Every finding on record at Arbors at Milford

Based on observation and staff interview, the facility failed to properly store food. This had the potential to affect 65 facility-identified residents of 69 who consumed food prepared in the facility kitchen. The facility census was 69 residents.Findings include: 1.Observation of dry storage area on 03/09/26 at 6:23 A.M. revealed there were three containers of cereal with ill-fitting lids which left the cereal open to air. There was also a bag of rice which was unsealed and open to air. Interview on 03/09/26 at 6:24 A.M. with the Assistant Kitchen Manager (AKM) confirmed the cereal and rice were open to air and should be discarded. 2.Observation of the walk-in freezer on 03/09/26 at 6:45 A.M. revealed it included a box of Salisbury steak patties in an unsealed bag which was unsealed and open to air and a box containing cookie dough balls in a bag that was unsealed and open to air. Interview on 03/09/26 at 6:46 A.M. with the AKM confirmed the Salisbury steak patties and cookie dough were open to air and should be discarded. 3.Observation of walk-in refrigerator on 03/09/26 at 7:07 A.M. revealed there was a tray of individual cups of apple juice dated 03/08/26 and a tray of individual cups of orange juice had no date on the cups or on the tray. Interview on 03/09/26 at 7:08 A.M. with the AKM confirmed the apple juice was expired and should be discarded, and the orange juice was not dated so there was no way to determine if it was expired or not.

Based on record review and staff interview, the facility failed to complete annual performance reviews for Certified Nursing Assistants (CNAs.) This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents.Findings include: 1.Review of the employee file for Certified Nursing Assistant (CNA) #228 revealed a hire date of 09/14/22. CNA #228's employee file did not include an annual performance review. 2.Review of the employee file for CNA #229 revealed a hire date of 12/19/18. CNA #229's employee file did not include an annual performance review. Interview on 03/12/26 at 7:36 A.M with the Administrator confirmed the facility had not completed annual performance reviews for CNAs #228 and #229.

Based on medical record review, observation, review of Self-Reported Incidents (SRIs), staff interview, resident interview, and review of the facility policy, the facility failed to ensure residents were free from emotional/verbal abuse. This affected one (Resident #67) of three residents reviewed for abuse. The facility census was 69 residents. Findings include:Review of the medical record for Resident #67 revealed an admission date of 10/29/25 with diagnoses including generalized anxiety, major depressive disorder, and insomnia. Review of the Minimum Data Set (MDS) assessment for Resident #67 dated 02/05/26 revealed the resident was cognitively intact and used a motorized wheelchair for mobility. Review of the nurse progress note for Resident #67 dated 02/24/26 per Registered Nurse (RN) #219 revealed the resident requested to go to the hospital because she could taste soap in her mouth. Resident #67 reported she had used vaginal soap to eliminate odors after others had complained about her smell and posted about it on Facebook. RN #219 notified management and social services of Resident #67's statements. Observation of an online video titled Folgers Incest Commercial at https://youtu.be/fhfcWTZeP1k?si=0Ezm5vlOUgDAHx87 revealed the video depicts a coffee commercial in which a brother and a sister are drinking coffee together and are confronted by their parents who accuse them of having romantic feelings for one another and of having a sexual relationship. A family argument ensues and the siblings reveal they are having a sexual relationship and they intend to get married. Review of the facility SRI dated 02/24/26 revealed the facility investigated an allegation of emotional/verbal abuse towards Resident #67 per [NAME] #322 wherein the employee was friends on Facebook with the resident and sent her a video with Facebook which had themes involving incest-the YouTube video titled Folgers Incest Commercial. Resident #67 reported feeling emotionally upset by the video. The facility's investigation revealed [NAME] #322's actions were emotionally abusive and upsetting to Resident #67, and the facility substantiated abuse had occurred. The facility terminated [NAME] #322 and in-serviced all staff on the abuse policy and the social media policy. Interview on 03/10/26 at 2:35 P.M. with the Director of Nursing (DON) confirmed Resident #67 reported on 02/24/26 she was upset because she had heard [NAME] #332 had made a statement that the resident smelled like tuna. Resident #67 confirmed she was friends on the social media website Facebook with [NAME] #332. Resident #67 stated [NAME] #332sent her the YouTube video entitled Folgers Incest Commercial via Facebook. Resident #67 confirmed she found the video [NAME] #332 sent to be upsetting because of her personal history of sexual abuse as a child. The DON further confirmed the facility's investigation revealed [NAME] #332 admitted he was friends with Resident #67 on Facebook and he had sent her the video which the resident found to be emotionally triggering. Interview on 03/10/26 at 2:40 P.M. with the Administrator confirmed the facility's investigation revealed [NAME] #332 had admitted he was friends on Facebook with Resident #67 and he had sent the video titled Folger's Incest Commercial to the resident. Interview on 03/11/26 at 1:16 P.M. with Resident #67 confirmed she was Facebook friends with [NAME] #332, and he sent her a YouTube video titled Folgers Incest Commercial, and she found it upsetting and triggering because her father and brother had sexually abused her when she was a child. Interview on 03/12/26 at 9:36 A.M. with [NAME] #322 confirmed he had been Facebook friends with Resident #67 when he worked at the facility. [NAME] #332 stated he did send the YouTube video titled Folgers Incest Commercial via Facebook to Resident #67, because he thought it was funny. [NAME] #332 stated the video was from a comedy skit performed on the television show, Saturday Night Live. [NAME] #332 stated he was unaware of Resident #67's sexual abuse history and he did not intend to upset her by sending the video. [NAME] #332 stated Resident #67 told him she was upset because she had heard he made a statement about her having body odor. [NAME] #332 confirmed he never made a statement about Resident #67 having body odor and he told the resident he had not done so. Review of facility policy titled Social Media dated 04/04/17 revealed that the company respected the desire of employees to use social media for expression, but employees should refrain from trying to connect with residents and resident family members through the use of personal social media. This violation represents noncompliance investigated under Complaint Number 2795466 and Complaint Number 2630244 and Complaint Number 2615289 and Complaint Number 2611017.

Based on medical record review and staff interview, the facility failed to hold quarterly care conferences for residents. This affected two (Residents #1 and #7) of 17 residents sampled. The facility census was 69 residents. Findings include: 1.Review of the medical record for Resident #7 revealed an admission date of 02/09/24 with diagnoses including acute osteomyelitis of right ankle and foot, epilepsy, end stage renal disease, type two diabetes mellitus, and systolic and diastolic heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 02/13/26 revealed the resident had intact cognition. Review of the medical record for Resident #7 revealed the only care conference documented for Resident #7 from March 2025 to March 2026 was held on 12/11/25. Interview with the Social Services Designee (SSD) on 03/11/26 at 11:21 A.M. confirmed the facility had held only one care conference for Resident #7 from March 2025 to March 2026, and the care conference was held on 12/11/25. 2.Review of the medical record for Resident #1 revealed an admission date of 12/26/23 with diagnoses including multiple sclerosis, osteomyelitis of vertebra, generalized anxiety disorder, and neuromuscular dysfunction of the bladder. Review of the MDS assessment for Resident #1 dated 02/06/2026 revealed the resident had intact cognition. Review of the medical record for Resident #1 revealed the only care conference documented for the resident from March 2025 to March 2026 was held on 09/16/25. Interview on 03/11/26 at 11:22 A.M. with the SSD confirmed the facility had held only one care conference for Resident #1 from March 2025 to March 2026, and the care conference was held on 09/16/25. The SSD confirmed resident care conferences should be held quarterly.

Based on medical record review, review of medication error logs, staff interview, observation, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected two (Residents #69 and #42) of 17 sampled residents. The facility census was 69 residents. Findings include: 1.Review of the medical record for Resident #42 revealed an admission date of 12/02/24 with diagnosis including end stage renal disease, diabetes, and osteomyelitis. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 12/18/25 revealed the resident was cognitively intact. Review of the physician's orders for Resident #42 revealed an order dated 01/04/26 for Cubicin 700 milligrams (mg) per intravenous (IV) administration every other day for 34 days for treatment of an abdominal abscess. Review of the medication error log revealed the facility had a medication error involving Resident #42 on 01/28/26. Interview on 03/12/26 at 10:15 A.M. with the Director of Nursing (DON) on 01/27/26 staff administered Cubicin 500 mg per IV to Resident #42. The DON stated the nurse gave Resident #42 the wrong dose of Cubicin, a bag of IV medication that was intended for another resident. The nurse recognized the error on 01/28/26 at 8:44 A.M. after the bag of Cubicin had been completely administered to Resident #42 and she saw the other resident's name on the IV bag. Interview on 03/10/26 at 4:17 P.M. with Resident #42 confirmed the facility told her there had been a medication error in January 2026 in which she had not received the full dose of Cubicin. Review of the facility policy titled Medication Administration dated 01/17/23 revealed that licensed nurses were to identify resident by photo in the Medication Administration Record (MAR) and to compare the medication source with MAR to verify resident name, medication name, form, dose, route and time of administration. 2.Review of the medical record for Resident #69 revealed an admission date of 01/23/26 with diagnoses including acute and chronic respiratory failure, polyneuropathy, and anxiety disorder. Review of physician's orders for Resident #69 revealed an order dated 01/31/26 for routine oxycodone 10 mg every four hours for pain to be administered at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of the MAR for Resident #69 dated 03/09/26 revealed the staff administered the resident's 8:00 A.M. dose of oxycodone at 11:18 A.M. Observation of medication administration on 03/12/26 at 10:05 A.M. to Resident #69 per Licensed Practical Nurse (LPN) #263 revealed the nurse administered the resident's 8:00 A.M. dose of oxycodone at 10:05 A.M. Interview on 03/12/26 at 10:10 A.M. with LPN #263 confirmed he had administered Resident #69's 8:00 A.M. dose of oxycodone at 10:05 A.M. LPN #263 further confirmed it was permissible to administer medications one hour before or after the due time, but Resident #69's medication was late. Interview on 03/12/26 at 1:57 P.M. with Regional Nurse (RN) #316 confirmed staff administered Resident #69's oxycodone late on 03/09/26 and again on 03/12/26. Review of the facility policy titled Medication Administration dated 01/17/23 revealed medications should be administered within 60 minutes prior to or after scheduled time. This deficiency represents noncompliance investigated under Complaint Number 2729892 and Complaint Number 2709832 and Complaint Number 2616693.

Based on record review, review of facility Self-Reported Incidents (SRIs), resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff spoke to residents in a respectful manner. This affected one resident (Resident #61) of three residents reviewed for dignity and respect. The facility census was 69 residents.Findings include: Review of the medical record for Resident #61 revealed an admission date of 12/03/20 with diagnoses including spinal muscular atrophy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and type two diabetes. Review of the nurse progress note for Resident #61 dated 11/05/25 per Licensed Practical Nurse (LPN) #247 revealed a Certified Nursing Assistant (CNA) had not treated the resident in a respectful manner. Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 01/08/26 revealed the resident was cognitively intact and required moderate to maximal assistance with staff for all activities of daily living (ADLs). Review of the facility SRI regarding Resident #61 dated 11/05/25 revealed the resident made an allegation of abuse per CNA #204. The facility's investigation determined abuse had not occurred. Interview on 03/09/26 at 8:31 A.M. with Resident #61 confirmed he didn't want CNA #204 to care for him anymore. Resident #61 stated he had complained to management about the way CNA #204 had treated him and he hadn't seen her since he reported his concerns. Interview on 03/11/26 at 1:40 P.M. with the Director of Nursing (DON) confirmed Resident #61 had complained about CNA #204 on 11/04/25 and the facility initiated a SRI and investigated the resident's concern. The DON stated the facility did not substantiate abuse, but did determine CNA #204 had spoken to Resident #61 in a disrespectful manner. The DON stated the facility gave CNA #204 a verbal warning and removed her from caring for Resident #61. Resident #61 had complained he asked CNA #204 if she was ignoring him and the aide responded that she was ignoring him. The DON confirmed CNA #204 admitted Resident #61's account of the incident was correct. This deficiency represents noncompliance investigated under Complaint Number 2796448 Complaint Number 2727533 and Complaint Number 2719129 and Complaint Number 2630244

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a hospital record, staff interview, review of the facility investigation, and policy review, the facility failed to ensure the physician or nurse practitioner was notified timely of a significant change in condition for a resident (#70). This resulted in Immediate Jeopardy and serious life-threatening harm, injuries, and/or death when on [DATE] at 7:46 P.M., Resident #70 was found to have elevated blood glucose levels by a nurse and after notification to the nurse practitioner, additional insulin was ordered, which the resident refused. The nurse did not make notification to the nurse practitioner or physician of the resident's refusal of additional insulin and no additional checks of the resident's blood glucose level were attempted. Resident #70 was later found on the floor, was not answering questions, but was able to move all extremities, and the right side of the resident's face was slightly swollen. Furthermore, the nurse did not complete a neurological assessment of the resident, and no notifications were made to the physician or nurse practitioner of the resident's change in condition. Resident #70 was found later the next morning on [DATE] at 2:42 A.M. with bluish-colored skin tone, abdominal breathing, an extremely edematous head, and was not responding to verbal or physical stimuli. The lack of notification to the physician or nurse practitioner contributed to Resident #70's untimely death when the resident was taken to the emergency department, was found to have a further elevated blood glucose level, was diagnosed with acute encephalopathy, with multiple metabolic/infectious abnormalities, acute metabolic acidosis, and ultimately died . This affected one (#70) of three residents reviewed for change in condition and notification. The facility census was 72. On [DATE] at 9:03 A.M., Regional Director of Operations #199 and Regional Director of Clinical Operations (RDCO) #595 were notified that Immediate Jeopardy began on [DATE] at 7:46 P.M. when Resident #70's blood glucose level measured 583 milligrams per deciliter (mg/dL) and previous Director of Nursing (DON) #395 notified the nurse practitioner of the elevated blood glucose level. The nurse practitioner ordered additional insulin which the resident refused, and previous DON #395 did not make notification to the nurse practitioner or physician of the resident's refusal of additional insulin and no additional checks of the resident's blood glucose level were attempted or documented in the medical record. Resident #70 was found on the floor on [DATE] at 2:42 A.M. and was not answering questions, but was able to move all extremities, and the right side of the resident's face was slightly swollen. Previous DON #395 did not complete a neurological assessment of the resident, and no notifications were made to the physician or nurse practitioner of the change in condition. On [DATE] at 7:15 A.M., Licensed Practical Nurse (LPN) #155 entered Resident #70's room to check the resident's blood glucose level and administer insulin and found Resident #70 in bed with bluish-colored skin tone, abdominal breathing, an extremely edematous head, and the resident was not responding to verbal or physical stimuli. A medical code was initiated by facility and emergency medical services (EMS) arrived at the facility and transported the resident to the hospital. At the hospital, Resident #70 was noted to have a blood glucose level greater than 784 mg/dL and had diagnoses of acute encephalopathy, with multiple metabolic/infectious abnormalities, and acute metabolic acidosis. Resident #70 ultimately died on [DATE]. The Immediate Jeopardy was removed on [DATE] at 4:00 P.M., when the facility sent Resident #70 to the ED for treatment following a change in condition, notification was made to the physician, the facility began an investigation, previous DON #395 was suspended, all residents were assessed for change in condition with all concerns addressed immediately, all staff members were educated, and all medical records were reviewed for change in condition and blood glucose levels with no concerns identified. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 7:32 A.M., Resident #70 was sent to the ED with notification made to the physician. On [DATE] beginning at 10:00 A.M., Previous Administrator #495 and Minimum Data Set (MDS) Nurse #146 reviewed the 24-hour report and self-identified a concern with Resident #70's refusal of an order for 16 units of insulin on [DATE] at 7:46 A.M. and failure to notify the physician/nurse practitioner during morning clinical meeting. This concluded at 12:00 P.M. On [DATE] at 12:00 P.M., Previous Administrator #495 and RDCO #595 obtained statements and conducted interviews with LPN Unit Manager #600, Medication Technician #127, LPN #130, LPN #155, Respiratory Therapist (RT) #82, Certified Nurse Aide (CNA) #605, RT #124, CNA (#610), and previous DON #395. This concluded at 9:00 P.M. On [DATE] at 2:30 P.M., RDCO #595 was notified by Previous Administrator #495 of the situation that involved Resident #70 and arrived at the facility at approximately 5:00 P.M. to assist with the investigation. On [DATE] at 8:00 P.M., Registered Nurse (RN)/Staff Development Coordinator (SDC) #375 assessed all residents who had a recent fall and completed a neurological check. There were no residents found with a neurological change in condition. On [DATE] at 9:00 P.M., LPN #116, LPN #146, RDCO #595, and LPN #600 assessed all residents for a change in condition. There were no residents found with a change in condition. On [DATE] at 9:30 P.M., Previous Administrator #495 suspended previous DON #395 pending investigation for his failure to notify Nurse Practitioner (NP) #195 of Resident #70's refusal to be administered insulin as ordered by the nurse practitioner and subsequent change in condition. Previous DON #395 was terminated from employment on [DATE]. On [DATE], RN/SDC #375 provided all nurses, medication technicians, and CNAs with education related to fall assessment protocols, notification of physicians for resident change of condition, the importance of initiating treatment, the importance of rounding every two hours, the importance of obtaining neurological checks when it was suspected the resident had a head injury and/or was on blood thinners, and the importance of initiating the risk management application in the electronic medical record. All staff were educated by [DATE]. On [DATE] at 10:00 A.M., RDCO #595 and previous Administrator #495 notified facility Medical Director #995 of the incident and reviewed the policy and procedure for change in condition/notification of change. There were no revisions made to the policy. The root cause analysis identified failure to follow facility policy for notification to a physician by previous DON #395 as the primary cause for Resident #70's deteriorating change in condition. On [DATE] at 10:00 A.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with previous Administrator #495, RDCO #595, and Medical Director #995. The policy for change in condition/physician notification was reviewed with no recommended revisions. The result of the facility's root cause analysis (RCA) was reviewed and the staff completed education was reviewed. On [DATE] at 10:00 A.M., RN #122, LPN #155, and LPN #800 completed walking rounds for resident change in condition. One resident was found with a change in condition, and it was addressed immediately. On [DATE] at 12:00 P.M., RDCO #595 reviewed all resident blood sugars to ensure notification of variances was made to the physician. There were no variances noted and was completed by 4:00 P.M. Beginning on [DATE], RDCO #595/designee provided education on resident change in condition and notification to the physician/nurse practitioner to all newly hired nurses and CNAs. Beginning on [DATE], RDCO #595/designee conducted a daily clinical meeting Monday through Friday, excluding holidays, to review residents with a change in condition and/or transfer to the hospital to ensure proper physician notification was made timely. The clinical meetings continue indefinitely with no concerns identified through the review period. Beginning on [DATE], RDCO #595/designee monitored the results of the daily clinical meeting for residents with a change in condition and notification to the physician and submitted the findings to the QAPI committee for review and recommendations. This continued monthly with QAPI meetings held on [DATE] and [DATE] and then as needed. There were no concerns noted in the QAPI meeting minutes. On [DATE], two (#1 and #19) additional resident medical records were reviewed for change in condition and notification of change with no concerns identified. Interviews on [DATE] from 9:35 A.M. to 10:05 A.M. with RN #98, RN #122, CNA #96, CNA #80, CNA #119, CNA #127, CNA #99, CNA #105, and CNA #144 verified they received education from the facility regarding a resident change in condition or mental status change from the resident's baseline. CNAs interviewed verified they would immediately notify the nurse of the change in condition and nurses interviewed indicated the physician would be notified immediately. All staff members were able to recall the training and demonstrated proficiency of the education provided. Findings include: Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, tracheostomy, end-stage renal disease (ESRD) with dependence on hemodialysis, diabetes mellitus Type I, hypertension, chronic obstructive pulmonary disease, and chronic viral Hepatitis C. Review of the Minimum Data Set (MDS) Discharge-return not anticipated assessment dated [DATE] revealed Resident #70 had no cognitive deficit and was always continent of bowel and occasionally incontinent of urine. The resident required set up assistance for eating, oral and personal hygiene, toileting and transfers, moderate assistance for bathing, supervision for dressing, and was independent with bed mobility. Review of a fall risk evaluation dated [DATE] revealed Resident #70 was a low risk for falls. Review of physician orders revealed an order dated [DATE] for Resident #70 to be administered aspart insulin with niacinamide 100 units per milliliter per sliding scale subcutaneously (SQ) before meals related to diabetes mellitus Type I. The sliding scale was as follows: for blood glucose levels between zero (0) and 59 mg/dL, implement hypoglycemia protocol; for blood glucose levels between 60 and 150 mg/dL, give 0 units; for blood glucose levels between 151 and 200 mg/dL, give two (2) units; for blood glucose levels between 201 and 250 mg/dL, give four (4) units; for blood glucose levels between 251 and 300 mg/dL, give six (6) units; for blood glucose levels between 301 and 350 mg/dL, give eight (8) units; for blood glucose levels between 351 and 400 mg/dL, give 10 units; for blood glucose levels between 401 and 450, give 12 units; and for blood glucose levels greater than 451 mg/dL, notify the physician. Review of Resident #70's [DATE] medication administration record (MAR) revealed Resident #70 refused aspart insulin with niacinamide 100 units per milliliter as per sliding scale SQ before meals related to diabetes mellitus type I doses on [DATE] at 11:00 A.M. when the blood glucose levels was 170 mg/dL and at 4:00 P.M. when blood sugar level was 400 mg/dL, on [DATE] at 7:00 A.M. when the blood glucose level was 465 mg/dL and at 4:00 P.M. when blood glucose level was 450 mg/dL, on [DATE] at 11:00 A.M. when the blood glucose level was 220 mg/dL, and on [DATE] at 11:00 A.M. when the blood glucose level was 587 mg/dL. Review of a nursing progress note dated [DATE] at 7:46 P.M., written by LPN #150, revealed Resident #70's glucose reading was 583 mg/dL. The nurse practitioner was notified, and an order was received to administer 16 units of insulin which Resident #70 refused. The resident had a history of non-compliance with the medication regimen. The resident was educated on the risks, up to and including death, of refusing physician orders. The resident was alert and oriented and repeated back understanding of the risks. Review of a nursing progress note dated [DATE] at 2:42 A.M., written by previous DON #395, revealed Resident #70 was found on the floor by a certified nurse aide. The resident was not answering questions but was able to move all extremities. The right side of the resident's face was slightly swollen. A neurologic examination was unable to be completed due to the resident not opening her eyes upon command. Review of a nursing progress note dated [DATE] at 2:43 A.M., written by previous DON #395, revealed Resident #70 was assessed and the resident continued to move all extremities and her bilateral lower extremities which were over the side of the bed. The resident's respirations were easy yet unlabored and the resident continued to not follow commands. Review of a nursing progress note dated [DATE] at 7:15 A.M., written by LPN #155, revealed LPN #155 entered Resident #70's room to administer morning medications and obtain a fingerstick to check the resident's blood sugar and found the resident laying sideways across the bed with her legs dangling off the bed. The resident was noted with a bluish-colored skin tone and abdominal breathing. The resident's head was extremely edematous. The resident's cool air mist tubing was laying on her chest and not connected to the tracheostomy. A thick brown and blood-tinged sputum was noted in and around the tracheostomy. Resident #70 was unresponsive to verbal stimuli and sternal rub. LPN #155 called an emergency medical code at that time and two respiratory therapists immediately responded and initiated suctioning and providing breaths to the resident via a resuscitation (Ambu) bag. The resident's oxygen saturation was 94 percent (%) on the tracheostomy, the heart rate was 144 beats per minute, and the blood pressure could not be obtained. The respiratory therapists continued to provide respirations to Resident #70. At 7:24 A.M., emergency medical transport (EMT) personnel arrived on the scene and care was transitioned to them. At 7:27 A.M., EMT personnel remained on the scene providing first aid to the resident who continued to be unresponsive and with abdominal breathing. The resident's skin tone returned to a natural color. At 7:32 A.M., EMT personnel transported the resident from the facility to the hospital. A report was called to the receiving hospital emergency department (ED), and notifications were made to the physician and the resident's family. At 12:52 P.M., the resident was admitted to the hospital with a diagnosis of acute metabolic encephalopathy. Review of hospital documents dated [DATE] at 1:09 P.M. revealed Resident #70 had a blood glucose level greater than 784 mg/dL and was admitted unresponsive on mechanical ventilation to the medical intensive care unit (MICU) with a concern for volume overload and flash pulmonary edema. The resident's temperature was 102.6 degrees Fahrenheit. The physician noted the resident was critically ill due to acute encephalopathy and comatose state and if untreated, there was a high risk of imminent or life-threatening deterioration of the resident's condition due to worsening hypoxic-ischemic brain injury, cerebral edema, seizures, brain compression and brain death. Further review of the hospital document revealed on [DATE] at 2:11 P.M., Resident #70 was also assigned a diagnosis of acute metabolic acidosis. Review of a nursing progress note dated [DATE] revealed the family reported Resident #70 expired in the hospital today. Interview on [DATE] at 12:41 P.M. with Registered Nurse (RN) #390 verified there was no documentation that indicated neurological checks were performed on Resident #70 from the time she was found on the floor at [DATE] at 2:42 A.M. until she was transported to the hospital on [DATE] at 7:32 A.M. by EMT personnel or that the physician was notified of the resident's change in condition until transport to the hospital on [DATE] at 7:32 A.M. Telephone interview on [DATE] at 1:12 P.M. with previous DON #395 verified neurological checks were not performed on Resident #70 after finding her on the floor on [DATE] at 2:42 A.M. through the time she was transported to the hospital on [DATE] at 7:32 A.M. Previous DON #395 also verified neither the physician, physician extender, nor family were notified of the resident's change in condition until after the resident was transported to the hospital. He was unable to provide rationale as to why neither neurological checks were obtained nor why the physician and family were not notified. Telephone interview on [DATE] at 8:32 A.M. with Nurse Practitioner (NP) #195 verified it was the expectation for the facility to make immediate notification to the physician or physician extender for any resident who was experiencing or who had experienced a change in condition. NP #195 verified the facility did not make notification for Resident #70's change in condition until the resident was transported to the hospital on [DATE] at 7:32 A.M. NP #195 stated she should have been called immediately after the resident was found on the floor on [DATE] at 2:42 A.M., especially when it was noted the resident had swelling noted to the face and was on an anticoagulant medication. Interview on [DATE] at 8:40 A.M. with the current DON revealed the findings of the facility's investigation were inconclusive as to how Resident #70 became to be on the floor in the early morning hours of [DATE]. The DON stated Resident #70 had a blanket on the floor and her oxygen tubing remained connected to her tracheostomy. The DON stated it was a strong possibility the resident placed herself on the floor and laid down. The DON did verify neurological checks were not completed on Resident #70 nor was the physician notified of the resident's change in condition until after transport to the hospital on [DATE] at 7:32 A.M. Interview on [DATE] at 11:55 P.M. with NP #195 verified Resident #70 had a history of erratic blood glucose levels and stated the resident was afraid of being administered greater than 8 units of insulin for fear of it stacking up due to her diagnosis of type I diabetes mellitus. NP #195 verified the facility, and specifically previous DON #395, should have notified her immediately of the resident refusing the order for the 16 units of insulin on [DATE] at 7:46 P.M. and the resident should have been reassessed between [DATE] at 7:46 P.M. and [DATE] at 2:42 A.M. with an update provided. NP #195 also verified she would have definitely ordered the resident be sent to the hospital on [DATE] at 2:42 A.M. had she been notified by previous DON #395. Review of the policy titled, Notification of Changes, revised [DATE], revealed the purpose of this policy was to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, resident's representative when there was a change requiring notification. Circumstances requiring notification include a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status that may include life-threatening conditions or clinical complications.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a hospital record, staff interview, review of the facility investigation, and policy review, the facility failed to ensure a resident (#70) was free from neglect when the facility failed to provide appropriate and timely assessment, treatment, service, and notification to the physician or nurse practitioner. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries, and/or death when on [DATE] at 7:46 P.M., Resident #70 was found to have elevated blood glucose levels by a nurse and after notification to the nurse practitioner, additional insulin was ordered, which the resident refused. The nurse did not make notification to the nurse practitioner or physician of the resident's refusal of additional insulin and no additional checks of the resident's blood glucose level were attempted. Resident #70 was later found on the floor, was not answering questions, but was able to move all extremities, and the right side of the resident's face was slightly swollen. Furthermore, the nurse did not complete a neurological assessment of the resident, and no notifications were made to the physician or nurse practitioner of the resident's change in condition. Resident #70 was found later the next morning on [DATE] at 2:42 A.M. with bluish-colored skin tone, abdominal breathing, an extremely edematous head, and was not responding to verbal or physical stimuli. The lack of timely assessments, treatments, services, and notification to the physician or nurse practitioner contributed to Resident #70's untimely death when the resident was taken to the emergency department, was found to have a further elevated blood glucose level, was diagnoses with acute encephalopathy, with multiple metabolic/infectious abnormalities, acute metabolic acidosis, and ultimately died . This affected one (#70) of three residents reviewed for abuse and neglect. The facility census was 72. On [DATE] at 9:03 A.M., Regional Director of Operations #199 and Regional Director of Clinical Operations (RDCO) #595 were notified that Immediate Jeopardy began on [DATE] at 7:46 P.M. when Resident #70's blood glucose level measured 583 milligrams per deciliter (mg/dL) and previous Director of Nursing (DON) #395 notified the nurse practitioner of the elevated blood glucose level. The nurse practitioner ordered additional insulin which the resident refused, and previous DON #395 did not make notification to the nurse practitioner or physician of the resident's refusal of additional insulin and no additional checks of the resident's blood glucose level were attempted or documented in the medical record. Resident #70 was found on the floor on [DATE] at 2:42 A.M. and was not answering questions, but was able to move all extremities, and the right side of the resident's face was slightly swollen. Previous DON #395 did not complete a neurological assessment of the resident, and no notifications were made to the physician or nurse practitioner of the change in condition. On [DATE] at 7:15 A.M., Licensed Practical Nurse (LPN) #155 entered Resident #70's room to check the resident's blood glucose level and administer insulin and found Resident #70 in bed with bluish-colored skin tone, abdominal breathing, an extremely edematous head, and the resident was not responding to verbal or physical stimuli. A medical code was initiated by facility and emergency medical services (EMS) arrived at the facility and transported the resident to the hospital. At the hospital, Resident #70 was noted to have a blood glucose level greater than 784 mg/dL and had diagnoses of acute encephalopathy, with multiple metabolic/infectious abnormalities, and acute metabolic acidosis. Resident #70 ultimately died on [DATE]. The Immediate Jeopardy was removed on [DATE] at 4:00 P.M., when the facility sent Resident #70 to the ED for treatment following a change in condition, notification was made to the physician, the facility began an investigation, previous DON #395 was suspended, all residents were assessed for change in condition with all concerns addressed immediately, all staff members were educated, and all medical records were reviewed for change in condition and blood glucose levels with no concerns identified. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 7:32 A.M., Resident #70 was sent to the ED with notification made to the physician. On [DATE] beginning at 10:00 A.M., Previous Administrator #495 and Minimum Data Set (MDS) Nurse #146 reviewed the 24-hour report and self-identified a concern with Resident #70's refusal of an order for 16 units of insulin on [DATE] at 7:46 A.M. and failure to notify the physician/nurse practitioner during morning clinical meeting. This concluded at 12:00 P.M. On [DATE] at 12:00 P.M., Previous Administrator #495 and RDCO #595 obtained statements and conducted interviews with LPN Unit Manager #600, Medication Technician #127, LPN #130, LPN #155, Respiratory Therapist (RT) #82, Certified Nurse Aide (CNA) #605, RT #124, CNA (#610), and previous DON #395. This concluded at 9:00 P.M. On [DATE] at 2:30 P.M., RDCO #595 was notified by Previous Administrator #495 of the situation that involved Resident #70 and arrived at the facility at approximately 5:00 P.M. to assist with the investigation. On [DATE] at 8:00 P.M., Registered Nurse (RN)/Staff Development Coordinator (SDC) #375 assessed all residents who had a recent fall and completed a neurological check. There were no residents found with a neurological change in condition. On [DATE] at 9:00 P.M., LPN #116, LPN #146, RDCO #595, and LPN #600 assessed all residents for a change in condition. There were no residents found with a change in condition. On [DATE] at 9:30 P.M., Previous Administrator #495 suspended previous DON #395 pending investigation for his failure to notify Nurse Practitioner (NP) #195 of Resident #70's refusal to be administered insulin as ordered by the nurse practitioner and subsequent change in condition. Previous DON #395 was terminated from employment on [DATE]. On [DATE], RN/SDC #375 provided all nurses, medication technicians, and CNAs with education related to fall assessment protocols, notification of physicians for resident change of condition, the importance of initiating treatment, the importance of rounding every two hours, the importance of obtaining neurological checks when it was suspected the resident had a head injury and/or was on blood thinners, and the importance of initiating the risk management application in the electronic medical record. All staff were educated by [DATE]. On [DATE] at 10:00 A.M., RDCO #595 and previous Administrator #495 notified facility Medical Director #995 of the incident and reviewed the policy and procedure for change in condition/notification of change. There were no revisions made to the policy. The root cause analysis identified failure to follow facility policy for notification to a physician by previous DON #395 as the primary cause for Resident #70's deteriorating change in condition. On [DATE] at 10:00 A.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with previous Administrator #495, RDCO #595, and Medical Director #995. The policy for change in condition/physician notification was reviewed with no recommended revisions. The result of the facility's root cause analysis (RCA) was reviewed and the staff completed education was reviewed. On [DATE] at 10:00 A.M., RN #122, LPN #155, and LPN #800 completed walking rounds for resident change in condition. One resident was found with a change in condition, and it was addressed immediately. On [DATE] at 12:00 P.M., RDCO #595 reviewed all resident blood sugars to ensure notification of variances was made to the physician. There were no variances noted and was completed by 4:00 P.M. Beginning on [DATE], RDCO #595/designee provided education on resident change in condition and notification to the physician/nurse practitioner to all newly hired nurses and CNAs. Beginning on [DATE], RDCO #595/designee conducted a daily clinical meeting Monday through Friday, excluding holidays, to review residents with a change in condition and/or transfer to the hospital to ensure proper physician notification was made timely. The clinical meetings continue indefinitely with no concerns identified through the review period. Beginning on [DATE], RDCO #595/designee monitored the results of the daily clinical meeting for residents with a change in condition and notification to the physician and submitted the findings to the QAPI committee for review and recommendations. This continued monthly with QAPI meetings held on [DATE] and [DATE] and then as needed. There were no concerns noted in the QAPI meeting minutes. On [DATE], two (#1 and #19) additional resident medical records were reviewed for abuse and neglect with no concerns identified. Interviews on [DATE] from 9:35 A.M. to 10:05 A.M. with RN #98, RN #122, CNA #96, CNA #80, CNA #119, CNA #127, CNA #99, CNA #105, and CNA #144 verified they received education from the facility regarding a resident change in condition or mental status change from the resident's baseline. CNAs interviewed verified they would immediately notify the nurse of the change in condition and nurses interviewed indicated the physician would be notified immediately. All staff members were able to recall the training and demonstrated proficiency of the education provided. Findings include: Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, tracheostomy, end-stage renal disease (ESRD) with dependence on hemodialysis, diabetes mellitus Type I, hypertension, chronic obstructive pulmonary disease, and chronic viral Hepatitis C. Review of the Minimum Data Set (MDS) Discharge-return not anticipated assessment dated [DATE] revealed Resident #70 had no cognitive deficit and was always continent of bowel and occasionally incontinent of urine. The resident required set up assistance for eating, oral and personal hygiene, toileting and transfers, moderate assistance for bathing, supervision for dressing, and was independent with bed mobility. Review of physician orders revealed Resident #70 had an order dated [DATE] to be administered the anticoagulant medication Eliquis 2.5 milligrams (mg) by mouth with instructions to give one tablet every morning and at bedtime. Review of a fall risk evaluation dated [DATE] revealed Resident #70 was a low risk for falls. Review of physician orders revealed an order dated [DATE] for Resident #70 to be administered aspart insulin with niacinamide 100 units per milliliter per sliding scale subcutaneously (SQ) before meals related to diabetes mellitus Type I. The sliding scale was as follows: for blood glucose levels between zero (0) and 59 mg/dL, implement hypoglycemia protocol; for blood glucose levels between 60 and 150 mg/dL, give 0 units; for blood glucose levels between 151 and 200 mg/dL, give two (2) units; for blood glucose levels between 201 and 250 mg/dL, give four (4) units; for blood glucose levels between 251 and 300 mg/dL, give six (6) units; for blood glucose levels between 301 and 350 mg/dL, give eight (8) units; for blood glucose levels between 351 and 400 mg/dL, give 10 units; for blood glucose levels between 401 and 450, give 12 units; and for blood glucose levels greater than 451 mg/dL, notify the physician. Review of Resident #70's [DATE] medication administration record (MAR) revealed Resident #70 refused aspart insulin with niacinamide 100 units per milliliter as per sliding scale SQ before meals related to diabetes mellitus type I doses on [DATE] at 11:00 A.M. when the blood glucose levels was 170 mg/dL and at 4:00 P.M. when blood sugar level was 400 mg/dL, on [DATE] at 7:00 A.M. when the blood glucose level was 465 mg/dL and at 4:00 P.M. when blood glucose level was 450 mg/dL, on [DATE] at 11:00 A.M. when the blood glucose level was 220 mg/dL, and on [DATE] at 11:00 A.M. when the blood glucose level was 587 mg/dL. Review of a nursing progress note dated [DATE] at 7:46 P.M., written by Licensed Practical Nurse (LPN) #150, revealed Resident #70's glucose reading was 583 mg/dL. The nurse practitioner was notified, and an order was received to administer 16 units of insulin which Resident #70 refused. The resident had a history of non-compliance with the medication regimen. The resident was educated on the risks, up to and including death, of refusing physician orders. The resident was alert and oriented and repeated back understanding of the risks. Review of a nursing progress note dated [DATE] at 2:42 A.M., written by previous DON #395, revealed Resident #70 was found on the floor by a certified nurse aide. The resident was not answering questions but was able to move all extremities. The right side of the resident's face was slightly swollen. A neurologic examination was unable to be completed due to the resident not opening her eyes upon command. Review of a nursing progress note dated [DATE] at 2:43 A.M., written by previous DON #395, revealed Resident #70 was assessed and the resident continued to move all extremities and her bilateral lower extremities which were over the side of the bed. The resident's respirations were easy yet unlabored and the resident continued to not follow commands. Review of a nursing progress note dated [DATE] at 7:15 A.M., written by LPN #155, revealed LPN #155 entered Resident #70's room to administer morning medications and obtain a fingerstick to check the resident's blood sugar and found the resident laying sideways across the bed with her legs dangling off the bed. The resident was noted with a bluish-colored skin tone and abdominal breathing. The resident's head was extremely edematous. The resident's cool air mist tubing was laying on her chest and not connected to the tracheostomy. A thick brown and blood-tinged sputum was noted in and around the tracheostomy. Resident #70 was unresponsive to verbal stimuli and sternal rub. LPN #155 called an emergency medical code at that time and two respiratory therapists immediately responded and initiated suctioning and providing breaths to the resident via a resuscitation (Ambu) bag. The resident's oxygen saturation was 94 percent (%) on the tracheostomy, the heart rate was 144 beats per minute, and the blood pressure could not be obtained. The respiratory therapists continued to provide respirations to Resident #70. At 7:24 A.M., emergency medical transport (EMT) personnel arrived on the scene and care was transitioned to them. At 7:27 A.M., EMT personnel remained on the scene providing first aid to the resident who continued to be unresponsive and with abdominal breathing. The resident's skin tone returned to a natural color. At 7:32 A.M., EMT personnel transported the resident from the facility to the hospital. A report was called to the receiving hospital emergency department (ED) and notifications were made to the physician and the resident's family. At 12:52 P.M., the resident was admitted to the hospital with a diagnosis of acute metabolic encephalopathy. Review of hospital documents dated [DATE] at 1:09 P.M. revealed Resident #70 had a blood glucose level greater than 784 mg/dL and was admitted unresponsive on mechanical ventilation to the medical intensive care unit (MICU) with a concern for volume overload and flash pulmonary edema. The resident's temperature was 102.6 degrees Fahrenheit. The physician noted the resident was critically ill due to acute encephalopathy and comatose state and if untreated, there was a high risk of imminent or life-threatening deterioration of the resident's condition due to worsening hypoxic-ischemic brain injury, cerebral edema, seizures, brain compression and brain death. Further review of the hospital document revealed on [DATE] at 2:11 P.M., Resident #70 was also assigned a diagnosis of acute metabolic acidosis. Review of a nursing progress note dated [DATE] revealed the family reported Resident #70 expired in the hospital today. Interview on [DATE] at 12:41 P.M. with RN #390 verified there was no documentation that indicated neurological checks were performed on Resident #70 from the time she was found on the floor at [DATE] at 2:42 A.M. until she was transported to the hospital on [DATE] at 7:32 A.M. by EMT personnel or that the physician was notified of the resident's change in condition until transport to the hospital on [DATE] at 7:32 A.M. Telephone interview on [DATE] at 1:12 P.M. with previous DON #395 verified neurological checks were not performed on Resident #70 after finding her on the floor on [DATE] at 2:42 A.M. through the time she was transported to the hospital on [DATE] at 7:32 A.M. Previous DON #395 also verified neither the physician, physician extender, nor family were notified of the resident's change in condition until after the resident was transported to the hospital. He was unable to provide rationale as to why neither neurological checks were obtained nor why the physician and family were not notified. Telephone interview on [DATE] at 8:32 A.M. with NP #195 verified it was the expectation for the facility to make immediate notification to the physician or physician extender for any resident who was experiencing or who had experienced a change in condition. NP #195 verified the facility did not make notification for Resident #70's change in condition until the resident was transported to the hospital on [DATE] at 7:32 A.M. NP #195 stated she should have been called immediately after the resident was found on the floor on [DATE] at 2:42 A.M., especially when it was noted the resident had swelling noted to the face and was on an anticoagulant medication. Interview on [DATE] at 8:40 A.M. with the current DON revealed the findings of the facility's investigation were inconclusive as to how Resident #70 became to be on the floor in the early morning hours of [DATE]. The DON stated Resident #70 had a blanket on the floor and her oxygen tubing remained connected to her tracheostomy. The DON stated it was a strong possibility the resident placed herself on the floor and laid down. The DON did verify neurological checks were not completed on Resident #70 nor was the physician notified of the resident's change in condition until after transport to the hospital on [DATE] at 7:32 A.M. Interview on [DATE] at 11:55 P.M. with NP #195 verified Resident #70 had a history of erratic blood glucose levels and stated the resident was afraid of being administered greater than 8 units of insulin for fear of it stacking up due to her diagnosis of type I diabetes mellitus. NP #195 verified the facility, and specifically previous DON #395, should have notified her immediately of the resident refusing the order for the 16 units of insulin on [DATE] at 7:46 P.M. and the resident should have been reassessed between [DATE] at 7:46 P.M. and [DATE] at 2:42 A.M. with an update provided. NP #195 also verified she would have definitely ordered the resident be sent to the hospital on [DATE] at 2:42 A.M. had she been notified by previous DON #395. Review of the policy titled, Abuse, Neglect, and Exploitation, revised [DATE], revealed it was the policy for the facility to provide protections for 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. Neglect was defined in the policy as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will develop and implement written policies and procedures that: prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This deficiency represents non-compliance investigated under Complaint Number OH00162132.

Based on medical record review, observation, staff interview, interview with the outside wound nurse practitioner (NP), review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess residents' skin and failed to identify pressure ulcers until they reached an advanced stage. This resulted in Actual Harm for Resident #123 who was admitted to the facility with a pressure ulcer to his sacrum and developed an additional pressure ulcer to his right scapula which was not identified until it was an unstageable ulcer with slough (nonviable tissue which could impede wound healing) and necrotic (dead) tissue. This affected one (Resident #123) of five residents reviewed for pressure ulcers. The facility identified five residents with in-house acquired pressure ulcers. The facility census was 72 residents. Findings include: Review of the medical record for Resident #123 revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, major depressive disorder, essential primary hypertension, pulmonary embolism, cerebral infarction, diabetes mellitus, and sacral pressure ulcer. Review of the admission skin assessment for Resident #123 dated 02/21/25 revealed the resident was admitted to the facility with a stage IV pressure ulcer to his sacrum. Review of the shower sheet for Resident #123 completed by the Certified Nursing Assistant (CNA) dated 02/26/25 revealed the resident had no new skin issues. Review of the progress note for Resident #123 dated 02/27/25 per Wound Nurse Practitioner (WNP) #250 revealed the resident had no wounds on his right shoulder. Review of the Minimum Data Set (MDS) assessment for Resident #123 dated 02/28/25 revealed the resident had impaired cognition and was dependent on staff for activities of daily living (ADLs). Review of the online bathing documentation for Resident #123 per the CNAs dated 03/01/25 to 03/06/25 revealed the resident had a bed bath on the following dates: 03/01/25, 03/02/25, 03/05/25. Review of the pressure ulcer risk assessment for Resident #123 dated 03/06/25 revealed the resident was at high risk for the development of pressure ulcers. Review of the care plan for Resident #123 updated 03/06/25 revealed the resident had impaired skin integrity and was at risk for impaired skin integrity related to being confined to a bed all or most of the time, history of pressure ulcers, the need for assistance with ADLs, the need for repositioning, status post cerebral vascular accident (CVA), and ventilator use. Interventions included the following: apply protective barrier cream after in continent episodes, assist resident with turning and reposition as needed, complete skin inspection weekly and as needed, consult dietician as needed, elevate heels off the mattress, notify nurse of any new areas of skin impairment noted during bathing or daily care, notify physician of any new skin areas of skin impairment, pressure redistribution mattress, preventative treatments per orders, provide incontinence care as needed, provide a non-irritating surface to reduce friction or shearing forces. Review of the nurse progress note for Resident #123 dated 03/06/25 per the facility wound nurse, Licensed Practical Nurse (LPN) #150, revealed during wound rounds the nurse and Wound Nurse Practitioner (WNP) #250 noted a Xeroform gauze dressing to the resident's right shoulder which was covering a pressure ulcer. Neither LPN #150 nor WNP #250 were able to determine how long the wound to the resident's right shoulder had been present. Review of the progress note for Resident #123 dated 03/06/25 per WNP #250 revealed the resident had an unstageable pressure area to the right shoulder which measured 1.5 centimeters (cm) in length by 1.0 cm in width by 0.3 cm in depth. There was a medium amount of serosanguineous drainage from the wound with no granulation tissue within the wound bed. There was a large area of 67 percent (%) to 100 % of necrotic tissue and adherent slough tissue within the wound bed. Review of the medical record for Resident #123 dated 02/21/25 to 03/06/25 revealed there were no skin checks completed by licensed nurses during this time frame. Interview on 03/13/25 at 9:06 A.M with the facility wound nurse, LPN#150 confirmed the facility had not completed a pressure ulcer risk assessment for Resident #123 until 03/06/25 and determined the resident was at high risk for development of pressure ulcers. LPN #150 confirmed she completed wound rounds every Thursday with WNP #250, and facility nurses were expected to complete resident skin assessments on shower days twice weekly and notify her if they identified a new wound on a resident. LPN #150 confirmed the facility nurses had not completed skin assessments for Resident #123 from 02/21/25 to 03/06/25 and the CNA documentation dated 02/21/25 to 03/06/25 indicated the resident had no new skin issues. LPN #150 confirmed during wound rounds with WNP #250 on 03/06/25 they identified a pressure ulcer to Resident #123's right shoulder which was covered with an undated Xeroform gauze dressing. LPN #150 further confirmed when she completed wound rounds with WNP #250 on 02/27/25 there was no pressure ulcer or dressing present to Resident #123's right shoulder. LPN #150 confirmed the facility was unable to determine who had placed the dressing to Resident #123's right shoulder, and the facility had not identified the resident's pressure ulcer until 03/06/25 when the pressure ulcer to the resident's right shoulder presented as an unstageable ulcer due to slough and necrotic tissue within the wound bed. Observation on 03/13/25 at 1:45 P.M. of wound care for Resident #123 per LPN #150 revealed the resident had a nickel-sized pressure ulcer to his right shoulder with yellow slough present in the wound bed. Interview on 03/13/24 at 2:38 P.M. with WNP #250 confirmed the facility identified a new unstageable pressure ulcer to Resident#123's right shoulder during wound rounds completed on 03/06/25. WNP #250 confirmed the wound on Resident #123's right scapula was not present during wound rounds on 02/27/25 and was not identified by the facility until it had reached an advanced stage with slough and necrotic tissue present in the wound bed. Review of the facility policy titled Pressure Injury Prevention Guidelines dated 10/30/20 revealed a resident at risk could develop a pressure ulcer within hours of the onset of pressure the at-risk resident needed to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Residents with pressure ulcers should receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers from forming. Review of the NPUAP guidelines, dated 2014, pages 70-71 and located at, https://npiap.com/general/custom.asp?page=2014Guidelines, revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.

Based on observation, staff interview, review of a planned menu, and policy review, revealed the faciity failed to follow the menu for residents ordered a regular diet. This affected 47 (#26, #21, #8, #28, #40, #58, #51, #49, #19, #31, #323, #44, #62, #56, #43, #30, #272, #37, #63, #24, #7, #48, #45, #271, #60, #57, #35, #3, #18, #32, #41, #10, #14, #324, #25, #33, #122, #15, #2, #50, #47, #64, #27, #38, #322, #39, and #54) of 47 residents ordered a regular diet. The facility census was 72. Findings include: Review of the menu for breakfast on 03/12/25 revealed assorted juice, choice of hot or cold cereal, scrambled eggs, bacon, hash browns, and milk/beverage. Observation on 03/12/25 at 7:15 A.M revealed food to be served included hot or cold cereal, scrambled eggs, and hashbrowns, but no bacon was observed on the steam table. Interview on 03/12/25 at 7:15 A.M with Dietary [NAME] #161 stated the kitchen did not have enough bacon for everyone, so they did not put any out and they were also out of sausage, so they did not prepare a substitute. Review of the facility policy titled, Menus and Adequate Nutrition, revised on 01/01/22, revealed menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable and substitutions shall comprise of foods with comparable nutritive value.

Based on medical record review, hospital documentation, personnel file review, review of self-reported incidents (SRIs), staff interview, and policy review, the facility failed to report allegations of neglect to the Administrator and State Survey Agency. This affected four (#59, #70, #122, and #123) of five residents reviewed for neglect. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, tracheostomy, end-stage renal disease (ESRD) with dependence on hemodialysis, diabetes mellitus Type I, hypertension, chronic obstructive pulmonary disease, and chronic viral Hepatitis C. Review of the Minimum Data Set (MDS) Discharge-return not anticipated assessment dated [DATE] revealed Resident #70 had no cognitive deficit and was always continent of bowel and occasionally incontinent of urine. The resident required set up assistance for eating, oral and personal hygiene, toileting and transfers, moderate assistance for bathing, supervision for dressing, and was independent with bed mobility. Review of physician orders revealed Resident #70 had an order dated [DATE] to be administered the anticoagulant medication Eliquis 2.5 milligrams (mg) by mouth with instructions to give one tablet every morning and at bedtime. Review of a fall risk evaluation dated [DATE] revealed Resident #70 was a low risk for falls. Review of physician orders revealed an order dated [DATE] for Resident #70 to be administered aspart insulin with niacinamide 100 units per milliliter per sliding scale subcutaneously (SQ) before meals related to diabetes mellitus Type I. The sliding scale was as follows: for blood glucose levels between zero (0) and 59 milligrams per deciliter (mg/dL), implement hypoglycemia protocol; for blood glucose levels between 60 and 150 mg/dL, give 0 units; for blood glucose levels between 151 and 200 mg/dL, give two (2) units; for blood glucose levels between 201 and 250 mg/dL, give four (4) units; for blood glucose levels between 251 and 300 mg/dL, give six (6) units; for blood glucose levels between 301 and 350 mg/dL, give eight (8) units; for blood glucose levels between 351 and 400 mg/dL, give 10 units; for blood glucose levels between 401 and 450, give 12 units; and for blood glucose levels greater than 451 mg/dL, notify the physician. Review of Resident #70's [DATE] medication administration record (MAR) revealed Resident #70 refused aspart insulin with niacinamide 100 units per milliliter as per sliding scale SQ before meals related to diabetes mellitus type I doses on [DATE] at 11:00 A.M. when the blood glucose levels was 170 mg/dL and at 4:00 P.M. when blood sugar level was 400 mg/dL, on [DATE] at 7:00 A.M. when the blood glucose level was 465 mg/dL and at 4:00 P.M. when blood glucose level was 450 mg/dL, on [DATE] at 11:00 A.M. when the blood glucose level was 220 mg/dL, and on [DATE] at 11:00 A.M. when the blood glucose level was 587 mg/dL. Review of a nursing progress note dated [DATE] at 7:46 P.M., written by Licensed Practical Nurse (LPN) #150, revealed Resident #70's glucose reading was 583 mg/dL. The nurse practitioner was notified, and an order was received to administer 16 units of insulin which Resident #70 refused. The resident had a history of non-compliance with the medication regimen. The resident was educated on the risks, up to and including death, of refusing physician orders. The resident was alert and oriented and repeated back understanding of the risks. Review of a nursing progress note dated [DATE] at 2:42 A.M., written by previous Director of Nursing (DON) #395, revealed Resident #70 was found on the floor by a certified nurse aide. The resident was not answering questions but was able to move all extremities. The right side of the resident's face was slightly swollen. A neurologic examination was unable to be completed due to the resident not opening her eyes upon command. Review of a nursing progress note dated [DATE] at 2:43 A.M., written by previous DON #395, revealed Resident #70 was assessed and the resident continued to move all extremities and her bilateral lower extremities which were over the side of the bed. The resident's respirations were easy yet unlabored and the resident continued to not follow commands. Review of a nursing progress note dated [DATE] at 7:15 A.M., written by Licensed Practical Nurse (LPN) #155, revealed LPN #155 entered Resident #70's room to administer morning medications and obtain a fingerstick to check the resident's blood sugar and found the resident laying sideways across the bed with her legs dangling off the bed. The resident was noted with a bluish-colored skin tone and abdominal breathing. The resident's head was extremely edematous. The resident's cool air mist tubing was laying on her chest and not connected to the tracheostomy. A thick brown and blood-tinged sputum was noted in and around the tracheostomy. Resident #70 was unresponsive to verbal stimuli and sternal rub. LPN #155 called an emergency medical code at that time and two respiratory therapists immediately responded and initiated suctioning and providing breaths to the resident via a resuscitation (Ambu) bag. The resident's oxygen saturation was 94 percent (%) on the tracheostomy, the heart rate was 144 beats per minute, and the blood pressure could not be obtained. The respiratory therapists continued to provide respirations to Resident #70. At 7:24 A.M., emergency medical transport (EMT) personnel arrived on the scene and care was transitioned to them. At 7:27 A.M., EMT personnel remained on the scene providing first aid to the resident who continued to be unresponsive and with abdominal breathing. The resident's skin tone returned to a natural color. At 7:32 A.M., EMT personnel transported the resident from the facility to the hospital. A report was called to the receiving hospital emergency department (ED) and notifications were made to the physician and the resident's family. At 12:52 P.M., the resident was admitted to the hospital with a diagnosis of acute metabolic encephalopathy. Review of hospital documents dated [DATE] at 1:09 P.M. revealed Resident #70 had a blood glucose level greater than 784 mg/dL and was admitted unresponsive on mechanical ventilation to the medical intensive care unit (MICU) with a concern for volume overload and flash pulmonary edema. The resident's temperature was 102.6 degrees Fahrenheit. The physician noted the resident was critically ill due to acute encephalopathy and comatose state and if untreated, there was a high risk of imminent or life-threatening deterioration of the resident's condition due to worsening hypoxic-ischemic brain injury, cerebral edema, seizures, brain compression and brain death. Further review of the hospital document revealed on [DATE] at 2:11 P.M., Resident #70 was also assigned a diagnosis of acute metabolic acidosis. Review of a nursing progress note dated [DATE] revealed the family reported Resident #70 expired in the hospital today. Interview on [DATE] at 12:41 P.M. with Registered Nurse (RN) #390 verified there was no documentation that indicated neurological checks were performed on Resident #70 from the time she was found on the floor at [DATE] at 2:42 A.M. until she was transported to the hospital on [DATE] at 7:32 A.M. by EMT personnel or that the physician was notified of the resident's change in condition until transport to the hospital on [DATE] at 7:32 A.M. Telephone interview on [DATE] at 1:12 P.M. with previous DON #395 verified neurological checks were not performed on Resident #70 after finding her on the floor on [DATE] at 2:42 A.M. through the time she was transported to the hospital on [DATE] at 7:32 A.M. Previous DON #395 also verified neither the physician, physician extender, nor family were notified of the resident's change in condition until after the resident was transported to the hospital. He was unable to provide rationale as to why neither neurological checks were obtained nor why the physician and family were not notified. Telephone interview on [DATE] at 8:32 A.M. with Nurse Practitioner (NP) #195 verified it was the expectation for the facility to make immediate notification to the physician or physician extender for any resident who was experiencing or who had experienced a change in condition. NP #195 verified the facility did not make notification for Resident #70's change in condition until the resident was transported to the hospital on [DATE] at 7:32 A.M. NP #195 stated she should have been called immediately after the resident was found on the floor on [DATE] at 2:42 A.M., especially when it was noted the resident had swelling noted to the face and was on an anticoagulant medication. Interview on [DATE] at 8:40 A.M. with the current DON revealed the findings of the facility's investigation were inconclusive as to how Resident #70 became to be on the floor in the early morning hours of [DATE]. The DON stated Resident #70 had a blanket on the floor and her oxygen tubing remained connected to her tracheostomy. The DON stated it was a strong possibility the resident placed herself on the floor and laid down. The DON did verify neurological checks were not completed on Resident #70 nor was the physician notified of the resident's change in condition until after transport to the hospital on [DATE] at 7:32 A.M. Interview on [DATE] at 11:55 P.M. with NP #195 verified Resident #70 had a history of erratic blood glucose levels and stated the resident was afraid of being administered greater than 8 units of insulin for fear of it stacking up due to her diagnosis of type I diabetes mellitus. NP #195 verified the facility, and specifically previous DON #395, should have notified her immediately of the resident refusing the order for the 16 units of insulin on [DATE] at 7:46 P.M. and the resident should have been reassessed between [DATE] at 7:46 P.M. and [DATE] at 2:42 A.M. with an update provided. NP #195 also verified she would have definitely ordered the resident be sent to the hospital on [DATE] at 2:42 A.M. had she been notified by previous DON #395. Review of facility self-reported incidents from [DATE] revealed no evidence the facility notified the State Survey Agency of a situation of neglect involving Resident #70's lack of assessment, treatment, and notification of change to the physician or nurse practitioner. Interview on [DATE] at 6:46 P.M. with Regional Director of Clinical Operations (RDCO) #199 verified the facility did not report the situation of neglect involving Resident #70 to the State Survey Agency. 2. Medical record review for Resident#59 revealed he admitted to the facility on [DATE]. Diagnoses included orthostatic hypertension, cerebral vascular accident, depression, hypertension, hyperlipidemia, diabetes mellitus (DM), and respiratory failure. Review of the MDS assessment for Resident #59, dated [DATE], revealed he had impaired cognition. Resident #59 was dependent on staff for oral hygiene, medication administration, toilet use, personal hygiene, bathing, dressing, transfers, and bed mobility. Resident #59 required a tube feed for nutrition and had an invasive mechanical ventilator. 3. Medical record review for Resident #122 revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, osteomyelitis, dependence on respiratory ventilator, major depressive disorder, atrial fibrillation, acute kidney failure, dysphasia, and anxiety disorder. Review of the MDS assessment, dated [DATE], revealed Resident #122 was cognitively intact. Further review of the MDS assessment confirmed Resident #122 was dependent on staff for medication administration, toilet use, lower body dressing, and putting on shoes. Resident #122 required assistance with meals and oral hygiene. He required maximum assistance with showering and required an invasive mechanical ventilator. 4. Medical record review for Resident #123 revealed he was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, major depressive disorder, essential primary hypertension, pulmonary embolism, cerebral infarction, and DM. Review of the MDS assessment, dated [DATE], revealed Resident #123 had impaired cognition. Resident #123 was dependent on staff for medication administration, oral hygiene, toilet use, bathing, personal hygiene, dressing, and transfers. Resident #123 required the use of oxygen, tracheostomy care, and required an invasive mechanical ventilator. Resident #123 was assessed at risk for the development of pressure ulcers. Review of Certified Nurse Aide (CNA) #145's personnel file revealed she was hired at the facility on [DATE]. Review of a disciplinary action document dated [DATE] revealed, upon doing wound rounds, it was noted several residents were soiled and not changed timely, not turned, and were not repositioned timely. The disciplinary action was marked as verbal counseling and was dated [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 10:54 A.M. confirmed she was aware of an incident related to CNA #145 getting behind on her work and failing to change her assigned residents within the past two weeks. The DON stated she disciplined CNA #145 for leaving her residents soiled. The DON confirmed the facility failed to report an allegation of neglect when CNA #145 failed to provide care and services for Resident #59, Resident #122, and Resident #123 on [DATE]. The DON confirmed she did not complete a thorough investigation of the incident because she felt CNA #145 was a good aide and the DON did not receive complaints about CNA #145's care. The DON stated CNA #145 told her the reason she was behind on resident care on [DATE] was because she had a bad day. Interview on [DATE] at 11:18 A.M. with CNA #145 confirmed she got very behind on her assignments on [DATE]. CNA #145 confirmed she failed to change the soiled sheets for Resident #59, Resident #122, and Resident #123 and confirmed she did not notify anyone that day of the care and services not being provided for those residents. CNA #145 confirmed did not ask the nurses or other CNAs for assistance with her residents because they were behind with care as well. Interview on [DATE] at 9:06 A.M. with Wound Nurse (WN) #150 confirmed three (#59, #122, and #123) residents were found lying on soiled sheets on [DATE] during her wound rounds. WN #150 stated on [DATE] at 5:00 P.M. she started her wound rounds down the 200 hallway. WN #150 confirmed Resident #59, Resident #122, and Resident #123 were all under the care of CNA #145 on [DATE]. WN #150 confirmed she found Resident #59 with very soiled and wet sheets, and Resident #123 was found with a dislodged tube feeding and had wet and dried tube feeding supplement all over his sheets. WN #150 stated Resident #123 had extremely compromised skin and should not lay in wet and soiled sheets. WN #150 also confirmed Resident #122 was found with his sheets soiled and saturated from his wounds. WN #150 explained how fragile Resident #122's skin was and the importance of keeping the resident's sheets clean and dry. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated [DATE], revealed an immediate investigation was warranted when suspicion of abuse, neglect, or exploitation, or report of abuse, neglect, or exploitation occur. The facility will identify the staff responsible for the investigation, identify and interview all involved persons, and provide complete and through documentation of the investigation. The facility will have written procedures for reporting alleged abuse, neglect, or exploitation. The procedures include reporting of alleged violations, immediately but no later than two hours after the allegation was made, if the events involve abuse or result in serious bodily injury, and no later than 24 hours if the events that cause the allegation do not involve abuse or result in bodily injury.

Based on observation, staff interview, and policy review, the facility failed to store and prepare foods in a manner to prevent spoilage and contamination. This had the potential to affect all 62 residents who received food from the facility kitchen. The facility identified 10 (#1, #5, #23, #29, #59, #65, #121, #123, #124, and #321) who received no food from the kitchen. The facility census was 72. Findings include: 1. Observation of the kitchen on 03/10/25 between 7:12 A.M. and 9:30 A.M., with Food Service Director (FSD) #157 revealed two packages of pie crusts undated and unlabeled in the dry food storage area. There were two packages of English muffins and six packages of rolls that were not dated. Observation of a garbage can located by the primary preparation station and a garbage can in the dishwashing room revealed neither garbage can had lids on them. Further observation of the kitchen revealed four ceiling air ventilator covers had black spots around the ventilators and a black substance built up on them. Interview with FSD #157 verified the two packages of pie crusts were undated and unlabeled, verified the garbage cans by the preparation station and in the dishwashing room had no lids on them, the undated packages of English muffins and rolls, and the four ceiling air ventilators with black spots around them and build up on the ventilator at the time of the observations. FSD #157 further stated the maintenance department was responsible for cleaning the air ventilators. Review of the facility policy titled, Food & Nutrition Services: QRT Food Storage, dated 09/01/21, revealed all food should be stored wrapped or in covered containers, labeled and dated, arranged in a manner to prevent cross contamination. Review of the facility policy titled, Kitchen Sanitation, revised on 01/01/22, revealed kitchens, kitchen areas, and dining areas shall be kept clean and free from litter. 2. Observation on 03/11/25 at 7:20 A.M. revealed Dietary [NAME] (DC) #161 had gloves on while serving food on the tray line using serving scoops. DC #161 grabbed bread to put in the toaster using the same gloves he used while handling the serving scoops. Interview on 03/11/25 at 9:00 AM with DC #161 stated he forgot to change his gloves and confirmed he touched food with his gloved hands without changing them. Review of a facility policy titled, Hand Hygiene, revised 12/13/23, revealed all staff will perform hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.

Based on medical record review, hospital documentation, personnel file review, review of self-reported incidents (SRIs), staff interview, and policy review, the facility failed to report the results of an investigation regarding resident neglect to the State Survey Agency in a timely manner and failed to thoroughly investigate allegations of neglect. This affected four (#59, #70, #122, and #123) of five residents reviewed for neglect. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, tracheostomy, end-stage renal disease (ESRD) with dependence on hemodialysis, diabetes mellitus Type I, hypertension, chronic obstructive pulmonary disease, and chronic viral Hepatitis C. Review of the Minimum Data Set (MDS) Discharge-return not anticipated assessment dated [DATE] revealed Resident #70 had no cognitive deficit and was always continent of bowel and occasionally incontinent of urine. The resident required set up assistance for eating, oral and personal hygiene, toileting and transfers, moderate assistance for bathing, supervision for dressing, and was independent with bed mobility. Review of physician orders revealed Resident #70 had an order dated [DATE] to be administered the anticoagulant medication Eliquis 2.5 milligrams (mg) by mouth with instructions to give one tablet every morning and at bedtime. Review of a fall risk evaluation dated [DATE] revealed Resident #70 was a low risk for falls. Review of physician orders revealed an order dated [DATE] for Resident #70 to be administered aspart insulin with niacinamide 100 units per milliliter per sliding scale subcutaneously (SQ) before meals related to diabetes mellitus Type I. The sliding scale was as follows: for blood glucose levels between zero (0) and 59 milligrams per deciliter (mg/dL), implement hypoglycemia protocol; for blood glucose levels between 60 and 150 mg/dL, give 0 units; for blood glucose levels between 151 and 200 mg/dL, give two (2) units; for blood glucose levels between 201 and 250 mg/dL, give four (4) units; for blood glucose levels between 251 and 300 mg/dL, give six (6) units; for blood glucose levels between 301 and 350 mg/dL, give eight (8) units; for blood glucose levels between 351 and 400 mg/dL, give 10 units; for blood glucose levels between 401 and 450, give 12 units; and for blood glucose levels greater than 451 mg/dL, notify the physician. Review of Resident #70's [DATE] medication administration record (MAR) revealed Resident #70 refused aspart insulin with niacinamide 100 units per milliliter as per sliding scale SQ before meals related to diabetes mellitus type I doses on [DATE] at 11:00 A.M. when the blood glucose levels was 170 mg/dL and at 4:00 P.M. when blood sugar level was 400 mg/dL, on [DATE] at 7:00 A.M. when the blood glucose level was 465 mg/dL and at 4:00 P.M. when blood glucose level was 450 mg/dL, on [DATE] at 11:00 A.M. when the blood glucose level was 220 mg/dL, and on [DATE] at 11:00 A.M. when the blood glucose level was 587 mg/dL. Review of a nursing progress note dated [DATE] at 7:46 P.M., written by Licensed Practical Nurse (LPN) #150, revealed Resident #70's glucose reading was 583 mg/dL. The nurse practitioner was notified, and an order was received to administer 16 units of insulin which Resident #70 refused. The resident had a history of non-compliance with the medication regimen. The resident was educated on the risks, up to and including death, of refusing physician orders. The resident was alert and oriented and repeated back understanding of the risks. Review of a nursing progress note dated [DATE] at 2:42 A.M., written by previous Director of Nursing (DON) #395, revealed Resident #70 was found on the floor by a certified nurse aide. The resident was not answering questions but was able to move all extremities. The right side of the resident's face was slightly swollen. A neurologic examination was unable to be completed due to the resident not opening her eyes upon command. Review of a nursing progress note dated [DATE] at 2:43 A.M., written by previous DON #395, revealed Resident #70 was assessed and the resident continued to move all extremities and her bilateral lower extremities which were over the side of the bed. The resident's respirations were easy yet unlabored and the resident continued to not follow commands. Review of a nursing progress note dated [DATE] at 7:15 A.M., written by Licensed Practical Nurse (LPN) #155, revealed LPN #155 entered Resident #70's room to administer morning medications and obtain a fingerstick to check the resident's blood sugar and found the resident laying sideways across the bed with her legs dangling off the bed. The resident was noted with a bluish-colored skin tone and abdominal breathing. The resident's head was extremely edematous. The resident's cool air mist tubing was laying on her chest and not connected to the tracheostomy. A thick brown and blood-tinged sputum was noted in and around the tracheostomy. Resident #70 was unresponsive to verbal stimuli and sternal rub. LPN #155 called an emergency medical code at that time and two respiratory therapists immediately responded and initiated suctioning and providing breaths to the resident via a resuscitation (Ambu) bag. The resident's oxygen saturation was 94 percent (%) on the tracheostomy, the heart rate was 144 beats per minute, and the blood pressure could not be obtained. The respiratory therapists continued to provide respirations to Resident #70. At 7:24 A.M., emergency medical transport (EMT) personnel arrived on the scene and care was transitioned to them. At 7:27 A.M., EMT personnel remained on the scene providing first aid to the resident who continued to be unresponsive and with abdominal breathing. The resident's skin tone returned to a natural color. At 7:32 A.M., EMT personnel transported the resident from the facility to the hospital. A report was called to the receiving hospital emergency department (ED) and notifications were made to the physician and the resident's family. At 12:52 P.M., the resident was admitted to the hospital with a diagnosis of acute metabolic encephalopathy. Review of hospital documents dated [DATE] at 1:09 P.M. revealed Resident #70 had a blood glucose level greater than 784 mg/dL and was admitted unresponsive on mechanical ventilation to the medical intensive care unit (MICU) with a concern for volume overload and flash pulmonary edema. The resident's temperature was 102.6 degrees Fahrenheit. The physician noted the resident was critically ill due to acute encephalopathy and comatose state and if untreated, there was a high risk of imminent or life-threatening deterioration of the resident's condition due to worsening hypoxic-ischemic brain injury, cerebral edema, seizures, brain compression and brain death. Further review of the hospital document revealed on [DATE] at 2:11 P.M., Resident #70 was also assigned a diagnosis of acute metabolic acidosis. Review of a nursing progress note dated [DATE] revealed the family reported Resident #70 expired in the hospital today. Interview on [DATE] at 12:41 P.M. with Registered Nurse (RN) #390 verified there was no documentation that indicated neurological checks were performed on Resident #70 from the time she was found on the floor at [DATE] at 2:42 A.M. until she was transported to the hospital on [DATE] at 7:32 A.M. by EMT personnel or that the physician was notified of the resident's change in condition until transport to the hospital on [DATE] at 7:32 A.M. Telephone interview on [DATE] at 1:12 P.M. with previous DON #395 verified neurological checks were not performed on Resident #70 after finding her on the floor on [DATE] at 2:42 A.M. through the time she was transported to the hospital on [DATE] at 7:32 A.M. Previous DON #395 also verified neither the physician, physician extender, nor family were notified of the resident's change in condition until after the resident was transported to the hospital. He was unable to provide rationale as to why neither neurological checks were obtained nor why the physician and family were not notified. Telephone interview on [DATE] at 8:32 A.M. with Nurse Practitioner (NP) #195 verified it was the expectation for the facility to make immediate notification to the physician or physician extender for any resident who was experiencing or who had experienced a change in condition. NP #195 verified the facility did not make notification for Resident #70's change in condition until the resident was transported to the hospital on [DATE] at 7:32 A.M. NP #195 stated she should have been called immediately after the resident was found on the floor on [DATE] at 2:42 A.M., especially when it was noted the resident had swelling noted to the face and was on an anticoagulant medication. Interview on [DATE] at 8:40 A.M. with the current DON revealed the findings of the facility's investigation were inconclusive as to how Resident #70 became to be on the floor in the early morning hours of [DATE]. The DON stated Resident #70 had a blanket on the floor and her oxygen tubing remained connected to her tracheostomy. The DON stated it was a strong possibility the resident placed herself on the floor and laid down. The DON did verify neurological checks were not completed on Resident #70 nor was the physician notified of the resident's change in condition until after transport to the hospital on [DATE] at 7:32 A.M. Interview on [DATE] at 11:55 P.M. with NP #195 verified Resident #70 had a history of erratic blood glucose levels and stated the resident was afraid of being administered greater than 8 units of insulin for fear of it stacking up due to her diagnosis of type I diabetes mellitus. NP #195 verified the facility, and specifically previous DON #395, should have notified her immediately of the resident refusing the order for the 16 units of insulin on [DATE] at 7:46 P.M. and the resident should have been reassessed between [DATE] at 7:46 P.M. and [DATE] at 2:42 A.M. with an update provided. NP #195 also verified she would have definitely ordered the resident be sent to the hospital on [DATE] at 2:42 A.M. had she been notified by previous DON #395. Review of facility self-reported incidents from [DATE] revealed no evidence the facility notified the State Survey Agency of a situation of neglect involving Resident #70's lack of assessment, treatment, and notification of change to the physician or nurse practitioner. Interview on [DATE] at 6:46 P.M. with Regional Director of Clinical Operations (RDCO) #199 verified the facility did not submit their results of the investigation regarding the incident with Resident #70 in [DATE] to the State Survey Agency within five working days of the incident. 2. Medical record review for Resident#59 revealed he admitted to the facility on [DATE]. Diagnoses included orthostatic hypertension, cerebral vascular accident, depression, hypertension, hyperlipidemia, diabetes mellitus (DM), and respiratory failure. Review of the MDS assessment for Resident #59, dated [DATE], revealed he had impaired cognition. Resident #59 was dependent on staff for oral hygiene, medication administration, toilet use, personal hygiene, bathing, dressing, transfers, and bed mobility. Resident #59 required a tube feed for nutrition and had an invasive mechanical ventilator. 3. Medical record review for Resident #122 revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, osteomyelitis, dependence on respiratory ventilator, major depressive disorder, atrial fibrillation, acute kidney failure, dysphasia, and anxiety disorder. Review of the MDS assessment, dated [DATE], revealed Resident #122 was cognitively intact. Further review of the MDS assessment confirmed Resident #122 was dependent on staff for medication administration, toilet use, lower body dressing, and putting on shoes. Resident #122 required assistance with meals and oral hygiene. He required maximum assistance with showering and required an invasive mechanical ventilator. 4. Medical record review for Resident #123 revealed he was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, major depressive disorder, essential primary hypertension, pulmonary embolism, cerebral infarction, and DM. Review of the MDS assessment, dated [DATE], revealed Resident #123 had impaired cognition. Resident #123 was dependent on staff for medication administration, oral hygiene, toilet use, bathing, personal hygiene, dressing, and transfers. Resident #123 required the use of oxygen, tracheostomy care, and required an invasive mechanical ventilator. Resident #123 was assessed at risk for the development of pressure ulcers. Review of Certified Nurse Aide (CNA) #145's personnel file revealed she was hired at the facility on [DATE]. Review of a disciplinary action document dated [DATE] revealed, upon doing wound rounds, it was noted several residents were soiled and not changed timely, not turned, and were not repositioned timely. The disciplinary action was marked as verbal counseling and was dated [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 10:54 A.M. confirmed she was aware of an incident related to CNA #145 getting behind on her work and failing to change her assigned residents within the past two weeks. The DON stated she disciplined CNA #145 for leaving her residents soiled. The DON confirmed the facility failed to report an allegation of neglect when CNA #145 failed to provide care and services for Resident #59, Resident #122, and Resident #123 on [DATE]. The DON confirmed she did not complete a thorough investigation of the incident because she felt CNA #145 was a good aide and the DON did not receive complaints about CNA #145's care. The DON stated CNA #145 told her the reason she was behind on resident care on [DATE] was because she had a bad day. Interview on [DATE] at 11:18 A.M. with CNA #145 confirmed she got very behind on her assignments on [DATE]. CNA #145 confirmed she failed to change the soiled sheets for Resident #59, Resident #122, and Resident #123 and confirmed she did not notify anyone that day of the care and services not being provided for those residents. CNA #145 confirmed did not ask the nurses or other CNAs for assistance with her residents because they were behind with care as well. Interview on [DATE] at 9:06 A.M. with Wound Nurse (WN) #150 confirmed three (#59, #122, and #123) residents were found lying on soiled sheets on [DATE] during her wound rounds. WN #150 stated on [DATE] at 5:00 P.M. she started her wound rounds down the 200 hallway. WN #150 confirmed Resident #59, Resident #122, and Resident #123 were all under the care of CNA #145 on [DATE]. WN #150 confirmed she found Resident #59 with very soiled and wet sheets, and Resident #123 was found with a dislodged tube feeding and had wet and dried tube feeding supplement all over his sheets. WN #150 stated Resident #123 had extremely compromised skin and should not lay in wet and soiled sheets. WN #150 also confirmed Resident #122 was found with his sheets soiled and saturated from his wounds. WN #150 explained how fragile Resident #122's skin was and the importance of keeping the resident's sheets clean and dry. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated [DATE], revealed an immediate investigation was warranted when suspicion of abuse, neglect, or exploitation, or report of abuse, neglect, or exploitation occur. The facility will identify the staff responsible for the investigation, identify and interview all involved persons, and provide complete and through documentation of the investigation. The facility will have written procedures for reporting alleged abuse, neglect, or exploitation. The procedures include reporting of alleged violations, immediately but no later than two hours after the allegation was made, if the events involve abuse or result in serious bodily injury, and no later than 24 hours if the events that cause the allegation do not involve abuse or result in bodily injury. The Administrator will follow up with government agencies, during business hours, to confirm 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.

Based on medical record review, observation, staff interview, pharmacist interview, and review of a facility policy, the facility failed to ensure insulin was properly dated and stored. This affected 10 (#2, #21, #23, #30, #49, #55, #62, #121, #124, and #321) of 26 residents the facility identified as receiving insulin. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, end-stage renal disease with dependence on hemodialysis, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe cognitive impairment and was always incontinent of bowel and bladder. The resident received nutrition through an enteral feeding tube and was dependent for oral and personal hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of physician orders revealed Resident #23 had an order dated [DATE] for Lispro insulin with meals per sliding scale and an order dated [DATE] for Basaglar insulin pen-injector 25 units subcutaneously at bedtime for diabetes mellitus type II. Observation and interview on [DATE] at approximately 8:20 A.M. of the 900 nursing unit medication cart with Licensed Practical Nurse (LPN) #155 confirmed Resident #23's Basaglar insulin and Lispro insulin pen-injectors were not dated when removed from refrigerated storage and placed in the medication cart. 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, acute respiratory failure with hypoxia, tracheostomy, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #55 had moderate cognitive impairment and was frequently incontinent of bowel and bladder. The resident required set up assistance for eating, supervision for oral hygiene and bed mobility, and moderate assistance for toileting, bathing, dressing, personal hygiene, and transfers. Review of physician orders revealed Resident #55 had an order dated [DATE] for Novolog insulin pen injector via sliding scale before meals. Observation and interview on [DATE] at approximately 8:20 A.M. of the 900 nursing unit medication cart with LPN #155 confirmed Resident #55 had two Novolog insulin pen-injectors in the medication cart. One was dated [DATE] as being removed from refrigerated storage and placed in the medication cart and should have been discarded on [DATE]. The other Novolog insulin pen-injector was undated. 3. Review of the medical record revealed Resident #321 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, malignant neoplasm of the brain, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #321 had no cognitive deficit and was always continent of bowel and bladder. The resident received nutrition through an enteral feeding tube and required set up assistance with oral hygiene, supervision with bed mobility and transfers, moderate assistance for toileting and dressing and maximal assistance with personal hygiene. Review of physician orders revealed Resident #321 had an order dated [DATE] to be administered Glargine (Semglee) insulin pen-injector 46 units subcutaneously at bedtime for diabetes mellitus type II. Observation and interview on [DATE] at approximately 8:20 A.M. of the 900 nursing unit medication cart with LPN #155 revealed Resident #321's Glargine (Semglee) insulin pen-injector was not dated when removed from refrigerated storage and placed in the medication cart. 4. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, end-stage renal disease with dependence on hemodialysis, and congestive heart failure. Review of the annual MDS assessment dated [DATE] revealed Resident #30 had no cognitive deficit and was always incontinent of bowel and frequently incontinent of bladder. The resident required set up assistance with eating, supervision with oral hygiene and bed mobility, dependent for toileting and transfers, moderate assistance for bathing and personal hygiene, and maximal assistance for dressing. Review of physician orders revealed Resident #30 had an order dated [DATE] for Glargine insulin pen-injector 11 units subcutaneously at bedtime for diabetes mellitus type II. Observation and interview on [DATE] at approximately 8:20 A.M. of the 900 nursing unit medication cart with LPN #155 confirmed Resident #30's Glargine insulin pen-injector was not dated when removed from refrigerated storage and placed in the medication cart. 5. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, cerebrovascular accident with right (dominant) side hemiplegia and hemiparesis, and atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 had no cognitive deficit and was always incontinent of bowel and occasionally incontinent of bladder. The resident required set up assistance for eating, moderate assistance for oral hygiene and bed mobility, and was dependent for toileting, bathing, dressing, personal hygiene, and transfers. Review of physician orders revealed Resident #2 had an order dated [DATE] for Glargine insulin pen-injector 24 units subcutaneously at bedtime for diabetes mellitus. This physician order was discontinued on [DATE]. Observation and interview on [DATE] at approximately 8:20 A.M. of the 900 nursing unit medication cart with LPN #155 revealed Resident #2's Glargine insulin pen-injector was not dated when removed from refrigerated storage and placed in the medication cart. In addition, the resident's Glargine insulin pen-injector remained in the medication cart since the physician discontinued the order on [DATE]. 6. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, end-stage renal disease with dependence on hemodialysis, and congestive heart failure. Review of the significant change MDS assessment dated [DATE] revealed Resident #49 had no cognitive impairment and was frequently incontinent of bowel and always incontinent of bladder. The resident required moderate assistance for eating and oral hygiene, was dependent for toileting, bathing, dressing, and transfers, and maximal assistance for personal hygiene and bed mobility. Review of physician orders revealed Resident #49 had an order dated [DATE] for Humalog insulin pen-injector subcutaneously one time a day for diabetes mellitus via sliding scale. Resident #49 was also ordered Glargine insulin insulin pen-injector 30 units subcutaneously at bedtime on [DATE] for diabetes mellitus type II. Observation and interview on [DATE] at approximately 8:20 A.M. of the 900 nursing unit medication cart with LPN #155 confirmed Resident #49 had two Glargine insulin pen-injectors in the medication cart. One was dated [DATE] as being removed from refrigerated storage and placed in the medication cart and should have been discarded on [DATE]. The other Glargine insulin pen-injector and Humalog insulin pen-injectors were not dated. Interview on [DATE] at 8:20 A.M. with LPN #155 verified the insulin pen-injectors for Resident #23, Resident #55, Resident #321, Resident #30, Resident #2, and Resident #49 were not dated when removed from refrigerated storage and placed in the medication cart. LPN #155 also confirmed Resident #55 and Resident #49 had insulin pen-injectors exceeded the 28 day use by date. 7. Review of the medical record revealed Resident #121 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, acute respiratory failure with hypoxia, and tracheostomy. Review of the MDS assessment dated [DATE] revealed Resident #121 had severe cognitive impairment and was always incontinent of bowel and bladder. The resident required an enteral feeding tube for nutrition and was dependent for oral and personal hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of physician orders revealed Resident #121 had an order dated [DATE] for Glargine insulin pen-injector 35 units subcutaneously at bedtime for diabetes mellitus type II and an order dated [DATE] for Lispro insulin pen-injector six (6) units subcutaneously four times a day for diabetes mellitus type II. Observation on [DATE] at approximately 8:29 A.M. of the 200 (top) nursing unit medication cart with LPN #122 revealed Resident #121's Glargine insulin pen-injector and Lispro insulin pen-injector were not dated when removed from refrigerated storage and placed in the medication cart. 8. Review of the medical record revealed Resident #124 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, acute respiratory failure with hypoxia, tracheostomy, and cerebrovascular accident with right (dominant) side hemiplegia and hemiparesis. Review of physician orders revealed Resident #124 had an order dated [DATE] for Lispro insulin pen-injector with meals via sliding scale for diabetes mellitus type II. Observation on [DATE] at approximately 8:29 A.M. of the 200 (top) nursing unit medication cart with LPN #122 revealed Resident #124's Lispro insulin pen-injector was not dated when removed from refrigerated storage and placed in the medication cart. Interview on [DATE] at 8:29 A.M. with LPN #122 verified the pen-injectors for Resident #121 and Resident #124 were not dated when removed from refrigerated storage and placed in the medication cart. 9. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, chronic kidney disease, and heart failure. Review of the annual MDS assessment dated [DATE] revealed Resident #21 had no cognitive deficit and was always incontinent of bowel and always incontinent of bladder. The resident required assistance with eating, partial to moderate assistance with oral hygiene and bed mobility, was dependent for toileting and transfers, require moderate assistance for bathing and personal hygiene, and required maximal assistance for dressing. Review of physician orders revealed Resident #21 had an order dated [DATE] for Glargine insulin pen-injector 15 units subcutaneously at bedtime for diabetes mellitus type II. Observation on [DATE] at approximately 8:35 A.M. of the 300 nursing unit medication cart with LPN #130 revealed Resident #21's Lispro insulin pen-injector was not dated when removed from refrigerated storage and placed in the medication cart. 10. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II with diabetic neuropathy, chronic obstructive pulmonary disease with (acute) exacerbation, and peripheral vascular disease. Review of the annual MDS assessment dated [DATE] revealed Resident #62 had no cognitive deficit and was always incontinent of bowel and always incontinent of bladder. The resident required setup or clean-up assistance with eating, oral hygiene, and bed mobility, partial to moderate assistance for toileting and transfers, substantial to maximal assistance for bathing and personal hygiene, and maximal assistance for dressing. Review of physician orders revealed Resident #62 had an order dated [DATE] for Glargine insulin pen-injector five (5) units subcutaneously at bedtime for diabetes mellitus type II. Observation on [DATE] at approximately 8:35 A.M. of the 300 nursing unit medication cart with LPN #130 revealed Resident #62's Lispro insulin pen-injector was not dated when removed from refrigerated storage and placed in the medication cart. Interview on [DATE] at 8:35 A.M. with LPN #130 verified the insulin pen-injectors for Resident #21 and Resident #62 were not dated when removed from refrigerated storage and placed in the medication cart. Interview on [DATE] at 1:57 P.M. with Consulting Pharmacist #385 verified insulin vials and/or pen-injectors must be dated when removed from refrigerated storage and that Glargine, Basaglar, Lantus, Lispro, Humalog, and Novolog insulins had an expiration date of 28 days after removal from refrigerated storage and placement in the medication cart. Interview on [DATE] at 1:45 P.M. with the Director of Nursing (DON) verified insulin pen-injectors must be dated when removed from refrigerated storage and expired 28 days after removed from refrigerated storage. Review of the policy titled, Storage of Medication, dated ,d+[DATE], revealed medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Insulin products should be stored in the refrigerator until they are opened and note the date on the label for insulin vials and pens when first used. The opened insulin pens should be stored at room temperature.

Based on observation, staff interview, and medical record review, the facility failed to ensure fall interventions were implemented as care planned. This affected one (#55) of five residents reviewed for falls. The facility census was 72. Findings Include: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, epilepsy, type II diabetes, major depressive disorder, and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of care plan dated 04/29/24 revealed Resident # 55 was at risk for falls related to generalized weakness, poor balance, decreased strength and endurance, and need for assistance with activities of daily living (ADLs). Interventions included to encourage to rest in the afternoon, encourage to lay in the center of the bed, frequently monitor for infection, grab bars to the bed for repositioning, educate on safety interventions, encourage to use the call light, fall mats on floor to bilateral sides of bed, perimeter mattress, observe and report changes in activity levels, call light within reach, encourage the resident to be in common areas when awake, therapy screens as needed, and provide visual cues to assist with transfers. Observation on 03/12/25 at 10:39 A.M. revealed Resident #55 had only one fall mat on floor located on the resident's right side of the bed. There were no other fall mats visible in the room, closet, or bathroom. Observation on 03/12/25 at 3:09 P.M. revealed Resident #55 had only one fall mat on floor located on the resident's right side of bed. There were no other fall mats visible in the room, closet, or bathroom. During an interview on 03/12/25 at 2:09 P.M. Registered Nurse (RN) #98 verified Resident #55 only had one mat on the floor in his room. RN #98 verified there were no other fall mats stored in the room and Resident #55 was care-planned for two fall mats. This deficiency represents non-compliance identified under Complaint Number OH00162508.

Based on medical record review, staff interview, and physician interview, the facility failed to ensure a resident was assessed timely by the physician after admission. This affected one (#25) of three residents reviewed for physician visits. The facility census was 72. Findings Include: Medical record review for Resident #25 revealed she was admitted to the facility on [DATE] with hospice services. Diagnoses included morbid obesity, acute and chronic respiratory failure, obstructive sleep apnea, hypothyroidism, bipolar disorder, diabetes mellitus, peripheral vascular disease, anxiety disorder, major depressive disorder, and alcohol dependence. Resident #25 was discharged to the hospital on 01/31/25 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #25, dated 02/15/25, revealed Resident #25 was cognitively intact. Resident #25 was dependent on staff for medication administration, toilet use, bathing, lower body dressing, sit to lying position, chair to bed transfer, and tub transfer. Resident #25 required moderate assistance from staff with oral hygiene and set up assistance from staff with eating. Resident #25 required maximum assistance with upper body dressing and personal hygiene. Review of the physician visit progress notes revealed Resident #25 was assessed by the physician on 11/11/24 and 12/16/24. Interview on 03/13/25 at 3:28 P.M. with Medical Director (MD) #500 confirmed Resident #25 had not been assessed by a facility physician since 12/16/24. MD #500 confirmed Resident #25 readmitted to the facility on [DATE] from the hospital and had not been assessed since her readmission. MD #500 confirmed Resident #25 should have been assessed within thirty days of her admission.

Based on observations, resident and staff interviews, medical record review, and policy review, the facility failed to develop care plans for dental care for residents with dental concerns. This affected one (#49) of three residents reviewed for dental care. The facility census was 72. Findings Include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with dependence on renal dialysis, combined congestive heart failure, and oropharyngeal dysphagia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #49 had no natural teeth and was not assessed as having loose fitting dentures. Review of the care plan dated 02/24/24 revealed Resident #49 had no care plan for dental care. During an interview on 03/10/25 at 1:01 P.M. Resident #49 stated his dentures did not fit due to recent gradual weight loss. During an interview on 03/12/25 at 12:57 P.M. Social Worker #91 stated she had a care conference earlier this month to discuss concerns with weight loss. Resident #49 stated his gums hurt because his dentures were loose. During an interview on 03/12/25 at 1:34 P.M. Registered Nurse (RN) #390 verified Resident #49 did not have an active care plan for dental care to address concerns with dental pain and loose-fitting dentures.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASRR) was accurately completed. This affected one (#25) of two residents reviewed for PASRR. The facility census was 72. Findings Include: Medical record review for Resident #25 revealed she was admitted to the facility on [DATE] with hospice services. Diagnoses included morbid obesity, acute and chronic respiratory failure, obstructive sleep apnea, hypothyroidism, bipolar disorder, diabetes mellitus, peripheral vascular disease, anxiety disorder, major depressive disorder, and alcohol dependence. Review of the Minimum Data Set (MDS) assessment for Resident #25, dated 02/15/25, revealed the resident was cognitively intact. Resident #25 was dependent on staff for medication administration, toilet use, bathing, lower body dressing, sit to lying position, chair to bed transfer, and tub transfer. Resident #25 required moderate assistance from staff with oral hygiene and set up assistance from staff with eating. Resident #25 required maximum assistance with upper body dressing and personal hygiene. Review of the document titled, Preadmission Screening and Resident Result Notice, dated 02/19/22, confirmed Resident #25's diagnoses of anxiety disorder and bipolar disorder was not marked. The resident indicator of a serious mental health condition was only marked for mood disorder. Interview on 03/11/25 at 2:39 P.M. with Director of Social Services (DSS) #191 confirmed Resident #25 admitted to the facility from another facility on 11/08/24. DSS #191 confirmed the PASRR dated, 02/18/22, was completed incorrectly and did not identify Resident #25's mental health diagnoses. DSS #191 confirmed the facility does not have a corrected PASRR on file. Review of the facility policy titled, PASARR, Preadmission Screen and Resident Review, dated 10/30/23, confirmed a facility must coordinate with the pre-admission screening and resident review program under Medicaid. A nursing facility must not admit on or before January 1, 1989, new Residents with mental health diagnoses. All residents are required to have a Level 1 PASRR screen upon admission to the facility. If a Level II screen is required the facility will complete notification on the State's PASRR program notice for the Level II screen prior to or upon admission to the facility.

Based on observation, resident and staff interview, medical record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and review of a government website, the facility failed to accurately code the status of a non-invasive mechanical ventilation on Minimum Data Set (MDS) assessments. This affected one (#60) of four residents reviewed for ventilators. The facility census was 72. Findings include: Medical record review for Resident #60 revealed she was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, pulmonary hypertension, congestive heart failure, asthma, essential primary hypertension, chronic kidney disease, anemia, dysphagia, and diabetes mellitus. Review of the MDS assessment, dated 02/18/25, for Resident #60 revealed she was cognitively intact. Resident #60 was dependent on staff for medication administration, toilet use, and lower body dressing. Resident #60 required maximum assistance from staff with showers. Further review of the MDS assessment revealed Resident #60 required an invasive mechanical ventilator. Review of the physician order summary for Resident #60 revealed an order, dated 02/14/25, for an Average Volume Pressure Support (AVAPS) Ventilator (VT) as needed with ordered settings every evening and night shift revealed to acute respiratory failure with hypoxia. Resident #60's also had an order dated 02/11/25 for staff to visually check ventilator dependent residents per the care plan and as needed every evening shift for resident status with instructions to check every two hours. Interview and observation on 03/12/25 at 2:30 P.M. with Resident #60 revealed a Trilogy AVAP (non- invasive ventilator) on a rolling pole the resident stated she was connected to nightly via a continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP) mask. At the time of the observation and interview, the resident was not connected to the Trilogy AVAP and not wearing the CPAP/BIPAP mask. Interview with MDS Nurse #104 on 03/11/25 at 8:55 A.M. confirmed Resident #60 was coded on the MDS assessment dated [DATE] that the resident required an invasive mechanical ventilator. MDS Nurse #104 confirmed that was incorrect and Resident #60 should have been coded as a non- invasive mechanical ventilator. MDS Nurse #104 confirmed the AVAP ventilator was a non-invasive mechanical ventilator. Review of a government website at, https://www.ncbi.nlm.nih.gov/books/NBK560600/#:~:text=Average%20volume%2Dassured%20pressure%20support%20(AVAPS)%20is%20a%20relatively,modality%20of%20non%2Dinvasive%20ventilation, under the title of, Average Volume-Assured Pressure Support, dated 08/08/23, revealed different modalities of non-invasive ventilation exist, with CPAP and BiPAP being the most commonly used modes. Average volume-assured pressure support (AVAPS) is a relatively newer modality of non-invasive ventilation that integrates the characteristics of both volume and pressure-controlled non-invasive ventilation. Review of the Long-Term Care Facility RAI 3.0 User's Manual, version 1.19.1, dated October 2024, revealed, in section O0110F1, under Invasive Mechanical Ventilator (ventilator or respirator), staff are to code any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support their own respiration in this item. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator. Residents receiving closed-system ventilation include those residents receiving ventilation via an endotracheal tube (e.g., nasally or orally intubated) or tracheostomy. A resident who has been weaned off a respirator or ventilator in the last 14 days or is currently being weaned off a respirator or ventilator, should also be coded here. Do not code this item when the ventilator or respirator is used only as a substitute for BiPAP or continuous positive airway pressure (CPAP). Further review of the Long-Term Care Facility RAI 3.0 User's Manual, revealed, in section O0110G1, under Non-invasive Mechanical Ventilator, staff are to code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support their own spontaneous respiration by providing enough pressure when the individual inhales to keep their airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device.

Based on medical record review and staff interview, the facility failed to ensure a resident's advance directive was fully completed and dated by the physician. This affected one (#65) of three residents reviewed for advanced directives. The facility census was 72. Findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, end stage renal disease, cutaneous abscess of the abdominal wall, renal dialysis, essential primary hypertension, heart failure, dysphagia, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, dated 02/04/25, revealed Resident #65 had impaired cognition. Resident #65 was dependent on staff for medication administration, eating, dressing, bathing, and personal hygiene. Review of the undated form titled, DNR Comfort Care, revealed Resident #65 was indicated to have a DNR Comfort Care (DNRCC) advanced directive selected; however, there was no selection made under the section titled Certification of DNR Comfort Care Status, with an indication that it was to be completed by a physician. The choices to select included Do-Not-Resuscitate-Order or Living Will (Declaration) and Qualifying Condition with instructions to check only one box, and neither were marked. Further review of the form revealed the physician signed the form but did not date it. Review of the physician orders for Resident #65 dated 02/07/25 revealed an order for a DNRCC advanced directive. Interview with Licensed Practical Nurse (LPN) #122 on 03/11/25 at 11:55 A.M. confirmed Resident #65's DNR Comfort Care form was signed by the physician; however, it was not dated. LPN #122 also confirmed the boxes were left blank related to Do Not Resuscitate Order and Living Will (Declaration) and Qualifying Condition. LPN #122 confirmed the physician's date was required.

Based on a closed medical record review, staff interviews, and review of the facility policy, the facility failed to administer appropriate respiratory care, administration of a ventilator at night, as ordered for Resident #10, who had a compromised respiratory status. This resulted in Immediate Jeopardy when the ventilator was not applied, and Resident #10 was found unresponsive, and required cardiopulmonary resuscitation (CPR) and hospitalization . This affected one (Resident #10) of five residents reviewed for ventilator use in the last three months. The census was 62 residents. On [DATE] at 11:06 A.M., the Administrator, Director of Nursing (DON), [NAME] President of Clinical (VPC) #900 and Regional Director of Operations (RDO) #901 were notified the Immediate Jeopardy began on [DATE] at bedtime when Resident #10 was not placed on a ventilator as ordered by physician from the hospital to apply a vent at hour of sleep and to wean as tolerated. On [DATE] at 6:04 P.M., Respiratory Therapist (RT) #400 transcribed the order for the ventilator at night to the resident's electronic medical record (EMR). Staff did not apply the ventilator to Resident #10 on [DATE] at bedtime and the resident was found unresponsive on [DATE] at 8:07 A.M. Staff initiated cardiopulmonary resuscitation (CPR) until emergency medical services (EMS) personnel arrived and took over CPR. The EMS personnel stopped CPR on [DATE] at 8:28 A.M. when Resident #10 regained a pulse and was transported to the hospital and was admitted with a diagnosis of acute respiratory failure. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the DON or designee(s) evaluated all residents with ventilators to ensure the residents with ventilators had proper orders and ventilator settings and care plans in place. No issues were identified at that time. The facility identified two residents with ventilators (Residents #16 and #20). On [DATE], the DON or designee reviewed all physician's orders for all residents residing in the facility to ensure that there were no orders in queue or pending confirmation status. The review revealed Resident #21 had an order for physical therapy/occupational (PT/OT) which was pending confirmation, and the DON confirmed the order. On [DATE], the DON/designee visually observed all residents in house with ventilators (Residents #16 and #20) to ensure the ventilators were in place and functioning per physician's orders. On [DATE], the DON/designee reviewed new/readmission resident charts for residents admitted on [DATE] to [DATE] (Residents #10, #22, #23) to ensure all orders were transcribed appropriately. No concerns were identified. On [DATE], the DON/designee began education of licensed nurses and respiratory therapists (RTs) on ensuring orders were transcribed correctly and confirmed with the physician and were not left in queue or pending confirmation status. Education also included that all changes in condition were reported to the nurse, responsible party and physician, that assessments were to be completed and documented in the EMR, and if there was a change in condition to complete a change in condition assessment in the EMR. On [DATE] three of six RTs on staff were educated, 14 of 14 Licensed Practical Nurses (LPNs) on staff were educated, and seven of seven Registered Nurses (RNs) on staff were educated. On [DATE] the DON/designee completed education of the other three RTs which completed education for all staff. The facility does not use agency staff, and none of the staff are currently on leave. On [DATE], the DON/designee began audits of all new physician's orders for residents on ventilators. On [DATE] the audits continued to be completed five times per week to ensure all orders were transcribed appropriately and confirmed by the physician. The audits will continue for four weeks. Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. On [DATE], the facility had an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to discuss the incident involving Resident #10. The facility will forward all audits to the QAPI Committee to determine the need for further monitoring. The Administrator, the DON and the Medical Director were in attendance. On [DATE], the DON/designee will audit ventilator/tracheostomy assessment/documentation for up to five residents weekly for four weeks. Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. On [DATE], the DON/designee will review all new admission/readmission orders Monday through Friday to ensure that all ventilator orders are in place and transcribed appropriately for four weeks. On [DATE], the DON/designee began to observe for completion of walking rounds at the change of shift between RTs to be completed three times per week for four weeks. On [DATE], the oncoming RT will audit the previous shift to ensure all ventilator settings are accurate for four weeks. On [DATE] at 11:30 A.M., LPN #250 verified she was educated on policies and procedures for Code Blue, admission orders, and reporting change in condition, refusal of care, and assessments. Interviews on [DATE] at 10:25 A.M. with RN #100, at 10:30 A.M. with LPN #220, and at 11:00 A.M. with RN #110 confirmed they received education on [DATE] on physician orders, change in condition, and ventilators. Interview on [DATE] at 12:40 P.M. with RT #430 confirmed he received education on [DATE] on physician's orders, change in condition, and ventilators. Although the Immediate Jeopardy was removed, 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 is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #10 revealed an initial admitted [DATE] and a readmitted [DATE] with diagnoses including respiratory disorder, dependence on respiratory, chronic obstructive pulmonary disease (COPD), diabetes mellitus type two, and congestive heart failure. Review of the care plan for Resident #10 dated [DATE] revealed the resident was ventilator dependent related to respiratory failure with interventions which included the following: maintain ventilator settings as ordered, observed or report to the physician as needed any signs or symptoms of upper respiratory infection or pneumonia, suction per orders and as needed. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated [DATE] revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs). Review of the hospital continuity of care orders for Resident #10 dated [DATE] revealed an order to apply a ventilator to the resident at the hour of sleep. Review of the progress note for Resident #10 dated [DATE] timed at 5:18 P.M. revealed the resident was admitted to the facility from a local hospital. Resident #10 was placed on continuous aerosol tracheostomy collar (CATC) with oxygen running at eight liters per minute (LPM). Review of the admission physician's orders for Resident #10 dated [DATE] revealed the order for the ventilator at night was not confirmed by the physician and had not been placed in the resident's Medication Administration Record (MAR.) Review of the MAR for Resident #10 dated [DATE] revealed the order for the ventilator at night was not included in the MAR. Review of the progress note for Resident #10 dated [DATE] timed at 8:20 P.M. per RT #410 revealed the resident had the tracheostomy with oxygen in place. There was no documentation regarding application of the ventilator for the resident. Review of the progress note for Resident #10 dated [DATE] timed at 8:20 A.M. per RT #400 revealed the resident had no pulse, staff called a code blue, and initiated CPR. Review of the physician's orders for Resident #10 revealed the order for the ventilator at night for the resident was confirmed with the physician and entered into the resident's MAR on [DATE] per LPN #200. Interview on [DATE] at 1:38 P.M. with RT #410 confirmed she cared for Resident #10 on the night of [DATE]. RT #410 confirmed she did not place or offer to place the ventilator on the resident at any time during the shift. RT #410 confirmed prior to Resident #10's readmission from the hospital on [DATE] the resident had been on a ventilator continuously. RT #410 confirmed there was no order entered into Resident #10's MAR for application of a ventilator at hour of sleep. RT #410 confirmed the last time she saw Resident #10 was on [DATE] at 5:30 A.M., and the resident was wearing a tracheostomy with oxygen in place and was breathing normally. RT #410 confirmed when she arrived home after work the morning of [DATE], RT #400 called her home and notified her Resident #10 had coded and been taken to the hospital. RT #410 confirmed RT #400 questioned if RT #410 had seen an order for a ventilator at night and RT #410 confirmed she told RT #400 she had not seen a valid order for the ventilator at night. Interview on [DATE] at 10:40 A.M. with the DON and the Administrator confirmed Resident #10 had been on a ventilator continuously prior to her readmission to the facility on [DATE]. Further interview confirmed the hospital COC form ordered Resident #10 to have a ventilator placed at night and RT #400 had entered the order in the EMR. The DON confirmed Registered Nurse (RN) #100 had confirmed the admitting medication orders with the physician on [DATE] but had not confirmed the order for the ventilator at night with the physician or entered the order into the MAR. The Administrator confirmed the facility began implementing corrective action on [DATE] after Resident #10 had coded and was transferred to the hospital after not having the ventilator placed at night as ordered. The DON and the Administrator confirmed staff should have placed a ventilator on Resident #10 at night on [DATE]. Review of the facility policy titled Ventilator Unit-Mechanical Ventilation: Setup and Monitoring dated [DATE], revealed staff should verify that there was a physician's order for use of a mechanical ventilator and should review the physician's orders and care plan for any special needs of the resident. This deficiency represents noncompliance investigated under Complaint Number OH00159870.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident received the appropriate care and services for a treatment change to a nephrostomy tube. This resulted in Actual Harm to Resident #42 when a registered nurse utilized scissors to cut a dressing off and accidentally cut Resident #42's nephrostomy tube. Resident #42 had to undergo a surgical procedure to put the nephrostomy tube back into the right kidney and be monitored at the hospital for seven days. This affected one of three residents reviewed for an ostomy tube. Findings include: Review of Resident #42's medical record revealed an admitted [DATE]. Diagnoses included neurogenic bladder disorder and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was severely cognitively impaired. Resident #42 was dependent on staff for transfers, personal care, and bed mobility. Review of the plan of care dated 02/17/24 revealed Resident #42 had bilateral nephrostomy tubes related to neurogenic bladder. Interventions were to observe signs and symptoms of urinary tract infection, change in mental status, fever, and blood in urine. Keep tubing free of kinks and twists. Maintain the drainage bag below the bladder level. Notify and report signs of peri-area redness, irritation, skin excoriation, and skin breakdown to the physician. Review of the physician order dated 02/22/24 for Resident #42 revealed to cleanse the right and left nephrostomy sites with soap and water, then apply four by four split gauze every night shift. Review of the progress note dated 03/03/24 documented by Registered Nurse (RN) #140 revealed RN #140 notified Nurse Practitioner (NP) #118 and received a new order to send Resident #42 to the local hospital due to right side nephrostomy tube disconnected. Review of the hospital document dated 03/03/24 through 03/09/24 revealed Resident #42 was admitted to the hospital due to an accidental cutting of nephrostomy tube. The urology department was consulted and recommended Interventional Radiology replacement of right nephrostomy tube. Resident #42 was admitted to hospital for the procedure, and to the telemetry unit for monitoring. Interview on 03/12/24 at 1:41 P.M. with RN #140 stated Resident #42's nephrostomy tube was tangled with tape and she could not get to the four-by-four gauze dressing to observe the skin and clean at the tubing site. RN #140 stated she cut the tape off the right nephrostomy tube accidentally when she was trying to cut the tape free from the tangled tubing, to get to the four-by-four gauze taken off and to cleanse the peri wound area at the external tubing of right abdomen. RN #140 stated she did tape the cut tubing back together to assist in closing off the open tubing. RN #140 stated she called the nurse practitioner. RN #140 stated she got an order to send Resident #42 to the hospital for evaluation of the right side nephrostomy. Interview on 03/12/24 at 1:45 P.M. with the Director of Nursing (DON) stated she was never notified about Resident #42's nephrostomy tube being cut and retaped back. Interview on 03/12/24 at 5:14 P.M. with NP #118 stated RN #140 should not have used scissors to remove the tape off of Resident #42's dressing and the injury was preventable to Resident #42. NP #118 verified Resident #42 had to be sent to the emergency room and did have a procedure for guided nephrostomy to place back into the right kidney. NP #118 stated there was no complication, but Resident #42 was admitted to the hospital for monitoring. Review of the facility policy titled Nephrostomy and Cystostomy Tube Care and Maintenance, dated 10/20/20, revealed the nurses were to monitor resident for discomfort associated with the tube, record output from each tube, specify location of output, document abnormalities, and report to physician immediately. This deficiency represents non-compliance investigated under Complaint Number OH00151795.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the Centers for Disease Control and Prevention (CDC) COVID Data tracker and guidance, observations, review of the facility policies and procedures, review of the facility's COVID-19 testing records, and staff interviews, the facility failed to implement effective and recommended infection control practices, including a system to ensure the appropriate use of Personal Protective Equipment (PPE) by staff to prevent the spread of COVID-19 in the building, a system to ensure staff were donning and doffing PPE when required, ensure residents who tested positive for COVID-19 remained in their room or were wearing appropriate PPE outside of the room, a system in place for when to utilize appropriate hand hygiene and appropriate cough etiquette, and a system in place to ensure contaminated surgical gloves were disposed of properly. This resulted in Immediate Jeopardy and the potential for serious negative health outcomes and/or life-threatening harm when 41 residents (#01, #03, #04, #05, #09, #11, #13, #14, #15, #16, #17, #20, #23, #26, #27, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #45, #47, #53, #54, #55, #56, #59, #60, #63, #340, #350, and #355) and 17 staff including: Licensed Practical Nurse (LPN) #212, State tested Nurse Aide (STNA) #271, STNA #229, Registered Nurse (RN) #220, Speech Therapist (ST) #317, Maintenance Director #275, Medical Records Staff #268, Unit Manager RN #259, Respiratory Therapist (RT) #257, Housekeeping Aide #308, LPN #264, Kitchen Aide #314, STNA #283, STNA #205, Maintenance Assistant #236, Occupational Therapist (OT) #305, and STNA #239 tested positive for COVID-19 without the aforementioned systems in place to prevent the spread of COVID-19 to vulnerable residents in the facility. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 66 residents at potential risk for the likelihood of harm, negative health complications and/or death. The facility census was 66 residents. On 11/09/22 at 3:56 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services #320, were notified that Immediate Jeopardy began on 10/17/22 when Resident #350 tested positive for COVID-19 and the facility failed to implement appropriate and recommended infection control practices during a COVID-19 outbreak at the facility including inappropriate usage of PPE, inappropriate donning and doffing of PPE when entering and exiting a COVID-19 isolation room, allowing residents diagnosed with COVID-19 to walk through the facility without any PPE, not performing hand hygiene after coughing, and inappropriate use of gloves and disposal to prevent the transmission and spread of COVID-19 to the vulnerable residents in the facility. Upon entrance to the facility on [DATE], a total of 41 residents had tested positive since 10/17/22. The Immediate Jeopardy was removed on 11/09/22 when the facility implemented the following corrective actions: On 11/09/22 at 3:56 P.M., the DON, Staff Development Coordinator (SDC) #204, and Minimum Data Set (MDS) Nurse #225 identified that all residents have the potential to be affected. On 11/09/22 at 5:30 P.M., all 126-facility staff and ancillary personnel were educated by the DON and/or designee on appropriate usage of PPE per facility policy to include gloves, gown, eye protection, and face masks by the facility nurse management. Staff must wear PPE appropriately and this included: N-95 mask must cover nose and mouth, both straps must be always secured to the head, N-95 masks straps cannot be altered in any way, eye protection must be worn during outbreak in resident care areas, staff must adhere to cough etiquette and prompt hand hygiene is to be completed after coughing, gloves are to be worn for single use, not to be worn in hallways, hand hygiene is to be completed when gloves are removed; residents who are COVID-19 positive, doors to their rooms should be closed, if safe to do so. If unable to close the door, the curtain should be pulled closest to the door and the resident's care plan updated to reflect the reason the door is unable to be closed; and residents who are COVID-19 positive should be encouraged to stay in their rooms and to wear a face mask if they come out of their room. If having difficulty redirecting residents back to their room or the resident does not want to wear a face mask, inform the DON to conduct risk versus benefit discussion with those residents that have the mental capacity. No staff will work and/or return to work without first receiving education as outlined above. This includes ancillary staff and new hires and staff from sister facilities that come to work in the facility. On 11/09/22, the Administrator, DON and Medical Director #500 reviewed all the facility's Infection Prevention and Control Policies and were found to follow the CDC guidelines/recommendations. On 11/09/22, all residents who were cognitively intact were educated by Social Service Director #209 and Social Service Worker #260 on the importance of wearing a face mask as tolerated and the importance of staying in their room if COVID-19 positive as well as keeping their door closed if COVID-19 positive. Education also included adhering to the core principles of Infection Prevention and Control. On 11/09/22 at 7:30 P.M., all residents were assessed for signs and symptoms of COVID-19 by the nurse assigned to the hall; no new residents currently residing in the facility were identified as having the aforementioned. All residents will continue to be monitored and assessed every eight hours, by the nurse assigned to each hall, for signs and symptoms for the duration of outbreak testing. On 11/09/22 at 8:00 P.M., the State Survey Agency findings were reviewed by the DON, Administrator, and Medical Director #500 during an ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting and agreed with plans, education, and audits. . Beginning 11/09/22, audits to be completed by the Administrator/designee five times per week for four weeks, then reviewed by the QAPI committee for compliance and further recommendations. The audits will include monitoring staff donning and doffing of proper PPE, proper usage of PPE including eye protection, face masks, and glove use. Residents who are COVID-19 positive will be monitored for being encouraged to stay in their room and keep the room door closed. Staff will be observed for following proper cough etiquette. Observation of staff with gloves to ensure that they are appropriately changing out of their gloves between use and hand hygiene after gloves were removed. Although the Immediate Jeopardy was removed on 11/09/22, 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 ongoing compliance. Findings include: Observations on 11/08/22 between 10:00 A.M. to 10:30 AM. revealed residents diagnosed with COVID-19 were spread throughout the facility, and the facility did not have a designated COVID-19 unit. Review of the CDC's County Transmission rate dated 11/02/22 revealed the facility was in a red county indicating a high county transmission rate. Observation on 11/08/22 at 11:25 A.M. with RN #295 revealed RN #295 took her N-95 mask down to her chin to expose her mouth and nose, her goggles were on the top of her head and not covering her eyes and began coughing into her hand at her medication cart at the nursing station. RN #295 did not perform hand hygiene after coughing into her hand. RN #295 proceeded to put her N-95 mask back on her face and covered her mouth and nose and walked over to a resident hallway to talk to an unidentified STNA. RN #295 and the unidentified STNA were less than four feet from Resident #10. RN #295 took her N-95 mask down to her chin to expose her mouth and nose again, and her goggles remained on the top of her head and coughed into her hand again. RN #295 did not perform hand hygiene after coughing into her hand. RN #295 then put the N-95 mask back on her face. Resident #10 was sitting in her wheelchair with a surgical mask at her chin and was not covering her mouth and remained near RN #295. Resident #10 was not diagnosed with COVID-19 and was not in isolation. Interview on 11/08/22 at 11:27 A.M. with RN #295 stated she didn't think she took her N-95 mask down to her chin but verified she coughed into her hand. RN #295 verified she did not perform hand hygiene after coughing into her hands. RN #295 verified she did have her goggles on her head, and they were not protecting her eyes. Observation on 11/08/22 at 11:29 A.M. of Housekeeping Aide #309 revealed the housekeeping aide was standing outside room [ROOM NUMBER], which was not a positive COVID-19 room, and entered room [ROOM NUMBER] to begin to clean the room. Housekeeping Aide #309 did not have her N-95 mask on correctly. The N-95 second loop was hanging in the front of Housekeeping Aide's neck. Interview on 11/08/22 at the time of the observation with Housekeeping Aide #309 verified she did not have her second loop on correctly and verified it was hanging in the front of her neck. Observation on 11/08/22 at 11:31 A.M. revealed Resident #37 was sitting in her wheelchair at her isolation room door with no surgical mask on. Resident #37 was asked by STNA #288 to come down the hallway to the shower room to have a shower. Resident #37 left her isolation room and propelled her wheelchair by herself out of her room and headed down the resident hallway to follow STNA #288 to the shower room. Resident #37 was observed not wearing any PPE. STNA #288 was observed not to provide any guidance to Resident #37 at that time regarding the usage of PPE when out of her room. During an interview on 11/08/22 at 11:33 A.M. with Resident #37 she stated no one asked her to wear a surgical mask to go to the shower room. Interview on 11/08/22 at 11:35 A.M. with STNA #288 verified Resident #37 was currently diagnosed with COVID-19, Resident #37 was not wearing any PPE and was not encouraged to don PPE, and she encouraged Resident #37 to leave her isolation room. Interview on 11/08/22 at 11:37 A.M. with the DON verified STNA #288 should have directed Resident #37 to wear a face mask. Observation on 11/08/22 at 11:54 A.M. with Housekeeping Aide #301 revealed her goggles were on her head and not covering her eyes and her N-95 mask was placed at her chin and not covering her mouth and nose. Housekeeping Aide #301 was mopping the floor on the long-term care resident hallway. Housekeeping Aide #301 mopped in front of Resident #53's room, who was in isolation for being COVID-19 positive. Resident #53 was in her room with the door opened. During an interview on 11/08/22 at 12:00 P.M. with Housekeeping Aide #301 she stated she was hot (referring to her body temperature) mopping the floor, so she didn't want to wear her PPE. Housekeeping Aide #301 verified she did have her N-95 mask placed at her chin and not covering her mouth and nose and her goggles were on top of her head. Observation on 11/08/22 at 12:07 P.M. with Activity Aide #232 revealed she had her N-95 mask down at her chin and not covering her mouth and nose and was serving food to Residents #32, #44, and #48 who were in the dining room. Residents #32, #44, and #48 were not diagnosed with COVID-19 and were not in isolation. Interview on 11/08/22 at 12:09 P.M. with Activity Aide #232 verified she did not have her N-95 mask on correctly and it was at her chin. Interview on 11/08/22 at 1:30 P.M. with the DON revealed the facility's COVID-19 outbreak began on 10/17/22 when Resident #350 and OT #305 tested positive. The facility began twice weekly testing of staff and residents. Resident #14 tested positive for COVID-19 on 10/19/22, LPN #212 tested positive on 10/24/22, and Resident #09 tested positive on 10/26/22. On 10/27/22, four more residents (#33, #36, #39, and #55) tested positive. On 10/28/22, one resident (#38) and one employee (STNA #271) tested positive for COVID-19. On 10/29/22, six residents (#01, #13, #35, #37, #42, and #43) tested positive. On 10/31/22, eleven residents (#04, #05, #20, #26, #27, #34, #45, #47, #59, #340, and #355) and three employees (RN #220, STNA #229, and ST #317) had tested positive. On 11/01/22, two residents (#15 and #30) and one employee (Maintenance Director #275) tested positive. On 11/02/22, two residents (#17 and #41) and three employees (RT #257, Unit Manager RN #259, and Medical Records Staff #268) tested positive. On 11/03/22, eight residents (#23, #29, #40, #53, #54, #56, #60, and #63) tested positive. On 11/04/22, no additional residents tested positive but four employees (LPN #264, STNA #283, Housekeeping Aide #308, and Kitchen Aide #314) tested positive. On 11/05/22, one resident (#11) and one employee (STNA #205) tested positive. On 11/06/22, two residents (#16 and #31) tested positive and on 11/07/22, one resident (#03) and two employees (Maintenance Assistant #236, and STNA #239) tested positive. Observation on 11/08/22 at 1:58 P.M. of Resident #45 revealed Resident #45's door was open. Resident #45 came out of his isolation room and brought his two water pitchers for the staff to fill with ice. Resident #45 was without his face mask but was directed by LPN #269 to go back to his room and she will send a staff person to fill his water pitchers for him. Observation on 11/08/22 at 2:00 P.M. revealed STNA #273 entered Resident #45's room and was wearing a N-95 mask and goggles over her eyes. STNA #273 left Resident #45's room with two water pitchers and was wearing surgical gloves on both hands and walked down to the middle of the hall to retrieve ice from an ice chest to put in both Resident #45's water pitchers. STNA #273 did not doff her gloves and perform hand hygiene. STNA #273 came back with two full water pitchers with ice, and only had one plastic surgical glove on her left hand. Interview on 11/08/22 with STNA #273 at the time of the observation verified she left Resident #45's room with surgical gloves on both hands, she did not perform hand hygiene prior to the use of the ice chest, and she returned to Resident #45's room with one surgical glove on her left hand. STNA #273 was unable to state where the right surgical glove was. Subsequent observation of the ice chest with the Administrator verified a surgical glove was turned inside out and sitting in front of the ice chest ledge outside the cooler. The Administrator verified Resident #45 was currently diagnosed with COVID-19. Observation on 11/08/22 at 2:03 P.M. with LPN #269 revealed she had an N-95 mask on her face and there was only one strap secured to her head. There was no second strap on the N-95 mask. Interview with LPN #269 at the time of the observation stated she did not realize the N-95 mask she was wearing only had one strap to it and was not aware the second strap was missing. Observations on 11/08/22 from 2:00 P.M. through 2:08 P.M. revealed Resident #35 was walking in the hallway with her walker with no face mask on, less than two feet from LPN #269. Review of the facility's COVID-19 testing records revealed Resident #35 was currently positive for COVID-19. Observation on 11/08/22 at 2:05 P.M. revealed Resident #37 was propelling herself past the long-term care nursing station with no face mask on her face. Resident #37 had food in her hand. There was no observation of staff encouraging Resident #37 to go back to her room or place a face mask on while in the hallway. Interview on 11/08/22 at the time of the observation with Resident #37 stated she just wheeled herself down to the kitchen to ask for a burger. Resident #37 stated she opened it up and was eating on the way back to her room. Resident #37 stated that she was hungry, and the burger was good. Review of the facility's COVID-19 testing records revealed Resident #37 was currently positive for COVID-19. Observation on 11/08/22 at 2:20 P.M. of ST #317 revealed she had her goggles on her head and not protecting her eyes and was in Resident #48's room. ST #317 was standing at the foot of Resident #48's bed talking to the resident who was laying down. Resident #48 was not diagnosed with COVID-19 and was not in isolation. Interview on 11/08/22 at 2:25 P.M. with ST #317 verified she was not wearing eye protection and her goggles were on her head. ST #317 was unaware if she was to be wearing eye protection. Observation on 11/08/22 at 2:28 P.M. with ST #317 revealed she proceeded to enter Resident #50's room to speak to the resident. ST #317 continued to have no eye protection. Resident #50 was not diagnosed with COVID-19 and was not in isolation. Interview on 11/08/22 at 3:47 P.M. with the DON revealed in the facility's COVID-19 Prevention and Response Policy, it does not state that residents at the facility must wear a face mask. The DON verified the policy does state on page four the facility staff were to limit resident transport and movement of the resident outside the room to medically essential purposes when possible. Review of the CDC guidance for Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated 09/23/22, revealed under Implement Source Control Measures: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. As community transmission levels increase, the potential for encountering asymptomatic or pre-symptomatic patients with [CONDITION(S)]-CoV-2 infection also likely increases. In these circumstances, healthcare facilities should consider implementing broader use of respirators and eye protection by HCP during patient care encounters. NIOSH-approved particulate respirators with N95 filters or higher can also be used by HCP working in other situations where additional risk factors for transmission are present, such as the patient is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated [CONDITION(S)]-CoV-2 transmission is identified and universal respirator use by HCP working in affected areas is not already in place. To simplify implementation, facilities in counties with high transmission may consider implementing universal use of NIOSH-approved particulate respirators with N95 filters or higher for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for [CONDITION(S)]-CoV-2 transmission. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters. Patient Placement: Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. [CONDITION(S)] ([CONDITION(S)]) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with [CONDITION(S)]-CoV-2 infection when the number of patients with [CONDITION(S)]-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with [CONDITION(S)]-CoV-2 infection. Limit transport and movement of the patient outside of the room to medically essential purposes. Personal Protective Equipment: HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard (29 CFR 1910.134). If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue affected unit(s) or facility-wide every three to seven days until there are no new cases for 14 days. Review of the CDC guidance titled How to Use Your N95 Respirator, last updated on 03/16/22, at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html revealed N95s must form a seal to the face to work properly. This is especially important for people at increased risk for severe disease. Your N95 mask has two head straps (not ear loops). The instructions state to wash your hands, then always inspect your N95 mask for damage before use. If it appears damaged, dirty, or damp, do not use it. Place N95 mask under your chin with the nose piece at the top. Put the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and not twisted. Review of the facility's policy titled COVID-19 Prevention and Response, dated 10/13/22, revealed in counties where community transmission level is high, the facility should use PPE as follows: 1. NIOSH-approved particulate respirators with N95 filters or higher used for: a. All aerosol-generating procedures. b. In other situations, where additional risk factors for transmission are present, such as the resident is unable to use source control and the area is poorly ventilated. c. Resident care encounters or in specific units or area of the facility at higher-risk for [CONDITION(S)]-CoV-2 transmission. 2. Limit transport and movement of the resident outside the room to medically essential purposes, when possible. 3. Health Care Providers who enter the room of a resident with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. Review of the facility's policy titled Personal Protective Equipment, dated 01/01/22 revealed the facility promoted appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. All staff who have contact with residents and or their environments must wear personal protective equipment. The change of gloves and performing hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated or when torn. Dispose of gloves in appropriate waste receptable. Review of the facility's policy titled Hand Hygiene, dated 01/01/22, revealed all staff will perform the proper hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility with the exception to food prep areas. Conditions when to perform hand hygiene include when hands are visibly soiled with blood or other body fluids, after sneezing, coughing, and/or blowing, or wiping nose, between resident contacts, after handling contaminated objects, and before applying and after removing PPE, including gloves. Review of the facility's policy titled Respiratory Hygiene and Cough Etiquette, dated 01/01/22, revealed source control measures are actions that contain respiratory secretion in persons who have signs and symptoms of a respiratory infections: to wear facemask during symptoms of respiratory infections, covering the mouth and nose with tissue when coughing or sneezing, prompt disposal of tissues, or coughing and sneezing into elbow or upper arm, and not hands and performing hand hygiene. This deficiency represents the noncompliance investigated under Complaint Number OH 332 and Complaint Number OH 260.

Based on record review, interview and policy review, the facility failed to ensure residents were assessed for alterations in skin integrity weekly and failed to ensure a treatment was ordered for a pressure ulcer. This resulted in Actual Harm when Resident #55 was admitted with a stage II pressure ulcer. No assessment or treatment was initiated on admission and the ulcer progressed to a stage III. This affected one (Resident #55) of ten residents reviewed for pressure ulcers. The census was 78. Findings include: Medical record review revealed Resident #55 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had severe cognitive impairment and required extensive assistance of two staff with activities of daily living (ADL). Review of the pressure ulcer risk assessment for Resident #55 dated 02/15/22 revealed resident was at high risk for the development of pressure ulcers. Review of the care plan for Resident #55, dated 02/16/22 revealed the resident was at risk for skin integrity impairments and pressure ulcers related to mobility deficits, medical diagnosed , decreased ADL self-performance and overall medical condition. Interventions included administer medications and treatments as ordered and monitor for effectiveness. Review of physician orders for February 2022 for Resident #55 revealed an order to complete skin assessment one day a week and document any skin issues and provide bathing two times a week. Review of the hospital discharge documentation date 03/27/22 reveal Resident #55 had a pressure injury on the right buttocks beginning on 03/24/22. There was no treatment ordered. Review of the nurses noted dated 03/27/22 at 8:00 P.M. revealed Resident #55 readmitted from the hospital. Orders were verified by the physician. Review of the nursing admission evaluation for Resident #55, dated 03/27/22, revealed the resident readmitted from the hospital on 03/27/22 with a right buttock pressure area stage II, measuring 2 centimeters (cm) by 1 cm by 0.1 cm. Interventions included administer treatment as ordered and evaluate for effectiveness and skin inspections by caregivers during care and showers and report changes to the licensed nurse immediately. Review of shower sheets and bathing document from 03/27/22 through 04/11/22 revealed caregivers completed three showers with no documentation of skin issues. Review of the skin assessment dated [DATE] revealed no skin area on the right buttock. Review of the wound evaluation dated 04/12/22 revealed a new pressure stage III area to the right buttock measuring 6.5 cm x 4.18 cm x 0.3 cm. Review of physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Resident #55, revised on 04/13/22, revealed the resident had a stage III pressure area on the coccyx and a low air loss mattress was added as a new intervention. During an interview on 05/04/22 at 2:12 PM, Registered Nurse (RN) #328, the wound nurse, stated 04/12/22, a charge nurse reported Resident #55 had a new stage III pressure ulcer to the coccyx area. RN #328 stated the physician orders upon initial admission, 02/15/22, were for preventative barrier cream treatment to buttocks, and weekly skin assessment. During an interview on 05/04/22 at 4:33 P.M. RN #328 stated on 03/27/22 RN #354 documented a stage II pressure ulcer to the right buttock measuring 2 cm by 1 cm by 0.1 cm. RN #354 did not notify the physician of the right buttock area and did not obtain a treatment order. RN #328 verified the physician should have been notified and a treatment order should have been obtained. RN #328 verified Resident #55 had no treatment to the right buttock and coccyx area from 03/27/22 through 04/12/2. The air mattress was new intervention beginning 04/13/22. The initial stage II right buttock area had increased in size to a stage III coccyx area. RN #328 stated the stage III pressure ulcer to the coccyx was avoidable. During interview on 04/05/22 at 1:30 P.M., the Director of Nursing, (DON), verified Resident #55's physician had not been notified of the new coccyx area on 03/27/22 and had no treatment to the coccyx ulcer from 03/27/22 through 04/11/22. The DON verified shower documentation sheets from 03/27/22 through 04/11/22 revealed no skin areas to the right buttocks and coccyx. During interview on 05/09/22 10:00 A.M., RN #354 verified she completed Resident #55 readmission documentation on 03/27/22. She verified a right buttocks pressure area that was noted in the hospital discharge documentation and removed the hospital wound treatment. The area measured 2 cm by 1 cm by 0.1 cm. RN #354 verified the physician was not notified of the hospital acquired right buttock pressure area. RN #354 stated RN #328 reviews the wound assessments, measures the wounds and notifies the physician to obtain treatment orders. RN #354 revealed on 04/12/22 she notified the Wound Nurse #328 the right buttock area had increased in size and required an air mattress. RN #354 verified no treatment was provided to the right buttock wound from 03/27/22 to 04/12/22. During observation on 05/10/22 at 9:45 A.M., Resident #55's wound treatment was observed with Licensed Practical Nurse (LPN) #346 and RN #328. The dressing was dated 05/09/22. The wound had a touch of slough, small amount of serosanguinous drainage, granulation, and measured approximately 2.5 cm by 3 cm. The wound was cleaned with normal saline and gauze. Santyl was placed in the wound bed and covered with calcium alginate and then covered with a Mepliex per physician orders. Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 01/01/22 revealed the physician was to be notified of all changes in condition and new skin alterations. This deficiency substantiates Complaint Number OH 420.

Based on record review, interview and policy review, the facility failed to ensure a resident experiencing chronic pain received as needed (PRN) pain medication in a timely manner. This resulted in actual harm when staff failed to ensure Resident #277 received PRN pain medication in a timely manner, when she reported pain. This affected one (#277) of three residents reviewed for pain. The facility identified 68 residents who received pain medication. The facility census was 78. Findings include: Review of the medical record of Resident #277 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing admission evaluation dated 04/23/22 revealed the resident reported occasional pain during the last five days, which limited her day-to-day activities. The resident described the pain as intermittent and dull pain to her legs. Dressing changes made pain worse. Pain was managed by medication and decreasing movement helped to reduce pain. Review of the care plan contained in the nursing admission evaluation revealed an intervention of administering pain medications as ordered and give 30 minutes prior to treatments or care. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/30/22, revealed the resident had intact cognition. The resident did not exhibit any behaviors during the assessment period. The resident required extensive assistance of two staff for bed mobility and toileting, dependent on two assist for transfers. The resident was receiving PRN pain medications having occasional pain during the past five days, which had made it difficult to sleep at night but did not limit her daily activities. The resident was assessed as having a pain rating as high as six on a one to ten scale during the prior five days. Review of the plan of care dated 05/01/22 revealed the resident was at risk for chronic pain related to acute [CONDITION(S)] and [CONDITION(S)]. Interventions included to administer pain medications as ordered and provide a half hour before treatments or care, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the physician orders revealed an order dated 04/23/22 for [MEDICATION(S)]-acetaminophen tablet 5-325 milligrams (mg), give one tablet every six hours as needed for pain. During observation on 05/02/22 at 10:15 A.M., Resident #277 informed State tested Nursing Assistant (STNA) #392 she was in pain. During observation on 05/02/22 at 10:17 A.M., Resident #277 was sitting on the edge of her bed with Physical Therapist (PT) #501 and an additional unidentified therapist at her bedside. Resident #277 complained of pain in her knees and was moaning. Resident #277 rated the pain a ten on on a one to ten scale. During interview at this time, Resident #277 stated she last received pain medication around 4:30 A.M. During observation on 05/02/22 at 12:07 P.M., Resident #277 was laying in bed, moaning. During interview at this time, Resident #277 rated her pain a ten and stated she had not received any pain medication. Observation on 05/02/22 at 12:48 P.M., Resident #277's call light was activated. Licensed Practical Nurse (LPN) #373 entered the room and Resident #277 requested to be repositioned in bed and to see the nurse. Resident #277 continued to moan. At 12:53 P.M., STNA #392 and LPN #373 entered Resident #277's room and pulled her up in bed. Resident #277 let out a groan following being pulled up in bed. During an interview on 05/02/22 at 12:56 P.M., STNA #392 stated she informed LPN #502 earlier of Resident #277's pain and LPN #502 told her she would go peek at Resident #277. During interview on 05/02/22 at 12:59 P.M., LPN #502 affirmed STNA #392 came and told her Resident #277 was complaining of pain at approximately 10:15 A.M. LPN #502 stated Resident #277 last had pain medication at 4:45 A.M. and could not have it again until 10:45 A.M LPN #502 stated she did not return to give Resident #277 after 10:45 A.M. LPN #502 stated she was in Resident #277's room two or three more times after that and she did not complain of pain again. LPN #502 stated she did not specifically ask Resident #277 about her pain again after talking with her at 10:15 A.M. During interview on 05/02/22 at 1:18 P.M., Resident #277 stated she had just received pain medication. During observation on 05/04/22 at 10:52 A.M., Resident #277 was laying in bed, moaning, and had tears streaming down her face. Resident #277 stated her pain level was a ten . She stated she told an STNA at 7:45 A.M. she needed pain medication but had not receive anything. Resident #277 stated her pain was in her legs and knees and attributed it to her [CONDITION(S)] and arthritis. Resident #277 stated she had not seen the nurse since telling the nursing assistant she needed pain medication. During observation on 05/04/22 at 10:56 A.M., STNA #403 entered Resident #277's room to answer her call light. Resident #277 informed STNA #403 she needed pain medication. At 11:00 A.M., STNA #403 affirmed Resident #277 appeared to be in pain. During an interview on 05/04/22 at 11:00 A.M., RN #328 stated she was notified earlier of Resident #277's pain and STNA #403 had reminded her again, just prior to the interview, of Resident #277's complaint of pain. RN #328 stated she went to take a break after being notified of Resident #277's pain and had not yet provided her with pain medication. Review of nursing progress notes dated 05/02/22 through 05/04/22 revealed no evidence of the physician being provided any update on Resident #277's pain not being controlled. During interview on 05/05/22 at 8:51 A.M., Resident #277 stated she asked for a pain pill before 7:00 A.M. and the nurse informed her she was taking care of other residents. Resident #277 rated pain a ten at this time and stated she hurt in her legs. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 8:54 A.M. During an interview on 05/05/22 at 9:03 A.M., LPN #345 stated she was notified of Resident #277's pain at approximately 8:50 A.M. LPN #345 stated Resident #277 was crying and whining and rated her pain a five. LPN #345 stated she had just provided Resident #277 with pain medication. During an interview on 05/05/22 at 11:05 A.M., PT #501 stated she worked with Resident #277 for 25 minutes on the morning of 05/02/22 and she whimpered and cried during the whole treatment. PT #501 stated Resident #277 rated the pain a ten and the resident told her she was always in pain. During observation 05/05/22 at 11:14 A.M., Resident #277 stated her pain was improved, however still rated her pain as a ten. During interview on 05/05/22 at 11:17 A.M., Rehab Coordinator (RC) #420 stated Resident #277's pain in her legs was limiting her progress in therapy. RC #420 stated on 05/04/22, he came to treat Resident #277 an hour after she received her pain medication and she continued to complain of pain. RC #420 stated he informed the nurse on duty. During interview on 05/05/22 at 3:34 P.M., Physician #500 stated she had not been notified of Resident #277's pain with her current regimen. During interview on 05/05/22 at 3:49 P.M. Physician #500 stated she spoke with facility staff regarding Resident #277's pain and changed Resident #277's [MEDICATION(S)] to routine due to breakthrough pain. Review of the facility policy titled, Pain Management, dated 01/01/21 revealed the facility is to ensure pain management is provided to residents who require such services, residents with pain should be reassessed regularly and, if the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, interview, police report review, facility investigation review and policy review, the facility to provide adequate supervision to prevent the elopement of a cognitively impaired resident who was assessed as being at risk for elopement. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries when one resident (Resident #100) eloped from the facility and was later found by the police approximately 1.4 miles away from the facility and had crossed a four-lane road. This affected one (Resident #100) of three residents reviewed for elopement. The facility identified seven residents at risk for elopement in the facility. The facility census was 69. On 01/08/21 at 3:37 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 12/23/20 at 7:30 P.M., when Resident #100 was not provided adequate supervision and eloped from the facility. Resident #100 was assessed at risk for wandering and elopement. Resident #100 had a history of [REDACTED]. On 12/23/20 between 7:30 P.M. and 7:45 P.M., State tested Nurse Aide (STNA) #43 went to Resident #100 ' s room to check on him and noticed the resident was missing. The police contacted the facility on 12/23/20 at 8:02 P.M. and reported they had found Resident #100 at a church 1.4 miles from the facility, that was located on the opposite side of a four-lane road. The Immediate Jeopardy was removed, and the deficient practice corrected on 12/31/20 when the facility implemented the following corrective actions: · On 12/23/20 at 8:17 P.M., a head to toe assessment was conducted on Resident #100. Resident #100 had no injuries noted and his vitals were stable. Resident #100 was immediately placed on one-to-one supervision until his discharge from the facility. · On 12/23/20 at 9:00 P.M., Resident #100's representative and nurse practitioner were notified of the elopement. No new orders were given. · On 12/24/20, all doors and code alert bracelets were checked for functionality. · On 12/24/20 at 10:00 A.M., the Administrator had a discussion with Resident #100's representative about transferring the resident to a facility with a secured unit. Resident #100's representative was agreeable. · On 12/24/20, a whole house audit on code alert bracelets was completed by the clinical team. All code alert bracelets were individually checked again by the unit manager. · On 12/24/20, education was completed on the elopement policy. · On 12/24/20, elopement risk resident pictures were updated in the electronic medical records system. The elopement binder was updated. · On 12/24/20, the Administrator initiated daily door checks to be conducted daily for two weeks and then weekly thereafter. · On 12/24/20, elopement assessments were completed on all seven residents identified at risk for elopement. · On 12/28/20, the Interdisciplinary Team (IDT) met and reviewed the elopement assessments for variances. The incident and follow-up actions were reviewed with the Medical Director. · On 12/30/20, the incident was reviewed with the Quality Assurance Performance Improvement (QAPI) team. · On 12/31/20, Resident #100 was discharged to a facility with a secured unit. Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #100 discharged to another skilled nursing facility on 12/31/20. Review of Resident #100's care plan for impaired cognition, dated 09/25/20 revealed the resident had impaired cognitive function or impaired thought processes due to Alzheimer ' s disease. Interventions included cue, reorient and supervise as needed and to monitor, report and document as needed any changes in cognitive function specifically changes in decision making ability, memory, recall, general awareness, expressing self, difficulty understanding others, level of consciousness and mental status. Review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, toileting and dressing; limited assistance with personal hygiene; and was independent with eating and bed mobility. Review of Resident #100 ' s risk of elopement and wandering review assessment, dated 12/01/20, documented the resident was cognitively impaired with poor decision-making skills. He had a history of [REDACTED]. Resident #100 was at risk for elopement. The resident's elopement risk was evidenced by attempts to climb out of room window, leave building through the front lobby and verbalizing a need to go home with anyone who will take him. Resident #100 had a code alert bracelet placed to his left leg. Review of Resident #100's progress note dated 12/01/20 at 7:31 P.M. revealed resident was at the nursing station every 15 minutes, in an agitated mood, talking about his wife divorcing him and putting him into the facility. He was easily redirected but behaviors were occurring with great frequency during the evening hours. The resident did not have the code alert bracelet to his left ankle. A second bracelet was obtained and replaced to his left ankle at that time. Review of Resident #100's elopement care plan, initiated on 12/08/20 and revised on 12/24/20 revealed the resident was at risk for elopement due to disease process [MEDICAL CONDITION]. Interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and book, maintain consistent daily routine and consistent bedtime routine, observe for acute process which may increase wandering and for resident to have a code alert bracelet. Review of Resident #100's progress note dated 12/18/20 at 6:07 P.M. revealed the resident's code alert bracelet was checked and missing from the resident. A new code alert bracelet was activated and applied to resident. The resident got angry and stated, I'm not going anywhere, and I don't live in a prison. Review of Resident #100's progress note dated 12/22/20 at 12:31 P.M. revealed staff checked for resident's code alert bracelet and it was missing from his leg. Resident #100 always had all his belongings packed up and ready to go. The resident removed code alert bracelet himself. Review of Resident #100's progress note dated 12/22/20 at 4:26 P.M. revealed resident had a code alert bracelet applied to his shoestring. Review of Resident #100's progress note dated 12/23/20 at 4:40 P.M. revealed resident came to the nurses station asking Registered Nurse (RN) #15 what he was doing at the facility. RN #15 walked resident back to his room and talked to him for a few minutes. Resident #100 ' s code alert was missing, and nurse asked resident what he did with it. Resident #100 opened the drawer and it was hidden inside a tissue box. RN #15 applied the code alert on the shoestring because the resident refused to put it on his leg. Review of the facility's timeline, dated 12/23/20, revealed RN #20 was notified by STNA #43 that the resident was not in his room. Room checks and a head count were conducted on 12/23/20 at 7:46 P.M. and the building and parking lot were searched. The DON was notified on 12/23/20 at 7:54 P.M. and the Administrator was notified on 12/23/20 at 7:56 P.M. The police department called the facility on 12/23/20 at 8:02 P.M. and stated that they had the resident. The police arrived at the facility on 12/23/20 at 8:22 P.M. with the resident. Resident #100 was dressed in jeans, a coat and shoes. Resident #100 also had his code alert bracelet on, and it went off upon his return. A head to toe assessment of the resident was completed on 12/23/20 at 8:17 P.M. with no injuries. The resident was placed on one to one supervision. The nurse practitioner was notified on 12/23/20 at 9:00 P.M. with no new orders. Review of STNA #79's witness statement revealed she passed dinner trays on 12/23/20 around 5:25 P.M. or 5:30 P.M. and Resident #100 was observed. STNA #79 picked up dinner trays and Resident #100 was again observed at 6:25 P.M. Review of the police report dated 12/23/20 revealed an officer was dispatched at 7:57 P.M. to the church near the facility for a report of an elderly male stating his car had broken down. On the scene at 8:03 P.M., the officer spoke to the resident and noticed the resident made the same statements repeatedly. The resident advised that his car had broken down and he was trying to get home to Batavia. The officer checked his address in the system and found his address to be the facility. The officer called the facility and they told the officer the resident had been missing since approximately 5:00 P.M. and they had been looking for him. The facility told the officer the resident had Alzheimer's and cuts off his alarm on his ankle to escape. The resident was transported from the church at 8:17 P.M. and arrived back at the facility at 8:22 P.M. Review of the facility's Self-Reported Incidents (SRI) revealed the incident was not reported to the State Agency. Review of Resident #100's progress note dated 12/24/20 at 7:16 A.M. revealed RN #20 received a call from a police officer stating Resident #100 was found and would be returned to the facility. RN #20 and an STNA met the police officer at the front door. The code alert alarm was triggered when the resident crossed the threshold confirming the code alert was in place and working properly. Resident #100 was placed under 24-hour watch. Review of Resident #100's progress note dated 12/24/20 at 7:19 A.M. revealed RN #15 was informed of the incident and that Resident #100's code alert bracelet was intact when the resident returned to the facility. Review of Resident #100's progress note dated 12/24/20 at 10:57 A.M. revealed Admissions Director #32 and the Administrator spoke with Resident #100's representative regarding the incident on 12/23/20 and discussed the resident going to a more secured memory care unit. Resident #100's representative acknowledged understanding and would like for Admissions Director #32 to look for other facilities. Admissions Director #32 placed referrals to facilities that had a secure unit as the representative requested. Review of Resident #100's risk of elopement and wandering review assessment, dated 12/24/20 revealed Resident #100 ' s elopement wandering risk was evidenced by packing behaviors, requests to leave to live with family and demonstrating the desire to leave facility without permission or supervision. Resident #100 was not easily re-directed and does not easily accept direction from female staff regarding his status as a resident. Review of Resident #100's progress note dated 12/31/20 revealed resident discharged to another facility on this date with a staff member. Resident #100's family was notified on the transfers and agreed with transferring Resident #100 to a more secure facility. E-mail communication from the Administrator on 01/08/21 at 9:19 A.M. verified Resident #100's elopement from the facility on 12/23/20 was not reported as an SRI. Interview with RN #08 on 01/08/21 at 6:40 P.M. revealed Resident #100 eloped from the facility on 12/23/20. RN #08 stated she came in on third shift and at 7:30 P.M. they finished report. The STNA ' s went to check on the residents and noticed Resident #100 was missing. Staff searched the facility and the parking lot. The DON was called on 12/23/20 around 7:54 P.M. The police called the facility at 8:15 P.M. to report they had found the resident. RN #08 stated the police brought Resident #100 back to the facility. During telephone interview on 01/08/21 at 10:28 A.M. with RN #20, she stated she was working at the facility on 12/23/20 and the staff gave report that Resident #100 had been agitated and had been taking off his code alert bracelet that day. After the report, STNA #43 went to check on the resident at approximately 7:30 P.M. and Resident #100 was not in his room. RN #20 stated they searched the facility and could not find the resident. RN #20 stated that the DON was called on 12/23/20 at around 8:00 P.M. and the police also called and reported they found him on 12/23/20 at around 8:00 P.M. RN #20 stated the resident was returned to the facility and he was wearing jeans, tennis shoes and a zip up hooded sweatshirt. Resident #100 was also wearing his code alert bracelet and it was going off when he came back in the door. A head to toe assessment was completed with no injuries and resident was placed on one to one supervision. RN #20 stated she did not know how Resident #100 got out of the facility. During telephone interview on 01/08/21 at 10:40 A.M., STNA #43 stated she came on shift on 12/23/20 at 7:00 P.M. After she had received report, around 7:30 P.M. to 7:45 P.M., she went to check on Resident #100. The resident was not in his room. STNA #43 stated staff searched the facility and parking lot. The police called the facility and stated they had found him. STNA #43 stated she did not know what time the police called to report they had found Resident #100. STNA #43 stated Resident #100 had been trying to leave for a few weeks and had been cutting his code alert bracelet off. During telephone interview on 01/08/21 at 10:45 A.M., RN #15 stated she worked day shift on 12/23/20 and that she last saw Resident #100 around 4:30 P.M. He had taken off his code alert bracelet and she replaced it. She did not see him after 4:30 P.M. RN #15 stated there was no issues with staffing. Review of the facility's policy titled Unsafe Wandering and Elopement Prevention, dated January 2019, revealed every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. All residents who are at risk for unsafe wandering will be assessed by the interdisciplinary care planning team. The resident care plan will be modified to indicate the resident is at risk for elopement episodes. Interventions for unsafe wandering and elopement attempts will be entered into the resident's care plan and medical record. Contributing factors and interventions tried would be documented in the nurse ' s notes. If a resident is discovered to be missing, a search should begin immediately. If an employee would discover that a resident is missing from the facility, the employee should determine if the resident is out on an authorized leave or pass and notify the licensed staff in charge immediately of the possible missing resident. The licensed nurse will assign a staff member to begin a head count of all current residents, the licensed nurse will designate a search leader, the search leader will delegate specific tasks to specific employees that may include but are not limited to assigning staff to conduct an interior search of the facility, assign staff to conduct an exterior search of the facility and to continue to expand the search as appropriate. The licensed nurse will also contact the Administrator and DON, the physician, the responsible party, validate the head count was accurate and all residents were accounted for and prepare information needed for outside search parties. The Administrator or their designee will direct further tasks to include as needed notifying the Regional Director of Operations and Regional Nurse, law enforcement, media and other agencies as required. Upon the return of the resident to the facility, the charge nurse should examine for injuries, contact the physician and report findings, notify the responsible party, complete and file an incident report, complete an elopement assessment and make appropriate entries into the resident's medical record. Review of the facility's policy titled Abuse, Neglect and Exploitation, revised on 07/28/20, revealed the facility will have written procedures that include reporting all alleged violations to the state agency no later than 24 hours if the events in the allegation do not involve abuse and do not result in serious bodily injury. This deficiency substantiates Master Complaint Number OH 028 including Complaint Number OH 643.

Based on medical record review and staff interview, the facility failed to ensure an alarm was in place on a resident's wheelchair as care planned to prevent a fall. Resident #63 suffered actual harm when she fell face first from her wheelchair, sustaining fractures to her face. This affected one (Resident #63) of three residents reviewed for falls. The facility census was 87. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and require extensive assistance with bed mobility, eating, transfer, dressing, toileting and personal hygiene. Review of Resident #63's physician's orders dated 01/04/19 revealed the resident was to have a pull tab alarm to her wheelchair to alert staff of unassisted transfers. Review of the care plan for falls, revised 08/08/19, indicated the resident was to have an alarm to her wheelchair to alert staff of unassisted transfers. Review of Resident #63's progress notes dated 08/18/19 revealed the resident was found on the floor by staff at 11:45 [NAME]M. Resident #63 fell out of her wheelchair face first in the hallway. The resident had a big knot on the right front forehead, a cut on her nose and small cuts on both her hands. Resident #63's family and physician were notified and the resident was sent out to the hospital. Resident #63 had swelling and bruising to her nose, face and right hand upon return from the hospital on [DATE]. There were no new orders. Review of the facility's fall investigation dated 08/18/19 revealed Resident #63 was sitting in her wheelchair and fell out face first on the hallway floor. The chair alarm was not in place at the time of the fall. Review of Resident #63's progress note dated 08/19/19 revealed the resident fell on [DATE]. Resident #63 was last seen in the hallway in front of the social services and scheduler's office in her wheelchair using her feet to propel herself. Scheduler #01 heard Resident #63 fall and immediately went out and got the nurse to assess the resident and assist her back into her wheelchair. Resident #63 used a chair alarm, but the alarm was not in place at the time of the fall. Interview with the Administrator on 09/25/19 at 9:24 [NAME]M. verified the resident fell in the hallway on 08/18/19 and she sustained facial fractures as a result of the incident. The Administrator confirmed the resident did not have her chair alarm in place at the time of the incident. Review of the facility policy titled Falls, dated (MONTH) (YEAR), revealed the facility fall interventions should be developed and implemented for falls. The policy also stated a care plan will be developed and implemented to address identified fall risks. This deficiency substantiates compliant number OH 171.

Based on closed medical record review, staff interviews, review of the Emergency Medical Squad (EMS) report, review of hospital records, review of manufacturer's recommendations for glucometers, review of facility policy, review of Med Scape.com (internet-based medication reference), and review of the American Diabetes Association guidelines, the facility failed to provide the necessary care and services when staff did not immediately address a resident's clinical change in condition, resulting in a critically low blood sugar level. This resulted in Immediate Jeopardy and life threatening serious injury when Resident #201 was found unresponsive, and had a critically low blood sugar level that measured Low (indicative of 20 milligrams per deciliter (mg/dL) or lower). The nurse failed to follow the physician order to check Resident #201's blood sugar at 8:00 P.M., and failed to call EMS in a timely manner, which resulted in the resident's continued unresponsiveness, and the resident's continuous vegetative state. This affected one (#201) of 31 current residents identified by the facility as having diabetes requiring finger stick blood sugar (FSBS) monitoring. The facility census was 87. On 06/29/18 at 1:30 P.M., the Licensed Nursing Home Administrator (LNHA), Registered Regional Nurse (RRN) #50, and Regional Director of Operations (RDO) #60, were notified Immediate Jeopardy began on 04/25/18 at 8:00 P.M when the facility failed to obtain an ordered FSBS on Resident #201. At 10:52 P.M., Licensed Practical Nurse (LPN) #5 found Resident #201 unresponsive and the resident's FSBS level read as Low. LPN #5 notified Registered Nurse (RN) #90 who got an order to administer glucose gel (oral medication to increase blood sugar levels), and the resident's blood sugar level remained low. An additional order was received for a [MEDICATION NAME] (to increase blood sugar rapidly) injection, intramuscular (IM). Resident #201 was also given orange juice via her gastric feeding tube ([DEVICE]). Resident #201 remained unresponsive and had a FSBS level of 22 mg/dL. EMS was then called. The Immediate Jeopardy was removed on 06/29/18 at 4:21 P.M. when all 31 (#94, #08, #10, #11, #20, #21, #22, #23, #24, #26, #28, #32, #36, #51, #54, #56, #60, #71, #101, #73, #76, #77, #81, #84, #86, #87, #91, #92, #62, #29, and #100) residents currently residing in the facility with a [DIAGNOSES REDACTED]. · On 06/29/18 from 3:30 P.M. to 5:00 P.M., a list of diabetic residents and their orders were reviewed by RN #46 and RN #150 at the facility. A list was generated to monitor the blood sugar testing remotely, by accessing the computer charting, via Point Click Care (PCC). The list will be utilized for the remote auditing. · On 06/29/18, all residents with the [DIAGNOSES REDACTED]. This will be completed by the corporate staff, or nursing manager. Any identified concerns will be corrected immediately by contacting the nurse assigned to confirm completion. This will be continued for seven days after Immediate Jeopardy has been removed, then daily for seven days, at which time, the facility's Quality Assurance and Performance Improvement (QAPI) committee will determine continued monitoring needs to maintain substantial compliance. · On 06/29/18, all licensed staff (RN's and LPN's) were re-educated in reference to obtaining blood sugar levels as ordered, as well as timely notification to the physician for resident change in condition. This included notifying their immediate supervisor of inability to complete tasks within ordered timeframes. The re-education was completed by the Director of Nursing (DON), nurse consultant's, staff educator or unit managers. · On 06/29/18, licensed nurses ensured all residents had orders to include glucose gel and [MEDICATION NAME] IM injections, as needed, to treat [DIAGNOSES REDACTED] (low blood sugar). · On 06/29/18, in-servicing was completed by RN #46, RN #37, RN #150, RN #5 and RN #113 for all nurses, nurse aides, and other support staff on diabetic care and blood sugar monitoring. · All new licensed nurses and agency nurses will receive education on blood sugar monitoring including [MEDICAL CONDITION] (high blood sugar), [DIAGNOSES REDACTED], and notification of changes in condition by a licensed nurse, and proper procedures regarding errors and omissions, prior to being scheduled to work. · On 06/2918, a QAPI committee meeting was held, and the plan was reviewed and accepted. The Medical Director was out of town and would be informed upon return. · On 06/29/18, 06/30/18, 07/01/18 and 07/02/18, all FSBS's for the 31 (#94, #08, #10, #11, #20, #21, #22, #23, #24, #26, #28, #32, #36, #51, #54, #56, #60, #71, #101, #73, #76, #77, #81, #84, #86, #87, #91, #92, #62, #29, #100) current diabetic residents were reviewed, and confirmed the facility was monitoring the FSBS, and was providing the required notifications and treatments as ordered. · Interviews on 07/02/18, between 3:45 P.M. and 4:00 P.M. with LPNs #87, #07, #74 and State tested Nurse Aide (STNA) #109, verified education by the facility on blood sugar monitoring including [MEDICAL CONDITION], [DIAGNOSES REDACTED], and notification of changes in condition by a licensed staff. All staff were able to correctly verbalize knowledge of the policy changes. Although the Immediate Jeopardy was removed, 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #201's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #201 was noted to be a Full Code. There was no evidence of a care plan for the resident's [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #201 was cognitively impaired, however was alert, oriented, and able to read lips. The resident was totally dependent on one staff for eating, was on a mechanically altered diet, and received greater than 51 percent of nutritional calories by [DEVICE]. Review of physician's orders dated 04/25/18 revealed an order for [REDACTED]. and 8:00 P.M. daily. The order was to begin at 8:00 P.M. on 04/25/18. There were no resident specific orders for treatment of [REDACTED]. Review of Resident #201's (MONTH) (YEAR)'s Medication Administration Record [REDACTED].M., with a blood sugar reading of 145 mg/dL. Review of the nursing progress note dated 04/25/18 at 10:52 P.M. revealed LPN #5 went to administer medications to Resident #201 and upon checking her blood sugar, found the reading to be Low. The resident was noted to be unresponsive. LPN #5 spoke with RN #90 and an order was received to administer glucose gel, however the blood sugar reading remained low. An additional order for [MEDICATION NAME] injection IM was received. The resident also received orange juice via gastric tube ([DEVICE]) and her blood sugar reading was 22 mg/dL. A few minutes later, the reading was 33 mg/dL and she remained unresponsive. EMS was called. Resident #201's blood sugar was 59 mg/dL when EMS arrived. Her blood pressure was 66/49 millimeters of Mercury (mmHg), (normal blood pressure 120/80 mm Hg). EMS worked with the resident, then transported her to a local emergency room for evaluation. It was noted the responsible party, and the physician on call were notified. Review of the EMS transport report dated 04/25/18 revealed EMS was called at 11:07 P.M., after Resident #201 was found unresponsive with a low blood sugar reading. EMS arrived at the facility at 11:11 P.M., and was at Resident #201's side at 11:13 P.M. The EMS report revealed Resident #201 was unresponsive upon arrival. The EMS were unable to obtain a blood pressure, and her heart rate (HR) was 20 beats per minute (bpm) (normal HR 60 to 100 bpm). The resident had to be suctioned a few times due to foaming from her mouth. Her blood sugar level was 65 mg/dL at 11:15 P.M., and she continued to remain unresponsive. At 11:39 P.M., Resident #201 was transported to the hospital. Review of the emergency room /hospital report dated 04/25/18, revealed Resident #201's admitting [DIAGNOSES REDACTED]. Interview with Certified Nurse Practitioner (CNP) #01 on 06/26/18 at 9:39 A.M. confirmed she changed the monitoring of Resident #201's FSBS to twice a day, at 8:00 A.M. and 8:00 P.M. on 04/25/18. CNP #01 further revealed she expected the FSBS to be completed on 04/25/18 at 8:00 P.M. Interview on 06/26/18 at 9:50 A.M. with Respiratory Therapist (RT) #112 revealed he completed [MEDICAL CONDITION] care of Resident #201 at 8:50 P.M. and the resident did not respond during the care, however stated the resident often slept through the care. Interview on 06/26/18 at 1:29 P.M. with STNA #86 revealed Resident #201 ate part of her dinner on 04/25/18 and did not notice anything different about the resident. Interview on 06/26/18 at 1:30 P.M. with LPN #05 revealed she started her shift on 04/25/18 at 7:45 P.M. LPN #05 was unable to remember the exact time she entered Resident #201's room and found her unresponsive. She stated when she found Resident #201 unresponsive, she called for RN #90 to come assess the resident. LPN #05 revealed she told RN #90 they needed to call EMS immediately, however RN #90 told her not to. LPN #05 revealed Resident #201 remained unresponsive and she eventually did call EMS, 25 minutes after RN #90 told her not to. Attempts to contact RN #90 were unsuccessful. The LNHA revealed RN #90 resigned and no longer worked at the facility. Interview with Resident #201's family member, also the resident's Power Of Attorney (POA) on 06/27/18 at 11:00 A.M., revealed Resident #201 remained in intensive care from 04/25/18 through 05/08/18. The family member further revealed the physician at the hospital told her the resident would remain unresponsive due to the fact that her blood glucose level had remained low for an extensive period of time. On 06/28/18 at 10:50 A.M., observation of Resident #201 at the facility she was transferred to from the hospital revealed the resident was unresponsive, with no signs of awareness. Review of manufacturer's instructions and guidelines for the facility's glucometer revealed a blood glucose level below 20 milligrams per deciliter (mg/dL) would result in a Low reading. There were no instructions regarding what to do if a Low reading was obtained. Review of the facility policy titled Nursing Care of the Resident with Diabetes Mellitus, dated 04/2018, revealed the purpose of the policy was to review the most common and serious conditions and complications associated with diabetes. Symptoms of severe [DIAGNOSES REDACTED] (low blood glucose levels) include unresponsiveness. Treatment would include administer intramuscular [MEDICATION NAME], or intravenous 50 percent [MEDICATION NAME], notify the physician for further orders, and if the resident remained unresponsive, call emergency services (911). Review of current medical professional references (www. Medscape.com), blood glucose should be maintained at near-normal levels. The recommended FSBS of pre-prandial (before meal) should be within levels of 90-130 mg/dL. According to the American Diabetes Association (www.diabetes.org http://www.diabetes.org>), older, and frail adults are at increased risk for [DIAGNOSES REDACTED]. Some of the effecting factors include impaired renal function, slower hormonal metabolism, and gastrointestinal absorption, polypharmacy, as well as variable oral intake, and activity levels. Therefore, the risk for [DIAGNOSES REDACTED] is paramount in establishing the treatment goals for diabetes among patients in long-term care and skilled nursing facilities. Severe and/or persistent [MEDICAL CONDITION] can increase the risks for dehydration, urinary incontinence, falls and electrolyte imbalances. treatment of [REDACTED]. Glycemic control among facility residents is recommended as fasting and pre-meal target glucose levels of 100 to 200 mg/dL This deficiency substantiates Complaint Control Number OH 084.

Based on observation, record review, and interview, the facility failed to follow physician's orders to remove a left lower leg brace and failed to perform skin integrity checks under the brace. This resulted in actual harm for one (#119) resident when an unstageable pressure ulcer was located to the resident's left heel. Four residents were reviewed for pressure ulcers. The facility identified seven residents with pressure ulcers in a census of 91. Findings include: Medical record review for Resident #119 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of hospital documentation dated 04/05/17 revealed the resident should remain in a left lower leg splint until follow up in two weeks. If absolutely necessary the dressing could be removed to the surgical site. Review of the admission assessment dated [DATE] revealed resident had discolored heels present with no foot ulcers. Review of the pressure ulcer risk assessment dated [DATE] identified Resident #119 to be at high risk for developing pressure ulcers. A pressure ulcer risk assessment dated [DATE] identified the resident to be at moderate risk for developing pressure ulcers. Review of orthopedic appointment documentation dated 04/27/17 revealed Resident #119 was one to two weeks status [REDACTED]. The resident was able to start active and passive range of motion exercises of the left ankle. The resident was to remain non-weight bearing. Included in the instructions was the use of a brace to the left ankle, which the resident could have removed periodically for active and passive range of motion. The resident was to continue to use the splint, to the left lower leg, which he did not need to wear 24 hours a day seven days a week. Instructions revealed the splint/brace should be worn for transfers and ambulation, and may be removed during periods of inactivity such as laying around or sleeping at night. The splint/brace could also be removed for bathing purposes and daily exercises as instructed. Review of weekly skin assessments dated 04/15/17 through 05/11/17 revealed no areas of skin breakdown were documented to either heel. A skin assessment dated [DATE] revealed the presence of an unstageable pressure ulcer to the left heel. The ulcer measured 3.4 centimeters (cm) by 5.9 cm by 0.1 cm deep. The wound bed was pink with a black area and a moderate amount of serosanguineous drainage was present. Review of nurses notes dated 05/19/17 revealed a new area of skin breakdown was noted to Resident #119's left heel underneath the are of the splint. New orders included splint checks every shift and to off load the resident's heels. Review of the April 2017 treatment administration record (TAR) revealed skin assessments every Tuesday night shift from 7:00 P.M. to 7:00 A.M. The TAR revealed on 04/27/17 a new order for a splint to left leg to be worn during transfers and ambulation and to use ace wrap as needed to control swelling. There was no order present to check skin integrity under the splint. Review of May 2017 TAR revealed on 05/19/17 an order was put into place to do skin checks to surrounding splint area on left lower leg every day and night shift due to breakdown Review of the 04/11/17 care plan for impaired skin integrity revealed it did not address the presence of the left ankle splint and to perform skin checks due to splint presence until 05/19/17. Interventions added on 05/19/17 included to complete splint checks every shift and to offload the resident's heels. Observation on 05/23/17 at 2:27 P.M. revealed Resident #119 to be in bed with brace/splint to the left lower leg that covered the bottom of the foot and heel. An ace wrap was present. Observation of wound care to resident's left heel on 05/23/17 at 2:30 P.M. with Registered Nurse (RN) #71 and Nurse Practioner (NP) #130 revealed an open area to the left heel with a black hardened center. The area measured 2 cm by 2 cm by 0.3 cm. NP #130 informed Resident #119 the brace was rubbing his foot. She directed the resident to keep his heels off of the bed and to pad the area under brace. Interview on 05/23/17 at 2:30 P.M., NP #130 stated she could not say what caused Resident #119's unstageable area to the left heel without investigating his chart and stated this could happen if he was not able to remove the brace. NP #130 revealed she was not aware of orthopedic orders on 04/27/17 that revealed he could take the brace off. Interview on 05/23/17 at 3:38 P.M., RN #105 stated the resident originally had orders not to remove the splint and she was not sure when the order changed or how often the brace could be removed. Interview on 05/23/17 at 3:44 P.M., Resident #119 stated he wears the brace every day to his left heel. He stated staff did not remove the brace until the area of skin breakdown was located to the left heel. Resident #119 stated they take it off every day now. He stated his left heel was sore before they noticed the area, but he never reported it to anyone. This deficiency substantiates Master Complaint Number OH 314.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on clinical record review, observation, review of the facility Accident/Incident report, review of the hospital emergency room report, review of the facility's restraint policy, review of the manufacturer guideline and staff interview, the facility failed to ensure the resident's environment remained free of accident hazards from a reverse seat belt resulting in Immediate Jeopardy for one (Resident #126) of 14 sampled residents. The facility identified 17 residents with restraints. On [DATE] at 12:10 P.M., the Administrator, Director of Nursing (DON) and Corporate Nurse #1 were notified Immediate Jeopardy began on [DATE] at 12:00 P.M. when State tested Nurse Aide (STNA) #5 became aware Resident #126 could remove the reverse seat belt by "wiggling" in the wheelchair to loosen the belt. Once loosened, Resident #126 unhooked the reverse seat belt from the wheelchair tilt levers. On [DATE] at approximately 4:56 P.M., Resident #126 was found in her room, seated on the floor with the reverse seat belt around her neck. Resident #126 was unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated and the resident was sent to the hospital via life squad, placed on a ventilator and expired on [DATE]. The Immediate Jeopardy was removed and the deficient practice corrected on [DATE] when the facility implemented the following corrective actions: - Reassessed seven residents for the use of reverse seat belts. Six reverse seat belts were discontinued or changed to other less restrictive devices. All care plans were updated. - The facility reassessed all residents with other safety devices (self release seat belt, lap buddy and pelvic belts) by [DATE]. - Unit managers are monitoring resident restraints on a daily basis and documenting the safety device and resident safety on a Performance Monitoring form. Review of Performance Monitoring forms dated [DATE]-[DATE] revealed residents with devices were being monitored. - On [DATE], all nursing staff were in-serviced on Review of Safety Device System. - Interviews with eight nursing staff on [DATE], [DATE] and [DATE] revealed they were aware of the proper use of safety devices. - Observations of ten residents with restraints which included one resident with a reverse seat belt on [DATE], [DATE] and [DATE] revealed the devices were applied in accordance with manufacturer instructions and resident care plans. Findings include: Review of Resident #126's Face Sheet revealed the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented Resident #126 as able to make herself understood and understood others. Resident #126 was assessed with [REDACTED]. Review of the Progress Note dated [DATE] at 2:40 P.M. by Licensed Practical Nurse (LPN) #20 revealed the resident was readmitted to the facility from the hospital. The Progress Note dated [DATE] at 3:00 P.M., revealed LPN #20 verified the physician orders [REDACTED]. Review of the Fall/Injury Assessment: Prevention and Management Plan of Care revealed Resident #126 had a Posey reverse seat belt (a lap belt that lays across the resident's lower abdomen and crosses in the back on the lower part of the wheelchair and hooks to the tilt levers) on [DATE] due to non-weight bearing status. The [DATE] physician orders [REDACTED]. Review of the Nurse's Notes dated [DATE] at 3:10 P.M. by LPN #2 revealed Resident #126 was alert and oriented to person and place with periods of confusion. The resident "attempted to shut her room door and was successful with removing the reverse seat belt two times. One to one was effective at the time of the conversation but the resident would try to remove the reverse seat belt again." The day shift Nursing Assistant Communication Tool dated [DATE] revealed Resident #126 took the reverse seat belt off two times during the shift and kept closing her room door and tried to remove the reverse seatbelt. There was no documentation of any reassessment, evaluation or analysis of the risks posed by Resident #126's ability to remove the reverse seatbelt. Review of an Accident/Incident Report dated [DATE] stated a resident's family member walked past Resident #126's room and notified State tested Nurse Aide (STNA) #14 that "a man was on the floor." STNA #14 yelled down the hallway to LPN #3. Both staff arrived to find Resident #126 seated on the floor in front of the wheelchair, her back against the seat with the reverse seat belt around her neck. LPN #3 stated Resident #126 was completely unresponsive with no pulse. LPN #3 and STNA #14 lifted the restraint from around Resident #126's neck and laid the resident on the floor. Registered Nurse (RN) #4 arrived in Resident #126's room with the crash cart and began CPR. RN #5 also responded to the resident's room. LPN #3 called "911" at 4:56 P.M., RN #4 did CPR until 911 arrived. A review of the hospital emergency room Report dated [DATE] stated the resident suffered an acute pulmonary arrest secondary to mechanical obstruction of the airway. She was admitted to the intensive care unit and maintained on mechanical ventilation. Review of the hospital History and Physical dated [DATE] revealed the patient most likely received a significant anoxic brain injury. Interview with LPN #3 on [DATE] at 3:20 P.M. revealed she was the nurse on the day and evening shift on [DATE] and responsible for the care of Resident #126. She stated Resident #126 had removed the reverse seat belt two times earlier that day ([DATE]). She stated she (LPN #3) had seen Resident #126's in her room around 4:15 P.M. LPN #126 stated later (not sure exact time) a resident's daughter reported a resident on the floor. She arrived at Resident #126's room the same time as STNA #14. LPN #3 stated Resident #126's back was resting on the seat of the wheelchair and her "butt" was on the floor. The reverse seat belt was around Resident #126's neck. LPN #3 stated that she and STNA #14 lifted the restraint over the resident's head and positioned the resident on the floor. LPN #3 stated Resident #126 was completely unresponsive and had no vital signs (pulse, respirations and blood pressure). LPN #3 affirmed there were no changes in interventions for Resident #126 on [DATE] after staff became aware Resident #126 could loosen the reverse seat belt from the wheelchair. Interview with STNA #14 on [DATE] at 5:00 P.M. revealed she was the second shift aide on [DATE] and responsible for the care of Resident #126. She described Resident #126 as small in size, who didn't like to ask for help and would try to do things herself. STNA #14 stated was aware Resident #126 had removed the rear reverse seat belt earlier on [DATE]. STNA #14 stated at 3:30 P.M. on [DATE], Resident #126 was fidgeting, wiggling and reaching behind her trying to get the reverse seat belt off. At 4:30 P.M. on [DATE], STNA #14 answered the call light of Resident #126. When STNA #14 left Resident #126's room she stated the resident was fidgeting and trying to reach her phone. STNA #14 stated about fifteen minutes later, another resident's family member told her someone was on the floor. Resident #126 was unresponsive, not breathing and bluish in color. The reverse seat belt was around Resident #126's neck. LPN #3 and I (STNA #14) pulled the reverse seat belt over Resident #126's head and laid her on the floor. Interview with STNA #5 on [DATE] at 9:55 A.M. revealed she was day shift aide for Resident #126 on [DATE]. STNA #5 described Resident #126 "antsy" that day and the resident couldn't fully understand why she had the reverse seat belt. She stated Resident #126 also tried to close her bedroom door to work on removing the reverse seat belt. STNA #5 stated the first time she found the reverse seat belt unsecured from the rear frame of the wheelchair was 12:00 P.M. on [DATE]. The second time was between 1:30 P.M. and 2:00 P.M. prior to assisting her to bed. Both times, the reverse seat belt was removed from the right rear wheelchair tilt levers. She stated she observed Resident #126 try to wiggle out of the seat belt and reach behind her to remove the seat belt. STNA #5 stated she informed LPN #3 both times of finding the reverse seat belt off and informed the oncoming second shift aide (STNA #14). Review of the manufacturer's guidelines for the Posey lap belt (reverse seat belt) revealed the straps should be crossed in the back of the wheelchair on the wheelchair tilt levers. The straps should be tightened snugly but allow an open flat hand between the device and the resident. Warning: Loose straps may allow the patient's body to slide forward, or down in a chair and become suspended in the restraint resulting in chest compression and suffocation. Review of the revised facility policy dated ,[DATE] for Safety Devices stated the facility recognized that safety devices increase risk of entrapment. Residents most at risk for entrapment are those who are frail or elderly, or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movements, hypoxia, fecal impaction, acute urinary retention. This deficiency substantiates Complaint Number OH 637.