Every finding on record at Arbors at Oregon

Based on medical record review, review of hospital documentation, resident interview, staff interview, and review of a facility policy, the facility failed to ensure residents ordered supplemental oxygen were provided timely care and services to maintain adequate oxygen levels and prevent a change in condition. Actual harm occurred to Resident #59 on 12/09/25 when the resident was removed from her bedroom to accommodate the need for maintenance staff to make repairs in the resident's room, and the resident was placed on an oxygen tank and taken to the dining room with no means to alert staff for clinical needs and no monitoring put into place to check the resident's condition. Subsequently, the oxygen tank provided to Resident #59 ran out of oxygen causing the resident to become hypoxic and lethargic, necessitating admission to the hospital after interventions in the facility did not stabilize the resident's respiratory status. Resident #59 was admitted to the intensive care unit (ICU) with diagnoses including acute on top of chronic respiratory failure and acute chronic obstructive pulmonary disease (COPD) exacerbation. This affected one (#59) of two residents reviewed for respiratory status. The facility census was 76. Findings include:Review of the medical record for Resident #59 revealed an admission date of 05/27/25. Diagnoses included acute respiratory failure, chronic obstructive pulmonary disease (COPD), and acute on chronic diastolic heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had moderate cognitive impairment. Further review of the MDS assessment revealed Resident #59 used a manual wheelchair and was dependent on staff for transportation and mobility. Resident #59 was on oxygen therapy and utilized a non-invasive mechanical ventilator. Review of the care plan dated 05/31/25 revealed Resident #59 had impaired pulmonary/respiratory status related to anxiety, congestive heart failure, and COPD. Interventions included for staff to observe for signs and symptoms of respiratory distress and administering oxygen as ordered. Additional review of the care plan revealed Resident #59 was ventilator dependent related to respiratory failure with an intervention included to observe for signs and symptoms of hypoxia (low levels of oxygen in the body tissues). Review of the physician's orders for Resident #59 revealed an order dated 02/26/26 for supplemental oxygen at four (4) to eight (8) liters per minute (L/min) via nasal cannula to keep oxygen saturation above 88 percent (%). Review of the respiratory progress notes dated 12/09/25 at 12:47 P.M. revealed Respiratory Therapist (RT) #217 was called to the room by a certified Nurse aide (CNA) to check on Resident #59. The resident was up in wheelchair with an oxygen saturation of 65%, a heart rate of 101 beats per minute, and Resident #59 was responding but was lethargic. Resident #59 was placed on average volume-assured pressure support (AVAPS), staff increased oxygen to 10 L/min, and the residents' oxygen saturation increased to 83%. Resident #59 was then placed on a non-rebreather mask and the resident's oxygen increased to 91%. Once oxygen was stable on the non-rebreather mask, the resident was placed back in bed with the head of the bed elevated. Resident #59 was still sleepy but responded appropriately. Resident #59 was tried back on AVAPS with 12 L/min, bleed up by mask (to help the oxygen be delivered to the user), and her oxygen saturation dropped to 85%. Resident #59 was placed back on a non-rebreather mask, and emergency medical services (EMS) were called. Review of an emergency room (ER) history and physical examination (exam) dated 12/09/25 at 1:41 P.M. revealed Resident #59 presented to the ER with shortness of breath (SOB). Resident #59 was in the dining area as the facility was doing some work on the rooms and the resident ran out of supplemental oxygen for one hour per the resident. The facility placed Resident #59 on a non- rebreather mask at 10 liters. The facility informed EMS they could not change her oxygen concentrator every hour, so they were unable to maintain her oxygen needs at the facility. Resident #59 was connected to a bilevel positive airway pressure (BiPAP) machine, so it was difficult to speak with her upon admission. Continued review revealed on arrival to the ER, Resident #59 was hypoxic, requiring increasing oxygen requirements, was connected to a BiPAP machine in the ER with improvement of oxygen saturation up to 99%. Resident #59's blood gases showed respiratory acidosis, and the chest x-ray showed small lung volumes with linear opacities at the lung bases favored to represent atelectasis (a collapsed lung). Resident #59 was admitted to the ICU. Review of the ER physical exam from hospital admission dated 12/09/25 revealed Resident #59 was in acute respiratory distress and was ill- and toxic-appearing. Diagnoses for admittance to the ICU included acute on top of chronic respiratory failure and acute COPD. Resident #59 was admitted to the ICU for risk of decompensation and possible need for intubation.Review of Resident #59's medical record revealed the resident was discharged from the hospital and returned to the facility on [DATE].Interview on 06/22/26 at 9:08 A.M. with Resident #59 revealed in December 2025 facility maintenance staff came to fix the ceiling in her room. The staff took her down to the dining room without her telephone. Resident #59 stated the facility put an oxygen tank on the back of the wheelchair and while down in the dining room, she ran out of oxygen and was unable to call for help. Resident #59 stated she was hospitalized for low oxygen due to her oxygen tank running out. Interview with Director of Maintenance (DOM) #255 on 06/23/26 at 9:51 A.M. revealed he worked on Resident #59's sprinkler system in December 2025 but could not recall the day. DOM #255 confirmed Resident #59 was not in her bedroom during this time, and it took approximately three hours to complete the work. Interview with RT #217 on 06/23/26 at 10:36 A.M. revealed CNA #248 came to the respiratory therapy office and indicated she needed someone quickly. Resident #59 was in her wheelchair having difficulty breathing. RT #217 noticed Resident #59's oxygen tank was empty, so an oxygen concentrator was used to attempt to raise her oxygen level. RT #217 further stated, due to not being able to maintain Resident #59's oxygen at an acceptable level, they sent her to the ER via EMS. RT #217 stated respiratory therapists check Resident #59's oxygen once at night while connected to the AVAPS system.Interview with CNA #248 on 06/23/26 at 10:49 A.M. revealed she assisted Resident #59 to get up and out of the room due to maintenance needing to work in the room. CNA #248 stated she took Resident #59 to the dining room around 9:00 A.M. CNA #248 stated she checked on Resident #59 periodically but noticed around 1:00 P.M. Resident #59 was not as responsive and her oxygen tank was empty. CNA #248 then stated she got RT #217, who came to the dining room. CNA #248 confirmed Resident #59 had no way to call for help from the dining room.Interview with the Director of Nursing (DON) on 06/23/26 at 11:44 A.M revealed she was unsure if Resident #59 was able to propel herself or not, and she was unsure if an oxygen tank or an oxygen concentrator would have been better for Resident #59. The DON stated education was provided about checking on residents more frequently, though the staff reported they were checking on Resident #59. The DON confirmed that the facility was not monitoring Resident #59's oxygen saturation daily to ensure her oxygen saturation was above 88% as ordered.Interview with Certified Nurse Practitioner (CNP) #308 on 06/23/26 at 12:07 P.M. confirmed the nurses should be checking Resident #59's oxygen saturation at least twice a day. CNP #308 further confirmed Resident #59 should not have been left alone when she was connected to an oxygen tank.Review of the policy titled, Oxygen Administration, dated 10/20/20, revealed staff should monitor oxygen saturation levels and/or vital signs, as ordered. Staff should document the ongoing assessment of the resident's condition and response to oxygen therapy.

Based on staff interview and medical record review, the facility failed to provide clinical rationale to support a provider's disagreement with a medication regimen review (MRR) as suggested by the pharmacist. This affected one ( #6) of five residents reviewed for unnecessary medications. The facility census was 76.Findings included:Review of the medical record for Resident #6 revealed an admission date of 05/20/26. Diagnoses included acute respiratory failure, depression, anxiety, and insomnia. Review of Resident #6's medical regimen review (MRR), dated 05/26/26, revealed a pharmacist recommendation to discontinue oxycodone (narcotic pain reliever), Trazodone (antidepressant), hydroxyzine (antihistamine), fluoxetine (antidepressant), Midodrine (vasopressor to raise blood pressure), Lisinopril (antihypertensive), Doxazosin (antihypertensive), diltiazem (antihypertensive), atorvastatin (used to lower cholesterol), insulin glargine (used to lower blood sugar), and Humalog (used to lower blood sugar) due to having a high and moderate fall risk. Continued review of the MRR revealed a pharmacist recommendation to discontinue diltiazem immediate-release (IR) 60 milligrams (mg) and change to diltiazem 60 mg extended-release (ER). Further review of the MRR revealed a pharmacist recommendation that Resident #6 had orders for two or more antidepressants - fluoxetine and Trazodone and noted the combined use of more than one antidepressant (especially at lower doses) may be viewed as duplicative therapy (and unnecessary) by surveyors and use of multiple antidepressants may increase the risk of side effects such as unwanted serotonergic effects. Review the MRR documents revealed the provider disagreed with the recommendations but did not provide clinical rationale for the decision. Interview on 06/24/26 at 1:00 P.M. with the Administrator verified there was no clinical rationale provided by the provider for the disagreement with the pharmacist's recommendations on 05/26/26 for Resident #6.

Based on observation, medical record review, and staff interview, review of manufacturer instructions, and review of a facility policy, the facility failed to ensure medications were properly labeled and dated. This affected three (#7, #19, and #3) of 19 residents who resided in the [NAME] hall. The facility census was 76.Findings include: 1. Review of the medical record for Resident #7 revealed an admission on [DATE]. Diagnoses included type II diabetes mellitus, end stage renal disease, and anxiety disorder. Review of the physician's order dated 04/04/26 revealed an order for Resident #7 to receive insulin glargine 100 units per milliliter (u/mL) with instructions to inject 15 units subcutaneously (SQ) in the morning for diabetes related to type II diabetes mellitus with diabetic nephropathy, and to hold the medication for blood sugar less than 150 milligrams per deciliter (mg/dL) and give in the morning per the doctor. 2. Review of the medical record for Resident #19 revealed an admission on [DATE]. Diagnoses included type II diabetes mellitus, hyperlipidemia, and major depressive disorder. Review of the physician's order dated 04/07/26 revealed an order for Resident #19 to receive insulin glargine 100 u/mL with instructions to inject 36 units SQ in the morning related to type II diabetes mellitus without complications, and to hold the medication for blood sugar less than 100 mg/dL. 3. Review of the medical record for Resident #3 revealed an admission on [DATE]. Diagnoses included type II diabetes mellitus without complications, heart failure, and atrial fibrillation. Review of the physician's order dated 06/20/26 revealed an order for Resident #3 to receive Toujeo SoloStar SQ solution pen-injector 300 u/mL with instruction to inject 68 units SQ in the morning related to type II diabetes, and to hold the medication for blood sugar less than 100 mg/dL. Observation on 06/24/26 at 8:45 A.M. of the [NAME] medication cart revealed Resident #7's insulin glargine, Resident #19's insulin glargine, and Resident #3's Toujeo Solostar were all opened and not dated. Also on the [NAME] hall medication cart was a vile of opened insulin glargine 100 u/mL that was not labeled or dated.Interview with the Director of Nursing (DON) on 06/24/26 at 8:50 A.M. confirmed Resident #7's insulin glargine, Resident #19's insulin glargine, and Resident #3's Toujeo Solostar were all opened and not dated. The DON also confirmed there was a vile of opened insulin glargine 100 u/ml that was not labeled or dated.Review of manufacturer instructions for insulin glargine, revised July 2015, revealed vials being used should be thrown away after 28 days, even if there is still insulin left in it.Review of a facility policy titled, Medication Storage, revised 01/30/24, revealed all medications housed on the facility premises will be stored according to manufacturer's recommendations.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure enhanced barrier precautions were implemented for residents with wounds and indwelling medical devices during resident care. This affected two (#66 and #73) of two residents observed receiving direct care from staff who met criteria for enhanced barrier precautions. The facility census was 76. Findings include: 1. Review of the medical record revealed Resident #66 admitted to the facility on [DATE] with the diagnoses including, cerebral vascular disease, heart failure, severe protein calorie malnutrition, hypoxemia, seizures, peripheral vascular disease, cardiomegaly, atrial fibrillation, malignant neoplasm of breast, dysphagia, and muscle wasting and atrophy. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had severe cognitive impairment, was dependent on staff for the provision of activities of daily living, was incontinent of bowel and bladder, was at risk for pressure ulcer development with two arterial/venous ulcers which required dressing application, and received hospice services. Review of Resident #66's physician orders revealed on 06/09/26 the resident was ordered a treatment to the right heel to include cleansing with in-house wound cleanser, pat dry, apply methylene blue foam, cover with abdominal dressing (ABD), and wrap with Kerlex every night shift on every Monday, Wednesday, Friday for wound care and as needed. For the resident's left foot, first toe an order was given to cleanse with in-house wound cleanser, pat dry, apply methylene blue foam, cover with ABD and wrap with Kerlex every night shift every Monday, Wednesday, Friday for wound care and as needed. For the resident's left lateral malleolus an order was given to cleanse with in-house wound cleanser, pat dry, apply methylene blue foam, cover with ABD and wrap with Kerlex every night shift every Monday, Wednesday, Friday for wound care and as needed. Resident #66 was also ordered for staff to apply betadine to a vascular area to the left lateral foot every night shift every Monday, Wednesday, Friday and as needed and cleanse the left heel with in-house wound cleanser, pat dry, apply methylene blue foam, cover with ABD and wrap with Kerlex every night shift every Monday, Wednesday, Friday for wound care and as needed. Further review of Resident #66's medical record revealed no physician order or plan of care regarding the implementation of enhanced barrier precautions (EBP). Observation on 06/23/26 at 9:49 A.M. with Certified Nurse Aide (CNA) #307 and CNA #266 identified Resident #66 with dressing/treatment applications to bilateral lower extremities. No personal protective equipment (PPE) was observed in the vicinity of the room nor was there a sign indicating EBPs were in place for the resident. CNA #307 and CNA #266 proceeded to don disposable surgical gloves and provided Resident #66 with incontinence care. No gown was applied by either staff member. Following the completion of incontinence care, Resident #66 was transferred from bed to a reclining geriatric chair using a mechanical lift. No PPE was applied other than disposable surgical gloves. On 06/23/26 at 10:09 A.M. interview with CNA #307 and CNA #266 verified they did not implement EBPs while providing direct care to Resident #66 and verified no gowns or additional PPE was accessible on Resident #66's unit (300 Hall). 2. Review of the medical record for Resident #73 revealed an admission on [DATE]. Diagnoses included cerebral infarction, dysphagia, tracheostomy, and epilepsy. Review of the admission MDS assessment dated [DATE] revealed Resident #73 had severe cognitive impairment. Further review of the MDS assessment revealed Resident #73 had a feeding tube and was dependent on staff for care. Review of the care plan dated 05/28/26, and revised on 06/19/26, revealed Resident #73 required EPBs related to tracheostomy and gastrostomy (g-tube) placement. Interventions included using a gown and gloves when providing direct care and face protection may be needed if performing activity with risk of splash or spray. Review of Resident #73's physician orders dated 05/29/26 revealed an order to use EBPs while performing high-contact activity. Observation on 06/22/26 at 9:13 A.M. of Resident #73's bedroom revealed no sign for EBPs or PPE available outside of the room. Concurrent observation revealed Licensed Practical Nurse (LPN) #206 administering Resident #73 medication, without a gown or gloves on. Observation on 06/22/26 at 9:41 A.M. revealed Registered Nurse (RN) #257 attempting to give Resident #73 medication without a gown or gloves on. Interview on 06/22/26 at 10:06 A.M. with RN Manager #210 confirmed Resident #73 had an order for EBPs and did not have a sign on the door or PPE available outside of the room. Interview on 06/22/26 at 10:20 A.M. with LPN #206 confirmed PPE was not worn when providing care to Resident #73. Interview on 06/22/26 at 10:21 A.M. with RN #257 confirmed PPE was not worn when providing care to Resident #73. Review of a facility policy for EBPs, dated 03/26/24, revealed EBPs refer to an infection control intervention designed to reduce transmission of multi drug-resistant organisms (MDRO) that employs targeted gowns and gloves during high-contact resident care activities. Even if the resident is not known to be infected or colonized with a MDRO, an order for enhanced barrier precautions will be obtained for residents with wounds including chronic wounds such as pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and indwelling medical devices including central lines, urinary catheters, feeding tubes, and tracheostomy/ventilator tubes. Implementation of EBPs may include but were not limited to making gowns and gloves readily available near or outside residents room. High contact resident care activities to consider included dressing, bathing, transferring, providing personal hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care.

Based on observation, medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure a dependent resident was provided with adequate facial hair grooming. This affected one (#25) of three residents reviewed for the provision of activities of daily living in a facility census of 76. Findings include: Review of the medical record revealed Resident #25 admitted to the facility on [DATE] with the diagnoses including, cerebral infarction with hemiplegia affecting the left side, hypertension, anxiety disorder, chronic pain syndrome, panic disorder, and depression. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was assessed with moderate cognitive impairment, had no recorded behaviors, had upper and lower extremity range of motion impairment on both sides, was dependent on staff for the provision of activities of daily living (ADLs), was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown. Review of a nursing plan of care dated 02/12/26 addressed Resident #25's ADLs self-care performance deficit related to cerebral infarction, hemiplegia, generalized anxiety disorder, panic disorder, low back pain, chronic pain syndrome, muscle weakness, and other abnormalities of gait and mobility. Interventions included bathing with one person assist, bed mobility with two person assist, dressing with two person assist and personal hygiene with two person assist. Review of Resident #25's physician orders revealed on 05/23/25 an order was implemented to verify the resident's bathing was completed every Tuesday and Friday and to document any refusals or requests for a different day or time. Review of Resident #25's shower task documentation noted showers provided by staff on 05/29/26, 06/02/26, 06/05/26, 06/09/26, 06/16/26, and 06/19/26. No documentation indicated Resident #25 refused bathing or grooming. In addition, no documentation indicated the resident was provided with facial hair grooming/removal. Observation on 06/22/26 at 11:07 A.M. discovered Resident #25 was seated alone in a wheelchair in the unit dining room. Resident #25 was dressed and heavy hair growth was identified covering her chin. Interview with Resident #25 at the time revealed she preferred not to have facial hair and she was not offered facial hair removal during the provision of morning ADLs. On 06/23/26 at 9:05 A.M. Resident #25 was observed in bed and remained with heavy facial growth to her chin. On 06/23/26 at 9:16 A.M. interview with Certified Nurse Aide (CNA) #284 and CNA #233 verified Resident #25's facial hair growth. CNA #284 proceeded to search Resident #25 room and discovered Resident #25 personal razor located in her bathroom. Review of the facility ADLs policy, dated 01/01/22, revealed a resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan.

Based on observation, medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure wound treatments and interventions were implemented as prescribed. This affected one (#33) of two residents reviewed with wounds and related treatment applications in a facility census of 76. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with the diagnoses including, cerebral infarction, metabolic encephalopathy, anemia, end stage renal disease with dependence on renal dialysis, type II diabetes mellitus with long term insulin use, chronic obstructive pulmonary disease, Crohn's disease, congestive heart failure, protein calorie malnutrition, coronary artery disease, osteoarthritis to the left hip, and muscle weakness. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #33 with severe cognitive impairment and no recorded behaviors. The resident required substantial to maximal assistance with activities of daily living, supervision or touching assistance with rolling side to side in bed, partial to moderate assistance with lying to sitting, was incontinent of bowel and bladder, was at risk for pressure ulcer development with one stage three pressure ulcer (full-thickness skin loss) on admission. Review of Resident #33's medical record revealed on 05/28/26 an assessment for predicting pressure ulcer risk assessed Resident #33 at risk of pressure ulcer development. Review of a nursing plan of care dated 06/16/26 addressed Resident #33's impaired skin integrity as evidenced by venous wounds to the left ankle and left heel and a skin tear to the left shin. Interventions included to administer treatment(s) per orders, assist the resident with turning and repositioning as needed, complete wound evaluation(s) to observe the progress of the resident's skin condition, encourage/assist as needed to elevate the resident's heels off the mattress as tolerated, a pressure redistribution mattress to the bed, and a wound consultation as needed. Review of a wound specialist evaluation dated 06/16/26 identified Resident #33 with a left shin skin tear with a duration greater than one day measuring 4.7 centimeters (cm) long by (x) 1.7 cm wide x 0.1 cm deep with moderate serosanguinous drainage. The resident also had an arterial wound to the left anterior ankle measuring 5.3 cm long x 5.1 cm wide x no measurable depth due to the presence of dried fibrinous exudate; and an arterial wound to the left heel measuring 3.3 cm long x 5.3 cm wide x with no measurable depth due to the presence of dried fibrinous exudate. Further review revealed physician recommendations including to off-load wounds and float heels in bed. Specific to visit recommendations included application of pressure off-loading boot and a primary dressing treatment plan to the left shin including the application of Xeroform gauze applied once daily and as needed if saturated, soiled, or dislodged. A secondary treatment dressing included application of a gauze island with border apply once daily and as needed if saturated, soiled, or dislodged. Review of Resident #33's physician order dated 06/16/26 revealed the resident was to have a treatment to a left shin skin tear including to cleanse with in-house wound cleanser, pat dry, apply Xeroform, and cover with boarder gauze. The treatment was to be completed every night shift every other day and needed for a skin tear. On 06/17/26, a physician order was implemented for off-loading boots to Resident #33's bilateral feet to be worn at all times (as tolerated) to be applied every day and night shift. Review of treatment administration records between night shift on 06/17/26 and day and night shift through 06/23/26 recorded Resident #33's off-loading boots to bilateral feet to be worn at all time every day and night shift were in place as ordered. There was no documentation in the record of resident refusals. Observation on 06/22/26 at 9:04 A.M. and 12:36 P.M. noted Resident #33 resting on the bed with bilateral heels resting directly on the mattress. No pressure relief boots or heel elevation was in place. On 06/23/26 at 8:50 A.M., Resident #33 was in bed with both heels resting on the mattress. At 10:16 A.M., the resident was in bed and interview with Resident #33 at that time stated he had pressure relief boots when he was admitted to the facility, but was not aware where they went and had not had them for an undisclosed amount of time. Resident #33 stated he would wear the boots if staff applied them. Further observation at that time revealed Resident #33's left shin skin tear was open to air with no dressing applied. On 6/23/26 at 10:58 A.M. interview with Certified Nurse Aide (CNA) #307 and CNA #266, during observation, verified Resident #33 was in bed with both feet resting on the mattress. Both CNAs verified no heel elevation or pressure relief boots were in place since assuming care of Resident #33 at 6:00 A.M. On 06/23/26 11:08 A.M. interview with Unit Manager Licensed Practical Nurse (LPN) #210 verified Resident #33 was to have pressure relief boots in place due to heel wounds. Observation on 06/24/26 at 5:13 A.M. revealed Resident #33 was in bed with his eyes closed. Socks were applied to the resident's bilateral lower extremities with his feet resting on mattress. No foot elevation or pressure relief boots were in place. At 06/24/26 at 5:30 A.M. interview with CNA #294 verified she assumed care of Resident #33 at 10:00 P.M. the previous night. CNA #294 stated she was unaware Resident #33 was to have pressure relief boot or lower extremity elevation due to the wounds on his left lower extremity. Review of a wound treatment management policy, dated 10/26/23, revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure gastrostomy (g-tube) care was complete and placement of the g-tube was verified prior to administering enteral feedings and flushes. This affected one (#73) of three residents reviewed for g-tubes. The facility census was 76. Findings include:Review of the medical record for Resident #73 revealed an admission date of 05/28/26. Diagnoses included cerebral infarction, dysphagia, tracheostomy, and epilepsy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had severe cognitive impairment, had a feeding tube, and was dependent on staff for care. Review of the care plan dated 06/19/26 revealed Resident #73 had impaired gastrointestinal status related to gastroesophageal reflux disease (GERD). Interventions included to flush the feeding tube per orders, administer enteral nutrition per orders, and check for tube placement and residual as indicated. Review of Resident #73's physician's orders dated 05/29/26 revealed an order for every day shift to cleanse the resident's gastrostomy tube (g-tube) site with soap and water daily and as needed, and apply drain and sponge as needed. The ordered continued that the site may be left open to air if it was clean and there was no drainage. Resident #73 received an order on 05/28/26 for every day and night shift to check tube placement prior to administration of medication and tube feeding/flush. Observation and interview on 06/22/26 at 9:13 A.M. revealed Licensed Practical Nurse (LPN) #206 attempting to administer morning medications to Resident #73 via the resident's g-tube. LPN #206 did not check for placement before flushing Resident #73's g-tube. LPN #206 then placed medication into Resident #73's g-tube; however, the medication would not flow into the tube. LPN #206 then tried to force the medication into the g-tube by pushing forcefully with the syringe plunger. LPN #206 could not get the medications into the g-tube and poured the medications from the syringe back into the medication cup. LPN #206 then attempted to expel the clogged tube by milking it (a technique used to help fluids flow in a g-tube using a similar motion as milking a cow) from the end of the g-tube to the tip, expelling a small amount of fluid, and old feeding supplement. LPN #206 then attempted to flush the g-tube with water without success. LPN #206 then stated she needed to go get a manager.Observation on 06/22/26 at 9:51 A.M. revealed Unit Manager Register Nurse (RN) #298 attempted to flush Resident #73's g-tube. RN #298 did not check for placement prior to attempting to flush the g-tube. RN #298 took a declogger and attempted to unclog the g-tube without success.Observation on 06/22/26 at 10:06 A.M. revealed Unit Manager RN #210 attempting to milk the g-tube without success. Resident #73's skin surrounding the g-tube had dark dried blood and drainage surrounding the area. There was no dressing noted to the area. RN #210 then attempted to forcefully push 30 milliliters (mL) of air into Resident #73's g-tube without success. RN #210 then attempted to pull back on the syringe with no residual noted. RN #210 then forcefully pushed 30 mLs of water into the g-tube.Interview on 06/25/26 at 10:20 A.M. with LPN #206 confirmed placement was not checked prior to attempting to give medications to Resident #73 through the g-tube. LPN #206 stated checking residual was the only way she knew how to check for placement. Concurrent interview with RN #298 revealed placement was not checked prior to attempting to flush the resident's g-tube. Additional interview with RN #210 at that time confirmed Resident #73's g-tube site had drainage and dried dark red blood and further confirmed Resident #73's skin should have been cleaned and a dressing applied to the area.Review of the facility policy titled, Feeding Tubes, dated 01/01/21, revealed a licensed nurse will monitor and check that the feeding tube is in the right location. Tube placement will be verified before beginning a feeding and before administering medications. Licensed nurses were to replace and/or change a feeding tube when a long-term feeding tube is worn or clogged.

Based on observation, record review, staff interview, review of the manufacturer instructions, and review of facility policy, the facility failed to maintain a medication administration error rate of less than five percent. This affected two (#04 and #24) of three residents reviewed for medication administration. There were 36 opportunities with two medication errors for a medication error rate that was 5.5 percent. The facility census was 77.1. Review of Resident #04's medical record revealed an initial admission date of 03/14/24 and a re-admission date of 08/12/25. Diagnoses included traumatic brain injury without loss of consciousness, type II diabetes mellitus, muscle weakness, depression, and dysphagia. Review of Resident #04's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had moderately impaired cognition and received hypoglycemic medication.Review of Resident #04's care plan dated 11/13/25 revealed Resident #04 had an impaired metabolic status related to diabetes, interventions included to administer medications and treatments as ordered, and to administer insulin per the physician orders.Review of Resident #04's physician orders revealed an order for insulin Degludec using a pen-injector 100 units per milliliter (unit/ml), 15 units to be administered subcutaneously in the morning for diabetes mellitus. Continuous observation on 12/16/25 from 8:23 A.M. until 8:32 A.M. of medication administration completed by Licensed Practical Nurse (LPN) #195 revealed LPN #195 began to prepare a Degludec insulin pen for Resident #04 by applying the needle to the insulin pen. LPN #195 dialed the pen injector to 15 units, entered Resident 4's room and administered the insulin subcutaneously.2. Review of Resident #24 medical record revealed an admission date of 11/07/25. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension. Review of Resident #24's admission MDS assessment dated [DATE] revealed Resident #24 had moderately impaired cognition and received hypoglycemic medication.Review of Resident #24's care plan dated 11/20/25 revealed Resident #24 had an impaired metabolic status related to diabetes, interventions included to administer medications and treatments as ordered, and to administer insulin per the physician orders.Review of Resident #24's physician orders revealed an order for insulin Lispro using a pen-injector, 100 units/ml, administer four units subcutaneously before meals and at bedtime for diabetes mellitus.Observation on 12/16/25 at 8:33 A.M. of medication administration, LPN #195 dialed the pen injector to four units, entered Resident #24's room and administered the insulin to Resident #24 in the . Interview on 12/16/25 at 8:57 A.M. with LPN #195 verified he did not prime the insulin pens prior to administering the insulin injections to Resident #4 and #24. LPN #195 stated there is no need to prime the insulin pens. Review of the manufacturer's instructions with a last revised date of July 2022 for insulin Degludec pen-injector revealed to apply the needle to the pen, dial up two units of insulin, hold the pen with the needle pointing up, gently tap on the needle a few times to allow air to rise to the top, press and hold the dose button until it shows zero, and a drop of insulin should be seen at the needle tip. Turn the dose selector to the needed dose and inject per the physician's orders.Review of the manufacturer's instructions with a last revised date of July 2023 for the Lispro pen-injector revealed to apply the needle to the pen, dial up two units of insulin, hold the pen with the needle pointing up, gently tap on the needle a few times to allow air to rise to the top, press and hold the dose button until it shows zero and hold the dose knob while slowly counting to five, and a drop of insulin should be seen at the needle tip. Turn the dose selector to the needed dose and inject per the physician order. Priming the insulin pen means removing the air from the needle and cartridge that may collect during normal use, and ensures the pen is working correctly. Not priming the before each injection, may provide too much or too little insulin. Review of the facility policy titled Medication Administration with a last revised date of 01/01/22 revealed to administer medication as ordered in accordance with manufacturer specifications.This deficiency represents non-compliance investigated under Master Complaint Number 2689998 and Complaint Number 2686783.

Based on observation, record review, staff interview, review of the manufacturer instructions, and review of facility policy, the facility failed to ensure insulin pens were primed prior to administration of insulin. This affected two residents (#04 and #24) of two residents reviewed for insulin administration. The facility census was 77.1. Review of Resident #04 ' s medical record revealed an initial admission date of 03/14/24 and a re-admission date of 08/12/25. Diagnoses included traumatic brain injury without loss of consciousness, type II diabetes mellitus, muscle weakness, depression, and dysphagia. Review of Resident #04 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had moderately impaired cognition and received hypoglycemic medication.Review of Resident #04 ' s care plan dated 11/13/25 revealed Resident #04 had an impaired metabolic status related to diabetes, interventions included to administer medications and treatments as ordered, and to administer insulin per the physician orders.Review of Resident #04 ' s physician orders revealed an order for insulin Degludec using a pen-injector 100 units per milliliter (unit/ml), 15 units to be administered subcutaneously in the morning for diabetes mellitus. Continuous observation on 12/16/25 from 8:23 A.M. until 8:32 A.M. of medication administration completed by Licensed Practical Nurse (LPN) #195 revealed LPN #195 began to prepare a Degludec insulin pen for Resident #04 by applying the needle to the insulin pen. LPN #195 dialed the pen injector to 15 units, entered Resident 4's room and administered the insulin subcutaneously.2. Review of Resident #24 medical record revealed an admission date of 11/07/25. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension. Review of Resident #24 ' s admission MDS assessment dated [DATE] revealed Resident #24 had moderately impaired cognition and received hypoglycemic medication.Review of Resident #24 ' s care plan dated 11/20/25 revealed Resident #24 had an impaired metabolic status related to diabetes, interventions included to administer medications and treatments as ordered, and to administer insulin per the physician orders.Review of Resident #24 ' s physician orders revealed an order for insulin Lispro using a pen-injector, 100 units/ml, administer four units subcutaneously before meals and at bedtime for diabetes mellitus.Observation on 12/16/25 at 8:33 A.M. of medication administration, LPN #195 dialed the pen injector to four units, entered Resident #24 ' s room and administered the insulin to Resident #24 in the . Interview on 12/16/25 at 8:57 A.M. with LPN #195 verified he did not prime the insulin pens prior to administering the insulin injections to Resident #4 and #24. LPN #195 stated there is no need to prime the insulin pens. Review of the manufacturer ' s instructions with a last revised date of July 2022 for insulin Degludec pen-injector revealed to apply the needle to the pen, dial up two units of insulin, hold the pen with the needle pointing up, gently tap on the needle a few times to allow air to rise to the top, press and hold the dose button until it shows zero, and a drop of insulin should be seen at the needle tip. Turn the dose selector to the needed dose and inject per the physician's orders.Review of the manufacturer ' s instructions with a last revised date of July 2023 for the Lispro pen-injector revealed to apply the needle to the pen, dial up two units of insulin, hold the pen with the needle pointing up, gently tap on the needle a few times to allow air to rise to the top, press and hold the dose button until it shows zero and hold the dose knob while slowly counting to five, and a drop of insulin should be seen at the needle tip. Turn the dose selector to the needed dose and inject per the physician order. Priming the insulin pen means removing the air from the needle and cartridge that may collect during normal use, and ensures the pen is working correctly. Not priming the before each injection, may provide too much or too little insulin. Review of the facility policy titled Medication Administration with a last revised date of 01/01/22 revealed to administer medication as ordered in accordance with manufacturer specifications.This deficiency represents non-compliance investigated under Master Complaint Number 2689998 and Complaint Number 2686783.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure infection control standards were maintained during the preparation of medication for administration. This affected two residents (#04 and #24) of three residents reviewed for infection control. The facility census was 77. 1. Review of Resident #04's medical record revealed an initial admission date of 03/14/24 and a re-entry date of 08/12/25. Diagnoses included traumatic brain injury without loss of consciousness, type II diabetes mellitus, muscle weakness, depression, and dysphagia. Review of Resident #04's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had moderately impaired cognition. Furthermore, Resident #04 took anti anxiety, antidepressant, hypoglycemic, and anticonvulsant medications. Review of Resident #04's physician orders revealed an order for Celexa 20 milligrams (mg) by mouth in the morning for depression and an order for Vimpat 100 mg by mouth every morning and at bedtime for seizures. Observation on 12/16/25 at 8:23 A.M. of medication administration completed by Licensed Practical Nurse (LPN) #195 revealed LPN #195 began to prepare medications for Resident #04. While preparing the medications, LPN #195 dropped Resident #04's Celexa onto the top of the medication cart. The pill bounced multiple times before LPN #195 picked up the pill with his bare right hand and placed the pill into the medication cup. While preparing Resident #04's Vimpat, the pill was also dropped onto the top of the medication cart where LPN #195 again picked up the pill with his bare right hand and placed it into the medication cup. After preparing all Resident #04's medications, LPN #195 returned the punch cards to the drawer, locked the medication cart, used the computer mouse to close the computer screen, picked up the medication cup containing the pills, walked into the resident's room, and handed the cup of pills to Resident #04. Resident #04 took the pills with water. 2. Review of Resident #24 medical record revealed an admission date of 11/07/25. Diagnoses included acute and chronic respiratory failure with hypoxia, type II diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension.Review of Resident #24's admission MDS assessment dated [DATE] revealed Resident #24 had moderately impaired cognition. Furthermore, Resident #24 took antipsychotic, anti anxiety, diuretic, opioid, antiplatelet, and hypoglycemic medication. Review of Resident #24's current physician orders revealed orders for Flomax 0.4mg by mouth in the morning for benign prostatic hyperplasia, buspar 5 mg, carvedilol 6.25 mg, clopidogrel 75 mg, ferrous sulfate 325 mg, folic acid 1000 micrograms (mcg), lasix 20 mg, levothyroxine 112 mcg, protonix 40 mg, potassium chloride 20 milliequivalents (meq), and seroquel 300 mg.Observation on 12/16/25 starting at 8:33 A.M. of medication administration completed by Licensed Practical Nurse (LPN) #195 revealed LPN #195 began to prepare medications for Resident #24. While preparing the medications, LPN #195 dropped Resident #24's Flomax, the pill bounced on the top of the medication cart and then between the narcotic book and a tray that held the water pitcher, medication cups and water cups. LPN #195 picked up the Flomax with his bare right hand and put it into the medication cup. Continued observation revealed LPN #195 picked up a medication card for buspar with his right hand, punched the 5 mg tablet into his left hand and then placed the tablet into the medication cup. LPN #195 placed the buspar medication card face down on the top of the medication cart and picked up a second medication card for carvedilol with his right hand, punch a 6.25 mg tablet into his left hand and then again placed the tablet into the medication cup, set the carvedilol medication card facedown on top the buspar medication card. The process of punching the medications from the medication card with the right hand into the left hand and placing the medication into the medication cup continued for each of the additional eight medications, clopidogrel 75 , ferrous sulfate 325 mg, folic acid 1000 mcg, lasix 20 mg, levothyroxine 112 mcg, protonix 40 mg, potassium chloride 20 meq, and seroquel 300 mg. After preparing all of Resident #24's medications, LPN #195 returned the punch cards to the drawer of the medication cart, locked the medication cart, used the computer mouse to close the computer screen from which LPN #195 was working from, picked up the medication cup of pills, walked into the Resident #24's room, handed the cup of pills to Resident #24 and observed Resident #24 take each of the pills with water. Interview on 12/16/25 at 8:57 A.M., following the observation, LPN #195 confirmed he had touched Resident #24's pills with his bare hands. LPN #195 verified he picked up the flomax tablet that he had dropped and bounced on the medication cart and further verified he punched each of Resident #24's medications into his bare hand prior to placing the pills into the medication cup and administered the medications to Resident #24 after touching them. Furthermore, LPN #195 verified that he usually punches the resident's pills into his bare hands because he drops them when he tries to punch them out directly into the medication cup. Review of the facility policy titled Medication Administration with a last revised date of 01/01/22 revealed when removing medication from the source, take care not to touch the medication with a bare hand.This deficiency represents non-compliance investigated under Complaint Number #2686783.

Based on record review, resident interview, staff interview, and policy review, the facility failed to investigate a report of alleged verbal abuse. This affected one (#48) of three residents reviewed for abuse. The facility census was 77. Review of Resident #48's medical record revealed an admission date of 03/20/24, diagnoses included spinal stenosis of the cervical region, osteomyelitis, type II diabetes mellitus, and muscle weakness. Review of Resident #48's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had intact cognition. Resident #48 was dependent for toilet hygiene, required partial/moderate assistance with personal hygiene, and was dependent for chair to bed transfers. Review of Resident #48's care plan dated 12/14/25 revealed Resident #48 had an activity of daily living (ADL) self-care performance deficit, interventions included the assistance of two people for bed mobility and the assistance of two people and the use of the mechanical lift for transfers. Review of Resident #48's progress notes from 12/12/25 to 12/16/25 revealed no notes regarding the alleged verbal abuse.Interview on 12/16/25 at 3:37 P.M. with Registered Nurse (RN) #157 revealed on 12/14/25, RN #157 asked Certified Nursing Assistant (CNA) #108 to transfer Resident #48 into bed so she could complete the resident's dressing changes. RN #157 stated a little after 4:00 P.M., CNA #108 came up to RN #157 and stated Resident #48 refused to get into bed. Further interview with RN #157 revealed CNA #108 reported Resident #48 asked for assistance to clean off her bed so the resident could be assisted with being transferred into the bed for her dressing changes. RN #157 stated CNA #108 told RN #157 that she told Resident #48 you made the mess on the bed, you can clean it up. RN #157 stated CNA #108 should have helped the resident, and it was inappropriate for CNA #108 to say what she did to Resident #48. RN #157 verified CNA #108 did not help the resident clean off her bed and did not assist with transferring Resident #48 into bed. RN #157 also verified Resident #48's dressing changes were not completed on 12/14/26 as a result. RN #157 stated she reported this to the Assistant Director of Nursing (ADON) that evening when she got home via text message.Interview on 12/16/25 at 4:10 P.M. with the ADON revealed RN #157 texted her on 12/14/25 at 7:06 P.M. and reported CNA #108 refused to help Resident #48 clean off her bed when asked and per the report of CNA #108 she told the resident you made the mess on the bed, you can clean it up. The ADON stated she did not feel the statement was verbal abuse and did nothing more with the information. The ADON verified if there is a concern of resident abuse it should be reported immediately to the Director of Nursing so an investigation can be started. The ADON verified on 12/16/25 at 4:15 P.M. she did not report the incident to the Director of Nursing and further verified an investigation of the incident had been initiated. Interview on 12/16/25 at 4:32 P.M. with Resident #48 revealed she did not recall CNA #108 telling her you made the mess on your bed, you need to clean it off, however Resident #48 did say that CNA #108 told the resident she needed to answer another call light and would come back but never did. Resident #48 verified her dressing was not changed on 12/14/25 as ordered. Interview on 12/16/25 at 4:44 P.M. with CNA #108 revealed RN #157 had asked her to transfer Resident #48 into bed. CNA #108 stated she went into Resident #48's room and she had personal items on her bed. CNA #108 stated Resident #48 stated she would move her items off of her bed and put her call light on when she was finished. CNA #108 denied saying you made the mess on your bed, you need to clean it off. CNA #108 stated she told RN #157 that Resident #48 needed to get her bed cleaned off.Interview on 12/16/25 at 5:31 P.M. with the Director of Nursing revealed the ADON had just reported the situation to her approximately an hour prior. The Director of Nursing verified the allegation of verbal abuse should have been promptly reported to her and an investigation should have been started immediately following the notification. Review of the facility policy last revised on 01/10/24 titled Abuse, Neglect, and Exploitation revealed possible indicators of abuse include but are not limited to resident, staff or family reporting abuse, verbal abuse, physical abuse, psychological abuse, and failure to provide care needs. The policy further stated an immediate investigation is warranted when there is a suspicion of abuse, neglect, or exploitation, or a report of abuse, neglect, or exploitation. The investigation should be thoroughly documented and include the identified person responsible for the investigation. Written procedures for the investigation include identifying and interviewing all involved persons, including the alleged victim. alleged perpetrator, and witnesses or others that may have knowledge of the allegation, and should focus on determining if abuse, neglect, exploitation and/or mistreatment occurred, the extent and the cause. This deficiency represents non-compliance investigated under Master Complaint Number 2689998.

Based on record review, resident interview, staff interview, and policy review, the facility failed to timely report an allegation verbal abuse to the state agency. This affected one (#48) of three residents reviewed for abuse. The facility census was 77. Review of Resident #48's medical record revealed an admission date of 03/20/24, diagnoses included spinal stenosis of the cervical region, osteomyelitis, type II diabetes mellitus, and muscle weakness. Review of Resident #48's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had intact cognition. Resident #48 was dependent for toilet hygiene, required partial/moderate assistance with personal hygiene, and was dependent for chair to bed transfers. Review of Resident #48's care plan dated 12/14/25 revealed Resident #48 had an activity of daily living (ADL) self-care performance deficit, interventions included the assistance of two people for bed mobility and the assistance of two people and the use of the mechanical lift for transfers. Review of Resident #48's progress notes from 12/12/25 to 12/16/25 revealed no notes regarding the alleged verbal abuse.Interview on 12/16/25 at 3:37 P.M. with Registered Nurse (RN) #157 revealed on 12/14/25, RN #157 asked Certified Nursing Assistant (CNA) #108 to transfer Resident #48 into bed so she could complete the resident's dressing changes. RN #157 stated a little after 4:00 P.M., CNA #108 came up to RN #157 and stated Resident #48 refused to get into bed. Further interview with RN #157 revealed CNA #108 reported Resident #48 asked for assistance to clean off her bed so the resident could be assisted with being transferred into the bed for her dressing changes. RN #157 stated CNA #108 told RN #157 that she told Resident #48 you made the mess on the bed, you can clean it up. RN #157 stated CNA #108 should have helped the resident, and it was inappropriate for CNA #108 to say what she did to Resident #48. RN #157 verified CNA #108 did not help the resident clean off her bed and did not assist with transferring Resident #48 into bed. RN #157 also verified Resident #48's dressing changes were not completed on 12/14/26 as a result. RN #157 stated she reported this to the Assistant Director of Nursing (ADON) that evening when she got home via text message.Interview on 12/16/25 at 4:10 P.M. with the ADON revealed RN #157 texted her on 12/14/25 at 7:06 P.M. and reported CNA #108 refused to help Resident #48 clean off her bed when asked and per the report of CNA #108 she told the resident you made the mess on the bed, you can clean it up. The ADON stated she did not feel the statement was verbal abuse and did nothing more with the information. The ADON verified if there is a concern of resident abuse it should be reported immediately to the Director of Nursing so an investigation can be started. The ADON verified on 12/16/25 at 4:15 P.M. she did not report the incident to the Director of Nursing and further verified an investigation of the incident had been initiated. Interview on 12/16/25 at 4:32 P.M. with Resident #48 revealed she did not recall CNA #108 telling her you made the mess on your bed, you need to clean it off, however Resident #48 did say that CNA #108 told the resident she needed to answer another call light and would come back but never did. Resident #48 verified her dressing was not changed on 12/14/25 as ordered. Interview on 12/16/25 at 4:44 P.M. with CNA #108 revealed RN #157 had asked her to transfer Resident #48 into bed. CNA #108 stated she went into Resident #48's room and she had personal items on her bed. CNA #108 stated Resident #48 stated she would move her items off of her bed and put her call light on when she was finished. CNA #108 denied saying you made the mess on your bed, you need to clean it off. CNA #108 stated she told RN #157 that Resident #48 needed to get her bed cleaned off.Interview on 12/16/25 at 5:31 P.M. with the Director of Nursing revealed the ADON had just reported the incident to her approximately an hour prior. The Director of Nursing verified the allegation of verbal abuse should have been promptly reported to her and an investigation should have been started immediately, and the state agency should have been notified. Review of the facility policy last revised on 01/10/24 titled Abuse, Neglect, and Exploitation revealed alleged violations will be reported to the Administrator, state agency, adult protective services and all other required agencies immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, and not later than 24 hours if the even does not involve abuse or serious bodily injury. This deficiency represents non-compliance investigated under Master Complaint Number 2689998.

Based on review of a social media post, medical record review, staff interview, Police Detective (PD) interview, review of the facility video surveillance, review of the Local Police Department (LPD) report, review of the local weather report and review of the facility policy, the facility failed to ensure Resident #23, who had a diagnosis of alcohol dependence with induced persisting dementia, had a history of an elopement from a previous facility, was assessed to be at risk for elopement, and had a Wanderguard (wearable bracelet that triggers alarms at the doors to alert staff when a resident attempts to exit) applied to his left ankle, did not elope from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on 08/09/25 at 10:38 A.M. when Resident #23 removed his Wanderguard and was able to exit through the front door of the facility. Facility staff were unaware Resident #23 was missing until 08/10/25 at approximately 2:00 A.M. (about 15.5 hours after the resident eloped). Furthermore, Resident #23 was missing for approximately 52 hours before facility staff, who were driving around the local area searching for the resident, found the resident at a bus stop, approximately three miles from the facility. This affected one (#23) of three residents reviewed for elopement. The facility identified six (#14, #22, #23, #28, #34, and #44) residents at risk for elopement. The facility census was 66.On 08/09/25 at 3:02 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/09/25 at 10:38 A.M. when Resident #23, who had removed his Wanderguard, was able to exit out of the front door without staff knowledge. Resident #23 ambulated through the parking lot and crossed a moderately traveled two lane road with a speed limit of 35 miles per hour (MPH) before the resident could no longer been seen on the video camera. Facility staff confused Resident #23 with another resident of the facility and did not identify that Resident #23 was missing until 08/10/25 at approximately 2:00 A.M., nearly 15.5 hours after Resident #23 eloped. Resident #23 was not located until 08/11/25 at 2:32 P.M., when facility staff found the resident at a public bus stop. The route traveled by Resident #23 was unknown; however, the area surrounding the facility included heavily traveled four lane roads with speed limits of 40 to 45 MPH and a major interstate highway with speed limits of 60 to 65 MPH. During the time that Resident #23 was missing, it was unknown where he stayed, how he obtained food or hydration, and high temperatures in the area ranged from 90 degrees Fahrenheit (F) on 08/09/25 to 91 degrees F on 08/10/25 and 08/11/25.The Immediate Jeopardy was removed 08/11/25, when the facility implemented the following corrective action plan: On 08/10/25, the DON or designee educated licensed and non-licensed nursing staff on checking assignments prior to starting their shift for assignment location, nurse and Certified Nursing Assistants (CNAs) assigned to the hall, validating residents' identity utilizing photographs in the electronic medical record (EMR), the facility's Leave of Absence (LOA) policy, and the elopement policy. On 8/10/25, the DON reassessed all residents for elopement risk to ensure accuracy of assessments and care plans were reviewed and updated as needed to ensure adequate interventions were in place. On 08/10/25, the DON completed a visual audit of all residents with orders for a Wanderguard to ensure placement, with no concerns identified. On 08/10/25, the DON or designee completed an elopement drill on each shift at the facility, with no concerns identified. On 08/11/25 at 2:32 P.M., Regional Director of Operations (RDO) #603 located Resident #23 in downtown [NAME] at a public bus hub, approximately three miles from the facility. Regional Director of Clinical Services (RDCS) #604 contacted the local police department (LPD) at 2:34 P.M. for assistance. Emergency Medical Services (EMS) and the LPD responded. EMS assessed Resident #23 and medically cleared him to return to the facility. Resident #23 was transported back to the facility by PD #600. On 08/11/25 at approximately 3:15 P.M, Resident #23 returned to the facility and was placed on one-to-one (1:1) staff supervision to ensure his safety. Resident #23 will remain on 1:1 staff supervision until a more appropriate placement can be found. Registered Nurse (RN) #583 assessed Resident #23 and notified his responsible party and attending physician of his return. On 08/11/25, the DON reassessed Resident #23 for elopement risk, which remained at high risk, and the resident's care plan was reviewed and updated, to include continuous 1:1 staff supervision. On 08/11/25, the Administrator and DON completed a root cause analysis and determined Resident #23 likely removed his Wanderguard by using the blades from disposable razors to cut through the band, allowing the resident to exit through the front door of the facility without activating the alarms and locking the door. Additionally, staff failed to complete proper and accurate communication to ensure Resident #23, who was assessed to be at risk for elopement and had a Wanderguard, was accounted for timely, resulting in a delay in identifying a missing resident and initiating an immediate search, notification, and elopement procedure. On 08/11/25, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held to review the facility's wandering and elopement policy and procedure and corrective action plan. In attendance were the Administrator, DON, Therapy Director (TD) #611, Assistant Director of Nursing (ADON) #551, Dietary Manager (DM) #541, Social Services Director (SSD) #573, Director of Maintenance (DOM) #581, Housekeeping Director (HD) #583, Human Resources Director (HRD) #564, and Medical Director (MD) #610 (via telephone). On 08/11/25, the DON or designee educated all facility staff on the facility's elopement policy and ensuring adequate supervision of residents to prevent resident elopement without staff knowledge. On 08/11/25, the DON and Central Supply (CS) #518 completed a whole house visual audit to verify residents did not have sharp objects in rooms/common areas, including disposable razors. On 08/11/25, SSD #539 and RDO #580, in collaboration with Resident #23's responsible party, began exploring alternative, more appropriate, placement for the resident, to include a secured unit. Beginning on 08/11/25, the DON or designee will ensure elopement assessments are completed upon admission, readmission and when there is a significant change in condition. Interventions will be implemented for those found to be at risk for elopement, with care plans initiated or updated as needed. Beginning on 08/11/25, Staff Development Coordinator (SDC) #551 or designee will ensure all new licensed and non-licensed nursing staff are educated upon hire on how to recognize and identify the residents they are providing care for by utilizing information, including photographs, in the EMR and on the facility's elopement policy. Beginning on 08/11/25, the DON or designee will audit all new admissions and readmissions for elopement assessments Monday through Friday for four weeks to ensure residents who are identified to be at risk for elopement have appropriate interventions implemented. Beginning on 08/11/25, the DON or designee will interview five direct care staff per week for four weeks to ensure staff are able to recognize the residents that they are providing care for and confirm understanding of the actions to take to ensure adequate supervision for impaired residents to prevent elopement without staff knowledge. Beginning on 08/11/25, the DON or designee will audit resident rooms and common areas one time weekly for four weeks to ensure no sharp objects are left unattended by staff, including disposable razors. Interviews on 08/12/25 from 8:13 A.M. through 8:56 A.M. with Certified Nursing Assistant (CNA) #579, CNA #566, CNA #584, Registered Nurse (RN) #581, and Housekeeper (HSK) #582 verified the facility provided education on the elopement policy and procedure, securing of sharps, and properly identifying residents utilizing information included in the EMR. Observation on 08/12/25 at 8:45 A.M. of Resident #23 verified staff were assigned to provide 1:1 supervision. Review of two (#14 and #22) additional open resident medical records, reviewed for elopement, revealed no additional concerns.Although the Immediate Jeopardy was removed on 08/11/25, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance.Findings include: Review of a social media post dated 08/10/25 at 4:40 P.M. revealed the facility had a resident with dementia missing from the facility. The post indicated the resident had been last seen at the facility before 6:00 P.M. the day prior (08/09/25).Review of Resident #23's medical record revealed an admission date of 07/17/25. Diagnoses included alcohol dependence with induced persisting dementia, cirrhosis, congestive heart failure (CHF), peripheral vascular disease (PVD), convulsions, diabetes mellitus, high blood pressure, cardiomyopathy (enlarged heart), and atherosclerotic heart disease (buildup of plaque on artery walls).Review of the hospital referral records, printed on 07/09/25, revealed Resident #23 presented to the hospital on [DATE] with altered mental status after leaving a long-term care (LTC) facility and being found at a bus stop (previous elopement from another facility).Review of the care plan, initiated on 07/17/25 and revised on 07/18/25, revealed Resident #23 was at risk for elopement, had a previous elopement from a facility, and was cognitively impaired. Interventions included to calmly redirect and divert the resident's attention and periodically evaluate the continued need of a Wanderguard. On 08/11/25, the plan of care was revised to include 1:1 (staff supervision).Review of the admission Minimum Data Set (MDS) assessment, dated 07/23/25, revealed Resident #23 was cognitively impaired.Review of the Brief Interview for Mental Status (BIMS) assessment, dated 07/18/25, revealed a score of zero, indicating Resident #23 was severely cognitively impaired.Review of the elopement risk assessment, dated 07/18/25, revealed Resident #23 was at risk of elopement due to a BIMS of zero and a history of elopement from a prior facility.Review of a physician order, initiated 07/18/25, revealed Resident #23 had an order for a Wangerguard to the left ankle, check placement and function each shift.Review of the Medication Administration Record (MAR) for August 2025 revealed Resident #23's Wanderguard was documented as in place and functioning, including on 08/09/25.Review of a nursing progress note, dated 08/10/25 at 6:00 A.M. and authored by the DON, revealed at approximately 2:00 A.M. the nurse, Licensed Practical Nurse (LPN) #505, entered the resident's room to see the resident and observed he was not in his room. A missing resident investigation was immediately initiated. According to video surveillance, Resident #23 exited through the front doors of the facility and exited on the south side of the property, crossed the street and walked toward the city's annual festival and did not return on 08/09/25. Upon investigation, Resident #23 called his ex-wife and left a voicemail indicating he did not want to be in the facility any longer and was going to the bus station. Resident #23 asked RN #515 to take a shower on the morning of 08/09/25. At that time, RN #515 verified the Wanderguard was on Resident #23 and functioning. Resident #23 was seen on the facility's video surveillance camera on 08/09/25 at 10:39 A.M. in the front lobby, directly around the corner where the front door was located, wearing khaki shorts and a red and white button up short sleeve shirt and tennis shoes. A CNA entered through the front door of the facility and, as the door was closing,Resident #23 was observed going around the corner and out through the front door before it closed. The facility's alarm system did not go off. Resident #23 was then observed under the front awning of the facility and the Wanderguard to the left ankle was no longer in place where it was previously located. A search of Resident #23's room and belongings revealed broken razors and a cell phone that did not belong to him. The facility staff conducted a head count and facility search inside and outside and were not able to locate Resident #23. The LPD was called to file a missing person report.An observation on 08/11/25 at 7:25 A.M. of Resident #23's room revealed the resident was not present. Further observation revealed the resident's bed was stripped of linens, with two garbage cans and a white telephone (landline) sitting on top of the bed. The overbed table had change (coins), toiletries were on the nightstand, and one pair of light khaki pants were in the closet. Concurrent interview with Resident #22 (Resident #23's roommate) revealed He's (Resident #23) been gone for almost two and a half days. I thought he would be back last night. Resident #22 further stated, I heard him on the phone talking to a woman, talking something about Hollywood, he then stated he was going to catch the bus, so I gave him five bucks. He didn't have any money.An observation on 08/11/25 at approximately 7:40 A.M. of the resident sign in/out book revealed Resident #23 did not have a dedicated sign in/out sheet for himself. Further observation revealed no evidence Resident #23 had signed out on a Leave of Absence (LOA) from the facility at any time, including 08/09/25.An interview on 08/11/25 at 9:01 A.M. with the Administrator verified Resident #23 eloped from the facility, without staff knowledge, on 08/09/25 at approximately 10:38 A.M. and had not been located. Concurrent review of the facility's video surveillance verified that Resident #23 was in the front lobby area and exited the facility through the front door on 08/09/25 at 10:38 A.M. Further observation revealed Resident #23 was just outside the front doors, under the awning, speaking to another resident and then walked south out of the parking lot to the edge of the street, crossed the street, and continued walking until he was out of range of the video surveillance camera. Resident #23 was wearing white/khaki shorts, a red and white short-sleeved shirt, and tennis shoes. A Wanderguard was not observed on Resident #23's left ankle.An interview on 08/11/25 at 10:22 A.M. with the DON confirmed Resident #23 eloped from the facility on 08/09/25. The DON stated Resident #23 was not capable of signing himself out of the facility and never had family visit him at the facility. The DON stated the nurse assigned to provide care for Resident #23 on 08/09/25 had him confused with another resident, who she believed had left to go to a local festival.Interview on 08/11/25 at 11:50 A.M. with Admissions #537 revealed the front reception desk was not staffed on the weekends and the front doors were unlocked during the day.A telephone interview on 08/11/25 at 12:20 P.M. with RN #515 revealed she was the nurse assigned to Resident #23 on 08/09/25. RN #515 stated her routine was to check Wanderguards in the morning and completed that task on the morning of 08/09/25 but did not recall the exact time. RN #515 stated Resident #23 requested a shower that morning and CNA #557 assisted the resident. RN #515 stated she passed on in report at shift change (approximately 6:00 P.M.) that Resident #23 was Okay, with nothing negative to report. RN #515 further stated she did not recall any staff informing her that Resident #23 did not eat his lunch or dinner that day.Interview on 08/11/25 at 12:58 P.M. with CNA #557 revealed she worked on 08/09/25 and assisted Resident #23 to the shower room, although he was not on her assignment for the day. CNA #557 stated this was the first time she provided care for Resident #23 and was advised by RN #515 that Resident #23 was independent with care, and he just needed assistance into the shower room and linen for a shower. CNA #557 stated she let the resident into the shower room and offered help, but he declined and shut the door. CNA #557 stated Resident #23 exited the shower room in the same clothes he was wearing when he went in and changed into different clothing in his room. CNA #557 did not recall if the Wanderguard was in place on the resident's left ankle at the time of the shower.Interview on 08/11/25 at 2:00 P.M. with PD #600 revealed the report received from the staff to the reporting officer on 08/10/25 was that Resident #23 went to the local festival to watch the fireworks with other residents and did not return with the other residents. PD #600 stated that based on the new information provided by the surveyor, he would initiate a search of the area, including along a creek.An interview on 08/11/25 at approximately 3:15 P.M. with the Administrator and DON revealed Resident #23 had been located by facility staff.A telephone interview on 08/13/25 at 8:01 A.M. with CNA #558 verified she worked on 08/09/25 and was assigned to provide care for Resident #23 from 6:00 P.M. to 10:00 P.M. CNA #558 stated she arrived on the unit and began answering call lights and on her rounds identified that Resident #23's dinner tray remained in his room, untouched. CNA #23 stated she asked LPN #505 about his whereabouts and learned Resident #23 went to a local festival (within walking distance) with family. CNA #558 stated that at 10:00 P.M., her assignment changed, and she was no longer assigned to Resident #23. CNA #558 stated when Resident #23 was identified as missing, at approximately 2:00 A.M. on 08/10/25, she assisted with conducting a head count of all residents, a search of the inside and outside of the facility, and provided a photograph of Resident #23 to other residents and the LPD when they arrived to take a report.A telephone interview on 08/13/25 at 9:07 A.M. with LPN #505 revealed she worked on 08/09/25 and was assigned to Resident #23. LPN #505 stated she received in report at shift change that Resident #23 went to a local festival with family. LPN #505 stated she did not recall if any of the staff reported Resident #23 did not eat his dinner and further stated if he was at the festival, she would have expected him to eat dinner with his family at the festival. LPN #505 stated that at approximately 2:00 A.M. on 08/10/25 she went to see if Resident #23 wanted his nighttime medications, even though they were late, and that was when she discovered he was not in his room and immediately began searching for him. LPN #505 stated she called the LPD and her supervisors to report the incident.Review of the LPD report, dated 08/10/25 at 4:48 A.M., revealed the facility filed a missing adult report for Resident #23. Further review revealed on 08/10/25 at 3:32 A.M., the facility notified the LPD that on 08/09/25, a resident (Resident #23) with dementia had left the facility and did not return. The facility staff could not confirm the last time the resident was seen at the facility and LPN #505 stated she believed Resident #23 left the facility during daylight hours, along with other residents, to attend Boomfest (local festival) and all other residents returned. Further review of the police supplemental report, dated 08/11/25 at 4:02 P.M., revealed Resident #23 had been located at a public bus hub and was safely returned to the facility by PD #600.Review of the local weather conditions from 08/09/25 through 08/11/25, located at https://wunderground.com/history/monthly/us/, revealed on 08/09/25, the high temperature in the area of the facility was 90 degrees F and on 08/10/25 and 08/11/25, the high temperature reached 91 degrees F.Review of the facility policy titled, Unsafe Wandering and Elopement Prevention, revised January 2022, revealed every effort would be made to prevent wandering and elopement episodes while maintaining the least restrictive environment for residents who were at risk for elopement. All residents who are at risk for harm because of unsafe wandering would be assessed by the interdisciplinary care planning team. The resident's care plan would be modified to indicate the resident was at risk for elopement episodes and staff would be informed at shift change of the modifications to the resident's care plan.This deficiency represents noncompliance investigated under Complaint Number 2588449.

Based on observation, staff interview, and review of the facility policy the facility failed to ensure foods were appropriately stored and further failed to ensure foods were discarded of past the use by dates. This had the potential to affect all residents residing in the facility, except for 13 (#3, #5, #6, #8, #12, #13, #15, #16, #17, #19, #20, #21, and #33) residents identified by the facility as receiving no food by mouth. The facility census was 66.Findings include:Observations on 08/06/25 from 7:20 A.M. to 7:42 A.M. of the kitchen revealed the milk cooler contained a crate holding 38 individual cartons of one percent milk with a stamped expiration date of 08/05/25, two unopened thickened orange juice containers with an expiration date of February 2024, and one unopened thickened apple juice with an expiration date of July 2025. Interview on 08/06/25 at 8:22 A.M. with Dietary Manager (DM) #541 verified the expired thickened orange juice, apple juice, and one percent milk. Observation on 08/06/25 at 8:25 A.M. of the east pantry (where the refrigerator was located to hold foods brought in by residents and/or family and visitors) revealed a bag containing food from a fast-food restaurant that was not labeled with a name and was dated 07/25/25; a container of potato salad, unlabeled with a name and dated 06/17/25; and food debris of cheese, lettuce, and croutons on the floor in front of the refrigerator. Concurrent interview with Licensed Practical Nurse (LPN) #506 verified the findings.Interview on 08/06/25 at 8:25 A.M. with DM #541 revealed dietary staff maintained the temperature logs for the pantry refrigerator and cleaned the refrigerator maybe two to three times per month but all staff were responsible for maintaining the refrigerator.Observation on 08/06/25 at 8:30 A.M. of the west pantry revealed an unlabeled plastic grocery bag of unknown food dated 07/04/25, one plastic grocery bag of unknown food unlabeled and undated, two different restaurant boxes that contained food that were undated, and an expired carton of milk that was dated 08/03/25. Concurrent interview with Medical Records Clerk (MRC) #561 verified the findings. Review of the facility policy title, Food Receiving and Storage revised July 2025, revealed foods should be received and stored in a manner that complied with safe food handling practices. All dry foods were labeled, dated, and rotated by using the first in-first out system. All foods stored in the refrigerator would be covered, labeled and dated. Review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitor, revised July 2025, revealed family members and visitors may bring the resident food of their choosing. All food items that were already prepared by the family or visitor must be labeled with the contents and dated. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. Food must be consumed by the resident within three days and, if not consumed within three days, the food would be thrown away by the facility staff. This deficiency represents non-compliance investigated under Complaint Number 1260630 and Complaint Number 1260631.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medication carts were secured when left unattended and further failed to appropriately dispose of oral syringes used for the administration of medication. This had the potential to affect seven (#22, #23, #28, #31, #34,#35, and #44) residents identified by the facility as being cognitively impaired, independently mobile, and resided on the C and D Halls. The facility census was 66. Findings include:Observation on 08/06/25 at 7:00 A.M., upon entry into the facility, revealed an unattended and unlocked medication cart near the beginning of the C and D Halls. On top of the medication cart was a clear plastic drinking cup that contained two small oral syringes (no needle attached), resembling the type of syringe that was used to administer liquid oral medications. Small droplets of an unknown clear substance were observed on the syringes and on the inside of the drinking cup. No facility staff were observed in the area. Continuous observation revealed at 7:05 A.M., Licensed Practical Nurse (LPN) #505 exited a resident's room, from behind a closed door, at the very end of the D Hall. Further observation revealed the D Hall had 13 resident rooms, a shower room, a soiled linen utility room, and other office type rooms. Interview on 08/06/25 at 7:05 A.M. with LPN #505 verified the medication cart was left unlocked and unattended. LPN #505 further confirmed the two syringes in the clear drinking cup on top of the medication cart had been used to administer morphine sulphate. LPN #505 stated this was not her medication cart and she was trying to clean up the mess left by night shift. LPN #505 verified shift change was at 6:00 A.M. (approximately one hour prior). Review of the facility policy titled, Medication Storage, revised January 2024, revealed it was the policy of the facility to ensure all medications housed on the premises would be stored according to the manufacturer's recommendations and ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. During a medication pass, medications would be under direct observation of the person administering medications or locked in the medication storage area or cart. This deficiency was an incidental finding discovered during the complaint investigation.

Based on medical record review, staff interview, and review of the facility policy the facility failed to ensure wound measurements were completed for ongoing assessment of wounds. This affected one (#64) of three residents reviewed for wound care. The facility census was 66. Findings include:Review of Resident #64's medical record revealed an admission date of 12/28/23. Diagnoses included diabetes mellitus, portal hypertension, transient ischemic attack (TIA), congestive heart failure, end stage renal disease, and dependence on renal dialysis.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/15/25, revealed Resident #64 had a diabetic foot ulcer.Review of the current physician orders for August 2025 revealed Resident #64 had a treatment order for a diabetic foot ulcer to the right plantar foot to cleanse the wound with wound cleaner, apply medihoney to the wound bed, then apply adaptic (non-stick moist dressing), and cover with abdominal pad and wrap in kerlix daily.Review of the care plan, revised July 2025, revealed Resident #64 had a diabetic foot ulcer with interventions in place to complete wound treatment as prescribed.Review of the skin and wound assessments from 06/16/25 through 07/28/25 revealed no measurements of Resident #64's diabetic wound. Interview on 08/13/25 at 10:44 A.M. with Registered Nurse (RN) #551 verified Resident #64's wound was not measured from 06/16/25 through 07/28/25.Review of the facility policy titled, Wound Treatment Management, revised October 2023, revealed to promote the healing of various types of wounds, it was the policy of the facility to provide evidence-based treatments in accordance with current wound standards of practice and physician orders. The effectiveness of treatments would be monitored through ongoing assessment of the wound and considerations for needed modifications.This deficiency represents non-compliance investigated under Complaint Number 2568913.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents with intravenous (IV) catheters received dressing changes as ordered and had active orders for care and treatment. This affected three (#1, #2, and #3) of three residents reviewed for IV catheter care and treatment. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with the diagnoses including acute and chronic respiratory failure with hypoxia, cerebral infarction, chronic kidney disease, tracheostomy, aphasia, type II diabetes mellitus, congestive heart failure, myocardial infarction, and severe protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with severe cognitive impairment, and the resident was dependent on staff for the completion of activities of daily living. Resident #1 was always incontinent of bowel and bladder, received nutrition via therapeutic diet and a tube feeding, and was at risk for pressure ulcer development with no skin breakdown. Review of infusion company documentation on 08/23/24 revealed a midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) was inserted into Resident #1. Review of the medical record revealed on 08/30/24 a physician order was obtained for the application of a transparent dressing change every seven (7) days and as needed and to document in the progress notes any concerns such as changes to the site, signs and symptoms of infection, or complications. Review of documentation in the medication administration records (MAR) noted Resident #1's midline catheter dressing was changed on 08/30/24 at 1:34 P.M., on 09/06/24 with no time indicated, and on 09/14/24 at 3:29 P.M. There was no further documentation contained in the medical record to indicate the dressing was changed after 09/14/24. Review of nursing progress notes on 09/23/24 at 2:52 P.M. documented Resident #1 was sent to the hospital for evaluation. Interview with the Assistant Director of Nursing (ADON) on 09/30/24 at 1:05 P.M., during a review of Resident #1's medical record, confirmed no documentation was contained in the record indicating the midline dressing was changed after 09/14/24 and resulted in the dressing not being changed every 7 days per physician order. 2. Review of Resident #2's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, chronic respiratory failure, dependence on ventilator, acute respiratory failure with hypoxia, congestive heart failure, tracheostomy, peripheral vascular disease, cerebral infarction, and chronic kidney disease. Review of the most current MDS assessment dated [DATE] assessed Resident #2 with intact cognition and was dependent on staff for the completion of activities of daily living. Resident #2 was incontinent of bowel and bladder, received nutrition via tube feeding, was at risk for pressure ulcer development with no skin breakdown, and received intravenous (IV) medications. Review of Resident #2's medical record revealed on 09/20/24 a physician order was obtain for the placement of a midline catheter to be placed for antibiotic therapy one time only for one day. On 09/21/24, the midline catheter was to be discontinued. Further review revealed no orders related to care or treatment application in the medical record following 09/21/24. Observation on 09/30/24 at 7:40 A.M. noted Resident #2 with a midline catheter inserted into the right arm. The dressing was peeling from the outer edges with a folded gauze dressing placed over the insertion site and a transparent dressing covering the entire site. Interview with Registered Nurse (RN) #300 during the observation revealed the dressing was to be changed every 7 days. On 09/30/24 at 9:08 A.M., observation with RN #300 during Resident #2's midline catheter dressing change noted the transparent dressing peeling off and once removed exposed a gauze dressing covering the insertion site with large amount dried blood tinged drainage. Interview with the ADON on 09/30/24 at 1:05 P.M., during a review of Resident #2's medical record, confirmed the physician ordered indicated Resident #2's midline catheter was to be placed for one day and removed on 09/21/24. The ADON verified there were no current orders in the medical record for the placement of the midline or associated dressing changes or insertion site care. 3. Review of Resident #3's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, chronic respiratory failure, dependence on ventilator, tracheostomy, peripheral vascular accident, neuromuscular dysfunction of bladder, anemia, persistent vegetative state, gastrostomy, hypertension, and encephalopathy. Review of the most current MDS assessment dated [DATE] assessed Resident #3 as comatose and dependent on staff for the completion of activities of daily living. Resident #3 utilized an indwelling urinary catheter, was incontinent of bowel, received nutrition via feeding tube, was at risk for pressure ulcer development with no skin breakdown, and had an intravenous (IV) access. Review of the medical record revealed on 06/15/24 a physician order was obtained for Resident #3 to have a central line (a long, thin, flexible tube that's inserted into a large vein near the heart) to the right chest with dressing change every 7 days and as needed. Observation on 09/30/24 at 8:02 A.M. with Licensed Practical Nurse (LPN) #400 noted Resident #3 with a right central line dressing in place and dated 09/22/24. Interview with LPN #400 at the time of the observation verified the dressing was to be changed every 7 days and was not. Review of Resident #3's medical record noted the right central venous catheter dressing was changed on 09/22/24 at 12:04 P.M. and 09/28/24 with no time indicated. According to facility Care and Maintenance of Central Venous Catheter policy, reviewed 12/13/23, revealed documentation is to be obtained for the indications of use, insertion date, and type of catheter in the residents medical record. Physician orders are to be obtained for the specific care and maintenance instructions. Staff are to document activities in nurses notes and or medication administration record (MAR). This deficiency represents non-compliance investigated under Master Complaint Number OH00158337.

AMENDED 08/27/24 Based on observation, medical record review, family and staff interview, and review of the facility's Pressure Ulcer/Skin Breakdown Clinical Protocol, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to accurately assess wounds, provide timely interventions to prevent the development of pressure ulcers or healing of existing pressure ulcers, failed to obtain timely treatments of existing wounds, and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. This resulted in Actual Harm to Residents #79 and #40 who were at risk for pressure ulcers and the facility found Resident #79's pressure ulcer as an unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) and Resident #40's pressure ulcer as a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed). Actual Harm occurred to Resident #184 when the resident was admitted with two unstageable pressure ulcers, and a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) and did not have any treatments in place while residing in the facility for six days. Resident #184 was sent to the emergency roiagnom on the sixth day due to decubitus pressure injury of the sacral region, sepsis and respiratory failure. This affected three (#40, #79, and #184) of six residents reviewed with pressure ulcers. The facility census was 74. Findings include: 1. Closed medical record review revealed Resident #79 was admitted to the facility on [DATE] with the diagnoses included cerebral infarction, cerebral aneurysm, type II diabetes mellitus, coronary artery disease, congestive heart failure, anemia, osteoarthritis, seizure disorder, dysphagia, chronic inflammatory disease of uterus, and anxiety disorder. Review of the physician order dated 01/26/23 revealed an order for the application of protective cream to buttocks each shift and as needed (PRN). On 03/02/23, an order for a frozen nutritional treat (or equivalent) (high calorie) one time a day with dinner related to weakness. Review of the nursing care plan dated 08/21/23 revealed Resident #79 was at risk for impaired skin integrity related to cerebral vascular accident with left sided weakness, diabetes, coronary artery disease, congestive heart failure, osteoarthritis, and weakness. Interventions were implemented on the following dates: on 08/21/23, an air mattress with bed bolsters to establish safe parameters, apply protective barrier cream after incontinent episodes, assist the resident with turning and repositioning as needed, encourage the resident to reposition self if able, notify nurse of any new areas of skin impairment noted during bathing or daily care (e.g. redness, blisters, bruises, discoloration), notify Physician/Physician Assistant/Nurse Practitioner of any new areas of skin impairment, preventive treatments per orders, complete skin inspection weekly and as needed, consult dietitian as needed, dietary supplements as ordered, encourage good nutrition and hydration. Assist as needed. Provide a non-irritating surface to reduce friction or shearing forces. Provide incontinence care as needed. On 08/29/23, a pressure redistribution device was placed in chair. On 03/19/24, monitor dressings each shift and change as ordered. Further review of the medical record revealed it lacked documentation indicating an air mattress with bed bolsters was applied to the bed, pressure redistribution device was placed to the chair, or turning and repositioning was provided consistently. Review of the skin risk assessment dated [DATE] revealed Resident #79 was at moderate risk for pressure ulcer development. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was assessed with moderate cognitive impairment and had no behaviors of refusal of care during the review period. Resident #79 was dependent on staff for the completion of activities of daily living, which included with bed mobility and transfers. Resident #79 utilized a wheelchair for mobility. Resident #79 was incontinent of bowel and bladder, had no reports of pain during the assessment period, no weight loss, received a mechanically altered and therapeutic diet, at risk for pressure ulcer development with no skin breakdown identified. Review of the Task Documentation Survey Report for tracking turning and repositioning per the care plan revealed it lacked documentation during May 2024 of every two hour turn and repositioning. The documentation noted repositioning was provided on 05/06/24 at 12:16 A.M., 05/11/24 and 05/19/24 between 12:00 A.M. and 6:00 A.M., 05/25/24 between 12:00 A.M. and 2:00 A.M. No further repositioning was documented between 12:00 A.M. and 6:00 A.M. during May 2024. Additional review of two hour turns and repositioning documentation revealed on 05/27/24 between 9:24 P.M. and 05/28/24 at 2:00 P.M., and 05/28/24 between 9:24 P.M. and 05/29/24 at 2:00 P.M., no repositioning was recorded in the medical record. The medical record lacked consistent documentation recording turning and repositioning every two hours through 06/18/24. Review of the skin assessment dated [DATE] at 5:21 P.M. revealed an abnormal skin area was identified to the sacrum. The area was described as moisture associated skin damage (MASD). No measurement or evaluation of the impaired skin was documented. No further assessment was contained in the medical record regarding the sacral MASD. On 05/29/24 at 2:25 P.M., a physician order was obtained by Licensed Practical Nurse (LPN) #455 for a treatment to Resident #79's coccyx. The order included to flush wound with normal saline, pack with Iodoform, cover with foam dressing everyday shift for open area. Review of the Incident Description New Pressure Ulcer documentation revealed on 05/29/24 at 5:15 P.M., LPN #455 was notified by care staff Resident #79 was discovered with an open area to coccyx. Resident stated her buttocks hurt. LPN #455 documented unaware Resident #79 had an open area. A treatment was applied to the area. The nursing note dated 05/29/24 at 5:19 P.M., revealed LPN #455 documented during care a staff member noticed open area to resident's coccyx and reported to nurse whom further evaluated. The skin assessment dated [DATE] at 5:26 P.M. revealed a pressure area to the coccyx. No documentation indicated wound measurements were obtained or an evaluation of the area was noted. The medical record was silent to wound measurements, descriptions, or additional interventions being implemented on 05/29/24. The initial wound description was completed on 05/30/24 and identified a right gluteal wound was evaluated as in-house acquired with origin date of 05/29/24. The wound descriptions noted it was an unstageable pressure ulcer to the right gluteal with 100% slough and moderate amount of serosanguineous (blood tinged) exudates (drainage). Measurements were noted 0.67 centimeters (cm) length by (x) 0.96 cm width x 0.2 cm depth, undermining was recorded 0.5 cm from 12 to 12 o'clock. The right gluteal dressing treatment was changed by the physician on 05/30/24 to include Santyl External Ointment (debriding agent) 250 unit/gram (gm) (Collagenase). Apply to right gluteus topically as needed for wound care, cleanse wound with in-house wound cleanser, pat dry, apply nickel thick layer of Santyl to wound bed, lightly pack with saline moisten gauze, and cover with dry dressing. The physician orders dated 05/30/24 included the application of an air mattress with bed bolsters to the bed and monitor dressing(s) every shift to ensure they were clean, dry, and intact. If not, replace dressing to be completed every day and night shift. On 06/06/24, the wound measurements and descriptions contained in the medical record noted the right gluteal wound measured 3.19 cm long x 2.43 cm wide x 0.2 cm deep. The wound bed was assessed with 20% granulation, 60% slough, 20% eschar, and moderate amount of serosanguineous drainage. The physician was notified on 06/06/24 and modified the order to the wound to include the application of Santyl External Ointment 250 unit/gm (Collagenase) to apply to right gluteus topically as needed for wound care, cleanse wound with in-house wound cleanser, pat dry, apply nickel thick layer of Santyl to wound bed, lightly pack with Dankin's moisten gauze, and cover with dry dressing every day shift for wound care. On 06/13/24, the right gluteal wound was documented with measurements 3.92 cm long x 5.48 cm wide x 0.5 cm deep and undermining of 0.3 cm from five to nine o'clock. Wound bed was described with 20% granulation, 40% slough, 40% eschar, and moderate amount of serosanguineous drainage. On 06/14/24, the physician ordered Santyl External Ointment 250 unit/gm (Collagenase) to apply to right gluteus topically as needed for wound care, cleanse wound with in-house wound cleanser, pat dry, apply nickel thick layer of Santyl to wound bed, lightly pack with calcium alginate, and cover with dry dressing. On 06/17/24, the physician ordered a referral to wound care for an unstageable pressure ulcer to the right gluteus. However, Resident #79 was not evaluated by the wound care specialist and was discharged to the hospital on 06/19/24. Resident #79 did not return to the facility. Interview on 07/31/24 at 7:55 A.M. with LPN #455 confirmed on 05/29/24, she was notified by care staff that Resident #79 had an area of skin breakdown to the right gluteal. LPN #455 was not informed the resident had an open area prior to assuming care of the resident. LPN #455 observed the wound and stated was open and draining. LPN #455 indicated she was unaware why the wound was not discovered before it was found to be open and draining blood-tinged exudates. LPN #455 verified Resident #79 was dependent on staff for repositioning and had a standard pressure relief mattress in place without an air mattress. The physician and family were notified, and a treatment was implemented. LPN #455 verified she did not obtain wound measurements, document wound description, or implement any additional interventions on 05/29/24. Interview on 07/31/24 at 8:06 A.M. with Unit Manager (UM) #422 revealed she was informed via incident report completed 05/29/24 that Resident #79 was discovered with a pressure ulcer to the right gluteus. On 05/29/24, LPN #455 completed an incident report with notifications of physician and family. UM #422 verified she initially assessed Resident #79's wound on 05/30/24 and obtained a photo. UM #422 indicated the wound was open and draining blood-tinged exudates. The wound photo was provided to the Director of Nursing (DON) and measurements with descriptions were obtained using the photo. UM #422 further stated Resident #79 had been declining with nutritional intake and was unable to reposition herself. UM #422 verified prior to 05/30/24, Resident #79 was on a standard mattress and not an air mattress as listed in the plan of care. UM #422 confirmed no measurements or wound description was obtained until 05/30/24 and confirmed there was no documentation indicating Resident #79 was repositioned in accordance with a repositioning program every two hours. Interview on 07/31/24 at 8:31 A.M. with the DON verified there were no measurements or description of Resident #79's wound obtained until 05/30/24, no evidence of an air mattress was in place until 05/30/24, and there was no consistent documentation of turning and repositioning during the third shift between 12:00 A.M. and 6:00 A.M. in the months of May and June 2024. The DON verified there was no investigation completed including staff interviews into the origin of the wound before it was discovered open and draining blood-tinged exudates. The DON also confirmed the wound was not staged while the resident resided at the facility due to the amount of slough contained inside the wound. Additional interview on 08/01/24 at 9:42 AM with the DON stated UM #522 observed Resident #79's wound and obtained a photo. The DON stated she reviewed pictures of the wound and utilized the pictures to determine the wound description. The DON further confirmed she did not physically observe the wound to determine a description and measurements. The wound was unable to be staged due to the amount of slough tissue inside the wound. 45445 2. Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, peripheral vascular disease, tracheostomy, dependence on respirator, atrial fibrillation, and neuromuscular dysfunction of the bladder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively impaired, was dependent on staff for activities of daily living and mobility, had an indwelling urinary catheter, was always incontinent of bowel, and was risk for pressure ulcer with no unhealed pressure ulcer present. Review of the care plan initiated on 09/06/23 revealed Resident #40 was at risk for impaired skin integrity related to respiratory failure, seizures, encephalopathy, peripheral vascular disease, atrial fibrillation, neurogenic bladder, anemia, vegetative state, and hypertension. Interventions included the administration of medications as ordered, the application of protective barrier with each incontinence episode, assistance with turning and reposition as needed, completing a Braden scale as needed, providing dietary supplements as ordered, elevation of heels off the mattress as tolerated, and to notify the nurse of any new skin areas of skin impairment during bathing or daily care, as well as notification to the provider of any new skin impairment. Resident #40 was also to have a pressure redistribution device to chair, specialty air mattress to bed with bilateral bolster, preventive treatments provided as ordered, and incontinence care as needed. The care plan was revised on 07/31/24 to reflect a stage III pressure ulcer to the coccyx with interventions to include monitoring the dressing every shift and change as needed. Review of the weekly skin assessments revealed Resident #40 had a pressure ulcer to the coccyx which was resolved on 04/17/24. From 04/17/24 to 07/15/24, Resident #40 had no abnormal skin areas. Resident #40 was sent out to the hospital for evaluation of shortness of breath on 07/16/24 and returned to the facility on [DATE]. Review of the hospital record revealed a wound care consult dated 07/18/24 for moisture associated skin damage (MASD) to the sacrum on 07/18/24. The wound care noted a sacral wound, history of a stage IV pressure ulcer in 2022. The wound assessment revealed a denudation to the buttocks and a linear area of erosion in gluteal cleft. Hospital staff did apply fecal pouch, as patient was having multiple loose stools overnight. A protective foam dressing in place over the gluteal cleft at time assessment, which was trapping a lot of moisture in gluteal cleft. Wound care recommendation was for triad cream twice a day and when incontinent after the area was cleansed with soap and water and patted dry. Additionally, Resident #40 was to be turned and repositioned every two hours while in bed, heels floated off the bed with pillows under calves, and a single layer moisture wicking under pad under the resident. Review of the continuation of care paperwork printed 07/20/24 at 10:11 A.M. revealed Resident #40's buttocks were to be cleaned with soap and water, patted dry, followed by the application of triad cream twice a day and as needed when incontinent. There was no physician order at the facility implemented for this skin treatment to continue as the hospital recommended. Review of the nursing readmission evaluation dated 07/20/24 and timed 3:27 P.M. Resident #40 was noted to have MASD of the coccyx. There was no mention of an open area to the coccyx. There were no weekly skin assessments completed from 07/21/24 to 07/30/24. There were no physician orders for a foam dressing to be in place until 07/31/24. There was no treatment for a foam dressing noted in the treatment administration record. Interview with Resident #40's family member on 07/30/24 at 3:15 P.M. revealed concerns related to the timeliness of care including suctioning, repositioning and incontinence care. The family member stated there was now a camera in the resident's room and if family member notices more than two and half hours have gone by without Resident #40 being checked, changed and repositioned, she called the facility to get someone into the room to provide the care. The family member verbalized concern over Resident #40's skin due to a pressure ulcer Resident #40 on the coccyx that took over two years to heal. There was no mention of an open area to Resident #40's coccyx until 07/31/24. Observation of incontinence care on 07/31/24 at 7:30 A.M. for Resident #40 completed by State tested Nursing Assistant (STNA) #423 and #463 revealed Resident #40 had a foam dressing on the coccyx dated 07/31/24 and timed 2:40 A.M., the foam dressing was loose and soiled with stool. STNA #463 removed the foam dressing and alerted the nurse of the dressing needing to be replaced. Observation of Resident #40's skin when the dressing was removed revealed an open reddened area of skin approximately 2.0 cm long by 2.0 cm wide in the upper gluteal cleft. Skin care was completed with soap and water, and the area was patted dry. Registered Nurse (RN) #515 entered the room at 7:40 A.M. and placed a new clean foam dressing over the open area on the coccyx. Interview on 07/31/24 at 7:45 A.M. with RN #515 verified Resident #40 had an open area and further verified the foam dressing was in place to protect to the area. Interview on 07/31/24 at 12:30 P.M. with the Director of Nursing (DON) revealed no knowledge of Resident #40 having an open area to the coccyx. Review of the skin and wound evaluation dated 07/31/24 at 3:14 P.M. revealed Resident #40 had a stage three pressure ulcer to the coccyx, measuring 1.9 centimeters (cm) long by 0.9 cm side by 0.1 cm deep with 100 percent of wound filled. The physician was notified, and an order was received on 07/31/24 to cleanse the coccyx with in-house wound cleaner, pat dry, apply collagen and cover with foam dressing every day and as needed. Review of the nursing progress note revealed a note dated 07/31/24 at 3:31 P.M. revealed a small open area on coccyx, area cleansed with soap and water and a foam dressing applied. Interview on 08/01/24 at 7:33 A.M. with the Assistant Director of Nursing (ADON) #510 verified Resident #40 had a stage III pressure ulcer to the coccyx, the physician was notified with treatment orders obtained and family was updated. ADON #510 verified the medical record for Resident #40 contained no evidence of the open area to the coccyx of Resident #40 prior to 07/31/24. 3. Review of the medical record for Resident #184 revealed an admitted [DATE]. Diagnoses included acute respiratory failure, chronic obstructive pulmonary disease, type II diabetes mellitus, end stage renal disease, dependence on dialysis, major depressive disorder, tracheostomy, and atrial fibrillation. Review of the continuation of care paperwork dated 07/24/24 revealed Resident #184 had a traumatic injury wound to the left anterior foot with a measurement of 1.2 centimeters (cm) long by 4.5 cm wide, an unstageable pressure ulcer to the left proximal dorsal thigh with a measurement of 3.1 cm long by 6.6 cm wide by 0.2 cm deep, an unstageable pressure ulcer to the sacrum, measurements 7.1 cm long by 6.9 cm wide by 0.1 cm deep, and a deep tissue injury (DTI) to the right heel with measurements of 2.5 cm long by 2.5 cm wide. Resident #184 was also noted to have redness to the left cheek and dry skin to the left abdomen. Review of the nursing admission evaluation completed on 07/25/24 at 12:11 A.M. revealed Resident #184 did not have any identified skin conditions. Review of the physician orders dated 07/25/24 revealed an order for protective cream to buttocks after episode of incontinence and to complete weekly skin assessments. There were no treatments in place to the unstageable pressure ulcers on the left proximal dorsal thigh and sacrum, or DTI to the right heel. Review of the care plan dated 07/25/24 revealed Resident #184 was identified at risk for impaired skin integrity. Interventions included to administer medications as ordered, apply protective barrier cream after incontinence episodes, completed Braden scale as needed, dietary supplements as ordered, pressure/redistribution mattress to bed/chair, report any new areas of skin impairment noted during bathing or daily care. Review of the Braden scale for predicting pressure sore risk completed on 07/25/24 at 12:10 A.M. revealed Resident #184 was at moderate risk for developing pressure ulcers. Resident #184 was identified as being unresponsive, with usually dry skin, was confined to bed with very limited mobility, had adequate nutrition and had no apparent problem with friction or shear as the resident moves in the bed and chair independently. Review of the physician history and physical completed on 07/25/24 revealed there was not a skin assessment completed for Resident #184. Review of the skilled nursing assessment completed on 07/26/24 at 12:23 P.M., on 07/28/24 at 12:46 A.M. and 3:13 P.M. revealed Resident #184 had no abnormal skin conditions. The skilled nursing assessment completed on 07/30/24 at 12:11 A.M. revealed Resident #184 had abnormal skin conditions. Review of the pulmonary nurse practitioner note dated 07/26/24 revealed Resident #184 had multiple wounds covered with dressings. Review of the nutritional note dated 07/29/24 and timed 8:18 A.M. revealed Resident #184 had intact skin. Review of the nursing progress notes revealed a note dated 07/30/24 at 7:10 P.M. revealed the day shift nurse reported Resident #184 had a necrotic area to the coccyx with Resident #184 requiring total care and repositioned on the right side. A progress note dated 07/30/24 at 9:00 P.M. stated Resident #184 was transported to the hospital with family updates provided. Observation on 07/30/24 at 4:30 P.M. revealed staff moving quickly into Resident #184's room, followed by the door being closed. Interview on 07/30/24 at 4:45 P.M. with Licensed Practical Nurse (LPN) #650 revealed Resident #184 had a wound to the coccyx that appeared to be necrotic. LPN #650 believes in contributing to a change in condition for Resident #184 as Resident #184 had been clammy all day. LPN #650 stated Resident #184 was going to be sent out to the hospital for evaluation. Interview on 07/30/24 at 5:15 P.M. with State tested Nursing Assistant (STNA) #503 at the bedside of Resident #184 verified Resident #184 had a necrotic area to the coccyx and after cleaning Resident #184 the resident was repositioned off his back. STNA #503 added she was remaining with Resident #184 until the nurse returned. Review of the Emergency Department record dated 07/30/24 revealed Resident #184 was sent to the emergency department for an evaluation of wounds with facility concerns about a decubitus ulcer on Resident #184's buttocks and developing wounds on the lower legs. Review of Resident #184's emergency department assessment revealed a wound of the left foot measured 0.5 cm long by 1.5 cm wide that goes down to the subcutaneous fascia, a coccyx wound, a right heel wound, and wounds to the left upper chest and face. left dorsal foot, right lateral calf, and right arm. Resident #184 was admitted to the hospital on 07/31/24 at 2:10 A.M. with a decubitus pressure injury of the sacral region, sepsis and respiratory failure. Interview on 08/05/24 at 3:30 P.M. with the Director of Nursing denied knowledge of Resident #184 having any wounds and further verified the medical record for Resident #184 was silent for wound treatment orders and the care and treatment of any wounds since Resident #184's admission on 07/24/24. Review of the facility's Pressure Ulcer/Skin Breakdown Clinical Protocol last revised 01/01/22 revealed because a resident at risk can develop a pressure ulcers/pressure injuries (PU/PI) within hours of onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. The interdisciplinary team will assess and document and individual's significant risk factors for developing PU/PI; for example, immobility, recent weight loss, history of PU/PI, modifiable and non-modifiable risk factors. The plan of care for prevention and/or treatment of PU/PIs will be developed based on the assessments. A resident with current PU/PI's is evaluated/assessed by the licensed nurse at each treatment and as needed. Review of the NPUAP guidelines dated 2014 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. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony 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. This deficiency represents non-compliance investigated under Master Complaint Number OH00156481, Complaint Number OH00156247, and Complaint Number OH00155863.

AMENDED 08/27/24 Based on observation, medical record review, resident interview, staff interview, and review of policy, the facility failed to ensure residents who required staff assistance with activities of daily living, received adequate and timely care to maintain good personal hygiene including nail care, bathing, and shaving. This affected four (#15, #16, #19, and #185) of seven residents reviewed for activities of daily living. The facility census was 74. Findings Include: 1. Review of Resident #16's medical record revealed an admitted [DATE]. Diagnoses included type II diabetes, chronic obstructive pulmonary disease, dementia, anxiety disorder, and anoxic brain damage. Review of Resident #16's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #16 was severely cognitively impaired. Resident #16 was dependent on staff for all activities of daily living. Review of Resident #16's care plan revised 07/18/24 revealed supports and interventions for self-care deficit. Interventions included one person assist for bathing and two person assist with personal hygiene. Observation on 07/29/24 at 3:05 P.M., of Resident #16 found Resident #16 was not able to be interviewed. Resident #16's fingernails were long and had a brown substance under his nails. Resident #16 had dried food on his shirt and his hair was oily and uncombed. Interview on 07/30/24 at 9:52 A.M., with State tested Nursing Assistant (STNA) #446 revealed Resident #16 was totally dependent on staff for all care needs including bathing and nail care. Coinciding observation of Resident #16 found his hair was unwashed and his finger nails were long and had a brown substance under his nails. STNA #446 verified Resident #16's nails were long and unclean. STNA #446 stated many of the staff were afraid of Resident #16 due to his behaviors and often did not provide nail care or showers. STNA #446 reported Resident #16 was to receive a shower on night shift and Resident #16 had not been showered in a long time. STNA #446 reported she provided bed baths daily but verified Resident #16 was not showered twice a week as he was supposed to. Review of the policy titled, Activities of Daily Living, revised 01/01/22, revealed a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the policy titled, Bathing a Resident, revised 10/01/23, revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. 15816 2. Review of the medical record of Resident #15 revealed an admitted [DATE], with the diagnoses including: urinary tract infection, chronic obstructive pulmonary disease, seizure disorder, diabetes mellitus, adjustment disorder with depressed mood, hypertension, bipolar disorder, bladder disorder, chronic pain syndrome, heart failure, and muscle weakness. According to the most current minimum data set assessment dated [DATE] assessed Resident #15 with intact cognition, no refusal of care, dependent on staff for the completion of activities of daily living (ADL), incontinent of bowel and bladder, at risk for pressure ulcer with a diabetic foot ulcer. Interview on 07/29/24 at 11:12 A.M., with Resident #15 revealed she had not received a shower since 05/13/24. The resident stated she had received a couple bed baths since that time. However, no showers. The resident indicated she did not feel clean. The residents hair appeared greasy and matted. Review of the plan of care revised 03/15/24, developed to address Resident #15 ADL self-care performance deficit related to diabetes, chronic obstructive pulmonary disease, hypertension, muscle wasting , bladder spasms, Insomnia and chronic pain. Interventions included; One person assist with bathing. Two person assist with personal hygiene. Transfer with two person assistance and use mechanical lift. Review of physician order date 05/23/24 revealed a physician order was implemented for Resident #15 scheduled bathing days, every Monday and Thursday during the evening shift. Review of shower documentation from June and July 2024 noted Resident #15 to be scheduled for showers twice weekly on Monday and Thursday during second shift. According to shower completion documentation Resident #15 was hospitalized between 06/09/24 and 06/11/24. During the month of June 2024 Resident #15 had five opportunities for scheduled showers. Of the five opportunities Resident #15 received showers two times on 06/13/24 and 06/20/24. Review of July 2024 shower documentation noted Resident #15 hospitalized between 07/07/24 and 07/08/24. Showers were documented as completed two of eight opportunities on 07/04/24 at 4:51 A.M. and 07/05/24 at 1:50 P.M. Interview on 07/30/24 at 3:05 P.M., with Licensed Practical Nurse (LPN) #482 Unit Manager during review of shower documentation confirmed missed showers on the described dates. Review of the policy titled, Activities of Daily Living, revised 01/01/22, revealed a resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the policy titled, Bathing a Resident, revised 10/01/23, revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. 45445 3. Review of the medical record for Resident #19 revealed an admitted [DATE], diagnoses included chronic respiratory failure, nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus, depression, anxiety disorder, dysphagia, hypertension, encephalopathy, and bipolar disorder. Resident #19 had a tracheostomy. Review of the annual MDS assessment dated [DATE] revealed Resident #19 had no speech, rarely never is understood and sometimes understands others. Resident #19's cognitive status was unable to be assessed due to a memory problem. Resident #19 had functional impairments to both upper and lower extremities, utilized a wheelchair for mobility and was dependent for mobility, as well Resident #19 was dependent for activities of daily living, and transfers, was always incontinent of bowel and bladder. Review of the care plan dated 09/06/23 revealed Resident #19 had an activities of daily living self-care performance deficit related to contracture's and encephalopathy. Interventions included bathing with the assistance of one person, bed mobility and incontinence care completed with the assistance of two people, and all transfers were completed with a mechanical lift with two staff assistance. Resident #19 had also been cared planned on 02/08/24 for impaired muscle skeletal status related to muscle wasting and atrophy. Interventions included to administer medications as ordered, observe for fatigue, provide assistance with turning and repositioning as resident will allow, allow ample time to reduce pain, and physical therapy, occupational therapy and speech therapy evaluation and treatment as needed. Review of the current physician orders for Resident #19 revealed bed baths are provided on first shift every Wednesday, Friday and Sunday. Review of the Treatment Administration Record (TAR) for July revealed a bed bath was provided on Sunday, 07/28/24, on Friday, 07/26/24 and on Wednesday, 07/24/24. Observation of Resident #19 on 07/29/24 at 5:03 P.M., revealed Resident #19 sat up right on bed, with head of bed elevated at approximately thirty degrees with hands clinched and white stubble about a quarter inch long on Resident #19's chin. An additional observation on 07/30/24 at 2:26 P.M., of Resident #19 sitting upright in reclining wheelchair in dining room with residents playing in bingo revealed white colored whiskers along Resident #19's chin line. Interview on 07/30/24 at 2:30 P.M., with STNA #477 verified Resident #19 had white colored whickers along chin line. STNA #477 stated Resident #19 is to be shaved when the resident is bathed or showered. 4. Review of the medical record for Resident #185 revealed an admitted [DATE], with a readmission on 07/13/24 diagnoses included acute respiratory failure with dependence on a respirator, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, peripheral vascular disease, anxiety disorder, dysphagia, iron deficiency anemia, hypertension, major depressive disorder, and right and left carotid stenosis. Review of the annual MDS assessment dated [DATE] revealed Resident #185 was cognitively intact, had clear speech, was understood, had no functional impairment and was independent with activities of daily living and mobility. Review of the admission MDS assessment dated [DATE] revealed Resident #185 was cognitively intact, had no speech, related to a tracheostomy and was ventilator dependent, was understood, had no functional impairment and was dependent on toilet hygiene, bathing, showering and personal hygiene and required maximal assistance for dressing. Review of the care plan dated 07/13/24 for Resident #185 revealed an activities of daily living self-care deficit with a goal to have activities of daily living needs met. Interventions included one assist with toilet hygiene, bathing and personal care. Review of the current physician orders revealed bathing days every Monday and Friday on evening shift. Review of the treatment administration record for July 2024 revealed no bathing occurred on 07/19/24, 07/22/24, and 07/29/24. Interview with Resident #185 on 07/29/24 at 12:13 P.M., revealed Resident #185 is not receiving showers or bathing assistance on a regular basis. Resident #185 stated I need a bath and assistance with shaving. Resident #185 shared that his brother had bought and brought in an electric razor, further stating, no one has helped with shaving even upon asking. Observation, at the time of the interview, revealed grayish-white stubble on face, prefers not to have a beard. Have razor that brother brought in, and no one has used. Additional interview on 07/30/24 at 11:00 A.M., with Resident #185 verified no bathing assistance was provided on 07/29/24. Interview on 07/31/24 at 7:48 A.M. with STNA #520 verbalized knowledge of Resident #185 not getting showers since returning from the hospital on 07/13/24. STNA #520 stated Resident #185 is to receive bed baths on the evening shift on Mondays and Fridays. STNA #520 denied no knowledge of bathing assistance not being provided. Review of the bathing documentation with STNA #520 verified no bed bath had been completed on 07/19/24, 07/22/24 and 07/29/24. STNA #520 also verified the grayish white colored stubble on Resident #185's face and further verified the resident likes to be cleaned shaved. Review of the policy titled, Activities of Daily Living, revised 01/01/22, revealed a resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the policy titled, Bathing a Resident, revised 10/01/23, revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.

Based on medical record review, observation, resident interview, staff interview, and review of the policy, the facility failed to develop comprehensive care plans which included supports for dental needs. This affected one (#1) of three residents reviewed for ancillary services. The facility census was 74. Findings Include: Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, altered mental status, chronic kidney disease, history of stroke, muscle wasting and atrophy, osteoporosis, and symbolic dysfunction. Review of Resident #1's Minimum Data Set (MDS) Annual Review dated 03/13/24 Resident #1 had no obvious or likely cavity or broken natural teeth. Review of Resident #1's most recent Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five indicating Resident #1 was severely cognitively impaired. Resident #1 required moderate assistance with toilet use, oral care, and dressing. Resident #1 displayed no behaviors at the time of the review. It was noted Resident #1 had no no broken or loose fitting dentures and had no mouth or facial pain, or difficulty chewing at the time of the review. Review of Resident #1's care plan revised 04/01/24 revealed supports and interventions for behaviors, self-care deficit, Alzheimer's disease, impaired cognitive function, potential for nutritional deficits, risk for impaired communication, risk for falls, and risk for pain. A care plan supports for Resident #1's broken and missing teeth and oral care needs were not found. Review of Resident #1's Dental Appointment information revealed on 03/23/23 Resident #1 was seen by the dentist and evaluated. It was documented Resident #1 had three decayed teeth, one missing tooth, and six noted root tips. It was recommended Resident #1 have six teeth extracted. It was noted at the time Resident #1 didn't want extractions, dentures, or partials. The facility was aware of the findings and Resident #1's care plan was not updated with supports or interventions for oral concerns. On 04/15/24 Resident #1 was scheduled to see the dentist and it was noted Resident #1 refused to be seen by the dentist. Interview on 07/29/24 at 2:10 P.M., with Resident #1 found her to be alert and aware. Resident #1 was observed having eaten only a portion of her lunch meal and had picked her sandwich bun apart. Resident #1 reported she had a hard time eating due to her broken and missing teeth. Coinciding observation of Resident #1's teeth found a number on the right side missing, some broken, and all her remaining teeth were various shades of brown. Resident #1 reported her teeth did not hurt her, but they got in the way of her eating because she would try and chew and food would fall out of the gaps or be too large for her to swallow. Interview on 08/01/24 at 9:30 A.M., with the Administrator verified there was not a dental care plan support for Resident #1. Review of the policy titled, Comprehensive Care Plans, revised 06/30/22 revealed the comprehensive care plan would include measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs, include an assessment of the resident's strengths and needs and would describe the services to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial wellbeing.

Based on closed record review, staff interviews, review of hospital documentation, review of witness statements, review of a fall policy, and review of the facility's fall investigation, the facility failed to ensure care was provided per Resident #71's plan of care, failed to prevent an avoidable fall with injuries and failed to conduct a thorough post-fall investigation including a root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls. This resulted in Actual Harm on 10/20/23 when State tested Nursing Assistant (STNA) #180 provided care to Resident #71, who was cognitively impaired and dependent on two staff for bed mobility and toileting, without the assistance of two staff resulting in the resident rolling away from the STNA and falling onto the floor. Subsequently, Resident #71 was transported to the hospital where he was found to have lacerations to his head and mouth due to the fall which required sutures. This affected one (#71) of three residents reviewed for falls. The census was 64. Findings include: Review of the closed medical record for Resident #71 revealed the resident was admitted on [DATE] and discharged on [DATE]. Resident #71 had diagnoses including chronic respiratory failure with ventilator (vent) dependent, tremor, constipation, cerebral vascular accident (stroke), muscle weakness, tracheostomy, encephalopathy, dysphagia, and pulmonary embolism. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #71 revealed the resident was cognitively impaired and required total dependence of two staff members for bed mobility, transfers, and toileting care. Review of the plan of care dated 08/21/23 for Resident #71, revealed the resident had an impaired musculoskeletal status, a self-care performance deficit and was at risk for falls and injuries related to respiratory failure, stroke, gunshot wound, multiple fractures, hepatic encephalopathy, history of physical injury and trauma, and muscle weakness and the resident was dependent on staff for all activities of daily living (ADLs). Interventions included for the resident to have assist bars for bed mobility and repositioning, bolsters to bed, Hoyer lift for transfers, and extensive assistance of two persons for bed mobility, and bathing. The care plan was revised on 10/20/23 to include fall mats to bilateral bedside. Review of the physician's orders dated 02/24/23 for Resident #71, revealed the resident was ordered to have a specialty air mattress with built in bolsters to establish safe parameters. The physician's orders dated 06/15/23, revealed the resident was ordered to be transferred via Hoyer lift with two staff members. The physician's orders dated 09/08/23, revealed the resident was ordered to have one quarter (1/4) side rails for bed mobility related to muscle weakness. The physician's orders dated 10/23/23, revealed the resident was ordered to be sent to the emergency room (ER) for an evaluation and for the resident to have floor mats placed to bilateral bedside to minimize risk of injury. Review of the Nurse Practitioner (NP) progress note dated 10/18/23 for Resident #71, revealed the resident was awake, not alert, and could not follow any commands. Review of the nurse's progress note dated 10/20/23 at 1:00 P.M. for Resident #71, revealed during ADL care, the resident fell out of the bed, landed face down and received a laceration to his head, above his eyebrow, his head, and lip. The staff applied pressure to his head, 911 was called and the resident was transported to the hospital. The NP, who was in the building was notified. Review of the hospital notes dated 10/20/23 at 2:02 P.M for Resident #71, revealed the resident arrived in the ER with a chief complaint of a fall with lacerations to left forehead and lower left lip. The hospital notes indicated while the facility staff was performing morning bathing care, the resident rolled and fell on to floor, sustaining a left frontal scalp hematoma, lacerations to left forehead and left lower lip. The resident was diagnosed with a status post fall with lacerations, required sutures and was admitted to the intensive care unit (ICU) for lower left pneumonia. The hospital notes indicated a computerized tomography (CT) scan showed new areas of hypodensity in the brain which radiology reported as being subacute and a neurology consulted was ordered due to the abnormal CT scan and an magnetic resonance imagine (MRI) was ordered for further testing. Review of the initial fall report dated 10/20/23 at 2:16 P.M. for Resident #71, revealed the resident was getting a bed bath when he fell . The resident was bleeding from his head above his nose and his eyebrow. New interventions included floor mats on both sides of the resident's bed. Review of the nurse's progress notes dated 10/20/23 at 2:31 P.M. and recorded as a late entry for Resident #71, revealed per the hospital report, there were no serious injuries, and the resident had a laceration above his eyebrow and lip. The resident was being admitted for pneumonia. Review of the Situation Background Assessment Request (SBAR) communication form and progress note dated 10/20/23 at 2:24 P.M. for Resident #71, revealed the resident had a fall with an injury to his face. The resident was getting ADL's done by staff, when the resident turned, and he fell out of the bed. The resident landed face down next to the bed and had lacerations above his nose, left eyebrow, was bleeding from his mouth and his front tooth was loose. The NP was in the facility and ordered for the resident to be sent to the hospital. Review of a witness statement by State tested Nursing Assistant (STNA) #180 dated 10/20/23 and recorded by Registered Nurse (RN) #150, revealed the STNA was doing the resident's ADLs and when she turned Resident #71 on his right side, his left leg went over the bolster and the resident kept going and she could not stop him. Review of the fall assessment dated [DATE] at 2:15 P.M., revealed Resident #71 had a fall on 10/20/23 where he rolled out of the bed during care. The report revealed the bed bolsters were in place and the cause of the fall was the resident's poor trunk control and poor safety awareness. The resident had lacerations on his eyebrow and lip and was transferred to the hospital. The assessment noted the resident had no serious injuries and was admitted for pneumonia. The Care plan modifications included placing floor mats on both sides of bed to minimize the risk of injury. Review of the facility's investigation and Quality Assurance Performance Improvement (QAPI) plan completed on 10/27/23, revealed STNA #180 was completing incontinence care for Resident #71 on 10/20/23 when the STNA rolled the resident on to his right side. The resident was noted with poor trunk control and began to roll and rolled over the bed bolster and on to the floor. The resident sustained lacerations above his eyebrow and lip and a bruise to his forehead. The resident was immediately sent to the ER for further evaluation and the hospital determined there were no other injuries. The resident was admitted for pneumonia. The resident was care planned for two staff members during bed mobility and this was also noted on the STNA's Kardex (document for a resident's care needs) as well. The QAPI plan revealed the facility only provided education to the STNAs ensuring that residents were receiving the appropriate assistance based on their needs. The education/training did not include additional staff that may be called on to assist, including the nursing staff. The QAPI plan also did not include a root cause analysis on why the staff used only one-person to provide assistance to Resident #71 when they were aware the resident required a two-person assistance. The QAPI plan also failed to document what interventions the facility would put in place to prevent further avoidable falls with injuries. Interview with STNA #160 on 11/08/23 at 10:16 A.M., revealed Resident #71 required total assistance from staff including two staff for his care. STNA #160 revealed she heard of Resident #71's fall on 10/20/23 and noted STNA #180 was newer and provided care by herself as she rolled the resident off the bed and onto the floor. STNA #160 revealed at times the facility does not have enough staffing and the high acuity residents and the resident's care would often be provided with one staff. STNA #160 indicated Resident #71 was in a hall where almost all of the residents required two-person assistance, but only one STNA was scheduled for hall. Interview with STNA #170 on 11/08/23 at 10:21 A.M., revealed the staff were able to check the assistance needs of each resident by checking the Kardex. STNA #170 was asked about a resident she provided care for, and the STNA referenced Resident #57, indicating this resident was independent with their ADLs. As STNA #170 was demonstrating how the staff could look up information on the Kardex, specifically for Resident #57, the STNA noted the Kardex information for Resident #57 differed from what she was informed. STNA #170 noted Resident #57's Kardex indicated the resident required assistance of one person assist. Interview with STNA #180 on 11/08/23 at 10:47 A.M., revealed she had worked at the facility for a few months and revealed she was caring for Resident #71 when he fell on [DATE]. STNA #180 revealed she was aware of Resident #71 needed two staff members for his care, but looked around and did not see any available staff so she decided to provide care by herself as she did not want resident sitting in a dirty brief. STNA #180 verified she did not ask anyone to assist her in the resident's care. STNA #180 revealed she first rolled the resident on his left side, which was closest to her and towards the resident's window. STNA #180 then rolled the resident towards the door and away from her. STNA #180 indicated the resident's leg must have gone over the bolster pad and once he started to roll off the bed, she could not stop or catch him. Interview with DON on 11/08/23 at 11:15 A.M., revealed the facility investigation found that STNA #180 was providing care to Resident #71, who was a dependent resident, unassisted, and the resident should have been cared for using two staff members. The DON stated after the fall, the facility put new interventions in place for fall mats to both sides of the resident's bed. The DON confirmed the fall interventions put in place for Resident #71 should have been related to the cause of the fall and to prevent a future fall and not necessarily an intervention for fall mats. The DON revealed the STNAs were educated related to using the Kardex to ensure proper number of staff were present and available for assistance with the resident's care. The DON indicated Resident #71 had poor trunk control, poor core strength and lack of safety awareness, but verified the fall was caused by staff not following the care plan and procedures for providing care to a dependent resident. The DON stated her expectations would be if a resident was assessed and required the need for two staff members, then the staff should be following the care plans. Interview with RN #150 on 11/08/23 at 11:55 A.M., revealed she was working on 10/20/23 around shift change when STNA #180 yelled for help from Resident#71's room. RN #150 noted the resident was found on the floor and was assessed to have lacerations to his head and mouth and 911 was called. RN #150 stated STNA #180 did not ask for assistance prior to the fall, and she was unaware STNA #180 was in the room when the fall occurred. RN #150 revealed the residents at the facility required more assistance than most nursing facilities since they have a vent population and many of their residents required two-person assistance. Interview with Resident #71's family member on 11/08/23 at 12:20 P.M., revealed the resident fell out of bed, went to the hospital, and had to get sutures. Resident #71's family noted the resident's sister took care of his medical needs and she would have the sister call the Surveyor with additional details. At the time of exiting the facility on 11/11/23, no return call from Resident #71's sister had been received. Interview with Administrator on 11/08/23 at 1:29 P.M., revealed the facility did not have a policy related to providing ADL care for dependent residents. Review of 11/02/23 facility policy titled Falls-Clinical Protocol, revealed as part of an ongoing resident assessment, staff shall help identify falls risk factors and include information in the care plan including necessary and appropriate interventions taking into account a resident's abilities and deficits, balance, adaptive equipment needs and proper use of mechanical lifts and transfer devices, shower beds, shower chairs and bathroom safety. Interventions should also be placed on the care card for the aides as well as the Kardex in the electronic health record. This deficiency represents non-compliance investigated under Complaint Number OH00148140.

Based on medical record review, review of an investigation statement, staff interview, family interview, and facility policy review, the facility failed to ensure Resident #40 was provided with safe care to prevent a fall. This resulted in actual harm when Resident #40 fell from her bed and was subsequently hospitalized with injuries including a fracture of the first cervical vertebra and second cervical vertebra, laceration of the forehead and her lip, multiple areas of bruising, skin tears to her left hand and forearm, and a nasal bone fracture. This affected one (Resident #40) of four residents reviewed who were identified as being at risk for falls. The facility census was 70. Findings include: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her Fall Risk Evaluation dated 02/09/17 revealed Resident #40 scored 22 on the risk assessment. A score of ten or higher indicated the resident was at risk for falls. In the section for balance which evaluated her balance while standing, sitting and during transitions, Resident #40 scored four indicating she was not able to attempt these activities without physical help. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two-person physical assistance with bed mobility and transfers. Review of the Plan of Care revealed Resident #40 had a self-care performance deficit related to limited mobility. Prior to the fall dated 08/07/17, her interventions included the resident was unable to walk and required transfer by stand-up-lift and two assist to wheelchair, bed, and recliner. She was partial weight bearing and therefore used stand up lift with two assist for transfers. She was at risk for falls related to being unaware of safety needs, osteoporosis and abnormal posture. Interventions included to ensure balance in wheelchair, cushion to wheelchair and bilateral leg rests. Review of the nurse's note dated 08/07/17 at 5:31 P.M. revealed State tested Nursing Assistant (STNA) #222 came and reported Resident #40 fell . The writer entered the residents room to find the resident on the floor face down between the bed and the bed side table. There was a pool of blood under the resident's head. STNA #222 stated she sat Resident #40 on the edge of the bed and turned to grab something, turning her attention away from the resident, when she fell forward out of bed, hitting her head. A full assessment with vital signs was completed. Resident #40 had a laceration on her forehead, a skin tear on her right hand and right wrist and a nose bleed. The family, Physician Assistant, and Hospice was notified. The resident was transferred to the emergency room (ER) for evaluation and treatment. Review of the investigation of the fall dated 08/07/17 revealed Resident #40 fell forward out of her bed, hit her head resulting in a cut on her forehead, skin tears to her right hand and wrist and a bleeding nose. Review of the statement from STNA #222 revealed Resident #40 was sitting up on the side of the bed. STNA #222 had her arm around Resident #40's shoulders, turned to reach for a brief and that was when resident #40 fell . STNA #222 notified the nurse and 911 was called. STNA #222 was preparing Resident #40 to get up while waiting on assistance from another STNA at the time of the occurrence. STNA #222 was suspended pending investigation. Resident #40 required two-person staff assistance with her care and a stand-up lift for transfers. A full assessment was completed and Resident #40 was sent to the hospital. Results of the investigation revealed new interventions initiated upon Resident #40's return included bed to be in lowest position when not providing care and when transferring resident, two staff assistance for all transfers and a therapy screening. Review of Resident #40's Trauma History and Physical hospital documentation dated 08/08/17 revealed Resident #40's [DIAGNOSES REDACTED]. Further examination revealed she also had a nasal bone fracture. The nurse's note dated 08/08/17 at 6:26 P.M. revealed Resident #40 returned to the facility from the hospital via ambulance on a stretcher. Notable at first glance assessment revealed extensive bruising on her face, left shoulder, right knee, and various smaller bruises covering body. Sutures were present on the resident's forehead and right upper lip. Dressings were on top of left hand and left forearm. Observation on 08/09/17 at 11:54 A.M. revealed Resident #40 was in her room in bed. She had a soft cervical collar on her neck, sutures on her forehead and lip, bilateral black eyes and bruising noted at her left shoulder. She was wearing a hospital gown. She had bruising and an abrasion at her posterior right hand. She had three mepilex border dressings at her left posterior hand and left forearm. Pillows were under her right side behind her back for positioning. Interview on 08/09/17 at 11:57 A.M. with Resident #40's granddaughter revealed her mother was contacted when Resident #40 fell on [DATE]. She verified she was informed that staff sat Resident #40 on the edge of bed and she fell off the bed. The granddaughter verified the neurosurgeon at the hospital assessed Resident #40. The neurosurgeon stated Resident #40 had shattered her first cervical vertebra (C1) and the second cervical vertebra (C2) was also fractured and unstable. She also had a fractured nose and sutures at the forehead and lip. She was not a surgical candidate. The surgeon recommended a soft collar for treatment. The surgeon did not report any paralysis from the cervical fractures. Interview on 08/09/17 at 12:33 P.M. with the Director of Nursing (DON) verified Resident #40 had a fall and an investigation was conducted. The DON verified STNA #222 was getting Resident #40 up for dinner on 08/07/17 around 5:40 P.M. and Resident #40 was sitting on the edge of her bed. STNA #222 had her arm around her shoulders. STNA #222 reached with her other arm to get a brief and Resident #40 fell forward onto the floor. STNA #222 was not able to catch her and prevent the fall. Further interview with the DON at 2:49 P.M. revealed human error was the cause of Resident #40's fall. The DON stated there should be two people in the room when Resident #40 was being cared for. She verified Resident #40 used a stand-up lift for transfers. She verified her bed had not been in low position when she fell . She stated the bed was raised for the STNA #222 to provide care. STNA #222 was suspended pending investigation. On 08/09/17 at 3:23 P.M. interview with STNA #222 revealed she was providing care for Resident #40 while waiting for another STNA to help her get Resident #40 up with the stand-up-lift. STNA #222 verified Resident #40 was seated on the edge of her bed and she had her hand on her shoulder. When she turned to reach for a brief that was when Resident #40 fell forward onto the floor. The bedside table was next to the bed and STNA #222 believed the resident hit her head on the table which was the cause of the forehead laceration. She stated Resident #40's feet were touching the floor. She had elevated the bed only about six inches from the lowest position in preparation for use of the stand-up-lift. STNA #222 stated she was aware Resident #40 was not able to sit up unassisted and she admitted she had made a mistake. Review of the facility policy titled Safe Lifting and movement of residents revised 04/2015 revealed each resident was assessed through the Resident Assessment Instrument and by the Interdisciplinary team to determine lifting and movement assistance needs. At times it was necessary to include the use of mechanical lifts to protect the safety and well-being of staff and residents and to promote quality care. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices. Two staff shall be present to assist during all resident lifts using mechanical lifts. The deficiency substantiates Complaint Number OH 869.