, interviews, and policy review, the facility failed to hold Resident #42's medication when blood pressure was outside the ordered parameters. This affected one (Resident #42) out of four residents observed during medication administration. The facility census was 81.Findings include:Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses that included type 2 diabetes, hypertension, and acquired absence of left leg above the knee. Resident #42 was ordered amlodipine (to treat high blood pressure) five milligram (mg) in the morning for hypertension. Amlodipine was to be held if the resident's systolic blood pressure was less than 110 millimeters of mercury (mmHg) and/or diastolic blood pressure was less than 60 mmHg. An observation on 07/28/26 at 7:37 A.M. revealed Medication Technician (MT) #437 administered Resident #42's medications including amlodipine. The portable blood pressure machine in Resident #42's room revealed the resident's blood pressure was 94/49 mmHg. An interview on 07/28/26 at 8:53 A.M. with MT #437 verified she notified the nurse that Resident #42's blood pressure was low and medication had been administered. An interview on 07/28/26 at 10:13 A.M. Assistant Director of Nursing (ADON) #435 verified the doctor had been notified that Resident #42's blood pressure was low, and amlodipine had not been administered. ADON #435 stated the medication administration record was marked that amlodipine was not administered so that was what she told the doctor. ADON #435 stated she would update the physician that amlodipine had been administered when Resident #42 had a blood pressure of 94/49 mmHg. A nurse note dated 07/28/26 at 10:30 A.M. authored by ADON #435 revealed a surveyor observed medication administration and informed nursing that MT #437 administered amlodipine. Resident #42's blood pressure was below the parameters to hold. The physician assistant was notified, and new orders were received to monitor Resident #42' blood pressure every hour for four hours. Review of the Mediation Administration policy, dated 01/17/23, revealed vital signs would be obtained and recorded when applicable or per physician orders. When applicable, medications should be held with vital signs outside of the physicians prescribed parameters. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. This deficiency represents non-compliance investigated under Master Complaint Number 2972842 and Complaint Numbers 2686109 and 2628195.

Based on record review, interview, and policy review, the facility failed to ensure showers were documented appropriately. This affected one (Resident #90) out of three residents reviewed for showers. The facility census was 81.Findings include:Review of Resident #90's medical record revealed an admission date of 12/03/25 with diagnoses of cerebral palsy, intellectual disability, chronic obstructive pulmonary disease, blindness, epilepsy, fracture of the right femur, depression, and anxiety.Review of Resident #90's comprehensive care plan dated 12/04/25 revealed a self-care performance deficit with bathing requiring two staff to assist. Also, two staff were to assist with transfers with a mechanical lift.Review of Resident #90's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed impaired cognition and dependent on staff for activities of daily living.Review of Resident #90's point of care documentation revealed showers charted on 12/19/25, 12/26/25, 12/29/25, 01/09/26, 01/16/26, 01/23/26, 01/26/26, no showers documented in February 2026, 03/02/26, 03/06/26, 03/09/26, 03/13/26, 03/20/26, 03/23/26, 03/30/26, 04/03/26, 04/06/26, 04/10/26, 04/13/26, 04/17/26, and 04/20/26.An interview on 07/29/26 at 2:23 P.M. with the Director of Nursing (DON) confirmed staff did not always document showers when Resident #90 was first admitted but documentation improved throughout the stay.Review of the facility's Activities of Daily Living Policy, revised 12/28/23, revealed the facility provided maintenance and restorative program to assist residents in achieving and maintaining the highest practicable outcome based on their comprehensive assessment. A resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.This deficiency represents non-compliance investigated under Master Complaint Number 2972842.

Based on observation, interviews, record review, and policy review, the facility failed to ensure the medication error rate was less than five percent. This affected two (Resident #42 and Resident #99) out of four residents observed for medication administration. The facility census was 81.Findings include:Observation on 07/28/26 from 7:37 A.M. to 8:21 A.M. of 34 medications administered to four residents (#12, #42, #93, and #99) by Registered Nurse (RN) #466, Licensed Practical Nurse (LPN) #452, Medication Technician (MT) #437, and MT #414 revealed a medication error rate of 5.88 percent. 1. Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses that included type II diabetes, hypertension, and acquired absence of left leg above the knee. Resident #42 was ordered amlodipine (to treat high blood pressure) five milligram (mg) in the morning for hypertension. Amlodipine was to be held if the resident's systolic blood pressure was less than 110 millimeters of mercury (mmHg) and/or diastolic blood pressure was less than 60 mmHg. An observation on 07/28/26 at 7:37 A.M. revealed MT #437 administered Resident #42's medications including amlodipine. The portable blood pressure machine in Resident #42's room revealed the resident's blood pressure was 94/49 mmHg. An interview on 07/28/26 at 8:53 A.M. with MT #437 verified she notified the nurse that Resident #42's blood pressure was low, and medication had been administered. An interview on 07/28/26 at 10:13 A.M. with Assistant Director of Nursing (ADON) #435 verified the doctor had been notified that Resident #42's blood pressure was low, and amlodipine had not been administered. ADON #435 stated the medication administration record was marked that amlodipine was not administered, so that was what she told the doctor. She stated she would update the physician that amlodipine had been administered when Resident #42 had a blood pressure of 94/49 mmHg. A nurse note dated 07/28/26 at 10:30 A.M. authored by ADON #435 revealed a surveyor observed medication administration and informed nursing management that (MT #437) administered amlodipine. Resident #42's blood pressure was below the parameters to hold. The physician assistant was notified, and new orders were received to monitor Resident #42' blood pressure every hour for four hours. Review of the Mediation Administration policy, dated 01/17/23, revealed vital signs would be obtained and recorded when applicable or per physician orders. When applicable, medications should be held with vital signs outside of the physicians prescribed parameters. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. 2. Review of the medical record revealed Resident #99 was admitted on [DATE] with diagnoses that included Alzheimer's disease, heart failure, history of malignant neoplasm of the skin, and diverticulitis. Review of the physician orders revealed an order dated 07/13/26 for Ketoconazole external cream 2% (antifungal for topical use) to affected areas every morning and at bed for dermatitis. An observation on 07/29/26 at 7:58 A.M. revealed MT #414 used a glove finger to insert Ketoconazole external cream 2% inside both of Resident #99's ear canals. An interview on 07/28/26 at 9:31 A.M. with MT #414 verified Ketoconazole cream was put in Resident #99's ear canals to help break up ear wax so the resident could hear better. Review of the Mediation Administration policy, dated 01/17/23, revealed vital signs would be obtained and recorded when applicable or per physician orders. When applicable, medications should be held with vital signs outside of the physicians prescribed parameters. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. If other than oral route, administer in accordance with the facility policy for the relevant route of administration. This deficiency represents non-compliance investigated under Master Complaint Number 2972842 and Complaint Numbers 2686109 and 2628195.

Based on record review, interviews, observations, and policy review, the facility failed to ensure parameters for the for the administration of as needed morphine and non-pharmacological interventions were in place for Resident #84. The facility also failed to ensure that as needed medication was not scheduled for routine daily use and that discontinued medications were not administered to Resident #84. Additionally, the facility failed to ensure controlled medications for Resident #55 were documented and administered as ordered, and that topical cream was applied correctly for Resident #99. This affected three residents (#55, #84, #99) out of seven reviewed for medication administration. The facility census was 81.Findings include:1. Review of the medical record revealed Resident #84 was admitted on [DATE] and discharged on 01/20/26. Resident #84 had diagnoses that included hypertensive heart disease, chronic kidney disease, dementia, benign prostatic hyperplasia, hypertension, urinary incontinence, depression, hyperlipidemia, and atrial fibrillation.Review of the physician orders dated 01/17/26 revealed Resident #84 was ordered morphine (opioid pain medication) five milligram (mg) every two hours as needed for pain.Review of the medication administration record (MAR) revealed Resident #84 received morphine on 01/17/26 at 10:38 P.M. for pain rated a zero out of ten, with 10 being the worst pain. Resident #84 also received morphine as needed on 01/18/26 at 6:14 P.M. and 01/19/26 at 2:21 A.M. for pain rated a zero. Resident #84 received morphine as needed on 01/19/26 at 4:32 P.M. for pain rated a three and at 7:35 P.M. for pain rated a five. Resident #84 received as needed morphine on 01/20/26 at 12:58 A.M. for pain rated a three. Review of the MAR and progress notes revealed no documentation of the non-pharmacological interventions. An interview on 08/03/26 at 12:18 P.M., the Director of Nursing (DON) verified there were no parameters for the pain rating when administering morphine. The DON also verified morphine was administered three times for zero pain, and the there was no documented evidence of non-pharmacological interventions being attempted.2. Review of the medical record revealed Resident #84 was admitted on [DATE] and discharged on 01/20/26. Resident #84 had diagnoses that included hypertensive heart disease, chronic kidney disease, dementia, benign prostatic hyperplasia, hypertension, urinary incontinence, depression, hyperlipidemia, and atrial fibrillation.Review of the admission order from hospice on 01/15/26 revealed Resident #84 was ordered bisacodyl (laxative) five mg daily as needed for constipation. Review of the MAR revealed Resident #84 received bisacodyl daily from 01/16/26 through 01/20/26. An interview on 08/03/26 at 10:03 A.M., the DON verified bisacodyl was ordered as needed for constipation, but the order was transcribed wrong and Resident #84 received bisacodyl every day for five days. 3. Review of the medical record revealed Resident #84 was admitted on [DATE] and discharged on 01/20/26. Resident #84 had diagnoses that included hypertensive heart disease, chronic kidney disease, dementia, benign prostatic hyperplasia, hypertension, urinary incontinence, depression, hyperlipidemia, and atrial fibrillation.Review of the admission order from hospice on 01/15/26 revealed metoprolol (to treat high blood pressure) 12.5 mg was discontinued. Review of the MAR revealed metoprolol 12.5 mg was administered daily from 01/16/26 through 01/20/26. An interview on 08/03/26 at 10:03 A.M., the DON verified hospice discontinued metoprolol when Resident #84 was admitted . The DON also verified Resident #84 received metoprolol daily for five days. 4. Review of the medical record revealed Resident #55 admitted on [DATE] diagnoses included polyneuropathy, cutaneous abscess, Sjogren syndrome, cervical disc degeneration, and osteoarthritis. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was independent with cognitive skills, received opioid medication, and received as needed pain medication. Review of the physician orders dated 07/22/26 revealed Resident #55 was ordered oxycodone (opioid for moderate to severe pain) was ordered every six hours as needed. On 07/22/26, Resident #55 was sent to the hospital, and the order for oxycodone was discontinued. On 07/22/26, Resident #55 returned to the facility and was ordered oxycodone five mg every six hours as needed for five doses and then oxycodone was to be increased to the prior dose of 10 mg every six hours as needed. Review of the controlled drug record revealed Resident #55 received five doses of oxycodone five mg on 07/22/26 at 2:00 P.M., on 07/23/26 at 5:10 A.M., on 07/23/26 at 11:30 A.M. and 6:00 P.M., and on 07/24/26 at 10:36 P.M. Review of the MAR revealed oxycodone five mg was documented as administered seven times from 07/22/26 through 07/26/26. On 07/28/26 at 8:00 A.M. an observation of Registered Nurse (RN) #466 revealed she questioned what the correct order was for Resident #55's oxycodone. The controlled drug sheet and packaged medication was oxycodone 10 mg. The electronic medications administration record revealed the order was for oxycodone five mg. RN #466 administered oxycodone 5 mg and wasted 5 mg. An interview on 07/30/26 at 11:28 A.M., the DON verified the MAR for Resident #55 was documented incorrectly for oxycodone five mg being administered. The correct order was for oxycodone 10 mg as needed. The DON verified RN #466 followed the order in the electronic record and administered five mg instead of the 10 mg that was actually ordered. Review of the Mediation Administration policy, dated 01/17/23, revealed the MAR should be reviewed to identify the medication to be administered. Compare the medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration. If a medication dispensed in a different dose/quantity per dose (example 1/2 pill) a sticker will be placed on the medication packaging to denote to check the MAR for clarification. 5. Review of the medical record revealed Resident #99 was admitted on [DATE] with diagnoses that included Alzheimer's disease, heart failure, history of malignant neoplasm of the skin, and diverticulitis.Review of physician orders revealed an order dated 07/13/26 for Ketoconazole external cream 2% (antifungal for topical use) to affected areas every morning and at bed for dermatitis. An observation on 07/29/26 at 7:58 A.M. revealed Medication Technician (MT) #414 used a glove finger to insert Ketoconazole external cream 2% inside both of Resident #99's ear canals. An interview on 07/28/26 at 9:31 A.M. MT #414 verified Ketoconazole cream was put in Resident #99's ear canals to help break up ear wax so the resident could hear better. The Mediation Administration policy, dated 01/17/23, revealed the staff should refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. If other than oral route, administer in accordance with the facility policy for the relevant route of administration. This deficiency represents non-compliance investigated under Complaint Numbers 2733362, 2686109 and 2628195.

Based on record review and interviews, the facility failed to ensure Resident #58 maintained regular bowel movements as ordered. This affected one resident (Resident #58) out of four residents reviewed for bowel and bladder incontinence. The facility census was 81.Findings include: Review of the medical record revealed Resident #58 was admitted on [DATE] diagnoses of chronic obstructive pulmonary disease, type II diabetes, dementia, and major depressive disorder.Review of the care plan dated 02/18/26 revealed Resident #58 had episodes of incontinence related to cognitive impairment, dementia, depression, diabetes, generalized weakness, impaired mobility. Interventions included administering medications as ordered, assisting the resident with toileting needs, checking at regular intervals and changing as needed, providing disposable incontinence products, and providing peri-care after each incontinent episode. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 had severe cognitive impairment. Resident #58 required partial to moderate assistance with toileting and was frequently incontinent of bowel and bladder. The MDS also revealed the resident required partial to moderate assistance for toileting.Review of the physician orders included an order for Milk of Magnesia (laxative) 30 milliliters every 24 hours as needed for constipation if no bowel movement for three days. Review of the bowel documentation revealed Resident #58 had a bowel movement on 07/05/26. There was no documented evidence of a bowel movement until 07/14/26, eight days later. The next bowel movement was documented on 07/24/26, ten days later. The resident also did not have a bowel movement for four days between 07/26/26 and 07/30/26. An interview on 07/30/26 at 1:04 P.M., the Director of Nursing (DON) verified the documentation revealed Resident #58 had gone more than three days without Milk of Magnesia being given. The DON stated the facility did not have a bowel protocol but did follow the orders of Milk of Magnesia. The dashboard on the electronic record notified the nurses when a resident did not have a bowel movement for three days. The DON stated Resident #58 did take himself to the bathroom independently at times and verified there was no documented evidence of the resident being asked about having a bowel movement, bowel sounds being assessed or an abdominal assessment being completed.This deficiency represents non-compliance investigated under Complaint Number 2628195.

Based on record review, interviews, and policy review, the facility failed to ensure Resident #85's guardian was notified and involved in the resident's transfer to another facility. This affected one resident (Resident #85) out of four reviewed for discharge. The facility census was 81.Findings include:Review of the medical record revealed Resident #85 was admitted on [DATE] and discharged on 05/15/26 with diagnoses that included metabolic encephalopathy, type II diabetes, dementia, asthma, depression, psychosis, and suicidal ideations.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 was cognitively intact and had no behaviors including wandering. Review of the nurse's note dated 05/15/26 at 1:37 P.M. revealed Resident #85's son was notified Resident #85 was being transferred to another facility at 4:30 P.M. The facility would take all the resident's belongings with her.Review of the nurse's note dated 05/15/26 at 3:25 P.M. revealed Resident #85 was being discharged to another facility at this time via the facility bus. All belongings were sent with Resident #85.An interview on 07/30/26 at 8:48 A.M. Resident #85's son/guardian revealed he was not involved in Resident #85 being discharged on 05/15/26. The resident's son stated the facility had said they were thinking about transferring the resident, but he had not heard any more about a transfer or discharge. He said, then all a sudden, they said Resident #85 was being transferred to another facility. The resident's son stated he had said he would be interested in having the resident transferred to a sister facility that was closer to him but that was not where Resident #85 was transferred to. Resident #85's son stated the resident did have behaviors, but he was not told the resident needed to be transferred until the day of the transfer. He felt the facility no longer wanted to deal with Resident #85, so they transferred her. He stated he did not have a chance to tour the facility where Resident #85 was transferred to, and had since found out it is a facility for people with behaviors, and now that Resident #85 resided at the behavioral facility, no other facility will take her. He stated he was Resident #85's guardian and should have been involved in the discharge/transfer process. An interview on 07/30/26 at 9:13 A.M. with Social Services #465 revealed she was off with COVID-19 the day Resident #85 was transferred to another facility. Social Services #465 stated the intradisciplinary team made the decision to transfer Resident #85 and was not sure if the transfer was discussed with Resident #85's son/guardian.An interview on 07/30/26 at 9:18 A.M. with the Administrator revealed she was on vacation when Resident #85 was transferred to another facility. The Administrator was unsure of what led up to Resident #85 being transferred on 05/15/26. She verified Social Services #465 was off work the day Resident #85 was transferred. An interview on 07/30/26 at 9:22 A.M. with the Director of Nursing (DON) verified she was aware Resident #85's son was the residents guardian. The DON stated Resident #85 kept trying to leave the facility but did not feel the discharge was an emergency. The facility close to Resident #85's son stated they could not take the resident due to history of suicidal ideation. The behavioral facility agreed to take Resident #85, and the resident needed to be at a secure facility. Review of the Transfer and Discharge policy dated 10/30/23 revealed the facility may initiate transfers or discharges if necessary for the resident's welfare and the resident's needs cannot be met in the facility. Non-emergency transfers or discharges initiated by the facility require documentation of the reasons for the transfer or discharge in the resident's medical record, the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs. Document any danger to the health or safety of the resident. At least 30 days before the resident is transferred or discharged , the Social Services Director will notify the resident and the resident's representative in writing in a language and manner they understand. The contents of the notice must include the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident is transferred or discharged , a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.

Based on record review, interviews, and policy review, the facility failed to ensure Resident #85 had an appropriate and planned discharge to another facility. This affected one (Resident #85) out of four residents reviewed for discharge. The facility census was 81. Findings include: Review of the medical record revealed Resident #85 was admitted on [DATE] and discharged on 05/15/26 with diagnoses that included metabolic encephalopathy, type II diabetes, dementia, asthma, depression, psychosis, and suicidal ideations. Review of the physician orders revealed an order dated 11/11/25 for Resident #85 to have a safety tracking device (Wanderguard) to prevent the resident from leaving the facility. Review of the care plan dated 11/11/25 revealed Resident #85 was at risk for elopement related to exit seeking behavior and verbalizing wanting to leave the facility. Interventions included redirecting and diverting the resident's attention. Distract the resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, books, etc. evaluate for the need of safety tracking device, periodically evaluate for continued use of tracking device, promptly check when alarm system goes off to ensure the resident is safe and remains in the facility, refer to psychiatrist/psychologist/behavior specialist as needed, resident wears tracking device to right ankle, set up meeting with family/guardian to determine if resident may need a more appropriate facility if elopement attempts continue. New interventions on 05/14/26 included educating the family about bringing/using sharp objects (scissors) and applying the tracking device to the wheelchair. Review of the care plan dated 11/15/25 revealed Resident #85 had behaviors related to dementia. Interventions included administering medication as ordered, approaching the resident in a calm manner, attempting to redirect, and keeping the resident safe during episodes of behaviors.Review of the care plan dated 11/15/25 revealed Resident #85 planned to stay long-term in the skilled nursing facility. Interventions included actively involve the resident/family in the resident's plan of care and encourage on-going involvement with family and friends. Review of the elopement risk assessment dated [DATE] revealed Resident #85 was at risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 was cognitively intact and had no behaviors including wandering. Resident #85 obtained guardianship on 03/12/26, and the facility was provided with a copy of the guardianship. Review of a risk for elopement/wandering review dated 05/04/26 at 1:07 P.M. revealed Resident #85 was at risk for elopement. Review of the interdisciplinary progress note (IDT) dated 05/13/26 at 4:01 P.M. authored by the Director of Nursing (DON) revealed Resident #85 wanted to go outside. The DON went outside with resident. The resident started self-propelling rapidly towards the sidewalk. Once the resident was back in the facility, the resident kept self-propelling back to the front door and was upset that she was not able to get out of the door due to the Wanderguard. An IDT note authored by the DON dated 05/13/26 at 4:25 P.M. revealed Resident #85 attempted to push the doors open and was yelling and paranoid. A one-time order for Haldol (antipsychotic) was received. Review of the nursing quarterly/significant change evaluation dated 05/14/26 revealed Resident #85 was alert, short-term and long-term memory was intact, was independent with decisions and had the ability to express ideas, wants, and consider both verbal and non-verbal expression. The resident was able to understand others and had adequate hearing and vision. Behavioral symptoms included being socially inappropriate/disruptive. Wandering and resistive to care were not marked. Resident #85 used anti-anxiety medication. Resident #85 was not cognitively impaired with poor decision-making skills, had not verbally expressed the desire to go home, packed belongings or stayed near the exit doors. Resident #85 did not wander aimlessly or have non-goal directed or wandering behavior. There had not been any changes in the residents' status or routine. The resident was not at risk for elopement at the time of the assessment. The resident had no alarms in place. Review of a psychiatry progress note dated 05/15/26 revealed Resident #85 was being seen after incident where she tried to elope. The patient received an intramuscular shot of Haldol on 05/13/26 after an incident of attempting to elope twice from the facility. Resident #85 also was paranoid, accusatory, refused medications and food, had increased anxiety and multiple attempts to redirect that were unsuccessful. Resident #85 expressed a desire to move to a more skilled facility that was closer to home so the resident's son could visit more easily. Resident #85 was not aware of any plans to move facilities, though the provider indicated this was in process, and it was unknown what time this would occur. Review of a nurse's note dated 05/15/26 at 1:37 P.M. revealed Resident #85's son was notified that Resident #85 was being transferred to another facility at 4:30 P.M. The facility would take all the resident's belongings with her.Review of a nurse's note dated 05/15/26 at 3:25 P.M. revealed Resident #85 was being discharged to another facility at this time via the facility bus. All belongings were sent with Resident #85. Review of a Discharge to Home/Community/AL (Assisted Living)/Equal Care Setting form dated 05/15/26 revealed Resident #85 was discharged to another facility on 05/15/26 at 4:30 P.M. The resident and belongings were transported by the facility bus and accompanied by facility staff. The social service and activities portion of the form were blank. There was no information that included the contact name, contact phone, resident, name of responsible party, and no signatures of responsible party, dietary services, social services, activities, nursing, or discharging nurse. An interview on 07/30/26 at 8:48 A.M. Resident #85's son/guardian revealed he was not involved in Resident #85 being discharged on 05/15/26. The resident's son stated the facility had said they were thinking about transferring the resident, but they did not. The resident's son said, all a sudden they said Resident #85 was being transferred to another facility. The resident's son stated he had said he would be interested in having the resident transferred to a sister facility that was closer to him, but that was not where Resident #85 was transferred to. Resident #85's son stated the resident did have behaviors, but he was not told the resident needed to be transferred until the day of the transfer. He felt the facility no longer wanted to deal with Resident #85, so they transferred her. The resident's son stated he did not have a chance to tour the facility where Resident #85 was transferred to. He has since found out it was a facility for people with behaviors and now that Resident #85 resided at the behavioral facility, no other facility would take her. He stated he was Resident #85's guardian and should have been involved in the discharge/transfer process. An interview on 07/30/26 at 9:13 A.M. with Social Services #465 revealed she was off with COVID-19 the day Resident #85 was transferred to another facility. Social Services #465 stated the intradisciplinary team made the decision to transfer Resident #85 and was not sure if the transfer was discussed with Resident #85's son/guardian. An interview on 07/30/26 at 9:18 A.M. with the Administrator revealed she was on vacation when Resident #85 was transferred to another facility. The Administrator was unsure of what lead up to Resident #85 being transferred on 05/15/26. She verified Social Services #465 was off work the day Resident #85 was transferred. An interview on 07/30/26 at 9:22 A.M., the DON stated Resident #85 kept trying to leave the facility but did not feel the discharge was an emergency. The facility close to Resident #85's son stated they could not take the resident due to history of suicidal ideation. The DON verified there was no documentation of the planning of the discharge or Resident #85 or the resident's son/ guardian being involved in the discharge. Review of the Transfer and Discharge, policy dated 10/30/23, revealed the facility may initiate transfers or discharges if necessary for the resident's welfare and the resident's needs cannot be met in the facility. Non-emergency transfers or discharges initiated by the facility require documentation of the reasons for the transfer or discharge in the resident's medical record, the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs. Document any danger to the health or safety of the resident. At least 30 days before the resident is transferred or discharged , the Social Services Director will notify the resident and the resident's representative in writing in a language and manner they understand. The contents of the notice must include the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident is transferred or discharged , a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.

Based on record reviews and interview, the facility failed to ensure Resident #90's safety after not returning timely after a leave of absence (LOA). This affected one resident (Resident #90) of three residents reviewed for LOA's. The census was 80. Findings include: Review of closed medical record for Resident #90 revealed an initial admitted [DATE] and re-admitted [DATE] with diagnoses included chronic obstructive pulmonary disorder, diabetes and congestive heart failure. Resident #90 was discharged on [DATE]. Review of the profile tab in the electronic medical record revealed Resident #90 listed first as his own responsible party then his daughter as the second contact. Review of the care plan dated [DATE] revealed the facility would honor Resident #90's preferences including leaving the building unsupervised and traveling throughout the community in his powerchair via public transport. Review of the elopement assessment dated [DATE] for Resident #90 revealed he was not at risk for elopement. Review of Resident #90's [DATE] orders revealed an order for LOA independently without medication effective [DATE]. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was cognitively intact and independent with chair to chair transfers. Review of Resident #90's LOA sheets from [DATE] through [DATE] revealed he returned prior to midnight of same day for all of his outings. Review of entry on [DATE] revealed he signed out at 11:55 A.M. with Barberton as his destination. Review of Resident #90's progress notes dated [DATE] at 11:49 P.M. and authored by Licensed Practical Nurse (LPN) #265 revealed the day nurse reported Resident #90 signed himself out on an LOA. The resident had not returned yet. Resident #90's note dated [DATE] at 4:03 A.M. authored by LPN #265 indicated LOA. Review of two progress notes dated [DATE] at 9:30 A.M. authored by LPN #211 stated Resident #90's daughter called the facility stating he passed away and the second note revealed LPN #211 informed the Director of Nursing and the physician assistant. Review of a progress note dated [DATE] at 4:21 P.M. authored by DON revealed she had spoken to the hospital case manager who stated Resident #90 arrived from the grocery store to the emergency room at 3:16 P.M. on [DATE]. He had expired from acute pulmonary arrest at 10:45 P.M. Interview on [DATE] at 2:14 P.M. with LPN #211 revealed she worked on [DATE]. When she learned Resident #90 was not back yet she reviewed the LOA book to see he logged out on [DATE] at 11:55 A.M. She stated she tried to call Resident #90's cell phone between 9:00 A.M. and 9:30 A.M. but there was no voicemail. About the same time the, Resident #90's daughter called the facility to notify them of his death. LPN #211 described Resident #90's routine LOA as taking public transport to nearby city via public transportation where he hung out with friends in stores of an area shopping plaza. She stated he had mentioned to her one time to contact the women at the one store if they needed to find him. She stated he would stay out past 10:00 P.M. some nights but had always returned before midnight. LPN #211 stated she was unsure if LPN #265 tried to call Resident #90's cell phone the night he didn't return, but her expectation was that he would be called. She was uncertain if management was notified on [DATE] that he had not returned from his LOA. Interview on [DATE] at 2:33 P.M. with Social Service Designee (SSD) #258 revealed she felt Resident #90 was going to do what he wanted. She stated her expectation was a call be made to the missing resident and a search take place. She was uncertain of what his care plan was at the time of interview. Interview on [DATE] at 2:53 P.M. with the Administrator revealed Resident #90 had been told in the past to be back in the facility by midnight. Her expectation would be to call his cell phone then call the hospitals and to search grounds in case his motorized wheelchair battery died . Interview on [DATE] at 3:53 P.M. with the Director of Nursing (DON) revealed her expectation, if a resident was not back as anticipated by midnight, staff were to call resident's cell phone, call the hospitals and to start looking for him. She stated LPN #265 had texted her at almost midnight on [DATE] that Resident #90 did not return from his LOA, and DON stated to call his cell phone. When she did not get a response DON texted and told her to call the hospitals. DON's expectation was to start searching for him if not at hospital. DON stated she fell back asleep but had no messages from the facility on her phone when she got up on [DATE]. She was not sure if he returned yet or not. DON called the facility around 9:00 A.M. and spoke to LPN #211 who told her Resident #90 had not returned. Within five minutes of their conversation LPN #211 had learned through a phone call from the hospital and a separate call from the daughter he had been at a local hospital where he passed away. The DON discovered LPN #265 never called the hospitals or daughter. LPN #265 was suspended and given a final written warning. Interview on [DATE] at 4:15 P.M. with LPN #265 revealed she worked on [DATE] from 6:00 P.M. to 6:00 A.M. She stated she called Resident #90's cell phone with no response. She stated she texted the DON who responded telling her to call the hospitals. She stated she did not call the hospitals because she was too busy. She stated she figured dayshift would do it. LPN #265 stated Resident #90 had always come back before midnight from his LOAs. Interview on [DATE] at 4:40 P.M. with DON revealed LPN #265 told her she didn't call the hospitals because she figured the hospital would call the facility. Review of the facility policy titled Resident Appointment/Outing including overnights (not transfer/discharge), dated [DATE] revealed the policy was to assure resident safety and staff knowledge of resident's whereabouts by signing out on the log. Residents should note destination and approximate time of return. The policy stated it should be documented in the medical record what time the resident left, with who and other pertinent information. This deficiency represents non-compliance investigated under Complaint Number OH00165215.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record reviews and interviews with staff the facility failed to notify Resident #90's physician and daughter of notification of changes. This affected one resident of three reviewed for notifications of change. The census was 80. Findings include: Review of the closed medical record for Resident #90 revealed an initial admitted [DATE] and re-admitted [DATE] with diagnoses including chronic obstructive pulmonary disorder, diabetes and congestive heart failure. Resident #90 was discharged on [DATE]. Review of the profile tab in the electronic medical record revealed Resident #90 was listed first as his own responsible party then his daughter as the second contact. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was cognitively intact. He was independent with chair to chair transfers. Review of Resident #90's progress note on 02/05/25 at 8:30 P.M. revealed Resident #90 wanted to go to the hospital. The resident was sent to the emergency room (ER). Resident was his own responsible party. There was no evidence his daughter was notified. Review of Resident #90's progress note on 03/16/25 at 9:06 A.M., 03/17/25 at 8:52 A.M., 03/18/25 at 9:38 A.M. and 12:38 P.M. and 03/19/25 at 7:41 A.M. revealed Resident #90 refused either treatments such as dialysis or vitals signs, and/or medications. There was no evidence Resident #90's physician or daughter was notified of the refusals. Review of Resident #90's progress note on 03/21/25 at 2:58 P.M. revealed Resident #90 was sent to the ER. There was no evidence Resident #90's daughter was notified. Review of Resident #90's progress notes dated 04/18/25 at 11:49 P.M. and authored by Licensed Practical Nurse (LPN) #265 revealed the day nurse reported Resident #90 signed himself out on an LOA. The resident had not returned yet. Resident #90's note dated 04/19/25 at 4:03 A.M. authored by LPN #265 indicated LOA. There was no evidence Resident 90's physician or daughter were notified of the resident not returning from LOA. Review of two progress notes dated 04/19/25 at 9:30 A.M. authored by LPN #211 stated Resident #90's daughter called the facility stating he passed away and the second note revealed LPN #211 informed the Director of Nursing and the physician assistant. Interview on 05/12/25 at 3:53 P.M. with the Director of Nursing (DON) confirmed there were inconsistencies in when the facility notified Resident #90's physician and daughter related to hospitalization , refusals of treatments, and not returning from LOA. The deficient practice was corrected on 04/24/25 when the facility implemented the following corrective actions: On 04/19/25 the DON suspended LPN #265 and gave her a final written warning. LPN #265 was educated by the DON on notifications of refusals of medications and treatments. On 04/20/25 the DON audited all residents progress notes, Medication Administration Records (MARs) and Treatment Administration Records (TARs), new orders and alerts for the past seven days for proper notifications of refusals or other changes. The DON or designee educated all nurses on notification on refusals of medications and treatments by 04/22/25. All residents' notes, MARs, TARs, orders and alerts reviewed at clinical meeting by the team (DON, Administrator, Unit Manager, MDS nurse and SSD) Monday through Friday for proper notifications of refusals and other changes. DON/Designee will interview five nurses weekly for four weeks on documenting refusals and notifications. Ad Hoc QAPI meeting was held on 04/21/25 including the Medical Director, Administrator and DON. Interdisciplinary team will identify residents who refuse treatments and medications or require notifications and ensure they are completed timely during the clinical meeting Monday through Friday. Results of audits will be reviewed at QAPI meeting for one month with revisions to the plan or changes deemed necessary by the team. Review of the facility policy titled Notification of Changes, revised 08/29/25 revealed the facility should ensure to promptly inform the resident, physician and notify the resident representative when there is a change requiring notification such as but not limited to: accidents, significant changes like deterioration in health, mental or psychosocial status or a circumstance requiring a need to alter treatment, exacerbation of a chronic condition or a transfer or discharge from the facility. When a resident is mentally competent, a designated family member should be notified of significant changes because the resident may not be able to notify them personally. This deficiency represents non-compliance investigated under OH00165215.

Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to provide sufficient staff to ensure the residents received timely assistance with showers/bathing, incontinence care, dressing, personal hygiene, and changing of soiled sheets. This affected six of six residents (Resident #9, #13, #38, #46, #49, and #56) reviewed for sufficient staffing and had the potential to affect all residents residing at the facility. The facility census was 73. Findings include: 1. Record review for Resident #46 revealed an admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required supervision or touch assistants with bathing and tub/shower transfers. Review of the facility tasks revealed Resident #46 preferred showers every Tuesday and Friday. From 02/26/25 through 03/11/25, Resident #46 did not receive or refuse the scheduled shower/bath on 02/28/25 or 03/07/25. Interview on 03/05/25 at 3:12 P.M. with Resident #46 stated the facility was shorthanded. Resident #46 stated a lot times he was scheduled for baths but did not receive it due to being staff shortage. Interview on 03/05/25 at 3:42 P.M. with Certified Nursing Assistant (CNA) #206 verified Resident #46 did not receive showers as scheduled and resident preference. CNA #206 stated there were staffing issues, and at times, the CNAs were unable to provide resident their showers because there was not enough staff. 2. Record review for Resident #38 revealed an admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Resident 38 was dependent on staff for bathing and dressing. Record review from 02/15/25 through 03/11/25 of scheduled showers revealed Resident #38 did not receive the shower /bath on 02/15/25 or 03/01/25. There was no record of Resident #38 refusing on 02/15/23 or 03/01/25. All documentation of completed baths revealed Resident #38 only received bed baths. Interview on 03/04/25 at 3:45 P.M. with Resident #38 stated he was not getting his showers like he should. Resident #38 stated there were days they switch staff, his showers were Tuesdays and Saturdays but they will just do a bed bath when he wants a shower because it was easier for staff to do a bed bath. Resident #38 stated, I feel forced at times to do a bed bath but depending on the nursing aide, some don't clean you up as well as others. Interview on 03/04/25 at 4:01 P.M. with Certified Nursing Assistant (CNA) #224 verified Resident #38 did not receive showers as scheduled. CNA #224 explained there was not enough staff to provide residents with a shower during her shift. CNA #224 stated she may have to do bed baths for the residents instead of showers because there was not enough time. 3. Record review for Resident #13 revealed an admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact and required supervision or touch assistance with showers and partial/moderate assistance with transfers and dressing. Record review from 02/15/25 through 03/11/25 of scheduled showers revealed Resident #13 did not receive/refuse a shower/bath on 02/16/25, 02/27/25, 03/06/25, or 03/09/25. Interview on 03/11/25 at 1139 A.M. with Resident #13 confirmed he did not receive showers every Thursday and Sunday as scheduled consistently and stated did not receive a shower on the previous Sunday (03/09/25) because the staff told him they were short staffed. 4. Record review for Resident #9 revealed an admitted [DATE]. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required substantial/maximal assistance with bathing and personal hygiene. Resident #9 had an indwelling catheter and was always incontinent of bowel. 4a. Record review from 02/26/25 through 03/11/25 of scheduled showers revealed Resident #9 did not receive or refuse a shower/bath on 03/07/25. Documentation revealed all other bed baths/showers were given as scheduled. Interview and observation on 03/04/25 at 4:07 P.M. with Resident #9 revealed the resident was lying in bed in his pajamas. Resident #9's hair was very oily, Resident #9 had a strong body odor. His finger nails were dirty and uneven. Resident #9 stated he was not getting his baths as scheduled. Observation and interview on 03/05/25 at 9:43 A.M. revealed Resident #9 was lying in bed. Observation revealed Resident #9's sheet and blanket was wet with a large spill. Resident #9 stated he spilled his whole cup of coffee when he was eating breakfast. Resident #9 stated he was not burned from the coffee but confirmed his blanket and sheet was wet. Observation and interview on 03/05/25 at 10:50 A.M. with Certified Nursing Assistant (CNA) #241 and #278 verified Resident #9 was still in bed. Resident #9 was still covered with the sheet and blanket that had the coffee spilled onto it at breakfast time. CNA #241 confirmed she was Resident #9's primary CNA and stated Resident #9 spilled his coffee on the blanket and sheet he was covering up with. CNA #241 confirmed she was aware of the spill but did not have time to assist him with any morning care until now stating she was busy with other residents. CNA #241 stated she still had three residents to go after Resident #9 for their first set of rounds of the day to check and change them. CNA #241 stated she started her shift at 6:00 A.M. and confirmed she had not been in yet on this day to provide morning care for Resident #9. 4b. Observation and interview on 03/05/25 at 9:43 A.M. revealed Resident #9 was lying in bed. Resident #9 had an odor of stool. Resident #9 confirmed he had a bowel movement (BM) but they have not changed him yet. Observation on 03/05/25 at 10:50 A.M. with Certified Nursing Assistant (CNA) #241 and #278 of incontinence care for Resident #9 revealed Resident #9 was still in bed. CNA #241 confirmed she was Resident #9's primary CNA and stated she had not been in yet on this day to change Resident #9. CNA #241 stated their shift started at 6:00 A.M. Observation of incontinence care revealed Resident #9's had a large BM. CNA #241 confirmed she never checked on Resident #9 for incontinence care needs until the surveyor requested to observe incontinence care for Resident #9. 5. Record review for Resident #49 revealed an admitted [DATE]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. Resident #49 was always incontinent of bowel and bladder, required substantial/maximal assistance with toileting hygiene. Observation on 03/05/25 at 11:22 A.M. of incontinence care for Resident #49 completed by Certified Nursing Assistant (CNA) #241 revealed Resident #49's brief was saturated with urine and bowel movement (BM). Resident #49's buttocks was red and the skin on the buttocks and back was creased and wrinkled from the wrinkled bedding she had been lying on. CNA #241 stated this was the first time on this shift she had checked Resident #49 for incontinence needs due to being busy with other residents. CNA #241 stated Resident #49 should have been up out of bed a long time ago. Resident #49 asked CNA #241 if today was her shower day. CNA #241 stated it was and asked Resident #49 if she wanted it today or tomorrow because she (CNA #241) had not had her lunch yet and she was supposed to take it at 11:30 A.M. CNA #241 stated to Resident #49 that she was sorry, she did not have time to do it today but promised she would do it tomorrow. Resident #49 agreed to take the shower the next day so CNA #241 could go to lunch. Resident #56 was Resident #49's roommate. While completing care for Resident #49, CNA #241 said to Resident #56 she would get to her as soon as she was done with Resident #49. CNA #241 then stated to Resident #56, she needed to take her break (it was now 11:32 A.M.) at 11:30 A.M. and asked Resident #56 (while still working with Resident #49) if she wanted to wait until after lunch to get changed. Resident #56 shouted, No, I do not want to sit here wet all day 6. Record review for Resident #56 revealed an admission day of 05/15/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact. Resident #56 was frequently incontinent of bowel and bladder. Resident #56 required supervision or touch assistance for toileting hygiene. Observation on 03/05/25 at 11:38 A.M. of incontinence care for Resident #56 completed by Certified Nursing Assistant (CNA) #241 revealed Resident #56 was sitting up in her bed. Resident #56 had a hospital gown on with one gown in the front and an additional gown in the back covering her back side. Resident #56 stated she was saturated with urine and had been waiting all day to be changed. Resident #56 had a foul odor of urine. Observation revealed CNA #241 ambulated with Resident #56 using a rollator to the bathroom. Resident #56's gown was saturated with urine covering the entire back side. The sheet and bed pad where Resident #56 was sitting was also saturated with urine. Resident #56's saturated brief was bulging with urine. CNA #241 confirmed this was the first time today getting to Resident #56 to assist with incontinence care. Interview on 03/05/25 at 11:49 A.M. with the Director of Nursing (DON) stated residents were checked and changed per plan of care and every two hours. The DON confirmed day shift started at 6:00 A.M. until 2:00 P.M. The DON stated by 8:30 A.M., every resident should be seen, checked and changed if needed. This deficiency represents non-compliance investigated under Complaint Number OH00161403.

Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) received assistance with bathing/showers. This affected four (Resident #9, #13, #38, and #46) of five residents reviewed for ADLs. The facility census was 73. Findings include: 1. Record review for Resident #46 revealed an admitted [DATE]. Diagnoses included cerebral infarction, foot drop right foot, acquired absence of left fingers, muscle weakness and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required supervision or touch assistants with bathing and tub/shower transfers. Review of the facility tasks revealed Resident #46 preferred showers every Tuesday and Friday. Record review from 02/26/25 through 03/11/25 of scheduled showers revealed Resident #46 did not receive or refuse the scheduled shower/bath on 02/28/25 or 03/07/25. Interview on 03/05/25 at 3:12 P.M. with Resident #46 stated the facility was shorthanded. Resident #46 stated a lot times he was scheduled for baths but did not receive it due to being staff shortage. Interview on 03/05/25 at 3:42 P.M. with Certified Nursing Assistant (CNA) #206 verified Resident #46 did not receive showers as scheduled and resident preference. CNA #206 stated there were staffing issues, and at times, the CNAs were unable to provide resident their showers because there was not enough staff. 2. Record review for Resident #38 revealed an admitted [DATE]. Diagnoses included spondylosis with myelopathy cervical region, radiculopathy cervical region, muscle weakness, quadriplegia, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Resident 38 was dependent on staff for bathing and dressing. Review of the care plan dated 09/18/23 for Resident #38 revealed Resident #38 had an ADL self-care performance deficit. Interventions included one-person assistance for bathing. Review of the facility tasks revealed Resident #38 preferred showers every Tuesday and Saturday. Record review from 02/15/25 through 03/11/25 of scheduled showers revealed Resident #38 did not receive the shower /bath on 02/15/25 or 03/01/25. There was no record of Resident #38 refusing on 02/15/23 or 03/01/25. All documentation of completed baths revealed Resident #38 only received bed baths. Interview on 03/04/25 at 3:45 P.M. with Resident #38 stated he was not getting his showers like he should. Resident #38 stated there were days they switch staff, his showers were Tuesdays and Saturdays but they will just do a bed bath when he wants a shower because it was easier for staff to do a bed bath. Resident #38 stated, I feel forced at times to do a bed bath but depending on the nursing aide, some don't clean you up as well as others. Interview on 03/04/25 at 4:01 P.M. with Certified Nursing Assistant (CNA) #224 verified Resident #38 did not receive showers as scheduled. CNA #224 explained there was not enough staff to provide residents with a shower during her shift. CNA #224 stated she may have to do bed baths for the residents instead of showers because there was not enough time. 3. Record review for Resident #9 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), obstructive and reflux uropathy, abnormalities of gait and mobility, muscle weakness and need for assistance with personal care. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required substantial/maximal assistance with bathing and personal hygiene. Review of the facility tasks revealed Resident #9 preferred showers on Friday and Tuesday. Record review from 02/26/25 through 03/11/25 of scheduled showers revealed Resident #9 did not receive or refuse a shower/bath on 03/07/25. Documentation revealed all other bed baths/showers were given as scheduled. Interview and observation on 03/04/25 at 4:07 P.M. with Resident #9 revealed the resident was lying in bed in his pajamas. Resident #9's hair was very oily, Resident #9 had a strong body odor. His finger nails were dirty and uneven. Resident #9 stated he was not getting his baths as scheduled. Interview and observation on 03/05/24 at 10:50 A.M. with Certified Nursing Assistant (CNA) #241 confirmed Resident #9 had a foul odor. 4. Record review for Resident #13 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left nondominant side, abnormalities of gait and balance and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 had impairment on one side of the upper and lower extremity, required set up or clean up assistance with toileting hygiene, supervision or touch assistance with showers and partial/moderate assistance with transfers and dressing. Review of the facility tasks revealed Resident #13 preferred showers every Thursday and Sunday. Record review from 02/15/25 through 03/11/25 of scheduled showers revealed Resident #13 did not receive/refuse a shower/bath on 02/16/25, 02/27/25, 03/06/25, or 03/09/25. Interview on 03/11/25 at 1139 A.M. with Resident #13 confirmed he did not receive showers every Thursday and Sunday as scheduled consistently and stated did not receive a shower on the previous Sunday (03/09/25) because the staff told him they were short staffed. Interview on 03/11/25 at 2:37 P.M. with the Director of Nursing (DON) confirmed Resident #13 did not receive his shower or bed bath the previous Sunday and stated the CNA who was assigned to him was required to float between both ends of the facility. Review of the facility policy titled, Activities of Daily Living revised 12/28/23 revealed a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents noncompliance investigated under Complaint Number OH00161403.

Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure the residents received timely incontinence care. This affected three (Residents #9, #49, and #56) of three residents reviewed for incontinence care. The facility census was 73. Findings include: 1. Record review for Resident #9 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), obstructive and reflux uropathy, abnormalities of gait and mobility, muscle weakness and need for assistance with personal care. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 had an indwelling catheter and was always incontinent of bowel. Resident #9 used a wheelchair for mobility, required substantial/maximum assistance with toileting hygiene, lower body dressing, partial/moderate assistants for bed mobility, and dependent on staff with transfers. Review of the care plan for Resident #9 dated 01/09/25 revealed Resident #9 had episodes of bowel incontinence related to benign prostatic hyperplasia, generalized weakness and pain. Interventions included to assist resident with toileting needs and check at regular intervals and change as needed. Observation and interview on 03/05/25 at 9:43 A.M. revealed Resident #9 was lying in bed. Resident #9 had an odor of stool. Resident #9 confirmed he had a bowel movement (BM) but they have not changed him yet. Observation on 03/05/25 at 10:50 A.M. with Certified Nursing Assistant (CNA) #241 and #278 of incontinence care for Resident #9 revealed Resident #9 was still in bed. CNA #241 confirmed she was Resident #9's primary CNA and stated she had not been in yet on this day to change Resident #9. CNA #241 stated their shift started at 6:00 A.M. Observation of incontinence care revealed Resident #9's had a large BM. CNA #241 confirmed she never checked on Resident #9 for incontinence care needs until the surveyor requested to observe incontinence care for Resident #9. 2. Record review for Resident #49 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, muscle weakness and need for assistance with personal care. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. Resident #49 used a wheelchair for mobility, was always incontinent of bowel and bladder, required substantial/maximal assistance with toileting hygiene, personal hygiene, upper and lower body dressing and bed mobility. Review of the care plan dated 10/30/23 revealed Resident #49 had an activities of daily living (ADL) self-care performance deficit. Interventions included one-person assistance for toileting, and personal hygiene. Review of the care plan dated 10/30/23 revealed Resident #49 had incontinent episodes of bladder/bowel related to debility and impaired mobility. Interventions included to assist resident with toileting needs, and check resident at regular intervals and change as needed. Observation on 03/05/25 at 11:22 A.M. of incontinence care for Resident #49 completed by Certified Nursing Assistant (CNA) #241 revealed Resident #49's brief was saturated with urine and bowel movement (BM). Resident #49's buttocks was red and the skin on the buttocks and back was creased and wrinkled from the wrinkled bedding she had been lying on. CNA #241 stated this was the first time on this shift she had checked Resident #49 for incontinence needs due to being busy with other residents. 3. Record review for Resident #56 revealed an admission day of 05/15/23. Diagnoses included adult failure to thrive, overactive bladder, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact. Resident #56 used a walker and a wheelchair for mobility. Resident #56 was frequently incontinent of bowel and bladder. Resident #56 required supervision or touch assistance for toileting hygiene, partial/moderate assistance for upper body dressing, substantial/maximal assistance for lower body dressing, and partial moderate assistance for personal hygiene. Review of the care plan dated 09/20/23 revealed Resident #56 had an activity of daily living (ADL) self-care performance deficit. Interventions included supervision with ambulation, and one person assistant with toileting and personal hygiene. Review of the care plan dated 05/06/24 revealed Resident #56 had episodes of functional bowel and bladder incontinence. Interventions included to assist the resident with toileting needs, and check resident at regular intervals and change as needed. Observation on 03/05/25 at 11:38 A.M. of incontinence care for Resident #56 completed by Certified Nursing Assistant (CNA) #241 revealed Resident #56 was sitting up in her bed. Resident #56 had a hospital gown on with one gown in the front and an additional gown in the back covering her back side. Resident #56 stated she was saturated with urine and had been waiting all day to be changed. Resident #56 had a foul odor of urine. Observation revealed CNA #241 ambulated with Resident #56 using a rollator to the bathroom. Resident #56's gown was saturated with urine covering the entire back side. The sheet and bed pad where Resident #56 was sitting was also saturated with urine. Resident #56's saturated brief was bulging with urine. CNA #241 confirmed this was the first time today getting to Resident #56 to assist with incontinence care. Interview on 03/05/25 at 11:49 A.M. with the Director of Nursing (DON) stated residents were checked and changed per plan of care and every two hours. The DON confirmed day shift started at 6:00 A.M. until 2:00 P.M. The DON stated by 8:30 A.M., every resident should be seen, checked and changed if needed. Review of the facility policy titled Incontinence revised 10/26/23 revealed based on a resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. This deficiency represents noncompliance investigated under Complaint Number OH00161403.

Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident with a history of falls and was a fall risk. This affected one (Resident #68) of three residents reviewed for falls. The facility census was 73. Findings include: Record review for Resident #68 revealed an admitted [DATE]. Diagnoses included dementia, anxiety disorder, history of falling, unsteadiness on feet, muscle weakness, and need for assistance with personal care. Review of the census revealed Resident #68 moved from 100 hall to 200 hall on 12/11/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was moderately cognitively impaired. Resident #68 used a wheelchair for mobility, required supervision or touching assistance with personal hygiene, transfers, and toilet transfers. Resident #68 had no falls since prior assessment. Review of the care plan for Resident #68 updated 11/13/23 revealed Resident #68 was at risk for falls related to cognitive impairment, dementia, anxiety, depression, vision, incontinence, decreased safety awareness, and history of falls including fall with fracture. Interventions included hipsters as tolerated dated 09/24/23, call light within reach dated 09/24/23, call before fall sign in room dated 09/24/23, and remove the wheelchair from the room while in bed dated 09/24/23, and the resident to be up in common area as tolerated dated 11/25/24. Review of the fall risk evaluation dated 11/09/24 revealed Resident #68 had a score of eight. The evaluation did not explain what level the score of eight was. Review of the fall history for Resident #68 from 11/01/24 through 03/05/25 revealed Resident #68 had a fall on 11/05/24, 11/10/24, 11/14/24, 01/02/25, 01/26/25 (injuries included bleeding from previous skin tear left forearm), 02/05/25, 02/21/25 (injuries included obtained a skin tear to the right leg), and 02/28/25 (injuries included skin tear to the right arm). Observation on 03/05/25 at 8:52 A.M. revealed Resident #68 was lying in bed awake. Observation revealed Resident #68's wheelchair was next to her bed. There was no call before you fall sign, and the call light was dangling between the mattress and transfer bar onto the floor. Observation on 03/05/25 at 8:54 A.M. with Medication Technician #203 confirmed Resident #68 was awake, lying in bed. Resident #68's call light was not within reach, there was no sign in the room to remind Resident #68 to call before you fall, and the wheelchair was next to the bed. Medication Technician #68 verified Resident #68 had frequent falls and she kept her wheelchair by the bed. Medication Technician #203 then left the room without moving the wheelchair. Interview and observation on 03/05/25 at 9:04 A.M. with Certified Nursing Assistant (CNA) #202 stated she will assist Resident #68 up out of bed around 10:00 A.M. CNA #202 stated Resident #68 was up once this morning and put herself back to bed. At 9:10 A.M., CNA #202 stated she was ready now to get Resident #68 up. CNA #202 assisted Resident #68 to the wheelchair then transferred Resident #68 to the toilet. Resident #68 did not have hipsters on. CNA #202 assisted Resident #68 with peri care, dressing, and transferred her back to her wheelchair. CNA #202 never offered to assist Resident #68 to put on her hipsters. CNA #202 then transferred Resident #68 back to her bed. CNA #202 then asked Resident #68 if she was going to use her wheelchair or walker. Resident #68 replied her walker. CNA #202 said, Ok, well then I will leave it right here next to your bed. CNA #202 left the wheelchair and walker near Resident #68 before exiting the room. CNA #202 stated when Resident #68 was on the 100-hall, she wore hipsters but has not worn any while on the 200-hall. CNA #202 returned to Resident #68's room and verified Resident #68 did not have hipsters available in her room. CNA #202 stated she was unsure why Resident #68 did not wear hipsters anymore. CNA #202 again left the wheelchair and walker near Resident #68 before exiting the room. Interview on 03/11/25 at 2:37 P.M. with the Director of Nursing (DON) confirmed Resident #68 was at a high risk for falls. The DON confirmed Resident #68's fall interventions still included hipsters as tolerated, the call light within reach, a call before fall sign in room and remove the wheelchair from her reach while she was in bed. The DON stated she also put into place that Resident #68 was to be up in the common area when was awake due to her frequent falls. Review of the facility policy titled Accidents and Supervision revised 12/27/23 revealed each resident will be assessed for accident risk and will receive care in accordance with their individualized care plan. This deficiency represents noncompliance investigated under Complaint Number OH00162486.

Based on record review and interview, the facility failed to ensure Resident #74 and resident representatives were properly notified in writing of an emergency discharge for Resident #74. This affected one resident (Resident #74) of three residents reviewed for discharges. The facility census was 72. Findings include: Review of the closed record for Resident #74 revealed an admitted [DATE] with diagnoses including schizoaffective and mood affective disorder, unspecified intellectual disabilities, sexual dysfunction not due to a substance or known physiological condition, anxiety, insomnia, manic episodes, and assistance with personal care. Resident #74 was transferred to the hospital for an acute, inpatient psychiatric stay on 12/09/24 and did not return to the facility. Resident #74 had a legal guardian of person. Review of Resident #74's Minimum Data Set (MDS) 3.0 discharge return not anticipated assessment dated [DATE] revealed Resident #74 was modified independent for cognitive daily decision making, no delirium was noted. Resident #74 was positive for inattention, but no disorganized thinking or altered level of consciousness was noted. No hallucination noted but delusions were present. No physical behaviors towards others were displayed but verbal behaviors towards others were displayed daily. Rejection of care occurred daily and wandering occurred daily. Resident #74 was independent for eating, oral hygiene, dressing and toilet hygiene but needed supervision for showers. Resident #74 was independent with mobility such as rolling left and right in bed, sitting on the side of the bed and bed transfers but needed supervision for shower transfers. Resident #74 was independent to walk ten feet. Review of Resident #74's care plan, dated 11/18/24 revealed Resident #74 had behaviors related to a diagnosis of schizoaffective disorder, generalized anxiety disorder, unspecified mood disorder and manic episodes, dementia as evidenced by aggressively hugging and grabbing staff, pacing throughout facility without footwear, attempts to chase after staff, nonsensical statements verbally and written notes on a note pad, taking items from residents rooms, and refused medication. Intervention included offer and provide activities of interest to keep resident engaged, administer medication as ordered, engage resident in simple, structured activities that avoid overly demanding tasks, labs as ordered, notify physician of any significant change in resident's baseline cognitive status. Physical therapy, occupational therapy and speech therapy as needed. Refer to psychological/psychiatrist as needed. Review of the Situation Background, Assessment and Recommendation (SBAR) note dated 12/09/24 at 11:00 A.M. written by Nurse Practitioner (NP) #511 revealed Resident #74 had a change in condition with psychotic behaviors that started on 12/06/24 and have gotten worse. Worse behaviors included following staff, unable to re-direct regarding personal space. Resident refused to allow vitals to be taken. Treatment included as needed psychological medication and inpatient psych stay. Resident #74 was admitted to the nursing home for long term needs. Mental status changes included new or worsening behavior symptoms, no functional status change, no gastrointestinal change, no urine change. Problems included increased psychotic behaviors due to inability to self-regulate, medication was ineffective, inappropriate level of care in facility. It was suggested Resident #74 transfer to the hospital. Guardian was notified of erratic behaviors, ineffective medication, inability to redirect, threatening others, intrusiveness, inappropriate touching and obsession with religion. The facility notified the guardian/mother of intention to send to the emergency department and not accept Resident #74 back since this was not an appropriate environment for Resident #74 to live in. Review of the facility document Application for Emergency Admission (commonly known as pink slip which commits the resident involuntarily to the hospital), dated 12/09/24, revealed Resident #74 represented a substantial risk of physical harm to others manifested by evidence of recent homicidal or other violent behavior and would benefit from treatment in a hospital for his mental illness and was in need of such treatment as manifested by evidence of behavior that created a grave and imminent risk to substantial right of others or himself. The documented revealed Resident #74 was exhibiting threatening, impulsive behaviors since admission. Behaviors escalated into obsession about religious persecution and ideation and threats of physical harm. Resident #74 was intrusive, threatening towards other nursing home residents and had threatened to kill staff members and was physically capable of acting out these threats. Resident #74 experienced auditory hallucinations but would not reveal what the voices said. Resident #74 had attempted to leave the facility unattended by going to the exit doors and pushing on the doors. This created a substantial risk to his safety as well as others because the facility was located on a highway exit. Resident #74 required admission to an inpatient intensive psychiatric stay to improve the quality of life and to provide safety to the community. The Application for Emergency Admission was signed by the facility Medical Doctor # 513. Review of the facility document titled Immediate Involuntary Discharge, dated 12/09/24, revealed the document indicated it was hand delivered. The document indicated Resident #74 was notified he was immediately discharged because an emergency arose in which the safety of individuals in the home was endangered. Resident #74 had the right to request an impartial hearing at the facility concerning the proposed discharge. Resident #74 could challenge the discharge and request a hearing by sending in a request by resident or sponsor for a hearing within 30 days of receipt of the notice to the Ohio Department of Health Legal Services Office. If the resident or sponsor received the request within 10 days of the date of the notice, the facility would not discharge the resident prior to the hearing. Agency contact and Ombudsman contact information was provided. Interview on 01/08/25 at 8:18 A.M. with the hospital Supervisor of Behavior Health Social Work ( SBHSW) #510 revealed Resident #74 was sent to the in-patient psychiatric unit for help and the current nursing facility he resided in would not take him back so he was still at the hospital while they tried to find him placement. The facility dropped off his belongings with a letter of immediate discharge in the bag which was not brought to the hospital or resident's attention at the time his belongings were dropped off at the hospital. SBHSW #510 stated Resident #74's mother and guardian stated to SBHSW #510 they did not receive an immediate discharge notice from the facility. Interview on 01/08/25 at 4:00 P.M. with Ombudsman #509 revealed the facility provided an immediate discharge notice to the hospital by placing it in Resident #74's bag of belongings the facility dropped off. Ombudsman #509 stated Resident #74's mother wanted him to return to the same nursing facility upon discharge from the hospital because he needed assistance with medication. Ombudsman #509 stated Resident #74's mother and legal guardian had not received in writing notification of emergency discharge. Interview on 01/08/25 at 4:32 P.M. with Resident #74's Legal Guardian #507 revealed as of 01/07/25 she was transitioned as legal guardian, but Resident #74's mother still had input in Resident #74's care. Legal Guardian #507 stated the nursing facility stated they could not handle his care so they implemented an emergency discharge. Legal Guardian #507 stated the facility did not communicate when Resident #74 was admitted to the hospital therefore Resident #74's mother was not able to communicate with her son in the hospital. Interview on 01/09/25 at 9:47 A.M. with facility Nurse Practitioner (NP) #511 revealed the facility recommended a pink slip because Resident #74 was running up the hallway, threatening staff and felt residents were not safe. NP #511 verified Resident #74 was immediately involuntarily discharged to the hospital on 12/09/24. Interview on 01/09/25 at 10:37 A.M. with the facility Social Services (SS) #503 verified Resident #74 was emergently discharged from the facility on 12/09/24 because of behaviors the facility could not manage placing other residents at risk. SS #503 also verified Resident #74's guardian or mother did not receive a 30-day discharge notice or right to appeal but was sent an emergent discharge notice and she did not call the hospital for discharge planning or goals to ensure the notice in writing was received by the resident or legal guardian. Interview on 01/09/25 at 11:00 A.M. with the Administrator who revealed the facility transportation person hand delivered the immediate discharge document to the resident in the emergency room , and the immediate discharge notice was sent to the Guardian and mother by mail but not certified mail so there was no evidence either had received the written notice. Interview on 01/09/25 at 1:14 P.M. with Resident #74's mother revealed currently the hospital could not find a nursing facility for her son to live and the facility would not take her son back. The facility did not tell her Resident #74 was discharged so she thought Resident #74 would be returning to the facility. She stated she never received an immediate discharge notice. Resident #74's mother also stated at no time did she agree with the facility not to take her son back. Interview on 01/09/25 at 1:47 P.M. with the Director of Nursing ( DON) revealed the immediate discharge letter was not sent by certified mail to Resident #74's mother or guardian therefore she had no proof the letter was sent. The DON also stated the facility did not plan to take Resident #74 back so he was discharged to the hospital with no anticipated return. Interview on 01/09/25 at 2:13 P.M. with hospital SBHSW #510 revealed on 12/10/24 Resident #74's mother stated she wanted her son to return to the facility and did not know her son was discharged from the facility. SBHSW #510 further added the immediate discharge letter was not hand delivered to the resident. Resident #74 was in the emergency department on 12/09/24 at 5:46 P.M. and was transferred to the psychiatric unit on 12/10/24 at 1:10 A.M., and all of resident #74 's belongings were brought with him from the emergency department. On 12/10/24 at 2:55 P.M. hospital security notified her Resident #74's belongings were dropped off on the second floor of the hospital. When SBHSW #510 inspected the bag on the unit the immediate discharge letter was in the bag of resident's belongings which the resident did not have access to. Review of facility policy titled Readmission to Facility dated 07/28/20 revealed if the facility does not permit the resident to return to the facility, the facility must notify the resident and resident representative in writing of the discharge including appeal rights. This deficiency represents non-compliance investigated under Complaint Number OH00160679.

Based on record review, interview and review of facility policy, the facility failed to collaborate with the hospital to ascertain an accurate status of Resident #74's condition before refusing to allow Resident #74 to return to the facility after hospitalization . This affected one resident (Resident #74) of three residents reviewed for discharges. The facility census was 72. Findings include: Review of the closed record for Resident #74 revealed an admitted [DATE] with diagnoses including schizoaffective and mood affective disorder, unspecified intellectual disabilities, sexual dysfunction not due to a substance or known physiological condition, anxiety, insomnia, manic episodes, and assistance with personal care. Resident #74 was transferred to the hospital for an acute, inpatient psychiatric stay on 12/09/24 and did not return to the facility. Resident #74 had a legal guardian of person. Review of Resident #74's Minimum Data Set (MDS) 3.0 discharge return not anticipated assessment dated [DATE] revealed Resident #74 was modified independent for cognitive daily decision making, no delirium was noted. Resident #74 was positive for inattention, but no disorganized thinking or altered level of consciousness was noted. No hallucination noted but delusions were present. No physical behaviors towards others were displayed but verbal behaviors towards others were displayed daily. Rejection of care occurred daily and wandering occurred daily. Resident #74 was independent for eating, oral hygiene, dressing and toilet hygiene but needed supervision for showers. Resident #74 was independent with mobility such as rolling left and right in bed, sitting on the side of the bed and bed transfers but needed supervision for shower transfers. Resident #74 was independent to walk ten feet. Review of Resident #74's care plan, dated 11/18/24 revealed Resident #74 had behaviors related to a diagnosis of schizoaffective disorder, generalized anxiety disorder, unspecified mood disorder and manic episodes, dementia as evidenced by aggressively hugging and grabbing staff, pacing throughout facility without footwear, attempts to chase after staff, nonsensical statements verbally and written notes on a note pad, taking items from residents rooms, and refused medication. Intervention included offer and provide activities of interest to keep resident engaged, administer medication as ordered, engage resident in simple, structured activities that avoid overly demanding tasks, labs as ordered, notify physician of any significant change in resident's baseline cognitive status. Physical therapy, occupational therapy and speech therapy as needed. Refer to psychological/psychiatrist as needed. Review of the Situation Background, Assessment and Recommendation (SBAR) note dated 12/09/24 at 11:00 A.M. written by Nurse Practitioner (NP) #511 revealed Resident #74 had a change in condition with psychotic behaviors that started on 12/06/24 and have gotten worse. Worse behaviors included following staff, unable to re-direct regarding personal space. Resident refused to allow vitals to be taken. Treatment included as needed psychological medication and inpatient psychiatric stay. Resident #74 was admitted to the nursing home for long term needs. Mental status changes included new or worsening behavior symptoms, no functional status change, no gastrointestinal change, no urine change. Problems included increased psychotic behaviors due to inability to self-regulate, medication was ineffective, inappropriate level of care in facility. It was suggested Resident #74 transfer to the hospital. Guardian was notified of erratic behaviors, ineffective medication, inability to redirect, threatening others, intrusiveness, inappropriate touching and obsession with religion. The facility notified the guardian/mother of intention to send to the emergency department and not accept Resident #74 back since this was not an appropriate environment for Resident #74 to live in. Review of an interdisciplinary progress note dated 12/09/24 at 12:58 P.M. written by Licensed Practical Nurse (LPN)/Unit Manager (UM) #502 revealed Resident #74 stated he heard voices. Resident #74 stated the voices told him to do things he did not want to do. When asked if the voices were telling Resident #74 to harm himself or others, Resident #74 refused to answer and walked away. Review of the Social Services progress note dated 12/09/24 at 5:35 P.M. revealed the Director of Nursing (DON) and medical doctor planned for Resident #74 to transfer to the emergency room for psychological evaluation and treatment. It was reported that over the weekend Resident #74 had increased agitation, disruptive behavior in group settings and during church services. Resident #74 was placed on a one-on-one monitoring but too much stimulation according to social services. Resident #74 paced around common areas, did not respect others space, raised his voice, unpredictable and was not appropriate for this setting. The note indicated the facility was working with Resident #74's case manager to find alternative placement for him. Review of the interdisciplinary progress note dated 12/09/24 written by Registered Nurse (RN) #500 revealed Resident #74 disrupted church service by attempting to take the pastor's bible. Resident #74 stated he was the dark angel and you need to hear what I have to say. Resident was unable to be re-directed. Resident #74 stated don't you know who I am, we are all going to be murdered like the CEO of United Healthcare and there's nothing you can do to stop it. Resident #74 was approached by RN #500 and agreed to go in his room to watch football. Resident #74 was medicated with evening medication and as needed Zyprexa (antipsychotic medication) was provided. One-on-one continued. Review of the facility document Application for Emergency Admission (commonly known as pink slip which commits the resident involuntarily to the hospital), dated 12/09/24, revealed Resident #74 represented a substantial risk of physical harm to others manifested by evidence of recent homicidal or other violent behavior and would benefit from treatment in a hospital for his mental illness and was in need of such treatment as manifested by evidence of behavior that created a grave and imminent risk to substantial right of others or himself. The documented revealed Resident #74 was exhibiting threatening, impulsive behaviors since admission. Behaviors escalated into obsession about religious persecution and ideation and threats of physical harm. Resident #74 was intrusive, threatening towards other nursing home residents and had threatened to kill staff members and was physically capable of acting out these threats. Resident #74 experienced auditory hallucinations but would not reveal what the voices said. Resident #74 had attempted to leave the facility unattended by going to the exit doors and pushing on the doors. This created a substantial risk to his safety as well as others because the facility was located on a highway exit. Resident #74 required admission to an inpatient intensive psychiatric stay to improve the quality of life and to provide safety to the community. The Application for Emergency Admission was signed by the facility medical doctor # 513. Further review of Resident #74's medical record revealed no documentation after 12/09/24 that attempts had been made by the facility, the facility physician or nurse practitioner to collaborate with the hospital to assess Resident #74's mental health status to determine if he was stable for discharge back to the facility. Review of the facility document titled Immediate Involuntary Discharge, dated 12/09/24, revealed the document indicated it was hand delivered. The document indicated Resident #74 was notified he was immediately discharged because an emergency arose in which the safety of individuals in the home was endangered. Resident #74 had the right to request an impartial hearing at the facility concerning the proposed discharge. Resident #74 could challenge the discharge and request a hearing by sending in a request by resident or sponsor for a hearing within 30 days of receipt of the notice to the Ohio Department of Health Legal Services Office. If the resident or sponsor received the request within 10 days of the date of the notice, the facility would not discharge the resident prior to the hearing. Agency contact and Ombudsman contact information was provided. Interview on 01/08/25 at 8:18 A.M. with the hospital Supervisor of Behavior Health Social Work ( SBHSW) #510 revealed Resident #74 was sent to the in-patient psychiatric unit for medication management and psychiatric stabilization and the current nursing facility he resided in would not take him back so he was still at the hospital while they tried to find him placement. The facility dropped off his belongings with a letter of immediate discharge in the bag which was not brought to the hospital or resident's attention at the time his belongings were dropped off at the hospital. SBHSW #510 stated Resident #74's mother and guardian stated to SBHSW #510 they did not receive an immediate discharge notice from the facility. SBHSW #510 stated the facility refused to perform an onsite visit of Resident #74. SBHSW #510 stated the worst of Resident #74's behaviors consisted of raised voice but was redirectable, there was no sexually inappropriate touching, or need for physical restraints while admitted to the hospital the past 29 days or a need for seclusion. Resident #74 took his medication, and the last time Resident #74 needed as needed medication was 01/06/25 per physician progress notes. SBHSW #510 stated at no time did the nursing facility physician or nurse practitioner reach out to the hospital social worker or physician regarding discharge needs. SBHSW #510 stated Resident #74 was stable and ready for discharge back to the nursing facility which he considered his home. Interview on 01/08/25 at 4:00 P.M. with Ombudsman #509 revealed the facility provided an immediate discharge notice to the hospital by placing it in his bag of belongings the facility dropped off. Ombudsman #509 stated Resident #74's mother wanted him to return to the same nursing facility upon discharge from the hospital because he needed assistance with medication. Ombudsman #509 stated the facility had not sent a liaison to the hospital to assess if Resident #74 was appropriate for re-admission to the facility. Interview on 01/08/25 at 4:32 P.M. with Resident #74's Legal Guardian #507 revealed as of 01/07/25 she was transitioned as legal guardian but Resident #74's mother still had input in Resident #74's care. Legal Guardian #507 stated the nursing facility stated they could not handle his care but in the hospital emergency room he did not display the same behaviors. Legal Guardian #507 stated the facility did not communicate when Resident #74 was admitted to the hospital therefore Resident #74's mother was not able to communicate with her son in the hospital. At no time had the facility physician or nurse practitioner reached out to Legal Guardian #507. Legal Guardian stated they would like Resident #74 back in the nursing facility. Interview on 01/09/25 at 9:47 A.M. with facility Nurse Practitioner (NP) #511 revealed the facility recommended a pink slip because Resident #74 was running up the hallway, threatening staff and felt residents were not safe. NP #511 verified she did not reach out the hospital to assess if Resident #74 was safe for discharge back to the facility. NP #511 stated as of her assessment , the nursing facility was meeting Resident #74's needs. NP #511 verified she did not speak with Legal Guardian #507 or Resident #74's mother regarding discharge from the facility. Interview on 01/09/25 at 10:37 A.M. with the facility Social Services (SS) #503 verified she did not speak with the hospital regarding if Resident #74 was stable or appropriate to return to the nursing facility, and the hospital only spoke with the Administrator. SS #503 verified the facility had been looking into placing him at another facility but Resident #74's guardian or mother did not receive a 30-day discharge notice or right to appeal, but instead was sent an emergent discharge notice. SS #503 verified she did not call the hospital for discharge planning or goals. Interview on 01/09/25 at 11:00 A.M. with the Administrator revealed the police were called regarding Resident #74's behaviors but no reports were made by the police because Resident #74 did not display behavior in front of the police. The Administrator stated the facility transportation person hand delivered the immediate discharge document to the resident in the emergency room . The immediate discharge notice was sent to the Guardian and mother by mail but not certified mail. The Administrator stated the hospital had stated Resident #74 was stable and the facility physician had not reached out to the hospital. The Administrator further stated the facility intention on 12/09/24 was to send Resident #74 to the hospital to stabilize and he would come back. She did not believe the hospital version of stable was the same version of stable as the nursing facility. The Administrator stated the facility could not take Resident #74 because the facility did not provide enough structure and there were some concerns for elopement. The Administrator stated Resident #74's mother did stated she wanted Resident #74 in a nursing home and to return back to his facility not back to his previous facilities. Interview on 01/09/25 at 11:35 A.M. with psychiatric NP #512 revealed Resident #74 displayed no physical abuse towards other resident , and Resident #74 did not make clear homicidal or suicidal indication during her assessment. Resident #74 needed one-on-one supervision because she felt he could be a threat to other residents. NP #512 stated the facility was capable of handling Resident #74's behavior. NP #512 did not recall that Resident #74 displayed violent or physical abuse to other residents in the nursing facility. NP #512 stated she assessed Resident #74 on her initial visit 11/11/24 and planned on visiting him every one to two months. NP #512 stated she was planned to see Resident #74 again but he was sent out to the hospital. NP #512 verified she did not speak with the hospital because she did not know he was sent to the hospital and felt Resident #74 could come back to the facility if Resident #74's mood and behavior was well managed such as 24/7 supervision. Interview on 01/09/25 at 12:29 P.M. with Unit Manager LPN # 502 revealed Resident #74 was not able to take his own medication and needed supervision with showers. Resident #74 did not physically assault another resident, and did not verbally or sexually assault another resident while admitted to the facility. Unit Manager LPN #502 verified she had not spoken with the hospital regarding Resident #74 status or visit Resident #74 on site. LPN #502 stated once Resident #74 stated he wanted to hurt himself but did not have a plan. Interview on 01/09/25 at 12:35 P.M. with Registered Nurse (RN) #500 revealed she worked the day Resident #74 was sent to the hospital. Resident #74 was hard to redirect, yelled and ran down the hallway. RN #500 stated Resident #74 never hit another resident or had an incident of sexual assault to another resident. Resident #74 could be verbally assaultive but could not provide an instance. Interview on 01/09/24 at 12:55 P.M. with Certified Nurse Assistant (CNA) #504 revealed the facility had educated staff on behavior management of residents and Resident #74 threatened staff but not residents. Resident #74 did not display physical or sexual assault to another resident. Interview on 01/09/25 at 1:12 P.M. with CNA #514 revealed the facility educated her on behavior management of residents and stated one time Resident #74 grabbed another resident's wheel chair but Resident #74 thought he was helping. Resident #74 did not physically hit another resident only threatened staff. Resident #74 did not sexually assault anyone but was verbally inappropriate. CNA #514 stated the facility was equipped to manage residents with behavior problems. Interview on 01/09/25 at 1:14 P.M. with Resident #74's mother revealed currently the hospital could not find a nursing facility for her son to live and the facility would not take her son back. The facility did not tell her Resident #74 was discharged . She stated she never received a 30-day discharge notice nor the immediate discharge notice. Resident #74's mother also stated at no time did she agree with the facility not to take her son back. Interview on 01/09/25 at 1:47 P.M. with the Director of Nursing ( DON) revealed the immediate discharge letter was not sent by certified mail to Resident #74's mother or guardian therefore she had no proof the letter was sent. The DON also stated the facility did not plan to take Resident #74 back so he was discharged to the hospital with no anticipated return. Interview on 01/09/25 at 2:13 P.M. with hospital SBHSW #510 revealed on 12/10/24 Resident #74's mother stated she wanted her son to return to the facility and did not know her son was discharged from the facility. The immediate discharge letter stated it was hand delivered but it was not. On 12/11/24 the hospital social worker reached out to the facility stating Resident #74 was safe for discharge, but the facility responded Resident #74 was an immediate discharge and would not take Resident #74 back. On 12/12/24 the hospital reached out to the facility stating Resident #74's medication was changed and Resident #74 was compliant and able to be redirected. The hospital offered an on-site visit, but the facility responded, not able to accept patient. On 12/19/24 the hospital SW reached out to the facility, but the Administrator responded the denial was upheld by the facility. Resident #74 had stated to the hospital the facility was his home, and he wanted to return. SBHSW #510 further added the immediate discharge letter was not hand delivered to the resident. Resident #74 was in the emergency department on 12/09/24 at 5:46 P.M. and was transferred to the psychiatric unit on 12/10/24 at 1:10 A.M., and all of resident #74 's belongings were brought with him from the emergency department. On 12/10/24 at 2:55 P.M. hospital security notified her Resident #74's belongings were dropped off on the second floor of the hospital. When SBHSW #510 inspected the bag on the unit the immediate discharge letter was in the bag of resident's belongings. Review of facility policy titled Readmission to Facility dated 07/28/20 revealed if a resident was transferred to the hospital due to a resident's clinical or behavioral condition, the facility would evaluate the resident to determine if the resident still required the services of the facility and was eligible for Medicare skilled nursing facility or Medicaid nursing facility services. The facility would also determine the accurate status of a resident's condition to ensure the resident's needs were within the facilities scope of care. This deficiency represents non-compliance investigated under Complaint Number OH00160679.

Based on medical record review, review of the ambulance run report, review of hospital documents, review of the facility Self-Reported Incident (SRI) investigation, and interviews, the facility failed to ensure Resident #73 was provided a transfer to bed in a safe manner to prevent an incident/accident with major injury. Actual harm occurred on 08/25/24 when Resident #73, who was severely cognitively impaired and dependent on two staff with maximal assistance needed for transfers, sustained a 10-centimeter laceration that went to the bone with profuse bleeding to her right calf during a staff assisted transfer. As a result of the incident/injury, Resident #73 was emergently transferred to the local hospital on 08/25/24 for treatment which included 21 sutures to the wound. The resident also exhibited increased pain because of the injury as evidenced by her yelling out following the incident. This affected one resident (Resident #73) of four residents reviewed for accident hazards. The facility census was 69. Findings include: Review of Resident #73's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease with late onset, dementia, cerebral vascular accident, hemiplegia, hemiparesis affecting the right dominant side, chronic kidney disease (Stage 3B), and hypertension. Resident #73 was discharged on [DATE] to the local hospital and then discharged home with her family from the hospital on 08/27/24. Review of Resident #73's care plan which was initiated on 08/12/24 revealed a care plan related to the resident having an activity of daily living (ADL) self-care performance deficit with interventions including one person assist for bed mobility, toileting/incontinence care, supervision with meals with staff to offer assistance with meal setup as needed. Additionally, there was an intervention initiated on 08/28/24 for a transfer status requiring two staff members and the use of the Hoyer(mechanical) lift. Review of Resident #73's physician orders dated August 2024 revealed there were no orders indicating how the resident should be transferred. Review of Resident #73's progress notes revealed there was an entry made on 08/25/24 at 11:10 P.M. authored by Licensed Practical Nurse (LPN) #655 indicating she was called into the resident's room for bleeding. LPN #655 pulled the resident's pant leg back and noticed excessive bleeding. The nurse applied pressure, cleaned and wrapped the resident's leg and called 911 for the resident to go to the emergency room (ER). There was no documentation explaining how the injury happened or whether the family or the physician were notified of the resident's transfer to ER. Review of the ambulance run report dated 08/25/24 revealed a 911 call was received at 9:39 P.M., the ambulance was dispatched to the facility at 9:41 P.M., arrived on scene at 9:48 P.M., made first contact with Resident #73 at 9:51 P.M., and departed the facility with Resident #73 at 10:07 P.M. The report revealed Emergency Medical Services (EMS) were dispatched to the facility for a female resident with a leg injury. Upon arrival EMS found the resident in bed, with her lower right leg wrapped. A nurse in the room advised EMS the resident had a six-inch laceration down to the bone and it was unknown how it happened. The nurse stated the leg was spurting blood. EMS were unable to examine the wound because the resident was not allowing them to touch her leg. Review of the local hospital paperwork revealed Resident #73 was brought to the emergency roiagnom on [DATE] at 10:24 P.M. and discharged home with her family on 08/27/24. The findings at the hospital included the resident had a 10-centimeter laceration to her right calf exposing bone and requiring 21 sutures. The laceration was thought to be caused by an accident at the facility. Resident #73 was not able to provide any history due to severe dementia and the resident's daughter said they did not know how the injury occurred but verified it did occur at the facility. Diagnostic work up included x-rays/scans to the head, pelvis and lower extremities. Besides the soft tissue swelling at the site of the laceration on the right calf, there were no additional findings of fractures or other acute injuries. There were no indications of infection related to the laceration. Review of Resident #73's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. The assessment revealed Resident #73 required set-up or clean up assistance for eating and was dependent on staff for all other ADL care including oral hygiene, toileting, showers, dressing, personal hygiene, and bed mobility. The assessment indicated Resident #73 was dependent on maximal assistance from two staff members for all transfers. Review of a facility Self-Reported Incident (SRI) dated 08/26/24 revealed the facility reported an injury of unknown origin involving Resident #73. Information contained in the SRI revealed Resident #73 sustained a laceration to the right lower extremity on 08/25/24 while being transferred to bed by State tested Nursing Assistant (STNA) #640 and STNA #658. The SRI noted the facility did not determine the incident was a result of resident abuse. Review of a witness statement dated 08/25/24 and authored by Licensed Practical Nurse (LPN) #655 revealed she had been sitting at the nurse's station when both aides came to me stating (resident's name) was bleeding from leg. I went to room, pulled down resident pant legs and notice blood and deep cut. I asked what happen, both aides stated they did not know. Resident was screaming in pain. I applied pressure to wound cleaned and called 911 to be sent out. Review of a witness statement dated 08/25/24 and authored by STNA #626 revealed Resident #73 had been sitting at the nurse's station until it was time for her to go to bed. Around 9:30 P.M. two aides (no names specified) went into her room to put her to bed, and one came back out yelling she was bleeding and went into the bathroom to clean up. STNA #626 went to help the nurse with Resident #73 and Resident #73 was laying in bed yelling while the nurse pulled up the resident's pant leg back and that was when STNA #626 saw the wound and blood all on the floor. There was no indication in the witness statement that Resident #73 had been bleeding while in the hallway prior to being transferred to bed by STNA #640 and STNA #658. Review of a witness statement dated 08/25/24 and authored by STNA #640 revealed she took Resident #73 to the nurse's station after dinner. At 9:30 P.M. she transferred Resident #73 to her bed with the assistance of STNA #658 and noticed blood. Before dinner, STNA #640 and STNA #658 had stood Resident #73 up to check her brief and it was dry, so they took her to the dining room for dinner. There was no indication in the witness statement that Resident #73 had been bleeding while at dinner prior to being transferred to bed by STNA #640 and STNA #658. Interview on 10/01/24 at 1:18 P.M. with Family Member #800 revealed they initially were told by the facility staff that the staff did not know how the injury occurred, however, after asking multiple questions they stated STNA #640 and STNA #658 explained to them it happened during the transfer from the resident's transport chair to the resident's bed. Family Member #800 stated STNA #640 and STNA #658 told them when they were transferring the resident with only two staff members it was difficult to do the transfer, and they should have been using a Hoyer lift on her. Family Member #800 felt the injury could have been avoided if they were transferring the resident correctly. Interview on 10/02/24 at 9:40 A.M. with LPN #655 revealed on 08/25/24 Resident #73 was taken down to her room so she could be put to bed. One STNA came out of the resident's room yelling the resident was bleeding and she had blood all over her pants and hands. The nurse went to the resident's room immediately and found the resident was laying in bed, she had on grey sweatpants and the resident's right leg was wet with blood, so she pulled the resident's pant leg back and found a bleeding laceration with blood coming out very fast, so she immediately applied pressure. LPN #655 stated there was a second nurse in the room who went to get supplies to dress the laceration. LPN #655 then stated she called the Director of Nursing (DON) on facetime to show her the resident's leg. The DON directed her to dress it and to call 911 to have the resident go to the emergency room (ER). LPN #655 stated she knew the resident would need stitches. She stated two STNAs transferred the resident to bed. When asked when the last time she saw the resident she stated just prior to the STNAs putting her to bed at the nurse's station. LPN #655 stated there was no blood at the nurse's station, however there was blood on the resident's floor next to and under her bed. LPN #655 did state she spoke to the resident's daughter and son. She stated Resident #73's son did call back in and began to ask questions on how the injury happened. LPN #655 stated she told the son it happened when the two STNAs transferred Resident #73 to bed. LPN #655 stated they told the resident's son she did not know exactly what happened though due to not being in the room for the transfer. LPN #655 also stated she had not received any education recently on gait belt use, resident transfer status, or with reporting changes. She stated she did not attend an in-person training, nor did she receive any messages from the facility regarding any education following the incident. Interview on 10/02/24 at 1:00 P.M. with the DON verified Resident #73 required the use of a mechanical (Hoyer) lift with two staff members for transfers since her admission on 08/12/24. The DON then stated there had been a communication breakdown between therapy and the nursing department on Resident #73's transfer status. She also confirmed at this time there were no behaviors documented for Resident #73, although she was anxious and would become resistive to care at times. Interview on 10/02/24 at 1:14 P.M. with Physical Therapist (PT) #675 revealed he completed an initial therapy assessment on Resident #73, and he was able to transfer the resident with a stand pivot technique. He stated he felt if the staff on the floor were to transfer the resident with two staff members, they would be able to complete the transfer with no issues but had heard some of the STNAs were having difficulty with this type of transfer. PT #675 denied being asked to re-evaluate the resident's transfer status. PT #675 stated after the incident on 08/25/24 he completed re-assessments on resident's related to their transfer status to ensure all were correct and adjustments were made if needed. Interview on 10/02/24 at 1:30 P.M. with Certified Occupational Therapy Assistant (COTA) #676 revealed Resident #73 did receive Occupational Therapy (OT) where they did stretch exercises with the resident. COTA #676 stated she remembered hearing Resident #73 was difficult to transfer. Interview on 10/02/24 at 2:05 P.M. with the DON revealed the facility had not completed any type of inspection on the resident's wheelchair (which had been brought with her at the time of admission). She stated the family brought the resident to the facility in a transport chair and they did not issue the resident a standard wheelchair. The family came in at around 7:00 A.M. on 08/26/24 and took all the residents' belongings including the transport chair. Interview on 10/02/24 at 3:07 P.M. with STNA #640 revealed she was assigned to Resident #73 on 08/25/24. STNA #640 stated she waited to put the resident to bed until last and had her at the nurse's station due to the resident being a fall risk. STNA #640 stated once STNA #658 came back in from supervising a smoke break with other residents between 9:30 P.M. and 9:45 P.M. STNA #658 stated Resident #73 was a two-assist transfer so both STNA's transferred the resident to her bed. As STNA #658 was lifting Resident #73's legs into the bed Resident #73 began to scream my leg, my Leg!. STNA #640 stated STNA #658 had blood all over her hands and on her pants. STNA #640 stated as STNA #658 ran out of the room she yelled to the nurse the resident was bleeding. STNA #640 stated there was a puddle of blood on the floor and the resident's sweatpants were soaked in blood on the right pant leg. STNA #640 stated when the resident first arrived at the facility no one informed her how to transfer the resident and Resident #73 was a very difficult two- person transfer. STNA #640 stated she felt the resident should have been a Hoyer lift. STNA #640 stated the resident was not able to help with the transfer as she could not or would not bear weight on her right leg as it was affected from when the resident had a previous stroke prior to coming to the facility. STNA #640 stated the resident was not anxious or combative with care as she was joking with STNA #658 prior to the transfer and hugged her. STNA #640 stated she was unsure what the resident cut her leg on but knew it happened during the transfer. There was no information provided during the interview to indicate the staff used a mechanical (Hoyer) lift at the time of this transfer. Interviews conducted on 10/02/24 at 3:55 P.M. with STNA #614 and at 3:59 P.M. with Registered Nurse (RN) #612 revealed they had not received any education recently on gait belt use, resident transfer status, or with reporting changes. They stated they did not attend any type of in-person training, nor did they receive any messages from the facility regarding education following the incident with Resident #73 on 08/25/24. Interview on 10/03/24 at 4:21 P.M. with STNA #658 verified she helped put Resident #73 to bed the night of 08/25/24. STNA #658 stated she was unsure of the time, but stated it was after the 9:00 P.M. smoke break. She stated Resident #73 did not bear weight and they would have to physically pick the resident up when transferring her to bed. The STNA also stated she did not believe the resident was using an appropriate wheelchair as the family brought her to the facility in a transport chair and they were not issued a standard wheelchair for the resident. STNA #658 stated she and STNA #640 manually transferred Resident #73 to bed and were picking up the resident's legs when they felt something wet. When she looked down there was blood all over her hands and on her pant leg. STNA #658 stated she ran out of the room and yelled for the nurse and ran to the bathroom to wash her hands and pant leg. STNA #658 stated she went back down to the room and found two nurses and STNA #640 applying pressure to the resident's leg and trying to dress it. STNA #658 stated there was blood dripping on the floor in a puddle and there was blood all over the resident's bed. STNA #658 stated an ambulance showed up and took the resident to the hospital, and the resident did not return to the facility. STNA #658 stated she was unsure what the resident cut her leg on but knew it happened during the transfer. There was no information provided during the interview to indicate the staff used a mechanical (Hoyer) lift at the time of this transfer. Interview on 10/08/24 at 5:23 P.M. with the DON confirmed Resident #73 had a transfer status in her care plan initiated on the day of admission 08/12/24 indicating the resident was to be transferred with the use of two staff members. The DON stated this was triggered from answers given during the completion of the admission assessment. The DON stated she was unsure who completed the admission assessment. Review of the facility policy titled Accidents and Supervision, date revised 12/27/23, revealed each resident would be assessed for accident risk and would receive care and services in accordance with their individualized care plan. Each resident would receive adequate supervision and assistive devices to prevent accidents including identifying, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring effectiveness and modifying interventions when necessary. An accident was defined as any unexpected or unintentional incident which resulted in injury or illness to the resident. Hazards referred to elements in the resident environment that had the potential to cause injury or illness. Risk referred to any external factor, facility characteristics (e.g.: staffing or physical environment) or characteristic of an individual resident that increases the likelihood of an accident. Supervision/Adequate Supervision referred to intervention and means of mitigating risk of an accident. The facility should make a reasonable effort to identify the hazards and risks for each resident. The facility should use specific interventions to try to reduce a resident's risk from hazards including providing training to staff, communicating the interventions to relevant staff and implementing specific interventions as part of the care plan. This deficiency represents non-compliance investigated under Complaint Number OH00157777.

Based on observation, record review, and interviews the facility failed to ensure all treatments were completed per physician orders for Resident #39. This affected one resident (Resident #39) of four residents reviewed for treatment administration. The facility census was 69. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses including malignant neoplasm of the skin, hypothyroidism, dementia, Alzheimer's disease, and hypertension. Review of Resident #39's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Resident #39 required set up help only for eating, partial to moderate assistance for oral hygiene, substantial to maximal assistance for toileting, dressing, personal hygiene, and bed mobility. Resident #39 was dependent for showers. Review of Resident #39's physician orders dated August 2024, September 2024, and October 2024 revealed orders to cleanse biopsy sites with soap and water, Mupirocin two percent (2%) cream to be applied to biopsy sites and covered with a bandage daily for 10 to 14 days post procedure. Review of Resident #39's Treatment Administration Record (TAR) dated August 2024 and September 2024 revealed the treatment to her biopsy sites were not completed on 08/28/24, 08/29/24, 09/07/24, 09/08/24, 09/23/24, 09/26/24, 09/29/24, and 09/30/24. Interviews conducted throughout the survey on 10/01/24 at 2:18 P.M. with Registered Nurse (RN) #605, on 10/02/24 at 9:40 A.M. with Licensed Practical Nurse (LPN) #655 and on 10/03/24 at 3:52 P.M. to 3:59 P.M. with RN #612 and RN #648 verified there were times when Resident #39 did not have her treatment to the biopsy sites completed as ordered by the physician. Interview conducted on 10/01/24 at 3:02 P.M. with Resident #13, on 10/02/24 at 11:00 A.M. and 2:15 P.M. with Resident #65 and Resident #64, and on 10/03/24 between 3:48 P.M. to 4:02 P.M. with Resident #53, #69 and #70 revealed at times their treatments were not completed as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00157498.

Based on observation and staff interview the facility failed to ensure the security and confidentiality of resident medical records. This affected thirteen (Residents #5, #10, #12, #16, #18, #20 #36,#42 #262, #263, #264, #265 #266) of thirty six sampled residents. The facility census was 59. Findings Include: Observation on 06/10/24 at 5:15 P.M. of the facilities information board on the wall after the main entrance area noted information such as contact information for advocacy agencies (i.e local social security office, local area agency on aging and local ombudsman office), resident rights, state agency contact information and numerous other important information for residents. On the wall was also a plastic file holder. In that filed holder was a file that was easily accessible that contained the following information -Specific information regarding medications taken by Residents #5, #10, #12, #16, #18, #20 #36,#42 #262, #263, #264, #265 #266. -Skilled therapy information for Resident #263. -Information concerning bowel movements for Residents #18 and #42. The Administrator verified that the records noted above were unsecure and easily accessible to the general public in an interview on 06/10/24 at 5:20 P.M.

Based on medical record review, staff and resident interviews, physician interview, review of an emergency medical services (EMS) run report, review of hospital documentation including a surgical operative note, medication manufacture guidelines, review of Centers for Disease Control guidance on sepsis, and review of facility policies regarding abuse, change of condition, and sepsis protocol, the facility failed to prevent an incident of neglect involving Resident #2 following an acute change in condition when the change was not timely identified and medical treatment was not timely obtained. This resulted in Immediate Jeopardy and serious life-threatening harm on 01/23/23 when Resident #2 experienced a low blood pressure of 81/50 and had an unwitnessed fall, abdominal pain and distention, nausea, vomiting and signs of gastrointestinal (GI) bleeding, telling staff he had an upset stomach, did not feel well, was bloated, and continued to receive medications for high blood pressure. Resident #2 experienced a second unwitnessed fall (on 01/25/23) with a low blood pressure of 67/38, pulse of 147 (tachycardia) and respirations of 38. Following this incident, on 01/25/23, Resident #2 requested to be transported and was sent via Emergency Medical Services (EMS) to the local hospital Emergency Department where he was assessed to have a life-threatening deterioration in condition requiring urgent intervention. This affected one resident (#2) of three residents reviewed for neglect. The facility census was 54. On 01/30/23 at 11:58 A.M. the Director of Nursing (DON) and Administrator were notified Immediate Jeopardy began on 01/23/23 at 2:57 P.M. when Resident #2 was first assessed to have an acute change in condition (hypotension) with no new orders/treatment. Between 01/23/23 through 01/24/23 Resident #2 had an unwitnessed fall, continued hypotension, emesis and complained of bloating, upset stomach and reported he did not feel well (all reflective of an acute change in condition) with no new treatment or interventions. On 01/25/23 Resident #2 sustained a second unwitnessed fall. The resident's vital signs included blood pressure 67/38 (hypotensive), pulse 147 (tachycardic) and respirations 38. The resident continued to complain of dizziness and had a small emesis. At this time, per Resident #2's request, he was transported to the local hospital Emergency Department and admitted to the hospital with septic shock (widespread infection causing organ failure and dangerously low blood pressure). Resident #2's blood work showed worsening kidney function, elevated white blood cell count, lactic acid of 5.2 (used to determine septic shock). Resident #2 was given a sepsis bolus and started on broad spectrum antibiotics (Vancomycin and Cefepime) with concern for possible spontaneous bacterial peritonitis (SBP). Resident #2 had greater than 1000 milliliters (ml) output from a nasogastric tube concerning for likely bowel obstruction. Resident #2 had severe abdominal pain and a CT scan showed possible pneumatosis intestinalis and portal venous gas (associated with bowel ischemia). Resident #2 was rushed urgently to surgery. Resident #2 had an exploratory laparotomy (surgical incision into the abdominal cavity), lysis of adhesions (procedure to destroy scar tissue causing abdominal pain), and release of small bowel obstruction. The post operative diagnosis was small bowel obstruction, ischemic bowel, severe sepsis and peritonitis. The Immediate Jeopardy was removed on 01/31/23 when the facility implemented the following corrective actions: Resident #2 was transferred and admitted to the hospital on 01/25/23. The facility identified a plan to ensure Resident #2 would be re-assessed upon readmission to facility. On 01/30/23 the facility identified all residents to be potentially affected by incidents of neglect. On 01/30/23 at 3:00 P.M. the Director of Nursing (DON) accessed the vital sign exception report triggered from the facility electronic system and set vital parameters for all residents. This report was sent to Medical Director #326, who reviewed and signed the report. Medical Director (MD) #326 added new parameters for four of the 23 residents identified with triggered vital signs on the report. As of 01/30/23 the facility indicated all residents would have vital signs monitored, as ordered by the physician, with a follow up assessment completed if warranted and reported to the physician by facility nursing staff. All residents with a change of condition (identified to include gastrointestinal (GI) upset, nausea, vomiting, bloating, change in bowel) would have a Situation Background Appearance Review (SBAR) completed and MD #326, Certified Nurse Practitioner (CNP) #324 would be notified by facility nursing staff. The plan also required any resident who sustained a fall to have post fall assessments completed every 12 hours for 72 hours. On 01/30/23 the facility Quality Assurance and Performance Improvement (QAPI) committee reviewed the following policies to ensure compliance with federal and state guidelines. o Abuse and neglect policy o Notification of change policy o Sepsis signs and symptoms On 1/31/23 the DON, Unit Manager (UM) #342, Registered Nurse (RN) #304 and Licensed Practical Nurse (LPN) #301 reviewed all residents through visual observation and interviews with facility direct care staff. Interventions were implemented for any resident with any identified change of condition. The vital signs exception report was reviewed (includes hypotension) with MD #326 and no new orders were given on this date. On 01/31/23 the DON and/or designee completed education for all nurses and State tested Nursing Assistant (STNA) staff which included eight RNs, eight LPNs and 23 STNAs on the following topics: o When residents have abnormal vital signs, the physician was to be notified and follow-up vital signs were to be observed. o An SBAR was o be completed on any resident who had a change in condition and the physician notified, as well as completing a follow up assessment and notification accordingly. o SBAR pathways were located in a binder at the nurses' station, and there were specific assessments related to different situations/body systems. o Residents with change in condition including GI upset, nausea, vomiting, bloating, or change in bowel habits needed an SBAR completed and MD #326, CNP #324 notified and documented. o Residents who had a fall would have a post-fall assessment completed every 12 hours as triggered by the electronic medical record for 72 hours. o STNAs were education to complete a stop and watch pointe of care (POC) alert in the electronic medical record for any resident who had a change in condition, as well as tell the nurse verbally. The nurse would complete the SBAR in the electronic medical record on the resident and notify the physician and responsible party of the change of condition and document any new orders received as well as any follow-up assessments. The facility implemented a plan to ensure no staff would work before receiving the education. On 01/31/23 Staff Development Coordinator (SCD) #327 educated eight RNs, eight LPNs and 23 STNAs on the signs and symptoms of sepsis, the facility Abuse and Neglect policy and procedure and the facility Notification of Change policy and procedure. On 01/30/23 at 3:36 P.M. the Director of Nursing was educated by the Regional Director of clinical services regarding daily review in clinical meeting of the Residents' 24-hour report to validate residents with an acute change of condition were identified and had been treated by MD #326 and/or CNP #324. By 01/31/23 by 11:59 P.M. all facility nurses (eight LPNs and eight RNs) were to be educated on completing post-fall assessments every 12 hours for 72 hours by the Director of Nursing or Designee. On 01/31/23 by 11:59 P.M. Facility Medical Director #326 counseled CNP #324 regarding the events of the Immediate Jeopardy with a plan for CNP #324 to collaborate with Medical Director #326. The facility implemented a plan, beginning on 01/31/23 for the DON/designee to review resident vital signs, 24-hour resident report, stop and watch tool every eight hours for one week to ensure that appropriate follow up assessment and notification occurred. After the one week of audits were completed, vital signs and appropriate follow up documentation would be reviewed by the DON/designee every 24 hours for one week with results to be reviewed by the QAPI committee for compliance and further recommendations. Although the Immediate Jeopardy was removed on 01/31/23, 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 in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses including malignant neoplasm of unspecified part of unspecified bronchus or lung, hypertension, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of Resident #2's Fall Risk Evaluation, dated 06/15/22 revealed Resident #2 was at high risk for falls. Review of Resident #2's blood pressures from 06/15/22 through 11/07/22 revealed a range from 90/50 through 158/73 with no specific frequency or orders for monitoring during this time period. Review of Resident #2's physician medication orders, dated 06/16/22 revealed an order for Lisinopril 10 milligrams (mg), give one tablet by mouth in the morning for hypertension. The resident had an order, dated 09/15/22 for Metoprolol Tartrate tablet 50 mg, one tablet by mouth every morning and at bedtime for hypertension. Further review did not reveal any blood pressure parameters for the administration of the medications ordered to treat hypertension. Review of the resident's medical record revealed the resident had a history of falls and/or incidents of hypotension not comprehensively assessed or monitored including the following: a. Review of Resident #2's progress note, dated 10/31/22 at 1:24 A.M., revealed Resident #2 had an unwitnessed fall, Resident #2 was found on the floor, in a sitting position next to his bed. Resident #2 stated he attempted to go to the bathroom, became weak and ended up on the floor. Record review revealed there were no vital signs including blood pressure documented when the fall occurred. Further review of the medical record did not reveal vital signs, including a blood pressure were taken on this date until 10/31/22 at 11:03 P.M. b. Review of Resident #2's progress notes dated 11/07/22 at 7:16 A.M., revealed staff responded to a call light and Resident #2 stated he fell around midnight and turned on his call bell. Resident #2 stated he was attempting to go to the bathroom and fell . When staff responded the resident was back in bed. Review of Resident #2's progress notes dated 11/07/22 at 7:24 A.M. revealed Resident #2's blood pressure was 74/44. Further review of Resident #2's medical record, including Medication Administration Record (MAR) revealed Metoprolol Tartrate 50 mg was administered on 11/07/22 in the morning between 7:00 A.M. and 10:00 A.M. and held on 11/07/22 at bedtime. Review of Resident #2's progress noted dated 11/07/22 as a late entry note for 7:11 A.M., stated to hold Resident #2's morning administration of Metoprolol Tartrate 50 mg. There was no documentation Resident #2's physician was notified of the blood pressure of 74/44 and no order to hold Resident #2's Metoprolol. No further blood pressures were documented until 01/23/23 at 3:00 P.M. Review of Resident #2's physician Encounter Note dated 11/09/22 and signed by Medical Director (MD) #326, included a box was checked next to the statement vital signs were checked and were stable unless noted. There was no mention of a blood pressure of 74/44 in the note. Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/21/22, revealed Resident #2 was cognitively intact. The assessment revealed Resident #2 was independent for activity of daily living care and required staff set-up help with bed mobility, transfers, and toilet use. The assessment revealed the resident was occasionally incontinent of urine and always continent of bowel. Review of Resident #2's plan of care, dated 01/09/23 revealed a plan reflecting the resident had hypertension (HTN). The goal developed was for the resident to remain free of complications related to hypertension through review date. Interventions included to administer anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. The care plan did not specify if or how often Resident #2's blood pressure and pulse should be monitored. Resident #2 was also on Aspirin (ASA) therapy. The goal for this plan included Resident #2 would be free from discomfort or adverse reactions related to anticoagulant use through the next review date. Interventions included to monitor, document, report to the physician as needed adverse reactions such as nausea, vomiting, diarrhea, lethargy, bruising, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. An additional plan of care revealed Resident #2 was at risk for return to the hospital related to comorbidities with a goal to have reduced risk to return to the hospital through related disease process and symptom management. Interventions included to notify the physician of changes in condition. Review of Resident #2's progress note, dated 01/23/23 at 12:44 P.M. revealed Resident #2 was administered two chewable Calcium Carbonate 500 mg tablets for indigestion. Review of Resident #2's progress note, dated 01/23/23 at 2:57 P.M. revealed Resident #2 complained of his blood pressure feeling low. The resident's blood pressure was checked and noted to be 80/51 (hypotensive) with a pulse rate of 59/minute. The note indicated Nurse Practitioner (NP) #324 was notified. The medical record did not identify the follow-up response from NP #324. Review of Resident #2's progress note, dated 01/23/23 at 3:08 P.M. and 3:19 P.M. revealed staff assisted Resident #2 off the floor after he attempted to transfer, no injuries were noted and his vital signs included blood pressure 81/50 (hypotensive), pulse 59, respirations 18, temperature 98 degrees Fahrenheit, and oxygen saturation 94 percent on room air. The note revealed Resident #2 had refused breakfast and lunch. The DON, NP #324, and the resident's power of attorney (POA) were notified. The medical record did not identify any follow-up response from the parties notified. Review of Resident #2's progress note, dated 01/23/23 at 5:04 P.M. revealed Resident #2 had a brown watery emesis and NP #324 was notified. The medical record did not identify the follow-up response from NP #324. Review of Resident #2's progress note, dated 01/23/23 at 7:07 P.M. revealed Resident #2 had an emesis, NP #324 was notified and an order was given for STAT blood work including a complete blood count (CBC) and basic metabolic panel (BMP). Review of Resident #2's progress notes from 01/23/23 at 7:07 P.M. through 01/25/23 at 12:19 A.M. revealed no evidence of monitoring or follow-up documentation related to Resident #2's condition including blood pressure, abdomen and/or nausea/vomiting. Review of Resident #2's bowel movement records from 01/23/23 through 01/25/23 revealed on 01/23/23 at 1:29 P.M. Resident #2 was incontinent of a large diarrhea bowel movement. Documentation on 01/23/23 at 9:02 P.M. and 11:55 P.M. revealed Resident #2 was incontinent of a large bowel movement, but it was not documented if it was diarrhea. On 01/24/23 at 11:52 A.M. Resident #2 was incontinent of a diarrhea bowel movement. There were no other bowel movements documented. Review of Resident #2's Medication Administration Record (MAR) revealed on 01/23/23 at bedtime (between 8:00 P.M. and 11:00 P.M.) Resident #2 was administered Metoprolol Tartrate 50 mg. On 01/24/23 in the morning (between 7:00 A.M. and 10:00 A.M.) Resident #2 received Lisinopril 10 milligram (mg) and Metoprolol Tartrate 50 mg. Further review revealed he was administered Metoprolol Tartrate 50 mg on 01/24/23 at bedtime. Review of Resident #2's blood pressure records, dated 01/23/23 through 01/25/23 revealed on 01/23/23 at 3:00 P.M. and 3:43 P.M. Resident #2's blood pressure was documented 81/50. On 01/24/23 at 4:36 A.M. Resident #2's blood pressure was 96/51 and on 01/25/23 his blood pressure was 67/38. Review of Resident #2's Fall Follow-Up, from the fall on 01/23/23, dated 01/24/23 at 4:34 A.M., revealed Resident #2 had a blood pressure of 96/51 lying in bed, pulse was 100, temperature 97.2 Fahrenheit and respirations were 18 per minute with an oxygen saturation of 98 percent. The assessment stated Resident #2 had no nausea or vomiting. There were no further Fall Follow-Up assessments documented in Resident #2's medical record or follow up to Resident #2's blood pressure. Review of Resident #2's progress note, dated 01/25/23 at 12:19 A.M. revealed Resident #2 had shortness of breath and the head of his bed was flat. Resident #2's head of bed was elevated, and resident was educated on the importance of a raised head of bed for decreased shortness of breath. The note indicated would monitor. Review of Resident #2's progress note, dated 01/25/23 at 2:35 A.M. revealed Resident #2 had an unwitnessed fall and was found sitting on his buttocks next to his bed with no injury was noted. Resident #2 was very short of breath, oxygen was administered at three liters via nasal cannula, his blood pressure was taken three times and was 68/51, 78/43 and 67/38 with a heart rate ranging from 149 to 153 and respirations were 38. The nurse was unable to obtain an oxygen saturation. There was a small amount of emesis noted on the bed and Resident #2 complained of feeling dizzy. Per the resident's request at this time, a call was placed to 911 for Emergency Medical Services due to the resident's respiratory status and blood pressure. EMS arrived and transported Resident #2 to the local hospital Emergency Department. Review of Resident #2's local fire department/EMS report, dated 01/25/23, incident number 2023-0000163 revealed a call was received on 01/25/23 at 12:42 A.M. and Emergency Medical Services were on the scene at 12:51 A.M. Resident #2 experienced difficulty breathing and hypotension. Resident #2 was alert and oriented, in moderate distress, and stated he felt like he was dying. Resident #2's blood pressure was 56/33, pulse of 143, and respirations were 30. The EMS report revealed staff stated the issue started on 01/24/23 with increasing respiratory effort and gradually decreasing blood pressure. Staff called 911 due to the resident's blood pressure of 68/51. Staff stated Resident #2 had a fall due to dizziness and fell on his bottom. The report also noted Resident #2 would like transport to the local Emergency department, and his abdomen was quite distended. Resident #2 complained of dizziness and nausea with no emesis. Review of Resident #2's Emergency Department to Hospital Admission notes, dated 01/25/23, revealed Resident #2 arrived at the hospital Emergency Department on 01/25/23 at 1:29 A.M. with a blood pressure of 58/34 and a pulse of 135. Resident #2 was in acute distress and ill-appearing. Resident #2's chief complaints were hypotension, distended abdomen, abdominal pain, nausea, vomiting, diarrhea, shortness of breath, and a history of having radiation for lung cancer. Resident #2 was alert and oriented, tired appearing and had a fall at the facility with no loss of consciousness and no injuries. Resident #2 stated he had the facility call Emergency Medical Services (EMS) because he felt like he was going to die. Resident #2 stated he had worsening hypotension, increased abdominal distention as well as shortness of breath. Resident #2 had a history of chronic obstructive pulmonary disease (COPD) and a lung mass. Resident #2 stated his symptoms worsened over the last ten days, he had poor intake by mouth, nausea, vomiting, and diarrhea. Resident #2 wanted everything (medically) done. Further review revealed sepsis was identified at 1:45 A.M. and Resident #2 had septic shock (widespread infection causing organ failure and dangerously low blood pressure). Resident #2's bloodwork showed worsening kidney function, elevated white blood cell count, lactic acid of 5.2 (used to determine septic shock). Resident #2 was given a sepsis bolus and started on broad spectrum antibiotics (Vancomycin and Cefepime) with concern for possible spontaneous bacterial peritonitis (SBP). Resident #2 had greater than 1000 milliliters (ml) output from a nasogastric tube concerning for likely bowel obstruction. There was a high probability of clinically significant, life-threatening deterioration in the patient's condition which required urgent intervention. Review of Resident #2's Department of Surgery Operative Note, dated 01/25/23 revealed Resident #2 was admitted acutely ill last night with severe abdominal pain and a computerized tomography (CT) scan showed possible pneumatosis intestinalis and portal venous gas (associated with bowel ischemia). Resident #2 was rushed urgently to surgery. Resident #2 had an exploratory laparotomy, lysis of adhesions, and release of a small bowel obstruction. The post operative diagnosis was small bowel obstruction, ischemic bowel, severe sepsis and peritonitis (usually infectious, often life-threatening, caused by a leakage or hole in the intestines). On 01/25/23 at 10:45 A.M. interview with Registered Nurse (RN) #304 revealed on 01/23/23 Resident #2 had an emesis on the floor of his room and was incontinent of bowel (diarrhea). RN #304 stated there was feces on the toilet seat and bathroom floor, emesis on the floor of his room and Resident #2's room was not cleaned immediately. RN #304 stated she did not know what time Resident #2 had the emesis or was incontinent of diarrhea, but he was sitting in a wheelchair in his room around 3:00 P.M. while his room was being cleaned. RN #304 revealed Resident #2 told an unidentified State tested Nursing Assistant (STNA) he thought his blood pressure was dropping, and the STNA had RN #304 come to the room. RN #304 took Resident #2's blood pressure, and it was 81/50 with a pulse of 59. RN #304 noticed Resident #2 was a little short of breath, did not have his oxygen on via nasal cannula, and put his oxygen back on him before she left the room. RN #304 left the room and immediately text Nurse Practitioner (NP) #324 to notify her Resident #2's blood pressure was 81/50. NP #324 text back OK, thanks but did not give RN #304 orders or instructions concerning the low blood pressure. Approximately ten minutes after his blood pressure was 81/50, Resident #2 had an unwitnessed fall and RN #304 text NP #324 again to notify her of Resident #2's fall. NP #324 text back thanks but did not give RN #304 orders or instructions for Resident #2. At around 5:00 P.M. Resident #2 had a brown, watery emesis, his blood sugar was 150 and he refused his insulin. RN #304 text NP #324 again to notify her. Resident #2 had another emesis around 7:00 P.M., NP #324 was notified via text and a laboratory testing, a stat CBC and BMP were ordered, but no questions, instructions or orders were given concerning Resident #2's low blood pressure or emesis. RN #304 stated it was a very busy day and she did not think she took Resident #2's blood pressure again. RN #304 stated she worked day shift on 01/24/23 and Resident #2 stated he felt better, but his abdomen was bloated. RN #304 stated Resident #2's blood pressure on night shift was 96/51, taken while he was lying in bed. RN #304 indicated she administered Resident #2's blood pressure medications (Metoprolol Tartrate 50 mg and Lisinopril 10 mg) on 01/24/23 and did not check his blood pressure. RN #304 stated NP #324 was notified of the results of the stat bloodwork drawn (CBC and BMP), which were a little bit off. No further orders were given. On 01/25/23 at 5:41 P.M. interview with NP #324 revealed she was informed Resident #2's blood pressure was 81/50 and was not concerned. NP #324 stated Resident #2's blood pressure goes up and down and it was not unusual for him to have a low blood pressure and he also had heart failure. When asked if NP #324 would expect the blood pressure to be checked again she stated the blood pressure should have been checked per the fall protocol but did not know what the facility fall protocol was. NP #324 confirmed she did not ask for Resident #2's blood pressure to be rechecked or ask any questions regarding the low blood pressure or emesis. NP #324 indicated she was not aware Resident #2 had an emesis. NP #324 revealed she asked for stat bloodwork to be drawn (CBC and BMP). When asked if Resident #2's Metoprolol Tartrate 50 mg and Lisinopril should have been held NP #324 stated the nurses were supposed to call if the systolic blood pressure was less than 100. NP #324 stated nurses did not need an order to take a blood pressure. On 01/26/23 at 7:55 A.M. interview with RN #333 revealed she spoke with a nurse at the hospital regarding Resident #2 and was told he was pretty sick, and it was good he got to the hospital when he did. RN #333 stated the nurse told her Resident #2's nasogastric tube drained three liters of coffee ground fluid (appearance comes from old and coagulated blood in the gastrointestinal tract; a sign of internal bleeding). On 01/26/23 at 9:00 A.M. interview with STNA #330 revealed when she arrived for work on 01/23/23 at 6:00 A.M. Resident #2's sheets and toilet were smeared with feces, and he had thrown up during the night before she arrived. STNA #330 stated she saw a watery emesis on the floor of his room but could not say what color it was. STNA #330 indicated Resident #2 did not eat breakfast, lunch or dinner on this date and kept asking for TUMS (antacid), saying he did not feel well. STNA #330 stated Resident #2's stomach was bloated. STNA #330 stated she told RN #304 Resident #2's stomach was hurting and he wanted TUMS. STNA #330 indicated she worked day shift on 01/24/23 and Resident #2 refused to get out of bed, wanted the door closed and the room light turned off. STNA #330 stated Resident #2 kept asking for ice water, which was unusual for him, and he only drank fluids offered to him during the day. STNA #330 stated she saw a big splotch of dark, watery, dried emesis at the head of his bed, and the emesis was also splattered under his bed and dresser. On 01/26/23 at 12:00 P.M. interview with the DON revealed on 01/23/23 in the afternoon Resident #2 had an unwitnessed fall and she was notified his blood pressure was 81/50. The DON stated she would expect the nurses to look at Resident #2's history of blood pressures and initiate some orthostatic blood pressures throughout the day. The DON stated Resident #2 had low blood pressures in the past, but he also had a fall, and she would expect to see the blood pressure taken again in an hour. The DON stated she did not know if Resident #2's blood pressure was rechecked. The DON revealed according to the fall protocol the follow up assessments including blood pressure were completed every twelve hours for three days, but this was not done for Resident #2. The DON indicated Resident #2's blood pressure should have been checked more often, and his blood pressure medication held if it was low. The DON stated NP #324 came to the facility every Monday morning and did not come back after that to evaluate residents. On 01/26/23 at 4:00 P.M. telephone interview with Resident #2 revealed he was still a patient at the local hospital. Resident #2 stated he felt so much better now and felt really sick while he was at the facility. Resident #2 stated he requested to be transported to the Emergency Department because he felt so ill. Resident #2 indicated he had two surgeries since he was admitted , one to place a sensor in his wrist to monitor his blood pressure (arterial line), and the second surgery was on his abdomen. Resident #2 stated while at the facility he could not eat, was throwing up, and he felt very ill. Resident #2 stated he had two falls, and he was so weak he could not assist staff when they were helping him off the floor. Resident #2 indicated he told the nurses and aides he felt really sick, but no one was paying attention to him because they were too busy fighting with each other over who was going to do the work that needed done. Resident #2 stated he was just going to ride it out. Resident #2 stated the staff had bad attitudes and at shift change it could be anywhere from one and half to four hours before his call light was answered. Resident #2 indicated his appetite was really poor, he could not eat and thought if he drank coca cola it would soothe his upset stomach and also put something in his stomach. On 01/30/23 at 6:00 P.M. telephone interview with Medical Director (MD) #326 revealed he did not have access to a computer with Resident #2's information prior to calling and could not comment on specific details. Discussion following the statement made by MD #326 revealed MD #326 felt a blood pressure of 81/50 would not always be a reason to be concerned and it would depend on the circumstances. MD #326 stated Resident #2 had heart failure and there were reasons to keep a resident on a beta blocker (Metoprolol) in face of heart failure. When told the surveyor was unable to find heart failure documented in Resident #2's record, MD #326 stated the DON told him Resident #2 had heart failure. MD #326 stated he could not check Resident #2's record to confirm heart failure as a diagnosis for the resident at that time. MD #326 indicated since Resident #2 had a fall ten minutes after his blood pressure was 81/50 his condition needed explored further. MD #326 stated the blood pressure of 81/50 could have been an early sign of sepsis. MD #326 stated Resident #2's blood pressure should have been rechecked and the nurses should have assessed his blood pressure on a routine basis. MD #326 indicated Resident #2's blood pressure could have been checked hourly or every four hours. MD #326 stated he was not happy with the situation, there were gaps in the notes that could not be accounted for, and when Resident #2's blood pressure was 81/50 things should have been escalated. MD #326 stated they were all taking the situation seriously. On 01/31/23 at 1:28 P.M. interview with the DON revealed she could not find documentation in Resident #2's medical record reflecting a diagnosis of heart failure. The DON stated she had staff from Medical Records check Resident #2's medical record and they could not find documentation related to heart failure. The DON denied reporting the resident had a diagnosis of heart failure to MD #326. Review of the manufacturer's recommendations titled Metoprolol dated, 07/01/22, included Metoprolol was contraindicated in patients with a systolic blood pressure < 100 mmHg. Review of guidance from the Centers for Disease Prevention and Control (CDC) titled Protect Your Residents From Sepsis dated, 08/04/22, included bacterial infections cause most cases of sepsis. Sepsis could be a result of other infections, including viral infections, such as COVID-19 or influenza, or fungal infections. Infections that lead to sepsis most often start in the lungs, urinary tract, skin and gastrointestinal tract. People at higher risk for sepsis included adults [AGE] years of age or older, people with chronic medical conditions such as diabetes, lung disease, cancer, and kidney disease. Signs and symptoms of sepsis included high heart rate or low blood pressure, shortness of breath, extreme pain or discomfort. Sepsis, or the infection causing sepsis, started before a patient went to the hospital in nearly 87 percent

Based on observation, record review, facility policy and procedure review and interview, the facility failed to ensure interventions were implemented to prevent and timely identify the development of pressure ulcers and/or to ensure adequate treatments were in place to promote healing. This affected two residents (#25 and #40) of three residents reviewed for pressure ulcers. The facility census was 54. Actual Harm occurred on 12/06/22 when Resident #40, who required extensive assistance from two staff for bed mobility, developed a new, in-house acquired deep tissue injury to the sacrum without evidence of adequate preventative interventions including turning and repositioning. The facility failed to identify the pressure ulcer prior to it being identified as a deep tissue injury. Actual Harm occurred on 01/10/23 when Resident #25, who required extensive assistance from one staff member for bed mobility, developed a red, blanchable area to her right buttock and the area was not further evaluated until 01/24/23 when the right buttock was identified as having a new unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed) pressure injury. Findings include: 1. Review of Resident #40's medical record revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, schizophrenia, and type two diabetes mellitus without complications. Review of Resident #40's Braden Scale for Predicting Pressure Sore Risk dated 08/11/22, revealed Resident #40 was at a moderate risk for developing a pressure ulcer, injury. Review of Resident #40's medical record including State tested Nursing Assistant (STNA) charting dated 11/01/22 through 12/06/22, revealed the charting lacked evidence turning and repositioning was completed. Review of Resident #40's Braden Scale for Predicting Pressure Sore Risk dated 12/06/22, revealed Resident #40 was assessed to be at a high risk for developing a pressure ulcer, injury. Review of Resident #40's Skin and Wound Evaluation dated 12/06/22, revealed Resident #40 had a new pressure injury, a suspected deep tissue injury to the sacrum. Measurements were a length of 1.75 centimeters (cm), width of 0.84 cm, and depth unable to be determined. Review of Resident #40's Surgical Wound Care Services Notes dated 12/06/22, revealed Resident #40 had a new, deep tissue injury to the sacrum. The wound was non blanchable and had purple discoloration. Review of Resident #40's physician's orders, dated 12/06/22 revealed orders to turn and reposition Resident #40 every two hours. Review of Resident #40's annual Minimum Data Set (MDS) 3.0 assessment, dated 12/19/22, revealed Resident #40 was cognitively intact. Resident #2 required extensive assistance of two staff members for bed mobility and toilet use. Resident #2 had total dependence of two staff for transfers and was always incontinent of urine and bowel. Resident #2 had an unstageable pressure ulcer presenting as a deep tissue injury, not present on admission. Review of Resident #40's care plan dated, 01/06/23 included Resident #40 was at risk for pressure ulcers related to type two diabetes mellitus, history of pressure ulcers and impaired mobility. The care plan reflected Resident #40 had a sacral pressure ulcer identified 12/06/22. The goal developed was for Resident #40 to have no area of skin impairment through the review date. Interventions included to turn and reposition Resident #40 every two hours and as needed; pressure relieving cushion to wheelchair; follow facility policies and protocols for the prevention and treatment of skin breakdown; inform the physician, nurse practitioner and family of any new area of skin breakdown; monitor, document and report any changes in skin status; low air loss (LAL) mattress to bed, check function every shift and as needed. Observation on 01/23/23 at 8:00 A.M. and 9:42 A.M. of Resident #40 revealed she was lying on her back in bed with the head of the bed elevated about 30 degrees, and her knees elevated above her ankles. There was no observation of staff turning and repositioning Resident #40 or encouraging Resident #40 to turn and reposition during this time period. Observation on 01/23/23 at 11:13 A.M. of Resident #40 revealed she was lying on her back in back in bed with the head of the bed elevated about 30 degrees, and her knees elevated above her ankles. State tested Nursing Assistant (STNA) #330 walked in the room to provide incontinence care. STNA #330 stated it had been a busy morning, this was the first time she was in Resident #40's room today to provide care, and confirmed she had not turned and repositioned the resident (as ordered/care planned). Resident #40's incontinence brief was very wet, and Resident #40 stated it had not been changed since 4:00 A.M. STNA #330 provided incontinence care according to standards of practice and observation of Resident #40's sacrum revealed a wound approximately one inch by one half inch with a pink wound bed and small amounts of yellowish colored tissue, with a small amount of yellowish drainage. STNA #330 stated the wound was not getting better. STNA #330 left the room to find ET mix (Aquafor and stoma adhesive powder) to apply to the wound. While STNA #330 was out of the room Resident #40 stated staff did not turn her every two hours. STNA #330 found the ET mix, applied the ointment to Resident #40's sacrum, assisted Resident #40 to put on a flowered dress, and stated she was going to have another STNA assist with a mechanical lift to place Resident #40 in her padded wheelchair. Observation on 01/23/23 at 4:19 P.M. of Resident #40 revealed she was sitting in a padded wheelchair in her room and State tested Nursing Assistant's (STNA's) #303 and #338 were using a mechanical lift to assist Resident #40 into her bed. STNA #338 stated Resident #40 should have been put to bed before now, she had been in the padded wheelchair since 11:30 A.M. and that was a long time. Observation of Resident #40's sacrum revealed an open area approximately one inch by one half inch. The wound bed was pink with a small amount of yellowish tissue, and the wound was draining a small amount of yellow colored fluid. There was no dressing on the wound. The Director of Nursing (DON) walked in the room and confirmed Resident #40 had an open pressure ulcer on her sacrum, and stated dressings were not used on sacral areas because they became soiled easily. The DON stated the pressure ulcer was treated with ET mix (Aquaphor and stomahesive paste), and felt it worked very well to heal pressure ulcers. Observation on 01/24/23 at 12:12 P.M. of Wound Nurse Practitioner (WNP) #325 treating Resident #40's sacral pressure ulcer revealed a sacral wound with a pink wound bed and small amount of yellow tissue. The wound was draining a small amount yellowish fluid and the wound was approximately one inch by one half inch. WNP #325 indicated a foam dressing was not used for the sacral pressure ulcer because it would become soiled and deteriorate. WNP #325 stated ET mix was to be used three times a day and as needed and worked very well to protect and heal the wound. WNP #325 indicated she believed Resident #40's wound was improving and looked a lot better today. Interview on 01/24/23 at 12:25 P.M. with DON revealed she recently became the Wound Nurse because Wound Nurse #332 resigned her position last week. The DON confirmed Resident #40 developed a new deep tissue injury, first identified on 12/06/22. The DON stated she was given the resident's wound information but did not have all the progress notes from WNP #325 and would have WNP #325 send the missing wound notes. Review of Resident #40's Surgical Wound Care Services note, dated 01/24/23 revealed Resident #40's unstageable pressure ulcer to the sacrum was improved with a scant amount of serosanguinous drainage. The wound bed had slough and pink tissue. Review of Resident #40's Skin and Wound Evaluation dated, 01/24/23 included Resident #40 had an in-house acquired unstageable pressure ulcer to the sacrum identified on 12/06/22. Measurements were length 1.5 cm, width 0.8 cm, and the depth was unable to be determined. Review of the facility policy titled Pressure Injury Prevention and Management, dated 01/01/21, included evidence-based interventions for prevention would be implemented for all residents who were assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but were not limited to redistribute pressure such as repositioning, protecting and or offloading heals etcetera, minimize exposure to moisture and keep skin clean, especially of fecal contamination. 2. Review of Resident #25's medical record revealed an admitted [DATE] with diagnoses including multiple sclerosis, chronic kidney disease and polyneuropathy. Review of Resident #25's Braden Scale for Predicting Pressure Sore Risk dated 08/11/22, revealed Resident #25 was at moderate risk for developing a pressure injury. Review of Resident #25's Braden Scale for Predicting Pressure Sore Risk dated 11/28/22, revealed Resident #25 was at high risk for developing a pressure injury. Review of Resident #25's physician's orders, dated 12/06/22, revealed to turn and reposition Resident #25 every two hours. Review of Resident #25's quarterly MDS 3.0 assessment, dated 12/22/22 revealed Resident #25 was cognitively intact. Resident #25 required extensive assistance of one staff member for bed mobility, total dependence of two staff members for transfers, and total dependence of one staff member for toilet use. Resident #25 was always incontinent of urine and bowel. Review of Resident #25's Skin assessment dated , 01/09/23 revealed her right buttock had a reddened area. Review of Resident #25's physician's orders dated 01/10/23, revealed orders to apply Calmoseptine ointment (skin protective ointment) to right buttock every shift and as needed after incontinence episodes. Review of Resident #25's Skin assessment dated [DATE] did not include any documentation regarding Resident #25's right buttock. Review of Resident #25's Surgical Wound Care Services notes, dated 01/17/23 revealed no documentation of a right buttock wound. Review of Resident #25's care plan dated, revised 01/17/23, revealed Resident #25 had impaired skin integrity in the form of moisture associated skin dermatitis (MASD) related to moisture associated skin damage to the left buttock. The goal developed was for the MASD to heal without becoming infected. Interventions included to observe area for increased redness, drainage, edema, and notify the physician as needed; skin assessments weekly and as needed; turn and reposition every two hours; use care when moving resident to prevent friction and shear as much as possible and as much as the resident can/will allow. Review of Resident #25's medical record including State tested Nursing Assistant charting dated 12/01/22 through 01/24/23, revealed the charting lacked evidence turning and repositioning was completed every two hours, every shift. Observation on 01/23/23 at 9:44 A.M. revealed STNA #322 and STNA #330 used a mechanical lift to transfer Resident #25 from her bed to a padded wheelchair. Observation on 01/23/23 at 10:27 A.M. revealed Resident #25 was sitting in a padded wheelchair in her room. At the time of the observation, interview with Resident #25 revealed she had a sore on her bottom, it did not hurt, but she knew it was there. Observation revealed there was not a low air mattress (LAL) mattress on Resident #25's bed. Observation on 01/23/23 at 11:00 A.M. revealed Resident #25 was sitting in a padded wheelchair in her room. Observation on 01/23/23 at 2:10 P.M. and 3:15 P.M. and 4:43 P.M. revealed Resident #25 sitting in padded wheelchair in the activity room. There were no observations of staff asking Resident #25 if she needed to reposition in the wheelchair or asking her if she wanted to lay down in her bed. Resident #25 had been observed sitting in the wheelchair since 9:30 A.M. Observation on 01/23/23 at 5:05 P.M. revealed STNA #317 was pushing Resident #25 who was still in her wheelchair to her room. STNA #317 stated she would not put Resident #25 back in bed until after her dinner. When STNA #317 was told Resident #25 had been in the wheelchair since 9:30 A.M. she changed her mind and found another STNA to assist her with the mechanical lift to put Resident #25 back in bed. STNA #317 stated the reason Resident #25 was in her wheelchair for such a long time was because a few of the mechanical lift batteries did not charge properly. STNA #317 stated only a couple batteries charged when placed on the battery charger and it made it kind of cutthroat, because the aides had to wait to use the mechanical lifts. Observation of Resident #25's incontinence care revealed Resident #25's pants and back of her shirt were soaked with urine, her incontinence brief was soaked with urine and a wound was noted on her right buttock. The wound was approximately a three-inch circle, was at the crease of Resident #25's buttock and posterior upper thigh, and the wound bed was pink with yellow spots and couple black areas. After surveyor intervention, Registered Nurse (RN) #304 walked in Resident #25's room and confirmed the presence of the wound on Resident #25's buttock and posterior upper thigh Observation on 01/24/23 at 12:19 P.M. with Wound Nurse Practitioner #325 and the DON of Resident #25 revealed Resident #25 was sitting in a padded wheelchair in her room. WNP #325 proceeded to evaluate Resident #25's right and left foot wounds (right medial foot venous ulcer, healed 01/24/23 and left foot venous ulcer , healed 01/24/23) and was getting ready to leave the room because she was finished. WNP #325 and the DON stated Resident #25 did not have any other wounds to evaluate and were told by the surveyor Resident #25 had a right buttock wound. After surveyor intervention Resident #25 was placed in bed using a mechanical lift and WNP #325 and the DON confirmed she did have a right buttock wound. Resident #25's incontinence brief was very wet and she had a moderate size brown, formed bowel movement. WNP #325 stated Resident #25 had a new unstageable pressure ulcer to her right buttock. WNP #325 told the DON, therapy should evaluate Resident #25's padded wheelchair and cushion, and Resident #25 needed a low air loss (LAL) mattress. WNP #325 further stated it was important to reposition Resident #25 and the standard of care was to turn and reposition every two hours, and also ordered ET mix to treat the wound every eight hours and as needed. The DON stated she recently became the Wound Nurse because the wound nurse no longer worked at the facility and no one told her Resident #25 had a wound to her right buttock. Review of Resident #25's physician's orders dated, 01/24/23 and 01/25/23, revealed orders to clean Resident #25's right ischium with soap and water, and apply ET mix to open area three times a day and as needed after incontinent episodes. Orders included a LAL mattress with perimeter, check function each shift, and a daily skin assessment. Interview on 01/25/23 at 11:30 A.M. with the DON revealed on 01/10/23 Licensed Practical Nurse (LPN) #331 documented Resident #25 had a red, blanchable area on her right buttock and started a treatment with Calmoseptine ointment, but did not notify anyone of the area from 01/10/23 through 01/24/23. Review of Resident #25's Surgical Wound Care Services note, dated 01/24/23 revealed Resident #25 had a new unstageable pressure ulcer to her right buttock. The wound bed had slough, necrotic and pink tissue with serosanguinous drainage. Review of Resident #25's Skin and Wound Assessment, dated 01/24/23 revealed Resident #25 had an in-house acquired, unstageable pressure ulcer to her right ischial tuberosity. Measurements were length 1.3 cm, width 3.67 cm, and depth was 0.1 cm. Review of Resident #25's Braden Scale For Predicting Pressure Sore Risk, dated 01/25/23 revealed Resident #25 was at high risk for developing a pressure injury. Review of the facility policy titled Pressure Injury Prevention and Management, dated 01/01/21, included evidence-based interventions for prevention will be implemented for all residents who were assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to redistribute pressure such as repositioning, protecting and or offloading heals etcetera, minimize exposure to moisture and keep skin clean, especially of fecal contamination. This deficiency represents non-compliance investigated under Complaint Number OH00137120.

Based on observation, interview, and record review, the facility failed to timely provide care and treatment to ensure one resident (Resident #50) did not develop a pressure injury of the sacrum. Actual harm occurred when Resident #50 developed a Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole [rolled edges], undermining and/or tunneling often occur. Depth varies by anatomical location.) of the sacrum. The facility also failed to ensure pressure injuries of a lower stage did not develop for Resident #47. This affected two of three residents (#47, #50, and #57) reviewed for pressure injuries. The facility identified five resident with pressure ulcers. The census was 58. Findings include: 1. Review of the medical record for Resident #50 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the skin assessment dated [DATE] revealed no new or existing abnormal skin areas. Review of the care plan dated 05/31/22 revealed Resident #50 had impaired skin integrity in the form of pressure wound to the sacrum. Interventions included medications and treatments as ordered; observe area for increased redness, drainage, and edema; observe for signs of pain and administer analgesics as ordered; turn and reposition frequently as tolerated by resident; and pressure redistribution mattress. Review of the skin and wound evaluation dated 05/31/22 revealed Resident #50 had a Stage 4 pressure ulcer that was in-house acquired on the sacrum which measured 3.7 centimeters (cm) in length, 2.1 cm in width, and depth not applicable. The wound bed was pink and moist with light amount of drainage and no odor. The Peri-wound was approximately 1.0 cm out from the wound bed and was blanchable [CONDITION(S)]. The skin appeared fragile and at-risk for breakdown. Review of the wound nurse practitioner note dated 05/31/22 revealed a new Stage 4 pressure ulcer on sacrum. The wound bed had slough and was necrotic with pink tissue. The peri wound was intact and fragile. Review of the dietary progress note dated 06/21/22 timed 3:47 P.M. revealed a wound review note indicating Resident #50 with pressure injury to sacrum. Diet order was carbohydrate-controlled diet (CCD), regular texture, thin liquids and intakes recorded were 25-50% on average with resident refusing meals on rare occasion. Supplements included Med Pass 120 milliliters (ml) three times per day with intakes 50-100% to provide 240 calories and 10 grams of protein per serving. Resident reported eating not so good due to being sore all over. Resident missing some teeth. Midline catheter in place for hydration, with one liter of normal saline administered on 06/14/22. Updated food preferences to include likes pudding and ice cream. Weight stable. No new registered dietitian (RD) recommendations at this time. Review of the skin and wound evaluation dated 06/28/22 revealed the Stage 4 pressure ulcer measured 1.1 cm in length x 0.6 cm width, and depth was not applicable. There was no evidence of infection, and the surrounding tissue was fragile skin. No pain noted and the wound was improving. Review of a physician order dated 07/11/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition, required extensive assistance of two staff for bed mobility, total dependence of two staff for transfer, supervision of one staff for eating, extensive assistance of one staff for toilet use. Resident #50 had one Stage 4 unhealed pressure ulcer/injury. Review of the skin and wound evaluation dated 07/26/22 revealed the Stage 4 pressure ulcer measured 1.5 cm in length x 1.0 cm in width and depth 2.7 cm. No pain was noted. Cat Scan (CT) to pelvis was done to rule out [CONDITION(S)] (bone infection), results were without definitive evidence of [CONDITION(S)]. CT showed subcutaneous [CONDITION(S)] to coccyx area. Follow-up Magnetic Resonance Imaging (MRI) scheduled to rule out [CONDITION(S)]. Wound culture of area as well. Wound bed area was unchanged since last assessment. Granulation tissue present. Moderate amount of serous drainage. Peri wound was intact, fragile, and at-risk for breakdown Review of the skin and wound evaluation dated 08/02/22 revealed the Stage 4 pressure ulcer measured 0.9 cm in length x 1.1 cm in width, and depth 3.0 cm. No pain noted. CT to pelvis done to rule out [CONDITION(S)], results were without definitive evidence of [CONDITION(S)]. CT showed subcutaneous [CONDITION(S)] to coccyx area. Follow-up MRI scheduled on 08/19/22 to rule out [CONDITION(S)]. Wound bed area was unchanged since last assessment. Granulation tissue present. Moderate amount of serous drainage. Peri wound was intact, fragile, and at-risk for breakdown. Review of physician orders dated 08/02/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the skin and wound evaluation dated 08/09/22 revealed the Stage 4 pressure ulcer measured 0.9 cm in length x 1.0 cm width and depth 2.0 cm. Noted resident complained of pain seven out of 10. Wound bed was unchanged, pink, and moist. Granulation tissue noted to 100% of wound bed. Moderate amount of serous drainage noted. No signs or symptoms of infection. Peri-wound was intact, fragile, [CONDITION(S)] noted. Resident #50 voiced discomfort/pain during wound assessment and dressing change. New order to medicate prior to dressing change. Review of the wound nurse practitioner note dated 08/09/22 revealed the Stage 4 pressure ulcer status was unchanged, wound bed had granulation tissue, pink tissue, and the periwound was intact and fragile. There was also new moisture associated skin [CONDITION(S)] (MASD) due to friction or contact to body fluids on on the left buttock. Observation on 08/10/22 at 10:35 A.M. of Licensed Practical Nurse/Wound Nurse (LPN/WN) #147 with the assistance of State tested Nursing Assistant (STNA) #142 providing Resident #50's sacral dressing change revealed the following: Observation of Resident #50's sacrum after removal of an ABD pad and calcium alginate revealed the sacral area, bilateral buttocks, and posterior upper thighs were very red and several open areas were noted on both the right and left buttocks. A small amount of reddish drainage was noted from the open areas on the bilateral buttocks, and an open area approximately the size of a dime was noted on Resident #50's sacral area. Observation of the dime sized wound revealed the wound bed could not be visualized due to depth of the wound. LPN/WN #147 stated she would get a light so the wound bed could be visualized. LPN/WN #147 found a light and returned to the room with the Director of Nursing (DON). LPN/WN #147 illuminated Resident #50's sacral wound bed with the light and another piece of calcium alginate was found and removed. The DON stated a long piece of calcium alginate should be used instead of two short pieces. Resident #50's sacral wound bed was pink with a small amount of slough noted in the upper right-hand area of the wound. LPN/WN #147 stated she did not measure the wounds because she measured them on 08/09/22, but the open areas on Resident #50's left buttock were not present on 08/09/22 and she would measure the wounds later today and document the measurements in Resident #50's medical record. LPN/WN #147 irrigated and cleansed the dime size wound with Dakin's solution, applied a long piece of calcium alginate, used [MEDICATION(S)] (barrier) ointment to the open areas on Resident #50's bilateral buttocks stating the open areas on the buttocks were MASD. LPN/WN #147 placed an ABD pad over the area and taped and dated the dressing. Interview on 08/11/22 at 8:39 A.M. with STNA #150 revealed Resident #50 was compliant with care. Prior to finding the wound Resident #50 complained of her bottom hurting her and she did not want to get up in her chair due to the pain. STNA #150 stated it was hard to find the wound; they had to spread her buttock cheeks open to find it. STNA #150 stated she alerted the nurse when she had found the wound during resident care. Interview on 08/11/22 at 8:45 A.M. with STNA #130 revealed she remember seeing Resident #50's wound when it was a small opening. STNA #130 notified the nurse when she noticed the opening getting deeper. STNA #130 indicated when it was a small hole they were putting cream on it. Prior to the wound being found Resident #50 had been crying and complaining of pain but they were not able to find anything. STNA #130 stated they had to spread open her buttock cheeks to find the wound. STNA #130 stated Resident #50 was heavier, so to ensure the resident was thoroughly cleaned when completing incontinence care and bathing, staff were to spread her buttock cheeks. STNA #130 stated when she noticed the wound getting deeper, she notified Registered Nurse (RN) #153. STNA #130 could not remember the time frames. Interview on 08/11/22 at 8:53 A.M. with RN #153 revealed she couldn't recall any of the exact dates or timeframe but stated STNA #130 had informed her Resident #50's wound was getting deeper. RN #153 assessed the wound and then informed LPN/WN #147. LPN/WN #147 told RN #153 they were already aware. LPN/WN #147 stated the resident had been complaining of her bottom hurting and she had not been getting out bed much and couldn't turn herself. Interview on 08/11/22 at 9:15 A.M. with LPN/WN #147 indicated she believed she was working the evening of 05/31/22 when the aide notified her Resident #50 had something on her bottom when they were doing incontinence care. LPN/WN #147 was not sure who the aide was that notified her. LPN/WN #147 stated because of the resident's anatomy and the location of the wound by the time it was noticed it was definitely at Stage 4. LPN/WN #147 stated the preventive measures that were in place prior to the development of the wound included incontinence care, turning and repositioning, house barrier cream, and a nutritional supplement that was started in February 2022. LPN/WN #147 stated the nurses completed weekly head to toe skin assessments. LPN/WN #147 stated when she assessed the wound on 05/31/22 it measured 3.7 centimeters (cm) in length, 2.1 cm in width, and 0.1 cm in depth, and the skin around it was fragile. LPN/WN #147 stated the current treatment included to clean with alginate to wound bed, cover with foam border dressing every night shift and as needed. LPN/WN #147 stated the wound was stable but as of 08/10/22 the resident acquired MASD because of the tape used to secure the dressing. A new order was obtained to use a silicone border foam that was gentler on the skin. LPN/WN #147 stated Resident #50 still had pain with the dressing changes. LPN/WN #147 stated when the wound was identified she notified the regional dietitian who was covering on 05/31/22 and then again on 06/14/22. LPN/WN #147 confirmed there was no nutritional re-assessment or new recommendations around that time period, but Resident #50 was on a nutritional supplement, Med pas, three times per day. Interview on 08/11/22 at 9:49 A.M. with Registered Dietitian (RD) #168 revealed she started working at the facility on 06/14/22 and first addressed Resident #50's nutritional status related to her wound on 06/21/22. RD #168 stated the nutritional assessment prior to 06/21/22 was dated 04/01/22. RD #168 stated when a dietitian is notified of wounds, they should address them as soon as possible. Interview on 08/11/22 at 11:52 A.M. with Wound Nurse Practitioner (WNP) #176 revealed she starting working at the facility sometime in June 2022. WNP #176 agreed Resident #50's wound to the sacrum was a Stage 4 pressure ulcer. WNP #176 said she would need more history on the resident to call it something else such as a pilonidal cyst. WNP #176 stated wounds could deteriorate to a Stage 4 fast depending on the preventative measures in place and nutrition was also an important role. WNP #176 stated Resident #50's wound was a Stage 4 when she got involved. Interview on 08/11/22 at 2:40 P.M. with the DON revealed she observed Resident #50's wound for the first time today. The DON felt it may not be pressure but something else such as a cyst that opened because the wound looked too perfect for a pressure ulcer. DON verified the skin assessment dated [DATE] documented no new skin issues. The DON stated Resident #50 had C-diff during that time, so she knew staff were observing the resident's skin during incontinence care. The DON confirmed documentation and treatment indicated a Stage 4 pressure ulcer. Interview on 08/11/22 at 2:57 P.M. with LPN #111 revealed when she completed Resident #50's skin assessment on 05/27/22 she didn't see anything. LPN #111 was informed on report by another nurse that something was found. LPN #111 stated when she first observed the wound after being told something was found it was a small, white circle or slit. LPN #111 stated there was not redness and she had to search for the wound to find it. LPN #111 had seen the wound recently and said it had gotten worse, much bigger, and it looked terrible now. LPN #111 stated Resident #50 had been complaining of pain on her bottom for two weeks prior to the wound being identified. Review of the facility's policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol revised 01/01/22 revealed based on the comprehensive assessment of a resident, a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. 2. Review of Resident #47's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's physician orders dated 06/12/19 revealed turn and reposition frequently every day and night shift. Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated 06/15/22 revealed the resident was at high risk for developing a pressure ulcer. Review of Resident #47's quarterly MDS assessment dated , 06/16/22 revealed the resident had severe cognitive impairment. Resident #47 required extensive assistance of one staff member for bed mobility and toilet use and had total dependence on two staff members for transfers. Resident #47 was always incontinent of urine and bowel and did not have a pressure ulcer. Review of Resident #47's physician orders dated 07/08/22 revealed Resident #47 was discontinued from hospice services. Review of Resident #47's care plan dated 07/20/22 included Resident #47 was at risk for pressure ulcer development related to incontinence, restricted mobility, mood and diagnoses. Resident #47's risk of significant skin injury would be reduced, minimized through the review date. Interventions included to apply barrier cream as ordered; Resident #47 needed reminding, assistance to turn and reposition frequently, at least every two hours, more often as needed or requested; monitor and document, report as needed any changes in skin status: appearance, color. Review of Resident #47's Skin assessment dated [DATE] revealed Resident #47 had no new abnormal skin areas. Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated 08/09/22 revealed the resident was at high risk for developing a pressure ulcer. Observation on 08/09/22 at 8:15 A.M. and 12:30 P.M. of Resident #47 revealed he was laying in bed, flat on his back with the head of his bed elevated. Interview on 08/09/22 at 3:15 P.M. with Certified Nursing Assistant (CNA) #127 revealed she had not taken care of Resident #47 for a couple days but he allowed her to change him when he needed it. CNA #127 stated when she provided Resident #47's incontinence care previously she noticed he had a little redness on his bottom. Observation on 08/09/22 at 3:59 P.M. of Certified Nursing Assistant (CNA) #127 providing incontinence care for Resident #47 revealed Resident #47's incontinence brief was saturated with urine. Resident #47's buttocks were very red and an open area about the size of a quarter was noted on the right buttock close to the sacrum and coccyx. Resident #47 cried out in pain when CNA #127 cleaned his buttocks and sacrum. CNA #127 did not apply barrier cream and was preparing to put a clean incontinence brief on Resident #47. After surveyor intervention CNA #127 confirmed Resident #47 had an open area on his right buttock. Registered Nurse (RN) #120 walked into the room and CNA #127 informed RN #120 about the open area on Resident #47's right buttock. RN #120 measured the wound for a length of 3.1 centimeters (cm), width 1.9 cm, depth of less than 0.1 cm. RN #120 sprayed the area with Skin prep (protective barrier) and applied a border gauze dressing. Resident #47 stated his bottom hurt and after surveyor intervention a pillow was placed under his right side. Review of Resident #47's progress notes dated 08/09/22 timed 5:53 P.M. revealed an STNA notified the nurse Resident #47 had a new area of skin impairment on his right buttocks. RN #120 assessed the area on the right buttocks which measured 3.1 cm by 1.9 cm by less than 0.1 cm depth. No drainage was noted, the wound bed was pink. The peri-wound (tissue surrounding wound) was within normal limits. The area was cleansed with normal saline, Skin prep applied topically and covered with small border foam gauze. Resident #47 repositioned for comfort. nurse practitioner notified, no further orders. Resident #47's guardian aware. Observation on 08/10/22 at 7:35 A.M. of Resident #47 revealed he was lying in bed, flat on his back with the head of his bed elevated. Observation on 08/10/22 at 9:21 A.M. of Resident #47 revealed he was lying in bed in the same position as 7:35 A.M., on his back with the head of his bed elevated. Observation on 08/10/22 at 10:15 A.M., and 08/10/22 at 11:47 A.M. of Resident #47 revealed he was lying in bed, flat on his back with the head of his bed elevated. Resident #47 was in the same position observed earlier in the day. Interview on 08/10/22 at 11:42 A.M. with STNA #159 revealed she did not ask Resident #47 if he wanted to get out of bed. STNA #159 stated she changed Resident #47's incontinence brief, but she did not reposition him or encourage him to let her reposition him at any time during her shift. STNA #159 stated Resident #47 liked to lay flat on his back. Interview on 08/10/22 at 3:45 P.M. of Licensed Practical Nurse/Wound Nurse (LPN/WN) #147 revealed she was not notified about Resident #47's wound on his right buttock. When asked why Resident #47 was not on a low air loss mattress due to his high risk for developing a pressure ulcer LPN/WN #147 stated Resident #47 was on hospice services and they did not use a low air loss mattress for him. LPN/WN #147 stated Resident #47 was no longer on hospice and she thought it was discontinued in 06/2022. Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol, revised 01/01/22 included based on comprehensive assessment of a resident, a resident received care consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable. A resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. The plan of care for prevention and or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, the facility failed to provide adequate supervision for Resident #24 during toileting. Actual harm occurred when Resident #24 was left unsupervised in the bathroom, fell and hit her head causing a laceration requiring an emergency room visit and a staple was needed to close her head/scalp laceration. This affected one of six residents reviewed for accidents. Findings include: Review of Resident #24's medical record revealed the she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she had severe cognitive impairment and memory impairment. Review of Resident #24's current fall care plan revealed she was high risk for falls related to her confusion, use of psychoactive medications, unsteadiness when walking, incontinence and history of falls. Interventions dated 08/08/17 and 03/05/18 indicated staff were educated on not leaving Resident #24 alone in the bathroom. There was an additional intervention dated 05/30/19 which indicated Resident #24 was to be supervised by staff when in the bathroom. Resident #24's Kardex (a reference care card providing information for staff for the provision of resident care) indicated she was to be supervised by staff during toileting. Review of Resident #24's progress note dated 07/27/19 at 2:16 P.M. indicated she was in the bathroom when she fell to the floor and was observed with blood coming from her head. Emergency Medical Services (EMS) were called and pressure with a towel was applied on the resident's head to stop the bleeding. The resident was transferred to the hospital. Review of Resident #24's progress note dated 07/27/19 at 5:44 P.M. revealed she returned from the hospital and she had a laceration to her scalp with one staple in place, which was used to close the laceration. Review of the undated fall witness statement authored by State tested Nursing Assistant (STNA) #609 indicated she put Resident #24 on the toilet and left her alone in the bathroom. She left and went to provide care to another resident. When STNA #609 was done with the other resident and was coming out of the their room, she was told Resident #24 had fallen and hit her head. Interview on 08/13/19 at 3:39 P.M. with the Director of Nursing (DON) confirmed STNA #609 left Resident #24 in the bathroom unsupervised to provide care to another resident. The DON said Resident #24 attempted to get off of the toilet by herself and fell . The DON verified this resulted in a head/scalp laceration requiring her to be transported to the hospital emergency room . A staple was placed in the back of the resident's head to close the laceration. The DON confirmed Resident #24's Kardex indicated she was to be supervised during toileting. Interview on 08/14/19 at 9:51 [NAME]M. with STNA #609 confirmed she had worked in the facility approximately fourteen months but was unaware Resident #24 required continuous supervision during toileting. STNA #609 confirmed she left Resident #24 unattended on 07/27/19 while the resident was in the bathroom to answer another resident's call light and the resident fell causing a laceration to the resident's head resulting in an emergency room visit for care and treatment.