Every finding on record at Arbors at Marietta

Based on observation, interview and record review the facility failed to develop a person centered care plan that met the resident's medical and physical care needs related to contractures and failed to implement the Activities of Daily Living (ADL) care plan as it was written when providing care to the resident. this affected on e resident (#102) of three sampled for care planning. The facility census was 122.Findings include: Review of the medical record for Resident #102 revealed an admission date of 01/15/26 diagnoses including acute and chronic respiratory failure with hypoxia, dependence on respirator (ventilator), Parkinson's disease, anemia, tracheostomy status, gastrostomy status, contracture of muscle, right lower leg, left lower leg, right upper arm and left upper arm, neuromuscular dysfunction of the bladder, and major depressive disorder. Review of Resident #102's quarterly Minimum Data Set (MDS) assessment, dated 04/15/26, revealed Resident #102 had severely impaired cognition. Further review of the MDS revealed Resident #102 was dependent on facility staff for all activities of daily living (ADLs)and indicated the resident had no impairments to her range of motion (ROM).Review of Resident #102's physician's progress note dated 01/15/26 written by Physician #403 revealed the resident had marked contractures of her upper and lower extremities.Review of Resident #102's plan of care for ADL self-care performance deficit dated 01/15/26 revealed Resident #102 was dependent on facility staff for all ADLs. Interventions included two-person assistance with bed mobility, toileting hygiene and bathing, and two-person assistance and mechanical lift for transfers. Further review of Resident #102's plan of care revealed no care plan for Resident #102's upper and lower extremity contractures.Review of Resident #102's physician's progress note dated 01/15/26 written by Physician #403 revealed the resident had marked contractures of her upper and lower extremities.Review of the physical therapy evaluation completed on 01/16/26 by Physical Therapist #404 revealed Resident #102 had contractures to all joints of her bilateral lower extremities.Review of the occupational therapy evaluation completed on 01/16/26 by Occupational Therapist #406 revealed Resident #102 had contractures to both shoulders, elbows ,wrists and hands.In an interview on 05/20/26 at 9:30 A.M. Nurse Practitioner (NP) #401 revealed Resident #102 was admitted with severe contractures to her arms and legs.An interview attempted on 05/20 26 at 11:45 A.M. with Resident #102 revealed resident to be nonverbal. In an interview on 05/21/26 at 9:33A.M. Registered Nurse (RN) #278 revealed she was changing the resident's catheter and had positioned the resident at the edge of the bed on her right side with her hip at the resident's side so that she could see to change her catheter and when she went to separate the SR's legs she heard a grinding noise that sounded like it was coming from the hip and immediately stopped the procedure. Certified Nursing Assistants # 308 and #202 were with her at that time but did not have their hands on the resident. In an interview on 05/21/26 at 2:42 P.M. CNA #202 revealed she was in the room when the nurse was attempting to insert the resident's catheter and was standing back out of the way in case she needed to get something for the nurse. Registered Nurse (RN) #278 was trying to move her legs apart when they heard a kind of popping/grinding noise. RN #278 immediately stopped what she was doing and called to have the resident sent to the hospital. She could not see the resident's face when she heard the noise, but the resident did not move or make any sound. They received education about passive ROM after the incident.In an interview on 05/21/26 at 3:31 P.M. CNA #308 revealed they were doing checks and changes and found the resident's bed wet because her catheter was leaking. RN #278 came in and placed pillows to position the resident and was trying to spread her legs to replace the catheter and they heard a popping grinding noise. CNA #308 stated that she was standing by the bed but did not have her hands on the resident. RN #278 was not pulling on the resident hard just trying to spread her legs. The resident's vital signs were normal and CNA #308 stated she did not see grimacing or hear the resident make noise or see her cry. Crying silent tears is usually how they know the resident is in pain. CNA #308 stated she did not feel the nurse did anything to cause the injury.In an interview on 05/27/26 at 1:05 P.M. Therapy Program Director and Certified Occupational Therapy Assistant #405 revealed Resident #102 was admitted with contractures in her legs and arms.In an interview on 05/27/26 at 1:30 P.M. Nursing Restorative Aide #334 revealed Resident #102 had contractures since she was admitted to the facility in both her arms and legs. In an interview on 05/27/26 at 4:00 P.M. Regional Nurse #402 revealed her expectation of the care plan is that it paints a picture of the resident and the care that they are to receive, and the intent is for it to be a delivery guide for care. Resident 102's care plan should have been updated to reflect that she would do better with one person doing her catheter insertion because the resident would be more uncomfortable and harder to catheterize if a second person was holding her leg in position. Regional Nurse #402 stated she would update care plan to reflect that the resident would require one to people.An observation on 05/20/26 at 11:45 A.M. revealed Resident #102 in bed tilted to her right side with inside of right knee visible. Resident #102 had a small cushion between her thighs to relieve pressure to her knees. Resident #102's bilateral arms and legs are observed to have contractures at all joints.Review of the policy titled Comprehensive Care Plan dated 01/01/21 and revised 06/30/22 revealed the care plan was to describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This deficiency represents non-compliance investigated under Complaint Number #3017045.

Based on observation, interview and record review the facility failed to ensure a resident assessment was completed that accurately reflected the resident's status at the time of the assessment. This affected one resident (#102) of three sampled for Minimum Data Set (MDS) accuracy. The facility census was 122.Findings include: Review of the medical record for Resident #102 revealed an admission date of 01/15/26 diagnoses including acute and chronic respiratory failure with hypoxia, dependence on respirator (ventilator), Parkinson's disease, anemia, tracheostomy status, gastrostomy status, contracture of muscle, right lower leg, left lower leg, right upper arm and left upper arm, neuromuscular dysfunction of the bladder, and major depressive disorder. Review of Resident #102's quarterly Minimum Data Set (MDS) assessment, dated 04/15/26, revealed Resident #102 had severely impaired cognition. Further review of the MDS revealed Resident #102 was dependent on facility staff for all activities of daily living (ADLs)and indicated the resident had no impairments to her range of motion (ROM).Review of Resident #102's physician's progress note dated 01/15/26 written by Physician #403 revealed the resident had marked contractures of her upper and lower extremities.Review of the physical therapy evaluation completed on 01/16/26 by Physical Therapist #404 revealed Resident #102 had contractures to all joints of her bilateral lower extremities.Review of the occupational therapy evaluation completed on 01/16/26 by Occupational Therapist #406 revealed Resident #102 had contractures to both shoulders, elbows ,wrists and hands.In an interview on 05/20/26 at 9:30 A.M. Nurse Practitioner (NP) #401 revealed Resident #102 was admitted with severe contractures to her arms and legs.In an interview on 05/27/26 at 1:05 P.M. Therapy Program Director and Certified Occupational Therapy Assistant #405 revealed Resident #102 was admitted with contractures in her legs and arms.In an interview on 05/27/26 at 1:30 P.M. Nursing Restorative Aide #334 revealed Resident #102 had contractures since she was admitted to the facility in both her arms and legs. In an Interview on 05/27/26 at 4:00 P.M. Regional Nurse #402 verified the MDS for 04/15/26 is marked incorrectly should have been marked as ROM impairment to both sides for both upper and lower extremities.An observation on 05/20/26 at 11:45 A.M. revealed Resident #102 in bed tilted to her right side with inside of right knee visible. Resident #102 had a small cushion between her thighs to relieve pressure to her knees. Resident #102's bilateral arms and legs are observed to have contractures at all joints.Review of the policy titled MDS policy dated 01/24/24 revealed it was the policy of the facility to utilize the Minimum Data Set 3.0 Resident Assessment Instrument manual as the source document for MDS completion. This deficiency represents non-compliance investigated under Complaint Number #3017045.

Based on review of the facility's cycle menus, observation, interview, and policy review, the facility failed to ensure meals were provided as per the menu and all substitutions of the meal that deviated from the planned menu were recorded and kept on record as required. This had the potential to affect all but 11 residents (#25, #26, #54, #55, #57, #58, #65, #66, #68, #119, and #127), who the facility identified as being on nothing by mouth (NPO) diets, and did not receive meals from the kitchen. The facility's census was 127. Findings include: Review of the facility's cycle menu for Week #1 of 2025- 2026 revealed the lunch menu for Wednesday 02/11/26 was to be cranberry orange chicken, roasted Brussels sprouts, garlic and rosemary roasted red skin potatoes, dinner roll, and Mandarin oranges. The alternate for that meal was cheese ravioli with marinara sauce and a tossed salad with dressing. The menu included a message that indicated meals were subject to change without notice due to product availability. On 02/11/26 at 11:21 A.M., a visit was made to the facility's kitchen for observation of the meal process for the lunch meal being served that day. The intent of the visit was to ensure the meal was being served as per the menu and proper portion sizes were being provided. Both had been mentioned as concerns and were part of the information obtained when the complaint was filed. Dietary staff were asked to provide the spreadsheet for the day's menu to be able to verify proper serving sizes. The spreadsheet provided was not the spreadsheet that correlated with the Week #1 menu for 2025-2026 that was being used for the current week's menu. The spreadsheet included a lunch meal for Tuesday (Day 10) that had been pulled from the 2023- 2024 Diet Guide Sheet. It had the following food items listed as part of that meal: smothered chicken thigh, poultry gravy, broccoli florets, mashed potatoes, dinner roll, and sliced pears. Observations confirmed that was the food items being served and not any of the food items listed as part of the facility's Week #1 cycle menu from 2025-2026 that the facility provided as this week's menu. Review of the facility's Menu Substitution Log for November 2025 thru January 2026 revealed multiple food substitutions had been recorded as having been made during that three month period. In all, 27 meal substitutes had been made deviating from the facility's planned cycle menu planned by a dietitian they were to follow. There had not been a Menu Substitution Log provided for February 2026 to reflect any changes to the menu that had occurred that month. The facility's Administrator obtained a new copy of the Menu Substitution Log for December 2025 thru January 2026 that had previously been provided and added the substitutions that had been made for the lunch meal served on 02/11/26. The substitutions added for 02/11/26 revealed the chicken thigh had been omitted and substituted with a chicken breast. Also omitted and replaced with another food item was the Brussels sprouts that was replaced with broccoli and roasted potatoes for mashed potatoes. It did not specific to indicate that cranberry orange chicken was substituted with smothered chicken or that the Mandarin oranges had also been omitted and replaced with pears. On 02/11/26 at 3:00 P.M., an interview with the facility's Administrator revealed the facility does use cycle menus and they were currently on Week #1 for the 2025-2026 menu. He stated the week of the menu they were using did not always match the week of the month explaining why Week #1 was currently being followed when it was actually Week #2 of the current month. They just rotate through them week after week, which causes them to be off. He confirmed the meal being followed for lunch that day was actually on the Week #1 menu for the 2025-2026 cycle menu. He further confirmed that lunch meal for Wednesday 02/11/26 should have been cranberry orange chicken, roasted Brussels sprouts, garlic and rosemary roasted red skin potatoes, a dinner roll, and Mandarin oranges. He was informed the meal served today for the lunch meal was smothered chicken, mashed potatoes, broccoli, and pears. It did not include the cranberry orange chicken, Brussel sprouts, red skin potatoes, and Mandarin oranges, as was on the menu. He further confirmed the Menu Substitution Log he provided with the day's substitution did not even mention the Mandarin oranges that had been replaced with the pears. He also acknowledged that the spreadsheet that was provided for that day's lunch meal was from 2023-2024 and was not the spreadsheet for Wednesday's lunch meal from the 2025-2026 menu. On 02/11/26 at 3:20 P.M., an interview with Regional Nurse #200 also confirmed the meal served to the residents for lunch on 02/11/26 was not consistent with the facility's cycle menu for Week #1 of the 2025-2026. She further confirmed the Menu Substitution Log did not properly record the Mandarin oranges being omitted and replaced with pears, as was served today, and not properly recording the meal as served. She acknowledged there were a lot of substitutions being made deviating from the facility's planned cycle menu during the past several months. She stated she would have to check to see what the issue was with ordering of food supplies, since they were making so many changes to the planned menus. She acknowledged residents had verbalized concerns that they were not being provided meals, as per the menu, and were saying they were not being informed when substitutions were being made. She reported planned meals should not be changed, unless the food items to be served were not available, and that should not be a common occurrence. On 02/12/26 at 9:09 A.M., an interview with Dietary [NAME] #225 revealed she was the cook on duty for the lunch meal served on 02/11/26. She was asked what was the meal served to the residents for that meal and why it deviated from the planned cycle menu. She reported they had smothered chicken, broccoli, mashed potatoes, dinner roll, and pears. She was asked what the chicken was smothered in and reported onions and gravy. They were supposed to have cranberry orange chicken, but the residents do not prefer that. It was decided during resident council at one time that they did not like that meal on the menu. She reported they did not have Brussels sprouts because 75% of the residents did not like them. They preferred cabbage or sauerkraut over that. Same with the red skin potatoes. They had them so often the residents were getting tired of them. She reported the majority of the substitutions being done were due to resident preferences. She was asked to clarify which residents preferences were being honored and she mentioned the names of a few residents that attended the resident council meetings. She indicated they typically had 15-25 residents who attended those meetings and they tried to follow what those residents suggested in regards to the menus. There was a rare occasion that they may not have something available from their food supplier, but that did not happen often. If there food service company was out of a particular food item, they would send something similar as a substitute. She reported the residents were made aware of the upcoming meals through receiving the daily chronicle. The daily chronicle would give them the next week's menus for all three meals for that seven day period. There were times when a menu would be changed, based on known resident preferences, that may not be communicated to the residents. She acknowledged it may be frustrating for residents to be informed they were going to be having a certain meal item, only to have it substituted with something else based on resident preference. She further acknowledged the number of residents actually attending resident council were a small sample size of the 127 residents that resided in the building. Those preferences being reported during resident council may not represent the majority of the residents, as a whole. She identified by looking at the Menu Substitution Logs that spinach, Brussels sprouts, roasted potatoes, broccoli, and shrimp were some of the food items the residents did not prefer. She acknowledged, just because the limited number of residents attending the resident council meetings did not like some of those food items, it did not mean other residents would not enjoy them. She agreed the dietary staff should try to serve the meal, as per the cycle menu, and make limited substitutions only based on availability of food or other unforeseen reasons the food items on the planned menus could not be served. If they were aware of menu items resident council members were reporting they did not prefer, the kitchen could ensure they had a like substitute for those food items available upon request. Having a second vegetable choice in place of Brussels sprouts or spinach may be a better option than never cooking those items, when some residents may enjoy them. On 02/12/26 at 4:00 P.M., an interview with Resident #118 revealed it was frustrating to him to receive a planned menu at the beginning of the week, when those menus were often changed without him being aware. He stated it typically happened two or three times a week that the menu would change without the residents being notified. He reported even the residents on the same hall were not receiving the same food items. He would be out in the designated smoking area and would ask another resident how they liked a particular food item. The resident in return would tell him that they did not get that to eat and would have liked to. He stated they were never given an explanation, as to why a meal was not served according to the menu. He would hear that the cook just did not make enough and ran out before all the residents had been served. Review of the facility's policy on Menus (revised October 2022) revealed menus would be prepared in advance to meet the nutritional needs of the residents in accordance with established national guidelines. Menus would be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the facility. The menu would identify the primary meal, the alternate meal, and any always offered food and beverage items. A registered dietitian (RD) or other clinically qualified nutrition professional reviewed and approved the menus. The RD or other clinically qualified nutrition professional would adjust the individual meal plan to meet the individual requests, as appropriate. Menus would be served as written, unless a substitution was provided in response to preference, unavailability of an item, or a special meal. A menu substitution log would be maintained on file and kept per state regulations. This deficiency represents non-compliance investigated under Complaint Number 2707159.

Based on record review, review of a facility investigation, staff interview, and policy review, the facility failed to ensure a possible situation of neglect was reported to the State survey agency, as required, when a resident choked during a meal resulting in the resident's death. This affected one resident (#128) of two residents reviewed for death. Findings include:Review of Resident #128's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a malignant neoplasm of the prostate and obesity. Review of Resident #128's advanced directives revealed the resident's code status was a Do Not Resuscitate Comfort Care Arrest (full treatment provided, including resuscitation efforts, until the resident experienced cardiac or respiratory arrest, when all life-saving interventions stop). The advanced directive had been signed into place by an advanced level provider on [DATE]. Review of Resident #128's physician's orders revealed he was to receive a regular diet, with regular texture, and thin liquids. That order had been in place, since [DATE]. Review of Resident #128's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He only required set up or clean up assistance with eating. He was not known to have any coughing or choking with meals or his medications. He had no complaints of difficulty or pain when swallowing and was not receiving speech therapy services at the time of the assessment. Review of Resident #128's care plans revealed the resident was at risk for an altered nutritional status related to being above his ideal body weight, having the diagnosis of diabetes mellitus, and a history of weight loss. The care plan originated on [DATE] and the interventions included providing meals based on his preference and as ordered. They were to provide assistance with meals as needed. He also had a dental care plan in place that indicated he was edentulous (no natural teeth). Review of Resident #128's progress notes revealed a nurse's note by Licensed Practical Nurse (LPN) #100 dated [DATE] at 2:20 P.M. revealed the resident was given his lunch tray at 12:36 P.M. by a certified nursing assistant (CNA). The resident was sitting up right with no concerns noted at that time. At 12:38 P.M., a CNA took a visitor in to see the resident and no concerns were noted at that time. At 12:54 P.M., a CNA went into to check on the resident and noted the resident was showing signs of choking. His face was noted to be losing color and, when asked if he was choking, the resident nodded his head up and down. The CNA yelled outside the room for help, then performed back thrusts. Another CNA came into the room and performed back thrusts to the resident, until another staff member could assist them in repositioning the resident to perform the Heimlich maneuver. At 12:55 P.M., the nurses validated the resident's code status, as being a DNRCC-A, before entering the room, positioning the resident on the side of the bed, and began performing the Heimlich maneuver on the resident. His oral cavity was assessed and no foreign object was visible. Resident #128 became unresponsive and had no pulse noted. At 12:56 P.M., 911 was called. The Heimlich maneuver and back thrusts continued without success in opening the resident's airway. At 1:01 P.M., Emergency Medical Services (EMS) arrived on scene and took over. An assessment was completed and an Automated External Defibrillator (AED) was applied confirming the resident had no pulse. At 1:17 P.M., the resident was pronounced deceased by EMS, with ER doctor assisting to confirm the death. The physician and family were notified. Prior to the choking incident, the resident was eating blueberries brought in by his son, yogurt, and a few bites of chicken off of the chicken leg that was served on the resident's lunch tray. The chicken leg was assessed and the bone was still on tray. The chicken was noted to be moist. Review of the facility's investigation into Resident #128's choking incident on [DATE] revealed an incident report pertaining to the incident and witness statements were obtained. The facility also included a timeline of the incident's occurrences. The incident report was reflective of the information documented under the nurse's progress note, which documented the incident. The incident report was completed by the facility's interim Director of Nursing (DON). Review of the witness statements obtained by the facility, as part of their investigation, revealed statements were obtained from the staff member that delivered Resident #128's lunch tray to him on [DATE], the CNA that found the resident choking, the nurses that responded, as well as other staff members working on the resident's unit that day. Review of the witness statement from CNA #115 revealed she delivered Resident #128's tray to him and then was the CNA that took a visitor into the resident's room to see him, after his lunch tray had been provided. At that time, the resident was eating blueberries that had been provided by his family, in addition to the lunch meal he was served. Review of a witness statement from CNA #150 revealed she was picking up trays and entered Resident #128's room, when she noticed he was sitting upright in bed and his face was turning blue. He was also pointing and pounding on his throat/ chest area. The CNA immediately yelled for help and sat the resident up in bed, where she could perform back thrusts. The nurses came in and took over. The resident was noted to be eating blueberries and yogurt his son had brought in earlier that day. Review of a witness statement from LPN #175 for a date and time of incident being [DATE] at 1:10 P.M. revealed nursing staff was called to Resident #128's room due to the resident choking. Upon entering his room, the resident was found unresponsive with a pulse and no respirations. The Heimlich maneuver was performed without success. All attempts to dislodge the choking material were unsuccessful. The local EMS arrived and called the resident's time of death at 1:17 P.M. On [DATE] at 12:53 P.M., an interview with the facility's Administrator revealed they did not submit a self-reporting incident (SRI) to the State survey agency pertaining to the choking incident involving Resident #128 on [DATE]. He questioned if that was something they were required to report, if their investigation determined that no wrong doing had occurred, and the facility felt the staff responded appropriately to the incident. He acknowledged it was an unusual occurrence in the facility that resulted in a resident's death and should have been reported as possible neglect of the resident. Any subsequent investigation the facility conducted could then be reported to the State survey agency with their conclusion determining if neglect had actually occurred. Review of the facility's policy on Abuse, Neglect, and Exploitation (revised [DATE]) revealed neglect meant failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. An alleged violation was defined as a situation or occurrence that was observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be indication of noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source. Under the reporting/ response section of the policy, the facility would have written procedures that include reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes as required by state and federal regulations. They were to report immediately, but no later than two hours after the allegation was made, if the events that cause the allegation involved abuse, or resulted in serious bodily injury. The Administrator would follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2739421.

Based on observation, record review, policy review and interview, the facility failed to ensure resident safety during facility provided transportation to prevent injury. In addition, the facility failed to ensure fall interventions were in place for residents at risk for falls. This affected two residents (#1 and #15) of three residents reviewed for falls. The facility census was 117. Actual Harm occurred on 10/27/25 when Resident #1, a resident dependent on staff for transportation, was on her way back to the facility from an appointment at a local hospital when Transport Aide (TA) #118 failed to ensure the wheel straps on the left side of Resident #1's wheelchair were secured appropriately. This resulted in Resident #1 being dislodged from her wheelchair as the bus turned, falling and hitting her head. Resident #1 was transported to the local hospital emergency room where she required medical treatment including 10 staples to a head laceration. Findings include:1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, paroxysmal atrial fibrillation and hypothyroidism.Review of a care plan revised on 08/18/25 revealed Resident #1 was at risk for falls related to cerebral vascular incident, generalized weakness, medications, pain, and need for assistance with activities of daily living. The goal was to reduce Resident #1's risk of injury through the next review. Interventions included but were not limited to anti-tippers to wheelchair, non-skid footwear, use call light, and ensure resident's room will be free from hazards.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was intact. The assessment revealed the resident had no behaviors and used a wheelchair for mobility.Review of the physician's orders revealed an order dated 10/03/25 for Resident #1 to receive Eliquis (a blood thinning medication) five milligrams (mg) by mouth every morning and at bedtime related to cardiomyopathy.There was no evidence Resident #1 had a care plan in place related to her use of a blood thinning medication that would include monitoring for abnormal signs or symptoms related to the resident's medical condition and use of a blood thinning medication.Review of a nursing note and corresponding incident report both dated 10/27/25 at 12:40 P.M. by the Director of Nursing (DON) revealed Resident #1 was on her way to an appointment with TA #118. TA #118 noticed a strap came loose and Resident #1 started to move backwards which caused the resident's wheelchair to upset. Resident #1 hit her head causing a laceration. The transportation assistant applied pressure with first aide gauze on the bus, and the driver got the bus pulled to safety, removed the wheelchair and assisted Resident #1 back into the wheelchair. Resident #1 maintained pressure on the wound until the driver arrived at a local emergency room per Medical Director (MD) #500. The note included Resident #1's family was updated with no concerns. TA #118 was with Resident #1, Resident #1 remained alert and oriented to person, place, and time with complaints of a mild headache and wanted to go home. Resident #1 was interviewed via phone and stated she slid back and the chair upset.Review of a nursing note dated 10/27/25 at 6:10 P.M. authored by Licensed Practical Nurse (LPN) #101 revealed Resident #1 returned to the facility from the emergency department with 10 staples to her posterior head, to remain (in place for 10-14 days). The area was clean, staples intact, some scant bleeding was noted when assessed. Instructions included, do not get the area wet for 24 hours, no other skin issues noted upon skin assessment. Vitals were obtained and no new orders.Review of a social service progress note dated 10/28/25 at 12:05 P.M. by Social Worker (SW) #131 revealed Resident #1 had been speaking to the unit manager when SW #131 approached. The note included Resident #1 stated she had some pain between her shoulders rating at a three out of 10 (this pain was a result of the resident's fall out of her wheelchair on 10/27/25). Nursing was made aware and planned to apply Biofreeze to the area. Review of a nursing note dated 10/28/25 at 5:20 P.M. by Social Worker (SW) #131 revealed Resident #1 refused a shower due to not feeling well, this nurse spoke with the resident who stated she was having head and neck pain (the pain was related to the resident's fall out of her wheelchair on 10/27/25) and would like to wait. MD #500 and representative were aware.Review of a social services note dated 10/29/25 at 11:13 A.M. by SW #131 revealed Resident #1 had an appointment later in the day. The note included when asked if she had reservations attending appointments, she denied any and stated she trusted the bus driver and was in good hands. Resident #1 stated she had some pain between her shoulders rating at a two, reported the day prior Biofreeze was applied and alleviated the pain, nursing was made aware and planned to put Biofreeze on the area. Review of a performance improvement form dated 10/30/25 revealed TA #118 was terminated from the facility. Interview on 12/03/25 at 4:00 P.M. with the DON revealed Resident #1 was in the transport van when it was noticed a strap was coming loose. Resident #1 tipped over in her wheelchair and hit her head, causing a laceration which required ten staples from the ER. The DON stated the facility had the bus inspected to determine the cause of the loose straps, the inspection came back with no concerns. The DON stated due to no concerns with the bus, it was determined user error must have been the cause when strapping the wheelchair down to the bus. The DON revealed the transport staff (TA #118) was terminated as a result of the incident.Interview on 12/03/25 at 4:41 P.M. with TA #126 revealed on 10/27/25 she and TA #118 had picked two residents up from the facility and were taking them to the hospital for their appointments. Upon arriving to the hospital, both residents were assisted off the bus, and Resident #1 was placed on the lift to the bus because she was being picked up from an appointment at the hospital. TA #126 stated she was unable to say what exactly happened with the four-point straps on the bus to hold Resident #1's wheelchair in place because once Resident #1 was in the van off the lift, TA #118 strapped her in while TA #126 took the other two residents to their appointments. TA #126 stated she was headed back downstairs from dropping off the residents when she received a phone call from TA #118 telling her to come to the ER for an emergency regarding Resident #1. TA #126 emphasized she was not on the bus with Resident #1 at the time of the incident. TA #126 stated she met Resident #1 at the ER, and the resident was holding paper towels to her head to apply pressure. When the incident statement dated 10/27/25 (that was included in the facility investigation and completed by the DON) was read to TA #126, she stated it was confusing because there was not a first aid kit on the bus and it sounded like there were two transport aides, TA #118 and an additional one but that wasn't accurate. At the time of the incident with Resident #1, there was only one transport aide present, TA #118.Interview on 12/03/25 at 5:50 P.M. with Resident #1 revealed she recalled the incident that had occurred on 10/27/25. The resident revealed TA #118 had strapped one side in then moved on to the other, but then TA #118 didn't lock both sides, only the right side. Resident #1 stated she recalled asking TA #118 if she was forgetting something to which TA #118 replied no. Resident #1 stated she did not question TA #118 any further. Resident #1 stated when they left the hospital going down the hill she was okay. At the bottom of the hill there was a stop sign, and they were turning left but TA #118 gunned it a little too hard and she (the resident) came out of her wheelchair. Resident #1 stated the wheelchair completely folded up and went to the right side of the van and she was on her back on the floor of the van. Resident #1 stated she hit her head and was bleeding. Resident #1 stated she felt TA #118 messed up because she did not call for an ambulance and someone had stopped to offer help, which TA #118 declined. Resident #1 stated TA #118 was panicking trying to figure out what to do and Resident #1 had to tell her to get it together because she needed help. Resident #1 stated she received paper towels from TA #118 and was helped back up into her chair. Once the chair was locked in, she was taken to the ER and she (Resident #1) applied pressure to her wound. Resident #1 stated the ER was concerned because she does take a blood thinner and was bleeding. Her representative was called because they were concerned about a potential brain bleed, but all the tests came back ok. Resident #1 reported getting nine staples in her head and being afraid to get in a vehicle to go back to the facility. Resident #1 reported having a hard time going to the first few appointments and stated she would only let TA #126 drive her now. Resident #1 stated even with TA #126 driving, she felt scared and when they go around a curve, she would still find herself reaching out to grab on to something.2. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including hypertension, type II diabetes, and end stage renal disease.Review of an incident log revealed Resident #15 had two falls on 09/28/25.Review of a care plan revised on 10/09/25 revealed Resident #15 was at risk for falls/injury related to decreased strength and endurance. The goal was to reduce the risk of injury through the next review. Interventions included but were not limited to 15 minutes checks, keep frequently used items within reach, traction strips to the floor on left of bed, visual reminder to call for assistance, apply side rails to bed to aid in repositioning, encourage resident to use call light, and place call light in reach.Review of an order dated 10/10/25 revealed Resident #15 had an order in place for traction strips to the left side of bed for fall intervention.Review of the MDS assessment dated [DATE] revealed Resident #15 had moderately impaired cognition, no behaviors, required maximum assistance for transfers, had one fall with no injury since admission, one fall with injury other than major injury since admission, and took an anticoagulant (blood thinning) medication.On 12/03/25 at 2:24 P.M. Resident #15 was observed in bed. Interview with the resident at the time of the observation revealed the resident stated she could not find her call light, but if she needed anything she could just call out to her roommate and ask her to put on her call light. During the observation of the room, the call light was not within reach to the resident and there were no traction strips observed to the left of Resident #15's bed.Interview and observation on 12/03/25 at 4:15 P.M. with the DON confirmed there were no traction strips to the left of Resident #15's bed and the resident's call light was not within reach.Review of policy titled Fall Prevention Program dated 10/26/23 revealed each resident would be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall was an event in which an individual unintentionally comes to rest on the ground, floor or other level but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. After risk assessment, a nurse would indicate the resident's fall risk and initiate interventions on the resident's baseline care plan in accordance with the resident's level of risk. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. When a resident experienced a fall, the facility would assess the resident, complete a post-fall assessment, complete an incident report, notify physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury.This deficiency represents non-compliance investigated under Complaint Number 2656047.

Based on observation, record review, interview and policy review the facility failed to maintain comprehensive, resident centered care plans. This affected three (#40, #104, and #178) of four residents reviewed for comprehensive care plans. The facility census was 124. Findings include: 1. Record review revealed Resident #40 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified part of unspecified bronchus or lung, chronic obstructive pulmonary disease, and atherosclerotic heart disease without angina. Review of a minimum data set (MDS) dated [DATE] revealed Resident #40's cognition was intact and the resident received injections and antibiotics. Review of an order dated 04/23/25 revealed Resident #40 had a PICC (peripherally inserted central catheter) line in place to be removed after the completion of antibiotic therapy. Review of a care plan dated 03/31/25 revealed Resident #40's comprehensive care plan was not completed related to the type of intravenous access she had for her antibiotics. Resident #40's care plan read, resident has an IV (intravenous) (SPECIFY: Central line, Peripherally inserted central catheter (PICC) line, Midline, Peripheral line) related to: (blank). Interview on 04/23/25 at 1:59 P.M. with the Director of Nursing (DON) confirmed Resident #40's comprehensive care plan was incomplete related to her IV status. 2. Record review revealed Resident #178 admitted to the facility on [DATE] with diagnoses including occlusion and stenosis of right carotid artery, peripheral vascular disease, atrial fibrillation, and benign prostatic hyperplasia. Review of a nursing note dated 04/01/25 at 1:00 P.M. by Unit Manager (UM) #595 revealed Resident #178 admitted to the facility with a #16 French (size of the catheter tube) indwelling catheter for urinary retention. Review of a Urinary Continence Evaluation dated 04/08/25 at 4:47 P.M. revealed Resident #178 was always continent and did not have a urinary catheter in use. Review of an admission MDS dated [DATE] revealed Resident #178's cognition remained intact, he did not have an indwelling catheter, and his urinary continence was not rated. Review of a care plan completed on 04/14/25 revealed no evidence of a care plan related to Resident #178's urinary catheter. Review of orders revealed no evidence of orders to care for Resident #178's urinary catheter. Interview on 04/21/25 at 2:23 P.M. with Resident #178 revealed he had been waiting for an appointment with the urologist to remove his catheter and would like an update. Observation on 04/22/25 at 8:31 A.M. revealed Resident #178 was seated in his wheelchair and had a breakfast tray in front of him. A catheter bag was noted. Interview on 04/22/25 at 8:33 A.M. with UM #595 revealed he does complete some care plans, but the MDS nurses' complete most of the care plans. UM #595 stated upon admission, the floor nurse will enter orders, but the unit managers will assist and complete a clinical review to ensure nothing was missed. Interview on 04/22/25 at 8:50 A.M. with MDS Nurse #513 and MDS Nurse #564 confirmed there was not a care plan in place for catheter. Both MDS Nurse #513 and #564 stated they thought Resident #178's catheter had been removed upon admission to the facility. Interview on 04/22/25 at 9:48 A.M. with the Director of Nursing (DON) and UM #595 confirmed Resident #178 did not have a care plan related to an indwelling catheter. The DON stated in conversations with his staff, everyone thought Resident #178's catheter had been removed upon admission. The DON stated he does see Resident #178 daily and is not sure how the catheter was missed. 52003 3. Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, tracheostomy status, and severe protein-calorie malnutrition. Interview and observation on 04/21/25 at 1:28 P.M. with Resident #104 revealed the resident had broken and missing teeth due to history of drug use. Review of Resident #104's current plan of care did not address oral/dental status. Interview on 04/22/25 at 2:33 P.M. with Certified Nursing Assistant (CNA) #592 confirmed staff provide oral care for Resident #104 and the resident has several missing and broken teeth but does not complain of pain during care. Interview on 04/22/25 at 2:38 P.M. with MDS Licensed Practical Nurse (LPN) #564 confirmed there was no care plan to address oral/dental status. Review of a policy titled Comprehensive Care Plans dated 06/30/22 revealed the facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completed of the MDS and will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and it will be prepared by the interdisciplinary team.

Based on observation, record review, interview and policy review the facility failed to ensure minimum data set (MDS) assessments were completed accurately for falls, dental status, catheter and continence status. This affected three (#86, #104, and #178) of four residents reviewed for accurate assessments. The facility census was 124. Findings include: 1. Record review revealed Resident #178 admitted to the facility on [DATE] with diagnoses including occlusion and stenosis of right carotid artery, peripheral vascular disease, atrial fibrillation, and benign prostatic hyperplasia. Review of a nursing note dated 04/01/25 at 1:00 P.M. by Unit Manager (UM) #595 revealed Resident #178 admitted to the facility with a #16 French (the size of the catheter) indwelling catheter for urinary retention. Review of a Urinary Continence Evaluation dated 04/08/25 at 4:47 P.M. revealed Resident #178 was always continent and did not have a urinary catheter in use. Review of an admission MDS dated [DATE] revealed Resident #178's cognition remained intact, he did not have an indwelling catheter, and his urinary continence was not rated. Review of orders revealed no evidence of orders to care for Resident #178's urinary catheter. Interview on 04/21/25 at 2:23 P.M. with Resident #178 revealed he had been waiting for an appointment with the urologist to remove his catheter and would like an update. Observation on 04/22/25 at 8:31 A.M. revealed Resident #178 was seated in his wheelchair and had a breakfast tray in front of him. A catheter bag was noted. Interview on 04/22/25 at 8:50 A.M. with MDS Nurse #513 and MDS Nurse #564 revealed Resident #178's MDS was coded incorrectly because Resident #178 had a catheter. MDS Nurse #513 and #564 stated they thought Resident #178's catheter had been removed upon admission to the facility. Interview on 04/22/25 at 9:48 A.M. with Director of Nursing (DON) and UM #595 confirmed everyone thought Resident #178's catheter had been removed upon admission. The DON stated he saw Resident #178 daily and is not sure how the catheter was missed. 52003 2. Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, tracheostomy status, and severe protein-calorie malnutrition. Review of Resident #104's admission Minimum Data Set (MDS) assessment completed on 01/21/25, revealed section L was marked no for broken natural teeth. Interview on 04/21/25 at 1:28 P.M. with Resident #104 revealed the resident reported broken and missing teeth due to a history of drug use. Interview on 04/22/25 at 2:33 P.M. with Certified Nursing Assistant (CNA) #592 confirmed staff provided oral care for Resident #104 and the resident had several missing and broken teeth. Interview on 04/22/25 at 2:38 P.M. with MDS Licensed Practical Nurse (LPN) #564 confirmed the MDS was incorrect and did not address broken or missing teeth. 50538 3. Review of Resident #86's medical record revealed an admitted [DATE], with a re-admitted [DATE] with diagnoses including transient cerebral ischemic attack, diabetes, asthma, atrial flutter, major depressive disorder, hypertension, hyperlipidemia, and hypothyroidism. Review of Resident #86's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 15 indicating the resident's cognition was intact. Review of Resident #86's medical record revealed a fall on 04/05/25 at 7:19 P.M. Resident #86 was getting up to go to the bathroom and lost her balance resulting in a bruise on the resident's back. Further review revealed no other falls since the 03/30/25 admission and no other injuries from the 04/05/25 fall. In an interview on 04/23/25 at 2:21 P.M. MDS Licensed Practical Nurse (LPN) #540 verified Resident #86 had not had a fall with major injury since the 03/30/25 admission. MDS LPN #540 confirmed that MDS section J1900 C. falls with major injury should not have been marked as a yes. Review of a policy titled MDS 3.0 dated 01/24/24 revealed it is the policy of the facility to utilize the MDS Resident Assessment Instrument (RAI) manual as the source document for any/all MDS scheduling, encoding, completion, submission, correction, and retention requirements as outlined in chapter two through six of the RAI manual.

Based on interview, observations and policy review, the facility failed to maintain the shower room and resident rooms in a clean and sanitary manner. This affected one (#43) of two residents reviewed for physical environment. The facility census was 124. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare, chronic obstructive pulmonary disease, and hypertension. Review of an admission minimum data set (MDS) completed on 03/27/25 revealed Resident #43's cognition remained intact. Interview on 04/21/25 at 3:07 P.M. with Resident #43 revealed sometimes the shower rooms are not cleaned well, and she had a stain on her shower curtain since her admission. Interview and tour on 04/23/25 at 4:01 P.M. with Housekeeping Supervisor (HS) #201 and Maintenance Staff (MS) #567 revealed the first-floor shower room had a quarter-sized, soft bowel movement on the floor next to the drain in the third stall, and a used washcloth hanging over the handrail of the second stall. HS #201 confirmed the findings and stated housekeeping staff mop the floors each morning and scrub the floors once per week, but in between residents, the floor staff should clean the shower room. The tour continued to Resident #43's room where a round stain was noted to the bottom right of her shower curtain. The observation was confirmed by HS #201 and MS #567. Review of a statement dated 04/23/25 with no time provided by Certified Nursing Assistant (CNA) #531 revealed she gave Resident #43 a shower and had taken her back to her room to help her get ready and was going to clean the shower room after. Interview on 04/24/25 at 4:03 P.M. with MS #567 confirmed after observing the first-floor shower room during the tour, Resident #43's room was observed directly after with no sign of a CNA or Resident #43 in her room or the shower room. Review of a policy titled Safe and Homelike Environment dated 01/01/22 revealed the facility will provide a safe, clean, homelike, and comfortable environment and ensure the building and equipment are kept sanitary.

Based on observations, interviews, medical record review and missing items log review, the facility failed to ensure missing hearing aides were reported to the appropriate staff and failed to ensure hearing aides were worn as directed to aide in communication. This affected one (Resident #32) of one resident reviewed for vision/hearing. The census was 124. Findings Include: Record review revealed Resident #32 admitted to the facility 09/04/23 with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, hyperlipidemia, diastolic heart failure, congestive heart failure, hearing loss. Review of Resident #32 care plan completed 08/16/23 and revised 02/10/24 revealed Resident is at risk for impaired communication related to being hard of hearing. Goals include Resident#32 will understand others when communicating through next review. Interventions include Allow ample time for the resident to comprehend what is being communicated and allow time for response, Audiology referral as needed. Encourage conversations in calm, quiet locations with minimal background noise. Maintain eye contact, approach resident from the front, pay attention to resident's body language and facial expressions, Request feedback, when needed, to ensure understanding, Speech Language Pathology screen / eval / treat as needed. Use simple and direct communication (i.e., yes/no questions) to promote understanding, use gestures or pictures if necessary. Record review of the audiology group note for Resident #32 dated 02/03/25 revealed Resident #32 had profound sensorineural hearing loss of the right eat and severe to profound sensorineural hearing loss of the left ear. Otoscopy revealed the right nor left ear were occluded. Recommendations included bilateral hearing aids, stating Resident #32 decided to try receiver-in-canal (RIC) hearing aids. Recommendations include Resident #32 to wear hearing aids daily, requiring assistance with insertion and manipulation of hearing aid daily. Signed by Certificate of Clinical Competence in Audiology (M.A., CCC-A) #1738 on 02/03/25. Record review of the minimum data set (MDS) completed 02/20/25 section B for hearing speech, and vision revealed Resident #32 has moderate difficulty hearing loss, but does not have hearing aids. Record review revealed a social service progress note dated 03/10/25 revealed Resident #32 answered questions in a low tone and moderate speed. Resident #32 did require social services to repeat questions due to hearing issues. Record review revealed a social services progress note dated 03/24/25 that the resident was seen in house by audiology. Record review of the audiology group note for Resident #32 dated 03/24/25 revealed Resident #32 received right and left hearing aides that fit good. Resident #32 stated she is hearing better with the hearing aids. Consulted as to daily use. Red is for the right ear and blue is for the left ear. Model for right ear hearing aides are BTE/[NAME] laboratories Inc. [NAME] evvolv A1 1000 RIC 312 2025 serial number #250069542. Model for left ear hearing aides are BTE/[NAME] laboratories Inc. [NAME] evvolv A1 1000 RIC 31 2025 serial number #250069553. Signed by M.A., CCC-A #1738 on 03/24/25. Record review revealed no refusal by Resident #32 to wear hearing aids and no evidence hearing aids were missing and not being utilized daily as recommended for Resident #32 to improve communication and understanding. Observation and interview of Resident #32 on 04/24/25 at 9:27 A.M. revealed a hearing aide case sitting on the bedside table. Resident #32 required questions to be repeated and having to raise tone of voice while asking questions so she could hear and understand the conversation. Resident #32 stated she was not wearing hearing aids at this time. She stated one was missing and she didn't know where it was. Resident #32 confirmed it was hard for her to hear and understand what someone was saying due to her hearing loss. Interview on 04/24/25 at 9:55 A.M. with Certified Nursing Assistant (CNA) #598 confirmed one hearing aid was in the box on Resident #32 bedside table and one hearing aid for Resident #32 was missing. Resident #32 stated it had been missing for a while. Interview on 04/24/25 at 11:36 A.M. with CNA #566 confirmed they have not found Resident #32's missing hearing aid and they have looked multiple times today. Interview on 04/24/25 at 11:30 A.M. with Registered Nurse #617 revealed that Resident #32's hearing aids have been missing and confirmed they are still missing at this time. She stated she was unsure who all was aware of this and who had been involved with the missing hearing aids. Interview on 04/24/25 at 11:51 A.M. with social services director #534 stated Resident # 32 did not have hearing aids when she was admitted . The surveyor informed social services that there was a case at Resident #32 bedside with one hearing aide in the case. She stated that the son bought hearing amplifiers at Wal-Mart and that is what those are, and if there is one missing this is the first she has heard about it. Social services director #534 stated she was going to complete a concern form. Social services director #534 confirmed the missing items on the concern log for Resident #32 on 04/09/25 did not include a hearing aid. Social services confirmed, upon review of the audiology note dated 03/24/25, Resident #32 does have bilateral hearing aids from the audiology group. Interview on 04/25/25 at 10:55 A.M. with customer care coordinator #1072 of the Audiology Group confirmed Resident #32 did receive hearing aids dispensed on 03/24/25 and was to wear them daily while requiring assistance to place them. They confirmed thr faciliy has not reached out to the audiology group regarding a missing hearing aid for Resident #32.

Based on observation, interview, medical record review and facility policy review the facility failed to provide a comprehensive treatment plan for altered skin integrity to Resident #48. This affected one resident (Resident #48) of two residents reviewed for non pressure skin conditions. The facility census was 124. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disorder, diabetes mellitus type two, peripheral vascular disease, congestive heart failure and atrial fibrillation. Review of the plan of care revised on 03/11/25 revealed Resident #48 was at risk for skin impairment with interventions in place to decrease risk. The plan of care did not include interventions for bilateral lower extremities discoloration and dry skin. Review of the Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was cognitively intact with no behaviors. Resident #48 was dependent on staff for toileting hygiene, showers, transfers and dressing. Resident #48 had no skin impairment documented. Review of the physician orders dated 04/25 revealed an order for daily skin checks with care by the Certified Nursing Assistants (CNA) and weekly skin assessment by nursing staff. Review of the nursing weekly skin assessment dated [DATE] revealed Resident #48 had redness to bilateral axilla area. No other skin impairment was noted. Observations on 04/21/25 at 1:47 P.M., and 04/23/25 at 11:12 A.M. revealed Resident #48 had his bilateral lower extremities elevated on a pillow. Bilateral lower extremities were dark blue in color, cool to touch and had dry, flaky skin. Interview on 04/23/25 at 11:12 A.M. with Resident #48 revealed he had a bath on 04/22/25. Resident #48 was not sure if the CNA had applied any lotion or ointment to his bilateral lower extremities. Interview on 04/23/25 at 11:14 A.M. with CNA #577 confirmed Resident #48 had dark blue colored bilateral lower extremities with dry, flaky skin. Interview on 04/23/25 at 1:58 P.M. with Licensed Practical Nurse (LPN) # 517 confirmed Resident #48 bilateral lower extremities were discolored and had dry flaky skin. LPN # 517 stated he would document his findings of Resident #48 skin and notify the physician for orders. LPN # 517 also stated he would update the plan of care to include the discoloration, dry, flaky skin to bilateral lower extremities. Review of the facility policy titled Non Pressure Skin revealed skin impairment would be monitored, assessed and treatment provided as ordered.

Based on observation, interview and record review the facility failed to ensure residents received comprehensive and resident centered care related to indwelling urinary catheters. This affected two residents (#28 and #178) of three sampled for catheters. The facility census was 124. Findings include: 1. Review of Resident #28's medical record revealed an admitted [DATE], a re-entry date of 05/21/18 and diagnoses including diabetes, anemia, neurogenic bladder, dementia, bipolar disorder, anxiety, attention-deficit hyperactivity disorder, and mild intellectual disabilities. Review of Resident #28's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact, used an indwelling catheter to empty her bladder and had a diagnosis of neurogenic bladder. An observation of Resident #28 on 04/21/25 at 10:45 A.M. revealed the resident to have a catheter and the catheter bag to be hanging on the positioning rail attached to the resident's bed above the resident's bladder. In an interview on 04/21/25 at 10:46 A.M. Licensed Practical Nurse (LPN) #581 verified the catheter bag was positioned above the resident's bladder. An observation of Resident #28 on 04/22/25 at 10:52 A.M. revealed her catheter bag to be positioned on the floor. In an interview on 04/22/25 at 10:55 A.M. Registered Nurse (RN) #536 confirmed the catheter bag was positioned on the floor. Review of the policy titled Catheter Care - Urinary dated 10/30/20 and revised 12/28/23 revealed the facility was to provide catheter care to all residents in a manner to reduce bladder and kidney infections. Further review revealed catheter were to be maintained to gravity drainage. 47985 2. Record review revealed Resident #178 admitted to the facility on [DATE] with diagnoses including occlusion and stenosis of right carotid artery, peripheral vascular disease, atrial fibrillation, and benign prostatic hyperplasia. Review of a nursing note dated 04/01/25 at 1:00 P.M. by Unit Manager (UM) #595 revealed Resident #178 admitted to the facility with a #16 French (size of catheter) indwelling catheter for urinary retention. Review of a Urinary Continence Evaluation dated 04/08/25 at 4:47 P.M. revealed Resident #178 was always continent and did not have a urinary catheter in use. Review of an admission MDS dated [DATE] revealed Resident #178's cognition remained intact, he did not have an indwelling catheter, and his urinary continence was not rated. Review of a care plan completed on 04/14/25 revealed no evidence of care planning related to Resident #178's urinary catheter. Review of orders revealed no evidence of orders to care for Resident #178's urinary catheter. Interview on 04/21/25 at 2:23 P.M. with Resident #178 revealed he had been waiting for an appointment with the urologist to remove his catheter and would like an update. Observation on 04/22/25 at 8:31 A.M. revealed Resident #178 was seated in his wheelchair and had a breakfast tray in front of him. A catheter bag was noted. Interview on 04/22/25 at 8:50 A.M. with MDS Nurse #513 and MDS Nurse #564 revealed Resident #178's MDS was coded incorrectly because Resident #178 had a catheter, they confirmed there was not a care plan in place for catheter, and there were no orders since admission for Resident #178 to have an indwelling catheter or catheter care. Both MDS Nurse #513 and #564 stated they thought Resident #178's catheter had been removed upon admission to the facility. Interview on 04/22/25 at 9:48 A.M. with the Director of Nursing (DON) and UM #595 confirmed Resident #178 did not have orders, a care plan, or an accurate assessment related to the resident's indwelling urinary catheter. The DON stated in conversations with his staff, everyone thought Resident #178's catheter had been removed upon admission. The DON stated he does see Resident #178 daily and is not sure how the catheter was missed. Review of a policy titled Catheter Care Procedure - Urinary dated 12/28/23 revealed the facility is to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections while maintaining their dignity and privacy. Residents with indwelling urinary catheters will be provided catheter care in accordance with current clinical standards including each shift, with each bowel movement, as needed and as requested.

Based on record review, interview and policy review the facility failed to ensure nursing staff planned to administer the appropriate dose of medication, without resident intervention, to prevent a potential overdose. This affected one resident (Resident #104) of one residents reviewed for a medication error. The census was 124. Findings Include: Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, pneumonitis due to inhalation of food and vomit, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 15. Record review revealed on 12/24/24 an order was received for Methadone 10 milligrams (mg): Give two tablets by mouth three times a day However the order was discontinued on 12/24/24. On 12/26/24, an order for Methadone 10 mg give two tablets via nasogastric (NG) tube three times a day however the order was discontinued on 12/26/24. On 12/26/24, an order was received for Methadone HCl Oral Tablet 10 mg give two tablet by mouth three times a day however the order was discontinued on 12/26/24. On 12/31/24 an order for Methadone liquid dated 12/31/24 for 60 mg/7.5 milliliters (ml) by mouth each morning one time a day. Further review of the medical record revealed a medication error which occurred on 12/31/24 for Methadone. Resident #104 was given 30 ml (four of the 7.5 ml bottles) instead of 7.5 ml (one bottle). The possible medication error was not found until the next day 01/01/25 when the morning dose was scheduled to be administered. Review of the medication administration record (MAR) dated 12/31/24 at 8:00 A.M. revealed the nurse documented administration of one Methadone 7.5 ml bottle. The narcotic sheet had four of the 7.5 ml bottles signed out for administration. Review of facility investigation dated 01/01/25, during narcotic count staff nurses found a narcotic discrepancy with the Methadone. The night shift nurse stated they were in a hurry, and they did not unlock the methadone case during the 12/31/24 7:00 P.M. count during sign off. It was discovered the dayshift nurse administered extra bottles of Methadone. On 01/01/25 the medication error was reported to the unit manager, Director of Nursing (DON) and the medical director. Interview on 04/24/25 at 9:13 A.M. with the the Regional Director of Clinical Operations, confirmed the prescription for Methadone was not entered correctly in the computer due to the supply amount from the pharmacy and the nurse thought the resident was to receive four bottles of Methadone instead of one bottle. Interview on 04/24/25 at 9:34 A.M. with the Regional Director of Clinical Operations revealed the first four orders of methadone were what the hospital ordered however were unable to fill the prescription due to the resident's diagnosis and the resident required a referral to a methadone clinic. Oxycodone was ordered until the Methadone was available for the resident. The appointment at the Methadone clinic was on 12/26/24 and they supplied 27 days worth of Methadone (27 bottles). The order was initially transcribed incorrectly and the nurse thought the order meant to administer four bottles and not one to get the ordered dose. When the nurse went to clarify the order, the DON did correct the order in the system however the order entered was set to start the following day and did not appear on the MAR at the time of administration, so the nurse prepared the incorrect dose. The Regional Director of Clinical Operations said the resident only received one dose of the methadone because the resident stopped the nurse and refused to take the additional medication, knowing what the ordered dose was. Interview on 04/24/25 at 4:58 P.M. with Licensed Practical Nurse (LPN) #569 via telephone confirmed she prepared the incorrect dose of Methadone for administration. Review of facility policy titled Medication reconciliation dated reviewed/revised: 01/30/24 states medication reconciliation refers to the process of verifying that the residents current medication list matches the physicians orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay.

Based on record review, staff interview and policy review, the facility failed to thoroughly investigate a potential medication error and the disposition of controlled medications. This affected one resident (#104) of one residents reviewed for a medication error. The facility census was 124. Findings Include: Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, pneumonitis due to inhalation of food and vomit, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 15. Record review revealed on 12/24/24 an order was received for Methadone 10 milligrams (mg): Give two tablets by mouth three times a day However the order was discontinued on 12/24/24. On 12/26/24, an order for Methadone 10 mg give two tablets via nasogastric (NG) tube three times a day however the order was discontinued on 12/26/24. On 12/26/24, an order was received for Methadone HCl Oral Tablet 10 mg give two tablet by mouth three times a day however the order was discontinued on 12/26/24. On 12/31/24 an order for Methadone liquid dated 12/31/24 for 60 mg/7.5 milliliters (ml) by mouth each morning one time a day. Further review of the medical record revealed a medication error which occurred on 12/31/24 for Methadone. Resident #104 was given 30 ml (four of the 7.5 ml bottles) instead of 7.5 ml (one bottle). The possible medication error was not found until the next day 01/01/25 when the morning dose was scheduled to be administered. Review of the medication administration record (MAR) dated 12/31/24 at 8:00 A.M. revealed the nurse documented administration of one Methadone 7.5 ml bottle. The narcotic sheet had four of the 7.5 ml bottles signed out for administration. There was no documentation of the wasted Methadone. Review of facility investigation dated 01/01/25, during narcotic count staff nurses found a narcotic discrepancy with the Methadone. The night shift nurse stated they were in a hurry, and they did not unlock the methadone case during the 12/31/24 7:00 P.M. count during sign off. It was discovered the dayshift nurse administered extra bottles of Methadone. On 01/01/25 the medication error was reported to the unit manager, Director of Nursing (DON) and the medical director. Interview on 04/24/25 at 9:13 A.M. with the Regional Director of Clinical Operations, confirmed the prescription for Methadone was not entered correctly in the computer due to the supply amount from the pharmacy and the nurse thought the resident was to receive four bottles of Methadone instead of one bottle. Interview on 04/24/25 at 9:34 A.M. with the Regional Director of Clinical Operations revealed the first four orders of methadone were what the hospital ordered however were unable to fill the prescription due to the resident's diagnosis and the resident required a referral to a methadone clinic. Oxycodone was ordered until the Methadone was available for the resident. The appointment at the Methadone clinic was on 12/26/24 and they supplied 27 days worth of Methadone (27 bottles). The order was initially transcribed incorrectly and the nurse thought the order meant to administer four bottles and not one to get the ordered dose. When the nurse went to clarify the order, the DON did correct the order in the system however the order entered was set to start the following day and did not appear on the MAR at the time of administration, so the nurse prepared the incorrect dose. The Regional Director of Clinical Operations said the resident only received one dose of the methadone because the resident stopped the nurse and refused to take the additional medication, knowing what the ordered dose was. Interview on 04/24/25 at 04:28 P.M. with the Regional Director of Clinical Operations confirmed the narcotic count was not completed correctly to identify the potential medication error timely (shift to shift count) and confirmed the narcotic log/waste was not completed to identify the second nurse who witnessed the medication waste. The Regional Director also confirmed the investigation did not identify the lack of a second nurse documented as witnessing the disposition of the Methadone not used. LPN #569 was contacted but she could not remember who the second nurse was when the medication was wasted. Interview on 04/24/25 at 4:58 P.M. with Licensed Practical Nurse (LPN) #569 via telephone confirmed she prepared the incorrect dose of Methadone for administration and she flushed the remaining medication in the toilet. Review of facility policy titled Medication-Destruction of Unused Drugs Date Reviewed/Revised: 01/18/24 states prescription drugs shall not be flushed down the toilet in accordance with Environmental Protection Agency regulations. Scheduled II, III, and IV controlled drugs must be destroyed by the Director of Nursing Services and another Licensed Nurse.

Based on review of facility alternative dispute resolution agreements, interview, record review, and policy review, the facility failed to ensure residents understood the agreement they signed. This affected three of three residents reviewed for arbitration agreements (Residents #31, #89, and #178). The facility census was 124. Findings include: 1. Review of the record for Resident #31 revealed an admitted [DATE]. Review of a Minimum Data Set (MDS) assessment completed 01/27/25 and 03/06/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 01/20/25 revealed Resident #31 electronically signed the agreement on 01/23/25. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or had been able to view an audio/visual recorded video that details this agreement and what it includes. Interview with Resident #31 on 04/24/25 at 9:40 A.M. revealed she did not remember signing the agreement. She also stated she did not watch a video explaining the agreement. She stated she did not understand what the agreement was for. 2. Review of the record for Resident #89 revealed an admitted [DATE]. Review of a MDS assessment completed 6/13/24 and 02/26/25 revealed a BIMS score of 15, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 6/05/24 revealed Resident #89 electronically signed the agreement on 6/14/24. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or have been able to view an audio/visual recorded video that details this agreement and what it includes. Interview with Resident #89 on 04/24/25 at 9:55 A.M. revealed she did not remember signing the dispute resolution agreement. She stated she did not remember doing her electronic signature on an iPad. She stated she was not offered to watch a video explaining the agreement and did not understand what the agreement was. 3. Review of the record for Resident #178 revealed an admitted [DATE]. Review of a MDS assessment completed 04/08/25 revealed a BIMS score of 15, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 04/01/25 revealed Resident #178 electronically signed the agreement on 04/04/25. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or have been able to view an audio/visual recorded video that details this agreement and what it includes. Interview with Resident #178 on 04/24/25 at 9:30 A.M. revealed he did not remember signing the agreement electronically on an iPad. He stated the agreement was not explained to him and he did not watch a video explaining the agreement. He stated he would not have signed the agreement had he known what it was. He stated he wanted to revoke the agreement. Interview with Admissions Director #599 on 04/24/25 at 10:05 A.M. revealed the agreement is part of the facility admission packet. She stated residents are told it is optional and they are offered a video to watch that explains the arbitration agreement. She stated residents are asked to sign the agreement electronically on an iPad. She stated it is usually just her and the resident in the room at the time (no witness). Review of the facility policy titled Binding Arbitration Agreements dated 07/28/20 and revised 11/01/22 revealed this facility asks all residents to enter into an agreement for binding arbitration. The facility shall explain to the resident or his or her representative in a form and manner that he or she understands.

Based on observation, interview and record review the facility failed to complete appropriate hand hygiene during medication administration and to maintain contact isolation precautions while in a resident's room with clostridium difficile. This affected two residents (#104 and #178) of five sampled for infection control. The facility census was 124. Findings include: 1. Review of Resident #104's medical record revealed an admitted [DATE] and diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage, chronic pancreatitis, anemia, pneumonitis due to inhalation of food or vomit, tracheostomy status, and gastrostomy status. Review of Resident #104's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Further review revealed the resident was receiving enteral feedings via a gastrostomy tube. Review of Resident #104's orders revealed an order for the resident to be on enhanced barrier precautions (due to the gastrostomy tube, considered an indwelling medical device). An observation on 04/23/25 at 8:20 A.M. of medication administration by Licensed Practical Nurse (LPN) #628 revealed LPN #628 administered Resident #104's medications via his gastrostomy tube and then changed her gloves to administer his nasal inhaler. LPN #628 did not complete hand hygiene when she changed her gloves and then preceded to administer the nasal inhaler. On 04/23/25 at 8:25 A.M. LPN #628 confirmed she did not complete hand hygiene when she changed her gloves prior to administering Resident #104's nasal inhaler. Review of the policy titled Flushing the Feeding Tube dated 01/01/21 and revised 06/30/22 revealed facility staff should wash their hands after administrating medications via the feeding tube. 52003 2. Review of Resident #178's medical record revealed an admitted [DATE] with diagnoses that included essential hypertension, peripheral vascular disease and contact with and suspected exposure to COVID-19. Physician's orders indicated Resident #178 required contact transmission-based precautions for c-diff (inflammation of the colon caused by the bacteria Clostridium difficile). Observation on 04/24/25 at 12:34 P.M. revealed Certified Nursing Assistant (CNA) # 531 entering Resident #178's room to deliver lunch tray. A sign was posted outside of the room door to Resident #178's room indicating he was on contact precautions and a cart containing personal protective supplies was noted below the sign and outside the resident's room door. Interview on 04/24/25 at 12:35 P.M. with CNA #531 verified the resident had contact precautions in place for C-Diff and she did not wear appropriate personal protective equipment (PPE) while she was in the resident's room. Review of facility policy titled Infection Prevention and Control Program: A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current Center for Disease Control guidelines.

Based on review of employee personnel files, review of the background check monitoring log, staff interview, and policy review, the facility failed to implement their criminal background check policy for one employee. This had the potential to affect all 124 residents. Findings include: Review of the personnel file for Registered Nurse (RN) #513 revealed she was hired on 05/14/24. There was no evidence that the facility determined whether RN #513 had resided in the state for the past five years. Review of the Background Check Monitoring Log revealed a Federal Bureau of Investigation (FBI) background check was not completed. It indicated that only a state Bureau of Criminal Investigation (BCI) check was completed with no findings. The facility had also conducted a background check with the Office of Inspector General (OIG) and the System for Award Management (SAM) on RN #513 at the time of hire with no findings. Interview with the Administrator on 04/24/25 at 1:19 P.M. revealed RN #513 did not reside in the state when hired and did not move to Ohio until August 2024. He confirmed an FBI background check was not done and should have been per state law. He stated that RN #513 would not work until an FBI background check was completed. Interview with the Administrator on 04/24/25 at 2:06 P.M. revealed an FBI background check was completed for RN #513 with no findings. Interview with the Administrator on 04/24/25 at 4:10 P.M. revealed that, at the time RN #513 was hired, the facility was not using the system they are now where they verify residency for the past seven years in writing. He stated at that time they only asked the employee if they had lived in Ohio for the past five years but there was no documentation of this. He also stated the Human Resource employee in charge of this at the time RN #513 was hired no longer works in that position and there is a new Human Resource employee. Review of the facility policy titled Criminal Background Checks dated 09/22/20 and revised 01/01/22 revealed it is the company's guideline that resident abuse, neglect, or misappropriation of resident property should not be tolerated. To ensure the safety of our residents, all employees will undergo a criminal background check before an employment offer is finalized. If your state has a law regarding criminal background checks, you should follow that state regulation.

Based on medical record review, review of facility self-reported incident (SRI) including investigation, observations, staff and resident interviews and review of facility Abuse, Neglect, and Misappropriation policy, the facility failed to ensure residents was free from physical and sexual abuse. This affected two residents (#57, #61) of four residents reviewed for abuse. The facility in-house census was 110. Findings included: 1. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, heart failure peripheral vascular disease, anemia, and mental disorder. Review of Resident #61's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact and he had one to three days of other behavioral symptoms not directed towards others. Review of Resident #61's orders and medication administration records dated 02/2024 revealed on 02/08/24 new orders were added to have two staff with care at all times, monitor bruising to right hand first and second digit until resolved and a revised order to monitor target behaviors of refusal of care, refuses to turn and reposition, false accusations with staff, sexually inappropriate, yelling at staff, and inappropriate finger gestures. Resident #61's medications that were due at 6:00 A.M. included Atorvastatin 40 milligrams (mg) once a day for hyperlipidemia, Lasix 20 mg daily for heart failure, Lisinopril 2.5 mg daily for elevated blood pressure, Metoprolol Extended Release (not recommended to crush) 40 mg daily for high blood pressure, Cholecalciferol 1000 units twice daily for supplement, and Eliquis 5 mg twice daily for atrial fibrillation. Further review revealed the resident had six behaviors of refusal to turn and reposition. There was no documented evidence the resident had any other targeted behaviors. Review of Resident #61's behavior plan of care dated 10/15/23 revealed to attempt to redirect when exhibiting behaviors; re-approach when resident had deescalated; communicate care; educate resident on need/benefit of care and risk of refusal, keep resident safe during episodes of behaviors; attempt to redirect, and offer distraction and re-approach later. Review of the facility SRI #243943 including investigation for physical abuse dated 02/08/24 revealed Resident #61 alleged he was provided his morning medication crushed and in pudding by Medication Technician (MT) #119. He stated to MT #119 he no longer received his medication crushed and declined to take the medication in that form. MT #119 left the room with the crushed medication and returned with four pills in a medication cup. Resident #61 stated all his medication was not in the cup and declined to take it until he received all medications that were due. MT #119 stated those were the medications ordered. The resident refused to return the four pills in the medication cup or take the pills until someone addressed his issues. Licensed Practical Nurse (LPN) #233 entered the room to speak to Resident #61 and again he stated he would not take the medications until he was provided all the pills that were due and refused to return the medication cup. Resident #61 stated LPN #233 grabbed his hand to retrieve the cup and caused bruising in the process. Review of LPN #233's statement revealed Resident #61 had refused to take the medication stating not all his medications were there and he would not give the medication back to MT #119. He said he was keeping them to show the dayshift nurse he was missing medications. LPN #233 went in and reviewed all medications with him reassuring him that all the medication ordered for that morning was there. He again refused. LPN #233 told him if he wasn't taking the medication, she would need them back because she was not allowed to leave them in the room. The LPN went to grab the cup and Resident #61 grabbed her right wrist and started twisting and wouldn't let go. MT #119 told the resident to let go. LPN #233 reported she did not touch the resident in any way that would potentially cause harm because he had a hold of her right arm, and she had another resident's medication in her left hand. Review of MT #119's statement was consistent with LPN #233's statement. MT #119 reported LPN #233 had grabbed the medications and the Resident (#61) grabbed her by the right wrist and started twisting her arm and would not let go. MT #119 further stated she had to tell the resident he couldn't do that before he finally let go of LPN #233. Review of a skin and pain assessment conducted on Resident #61 revealed a bruise noted on his 1st and 2nd digit on the right hand. It was important to note Resident #61 was on blood thinners causing him to easily bruise. A whole house staff education on abuse was conducted as well as one on one with LPN #233. The resident was able to provide meaningful information when interviewed and the resident (#61) had no effect noticed as a result of the incident. There were two witnesses identified (Stated tested Nurse's Aide (STNA) #137 and MT #119). The SRI was unsubstantiated as there was no evidence that indicated abuse had occurred. Further review of the investigation revealed no evidence of written statements from LPN #233 and MT #119. Review of STNA #137's statement dated 02/08/24 at 8:05 A.M., revealed Resident #61 informed me about what happened last night when I went to change him this morning. LPN #233 said he took his pills crushed and not whole, but he had been taking them whole for a long time and when she went back there were only four or five pills and he takes about seven. LPN #233 told him if you aren't going to take them, you're not getting any at all. She went to put his pills in his hand and grabbed his right index finger and that's when he grabbed her wrist and told her to get out of here. So, STNA #137 looked at this right index finger and it was red and bruised. STNA #137 informed her nurse and unit manager when he told her, and the nurse went to look at it and talk to the resident. Review of STNA #146's statement dated 02/08/24 revealed when she first arrived at work, she overheard LPN #233 talking about an altercation with a resident to MT #119. LPN #233 told her she went to take Resident #61's pills and had crushed them, but he was upset about it, so she got him new that were whole. LPN #233 stated that he told her they still were not correct and wanted to keep hold of them anyway and she wouldn't let him. She then said she went to grab the pill to take them to be discarded and said the resident grabbed her arm and started to twist it. MT #119 then said he only let go of LPN #223 because MT #119 told him to. Further review of the staff questionnaires revealed the staff interview questions asked if they were aware of any incidents that happened with Resident #61, when were you notified of the incident and by whom, and if notified by the Resident, what did he say. The statement was answered yes or no for the first question, date and time and name for the second question and if there was a statement if the resident said anything. Review of the staff questionnaires revealed the surveyor could not determine the last name on the questionnaire dated 02/08/24 that revealed Resident #61 reported LPN #233 had brought his pills in crushed and he takes them whole. He gets about seven pills, and she only gave him four pills. The LPN told him to take it or leave it. He had the pill cup in his hand and wanted to show someone it wasn't his complete morning meds and LPN #233 had grabbed it out of his hands. Review of the facility investigation revealed interviewable residents were asked if they experienced abuse, and if so explain, and if they felt safe in the facility. There was no evidence skin assessments were completed on not interviewable residents. Review of LPN #186's questionnaire revealed the resident reported his medications were crushed and the medication tech had brought in the cup of medications. He held the cup of medication to ask LPN #233 which pills were missing. He said she stated take it or not. Then she took the pill cup from him. He stated she bruised his fingers. The unit manager was notified. Review of the incident report completed by the Director of Nursing (DON) on 02/08/24 revealed an STNA reported that a resident (#61) stated the nurse on the previous shift grabbed his hand trying to take the cup of pills away. Resident stated that the med tech brought in his morning medications, and they were crushed in pudding. He told the med tech he doesn't take them crushed. States the med tech asked if he was refusing. He replied, no I just don't take them crushed. The med tech left the room and returned with his meds whole in a cup. Resident stated there were only four pills in the up and told the med tech that wasn't all his medications. Med tech stated that was what was ordered. Resident says he told her he was not taking them and was waiting to show someone that his wasn't medication wasn't correct. Med tech told the resident she cannot leave unless you return the meds or take them. The resident refused and the Med tech left. LPN #233 came in and moved the resident's tray table and attempted to take the cup of pills from the resident's hand. The resident turned away and she grabbed my hand. The resident had bruises on the 1st and 2nd digits on the right hand. Pain medication offered but declined. Per the incident report, LPN #233 reported to the DON the resident's medications had always been crushed in pudding. So, she got his meds and crushed them in pudding. MT #119 went to give him his medication and he refused them stating he takes them whole. LPN #233 went in and spoke with him and said you've always taken your pills this way. He replied, I have never taken my pills crushed in pudding. LPN #233 left the room and MT #119 returned with his meds whole in a cup. She told me he refused to take the medications stating not all his meds were there. He wouldn't give the meds back to MT #119. He said he was keeping them to show the dayshift nurse he was missing meds. LPN #233 went in and reviewed all medications with him reassuring him that all the meds ordered for this morning were there. He again refused. LPN #233 told him if he wasn't taking the meds, she needed them back because she is not allowed to leave the meds in the room. LPN #233 went to grab the cup and the resident grabbed her by her right wrist and started twisting her wrist. He wouldn't let go. MT #119 had come in and told him to let go of my arm. The LPN #233 reported she did not touch him in any way to cause harm because he had her right arm, and she had other residents' medications in her left hand. She did not notice any bruising to the resident. Per the incident report, MT #119 reported to the DON she went to give Resident #61 his medications crushed in pudding. The resident stated he doesn't take the crushed in pudding. She went out and told LPN #233. MT brought back the resident meds whole in a cup. The resident still refused to take them stating there were meds missing. MT #119 tried to explain that they were all there and he declined. MT #119 told him if he wasn't going to take them, she needed them back because she is not allowed to leave medication in a room. He refused. MT #119 went and told LPN #233. She came in to tell the resident the same thing. She went to grab the medication and he grabbed her by the right wrist and started twisting her arm. He wouldn't let go. MT #119 had to tell him he couldn't do that before he finally let go. Review of Resident #61's pertinent charting note-behavior and nursing progress note dated 02/08/24 at 6:26 A.M. revealed when administering morning medications, this nurse crushed resident's meds as have done any other time this nurse has given meds to this resident. Resident refused to take the medication. This nurse then gave the resident whole pills and resident refused to take them stating they were not all there. This nurse explained they were all there and went through every medication he was to have, and the resident began yelling at this nurse and refused to take them again. When this nurse went to take cup of meds back due to refusal, resident grabbed this nurse's right arm squeezing and twisting. Review of Resident #61's pertinent charting for change of condition dated 02/08/24 revealed the resident had maroon colored bruising to the right-hand 1st and 2nd digit. The reported nurse grabbed right hand to try and take the cup of pills from him. Investigation initiated, nurse suspended, and pain and skin assessment completed. Review of Resident #61's psychosocial note dated 02/12/24 revealed the resident stated that he wasn't having difficulty sleeping but doesn't think about the incident often. The resident would be observed for seven days per the abuse policy related to psychosocial. Review of Resident #61 charting dated 12/01/23 to 02/20/24 revealed only two behaviors noted. One on 12/04/23 for refusing to have barrier between skin and the bed and the incident on 02/08/24 with LPN #233. Interview on 02/20/24 at 9:54 A.M., with Resident #61 revealed the resident resided next to the window. When the surveyor asked the resident if he had ever been abused, the resident reported yes. The surveyor asked the resident to explain the abuse. The resident reported on February 8th, 2024, the unit manager Licensed Practical Nurse (LPN) #233 was preparing the medications and having Medication Technician (MT) #119 administering the medication to the residents. MT #119 entered his room and placed a medication cup on his bedside table. The medications were crushed in pudding. The MT #119 reported LPN #233 had prepared his medication and she was supposed to bring it to him. The resident responded, I don't take my medication that way, I take them whole. The resident explained to the surveyor that one of the medications was extended release and he was told it could not be crushed. The MT replied, Are you refusing to take them?. The resident replied No, I just need them the way I'm supposed to take them. The MT took the medication cup and left the room. She then returned with the medication cup with the crushed medication and said, You need to take them, or we will chart you refused them. The resident requested that the MT provide him with her name, however he reported she refused to provide it and stated, I don't have to give you my name. He asked her again for her name and she responded Puddin Tane and then she said LPN #233 first name. The MT took the medication cup with the crushed medication and left the room again. MT #119 returned to his room with a medication cup with four whole pills in the cup. The resident told the MT he was supposed to have six pills. The MT reported she would ask the nurse and she came back in and said, This is what the nurse said you are going to get. The resident reported he had the medication cup in his right hand when the MT asked for them back if he wasn't going to take them. The resident reported he was going to keep them until he could show the nurse. At that time LPN #233 stormed in and pushed his bedside tray out of the way and attempted to grab the medication cup out of his hand. The resident reported he moved his right arm over his abdomen towards the window to prevent the nurse from grabbing the medication cup from his hand. The LPN held his arm and leaned over him attempting to get the medication cup out of his hand. The resident reported the LPN was squeezing his hand so hard the cup was pressing into his hand and causing pain. He used his other hand (left hand) to grab her arm and was told to let go so he did, and the LPN took the medication cup and left the room. The resident reported the LPN had squeezed his hand so hard it left bruises on two of his fingers where he was holding the medication cups. The resident showed the surveyor there was still a red mark on this thumb and the pointer finger bruise had resolved. The resident reported one of pills that was missing was red/orange in color, but he did not know the name of the medication. At 11:00 A.M. he finally got all his medications. He has spoken to Social Service and the Administrator; however, he feels the Administrator should be protecting the residents and not the staff. He had recently found out from other staff and residents that LPN #233 had been rude to other people. He was considering filing charges against the nurse and was still very upset about the situation and was concerned about other residents residing in the facility due to LPN #233 had physically abused him. He has requested that LPN #233 not provide care to him and was told she was suspended but she was back to work already. Review of Quality Assurance Form completed on 02/16/24 (completed because of an abuse allegation that occurred on 02/14/24 between resident to resident) revealed Resident #61 told Admission Staff #194 he did not feel safe due to issues with a staff member a couple days ago LPN #233. Interview on 02/20/24 at 10:28 A.M., with the Administrator and DON revealed LPN #233 was suspended after the allegation was reported until the following Monday. The resident did not have an order to crush his medication and the LPN should have administered his medication whole and since she had prepared the medication, she should not have had the MT administer the medications she prepared. The LPN had one on one education on abuse and medication administration. The Administrator and DON reported they unsubstantiated the abuse allegation based off staff statements were consistent. The DON reported she determined the bruises were a result of the resident twisting the staff's arm and, on a blood, thinner, not caused by the resident holding the pill cup in his hand. Interview on 02/20/24 at 11:11 A.M., with LPN #233 and DON revealed she was working midnights on the third floor due to there was a call off, but usually works day shift as a unit manager on the first floor. The LPN reported she was administering morning medication and had provided care to Resident #61 a year ago when she worked the 3rd floor and he had received his medication crushed at that time, so she thought he was still a crushed med. The LPN confirmed the resident did not have an order to crush meds. She could not recall which meds he was on but remembers crushing five or six meds. The LPN confirmed she had prepared the meds but handed them to the med tech to administer. LPN #233 reported she was standing outside the door preparing the next resident's medications and the med tech came back out of the room and reported the resident didn't take his medication crushed. She went into the room and the resident told her that he took them whole now. She went back out to get all the new meds and gave them to the med tech to administer. She heard the resident say they were not all there, so she wrote all his meds down and went back into the room and read off the medication he was to receive. Resident #61 kept saying they were not the right medication and she reassured him they were correct. He refused to take them until the nurse came in. She explained she had to stay with him until he took them. He placed the cup on the bed beside his leg by his knees. She reached across his knees to get the med cup and he grabbed her right arm and hand and started to twist it. She had a pill cup and glucometer in her other hand so there was no way she could have touched him. She grabbed the pills with her right hand. The LPN denied squeezing the resident's hand. The LPN reported she was provided education on abuse and med administration. She was suspended on the 8th and was off the weekend anyway and returned on Monday. She was aware the resident requested that she not provide him service/care in the future. Interview on 02/21/24 at 8:46 A.M., with the DON revealed she did not have any written statements from LPN #233 or MT #119 regarding the incident with Resident #61. The DON confirmed she had received verbal statements and typed the statements on the incident report. She was not aware until yesterday the resident and staff had reported to Resident #61 that LPN #233 had been mean to others. Interview on 02/21/24 at 10:35 A.M. with STNA #117 and Registered Nurse (RN) #197 revealed they were unaware of Resident #61 making false accusations against staff. RN #197 and STNA #117 reported the resident is particular about his care. Usually if he refuses care, if you re-approach him, he was usually pretty complaint. He has never been combative with care. Interview on 02/21/24 at 11:42 A.M., with Resident #61 and the Administrator revealed the resident denied that the LPN #233 reviewed his medication with him on February 8th (2024) when he had voiced concern that he did not receive all his morning medication per LPN #233 interview. The resident voiced concerns to the Administrator that he felt the Administrator was more concerned about the food menu the day they spoke instead of the assault. The Administrator confirmed she had spoken to him regarding the alterative menu. The resident reviewed the resident statement that was taken on 02/20/24 at 9:45 A.M. by the surveyor for accuracy. The resident confirmed with the Administrator and surveyor that the statement taken by the surveyor on 02/20/24 at 9:45 A.M. was an accurate timeline of events that occurred on February 8th with LPN #233 and MT #119. Interview via phone on 02/21/24 at 3:12 P.M., with MT #119 revealed she was working the midnight shift and had finished administering her medication and was helping LPN #233 administer medication on her unit. LPN #233 had prepared Resident #61's medications and she took the medication into the resident's room to administering them. She thought his pills looked funny because she had never crushed his pills before when she had administered his medication, but she took them into the resident anyway. The resident reported to her he doesn't take his medication crushed. The MT reported she took the medications back out to LPN #233 and LPN #233 told her to tell the resident that that's all he had. MT reported she took the crushed medication cup back into the resident's room and told him the nurse said that's all he had, and he refused to take them, so she took them back out to LPN #233. LPN #233 then popped out 3-4 pills into a medication cup and gave them to her to administer to the resident. The MT reported Resident #61 usually takes 5-6 meds in the morning, however LPN #233 only gave her 3-4 (pills) to give him. The resident refused to take them again because there were some medications missing. LPN #233 came into the resident's room and leaned over the resident and took the medication out of the resident's right hand. When the surveyor asked MT #119 if this was abuse, MT #119 confirmed LPN #233 was aggressive with the resident and she would have never done that. MT #119 reported she doesn't recall LPN #233 having anything else in her left hand when asked and the resident had the medication cup in his right hand not on the bed when LPN #233 removed them when asked for clarification by the surveyor. The resident grabbed the LPN's arm when she was leaning over him trying to get the medication cup, however he released his hand when asked to let go. MT #119 confirmed she did not provide a written statement and the Director of Nursing (DON) called her about the incident after she had left the facility when her shift ended. Reviewed interview for accuracy and MT #119 confirmed interview statement was accurate. 2 Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia, unspecified severity, with agitation, concussion with loss of consciousness, history of traumatic brain injury, insomnia, anxiety, depression, cognitive deficit, and amnesia. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making. The resident was noted to have one to three days of other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds). The resident did not reject care or had wandering. The resident had no impairment in upper or lower extremity and used a wheelchair for mobility. Review of Resident #57's treatment administration record (TAR) dated 02/2024 revealed to monitor target behaviors of sexual inappropriateness, restless, refusal of meds/showers, tearful, and sleepless. The non-pharmacological interventions included food/fluids and distraction. The resident had no sexual inappropriateness behaviors documented in February 2024. Review of care plan dated 10/02/23 revealed Resident #57 was a two person assist with bed mobility and one person assist with dressing, hygiene, toileting, and transfers. Review of behavior plan of care dated 10/02/23 and revised on 02/19/24 revealed the resident has behavior(s) related to dementia and traumatic brain injury as evidenced by refuses medications, refuses showers, sexually inappropriate toward other residents (flashes others), refuses to let staff cut fingernails, refuses to be weighed at times, refuses to let staff take vital signs at times. On 02/19/24 strips off clothes was added. Interventions included to administer medication as ordered, approach resident in a calm manner to avoid frustration and behavior escalation, keep resident safe during episode of behavior, observe, and document inappropriate behaviors and notify physician when behaviors persist or won't de-escalate, distract with food/fluids, and refer to psychologist/psychiatrist services as needed. On 02/15/24 15-minute checks for 72 hours was added and on 02/17/24 the intervention was revised to discontinue the abdominal binder over breast and added to ensure the resident had appropriate size garments on upper body to prevent from sliding up. Review of Resident #57's pertinent charting dated 01/12/24 revealed resident roaming up and down halls stops at male rooms and rooms that people have snacks in. Male resident reported she tries to show him her chest but had a white under shirt on. Review of Resident #57 pertinent charting dated 01/13/24 revealed staff reports resident sitting in front of male resident's door with shirt up, fondling her breast making moaning and groaning sounds. The resident was removed from the male resident's doorway and taken to her room. This is an ongoing issue with resident with male residents. Resident takes binder off after staff places it on her. Review of Resident #57's physician note dated 01/15/24 revealed the [AGE] year-old female with a history of anoxic brain injury with dementia and behaviors, being seen today due to continuously pulling up her shirt. She does have hypersexual behaviors at times and that has increased. She does wear an abdominal binder to help prevent her from pulling up her shift, and easily flashing people, but she had started to do it more again. Review of Resident #57's psych note dated 01/17/24 (signed on 02/21/24) and not in the resident medical record revealed the resident continues to make very sexualized advances and exhibits very sexualized behaviors towards others. The patient was observed to be raising her shirt towards other people, male or female, staff, and residents. The resident very sexualized in her verbalization. The patient appeared to be unaware of the impact she was having on those around her and voiced no concerns for her current behavior. Plan to increase her Effexor to 75 milligrams daily to see if that helps. Continue the Tagamet that she is already on and the Ativan. Review of progress note dated 02/14/24 revealed RN #234 was walking down the hall when she observed Resident #57 and a male resident sitting in the hallway, both in their wheelchair. RN #234 noted that Resident #57's brief was unfastened, and male resident (#113)'s hand was noted to be flat palmed inside the brief up to the 1st set of knuckles. RN #234 immediately intervened and separated the residents. The power of attorney was notified and declined to have the resident be sent out for evaluation. Further review of Resident #57's medical record after the incident on 02/14/24 revealed: On 02/15/24 the resident refused a bath. On 02/17/24 the resident was removed from male resident rooms twice today; has a history of inappropriate sexual behaviors. On 02/17/24 abdominal binder intervention removed today due to resident persistently removing it. On 02/18/24 the resident was noted wheeling self-down hallway completely naked. 02/18/24 the resident had noted increased anxiety and was yelling out to men. Place on 15-minute checks for 72 hours. Record review revealed Resident #113 was admitted [DATE] with diagnosis including mild cognitive impairment, sexual dysfunction not due to a substance of known psychological condition, depression, vascular dementia, mood disorder, history of traumatic brain injury, and diabetes. Review of Resident #113 room census revealed he was admitted to the 3rd floor in a semiprivate room on 01/31/24. He was moved on 02/05/24 to a room on the first floor. On 02/06/24 he was moved back to the third floor and on 02/15/24 until 02/16/24 (discharged ) he remained in that room. Review of Resident #113's social service progress note dated 02/01/24 revealed the resident entered the facility from another skilled nursing facility on 01/31/24. BIMS was assessed at a five showing a severe cognitive impairment. The resident was very concerned that people don't think of him as crazy. Review of the admission MDS dated [DATE] revealed his BIMS was 12 (cognition intact), the resident did not have any behaviors or moods, psychosis present. He had verbal symptoms directed towards other and not directed towards others 1 to 3 days no rejection of care. He had been wandering for one to three days. He had no functional limitation in range of motion and used a walker and wheelchair mobility devices. He was independent with eating, dependent with shower, toileting, and required substantial/maximal assistance with dressing upper and lower body. He had diagnoses of persistent mood disorder and other sexual dysfunction not due to a sub or known physiological condition. Review of Resident #113's admission orders revealed Estradiol 1 milligram (mg) daily for hypersexuality and have psych see resident regarding dementia and sexual behaviors. Review of Resident #113's behavior plan of care dated 02/05/24 revealed the resident was sexually inappropriate towards staff. Interventions included communicating care to residents before starting task, keeping resident safe during episodes of behavior and attempt to redirect. Observe and document episodes of inappropriate behaviors; notify physician when behaviors persist or won't de-escalate; redirect, reposition, one on one, food/fluids. Review of Resident #113's psych note dated 02/09/24 (signed 02/21/24) revealed nursing staff reported increased hypersexual like behaviors and patient did not deny these but attempted to minimize the severity of which it was described. Patient openly acknowledged his willingness to be more mindful in his interactions with others. Review of Resident #113's TAR dated 02/01/24 to 02/16/24 (discharge date ) revealed on 02/05/24 the resident targeted behaviors were sexually inappropriate and verbally aggressive with staff, wandering, agitation, refuses care, restless, and sleepless. The non-pharmacological intervention included reposition, redirection, and offer food and fluids. The resident had behaviors of agitation and wandering, however no evidence he was sexually inappropriate. Review of Resident #113's task for the last 30 days revealed on 02/13/24 the facility started monitoring target behavior of agitation, sexually inapp [TRUNCATED]

Based on observation, medical record review, interviews, policy review, mechanical lift user manual review, and review of fall assessments, the facility failed to provide adequate assistance, supervision and/or interventions to prevent resident falls. The facility also failed to develop and implement adequate safety interventions for resident smoking to prevent accidents/injury. This affected five residents (#24, #42, #47, #70, and #80) of five residents reviewed for accidents. Actual psychosocial and physical harm occurred on 12/27/23 during a staff assisted transfer using a mechanical lift for Resident #47 resulting in a fall. During the transfer facility staff failed to provide a safe, clear, environment resulting in the lift becoming stuck under the resident's wheelchair. Staff pulled the mechanical lift in an effort to release it from under the wheelchair causing Resident #47 to bounce in the mechanical lift which then leaned too far to the left, tipping over and Resident #47 made contact with her roommate's bed causing the resident to fall to the floor. Following the incident, the resident complained of neck and shoulder pain that was described as intermittent aching, burning and pressing, causing occasional disruption of her sleep and activities requiring medication to control the pain that did not have a lasting effect. In addition, following the incident, Resident #47 was noted to be afraid and sad of using the hoyer lift and cried when she was required to use it. Actual harm occurred on 12/07/23 when Resident #80, who was cognitively impaired attempted to get out bed, slipped, fell and fractured her right ankle. At the time of the incident, the resident's floor was identified to have been wet due to just being mopped creating an environmental hazard for the resident. Findings included: 1. Record review revealed Resident #47 admitted to the facility on [DATE] with diagnoses including Crohn's disease, chronic respiratory failure, type II diabetes, hypertensive heart disease, acute kidney failure, adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, major depressive disorder, and congestive heart failure. Review of physician orders revealed Resident #47 was ordered buspirone, an anti-anxiety medication, 10 milligrams (mg) two tablets every morning and at bedtime on 09/14/23, Eliquis, a blood thinning medication, five mg twice a day on 11/14/23, fluoxetine, an antidepressant, 60 mg once a day on 09/15/23, and hydrocodone-acetaminophen 5-325 mg once every eight hours as needed for pain on 09/15/23. Review of a quarterly Minimum Data Set (MDS) completed on 10/04/23 revealed Resident #47 had intact cognition, had a depression scale score of zero indicating no depression, and was dependent on staff for transfers. Review of the care plan dated 10/18/23 revealed Resident #47 was at risk for an impaired mood/psychiatric status related to anxiety, depression with potential for restlessness, agitation, tearfulness, and being withdrawn with a goal of having reduced complications related to altered mood status through 01/16/24. Interventions included observing for and reporting any signs or symptoms for change in mood from Resident #47's baseline to physician, observe for signs of distress, observe mood to determine if problems appear to be related to external causes, and offer encouragement. Review of an initial fall assessment completed on 12/27/23 at 2:35 P.M. revealed Resident #47 was being transferred from her bed to chair when she fell . The facility initiated an intervention to ensure clean and safe environment when completing hoyer transfers and ask visitors to step outside if needed. A Fall Risk Evaluation completed on 12/27/23 at 2:44 P.M. revealed Resident #47's most recent fall occurred on 12/27/23, conditions that placed her at risk for falls included pain, psychiatric or cognitive, orthopedic, abnormal labs, and circulatory issues. Resident #47's fall risk was scored at 20. A skin check completed on 12/27/23 at 2:46 P.M. revealed no new skin issues related to the fall. An assessment titled Resident/Family Education Record completed on 12/27/23 at 4:07 P.M. revealed Resident #47 was verbally educated regarding a staff assisted fall resulting in shoulder and neck discomfort but Resident #47 had declined to go to the emergency department and wanted to see how she was feeling tomorrow (12/28/23). Review of staff education for Safe Lifting and Movement of Residents completed on 12/27/23 revealed State-tested Nursing Assistant (STNA) #136 and STNA #182 were educated on safe hoyer transfers. Review of a fall investigation completed on 12/27/23 by Licensed Practical Nurse (LPN) #175 revealed LPN #175 was called to Resident #47's room where she observed the resident lying on the floor with a hoyer pad under her and the hoyer lift still attached to the pad. Nursing aides stated the hoyer lift leg got stuck under the wheelchair and it tipped the hoyer but the aides were able to slowly lower the resident to the floor without any injuries and the resident described the incident as I knew I was going down but slowly. LPN #175 documented no injuries at the time of the fall and reported Resident #47 had zero pain. LPN #175 documented the predisposing factors for the fall as crowding. Review of a statement from STNA #136 on 12/27/23 revealed she and another STNA (#182) were transferring Resident #47 from her bed to her wheelchair, they had requested the visitors to leave the room so there was plenty of space to work but one visitor remained in the room seated in a chair. STNA #136 continued by stating she and STNA #182 began the transfer while trying not to touch the visitor, and once they began connecting the hoyer to the wheelchair and sliding the legs of the hoyer open, they realized one leg of the lift was stuck under the wheelchair. STNA #136 stated Resident #47's body then started going towards the left and they tried to balance her but they were unable to manage the weight, but due to the leg of the hoyer being stuck under the chair, they were able to slowly lower Resident #47 to the ground without injuring her. A statement from STNA #182 from 12/27/23 revealed she and STNA #136 had Resident #47 in the hoyer lift to move her from the bed to the wheelchair when a leg of the hoyer lift became lodged under the wheelchair. In an effort to dislodge the hoyer leg, STNA #182 pulled the lift back as STNA #136 pushed back on the lift and the lift became unsteady. STNA #182 stated Resident #47's weight combined with the hoyer lift being unsteady caused the lift to tip over but the aides were able to control the fall and slowly lowered Resident #47 to the ground. STNA #182 stated Resident #47 was sore in her back but proceeded to attend activities after the incident. Review of follow up fall assessments completed on 12/28/23 at 3:16 A.M. and 12/28/23 at 11:24 P.M. revealed Resident #47 remained without pain related to the fall. Review of follow up fall assessments completed on 12/30/23 at 11:26 P.M., 12/31/23 at 9:14 P.M., and 01/01/24 at 3:14 P.M. revealed Resident #47 rated her pain as a two. Review of a follow up fall assessment completed on 01/02/24 at 3:47 P.M. revealed Resident #47 rated her pain as a one. Review of a pain evaluation completed on 01/04/24 at 12:42 P.M. revealed Resident #47 reported she was having frequent pain that occasionally disrupted her sleep and activities. Resident #47 stated her pain impacted day-to-day activities, limited extracurricular activity, and impacted her mood. Resident #47 reported the pain was an eight (1-10 scale) and the intensity of it was severe in her right neck and shoulder area. Resident #47 described the pain as aching, burning, and pressing and the pain was intermittent. Resident #47 indicated the pain became worse when she turned her head and the medication she received was not lasting. New orders were received from certified nurse practitioner (CNP) #301 for x-rays of the right side neck, right shoulder scapula, and clavicle and a lidocaine pain relief patch four percent apply to right shoulder for seven days and Biofreeze external gel four percent apply to right shoulder/neck every six hours as needed. Review of an assessment titled Pertinent Charting Initial-Pain completed on 01/04/24 at 12:59 P.M. revealed Resident #47 was having unrelieved pain due to medication not lasting long enough with complaints of pain and discomfort to the right neck and shoulder area. Resident #47 described the pain as an aching, burning, pressing sensation. Current interventions were successful at times but do not last and include distraction, repositioning, and pain medication. Review of an assessment titled Pertinent Charting Follow-up- Pain completed on 01/05/24 at 3:19 A.M. revealed the results of the x-rays included degenerative changes. Interview on 01/02/24 at 9:50 A.M. with Resident #47 revealed she fell while in the Hoyer lift on 12/27/23 and injured the right side of her body, and she continued to be sore. Resident #47 stated she was not sent out to the hospital. A follow-up Interview on 01/04/24 at 1:51 P.M. with Resident #47 revealed she was not sure what happened to cause the fall while she was in the hoyer lift. Resident #47 stated she thought the hoyer lift was leaning and then she went down as well. Resident #47 stated she landed kind of on her back, halfway on the floor and halfway on the hoyer lift. Resident #47 stated she was so upset about the incident, a whole bunch of people were there, and she continued to hurt from her neck all the way down her right side to her knee. Resident #47 stated she reported the pain to the nursing staff and aides. Resident #47 stated she relayed to staff that she was in pain on this date, but she could not remember to who. Resident #47 described the pain as an ache that radiated and stated it was constant unless she had received pain medication. Interview on 01/09/24 at 1:27 P.M. with STNA #157 revealed Resident #47 was transferred by mechanical lift which takes two staff members. STNA #157 stated following the incident on 12/27/23 Resident #47 would not let the two staff who were attempting to weigh her on 01/08/24 get her out of bed because she was so afraid. STNA #157 stated she spoke with Resident #47 who agreed to let the staff weigh her as long as she was lifted above her bed and just enough, so her bottom was not touching the bed. Interview on 01/09/24 at 4:45 P.M. with STNA #157 revealed Resident #47 allowed staff to get her up today so she could attend activities. STNA #157 stated Resident #47 was so scared she cried during the transfer. Observation on 01/09/24 at 4:50 P.M. of Resident #47 revealed she was sitting in her room with the light off facing away from the door and crying. Resident #47 reported she was sad because of the hoyer lift incident. Resident #47 stated she was afraid to get in the hoyer lift and she was upset because since she was up in her chair, she knows she has to get back in the lift to go to bed. Resident #47 recalled the (fall) incident on 12/27/23, stating she felt like it was slow motion. Resident #47 reported she was unsure how hard she hit the ground, but stated the fall knocked the air out of her. Resident #47 reported she was having a hard time turning her neck. Resident #47 attempted to turn her neck to the right, at approximately 10 degrees she visibly winced in pain. Resident #47 stated the only reason she received x-rays was because she requested them, and the results were arthritis and getting older. Resident #47 stated she was still experiencing pain under her shoulder as a result of the incident. Interview on 01/10/24 at 8:19 A.M. with Resident #47 revealed she would now always be nervous to use the hoyer lift. As Resident #47 spoke, she appeared to be sad with a flat affect. Interview on 01/10/24 at 8:54 A.M. with STNA #182 revealed while transferring Resident #47 from her bed to her chair, there was not a lot of room due to guests visiting her roommate. STNA #182 stated one guest stayed in the room, but the others exited the room. STNA #182 stated they were moving fast and probably not as cautious as they should have been, the leg of the hoyer got stuck under the power chair and Resident #47 was not in the correct position to lower into her seat. STNA #182 stated the momentum from pulling the hoyer leg from under the chair caused Resident #47 to swing and the lift began to tip. STNA #182 reported she was able to ease the lift down at the foot of her roommates' bed but stated Resident #47 did not hit anything. STNA #182 stated the fall happened in slow motion and controlled, but they should have made everyone leave the room to allow adequate space to complete the transfer slowly and safely. STNA #182 stated the incident was scary and her back and legs were sore afterward. STNA #182 reported Resident #47 was sore for a few days after the incident, but stated it was muscle soreness in her neck and shoulder. STNA #182 reported they tried to do too much, too fast, and in not enough space. Interview on 01/10/24 at 9:05 A.M. with Social Services Director (SSD) #121 revealed she did not follow up with Resident #47 after the fall occurred but Resident #47 seemed to be fine. SSD #121 stated no one had reported to her Resident #47 had been tearful or scared of getting in the hoyer lift. Interview on 01/10/24 at 9:07 A.M. with STNA #136 revealed at around 1:30 P.M. to 2:00 P.M. every day, Resident #47 liked to get up in her wheelchair. STNA #136 stated it was close to 2:00 P.M. so she and STNA #182 were trying to hurry and they had to wait their turn to use the hoyer lift so they were both a bit agitated. Once they had the hoyer lift, STNA #136 stated they requested Resident #47's roommates' family excuse themselves so there was space to work. STNA #136 stated she had not noticed one family member stayed in the room seated in a chair next to the head of the bed until they began the transfer. STNA #136 stated they began to move Resident #47 like normal except STNA #136 usually manages the hoyer lift operations, but this time STNA #182 did. STNA #136 stated she believed she made a mistake by not controlling the lift herself. STNA #136 stated once they got Resident #47 lifted out of her bed, they began to move the lift when they noticed the family member sitting in the chair. STNA #136 stated the presence of the family member made them go too far to the right. When they went to move the lift they noticed the leg of the hoyer lift was trapped under the wheelchair. Once they started trying to move the lift, STNA #136 reported Resident #147 began to bounce too far to the left and when the hoyer lift tipped, it was slow due to being trapped under the chair. STNA #136 stated they lowered her to the floor then called for help to check on Resident #47. Another hoyer lift had to be used to raise Resident #47 from the floor. STNA #136 stated while discussing the situation with STNA #182, they came to the determination the incident occurred due to the lack of space in the room. At this point, STNA #136 provided a visual recreation of the incident. Resident #47's wheelchair was located in the center of the front of the room and the hoyer lift was in the middle of the room next to her bed. STNA #182 was operating the lift while STNA #136 was standing to the right of the lift to assist in maneuvering the resident. STNA #136 stated due to where the guest was seated, STNA #182 was not able to move back far enough to position the lift correctly over Resident #47's wheelchair causing the right leg of the hoyer lift to get stuck under the wheelchair and staff unable to open the legs of the lift, so STNA #182 began to pull on the hoyer which made the lift jolt. The jolting of the hoyer lift caused Resident #47 to bounce and sway too far to the left, then tipped over. The leg of the lift was still under the wheelchair which helped carry the weight of the resident. Resident #47 did make contact with the footboard of her roommates' bed causing her head and neck to be pushed at an awkward angle. STNA #136 stated Resident #47 did not hit the ground hard but did complain of neck pain and the nurse administered as needed pain medication. Review of manual titled Invacare Reliant Battery Powered Patient Lift dated 2018 revealed when using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the patient for optimum safety and stability. Before positioning the legs of a hoyer lift under the bed, the area should be cleared of any obstructions. 07316 2. Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses including dementia and hypertension. The resident resided on the secured dementia unit. Review of the plan of care dated 09/28/23 revealed the resident was at risk for falls/injury related to impaired cognition with decreased safety awareness, wandering, history of falls. The goal was to reduce the risk of injury. Interventions included to ensure the resident's room was free from accident hazards including no trip hazards. The plan of care was revised 12/08/23 to educate housekeeping to ensure parameters were marked off when mopping floor and excess water is not left on floor. A Minimum Data Set (MDS) assessment completed 10/01/23 documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS noted the resident had no functional limitation in range of motion and required only supervision or touching assistance for sit to stand, chair to bed, toilet transfer, and walking 10 feet. The MDS also noted the resident had a fall history but no falls since admission. A fall risk assessment on 12/07/23 indicated no falls and a score of 13. (A score of 10 or higher is at risk for falls per fall risk evaluation form). Review of nurse's progress notes revealed on 12/07/23 at 11:27 A.M. the nurse was alerted by an STNA of Resident #80's fall. When entering the room it was noticeable the floor had just been mopped. Resident on the floor laying on her back complaining of pain in right ankle. Skin assessment completed with no physical injuries noted. Resident denied hitting head. Resident lifted off floor via hoyer lift and placed on bed. Ice pack applied to ankle. Physician notified. 911 called for transport to emergency room . Review of an x-ray report for Resident #80 on 12/07/23 revealed an oblique fracture of the distal fibula which is mildly displaced and a mildly comminuted fracture of the medial malleolus noted. Review of emergency room notes from 12/07/23 revealed an orthopedic glass splint was applied. The resident was to be non-weight bearing and follow up with orthopedics in one week. The resident returned to the facility on [DATE]. Physician's orders were obtained on 12/08/23 for vascular checks to the right foot every shift and as needed. On 12/10/23 there was an order for non-weight bearing to right leg every shift for fracture. A nurse practitioner note on 12/07/23 revealed the resident slipped on wet floor today and had fall related to that. Went to the emergency room and found to have a distal tibia fracture that was mildly displaced. Put on splint and bedrest. Follow up with orthopedics. Review of an incident report dated 12/07/23 at 8:45 A.M. revealed alerted by STNA of resident fall. (as described earlier in nurses note 12/07/23 at 11:27 A.M.). It indicated the resident had a pain level of eight (out of 10). Pre-disposing factors were wet floor, impaired memory, and ambulating without assistance. A statement from STNA #248 on 12/07/23 revealed she was collecting breakfast trays and another STNA asked for help pulling a resident up. She helped pull up other resident. STNA #248 heard the housekeeper telling us someone was on the floor and Resident #80 was yelling. STNA #248 went to check on the resident while other STNA went to get the nurse. Resident #80 was on the floor saying her right leg hurt. The floor was very wet. A statement from STNA #167 on 12/07/23 revealed she was outside on a 15 minute break. Came back in and heard the housekeeper say someone was on the floor. Resident #80 was on the floor close to the bathroom door on her back saying her right leg was hurting. STNA #167 got the nurse. The resident's floor was soaking wet and very slick when we went in there. A statement from STNA #131 on 12/07/23 revealed she was feeding a resident in her room while another aide was picking up breakfast trays. The third aide was on break. We heard the housekeeper yell someone was on the floor and Resident #80 was screaming for help. When she got to the room, Resident #80 was laying on the floor on her back holding her leg. The floor was very wet. There was a wet floor sign outside the door. Notified nurse. Review of a statement (undated) by Housekeeper #204 revealed she was cleaning Resident #80's room. Finished up mopping and headed across the hall to G2 to begin cleaning when she heard a loud thump. Nurses aides came out of the dining area where she immediately told them that Resident #80 had fallen. Wet floor sign was up and she mopped Resident #80's room like all 20 rooms she'd been mopping for five years. Wet floor signs were always placed at the door of the areas being mopped. Resident #80 was constantly wandering and sometimes stumbling around. (The statement did not indicate where Resident #80 was at the time the mopping of her room was done). A significant change MDS assessment completed 12/12/23 documented a BIMS of five reflecting severe cognitive impairment. The MDS also noted the resident now had impairment in range of motion on one side of lower extremity, and was dependent on staff for sit to stand, chair to bed mobility, and toilet transfer. The MDS noted the resident had one fall with major injury since admission (12/07/23). A nurse's progress note on 12/13/23 at 3:54 P.M. indicated an orthopedic appointment on 12/15/23. Review of the orthopedic consultation notes on 12/15/23 revealed Resident #80 was seen status post bimalleolar right ankle fracture. Patient should be non-weight bearing. Please take boot off three times a day for skin checks. Follow up in office in one week. Observations on 01/08/24 at 7:50 A.M. revealed the resident was seated in a wheelchair with a fracture boot on the right foot. Interview with Housekeeper #204 on 01/08/24 at 1:15 P.M. revealed Resident #80 was in bed when she mopped the floor in her room. She stated the resident then got up and fell and did not pay any attention to the wet floor sign she put up. She stated after the incident, she was instructed to only mop if a resident was not in the room and stated she must put up a velcro strip with stop sign across the door to keep the resident out of the room until the floor dries. She stated they also now close the dining room doors to keep residents out while it is mopped. A follow-up interview with Housekeeper #204 on 01/09/24 at 8:40 A.M. confirmed Resident #80 was in bed when she mopped the room. She stated she placed the wet floor sign just inside the door. She stated Resident #80 looked like she was sleeping so she did not say anything to her about not getting up while the floor was wet. She stated she left the room and later observed the resident on the floor in her room. She stated the resident was laying on the floor about half way between the bed and door. Interview with Registered Nurse #143 on 01/09/24 at 8:15 A.M. revealed the resident's on the secured dementia unit were cognitively impaired so they don't read wet floor signs. Review of the fall prevention program policy dated 10/30/20 and revised 10/26/23 revealed each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. Interventions would be monitored for effectiveness. 32801 3. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including dementia, unsteadiness on feet, muscle weakness, cognitive communication deficit, abnormalities of gait and mobility, depression, high blood pressure, and heart disease. Review of Resident #70's fall risk evaluation dated 06/08/23, 07/08/23, and 09/19/23 revealed the resident was a high risk for falls. Review of Resident #70's fall plan of care dated 10/13/23 revealed non-skid strips to the foot of the bed to reduce the risk of slipping. Observation on 01/04/24 at 7:53 A.M. of Resident #70 revealed the resident was resting in bed. The bed was against the wall on the left side. There was a floor mat on the right side. There was non-skid strips noted on the floor on the other side of the mat (not near the foot of the bed) in the middle of the floor. Observation on 01/08/24 7:57 A.M. with State tested Nurse's Aide (STNA) #107 and STNA #112 confirmed the non-skid strips were not located at the foot of bed to reduce the risk of falling per the plan of care. The STNA's confirmed the resident was ambulatory and wanders hallways frequently. Interview on 01/08/24 at 8:04 A.M. and 9:44 A.M. with the Director of Nursing (DON) confirmed the plan of care indicated there were to be non-skid strips to the foot of the bed and she would have staff move the non-skid strips right away. Review of Resident #70's fall investigation, progress notes, SOC form, and initial fall reports revealed: a. Review of the initial fall assessment dated [DATE] revealed the resident had fallen on 02/06/23, however there was no detail regarding the actual fall. Review of Resident #70's progress notes revealed no evidence of documentation regarding the fall. Review of the fall investigation, which was not part of the medical record, dated 02/06/23 revealed the resident was found by an STNA on the floor beside the bed with the blanket tangled around both legs. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed there were no documented details of the residents fall in the medical record. b. Review of Resident #70's progress note dated 05/15/23 revealed the resident had fallen on 05/14/23 and hit the back of her head. Review of Resident #70's SOC form dated 05/15/23 revealed on 05/14/23 the resident had fallen and had a head injury. The new intervention was a medication review. Review of the fall investigation, which was not part of the medical record, dated 05/14/23 revealed the staff heard the door alarm sounding and staff found the resident lying on her left side holding her head. The new intervention was a medication review. Review of Resident #70's medical record revealed no evidence a medication review was conducted. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed there was no documented evidence a medication review was conducted. c. Review of the initial fall note dated 05/23/23 revealed the resident had fallen on 05/23/23 and new orders were received for orthostatic blood pressures and pulse every shift for three days, medication review, and to monitor tooth. Review of the fall investigation, which was not part of the medical record, dated 05/23/23 revealed the resident found by an STNA on her knees on the floor attempting to stand up. The resident was bleeding from her mouth and nose. The resident had a tooth that was slightly loose and had complaints of pain but could not rate. There was no evidence of the root cause of the fall. Review of the resident's medical record revealed no evidence the orthostatic blood pressure and pulse was monitored for three days, a medication review was completed, or documented evidence the tooth was monitored. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed there was no documented evidence that orthostatic blood pressure and pulse were monitored for three days following the fall, no evidence a medication review was conducted, or documented evidence the tooth was monitored. d. Review of the fall investigation, which was not part of the medical record, dated 05/31/23 revealed no evidence of the root cause of the fall. The resident was found in the bathroom by housekeeping with blood on her hands and forehead. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed there was no documented evidence of what the root cause of the fall was. e. Review of Resident #70's initial fall note dated 06/08/23 revealed the resident had fallen on 06/08/23. Intervention includes ensuring the resident had non-skid socks on while awake, which was an intervention already implemented on 05/19/23 because of a fall. Review of the fall investigation, which was not part of the medical record, dated 06/08/23 revealed an aide saw the resident tried to sit on the chair and fell and bumped her head. The resident was not wearing appropriate footwear. The immediate action taken was to ensure the resident had nonskid socks on while awake. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed the resident did not have non-skid socks on which was the root cause of the fall. The DON confirmed a staff member observed the fall and there was no evidence the staff member intervened to prevent the fall. f. Review of Resident #70's initial fall note dated 07/08/23 revealed the resident had fallen on 07/08/23 and had a soft hematoma on the left side of the head. Staff were re-educated in the use of proper footwear and cleaning up spills. Review of fall investigation, which was not part of the medical record, dated 07/08/23 revealed the resident did not have appropriate footwear on (bare feet) and slipped on orange juice on the floor. Interview on 01/08/24 at 2:05 P.M., with the DON confirmed the resident had fallen again because of not having proper footwear in-place and there was orange juice on the floor which resulted in the resident falling. Review on the facility policy titled Fall Prevention Program dated 10/26/23 revealed each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. The facility would utilize a standardized risk assessment for determining a resident's fall risk. When a resident experiences a fall the facility would assess the resident, complete a post-fall assessment, complete and incident report, notify the physician and family, review, and update plan of care, document all assessments and actions, and obtain witness statement in the care of injury. 28923 4. A review of Resident #42's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, a non-displaced fracture of the upper end of the left humerus (shoulder), unsteadiness on feet, abnormalities of gait and mobility, and muscle weakness. A review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. She had a functional limitation in her range of motion to one side of her upper extremities and no mobility devices were used. The resident was indicated to have had a fall since her prior assessment. She had one fall with an injury that was not major injury and one fall with major injury. Her last annual MDS assessment completed on 08/09/23 revealed the resident required supervision with the assist of one for transfers, ambulation, locomotion, and toilet use. Balance issues were present at that time, but the resident was able to stabilize without assistance. A review of Resident #42's care plans revealed she was at risk for falls/injury related to a history of falls and hypotension. The goal was to reduce the risk of injury through the next review date. Interventions included ensuring the resident was wearing appropriate footwear when out of bed (10/24/23), remove slippers from room (10/31/23), non-skid footwear to reduce the risk of slipping as the resident allows (11/07 [TRUNCATED]

Based on observation, interview, and facility policy review, the facility failed to store food in a sanitary manner and failed to ensure food preparation equipment was clean. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility also failed to ensure two residents (#32 and #62)'s personal refrigerators were kept clean and at an appropriate temperature and failed to ensure four residents (#10, #33, #62, and #81)'s personal refrigerator temperatures were logged for safety. The facility census was 97. Findings included: 1. Observation on 01/02/24 at 8:09 A.M. revealed the onion powder and ground cinnamon containers were not closed properly. Observation on 01/03/24 at 9:15 A.M. revealed the onion powder, ground cinnamon, garlic powder, and lemon pepper seasoning salt containers were not closed properly. Interview on 01/03/24 at 10:10 A.M. with Cook #192 verified the spice container noted above were open, not closed properly and should have been closed for sanitation. 2. Observation on 01/02/24 at 8:09 A.M. of the can opener with a dried black substance on the puncture. There was also a white dried substance noted on the puncture. Interview on 01/02/24 at 8:20 A.M. with Dietary Manager #191 verified the can opener was dirty with dried substances. He reported the can opener was to be cleaned after each use and it was on the cleaning schedule for each evening to be cleaned and sanitized. He verified the can opener had not been used in preparing breakfast. Review of the facility document titled, CH2 End of Shift Checkout Sheet, undated, revealed the can opener was to be cleaned and sanitized at the end of the shift. Review of the policy titled, Environment, revised 09/2017, revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Further review revealed all food contact surfaces will be cleaned and sanitized after each use. 3. a. Observation on 01/08/24 at 8:03 A.M. of Resident #10's personal refrigerator revealed no temperature log on the refrigerator unit or in the room. Interview on 01/08/24 at 8:09 A.M. with Med Tech #225 verified there was no refrigerator temperature log on or around Resident #10's refrigerator. b. Observation on 01/08/24 at 8:03 A.M. of Resident #62's personal refrigerator revealed the thermometer inside read 48 degrees Fahrenheit and the mechanical unit was iced over. The refrigerator held the following perishable items: five cartons of milk, a container of sour cream, two containers of mayonnaise, and a bottle of ranch dressing. There was no temperature log noted on the refrigerator unit or in the room. An interview at the time with Resident #62 revealed the facility staff used to check the temperature of her refrigerator every day, but they hadn't for a while. Interview on 01/08/24 at 8:10 A.M. with Med Tech #255 verified the unit was not at an acceptable temperature of 41 degrees Fahrenheit or less, the mechanical unit was iced over and there was food in the unit that was perishable. She also verified there was no temperature log on or around Resident #62's refrigerator. c. Observation on 01/08/24 at 8:05 A.M. of Resident #33's personal refrigerator revealed no thermometer in the refrigerator and no temperature log on the refrigerator or in the room. Interview on 01/08/24 at 8:09 A.M. with STNA #103 revealed she did not know who was responsible for monitoring resident refrigerator temperatures. Interview on 01/08/24 at 8:10 A.M. with Med Tech #225 verified there was no thermometer in Resident #33's refrigerator and there should be. She also verified there was no temperature log on or around Resident #33's refrigerator. Med Tech #225 did not know who was responsible for monitoring resident refrigerator temperatures. She thought it may be housekeeping. d. Observation on 01/08/24 at 8:06 A.M. of Resident #81's personal refrigerator revealed no temperature log on the unit or in the room. Interview on 01/08/24 at 8:10 A.M. with Med Tech #225 verified there was no refrigerator temperature log on or around Resident #81's refrigerator. e. Observation on 01/08/24 at 8:11 A.M. of Resident #32's personal refrigerator revealed the thermometer inside read 50 degrees Fahrenheit, the mechanic unit was iced over, and the interior of the unit was dirty. The refrigerator held lunch meat sandwiches. Interview on 01/08/24 at 8:15 A.M. with State tested Nursing Assistant (STNA) #111 verified the unit was not at an acceptable temperature of 41 degrees Fahrenheit or less, the mechanical unit was iced over, the refrigerator was dirty and there was food in the unit that was perishable. Interview on 01/08/24 at 8:40 A.M. with Licensed Practical Nurse (LPN) #211 revealed any staff can document a resident refrigerator temperature and the log should be on or near the refrigerator unit. Interview on 01/08/24 at 8:41 A.M. with the Director of Nursing (DON) revealed the resident refrigerator temperature logs should be in the unit narcotic books. Observation of the unit E and F narcotic books with the DON revealed no resident refrigerator temperature logs. Interview on 01/08/24 at 10:25 A.M. with the DON verified third floor residents' refrigerator temperatures should have been checked and logged daily but there was no documentation to support this was done. Review of the facility policy titled, Resident Refrigerators, (reviewed/revised 01/01/22), revealed the facility did not provide a refrigerator in a resident's room. However, it was the policy of the facility to ensure safe and sanitary use of any resident-owned refrigerators when approved by the administrator for use in the facility. Further review revealed housekeeping staff shall record refrigerator temperatures daily on a temperature log attached to the refrigerator. A thermometer shall remain in the refrigerator. Temperatures will be at or below 41 degrees. If temperatures are out of range, maintenance staff shall be notified and all foods that require refrigeration will be discarded immediately, and remedies will be put into place. Housekeeping staff shall clean the refrigerator daily and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed or refer to housekeeping staff.

Based on observation, interview, and facility policy review, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 97 residents residing in the facility. Findings included: Observation on 01/02/24 at 9:20 A.M. of the facility dumpster/compactor revealed trash on the ground around the dumpster/compactor. The trash included milk cartons, straws, lids, rubber gloves and a used depends. Interview on 01/02/24 at 9:22 A.M. with State tested Nursing Assistant (STNA) #131 verified the debris on the ground around the dumpster/compactor and that it should not be there. Review of the facility policy titled, Environment, (revised 09/2017), revealed all trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. Review of the facility policy titled, Disposal of Garbage and Refuse, (reviewed/revised 01/01/22), revealed refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Based on record review, observation, review of a facility self-reported incident (SRI) and facility investigation, facility policy review, and interview, the facility failed to ensure residents were free from sexual abuse when Resident #1 was sexually abused by Resident #2. This affected one (Resident #1) of three residents reviewed for sexual abuse. Actual physical and/or psychosocial harm occurred, applying the reasonable person concept, on 12/30/22 to Resident #1, a resident with impaired cognition and communication, when Resident #2 was found fondling the resident's breast. Findings include: Review of the medical record for the Resident #1 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, psychosis, major depressive disorder, dysphagia, muscle weakness, difficulty walking, and macular degeneration. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/04/22, revealed Resident #1 had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of the resident's behaviors revealed delusions and the rejection of care. Review of a Self-Reported Incident (SRI), tracking number 230623, dated 12/30/22 at 9:26 A.M., revealed the facility reported an incident of sexual abuse involving Resident #1 and Resident #2. The SRI noted Resident #1's diagnoses included Alzheimer's disease with late onset and Resident #2's diagnoses included dementia with agitation and schizoaffective disorder with a traumatic brain injury. The incident occurred on 12/30/22 at 6:50 A.M., in the dining room, when Resident #2 was observed with his hand down Resident #1's shirt. The residents were immediately separated, and Resident #2 was placed on one-to-one observation. Observation of Resident #2 was started on 12/30/22 at 7:00 A.M. and continued every 15 minutes until 01/02/23. Review of a social services progress note, dated 12/30/22 at 10:26 A.M., revealed Resident #1 was interviewed after a report of peer-to-peer contact. The resident had a Brief Interview for Mental Status (BIMS) score of 0 (cognitive impairment). The note revealed the resident had no increased anxiety, emotional distress, or depression reported by the staff or the resident. The resident did not recall the occurrence and staff stated the resident did not appear to understand or be bothered when the incident occurred. When asked if she felt safe in the facility, the resident began reciting illogical and irrelevant topics that were difficult to follow. The resident spoke of someone moving to a new location and asked if they had passed. The subject then changed to the resident going to the store for her arm. Review of a nurse progress note, dated 12/30/22 at 11:02 A.M., revealed Resident #1 did not remember the incident and stated she felt safe in the environment. A skin check was completed. The resident denied pain, and the physician and responsible party were notified. Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included malignant neoplasm of cerebrum, traumatic subdural hemorrhage, aphasia, dementia, schizoaffective disorder, seizures, and muscle weakness. The resident was discharged from the facility on 01/09/23. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/22, revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of the resident's behaviors revealed delusions, physical behaviors directed to others and other behavioral symptoms not directed toward others such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, screaming, and disruptive sounds. Review of Resident #2's physician order, dated 03/02/22, revealed the order to monitor behaviors, every shift, for urinating in inappropriate areas, tearfulness, delusions, taking other's drinks, hitting other residents, turning lights on and off, exposing self in hallway, wandering in and out of other's rooms, exiting, restlessness, being combative with staff, sleeplessness, pushing other residents in their wheelchairs, and for shutting other's doors. Review of a social services progress note, dated 12/30/22 at 12:33 P.M., revealed it was reported Resident #2 was involved in inappropriate resident-to-resident contact. The resident's BIMS score was 3. There was no increased anxiety or depression reported. Resident #2 stated he felt safe in the facility. The resident could not recall the earlier incident. Staff were interviewed and reported the resident said he thought Resident #1 was his grandmother. Staff reported a significant increase in sexual behaviors for Resident #2 during the past 14 days which included standing directly behind staff members and attempting to grab their waists, but with no body-to-body contact. The resident was resistant to redirection with less physical aggression noted but with more verbal outbursts reported. Review of the facility investigation, dated 12/30/22, revealed all residents residing on the memory care unit were assessed for skin impairment or injury and staff interviews were conducted. On 12/30/22, a referral was made for Resident #2 to be discharged to an all-male behavioral unit. The facility completed their investigation on 01/06/23 at 3:02 P.M. and substantiated the allegation of abuse. Review of State-tested Nurse Aide (STNA) #100's witness statement, dated 12/30/22, revealed STNA #100 came into the dining room and observed Resident #2 with his hand down the left side of Resident #1's shirt and rubbing her breast. STNA #100 asked Resident #2, why did you do this? Resident #2 stated, because she likes it. Review of Registered Nurse (RN) #105's witness statement, dated 12/30/22 at 6:50 A.M., revealed RN #105 was informed by STNA #100 of Resident #2 fondling Resident #1's left breast. The residents were separated, Resident #1 was taken to her room and a skin sweep was conducted with no concerns. During interview on 01/11/23 at 10:48 A.M., the Director of Nursing (DON) confirmed the facility investigation did substantiate the allegation of sexual abuse between Resident #1 and Resident #2. During observation on 01/11/23 at 11:10 A.M., Resident #1 was sitting in her wheelchair, in the dining room of the memory care unit. The resident was smiling and holding a baby doll. The resident only smiled and did not answer any questions. Resident #2 was discharged from the facility and was unable to be observed or interviewed. Interview on 01/11/23 at 11:15 A.M., STNA #100 revealed she walked into the dining room of the memory care unit and observed Resident #1 sitting in her wheelchair, in the middle of the room. Resident #2 was standing behind Resident #1's wheelchair with his back toward the door. STNA #100 stated Resident #2's hand was down Resident #1's shirt, on the left side of her body. STNA #100 stated she asked Resident #2 what he was doing, and he replied, nothing much, which was his usual response when asked a question. STNA #100 revealed she took Resident #2 aside and asked again, what were you doing. The resident stated, I was playing with her nipple because she likes it. STNA #100 revealed she asked Resident #2 if he knew who the other resident was, and he said Resident #1 was his grandmother. STNA #100 revealed the residents were separated and she notified RN #105 of the incident. Resident #2 was placed on one-to-one observation. STNA #100 confirmed there was no staff member in the dining room at the time of the incident. Reviewed facility policy, Abuse, Neglect, and Misappropriation, dated 07/28/20, revealed it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Investigation of Alleged Abuse: an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation. Written procedures for investigations include identifying staff responsible for the investigation; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increase supervision of the alleged victim and residents; room or staffing changes, if necessary, to protect the residents from the alleged perpetrator. This deficiency represents non-compliance investigated under Master Complaint Number OH00139296, Self Reported Incident Control Number OH00139364, and Self Reported Incident Control Number OH00139182.

Based on closed record review, review of a facility self-reported incident (SRI) and the facility related investigation, review of controlled drug record/disposition forms and staff interview the facility failed to ensure Resident #86 was provided an adequate and effective pain management program, including the administration of as needed (PRN) narcotic pain medication as requested and to meet the resident's pain and total care needs. Actual Harm occurred beginning on 10/11/22 when Resident #86 requested the ordered narcotic pain medication ([MEDICATION(S)]) but was administered [MEDICATION(S)] (a stool softener) in place of the medication resulting in the resident having increased bowel movements during the night, increased pain and an inability to sleep. Subsequent requests by the resident for the [MEDICATION(S)] from the same nurse (Registered Nurse (RN)) #125 resulted in additional doses of [MEDICATION(S)] being administered and not the [MEDICATION(S)] as ordered resulting in unrelieved pain for the resident. This affected one resident (#86) of three residents reviewed for misappropriation of property. Findings include: A review of Resident #86's closed medical record revealed the resident was originally admitted to the facility on [DATE] with a readmitted [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident was discharged home on 10/24/22. A review of Resident #86's admission Minimum Data Set 3.0 (MDS) assessment, dated 07/14/22 revealed the resident did not have any communication issues as he was able to make himself understood and was able to understand others. The assessment revealed the resident was cognitively intact and was not known to display any behaviors. A pain assessment revealed the resident did report having pain in the last five days and the pain was almost constantly. He rated the pain a 10 on a 1-10 scale at the worst during the last five days. The MDS assessment noted the pain did not affect his sleep at night but did limit his day-to-day activities. A review of Resident #86's care plans revealed a plan of care, initiated 10/01/22 related to the resident's risk for pain related to a left hip fracture, [CONDITION(S)], low back pain, and spinal stenosis. The goal was for the resident to have adequate pain control and for him to verbalize adequate relief of pain or the ability to cope with incompletely relieved pain. The interventions included administering his pain medications as ordered. A review of Resident #86's physician's orders revealed the resident had an order in place to receive [MEDICATION(S)] (a controlled narcotic pain medication used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The instructions indicated two tablets could be given for pain levels between a seven and 10 on a 1-10 scale. A review of Resident #86's medication administration record (MAR) for October 2022 revealed RN #125 documented administering the resident his PRN [MEDICATION(S)] twice during her night shift going from the evening of 10/11/22 into the morning of 10/12/22 and again the evening of 10/12/22 going into the morning of 10/13/22. During all four administrations of the PRN [MEDICATION(S)], RN #125 documented she gave the resident two of the 5-325 mg tablets with each dose given. The two tablets of [MEDICATION(S)] that were documented as having been given to the resident on 10/11/22 at 10:20 P.M. did not follow the parameters set forth by the physician on when to administer the PRN [MEDICATION(S)]. The resident's pain level was recorded as only being a 2 on a 1-10 scale at the time of the administration. The physician's orders did not permit the PRN [MEDICATION(S)] to be given unless the resident's pain level was a 3 or higher. The resident was only to receive two tablets of the PRN [MEDICATION(S)] when his pain level was 7 or higher. RN #125 did not follow the parameters specified with the physician's orders again on 10/13/22 at 6:07 A.M. when she documented she gave two [MEDICATION(S)] 5- 325 mg tablets for a pain level of a 6 on a 1-10 scale. Documentation on the MAR and Controlled Drug Record/ Disposition form included RN #125 administered a total of four [MEDICATION(S)] tablets the night of 10/13/22. A review of facility self-reported incident (SRI), tracking number 5 revealed an allegation of misappropriation of resident property was made on 10/13/22. The initial source of the allegation was from Resident #86, who was identified to be the resident victim. Resident #86 was noted to have been able to provide meaningful information when interviewed and the effect the incident had on the resident was reports of diarrhea. The alleged/ suspected perpetrator was a staff member not identified in the initial report. The final report for SRI tracking number 5 revealed the date/ time/ location of the occurrence was on 10/13/22 at 5:40 A.M. in the resident's room. The narrative summary of the incident revealed the facility Administrator was made aware Resident #86 was concerned he was given the wrong medication in place of his prescribed pain medication by RN #125. As a result, the resident did not take the medication and sat it to the side, so the oncoming day shift nurse could see what he had been given. Shortly after 7:00 A.M., Resident #86 called for Licensed Practical Nurse (LPN) #112 to come to his room. He showed the nurse the pills that had been given to him that night by RN #125 as his PRN pain ([MEDICATION(S)]) medication. Upon further investigation, it was confirmed the pills Resident #86 received were actual stool softener, [MEDICATION(S)] 100 mg capsules and not his PRN [MEDICATION(S)] ordered for pain. The information was brought to the Administrator's attention and an investigation began with RN #125 being suspended pending the outcome of the investigation. Resident #86's physician's orders were reviewed as part of the facility's investigation, and it was determined the resident did not have a physician's order to receive [MEDICATION(S)] 100 mg capsules on a scheduled or a PRN basis. Statements were obtained from Resident #86 and LPN #112 as part of the facility's investigation. The local police department were also informed of the alleged misappropriation of controlled narcotic pain medication. The facility unsubstantiated the allegation of misappropriation at the conclusion of their investigation indicating the evidence was inconclusive, although misappropriation was suspected. RN #125 was terminated from employment but was terminated due to nursing policies in regard to medication and documentation being violated. A review of the facility's investigation revealed a witness statement from Resident #86 was obtained. The resident reported in his statement the night before (10/11/22- 10/12/22) the nurse (RN #125) gave him pills for pain and he did not get any relief from his pain after taking the pills nor did they make him sleep. He informed another nurse about it (LPN #112) and she encouraged him to check his pills the next time they were given to him and told him what to look for. The resident alleged he had received four pills that were not the same pain pills he was familiar with receiving. The evening of 10/12/22 going into the morning of 10/13/22, the resident indicated he informed the nurse (RN #125) the pills she was giving him did not look right. The nurse took them back, looked at them, and handed them back to him while telling him they had come from a new box. He had to put them in his mouth under his tongue until she left and then he took them out of his mouth. A witness statement from LPN #112 confirmed Resident #86 had reported to her the morning of 10/12/22 that he did not know what the night shift nurse (RN #125) had given him, but that it was not his pain pills. Resident #86 informed LPN #112 he was in pain all night (10/11/22- 10/12/22) and could not sleep. He also reported to her that he was using the bathroom all night to defecate. She offered for him to file a complaint then, but the resident declined. The resident remained adamant he did not receive the proper pain medication. LPN #112 stated she told the resident to look at his pills the next time and if they did not have the identifying numbers on them as his PRN [MEDICATION(S)] did then they were not his pills. The nurse hoped that would clear things up and prove he was getting the proper medication. She stated, however, it did not. The resident kept his pills he was given the next night (10/12/22) as his PRN pain medication and showed her the morning of 10/13/22. The nurse indicated in her witness statement that what was given to the resident were stool softeners. At that time, the resident requested to file a complaint. A review of an email from RN #125 to the facility's Administrator, sent 10/20/22 at 10:36 A.M. revealed, on her shift from the evening of 10/12/22 to the morning of 10/13/22, she woke Resident #86 that morning to give him his pain medication. She also gave the resident stool softeners as he had told her earlier he had not gone to the bathroom, so she gave him two stool softeners after his pain medication. The facility's investigation file also included a complaint form to the State of Ohio Board of Nursing, dated 10/27/22 that revealed the facility's Director of Nursing (DON) filed a complaint with the Board of Nursing about RN #125. A description of the complaint or violation revealed RN #125 had been suspended for misappropriation. Their investigation revealed violations of three company policies that resulted in her termination from employment. The involved resident was mentioned in the complaint and the resident was indicated to have had pain management issues related to the practice breakdown. The resident was indicated to have received the wrong medication and reported he did not receive the pain medication that was signed off as having been administered to him. The DON indicated no harm occurred to the resident despite him having unrelieved pain that kept him up all night. The involved nurse was also indicated to have administered a medication ([MEDICATION(S)]) without a physician's order to do so. The DON added the resident reported he was given the wrong medication when he asked for his PRN pain medication. Their investigation revealed the nurse gave [MEDICATION(S)] to the resident without an order, inappropriate documentation related to signing the medication administration record (MAR's) at the correct times, and improper waste of a narcotic medication. A review of a Controlled Drug Receipt/ Record/ Disposition form for Resident #86's [MEDICATION(S)] that was included in the facility's investigation file revealed RN #125 documented she gave the resident his PRN [MEDICATION(S)] twice on the evening of 10/11/22 going into the morning hours of 10/12/22 and again the evening of 10/12/22 going into the morning hours of 10/13/22. Both times she signed to reflect she gave the resident two tablets of [MEDICATION(S)] ([MEDICATION(S)]/ Acetaminophen) 5-325 milligrams (mg) at each administration totaling four tablets each of the two shifts. On 11/02/22 at 8:27 A.M. interview with LPN #112 revealed the incident involving Resident #86 happened about three weeks ago. The resident told her the morning of 10/12/22 (the day before the incident was reported to administration) he did not get his pain medication from the night shift nurse (RN #125) as he requested and the resident suspected the nurse gave him something else instead. The LPN stated she showed the resident what his PRN [MEDICATION(S)] looked like after he questioned whether he was being given the correct medication. The next morning (10/13/22) when she came to work, the resident asked to see her. The resident had four stool softeners to show her that he stated had been given to him by RN #125 after he had requested his [MEDICATION(S)] pain medication. LPN #112 verified what the resident was given was [MEDICATION(S)] and not his PRN [MEDICATION(S)]. She denied the resident had an order to receive [MEDICATION(S)]. The LPN revealed the night before (10/11/22- 10/12/22), the resident reported he was up all night with pain and had to go to the bathroom to defecate. She stated the PRN [MEDICATION(S)] was ordered on a PRN basis and the resident would have to ask for it before it being administered. The LPN revealed the resident was given two [MEDICATION(S)] capsules each time he asked for his PRN [MEDICATION(S)]. The second time the resident was supposedly given his PRN [MEDICATION(S)] (the morning of 10/13/22), LPN #112 revealed the resident got two more [MEDICATION(S)] in place of his PRN [MEDICATION(S)] when he did not even ask for it. The resident was reportedly told (by RN #125) they looked different because they came out of a different box when the resident questioned why they looked different from his usual PRN pain medication. The resident recognized the PRN [MEDICATION(S)] given to him by RN #125 were not the same that he had received previously. On 11/02/22 at 5:38 P.M. interview with the facility Administrator and Director of Nursing (DON) revealed they both were involved in the investigation of SRI tracking number 5 and RN #125's alleged misappropriation of Resident #86's PRN [MEDICATION(S)]. Resident #86 thought things did not seem right with his medications. LPN #112 was the first to hear about the resident's concerns (on 10/11/22), but stated she did not have immediate concerns when it was first brought to her attention. The Administrator and DON were aware LPN #112 showed the resident what his [MEDICATION(S)] looked like so in the event he thought something was wrong, he would know. On the evening of 10/12/22 going into 10/13/22, the resident reported he requested pain mediation and RN #125 brought medication into him that didn't look right. He placed the medication to the side after not taking them. Later that morning, RN #125 came in again with his PRN pain medication and he informed her they did not look right. RN #125 looked at them then gave them back to him telling him they came in a new box. The resident placed the medication under his tongue and removed them after she left the room. LPN #112 came in around 7:00 A.M. that morning as the day shift nurse. He showed LPN #112 the medication that was given to him by RN #125 as his PRN pain medication. LPN #112 verified the PRN pain medication was not his [MEDICATION(S)] but was [MEDICATION(S)] instead. The Administrator confirmed four capsules of [MEDICATION(S)] were shown to LPN #112 that morning. It was after this second night that LPN #112 reported the incident to the Administrator. Witness statements were obtained and a SRI was initiated. The facility suspended RN #125 pending an investigation. The Administrator revealed although the suspected RN #125 took the PRN [MEDICATION(S)], they did not feel they could prove it. This deficiency represents non-compliance investigated under Complaint Number OH 857, Control Number OH 889 and Control Number OH 939.

Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure one resident (Resident #94) did not develop an avoidable pressure ulcer that declined from a Stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) to Unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) , failed to ensure one resident, (Resident #41)who was admitted with pressure ulcers, did not develop an additional Unstageable pressure ulcer, and failed to ensure one resident (Resident #2) did not develop a Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer in the facility. This affected three of three residents reviewed for pressure ulcers (Residents #2, #41, and #94). The facility census was 106. This resulted in actual physical harm for Residents #41 and #94 who developed Unstageable pressure ulcers with necrosis on the heels in the facility. Findings include: 1. Review of the medical record for Resident #94 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden skin risk assessment completed on 11/14/21 indicated the resident was at high risk for the development of pressure ulcers. A Minimum Data Set 3.0 (MDS) assessment completed 11/19/21 indicated the resident had long and short term memory problems, required extensive assistance from two staff with bed mobility, and had no pressure ulcers. Review of physician's orders revealed orders dated 08/17/20 to encourage/assist to float heels in bed as tolerated and encourage/assist to turn and reposition frequently. Review of nurse's notes dated 02/14/22 at 3:35 P.M. revealed Resident #94 was noted to have an area on the right heel that appeared to have been a blister that is now open to a Stage 2. The physician was notified and new treatment orders were obtained to cleanse right heel with wound cleanser and pat dry. Apply Collagen to wound bed, cover with a non-woven gauze, wrap with gauze, and secure with tape every shift. Review of a Skin and Wound evaluation dated 02/14/22 revealed Resident #94 was noted to have a new in-house acquired Stage 2 (partial thickness skin loss with exposed dermis) pressure ulcer on the right heel measuring 2.7 centimeters (cm) long by 2.8 cm wide by 0.1 cm deep. Review of a Skin and Wound evaluation dated 02/24/22 revealed the resident's right heel was 2.2 cm long by 1.9 cm wide with depth marked not applicable. It stated the wound bed had 80 percent of the wound covered with epithelial tissue. (No necrosis was noted). It was noted to have bloody exudate. On 02/28/22 a Skin Assessment indicated the resident had an Unstageable area on the right heel (no measurements or description included). On 02/28/22 a physician's order was obtained for an air mattress for the bed due to poor mobility and poor skin integrity. Review of the plan of care, initiated 08/14/20, revealed the resident had pressure ulcer development on the right heel on 02/14/22. Interventions included encourage/assist to float heels when in bed as tolerated and remind/assist to turn/reposition frequently, more often as needed or requested. Observations on 02/28/22 at 9:30 A.M. revealed Resident #94 in bed on his right side with his heels touching the mattress. Observations of the right heel revealed a 2.8 cm long by 1.9 cm wide Unstageable area with black, necrotic skin on the outer heel. Licensed Practical Nurse (LPN) #150 stated, at that time, that the staff could not keep his heels elevated off the mattress with pillows. The Director of Nursing was in the room also and stated they could get some heel elevator boots for him. Observations on 02/28/22 at 2:45 P.M. revealed the resident in bed with his heels not elevated off the mattress (no heel elevation devices in place). Observations on 03/01/22 at 8:30 A.M., 10:30 A.M., and 12:36 P.M. revealed Resident #94 in bed on his right side with his heels resting on the mattress. The resident was not observed to have an air mattress on his bed. On 03/01/22 at 2:55 P.M. the resident was observed up in a wheelchair in the hallway. The resident was observed to have a hard soled tennis shoe on his right foot with his feet resting on the floor. Observations on 03/02/22 at 8:40 A.M. revealed the resident in bed on his right side with his heels resting on the mattress. No air mattress was observed on the bed. Interview with LPN #150, at that time, revealed the air mattress was ordered but had not come in yet. She stated she did not know if the facility had any heel elevator boots for the resident or not. Review of the treatment administration record for February 2022 revealed on 02/28/22 staff had documented that assistance to float heels in bed was provided with no refusals documented. Review of the treatment administration record for March 2022 revealed on 03/01/22 staff documented that assistance to float heels in bed and assistance to turn and reposition frequently was provided each shift. It was also documented that the resident had an air mattress on the bed every shift. Interview with the Director of Nursing on 03/02/22 at 9:15 A.M. revealed she did not realize the resident would not keep his heels elevated until he had a pressure ulcer on his heel. She stated they were in the process of getting him an air mattress for the bed and heel elevator boots, but they were not available yet. She further stated the resident should not be wearing hard soled tennis shoes on his right foot as it would put further pressure on the right heel. On 03/02/22 at 9:45 A.M. she confirmed the pressure ulcer on the heel developed in the facility on 02/14/22 and had not been measured since it had developed necrotic skin over the wound. She confirmed the skin assessment on 02/28/22 indicated an Unstageable area but did not include any measurements. On 03/03/22 at 9:00 A.M. she confirmed the pressure on the right heel was worse as it now had necrotic tissue over the wound. Review of the facility policy titled Pressure Injury Prevention and Management dated 01/01/21 revealed evidence based interventions for prevention would be implemented for all residents who are at risk or who have a pressure injury present. Interventions could include: redistribute pressure (such as repositioning, protecting and/or offloading heels); provide appropriate pressure redistributing support surfaces. Resident #94 developed an Unstageable pressure ulcer with necrotic tissue on the right heel without evidence physician ordered turning/repositioning and pressure relief to the heels was provided. 2. Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident went out for [CONDITION(S)] twice weekly. On 01/28/22 physician's orders were obtained to encourage to float heels as tolerated and encourage to turn and reposition as tolerated. On 01/28/22 a Braden skin risk assessment indicated the resident was at risk for the development of pressure ulcers. There was no evidence the resident's skin was assessed on admission for any skin breakdown. The first skin assessment was dated 02/03/22 (six days after admission). Interview with the Director of Nursing on 03/02/22 at 10:45 A.M. confirmed there was no assessment of Resident #41's skin until 02/03/22. She stated staff are to assess residents' skin on admission for any pressure ulcers/wounds. On 02/03/22 a Skin and Wound evaluation noted a deep tissue pressure injury (DTPI) (persistent non-blanchable deep red, maroon or purple discoloration, intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on the right heel that was documented as being present on admission. The area measured 2.3 cm long by 3.4 cm wide with depth marked not applicable. It indicated the wound was covered with 100 percent epithelial tissue (tissue which manifests as light pink with a shiny pearl appearance). No necrosis (eschar) was noted. The resident was also noted with a Stage 2 pressure ulcer present on admission on the left ischial tuberosity measuring 0.6 cm long by 0.9 cm wide by 0.1 cm deep. The resident had a treatment ordered to cleanse the left ischial tuberosity with wound cleanser, pat dry, apply collagen, cover with foam dressing daily. On 02/05/22 a weekly skin assessment did not indicate any pressure areas on the right heel or left ischial tuberosity. An MDS assessment completed 02/07/22 indicated the resident required extensive assistance from two staff with bed mobility. On 02/17/22 Skin and Wound evaluations noted the right heel to be a deep tissue injury pressure ulcer measuring 2.9 cm long by 3.9 cm wide with depth marked not applicable. It indicated the wound was covered with 100 percent epithelial tissue. No necrosis (eschar) was noted. The left ischial tuberosity was noted to be a Stage 2 pressure ulcer measuring 1.3 cm long by 1.3 cm wide. No depth documented. On 02/17/22 it was noted the resident had developed a new deep tissue pressure injury on the left heel measuring 2.6 cm long by 2.6 cm wide with depth marked not applicable. It indicated the wound was covered with 100 percent epithelial tissue. No necrosis (eschar) was noted. On 02/17/22 a physician's order was written for heel elevator boots to bilateral heels. On 02/23/22 an air mattress was ordered for the bed. Interview with the Director of Nursing on 03/02/22 at 10:45 A.M. confirmed the pressure ulcer on the left heel developed in the facility. On 02/24/22 Skin and Wound evaluations indicated the right heel was a deep tissue pressure ulcer measuring 1.6 cm long by 4.2 cm wide with depth not applicable. It indicated the wound was covered with 100 percent epithelial tissue. No necrosis (eschar) was noted. The left ischial tuberosity was noted to be a Stage 2 pressure ulcer measuring 1.0 cm long by 1.4 cm wide by 0.1 cm deep. The left heel was noted to be a deep tissue pressure injury (in house acquired) measuring 3.1 cm long by 2.6 cm wide with depth not applicable. It indicated the wound was covered with 100 percent epithelial tissue. No necrosis (eschar) was noted. Observations on 02/28/22 at 7:40 A.M. revealed Resident #41 to be in bed. The resident was observed with a 0.5 cm long by 2.5 cm wide by 0.1 cm deep open area on the left buttock covered with a piece of collagen. The skin around the wound was dark red/purple. There was no dressing over the collagen. Interview with the Director of Nursing, at that time, revealed she did not know why the resident did not have a dressing over the open pressure ulcer. Review of the treatment administration record revealed the dressing was documented as completed on the morning of 02/27/22. Interview with LPN #151 on 02/28/22 at 8:00 A.M. (the nurse providing care for Resident #41) revealed she was not aware the resident did not have a dressing on the pressure ulcer on the left buttock (documented as ischial tuberosity). Observations on 03/01/22 at 8:25 A.M., 10:25 A.M. and 12:35 P.M. revealed Resident #41 in bed with her heels resting on the mattress. The resident did not have any heel elevator boots on. Observations on 03/02/22 at 10:00 A.M. of Resident #41's heels revealed the left heel to have a 4.1 cm long by 3.1 cm wide Unstageable pressure ulcer covered with brown eschar. The right heel had a 2.5 cm long by 4 cm wide Unstageable pressure ulcer covered with dark brown/black eschar. Review of the treatment administration record for March 2022 revealed that on 03/01/22 the heel elevator boots were documented to indicate they were worn by the resident for the day shift. It was also documented that the heels were floated. The treatment administration record also monitored a target behavior of refusing care but documented this did not occur on 03/01/22. Interview with the Director of Nursing on 03/02/22 at 10:00 A.M. and 10:45 A.M. revealed Resident #41 was to have heel elevator boots on when in bed. She also confirmed there was no documentation to indicate the resident refused care on 03/01/22. She confirmed the skin and wound evaluations did not indicate the resident had any eschar on the heels. She stated the resident had eschar on her heels prior to 03/02/22 but the skin and wound evaluations were inaccurate. She confirmed the resident could not have 100 percent epithelial skin over the wounds when eschar was present. Resident #41 developed an Unstageable pressure ulcer with necrotic tissue to the left heel in the facility and had worsening of an Unstageable pressure ulcer on the right heel without evidence that physician ordered pressure relief was provided. 3. Review of the medical record for Resident #2 revealed a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden pressure ulcer risk assessment completed on 12/20/21 indicated the resident was high risk for the development of pressure ulcers. The admission skin assessment documented the resident did not have any pressure ulcers. The resident was receiving hospice services. A MDS assessment completed 01/21/22 indicated the resident had a brief interview for mental status score of 2, indicating severe cognitive impairment. The resident required extensive assistance from two staff for bed mobility and had no pressure ulcers. A weekly skin assessment on 01/10/22 stated the resident had no existing or new skin areas. A nurses note on 01/16/22 at 8:03 A.M. documented a new order was obtained for wound care for the midspine. There was no description or measurements of the area. There was no evidence a physician's order was implemented for a treatment to the midspine at that time. A weekly skin assessment on 01/18/22 stated the resident had no existing or new skin areas. A nurses note on 01/19/22 at 3:36 P.M. documented a new order was obtained to cleanse area on spine and apply hydrocortisone ointment and cover with dressing three times per week. However, review of the treatment administration record for January 2022 revealed a treatment to the spine was first documented on 01/21/22. (5 days after it was identified). A weekly skin assessment on 02/03/22 documented the resident had no existing or new skin areas. A skin and wound evaluation on 02/10/22 stated the resident had a Stage 3 (full-thickness skin loss) pressure ulcer, in house acquired, on the spine measuring 0.2 cm long by 0.4 cm wide by <0.1 cm deep. It indicated the wound was filled with 100 percent slough. This was the first time the wound was measured or described since noted in the nurses notes on 01/16/22. Interview with the Director of Nursing on 03/02/22 at 9:00 A.M. confirmed the pressure ulcer assessments were inaccurate and the area was not measured until 02/10/22 (after being identified on 01/16/22). She confirmed pressure ulcers are to be monitored weekly. She stated hospice had documentation on the pressure ulcer but that the facility did not have those records. She confirmed there was no evidence a physician's order was obtained for a treatment to the area until 01/19/22. A weekly skin assessment on 02/17/22 documented the resident had no existing or new skin areas. However, a Skin and Wound evaluation on 02/17/22 stated the resident had a Stage 3 pressure ulcer on the spine measuring 0.5 cm long by 0.5 cm wide, with depth as not applicable. It was noted to be improving. A weekly skin assessment on 02/24/22 stated the resident had an area on the spine appearing as a Stage 1. A Skin and Wound evaluation on 02/24/22 stated the area measured 1.0 cm long by 1.0 cm wide with depth not applicable. Review of physician's orders revealed an order 01/19/22 to reposition the resident every two hours as tolerated. Review of the plan of care, initiated 10/26/21, revealed an intervention stating the resident needed reminding/assistance to turn/reposition every two hours, more often as needed or requested. Observations on 02/28/22 at 2:30 P.M. revealed Resident #2 to have a 1.0 cm in diameter moist wound with a white center on the mid back. The skin around the wound was reddened. The wound was near a protrusion of the spine. Observations on 03/01/22 at 8:15 A.M., 10:32 A.M. and 12:30 P.M. revealed Resident #2 to be in bed in the same position with a pillow under her left side, tilting the resident slightly to the right. The resident was observed to have a regular pressure reducing mattress on the bed. Review of the treatment administration record for 03/01/22 revealed it was documented the resident was repositioned every two hours at 8:00 A.M., 10:00 A.M., and 12:00 P.M. There was no evidence of any refusals to turn/reposition. Interview with Medication Technician #152 (who signed off the treatment administration record for turning on 03/01/22 at 8:00 A.M., 10:00 A.M. and 12:00 P.M.) on 03/01/22 at 3:45 P.M. revealed the resident should be repositioned rotating from the back to left side to right side every two hours. She stated she did not verify the position every two hours but went on what the nursing assistants told her. She confirmed she documented the resident was repositioned every two hours. Interview with State tested Nursing Assistant (STNA) #153 on 03/01/22 at 3:50 P.M. (STNA providing care for Resident #2) revealed they shove a pillow under the resident but do what the resident wants. She stated the resident will pull the pillow out and return to laying on her back. (Although the resident was observed in the same position with the pillow under her left side from 8:15 A.M. to 12:30 P.M.). Review of the facility policy titled Pressure Injury Prevention and Management dated 01/01/21 revealed licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Interview with the Director of Nursing on 03/02/22 at 9:00 A.M. revealed the facility was in the process of obtaining an air mattress for the resident's bed. She stated when the Stage 3 was identified, the resident should have had an air mattress added to the bed. This deficiency substantiated Master Complaint Number OH 269.

Based on record review, hospital record review, facility policy and procedure review and interview the facility failed to ensure appropriate equipment and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred when Resident #5, who was admitted to the facility on [DATE] with hospital transfer orders for peritoneal [CONDITION(S)] (a type of [CONDITION(S)] that uses the peritoneum in a person's abdomen as the membrane through which fluid and dissolved substances are exchanged with the blood. It is used to remove excess fluid, correct electrolyte imbalances and remove toxins in those with kidney failure) was not provided the [CONDITION(S)] due to the facility not having the necessary equipment to provide it for the resident. This resulted in a significant change in condition requiring emergency transport to the hospital on [DATE] and an intensive care hospital stay for hyperbole (elevated potassium level), fluid overload, acute hypoxic respiratory failure and hypertensive crisis (elevated blood pressure) as a result of the resident not receiving peritoneal [CONDITION(S)] at the nursing home. The resident was hospitalized until [DATE]. This affected one resident (Resident #5) of three sampled residents. Findings include: Review of Resident #5's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's hospital discharge orders, dated [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no additional specific orders related to the [CONDITION(S)] provided. Review of the physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed an incomplete Nursing Admission Evaluation Part One Version 2 which contained the resident's vital signs: Temperature 97.1, pulse 86 per minute and regular, respirations 17 per minute and oxygen saturation 90% (normal greater than 92%) on room air. No assessment of the resident's skin, [CONDITION(S)] catheter, lungs or other systems were noted on the assessment. Further review of the medical record revealed no documentation of the resident's disposition upon arrival to the facility or the resident's arrival time. The first progress note was dated [DATE] at 8:00 P.M. and indicated the resident's wife called and wanted to know if the resident's [CONDITION(S)] had been started and the nurse explained the resident's [CONDITION(S)] would have to be run by gravity and the resident's wife stated that would be fine. Further review of the progress note revealed an entry dated [DATE] at 10:45 P.M. that indicated while reviewing Resident #5's orders it was noted there were no orders for [CONDITION(S)], the discharging hospital was notified and they indicated they would fax the orders when they found them. An additional progress note, dated [DATE] at 1:47 A.M. revealed the discharging hospital could not find the resident's orders for [CONDITION(S)] and that it would have to wait until the nephrology (kidney specialists) team comes in the morning. There was no evidence the resident's physician was notified per review of the progress note. Review of an Admission Meeting Note, dated [DATE] at 2:20 P.M. revealed an admission meeting was held at this time in Resident #5's room. The resident reported he was not feeling well and voiced no concerns other than his health at that time. The note revealed the resident received [CONDITION(S)] at home. Review of the New Admission History and Physical, dated [DATE] and completed by Physician #375, revealed Resident #5 had a [CONDITION(S)] and required cardiopulmonary resuscitation during his hospitalization prior to admission to the facility and seeing how they did CPR, I am sure he is having some shortness of breath. I figure out some of this could just be (due) to the possibility that he had some fractured ribs during that episode of CPR. The resident's biggest complaint was some shortness of breath. The plan was for the resident to follow up with cardiology given the [CONDITION(S)] and the new onset of [CONDITION(S)] (irregular heartbeat) and the resident would need started on his [CONDITION(S)]. The note was dictated on [DATE] at 1:12 P.M. Review of the Situation, Background, Assessment and Recommendation (SBAR) Communication Form and Progress Note V3, dated [DATE] revealed Resident #5's vital signs at 12:09 P.M. were pulse 86 and regular, respirations 17, blood pressure ,d+[DATE] and oxygen saturation 90% on room air. The resident was lying in bed with slow, deep respirations with a rate of 13. The resident did not receive [CONDITION(S)] overnight and was short of breath and had labored breathing. The resident's overall condition was poor. The physician was notified on [DATE] at 3:00 P.M. and the resident was transported to the hospital. Review of the admitting hospital documentation, dated [DATE] revealed Resident #5, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the intensive care unit (ICU) for hemodialysis to treat [CONDITION(S)] and volume overload. The resident had acute hypoxic respiratory failure/volume overload due to inability to receive PD. The resident's betanaturetic peptide was 49,312 and a chest x-ray was suggestive of heart failure. Hemodialysis (HD) was ordered. The resident was currently on six liters of oxygen. The resident also had [CONDITION(S)] due to his inability to receive PD. Nephrology ordered hemodialysis. The resident's blood pressure on presentation to the hospital was ,d+[DATE] (normal ,d+[DATE]). The resident was started on a [MEDICATION(S)] drip until HD could be started. Review of the Hospital Discharge Summary, dated [DATE] revealed Resident #5 presented to the hospital after worsening shortness of breath for two days after being unable to receive his PD. The resident had acute hypoxic respiratory failure in context of an exacerbation of congestive heart failure/volume overload due to the resident's inability to receive PD. The resident's condition improved after [CONDITION(S)] was resumed. The resident had acute diastolic and systolic CHF due to missed PD and was stabilized with [CONDITION(S)]. [CONDITION(S)] improved after hemodialysis and peritoneal [CONDITION(S)] resumed. The resident was able to discharge back to the facility per nephrology once it was ensured the facility would have all the peritoneal [CONDITION(S)] supplies and were able to continue PD. On [DATE] at 12:08 P.M. interview with Clinic Manager (CM) #425 revealed the facility contacted his company since Resident #5 received their services at home. CM #425 stated he made the facility aware they would not be able to provide the equipment needed for the resident's PD on the date he was admitted . Further interview revealed the facility should have the necessary PD equipment on hand for when they admit a resident who required PD. On [DATE] at 2:23 P.M. interview with Resident #5 revealed he was sent out to the hospital following his admission to the facility on [DATE] because he wasn't able to receive his peritoneal [CONDITION(S)] upon admission to the facility and he was admitted to the hospital due to extra fluid in my body from not getting [CONDITION(S)] The resident stated this caused him to be admitted to the hospital and receive hemodialysis. The resident stated the facility did not have the necessary equipment to provide his [CONDITION(S)] when he was admitted . On [DATE] at 3:57 P.M. interview with Physician #400 revealed he was one of the physicians caring for Resident #5 and his expectation would have been for the [CONDITION(S)] company/provider to have had the equipment at the facility for the facility to provide PD to the resident. On [DATE] at 4:10 P.M. interview with the Director of Nursing (DON) verified the medical record contained no evidence Resident #5 received his [CONDITION(S)] and the facility did not have the necessary equipment to provide PD to the resident when he was admitted to the facility. The DON also verified the hospital documentation from [DATE] indicated the resident was admitted to the hospital due to hypertensive crisis, acute hypoxic respiratory failure and [CONDITION(S)] due to not receiving his PD. The DON revealed the [CONDITION(S)] company was to have the equipment to them prior to the resident's admission but this did not happen. Lastly, the DON verified the medical record did not contain documentation of the resident's condition on admission to the facility on [DATE]. On [DATE] at 4:11 P.M. interview with the Administrator revealed the facility did not re-admit Resident #5 until they were able to get the appropriate equipment to provide the resident's PD. On [DATE] at 4:22 P.M. interview with Registered Nurse (RN) #325 revealed the RN arrived to the facility around 8:00 P.M. on [DATE] and staff did not have the necessary equipment to provide Resident #5 with PD. Further interview revealed the nursing staff attempted to get the orders for [CONDITION(S)] but they had to wait until the following day. The facility received the orders from the hospital on [DATE] at 9:07 A.M. but then they were unable to get equipment for the resident from the original [CONDITION(S)] center and they reached out to a local [CONDITION(S)] provider that afternoon but the resident was sent to the hospital and admitted without receiving peritoneal [CONDITION(S)] at the facility. On [DATE] at 12:10 P.M. telephone interview with Licensed Practical Nurse (LPN) #450 revealed she was the nurse working the day Resident #5 had to be transferred to the hospital and admitted . The nurse stated she did not receive much information from the admitting nurse about the resident and was not informed he did not receive his [CONDITION(S)] throughout the night. LPN #450 stated the resident had no sign of receiving [CONDITION(S)] such as discarded supplies or any supplies in his room, she did not disconnect the resident from his [CONDITION(S)] the following morning and the resident reported to her he did not receive [CONDITION(S)] Further interview revealed the resident was admitted to the facility without a clarification of [CONDITION(S)] orders or necessary equipment to provide the [CONDITION(S)]. The LPN revealed the resident was initially short of breath but his condition continued to worsen and once the physician came in for rounds, she sent the physician back to the resident's room first for an evaluation and shortly after, the resident was sent out to the hospital and admitted with the listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 561.

Based on observation, record review and staff interview the facility failed to implement timely and adequate skin risk interventions to prevent the development of a deep tissue injury and unstageable pressure ulcer for Resident #27 and an unstageable pressure ulcer for Resident #89. This affected two residents (#27 and #89) of three residents reviewed for pressure ulcers. Actual harm occurred on 07/21/20 when Resident #27, who was cognitively impaired and dependent on staff for activities of daily living including turning and repositioning developed a deep tissue injury pressure ulcer to the left upper buttocks. At the time the pressure ulcer was first identified there was no assessment or measurement of the ulcer. On 07/24/20 the pressure ulcer was assessed to measure 3.9 centimeters (cm) in length by 2.6 cm width, with depth that could not be determined. On 07/27/20 Resident #27 was assessed to have an unstageable pressure ulcer to the back of the head measuring 1.6 cm in length and 0.8 cm in width. The wound bed had 100% slough tissue and yellow purulent drainage. Actual harm occurred on 09/21/20 when Resident #89, who was cognitively impaired and dependent on staff for activities of daily living including turning and repositioning was identified to have an unstageable pressure ulcer to the coccyx. The pressure ulcer was assessed to have slough and necrotic tissue present and measured 5.4 cm in length by 6.5 cm width, with depth that could not be determined. Findings include: 1. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Norton scale (used for predicting pressure ulcer risk), dated 07/13/20 revealed Resident #27 was at very high risk for skin breakdown with a score of three. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/13/20 revealed Resident #27 had severely impaired cognition and was at risk for pressure ulcers or injuries. Further review revealed Resident #27 required extensive assistance from two staff for bed mobility, transfers and bathing. The MDS revealed Resident #27 had one Stage I (non-blanchable [DIAGNOSES REDACTED] of intact skin) pressure ulcer present at the time of the assessment. Review of the initial plan of care (POC) dated 07/14/20 revealed Resident #27 was at risk for skin breakdown and had a Stage I pressure area located on the left foot fifth digit (pinky toe) at that time. Interventions included a daily skin assessment to be performed by a licensed nurse, skin inspections by a state tested nursing assistant (STNA) during care and bathing with any changes to be reported to the nurse immediately and the use of a specialty air mattress to the bed. Review of the STNA skin assessment bathing sheets, dated 07/15/20, 07/17/20, 07/18/20, 07/19/20, 07/21/20, 07/24/20 and 7/26/20 revealed no evidence of any skin issues identified or reported to the nurse. However, review of a skin assessment, completed by the licensed nurse, dated 07/21/20 at 1:50 P.M. revealed Resident #27 had an abnormal skin area to the left upper buttock described as a deep tissue injury. A Deep Tissue Pressure Injury (DTPI) is described as a persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The skin assessment completed by the facility failed to include a description or wound dimensions/measurements of the area. Review of a wound nurse progress note, dated 07/24/20 revealed Resident #27 had a pressure area to the left upper buttocks described as a deep tissue pressure injury that measured 3.9 cm in length and 2.6 cm in width. The depth was unable to be determined. The note revealed the nurse applied a foam dressing. Review of the physician's orders [REDACTED].#27 was ordered a specialty air mattress to the bed. Review of a wound nurse progress note, dated 07/27/20 revealed Resident #27 was noted to have an unstageable (obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure area to the back of the head that measured 1.6 cm in length and 0.8 cm in width. The wound bed had 100% slough and yellow purulent drainage. On 10/01/20 at 9:38 A.M. an observation of Resident #27's wound dressing change revealed the resident continued to have a pressure ulcer to the left upper buttocks that required treatment. The pressure ulcer to the resident's head was observed to be healed. On 10/07/20 at 11:30 A.M. interview with Licensed Practical Nurse (LPN) #1 revealed although Resident #27's plan of care indicated the resident was to have daily skin checks completed by the licensed nurse, they were only being completed weekly. On 10/07/20 at 12:08 P.M. interview with Registered Nurse (RN) #10 revealed Resident #27 was admitted without a pressure area to either the left upper buttocks or the back of the head. RN #10 verified the Norton scale revealed Resident #27 was at a severely high risk for the development of pressure areas, cognitively impaired and dependent on staff for activities of daily living including turning and repositioning in bed. RN #10 verified Resident #27's care plan dated 07/14/20 revealed the resident was to have a specialty air mattress. However, the specialty air mattress was not put in place until 07/24/20 after the pressure area to Resident #27's left upper buttock developed. During the onsite investigation, the facility was unable to provide any additional information related to how or why these two pressure ulcers developed for Resident #27, a resident who was cognitively impaired and dependent on staff for activities of daily living care needs. 2. Review of Resident #89's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial plan of care (POC) dated 08/28/20 revealed Resident #89 was at risk for skin breakdown. Interventions included a daily skin assessment to be performed by a licensed nurse, skin inspections by STNA staff during care and bathing and a specialty air mattress to the bed. Review of the Norton scale dated 08/28/20 revealed Resident #89 was at high risk for skin breakdown with a score of 10. Review of the MDS 3.0 assessment, dated 08/28/20 revealed Resident #89 had Brief Interview for Mental Status (BIMS) score of 99, an indication the resident was unable to complete the interview. The MDS also revealed Resident #89 was at risk for pressure ulcers or injuries. Further review revealed Resident #89 required extensive assistance from two staff for bed mobility, transfers and bathing. The MDS revealed Resident #89 had no pressure areas on admission. Record review revealed STNA bathing sheets were completed on 08/29/20, 08/30/20, 09/02/20, 09/03/20, 09/07/20, 09/10/20, 09/12/20, 09/13/20, 09/19/20, 09/21/20 and 09/22/20 with no evidence of any areas of skin breakdown documented. Review of a skin assessment, dated 09/04/20 revealed no skin issues were identified for Resident #89. On 09/06/20 a physician's orders [REDACTED].#89's coccyx area. The medical record was without a description or wound dimensions/measurements of the area at that time. Review of a skin assessment, dated 09/11/20 revealed Resident #89 had an existing skin area. However, the assessment was without a description or wound dimensions/measurements of the area. Review of a wound nurse progress note, dated 09/21/20, revealed Resident #89 had an unstageable pressure area to the coccyx measuring 5.4 cm in length and 6.5 cm in width. The depth was not able to be determined. The wound bed was noted to have slough and necrotic tissue. Further review of Resident #89 medical record, dated 09/21/20 revealed the wound nurse had identified a second pressure area to the resident's right gluteal fold at this time. This wound measured 2.9 cm in length and 3.5 cm in width and 0.3 cm in depth and had 100% granulation tissue noted. Review of the physician's orders [REDACTED].#89 was ordered a specialty air mattress to the bed. On 10/01/20, Resident #89 was transferred to the hospital. The resident did not return to the facility during the investigation and therefore could not be observed. On 10/07/20 at 11:30 A.M. interview with LPN #1 revealed although Resident #89's plan of care indicated the resident was to have daily skin checks completed by the licensed nurse, they were only being completed weekly. Interview on 10/07/20 at 12:20 P.M. with RN #10 revealed Resident #89 was admitted without a pressure area to either the coccyx or the right gluteal fold. RN #10 verified the Norton scale revealed Resident #89 was at a high risk for development of pressure areas, cognitively impaired and dependent on staff for activities of daily living including turning and repositioning. RN #10 also verified Resident #89's care plan dated 08/28/20 revealed the resident was to have a specialty air mattress. However, the specialty air mattress was not put in place until 09/22/20 after the resident was identified to have skin breakdown. During the onsite investigation, the facility was unable to provide any additional information related to how or why these two pressure ulcers developed for Resident #89, a resident who was cognitively impaired and dependent on staff for activities of daily living care needs. This deficiency substantiates Complaint Number OH 336.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of a facility investigation and timeline, COVID-19 testing log and infection control log and review of facility policy and procedures, observations and interviews with staff and local health department staff, the facility failed to implement effective and recommended infection control practices including the adequate monitoring and prevention of the transmission of COVID-19 in the facility. The facility also failed to report suspected and confirmed cases of COVID-19 to the local health department timely. This resulted in Immediate Jeopardy on [DATE] when State tested Nursing Assistant (STNA) #10 was instructed to come to work after reporting he had a fever for the past two days. The STNA began working (on [DATE] at 1:44 P.M.) on the second floor of the facility and then went and worked on the COVID-19 A unit until 1:39 A.M. when he was sent home ill with a fever of 101.2 degrees Fahrenheit. The STNA subsequently tested positive for COVID-19 with results received on [DATE]. The facility failed to perform an investigation/contact tracing to determine those residents or staff the STNA had contact with for exposure to COVID-19 or notify the local health department of the positive case. Further investigation revealed Resident #2, had exposure to STNA #10 on the afternoon of [DATE] and early morning of [DATE]. On [DATE] Resident #2 developed symptoms of COVID-19, however these symptoms were not communicated to the physician and no COVID-19 testing was performed. The resident expired on [DATE]. On [DATE] STNA #11 tested positive for COVID-19. The facility failed to perform an investigation/contact tracing to determine those residents or staff the STNA had contact with for exposure to COVID-19 or notify the appropriate local health department of the positive case. Further investigation revealed Resident #1 may have had direct contact with STNA #11 and had also resided in a room with Resident #2, developed symptoms of COVID-19 on [DATE] but was not tested until [DATE] (with positive results noted). The lack of current effective infection control practices and implementation of effective infection control policies and procedures placed all residents at risk for harm, complications and/or death related to the facilities failure to control the spread of COVID-19 throughout the facility. The facility census was 118. On [DATE] at 4:14 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when STNA #10 worked, providing direct resident care while having symptoms of COVID-19. The STNA subsequently tested positive for COVID-19. The facility failed to timely and adequately determine which staff or residents STNA #10 had contact with to implement infection control precautions. The facility failed to determine which staff or residents STNA #11 had contact with to implement infection control precautions after this STNA tested positive for COVID-19 on [DATE]. In addition, the facility failed to timely identify symptoms and staff/resident exposure involving Resident #1 resulting in the resident contracting COVID-19. Resident #2 subsequently passed away and was not tested to confirm COVID, however it was suspected. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following correction actions: · On [DATE] at 8:30 P.M. a whole facility house audit for all residents and staff was completed by the Infection Control Nurse to identify potential residents exposed to a positive COVID-19 staff member. No new residents were identified with signs and symptoms of COVID-19 at this time. · On [DATE] at 10:17 P.M. all suspected and positive COVID-19 cases (staff and residents) were reported to the local health department by the Director of Nursing via email on [DATE] at 10:17 P.M. and [DATE] at 3:02 P.M. with additional information requested by the local health department. · On [DATE] at 9:30 P.M. the Director of Clinical Services educated the Administrator, Director of Nursing and Infection Control Nurse regarding requirements for notifying the local health department of any suspected or confirmed cases of COVID-19 staff members or residents. · On [DATE] at 10:00 P.M. the Director of Clinical Services educated the Medical Director, Administrator, Director of Nursing and Infection Control Nurse related to contact tracing through guidance from the local health department related to staff testing positive for COVID-19. · On [DATE] at 1:31 P.M. the Medical Director, Administrator and Director of Nursing reviewed and revised the facility infection control plan regarding the pandemic and related to the medical directors COVID-19 testing protocol which stated as needed Tylenol orders would be discontinued, staff would alert the primary care physician of a change of condition, residents whose temperature was 99.0 degrees Fahrenheit or higher would be communicated to the primary care physician for further direction and the resident would be placed on transmission (isolation) precautions. · On [DATE] a plan for high touch areas to be cleaned every four hours by housekeeping staff was implemented. · On [DATE] a plan for all resident ' s vital signs including temperature and oxygen saturation to be obtained every four hours. Any resident who had a temperature of 99.0 or higher or oxygen saturation of 90% or less would be reported to the physician for further direction and the resident would be placed on transmission (isolation) based precautions. · On [DATE] a plan for the Director of Nursing/designee to review the clinical alert report four times a day five times a week for three months then weekly for two months then randomly thereafter to ensure temperatures of 99.0 or greater or oxygen saturation of 90% or less were addressed with the primary care physician for direction. · On [DATE] a plan for the Infection Control Nurse to add employees and resident's being tested for COVID-19 to the COVID-19 log was implemented. The Infection Control Nurse would then complete contact tracing. · On [DATE] a plan for the Director of Nursing /designee to review the log during the daily clinical meeting five times a week for two months then weekly for four weeks then randomly thereafter validating contact tracing was completed. The results of these reviews will be discussed in quality assessment/performance improvement (QAPI) meetings for compliance and further recommendations. · On [DATE] a plan for the Infection Control Nurse to contact the Director of Nursing and Administrator immediately as positive COVID-19 staff members are identified to ensure residents who have been potentially exposed are placed in quarantine for fourteen days and monitored for signs and symptoms including vital signs and pulse oximetry every four hours. · On [DATE] a plan for the Director of Nursing /designee to review the positive COVID-19 staff and staffing schedule validating the residents who were potentially exposed were placed on quarantine for fourteen days and monitored for signs and symptoms to include vital signs and oxygen saturation every four hours. Monitoring will occur daily five times a week for two months then weekly for one month then randomly thereafter. Results of review will be discussed in QAPI meetings for compliance and further recommendations. · On [DATE] a plan for the Medical Director, Administrator, Director of Nursing and Infection Control Nurse to review the infection control plan regarding the pandemic policies and procedures weekly in QAPI meeting was implemented. · On [DATE] a plan for the Regional Director of Clinical Services to attend QAPI meetings weekly for four months then randomly thereafter validating policies and procedures was implemented. · On [DATE] a plan for the Director of Nursing and the Infection Control Nurse to notify the local health department collaboratively via email with a follow up phone call as suspected and or confirmed COVID-19 staff members or residents were identified was implemented. · On [DATE] a plan for the Administrator to also contact the local health department via email with follow up phone call as the COVID-19 log identified newly suspected or confirmed COVID-19 staff members or residents validating notification on going was implemented. · Beginning on [DATE] at 8:30 P.M. the Infection Control Nurse initiated staff training. Licensed nurses (18 Registered Nurses, 28 Licensed Practical Nurses, 2 Medication Techs, 14 housekeepers, 82 State tested Nursing Assistants, eight Administration staff, two social service staff, five respiratory staff, a therapist, one medical record staff, eight therapy staff and three activity personal) were educated via telephone and in person on the signs and symptoms of COVID-19 and related to the need to notify the physician of these signs/symptoms. · On [DATE] at 4:00 P.M. the Infection Control Nurse educated staff (including 18 Registered Nurses, 28 Licensed Practical Nurses, 2 Medication Techs, 14 housekeepers, 82 State tested Nursing Assistants, eight Administration staff, two social service staff, five respiratory staff, one therapist, one medical record staff, eight therapy staff and three activity personal related to updated COVID policies and procedures. · On [DATE] a plan for the Director of Nursing /designee to review the twenty-four-hour report and progress note report in the daily clinical meeting on an ongoing basis to validate the physician was updated with residents showing signs and symptoms of COVID-19 was implemented. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Finding include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America ' s health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii). 1. On [DATE] at 1:44 P.M. STNA #10 began his regularly scheduled shift working on the second floor (non-COVID unit) of the facility. At some point during the shift, the STNA also worked on the A hall, the facility COVID-19 unit. Although the facility had a COVID-19 unit on this date, there were no residents residing on the A unit with positive COVID-19 test results. Resident #2 resided on the COVID unit due to being readmitted to the facility from the hospital on [DATE] as a precautionary/quarantine measure due to an unknown COVID status. STNA #10 left the facility ill, with a temperature of 101.2 on [DATE] at 1:39 A.M. A COVID-19 test was obtained on this date with positive results reported on [DATE]. After the facility reviewed the staffing schedule and assignment sheets and investigation, they determined STNA #10 had been assigned to care for Resident #2 on the COVID unit/A hall during his shift from [DATE] until he left the facility ill on [DATE] at 1:39 A.M. Review of Resident #2's closed medical record revealed the resident was originally admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's current orders, for [DATE] revealed orders for oxygen two liters per minute to keep oxygen levels greater than 90. There was an order to monitor for signs and symptoms of respiratory infections (fever, cough, shortness of breath, fatigue, muscle and body aches, headaches, new loss of taste or smell, congestion, runny nose, sore throat, nausea, vomiting, diarrhea, and low oxygen saturation) every shift. Notify physician if new signs and symptoms every shift, if new signs or symptoms present document in the progress notes and notify physician. On [DATE] a new order was received to check temperature every 2 hours. Prior to this order on [DATE] there were no orders to check temperature. Review of a progress note, dated [DATE] revealed the resident's main goal was to remain in long term care facility. Per therapy documentation, the resident required dependent assistance with upper and lower body dressing as well as dependent assistance with upper and lower body bathing. He required maximum to substantial assistance with all transfers and requires partial assistance with transfers. The resident was non-ambulatory. The resident's brief interview for mental status score (BIMS) on [DATE] was eight which indicated the resident had moderate cognitive impairment. Review of Resident #2's electronic vital sign records revealed the following: On [DATE] the resident's temperature was 100.1 degrees Fahrenheit, [DATE] -99.0, [DATE]- 99.5, 99.5, and 99.1, [DATE]- 99.0 and 99.3 and on [DATE]- 99.2 and 99.9. The resident did not have a temperature check on [DATE] or [DATE]. Further review revealed the resident's oxygen saturation level was only checked one time in July on [DATE] and it was 92% on room air. Review of progress notes dated [DATE] to [DATE] revealed no evidence the physician was notified of temperatures greater than 99.0 nor were the elevated temperatures noted in the progress notes. Review of Resident #2's medication administration and treatment record, dated [DATE] revealed on [DATE] the resident received Tylenol 325 milligrams (mg) two tablets for a temperature of 99.5. Further review revealed droplet isolation was discontinued on [DATE], the resident did not have any fever, and there was no evidence an oxygen level was obtained every shift per orders to monitor for respiratory infections (see above order). Review of progress note, dated [DATE] revealed Resident #2 was moved from the COVID-19 unit to a room on the F-hall (a non-COVID unit) with a roommate, Resident #1. Review of a change of condition assessment, dated [DATE] revealed Resident #2 had declined. He was not eating or taking medications. On [DATE] he had headache and nosebleed. Review of the infection control log for [DATE] revealed no evidence Resident #2 was included on the log for any type of infection or related to COVID-19. Interview on [DATE] at 8:06 A.M. and 1:22 P.M., with the Medical Director (MD), who was also Resident #2's physician revealed any change of condition warranted testing for COVID-19. The MD stated he was not aware STNA #10 had worked on the COVID unit and possibly provided care to Resident #2. He was not aware Resident #2 had a temperature greater than 99 degrees (as noted above) nor had this been reported/communicated to him. The MD reported himself and his Nurse Practitioner had told staff repeatedly they wanted notified of any resident having a temperature greater than 99 degrees. He stated he had also asked the facility to discontinue all Tylenol orders and told staff they would need to call for approval to give Tylenol. During the interview, the MD revealed it would be his expectation that all residents on A hall should have been quarantined an additional 14 days after exposure to STNA #10 who tested positive for COVID-19. The MD revealed Resident #2 should have been tested for COVID-19 and he regretted he did not order a test. During the interview, the MD revealed the local health department (LHD) had contacted him with concerns they had regarding this resident and another resident because both residents had symptoms of COVID-19 and were not tested and then subsequently expired. The MD stated he did not feel comfortable changing death certificates at this time without these resident ' s having actual COVID-19 positive test results. The MD again verified no COVID test had been completed for Resident #2. On [DATE] at 9:38 A.M. interview with the DON revealed STNA #10 had worked on the second floor on [DATE]. Following the identification of STNA #10 testing positive, there was no facility investigation/contact tracing completed to determine which residents or staff STNA #10 had direct contact with on the second floor to implement infection control measures to prevent the spread of COVID-19. Interview on [DATE] at 9:09 A.M., 11:52 A.M. and 1:10 P.M. with the Director of Nursing (DON) revealed after reviewing Resident #2's medical record with the MD it was determined Resident #2 should have been tested for COVID. The DON verified the resident had a temperature (as noted above) and verified his oxygen level was only checked once in [DATE] on [DATE]. The DON reported the oxygen levels should have been checked daily and documented on the treatment records. The DON verified the resident's temperatures were not reported to the physician, nor was there documented evidence to support notification. She had spoken to the MD and he wanted all low-grade temperatures checked for COVID moving forward. The DON verified STNA #10 had also worked midnight shift on the COVID unit [DATE] into the morning of [DATE] at which time he left and went to the emergency room due to being ill. The DON stated STNA #10 had originally self-reported his COVID-19 test was negative, but she later received a call from the local health department notifying her the STNA had tested positive for COVID-19. The DON revealed she did not investigate to see who the STNA had been in contact with (resident or staff wise) and just implemented every two-hour temperature checks per the nurse practitioners orders. During the interview, the DON also confirmed Resident #2 was not included on the infection control log and should have been based on his re-admission on [DATE] and symptoms. Interview on [DATE] at 3:02 P.M., with STNA #10 revealed on [DATE] he worked part of the shift on the second floor (C and D units/non-COVID units) then he went to the COVID A unit and worked until around 2:00 A.M., when his temperature spiked to 101.2. He stated he had told the facility he had been running a temperature (,[DATE].6) for the last two days prior to his shift and the scheduler told him to come to work, if his temperature was under 100.4 degrees, he could work. The STNA stated he had just recently returned from a vacation as well. The STNA revealed on [DATE] before leaving for work his temperature was 100 degrees and when he got to work it was 98.6. The STNA revealed around 2:00 A.M. his temperature was up to 101.2 degrees. The supervisor sent him home and he went to the local emergency room . He stated he tested positive for COVID-19 at the hospital and then the facility wanted him tested by the National Guard, so he was retested on [DATE]. He stated both tests came back positive. The STNA revealed he had not had any communication with management staff regarding contact tracing. He stated he recalled being in Resident #2's room on the COVID unit on [DATE] into the morning of [DATE]. STNA #10 revealed before the facility had any resident test positive for COVID-19 staff were leaving the COVID unit to chart and take breaks but this week, staff were no longer permitted to leave the unit. The STNA revealed staff were required to wear a paper mask/or homemade mask on all the units except the COVID unit until this week and now they were required to wear a mask and glasses. On the COVID unit staff were required to wear a paper mask, gown, gloves, and eye wear except for when caring for a COVID positive resident which would require a face shield in addition to the other PPE. 2. Record review revealed Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1's orders, for [DATE] revealed to monitor for signs and symptoms of respiratory infections (fever, cough, shortness of breath, fatigue, muscle and body aches, headaches, new loss of taste or smell, congestion, runny nose, sore throat, nausea, vomiting, diarrhea, and low oxygen saturation). Notify physician if new signs and symptoms every shift, if new signs or symptoms present document in the progress notes and notify physician. Review of Resident #1's medication and treatment records dated July, 2020 indicated the resident had no respiratory signs and symptoms (fever or headaches) except on [DATE], however the progress notes indicated he had complaints of headaches on [DATE]. Review of Resident #1's temperature dated [DATE] to [DATE] revealed on [DATE] the resident's temperature was 99.4 and 99.3, [DATE]- 99.1, [DATE]- 99.0 and 99.3, [DATE]- 99.1 and 99.1, [DATE]- 99.5, [DATE]- 99.0, 99.0. 99.0, [DATE]- 99.3, 99.3, 99.7, [DATE] -99.4, 99.1, 99.4, 99.4, 99.1 and [DATE]- 99.0. Review of Resident #1's progress notes dated [DATE] revealed the resident had complaints of shoulder pain. An x-ray was ordered of the shoulder and it was negative. On [DATE] the resident was not able to feed himself due to the shoulder pain. On [DATE] the resident was tested for COVID-19 due to low grade fever and complaints of headache. On [DATE] chest x-ray showed pneumonia and the resident was ordered antibiotics. There was no evidence the physician was notified of low-grade temperatures from [DATE] until [DATE]. There was no evidence the resident was on any type of isolation until [DATE] when his test results returned. Review of the facility undated investigation for Resident #1 revealed the resident resided on the third floor and had no roommate. On [DATE] the resident had a low-grade temperature of 99.3 and complaints of a headache. The resident was moved to the COVID unit (A-hall). The investigation revealed three STNA's were going to be sent for COVID testing because they had worked with Resident #1. However, there was no evidence which staff were interviewed or which staff provided care to Resident #1. Review of the infection control log dated ,[DATE] revealed Resident #1 had headache and a temperature. He was put on droplet isolation precautions on [DATE]. However, the log failed to contain documentation of the resident being tested for COVID or the results. Interview on [DATE] at 11:12 A.M., with the Director of Nursing (DON) revealed Resident #1 required two staff assistance for activities of daily living. The DON also confirmed the resident had not left his room except occasionally he would go out the nurse's station. During the interview, the DON revealed STNA #11 who tested positive for COVID on [DATE] (last worked on [DATE]) worked on the third floor (where Resident #1 resided). The DON also stated Resident #1 did have a roommate, Resident #2 who expired on [DATE]. During the interview, the DON revealed the facility had not determined how Resident #1 had contracted COVID-19 while residing in the facility. Interview on [DATE] at 8:06 A.M. and 1:22 P.M., with the Medical Director (MD), who was also Resident #1's physician revealed it was unknown where Resident #1 contacted COVID-19. It could have possibility been from his roommate, Resident #2 or the STNA who tested positive who worked on the same floor. The MD indicated he would need to work with the facility to update the policies and procedures. 3. Interview on [DATE] at 12:29 P.M. with the DON revealed the list of suspected cases and the COVID-19 testing log provided to the surveyor to review was inaccurate. There were six residents (#5, #6, #7, #8, #9 and #10) not on the log/list who should have been. Also, information was also not correct related to the number of staff on quarantine after being exposed to Resident #1. On Monday [DATE] the DON revealed she had two staff come forward and report they had direct contact with Resident #1 and the facility put these two staff members on quarantine due to their age and being high risk for COVID-19. Interview on [DATE] at 2:29 P.M., with Certified Nurse Practitioner (CNP) revealed she had concerns with the facility not using dedicated staff or wearing PPE appropriately on the COVID unit, however it had improved since a resident had tested positive. The CNP also revealed staff had been leaving the COVID unit and coming out to the nurse ' s station to type and they were not using N95 masks. She was not aware residents were not being tested for COVID before admission to the facility. She had thought Resident #2 had been tested already. She was not notified Resident #2 had a temperature and he should have been tested . She had recommended hospice services for Resident #2 due to the facility reporting he was declining. Residents with a temperature over 99 should be tested as well as anyone being discharged from the COVID unit. She stated the residents should have been quarantined after being exposed to the positive staff members. The CNP stated this weekend she started pulling the temperature logs up from home and noticed there was a few residents with temperatures greater than 99 so she called the facility and testing was ordered on those residents. She had told the DON the unit manager should be checking the temperatures logs daily and reporting anything over 99. The CNP revealed two or three week ago the MD and herself discontinued all the as needed Tylenol due to staff administering Tylenol for temperatures and not notifying them of the temperatures. She stated she had spoke to the DON and volunteered to help the facility develop new policies and procedures. Review of the facilities Coronavirus Surveillance policy dated [DATE] revealed residents would be monitored for signs and symptoms of coronavirus illness: fever, cough, shortness of breath. The physician would be notified immediately, if evident. Staff shall follow established procedures when COVID-19 is suspected. Considerations for managing residents with suspected or confirmed COVID-19 infection. Test for COVID-19 in accordance with current CDC guidelines, collaborate with local health department. Increase monitoring of all residents when COVID-19 is suspected or confirmed. Review of the facility policy from the American Health Care Association Steps to Limit COVID-19 Spread and Outbreaks in Long Term Care dated [DATE] revealed: Implement physical distancing among your staff and use source control mask (source control mask that can include cloth mask are not the same as surgical masks or N-95 and not a substitute for the use in transmission-based precautions during care.) at all time for all people in the building. Ensure symptom checks for all residents and staff. Consider checking residents for symptoms or respiratory illness and fever two or three times daily and track monitoring steps. Limit the number of different staff going into each resident ' s room and increase efficiency of tasks performed. Implement protocols for cohorting ill residents with dedicated staff. Assign staff to specific residents, and only those residents. Implement, or increase if already in place, transmission-based precautions. Staff wear all recommended PPE (gown, gloves, eye protection, N-95 or facial masks for all resident, regardless of presence of symptoms. If a resident leaves their room require them to wear a facemask, perform hand hygiene, limit movement in the facility, and use social distancing. Isolation for all residents. Review of the facility COVID-19 memo, dated [DATE] revealed a screening test should be run before running a COVID-19 test per the Corporate Medical Director. Also contact your medical director for any additional guidance specific to your facility. PPE for staff for COVID-19 positive or suspected cases include respirator or face mask, gown, gloves, and eye protection. Refer to links attached for CDC recommendations. Guidelines for staff include to stay home if you are sick. Monitoring for residents include increase monitoring to every four hours if a positive case in noted in the facility and complete a set a vital signs and respiratory assessment every ,[DATE] hours. Review of the CDC guidelines for older adults dated [DATE] revealed people at any age with, [MEDICAL CONDITIONS] and serious heart condition were at an increased risk for COVID-19. Symptoms may appear ,[DATE] days after exposure. In older adults ([AGE] years and older), normal body temperatures can be lower than in younger adults. If an older adult experiencing fever or other symptoms (headaches, fatigue, sore throat, nausea, vomiting, diarrhea, or new loss of taste or smell) and wanted to get tested , they should call their healthcare provider. If caring for a patient aged 65 or older, be aware that a single reading higher than 100.0 degrees F, multiple readings above 99 F, or rise in temperature greater than two degrees F above the patient's normal (baseline) temperature may be sign of infection. Further review of CDC guidelines revealed if you had close contact (six feet for greater than 15 minutes, direct contact (touching, hugged, or kissed) with a positive person the patient should quarantine for 14 days after the last contact day with the person. Review of the CDC health care personnel (HCP) who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset revealed: · Prioritize these HCP for [DIAGNOSES REDACTED]-CoV-2 testing. Exclude HCP with COVID-19 from work until they have met all return to work criteria. · Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. · Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED]. · Exposed HCP should be assessed for risk and need for work exclusions. · If testing is available, asymptomatic residents and HCP who were exposed to HCP with COVID-19 should be considered for testing (see information on testing below). If testing identifies infections among additional HCP, further evaluation for infections among residents and HCP exposed to those indiv (TRUNCATED)

Based on record review and staff interview, the facility failed to ensure a resident who had a decline in urinary function was assessed and evaluated for the appropriateness of a toileting program to restore as much normal bladder function as possible. This affected one (Resident #99) of one residents reviewed for bladder incontinence. Actual Harm occurred when Resident #99 declined from always continent of bladder to frequently incontinent of bladder without intervention or assessment to address continence decline. Findings include: A review of Resident #99's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #99's annual Minimum Data Set (MDS) assessment, dated 07/26/18 revealed the resident had clear speech. She was able to make herself understood and was able to understand others. Her cognition was moderately impaired. She was not known to display any behaviors and was not known to reject care. The resident required supervision with the assist of one for transfers and toilet use. The MDS was coded to show she was always continent of her bladder. A review of Resident #99's quarterly MDS dated [DATE] revealed there was no change in the resident's communication ability or her cognition. She did not have any behaviors, nor was she known to reject care. She required a limited assist of one for transfers and toilet use. The MDS indicated she was frequently incontinent of her bladder and was not on a toileting program. A review of Resident #99's bladder elimination record, used to gather information of the resident's continence status for the look back period of the quarterly MDS, confirmed the resident was incontinent bladder 12 times during that seven day look back period. The MDS was coded to reflect she was frequently incontinent of her bladder. A review of Resident #99's care plans revealed no evidence of a care plan being in place that indicated the resident was incontinent of her bladder or was on any type of toileting plan. A review of Resident #99's physician's orders [REDACTED]. The order had been in place since 08/28/18. Resident #99's medical record did not include any urinary continence evaluations since 04/20/18. A new urinary continence evaluation had not been completed after 10/22/18, when the resident was noted to have declined from being always continent to frequently incontinent of her bladder. On 11/29/18 at 2:15 P.M., an interview with the Director of Nursing (DON) revealed she could not find evidence the resident had a bladder evaluation or a bladder diary completed after 10/22/18, when the resident's urinary continence status declined from being always continent of bladder to frequently incontinent of bladder as noted on the MDS assessments. The DON acknowledged the facility should have assessed the resident's bladder status when she showed a decline. The DON acknowledged they needed to complete a bladder diary and a bladder assessment to determine the resident's type of urinary incontinence and to determine if the resident was appropriate for a toileting program. The DON indicated they were toileting her before and after meals and at bedtime, but it was not an individualized toileting program based on the resident's individualized voiding pattern as they had never done a bladder diary for the resident to determine what her individualized voiding pattern was.

Based on observation, record review and interview the facility failed to ensure the timely implementation of nutritional interventions to prevent a severe weight loss for Resident #226 and failed to ensure the resident received timely assistance with the lunch meal on 09/13/17. Actual harm occurred when Resident #226, who was assessed to sustain a severe (11.1%) weight loss within thirty days of admission, did not receive timely or adequate assistance with her meal tray to promote oral intake. This affected one resident (Resident #226) of three residents reviewed for significant/severe weight loss. Findings include: Record review revealed Resident #226 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. Record review revealed an admission weight, dated 08/08/17 that reflected the resident weighed 112 pounds. A diet order, dated 08/08/17 revealed the resident received a regular mechanical soft texture diet. A nutritional assessment, dated 08/08/17 revealed the resident's weight was 112 pounds, the resident needed assistance with meals and her estimated nutritional needs were 1275-1530 kilocalories per day, 51-66 grams of protein per day and 1530 milliliters of fluid/day. The nutritional assessment revealed a recommendation for the nutritional supplement, Med Pass 60 milliliters twice a day. On 08/09/17 an order was received for the nutritional supplement, Med pass 2.0, 60 milliliters twice a day. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/14/17 and 09/04/17 revealed the resident required extensive assistance from staff during meals. Resident #226's current care plan also indicated the resident required staff assistance during meals. Review of the resident's weights revealed on 08/14/17 the resident weighed 109 pounds, on 08/15/17 the resident weighed 104 pounds, on 08/22/17 the resident weighed 103.6 pounds and on 08/28/17 the resident weighed 101 pounds. On 09/02/17 and 09/04/17 the resident was documented to weigh 99.6 pounds, which was noted to be a 12.4 pound/11.1% severe weight loss in four weeks. On 09/04/17 an order was received for a regular diet, pureed texture with thin consistency liquids. A nutrition progress note, dated 09/06/17 revealed the resident weighed 99.6 pounds which was an 11% weight loss in one month. The note indicated the resident's diet was changed to pureed texture and her meal intakes were 54%. The note revealed the resident consumed the Med pass 60 milliliter supplement well and a recommendation was made to increase the supplement to 120 milliliters twice a day. The note failed to contain any additional information about the level of assistance required or received by the resident for meals or evidence the dietitian assessed the resident for a cause of the significant/severe weight loss. On 09/07/17 an interdisciplinary meeting was held related to the resident's significant weight loss over the previous month and hydration concerns. The notes indicated the resident's intakes varied and she accepted the med pass nutritional supplement. A recommendation was made to increase the med pass supplement at that time. There was no evidence the meeting discussed the level of assistance required or received by the resident for meals or evidence the team evaluated or determined a cause of the significant/severe weight loss. On 09/08/17, six days after the severe weight loss was identified, a new order was obtained to increase the resident's nutritional supplement to 120 milliliters twice a day. On 09/13/17 beginning at 12:00 P.M. observation of the lunch meal in the G unit dining room revealed Resident #226 received her lunch tray at 12:04 P.M. The resident was observed to attempt to eat her meal independently, without staff assistance until 12:15 P.M. when she no longer was observed eating her meal. The resident had consumed less than 25% of the meal as of that time. Two state tested nursing assistants (STNAs) were observed in the dining room assisting other residents at that time and throughout the observation. Resident #226 remained seated in front of her lunch meal with no evidence of any staff assistance being offered or encouragement provided by staff for the resident to eat her meal. At 12:43 P.M., STNA #75 removed Resident #226's lunch plate without offering any assistance to the resident. Interview with STNA #75 on 09/13/17 at 12:45 P.M. verified Resident #226 required staff assistance during meals and was not assisted or encouraged to eat. Interview with STNA #41 on 09/13/17 at 12:50 P.M. also verified Resident #226 required staff assistance during meals and was not assisted or encouraged to eat. During the interview, STNA #41 added that only two STNAs were in the dining room to provide assistance and there were more residents who required assistance with meals than two STNAs were able to assist timely. Review of the resident's meal intakes from admission through 09/13/17 revealed intakes were recorded by STNA staff. The intake records revealed the resident's intakes varied from 0-100% with an average of approximately 50% at each meal.

Based on medical record reviews, review of wound center notes, review of facility's policy, wound observations, interview with the medical director, resident and staff interviews, and interview with the wound care center staff, the facility failed to provide physician ordered treatments, accurately assess the condition of pressure ulcers, and provide interventions for pressure ulcers for four of four residents reviewed for pressure ulcers (Residents #1, #2, #3, and #4). This resulted in Immediate Jeopardy for four residents (Residents #1, #2, #3 and #4). Actual harm occurred when Resident #2 required a second surgical procedure to the coccyx due to a deterioration of a coccyx wound from treatments and interventions not being provided per physician orders. Resident #1 sustained actual harm when the facility failed to accurately identify and provide ordered treatments resulting in a decline in a coccyx wound with exposure of the resident ' s bone identified as a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). In addition, Resident #3 experienced actual harm with a decline in a coccyx pressure ulcer from a Stage III (defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling), to a Stage IV pressure ulcer that developed tunneling. Resident #4 sustained actual harm when the facility failed to accurately assess and provide treatments resulting in a deterioration of pressure ulcers on his coccyx and buttocks. The facility identified eight residents with pressure ulcers and four of the residents presented with in-house acquired pressure ulcers. The facility census was 137. On 05/12/16 at 2:40 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDO) #50, and Corporate Nurse (CN) #151 were notified Immediate Jeopardy began on 04/21/16, when Resident #2 returned from the wound center with new treatment orders to the coccyx, however, the orders were not transcribed on the treatment administration records and treatments were not completed. Resident #2 requires an additional surgical procedure (scheduled 05/26/16) to the coccyx pressure ulcer area. Resident #2 had a decline in pressure ulcers without appropriate interventions to promote healing, multiple missed treatments, and treatments not provided according to physician orders. The Immediate Jeopardy continued for Resident #1 when the facility's failure to provide physician ordered treatments resulted in the deterioration of the resident's coccyx pressure ulcer with deepening of the wound to bone exposure. The Immediate jeopardy continued for Resident #3 who experienced actual harm with a decline in a coccyx wound from a Stage III to Stage IV. Resident #4 sustained actual harm when the facility failed to accurately assess and provide treatments resulting in a deterioration of pressure ulcers on his coccyx and buttocks that required treatment outside the facility. The Immediate Jeopardy was removed on 05/16/16, when the facility implemented the following corrective actions: · On 05/12/16 at 10:00 P.M., Registered Nurse (RN) #152, Licensed Practical Nurse (LPN) #50, RN #144, and LPN #88 reviewed and updated the pressure ulcer care plans for Resident#1, Resident #2, Resident #3, and Resident #4. · On 05/12/16 at 11:00 P.M. RN #63, RN #42, RN #73, and CN#151 completed a facility wide skin sweep on 131 residents to identify skin impairments. One resident (Resident #28) of 131 refused the skin sweep. · On 05/13/16 at 12:00 A.M., RN #152, reviewed and updated care plans of all 131 residents as needed for wounds and risk for skin breakdown. · On 05/13/16 at 2:00 A.M., RN #153 and RN #154 reviewed current treatment orders for Resident #1, Resident #2, Resident #3 and Resident #4 to determine effectiveness of treatment and clarified and revised orders. · On 05/13/16 at 12:00 P.M., the DON completed an evaluation of the current pressure reducing devices being utilized on all 131 residents in the facility and care plans were updated if indicated. · On 05/13/16 at 2:00 P.M., CN #151, RN #154, and RN #133 reviewed skin care and wound supplies to ensure all supplies were available and in the cart or storage. · On 05/13/16 at 11:00 P.M., RN #153 and RN #154 provided one on one education with RN #35 with 12 additional return demonstrations. Topics of education included: dressing change procedure and completing the Norton Scale (tool used to establish a resident ' s risk for developing pressure ulcers). · On 05/13/16 at 4:00 P.M., RN #153 audited the agency training book and included a section on wound care protocols, instructions, and location of supplies. Education was provided to the four agency nurses. The four agency nurses were also included in the training plan for the facility. · On 05/13/16, a plan was implemented to observe all licensed staff on wound care by the DON with follow-up one on one education by 06/15/16. · On 05/13/16, a plan was implemented to audit treatment carts to ensure supplies were available and match orders weekly for eight (8) weeks to be completed by RN #43. · On 05/14/16 at 7:35 A.M., RN #135 provided education to 35 nurses on taking orders, noting orders, and transcribing orders as well as writing a nurses note when a new order was obtained. · On 05/14/16 at 7:35 A.M., RN #153 and RN #154 completed education to all 35 nurses (21 LPNs and 14 RNs) on skin process guidelines, wound care, pressure ulcer prevention, push tool, repositioning, and support services. · On 05/14/16 at 5:00 P.M., an audit was completed by RN #135 for 10 residents with IV therapy for accuracy, completion, and documentation. · On 05/14/16 at 9:00 P.M., LPN #114, LPN #50, the DON, RN #133, and RN #152 reviewed all 131 residents' Norton scale to establish the potential risk for skin breakdown. · On 05/15/16 at 12:30 P.M., CN #151, Regional Director of Operations (RDOO) #150, and Office Administrator #27, completed education on turning and repositioning to 55 State tested Nurse Aides (STNA), 19 LPNs, and 13 RNs. Staff not trained were removed from the schedule until training is completed. · On 05/14/16 at 7:05 A.M., interview with LPN #96, LPN #94 on 05/14/16 at 7:35 A.M., STNA #107 on 05/14/16 at 8:00 A.M., LPN #207 on 05/14/16 at 8:15 A.M., LPN #208 on 05/16/16 at 3:05 P.M., and RN #77 on 05/16/16 at 3:10 P.M., confirmed they had been in-serviced on wounds (assessment), turning and positioning, beds, and orders. · As of 05/16/16, one nurse and three STNAs had not been trained and were not on the schedule. Although the Immediate Jeopardy was removed on 05/16/16, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as all staff had not been in-serviced on skin and wound management, and the facility was in the process of implementing weekly audits to monitor for on-going compliance. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #2 was high risk for developing pressure ulcers. Review of the quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #2's cognition was moderately impaired. She was at risk for developing pressure ulcers, had a pressure reducing device for the bed, was on a turning and repositioning program, and had an open lesion. Resident #2 was identified to require extensive assist of two or more for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of a telephone order for wound care dated 04/08/16 indicated to change the coccyx wound to one inch plain packing strip twice daily. The wound was to be irrigated with normal saline, pack tunneling at 7:00 and 5:00, not too tightly and cover with ABD and [MEDICATION NAME] twice daily. Review of lab results dated 04/17/16 revealed Resident #2's wound culture to the coccyx grew Escherichia Coli and proteus mirabilis. Review of the facility's wound care notes revealed on 04/19/16 Resident #2's coccyx wound measured 0.5 cm by 0.5 cm by 0.5 cm with depth 0.6 cm at 7:00 with heavy purulent drainage. The wound was irrigated with normal saline, packed with plain packing strip, covered with ABD, and secured with [MEDICATION NAME]. Review of wound center notes dated 04/21/16 revealed orders to cleanse the coccyx wound with saline wound wash, irrigate with Dakin ' s solution, moisten gauze with quarter strength Dakin's solution, pack into any deep areas of the wound, secure with [MEDICATION NAME] tape twice daily. Review of the wound center notes indicated orders for Imipenem-clilastatin (antibiotic) intravenous. Further review revealed an appointment was scheduled on 04/28/16 with an infectious disease doctor regarding a culture report. The wound center note identified the coccyx wound measured 0.5 centimeter (cm) by 0.5 cm by 1.2 cm with a large amount of serous drainage and a small amount of necrotic (dead) tissue. Further review revealed a peripherally inserted central catheter (PICC) line was inserted on 04/21/16. Review of telephone orders dated 04/23/16 revealed Imipenem-cilastatin via PICC line every 8 hours until further notice. Review of the wound center notes dated 04/26/16 revealed additional notes to turn the resident every two hours, physician office will schedule appointment of surgery, and to continue current treatment of [REDACTED]. Review of the April 2016, Medication Administration Record [REDACTED]. There was no documented evidence the medication was administered on 04/28/16 at 4:00 P.M., or 04/29/16 and 04/30/16 at midnight. Review of the May 2016, MAR indicated [REDACTED].M., 05/04/16 at 8:00 A.M. and 05/05/16 at midnight. The medication was discontinued on 05/07/16 at 4:00 P.M. Review of the April 2016, Treatment Administration Records (TAR) revealed new orders were received on 04/09/16 to irrigate the coccyx wound with normal saline, pack tunneling at 7:00 and 5:00 with one inch plain packing strip, do not pack tightly, and cover with ABD and [MEDICATION NAME] twice daily. Further review revealed Resident #2 had 17 treatments not documented as completed from 04/09/16 to 04/30/16. Review of additional pressure interventions listed on the TAR included out of bed to chair for one hour daily, turn and reposition every two hours and as needed, float heels while in bed, may sit up in chair, no pressure to wound limited to one hour at a time, and Dolphin bed (fluid immersion bed used to offload pressure) for ulcer care. Review of 05/03/16 facility wound notes revealed the wound was irrigated with prescription concoction, packed with plain packing strip, moistened with same concoction, covered with dry dressing, and secured with [MEDICATION NAME]. The wound dressing was to be changed twice daily. There was no documentation to explain what was in the concoction. Review of the May 2016, TAR revealed treatment to irrigate the coccyx wound with normal saline, pack tunneling at 7:00 and 5:00 with 1 inch plain packing strip, do not pack tightly, and cover with ABD and [MEDICATION NAME] twice daily. Further review revealed Resident #2 had 14 treatments not documented as completed from 05/01/16 to 05/11/16. Review of the care plan conference summary dated 05/02/16, revealed Resident #2 and her family member had reported to RN #73 and Social Service #66 that her wounds were not getting changed, not getting incontinence care frequently, not getting turned every 2 hours, and not getting up for one hour a day. Review of a telephone order dated 05/09/16, revealed Resident #2 was scheduled for surgery of the coccyx on 05/26/16. Nurse's notes revealed on 05/10/16, Resident #2's coccyx wound had a foul odor and moderate amount of sero-sanguanious drainage. There was no evidence the physician was notified. Interview with LPN #202 on 05/10/16 at 3:45 A.M., revealed treatments were not being done after the wound care nurse left the building as the staff did not have access to the treatment cart. The wound nurse was the only one with keys. LPN #202 confirmed she had reported concerns regarding keys not being available and treatments not being done. LPN #202 verified she was unable to provide treatment to Resident #2 and five other residents the previous night because she did not have access to their supplies. On 05/11/16 at 2:15 P.M., observation of Resident #2's dressing change with RN #35 revealed the un-dated dressing was removed and a large amount of thin tan drainage was noted on the old dressing. RN #35 moistened 4 X 4 gauze with Dakin's solution and cleansed the outside of the wound. The wound continued to drain thin tan drainage. RN #35 soaked plain packing with Dakin's solution; balled up packing, placed it in the wound on the coccyx, and covered it with a dressing. There was no evidence the wound was irrigated with Dakin's solution or the wound was packed as ordered. Interview with Resident #2 on 05/11/16 at 2:00 P.M., revealed staff did not change her dressing to the coccyx or turn her every two hours. Resident #2 reported she had gone three days without having the dressing changed to her coccyx and had to lay in urine for hours. Resident #2 reported she had to have another surgery to her coccyx due to staff not turning her every two hours or changing her dressing per orders. Interview with RN #35 on 05/11/16 at 2:30 P.M., verified new treatment orders for Resident #2 for Dakin's solution were received from the wound care center on 04/21/16 and were not transcribed and were not completed. RN #35 verified it was the floor nurse ' s responsibility to take the orders off the wound care center notes and write them on a telephone order and transcribe the new orders on the TAR. RN #35 verified she did not irrigate the coccyx wound or pack the tunneled area during the wound care observation on 05/11/16. RN #35 verified she had observed Resident #2's dressing and there had been times it had not been changed every day. RN #35 verified she did not confirm the treatment orders prior to administering treatment to Resident #2's coccyx; however, she stated she had recalled reading the 04/26/16 orders from the wound care center. Interview with Wound Center RN (WCRN) #201 on 05/12/16 at 9:14 A.M., revealed they recently had concerns with the facility. WCRN #201 reported concerns with treatment orders and turning not being performed. WCRN #201 reported most residents were ordered treatments twice daily and the wound center staff hoped the facility at least provided treatments once daily. WCRN #201 stated she spoke to the wound center physician and he had reported he could not pinpoint Resident #2's decline in the coccyx wound; however, contributing factors for decline would be not providing treatments per orders and not turning the resident every 2 hours. Interview with the facility's Medical Director on 05/13/16 at 9:05 A.M., revealed he was aware of concerns with pressure ulcers and especially with Resident #2's dressing not being performed according to his orders. He stated he was aware of concerns staff were not using the Dolphin bed correctly. Interview with Visitor #200 (Resident #2's family member) on 05/13/16 at 12:40 P.M., revealed she had voiced concerns with the facility regarding Resident #2 not being turned every two hours and the dressing on the coccyx not being changed. Visitor #200 had reported Resident #2's dressing had not been changed for up to two days at a time and her IV antibiotics were not supposed to be stopped until June 4th. Visitor #200 reported the facility was short on staff and it was the worst care she had ever seen. Visitor #200 reported she had called the ombudsman and they had been investigating her concerns. Interview with the DON on 05/13/16 at 1:30 P.M., verified Resident #2 was ordered the Imipenem-cilastatin on 04/23/16 every 8 hours until further notice. The DON verified there was not an order to discontinue the Imipenem-cilastatin and the staff stopped it on 05/06/16. The DON verified according to the MAR, Resident #2 had missed multiple doses of the antibiotic. The DON verified the physician was notified and new orders were received to continue the Imipenem-cilastatin for four more weeks. Interview with RN #205 on 05/16/16 at 12:25 P.M,. revealed the facility called the infectious disease physician office and had progress notes from the 04/28/16 visit faxed to confirm Resident #2 was to continue the IV antibiotics for six more weeks for the infected sacral wound. 2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was identified as a high risk for developing pressure ulcers. Review of Resident #1's quarterly MDS dated [DATE], revealed the resident was cognitively intact, at risk for developing pressure ulcers, had one Stage II pressure ulcer (defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister), and had pressure relieving devices, turning and repositioning program, pressure ulcer care, and nutrition interventions. Further review revealed Resident #1 required extensive assist of two or more for bed mobility, dressing, toileting, and personal hygiene. Review of wound center notes dated 04/26/16, revealed Resident #1 had a Stage III pressure ulcer on the right lower leg, Stage IV pressure ulcer on the coccyx with bone exposure, and Stage II ulcer on the left gluteal fold. Further review revealed orders to cleanse the coccyx and left gluteal fold with saline, apply solosite gel to the base of the wound, apply saline wet to dry dressing and secure with [MEDICATION NAME] twice daily. Record review revealed orders not to remove the wound vac. The wound vac dressing was changed by wound care center staff only. Review of the facility wound care notes dated 01/20/16 to 05/06/16 revealed Resident #1 had a Stage II pressure ulcer to the coccyx and no evidence of pressure areas on the right leg or left gluteal fold. Review of the April 2016, TAR indicated to cleanse the coccyx and left gluteal wounds with soap and water, apply solosite gel and gauze moistened with normal saline, cover with dry gauze, and border foam twice a day. Further review revealed 10 treatments to the coccyx and nine treatments to the left gluteal fold were not documented as completed in April, 2016. Review of the May 2016, TAR revealed Resident #1 had five treatments to the coccyx, and four treatments on the left gluteal fold not documented as completed. Review of Resident #1's laboratory results dated [DATE], revealed the coccyx wound culture grew pseudomonas aeruginosa and Escherichia coli. Review of orders dated 05/04/16, revealed to administer [MEDICATION NAME] (antibiotic) IV 3.375 gram every six hours for seven days via PICC line. Review of Resident #1's May 2016, MAR indicated [REDACTED]. Interview with RN #35 on 05/11/16 at 1:00 P.M., verified she was responsible for measuring and staging pressure ulcers in the facility. She verified she had the coccyx pressure ulcer for Resident #1 staged as a Stage II pressure and bone exposure was noted. RN #35 verified she did not have the area on the right leg or left gluteal fold identified as pressure ulcers. RN #35 confirmed Resident #1 had several missed treatments to the coccyx and left gluteal fold for both April and May 2016. RN #35 verified the wound center did not permit the facility to change the wound vac on Resident #1's right leg. RN #35 verified the wounds were acquired in the facility. Observation of wound care for Resident #1 with LPN #20 on 05/12/16 at 8:10 A.M. revealed LPN #20 was unable to find Resident #1's solosite gel and she was going to use a solosite dressing instead on the pressure ulcers on the coccyx and left gluteal fold. LPN #20 verified the treatment cart was locked and she did not have keys to access the cart. LPN #20 verified the resident ' s bone was exposed on the coccyx pressure ulcer and there was a scant amount of thick purulent drainage noted on the old dressing. The wound on the left gluteal fold had 90% slough noted to the wound bed. The wound had an odor and blood was noted on the old dressing. Resident #1 reported staff took all his supplies out of his room that morning due to State was in. LPN #20 spoke to the unit manager after the dressing was reapplied and they found a large white trash bag filled with treatment supplies in the unit manager's office under the desk. LPN #20 affirmed Resident #1's solosite gel was in the bag. Interview with WCRN #201 on 05/12/16 at 9:14 A.M., verified not turning and repositioning and not providing wound care per orders could have contributed to Resident #1's wound decline. Interview with the DON on 05/13/16 at 1:30 P.M., verified Resident #1's May 2016, MAR indicated [REDACTED]. 3. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the pressure ulcer risk assessment dated [DATE] revealed Resident #3 was at moderate risk for developing pressure ulcers. Review of Resident #3's comprehensive MDS assessment dated [DATE], revealed the resident was severely cognitively impaired, at risk for developing pressure ulcers, and had a Stage III pressure ulcer measuring 2.0 cm by 2 .8 cm by 0.2 cm with slough. Resident #3 was receiving pressure reducing devices to the bed and chair, turning and repositioning, and pressure ulcer care. Further review revealed Resident #3 required extensive assist of two or more for bed mobility, transfers, dressing, toileting and personal hygiene. Review of Resident #3's wound notes dated 12/15/15 to 05/09/16, revealed Resident #3 had an in-house acquired Stage III pressure area to the coccyx. Further review revealed the area measured 1.0 cm by 1.5 cm by 0.2 cm on 05/09/16. The wound notes revealed the wound was cleansed with saline wound wash, medi-honey to the wound bed, and covered with a bordered foam dressing. Further review of the wound notes revealed medi-honey was applied to the wound from 03/07/16 to 05/09/16. Review of the March 2016, monthly orders revealed an order for [REDACTED]. Review of Resident 3's TARs for April and May 2016, revealed treatments were indicated despite having no physician order. Review of Resident #3's April 2016, TAR revealed to change wound dressing to coccyx daily, cleanse with normal saline apply medi-honey to wound bed and cover with foam dressing. Further review revealed three treatments were not documented as completed in April 2016. The TAR indicated three treatments were not documented as completed between 05/01/16 to 05/09/16. Interview with RN #35 on 05/11/16 at 12:35 P.M., verified Resident #3 had missed treatments to the coccyx in April and May 2016. RN #35 confirmed there was no current order for treatment to Resident #3's coccyx wound since March 2016. Observation and interview with LPN #5 on 05/12/16 at 10:56 A.M,. revealed she was going to perform a treatment to Resident #3's coccyx using medi-honey. LPN #5 verified there was no order for the medi-honey or any evidence of orders for treatment to the coccyx. Observation and interview with RN #35 on 05/12/16 at 11:30 A.M., revealed the wound on the coccyx had declined from the wound measurement notes from 05/09/16. Resident #3's coccyx wound had an open area in the center of the wound measuring 0.2 cm by 0.4 cm by 0.5 cm with tunneling at 6:00. Resident #3 yelled ouch when RN #35 applied pressure on the area. RN #35 verified the area had deteriorated. RN #35 stated she would call the physician to receive new orders. Review of the pressure ulcer tracking form dated 05/13/16, revealed Resident #3's coccyx wound had further declined to a Stage IV with the tissue type identified as slough. Measurements included length 1.5 cm, width 1.8 cm, and depth 1.0 cm. A moderate amount of serous exudate was note. The surrounding skin was intact. 4. Review of Resident #4's medical record revealed the resident was originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #4's pressure ulcer risk assessment dated [DATE] revealed the resident was at moderate risk for development of pressure ulcers. Review of Resident #4's quarterly MDS dated [DATE], revealed the resident was cognitively intact, at risk for developing pressure ulcers, had one Stage III pressure ulcer measuring 16 cm by 52 cm by 0.3 cm with granulation tissue. Resident #4 had pressure reducing devices, turning and repositioning program, pressure ulcer care and nutrition interventions. Resident #4 required extensive assist of two or more with bed mobility, toilet use, and personal hygiene. Review of Resident #4's May 2016, monthly orders revealed to apply medi-honey to coccyx and left buttocks, cover with border foam dressing, change daily and as needed. Further review revealed to apply liberal amount of medi-honey to the left hip crease and back, cover with a dry gauze dressing and change daily as needed. Review of Resident #4's May 2016, TAR revealed treatments for the coccyx, left buttocks, and left hip/lower back were not documented as administered from 05/06/16 to 05/10/16. Review of Resident #4's facility wound measurements dated 04/18/16 and 04/25/16, revealed Resident #4 had a Stage III pressure ulcer to left buttocks. The width was 52.0 cm. The measurement prior to and after those dates indicated the width of the area was 16-28 cm. Further review revealed from 02/17/16 to 05/09/16, the wounds were cleansed with saline wound cleanser and Xeroform was applied to multiple areas, and then covered with border foam dressing. Observation of Resident #4 on 05/11/16 at 3:00 P.M., revealed the resident had a large open area from the coccyx area to the left hip with bridges of healed areas. The open area on the coccyx had a macerated area/slough. RN #35 cleansed the wounds and applied Xeroform dressing to the areas. There was no evidence medi-honey was applied. RN #35 affirmed she applied Xeroform to all the open areas and covered with a dressing. Interview with RN #205 on 05/16/16 at 1:00 P.M., verified Resident #4 had undated orders for wound care to left buttocks, coccyx, left hip crease, left lower back, and left upper back. RN #205 verified the entire wound was measured as one wound under the left buttocks and the measurements were inaccurate on 04/18/16 and 04/25/16. RN #205 verified Resident #4's treatments were not performed from 05/06/16 to 05/10/16 to the left buttocks, coccyx, left hip crease, left lower back, and left upper back. Review of the pressure ulcer treatment policy dated 03/23/11, revealed the pressure treatment program should focus on assessing the residents pressure ulcer, managing tissue loads, pressure ulcer care, managing bacterial colonization and infections, operative repair of the pressure ulcers, and education and quality improvement. Further review revealed to document in the medical record any changes in the resident ' s condition, all assessment data when inspecting the wound, resident's refusal, and notifying the supervisor of any resident refusals. This deficiency substantiates Complaint Number OH 241.

Based on review of self-reported incident (SRI), SRI investigation, medical record review, staff interview and resident interview, the facility failed to ensure one resident (Resident #26) was not physically restrained during assessment of vital signs. Actual harm occurred when State tested Nurse Aide (STNA) #301 laid across Resident #26 holding down her arms, and STNA #300 held the resident's legs while attempting to obtain a blood pressure and the resident complained of pain from the incident. This affected one of three residents reviewed for abuse (Resident #126). The facility census was 137. Findings included: Review of Resident #126's history and physical dated 03/30/16 revealed [DIAGNOSES REDACTED]. Further review revealed Resident #126 had a Peripherally Inserted Central Catheter (PICC) line in right upper arm. Review of an SRI dated 04/30/16, revealed Resident #126 reported on 04/30/16 to two visitors, that STNAs #300 and #301 held her down and attempted to take her blood pressure after she told them no due to having a PICC line in her arm and a double [PROCEDURE]. Resident #126 reported she yelled out for help and STNA #75 came into the room and they stopped. Further review revealed STNAs #300 and #301 were terminated. Interview with Resident #126 on 05/11/16 at 12:45 P.M, revealed STNA #301 put her body across her (the resident) and held both arms down. STNA #300 stood at the bottom of the bed. STNA #300 asked STNA #301 what was she doing and she responded she was holding her down to put the blood pressure cuff where she wanted it. Resident #126 reported she felt threatened and scared at the time of the incident due to having a PICC line and double [PROCEDURE]. Resident #126 affirmed she was never to have her blood pressure taken in her arms. Resident #126 stated after the incident staff hung a sign above her bed stating only to apply the blood pressure cuff to her ankles. Review of Resident #126 statement dated 04/30/16 corroborated information in the surveyor's interview. Further review revealed Resident #126 was complaining of arm pain and x-ray of the right arm was ordered. Review of STNA #300's statement dated 04/30/16 revealed only that he was in training and he reported he just stood at the foot of the bed and observed his trainer. There were no details regarding the incident except the resident became combative and verbally abusive. Review of STNA #75's statement dated 05/02/16 revealed she heard two STNAs yelling at Resident #126 that they had to get her vitals done. STNA #75 reported STNA #301 was holding the resident's arms down crossed over each other and STNA #300 was holding her legs down. STNA #75 reported she told them that if the resident refused to have her vital signs taken that was her right. STNA's #300 and #301 then left the room. Review of License Practical Nurse (LPN) #45's undated statement revealed staff reported on 04/27/16 not 04/25/16 that Resident #126 had refused vital signs and became combative and verbally abusive. LPN #45 reported Resident #126 required vital signs due to an unwitnessed fall on 04/27/16 at 11:30 P.M. Review of Resident #126's nurse notes dated 04/27/16 revealed no evidence the resident was combative, verbally abusive, or refusing care. Review of x-ray report dated 05/01/16 revealed no acute abnormalities. Interview with the Administrator on 05/11/16 at 10:50 A.M., revealed after the investigation was complete it was determined the incident actually occurred on 04/27/16. The Administrator affirmed STNA's #300 and #301 involved in the incident were terminated for not respecting the resident's request. STNA #75 was verbally disciplined for not reporting the incident. This deficiency substantiates Complaint Number OH 244.